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Event Notification Report for December 26, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/24/2013 - 12/26/2013

** EVENT NUMBERS **


49635 49636 49640 49643 49649 49654 49655 49656 49658

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Agreement State Event Number: 49635
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: MARYLAND QC LABORATORIES
Region: 1
City: BELCAMP State: MD
County:
License #: MD-25-022-01
Agreement: Y
Docket:
NRC Notified By: ALAN JACOBSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/16/2013
Notification Time: 15:12 [ET]
Event Date: 12/16/2013
Event Time: [EST]
Last Update Date: 12/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

MARYLAND AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY SOURCE

The following information was obtained from the State of Maryland via email:

"At 12:17 PM on December 16, 2013, the Radiation Safety Officer of Maryland Q.C. Laboratories, called [the State of Maryland] to report an incident that occurred today in their radiography vault. She reported that they were performing industrial radiography using a 34.7 Ci Ir-192 source, QSA model A424-9 in a model 880 D camera, when a steel pipe fell on the guide tube preventing the source from retracting into the shielded position. She stated that attempts to retract the source were not successful. She further stated that QSA Global will arrive at the licensed facility tomorrow to recover the source. The source is in a tungsten collimator inside the vault. The assistant radiographer reported 10 mRem on his SRD. For security, Maryland Q.C. locked the door to the vault and will post a 2-man crew at the facility until QSA arrives. Maryland Health Physicist Bob Nelson is on site at this time conducting an investigation. He reports that the dose rates outside the vault are less than 1.0 mRem per hour."

* * * UPDATE FROM ALAN JACOBSON TO CHARLES TEAL AT 0937 EST ON 12/17/13 * * *

"The Maryland Health Physicists conducting the investigation at Maryland QC Laboratories reported on 12/17/2013 at 0930 hours that the source has been safely retrieved and stored in the camera."

Notified R1DO (Dimitriadis) and FSME Events Resource via email.

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Agreement State Event Number: 49636
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: MISTRAS GROUP, INC.
Region: 4
City: REDMOND State: WA
County:
License #: WN-IR011-1
Agreement: Y
Docket:
NRC Notified By: STEPHEN MATTHEWS
HQ OPS Officer: DANIEL MILLS
Notification Date: 12/16/2013
Notification Time: 20:02 [ET]
Event Date: 12/14/2013
Event Time: [PST]
Last Update Date: 12/19/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
FSME_Events Resource (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY SOURCE

The following was received via facsimile:

"Event Narrative: While performing radiography operations at Microsoft Bld. 32 in Redmond, Washington, the radiography source could not be retracted from the collimator back into camera. The Radiation Safety Officer (RSO) of Mistras then called the Washington State Department of Health (DOH) emergency line (206 Nuclear) and an inspector was dispatched to the scene. At the scene was the RSO, Assistant RSO (trained in source recovery), assistant radiographer, and another radiographer. Assistance was being provided via telephone by QSA Global. It is not known yet if previous attempts brought the source through the camera and into the crank cable tube. However, while attempting to remedy the situation the (0-200 mR) pocket dosimeter of the radiographer had gone off scale. The radiographer was removed from the scene and his TLD has been sent in via overnight mail for emergency processing. The collimator was attached to the camera with a 2-3 inch long fitting (there was no guide tube). After disconnecting the crank cable from the camera, the crank cable was pulled back to the crank (while observing survey meters), and it was discovered that the connector at the end of the cable where it was attached to the pig tail was broken. The camera and collimator were loaded onto a dry wall cart and covered with several bags of lead shot. A moving 2 mR/hr barrier was established around the cart during this movement. The apparatus was then moved to a remote area of the parking lot. Once in the parking lot, 2 mR/hr barricades were set up. Eight foot long tools were made in order to unscrew the fitting from the collimator. Once the fitting was removed, the connector end of the pigtail was exposed and could be pulled out (with eight foot grappler) of the collimator and inserted into another camera. This procedure was practiced several times with a dummy source prior to the actual transfer. The highest dose received on the retrieval team was 93 mR. An investigation is about to begin, and Mistras was performing reenactments earlier today. More information pending."

* * * UPDATE ON 12/19/13 AT 1439 EST FROM STEPHEN MATTHEWS TO DONG PARK * * *

The retrieval team leader received 43 mR with pocket dosimeter, the licensee RSO received 93 mR with pocket dosimeter, the assistant radiographer received 85 mR with pocket dosimeter, and the radiographer received 40 mR with pocket dosimeter.

Notified R4DO (Lantz) and FSME Events Resource via email.

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Non-Agreement State Event Number: 49640
Rep Org: CONNECTICUT RADIATION DIVISION
Licensee: NEW HAVEN HEALTH DEPARTMENT
Region: 1
City: NEW HAVEN State: CT
County:
License #: Permit # 0914
Agreement: N
Docket:
NRC Notified By: ANDREW ZWICK
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/17/2013
Notification Time: 11:15 [ET]
Event Date: 12/16/2013
Event Time: 22:00 [EST]
Last Update Date: 12/17/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENT RESOURCE (EMAI)
BARRY WRAY (ILTA)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

LEAD ANALYZER STOLEN FROM CAR

A lead analyzer was stolen from the trunk of a car belonging to an employee of the New Haven Health Department. The device was a RMD XRF Lead Analyzer, Model LPA-1, serial #3520, and contained a Co-57, 10-12 mCi source.

The missing device was reported to the New Haven, CT police department.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 49643
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: RADIOTHERAPY CLINICS OF GEORGIA
Region: 1
City: SNELLVILLE State: GA
County: GWINNETT
License #: GA 848-5
Agreement: Y
Docket:
NRC Notified By: KIT RAMDEEN
HQ OPS Officer: DANIEL MILLS
Notification Date: 12/17/2013
Notification Time: 14:19 [ET]
Event Date: 12/16/2013
Event Time: [EST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (EMAI)
ANGELA MCINTOSH (FSME)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - POSSIBLE MEDICAL MISADMINISTRATION

The following report was received via email:

"Description of Event: [The Georgia Department of Natural Resources] Received a call from the RSO [Radiation Safety Officer] of RCG [Radiotherapy Clinics of Georgia] on December 17, 2013 at 0930 EST, informing the Department of a possible misadministration that occurred at the Snellville location.

"The wrong [High Dose Rate] HDR treatment plan was selected and used on a patient resulting in some possible injury to the patient. An investigation is currently being initiated to determine the cause and effects of the error. The licensee will provide an official report to the Department within 15 days."

Georgia Incident Number 121613.

* * * UPDATE RECEIVED FROM DAVID CROWLEY TO JOHN SHOEMAKER AT 2034 EST ON 12/18/13 * * *

"[The Georgia State Investigator] received the initial call on 12/17/2013 at 0930 EST. The incident regarded an Ir-192 HDR afterloader and had occurred on 12/16/2013.
.
"[The initial report stated:] It was determined that the wrong treatment plan was given and a misadministration had occurred. The correct site and applicator were used; however, a gynecological treatment plan ran in place of the intended skin treatment plan. No symptoms were evident at this time, but the patient was alerted to look for a reddening of the skin.

"The RSO did not communicate much information and left many details open until they could submit the final report. [The Georgia State Investigator] forwarded this information to the [NRC] upon documenting it.

"[A Georgia State Investigator] performed a reactive site [follow-up] inspection on 12/18/2013 to discern more information about the incident. One of the contributing causes appears to be similar last names on the two patient plans. No other verification of the treatment plans seemed to be conducted other than selecting the name; which the physicist inadvertently clicked on the wrong patient name in this selection process.

"113 seconds passed before the error was caught and the physicist pressed for manual interrupt of the treatment. The treatment was intended for the skin on the temporal region of the patient's head. This used a skin plaque type applicator. Instead, a gynecological plan ran in the system but with the skin plaque applicator in place on the correct location of the patient.

"The error caused the Ir-192 source to hit a dead end at the first channel due to it having a shorter channel length than the other plan anticipated. From what the physicist could determine it was stuck in that position for nearly the entire time.

"The prescribed procedure was for 40 (4000 rem) Gy to be delivered in a fractionated schedule. An actual delivered dose is yet to be calculated and will determine whether a corrective fractionation schedule will be prescribed to correct for this since most of the dose was deposited in the vicinity of the treatment site. This determination will be included in the final report. At this time, the only expected acute effects to the patient may
be reddening of the skin in the immediate location of the source.

"The source had an 8.0 Ci Ir-192 source from Alpha Omega Services, Inc. (Serial#: 24-01-2470-001-110113-12043-45). This was in a mobile HDR unit made by Varian (Model: Gamma Med(+)iX / Serial#: H640510-GM).

"Corrective actions are still being discussed and will be clearly identified in the final report to prevent future occurrences."

Notified the R1DO (Dimitriadis), FSME Events Resource and FSME (McIntosh) via email only.

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Agreement State Event Number: 49649
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MEMORIAL SLOAN-KETTERING CANCER CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: 75-2968-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/18/2013
Notification Time: 12:22 [ET]
Event Date: 11/21/2013
Event Time: [EST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - HDR BRACHYTHERAPY SOURCE PLACED INCORRECTLY

"Description of incident: HDR brachytherapy treatment of the bronchial, tracheal area. The source was placed incorrectly, resulting in underdose to intended treatment area.

"An additional treatment fraction will be prescribed to compensate for underdose to intended treatment area. Underdose was discovered on 1st of 3 fractions, prior to delivery of 2nd fractions.

"Sequelea: No adverse effects expected as a result of medical event, since the patient is terminally ill.

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Non-Agreement State Event Number: 49654
Rep Org: U. S. ARMY
Licensee: U. S. ARMY
Region: 1
City: FORT BRAGG State: NC
County:
License #: 21-32838-01
Agreement: Y
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/18/2013
Notification Time: 13:50 [ET]
Event Date: 12/13/2013
Event Time: 09:30 [EST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
KENNETH RIEMER (R3DO)
FSME EVENTS RESOURCE (EMAI)
BARRY WRAY (ILTA)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

STOLEN CHEMICAL AGENT MONITORS

The US Army in Warren, Michigan, reported that 3 improved chemical agent monitors were stolen from a storage facility at Fort Bragg, NC. Each of the 3 detectors contained a sealed 15 mCi Ni-63 source. The detectors were stored in building N-5342 and the locks on the building, storage area, and storage locker were damaged. The Fort Bragg Criminal Investigation Unit is conducting an investigation.

The US Army has also notified NRC Region 3.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 49655
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA DAVIS
Region: 4
City: SACRAMENTO State: CA
County:
License #: 1334
Agreement: Y
Docket:
NRC Notified By: GENE FORRER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/18/2013
Notification Time: 15:31 [ET]
Event Date: 12/18/2013
Event Time: [PST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)
MEXICO (FAX)
BARRY WRAY (ILTA)
ANTHONY DIMITRIADIS (R1DO)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST MATERIAL SHIPMENT

An outgoing shipment of a Strontium (Sr-82, 23.6 mCi; Sr-85, 54 mCi) Generator, from the University of California Davis to Los Alamos, NM, cannot be located by the shipping company. Shipment tracking shows the items last seen in Memphis, TN. It is suspected the shipment is only temporarily misplaced due to holiday shipping traffic and the shipping company is continuing attempts to locate the shipment.

California Report #121713.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL

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Agreement State Event Number: 49656
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: GE HEALTHCARE
Region: 3
City: ARLINGTON HEIGHTS State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/18/2013
Notification Time: 14:09 [ET]
Event Date: 12/16/2013
Event Time: [CST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE (E-ma)
BARRY WRAY (ILTA)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST VIAL OF THALLIUM-201

"The Radiation Safety Officer at GE Healthcare (Mediphysics) [IL-01109-01] Arlington Heights, IL called the Agency [IL Emergency Management Agency] on December 18, 2013 to report an incident concerning an over pack shipment intended for their pharmacy in Atlanta, Georgia. On Sunday December 15, a package containing 12 shielded vials of TL-201, 31 milliCi each, was transferred to Delta Airlines Freight services at Chicago's O'Hare international airport for shipping to Atlanta. The package arrived at Atlanta's Hartsfield International Airport the next day and was unloaded. However during the trip from the air plane cargo hold to the freight hub, the package tumbled off the conveyance and was broken open. This occurred on Sunday night, December 16. That night and the next morning a 3rd party contractor hired by the airlines/airport collected the vials and its packaging and placed the material into an over pack and secured the drum until it could be claimed by GE Healthcare. Based on the description and measurements performed by the company which were provided to GE Healthcare, it appeared none of the glass vials within their shielded containers were broken. As such it was determined that the vials were to be repackaged and forwarded to the pharmacy for evaluation. When repackaging at the freight hub was attempted by the GE Atlanta pharmacist on Tuesday, December 17, it was confirmed that no contamination was present on the packaging or the interior containers, however, it became clear that only 11 of the 12 vials were present in the salvage drum, contrary to the contractor's initial assertions. GE Healthcare contacted the Georgia agreement state program regarding the matter. The contractor is conducting additional visual and radiological surveys of the tarmac and freight hub. As of today (12/18/13), calculations show that a single vial contains approximately 16 milliCi of TL-201. If intact and still shielded as the other vials which were found, GE Healthcare estimates that the vial would have a dose rate of approximately 350 microR/hr at one foot.

"A report on the matter from GE Healthcare is anticipated. They have indicated that they would keep us appraised of developments as this matter moves forward. The Agency has been in touch with a representative of the Georgia program regarding potential additional actions to recover the vial. Given the 72 hour half life of the material, there will be no TL-201 present within the next 30 days. Also given that no contamination was detected on the packaging and the other 11 containers of Tl-201 were found intact, there is reason to assume the missing container was still intact at the time of the accident and the search is being conducted accordingly."

Illinois Event Number: IL13036

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 49658
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: DOMTAR A.W., LLC
Region: 4
City: ASHTOWN State: AR
County:
License #: ARK-0354-0312
Agreement: Y
Docket:
NRC Notified By: KAYLA AVERY
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 12/18/2013
Notification Time: 17:06 [ET]
Event Date: 12/18/2013
Event Time: [CST]
Last Update Date: 12/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MULTIPLE STUCK SHUTTERS AT A PAPER MILL PLANT

The following report was received via email:

"The following are the preliminary findings of the Arkansas Department of Health, Radioactive Materials Program, involving multiple stuck shutters at a paper mill plant.

"An onsite inspection of this licensee was conducted on December 17, 2013. During this inspection, it was discovered that since 2008, multiple shutters were found to have been stuck open and were not able to be locked out. Based on the records reviewed at the time of inspection, it appears that there were a total of 17 gauges with stuck shutters since May 2010. It appears at this time that all but nine (9) of these gauges have been repaired, dismounted and/or disposed. Currently, these nine gauges (9) are still in use with the shutters stuck in the open position. In accordance with RH-1502.f.2. (equivalent 10 CFR 30.50(b)(2)), each stuck shutter event should have been reported to the State of Arkansas within 24 hours. The licensee failed to notify the State of Arkansas of all of these events.

"The information concerning the 17 gauges is as follows:

Radionuclide Manufacturer Model # Activity

Cesium-137 Berthold LB 7440 50 mCi
Cesium-137 Berthold LB7440 100 mCi
Cesium-137 Berthold LB 7440 30 mCi
Cesium-137 Berthold LB 7440 250 mCi
Cobalt-60 Berthold LB 300L 0.2 mCi
Cobalt-60 Berthold LB 300L 0.5 mCi
Cobalt -60 Berthold LB 300L 0.19 mCi
Cobalt-60 Berthold LB 300L 0.7 mCi
Cobalt-60 Berthold LB 300L 4.14 mCi
Cobalt-60 Berthold LB 300L 0.46 mCi
Cobalt-60 Berthold LB 300L 1.8 mCi
Cobalt-60 Berthold LB 300L 1.51 mCi
Cesium-137 Berthold LB 330 24 mCi
Cobalt-60 Berthold LB 300L 1.8 mCi
Cobalt-60 Berthold LB 300L 0.46 mCi
Cobalt-60 Berthold LB 300L 1.51 mCi
Cobalt-60 Berthold LB 300L 0.22 mCi

"The licensee is in the process of submitting additional records. Information related to the gauge serial numbers and event date will be provided in another update. The Department is continuing to investigate and will provide updates as information is received."

Page Last Reviewed/Updated Thursday, December 26, 2013
Thursday, December 26, 2013