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Event Notification Report for July 10, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/09/2014 - 07/10/2014

** EVENT NUMBERS **


50248 50249 50251

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Agreement State Event Number: 50248
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: SOLAR TESTING OF PA
Region: 1
City: MT. LEBANON State: PA
County:
License #: PA-1377
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/01/2014
Notification Time: 19:16 [ET]
Event Date: 06/30/2014
Event Time: [EDT]
Last Update Date: 07/01/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE ()

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

Event Text

AGREEMENT STATE REPORT - LOST OR STOLEN NUCLEAR DENSITY GAUGE

The following report was received from the Commonwealth of Pennsylvania via facsimile:

"Notifications: The Department's [Pennsylvania Department of Environmental Protection and Bureau of Radiation Protection] Southwest Office received a phone call on July 1, 2014 regarding a lost nuclear density gauge. This event is reportable per 10 CFR 20.2201(a)(1)(i).

"Event Description: The nuclear density gauge in question was last used on Friday, June 27th, at a job site in Mt. Lebanon, PA. The employee who used the gauge, reported returning the gauge (in its case) to the licensee's storage area that afternoon. That same employee reported, at close of business on Monday June 30th, that 'the case was now empty.' An inspection by the licensee [revealed] the case and lock were both intact inside the locked storage area. There were no signs of forced entry and nothing else was missing. The employee has been questioned multiple times and maintains that the gauge was returned to the storage area in the case on Friday, June 27th. The licensee also went back to [search] the job site in Mt. Lebanon, but did not find the gauge.

"Gauge Model: Troxler 3411B, Serial # 5434, containing 9 mCi Cs-137 and 44 mCi Am-241 sources.

"Cause of the Event: Unknown at this time.

"Actions: The local police are being notified and the licensee is offering a reward for the return of the gauge. The Department issued a press release on July 1, 2014, with a photo of the Troxler gauge and noting the reward. The Department's Southwest Regional Office will conduct an reactive inspection. More information will be provided upon receipt."

PA Report #: PA140014

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: 50249
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: CLARION BOARDS
Region: 1
City: SHIPPENVILLE State: PA
County:
License #: PA-G0084
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/01/2014
Notification Time: 21:46 [ET]
Event Date: 05/21/2014
Event Time: [EDT]
Last Update Date: 07/01/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE ()

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

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE

The following report was received from the Commonwealth of Pennsylvania via facsimile:

"Notifications: The DEP [Pennsylvania Department of Environmental Protection and Bureau of Radiation Protection] Southwest Regional Office contacted the licensee upon our DEP Central Office receiving a reciprocity notification for a scheduled repair to be done on a level gauge with a stuck shutter. The RSO from the licensee was unaware that this shutter failure was a reportable event. This event is reportable within 24-hours per 10 CFR 30.50(b)(2).

"Event Description: The licensee made a service call to a service provider on May 21, 2014, for a quote on a stuck gauge shutter. This situation was discovered by the licensee during a shutter check and leak test. It is unclear if the shutter was stuck open or closed. However, the licensee does have a 'lock-out/tag-out' procedure, and personnel were restricted from the gauge area. It is also unknown at this time of the actual event date.

"Gauge Manufacturer: Ronan Engineering; Model: SA 1-F37; Serial Number: M7255; Source Isotope: Cesium-137; Activity: 10 millicuries (mCi).

"Cause of the Event: Unknown at this time.

"Actions: The Department plans to do a reactive inspection. More information will be provided when more information is received."

PA State Report #: PA140015

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Agreement State Event Number: 50251
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: LONG ISLAND JEWISH MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County:
License #: 75-2986-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 07/02/2014
Notification Time: 16:23 [ET]
Event Date: 07/02/2014
Event Time: 13:00 [EDT]
Last Update Date: 07/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE ADMINISTRATION FOR TREATMENT OF PROSTATE CANCER

The following report was received from the New York City Office of Radiological Health (NYC ORH) via facsimile:

"Type of Incident: Underdose of Sm-153 administration IV for treatment of prostate cancer.

"Location of Incident: Long Island Jewish Medical Center. New York City Radioactive Materials License No. 75-2986-01

"Date and time of Incident: 07/02/14 at 1300 EDT.

"Date and time of Report to NYC ORH: 07/02/14 at 1530 EDT.

"Date of Investigation by ORH inspector: Inspection will be assigned no later than 24 hours from time of report to the Office of Radiological Health.

"Description of event: Patient was being injected with Samarium-153 intravenously [IV], in the arm for treatment of prostate cancer.

"In preliminary telephone report by hospital, RSO stated that administration was made into the skin, rather than IV as intended. Physician's prescription was for 100 microcuries (reporting RSO twice stated 'microcuries'). Of the prescribed 100 microcuries, it was estimated that only 39.2 microcuries was delivered. Procedure was stopped in the course of delivery.

"Reporting RSO at Medical Center stated that preliminary report would be sent by email later today. Letter with details to follow."

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.

Page Last Reviewed/Updated Thursday, July 10, 2014
Thursday, July 10, 2014