Alert

Due to a lapse in appropriations, the NRC has ceased normal operations. However, excepted and exempted activities necessary to maintain critical health and safety functions—as well as essential progress on designated critical activities, including those specified in Executive Order 14300—will continue, consistent with the OMB-Approved NRC Lapse Plan.

Event Notification Report for September 30, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/29/2014 - 09/30/2014

** EVENT NUMBERS **

Agreement State	Event Number: 50471
Rep Org: NJ RAD PROT AND REL PREVENTION PGM Licensee: FRENCH & PARRELLO Region: 1 City: WALL TOWNSHIP State: NJ County: License #: 507834-RAD110 Agreement: Y Docket: NRC Notified By: JACK TWAY HQ OPS Officer: DANIEL MILLS	Notification Date: 09/19/2014 Notification Time: 10:09 [ET] Event Date: 09/19/2014 Event Time: [EDT] Last Update Date: 09/19/2014
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOHNATHAN LILLIENDAH (R1DO) FSME EVENTS RESOURCE (EMAI) ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The state of New Jersey provided notification that a licensee (French and Parrello) reported a Troxler moisture density gauge (Model 3430, Serial #38931) stolen. The gauge was in the possession of a contractor (employed by Aerotek staffing agency) who has not shown up for work for several days. Attempts have been made to contact the contractor. New Jersey instructed the licensee to contact local law enforcement. The gauge contains 40mCi Am-241 and 8mCi Cs-137.

NJ EVENT: 14-09-19-1107-54

* * * UPDATE FROM JACK TWAY TO HOWIE CROUCH (VIA EMAIL) ON 9/19/14 AT 1231 EDT * * *

The gauge operator contacted the Wall Township Police Department to inform them that he was in possession of the gauge and would be returning it to the licensee today.

Notified R1DO (Lilliendahl), FSME Events Resource (email), and ILTAB (email).

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

Agreement State	Event Number: 50472
Rep Org: MONONGALIA GENERAL HOSPITAL Licensee: MONONGALIA GENERAL HOSPITAL Region: 1 City: MORGANTOWN State: WV County: License #: 47-16259-01 Agreement: N Docket: NRC Notified By: MARK PERNA HQ OPS Officer: HOWIE CROUCH	Notification Date: 09/19/2014 Notification Time: 13:56 [ET] Event Date: 09/19/2014 Event Time: [EDT] Last Update Date: 09/19/2014
Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE	Person (Organization): JOHNATHAN LILLIENDAH (R1DO) FSME EVENTS RESOURCE (EMAI)

Event Text

BRACHYTHERAPY PATIENT RECEIVED 54% OF PRESCRIBED DOSE

The authorized user determined that, due to scar tissue from a previous procedure , the patient received only 54% of the intended dose during a I-125 prostate brachytherapy treatment. The patient was implanted with 72 seeds (nominal 0.269 mCi each), some of which were inadvertently implanted in the scar tissue. The authorized user/physician expects no adverse effects on the patient and does not intend to repeat the treatment. The patient has been notified.

The investigation into the event is ongoing.

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.

Agreement State	Event Number: 50473
Rep Org: TEXAS DEPARTMENT OF HEALTH Licensee: DESERT NDT, LLC Region: 4 City: ABILENE State: TX County: License #: 06462 Agreement: Y Docket: NRC Notified By: ART TUCKER HQ OPS Officer: HOWIE CROUCH	Notification Date: 09/19/2014 Notification Time: 14:12 [ET] Event Date: 09/17/2014 Event Time: [CDT] Last Update Date: 09/19/2014
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): TOM ANDREWS (R4DO) FSME EVENTS NOTIFICA (EMAI) ANGELA MCINTOSH (FSME) PATRICIA MILLIGAN (NSIR)

Event Text

TEXAS AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURES TO TWO RADIOGRAPHERS

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

"On September 18, 2014, the Agency [Texas Department of Health] was notified by the Licensee's Radiation Safety Officer (RSO) that two radiographers working at a field location may have received exposures in excess of the annual whole body exposure limit. The RSO stated two qualified radiographers were working at a temporary field site using an INC IR-100 exposure device containing a 55 curie iridium-192 source. One radiographer (RA) was performing the exposures and the other (RB) was developing the film. The RSO stated RA walked out of the darkroom and saw the camera setting on the truck's tailgate. The radiographer also observed the dose rate meter sitting on the truck's tailgate was reading pegged high. The radiographers picked up the crankout device and cranked the handle approximately one-half turn which locked the source in the fully shielded position. The RSO stated RA read their self-reading dosimeter (SRD) and it was off scale. The RSO stated RB was not wearing a SRD or OSL [optically stimulated luminescence] dosimeter. The RSO stated RB was wearing an alarming rate meter, but they are hard to hear and with the background noise of the generator they did not hear it alarming.

"The RSO stated RB was five feet from the exposure device for about 20 minutes. The RSO stated the calculated dose to RB is 12.8 rem based on their current information. The RSO stated RA was near the camera for about 30 seconds and his dose was calculated to be 10.8 rem. Both radiographers' dosimeters have been sent to the licensee's processor for reading. The RSO stated they have not calculated the dose to RA's hand yet. The RSO stated they are reenacting the event on September 19, 2014, to help calculate the dose to both workers. The licensee has contracted a consultant (Bruce Bristow) to aid in the dose calculations. The RSO stated the cause for the high exposures was failure of RA to fully retract the source. The RSO stated the exposure device was working properly. No other individuals received any exposure due to this event.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # I-9235

Agreement State	Event Number: 50477
Rep Org: TEXAS DEPARTMENT OF HEALTH Licensee: BAKER HUGHES OILFIELD OPERATIONS INC Region: 4 City: HOUSTON State: TX County: DIMMIT License #: 06453 Agreement: Y Docket: NRC Notified By: CHRIS MOORE HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 09/21/2014 Notification Time: 09:09 [ET] Event Date: 09/20/2014 Event Time: [CDT] Last Update Date: 09/22/2014
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): TOM ANDREWS (R4DO) FSME EVENTS RESOURCE (E-MA) PAM HENDERSON (FSME)

Event Text

AGREEMENT STATE REPORT - VEHICLE FIRE INVOLVING TWO DENSITY GAUGES

The following report was received via e-mail:

"On September 20, 2014, the licensee notified the Agency [Texas Department of State Health Services] that two nuclear gauges, Thermo Fisher Scientific Model 5190 density gauges containing a 200 milliCurie cesium (Cs) - 137 source, were inside a large fire that occurred in the early morning hours. The fire at an oil field temporary job site in Dimmit County, Texas burned over twenty vehicles and the two gauges stored in Type A containers were in the fire. Status of the gauges is unknown. An additional two similar gauges were at the site but not in the area of the fire. An investigation is ongoing and additional information in accordance with SA-300 will be reported. There was no public or worker exposures due to the incident as no one was on site at the time of the fire.

"Gauge Serial Numbers are B6610 and B7600."

Texas Incident #I-9236

* * * UPDATE FROM KAREN BLANCHARD TO JOHN SHOEMAKER AT 1247 EDT ON 9/22/14 * * *

The following event report update was received from the State of Texas via email:

"[The State was informed by the licensee at 1345 CDT on 9/22/14, that] the licensee surveyed and inspected the two Thermo Fisher Scientific Model 5190 gauges that were in a fire on September 20, 2014. Radiation measurement of 7 R/hr on contact with the outer surface of one of the gauges was detected, indicating that the lead shielding had been compromised (gauge SN: B7500). There were no elevated radiation levels detected on the second gauge. The licensee has secured all four gauges that were at the site and set up appropriate barrier while it awaits permission to remove them from the site. The cause of the fire is still under investigation. The manufacturer is sending a transport container. The licensee reported it will add external lead around the compromised gauge for transport. Upon receipt, the manufacturer will inspect/evaluate all four gauges."

Notified R4DO (Drake), FSME Events Resource via email.

Agreement State	Event Number: 50479
Rep Org: COLORADO DEPT OF HEALTH Licensee: AVISTA ADVENTIST HOSPITAL Region: 4 City: LOUISVILLE State: CO County: License #: CO 793-01 Agreement: Y Docket: NRC Notified By: PHILLIP PETERSON HQ OPS Officer: JOHN SHOEMAKER	Notification Date: 09/22/2014 Notification Time: 13:06 [ET] Event Date: 09/20/2014 Event Time: 12:30 [MDT] Last Update Date: 09/22/2014
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMES DRAKE (R4DO) FSME EVENTS RESOURCE (EMAI) PATRICIA MILLIGAN (EMAI) ANGELA MCINTOSH (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following report was received from the State of Colorado via email:

"The State of Colorado received a report this morning from a medical licensee of a misadministration. The licensee reported that at 1230 [MDT] on Saturday 9/20/14, the technologist injected a patient with a bulk dose of Tc-99m instead of a [smaller] patient dose. The initial estimate for the amount injected is 140 mCi. The initial potential whole body dose is 6-7 rem with 30 rad as the highest potential organ dose (upper intestine). The investigation is ongoing."

Additional information regarding the intended patient dose will be provided when available. The attending physician and patient will be informed by the licensee.

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.

Agreement State	Event Number: 50481
Rep Org: WA OFFICE OF RADIATION PROTECTION Licensee: CARDINAL HEALTH Region: 4 City: SEATTLE State: WA County: License #: WN-NP011-1 Agreement: Y Docket: NRC Notified By: CURT DEMARIS HQ OPS Officer: JOHN SHOEMAKER	Notification Date: 09/22/2014 Notification Time: 17:34 [ET] Event Date: 08/27/2014 Event Time: [PDT] Last Update Date: 09/22/2014
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMES DRAKE (R4DO) FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOACTIVE MATERIAL RELEASE EXCEEDING EMISSION LIMIT

The following report was received from the State of Washington via email:

"Event Narrative: Notification [was given] to [Washington] State by the licensee for exceeding the allowable total abated emission limit for this unit [Cardinal Health 414, LLC]. The limit is 7.4 mRem to the MEI [Maximally Exposed Individual] while the licensee acknowledges a release so far in 2014 of a total of 23.7 mRem (21.5 from Fluorine 18 and 2.2 from Carbon 11). The licensee believes the problem is a combination of errors including both human and engineering. Proposed corrective actions include changes in procedures as well as changes in the air discharge system components."

NMED Report Number: WA-14-039.

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