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Event Notification Report for November 24, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/21/2014 - 11/24/2014

** EVENT NUMBERS **


50603 50608 50609 50611 50612 50613 50615 50616 50617

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 50603
Rep Org: PARKVIEW HEALTH
Licensee: PARKVIEW HEALTH
Region: 3
City: FORT WAYNE State: IN
County:
License #: 13-01284-02
Agreement: N
Docket:
NRC Notified By: YUENIAN ZHANG
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/11/2014
Notification Time: 16:25 [ET]
Event Date: 11/11/2014
Event Time: [EST]
Last Update Date: 11/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
DAVID HILLS (R3DO)
FSME EVENTS RESOURCE (EMAI)
NMSS EVENTS RESOURCE (EMAI)

Event Text

GYNECOLOGICAL BRACHYTHERAPY TREATMENT TO LARGER AREA THAN PRESCRIBED AREA

A patient was prescribed four 550 cGy gynecologic brachytherapy treatments totaling 2200 cGy. The third treatment prescribed a treatment area of 5 cm instead of the actual treated area of 7 cm. The patient was released after the outpatient treatment. The hospital in attempting to notify the physician of the incident.

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.

* * * RETRACTION FROM YUENIAN ZHANG TO HOWIE CROUCH AT 0929 EST ON 11/21/14 * * *

Based on the results of an onsite inspection from NRC Region 3 Inspectors (Craffey and Lambert), it was determined that this event did not meet the regulatory report threshold and is being retracted by the licensee.

Notified R3DO (Peterson) and NMSS Events Notification (email).

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Agreement State Event Number: 50608
Rep Org: COLORADO DEPT OF HEALTH
Licensee: INTERMOUNTAIN TESTING COMPANY
Region: 4
City: DENVER State: CO
County:
License #: CO 060-01
Agreement: Y
Docket:
NRC Notified By: JENNIFER OPILA
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/13/2014
Notification Time: 10:54 [ET]
Event Date: 11/09/2014
Event Time: [MST]
Last Update Date: 11/13/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE GUIDE TUBE CRUSHED PREVENTING SOURCE FROM RETRACTING

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

"Event description: On 11/9/14, the licensee was working at Denver International Airport when an object fell onto the guide tube damaging it in such a way that the source could not be retracted. The radiography crew contacted the RSO [Radiation Safety Officer] who arrived at the scene, cut the guide tube open, removed the drive cable and retracted the source. At all times during the incident, the public dose line was maintained therefore the RSO believes that there were no exposures to the public above dose limits. Additionally doses to radiation workers were minimal.

"The RSO notified the [Colorado Department of Health] Department on 11/9/14, however they used the wrong phone number and left a message for someone in a different division than the Radiation Program. The licensee contacted the [Colorado State] Radiation Program at approximately 8 am on 11/10/14 to describe the incident.

"The licensee is preparing a detailed report to submit to the [Colorado Department of Health] Department."

Colorado Event Report ID No.: CO14-I14-26

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Agreement State Event Number: 50609
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: PHOENIX NON-DESTRUCTIVE TESTING INC.
Region: 4
City: CHANNELVIEW State: TX
County:
License #: L04454
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: VINCE KLCO
Notification Date: 11/13/2014
Notification Time: 11:58 [ET]
Event Date: 11/12/2014
Event Time: 12:45 [CST]
Last Update Date: 11/13/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
ANGELA MCINTOSH (FSME)
DAVEY TOTTERER (ILTA)
JEFFERY GRANT (IRD)
NMSS EVENTS NOTIFICA (EMAI)
MEXICO (FAX)

This material event contains a "Category 2 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT- LOST AND THEN FOUND RADIOGRAPHY CAMERA

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

"On November 13, 2014, the licensee notified the Agency [Texas Department of State Health Services, Radiation Branch] that on November 12, 2014, at approximately [1500 CST] it was notified by local law enforcement that one of its industrial radiography cameras had been found on the side of a road approximately 3 miles from the licensee's facility. The licensee determined that the SPEC 150 camera containing a 38 Curie Iridium-192 source had fallen from one of its trucks at approximately [1245 CST] while in route to a temporary job site. The camera had not been secured inside the truck before it left the licensee's facility but had been left on the tailgate. The licensee retrieved the camera and there was no apparent damage to the device. There are no known exposures resulting from this event. Further information will be provided as it is obtained in accordance with SA- 300."

Notified DHS SWO, DOE, FEMA, HHS, NICC, USDA and EPA. Notified FDA, NuclearSSA and DNDO-JAC via email.

Texas Incident: I-9251

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 50611
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: HEIDER ENGINEERING SERVICES, INC
Region: 4
City: UPLAND State: CA
County:
License #: 6463-36
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/13/2014
Notification Time: 15:47 [ET]
Event Date: 11/13/2014
Event Time: [PST]
Last Update Date: 11/13/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received from the State of California via email:

"On November 13, 2014, at approximately 0648 [PST], the RSO of Heider Engineering Services, Inc., RML #6463-36, contacted Cal OES [California Office of Emergency Services] concerning the moisture/density gauge, Troxler, Model 3430, serial number 63801 (Cs-137, 0.3 GBq, Am-241, 1.50 GBq) that had been stolen from a transport vehicle in front of a private residence at 140 North Shasta Way, Upland, CA 91786, between the evening of November 12, 2014 and approximately 0600 [PST] November 13, 2014 when the Authorized User left his home to go to the worksite. The Authorized User has contacted Local Law Enforcement officials in Upland, CA to request an investigation of the private residence where the Troxler radioactive gauge was taken and to take the report of the authorized user that was in possession of the gauge prior to the theft. A copy of the theft report will be sent to RHB Brea [California Radiological Health Branch -Brea] as part of this report. The RSO will utilize local papers to attempt to retrieve the stolen gauge as well as notifying local servicing vendors of radioactive gauges to be alert of the serial number of the stolen gauge in case it turns up for any of their services.

"The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. This is being reported to the NRC Operations Center as a 24-hour report under 10CFR30.50(b)(2) since the radioactive gauge has been stolen and it cannot be determined what condition the sources are currently in."

CA 5010 NUMBER 111314

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: 50612
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: TOXCO, INC
Region: 1
City: OAK RIDGE State: TN
County:
License #: R-01037-E16
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/14/2014
Notification Time: 10:52 [ET]
Event Date: 11/13/2014
Event Time: 09:00 [EST]
Last Update Date: 11/14/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FIRE IMPACTING LICENSABLE MATERIAL

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

"[Tennessee Department of Environment Conservation] TDEC was notified on 11/13/14, by a representative of [Toxco, Inc. d/b/a Toxco Materials Management Center] TMMC that a fire had occurred [at approximately 0900 EST] in an area in Building B where evaporation of liquid radioactive wastes was being conducted. Four employees attempted to extinguish the fire but were unsuccessful. The City of Oak Ridge fire department responded to the site and extinguished the fire. Four TMMC employees were sent to the local hospital for smoke inhalation related symptoms and are being evaluated for potential intake of radioactive materials. Air sampling of the building and area were performed during the event. The samples are being evaluated for results and consideration of potential impacts. [Tennessee] State inspectors are onsite investigating. The quantity of mixed fission product involved is unknown at this time. [Tennessee Department of Health] DRH inspectors are onsite and detailed information will be forthcoming."

State Event Report ID NO: TN-14-211

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Agreement State Event Number: 50613
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: WEATHERFORD INTERNATIONAL
Region: 4
City: HOUSTON State: TX
County:
License #: L00747
Agreement: Y
Docket:
NRC Notified By: ROBERT FREE
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/14/2014
Notification Time: 12:01 [ET]
Event Date: 11/13/2014
Event Time: [CST]
Last Update Date: 11/14/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4DO)
NMSS EVENT NOTIFICAT (EMAI)
MEXICO (FAX)

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

Event Text

AGREEMENT STATE REPORT - LOST CHECK SOURCE

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

"On November 14, 2014, the agency [Texas Department of State Health Services] was notified by the licensee, Weatherford International, that a 10 microCurie Americium-241 source [Serial # A1-531] was lost from its R&D facility in Houston, TX. The source was identified as missing during an inventory on 11/10/2014. After searching the company's R&D facility, the loss was reported to the [Texas] Department of State Health Services. The licensee's RSO suggested the source may have been swept out with trash. The source was last verified to be in its storage location December of last year [2013]. The company keeps a log of source usage and searched each use location in the building. The source is only used in the same building where it is stored."

Texas incident # I-9252

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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Non-Agreement State Event Number: 50615
Rep Org: QAL-TEK ASSOCIATES, LLC
Licensee: QAL-TEK ASSOCIATES, LLC
Region: 4
City: IDAHO FALLS State: ID
County:
License #: 11-27610-01
Agreement: N
Docket:
NRC Notified By: GLENN SAWTELLE
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/14/2014
Notification Time: 15:56 [ET]
Event Date: 11/14/2014
Event Time: 12:50 [MST]
Last Update Date: 11/17/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
GREG WERNER (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
CANADA (FAX)

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

Event Text

MOISTURE DENSITY GAUGE LOST IN TRANSIT

Qal-Tek Associates, LLC reported that a Troxler Model 3450 Moisture/Density Gauge (Serial # 355) was lost in transit by the shipper. The device was being shipped from the owner, Simon Contracting in North Platte, NE, to Qal-Tek for repair. The device contains 8mCi Cs-137 and 40 mCi Am/Be.

This is the same incident as NRC Event # 50619.

* * * UPDATE ON 11/17/14 AT 1703 EST FROM GLENN SAWTELLE TO DONG PARK * * *

The following was received from the licensee via email:

"The event 50615 initiated last Friday, November 14th has been resolved. The shipping company YRC Freight notified Qal-Tek Associates and Simon Consultants today, November 17th, that the Troxler nuclear density gauge reported 'lost' in this event was located in a YRC Hazardous Materials storage trailer. Apparently, the shipping information had separated from the device case. The NDG [Nuclear Density Gauge] was not damaged in any way and has all other Radioactive Materials labels intact. The NDG will be shipped to the Qal-Tek office in Idaho Falls, ID, for previously anticipated service. The Nebraska state Radiation Protection authorities have been informed."

Notified R1DO (Jackson), ILTAB and NMSS Events Notification via email. Notified Canada via facsimile.

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: 50616
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: IRISNDT, INC.
Region: 4
City: NEW ORLEANS State: LA
County:
License #: LA12236-L01,A
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DANIEL MILLS
Notification Date: 11/14/2014
Notification Time: 18:12 [ET]
Event Date: 11/14/2014
Event Time: 10:45 [CST]
Last Update Date: 11/14/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - TRUCK CARRYING RADIOGRAPHY CAMERA INVOLVED IN TRAFFIC ACCIDENT

The following was received from the State of Louisiana via email:

"IRISNDT-LA was transporting a SPEC Model 300 exposure device, S/N 004, loaded with Co-60 greater than Cat. 2 concerns, S/N C 60-49. The exposure device and source were being returned to IRISNDT, 905 GA Ave., Deer Park, TX. Texas License TX L0 6435. They were driving in the flow of traffic when the utility trailer, loaded with the exposure device was rear-ended by a pick-up truck at 1030 [CST]. The LSP [Louisiana State Police] and LDEQ [Louisiana department of Environmental Quality] responded as well as the LA RSO and the CRSO who was in town on other business. A field assessment was conducted at the site and then the device was transported to the New Orleans, LA office. Additional evaluations and wipe test were performed and sent for evaluation. It appears that no shielding or radiation containment was compromised. The exposure device is being transported to Source Production & Equipment, the manufacturer, for a more extensive evaluation. All personnel involved with the radioactive source during this incident were T&Red by IRISNDT under their IC security procedures. LA and TX Licenses and other documents were with the device. All radioactive sources are secured at the New Orleans office. No radioactive material was released or determined to be leaking at the time of this preliminary report. The radiography equipment will be transported to a location where an extensive evaluation of the equipment will be conducted. The outward appearance does not indicate there is severe or excessive damage to the exposure device resulting in a radioactive material release. The two carded radiographers involved in the traffic accident were taken for a medical evaluation and released with no serious injuries. Updates will be provided when 'new' information is available."

Louisiana incident # LA1400011

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 50617
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: US NAVY
Region: 4
City: SAN FRANCISCO State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GENE FORRER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/14/2014
Notification Time: 23:17 [ET]
Event Date: 11/05/2014
Event Time: 07:29 [PST]
Last Update Date: 11/17/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS EVENTS NOTIFICA (EMAI)
BLAKE WELLING (R1DO)

Event Text

AGREEMENT STATE REPORT - NON-CONSERVATIVE RADIOLOGICAL SCAN FOR BUILDINGS RELEASED FOR USE

The following report was received via e-mail:

"The Department of the Navy has provided the California Department of Public Health with a cover letter and report dealing with nonconservative scan speeds being used for the release of buildings on the Hunters Point Naval Facility. Some of the buildings involved are under NRC jurisdiction and some under State of California jurisdiction. The buildings involved that are NRC jurisdiction are Parcel B (103, 113, 113A, 130, 140, 146), Parcel C (203, 214, 241, 271, 272), Parcel E (half of Bldg 439, half of Bldg 810), and Parcel G (351, 351A, 365, 366, 401, 411). We are informing NRC of this issue so you can independently review this report and take whatever action they deem necessary.

The buildings that are under State jurisdiction are all in Parcel E (406, 414, 521, half of Bldg 439, and half of Bldg 810). RHB will schedule additional surveys as required to verify the safety of release of these buildings. RHB does not perceive any particular threat to the public or workers from these buildings but an evaluation should be done just to be sure."

California Event #: 111414

* * * RETRACTION FROM JOHN FASSELL TO DANIEL MILLS AT 1308 EST ON 11/17/14 * * *

This event is being retracted, because it has been determined that it is not a 24-hr reportable event.

Notified R1DO (Jackson), R4DO (Hagar), NMSS Events Notification (Email).

Page Last Reviewed/Updated Monday, November 24, 2014
Monday, November 24, 2014