Event Notification Report for November 24, 2014

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA STUCK SOURCE

The following was received via email:

"On November 25, 2014, the Agency [State of Texas] was notified by the licensee that on November 24, 2014, an INC IR100 radiography camera, Serial # 4374 with an Iridium-192 source, Model 32, Serial #W951, Activity - 1887 GBq (51 Ci) failed to operate properly at a field site. While the source was being cranked out, the drive cable went too far when the stopper in the pistol grip failed, resulting in the inability to reengage the drive cable and retrieve the source back into the camera. The licensee's RSO responded to the scene to inspect and retrieve the source. No individual received any significant additional exposure due to this event. The RSO received the highest dose of 23 mrem. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9256

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following was received via email:

"A patient arrived for a rest/stress imaging procedure on 11/24/14. The rest dose was written to be 8 mCi Tc-99m, and the stress dose was written to be 24 mCi Tc-99m. The patient received the rest dose as written and the scan was performed. The patient was then to receive the 24 mCi stress dose, but instead received a 5 mCi stress dose (same drug, but only 21% of the intended activity) that was intended as the rest dose for another patient. Once the error was discovered, the patient was informed of the error and sent home with the intention of rescheduling the procedure at a later date. The licensee will submit the 15 day report to VRMP [Virginia Radioactive Materials Program] at which time the corrective actions will be reviewed and verified during their next inspection. "

Virginia Incident #: VA-14-23

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 ON 11/25/14 AT 1637 EST FROM MIKE WELLING TO DONG PARK * * *

This report is being retracted, because it does not meet 10CFR35.3045 criteria.

Notified R1DO (Noggle) and NMSS Events Notification via email.

KENTUCKY AGREEMENT STATE REPORT - FAILURE OF FIXED GAUGE ACTUATORS

The following information was obtained from the Commonwealth of Kentucky via facsimile:

"Failure of on/off mechanisms on three fixed gauges to function as designed. Failure discovered during routine testing of on/off mechanism by [the] licensee. The licensee has contacted the manufacturer to schedule removal/repair."

The fixed gauges are in a normally inaccessible area and don't present a personnel exposure concern. The gauges contain Cs-137 with 100 mCi, 25 mCi, and 10 mCi respectively and are used at a coal fired facility.

Kentucky Event Report ID: KY-14-0005