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Event Notification Report for November 28, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/26/2014 - 11/28/2014

** EVENT NUMBERS **


50620 50621

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Agreement State Event Number: 50620
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: ROSWELL PARK CANCER INSTITUTE
Region: 1
City: BUFFALO State: NY
County:
License #: NYS #2923
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/18/2014
Notification Time: 09:32 [ET]
Event Date: 11/04/2014
Event Time: [EST]
Last Update Date: 11/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

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

Event Text

AGREEMENT STATE REPORT - I-125 SEED RETRIEVED FROM PATIENT AND THEN LOST

The following information was obtained from the State of New York via facsimile:

"A radioactive source or I-125 seed used for localization in breast surgery was misplaced by the Pathology Department at Roswell Park Cancer Institute (DOH# 2923). This event occurred on Thursday, October 9, 2014 and the source was officially determined to be lost on November 4, 2014.

"Two breast localization seeds (I-125) were not extracted from a specimen on October 9, 2014 by a Clinical Pathology Fellow. The Pathology department did, however, receive written documentation that the seeds were removed from the patient and they were sent with the specimen to the Pathology Department. The seeds were not returned to Nuclear Medicine per Institute Policy.

"An extensive search and survey was conducted of Pathology, Nuclear Medicine and Environmental Services areas. One of the two seeds was discovered in trash removed from the Pathology department. Further search and surveys of these areas were repeated but to no avail. Trash and regulated medical waste were surveyed and inspected. Over the course of the next few weeks, Radiation Safety surveyed and explored all radioactive waste in an effort to locate the lost source. Aforementioned search and surveys were again conducted without discovery of the missing seed. It was believed that the missing source would eventually be located in Institute trash or more likely Institute radioactive waste.

"All Institute trash and waste is surveyed for radioactive material. The radioactive waste may be stored in various short and long-term storage locations. Unfortunately, the seed was never found and officially declared lost on November 4, 2014.

"Corrective Action and Recommendations:
1. The incident was reviewed and discussed with pertinent Pathology staff. A training oversight was discovered and Pathology Department Fellows are now trained to anticipate radioactive seeds in breast surgical specimens and to remove them prior to surgical specimen evaluation. (Required Corrective Action)
2. Radiation Safety and Environmental Services have emphasized the importance of monitoring all trash and regulated medical waste during the annual in-service conducted on August 6, 2014 and again on October 29, 2014. (Required Corrective Action)
3. Any further information regarding this matter will be communicated to the Bureau of Environmental Radiation Protection, NYS DOH [New York State Department of health]. (Required Corrective Action)"

New York State Event Report Number: NY-14-05

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: 50621
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ARIAS & ASSOCIATES INC
Region: 4
City: EAGLE PASS State: TX
County:
License #: 04964
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/18/2014
Notification Time: 11:25 [ET]
Event Date: 11/17/2014
Event Time: [CST]
Last Update Date: 11/18/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received via e-mail:

"On November 17, 2014, the Agency [Texas Department of State Health] was notified by the licensee that a Troxler Model 3430, Gauge Serial No. 26893 containing a cesium-137 source, serial No. 750-92, activity - 0.30 GBq (8 mCi), and an americium-241 source, serial No. 47-23385, activity - 1.48 GBq (40 mCi), was damaged at a field site. The technician had placed the device at a sample location and extended the cesium source into the inspection hole. The technician then noticed a road grader driving directly at him so he ran out of the way and when he turned around the grader had run over the moisture density gauge. The licensee's RSO [Radiation Safety Officer] responded to the scene to inspect and recover the gauge. The device case was severely damaged, but the licensee was able to return the cesium source to the shielded position and secure it in position. The RSO verified the americium source was still in the device. The RSO took the damaged device to their facility for disposal. No individual received any significant additional exposure due to this event."

Texas Event #I-9254

Page Last Reviewed/Updated Friday, November 28, 2014
Friday, November 28, 2014