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Event Notification Report for October 14, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/13/2016 - 10/14/2016

** EVENT NUMBERS **


52281 52282 52284

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Agreement State Event Number: 52281
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: CHEMTURA CORPORATION
Region: 3
City: MAPLETON State: IL
County:
License #: IL-01314-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/06/2016
Notification Time: 13:24 [ET]
Event Date: 10/04/2016
Event Time: [CDT]
Last Update Date: 10/06/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - STUCK CLOSED SHUTTER ON FIXED RADIOACTIVE GAUGE

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

"On October 4, [2016], the licensee's radiation safety officer contacted the Agency [Illinois Emergency Management Agency] to report a defective fixed gauge. While performing routine operational checks of fixed gauges at the site, the shutter on a device appears to have become disconnected from its handle and will not operate properly. It was determined from radiation measurements that the shutter is currently in the 'closed' position. Radiation levels are less than 2 mR/h surrounding the device and it is in an area that is routinely inaccessible. The gauge is mounted on a reaction process vessel and is subject to the ambient weather conditions with no prior operational issues for 27 years until now. Arrangements are pending with a manufacturer's representative to investigate the matter and repair/replace the device.

"Source/Radioactive Material: SEALED SOURCE GAUGE
Radionuclide: Cs-137, 0.064 Ci, 2.368 GBq
Manufacturer: VEGA AMERICAS, INC.
Model Number: A-2102
Serial Number: M3107
IAEA Category: 4"

Illinois Report No.: IL16009

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Agreement State Event Number: 52282
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: C. Y. GEOTECH, INC.
Region: 4
City: CHATSWORTH State: CA
County:
License #: 6617-19
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/06/2016
Notification Time: 13:21 [ET]
Event Date: 10/05/2016
Event Time: 16:00 [PDT]
Last Update Date: 10/06/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSNS (MEXICO) (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT: STOLEN NUCLEAR DENSITY GAUGE

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

"At 1600 [PDT] on October 5, 2016, the RSO [Radiation Safety Officer] for C. Y. Geotech Inc. reported to RHB [Radiation Health Branch] that one of their nuclear density gauges (CPN model MC-1DR-P; #MD90404953 containing 10 mCi of Cs-137 and 50 mCi of Am-241/Be) had been stolen from a temporary job site. RHB informed the RSO to file a police report and place a notice into the local newspaper offering a reward for information leading to the safe return of the gauge. The RSO will require the gauge operator to make a report of exactly what happened and specifically if the Cs-137 handle was locked in the safe mode.

"The gauge was not discovered missing until the morning of October 5, 2016 and the operator returned to look for the gauge. The RSO posted a lost gauge sign at the job site notifying personnel of the loss of the gauge and C. Y. Geotech's contact information for its safe return.

"On Oct. 4, 2016, around 1300 [PDT], the gauge operator had finished his work with the CPN gauge and was completing paperwork at his vehicle. He forgot about the gauge and failed to secure it into the transport case before departing the job site. He believes he left the gauge on the curbside. The gauge had been recently leak tested in May 2016."

5010 Number: 100416

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: 52284
Rep Org: DEPARTMENT OF VETERANS AFFAIRS
Licensee: VA PALO ALTO HEALTH CARE SYSTEM
Region: 4
City: PALO ALTO State: CA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: CRAIG ADAMS
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/06/2016
Notification Time: 16:06 [ET]
Event Date: 09/26/2014
Event Time: [PDT]
Last Update Date: 10/06/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

PRESCRIBED DOSAGE INCORRECTLY WRITTEN

"This is a notification, pursuant to 10 CFR 35.3045(a)(1), of a medical event that occurred on September 26, 2014, at the VA Palo Alto Health Care System, Palo Alto, California.

"On September 26, 2014, a dosage of about 110 microCuries (Ci) of radium-223 dichloride was administered to a patient. The prescribed dosage on the written directive was incorrectly written by the authorized user physician as 113.8 milliCuries (mCi). The basis for identifying this as a medical event is that the administered dosage differed from the prescribed dosage, as written on the written directive, by more than 20 percent. The authorized user physician was interviewed and stated that the intended prescription for injection was 113.8 Ci of radium-223 dichloride. Another authorized user physician, the Chief, Nuclear Medicine Service, who administered the dosage, confirmed that this was an appropriate dosage for this patient. No harm to the patient is expected since the treatment was successfully performed with the administration of a dosage nearly identical to the intended dosage. The medical event was discovered October 5, 2016, during an unannounced inspection of this facility conducted by the National Health Physics Program (NHPP). The permittee is required to submit a written report to NHPP within 15 days of discovery. NHPP will, in turn submit the report to NRC per regulatory requirements. The NHPP inspection is ongoing to determine overall compliance with 10 CFR 35.40, 10 CFR 35.41, and 10 CFR 35.3045."

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 Friday, October 14, 2016
Friday, October 14, 2016