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Event Notification Report for April 12, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/11/2017 - 04/12/2017

** EVENT NUMBERS **


52659 52660 52661

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Agreement State Event Number: 52659
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CARDINAL HEALTH
Region: 3
City: DUBLIN State: OH
County:
License #: 02500250000
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/03/2017
Notification Time: 14:33 [ET]
Event Date: 03/22/2017
Event Time: [EDT]
Last Update Date: 04/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - PACKAGE LOST DURING SHIPMENT

The following information was provided by the State of Ohio via email:

"On 3/31/17 the licensee (Cardinal Health) notified ODH [Ohio Department of Health] that a package containing a Ge [Germanium] Generator was being returned to the manufacturer (IRE Elit) in Belgium.

"The package was sent on 3/7/17 and on 3/22/17 Cardinal was notified by IRE that the package had not arrived. Cardinal immediately contacted the shipper [common carrier] concerning the package and at that time they had indication that it was stuck in customs in Paris, France.

"On 3/31/17 Cardinal was told by [common carrier] that the package has not been located in customs and they are continually searching for the package.

"On 4/3/17 licensee told by [common carrier] that there was no record that the package had ever left the [common carrier] hub in . . . and still have not located the package.

"Package is labeled as a Yellow II DOT Type A container with 1371 MBq (37 mCi) of Germanium 68. Solid/self-shielded container with a TI at shipment of 0.3.

"Item No.: OH170002

"Reference Number: OH 2017-017"

* * *UPDATE FROM STEPHEN JAMES TO VINCE KLCO ON 4/11/17 AT 1618 EDT * * *

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

"Package was located by common carrier and returned to the licensee (Cardinal Health) in Dublin, Ohio. Package had one of two security seals still intact; however, licensee stated that there was no indication that package had been opened during time in transit. Package will be wipe tested and repacked for return to manufacturer."

Notified the R1DO (Jackson), R3DO (Jeffers) and NMSS Events via 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

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Agreement State Event Number: 52660
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: UNIVERSITY OF VIRGINIA OFFICE OF ENVIRONMENTAL HEALTH AND SA
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #: 540-248-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/03/2017
Notification Time: 16:07 [ET]
Event Date: 03/22/2017
Event Time: [EDT]
Last Update Date: 04/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - WRITTEN DIRECTIVE INCORRECTLY IDENTIFIED THE TARGET ORGAN

The following information was received from the Commonwealth of Virginia via fax:

"On March 31, 2017 the licensee notified the Virginia Office of Radiological Health (ORH) that an eye plaque therapy procedure was not performed in accordance with the procedure's written directive.

"The plaque was installed on the patient's right eye on March 22 and removed on March 31. The source, 38.8 mCi of l-125, delivered a dose of 85 Gy to the right eye. The right eye was the intended treatment location but the written directive incorrectly identified the target organ as the left eye. The disagreement between the written directive and the treatment location meets the definition of a medical event even though the correct target organ was treated.

"ORH will review the licensee's written report and determine additional actions to be taken.

"Event Report ID No.: VA-17-004"

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.

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Agreement State Event Number: 52661
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: KIRKHAM MICHAEL & ASSOCIATES, INC
Region: 4
City: ELLSWORTH State: KS
County:
License #: 22-B683-01
Agreement: Y
Docket:
NRC Notified By: JAMES UHLEMEYER
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/03/2017
Notification Time: 16:37 [ET]
Event Date: 04/03/2017
Event Time: 13:48 [CDT]
Last Update Date: 04/03/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - TROXLER GAUGE DAMAGED BY HEAVY EQUIPMENT AT CONSTRUCTION SITE

An in-use Troxler gauge was damaged at a construction site on US 83 near Garden City, KS. The gauge, a Troxler model 3430, S/N 28271, contains a 0.3 GBq [8 mCi] Cs-137 source and a 1.48 GBq [40 mCi] Am-241/Be source. The Cs-137 source rod was extended at the time of the incident and could not be withdrawn into the shielded volume. Rad surveys on-site confirmed that both sources were intact [No contamination at the jobsite]. The gauge was returned to its case and temporary shielding used to prevent personnel exposure during transport back to the licensee's Ellsworth Office. The licensee will return the gauge to the manufacturer for disposition.

Item Number: KS170004

Page Last Reviewed/Updated Wednesday, April 12, 2017
Wednesday, April 12, 2017