United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2017 > April 28

Event Notification Report for April 28, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/27/2017 - 04/28/2017

** EVENT NUMBERS **


52693 52694 52695 52697

To top of page
Agreement State Event Number: 52693
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: TULSA GAMMA RAY
Region: 4
City: TULSA State: OK
County:
License #: OK-17178-02
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/19/2017
Notification Time: 10:59 [ET]
Event Date: 12/31/2016
Event Time: [CDT]
Last Update Date: 04/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
ANGELA MCINTOSH (EMAI)
TRISH MILLIGAN (EMAI)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHER OVEREXPOSURE

The following report was received via e-mail:

"On April 14, 2017 we [Oklahoma Department of Environmental Quality] learned that a certified radiographer employed by Tulsa Gamma Ray (OK-17178-02) received a TEDE of 5.808 REM for calendar year 2016. The licensee was unaware of this until it was pointed out by the inspectors during their routine inspection."

To top of page
Agreement State Event Number: 52694
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: CONSTRUCTION MATERIALS TESTING SERVICES INC.
Region: 4
City: HOT SPRINGS State: AR
County: GARLAND
License #: ARK-0750-0312
Agreement: Y
Docket:
NRC Notified By: DAVID STEPHENS
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/19/2017
Notification Time: 11:31 [ET]
Event Date: 04/18/2017
Event Time: 12:10 [CDT]
Last Update Date: 04/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

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

"On April 18, 2017, at 1210 [CDT], the licensee contacted the Department [Arkansas Department of Health] reporting that a moisture density gauge was missing from the permanent storage facility in Hot Springs, Arkansas and presumed stolen. In addition to the Department, the licensee had notified local law enforcement offices.

"The licensee believes that the gauge was taken between Friday, April 14, 2017 and Tuesday morning, April 18, 2017. The licensee believes that the gauge may be in possession of a former employee.

"The gauge is a Troxler, Model 3440, Serial Number 15160, containing 40 milliCuries of Americium-241 and 8 milliCuries of Cesium-137.

"In accordance with RH-1501.c.1.A. (10 CFR 20.2201(a)(1)(i)) the stolen gauge is immediately reportable.

"Law Enforcement is investigating.

"The State of Arkansas is awaiting the outcome of the law enforcement investigation and a written report from the licensee. The State's event number is AR-2017-001."

* * * UPDATE FROM DAVID STEPHENS TO DONALD NORWOOD AT 1338 EDT ON 4/20/2017 * * *

The following information was received via E-mail:

"The Arkansas Department of Health Radiation Control Section received notification that the Troxler Electronic Laboratories Gauge (Model 3440, Serial Number 15160) reported stolen on April 19, 2017, was recovered in Hot Springs Village by the Garland County Sheriff's office. The gauge does not appear to be damaged, and has been transported to the licensee's permanent storage location. A leak test has been performed by the licensee. The Department considers the matter closed pending receipt of the licensee's report and leak test results."

Notified R4DO (Azua), ILTAB (Salisbury), and NMSS Events Notification Group.

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.

To top of page
Agreement State Event Number: 52695
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: ZEVACOR PHARMA INC.
Region: 1
City:  State: NJ
County:
License #: 527488
Agreement: Y
Docket:
NRC Notified By: CATHY BIEL
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/19/2017
Notification Time: 17:30 [ET]
Event Date: 04/19/2017
Event Time: [EDT]
Last Update Date: 04/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
DANIEL COLLINS (NMSS)

Event Text

AGREEMENT STATE REPORT - CONTAMINATED PACKAGE

The following was received from the State of New Jersey via email:

"The RSO [Radiation Safety Officer] for this radiopharmacy called to report the receipt of a contaminated package. The package arrived from another Zevacor facility located in Virginia (Virginia license # 107113-1). The package as shipped contained 21 mCi of liquid Zr-89. While performing their routine wipe test during the opening of the package, the wipe test of the inner package found removable contamination of 240,000 counts per minute. The outer package was not found to be contaminated. The RSO of the New Jersey facility contacted their counterpart at the Virginia facility. The Virginia facility maintained that the package was free of contamination when it was shipped. Zevacor believes the primary container was not sealed properly. This may have caused some of the material to evaporate during shipment and contaminate the exterior of the primary container. A written report will be supplied within 30 days."

To top of page
Agreement State Event Number: 52697
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City: NOT PROVIDED State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JANAKI KRISHNAMOORTHY
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/20/2017
Notification Time: 15:38 [ET]
Event Date: 04/12/2017
Event Time: [EDT]
Last Update Date: 04/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - LESS THAN INTENDED DOSE ADMINISTERED TO THE PATIENT

The following information was provided by the State of New York via facsimile:

"On 04/12/2017, a patient with widespread neoplasm of liver, intrahepatic bile duct, received treatment with Y90 SIRTEX microspheres to 2 separate segments in the right lobe. The intended activities were 0.946 GBq (25.6 mCi) to a small segment and 2.38 GBq (64.3 mCi) to the large segment.

"On 4/18/17, during a review of the patient's medical record, the AU [authorized user] physician discovered that the activity ordered for the large lesion was 0.38 GBq, not 2.38 GBq, as the written directive had stated. NYS DOH [New York State Department of Health] was informed on 4/19/17. Both the patient and the referring physician have been informed. AU physician stated that there is no harm to the patient, because they plan to administer the deficit dose to this segment in the right lobe during the procedure scheduled to treat the left lobe next month.

"The licensee stated that documentation/communication appears to be the primary cause. Facility is investigating. Will update when more information becomes available."

NY Event Report ID No. NYDOH-NY-17-07

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, April 28, 2017
Friday, April 28, 2017