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Event Notification Report for September 1, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/31/2017 - 09/01/2017

** EVENT NUMBERS **


52920 52923 52925

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Agreement State Event Number: 52920
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CHESAPEAKE UROLOGY
Region: 1
City: OWINGS MILLS State: MD
County:
License #: MD-05-208-01
Agreement: Y
Docket:
NRC Notified By: ALLEN GOLDERY
HQ OPS Officer: RICHARD SMITH
Notification Date: 08/23/2017
Notification Time: 10:45 [ET]
Event Date: 08/22/2017
Event Time: 09:30 [EDT]
Last Update Date: 08/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT- MEDICAL EVENT MISADMINISTRATION

This following report was phoned in, followed by an email:

"On August 22, 2017, Chesapeake Urology, notified the Maryland Radiological Health Program (RHP) that a male patient was injected with 176.1 microCuries of Ra-223 (Xofigo) instead of 108.4 microCuries of Ra-223 (Xofigo); 62.5 percent greater than the prescribed dose. The wrong unit dose was handed to the authorized user for patient administration. The event occurred at approximately 0930 [EDT] hours on 08/22/2017 at the licensee's address of 21 Crossroads Drive, Suite 200, Owings Mills, MD 21117. Maryland RHP was notified by telephone at 1505 hours. Two patients were scheduled for treatment on August 22, 2017. Both doses were assayed in the morning. Each dose had the proper patient name on the lead pig and on each respective syringe. The incorrect dose was selected and injected without cross referencing the identity of the patient. The event was discovered at approximately 1130 hours when the second Xofigo dose was to be administered. The patient and the referring physician have been informed of the misadministration. A written notification from the licensee is expected in about a week. This is a preliminary notification."

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: 52923
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: EAGLE US 2 LLC
Region: 4
City: LAKE CHARLES State: LA
County:
License #: LA-2257-L01;
Agreement: Y
Docket:
NRC Notified By: JUDITH SCHUERMAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/24/2017
Notification Time: 12:19 [ET]
Event Date: 08/23/2017
Event Time: 16:00 [CDT]
Last Update Date: 08/24/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST SOURCE FROM A DENSITY GAUGE

The following information was received via E-mail:

"Eagle US 2 LLC in Lake Charles (formerly Westlake Chemicals) called to say they lost a Cs-137 source from a density gauge at 1600 [CDT] Wednesday, August 23, 2017. At purchase, the source was 200 mCi. The source is no longer in the device holder/housing. They surveyed for it and have not located it yet. They are continuing to search for it. Source housing is Ronan Model # SAIC10 and Source Serial Number is Ronan # 9527GG."

Louisiana Event Report ID No.: LA20170014

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: 52925
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: ECS SOUTHEAST, LLP
Region: 1
City: RALEIGH State: NC
County:
License #: 092-0253-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/24/2017
Notification Time: 22:09 [ET]
Event Date: 08/24/2017
Event Time: 18:00 [EDT]
Last Update Date: 08/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
ILTAB (EMAI)

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

Event Text

NORTH CAROLINA AGREEMENT STATE REPORT - MISSING PORTABLE NUCLEAR GAUGE

The following information was obtained from the state of North Carolina via email:

"North Carolina Radioactive Materials Branch (RMB) was notified on 8/24/17 at 7:58 PM [EDT] that a portable nuclear gauge went missing at around 6:00 PM at a job site at Ten-Ten Road in Garner, NC 27603.

"Licensee: ECS Southeast, LLP
License Number: 092-0253-1
Gauge Manufacturer: Instrotek Xplorer
Model #: 3500
Serial #: 3194

"The gauge contains 11 milliCuries of cesium-137 and 44 milliCuries of americium-241: beryllium. The gauge was not trigger locked and not locked in its original carrying case at the time it went missing. RMB is investigating the incident and working with local authorities to develop a press release. Local law enforcement and the FBI have been notified. Follow-up information will be provided to the NRC as this investigation is ongoing."

* * * UPDATE AT 1058EDT ON 08/25/17 FROM TRAVIS CARTOSKI TO S. SANDIN VIA EMAIL * * *

"NC Radioactive Materials Branch (RMB) would like to report that the missing gauge has been found this morning 8/25. Three members of the RMB were dispatched last night to initiate an investigation and reconvened this morning to continue. The gauge appeared to have no damage and is being returned to the manufacturer for verification. Surveys were taken on and around the gauge once it was found and all surveys appeared normal indicating the sources were still intact within the gauge.

"Through interviews of personnel on-site, it was determined that source rod was never extended from when the gauge went missing to when it was found. An on-site construction worker found the gauge unattended yesterday afternoon and secured it until this morning.

"RMB is continuing its investigation from a compliance stand point. Further details will be provided to satisfy the details of this incident following conclusion of this investigation."

Notified R1DO (Kennedy) and NMSS Events Notification and ILTAB 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

Page Last Reviewed/Updated Friday, September 01, 2017
Friday, September 01, 2017