United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2018 > March 28

Event Notification Report for March 28, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/27/2018 - 03/28/2018

** EVENT NUMBERS **


50339 53273

To top of page
Non-Agreement State Event Number: 50339
Rep Org: MONTANA STATE UNIVERSITY
Licensee: MONTANA STATE UNIVERSITY
Region: 4
City: BOZEMAN State: MT
County:
License #: 25-00326-06
Agreement: N
Docket:
NRC Notified By: CURTIS HOFER
HQ OPS Officer: JEFF ROTTON
Notification Date: 08/04/2014
Notification Time: 11:57 [ET]
Event Date: 07/03/2014
Event Time: [MDT]
Last Update Date: 03/27/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
GREG WERNER (R4DO)
FSME EVENTS RESOURCE (EMAI)
ILTAB (EMAI)
CANADA (FAX)

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

Event Text

MISSING NICKEL-63 SOURCE

"On July 3, 2014, Montana State University's Radiation Safety Officer (RSO) went to remove the Ni-63 sealed source (14 mCi) from a Varian Model 3400, Serial #13762 (Source Serial #A1059), Gas Chromatograph/Electron Capture Detector (GC/ECD) that was in storage. The RSO is in the process of disposing of all unwanted/unused sources. Upon arriving, the RSO found that the GC/ECD was no longer in CB 28 [Chemistry/Biochemistry Room 28] as it was three months earlier during the semi-annual sealed source leak test inspection. None of the individuals occupying the space had any idea what happened to the device.

"An email, including a picture of the device was sent to all personnel in both the transferor (Land Resources/Environmental Science) and transferee (Chemistry/Biochemistry) departments. In addition a lab by lab search of all chemistry labs was conducted by the RSO. As of this date, the GC/ECD has not been found. The RSO is in the process of continuing the search on the rest of the campus.

"Ni-63 is a low energy (67 keV) beta emitter. The beta energy necessary to penetrate the skin is 70 keV. Therefore, it is very unlikely for anyone to receive a dose from it unless it was broken open and injected, ingested, or inhaled.

"Corrective actions:
1. Two other unused GC/ECDs were picked up by the RSO and taken to his secure lab for removal of the Ni-63 sources to prevent the incident from happening again.
2. The three remaining GC/ECDs are being required to be put on active protocols.
3. During the search for the missing GC/ECD, another GC/ECD was revealed to be in another lab which has not been registered with the RSO. Therefore, the RSO has requested that all Principal Investigators (PIs) report all radiation producing equipment to him immediately.
4. The RSO is also currently meeting with each PI using radioactive material to verify they do not have the missing GC/ECD nor are there any other unreported radiation producing devices on campus.
5. The RSO has also placed a notice on all GC/ECDs stating, the RSO must be contacted prior to relocating this device.
6. All personnel in labs containing radiation producing equipment will be trained to report to the RSO any relocation of these devices.
7. The RSO has been placed under disciplinary action by the Director of the Office of Research Compliance.
8. The RSO will be conducting a search of the remainder of the MSU campus to locate the missing GC."


* * * UPDATE FROM NICHOLAS CHILDS TO DONALD NORWOOD AT 1351 on 3/27/2018 EDT * * *

"In August of 2014, Montana State University's (MSU's) previous RSO [Radiation Safety Officer] reported that a Ni-63 sealed source with a serial number of A1059 (15 mCi on 4/1/2004) was missing. The current RSO, as of October 2014, conducted a thorough review of MSU's sealed source inventory and located the source A1059.

"The source was leak tested with results indicating less than 0.005 microCi of removable contamination and subsequently added to MSU's sealed source inventory. The source was removed from MSU through the Source Consolidation And Threat Reduction Program (SCATR) on July 1, 2015."

Notified R4DO (Gaddy). Notified via E-mail: ILTAB (Whitney) and NMSS Events Notifications. Notified via fax: Canada.

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
Non-Agreement State Event Number: 53273
Rep Org: RAPID CITY REGIONAL HOSPITAL
Licensee: RAPID CITY REGIONAL HOSPITAL
Region: 4
City: RAPID CITY State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: JAMES McKEE
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/19/2018
Notification Time: 16:43 [ET]
Event Date: 03/08/2018
Event Time: [MDT]
Last Update Date: 03/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS EVENTS RESOURCE (EMAI)

Event Text

MEDICAL EVENT INVOLVING DELIVERED DOSE 50 PERCENT LESS THAN PRESCRIBED DOSE

A patient was prescribed 8 fractions of 500 cGy to the temple area. During the third fraction, the physician noticed the first two fractions were performed incorrectly. The first two fractions were performed with an incorrect setup, and the patient received less than 50 percent of the prescribed dose to the temple. The Radiation Safety Officer will provide a detailed written report after an investigation.

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 Wednesday, March 28, 2018
Wednesday, March 28, 2018