Event Notification Report for January 11, 2022

EN Revision Imported Date: 1/11/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received via email from the Mississippi State Department of Health (the agency) via email:

"On 22 November 2021, the licensee notified the Agency by email regarding an incident that took place on 19 November 2021. The [Berthold Technologies] reciprocity crew, working under reciprocal recognition, was conducting turn around, replacing three gauge systems at the Licensee plant's Operating Processes. Two of the three sources retracted while one source was discovered to be stuck in the dip tube (Source Information: Co-60, 7.43 mCi, Manufacturer/Model: EG&G Berthold Model P-2608-100, Serial #: 1540-08-05, Device Information: Manufacturer EG&G Berthold, Device Model#: LB 7671, Serial Number: TBD). Reciprocity personnel attempted to dislodge the source to get it to retract but all attempts failed. The technician attached a blind plate (surveys below background) to prevent access and he documented surveys which the reciprocity personnel stated will be provided at a later time. According to the reciprocity licensee personnel, surveys were approximately 0.2 to 0.3 mR/hr at the detector side. Licensee personnel stated that the source is secured and remains shielded. Reciprocity licensee stated that they will continue to consider options to dislodge the source. The investigation into this event is ongoing and information will be provided as it is received in accordance with SA-300."

Mississippi Item Number: MS-210003

* * * RETRACTION ON January 10, 2022 AT 1726 EST FROM ROBERT SIMS TO TOM KENDZIA * * *

The following information was received from the Mississippi State Department of Health (the agency) via e-mail:

"Investigation findings indicate this event is not reportable. The highest survey reading is 0.2 mR per hour. This does not exceed public dose limit or an exposure that would cause a 25 milllirem TEDE. It is not lost or stolen. The source activity is 0.64 mCi. The source is at the top of the dip tube in the normal operating position in a safe position. The tank is approximately 30 foot tall and 20 foot wide in which the tank and the fluid is shielding the low activity source. The source will not expose the workers. The tank and gauge are on the 3rd floor of the refinery and only RSO's and workers supervised by RSO are allowed in this area.

"The engineer tried to remove it from this position for a scheduled source change out, and it could not be removed. At present, without shutting the production line down which makes plastic, this could cause a revenue loss of millions of dollars to the company. In the opinion of the Mississippi Health Physicist, this is not reportable. It does not meet SA 300 reporting requirements. The RSO has agreed to perform surveys at shift change and report any changes. This event is closed. If any changes occur and are reported. The agency will meet reporting requirements."

Notified R4DO (Groom) and NMSS Events (by email).

EN Revision Imported Date: 1/11/2022

EN Revision Text: AGREEMENT STATE REPORT - DESTROYED TRITIUM EXIT SIGNS

The following was sent by the state of Colorado by email:

"On 12/30/2021 - 12/31/2021, the Marshall wildfire damaged or destroyed nearly 1000 buildings in the towns of Superior and Louisville, Colorado. On 01/01/2022, Boulder County released a preliminary address list of affected properties. The Element Hotel is listed on the property list as destroyed. The Element Hotel has registered with Colorado 33 tritium exit signs. Based on photos of the Element Hotel, it is assumed that all 33 tritium exit signs were consumed and destroyed in the fire.

"Isotope: Hydrogen-3
"Manufacturer: Isolite Corporation
"Model: 2000
"Serial numbers: H118210, H118212 - H118241, H118243 - H118244
"Activity: 7.62 Ci per sign (251.46 Ci total)"

Event Report ID No.: CO220001

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

EN Revision Imported Date: 1/11/2022

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO INCORRECT TREATMENT AREA

The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:

"On Friday, December 31, 2021, the Bureau was contacted by [the Radiation Safety Officer] to report a medical event at Horizon Medical Services that occurred on December 15, 2021. The medical event was the [high dose rate therapy] treatment of the incorrect hand using iridium-192 to a single dose fraction of 250 cGy [(250 rem)] to a depth of 3mm below the skin surface."

The licensee's report to the Bureau stated, "Remedial action included an immediate in-service discussion of this event with the entire clinical staff to verify the correct anatomical treatment site regarding all patient prescriptions. The patient has been informed of this medical event."

Florida Incident No.: FL 21-152

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.

EN Revision Imported Date: 1/11/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE

The following was received from the state of Texas (the Agency) via email:

"On January 4, 2022, the licensee notified the Agency that on January 3, 2022, one of its technicians lost a Humboldt model 5001EZ moisture/density gauge (SN: 9313), containing a 40 millicurie americium-241 source and a 10 millicurie cesium-137 source, at a temporary job site. The technician reported that he had placed the gauge, without the source insertion rod locked, into the transport case and then into the transport box in the bed of the pickup but did not lock the box since he was going across the job site. He traversed bumpy ground to the next testing area and when he went to get the gauge he found it was not in the box. He returned to the previous test area and found the transport case but not the gauge. The job site was thoroughly searched and other workers at the job site were questioned.

"The search resumed on January 4, 2022. In addition, onsite workers are being contacted and a reward is being offered. Local police have been notified. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 9606

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