Event Notification Report for February 11, 2022

EN Revision Imported Date: 2/11/2022

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SHUTTER ON NUCLEAR GAUGE

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

"On February 3, 2022, the Agency was contacted by the licensee's service company and notified that while removing a Vega SH-F1B nuclear gauge from its mounted position it was dropped about 2 feet and the operating arm for the shutter was bent. The shutter was locked in the closed position and remained closed. The gauge contains a 20 millicurie (original activity) cesium - 137 source. Dose rates taken on the gauge housing after the gauge was dropped were normal. A leak test was performed on the source and the results were satisfactory. The gauge was placed in storage. The manufacturer is being contacted to repair the gauge. No overexposures occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # I-9909

EN Revision Imported Date: 2/11/2022

EN Revision Text: AGREEMENT STATE REPORT - LEAKING VIAL SOURCE

The following information was received from the state of South Carolina via email:

"The South Carolina Department of Health and Environmental Control was notified via email at 1327 EST on 02/01/22 that during a quarterly nuclear medicine audit conducted on 01/27/22, a leak test result of a Cs-137 vial source was above the regulatory limit of 0.005 microCi of removable contamination. The licensee is reporting that the Cs-137 vial source is a 203.9 microCi Isotope Product Laboratory Model RV-137-200U, serial number 788-6-7. The leak test result indicated a net removable contamination of 0.0155 microCi. The licensee is reporting that area survey results indicated no other contamination within the nuclear medicine department. The vial source has been placed inside a lead container, sealed, and stored in the nuclear medicine hot lab. Department inspectors were dispatched to the facility on 02/02/22. The vial source was found packaged as the licensee described. Dose rate readings using a Ludlum 14-C (calibrated 10/12/21) indicated readings as high as 12 milliR/hr on the surface of the container. Removable contamination wipes were also taken and no further contamination was detected. The vial source is awaiting disposal/transfer back to the manufacturer. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

EN Revision Imported Date: 2/11/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was received from the state of Minnesota via email:

"The Minnesota Department of Health was notified by email on 02/02/2022 at 1652 CST of a shutter stuck in the open position on a generally licensed gauge. The gauge is an Endress+Hauser model FQG61, serial number S700290113F containing 2 milliCi of Cesium-137. The licensee isolated the area and has service for the gauge scheduled for Monday, 02/07/2022."

MN report no.: MN220001

EN Revision Imported Date: 2/11/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST PACKAGE CONTAINING RADIOACTIVE MATERIAL

The following was received via email from the Massachusetts Radiation Control Program:

"On 01/18/22 the Massachusetts Radiation Control Program (the `Agency') received a telephone report of a missing shipment of radioactive material. The package contained 28 mCi of S-35 (half-life of 87.3 days) in liquid form, in 4 vials at 0.561 mL per vial, in one White-I package, and was sent by PerkinElmer, Inc. (the `licensee') to Associated Regional and University Pathologists, Inc. (the `customer') via [common courier]. The package was sent from the licensee on 12/15/21 and tracking information showed it arrived at the courier's facility on 12/16/21 but never left. The customer notified the licensee on 12/21/21 that they never received the package. The licensee was periodically contacting the courier for status updates in an attempt to recover the package. The licensee informed the courier of the importance of maintaining custody of radioactive material shipments until they are delivered.

"On 02/02/22 the licensee notified the Agency that their internal investigation to locate the package was closed and that the licensee considers the package lost for good. The licensee estimates that no person received greater than 1 mrem TEDE [total effective dose equivalent] as a result of the missing package.

"The Agency considers this event to be closed."

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: 2/11/2022

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

The following information was received from the state of Arizona via email:

"The Department received a call from a construction project manager who stated that 110-116 tritium exit signs were stolen by a contractor and are being held at his residence in Flagstaff, Arizona. A police report has been filed with the Coconino Police Department.

"Additional information will be provided as it is received in accordance with SA-300."

AZ report no.: 22-001

EN Revision Imported Date: 2/11/2022

EN Revision Text: AGREEMENT STATE REPORT - MISSING SOURCE

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

"On 1/28/22 a verification of source inventory indicated a sealed source was missing. The source is an Sr-90 sealed source, activity of 0.32 milliCi, used in a Model 2210 irradiator. Subsequent surveys were performed in the area where the source should be and where it may have been handled, as well as a visual search of the entire facility was conducted and the source could not be located. A voicemail was left with the Ohio Department of Health (ODH) as a "heads up" of the ongoing investigation. A follow-up call was made to ODH on the morning of 1/31/22 to ensure that the message had been received.

"An investigation was conducted including interviews with personnel who have access to the locked cabinet the 2210 irradiator was stored in. The previous inventory check conducted on 7/20/2021 indicated the 2210 irradiator was stored in a secure cabinet. Access is limited to 3 employees only. The employee who indicated he most likely handled the irradiator last in the August 2021 timeframe could not remember if he removed the source holder and cap from the irradiator or not. There was also no communication to the Radiation Safety Officer to indicate movement of the source took place.

"It was also determined that a radioactive waste shipment was made on 12/6/2021 (Veolia Environmental Services/Alaron Nuclear Services). Alaron was called to determine if the shipment was still available. The shipment is still at the Alaron facility and the contents will be verified the week of 2/7/2022. There is a chance the source was included in the shipment since it is an old source with an assay date of approximately 2003. The employee who handled the source last also assisted in determining and gathering the older sources for disposal.

"To insure employee safety and find the missing source, surveys of all areas of the building were started utilizing a calibrated Bicron Microrem. Employees of all departments were asked to search their areas for the missing source and irradiator. Additional discussions and a meeting were conducted to further investigate what could have happened. The employee cannot be sure if he disassembled the irradiator or not. If the source holder and cap were removed, he would have placed it in a white plastic pig and applied a label with the serial number on it. The source capsule is received from our source supplier already in the holder and cap. We do not remove the actual source capsule from the holder and cap. Photos of the source holder and cap as well as the white plastic pig have been sent to Alaron for their reference when they inventory the waste shipment.

"Surveys of all bench tops and storage areas have been conducted and all are at their normal background levels.

"As of this writing, the source has not been located."

OH report no.: OH220002

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