Event Notification Report for April 14, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
04/13/2022 - 04/14/2022

EVENT NUMBERS
55824 55825 55826 55829 55830
Agreement State
Event Number: 55824
Rep Org: WA Office of Radiation Protection
Licensee: Nelson Geotechnical Asso
Region: 4
City: Trinidad   State: WA
County:
License #: WN-I0421-1
Agreement: Y
Docket:
NRC Notified By: RAJ MAHARJAN
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/07/2022
Notification Time: 12:31 [ET]
Event Date: 04/06/2022
Event Time: 09:00 [PDT]
Last Update Date: 04/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 4/14/2022

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following was received from the Washington State Department of Health, Office of Radiation Protection, via email:

"Washington State received a report of a portable gauge incident on 4/6/2022. The incident took place on the same day around 0900 PDT at Trinidad, WA. A Troxler 3440 portable gauge [containing 9 mCi Cs-137 and 44 mCi Am/Be-241 sources] was run over by a bulldozer at a construction site. The gauge was damaged. No over exposure or contamination [occurred]. The sources appear to be intact pending further report. Washington State will provide a detailed report once available within the required time frame."

Washington State Incident Number: WA-22-009.


Agreement State
Event Number: 55825
Rep Org: New Mexico Rad Control Program
Licensee: Freeport-McMorin - Chino Mine
Region: 4
City: Vanadium   State: NM
County:
License #: GA045-46
Agreement: Y
Docket:
NRC Notified By: Carl Sullivan
HQ OPS Officer: Thomas Herrity
Notification Date: 04/07/2022
Notification Time: 12:03 [ET]
Event Date: 04/06/2022
Event Time: 14:52 [MDT]
Last Update Date: 04/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 4/14/2022

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTERS

The following is a synopsis of a report received from the state of New Mexico via phone call:

The Chino Mine in Vanadium, NM has two Berthold model LB7440 gauge devices malfunctioning. Unit Serial Number 3175, with a 250 milliCi Cs-137 source, has a broken latch and cannot be held in the closed position. Unit Serial Number DZ256A, 150 milliCi Cs-137 source, is stuck in the open position. Open is the normal operating position for both units and the units will remain in service until the service contractor arrives in May 2022. Both units have been roped off to prevent personnel from exposure.

NM item number: N/A


Agreement State
Event Number: 55826
Rep Org: Pennsylvania, DEP
Licensee: KAKS and Co
Region: 1
City: Harleysville   State: PA
County:
License #: PA-1394
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Notification Date: 04/07/2022
Notification Time: 14:06 [ET]
Event Date: 04/07/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (EMAIL)
Event Text
EN Revision Imported Date: 4/14/2022

EN Revision Text: AGREEMENT STATE REPORT - STOLEN GAUGE

The following was received from the Commonwealth of Pennsylvania (the department or DEP) via email:

"On April 7, 2022, the licensee informed the department that a Troxler Model 3440 nuclear density gauge, serial number 31109, containing 8 milliCuries of cesium-137 and 40 milliCuries of americium-241 had been stolen. The gauge was secured in the back of the technician's vehicle at his residence. The technician was leaving his residence this morning around 0800 EDT and the vehicle was missing with the gauge inside. The incident was reported to the Philadelphia Police Department and they have yet to respond to the situation.

"The DEP will update this event as soon as more information is provided."

Event Report ID No: PA220012

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


Agreement State
Event Number: 55829
Rep Org: Georgia Radioactive Material Pgm
Licensee: Graphic Packaging International
Region: 1
City:   State: GA
County:
License #: GA 179-2
Agreement: Y
Docket:
NRC Notified By: Stacy Allman
HQ OPS Officer: Thomas Herrity
Notification Date: 04/07/2022
Notification Time: 16:58 [ET]
Event Date: 04/07/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/07/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 4/14/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST/MISSING GAUGE

The following was received from the State of Georgia, via email:

"Graphic Packaging International called us this afternoon to report a missing gauge. The gauge is a Berthold Model LB7441 S/N 2212 and is believed to be about 41 milliCuries. It is unknown to us at this time if the source is Cobalt-60 or Cesium-137. The last leak test was conducted on December 13, 2021. The licensee says that the gauge was installed on a part of the line that they haven't used in a long time. The Radioactivity Safety Officer (RSO) went to that part of the line to clean the tags and discovered that entire end of the line was gone. They have been having demolition work done, so it is his belief that the gauge was in the demolition. The demolition company is Grey Wolf. We are following up with the licensee and the company for more information and will keep you informed."

Georgia item number: N/A

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


Agreement State
Event Number: 55830
Rep Org: California Radiation Control Prgm
Licensee: Loma Linda University Health
Region: 4
City: San Bernardino   State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Thomas Herrity
Notification Date: 04/07/2022
Notification Time: 21:09 [ET]
Event Date: 04/06/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS DAY)
Event Text
EN Revision Imported Date: 4/14/2022

EN Revision Text: AGREEMENT STATE REPORT - OVERDOSE TO PATIENT

The following was received from the State of California, Department of Public Health (RHB), via email:

"On April 6, 2022, Loma Linda University Health's (LLUH) Radiation Safety Officer was notified by a medical authorized user that a reportable medical event had occurred during a Y-90 Therasphere patient brachytherapy treatment on April 5, 2022.

"There were two patients scheduled for brachytherapy on the same day. Patient 1 had two tailored dose vials of Y-90 and Patient 2 had three tailored dose vials of Y-90 stored in the hot lab. A certified nuclear medical technologist mistakenly selected one of Patient 2's vials for Patient 1's treatment. The selected vial contained 4.0 GBq (108 milliCuries) with calibration date April 3, 2022 at 1200 PDT. It contained approximately 58.6 milliCuries at the time of administration.

"The two vials were taken to the therapy suite, where they were approved and used by the authorized user. The authorized user's written directive for Patient 1's liver segments 2 and 3 was to deliver a dose of 120 Gy. However, the mistake resulted in a dose of 750 Gy to the two liver segments. If the proper vial had been selected, the administered activity would have been 9.6 milliCuries.

"The error also resulted in the cancellation of Patient 2's treatment, as the Y-90 dose was no longer available. LLUH will be submitting a 15-day report to RHB. Abnormal Occurrence criteria for Medical Event's: Unplanned dose greater than or equal to 1000 rad to any other organ AND dose is greater than 150 percent of the prescribed dose."


California Event Number: 040622

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.