Event Notification Report for April 19, 2022

EN Revision Imported Date: 4/15/2022

EN Revision Text: AGREEMENT STATE REPORT - STOLEN GAUGE

The following was received via an email from the state of North Carolina:

"A portable nuclear density gauge was reported stolen from a job site located at a large construction site in Kernersville, NC. The gauge was secured in a large Conex box (large cargo container) at the site. Inside the Conex box there is a rigid box secured to the inside of the Conex box. The gauge was secured and locked inside of this rigid box and the Conex box itself was locked as well. On 4/11, licensee personnel discovered that the rigid box containing the gauge was missing from inside the Conex box.

"An inspector has been assigned this incident for investigation and details will follow to update, close, and complete this report."

North Carolina Tracking Number: 220003.

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: 4/15/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR

The following information was provided by the state of Colorado via email:

"Static Eliminator Model P-2021 reported as lost by new tenant of building previously occupied by Service King. Service King ended a lease agreement with the owner and was noted on Service King's registration that the static eliminator was surrendered as property of the building per lease agreement and they were not allowed in the building to retrieve the unit. After connecting and corresponding with the current tenants' (Classic Collision) manager he informed [the CO Department of Health] when they moved into the building everything had been removed except for a spray booth. He did look for the device but it was not found.

"Isotope: Po-210
Manufacturer: NRD, LLC.
Model: P-2021
Device: Static Eliminator
Serial number: A2LT196
Activity: .01 Ci"

CO Event Report ID No.: CO220009

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: 4/15/2022

EN Revision Text: AGREEMENT STATE REPORT - FAILURE OF A COMPONENT OF THE ACCESS CONTROL SYSTEM

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"At 0920 CDT on 4/12/2022, the Corporate Radiation Safety Officer (RSO) at Isomedix Operations, Inc. called to report a failure of the electronic brake on the irradiator vault entrance door located in Libertyville. The failure was discovered by licensee personnel at 1200 CDT on 4/11/2022. The licensee stated that operations were discontinued at this time. Following trouble shooting and diagnosis of the issue, the failure was reported to the Corporate RSO at 1830 CDT that same day. The licensee reinitiated operations after implementing temporary remedial access control measures and completing training of staff on revised procedures.

"As of 1030 CDT on 4/12/2022, the licensee was advised to cease operation of the affected irradiator until further notice. Agency inspectors were dispatched on 4/12/2022 to perform a reactionary inspection. The event was called into the [NRC Headquarters Operations Officer] as required.

"No personnel injuries or exposures and no adverse effects on the security system were reported."

Item Number: IL220011

EN Revision Imported Date: 4/15/2022

EN Revision Text: AGREEMENT STATE REPORT - SOURCE NOT SECURE WITHIN GAUGE

The following information was received from the Texas Department of State Health Services (the Agency) via E-mail:

"On April 12, 2022, the Agency received an email from a licensee regarding an Am-241 source that was no longer within the source holder of a Troxler Model 3430 (source assay date 9/29/1997 and serial 28367). The source capsule, source holder, and source cap were all loose within the gauge. This was the first notification to this Agency of this issue. The licensee reported that on March 25, 2022, a licensee technician reported measurement issues with this device. A survey of the device did not find any elevated readings. The device was pulled from service and inspected on March 30, 2022, at which point the loose components were discovered. This licensee had experience with this issue before (see EN 55774) and repaired the assembly using Loctite.
Licensee reports the source is not leaking and is secured within the source holder. Investigation is ongoing and additional information will be provided per SA-300."

Texas Incident Number: I-9925

EN Revision Imported Date: 4/15/2022

EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED

The following was received from the State of California, Department of Public Health, Radiologic Health Branch, via email:

"The Radiologic Health Branch was notified on April 12, 2022 regarding a medical event that occurred on April 11, 2022 at Loma Linda University Health. An authorized user was performing Y-90 brachytherapy using Nordion TheraSpheres on a patient's liver. After catheterizing and delivering Y-90 to the first segment, it was discovered that due to the patient's variant anatomy, the segment had been misidentified. The written directive called for 2.228 GBq to deliver 950 Gy to the patient's liver segment 7. However, post treatment analysis of the source vial determined that 2.840 GBq (76.7 mCi) was delivered. As a result, the dose delivered to that segment was approximately 27 percent above the dose specified in the written directive. A 15-day report will be generated by the licensee per 10 CFR 35.3045."

California Event Number: 041222

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.