Event Notification Report for April 22, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
04/21/2022 - 04/22/2022

EVENT NUMBERS
55797 55806 55845 55846 55847
Non-Agreement State
Event Number: 55797
Rep Org: Agilent Technologies
Licensee: Agilent Technologies
Region: 1
City: Wilmington   State: DE
County:
License #: 07-28762-01
Agreement: N
Docket:
NRC Notified By: David Bennett
HQ OPS Officer: Thomas Kendzia
Notification Date: 03/22/2022
Notification Time: 12:33 [ET]
Event Date: 02/22/2022
Event Time: 10:00 [EST]
Last Update Date: 04/21/2022
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Elizabeth Ullrich (R1)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 4/22/2022

EN Revision Text: LOST SOURCE
The following information was provided by the licensee via phone and email:

"Agilent Technologies manufacturers ECDs [Electron Capture Detectors], containing 15 millicuries each, of Ni-63 for use in Gas Chromatographs (for generation of ionized atmospheres for chemical analysis). We have a number of ECDs in use at our facility as addressed below for customer support and R&D. We are required by our license to perform wipe (swipe) tests every six months. The ECD in question was last wiped in August. We were in the process of performing our most recent wipe test last month (February) when we discovered the ECD and its host GC were no longer in the lab they were being used in. [Source was determined to be missing on February 22, 2022 at 1000 EDT when it could not be found for the scheduled swipe test.] We discovered quickly that the individual chemist with ownership of the ECD retired in November of 2021 [last date the device was accounted for]. Investigations to date have not been successful in recovering the ECD. Information pertinent to the incident to follow. I will also be submitting a letter to the appropriate address in one month if we are still unable to recover the ECD."

"ECD Model # G2397A
ECD Serial Number # U25487
Activity: 15 millicurie Ni-63
Facility security: Access to building is limited to those issued electronic badges. Labs are further secured by electronic access only to necessary personnel. [Therefore the source is not suspected to have been stolen.]"

* * * UPDATE ON 4/21/2022 AT 1244 EDT FROM DAVID BENNETT TO BETHANY CECERE * * *

The following information was provided by the licensee via phone:

The source is still lost. The licensee is submitting a written report to Region 1.

Notified R1DO (Dentel), ILTAB, and NMSS Events Notification by email.


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: 55806
Rep Org: New York State Dept. of Health
Licensee: Northwell Health Imaging
Region: 1
City: Lake Success   State: NY
County:
License #: 5255
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Howie Crouch
Notification Date: 03/29/2022
Notification Time: 09:34 [ET]
Event Date: 03/17/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/21/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (Email)
Event Text
EN Revision Imported Date: 4/22/2022

EN Revision Text: AGREEMENT STATE REPORT - LOST GD-153 and CO-57 SOURCES

The following information was received from the state of New York (NYSDOH) via fax:

"Four transmission/reference/calibration sources were shipped out in two separate shipments via [a common carrier] to Eckert & Ziegler on 3/17/2022 under two-day shipping and have been listed as 'delayed' since 3/18/2022. Upon contacting [the common carrier], an incident (No. C-61803614) was opened to attempt to locate the sources as [the common carrier] was unable to locate the two shipments. The licensee formally reported the sources as missing to NYSDOH on 3/28/2022.

"The Gd-153 source, (1.27 mCi as of 3/17/22), is deemed a reportable quantity under 20.2201 (a)(1)(ii), as greater than 10 times the Appendix C to Part 20 value (10 microCi), but less than 1000 times. The three other sources (Cobalt-57) fall below the values in Appendix C of 10 CFR 20 and are not reportable under 10 CFR 20.2201.

"The licensee is continuing to contact [the common carrier] regarding these sources and keeping NYSDOH updated on the status. NYS is consistently monitoring this situation under Incident No. 1389:
Device Manufacturer: Eckart & Zeigler
Device Model: TBD
Device S/N: S5-864
Source Manufacturer: Eckart & Zeigler
Source Model: TBD
Source S/N: S5-864
Isotope: Gd-153
Activity: 1.27 millicuries on 3/17/2022 (10 mCi assayed on 4/1/2020)

* * * UPDATE ON 04/21/22 AT 1216 EDT FROM DANIEL SAMSON TO TOM HERRITY * * *

The following information was received from the state of New York (NYSDOH) via fax:

"Updated Event description:

"The previously reported Gd-153 source (1.27 mCi on 3/17/22) was recovered on Friday, April 1, 2022. The Gd-153 source was successfully delivered to the intended recipient (Eckert & Ziegler) without any signs of tampering, opening, or modification. All sources in question were accounted for by the NY state medical licensee and Eckert & Ziegler. This event is attributed to a logistical error in transporting these packages by the common courier.

"As previously reported, the Gd-153 source was deemed a reportable quantity under 20.2201(a)(1)(ii) (1.27 mCi as of 3/17/22), as greater than 10 times the Appendix C to Part 20 Value, but less than 1000 times (10 micro-Ci). The 3 other sources (Cobalt-57) fell below the values in Appendix C of 10 CFR 20 and are not reportable under 10 CFR 20.2201. All other Cobalt-57 sources were also recovered without any signs of tampering, opening, or modification, and were all accounted for by the NY state medical licensee and Eckert & Ziegler on 4/1/2022.

"NYS opened Incident No.1389 to track this event. As of today, Incident No.1389 has been closed.
Device Manufacturer: Eckert & Ziegler
Device Model: HEGL-0133
Device S/N: S5-864
Source Manufacturer: Eckert & Ziegler
Source Model: HEGL-0133
Source S/N: S5-864
Isotope: Gd-153
Activity: 1.27 milliCuries on 3/17/2022 (10 mCi assayed on 4/1/2020)"

Event Report ID No.: Update to NYDOH - 22-02

Notified R1DO (Dentel), NMSS Events Notification, ILTAB, CNSC (Canada) via email.

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: 55845
Rep Org: Virginia Rad Materials Program
Licensee: Newport News Shipbuilding
Region: 1
City: Newport News   State: VA
County:
License #: 700-383-1
Agreement: Y
Docket:
NRC Notified By: Rose Yankoski
HQ OPS Officer: Brian Parks
Notification Date: 04/15/2022
Notification Time: 14:50 [ET]
Event Date: 04/14/2022
Event Time: 11:03 [EDT]
Last Update Date: 04/15/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - SOURCE UNABLE TO RETRACT TO SAFE POSITION

The following was received from the Commonwealth of Virginia via email:

"On April 14, 2022 at 2249 hours EDT, the Office of Radiological Health Radioactive Materials Program (ORH) received an incident report from the licensee, Huntington Ingalls Incorporated Newport News Shipbuilding. The source, 79 curies of Ir-192, could not be retracted to its shielded position during radiographic work. The incident occurred on April 14, 2022 at about 1103, while a radiographic work was being performed in a permanent radiography booth to inspect a pipe for use upon a naval vessel at Newport News Shipbuilding. The incident occurred because the metal pipe fell off of the metal sawhorse, crushing the source tube and preventing full retraction back into the shielded position. The root cause of the pipe falling off of the sawhorse has yet to be determined. The radiography crew immediately closed the permanent radiography booth, took radiation surveys to ensure that with the door closed the radiation levels were below 2 mR/hr, and notified the Radiation Safety Officer (RSO). The site was supervised by the radiography crew constantly between the time of the incident until the source was retracted at approximately 1310 on April 15, 2022. The highest exposure of the crew from the pocket dosimeters was 5.5 mrem. In addition, the whole body dosimeters were sent to the licensee's internal dosimetry program for analysis. The results are not yet available. The RMP Southeast regional inspector responded to the incident and performed radiation safety assessment at the event site."

Virginia Event Report ID Number: VA220001


Agreement State
Event Number: 55846
Rep Org: Nebraska Dept. of Health
Licensee: Central Valley Agriculture
Region: 4
City: Wakefield   State: NE
County:
License #: GL0746
Agreement: Y
Docket:
NRC Notified By: Deb Wilson
HQ OPS Officer: Thomas Herrity
Notification Date: 04/15/2022
Notification Time: 14:56 [ET]
Event Date: 04/15/2022
Event Time: 00:00 [CDT]
Last Update Date: 04/15/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was received from the state of Nebraska, Office of Radiological Health via email:

"We [Office of Radiological Health] received Central Valley Agriculture GL0746's Annual Radioactive Material Current Inventory and they indicated that they were no longer in possession of 2 tritium exit signs. We spoke with them and they said that the Oak Street property had been sold several years ago and the building torn down. We contacted the new property tenant to confirm, and it was determined that the signs were not on the property, assumed to have been demolished with the previous building. Follow-up complete, no further investigation is needed."

Nebraska event number: NE220001

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: 55847
Rep Org: California Radiation Control Prgm
Licensee: SF Medical Center
Region: 4
City: San Francisco   State: CA
County:
License #: 1725-38
Agreement: Y
Docket:
NRC Notified By: K. Arunika Hewadikaram
HQ OPS Officer: Thomas Herrity
Notification Date: 04/15/2022
Notification Time: 18:58 [ET]
Event Date: 04/08/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/15/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

The following was received from the state of California Radiologic Health Branch (RHB) via email:

"On 4/14/22, Radiation Safety Officer (RSO) contacted RHB to report a Medical Event associated with a High Dose Rate (HDR) unit.

"Licensee's written notification on 4/15/22, stated the following:

"Sometime on Friday, April 8th [2022], an HDR therapist replaced a source transfer tube/catheter with a longer length transfer tube/catheter than intended for the three HDR treatments planned for that day. The difference in lengths was 123 mm. Since the treatment plan was with a shorter transfer tube/catheter, the source didn't make it all the way to the treatment locations and resulted in underdosing the three patients on that day, and likely delivering unplanned doses to non-treatment sites for the three patients. The error was discovered on Wednesday, April 13th, as another HDR therapist was getting ready for an HDR treatment. No HDR treatments had occurred since Friday, April 8. The first therapist wasn't certain if she changed the transfer tube/catheter in the morning or after the patients, but she thinks she likely changed it in the morning. The licensee is still evaluating the delivered doses to the patients treated on that Friday, but at least two of them are believed to have received an underdose that is reportable. The doses to non-treatment sites have not been fully evaluated. All three patients and their referring physicians were notified on Thursday, April 14th.

"RHB is continuing to follow up with the investigation."

California Event Number: 041422

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.