Event Notification Report for October 12, 2022

MEDICAL EVENT - INCORRECT WRITTEN DIRECTIVE

The following information was provided by the licensee via phone:

On 10/3/22, a medical event occurred when a written directive was incorrect. The nuclear medicine staff recognized the written directive was incorrect and delivered the correct dose to the proper location. The patient was not harmed.

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.

NUCLEAR DENSITY GAUGE DAMAGED BY VEHICLE

The following information was provided by the licensee via phone call:

At 1030 CDT on June 12, 2022, a Humboldt gauge Model 5001, containing 10 mCi of Cs-137 and 40 mCi of Am 241, was damaged by a construction vehicle. The sources were in the safe position at the time of the event. The unit's case was damaged, but the sources were not damaged. The gauge area was quarantined. A repair company was contacted. The repair company surveyed the area, and the survey indicated that there was no leakage or contamination. The repair company took possession of the gauge.

AGREEMENT STATE REPORT - INADVERTENT PAUSE IN TREATMENT

The following was received from the state of New Jersey via email:

"While treating a patient with a gamma-knife icon unit, there was an apparent activation of the emergency stop. No one admits to touching the emergency stop button, but the sources retracted, the unit doors remained open, and the table functions were frozen. One of the authorized medical physicists (AMP) entered the room and manually retracted the table from the unit, as per emergency procedures. The licensee reported that this is the protocol when the emergency (red) console button is pushed. The AMP and one of the authorized users (AU) helped the patient off the table. The couch lever was pushed back into place and the unit was reset so the doors would close.

"The AMP observed the treatment time at the back of the unit. The AMP repeated the sector position check of the unit without incident. The licensee contacted the device manufacturer, Elekta, about the incident. They reported that Elekta informed them it was acceptable to proceed and complete the patient treatment. They then resumed and completed the patient's treatment without further incident. The events were documented in the patient's record.

"The manufacturer sent a service technician to the licensee the next day (i.e., today, October 4, 2022) to inspect the unit, make any needed repairs and check the log files. After review of the logs, the AMP and Elekta believe patient movement triggered the incident. The dose to the AMP and AU was estimated to be 0.134 mrem. This was not a medical event, since the planned treatment was completed."

AGREEMENT STATE REPORT - LOST EXIT SIGN

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

On 10/5/22, the licensee reported a lost exit sign.

Manufacturer: Isolite Corporation
Model Number: 2000
Isotope and Activity: H3, 7.5 Curies

Colorado Event Report Identification Number: C0220032

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 REPORT - LOST EXIT SIGN

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

On 10/5/22, the licensee reported the loss of 2 exit signs.

Manufacturer: Isolite Corporation
Model Number: 2040
Isotope and Activity: H3, 7.5 Curies each

Colorado Event Report Identification Number: C0220032


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 REPORT - LOST SHIPMENT

The following was received from the Illinois Emergency Materials Agency (the Agency) via email:

"The Agency received a phone call from the Radiation Safety Officer at Bard Brachytherapy (IL-02062-01) on 10/5/22 indicating the loss of a package containing (10) ten I-125 brachytherapy seeds, accounting for a maximum estimated activity of 7.29 mCi (0.729 mCi per source). The package appears to have been lost at the [common carrier] warehouse in Vermont. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion.

"DETAILS: On 9/30/2022, Bard Brachytherapy shipped two boxes to the University of Vermont Medical Center in Burlington, VT. One of the boxes, which contained (10) ten I-125 brachytherapy seeds did not arrive with the shipment. [The common carrier] initially reported that it was still in the VT warehouse. [The common carrier] reportedly conducted a search yesterday and did not find the package and notified Bard Brachytherapy this morning that it was lost."

Illinois Item Number: IL220038

* * * UPDATE ON 10/07/2022 AT 1233 EDT FROM GARY FORSEE TO LLOYD DESOTELL * * *

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

"Licensee advised the common carrier located the package and confirmed delivery. This matter is considered closed."

Notified R3DO (Betancourt-Roldan) and R1DO (Ferdas). Notified via email: NMSS Event Notification and ILTAB

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 REPORT - FIRE DAMAGED FIXED GAUGES

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

"On October 03, 2022, at about 1300 EDT, the Maryland Department of the Environment, Radiological Health Program (MDE/RHP) was contacted via telephone from the Radiation Safety Officer (RSO) of Brandon Shores, LLC. [The licensee] followed-up by email message on October 04, 2022 at 1342 EDT. The RSO reported that on September 22, 2022, a bunker fire started at the Brandon Shores Power Plant, and it has caused a coal pipe mounted with two sealed sources to become exceedingly hot.

"It was reported that the coal from the bunker is delivered to a stock feeder via an 8 foot vertical pipe that has two gauges mounted on it. The two gauges on the coal pipe were affected by the operations to contain the fire. The RSO further reported on the conditions of the gauges that 'there does not appear to be visible signs of physical damage. Based on survey readings there does not appear to be indication of radiological issues.' The licensee has contacted Thermo Fisher to assess the damage and perform a leak test of the devices.

"The two fixed gauges are manufactured by Texas Nuclear Corporation, both model 5200 with device serial numbers B1421 and B1426. They contain Cesium-137 sealed sources with estimated nominal activities of 50 millicuries each with assay dates of September 1988.

"Results of the leak test and a detailed safety report is expected. The case has been reported to the Nuclear Material Events Database (NMED) on 10/05/2022.

"MDE/RHP will finalize a reactive investigation."

MOISTURE DENSITY GAUGE DAMAGED BY VEHICLE

The following information was provided by the licensee via phone call:

At 1530 EDT on October 5, 2022, a Troxler gauge Model 3430, containing 8 mCi of Cs-137 and 40 mCi of Am 241, was damaged by a construction vehicle. The sources were in the test position at the time of the event. The unit's source rod was damaged, but the sources were not damaged. The gauge area was quarantined and a repair company was contacted. The repair company provided the licensee a lead lined container for the damaged gauge to be transported back to the vendor. There were no exposures and a leak test is in progress. The repair company took possession of the gauge.