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Event Notification Report for January 17, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
1/16/2020 - 1/17/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54402
Rep Org: ARKANSAS DEPARTMENT OF HEALTH Licensee: PROFESSIONAL SERVICE INDUSTRIES Region: 4 City: Cave City State: AR County: License #: ARK-0943-03121 Agreement: Y Docket: NRC Notified By: CHRIS TALLEY HQ OPS Officer: BRIAN P. SMITH	Notification Date: 11/21/2019 Notification Time: 14:53 [ET] Event Date: 11/19/2019 Event Time: 16:00 [CST] Last Update Date: 01/16/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): NEIL O'KEEFE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

EN Revision Imported Date : 1/17/2020

EN Revision Text: AGREEMENT STATE REPORT - DENSITY GAUGE DAMAGED

The following was received from the State of Arkansas via email:

"The [Arkansas] Department [of Health] received notification on November 20, 2019, from licensee Professional Services Industries, Inc., that a Troxler gauge model 3430 had been struck by a skid-steer while performing routine measurements at a road construction site. The gauge was not being used at the time it was struck and the sources were in the shielded position.

"Upon review of the event, it was noted that the technician quickly created a thirty foot containment barrier and notified his company's Radiation Safety Officer (RSO). The RSO for Professional Services Industries mobilized to the event location.

"Once onsite, the RSO surveyed the immediate area around the damaged gauge and the gauge itself. The RSO determined that no radiation measurements were found to be above normal levels for that model of portable gauge. A leak test of the sealed sources was immediately conducted and the remnants of the gauge were collected and returned to the permanent storage location on November 19, 2019. The RSO and the Authorized User operating the portable gauge were wearing dosimetry.

"The Arkansas Department of Health considers this investigation open pending receipt and review of the licensee's 30 day report."

Arkansas Event No.: AR-2019-005

* * * UPDATE 0N 1/16/2020 AT 1035 EST FROM CHRIS TALLEY TO THOMAS KENDZIA * * *

The following was received from the Arkansas Department of Health via email:

"Upon review of the licensees 30 Day Report, received December 26, 2019, it was noted that the dosimetry badges worn by the Authorized User and RSO during the retrieval and transportation of the sources showed no measurable dose. The dosimetry badges worn were issued to the users on October 15, 2019 and the event occurred on November 19, 2019.

"The report contained leak test results for the sources taken immediately following the event, November 19, 2019. The results for the leak tests in both instances were measured to be below 185 Bq (0.001microCi), considering the sources to be non-leaking sources.

"The company conducted mandatory safety meetings with all staff in the PSI-Sherwood office who work with the portable gauges as a result of the event. Topics discussed during the meetings and e-mail included radiation safety, gauge security, and gauge control. The company also has re-trained the individual authorized user responsible for the gauge during the event via a 're-entrance' exam.

"The radioactive sources and associated nuclear gauge remnants were returned to the manufacturer for disposal. The sources are now listed under North Carolina Radioactive Materials License #032-0182-1.

"The [Arkansas] Department [of Health] considers this event to be closed, providing that no new information is received."

Notified the R4DO (Young) and the NMSS Events Notification group (email).

Agreement State	Event Number: 54468
Rep Org: VT DEPARTMENT OF HEALTH Licensee: UNIVERSITY OF VERMONT MEDICAL CENTER Region: 1 City: State: VT County: License #: Agreement: Y Docket: NRC Notified By: FRANCIS O'NEILL HQ OPS Officer: MICHAEL BLOODGOOD	Notification Date: 01/09/2020 Notification Time: 07:33 [ET] Event Date: 11/27/2019 Event Time: 00:00 [EST] Last Update Date: 01/09/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAN SCHROEDER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - IODINE-125 PROSTATE IMPLANT SEED

The following is a synopsis of a report from the Vermont (VT) Department of Health (the Department):

On November 27, 2019, a prostate seed implant (PSI) procedure using Iodine-125 (I-125) seeds was performed. During the latter part of the procedure, while loading one last, extra needle for the radiation oncologist (the Authorized User), the authorized medical physicist (AMP) lost control of one I-125 seed.

A number of surveys were conducted immediately following the loss of the seed, producing only background readings.

On December 4, 2019, a Department Senior Radiological Health Specialist conducted a follow-up survey in the PSI procedure room and waste storage areas. The lost seed was not located.

As a corrective action, the licensee may consider ordering additional seeds in the form of preloaded needles to avoid handling individual prostate seeds.

The lost prostate seed is believed to have fallen into the bore of the implanting needle and was subsequently implanted into the prostate. This is not believed to have any clinical significance on the resulting absorbed dose to the prostate, urethra, or rectum. The patient had 76 prostate seeds planned to be implanted and a single extra seed would result in approximately 1 percent additional absorbed dose to the treatment volume.

As verification, a post-implant treatment plan was calculated with an extra prostate seed placed near the location of the last needle within the treatment volume. The resulting dose metrics confirmed that absorbed doses increased by about 1 percent.

The potential radiation exposure to an individual that is continuously present near the lost seed was evaluated and determined to be less than the 0.1 rem annual public exposure limit.

No personnel contamination occurred as a result of this event.

VT Incident Number: VT19-002

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.

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: 54469
Rep Org: MISSISSIPPI DIV OF RAD HEALTH Licensee: ALS INDUSTRIAL PTY Region: 4 City: VICKSBURG State: MS County: License #: LA-13553-L01 Agreement: Y Docket: NRC Notified By: JAYSON MOAK HQ OPS Officer: KARL DIEDERICH	Notification Date: 01/09/2020 Notification Time: 12:50 [ET] Event Date: 12/30/2019 Event Time: 00:00 [CST] Last Update Date: 01/09/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): HEATHER GEPFORD (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE COULDN'T BE RETRACTED

The following was received from the Agreement State via e-mail:

"RSO reported inability to retract a 40.2 Ci Ir-192 source (Source Model A424-9), (Source Serial No. 89706G) into the Sentinel/QSA 880 Delta exposure device (Serial No. D12297) during the period of 12/31/2019 to 1/1/2020.

"Licensee notified of 24 hour reporting requirement and to send written 30-day report."

Mississippi report number: MS-200001.

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