Event Notification Report for January 14, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/13/2015 - 01/14/2015
Agreement State
Event Number: 50735
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL, INC.
Region: 1
City: BURLINGTON State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: MEDWELL HILL
HQ OPS Officer: STEVE SANDIN
Licensee: QSA GLOBAL, INC.
Region: 1
City: BURLINGTON State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: MEDWELL HILL
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/14/2015
Notification Time: 16:15 [ET]
Event Date: 01/14/2015
Event Time: 13:47 [EST]
Last Update Date: 01/14/2015
Notification Time: 16:15 [ET]
Event Date: 01/14/2015
Event Time: 13:47 [EST]
Last Update Date: 01/14/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ART BURRITT (R1DO)
ANTHONY HSIA (NMSS)
PAM HENDERSON (MSTR)
ILTAB (EMAI)
NMSS EVENTS NOTIFICA (EMAI)
ART BURRITT (R1DO)
ANTHONY HSIA (NMSS)
PAM HENDERSON (MSTR)
ILTAB (EMAI)
NMSS EVENTS NOTIFICA (EMAI)
AGREEMENT STATE REPORT - TWO CATEGORY 2 IRIDIUM SOURCES UNACCOUNTED FOR DURING SHIPMENT
The following information was provided by the Commonwealth of Massachusetts via email.
QSA Global (Shipper) initially provided notification to the Commonwealth of Massachusetts of the following:
"On Tuesday, January 13, 2015, QSA was notified by the customer a routine shipment of two Ir-192 sources from QSA Global, Inc. to Huntington Testing and Technology did not arrive as expected. They (HT&T) contacted the carrier and were told that the shipment could not be located. A trace was initiated. This trace is still actively being pursued by [the carrier's representative] and as of the writing of this email, the shipment is suspected of being at a US Postal Service facility in Charleston, SC."
QSA Global subsequently provided notification to the Commonwealth of Massachusetts of the following:
"Please be advised that QSA has received notification by [the carrier's representative] that the shipment to Huntington Test and Technologies reported missing has been located and physically verified in Memphis, TN at the [shipper's] hub. Additional information will be forthcoming in a followup 30 day report. "
The two Iridium-192 sources are 102.8 Ci (SN: 14381G) and 102.7 Ci (SN: 14382G), respectively shipped in an SC-650L Source Changer (SN: 202). The shipment has no indication of tampering and is currently enroute to HT&T.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL
Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The following information was provided by the Commonwealth of Massachusetts via email.
QSA Global (Shipper) initially provided notification to the Commonwealth of Massachusetts of the following:
"On Tuesday, January 13, 2015, QSA was notified by the customer a routine shipment of two Ir-192 sources from QSA Global, Inc. to Huntington Testing and Technology did not arrive as expected. They (HT&T) contacted the carrier and were told that the shipment could not be located. A trace was initiated. This trace is still actively being pursued by [the carrier's representative] and as of the writing of this email, the shipment is suspected of being at a US Postal Service facility in Charleston, SC."
QSA Global subsequently provided notification to the Commonwealth of Massachusetts of the following:
"Please be advised that QSA has received notification by [the carrier's representative] that the shipment to Huntington Test and Technologies reported missing has been located and physically verified in Memphis, TN at the [shipper's] hub. Additional information will be forthcoming in a followup 30 day report. "
The two Iridium-192 sources are 102.8 Ci (SN: 14381G) and 102.7 Ci (SN: 14382G), respectively shipped in an SC-650L Source Changer (SN: 202). The shipment has no indication of tampering and is currently enroute to HT&T.
THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL
Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Non-Agreement State
Event Number: 50736
Rep Org: SAINT VINCENTS MEDICAL CENTER
Licensee: SAINT VINCENTS MEDICAL CENTER
Region: 1
City: BRIDGEPORT State: CT
County:
License #: 06-00843-03
Agreement: N
Docket:
NRC Notified By: SHAWN MATTHEWS
HQ OPS Officer: JOHN SHOEMAKER
Licensee: SAINT VINCENTS MEDICAL CENTER
Region: 1
City: BRIDGEPORT State: CT
County:
License #: 06-00843-03
Agreement: N
Docket:
NRC Notified By: SHAWN MATTHEWS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/15/2015
Notification Time: 12:00 [ET]
Event Date: 01/14/2015
Event Time: 13:30 [EST]
Last Update Date: 01/15/2015
Notification Time: 12:00 [ET]
Event Date: 01/14/2015
Event Time: 13:30 [EST]
Last Update Date: 01/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ART BURRITT (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
ART BURRITT (R1DO)
NMSS EVENTS NOTIFICA (EMAI)
MEDICAL EVENT INVOLVING A Y-90 SIR-SPHERE UNDER DOSE
Notification of a medical event that occurred on January 14, 2015 at 1330 EST, in which the Y-90 SIR-Sphere dose delivered to the patient's liver was less than the prescribed dose. The intended dose to the patient was 22 mCi, however the catheter disconnected during administration, resulting in a spill on the table which caused the underdose to the patient. It is estimated the patient received only 11.5 mCi or approximately 52% of intended dose and there was no harm to the patient.
The patient and prescribing physician have been informed and a follow-up treatment is planned. There was no contamination or exposure to other personal.
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.
Notification of a medical event that occurred on January 14, 2015 at 1330 EST, in which the Y-90 SIR-Sphere dose delivered to the patient's liver was less than the prescribed dose. The intended dose to the patient was 22 mCi, however the catheter disconnected during administration, resulting in a spill on the table which caused the underdose to the patient. It is estimated the patient received only 11.5 mCi or approximately 52% of intended dose and there was no harm to the patient.
The patient and prescribing physician have been informed and a follow-up treatment is planned. There was no contamination or exposure to other personal.
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.
Agreement State
Event Number: 50746
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: THE COLLEGE OF NEW JERSEY
Region: 1
City: EWING State: NJ
County:
License #: 507375
Agreement: Y
Docket:
NRC Notified By: JAMES T MCCULLOUGH
HQ OPS Officer: VINCE KLCO
Licensee: THE COLLEGE OF NEW JERSEY
Region: 1
City: EWING State: NJ
County:
License #: 507375
Agreement: Y
Docket:
NRC Notified By: JAMES T MCCULLOUGH
HQ OPS Officer: VINCE KLCO
Notification Date: 01/20/2015
Notification Time: 15:44 [ET]
Event Date: 01/14/2015
Event Time: 00:00 [EST]
Last Update Date: 02/09/2015
Notification Time: 15:44 [ET]
Event Date: 01/14/2015
Event Time: 00:00 [EST]
Last Update Date: 02/09/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS EVENTS (EMAI)
ILTAB (EMAI)
RAY MCKINLEY (R1DO)
NMSS EVENTS (EMAI)
ILTAB (EMAI)
AGREEMENT STATE REPORT - LOST GENERALLY LICENSED TRITIUM EXIT SIGNS
The following information was received by email:
"Event Description: A specific licensee reported the loss (potential theft) of two generally licensed tritium (H-3) exit signs. The signs had been removed from installation and are missing from the storage location. The licensee became aware of the missing material on 1/14/2015, however, it is possible the material was missing for approximately one month. The devices were last seen by licensee staff in mid-December 2014. Specific details about the device model and activity have not yet been provided, potentially up to 15 Ci H-3 per device. An NJDEP [New Jersey Department of Environmental Protection] inspector will visit the site to investigate the incident."
New Jersey Event: #C545467
* * * UPDATE FROM JAMES MCCULLOUGH TO JEFF HERRERA ON 2/9/15 AT 1638 EST * * *
The following update was received from the New Jersey Department of Environmental Protection via email:
"The College of New Jersey (TCNJ) reported the loss or possible theft of two radioluminescent exit signs. The signs had been removed from installation and were placed into storage. The signs were discovered to be missing from the storage location on 1/14/2015. However, TCNJ stated that it was possible the signs had been missing for approximately one month. The signs were last seen by TCNJ in mid-December 2014. Each sign contained approximately 137 GBq (3.7 Ci) of H-3. A New Jersey Department of Environmental Protection inspector visited the site on 1/21/2015 and determined the most likely scenario was accidental disposal. The licensee submitted a full report in accordance with N.J.A.C. 7:28-6.1 [10 CFR 20.2201]. The missing signs were not located. Although there was no evidence of contamination, the licensee estimated a dose of 8.5 mrem if the signs had been broken.
"NJDEP tracked the event as Incident # C545467 and Investigation #: 507375-INV15001.
"Corrective Actions: Commitment to increased security should they be in possession of other sources. [The College of New Jersey] reports no inventory of generally licensed devices.
"Device Number: 1
Device/Equipment: RADIOLUMINESCENT EXIT SIGN
Model Number: LE
Manufacturer: SAFETY LIGHT CORP
Serial Number: 201864
"Device Number: 2
Device/Equipment: RADIOLUMINESCENT EXIT SIGN
Model Number: LE
Manufacturer: SAFETY LIGHT CORP
Serial Number: 201865"
Notified R1DO(Powell), NMSS Events Notification and ILTAB (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
The following information was received by email:
"Event Description: A specific licensee reported the loss (potential theft) of two generally licensed tritium (H-3) exit signs. The signs had been removed from installation and are missing from the storage location. The licensee became aware of the missing material on 1/14/2015, however, it is possible the material was missing for approximately one month. The devices were last seen by licensee staff in mid-December 2014. Specific details about the device model and activity have not yet been provided, potentially up to 15 Ci H-3 per device. An NJDEP [New Jersey Department of Environmental Protection] inspector will visit the site to investigate the incident."
New Jersey Event: #C545467
* * * UPDATE FROM JAMES MCCULLOUGH TO JEFF HERRERA ON 2/9/15 AT 1638 EST * * *
The following update was received from the New Jersey Department of Environmental Protection via email:
"The College of New Jersey (TCNJ) reported the loss or possible theft of two radioluminescent exit signs. The signs had been removed from installation and were placed into storage. The signs were discovered to be missing from the storage location on 1/14/2015. However, TCNJ stated that it was possible the signs had been missing for approximately one month. The signs were last seen by TCNJ in mid-December 2014. Each sign contained approximately 137 GBq (3.7 Ci) of H-3. A New Jersey Department of Environmental Protection inspector visited the site on 1/21/2015 and determined the most likely scenario was accidental disposal. The licensee submitted a full report in accordance with N.J.A.C. 7:28-6.1 [10 CFR 20.2201]. The missing signs were not located. Although there was no evidence of contamination, the licensee estimated a dose of 8.5 mrem if the signs had been broken.
"NJDEP tracked the event as Incident # C545467 and Investigation #: 507375-INV15001.
"Corrective Actions: Commitment to increased security should they be in possession of other sources. [The College of New Jersey] reports no inventory of generally licensed devices.
"Device Number: 1
Device/Equipment: RADIOLUMINESCENT EXIT SIGN
Model Number: LE
Manufacturer: SAFETY LIGHT CORP
Serial Number: 201864
"Device Number: 2
Device/Equipment: RADIOLUMINESCENT EXIT SIGN
Model Number: LE
Manufacturer: SAFETY LIGHT CORP
Serial Number: 201865"
Notified R1DO(Powell), NMSS Events Notification and ILTAB (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