Event Notification Report for September 28, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/27/2018 - 09/28/2018
Agreement State
Event Number: 53638
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GEOCON, INC.
Region: 4
City: SAN DIEGO State: CA
County:
License #: 3924-37
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: RICHARD SMITH
Licensee: GEOCON, INC.
Region: 4
City: SAN DIEGO State: CA
County:
License #: 3924-37
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/03/2018
Notification Time: 10:57 [ET]
Event Date: 09/28/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/03/2018
Notification Time: 10:57 [ET]
Event Date: 09/28/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CNSNS (MEXICO) (EMAIL)
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CNSNS (MEXICO) (EMAIL)
AGREEMENT STATE - STOLEN DENSITY GAUGE
The following was received via email from the State of California:
"On October 2, 2018, at approximately 0830 [PDT] the, Radiation Safety Officer (RSO) for Geocon, Inc. contacted [California Radiologic Health Branch] RHB Brea concerning the moisture/density gauge, Troxler, model 3440, serial #33877 (Cs-137, 0.333 gigaBecquerel; Am-241, 1.6 gigaBecquerel) that had been stolen along with a transport vehicle parked in San Ysidro, CA, at approximately 0600 to 0700 [PDT], on Friday morning, September 28, 2018.
"The authorized user whose truck was stolen did not inform the RSO until 1000 to 1030 [PDT] on Monday, October 1, 2018, of the stolen radioactive gauge. The RSO has contacted local law enforcement in San Diego and is awaiting the completed police report, a copy of which he will send to RHB Brea to be included as part of this report. The RSO will contact local newspapers to attempt to retrieve the stolen radioactive gauge as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. California Notices of Violation will be issued to the licensee for failure to report the loss in a timely manner, and loss of control of the radioactive material."
California Report No. 5010-100218
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 was received via email from the State of California:
"On October 2, 2018, at approximately 0830 [PDT] the, Radiation Safety Officer (RSO) for Geocon, Inc. contacted [California Radiologic Health Branch] RHB Brea concerning the moisture/density gauge, Troxler, model 3440, serial #33877 (Cs-137, 0.333 gigaBecquerel; Am-241, 1.6 gigaBecquerel) that had been stolen along with a transport vehicle parked in San Ysidro, CA, at approximately 0600 to 0700 [PDT], on Friday morning, September 28, 2018.
"The authorized user whose truck was stolen did not inform the RSO until 1000 to 1030 [PDT] on Monday, October 1, 2018, of the stolen radioactive gauge. The RSO has contacted local law enforcement in San Diego and is awaiting the completed police report, a copy of which he will send to RHB Brea to be included as part of this report. The RSO will contact local newspapers to attempt to retrieve the stolen radioactive gauge as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. California Notices of Violation will be issued to the licensee for failure to report the loss in a timely manner, and loss of control of the radioactive material."
California Report No. 5010-100218
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: 53639
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SANTA CLARA VALLEY HEALTH AND HOSPITAL SYSTEM
Region: 4
City: SAN JOSE State: CA
County:
License #: 0741-43
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: RYAN ALEXANDER
Licensee: SANTA CLARA VALLEY HEALTH AND HOSPITAL SYSTEM
Region: 4
City: SAN JOSE State: CA
County:
License #: 0741-43
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: RYAN ALEXANDER
Notification Date: 10/03/2018
Notification Time: 12:06 [ET]
Event Date: 09/28/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/03/2018
Notification Time: 12:06 [ET]
Event Date: 09/28/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - UNDERDOSAGE OF YTTRIUM 90 THERASPHERES
The following was received via email from the State of California:
"On 09/28/18, [the Radiation Safety Officer] RSO initially contacted [Radiologic Health Branch] RHB to report a problem related to patient therapy treatment with Yttrium 90 TheraSpheres performed on 09/28/18. The intended activity of the dosage was 11.9 milliCurie, but only approximately 36 percent was delivered to the target tissue based on the measurement of activity remaining in the delivery system after the procedure. The desired dose for the target volume was 135 Gy and the dose delivered was 49 Gy. At the time of the RSO contact, the licensee was uncertain whether the problem was due to patient stasis or an issue with the delivery system (e.g., a kink in the catheter).
"On 10/02/18, RHB received an email from the RSO stating that the physician (Authorized User) had used a micro catheter on the thinner end and it was very tortuous and made the resistance in the circuit higher than the administration box can tolerate such that the delivery system was not able to work properly in this situation. Licensee stated that the problem was not due to patient stasis.
"The licensee will submit a written report in accordance with 10 CFR 35.3945(d)."
California Report No. 5010-092818
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.
The following was received via email from the State of California:
"On 09/28/18, [the Radiation Safety Officer] RSO initially contacted [Radiologic Health Branch] RHB to report a problem related to patient therapy treatment with Yttrium 90 TheraSpheres performed on 09/28/18. The intended activity of the dosage was 11.9 milliCurie, but only approximately 36 percent was delivered to the target tissue based on the measurement of activity remaining in the delivery system after the procedure. The desired dose for the target volume was 135 Gy and the dose delivered was 49 Gy. At the time of the RSO contact, the licensee was uncertain whether the problem was due to patient stasis or an issue with the delivery system (e.g., a kink in the catheter).
"On 10/02/18, RHB received an email from the RSO stating that the physician (Authorized User) had used a micro catheter on the thinner end and it was very tortuous and made the resistance in the circuit higher than the administration box can tolerate such that the delivery system was not able to work properly in this situation. Licensee stated that the problem was not due to patient stasis.
"The licensee will submit a written report in accordance with 10 CFR 35.3945(d)."
California Report No. 5010-092818
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.