Event Notification Report for July 02, 2019

AGREEMENT STATE REPORT - LOST PORTABLE GAUGE

This is a summary of information received from the state of Nebraska via phone call:

On July 2, 2019, at approximately 1330 CDT, the licensee, Mid-State Engineering and Testing, lost a CPN-International MC Series Protaprobe gauge with 10 mCi Cs-137 and 50 mCi Am/Be-241 sources. This gauge is believed to be lost somewhere between Aurora and Columbus, Nebraska on the route that includes highways 14 and 30. The truck's tail gate was not closed causing the gauge to fall out of the truck. The licensee has attempted to locate the gauge but so far has been unsuccessful. The Nebraska State Patrol has been notified along with the Platte County Sheriff department. This was reported to the State of Nebraska Health and Human Services Agency at 1645 CDT. The State will be issuing a follow up written report later.

* * * UPDATE ON 7/3/2019 AT 1758 EDT FROM JULIA SCHMITT TO ANDREW WAUGH * * *

This is a summary of information received from the state of Nebraska via phone:

On July 3, 2019, the gauge was found by a member of the public and retrieved by the licensee. The gauge does not appear to be damaged.

Notified R4DO (Haire), NMSS Events (email), 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

AGREEMENT STATE REPORT - LOST AND RECOVERY OF A MOISTURE DENSITY GAUGE

The following was received from the Nebraska Department of Health and Human Services via email:

"Mid-State Engineering and Testing (MSET) reported the loss and recovery of a moisture/density gauge (CPN International MC Series) that contained a 1.85 GBq (50 mCi) Am-Be source and a 0.37 GBq (10 mCi) Cs-137 source. The gauge was initially believed to have been lost on July 2, 2019, somewhere between Aurora and Columbus, Nebraska, on a route that included Highways 14 and 30. The driver reported that approximately 1.5 miles west of the Highway 30 and Highway 81 intersection he had to forcefully apply the truck brakes to avoid a collision. The gauge was locked inside of a transportation case and secured to the truck with a lock and chain. When the brakes were applied, the transportation case handle was pulled out of the case and the tailgate of the truck fell open. When the truck accelerated after stopping at the intersection of Highways 30 and 81, the transportation case fell out of the vehicle. MSET attempted to locate the gauge without success.

"Nebraska State Patrol, Nebraska Department of Roads, Columbus Police Department and Platte County Sheriffs Department were notified. The gauge was found by a member of the public on July 2, 2019. The member of the public contacted MSET on July 2, 2019, and the gauge was retrieved by MSET. The handle on the locked transportation case was damaged. The gauge inside did not appear to be damaged. The Nebraska Office of Radiological Health is investigating."

Nebraska State Report # 190003

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

WRITTEN DIRECTIVE FOR MICRO-SPHERE LIVER TREATMENT WAS INCORRECT

On 7/24/19 while preparing to administer micro-sphere liver treatment the health physicist discovered that the paperwork for a previous treatment on a different patient was incorrect. The paperwork indicated that the treatment was for the left lobe of the liver. The patient's left liver was removed in a previous surgery. The prescribing physician realized that the treatment was for the right lobe of the liver and administered treatment to the right lobe. The physician failed to correct the paperwork. The treatment was on 7/2/19. The prescribed dose was 0.77 GBq and the administered dose was 0.78 GBq. There was no harm to the patient.

The licensee notified the NRC R1 Office (Tara Weidner, Penny Lanzisera).

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.