Event Notification Report for July 17, 2019

AGREEMENT STATE REPORT - TWO RADIOPHARMACEUTICAL PACKAGES HAD HIGH SURFACE CONTAMINATION LEVELS WHEN DELIVERED

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

"On July 10, 2019, a health physics consultant contacted the Maryland Department of the Environment Radiological Health Program (MDE/RHP) concerning a discovery during a routine audit conducted on July 10, 2019 at a licensed medical facility.

"A review of incoming Department of Transportation wipe/survey listing reports at the licensed facility [St. Agnes Hospital in Baltimore, MD] indicated that two packages received on June 12, 2019 from the radiopharmacy had high wipe test values recorded at 400,000 dpm per 100 cm2. These values were documented for surface and contents of the packages. Both packages were labeled as White I and had no abnormal outer package surface exposure rate readings. The computer record contained a note stating that, 'dpm verified and Cardinal [Health] notified. Case stored for decay.'

"The technologists did not notify the Radiation Safety Officer or MDE/RHP. The cases were opened, the doses unpacked, and used. The computer record indicated good condition for each box. One box contained one syringe of Tc-99m Ceretec at 17.25 mCi. The other box contained one vial of Tc-99m sodium pertechnetate at 104.22 mCi, one syringe of Tc-99m macro aggregated albumin at 10.61 mCi, and one syringe Tc-99m Sestamibi at 30.41 mCi.

"A reactive inspection is planned [by the state of Maryland]."

Cardinal Health was the radiopharmaceutical provider. The delivery vehicle and the driver were both surveyed on June 12, 2019, with negative results. No other contaminations or any overexposures were identified when the hospital performed surveys of the facility.

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILURE TO RETRACT

The following is an abstract of information received via E-mail:

On July 17, 2019, a Capitol Ultrasonics (CU) three-person crew was making exposures on a compressor at a chemical plant at ExxonMobil Refinery, at a temporary jobsite in Baton Rouge, Louisiana. The three-person radiography crew consisted of two radiography instructors and an assistant radiographer.

After performing three approximately one minute and 25 second exposures and upon completing the fourth exposure and cranking in the source, the radiography instructor noticed, after rocking the crank-out handle back and forth, that the exposure device auto-lock was not engaging. Before reaching the exposure device, the instructor noticed higher than expected survey readings. Several more attempts were made to crank in the source without success. The instructor at once contacted his Radiation Safety Officer (RSO), as well as the ExxonMobil Safety Superintendent. The crew then immediately extended their restricted area boundary to the 2 mR/hr line. Six to seven radiography technicians of the licensee maintained visual surveillance of the boundary and awaited arrival of their RSO. The exposure device was a QSA Global Model 741OP, serial number, B107, containing 15.1 Ci of Co-60, source Model number, A424-18 and source serial number, 60487B.

The lead technician of the crew leading the incident response prior to the arrival of the RSO, received 30 mR on his direct-reading dosimeter (DRD). The RSO received approximately 17 mR on his DRD by the time that the source was finally placed back in the exposure device in the shielded position. An environmental scientist from the Louisiana Department of Environmental Quality made a site visit to the temporary jobsite of the incident and performed preliminary investigation to include observing the successful retrieval of the source on July 17, 2019, by QSA Global. QSA Radiation Technicians received from 40 to 78.3 mR whole body exposure as a result of performing the source retrieval.

Louisiana Event Report ID No.: LA 190010

AGREEMENT STATE REPORT - STOLEN MOISTURE-DENSITY GAUGE

The following was received via e-mail:

"On 07/17/19, the California Governor's Office of Emergency Services contacted the Radiologic Health Branch (RHB) to report a stolen moisture-density gauge. The gauge involved is a Troxler Model 3450A, S/N 483, containing 9 mCi of Cs-137 and 44 mCi of Am-241. The gauge was stolen out of a gauge technician's truck parked at a Motel 6 parking lot around 2100 PDT in Oakland, CA. The user had immediately called the Oakland Police Department and was advised to call back at a later time. On the morning of 7/18/19, the Oakland Police Department was contacted again and they declined to take a report due to high volume of incidents. The gauge was chained to the bed of the truck and there were guards present at the parking lot. The licensee will be posting a reward for the safe return of the gauge. RHB will be following up on this investigation."

California 5010 Number: 071719

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