Event Notification Report for January 29, 2020

AGREEMENT STATE REPORT - STOLEN NUCLEAR DENSITY GAUGE

The following was received from the Pennsylvania Bureau of Radiation Protection (the Department) via email:

"On January 29, 2020, the licensee informed the Department that one of their vehicles, with a nuclear density gauge in the trunk, was stolen earlier that day. The licensee has filed a police report. The Department has been in contact with the licensee and will update this event as soon as more information is provided."

The gauge is a CPN International, Model MC-1 DR-P (Serial Number: M7077803), with a 10 mCi Cs-137 source and a 50 mCi Am-241/Be source.

PA Event Report ID No.: PA200002

* * * UPDATE ON 1/30/2020 AT 1346 EST FROM JOHN CHIPPO TO ANDREW WAUGH * * *

The following was received from the Pennsylvania Bureau of Radiation Protection (the Department) via email:

"At approximately 2250 EST on January 29, 2020 the licensee informed the Department the stolen car had been recovered with the gauge still padlocked in the trunk of the car and secured with a padlocked chain. The employee had started his car and then returned to his house to get his lunch, and the car was stolen during this time."

Notified R1DO (Henrion), NMSS Events (email), ILTAB (email), and CNSC (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 - STOLEN SOURCE

The following report was received from the Arizona Department of Health Services (Department) via email:

"The Department received notification from the licensee that they reported their RMD XRF Lead-Based Paint Analyzer, serial number 1115, stolen on January 29, 2020. The analyzer possesses approximately 1 milliCurie of Co-57. The licensee shipped the equipment to Protec Instrument Corporation in Waltham, MA for resourcing. It was received by Protec Instruments on September 11, 2019. Since that date, the licensee stated that they have not heard from the company and have called and left messages for months with no response.

"The licensee contacted their equipment insurance company to process a claim and were told that they would need to report the equipment stolen. They reported the equipment stolen to the Flagstaff Police Department and the report number is P20-01171. The Department has requested additional information and continues to investigate the event."

Arizona Incident: 20-001

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

TEXAS AGREEMENT STATE REPORT - CONTAMINATION EVENT RESULTING IN RESTRICTED ACCESS

The following is a summary of information obtained from the state of Texas via email:

On January 28, 2020, the licensee notified the Agency [Texas Department of State Health Services], that it had discovered a load of soil containing Radium-228, collected during remediation/decommissioning activities for another licensee, had been taken to the municipal landfill in error. The soil was taken to the landfill on January 15, 2020, and was identified by the licensee on January 24, 2020. The error was identified while processing sample reports and other paperwork. A sample indicated the material had a concentration of 776 picoCuries of Radium-228 per gram. The Agency has confirmed the material does not pose a risk of becoming an uncontrolled contamination event, because it is in a cell at the landfill with clean soil covering it. The area has been cordoned off and the material does not pose a risk of exposure to any individual. The licensee has coordinated with the landfill to go onsite February 3, 2020, to take surveys and get information to develop a plan to recover the material so it can be properly disposed of. An investigation into this event is ongoing.

More information will be provided as it is obtained in accordance with SA-300.

Texas Incident No.: 9736

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

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

On 1/29/2020, the licensee notified Nebraska that they are currently unable to locate 31 tritium exit signs. The tritium exit signs have all been replaced by LED signs, but management has been unable to locate the disposal records and are considering the signs lost at this time.

29 of the signs contain approximately 9.21 Ci of tritium each and 2 of the signs contain approximately 7.09 Ci of tritium each.

Nebraska incident number: NE200002

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 - INCORRECT ORGAN RECEIVED TREATMENT

The following was received from the South Carolina Department of Health and Environmental Control via email:

"The South Carolina Department of Health and Environmental Control was notified on 02/03/2020 of a potential medical event involving a prostate seed implant. The procedure occurred on 01/29/2020, and the licensee's radiation safety officer was notified of the potential medical event on 02/03/2020. The prescribed dose to the prostate was 145 Gray, with 76 seeds being implanted. Total activity of the seeds is being reported as 26.6 milliCuries. The licensee is reporting that the seeds were implanted into the bladder and not the prostate. As of 01/31/2020, 41 seeds of the implanted 76 seeds were still implanted in the patient. The licensee is also reporting the loss of 35 seeds. The prostate seed manufacturer is ISOAID, LLC ADVANTAGE I-125. The model of the seeds is IAI-125A. This event is still under investigation by the licensee and the South Carolina Department of Health and Environmental Control."

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.

Notified R1DO (Henrion) and NMSS Events (email)