Event Notification Report for August 18, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/17/2020 - 08/18/2020
EVENT NUMBERS
54843548405484154850
Agreement State
Event Number: 54843
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: Brazos Geotech, Inc.
Region: 4
City: Tucson State: AZ
County:
License #: 10-158
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Bethany Cecere
Licensee: Brazos Geotech, Inc.
Region: 4
City: Tucson State: AZ
County:
License #: 10-158
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Bethany Cecere
Notification Date: 08/19/2020
Notification Time: 00:19 [ET]
Event Date: 08/18/2020
Event Time: 00:00 [MST]
Last Update Date: 08/19/2020
Notification Time: 00:19 [ET]
Event Date: 08/18/2020
Event Time: 00:00 [MST]
Last Update Date: 08/19/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MISSING SOURCE ROD SHUTTER
The following report from the Arizona Department of Health Services (Department) was received by email:
"On August 18, 2020, during a routine inspection, the Department discovered that a licensee was in possession of a portable gauge which appeared to be missing its Cs-137 source rod shutter. The gauge was a Troxler Model 3430, Serial# 38482, containing 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241/Beryllium. While performing a survey of the gauge, inspectors recorded an exposure rate of 175 mR/hr over the shutter opening while the handle was in its locked position.
"The Department has requested additional information and continues to investigate the event."
AZ Incident Number: 20-014
The following report from the Arizona Department of Health Services (Department) was received by email:
"On August 18, 2020, during a routine inspection, the Department discovered that a licensee was in possession of a portable gauge which appeared to be missing its Cs-137 source rod shutter. The gauge was a Troxler Model 3430, Serial# 38482, containing 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241/Beryllium. While performing a survey of the gauge, inspectors recorded an exposure rate of 175 mR/hr over the shutter opening while the handle was in its locked position.
"The Department has requested additional information and continues to investigate the event."
AZ Incident Number: 20-014
Agreement State
Event Number: 54840
Rep Org: OHIO DEPARTMENT OF HEALTH
Licensee: RIVERSIDE METHODIST HOSPITAL
Region: 3
City: Columbus State: OH
County:
License #: OH-02120250070
Agreement: Y
Docket:
NRC Notified By: Michael Rubadue
HQ OPS Officer: Michael Bloodgood
Licensee: RIVERSIDE METHODIST HOSPITAL
Region: 3
City: Columbus State: OH
County:
License #: OH-02120250070
Agreement: Y
Docket:
NRC Notified By: Michael Rubadue
HQ OPS Officer: Michael Bloodgood
Notification Date: 08/18/2020
Notification Time: 13:13 [ET]
Event Date: 08/18/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/18/2020
Notification Time: 13:13 [ET]
Event Date: 08/18/2020
Event Time: 00:00 [EDT]
Last Update Date: 08/18/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RICHARD SKOKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following report was received from the Ohio Department of Health via email.
"On August 14, 2020, the licensee attempted to treat a patient with Y-90 TheraSphere microspheres. Under the guidance of the manufacturer's representative, the AU [Authorized User] performed pre-patient checks on the device, including tubing patency check. After the infusion was started it became apparent the patient was not receiving the dose, and the licensee was unable to clear the blockage in the tubing. The procedure was terminated and the patient and referring physician were notified. Approximately 93% of the activity remained in the device. Static imaging was performed on the patient to determine the dose received. There was no measurable activity in the patient."
Ohio Event No.: OH200004
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 report was received from the Ohio Department of Health via email.
"On August 14, 2020, the licensee attempted to treat a patient with Y-90 TheraSphere microspheres. Under the guidance of the manufacturer's representative, the AU [Authorized User] performed pre-patient checks on the device, including tubing patency check. After the infusion was started it became apparent the patient was not receiving the dose, and the licensee was unable to clear the blockage in the tubing. The procedure was terminated and the patient and referring physician were notified. Approximately 93% of the activity remained in the device. Static imaging was performed on the patient to determine the dose received. There was no measurable activity in the patient."
Ohio Event No.: OH200004
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: 54841
Rep Org: COLORADO DEPT OF HEALTH
Licensee: COS School District #11, Holmes Middle School
Region: 4
City: Colorado Springs State: CO
County:
License #: GL002325
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Michael Bloodgood
Licensee: COS School District #11, Holmes Middle School
Region: 4
City: Colorado Springs State: CO
County:
License #: GL002325
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Michael Bloodgood
Notification Date: 08/18/2020
Notification Time: 16:47 [ET]
Event Date: 08/18/2020
Event Time: 00:00 [MDT]
Last Update Date: 08/18/2020
Notification Time: 16:47 [ET]
Event Date: 08/18/2020
Event Time: 00:00 [MDT]
Last Update Date: 08/18/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
AGREEMENT STATE - LOST TRITIUM EXIT SIGNS
The following information was received from the Colorado Department of Health via email.
The licensee is unable to locate sixteen tritium exit signs that have an activity of 11.5 Ci each. The signs may have been removed by a contractor.
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 from the Colorado Department of Health via email.
The licensee is unable to locate sixteen tritium exit signs that have an activity of 11.5 Ci each. The signs may have been removed by a contractor.
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.
Non-Agreement State
Event Number: 54850
Rep Org: Uniformed Services University
Licensee: Uniformed Services University
Region: 1
City: Bethesda State: MD
County:
License #: 19-23344-02
Agreement: Y
Docket:
NRC Notified By: Brian Champaine
HQ OPS Officer: Brian P. Smith
Licensee: Uniformed Services University
Region: 1
City: Bethesda State: MD
County:
License #: 19-23344-02
Agreement: Y
Docket:
NRC Notified By: Brian Champaine
HQ OPS Officer: Brian P. Smith
Notification Date: 08/21/2020
Notification Time: 13:03 [ET]
Event Date: 08/18/2020
Event Time: 19:00 [EDT]
Last Update Date: 08/21/2020
Notification Time: 13:03 [ET]
Event Date: 08/18/2020
Event Time: 19:00 [EDT]
Last Update Date: 08/21/2020
Emergency Class: Non Emergency
10 CFR Section:
20.2202(b)(1) - Pers Overexposure/Tede >= 5 Rem
10 CFR Section:
20.2202(b)(1) - Pers Overexposure/Tede >= 5 Rem
Person (Organization):
JONATHAN GREIVES (R1DO)
KELLEE JAMERSON (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JONATHAN GREIVES (R1DO)
KELLEE JAMERSON (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)
POTENTIAL OVEREXPOSURE RESULTING IN BURN
The following is a summary from a phone call with the Radiation Safety Officer (RSO) at Uniformed Services University of Health Services:
At the Uniformed Services University of Health Services, a research individual, authorized to operate the self-shielded CO-60 irradiator, last operated the irradiator on Tuesday, August 18, 2020 at 1900 EDT. On Wednesday, August 19, 2020, she experienced a burn on her left hand and went to the hospital believing it to be from a radiation overexposure. From information she received at the hospital, in order for her to have received that burn from a radiation overexposure the dose equivalent would have to be estimated to be 600R. The RSO does not believe that to be the case since the highest surveyed area both before and after the event where her hand could have come in contact was a thin pipe reading 150mR/hour on contact. The individual has been in contact with her physician, fingernail samples have been sent out for analysis, the Radiation Emergency Assistance Center/Training Site (REAC/TS) has been contacted by both the individual and the RSO, and her TLD has been sent out for analysis. The site has taken the machine out-of-service until more information can be collected.
The RSO had been in contact with specialists in Region 1.
The following is a summary from a phone call with the Radiation Safety Officer (RSO) at Uniformed Services University of Health Services:
At the Uniformed Services University of Health Services, a research individual, authorized to operate the self-shielded CO-60 irradiator, last operated the irradiator on Tuesday, August 18, 2020 at 1900 EDT. On Wednesday, August 19, 2020, she experienced a burn on her left hand and went to the hospital believing it to be from a radiation overexposure. From information she received at the hospital, in order for her to have received that burn from a radiation overexposure the dose equivalent would have to be estimated to be 600R. The RSO does not believe that to be the case since the highest surveyed area both before and after the event where her hand could have come in contact was a thin pipe reading 150mR/hour on contact. The individual has been in contact with her physician, fingernail samples have been sent out for analysis, the Radiation Emergency Assistance Center/Training Site (REAC/TS) has been contacted by both the individual and the RSO, and her TLD has been sent out for analysis. The site has taken the machine out-of-service until more information can be collected.
The RSO had been in contact with specialists in Region 1.