Event Notification Report for August 23, 2012

AGREEMENT STATE REPORT - MISSING AMERICIUM-241 AND RADIUM-226 SOURCES

The following information was received from the Arizona Radiation Regulatory Agency via e-mail:

"At approximately 9:00 AM August 23, 2012, the Agency was informed that the licensee lost a 3 millicurie Americium-241 source and a 0.9 microcurie Radium-226 source.

"The licensee was performing a clean-up at their facility between the dates of February 15, 2012 and June 11, 2012. The licensee assumes during those dates is when the sources went missing. However, the radiation safety officer for the license left on October 21, 2011 and the licensee cannot verify the location of the sources after that date.

"The licensee is currently interviewing employees involved in the cleanup to attempt to determine the location of the missing sources.

"The Arizona Regulatory Agency continues to investigate the event.

"The states of CA, NV, CO, UT, and NM and Mexico and U.S. NRC and FBI are being notified of this event."

AZ Report Number 12-014

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

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

AGREEMENT STATE REPORT - DAMAGED AND UNACCOUNTED FOR TRITIUM LIGHT SOURCES

The following information was received from the Arizona Radiation Regulatory Agency via e-mail:

"At approximately 8:00 AM on August 23, 2012, the Agency was informed that the Licensee had one damaged light source, two light sources unaccounted for, and identification of an intake of radioactive material by two TLS Systems employees.

"The Licensee was taking back 148 drogue light assemblies for disposal/recycling. After receiving the sources, the Licensee noticed minute fragments of a light source on a stainless steel bench top on which the sources were being examined. The fragments were placed in empty liquid scintillation vials and an initial decontamination of the workbench was performed. In addition, an inventory of the sources was performed and 297 intact sources were counted. A total of 298 sources implied 149 drogue light assemblies, not 148 as indicated by the company who returned the sources. Also, 150 radiation labels, stainless steel housings, and Lucite inserts were counted, which would indicate 300 light sources.

"Each drogue light assembly contained two mb-Microtec Model T-4376-1 tritium light sources. The sources had an initial activity of 450 millicuries each. The drogue lights are approximately 4 years old.

"Bioassays were given to individuals present in the lab and are currently awaiting results.

"The investigation into this event is ongoing. The U.S. NRC and AZ governor's office have been notified."

AZ Report Number: 12-013


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

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

MATERIAL CONTROL AND ACCOUNTABILITY ALARM RESOLUTION

"10 CFR 74.57 (f)(2) requires notification within 24 hours that a Material Control & Accountability (MC&A) alarm resolution procedure has been initiated. In the Solvent Extraction Area of Building 333, the input minus output value exceeded the MC&A limit. Because the alarm investigation procedure has been initiated, this notification is being made. There was no material loss and the issue was resolved on 8/24/2012.

"MC&A process monitoring tests for material balance were run as specified by applicable procedures and requirements. Based on the test results for Building 333 solvent extraction area, the test limit was exceeded. The investigation was completed and the alarm was resolved on 8/24/2012.

"There was no actual or potential safety consequences to workers, the public, or the environment."

The NRC Resident Inspector has been informed.

AGREEMENT STATE REPORT - PATIENT UNDEREXPOSURE USING YTTRIUM-90 SIR-SPHERES TREATMENT

The following event was received from the Pennsylvania Bureau of Radiation Protection via facsimile:

"Event type: A medical event (ME) involving the administration of yttrium-90 SIR-Spheres which is reportable under 10 CFR 35.3045(a)(1)(i).

"Notifications: On August 24,2012, the Department's Southeast Regional Office received notification via a phone call and follow-up electronic correspondence about this ME.

"Event Description: The patient was being treated for disease of the liver and received 71% of the intended dose as identified by post treatment measurements. The treating physician, who also is the referring physician, notified the patient.

"Cause of the Event: Currently under investigation and unknown at this time.

"Actions: No harm to the patient is expected. The Department plans to do a reactive
inspection"

PA Report Number: 120026

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.