Event Notification Report for February 13, 2015

AGREEMENT STATE REPORT - CAT 1 IRIDIUM-192 SHIPMENT LOST/FOUND DURING TRANSIT

The following information was received from the Commonwealth of Massachusetts:

"QSA Global reported that [the common carrier] has initiated a trace of the shipment or packages to find the missing materials.

"Abstract:

"At 12:35 p.m. February 13th, the licensee (QSA Global, Inc.) made a telephone notification to the Massachusetts Radiation Control Program.

"At 9:30 a.m. February 13th, QSA Global, Inc. was notified by [the common carrier] that a shipment of 6 packages was missing and that [the common carrier] had initiated a trace on the shipment or packages.

"QSA Global reported [the common carrier] stated that the packages were last observed by [the common carrier] to be at [their] facility on Thursday, February 12th.

"The total activity of all 6 packages was reported by QSA Global to be 73,000 curies of lridum-192.

"QSA Global described the packages to each be Model 702 bulk shipping containers. Two of the packages each contain four Model 849 special form capsules and four of the packages each contain three Model 849 special form capsules. All special form capsules contain iridium-192 wafers. QSA Global reported that it was not certain whether or not the six packages were together or separated at the [common carrier] facility.

"QSA Global reported that the shipment originated from the Netherlands and was intended for delivery to their QSA Global's Burlington, MA facility.

"The reporting requirement is immediate. 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C."

* * * UPDATE AT 1515 EST ON 02/13/15 FROM JOSHUA E. DAEHLER TO S. SANDIN * * *

"The Agency (Massachusetts Radiation Control Program) was notified at 3:15 p.m. today by our licensee (QSA Global, Inc.) that the iridium-192 missing sources had been located at [common carrier hub] and are under their control .

Notified NMSS (Dudes), IRD (Stapleton), R1DO (Powell) and NMSS Event Notification via email.

Notified the following Federal Agencies: DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, NICC Watch Officer, USDA Ops Center, EPA EOC, FDA EOC, FEMA NWC (email), Nuclear SSA (email) and, DNDO-JAC (email).

* * * UPDATE AT 1428 EST ON 02/17/15 FROM EDWARD SALOMON VIA EMAIL * * *

"The licensee (QSA Global, Inc.) notified our Agency [Massachusetts Radiation Control] (email message, dated 2/16/2015) that the formerly missing packages were physically delivered to their QSA Global, Inc. facility in Burlington , MA on Monday, 2/16/2015.

"The Agency considers this matter to still be OPEN pending follow-up report from licensee. The licensee is expected to file a written report to our agency within 30 days of the immediate notification related to 105 CMR 1281 (A)(1), an immediate report."

Notified R1DO (Powell) and NMSS Events Notification via email.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 1" LEVEL OF RADIOACTIVE MATERIAL

Category 1 sources, if not safely managed or securely protected would be likely to cause permanent injury to a person who handled them, or were otherwise in contact with them, for more than a few minutes. It would probably be fatal to be close to this amount of unshielded material for a period of a few minutes to an hour. These sources are typically used in practices such as radiothermal generators, irradiators and radiation teletherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - ONE I-125 SEED LOST/RECOVERED DURING SHIPMENT

The following information was received from the State of Florida via email:

"[The common carrier] was delivering 2 packages from CA to Isoaid in Port Richey (they dispose of the used material sent in by customers). The boxes at some point fell out of the truck and they were not discovered missing until the driver reached Isoaid. It is not known the exact time this [occurred], the phone call to the BRC [Bureau of Radiation Control] was at 1:40 pm. They did locate them but one package was run over and (1) I-125 seed was missing from the box. As of 2:35 pm they have found the missing seed."

Florida Incident No.: FL15-008

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

OFFSITE NOTIFICATION TO MICHIGAN OSHA

"At 1123 EST on 2/13/2015, an emergency medical report was received in both unit's Control Rooms that an individual was having a personal medical issue outside the protected area. Onsite Emergency Medical personnel were dispatched to the scene. Off-site medical assistance was immediately requested. CPR was administered and the individual was transferred by off-site medical ambulance service to a local hospital.

"The Operations Shift Manager received confirmation of a fatality at 1315 EST on 2/13/2015. Notification was made to the Michigan Occupational Safety and Health Administration (MIOSHA).

"Both Units remain at 100% power. This Event Notification is being made due to the fatality and notification to a government agency.

"The NRC Resident Inspector has been notified."

The individual was at the workout facility when this incident occurred.

AGREEMENT STATE REPORT - GAMMA KNIFE UNIT FAILED TO FUNCTION AS DESIGNED

The following information was received from the State of Wisconsin via email:

"On Friday, February 13, 2015, the Wisconsin Radiation Protection Section received notice from the Radiation Safety Officer (RSO) of Marshfield Clinic that their Leksell Gamma Knife Perfexion gamma stereotactic radiosurgery unit failed to function as designed. The Gamma Knife unit became stuck open and staff had to manually retract the patient bed and close the shielding doors on the unit. It is not believed that the patient received a dose higher than was planned but it is unknown if it is a medical event at this time.

"The Wisconsin Radiation Protection Section will conduct an investigation on Monday, February 16, 2015 and provide updates through NMED."

WI Event ID: WI150001

GERMANIUM-68 SOURCES LOST DURING SHIPMENT

On 1/30/2015, two packages containing radioactive materials were shipped via common carrier from Nanticoke Memorial Hospital in Seaford, DE to Sanders Medical Products, Inc. in Knoxville, TN for disposal. One package arrived on 2/3/2015. The second package has not arrived, and on 2/13/2015, the second package was declared lost. The lost package contained two Germanium-68 source rods used in daily calibration of the hospital's PET scanner. Activity of the source rods was less than 0.3 millicuries each (0.6 millicuries total). Serial numbers for the source rods are: K4-124 and K4-125. The common carrier has completed a search for the lost package with negative results. The last known location of the lost package was in Harrington, DE where it was scanned on 1/30/2015.


* * * UPDATE FROM MARIANNA RETZLAFF TO DONALD NORWOOD AT 1133 EDT ON 7/2/2015 * * *

On Monday, June 29, 2015, the lost package was returned by the common carrier to Nanticoke Memorial Hospital. The package had not been opened and was undamaged. When opened by hospital personnel, the package contained the two Germanium-68 source rods that had originally been placed in the package. When questioned, the common carrier had no explanation as to what had happened to the package and could not explain where the package had been or even how it came to be returned to the hospital. The hospital plans to repackage the source rods and ship them via a different common carrier to Sanders Medical Products in the near future.

Notified R1DO (Dimitriadis) and ILTAB (Johnson) and via E-mail, NMSS Events Notification.

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