Event Notification Report for July 22, 2016

AGREEMENT STATE REPORT - LOSS OF LICENSED MEDICAL TREATMENT SEEDS

The following information was provided via email from the State of Tennessee:

"A patient was treated with 50 I-125 seeds. The patient was apparently not responding well to the treatment so he was brought back to Vanderbilt to have the seeds removed. Today, only 39 of the 50 seeds were recovered from the patient. According to the patient, prior to returning to Vanderbilt to have the seeds removed the patient stated that he 'picked' the 11 seeds out and threw them in the trash can at his home near Huntsville, Al. Total activity of the 11 missing seeds, after decay, equals 1.71 mCi of I-125. Patient is currently still at Vanderbilt Medical Center."

"The State of Tennessee has notified the State of Alabama's Office of Radiation Protection."

TN State Event Report ID no: TN-16-102

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 - LOST AND THEN FOUND SHIPMENT OF RADIOACTIVE MATERIALS

The following was received via email:

"The licensee (QSA Global, Inc.) made telephone notification at 1026 [EDT] on July 22, 2016 followed by written report to the Agency (Massachusetts Radiation Control Program), that the licensee was notified by carrier that one piece of a four piece shipment incoming from Australia and destined for QSA Global, Inc., Burlington, Massachusetts is unaccounted for. The licensee initially identified that it did not know which of the four pieces is the one missing. The licensee provided update by telephone at 1335 on July 22, 2016 that it had determined that the piece missing is a Model 650L source changer, Type B(U) package, UN2916, containing two special form iridium-192 sources, 0.44 TBq (12 curies) total of iridium-192. The missing package is believed by the licensee to possibly be in Memphis, Tennessee at the carrier's hub.

"The licensee reports that it initiated a trace yesterday with the carrier and has also requested a ramp search of the Boston (Logan Airport) facility in case it was separated there.

"The reporting requirement is immediate and is of 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.

"The Agency made notification to FBI.

"The Agency considers this event to be open.

"At 1616 [EDT], on July 22, 2016, the licensee (QSA Global, Inc. of Burlington, MA) notified us (Massachusetts Radiation Control Program) by telephone that the missing package has been located by the carrier at its Memphis, Tennessee hub and that the package is expected to be delivered to the licensee on Monday. The licensee reports that a label had apparently fallen off of the package."

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - SOURCE DISCONNECT

The following was received via email:

"Qualspec, LLC. Radiation Safety Officer, reported the following source disconnect incident on July 21, 2016, at [1843 PDT] via email. The incident took place at the Valero refinery, located at 3400 East Second St., Benicia, CA, at approximately 1430. During their 4th and last exposure, they were not able to return the radiography source (Ir-192, 63 Ci) to the INC 100, S/N 4848 radiography camera's shielded position. The RSO and ARSO, were notified right away and responded immediately to the location. After their assessment, they determined the source pigtail had become detached from the drive cable due to the drive cable ball connector breaking off. There was no other sign of physical damage to the camera, the crank assembly or related equipment. After phone consultation with the manufacturer, a retrieval method was determined and the source was safely secured back into the exposure device. TLD dosimeters have been sent to Radiation Detection Company for emergency processing. Individuals involved [received] based on their pocket dosimeter [readings] - Radiographer Trainer 20 mR, Radiographer 10 mR, Radiographer Assistant 10 mR [as measured by] 200 mR scale Arrow pocket dosimeter; Radiation Safety Officer 400 mR, Assistant RSO 300 mR [as measured by] 5R scale Arrow pocket dosimeter."

California 5010 # 072116