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Event Notification Report for October 23, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/20/2017 - 10/23/2017

** EVENT NUMBERS **


53011 53012 53013

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Agreement State Event Number: 53011
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ADENA REGIONAL MEDICAL CENTER
Region: 3
City: CHILLICOTHE State: OH
County: ROSS
License #: 02120720000
Agreement: Y
Docket:
NRC Notified By: MICHAEL J. RUBADUE
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/13/2017
Notification Time: 13:45 [ET]
Event Date: 10/12/2017
Event Time: 11:05 [EDT]
Last Update Date: 10/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PATRICIA PELKE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED LESS THAN PRESCRIBED

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

"On 10/12/17 during an infusion of Y-90 SIRSpheres that began at 11:05 a.m. [EDT], the treatment device malfunctioned and ceased delivery of the radioisotope, resulting in an under-dosing of the patient's liver. No contamination of the facilities or personnel was detected. All activity that was not delivered into the patient was placed back into the acrylic box and secured in the nuclear medicine hot lab for decay. A SIRSpheres representative was present during the treatment, but the cause of the malfunction is not known at this time. Once sufficient decay of the radioisotope has occurred, the delivery device will be shipped to SIRSpheres for technical analysis and root cause determination."

The patient was informed on the day of the event.

Ohio Item Number: OH170006

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.

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Non-Agreement State Event Number: 53012
Rep Org: IDAHO STATE UNIVERSITY
Licensee: IDAHO STATE UNIVERSITY
Region: 4
City: POCATELLO State: ID
County: BANNOCK
License #: 1127380-01
Agreement: N
Docket: 030-32-3
NRC Notified By: RICH BREY
HQ OPS Officer: KARL DIEDERICH
Notification Date: 10/13/2017
Notification Time: 15:46 [ET]
Event Date: 10/13/2017
Event Time: [MDT]
Last Update Date: 10/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSC (CANADA) (FAX)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

LOST OR MISSING MATERIAL

A series 50 nuclear accident dosimeter S/N AP237 with a 1 gram 62 mCi Pu-239 source was determined missing on 10/13/17. The dosimeter was one of 14 received by Idaho State University from the Department of Energy (DOE) in 1991. In 2003, this particular dosimeter was found to have detectable surface contamination and determined to have a compromised source. The device was removed from local inventory in 2003 pending transfer. Attempts were made to transfer the device to Idaho National Lab (INEL), but were declined. The device is believed to have been placed in the Idaho State University nuclear waste stream, and may have been transferred in 2006 or 2011 with other waste via Thomas Gray to US Ecology, but there are no supporting records. Investigation is ongoing.

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

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Agreement State Event Number: 53013
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: SOUTHERN RECYCLING
Region: 4
City: WALLS State: MS
County: DESOTO
License #: GL-397
Agreement: Y
Docket:
NRC Notified By: BENJAMIN CULPEPPER
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/13/2017
Notification Time: 15:38 [ET]
Event Date: 09/08/2017
Event Time: [CDT]
Last Update Date: 10/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOSS OR THEFT OF LICENSED NUCLEAR MATERIAL

The following was reported from the State of Mississippi:

Description of Incident: Licensee reported that their Niton gun was discovered to be misplaced or stolen on September 8, 2017. A letter was received by Mississippi State Department of Health: Division of Radiological Health (DRH) from the licensee on October 13, 2017 briefly detailing that their equipment had been lost or stolen.

DRH intends to issue a violation letter to Southern Recycling due to the late notification. Also, due to lacking information, DRH cannot confirm if the device reported to have been stolen/lost contains radioactive material.

DRH has attempted to contact the Licensee a number of times to acquire more information; however, there has been no response. DRH will continue contacting the licensee for more information and will update this report once complete.

Isotope(s): Cd-109 (potentially lost source not confirmed), with an activity of 10 mCi.

The DRH Health Physicist stated that this would give a reading of approximately 20 mRem at one foot if unshielded.

Mississippi has assigned an incident number of MS17006.

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

Page Last Reviewed/Updated Monday, October 23, 2017
Monday, October 23, 2017