Event Notification Report for November 09, 2018

AGREEMENT STATE REPORT - RADIOGRAPHERS EXPOSED TO UNSHIELDED SOURCE

The following was received via email from the State of Colorado:

"After changing film between exposures, the radiography crew went to expose the source and realized the source was still in the unshielded, collimated position. The crew retracted the source and checked their pocket dosimeters and found them to be off-scale. The survey meter was found to be in the 'off' position. Dosimeters were sent in for emergency processing. The camera was a 96 Ci, Ir-192, model QSA 880D."

Incident Report #: CO 997-01

STUCK OPEN SHUTTER ON PROCESS GAUGE

"In the process of performing the inventory/shutter check it was reported on November 09, 2018 at 1030 [EST] that our [Tilden Mining Co.] Kay Ray Model #7050, Serial #1412, 200mCi, Cs-137 gauge located on 6B DTU (Deslime Thickener U/Flow) in the deslime basement had a broken handle on the shutter mechanism, rendering the shutter non-operable. Work order (1836130) was entered into Ellipse. It was determined that the area in which the gauge is located does not create an exposure hazard.

"The plant process requires the shutter to remain in the open position during normal operation and does not create a hazard to individuals, the course of action will be to remove and replace the gauge at the first opportunity. Once the gauge is removed, it will be placed and locked in [a] cage. The gauge will be placed on top of the required amount of lead to remove any potential exposure hazard; surveys will be performed to confirm personal safety."

PATIENT UNDERDOSAGE DUE TO LOSS OF AIR SEAL INTEGRITY

"Today, Nov 9, 2018 a medical event occurred at our facility in which 145.7 mCi of Lutathera Lutetium-177 was delivered out of the prescribed 200 mCi. The full dose could not be delivered as there was loss of integrity of the air seal on the Lutathera vial."

The licensee indicated the cause of the event was still under investigation and the Doctor and patient were informed of the issue.

The licensee has not notified the Region III office.

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 REPORT - IRRADIATOR SOURCE RACK FAILS TO RETRACT

The following was received via fax from the State of New York:

"The New York State Department of Health (NYSDOH) was notified by the radiation safety officer (RSO) of Pall Hauppauge (C1935) that they had a source rack which did not retract completely leaving the source partially exposed for a period of time. Pall Hauppauge is licensed to possess Cobalt 60 in sealed source use in a Nordian International dry panoramic storage irradiator.

"The RSO activated the radiation monitor remotely and confirmed elevated radiation readings. He indicated that he was able to raise the rack up and then lowered it down. This time it went completely down, resulting in the source being completely shielded.

"According to [the RSO], at no time were any workers exposed or potentially exposed, since there was no access to the vault. All other systems worked properly.

"[The RSO] indicated that they are conducting a root cause investigation. A written report will be forwarded to the Department."

Incident Report#: NY-18-03

AGREEMENT STATE REPORT - LOSS OF PET RADIOACTIVE MATERIALS DUE TO WILDFIRE

The following report was received from the State of California via email:

"On 11/09/18, RSO [Radiation Safety Officer] at Alliance Healthcare Services contacted the California OES [Office of Emergency Services] to report possible loss of control of radioactive materials that are located in one of their mobile PET [Positron Emission Tomography] Coaches stationed at the Feather River Hospital in Paradise, CA, due to a wildfire. A huge wildfire is still burning and spreading in the area and the extent of the damage is unknown, although the town of Paradise is reported to have been evacuated and heavily damaged in the fire. The PET Coach is believed to have contained Cs-137 (210 microCuries), Ba-133 (260 microCuries), and Ge-68 (3 milliCuries). RHB [California Radiation Health Branch] will be following up with the licensee once the area becomes accessible for inspection. This event report is being filed on the information that is known now about the extent of the fire and damage, and will be updated as appropriate when more complete information becomes available."

CA 5010 Number: 110918

* * * EVENT RETRACTED ON 11/15/2018 AT 1700 EST BY ROBERT GREGER TO MARK ABRAMOVITZ * * *

The event is retracted via e-mail:

"The CA licensee and Radiologic Health Branch personnel have accessed the fire devastated town of Paradise in northern CA, and have determined that the PET coach and its radioactive material contents were undamaged in the recent wildfire. The radioactive sources were accounted for."

Notified the R4DO (Haire) and NMSS (via e-mail).

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 - LOSS OF NUCLEAR MEDICINE MATERIALS DUE TO WILDFIRE

The following was received via fax from the State of California:

"A wild fire is burning in Butte County where the Feather River Hospital is located. This facility has a small Nuclear Medicine operation with radioactive materials permitted by 10 CFR 35.100, 200, and 300 (Ra-223 only). RHB [California Radiation Health Branch] has not received any notifications from this licensee (nor can the hospital be reached by telephone). Based on news reports, the extent of fire damage to the hospital may be severe. According to the previous inspection reports, the Nuclear Medicine Department should currently possess the following radioactive materials: two Co-57 flood sources (2.6 milliCuries and 2.1 milliCuries as of 11/9/18), and two Cs-137 check sources (96.9 microCuries and 16.7 microCuries as of 11/9/18). The California Department of Health-Radiologic Health Branch (CDPH-RHB) will be following up with the licensee once the area becomes accessible for inspection. This event report is being filed based on the general information that is known currently about the extent of the fire and damage in the town of Paradise, and will be updated as appropriate when more complete information becomes available."

CA 5010 Number: 110918

* * * RETRACTION ON 11/15/2018 AT 1658 EST BY ROBERT GREGER TO MARK ABRAMOVITZ * * *

The following retraction was received via e-mail:

"A CA Department of Public Health-Radiologic Health Branch individual has accessed the fire devastated town of Paradise in northern CA, and has determined that the portion of the Feather River Hospital containing licensed radioactive material was undamaged in the recent wildfire. The radioactive sources were accounted for."

Notified the R4DO (Haire) and NMSS (via e-mail).

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