Event Notification Report for April 16, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/15/2019 - 04/16/2019
Agreement State
Event Number: 54006
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TSI LABORATORIES INC.
Region: 4
City: VICTORIA State: TX
County:
License #: RAM-L04767
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: TSI LABORATORIES INC.
Region: 4
City: VICTORIA State: TX
County:
License #: RAM-L04767
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/17/2019
Notification Time: 12:22 [ET]
Event Date: 04/16/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/17/2019
Notification Time: 12:22 [ET]
Event Date: 04/16/2019
Event Time: 00:00 [CDT]
Last Update Date: 04/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The following report was received via e-mail:
"On April 16, 2019, the licensee notified the Agency that one of its Humboldt model 5001-C moisture/density gauges (SN: 2076), containing 40 milliCuries americium-241/beryllium (SN: 47-6041) and 10 milliCuries of cesium-137 (SN: 40-6862), had been run over and damaged by a dump truck at a temporary job site in Danbury, Texas. While a density test was being performed and the cesium source was extended into the ground, a dump truck backed up into the test area. The technician had to jump out of the way. The truck tire ran over and shattered the housing on one side of the gauge. The source was retracted, with some difficulty, into its shielded position. Radiation surveys indicated the shielding was intact. However, the technician reported that the source rod could be pulled completely out of the top of the housing. With the source in the normal shielded position, the gauge was placed inside its transport case and returned to the licensee's facility. The licensee is making arrangements for repair/disposal. There were no exposures as a result of this event. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident: 9675
The following report was received via e-mail:
"On April 16, 2019, the licensee notified the Agency that one of its Humboldt model 5001-C moisture/density gauges (SN: 2076), containing 40 milliCuries americium-241/beryllium (SN: 47-6041) and 10 milliCuries of cesium-137 (SN: 40-6862), had been run over and damaged by a dump truck at a temporary job site in Danbury, Texas. While a density test was being performed and the cesium source was extended into the ground, a dump truck backed up into the test area. The technician had to jump out of the way. The truck tire ran over and shattered the housing on one side of the gauge. The source was retracted, with some difficulty, into its shielded position. Radiation surveys indicated the shielding was intact. However, the technician reported that the source rod could be pulled completely out of the top of the housing. With the source in the normal shielded position, the gauge was placed inside its transport case and returned to the licensee's facility. The licensee is making arrangements for repair/disposal. There were no exposures as a result of this event. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident: 9675
Agreement State
Event Number: 54004
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: BANNER UNIVERSITY MEDICAL CENTER - TUCSON
Region: 4
City: TUCSON State: AZ
County:
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: BRIAN D. GORETZKI
HQ OPS Officer: THOMAS KENDZIA
Licensee: BANNER UNIVERSITY MEDICAL CENTER - TUCSON
Region: 4
City: TUCSON State: AZ
County:
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: BRIAN D. GORETZKI
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 04/16/2019
Notification Time: 23:34 [ET]
Event Date: 04/16/2019
Event Time: 00:00 [MST]
Last Update Date: 04/17/2019
Notification Time: 23:34 [ET]
Event Date: 04/16/2019
Event Time: 00:00 [MST]
Last Update Date: 04/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNABLE TO INJECT FULL PRESCRIBED DOSE DURING MEDICAL TREATMENT
The following was received via e-mail:
"On April 16, 2019, the Department [Arizona Department of Radiation Control] received notification from the licensee [Banner University Medical Center - Tucson] of a possible medical event involving yttrium-90 radiolabeled glass microspheres (Therasphere). The pre-treatment calibration measured an activity of 2.91 GBq and the post-treatment calibration measured 2.65 GBq. The patient was being treated for a hepatocellular carcinoma in the left hepatic lobe, segment II. The Department has requested additional information and continues to investigate the event."
Additional information from call to licensee Radiation Safety Officer:
During injection of the prescribed dose to the patient, backpressure during the injection prevented injecting the full dose, with 2.65 GBq of a prescribed dose of 2.91 GBq not delivered (24 percent was delivered).
Arizona Incident 19-006
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.
The following was received via e-mail:
"On April 16, 2019, the Department [Arizona Department of Radiation Control] received notification from the licensee [Banner University Medical Center - Tucson] of a possible medical event involving yttrium-90 radiolabeled glass microspheres (Therasphere). The pre-treatment calibration measured an activity of 2.91 GBq and the post-treatment calibration measured 2.65 GBq. The patient was being treated for a hepatocellular carcinoma in the left hepatic lobe, segment II. The Department has requested additional information and continues to investigate the event."
Additional information from call to licensee Radiation Safety Officer:
During injection of the prescribed dose to the patient, backpressure during the injection prevented injecting the full dose, with 2.65 GBq of a prescribed dose of 2.91 GBq not delivered (24 percent was delivered).
Arizona Incident 19-006
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.