Event Notification Report for June 26, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/25/2019 - 06/26/2019
Agreement State
Event Number: 54138
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: BHATE GEOSCIENCES CORPORATION
Region: 4
City: D'IBERVILLE State: MS
County:
License #: MS-1018-01
Agreement: Y
Docket:
NRC Notified By: ROBERT SIMS
HQ OPS Officer: RICHARD SMITH
Licensee: BHATE GEOSCIENCES CORPORATION
Region: 4
City: D'IBERVILLE State: MS
County:
License #: MS-1018-01
Agreement: Y
Docket:
NRC Notified By: ROBERT SIMS
HQ OPS Officer: RICHARD SMITH
Notification Date: 06/28/2019
Notification Time: 16:48 [ET]
Event Date: 06/26/2019
Event Time: 00:00 [CDT]
Last Update Date: 06/28/2019
Notification Time: 16:48 [ET]
Event Date: 06/26/2019
Event Time: 00:00 [CDT]
Last Update Date: 06/28/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
LEAH SMITH (ILTAB)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JEREMY GROOM (R4DO)
LEAH SMITH (ILTAB)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE
The following is a synopsis of an email from the state of Mississippi:
On June 28, 2019, the Mississippi Division of Radiological Health (DRH), Radioactive Material Branch, reported that a Troxler moisture density gauge serial number 29421, was stolen on June 26 or 27, 2019, from a person's residence in Moss Point, Mississippi. The gauge was stolen from the back of the company pickup truck; the padlocks on the chains were cut and the gauge was removed from the storage box. The company Radiation Safety Officer (RSO) contacted the Moss Point Police Department. The RSO contacted the state of Mississippi Health Physicist (HP) and the state HP contacted the Department of Homeland Security.
The Troxler gauge contained a 9 mCi Cs-137 and a 44 mCi Am/Be-241 sources.
Mississippi Report Number: MS-190003
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
The following is a synopsis of an email from the state of Mississippi:
On June 28, 2019, the Mississippi Division of Radiological Health (DRH), Radioactive Material Branch, reported that a Troxler moisture density gauge serial number 29421, was stolen on June 26 or 27, 2019, from a person's residence in Moss Point, Mississippi. The gauge was stolen from the back of the company pickup truck; the padlocks on the chains were cut and the gauge was removed from the storage box. The company Radiation Safety Officer (RSO) contacted the Moss Point Police Department. The RSO contacted the state of Mississippi Health Physicist (HP) and the state HP contacted the Department of Homeland Security.
The Troxler gauge contained a 9 mCi Cs-137 and a 44 mCi Am/Be-241 sources.
Mississippi Report Number: MS-190003
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
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 54136
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: THE CLEVELAND CLINIC FOUNDATION
Region: 3
City: SANDUSKY State: OH
County:
License #: 02230220000
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: JEFFREY WHITED
Licensee: THE CLEVELAND CLINIC FOUNDATION
Region: 3
City: SANDUSKY State: OH
County:
License #: 02230220000
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: JEFFREY WHITED
Notification Date: 06/27/2019
Notification Time: 13:32 [ET]
Event Date: 06/26/2019
Event Time: 00:00 [EDT]
Last Update Date: 07/17/2019
Notification Time: 13:32 [ET]
Event Date: 06/26/2019
Event Time: 00:00 [EDT]
Last Update Date: 07/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE DUE TO DISLODGING OF DEVICE
The following was received via e-mail:
"A patient was planned for a HDR [high dose rate] brachytherapy vaginal cuff treatment, fraction 1 of 2, at 5 Gy per fraction. A vaginal cylinder was placed in the vaginal canal and the positioning was verified with a cone beam CT scan. The cylinder was then connected to the afterloader containing the Ir-192 source [3.449 Ci; GammaMed 232 S/N: 24-01-7273-001-020819-12601-99] and treatment commenced. Upon completion of the treatment, it was observed that the vaginal cylinder was dislodged from the initial position. The cylinder was found between the legs, outside the vaginal canal, in contact with the perineal region. The patient indicated that she had coughed at some point during the treatment, which may have contributed to the dislodgement of the cylinder.
"The estimated skin dose is 5 Gy (500 rad). No erythema was observed at the time of discovery.
"The patient and referring physician have been notified."
Ohio Item Number: OH190009
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.
* * * RETRACTION ON 7/17/19 AT 1342 EDT FROM MICHAEL RUBADUE TO HOWIE CROUCH * * *
The following retraction information was obtained from the state of Ohio via email:
"An inspection was conducted on July 15, 2019 to investigate the event. It was determined that the applicator was properly secured for the prescribed treatment, but was dislodged by the patient. Since the cause was patient intervention, this is not a medical event."
Notified R3DO (Edwards) and NMSS Events Notification (email).
The following was received via e-mail:
"A patient was planned for a HDR [high dose rate] brachytherapy vaginal cuff treatment, fraction 1 of 2, at 5 Gy per fraction. A vaginal cylinder was placed in the vaginal canal and the positioning was verified with a cone beam CT scan. The cylinder was then connected to the afterloader containing the Ir-192 source [3.449 Ci; GammaMed 232 S/N: 24-01-7273-001-020819-12601-99] and treatment commenced. Upon completion of the treatment, it was observed that the vaginal cylinder was dislodged from the initial position. The cylinder was found between the legs, outside the vaginal canal, in contact with the perineal region. The patient indicated that she had coughed at some point during the treatment, which may have contributed to the dislodgement of the cylinder.
"The estimated skin dose is 5 Gy (500 rad). No erythema was observed at the time of discovery.
"The patient and referring physician have been notified."
Ohio Item Number: OH190009
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.
* * * RETRACTION ON 7/17/19 AT 1342 EDT FROM MICHAEL RUBADUE TO HOWIE CROUCH * * *
The following retraction information was obtained from the state of Ohio via email:
"An inspection was conducted on July 15, 2019 to investigate the event. It was determined that the applicator was properly secured for the prescribed treatment, but was dislodged by the patient. Since the cause was patient intervention, this is not a medical event."
Notified R3DO (Edwards) and NMSS Events Notification (email).