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Event Notification Report for July 10, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/9/2019 - 7/10/2019

** EVENT NUMBERS **

Non-Agreement State	Event Number: 54139
Rep Org: TRI STATE MATERIALS TESTING LAB Licensee: TRI STATE MATERIALS TESTING LAB, LLC Region: 1 City: BERLIN State: CT County: License #: 06-31462-01 Agreement: N Docket: NRC Notified By: HABIB CHAUDHARRY HQ OPS Officer: JEFF HERRERA	Notification Date: 07/01/2019 Notification Time: 05:55 [ET] Event Date: 06/30/2019 Event Time: 01:00 [EDT] Last Update Date: 07/09/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X	Person (Organization): DONNA JANDA (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

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

Event Text

STOLEN TROXLER NUCLEAR DENSITY GAUGE

At approximately 1400 EDT, on 6/30/19, a company technician discovered that his personal vehicle was stolen from his residence driveway in Tolland, CT. The vehicle contained a Troxler density gauge locked in the trunk of the vehicle. The technician contacted the Connecticut State Police and reported the stolen vehicle and the stolen density gauge. The state police are still investigating the issue.

The nuclear density gauge is a Troxler model 3440, serial number 69523, containing 10 mCi of Cs-137 and 40 mCi of Am-241.

* * * UPDATE ON JULY 9, 2019 AT 1008 EDT FROM HABIB CHAUDHARY TO BETHANY CECERE * * *

On July 8, 2019, a State Trooper found the gauge in a portable restroom in Highland Park in Hartford, CT. Connecticut Department of Energy and Environmental Protection determined the gauge was intact. The licensee's radiation safety officer is sending the gauge for leak testing.

Notified R1DO (Dimitriadis), and ILTAB and NMSS Events Notification (via email).

* * * UPDATE ON JULY 9, 2019 AT 1652 EDT FROM SHAWN CHAUDHARY TO CATY NOLAN * * *

"The Connecticut Department of Energy & Environmental Protection representative stated that he surveyed the gauge and cleared it since no damage was done. Tri State has also visually inspected and surveyed the gauge and found it to be intact and not tampered with. For extra precautions, a leak test of the gauge was taken and sent to a certified lab. The gauge will not be used until we have received the results from the lab.

"Moving forward, all technicians have been instructed to make every attempt to drop off their gauge at Tri State Materials Testing Lab's designated gauge room every day at the end of their field work. If they cannot make it back due to weekend and night work, they must store the gauge at their home securely to prevent this type of incident recurrence."

Notified R1DO (Dimitriadis), and ILTAB and NMSS Events Notification (via email).

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	Event Number: 54140
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: ALEXIAN BROTHERS MEDICAL CENTER Region: 3 City: ELK GROVE VILLAGE State: IL County: License #: IL-01418-01 Agreement: Y Docket: NRC Notified By: GARY FORSEE HQ OPS Officer: RICHARD SMITH	Notification Date: 07/02/2019 Notification Time: 14:50 [ET] Event Date: 07/01/2019 Event Time: 00:00 [CDT] Last Update Date: 07/02/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): LAURA KOZAK (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the state of Illinois via email:

"The Agency [Illinois Bureau of Radiation Safety] was notified at approximately 1530 CDT on 7/1/19, that a medical event had occurred at Alexian Brothers Medical Center, in Elk Grove Village. The circumstances are near identical to those in an event reported by the licensee in February of this year (EN53859). An attempted intravascular brachytherapy procedure utilizing a Novoste BetaCath 3.5F System was aborted when the source train could not successfully reach the intended treatment site after three attempts. The source train was retracted without complication and there were no indications of kinks in the delivery catheter. Aborting the procedure resulted in an underdose exceeding 20 percent of the prescribed dose (prescribed dose was 18.4 Gy of Y-90 and delivered dose was 0.0 Gy). The three attempts also resulted in an exposure exceeding 50 rem to tissue other than the treatment site (treatment site was in the circumflex artery). The source train stopped each of three times 10mm proximal to the treatment site in the junction between the left coronary artery and the circumflex artery. The inadvertently exposed region received approximately 0.98 Gy or a dose equivalent of approximately 100 rem.

"A reactionary inspection was conducted by Agency staff on the morning of July 2, 2019. A written report was received by the licensee that same day in which tortuous patient anatomy was identified as the root cause. Agency inspectors will meet with the authorized user on the afternoon of July 3, 2019, to discuss each step of the intravascular brachytherapy procedure in an effort to further isolate the root cause. No adverse medical impact is expected to the patient as a result of this event, per the authorized user. Patient has been notified and referring physician was present. This report will be updated as additional information becomes available."

Illinois Item Number: IL190016

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	Event Number: 54141
Rep Org: NE DIV OF RADIOACTIVE MATERIALS Licensee: MID-STATE ENGINEERING AND TESTING Region: 4 City: COLUMBUS State: NE County: License #: 09-07-01 Agreement: Y Docket: NRC Notified By: JULIA SCHMITT HQ OPS Officer: RICHARD SMITH	Notification Date: 07/02/2019 Notification Time: 18:17 [ET] Event Date: 07/02/2019 Event Time: 13:30 [CDT] Last Update Date: 07/03/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MARK HAIRE (R4DO) ILTAB (EMAIL) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - LOST PORTABLE GAUGE

This is a summary of information received from the state of Nebraska via phone call:

On July 2, 2019, at approximately 1330 CDT, the licensee, Mid-State Engineering and Testing, lost a CPN-International MC Series Protaprobe gauge with 10 mCi Cs-137 and 50 mCi Am/Be-241 sources. This gauge is believed to be lost somewhere between Aurora and Columbus, Nebraska on the route that includes highways 14 and 30. The truck's tail gate was not closed causing the gauge to fall out of the truck. The licensee has attempted to locate the gauge but so far has been unsuccessful. The Nebraska State Patrol has been notified along with the Platte County Sheriff department. This was reported to the State of Nebraska Health and Human Services Agency at 1645 CDT. The State will be issuing a follow up written report later.

* * * UPDATE ON 7/3/2019 AT 1758 EDT FROM JULIA SCHMITT TO ANDREW WAUGH * * *

This is a summary of information received from the state of Nebraska via phone:

On July 3, 2019, the gauge was found by a member of the public and retrieved by the licensee. The gauge does not appear to be damaged.

Notified R4DO (Haire), NMSS Events (email), and ILTAB (email).

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 Wednesday, March 24, 2021