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Event Notification Report for July 18, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/17/2019 - 7/18/2019

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!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	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
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANN MARIE STONE (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

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).

Agreement State	Event Number: 54153
Rep Org: NC DIV OF HEALTH SERVICE REGULATION Licensee: SUMMIT ENGINEERING Region: 1 City: DURHAM State: NC County: License #: 092-1532-1 Agreement: Y Docket: NRC Notified By: TRAVIS CARTOSKI HQ OPS Officer: BETHANY CECERE	Notification Date: 07/09/2019 Notification Time: 09:06 [ET] Event Date: 07/08/2019 Event Time: 12:00 [EDT] Last Update Date: 07/09/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANTHONY DIMITRIADIS (R1DO) JIM WHITNEY (ILTAB) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - FOUND PORTABLE GAUGE

The following report was received from the State of North Carolina:

"On 7/8/19 around 1200 EDT, the North Carolina Radioactive Materials Branch (RMB) received a call from NC Emergency Management and Durham area police that a yellow package was found on the side of the road at a carwash in Durham, NC. Emergency management and police recognized the package as a possible portable gauge contained in a standard transport case. Readings were immediately taken and the package cordoned off to prevent any public exposures. RMB dispatched an inspector and was on-site within an hour of notification. It was found that the licensee who possessed the portable gauge had removed the gauge in its transport box from his vehicle earlier that morning to wash the vehicle. After finishing, the gauge fell off the vehicle when the licensee departed the car wash. Once the licensee noticed the gauge was missing, they retraced their steps back to the car wash to attempt to reclaim the gauge and were met by local police and emergency management. The gauge was left unattended for approximately 4-5 hours. The licensee is now in possession of the gauge. The RMB inspector discovered multiple violations as a result of this incident.

"Gauge: Humboldt
Model: HS-5001 EZ
S/N: 1599
Sources: Cs-137, 10 mCi; Am:Be, 40 mCi"

NC Tracking Number: 190019

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: 54155
Rep Org: MA RADIATION CONTROL PROGRAM Licensee: JOSEPH FREEDMAN COMPANY Region: 1 City: SPRINGFIELD State: MA County: License #: Agreement: Y Docket: 19-3801 NRC Notified By: KENATH TRAEGDE HQ OPS Officer: CATY NOLAN	Notification Date: 07/09/2019 Notification Time: 14:19 [ET] Event Date: 06/27/2019 Event Time: 15:30 [EDT] Last Update Date: 07/09/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANTHONY DIMITRIADIS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE - TWO DEVICES CONTAINING SEALED RADIOACTIVE SOURCES FOUND

The following was received from the Commonwealth of Massachusetts via email:

"This shipment containing scrap metal with radioactive material was first discovered at Sims Metal Management in North Haven, CT on June 27, 2019. As a result, SP 10656 Number CT-MA-19-01 was issued by members of the Connecticut Department of Energy and Environmental Protection and the shipment was sent back to Joseph Freedman Company in Springfield, MA. The material was received at the licensee and the radioactive items were removed, isolated, and stored in a locked 55 gallon drum on site in a secure area for further analysis.

"The site hired a contract health physics service to aid in the identification of the material and to perform radiation surveys. That occurred on 7/8/19. Two devices were discovered. The contractor provided survey information and attempted isotope identification for the two devices. One source was identified as Ra-226 and the other could not be clearly identified. Since the identification of one of the two sources was in question, the Massachusetts Radiation Control Program Director visited the site on 7/9/19 carrying multiple survey instruments for additional measurements and for visual inspection of the two units.

"One of the devices was identified as a Pyralarm Demonstrator Unit manufactured by Pyrotronics, Inc. The isotope was identified as Ra-226 with an approximate activity of 56 microCuries. The other device appeared to be an industrial nuclear gauge, but there were no legible markings on it other than a Radioactive Material sticker. The isotope identified was Am-241 with an approximate activity of 15 milliCuries as determined on 7/9/19. The spectra for this source contained peak energy channels in addition to the Am-241 peak that could not be readily identified given the proposed use of the device. It is possible other isotopes are there and we will continue to evaluate with the contractor until appropriate disposal by a licensed waste broker.

"Dose rates provided for the Pyralarm smoke detector containing Ra-226 were 37 mR/hr at one centimeter, 0.275 mR/hr at 30 centimeters and 0.42 mR/hr at one meter inclusive of approximately 0.5 cm of lead shielding. Dose rates for the unidentified gauge containing Am-241 were measured as 85 mR/hr at 2.5 centimeters and 2.8 mR/hr at 30 centimeters. The highest dose rate on contact with the storage drum containing the two devices was 0.550 mR/hr. Wipe surveys were taken on all surfaces by the contractor and there was no radioactive contamination found.

"These devices were discarded by unknown persons and are pending disposal by a licensed waste broker."

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: 54156
Rep Org: TENNESSEE DIV OF RAD HEALTH Licensee: EASTMAN CHEMICAL Region: 1 City: KINGSPORT State: TN County: License #: R-82007-K28 Agreement: Y Docket: NRC Notified By: ANDREW HOLCOMB HQ OPS Officer: RYAN ALEXANDER	Notification Date: 07/10/2019 Notification Time: 15:08 [ET] Event Date: 07/08/2019 Event Time: 00:00 [EDT] Last Update Date: 07/10/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANTHONY DIMITRIADIS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - INOPERABLE FIXED GAUGE SHUTTER

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

"On July 8, 2019, technicians at Eastman Chemical were performing procedures that involved securing radioactive sources on the outside of a vessel. One source had rust and corrosion around the shutter mechanism. After 4 hours with lubricant on the mechanism, the shutter was still inoperable. Eastman Chemical contacted the VEGA technician and scheduled a repair appointment for 7/12/19.

"Manufacturer: VEGA
Model #: SHF1B
Serial #: (Will be included in follow-up report)
Source Serial #: 7386 CP
Isotope: Cs-137 (20 mCi)

"A follow-up report will be submitted within 30 days."

TN Tracking Number: TN-19-090

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

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

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