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Event Notification Report for September 09, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/8/2019 - 9/9/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54247
Rep Org: OK DEQ RAD MANAGEMENT Licensee: W2 ENGINEERING Region: 4 City: OKLAHOMA CITY State: OK County: License #: OK-32142-01 Agreement: Y Docket: NRC Notified By: MIKE BRODERICK HQ OPS Officer: CATY NOLAN	Notification Date: 08/30/2019 Notification Time: 10:51 [ET] Event Date: 08/30/2019 Event Time: 00:00 [CDT] Last Update Date: 09/01/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY AZUA (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - MISSING PORTABLE GAUGE

The following is a summary of information received from the Department of Environmental Quality (DEQ) via email:

At about 0910 [CDT] on 8/30/19, DEQ received a call from W2 Engineering, Oklahoma license OK-32142-01. W2 Engineering holds an Oklahoma license for portable gauges and is based in Oklahoma City. [W2 Engineering] reported that it had lost contact with one of the technicians who had been driving one of the company's vehicles with a Humboldt portable gauge (s/n 8700) in it. The last known location for [the technician] (and presumably the gauge) was at 0856 [CDT] Thursday when [the technician] made a purchase at Perry, Oklahoma. [The technician] had not made contact since then, nor had [the individual] responded to numerous messages and efforts to contact. [W2 Engineering] now considers the gauge out of the licensee's control. [W2 Engineering] has advised the [Oklahoma Highway Police], and they say the vehicle is not known to be in any of their impound yards. [W2 Engineering] has filed a report with Oklahoma City police, and a police officer is on site taking the report now.

This report is based on an initial phone notification, and more information will be added when it becomes available.

* * * UPDATE FROM MIKE BRODERICK TO DONALD NORWOOD AT 1717 EDT ON 9/1/2019 * * *

The following information was received via E-mail:

"The gauge missing from W2 engineering has been recovered along with the vehicle in Blackwell, Oklahoma. More details will be provided as they become available."

Notified R4DO (Drake) and the NMSS Events Notification E-mail group.

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: 54248
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: CARLE FOUNDATION HOSPITAL Region: 3 City: URBANA State: IL County: License #: IL-01156-01 Agreement: Y Docket: NRC Notified By: C. GIBB VINSON HQ OPS Officer: OSSY FONT	Notification Date: 08/30/2019 Notification Time: 11:08 [ET] Event Date: 08/28/2019 Event Time: 00:00 [CDT] Last Update Date: 08/30/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): KARLA STOEDTER (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - LOST I-125 SEED

The following was received from the Illinois Emergency Management Agency (IEMA) via email:

"Carle Foundation Hospital (Urbana, IL) reported a lost I-125 seed that occurred during a seed localization procedure in the mammography suite. The seed was 166 microCi (6.142 MBq). Three seeds were delivered for the procedure. One was used, and one was returned to the vendor. The third seed could not be found the next morning when staff performed the final inventory. It is believed the seed was thrown in the trash immediately after the procedure and went to a landfill the following morning. The investigation is ongoing and a final report to IEMA is pending."

Item Number: IL 190027

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: 54249
Rep Org: NEW YORK STATE DEPT. OF HEALTH Licensee: PALL HAUPPAUGE Region: 1 City: HAUPPAUGE State: NY County: License #: C1935 Agreement: Y Docket: NRC Notified By: DESMOND GORDON HQ OPS Officer: DONALD NORWOOD	Notification Date: 08/30/2019 Notification Time: 14:42 [ET] Event Date: 08/28/2019 Event Time: 18:00 [EDT] Last Update Date: 08/30/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JON LILLIENDAHL (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PANORAMIC IRRADIATOR SOURCE FAILED TO RETRACT

The following information was received via facsimile:

"The New York State Department of Health (NYSDOH) was notified by the radiation safety officer (RSO) of Pall Hauppauge that they had an incident where the source did not retract completely, leaving the source partially exposed for a period of time.

"According to the RSO, on August 28, 2019 at about 1800 EDT, the source at Vault 4 had gotten stuck three inches above the down (safe) position. All of the safety and alarm systems worked as designed, and the operator did not attempt to enter the irradiator or take any action. The RSO indicated he was able to free the source by lifting it 'just an inch or two' then letting it back down.

"This is the same vault that had previous stuck source incidents (NY-19-05 and NY-19-06) [EN53984 and EN54025] this year. At that time Nordion removed the vault, re-conditioned it, and returned it to Pall.

"The RSO contacted Nordion and they are expected to be on-site the week of September 2nd. The vault will not be used until the issue is resolved. The RSO indicated he locked out all operators' key access to the vault until Nordion is on-site.

"The root cause for the source getting stuck has not yet been determined.

"DOH will continue to monitor this incident.

"Paul Hauppauge is licensed to possess Cobalt 60 in sealed source use in a Nordion International dry panoramic storage irradiator."

NY Event Report ID No.: NY-19-08

Non-Agreement State	Event Number: 54250
Rep Org: ST LUKE'S REGIONAL MEDICAL CENTER Licensee: SAINT LUKE'S MAGIC VALLEY MEDICAL CENTER Region: 4 City: Twin Falls State: ID County: Twin Falls License #: 11-27312-01 Agreement: N Docket: NRC Notified By: SCOTT FULLER HQ OPS Officer: BRIAN LIN	Notification Date: 08/30/2019 Notification Time: 15:18 [ET] Event Date: 02/20/2019 Event Time: 12:05 [MDT] Last Update Date: 08/30/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE	Person (Organization): JAMES DRAKE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED DOSE

Summary via phone call:

This is a notification of a medical event that occurred on February 20, 2019 at 1205 MDT, in which 81 microCi of Radium-223 (Xofigo) was administered intravenously to the patient for metastatic prostate cancer that had spread to the bone. The original written directive from the patient's physician was for 56 microCi of Radium-223, however the pharmacy label was written for 81 microCi. The medical event was discovered during the Radiation Safety Officer's internal audit with the conclusion that the 81 microCi was the correct dosage at the intended organ. No adverse effect is expected for the patient.

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: 54251
Rep Org: CALIFORNIA RADIATION CONTROL PRGM Licensee: CONSTRUCTION TESTING AND ENGINEERING, SOUTH, INC. Region: 4 City: BARSTOW State: CA County: License #: 8217-33 Agreement: Y Docket: NRC Notified By: DONALD OESTERLE HQ OPS Officer: ANDREW WAUGH	Notification Date: 08/30/2019 Notification Time: 15:54 [ET] Event Date: 08/29/2019 Event Time: 07:30 [PDT] Last Update Date: 08/30/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMES DRAKE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following is a synopsis of information received via email from the State of California:

On 8/29/2019, California's Radiologic Health Branch (RHB) was contacted by the Radiation Safety Officer (RSO) of Construction Testing and Engineering, South, Inc. to report a damaged moisture/density gauge. The gauge was damaged on 8/29/2019 at 0730 PDT, when it was run over by construction equipment at a building site located on the Marine Corps Logistic Base in Barstow, CA. It was determined that the gauge's source rod was damaged, but the source appeared to be undamaged and remained in the encapsulated container. The RSO placed the damaged gauge back in the Type A transport container and the gauge will be taken to Maurer Technical Services for evaluation and disposal.

The gauge is a CPN model MC3 moisture/density gauge (serial number: M38058257) with a 0.37 GBq Cs-137 and 1.9 GBq Am-241 source.

This is being reported to the NRC Operations Center as a 24-hour report under 10 CFR 30.50(b)(2) since the radioactive gauge cannot be locked in the shielded position (due to the source rod being broken).

California 5010 Number: 082919

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