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Event Notification Report for December 03, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/2/2019 - 12/3/2019

** EVENT NUMBERS **


54404 54405 54406 54407 54408 54410 54411

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Agreement State Event Number: 54404
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: QSA GLOBAL, INC
Region: 1
City: BURLINGTON   State: MA
County:
License #: 12-8361
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: BETHANY CECERE
Notification Date: 11/22/2019
Notification Time: 10:50 [ET]
Event Date: 11/21/2019
Event Time: 15:14 [EST]
Last Update Date: 11/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DESIREE DAVIS (ILTAB)
This material event contains a "Category 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST RADIOGRAPHY SOURCE

The following information was received via E-mail from the Commonwealth of Massachusetts:

"The licensee (QSA Global, Inc.) made telephone notification at 0948 EST, on November 22, 2019, preceded by E-mail to the Agency (Massachusetts Radiation Control Program) day prior, that licensee was notified by carrier on November 21, 2019, that an incoming shipment from Edmonton, Canada and destined for QSA Global, Inc., Burlington, Massachusetts is missing.

"The licensee provided that the shipment missing is a Model 650L source changer, serial number 2239, Type B(U) package, Yellow II, UN2916, containing a single 11.9 curie (440 GBq) iridium-192 radiography source.

"The licensee provided that the shipper is Acuren Group Inc. and that the date of exportation was supposed to be October 22, 2019. The activity of the shipment was 584 GBq (15.8) curies of iridium on October 22, 2019.

"The licensee reported that an active search by the carrier is underway to find the missing materials and that so far the carrier performed search of expected travel location in Boston, Massachusetts without finding the package and is tracing the expected route back through Canada, the shipment origin.

"The reporting requirement is immediate and is of 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C.

"The Agency considers this event to be open."


* * * UPDATE FROM JOSHUA DAEHLER TO DONALD NORWOOD AT 1310 EST ON 11/22/2019 * * *

The following information was received via E-mail from the Commonwealth of Massachusetts:

"At 1231 EST today (November 22, 2019), the licensee provided update to the Agency (Massachusetts Radiation Control Program) that the source was found; that this was a clerical error, and at no time was the shipment lost or missing. The source had been delivered on November 14, 2019, but put into the QSA Global, Inc.'s system under the wrong tracking number.

"The licensee also submitted that as a notification was made, it will write the 30-day report and forward it to the Agency. In addition a QSA Condition Report will be generated to address the receipt issue."

Notified R1DO (Cahill), ILTAB (Davis), and the NMSS Events Notifications E-mail group.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. 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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Agreement State Event Number: 54405
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: BASF CORPORATION CHEMICALS DIVISION
Region: 4
City: GEISMAR   State: LA
County:
License #: LA-2304-L01, Amendment 71, AI# 2049
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: OSSY FONT
Notification Date: 11/22/2019
Notification Time: 11:10 [ET]
Event Date: 11/19/2019
Event Time: 00:00 [CST]
Last Update Date: 11/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received via email from the Louisiana Department of Environmental Quality (the department):

"On 11/21/2019, at 1245 [CST], [the licensee] called [the department] to report that a stuck shutter [model - OHMART SH-F1 with 50 mCi of Cs-137] was found during the annual shutter check test. An equipment malfunction, which was a stuck shutter, was found on 11/19/2019, at approximately 1030 [CST] at BASF Corporation Chemicals Division. The shutter is stuck in the open condition and does not affect operation.

"BASF has contacted BBP Sales, Inc. to come in to replace the handle and any other parts needing replacing."

Event Report ID No.: LA190013

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Agreement State Event Number: 54406
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: DEVINS RECYCLING
Region: 1
City: DEVENS   State: MA
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: KENATH TRAEGDE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/22/2019
Notification Time: 14:46 [ET]
Event Date: 11/18/2019
Event Time: 11:00 [EST]
Last Update Date: 11/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DESIREE DAVIS (ILTAB)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - AIRCRAFT INSTRUMENT WITH RADIUM-226 PAINTED DIAL FOUND

The following information was received via E-mail:

"On 11/18/2019, Massachusetts Radiation Control Program (MARCP) was informed by Schnitzer Steel Industries, Inc., that a scrap metal shipment from Devens Recycling in Danvers, MA set off the radiation monitor alarm. The vehicle was redirected back to Devens Recycling for follow-up survey and mitigation in accordance with MA RCP DOT Special Permit MA-MA-19-10. On 11/19/2019, the material was identified and segregated from the scrap metal load by an independent radiation consultant. The radioactive material discovered was radium-226 painted on the dial of an abandoned (lost), old Aircraft Turn/Slip Coordinator instrument. The dose rate at 6 inches from the instrument was 200 microR/hr. The background dose rate was 20 microR/hour. The radiation survey instrument used to locate the source was a Ludlum Model 193-6. A Ludlum Model 9DP-1 ion chamber was used for direct measurements on the instrument. A Ludlum Model 702 Multi Channel Analyzer was used to identify the radioisotope. The radium-226 activity was estimated to be approximately 6.31 microCuries based on the dose rate measured. This material is being stored in a sealed polyethylene bag placed in a sealed 55 gallon drum and labeled as radioactive material held for disposal.

"This activity meets the 30-day event report requirement for lost or abandoned radioactive material greater than 10 times the quantities specified in 10 CFR 20 Appendix C, or the Massachusetts equivalent, 105 CMR 120.297 Appendix C, which is ten times reportable quantity for Radium-226 (1 microCurie).

"The Agency [MARCP] considers this event to be open until proper disposal of this instrument is confirmed."

Massachusetts Docket No.: 23-3968

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

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Agreement State Event Number: 54407
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: DEVENS RECYCLING
Region: 1
City: DEVENS   State: MA
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: KENATH TRAEGDE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/22/2019
Notification Time: 14:46 [ET]
Event Date: 11/20/2019
Event Time: 00:00 [EST]
Last Update Date: 11/22/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DESIREE DAVIS (ILTAB)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - AIRCRAFT INSTRUMENT WITH RADIUM-226 PAINTED DIAL FOUND

The following information was received via E-mail:

"On 11/20/2019, Massachusetts Radiation Control Program (MARCP) was informed by Schnitzer Steel Industries, Inc., that a scrap metal shipment from Devens Recycling in Danvers, MA set off the radiation monitor alarm. The vehicle was redirected back to Devens Recycling for follow-up survey and mitigation in accordance with MA RCP DOT Special Permit MA-MA-19-11. On 11/21/2019, the material was identified and segregated from the scrap metal load by an independent radiation consultant. The radioactive material discovered was radium-226 painted on the dial of an abandoned (lost), old Aircraft Altimeter instrument. The dose rate at 6 inches from the instrument was 150 microR/hr. The background dose rate was 20 microR/hour. The radiation survey instrument used to locate the source was a Ludlum Model 193-6. A Ludlum Model 9DP-1 ion chamber was used for direct measurements on the instrument. A Ludlum Model 702 Multi Channel Analyzer was used to identify the radioisotope. The radium-226 activity was estimated to be approximately 4.73 microCuries based on the dose rate measured. This material is being stored in a sealed polyethylene bag placed in a sealed 55 gallon drum and labeled as radioactive material held for disposal.

"This activity meets the 30-day event report requirement for lost or abandoned radioactive material greater than 10 times the quantities specified in 10 CFR 20 Appendix C, or the Massachusetts equivalent, 105 CMR 120.297 Appendix C, which is ten times reportable quantity for Radium-226 (1 microCurie).

"The Agency [MARCP] considers this event to be open until proper disposal of this instrument is confirmed."

Massachusetts Docket No.: TBD

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

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Agreement State Event Number: 54408
Rep Org: VT OFFICE OF RADIOLOGICAL HEALTH
Licensee: THE UNIVERSITY OF VERMONT MEDICAL CENTER
Region: 1
City: BURLINGTON   State: VT
County:
License #: 44-10187-03
Agreement: Y
Docket:
NRC Notified By: FRANCIS O'NEILL
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/20/2019
Notification Time: 15:48 [ET]
Event Date: 11/18/2019
Event Time: 00:00 [EST]
Last Update Date: 11/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HENRION (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSAGE OF Y-90 RESIN SIR-SPHERES

The following report was received from the Vermont Department of Health via email:

"Medical Event: Y90 resin Sir-Spheres treatment infusion aborted due to kinked microcatheter. 99.5 [percent] of the drawn dose was not delivered to the treatment site. Contamination of IR [interventional radiology] suite floor detected. Contamination of infusion paraphernalia (gloves, shoe covers, gauze, towels) detected. Contaminated items were contained and floor was decontaminated to acceptable levels by RSO [Radiation Safety Officer].

"Date of Event: 11/18/2019

"11/18/19 AU [Authorized User] notified referring physician and patient of the medical event
11/19/19 RSO contacted State of Vermont
11/19/19 NRC contacted for clarification of event
11/20/19 RSO contacted Sirtex

"Incident Details:
Terumo Progreat, I.D. 0.027[inches] (0.7mm), 130cm length, was used initially to access treatment site.
Boston Scientific, I.D. 0.021[inches] (0.5mm), 130cm length, was used to access treatment site after unsuccessful attempt with Progreat.

"IR [Interventional Radiologist] Fellow assembled the delivery device.

"The original dose measurement was 2.2 mR/hr at 1230 [EST]. The Nalgene with undelivered dose vial and the second Nalgene with delivery catheter were measured in exactly the same setup as original dose measurement. The total residual in the 2 Nalgene containers were 1.9 mR/hr + 0.25 mR/hr = 2.15 mR/hr at 1430. With 2 hours decay correction, the Nalgene containers reading should be 2.15 x 1.02 = 2.19 mR/hr.

"2.19 / 2.2 = 0.995 or 99.5 [percent] for Vial + Catheter. Therefore, about 0.5 [percent] of the drawn dose (44.3 mCi) was lost. 0.5 [percent] of 44.3 mCi is 0.2 mCi (This is the calculated amount of Y90 lost)

"The DAVYR [Dosimetry and Activity Visualizer for Y-90 Radioembolization] application provides the following liver dose calculation based on the partition model:
Liver = 27.5 Gy for a 1.5 GBq (or 40.5 mCi) dose delivery. This is based on 100 [percent] of prescribed dose being delivered.

"In the worst-case scenario where all the lost activity (0.2 mCi) was delivered to the patient, the liver dose calculation is:
Liver = 27.5 Gy x (0.2 mCi / 40.5 mCi) = 0.14 Gy (or 14 rem)

"The only way to properly measure the bags of contaminated paraphernalia (towels, gloves, gauze, shoe covers) in the same setup as the original dose measurement would involve transferring the contents into several Nalgene containers. This can be done next day to properly account for lost Y90 activity.

"Medical event criteria - the byproduct material administration has to meet the following (10 CFR 35.3045):

"1. The dose differs from a dose that would have resulted from the prescribed dosage by more than 50 rem to an organ or tissue. The unintended dose to any organ or tissue from the lost 0.2 mCi Y90 would be similar to the Liver dose calculated above (14 rem) and does not exceed 50 rem difference.
Note: The highest delivered dose to Liver from the lost Y90 is calculated to be 14 rem. This is below the target dose of 110 Gy (or 11,000 rem) and does exceed the 50 rem difference; however, this was a medical safety decision resulting from unforeseen microcatheter kinking due to patient anatomy.

"2. The total dose delivered differs from the prescribed dose by 20 [percent] or more. Yes, the total dose delivered is calculated to be about 0.2 mCi and is much below the prescribed dose of 40.5 mCi. A medical safety decision to abort the infusion was due to an unforeseen device event (kinked microcatheter) that prevented the safe delivery of Y90 microspheres."

* * * UPDATE ON 11/26/19 AT 0738 EST FROM FRANCIS ONEILL TO OSSY FONT * * *

The following update was received from the Vermont Department of Health via email:

"As a follow up to Event Number 54408, Y-90 Sirsphere event, the calculated dose to the unintended organ, the pancreas, is 14 Rem or 0.14 Gray."

Notified R1DO (Henrion) and NMSS Events Notification via email.

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.

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Agreement State Event Number: 54410
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: SCOTTSDALE MEDICAL IMAGING, LTD.
Region: 4
City: SCOTTSDALE   State: AZ
County:
License #: 07-507
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/25/2019
Notification Time: 20:00 [ET]
Event Date: 11/21/2019
Event Time: 00:00 [MST]
Last Update Date: 11/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
- CNSNS (MEXICO) (EMAIL)
ILTAB (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 report was received from the Arizona Department of Health Services (Department) via email:

"On November 25, 2019, the Department was notified of a lost I-125 seed. The licensee believes that the seed was most likely lost in pathology on November 21, 2019. The Department is continuing to investigate the event."

Arizona Incident: 19-028.

* * * UPDATE SENT BY BRAIN GORETZKI RECEIVED BY RICHARD SMITH ON NOVEMBER 26, 2019 AT 9:45 EST * * *

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

Vender for the I-125 seed was Isoaid, description of the seed was 5 cm stranded seed, Lot Number 63917-5, and activity was 0.197mCi I-125.

Notified: R4DO (Pick).

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

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Non-Agreement State Event Number: 54411
Rep Org: TERRACON CONSULTANTS
Licensee: TERRACON CONSULTANTS
Region: 1
City: ROCKY HILL   State: CT
County:
License #: 15-27070-01
Agreement: N
Docket:
NRC Notified By: ADAM MAIER
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/25/2019
Notification Time: 22:16 [ET]
Event Date: 11/25/2019
Event Time: 17:00 [EST]
Last Update Date: 11/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
MARK HENRION (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

LOST AND FOUND NUCLEAR DENSITY GAUGE

At approximately 1500 EST, on 11/25/2019, a technician departed a job site when they realized that they left the tailgate opened and the density gauge was no longer in the back of the truck. The technician turned around to look for the gauge, however, the gauge could not be found. The licensee searched for the gauge for approximately 4 hours and then contacted local law enforcement. The gauge was reported by local law enforcement to have been picked up at approximately 1630 EST.

The licensee went to the police department to examine the gauge and it was reported not to be leaking.

The gauge information is a Humboldt model 5001C, Serial Number 2301 containing 10 milliCuries of Cs-137 and 40 milliCuries of Am-241.

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 Tuesday, December 03, 2019
Tuesday, December 03, 2019