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Event Notification Report for December 04, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/3/2019 - 12/4/2019

** EVENT NUMBERS **


54408 54410 54411 54412 54413 54414 54415

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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

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Agreement State Event Number: 54412
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee:
Region: 4
City: GLOBE   State: AZ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: KARL DIEDERICH
Notification Date: 11/26/2019
Notification Time: 13:53 [ET]
Event Date: 11/26/2019
Event Time: 00:00 [MST]
Last Update Date: 11/27/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - POSSIBLE FOUND RADIOACTIVE MATERIAL

The following information was received via phone call:

A member of the public earlier today identified a container on National Forest Service land near Globe, Arizona that is labeled as having radioactive material. Pictures of the container show "B of E permit 681, Serial Number D-8011, Radiation, Return to Dow Chemical Company, Rocky Flats." This is an initial report. Arizona Department of Health Services personnel will investigate presently and provide an update.

* * * UPDATE AT 1403 EDT ON 11/27/19 FROM BRIAN GORETZKI TO JEFF HERRERA * * *

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

"The container turned out to be a metal lid based on the orientation of the data plaques and the safety top. We [Arizona Department of Health Services] performed exposure and contamination surveys onsite and everything came back at background."

Notified the R4DO (Pick) and NMSS via email.

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Agreement State Event Number: 54413
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LARSON DESIGN GROUP
Region: 1
City: MORGANTOWN   State: WV
County:
License #: 47-35062-01
Agreement: N
Docket:
NRC Notified By: BENJAMIN SEIBER
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/26/2019
Notification Time: 15:00 [ET]
Event Date: 11/26/2019
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)
ILTAB (EMAIL)
CNSC (CANADA) (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOSS OF A NUCLEAR DENSITY GAUGE

The following report was received from the Pennsylvania Bureau of Radiation Protection via email:

"On November 26, 2019 a lawyer representing the licensee reported the event via telephone. The licensee is Larson Design Group, USNRC Radioactive Material License No. 47-35062-01, PA reciprocity license PA-R0218. Details are sparse at this time. The lawyer stated an employee wrecked a vehicle carrying a nuclear gauge (with Cesium 137 and Americium 241) in a ditch late Friday night. He had a friend pick him up, leaving the vehicle and gauge unattended. At some point police found the vehicle and impounded it. The police recognized the radioactive material shipping case in the vehicle. They allowed the employee to claim the vehicle only after producing documentation indicating he was authorized to possess it. It is believed the gauge never left the vehicle and it is back in possession of the licensee. The DEP [Department of Environmental Protection] will update this event as soon as more information is provided."

PA Event Report ID No.: 190028

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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 54414
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: DUPONT SPECIALTY PRODUCTS USA, LLC
Region: 1
City: RICHMOND   State: VA
County:
License #: 041-313-1
Agreement: Y
Docket:
NRC Notified By: ASFAW FENTA
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/26/2019
Notification Time: 15:04 [ET]
Event Date: 11/25/2019
Event Time: 00:00 [EST]
Last Update Date: 12/02/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HENRION (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILED TO CLOSE DURING SEMI-ANNUAL TESTING

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

"On November 25, 2019 a licensee reported that the shutter of a fixed gauge used to measure the level of material inside a process vessel might have failed to close during the semi-annual radiological testing. The gauge is a Ronan Engineering, Model SA1-F37, serial number M7407, containing 40 mCi of Cs-137. The shutter arm is actuating, but the radiation reading at approximately 3 inches below the source remained the same (0.8 mR/hr) when the shutter was opened and closed. The source is located approximately 10 feet from the ground level and is only accessible by a stepladder. There are no routine activities that bring employees in close proximity to the source. There was no public exposure or environmental release from this event. The licensee has contacted the manufacturer for further investigation.

"The Virginia Office of Radiological Health will review the licensee's written report and determine additional actions to be taken."

Event Report ID No.: VA-19-006

* * * RETRACTION ON 12/2/19 AT 1255 EST FROM ASFAW FENTA TO KERBY SCALES * * *

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

"Please retract the incident report that was submitted on November 26, 2019.

"The licensee was advised by Ronan Engineering to take measurements directly from the detector side by closing and opening the shutter instead of taking a reading at approximately 3 inches below the source. On November 27, 2019, the licensee retested the shutter by measuring directly to the detector side and found 0.4 mR/hr when the shutter was opened and 0.2 mR/hr when the shutter was closed. The licensee reported to the agency that the gauge was working properly. There was no problem on the gauge; rather, it was an error on the measurement technique."

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Agreement State Event Number: 54415
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: MOSHER ENGINEERING
Region: 1
City: CHAPEL HILL   State: NC
County:
License #: 092-1311-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/26/2019
Notification Time: 16:28 [ET]
Event Date: 11/26/2019
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 - PORTABLE NUCLEAR GAUGE RUN OVER AT JOB SITE

The following report was received from the North Carolina Department of Health and Human Services via email:

"RMB [North Carolina Radioactive Materials Branch] received a report of a portable nuclear gauge that was run over at a job site. The gauge was cordoned off and is away from any pedestrian areas. At the time of this report, based on on-site photos provided by the licensee; the source rod is retracted and is undamaged and initial surveys show no leakage. Gauge outer housing appears damaged but intact. Intertek will be arriving to take possession of the gauge to transport for repair. Inspector has been dispatched to conduct an on-site investigation. Additional information will be provided to update, complete & close this report. Our [North Carolina Department of Health and Human Services] investigation is ongoing."

The gauge is a Troxler model number 3430.

NC Event Report ID. NO.: 190041


Page Last Reviewed/Updated Wednesday, December 04, 2019
Wednesday, December 04, 2019