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Event Notification Report for December 16, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/13/2019 - 12/16/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54426
Rep Org: WISCONSIN RADIATION PROTECTION Licensee: UNKNOWN Region: 3 City: FRANKSVILLE State: WI County: License #: UNKNOWN Agreement: Y Docket: NRC Notified By: KYLE WALTON HQ OPS Officer: OSSY FONT	Notification Date: 12/06/2019 Notification Time: 15:19 [ET] Event Date: 12/06/2019 Event Time: 00:00 [CST] Last Update Date: 12/06/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ROBERT DALEY (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - DENSITY GAUGE FOUND AT SCRAP YARD

The following was received from the Wisconsin Department of Health Services Radiation Protection Section (the Department) via email:

"On December 6, 2019, the Department was notified by a local scrap facility that they had refused a load of material on December 4 after setting off portal monitors at their site. No reports were made at that time. On December 6, safety staff from the scrap facility assisted in characterization of the material at the originating location. The device was identified as a Seaman Nuclear Density Gauge (Model R-75, SN: 3032). These are manufactured with a maximum activity of 5 mCi Radium-226. No residual contamination was identified in any areas the gauge had been.

"The Department has dispatched inspectors to perform their own investigation and characterization of the material, and will provide updates as they become available."

* * * UPDATE ON 12/06/019 AT 1805 EST FROM KYLE WALTON TO OSSY FONT * * *

The following update was received from the Wisconsin Department of Health Services (the Department) via email:

"Inspectors arrived at the originating location. The material is currently secured in a cargo container away from members of the public. Surveys and swipes do not indicate a leaking source or removable contamination. Surface readings of up to 13 mR/h were observed. The manufacturer has been contacted to identify the last known owner of the gauge."

Event Report ID No.: WI190016

Notified R3DO (Daley) 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: 54427
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT Licensee: UNIVERSITY OF KANSAS HOSPITAL AUTHORITY Region: 4 City: TOPEKA State: KS County: License #: 18-C800 Agreement: Y Docket: NRC Notified By: DAVID M LAWRENZ HQ OPS Officer: OSSY FONT	Notification Date: 12/06/2019 Notification Time: 15:33 [ET] Event Date: 12/06/2019 Event Time: 13:28 [CST] Last Update Date: 12/06/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): NICK TAYLOR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED DIFFERED BY MORE THAN 20 PERCENT

The following was received from the Kansas Department of Health and Environment via email:

"On December 6, 2019, at 1328 [CST], [the University of Kansas Hospital Authority] reported a medical event involving Y-90 Microspheres to the Kansas Radiation Control Program (RCP). The licensee stated that the patient had unusually small blood vessel feeding the tumor and prevented a larger than anticipated dose to the tumor. An initial written report was received at 1354 [CST] from the RSO [Radiation Safety Officer] stating that there were no errors or problems during the procedure administration. The dose differed by more than 20 percent, though the physician stated that the dose was therapeutic and will not plan to retreat. There was no report of contamination at the facility or of the patient.

"The Kansas RCP is preparing for an onsite investigation to review the incident. That investigation will be the basis for a final NMED report to follow."

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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