Event Notification Report for February 24, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/23/2020 - 02/24/2020
EVENT NUMBERS
545485454454626546835454055082
Agreement State
Event Number: 54548
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CLEVELAND CLINIC FLORIDA
Region: 1
City: WESTON State: FL
County:
License #: 3748-2
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTICKER
HQ OPS Officer: DONALD NORWOOD
Licensee: CLEVELAND CLINIC FLORIDA
Region: 1
City: WESTON State: FL
County:
License #: 3748-2
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTICKER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/27/2020
Notification Time: 15:54 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [EST]
Last Update Date: 02/27/2020
Notification Time: 15:54 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [EST]
Last Update Date: 02/27/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - HDR UNDERDOSE TO PATIENT
The following information was received from the state of Florida via E-mail:
"[The licensee] reported to the BRC [Bureau of Radiation Control] on 25 Feb 2020, and e-mailed an incident report on 26 Feb 2020 at 1224 EST that on 24 Feb 2020 at 1315 EST an HDR [high dose rate] incident occurred to a patient receiving skin therapy.
"The patient was prescribed 7.5 Gray x 5 fractions, on five different parts of the left hand. On the first dose of the first fraction, it was observed that catheter numbers 1 - 15 were reversed, causing an underdose to the patient by 56.25 percent. No Authorized Users were exposed to the source or otherwise contaminated."
Florida Incident Number: FL20-022
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.
The following information was received from the state of Florida via E-mail:
"[The licensee] reported to the BRC [Bureau of Radiation Control] on 25 Feb 2020, and e-mailed an incident report on 26 Feb 2020 at 1224 EST that on 24 Feb 2020 at 1315 EST an HDR [high dose rate] incident occurred to a patient receiving skin therapy.
"The patient was prescribed 7.5 Gray x 5 fractions, on five different parts of the left hand. On the first dose of the first fraction, it was observed that catheter numbers 1 - 15 were reversed, causing an underdose to the patient by 56.25 percent. No Authorized Users were exposed to the source or otherwise contaminated."
Florida Incident Number: FL20-022
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: 54544
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: CLEVELAND CLINIC FLORIDA
Region: 1
City: WESTON State: FL
County:
License #: 3748-2
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: BETHANY CECERE
Licensee: CLEVELAND CLINIC FLORIDA
Region: 1
City: WESTON State: FL
County:
License #: 3748-2
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: BETHANY CECERE
Notification Date: 02/25/2020
Notification Time: 18:03 [ET]
Event Date: 02/24/2020
Event Time: 13:15 [EST]
Last Update Date: 02/25/2020
Notification Time: 18:03 [ET]
Event Date: 02/24/2020
Event Time: 13:15 [EST]
Last Update Date: 02/25/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MARC FERDAS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following was received from the state of Florida via email:
"On 24 Feb. 2020, at 1315 EST, an underdose of radiation to a patient receiving skin therapy occurred. The patient was scheduled to receive five fractions, at 7.5 grays per fraction, on five different parts of the left hand per fraction. On the first dose of the first fraction, it was observed that catheter numbers 1 - 15 were reversed, causing an underdose to the patient. No Authorized Users were exposed to the source or otherwise contaminated. The licensee has agreed to submit further information on 26 Feb 2020. Since the cause of this incident is machine generated, in accordance with BRC [State of Florida Bureau of Radiation Control] procedures, it is not being given an incident number, and is being forwarded to ERCX [the X-Ray Machine Section of the BRC]."
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.
The following was received from the state of Florida via email:
"On 24 Feb. 2020, at 1315 EST, an underdose of radiation to a patient receiving skin therapy occurred. The patient was scheduled to receive five fractions, at 7.5 grays per fraction, on five different parts of the left hand per fraction. On the first dose of the first fraction, it was observed that catheter numbers 1 - 15 were reversed, causing an underdose to the patient. No Authorized Users were exposed to the source or otherwise contaminated. The licensee has agreed to submit further information on 26 Feb 2020. Since the cause of this incident is machine generated, in accordance with BRC [State of Florida Bureau of Radiation Control] procedures, it is not being given an incident number, and is being forwarded to ERCX [the X-Ray Machine Section of the BRC]."
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: 54626
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: GEMINI SIGN PRODUCTS
Region: 4
City: TAYLOR State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: BRIAN LIN
Licensee: GEMINI SIGN PRODUCTS
Region: 4
City: TAYLOR State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: BRIAN LIN
Notification Date: 03/31/2020
Notification Time: 17:12 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [CDT]
Last Update Date: 03/31/2020
Notification Time: 17:12 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [CDT]
Last Update Date: 03/31/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
LAURA PEARSON (ILTAB)
- CNSNS (MEXICO) (EMAIL)
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
LAURA PEARSON (ILTAB)
- CNSNS (MEXICO) (EMAIL)
AGREEMENT STATE REPORT - LOST STATIC CONTROL DEVICE
The following was received from the State of Texas via email:
"On March 31, 2020, the Texas Department of State Health Services (Agency) received a letter that had been originally sent to the Texas Commission on Environmental Quality, received March 3, 2020, which was forwarded via email. The letter was reporting a lost static control device: NRD Neutralizer model P-2021-Z705, SN: A2LP525, containing 10 milliCuries of polonium-210. This is a general license device. It was last used on February 20, 2020, and then replaced. On February 25, 2020, [employees at Gemini Sign Products] realized the box containing the device (to be shipped back to manufacturer) was missing. It was determined that on February 24, 2020, the device and its associated paperwork, which was in a box in an office awaiting paperwork completion/packing for transit back to the manufacturer, was mistaken by a custodian for waste, and it was thrown away in an outdoor dumpster. The dumpster was searched, but the waste had already been picked up and they learned from the waste company that the contents of that load were already at the landfill and buried. The report included the company's corrective actions: reminders to staff about the equipment and the regulations associated with it and new policy and procedure for changing out the devices in the future. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: I-9757
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
The following was received from the State of Texas via email:
"On March 31, 2020, the Texas Department of State Health Services (Agency) received a letter that had been originally sent to the Texas Commission on Environmental Quality, received March 3, 2020, which was forwarded via email. The letter was reporting a lost static control device: NRD Neutralizer model P-2021-Z705, SN: A2LP525, containing 10 milliCuries of polonium-210. This is a general license device. It was last used on February 20, 2020, and then replaced. On February 25, 2020, [employees at Gemini Sign Products] realized the box containing the device (to be shipped back to manufacturer) was missing. It was determined that on February 24, 2020, the device and its associated paperwork, which was in a box in an office awaiting paperwork completion/packing for transit back to the manufacturer, was mistaken by a custodian for waste, and it was thrown away in an outdoor dumpster. The dumpster was searched, but the waste had already been picked up and they learned from the waste company that the contents of that load were already at the landfill and buried. The report included the company's corrective actions: reminders to staff about the equipment and the regulations associated with it and new policy and procedure for changing out the devices in the future. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: I-9757
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: 54683
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: SERVICE KING COLLISION REPAIR
Region: 1
City: MT. JULIET State: TN
County:
License #: GL1192/GL1193
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: HOWIE CROUCH
Licensee: SERVICE KING COLLISION REPAIR
Region: 1
City: MT. JULIET State: TN
County:
License #: GL1192/GL1193
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/28/2020
Notification Time: 14:49 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [EDT]
Last Update Date: 04/28/2020
Notification Time: 14:49 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [EDT]
Last Update Date: 04/28/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
LAURA PEARSON (ILTAB)
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
LAURA PEARSON (ILTAB)
AGREEMENT STATE REPORT - LOST STATIC ELIMINATORS CONTAINING POLONIUM-210
The following information was obtained from the state of Tennessee via email:
"During a recent inventory at two different locations of Service King Collision Repair Centers, two static elimination devices were found to be missing. One location in Chattanooga, TN, lost the device during the transition of closing the repair center. Updated information will be included in a follow-up report. The information for the devices is below:
Manufacturer Model Serial# Isotope Activity
NRD, LLC P-2021 A2LV457 Po-210 10 mCi
NRD, LLC P-2021 A2LU553 Po-210 10 mCi"
Tennessee Event Report ID No.: TN-20-076
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
The following information was obtained from the state of Tennessee via email:
"During a recent inventory at two different locations of Service King Collision Repair Centers, two static elimination devices were found to be missing. One location in Chattanooga, TN, lost the device during the transition of closing the repair center. Updated information will be included in a follow-up report. The information for the devices is below:
Manufacturer Model Serial# Isotope Activity
NRD, LLC P-2021 A2LV457 Po-210 10 mCi
NRD, LLC P-2021 A2LU553 Po-210 10 mCi"
Tennessee Event Report ID No.: TN-20-076
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: 54540
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BRAUN INTERTEC CORPATION
Region: 4
City: TYLER State: TX
County:
License #: LL06681
Agreement: Y
Docket:
NRC Notified By: RANDALL REDD
HQ OPS Officer: RICHARD SMITH
Licensee: BRAUN INTERTEC CORPATION
Region: 4
City: TYLER State: TX
County:
License #: LL06681
Agreement: Y
Docket:
NRC Notified By: RANDALL REDD
HQ OPS Officer: RICHARD SMITH
Notification Date: 02/24/2020
Notification Time: 19:10 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [CST]
Last Update Date: 06/18/2020
Notification Time: 19:10 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [CST]
Last Update Date: 06/18/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
- CNSNS (MEXICO) (EMAIL)
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
- CNSNS (MEXICO) (EMAIL)
AGREEMENT STATE REPORT - STOLEN DENSITY GAUGE
The following is a synopsis of a event reported by the state of Texas via email and phone call:
On February 24, 2020, the Texas Department of State Health Services (Agency) was contacted by the Braun Intertec Corporation RSO to report a stolen moisture density gauge.
The gauge was last seen on February 19, 2020 at the end of work in McKinney Texas. It was locked in a box in the back of a truck which was then driven to Euless, Texas where it reported to stay until February 24, 2020. The truck was then driven to a jobsite in Richardson, TX on February 24, 2020 at which point the employee realized that the locks were gone and the moisture density gauge was removed from the box in the back of the truck.
Euless Police were notified.
The activity for the density gauge is estimated to be 10 mCi Cs-137 and 40 mCi of Am241/Be.
An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA- 300.
Texas Incident number: 9746
* * * UPDATE ON 6/18/20 AT 1721 EDT FROM KAREN BLANCHARD TO ANDREW WAUGH * * *
The following information was received from the state of Texas via email:
"On June 17, 2020, the Agency was notified by a steel mill in Midlothian, Texas, that it had found a moisture/density gauge in a load of metal from a recycler. The serial number was checked and it was determined to be this licensee's gauge that was stolen February 24, 2020. The licensee was notified and picked up the device on June 18, 2020. The licensee transported the device to a manufacturer's facility in Arlington, Texas, and transferred it for disposal. The manufacturer will complete leak tests and provide the licensee with the results. [There were] no exposures that would exceed any regulatory limit at the steel mill. Investigation will continue to determine if any exposures occurred at the recycler and if the recycler can provide information on where, or from whom, it got the device.
"More information will be provided as it is obtained in accordance with SA-300."
Notified R4DO (Warnick), NMSS Events Notification (email), ILTAB (email), and CNSNS (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
The following is a synopsis of a event reported by the state of Texas via email and phone call:
On February 24, 2020, the Texas Department of State Health Services (Agency) was contacted by the Braun Intertec Corporation RSO to report a stolen moisture density gauge.
The gauge was last seen on February 19, 2020 at the end of work in McKinney Texas. It was locked in a box in the back of a truck which was then driven to Euless, Texas where it reported to stay until February 24, 2020. The truck was then driven to a jobsite in Richardson, TX on February 24, 2020 at which point the employee realized that the locks were gone and the moisture density gauge was removed from the box in the back of the truck.
Euless Police were notified.
The activity for the density gauge is estimated to be 10 mCi Cs-137 and 40 mCi of Am241/Be.
An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA- 300.
Texas Incident number: 9746
* * * UPDATE ON 6/18/20 AT 1721 EDT FROM KAREN BLANCHARD TO ANDREW WAUGH * * *
The following information was received from the state of Texas via email:
"On June 17, 2020, the Agency was notified by a steel mill in Midlothian, Texas, that it had found a moisture/density gauge in a load of metal from a recycler. The serial number was checked and it was determined to be this licensee's gauge that was stolen February 24, 2020. The licensee was notified and picked up the device on June 18, 2020. The licensee transported the device to a manufacturer's facility in Arlington, Texas, and transferred it for disposal. The manufacturer will complete leak tests and provide the licensee with the results. [There were] no exposures that would exceed any regulatory limit at the steel mill. Investigation will continue to determine if any exposures occurred at the recycler and if the recycler can provide information on where, or from whom, it got the device.
"More information will be provided as it is obtained in accordance with SA-300."
Notified R4DO (Warnick), NMSS Events Notification (email), ILTAB (email), and CNSNS (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: 55082
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: Nucor Steel
Region: 1
City: Memphis State: TN
County:
License #: R-79303-B28
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Ossy Font
Licensee: Nucor Steel
Region: 1
City: Memphis State: TN
County:
License #: R-79303-B28
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Ossy Font
Notification Date: 01/22/2021
Notification Time: 16:51 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [EST]
Last Update Date: 01/22/2021
Notification Time: 16:51 [ET]
Event Date: 02/24/2020
Event Time: 00:00 [EST]
Last Update Date: 01/22/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
BICKETT, BRICE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
BICKETT, BRICE (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 2/7/2021
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SOURCE HOLDER
The following was received from the Tennessee Division of Radiological Health via email:
"On February 24, 2020, an evaluation was conducted by Radiametrics Technologies and damage to the source holder was noted on [a Berthold model LB300MLT (device serial no: 45132-004-10009) containing 3.405 mCi of Co-60 (source serial no.: 1043-05-08)]. The source holder was locked out of service with the shutter in a closed position. A source holder replacement and leak test were performed on December 2, 2020."
TN Item No.: TN-20-044
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SOURCE HOLDER
The following was received from the Tennessee Division of Radiological Health via email:
"On February 24, 2020, an evaluation was conducted by Radiametrics Technologies and damage to the source holder was noted on [a Berthold model LB300MLT (device serial no: 45132-004-10009) containing 3.405 mCi of Co-60 (source serial no.: 1043-05-08)]. The source holder was locked out of service with the shutter in a closed position. A source holder replacement and leak test were performed on December 2, 2020."
TN Item No.: TN-20-044