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Event Notification Report for March 02, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/28/2020 - 3/2/2020

** EVENT NUMBERS **


54534 54535 54536

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Agreement State Event Number: 54534
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO
Region: 4
City: SAN ANTONIO   State: TX
County:
License #: L01279
Agreement: Y
Docket:
NRC Notified By: RANDALL REDD
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 02/20/2020
Notification Time: 17:50 [ET]
Event Date: 02/19/2020
Event Time: 00:00 [CST]
Last Update Date: 02/20/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 DURING TREATMENT

"On February 20, 2020, the Radiation Safety Officer for the Licensee notified this Agency of a medical event involving yttrium-90 Theraspheres. The prescribed dose was 120 Gy but only 85.2 Gy was administered with the remaining intended dose left in the tubing. The remainder could not be flushed out and the procedure was halted. The Licensee will meet with the manufacturer next week at the Licensee's facility to address this issue. This investigation is ongoing. More information will be provided when obtained in accordance with SA-300."

Texas Incident Number: I-9745

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: 54535
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: HAWKE INSPECTION AND TESTING
Region: 1
City: LINDEN   State: NJ
County:
License #: 506983
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: KERBY SCALES
Notification Date: 02/21/2020
Notification Time: 10:30 [ET]
Event Date: 02/20/2020
Event Time: 00:00 [EST]
Last Update Date: 02/21/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - ABANDONED PORTABLE MOISTURE DENSITY GAUGE

The following was received from the state of New Jersey via email:

"A local Police Department informed [NJ Department Radioactive Materials Program] that a suspicious package was discovered behind a deli/apartment building. Hazmat officials responded. The package was identified as the transport container for a portable moisture density gauge. Labeling on the container identified the gauge as a CPN International, Inc., MC Series Portaprobe, serial number M380404223. The labeling further stated that the gauge contained a Cs-137/Am-241/Be source. The listed activities were 10 mCi of Cs-137 as of 11/19/97 and 50 mCi of Am-241/Be as of 6/6/97. The shipping container appeared intact, with appropriate cautionary labeling. The highest exposure rate reported was 0.9 mR/hr at two feet from the container. The licensee reportedly told officials on the scene that they were out of business and could not explain how the device got to the location where it was found. Due to the lack of security that allowed the device to be moved to the location where it was found, we were not confident that the licensee would be able to secure the item if it was returned to them. The hazmat team secured the device overnight at their office location. The device will be secured pending completion of the investigation and subsequent proper disposition of the device.

"The State of New Jersey Department of Environmental Protection's Bureau of Environmental Radiation was notified."

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Agreement State Event Number: 54536
Rep Org: COLORADO DEPT OF HEALTH
Licensee: BOULDER COUNTY ADMINISTRATION
Region: 4
City: BOULDER   State: CO
County:
License #: GL000708
Agreement: Y
Docket:
NRC Notified By: KATHRYN MOTE
HQ OPS Officer: BETHANY CECERE
Notification Date: 02/21/2020
Notification Time: 14:57 [ET]
Event Date: 12/21/2017
Event Time: 00:00 [MST]
Last Update Date: 02/21/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
LAURA PEARSON (ILTAB)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following was received from the state of Colorado by email:

"Reported one lost tritium exit sign when conducting the annual reconciliation."

The initial date reported to the State was verbally in 2016.

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 Monday, March 02, 2020
Monday, March 02, 2020