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Event Notification Report for April 07, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/6/2020 - 4/7/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54622
Rep Org: NE DIV OF RADIOACTIVE MATERIALS Licensee: PLATTE PIPELINE COMPANY Region: 4 City: HOLDREGE State: NE County: License #: GL-0102 Agreement: Y Docket: NRC Notified By: BRYAN MILLER HQ OPS Officer: THOMAS KENDZIA	Notification Date: 03/27/2020 Notification Time: 15:20 [ET] Event Date: 03/05/2020 Event Time: 00:00 [CDT] Last Update Date: 03/27/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER ON DENSITY GAUGE

The following is a synopsis of information provided by the Nebraska, Department of Health & Human Services, via phone notification:

Licensee reported to the Nebraska Department of Health and Human Services on March, 24, 2020, that during their 6 month check of the shutter functionality on March 5, 2020, the shutter on a density gauge would not close all the way. The density gauge is an Ohmart/Vega Corporation model SH-F2 density gauge with a Cs-137 500 milliCurie source. The serial number for the gauge is 9103GK. The gauge is installed in a process system and provides no threat to personnel. The licensee has contacted the gauge manufacturer for repair.

Nebraska report number NE20004

Agreement State	Event Number: 54623
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: CHI ST LUKES HEALTH BAYLOR COLLEGE OF MEDICINE Region: 4 City: HOUSTON State: TX County: License #: L06661 Agreement: Y Docket: NRC Notified By: KAREN BLANCHARD HQ OPS Officer: BRIAN P. SMITH	Notification Date: 03/27/2020 Notification Time: 20:22 [ET] Event Date: 03/27/2020 Event Time: 00:00 [CDT] Last Update Date: 03/27/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF PATIENT MEDICAL EVENT

The following was received from the State of Texas via email:

"On March 27, 2020, the licensee reported that at the completion of a procedure during which 26 milliCuries of Yttrium-90 Sirspheres were administered to a patient, the assay of the tubing, vial, catheter, etc., revealed that the patient had only received approximately 16 milliCuries of the administered dose. Approximately 10 milliCuries were still in the equipment. The authorized user determined this was not the result of vascular stasis. The licensee plans to hold the administration equipment for decay for approximately seven days at which time they will assay and inspect the equipment and attempt to determine the cause. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 9755

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: 54624
Rep Org: COLORADO DEPT OF HEALTH Licensee: CURTIS HOTEL Region: 4 City: Denver State: CO County: License #: GL002245 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: BRIAN P. SMITH	Notification Date: 03/30/2020 Notification Time: 17:40 [ET] Event Date: 05/30/2018 Event Time: 00:00 [MDT] Last Update Date: 03/30/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): VINCENT GADDY (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (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 summarized from the email received from the state of Colorado:

One tritium exit sign, containing 10.0 Curies, was determined lost after renovation.

Initial Date Reported: 5/30/18

Final Decision Material Lost Date: 5/30/18"

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 Wednesday, March 24, 2021