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Event Notification Report for September 15, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/14/2020 - 9/15/2020

** EVENT NUMBERS **
 
54881 54882 54883 54884 54886

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 54881
Rep Org: Eli Lilly Company Manufacturers
Licensee: Eli Lilly Company Manufacturers
Region: 3
City: Indianapolis   State: IN
County:
License #: 13-01133-02
Agreement: N
Docket:
NRC Notified By: James Maker
HQ OPS Officer: Jeffrey Whited		 Notification Date: 09/04/2020
Notification Time: 13:38 [ET]
Event Date: 09/04/2020
Event Time: 00:00 [EDT]
Last Update Date: 09/09/2020
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen Lnm>10x		 Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text



EN Revision Imported Date : 9/10/2020

EN Revision Text: LOST TRITIUM EXIT SIGN

The following is the summary of a call with the licensee:

During an annual inventory review, the licensee noticed that an exit sign had been removed from the wall. It was supposed to have been repurposed and moved to a different location but the licensee has lost confidence that the exit sign is in its control.

The licensee is continuing to look for the exit sign.

Exit sign details: purchased from SRBT, s/n C083911, manufacture date 2/2011, original activity: 21.6 Ci, current activity 12.6 Ci.

* * * RETRACTION ON 9/9/2020 AT 1455 EDT FROM TRENTON MAYS TO THOMAS HERRITY * * *

The following is the summary of a call with the licensee:

The licensee is retracting this event. After further searching for the exit sign, the licensee was able to recover the sign and determined that it had continuously been in its possession.

The licensee notified R3 (Warren) that the sign had been found.

Notified R3DO (Hills) and NMSS Events Notification and ILTAB 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: 54882
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: Cancer Treatment Centers of America
Region: 1
City: Newman   State: GA
County:
License #: GA 1632-1
Agreement: Y
Docket:
NRC Notified By: Irene Bennett
HQ OPS Officer: Jeffrey Whited		 Notification Date: 09/04/2020
Notification Time: 15:01 [ET]
Event Date: 09/02/2020
Event Time: 00:00 [EDT]
Last Update Date: 09/04/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State		 Person (Organization):
JOSEPHINE AMBROSINI (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT - UNDERDOSE

The following was received from the Georgia Radioactive Materials Program via email:

"At the end of the administration of Y-90 SIR Spheres [for the treatment of tumors in the right lobe of the liver], the delivery vial (D-Vial) appeared to overfill as the radiologist was attempting to mix the spheres with a 50/50 solution of contrast and 5 percent dextrose/glucose (D5W). The radiologist noticed some clumping and after attempting to gently disperse the Spheres, he gave a couple hard pushes of the contrast/D5W into the D-Vial. At that time, he noticed the leak. He examined the septum and found it to be dry. As a precaution the radiologist put Durabond on top of the septum. Further examination showed that the material leaked out of the sides of the crimped vial top rather than the septum. The procedure was stopped to prevent further contamination.

"The event occurred while using SIRTEX new SIROS delivery system. The SIRTEX representative was present providing guidance to the radiologist as this was the first time he used the new system.

"It is estimated that 75 percent of Y-90 SIR-Spheres were administered to the patient [Prescribed Activity: 3.1 GBq (83.7 mCi); Delivered Activity (estimated): 2.87 Gbq (77.7 mCi)]. It is likely that the residual activity was over estimated due to contamination of the SIROS delivery dome. The usual waste from the procedure is contained in a 1-liter Nalgene containers and then placed in a Lucite shield for dose rate measurements to determine the residual activity. The Siros delivery dome could not be measured in the same geometry and likely resulted in an increased dose rate and underestimate of the total dose delivered.

"At this time, the prescribing physician indicated he does not expect any adverse effects for the patient and is awaiting the dosimetry evaluation from the patients PET/CT Scan.

"Attempts have been made to recreate the event without success. There is speculation regarding the size of the dose and that the number of Spheres may have been a factor (larger than typically administered). Representatives from SIRTEX indicate that this has not been an issue at other sites.

"Prior and subsequent studies with the new SIROS delivery system were successful with less activity.

"Further evaluation of the equipment to determine why the vial leaked, will be performed following decay and return the manufacturer."

Georgia Incident Number: 30

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.

Non-Agreement State Event Number: 54883
Rep Org: Soil and Materials Engineering, Inc
Licensee: Soil and Materials Engineering, Inc.
Region: 3
City: Canton   State: MI
County:
License #: 21-17158-02
Agreement: N
Docket:
NRC Notified By: Trevor Shaheen
HQ OPS Officer: Jeffrey Whited		 Notification Date: 09/04/2020
Notification Time: 16:28 [ET]
Event Date: 09/04/2020
Event Time: 14:40 [EDT]
Last Update Date: 09/04/2020
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure		 Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

DAMAGED GAUGE DUE TO VEHICLE INCIDENT

The following was received via email from the licensee:

"[The Engineering Technician] was performing density tests on an aggregate base with a nuclear density gauge (nuc) [gauge: Troxler 3411 s/n 14468; 8.0 mCi Cs-137; 40.0 mCi Am-241] and the loader operator was also working in the area. The [loader] operator was trying to back-up and grazed [the Engineering Technician] on his left shoulder slightly with the rear bumper end, just after [the Engineering Technician] had brought the source rod into the safe position to record the test results. [The Engineering Technician] rolled out of the way and as the loader came to a stop it had hit the nuc gauge and broke the guide rod. Unsure if the source was intact, [the Engineering Technician] kept the loader in-place and kept people more than 15 feet away until [the Operations Manager and the Senior Project Consultant] could arrive on-site to assess the situation. [The Engineering Technician] informed [the Operations Manager and the Senior Project Consultant] on the phone and once they arrived on-site that he was uninjured, since he was able to easily roll out of the way of the loader. [The licensee] then determined that both sources were still intact and the source tip was in the shielded position within the gauge. [The licensee] took a Geiger Counter reading at the site (0.06 mRem/hr 3 feet from the gauge) and again after loading the gauge into the transport box (less than 0.03 mRem/hr 3 feet from the box). Prior to loading the gauge into the box, [the licensee] performed a leak test on the gauge and shipped the leak test to Instrotek as soon as [the licensee] returned to the office with the damaged gauge."

The licensee noted that the gauge is currently locked-out/tagged-out and once they receive the leak test results they will most likely transfer the gauge to Instrotek for disposal.

Agreement State Event Number: 54884
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Sterigenics US, LLC
Region: 4
City: Tustin   State: CA
County:
License #: 3390
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Jeffrey Whited		 Notification Date: 09/04/2020
Notification Time: 20:51 [ET]
Event Date: 09/03/2020
Event Time: 00:00 [PDT]
Last Update Date: 09/04/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State		 Person (Organization):
RICK DEESE (R4DO)
JEFFERY GRANT (IRD)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POOL WATER CONDUCTIVITY EXCEEDED LIMITS

The following was received from the State of California Department of Public Health - Radiologic Health Branch (CDPH/RHB) via email:

"The licensee Radiation Safety Officer reported that the pool water conductivity exceeded 100 microSiemens/cm on 9/3/20. The reason was the loss of operability of the demineralizer pump. The pump has been repaired and is currently operable with declining pool water conductivity, but the pool water is still in excess of 100 microSiemens/cm. CDPH/RHB is continuing to investigate the circumstances surrounding this event."

Agreement State Event Number: 54886
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ECS Southwest LLC
Region: 4
City: Carrollton   State: TX
County:
License #: L 05384
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Jeffrey Whited		 Notification Date: 09/05/2020
Notification Time: 14:35 [ET]
Event Date: 09/05/2020
Event Time: 00:00 [CDT]
Last Update Date: 09/05/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State		 Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE DAMAGED WHEN STRUCK BY VEHICLE

The following was received from the Texas Department of State Health Services (the Agency) via email:

"On September 5, 2020, The Agency was notified by the licensee's site radiation safety officer (SRSO) that a Humboldt EZ 5001 moisture/density gauge was damaged at a temporary job site when a bulldozer struck the gauge. The gauge contains a 40 milliCurie americium-241 source and a 10 milliCurie cesium-137 source. The cesium source was in the shielded position when the event occurred. The operating rod was bent, and the SRSO stated he did not believe the cesium source rod would move. The SRSO stated they performed radiation surveys around the gauge and the highest reading they obtained was 1.3 millirem per hour, which is a normal reading. The SRSO stated they were taking the gauge back to their storage location and would perform a leak test of the gauge. The event did not present an exposure risk to any individual. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: 9795

Page Last Reviewed/Updated Wednesday, March 24, 2021