Event Notification Report for October 19, 2020

AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE

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

"On October 8, 2020, the Agency was contacted by the licensee and notified that while being used at a job site, a Troxler 3440 nuclear gauge was damaged by a road grader. The gauge contains a 40 milliCurie americium-241 source and an 8 milliCurie cesium-137 source. The licensee's technician had started a measurement and walked back to their truck when the grader came around a dirt pile and struck the gauge before the technician could respond. The cesium source operating rod was extended about 6 inches into the soil. The licensee performed a survey at the gauge and the reading at 3 feet was 1.2 millirem per hour. The licensee established a boundary at 15 feet from the gauge. The radiation safety officer (RSO) responded to the location. The RSO inspected the gauge and thought they could retract the cesium source back to the shielded position. The RSO's attempt to retract the source was successful. The RSO took a radiation reading 3 feet from the source and it was 0.14 millirem per hour. The gauge was placed in the transport case and will be taken to the licensee's storage area. The RSO stated they would contact the manufacturer to dispose of the gauge. No individual received an exposure due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I - 9805

AGREEMENT STATE REPORT - A NON-LICENSED INDIVIDUAL PARTICIPATED IN MEDICAL TREATMENT

The following event was received from the Florida Bureau of Radiation Control (BRC, ERCM) via email:

"The incident was reported by [the medical physicist (MP)], who is standing in for local physics administrator who is on vacation. A 50 year old female was being treated with Ir-192 High Dose Rate (HDR). The Authorized Radiation Therapist and Physician were in the room along with [an acting MP with a] temporary license TMP-1. The supervising MP was remote. The supervising MP told the facility that the acting MP was on the license as an AMP [(Authorized MP)], which is why the AMP was in the room. The AMP was actually not on the license. After treatment was complete, the error about the AMP not being on the license was discovered, and the report to the Florida BRC was made. The treatment plan was confirmed before treatment by the AMP. Treatment was delivered as prescribed. Per ERCM: The AMP's license is null and void and TMP-1 is expired."

Florida Incident Number: FL20-116.

THIS MATERIAL EVENT CONTAINS A "NOT RECORDED" LEVEL OF RADIOACTIVE MATERIAL

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

AGREEMENT STATE REPORT - LOST THEN FOUND MOISTURE / DENSITY GAUGE

The following is a synopsis of information received via phone and facsimile:

The Department (Nebraska Department of Health and Human Services, Office of Radiological Health) was notified around 0815 CDT on October 9, 2020, by the Nebraska State Patrol, of a lost, and subsequently recovered, nuclear gauge. The gauge was a Troxler 3400 series moisture density gauge containing a 9 mCi Cs-137 source and a 44 mCi Am-241/Be source.

During the afternoon of October 8, 2020, the gauge was on the tailgate of a pickup truck. The gauge user entered the vehicle before securing the gauge package. The user was distracted and began driving away. The gauge fell out of the back of the vehicle. An employee from the Nebraska Department of Transportation (NDOT) found the lost gauge near Norfolk, NE. The NDOT employee notified the Nebraska State Patrol and the gauge manufacturer, Troxler. Using the serial number of the gauge, Troxler was able to determine the gauge belonged to Olsson Associates. Olsson Associates was notified of the recovered gauge, and the gauge user retrieved the gauge. The estimated time between the loss of control and recovery is estimated to be one hour.

During the evening of October 8, 2020, the corporate Radiation Safety Officer (RSO) for Olsson Associates was notified of the incident. He did not report the event to the Department. A representative of the Department spoke with him at 1030 CDT on October 9, 2020. The RSO then provided a brief account of the incident to the Department representative.

The RSO noted that the gauge package appeared to be undamaged. The gauge itself did not appear damaged. The gauge was surveyed to confirm the presence of the source, and a leak test will be performed immediately.


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

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

AGREEMENT STATE REPORT - MISSING IODINE-125 SEED

The following information was received via facsimile:

"On April 29, 2020, the Department [New York State Department of Health, Bureau of Environmental Radiation Protection] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 220 microCuries) at Roswell Park Cancer Institute in Buffalo, New York.

"In this incident, two seeds were placed into a patient on 4/10/2020 and removed on 4/14/2020. One of the two seeds was lost by the attending surgeon. An extensive survey of the patient was performed to verify that the seed was not in the patient and the Nuclear Medicine Department was notified. A survey of the operating room (OR) suite was conducted and the seed was not recovered. The Radiation Safety Office was notified, another survey of the OR was performed, again the seed was not recovered. The patient also had a lymphoscintigraphy with Tc-99m so the surgical trash that was still in the room was sequestered. After three days, the trash was surveyed and examined but the seed was not recovered.

"Searches and surveys were performed in surgery, pathology, radiation safety and environmental service areas. Trash and regulated medical waste were also surveyed and inspected.

"Ultimate disposition of the source is unknown and it is possible that the source may still be recovered."

New York State Event Report ID No.: NYDOH - 20-05

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 REPORT - RADIOGRAPHY CAMERA STUCK HAND-CRANK ASSEMBLY

The following information was received via E-mail:

"ND Testing Inc. made a 24-hour report to the Radiologic Health Branch that on October 8, 2020, at 1256 PDT a hand-crank assembly became stuck/seized and would not allow the source to travel forward or backwards at a temporary job site. The team of two experienced radiographers contacted their Radiation Safety Officer (RSO) for assistance and secured the area around their QSA Global 880 exposure device.

"The RSO arrived onsite at 1445 EDT with extra lead shielding and survey meters. He and the radiographers were able to place lead blankets and some solid lead blocks over the guidetube containing the Ir-192 source, open the crank assembly to remove some metal shavings and close the assembly. This allowed them to secure the Ir-192 source after approximately 2 hours at 1645 EDT. The highest individual dose received was 195 mrem by one of the radiographers.

"The Ir-192 source was a QSA Global model A424-9, with an activity of 67.1 Ci of Ir-192."

California 5010 Number: 100920