Event Notification Report for October 27, 2020

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

AGREEMENT STATE REPORT - LOST AND FOUND PORTABLE GAUGE

The following was received from the Utah Division of Radiation Control (the Division) via email:

"A portable gauge user failed to adequately secure the transportation case containing a Troxler 3430 gauge when leaving the jobsite. The user noticed the gauge was missing after travelling some distance from the jobsite. The user retraced his path back to the jobsite, but was unable to locate the gauge. The licensee then contacted the Division [at 1422 MDT] to report that the gauge was missing. During a subsequent telephone call [at 1503 MDT], the licensee informed the Division that the gauge had been located during an additional search by the user. The gauge was found just outside the jobsite entrance. The Troxler gauge contains a 40 mCi Am-241/Be sealed source and an 8 mCi Cs-137 sealed source."

Utah Event Number: UT 200006

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 - GREATER THAN INTENDED DOSE TO LIVER LOBE

The following was received via email from the California Radiation Control Program:

"On October 16, 2020, the [Radiation Safety Officer] RSO of Stanford University emailed [the Radiation Health Branch] RHB to inform a medical event with a Y-90 patient treatment. The physician mistakenly delivered the larger dose (approximately 30 mCi) to the liver lobe that was to get the smaller dose (approximately 13 mCi). The dose to the second lobe was adjusted with left over Y-90 from the dose draw to give the proper dose to the other lobe (approximately 30 mCi). So one lobe received much greater than the intended dose, while the other lobe received the proper dose. RHB will follow up on this investigation."

California 5010 Number: 101620

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.

EN Revision Imported Date: 10/26/2020

EN Revision Text: AGREEMENT STATE REPORT - GAUGE DAMAGED ON CONSTRUCTION SITE

The following was received from the state of Nevada via email:

"A front-end loader ran over and crushed a Humboldt 5001EZ, S/N 3246, Portable Nuclear Gauge while the Authorized User was performing the standard count. The source was still in the shielded position during the incident, but the source rod was broken off and the gauge can no longer be used. No injuries or exposures occurred, but the device was damaged beyond repair and will be returned to the manufacturer for disposal."

State Event Report ID: NV-20-0010

* * * UPDATE VIA EMAIL FROM HALEY BROWN TO HOWIE CROUCH AT 1458 EST ON 10/23/2020 * * *

Leak Test results confirm that the Humboldt Portable Nuclear Gauge SN 3246 (11 mCi Cs-137/ 44 mCi Am-241) is not leaking. The licensee will be shipping this device to the manufacturer on Monday, October 26th for disposal.

Notified R4DO (Pick) and NMSS Events notification (email).