Event Notification Report for November 23, 2020

AGREEMENT STATE REPORT - LOST AM-241 SEALED SOURCE PACKAGE

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"The Agency was contacted on 11/23/2020 by the Radiation Safety Officer for Heuft USA, Inc. to advise that a package scheduled to arrive today at their Downers Grove, IL facility had not arrived. The carrier, [common carrier], could not immediately locate the package. The package contained (1) special form model AMC-25 sealed source containing approximately 45 mCi of Am-241. The source serial number is 1535AR. The source is contained in a 6"x6"x6" brown "U-Line" cardboard box. As it was an excepted package, it only bears UN2910 and does not have radioactive labels on the exterior. Should the package be opened, there is an aluminum 5"x5" round can filled with foam and a zip lock bag. The bag contains a shielded source holder with the Am-241 capsule therein. The bag and the can are reportedly labeled with a trefoil and the words "Radioactive Material". Unshielded, the source would yield an exposure rate of about 8 mR/hour at one foot. This is not an immediate hazard to workers or members of the public that locate the package.

"The package is assigned tracking number 349-162302-3 by [the common carrier]. The package left their Kearny, NJ terminal on 11/19/2020. There is conflicting information on whether or not the package arrived at [the common carrier's] Akron, OH terminal. The package was bound for [the common carrier's] Bolingbrook, IL terminal but reportedly never arrived. The carrier is actively searching and Illinois staff are in contact. New Jersey program staff have been notified as well. This report will be updated as additional information becomes available."

Illinois Item Number: IL200023

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 - DOSED INCORRECT ORGAN

The following information was received from the state of New York via fax:

"A medical licensee reported on 11/23/2020 that a Y90 microsphere procedure performed on Friday 11/20/2020 was later discovered to have had the catheter connected to the gallbladder instead of the liver as prescribed in the written directive. More information will be forthcoming but preliminary information shows that the microspheres were Sirtex SIR-Spheres."

New York Incident Number: NYDOH-20-07.


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 REPORT - STUCK SHUTTER

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

"Marathon Petroleum Company contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section on November 24, 2020, concerning a stuck shutter. The fixed gauge is stuck open and determined on November 23, 2020 to be in this condition. The fixed gauge is an Ohmart/Vega Model Number SHGL-2, s/n for housing and source is 9853 CN. The source is Cs-137 with an activity of 5000 mR (185 GBq). There were no radiation exposures. A technician from BBP will be out at the facility on December 1, 2020 for repair."

Louisiana Incident No.: LA20200009