Event Notification Report for January 08, 2021

PROCESS GAUGE SHUTTER STUCK OPEN

The following is a synopsis of the phone call and email from Dow Chemical, Midland:

While conducting a troubleshooting evaluation on the process gauge, personnel became aware that the shutter for the gauge was stuck in the open (normal operating) position. The unit is located approximately fifteen feet above the operating level. Personnel exposure is precluded by the location. The vendor has been contacted to determine a resolution plan and will be on-site next week.

Gauge Info:
Manufacturer: Vega Americas
Source Holder Model: SH-F2B
Isotope and quantity: Cesium-137, 750 mCi
Source serial number 9006CP
Source holder serial number 46168107

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT UNDERGOING RADIATION TREATMENT

The following information was received from the Radiologic Health Branch, California Department of Public Health via email:

"On Friday, January 8, 2021, the University of California Los Angeles (UCLA) notified the Radiologic Health Branch that a potential medical event involving Y-90 had occurred that day. A liver cancer patient was administered four vials of Y-90 BTG Nordion Inc. TheraSpheres to the patient's liver segments 4, 5, 6 and 7.

"Segment 4 was prescribed 120 Gy ( 0.86 GBq) and the delivered dose was 110.6 Gy (92.17%). Segment 5 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 113.4 Gy (94.5%). Segment 6 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 111.7 Gy (93.08%). Segment 7 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 50.2 Gy (41.83%), which is less than 20 % of the prescribed amount. Overall, the average of the four administrations to the patient's liver was 80.4%.

"On January 10, 2021, the Radiologic Health Branch, sent an email to UCLA's Radiation Safety Officer requesting that UCLA's Environmental Health and Safety medical team perform an investigation to try to determine the root cause of the delivery failure for segment 7. They were asked to interview the authorized user and all other personnel attending the procedure and also to provide copies of the authorized user's written directives. The patient was notified of the under-dosage and potential continuation of their cancer treatment. "

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 - HDR SOURCE NOT FULLY SECURED IN TRANSPORT PIG

The following information was received from New Jersey Department of Environmental Protection (the Agency) via email:

"On January 11, 2021, the Agency was notified by the licensee that during a vendor source exchange of the center's radiation oncology Iridium-192 remote afterloader source (approximately 5.2 Curies at time of incident), the service engineer, noted the failure of the source to be fully secured in its transport pig bucket. This was discovered because the service technician's personal monitor and the in-room monitor both indicated the presence of radiation. The service technician promptly left the vault, closed the door, notified the physicist on site, and the room was secured from further entry.

"This engineer, another service engineer, the vendor RSO and source recovery team then worked to fully secure the source as per their source exchange procedure. The estimated doses received during the incident are 52.8 mrem and 39.9 mrem to the service engineers involved in securing the source. Their dosimeter readings will be available in the future. No patients or hospital staff were exposed. The vendor will supply the hospital with a full report on the incident, including possible cause."

Equipment/device involved, Isotope and activity, manufacturer, model and serial number, leak test results as applicable: Varian Medical Systems, VariSource ix HDR, serial number VS-321, Ir-192, 5.2 Ci (at time of incident), manufactured by Alpha Omega Services, model VS2000, serial number 02-01-2823-001-101420-11593-17.


New jersey Incident No.: N/A


Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)