Event Notification Report for March 26, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/25/2021 - 03/26/2021
Agreement State
Event Number: 55210
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Advent Health
Region: 2
City: Altamonte Springs State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: Matt Senison
HQ OPS Officer: Thomas Kendzia
Licensee: Advent Health
Region: 2
City: Altamonte Springs State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: Matt Senison
HQ OPS Officer: Thomas Kendzia
Notification Date: 04/23/2021
Notification Time: 14:34 [ET]
Event Date: 03/26/2021
Event Time: 00:00 [EDT]
Last Update Date: 04/23/2021
Notification Time: 14:34 [ET]
Event Date: 03/26/2021
Event Time: 00:00 [EDT]
Last Update Date: 04/23/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
ARNER, FRANK (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
ARNER, FRANK (R1DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 5/21/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST RADIOLOGICAL DEVICE
The following was received by email from the state of Florida:
"On March 26, 2021, a Co-57 reference vial was left by NMT (Advent Health) with ammo cases in the hotlab for pickup by Jubiliant pharmacy. On March 29, 2021, NMT noted the vial was gone, and later inquired of Jubiliant for transfer paperwork. Jubiliant denied picking up the source. Advent Health has conducted a thorough investigation and search for source and has contacted Jubiliant several more times and have not found the source. Source calibration certificate 07-21-2017, 5.51 mCi [Mfg - Benchmark, Model BM06E, serial # BM06057E17200109]. Jubiliant manager [was contacted]. Advent Health will send in a written report."
Florida Incident Number: FL21-048
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
EN Revision Text: AGREEMENT STATE REPORT - LOST RADIOLOGICAL DEVICE
The following was received by email from the state of Florida:
"On March 26, 2021, a Co-57 reference vial was left by NMT (Advent Health) with ammo cases in the hotlab for pickup by Jubiliant pharmacy. On March 29, 2021, NMT noted the vial was gone, and later inquired of Jubiliant for transfer paperwork. Jubiliant denied picking up the source. Advent Health has conducted a thorough investigation and search for source and has contacted Jubiliant several more times and have not found the source. Source calibration certificate 07-21-2017, 5.51 mCi [Mfg - Benchmark, Model BM06E, serial # BM06057E17200109]. Jubiliant manager [was contacted]. Advent Health will send in a written report."
Florida Incident Number: FL21-048
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: 55159
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Construction Testing Services, Inc.
Region: 4
City: Sacramento State: CA
County:
License #: 6431
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Brian P. Smith
Licensee: Construction Testing Services, Inc.
Region: 4
City: Sacramento State: CA
County:
License #: 6431
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Brian P. Smith
Notification Date: 03/29/2021
Notification Time: 21:05 [ET]
Event Date: 03/26/2021
Event Time: 08:13 [PDT]
Last Update Date: 03/29/2021
Notification Time: 21:05 [ET]
Event Date: 03/26/2021
Event Time: 08:13 [PDT]
Last Update Date: 03/29/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE REPORT - GAUGE ABANDONED ON SIDE OF ROAD
The following report is from the California Department of Public Health, Radiation Health Branch (CDPH-RHB):
"CDPH-RHB forwarded a March 26, 2021, 0813 [PDT] email from a Sacramento County Environmental Specialist. The message stated that a moisture density gauge had been found alongside Jackson Highway in Sacramento the previous night and was being stored at the Caltrans yard in Sacramento. A separate report of the recovered gauge was received from the Department of Energy Radiological Assistance Program, Region 7, after they received a report from Sacramento Hazmat of the recovered gauge.
"CDPH-RHB opened an investigation on March 26, 2021 to determine the gauge owner (Construction Testing Services, Reactor Materials License Number 6431), and the circumstances of how the Troxler gauge (partial serial number 12475) ended up abandoned on the side of Jackson Highway in Sacramento."
California Event No: 032621
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
EN Revision Text: AGREEMENT STATE REPORT - GAUGE ABANDONED ON SIDE OF ROAD
The following report is from the California Department of Public Health, Radiation Health Branch (CDPH-RHB):
"CDPH-RHB forwarded a March 26, 2021, 0813 [PDT] email from a Sacramento County Environmental Specialist. The message stated that a moisture density gauge had been found alongside Jackson Highway in Sacramento the previous night and was being stored at the Caltrans yard in Sacramento. A separate report of the recovered gauge was received from the Department of Energy Radiological Assistance Program, Region 7, after they received a report from Sacramento Hazmat of the recovered gauge.
"CDPH-RHB opened an investigation on March 26, 2021 to determine the gauge owner (Construction Testing Services, Reactor Materials License Number 6431), and the circumstances of how the Troxler gauge (partial serial number 12475) ended up abandoned on the side of Jackson Highway in Sacramento."
California Event No: 032621
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: 55155
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: Environmental Concerns Inc.
Region: 1
City: Louisville State: KY
County:
License #: 201-651-58
Agreement: Y
Docket:
NRC Notified By: Anjan Bhattacharyya
HQ OPS Officer: Lloyd Desotell
Licensee: Environmental Concerns Inc.
Region: 1
City: Louisville State: KY
County:
License #: 201-651-58
Agreement: Y
Docket:
NRC Notified By: Anjan Bhattacharyya
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/26/2021
Notification Time: 13:05 [ET]
Event Date: 03/26/2021
Event Time: 05:55 [EDT]
Last Update Date: 03/26/2021
Notification Time: 13:05 [ET]
Event Date: 03/26/2021
Event Time: 05:55 [EDT]
Last Update Date: 03/26/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE REPORT - STOLEN RADIOLOGICAL DEVICE
The following information was received via E-mail from the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB):
"The Radiation Safety Officer [RSO] for Kentucky Radioactive Materials Licensee Environmental Concerns Inc., reported the theft of a single Viken Pb200i [TM] XRF device (Serial No: 2374 with sealed source model IPL 3901 Series, serial number SI-705, with 5 milliCuries of cobalt-57) from the RSO's vehicle while parked overnight at the user's residence located in Louisville, KY. The device case was secured by a cable to the rear seat support within the cab of the locked vehicle, and was stolen from within the vehicle. The cable and lock combination were recovered in the vehicle. A report was made to the Louisville Metro Police Department which is investigating the theft (Report No. 8021016661). The Kentucky Radiation Health Branch, will follow up with an interview with the RSO."
Kentucky Event Report ID Number: KY210001
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
EN Revision Text: AGREEMENT STATE REPORT - STOLEN RADIOLOGICAL DEVICE
The following information was received via E-mail from the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB):
"The Radiation Safety Officer [RSO] for Kentucky Radioactive Materials Licensee Environmental Concerns Inc., reported the theft of a single Viken Pb200i [TM] XRF device (Serial No: 2374 with sealed source model IPL 3901 Series, serial number SI-705, with 5 milliCuries of cobalt-57) from the RSO's vehicle while parked overnight at the user's residence located in Louisville, KY. The device case was secured by a cable to the rear seat support within the cab of the locked vehicle, and was stolen from within the vehicle. The cable and lock combination were recovered in the vehicle. A report was made to the Louisville Metro Police Department which is investigating the theft (Report No. 8021016661). The Kentucky Radiation Health Branch, will follow up with an interview with the RSO."
Kentucky Event Report ID Number: KY210001
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: 55156
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Isomedix Operations Inc.
Region: 4
City: El Paso State: TX
County:
License #: L04268
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Brian P. Smith
Licensee: Isomedix Operations Inc.
Region: 4
City: El Paso State: TX
County:
License #: L04268
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Brian P. Smith
Notification Date: 03/27/2021
Notification Time: 21:03 [ET]
Event Date: 03/26/2021
Event Time: 18:00 [MDT]
Last Update Date: 03/27/2021
Notification Time: 21:03 [ET]
Event Date: 03/26/2021
Event Time: 18:00 [MDT]
Last Update Date: 03/27/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE REPORT - LOSS OF POWER TO IRRADIATOR
The following was received from the State of Texas (The Agency) via email:
"On March 27, 2021 at approximately 1021 [CDT], the licensee reported that on March 26, 2021, at approximately 1800 [MDT], their facility in El Paso, Texas, experienced the loss of an electrical breaker which resulted in loss of power to their irradiator, irradiator control system, and equipment room. The source racks immediately descended to the fully shielded position verified by the licensee. There was no exposure to any employee during this event.
"The access control radiation monitor was not operable due to power loss. The irradiator entry door, as designed, remained locked and unable to be opened. The building security system and security access alarm remained in full operation and the facility was manned. Product entry and exit portals were secured. The pool water circulation stopped due to the power loss and the radiation monitor that monitors the pool water for contamination from leaking sources also stopped working. The deionization monitor had been working properly until the time of the power loss and no levels above background had been detected. An authorized employee was scheduled to collect a water sample from the pool to be analyzed.
"The electrical breaker was replaced, all systems tested, and the irradiator resumed full operation by 1700 [MDT] on March 27, 2021. The irradiator is a Nordion Model 8900."
Texas Incident Number has not yet been assigned.
EN Revision Text: AGREEMENT STATE REPORT - LOSS OF POWER TO IRRADIATOR
The following was received from the State of Texas (The Agency) via email:
"On March 27, 2021 at approximately 1021 [CDT], the licensee reported that on March 26, 2021, at approximately 1800 [MDT], their facility in El Paso, Texas, experienced the loss of an electrical breaker which resulted in loss of power to their irradiator, irradiator control system, and equipment room. The source racks immediately descended to the fully shielded position verified by the licensee. There was no exposure to any employee during this event.
"The access control radiation monitor was not operable due to power loss. The irradiator entry door, as designed, remained locked and unable to be opened. The building security system and security access alarm remained in full operation and the facility was manned. Product entry and exit portals were secured. The pool water circulation stopped due to the power loss and the radiation monitor that monitors the pool water for contamination from leaking sources also stopped working. The deionization monitor had been working properly until the time of the power loss and no levels above background had been detected. An authorized employee was scheduled to collect a water sample from the pool to be analyzed.
"The electrical breaker was replaced, all systems tested, and the irradiator resumed full operation by 1700 [MDT] on March 27, 2021. The irradiator is a Nordion Model 8900."
Texas Incident Number has not yet been assigned.
Agreement State
Event Number: 55157
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: Cleveland Clinic Foundation
Region: 3
City: Cleveland State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: Michael J Rubadue
HQ OPS Officer: Lloyd Desotell
Licensee: Cleveland Clinic Foundation
Region: 3
City: Cleveland State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: Michael J Rubadue
HQ OPS Officer: Lloyd Desotell
Notification Date: 03/29/2021
Notification Time: 09:10 [ET]
Event Date: 03/26/2021
Event Time: 14:00 [EDT]
Last Update Date: 03/29/2021
Notification Time: 09:10 [ET]
Event Date: 03/26/2021
Event Time: 14:00 [EDT]
Last Update Date: 03/29/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT REPORT - UNDERDOSAGE
The following was received from the Ohio Radioactive Materials Program via email:
"On Friday March 26, 2021 at approximately 1400 [EDT], a patient was treated with a single dose of Yttrium-90 Theraspheres. Following the procedure, the licensee determined that 76.1 percent of the prescribed dose was delivered to the patient based upon post treatment surveys of the catheter, tubing and other waste.
"No contamination was detected on the delivery system or in the room post procedure. No staff members were contaminated and there was no harm to the patient. The patient and referring physician were notified."
Ohio NMED Report: OH210002
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 Text: AGREEMENT STATE REPORT - MEDICAL EVENT REPORT - UNDERDOSAGE
The following was received from the Ohio Radioactive Materials Program via email:
"On Friday March 26, 2021 at approximately 1400 [EDT], a patient was treated with a single dose of Yttrium-90 Theraspheres. Following the procedure, the licensee determined that 76.1 percent of the prescribed dose was delivered to the patient based upon post treatment surveys of the catheter, tubing and other waste.
"No contamination was detected on the delivery system or in the room post procedure. No staff members were contaminated and there was no harm to the patient. The patient and referring physician were notified."
Ohio NMED Report: OH210002
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.