Event Notification Report for April 06, 2021

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

EN Revision Imported Date: 4/6/2021

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 Imported Date: 4/6/2021

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 Imported Date: 4/6/2021

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 Imported Date: 4/6/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILED TO RETRACT

The following was received by email from the Commonwealth of Pennsylvania:

"The licensee reported that on February 12, 2021 while using a QSA Global Model 880, Serial # D15520, containing a 128 Curie source of iridium-192, the source failed to fully retract and lock. The technicians secured the area by adjusting their 2 mR/hr boundaries to an unshielded source distance and immediately contacted their company designee. Once on scene, the designee surveyed the scene and device and found elevated readings. Working the crank handle back and forth several times he was able to return the source to the secured and locked position. The device was taken back to the licensee's storage vault in Williamsport, PA for inspection. The cause of the incident is believed to be cold temperature and freezing of the lock mechanism. The Radiation Safety Officer (RSO) subsequently investigated the incident and found that neither the radiographer nor the assistant radiographer had been performing proper radiation surveys during the workday which would have identified the lock failure sooner. As a result, the radiographer received a dose of 876 mR. We are still awaiting a dose on the assistant radiographer. Corrective actions include retraining all radiography employees to follow proper procedure. Also, both the radiographer and assistant radiographer are no longer employed by the licensee."

PA Event Report ID No: PA210003

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

EN Revision Imported Date: 4/6/2021

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