Event Notification Report for April 12, 2021

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

EN Revision Imported Date: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST MOISTURE GAUGE

The following information was received from the State of California via email:

"On March 31, 2021, Kern County Roads Department contacted the California Office of Emergency Services to report that one of their moisture-density gauges was lost while transporting the gauge back to their facility. The gauge was a CPN model MC1-DPR, Serial Number MD00505649 (10 mCi Cs-137, 50 mCi Am:Be-241, Nominal). At approximately 1130 PDT, the gauge, with the handle/trigger lock in place but outside of the transport case, was left on the tailgate of the truck by the gauge operator. The operator then went into the cab of the truck and started working on paperwork. The gauge operator then left the worksite without securing the gauge. Approximately two minutes later, the operator stopped for gas and found the gauge missing. The operator then retraced his path and could not find the gauge. The Alternate Radiation Safety Officer was contacted and went to the worksite with a survey meter to search for the gauge and could not find it. Kern County Sheriff's Department was contacted and a report was made. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."

California Report Number: 033121


* * * UPDATE ON 4/2/2021 AT 1446 EDT FROM ANDREW TAYLOR TO KERBY SCALES * * *

The following update was received from the State of California via email:

"On April 1, 2021, the Alternate Radiation Safety Officer notified the California Department of Public Health that the gauge was recovered after an individual found it and returned it to the worksite. He stated that the gauge appeared to be intact with no apparent damage. A leak test will be performed to ensure that the sealed sources are intact and not leaking."

Notified R4DO (Alexander), NMSS Events Notification, ILTAB, CSNS (Mexico) via email.


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: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - GAUGE DAMAGED BY CONSTRUCTION VEHICLE

The following was received from the Texas Department of State Health Services (the Agency) via email:

"On April 1, 2021, at 1647 CDT, the Agency was notified by the licensee's radiation safety officer (RSO) that a Troxler model 3440 moisture density gauge containing an eight millicurie cesium-137 source and a 40 millicurie americium-241 source had been run over at a field site by a piece of equipment.

"The RSO stated the technician using the gauge stated that the cesium-137 source was in the fully shielded position when the event occurred. The RSO stated the technician was moving his equipment to a new test location at the site when the gauge was damaged. The RSO stated the gauge case was shattered and he was not sure how they would recover the gauge. He stated the gauge was reading 40 millirem per hour on contact near the cesium source. The RSO stated a barrier was establish around the gauge and the dose rate readings at the barrier were at background.

"The Agency advised the RSO to contact the manufacturer and request assistance in recovering the gauge. The RSO contacted the Agency a short time later and reported the manufacturer could not assist in the recovery. The RSO also stated that during his inspection of the gauge they discovered the cesium source was not in the fully shielded position. Also, it appeared that the source rod was no longer attached to the gauge housing. The RSO stated the source rod was bent so they could not retract the source into the shield.

"The licensee decided to recover the source by picking the source rod up from the end opposite of the source using channel locks and placing it in a thirty gallon can half full with sand and then covering the source with sand. The RSO reported the highest dose rate on the container after placing the source in the can and covering it with sand was 0.8 millirem per hour. The RSO contacted the Agency at 1828 CDT on April 1, 2021, and reported that the source was locked in their storage facility. The RSO stated they would work with the manufacturer to dispose of the gauge and sources. The RSO stated the gauge would be leak tested on April 2, 2021. The RSO stated the americium-241 source was not affected by the event. No individual received a significant exposure from the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9835

EN Revision Imported Date: 4/16/2021

EN Revision Text: PATIENT RECEIVES WRONG DOSE

The following is a summary from a phone call and subsequent e-mail from the technologist at the Good Samaritan Hospital in Vincennes, Indiana:

On Sunday, April 4th, 2021 at approximately 1130 EDT, a reportable event occurred when the technologist was called in to administer injections for two patients. The first patient was to have a lung scan. Instead of injecting the patient with Tc99m MAA for a lung perfusion, the technologist injected him with Tc99m Choletec that was to be used for the second patient. Both the lung dose and the gallbladder dose were calibrated for the same time and both were 5 mCi doses. The technologist picked up the wrong dose but did not double check the syringe sticker before administration. The patient suffered no visible harm and picked up an additional exposure from the 5.23 mCi of Tc99m Choletec and a delay in completing the exam since pictures would not be diagnostic if done before the choletec has had the chance to dissipate. The technologist notified the NRC Operations Center and completed an incident report for the hospital. The technologist plans to notify her supervisor, the Radiation Safety Officer, the patient's nurse, patient, and radiologist.


* * * RETRACTION ON 4/5/21 AT 1519 EDT FROM BROOK STRAHLE TO BETHANY CECERE * * *

On further evaluation, this event did not meet reportability requirements.

Notified R3DO (Pelke), NMSS (Williams), and NMSS Events Notification (by email)

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: 4/16/2021

EN Revision Text: AGREEMENT STATE REPORT - FAILED SHUTTER HANDLE ON NUCLEAR GAUGE

"On April 5, 2021, the licensee reported that on April 4, 2021, the roll pin in the shutter handle on a Berthold Model 8010 density gauge containing 20 milliCuries of cesium-137 had failed and the shutter handle came off. The gauge had been mounted on a pipe near the well head on a well in La Salle County, Texas. The licensee is authorized to replace the roll pin so one of its trained technicians responded to the site and removed the gauge and repaired the roll pin. The technician found the shutter was closed when he surveyed prior to beginning work. The licensee also reported the technician found that the nuts had backed off of the bolts where the gauge was mounted to the pipe, so the gauge was not snug to the pipe. The licensee contacted Berthold to discuss effects of vibration as it pertains to this event (and potential effect for its other gauges mounted similarly) as well as the corrosion that was observed on roll pin(s). The licensee's determination was that there would not have been any exposures as a result of this event. The licensee will keep the gauge in storage until it can complete an evaluation of the gauge mounting location and the roll pin type for this and its other gauges. An investigation into this event is ongoing. Further information will be provided as it is obtained in accordance with SA-300.

"Device/Source Information:
"Berthold Model 8010 SN: 10455
"20 milliCurie cesium-137 source: SN: 0330/12 (Eckert-Zigler Model CS7.P02)"

Texas Incident Number: 9836

EN Revision Imported Date: 4/16/2021

EN Revision Text: FITNESS FOR DUTY REPORT

A contract employee supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The employee's access to the plant had been terminated.