Event Notification Report for April 29, 2021

EN Revision Imported Date: 4/29/2021

EN Revision Text: LOST THEN FOUND SOURCE MATERIAL

The following is a summary of information received from the U.S. Navy via phone and email:

On March 5, 2021, the it was discovered that IBIS units (400 micro Ci total) had not been properly removed from 4 helicopter blades that were sent for recycling. The IBIS units were discovered when the detectors alarmed at the recycling facility in Bedford, IN. The blades were redirected to the Army Joint Munitions Command Morris Consolidation facility in Rock Island, IL for proper disposal.

Based on the shipping paperwork, the helicopter blades that contained the four IBIS were received at the recycling facility on 11/17/2020, and were picked up from the facility on 3/16/2021.

The highest reading was 0.7 mR/hr on contact without the cover installed for one blade. For the 3 other blades in their casing, needle deflection was observed, but had no appreciable dose rate.

It is not likely that personnel spent an appreciable amount of time in the vicinity of the helicopter blades.

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

* * * UPDATE ON APRIL 28, 2021 AT 14:27 FROM ANTHONY WILLIAMS TO THOMAS HERRITY * * *

Additional investigation has shown that the IBIS (Sr-90) sources were 500 microCuries each for a total of 2,000 microCuries sent to the recycling center.

Notified R1DO (Schroeder), ILTAB and NMSS via email.

EN Revision Imported Date: 4/29/2021

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was received from the Washington State Department of Health:

"University of Washington broad scope license C001 reported a medical event. The event involves Y-90 microspheres contained in two vials of different activity. Vial A and Vial B were to be delivered to different treatment sites. However, the vials were mixed up and the lower activity vial was delivered to the wrong site, the Authorized User (AU) realized it was the wrong vial and did not inject the second vial. This resulted in an underdose of more than 20 percent. A full report is expected in 15 days and will be forwarded."

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.

* * * UPDATE ON 04/28/2021 AT 1321 EDT FROM TRISTAN DAY TO BRIAN P. SMITH * * *

The following update is from the report received via e-mail from the Washington State Department of Health:

"On Friday April 9, 2021, a patient had been prescribed two dosages of yttrium-90 microspheres intended for two different liver treatment sites. One treatment dosage was a larger amount than the other, 35.9 mCi and 21.4 mCi. Both dosages were measured in the Nuclear Medicine CRC 15R dose calibrator prior to use. They were found to be the correctly prescribed amounts and the vials were labelled correctly. Both dosages were transported to the Interventional Radiology suite. When the authorized user (AU) called for the first dosage, the higher of the two activities (35.9 mCi), it was set up and administered, including the required radiation dose rate measurement taken prior to and during the dosing. When the AU called for the second dosage (21.4 mCi), he noticed that the radiation dose rate measurement of the second dosage was higher than it had read for the first administration, which was supposed to be the larger of the two dosages. Realizing that the smaller of the two dosages was mistakenly administered first, the physician stopped the treatment and did not administer the second dosage. It was then confirmed that the patient received the lower of the two dosages (21.4 mCi) to the treatment site that was supposed to receive the higher dosage (35.9 mCi). Nuclear Medicine informed the Environmental Health and Safety Department's (EHS) Medical Health Physicist (MHP), and the MHP subsequently informed the Radiation Safety Officer (RSO).

"Initially, there were questions regarding the need to evaluate this event as a possible Medical Event. There was uncertainty regarding applying the medical event criteria to both sites together or to each individual site. Additionally, the first treatment site was under-dosed and the AU subsequently had determined that the dose delivered was adequate for that site.

"After discussing the event with the MHP on Monday morning, April 12, 2021, the RSO requested a meeting with Department of Health (DOH) to discuss the event. The MHP and RSO discussed the event with DOH that afternoon, and DOH informed that it would depend if the written directive included both sites, or if there was a written directive for each site.

"On Tuesday, April 13, 2021, all the required information was obtained, and the MHP and RSO reviewed the dosage and dose calculations and determined that the medical event criteria was met. The dose delivered is less than prescribed, and will result in no harm to the patient and it is the intention of the physician to treat the second site at some future time."

Washington Event Report Number: WA-21-006

Notified R4DO (Proulx) and NMSS Events Notification via email.

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following information was received from the Alabama Department of Public Health Office of Radiation Control via email:

"On April 20, 2021 about 1130 [EDT], Alabama licensee Building and Earth Sciences, Inc. (license number 1266) called to report that a moisture density gauge had been run over by a compactor while at a temporary job site. The licensee's representative stated that the gauge was in several pieces, and the source rod/probe could not be retracted into the safe shielded position. The licensee collected a leak test once the gauge was safely stored; exposure measurements from the leak test envelope were less than or equal to background. The gauge is a Troxler 3430 s/n 32716, with 9 milliCuries Cs-137 and 44 milliCuries Am-241:Be. The Agency is waiting on the licensee's report of this matter. More information to follow."

Alabama Report No.: 21-12

AGREEMENT STATE REPORT - STATIC ELIMINATOR LOST IN SHIPPING

The following information was received from the Minnesota Department of Health via E-mail:

"On 4/15/2021, 3M Company received three of four boxes containing radioactive material shipped from NRD, LLC, in Grand Island, NY. The fourth package, containing one NRD model P-2042 static eliminator with an activity of 5 milliCuries of Po-210, was not received with the other three.

"3M contacted NRD and the common carrier to inquire about the status of the missing package. The common carrier's website indicates that the package in question is still in shipment. The common carrier initially stated that they believed the package was delivered on 4/15/2021 with the other packages in the shipment.

"When the package did not arrive on 4/15/2021, 3M started looking for the missing package in case it actually had been delivered and misplaced on the shipping dock, but the package has not been located. 3M has requested that a formal investigation be performed by the common carrier. The investigation is ongoing at the time of this notification."

* * * UPDATE ON 4/21/21 AT 1443 EDT FROM TYLER KRUSE TO DONALD NORWOOD * * *

The following information was received via from the Minnesota Department of Health via E-mail:

"Minnesota Department of Health was informed by the licensee that the source has been recovered. It was at the licensee's facility and had arrived in a mislabeled package from the manufacturer."

State Event Report ID No.: MN-21-0002

Notified R3DO (Peterson), ILTAB, NMSS Events Notification, and CNSC (Canada) 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: 4/26/2021

EN Revision Text: AGREEMENT STATE REPORT - UNREGISTERED GAUGES FOUND THEN ONE LOST

The following is a summary of a phone call from the state of Nevada:

A plant manager for the HC Companies Inc. was performing a walkthrough when three NDC-102 thickness gauges were discovered. The manager was familiar with the gauges from a different site, but this site did not have any registered, nor does this site have a license for any material. The gauges, potentially only requiring a general license, were moved and the corporate safety group notified in order to secure them. When the safety group arrived, one of the gauges was missing (s/n: 2690; source: 150 mCi of Am-241).

Item Number: NV210004

* * * UPDATE ON 4/23/2021 AT 1720 EDT FROM COREY CREVELING TO THOMAS KENDZIA * * *
The state of Nevada sent a picture of the missing source via email:

The picture confirms the the previous information and the date of the radiological strength was 1/92.

Notified: R4DO (Azua) (email), NMSS Event Notifications (email), and ILTAB (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