Event Notification Report for July 02, 2021

EN Revision Imported Date: 7/2/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING FIXED GAUGING DEVICE

The following information from the state of Utah was received by email:

"The Utah Division of Waste Management and Radiation Control (DWMRC) was notified by the licensee that a fixed gauge was missing on 06/04/2021 at approximately 1430 MST.

"The licensee was reconfiguring a portion of their facility and had relocated a number of gauges from one location to another location in their operations for use at the new location. One of the fixed gauging devices, a Thermo Fisher, model 5202, serial number B3339, containing 500 milliCuries of cesium-137 (Cs-137) would not fit at the new location. The fixed gauge was supposed to be removed from the hopper where it was located and placed in storage for future use. For some reason, this removal did not occur. The fixed gauge was left in place and had not been moved to a secured storage location. The shutter on the gauge was locked in the closed position.

"Yesterday afternoon (06/03/2021), the Radiation Safety Officer (RSO) was notified that the structure that the gauge had been located on had been demolished and the whereabouts of the gauge was not known. All of the materials from the demolition of the structure are still located in the area and are on the licensee's property. The licensee's staff began looking for the device. At about 1000 to 1100 MST this morning (06/04/2021), the licensee indicated that they had verified which gauge was missing and that it could not be located. The RSO began notifying all of the company personnel he is to notify when this occurs. The RSO thought he had 24 hours to report the gauge as missing to the DWMRC instead of the immediate notification that was required and did not immediately notify the DWMRC.

"At this point, the licensee is continuing to search through the demolished parts of the structure for the gauge and will continue to do so. The materials from the demolition are not to be relocated or removed from the licensee's property until a through search of all of the materials can be made or the device is located. The DWMRC will conduct an on-site investigation of this issue."

UT Event Report ID No.: UT-21-0001

* * * UPDATE ON 7/1/21 AT 1744 EDT FROM CONLEY CHRISTOFFERSEN TO BETHANY CECERE * * *

The following is a synopsis of information reported by the state of Utah by email:

"The device is a density meter used in a conveyance system. The conveyance system has been recently upgraded. Several similar devices were transferred to the upgraded system. This device was not scheduled to be transferred and was to be placed in storage for evaluation upon the completion of the project. Miscommunication occurred in that this device was not removed when the other devices were transferred and was instead left in place during initial demolition activities of the conveyance system. The device remained onsite, located in a pile of the larger scrap materials pending further processing (size reduction and sorting) prior to offsite recycling. It was in this scrap pile that the device was recovered intact.

"The device was located and recovered shortly after the recovery effort began on June 10, 2021, and transported offsite for disposal on June 11, 2021."

Notified R4DO (Werner), NMSS Events Notification, 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

EN Revision Imported Date: 7/2/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT
The following was received from the state of Ohio via email:

"Event occurred on 6/22/21. The patient was scheduled for therapy with Y-90 Sir-Spheres. The prescribed dose was 4389 rem. [However, they] administered only 3336 rem, or 76 percent (-24 percent) of the prescribed dose. During the infusion of the Sir-Sphere particles, the infusion catheter became clogged due to the high volume of particles. The catheter was removed, a new catheter placed and used for the infusion of the remaining particles. Stasis was not reached, there was not a patient event, and the estimated difference in dose to the patient exceeds 50 rem to the liver. There were no negative effect to the individual patient, no additional treatment is necessary as a result of this occurrence (administered therapy is sufficient), and no further actions are necessary to prevent recurrence. The physician notified the patient and [their] personal representative of the event, post therapy on 6/22/2021."

Ohio Item Number: OH210005

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: 7/2/2021

EN Revision Text: UNPLANNED CONTAMINATION TO AN INDIVIDUAL

The following synopsis was received via phone call from the licensee's Radiation Safety Officer (RSO):

At 1800 EDT on June 24, 2021 at the licensee facility, an employee left the work site unaware that he was contaminated on his skin and his clothing. The only places the individual traveled to were his car and his home before being called back to work at 1924 EDT to investigate the contamination event. When the individual came back to the facility, contamination was found on his hand including Sr-82, Sr-85, Rb-83, and Rb-84. The activity was 600,000 counts or 0.18 micro curies. Dose calculations have not been performed, however, the RSO does not believe the dose will be near any federal limits. The work area has been decontaminated and the individual's car has been surveyed and no contamination was found. The licensee plans to survey the individual's home as well as contact the NRC Region 3 materials inspector. The licensee is reporting the event under both 30.50(a) and 30.50(b)(1) as a precaution as more data is being collected.

* * * Update from Matthew Trusner to Donald Norwood at 1914 EDT on 6/25/2021 * * *

The following information was received via E-mail:

"On June 24, 2021, at approximately 1800 EDT, Curium-Noblesville RSO became aware of a radioactive spill in a restricted (production) area. The spill occurred behind the production hot cells. The affected area is designated as a triple shoe cover area and cordoned to limit access.

"The RSO directed a Radiation Safety Technician to respond to and initiate the investigation and data collection. The Radiation Safety Technician performed contamination surveys and found a maximum count rate of 800,000 cpm. The Radiation Safety Technician subsequently remediated the spill to 70,000 cpm (below the administrative level of 100,000 cpm) within minutes of completing the survey.

"The spill initiated when a Chemist tried to manually un-crimp a vial containing approximately 695 mCi of Sr-82 and 703 mCi of Sr-85. As the the Chemist tried to un-crimp the vial, the glass below the crimp broke leading to a few drops to fall on the concrete floor behind the hot cells. During the initial investigation surveys, the RSO discovered that the production batch record was contaminated. This prompted the RSO to find the Chemist to ensure he was free of contamination. The RSO discovered that the Chemist had already left the site.

"The RSO immediately contacted the Director of Health Physics for assistance. They made the decision to bring the Chemist onsite for a survey. The RSO discovered that the Chemist's work clothes presented spots reading approximately 600,000 cpm on contact with the pants and 200,000 with the shirt. The RSO also found contamination on the right hand reading approximately 34,000 cpm. Because the Chemist had left the site, the RSO surveyed the Chemist's car and did not identify contamination above background levels. The RSO communicated the findings to the Director of Health Physics and initiated the decontamination activities for the Chemist.

"Prior to decontaminating the Chemist's hand, the RSO obtained a gamma spectrum to identify the radioactive contaminants. He found a mixture of Sr-82, Sr-85, Rb-83 and Rb-84. The Director of Health Physics reviewed the notification requirements prescribed in Part 20 and Part 30 and escalated the event to Curium management and legal teams. Curium made the decision to proactively report the event to the NRC Operations Center under 10 CFR 30.50(a) given that the notification was required within 4 hours of discovery and Curium had not acquired enough data to verify if any regulatory limit was exceeded or not. After the notification, the RSO stopped the decontamination activities after no further contamination was being removed. The RSO measured a residual contamination of 4,200 cpm on the hand. He then followed the Chemist to his home and performed a contamination survey of the areas in which the Chemist indicated that he had been present after leaving the work site that day. The RSO found no contamination above background levels.

"The Director of Health Physics performed an initial dose estimate on June 25, 2021. The RSO used Rb-84 as the most restrictive nuclide that yielded the highest dose in the mixture. The estimates indicated that the Chemist received approximately 1,203 mrem to the maximally exposed shallow dose equivalent (extremity), 636 mrem shallow dose equivalent (whole body) and 13 mrem deep dose equivalent. The RSO performed 24-hour urinalysis and did not find the presence of the radionuclides. All license material was accounted for.

"Curium personnel discussed the incident with NRC Region-III on June 25, 2021. Curium is in the process of completing formal root cause analysis."

Notified R3DO (Stone) and the NMSS Events Notification E-mail group.

EN Revision Imported Date: 7/2/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE DISCONNECT

The following information was received via E-mail:

"On June 25, 2021, the Agency [Texas Department of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that while conducting radiography in their shooting bay, they experienced a source disconnect. The disconnect involved a QSA 880D exposure device containing a 60 curie iridium-192 source.

"The RSO stated the radiographer had completed an exposure and was entering the bay to exchange the film. As they passed the entrance beam the radiation alarm went off. The radiographer exited the area. The licensee was unable to retract the source. They contacted a service company who came to the licensee's location.

"It was determined that the ball on the drive cable had broken free of the drive cable. The service company was able to retract the source into the exposure device. No overexposures occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9860.

EN Revision Imported Date: 7/2/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

The following report was received from the Wisconsin Radiation Protection Section [the State]:

"On June 25, 2021, the licensee reported to the State a misadministration of Y-90 Theraspheres on the morning of the same day. The prescribed dose was 126 Gy to the right lobe of the liver, corresponding to 2.31 GBq. After the administration was complete, the licensee surveyed the residual material and noticed that an unusually high amount of material was still present in the administration setup. Initial calculations indicate that approximately 1.572 GBq of material was delivered to the patient. This corresponds to 68.8 percent of the prescribed dose resulting in a dose to the right lobe of the liver that differed from the prescribed dose by 39.2 Gy. The technologist notified the Authorized User immediately and the Authorized User then notified the patient. No unusual circumstances or events were noted during the administration, and there are no suspected spills or outside exposures resulting from this event. The State will continue to follow up on the event."

Wisconsin Event Report: WI210005

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.