Event Notification Report for July 08, 2021

EN Revision Imported Date: 7/8/2021

EN Revision Text: AGREEMENT STATE REPORT - SOURCE LOST DURING SHIPPING

The following was received from the Georgia Radioactive Materials Program (Agency) via email:

"Hurst Boiler Welding Company used [a common carrier] to ship a source changer back to QSA Global. It was shipped on May 19, 2021, and officially declared lost on 6/14/21. Hurst Boiler reported the loss to [the Agency] on 6/16/21. The licensee intended to ship a source changer back to QSA global via [a common carrier] on 5/19/2021. After approximately 14 days without a confirmation of receipt. The licensee contacted [the common carrier] on 6/14/21, who confirmed the source had been lost. The Radiation Safety Officer (RSO) then contacted [the Agency] on 6/16/21. When speaking with the RSO by phone, he stated the source changer contains an Ir-192 source (Serial # 9887G Model SC-800). The source activity when shipped (5/19/21) was 8.3 Ci and as of 6/16/21 it has decayed to 6.3 Ci. The most current leak test was performed on 8/31/21. The RSO was advised to provide a written report and submit all supporting documents as soon as possible."

Georgia Incident #41

* * * UPDATE ON 7/7/21 AT 1700 EDT FROM SHATAVIA WALKER TO BRIAN P. SMITH * * *

The source has been retrieved in North Carolina. The following e-mail was received from the North Carolina Department of Health and Human Services in regards to finding the lost source:

"[The common carrier] confirmed with our staff this morning that the shipment was located in Durham, NC. It had been delivered to an incorrect shipping warehouse. [The common carrier] picked the source up from that location and got it back on route to the vendor in Massachusetts. The RSO provided receipt confirmation from the vendor that the source had been returned. The error was discovered by reviewing video footage and noticing it being loaded to the truck bound for Durham."

Notified R1DO (Lilliendahl), NMSS Events Notification (E-mail), and ILTAB (E-mail)

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

EN Revision Imported Date: 7/8/2021

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following event description was received via e-mail from the Virginia Radioactive Materials Program (VRMP):

"On June 29, 2021, at 1039 EDT, a representative of the VRMP received a report from a licensee's Radiation Safety Officer (RSO) via telephone call that a portable nuclear moisture/density gauge was damaged when hit by a car at a jobsite. The report indicated that a Troxler density gauge (Model 4640-B, containing 9 milliCuries of Cesium-137) was being used for asphalt testing when a car drove into the closed lane and hit the gauge. During the accident, the gauge housing was damaged but the source appeared to remain intact within the housing. The licensee's survey of the gauge yielded readings of 0.05 mR/hr at about 3-4 feet distance from the gauge. The gauge was taken to the licensee's office in its transport container and then was sent for further evaluation and leak testing on the morning of June 30, 2021. The VRMP is working with the licensee to obtain additional information. This report will be updated once the licensee's investigation is complete and the information is received. According to the RSO, no public exposure occurred."

Virginia Event Report Number: VA21003

EN Revision Imported Date: 7/8/2021

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SOIL MOISTURE DENSITY GAUGE

The following event report was received via e-mail from the Florida Bureau of Radiation Control (BRC):

"The vice president (VP) of the licensee called the BRC at 1015 EDT to report that a SMDG [(small moisture density gauge)] was hit or run over by a front end loader at 1010 EDT this morning. The location is a construction site north of the intersection of Connorton Blvd. and US-41 Land O' Lakes, FL 34637. The VP intends to evaluate SMDG, then send it to Troxler. The VP will provide a written report to the BRC."

Florida Incident Number: FL21-087

EN Revision Imported Date: 7/8/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

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

"On June 30, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that a Troxler model 3440P was stolen from a truck parked overnight at a technician's home. The gauge contains a 40 milliCurie americium - 241 source and an 8 milliCurie cesium - 137 source. The technician had taken the gauge home on June 29, 2021. The gauge was inside a locked transport container that was located inside a locked metal container which was chained with two independent chains and locked to the back of the truck. The chains were cut and the metal container was stolen. The technician went to their truck at 0530 [CDT] hours on June 30, 2021, and discovered the theft. The technician spoke with neighbors that told him their dogs were barking at around 0230 [CDT] hours, and he suspects this may have been when the gauge was stolen. The RSO stated the operating arm was locked in the shielded position and that local law enforcement [Fort Worth Police] was notified."

Texas Incident Number: 9862


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: 7/8/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN FIXED NUCLEAR GAUGE

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

"On June 30, 2021, the Agency was notified by one of its General License Acknowledgement holders that it had determined that a Vega model SHLD1 nuclear gauge, containing 50 milliCuries of cesium-137, was missing and suspected stolen. The gauge had been mounted at a facility [in Kosse, TX] that was closed in 2019. The gauge is thought to have been stolen at some point after the facility closed."

Texas Incident Number: 9863

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: 7/8/2021

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDER DOSE

The following was submitted by the California Department of Public Health - Radiologic Health Branch (RHB) by email:

"On 07/01/2021, licensee contacted RHB to report a medical event associated with Ytrrium-90 TheraSpheres. On the written directive, Authorized User's (AU) desired dose to the target volume was 800 Gy. Based on the calculations, radiation dose delivered was 400.2 Gy.

"During the procedure, patient was infused with 1.067 Gbq of Y-90. Upon completion of the infusion, based on residual exposure readings, it was determined that an estimated dose of 0.522 Gbq was delivered to the patient, 50% of the written directive. Given the Y-90 supply vial was empty, based on the 0.00 mR/hr reading on the adjacent dosimeter, it has been speculated that Y-90 was held up in the micro-catheter. AU suspects this high residual waste reading was due to a slower infusion of the treatment dose and flushing fluid; this will be determined at a later date when the yttrium-90 waste material has decayed and can be safely broken down with individual components measured. The referring physician (AU), informed the patient of the event.

"RHB will be following up on the medical event."

CA 5010 Number: 070121

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.