Event Notification Report for September 07, 2021

EN Revision Imported Date: 9/7/2021

EN Revision Text: AGREEMENT STATE REPORT - REMOVABLE CONTAMINATION ON PACKAGE

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

"On August 30, 2021, a licensee reported to the Agency a package delivered to the licensee containing 39 mCi of Tc-99m had removable contamination on the exterior of the package of approximately 652 dpm/cm^2. The package arrived at about 1045 CDT. The licensee discovered the contamination during the routine package check-in survey at around 1130 CDT. The licensee confirmed that the vial inside the container was intact and that the contamination was only on the exterior of the package. The licensee notified the shipper and carrier of the contamination. An investigation into this event is ongoing."

Texas Incident Number: 9879

EN Revision Imported Date: 9/7/2021

EN Revision Text: AGREEMENT STATE - STUCK OPEN SHUTTER

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

"On August 30, 2021, a health physics service contractor reported a stuck shutter for the licensee. During a 6-month inspection check, the shutter was discovered to be stuck in the open position, which is the normal operating position. The contractor reports there will be no additional dose risk to personnel outside of the normal operations. The shutter is a Vega model SH F1B with serial number ov0895 with a 70 mCi Cs-137 source. The serial number for the source and the installation date were not known at the time of the initial reporting but will be given in the report. The contractor indicated the manufacturer would be contacted for repairs or replacement. Additional information will be provided per SA-300."

Texas Incident Number: 9880

EN Revision Imported Date: 9/7/2021

EN Revision Text: AGREEMENT STATE - STOLEN TROXLER GAUGE

The following was received from the South Carolina Department of Health and Environmental Control (the Department) via e-mail:

"On August 31, 2021, the Department was notified by the licensee's RSO at approximately 1230 EDT that one of its trucks containing a portable density gauge had been stolen from the side of the road on Meeting Street in Charleston, SC. The gauge was a Troxler Model 3440 s/n 38444 containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be. The licensee stated the police have been to the scene and took a police report. The truck is equipped with GPS and an active investigation is underway."

* * * UPDATE ON 9/3/2021 AT 0730 EDT FROM ANDREW ROXBURGH TO HOWIE CROUCH * * *

The following information was received from the South Carolina Department of Health and Environmental Control via e-mail:

"On August 31, 2021 at 1555 EDT, officers apprehended the suspect that stole the licensee's truck containing Troxler Model 3440 s/n 38444. The gauge was recovered undamaged and a radiation surveys performed indicated that radiation readings were within the limits specified in the SSD [sealed source and device sheet] for this gauge.

"The Department's on-call duty officer performed an on-site investigation on September 1, 2021."

Notified R1DO (Dimitriadis), NMSS Events Resource and ILTAB 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: 9/7/2021

EN Revision Text: AGREEMENT STATE - INCORRECT RADIOPHARMACEUTICAL ADMINISTERED

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

"On August 31, 2021, the Agency received a notification from the Nuclear Regulatory Commission (NRC) stating that a Missouri supplier of radiopharmaceuticals had reported a misadministration that occurred on July 12, 2021, with one of their products at a Texas licensee. The licensee contacted the Agency to report the event shortly after receiving the notification from the NRC. The licensee stated that a patient was to receive 0.041 mCi of Th-227 with enzymes to affect breast cancer but was given 0.041 mCi of Th-227 with enzymes to affect mesothelioma. The event resulted in approximately 6 Gy dose to the liver. The patient refused a post therapy scan and the licensee was not able to confirm that the radiopharmaceutical went to the correct tissue in the body. The mislabeling was discovered by the radiopharmaceutical supplier who then notified the licensee that the drug administered was not correct. The licensee has notified the patient and physician. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9882

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: 9/7/2021

EN Revision Text: AGREEMENT STATE - UNABLE TO RETRACT SOURCE

The following was received from the State of Texas (the Agency) via e-mail:

"On August 31, 2021, the Agency was contacted by the licensee and informed that they could not retract a 70 Curie, iridium - 192 source into an INC IR100 exposure device. The licensee stated they were working at a fab shop and could not retract the source back into the camera. The licensee did not believe a disconnect had occurred. The licensee stated a 2 millirem barrier was in place. The licensee stated they did not have anyone on its license to retract the source and requested the Agency's assistance in location a qualified company to retrieve the source. The licensee stated it contacted the manufacturer and it stated they could not assist them. The Agency provided them with the contact information of another manufacturer. The licensee contacted the other manufacturer, but it did not offer immediate assistance. The licensee told the Agency that one of its radiographers had received the training for retracting sources but was never added to the license. The licensee was given the contact information for the Agency's licensing group to see if the individual could be added to the license for source retrieval. At 1515 [CDT] the licensee reported the licensing group was able to accept the radiographer's training and amended the license for the retrieval. The licensee stated the individual qualified to retrieve the source was leaving for the site to perform the retrieval. The licensee will contact the agency when the source is retrieved. Additional information has been requested. Additional information will be provided as it is received in accordance with SA - 300.

Texas Incident No.: 9881

* * * UPDATE ON 8/31/21 AT 2237 EDT FROM ARTHUR TUCKER TO JOANNA BRIDGE * * *

The following was received from the State of Texas (the Agency) via e-mail:

"The licensee just reported the individual who will perform the recovery has just landed in Midland, Texas and will head to the site. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Josey) and NMSS via e-mail.

* * * UPDATE ON 8/31/21 AT 2351 EDT FROM ARTHUR TUCKER TO BRIAN P. SMITH * * *

The following was received from the State of Texas (the Agency) via e-mail:

"On August 31, 2021 at 2040 CDT the licensee reported that the source had been recovered to the fully shielded position. The individual who performed the recovery received 190 millirem. The licensee stated the exposure device and associated equipment will returned to the storage location and examined. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Josey) and NMSS via e-mail.

* * * UPDATE ON 9/2/21 AT 1548 EDT FROM ARTHUR TUCKER TO JOANNA BRIDGE * * *

The following was received from the State of Texas (the Agency) via e-mail:

"On September 2, 2021, the licensee contacted the Agency to find out where to send the written report. During the conversation the licensee stated, 'just for your information it appears that the connector spring was malfunctioning as the spring did not engage until about halfway depressed. [The licensee] talked with INC corporate [Radiation Safety Officer] (RSO) and the source will be sent to INC for failure analysis.' The Agency asked if that meant that the spring had disconnected and they stated that it had. The Agency stated that the initial report did not reflect that. [The licensee] stated he knew that and that he had misunderstood what the radiographer had told him over the phone. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Josey) and NMSS via e-mail.