Event Notification Report for November 02, 2021

EN Revision Imported Date: 12/3/2021

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL

The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email:

"The licensee was at a temporary jobsite and stepped away from their vehicle. An unknown man ran up to the vehicle and stole the truck and its contents. At the time the truck was stolen, a Moisture Density Gauge containing licensed material was secured in the bed of the licensee's truck in its transportation case. The licensee notified the police and has begun actions to recover the gauge. The Division is waiting for additional information from the licensee. "

Utah Event Report ID Number: UT 210006

* * * UPDATE FROM SPENCER WICKHAM TO THOMAS KENDZIA AT 1259 EDT ON 11/4/21 * * *
The following information was received via e-mail:

"At the time of this notification (UT 210006) we did not have information pertaining to the gauge. Please see the following gauge information.
Model: Instrotek 3500, Serial Number: 3823, Cs-137: 11 mCi, Am-241: 44 mCi.

"The licensee has recovered the stolen gauge. The gauge was still locked and chained in the transport vehicle in it's transport package and had not been tampered with. The Division will update and send the NMED report once the event is closed."

Notified R4DO (KOZAL), NMSS Events Notification group (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

EN Revision Imported Date: 12/3/2021

EN Revision Text: AGREEMENT STATE REPORT - FIRE IN POOL IRRADIATOR FACILITY

The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:

"The [Illinois Emergency Management] Agency was contacted at approximately 16:00 [CDT] on 11/2/21 by Isomedix Operations, Inc. (d/b/a Steris Applied Sterizliation Technologies, RML IL-01123-02) to advise of a fire in one of their irradiation cells that occurred at approximately 05:00 [CDT] this morning in Libertyville, IL. Sources, irradiator lift mechanisms, and associated safety/security systems were reportedly unaffected. Local fire personnel did respond, but maintenance crew were able to extinguish the fire prior to their arrival. This matter is reportable under 32 Ill. Adm. Code 346.830(a)(2).

"The radiation safety officer for Isomedix Operations, contacted the Agency at 16:00 [CDT] today and informed of a fire in a radiation room at their pool irradiator facility. Reportedly, maintenance crews were performing overhead welding in the source room when hot slag fell on a product tote. The tote was located near the portal entry of irradiator 192. The fire alarm was pulled and the maintenance crew was able to put out the fire using a handheld extinguisher. Local fire arrived, performed an investigation and departed without further concern. The irradiator was removed from service as Isomedix staff spent the duration of the day assessing safety systems. Water purity checks and exposure rates indicate no impacts to sources. Cables, cable shrouds and associated lifting mechanisms were assessed and were not impacted. Having found no additional radiological or safety mechanisms impacted, the facility returned to routine operations at 16:00 [CDT] today.

"IEMA staff are pursuing additional information from the licensee and performing a reactionary inspection on 11/3/21. Additional information will be communicated as it becomes available."

Illinois Report Number : IL210036

EN Revision Imported Date: 12/3/2021

EN Revision Text: AGREEMENT STATE REPORT - Y-90 MICROSPHERE MEDICAL EVENT

The following information was received from the Commonwealth of Massachusetts via email:

"On November 2, 2021, 3:00 PM [EDT], licensee reported medical event under license 60-0160 for Sirtex Wilmington LLC SIR-Spheres Y-90 microspheres (SS&D MA-1229-D-101-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more. A portion of a Y-90 5 mCi microsphere therapy treatment delivered to patient liver on November 2, 2021 remained in the delivery system causing delivery of approximately 3.67 mCi Y-90 of the prescribed 5 mCi. The error was discovered immediately after treatment. Administered dose to treatment area differed from prescribed dose by approximately 27 percent. Licensee stated the cause, including possible equipment malfunction, has not yet been determined. Prescribing physician, referring physician and patient have been notified. Licensee stated no negative health effects to patient due to situation. No additional Y-90 therapy treatment would be required due to this situation. Licensee stated all Y-90 was accounted for. Licensee stated 5 mCi prescription was unusually small compared to previous procedures (range 9-to-39 mCi with 15 mCi being the most prescribed dose). Licensee to submit written report within 15 days of discovery date. This is a next day reportable medical event per regulation.

Investigation ongoing. Agency considers this event docket to still be OPEN.

Report by Anthony Carpenito, 11/3/2021.

EN Revision Imported Date: 2/18/2022

EN Revision Text: LOST SOURCE MATERIAL

The following is a summary of information received from the U.S. Navy, Naval Radiation Safety Committee via phone and email:

10 CFR 20.2201(b) requires that each licensee shall submit a written report within 30 days after learning of the following: Any lost, stolen, or missing licensed material becomes known to the licensee, licensed material in a quantity greater than 10 times the quantity specified in appendix C to part 20 that is still missing at 30 day. Naval Surface Warfare Center Crane Division (NSWC Crane), Crane, Indiana self-reported the loss of permitted radioactive material consisting of one Vapor Tracer 2 Hand Held Explosive Detector (HHED). The Vapor Tracer 2 HHED, contained one Ecker and Ziegler Isotope Products Laboratories Model NER-004 Nickel-63 (Ni-63) sealed source not exceeding 10 millicuries (370 Mega-Becquerel).

Over the past years, NSWC Crane has recalled all the Vapor Tracer 2 HHED devices from all commands as the new, non-radioactive units are fielded for replacement.

Vapor Tracer 2 HHED, S/N: 09-8347, which was issued to the USS John S. McCain (DDG 56), was misplaced during the recall process, sometime between March 2020 and January 2021. An administrative Judge Advocate General Manual (JAGMAN) investigation was performed on the lost Vapor Tracer 2 HHED and determined the device was lost during shipment from Defense Logistics Agency (DLA) San Joaquin in Tracy, California to NSWC Crane.

On November 2, 2021 the Navy determined that radioactive material consisting of one Vapor Tracer 2 Hand Held Explosive Detector (HHED), was lost. The Vapor Tracer 2 HHED, contained one Ecker and Ziegler Isotope Products Laboratories Model NER-004 Nickel-63 (Ni-63) sealed source not exceeding 10 millicuries (370 Mega-Becquerel). The Radiation Safety Officer reported to the Navy master material license technical support center the loss of the licensed material on December 22, 2021.

The HHED was being shipped by Defense Logistics Agency (DLA) from San Joaquin in Tracy, California to Nuclear Surface Warfare Center in Crane Indiana. Extensive research for the lost HHED did not locate the device.

No exposure is known to have occurred. Exposure to individuals from radiation from the Vapor Tracer 2 is unlikely. The Ni-63 source, a weak beta emitter, does not pose an external exposure risk and is mounted as an internal component to the device. Under ordinary conditions of handling, storage, and use, the radioactive material contained in the device will not be released or inadvertently removed from the source housing. In addition, there are two radioactive material labels to warn personnel of the radioactive source that resides inside the device. One label is on the outside of the device and the other is on the detector housing on the inside of the instrument.

The Navy notified the NRC Regional Inspector (Shaffer).


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