Event Notification Report for November 02, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/01/2021 - 11/02/2021
Agreement State
Event Number: 55542
Rep Org: Ohio Bureau of Radiation Protection
Licensee: University of Cincinnati Medical Center
Region: 3
City: Cincinnati State: OH
County:
License #: 02110310001
Agreement: Y
Docket:
NRC Notified By: Michael Rubadue
HQ OPS Officer: Brian P. Smith
Notification Date: 10/25/2021
Notification Time: 15:40 [ET]
Event Date: 10/22/2021
Event Time: 12:00 [EDT]
Last Update Date: 10/25/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Orlikowski, Robert (R3)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 11/2/2021
EN Revision Text: AGREEMENT STATE - EQUIPMENT FAILURE
The following report was received by the Ohio Bureau of Radiation Protection via email:
"The licensee reported a Varian Varisource 200 HDR unit failed to indicate the source was fully retracted at the conclusion of patient treatment. The licensee initiated emergency procedures and entered the room. Surveys confirmed the source had fully retracted into the unit and the patient did not receive any additional dose beyond what was prescribed. The unit console has been locked and placed out of service until the manufacturer can inspect and repair the device."
Ohio Report Number: OH210008
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.
Agreement State
Event Number: 55543
Rep Org: NJ Dept of Environmental Protection
Licensee: SOFIE
Region: 1
City: Totowa State: NJ
County:
License #: 832599-RAD-210001
Agreement: Y
Docket:
NRC Notified By: Nancy Stanley
HQ OPS Officer: Brian P. Smith
Notification Date: 10/25/2021
Notification Time: 16:36 [ET]
Event Date: 10/25/2021
Event Time: 10:45 [EDT]
Last Update Date: 10/25/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Ferdas, Marc (R1)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 11/2/2021
EN Revision Text: AGREEMENT STATE - CONTAMINATED PACKAGE
The following information was received from the New Jersey Department of Environmental Protection via email:
"At 1030 EDT on October 25, 2021, a package containing Zr-89 was received from the common carrier (airway bill number 770242368189) at the licensee's facility in New Jersey. At 1045 EDT, the package was wipe tested by a licensee employee and results indicated a high level of removable contamination. The bottom of the box read 217,410 counts per minute (cpm), while the background read 1,510 cpm. The box was opened and the top of the lead pig which holds the vial of liquid (approximately 200 microliters) radioactive Zr-89, which was 2,139 MBq at time of packaging on October 22, 2021, was found to be detached from the bottom of the lead pig. Pieces of the vial were observed to be outside of the lead pig which indicates the vial was indeed broken. The box was re-sealed and placed into the cyclotron vault at the licensee's facility for safety and containment purposes. At 1100 EDT, the Zr-89 manufacturer and shipper were notified of the situation. The box has been secured and contained within the cyclotron vault, 50 feet away from personnel at the facility."
Agreement State
Event Number: 55544
Rep Org: Arizona Dept of Health Services
Licensee: Honorhealth dba Scottsdale Osborn Medical Center
Region: 4
City: Scottsdale State: AZ
County:
License #: 07-177
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Lloyd Desotell
Notification Date: 10/26/2021
Notification Time: 11:03 [ET]
Event Date: 10/25/2021
Event Time: 00:00 [MST]
Last Update Date: 10/26/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Pick, Greg (R4)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 11/2/2021
EN Revision Text: AGREEMENT STATE REPORT - DISLODGED I-125 EYE PLAQUE
The following information was received from the Arizona Department of Health Services (the Department) via email:
"On October 25, 2021, the Department received notification that an I-125 eye plaque became dislodged from a patient's eye and fell to the floor. The eye plaque contained 30 Iso-Aid High Activity Advantage seeds with an activity of 1.33 mCi per seed. The patient placed the eye plaque in a lead pouch and then contacted the Authorized User, who was able to take possession of the seeds. The Ophthalmologist that performed the surgery has been notified. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
Arizona Incident No: 21-007
Agreement State
Event Number: 55545
Rep Org: California Radiation Control Prgm
Licensee: CTE CAL, Inc.
Region: 4
City: Fremont State: CA
County:
License #: 8327-01
Agreement: Y
Docket:
NRC Notified By: Arunika Hewadikaram
HQ OPS Officer: Donald Norwood
Notification Date: 10/26/2021
Notification Time: 18:59 [ET]
Event Date: 10/26/2021
Event Time: 05:30 [PDT]
Last Update Date: 10/26/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Pick, Greg (R4)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
CNSNS (Mexico), - (EMAIL)
Event Text
EN Revision Imported Date: 11/2/2021
EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following information was received via E-mail:
"On 10/26/21, California Office of Emergency Services (CALOES) contacted the Radiologic Health Branch (RHB) to report a stolen moisture density gauge. The gauge stolen is a Troxler Model 3430, S/N 23760, containing 9 mCi of Cs-137 and 44 mCi of Am-241. The report stated that the gauge was stolen out of user's truck parked at his residence located in San Leandro, CA, between 5:30-6:00 am on 10/26/2021. The licensee had notified San Leandro Police Department of the theft (report number unavailable).
"RHB will be following up on this investigation."
California 5010 Number: 102621
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