Event Notification Report for November 03, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
11/02/2021 - 11/03/2021

EVENT NUMBERS
55544 55545 55547 55548
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: 11/3/2021

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: 11/3/2021

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 a.m. PDT 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


Agreement State
Event Number: 55547
Rep Org: Louisiana Deq
Licensee: QSA Global, Inc.
Region: 4
City: Baton Rouge   State: LA
County:
License #: LA-5934-L01
Agreement: Y
Docket:
NRC Notified By: Richard Blackwell
HQ OPS Officer: Donald Norwood
Notification Date: 10/27/2021
Notification Time: 14:32 [ET]
Event Date: 10/26/2021
Event Time: 15:50 [CDT]
Last Update Date: 10/27/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Pick, Greg (R4)
NMSS_Events_Notification, (EMAIL)
Gott, William (IR)
Event Text
EN Revision Imported Date: 11/3/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA DELIVERED TO WRONG ADDRESS

The following is a synopsis of information received via E-mail:

The Louisiana Department of Environmental Quality (LDEQ) was notified by the QSA Global Radiation Safety Officer (RSO) concerning an industrial radiography camera that had been shipped, but did not reach its intended destination on October 26, 2021. This notification was made via the LDEQ Radiation Hotline at approximately 1215 CDT on October 27, 2021. According to the QSA Global RSO, the common carrier said the package had been delivered on October 26, 2021 at 1550 CDT and signed for by an individual. The RSO for Ohmstede, the intended recipient, said the package had not been delivered. The package with the industrial radiography camera, a QSA Global model 880 Delta (s/n D11151) with 105 Ci of Ir-192 (s/n 34970M), was mistakenly delivered to an address on Hwy 75 instead of the correct address on Highway 30, St. Gabriel, LA. On October 27, 2021, the common carrier driver picked up the package from the incorrect address and delivered it to the correct location around 1300 CDT on October 27, 2021. No further action required.

Louisiana Event Report ID No.: LA 20210009

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf


Agreement State
Event Number: 55548
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Siemens Medical Solutions
Region: 3
City: Hoffman Estates   State: IL
County:
License #: IL-01130-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Donald Norwood
Notification Date: 10/27/2021
Notification Time: 16:11 [ET]
Event Date: 10/27/2021
Event Time: 00:00 [CDT]
Last Update Date: 10/27/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Orlikowski, Robert (R3)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 11/3/2021

EN Revision Text: AGREEMENT STATE REPORT - FOUND Ge-68 SOURCE

The following information was received via E-mail:

"The Illinois Emergency Management Agency (the Agency / IEMA) was notified on 10/27/21 by Siemens Medical Solutions that a PET phantom source had been identified at a scrap recycling facility in Gilberts, Illinois. IEMA staff should be on site at approximately 1500 CDT today (10/27/21) to impound the source and assess for contamination. Updates will be provided as they become available.

"The radiation safety officer for Siemens Medical Solutions contacted the Agency to advise that a cylindrical PET phantom source (Ge-68, typically around 4 mCi) had been identified at Elgin Recycling. The Elgin Recycling facility is located in Gilberts, Illinois. Reportedly, the facility identified a shielded container (pig) and surveyed it prior to processing. Their handheld meter identified radioactivity and they contacted the manufacturer listed on the container (Siemens). Siemens advised the facility to secure the source away from the public and await pickup (likely late next week). Rather than have an unlicensed facility responsible for security, shielding and accountability of a licensed source; IEMA staff will facilitate pickup today and transfer the source over to Siemens staff when they are available next week.

"Preliminary information indicates the source was returned from India and sent to Hegele Logistics in Wood Dale, Illinois. Hegele Logistics failed to identify the source and sent the material for recycling. Agency staff have previously responded to Hegele Logistics in August of 2019. Siemens is researching the shipment to determine if additional sources could be present.

"Safety Assessment: Agency staff will retrieve information on the source and actions taken by Elgin Recycling staff which will facilitate a characterization of exposures, if any. Assuming the source has not decayed at all (271 day half-life), a 4 mCi Ge-68 source would have an exposure rate of approximately 2.3 mR/hour at one meter. The sources are typically a sealed, cylindrical epoxy not lending itself to removable contamination. Updates to this assessment will be provided."

Illinois Item Number: IL210034

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

Page Last Reviewed/Updated Wednesday, November 03, 2021