Event Notification Report for December 15, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
12/14/2021 - 12/15/2021

EVENT NUMBERS
55630 55631 55633
Agreement State
Event Number: 55630
Rep Org: PA Bureau of Radiation Protection
Licensee: Thomas Jefferson Univ. Hospitals
Region: 1
City: Philadelphia   State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Bethany Cecere
Notification Date: 12/08/2021
Notification Time: 09:01 [ET]
Event Date: 12/06/2021
Event Time: 00:00 [EST]
Last Update Date: 12/08/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dentel, Glenn (R1)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 12/15/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF Y-90

The following was received from the Commonwealth of Pennsylvania by email:

"On December 6, 2021, a patient underwent a Y-90 TheraSphere treatment. There were no apparent issues during the treatment, but the four-sided equipment readings before and after treatment indicated that only 63% of the prescribed dosage got into the patient. The prescribed dose was 4.08 GBq and the calculated received dose was 2.57 GBq. Preliminarily the licensee believes there was a flow issue and the micro catheter caused some of the material to precipitate out. The licensee is currently investigating to determine if that is the cause. The patient and physician have been informed. No adverse effects to the patient are anticipated."

PA Event Report ID No: PA210019

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: 55631
Rep Org: Colorado Dept of Health
Licensee: Denver Art Museum
Region: 4
City: Denver   State: CO
County:
License #: GL001407
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Bethany Cecere
Notification Date: 12/08/2021
Notification Time: 10:53 [ET]
Event Date: 06/23/2021
Event Time: 00:00 [MST]
Last Update Date: 12/08/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 12/15/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was sent by the state of Colorado by email:

Two Tritium (H-3) exit signs (6.2 Ci each) reported as lost on annual registration 12/07/2021.


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: 55633
Rep Org: Utah Division of Radiation Control
Licensee: CMT Engineering Laboratories
Region: 4
City: West Jordan   State: UT
County:
License #: 1800143
Agreement: Y
Docket:
NRC Notified By: Phil Goble
HQ OPS Officer: Thomas Kendzia
Notification Date: 12/08/2021
Notification Time: 15:25 [ET]
Event Date: 12/08/2021
Event Time: 08:30 [MST]
Last Update Date: 12/10/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 12/15/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TROXLER DENSITY GAUGE

The following information from the state of Utah Division of Radiation Control (Division) was received by email:

"A licensee gauge operator lost/misplaced a Troxler portable nuclear density gauge model 3411 (SN 12109), [containing 8 mCi of Cs and 40 mCi of Am-Be]. He claims he arrived at the licensee laboratory and signed his gauge out on the shipping log at 0615 [MST]. He then took his gauge within the transportation case outside of the secured storage room and set it down on the floor inside the laboratory next to the storage room and proceeded to load additional equipment into his truck parked out back. He was outside loading this equipment and was having a conversation with another employee. The other employee said he had to leave and the gauge operator said he had to leave also and got in his truck and drove to his first project at 0630 [MST]. At his first project site in Riverton, he then realized he had forgotten the gauge at the lab. At 0730 [MST] he left the project and drove back to the lab to discover that the gauge was not there on the floor at approximately 0830 [MST]. He searched the lab, storage room, and questioned lab personal. The RSO was informed of this situation at 0850 [MST].

"The licensee has notified law enforcement of the missing gauge. The Division is waiting for additional information from the licensee."

UT Event Report ID No.: UT-21-0007


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