Event Notification Report for December 22, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/21/2021 - 12/22/2021
Hospital
Event Number: 55643
Rep Org: Monument Health
Licensee: Monument Health
Region: 4
City: Rapid City State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: Jim McKee
HQ OPS Officer: Mike Stafford
Licensee: Monument Health
Region: 4
City: Rapid City State: SD
County:
License #: 40-00238-04
Agreement: N
Docket:
NRC Notified By: Jim McKee
HQ OPS Officer: Mike Stafford
Notification Date: 12/14/2021
Notification Time: 15:38 [ET]
Event Date: 12/14/2021
Event Time: 09:00 [MST]
Last Update Date: 12/14/2021
Notification Time: 15:38 [ET]
Event Date: 12/14/2021
Event Time: 09:00 [MST]
Last Update Date: 12/14/2021
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/22/2021
EN Revision Text: NON-AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following is a summary of a phone call with the licensee:
A patient was implanted with an I-125 seed of 21.45 millicuries for the radiation therapy. The patient was prescribed to receive radiation therapy to 93.17% of their prostate. Post implant dosimetry indicated that the patient only received a dose to 39.10% of the prostate. There were no unintended health affects as a result of this event.
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 Text: NON-AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following is a summary of a phone call with the licensee:
A patient was implanted with an I-125 seed of 21.45 millicuries for the radiation therapy. The patient was prescribed to receive radiation therapy to 93.17% of their prostate. Post implant dosimetry indicated that the patient only received a dose to 39.10% of the prostate. There were no unintended health affects as a result of this event.
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: 55644
Rep Org: MA Radiation Control Program
Licensee: Lantheus Medical Imaging
Region: 1
City: North Billerica State: MA
County:
License #: 60-0088
Agreement: Y
Docket:
NRC Notified By: Bob Locke
HQ OPS Officer: Brian Lin
Licensee: Lantheus Medical Imaging
Region: 1
City: North Billerica State: MA
County:
License #: 60-0088
Agreement: Y
Docket:
NRC Notified By: Bob Locke
HQ OPS Officer: Brian Lin
Notification Date: 12/14/2021
Notification Time: 16:41 [ET]
Event Date: 12/13/2021
Event Time: 00:00 [EST]
Last Update Date: 12/16/2021
Notification Time: 16:41 [ET]
Event Date: 12/13/2021
Event Time: 00:00 [EST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
Young, Matt (R1)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/22/2021
EN Revision Text: AGREEMENT STATE REPORT - MISSING THALIUM-201 SHIPMENT
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"Lantheus Medical Imaging, Inc. notified the Agency at 1145 EST on 12/14/2021 that a thalium-201 (73.1 hr half-life) shipment in route to RLS USA, Inc. went missing in transit during vehicle maintenance operations. The vehicle had a flat tire that needed to be replaced. The flat tire occurred the early morning of 12/13/2021 around 0000 EST, but possibly before 0000 EST on the evening of 12/12/2021, [near Pallisades Park, NJ]. During the tire change, the packages were removed from the vehicle in order to complete the maintenance. RLS USA, Inc. reported to Lantheus Medical Imaging, Inc. on the evening of 12/13/2021 that the thallium material was not received. A Tc-99m generator package shipped in the same vehicle was received by RLS USA, Inc. as part of the delivery, but the thalium-201 package was not received.
"The missing package contained 117 mCi of thalium-201 as of 12/12/2021 (Yellow II package, 0.3 TI).
"The reporting requirement is within 30 days and is of 105 CMR 120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C.
"The Agency considers this event to be open. New York State and New Jersey Agencies were contacted."
* * * UPDATE FROM ROBERT LOCK TO THOMAS KENDZIA AT 1121 EDT ON 12/16/21 * * *
The following information was received from the Agency via e-mail:
"Correction: Lantheus Medical Imaging, Inc. reports that the flat tire on the delivery vehicle occurred at 6:45 PM on 12/12/2021.
"Correction: The event was reported to the Massachusetts Radiation Control Program at 11:45 a.m. on 12/14/2021 (the 11:45 p.m. in the narrative is a typo and should be a.m.).
"MDS performed searches for the package [where the flat tire was changed] and surrounding areas, performed searches at another location on the delivery route (MDS warehouse located in Little Ferry, NJ) and contacted other facilities on the route where other packages were delivered.
"The package continues to be missing."
Notified R1DO (YOUNG), 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 Text: AGREEMENT STATE REPORT - MISSING THALIUM-201 SHIPMENT
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"Lantheus Medical Imaging, Inc. notified the Agency at 1145 EST on 12/14/2021 that a thalium-201 (73.1 hr half-life) shipment in route to RLS USA, Inc. went missing in transit during vehicle maintenance operations. The vehicle had a flat tire that needed to be replaced. The flat tire occurred the early morning of 12/13/2021 around 0000 EST, but possibly before 0000 EST on the evening of 12/12/2021, [near Pallisades Park, NJ]. During the tire change, the packages were removed from the vehicle in order to complete the maintenance. RLS USA, Inc. reported to Lantheus Medical Imaging, Inc. on the evening of 12/13/2021 that the thallium material was not received. A Tc-99m generator package shipped in the same vehicle was received by RLS USA, Inc. as part of the delivery, but the thalium-201 package was not received.
"The missing package contained 117 mCi of thalium-201 as of 12/12/2021 (Yellow II package, 0.3 TI).
"The reporting requirement is within 30 days and is of 105 CMR 120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C.
"The Agency considers this event to be open. New York State and New Jersey Agencies were contacted."
* * * UPDATE FROM ROBERT LOCK TO THOMAS KENDZIA AT 1121 EDT ON 12/16/21 * * *
The following information was received from the Agency via e-mail:
"Correction: Lantheus Medical Imaging, Inc. reports that the flat tire on the delivery vehicle occurred at 6:45 PM on 12/12/2021.
"Correction: The event was reported to the Massachusetts Radiation Control Program at 11:45 a.m. on 12/14/2021 (the 11:45 p.m. in the narrative is a typo and should be a.m.).
"MDS performed searches for the package [where the flat tire was changed] and surrounding areas, performed searches at another location on the delivery route (MDS warehouse located in Little Ferry, NJ) and contacted other facilities on the route where other packages were delivered.
"The package continues to be missing."
Notified R1DO (YOUNG), 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
Agreement State
Event Number: 55645
Rep Org: Alabama Radiation Control
Licensee: Agriculture Veterinary Diagnostic Lab
Region: 1
City: Auburn State: AL
County:
License #: 15
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Licensee: Agriculture Veterinary Diagnostic Lab
Region: 1
City: Auburn State: AL
County:
License #: 15
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 12/14/2021
Notification Time: 17:34 [ET]
Event Date: 12/14/2021
Event Time: 00:00 [CST]
Last Update Date: 12/14/2021
Notification Time: 17:34 [ET]
Event Date: 12/14/2021
Event Time: 00:00 [CST]
Last Update Date: 12/14/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 12/22/2021
EN Revision Text: AGREEMENT STATE REPORT - UNAUTHORIZED DISPOSAL OF RADIOACTIVE MATERIALS
The following information was received by the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"On 12/14/21, the Agency spoke with a representative of Alabama Dept. of Agriculture Veterinary Diagnostic Lab in Auburn, Alabama regarding information in a letter related to disposal of an ECD [electron capture detector]. The representative confirmed that the ECD was incinerated by an unauthorized/unlicensed company. The Agency is continuing to investigate. The Veterinary Diagnostic lab does not have a specific license; the Agency has identified it as GL registration no. 15. The device was manufactured by Varian, with source model 02-001972-00, nominal activity of 15 millicuries of nickel-63."
AL incident no.: 21-35
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 Text: AGREEMENT STATE REPORT - UNAUTHORIZED DISPOSAL OF RADIOACTIVE MATERIALS
The following information was received by the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"On 12/14/21, the Agency spoke with a representative of Alabama Dept. of Agriculture Veterinary Diagnostic Lab in Auburn, Alabama regarding information in a letter related to disposal of an ECD [electron capture detector]. The representative confirmed that the ECD was incinerated by an unauthorized/unlicensed company. The Agency is continuing to investigate. The Veterinary Diagnostic lab does not have a specific license; the Agency has identified it as GL registration no. 15. The device was manufactured by Varian, with source model 02-001972-00, nominal activity of 15 millicuries of nickel-63."
AL incident no.: 21-35
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: 55646
Rep Org: Minnesota Department of Health
Licensee: Park Nicollette Methodist Hospital
Region: 3
City: St Louis Park State: MN
County:
License #: 1052
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: Brian Lin
Licensee: Park Nicollette Methodist Hospital
Region: 3
City: St Louis Park State: MN
County:
License #: 1052
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: Brian Lin
Notification Date: 12/15/2021
Notification Time: 10:54 [ET]
Event Date: 10/24/2021
Event Time: 00:00 [CST]
Last Update Date: 12/15/2021
Notification Time: 10:54 [ET]
Event Date: 10/24/2021
Event Time: 00:00 [CST]
Last Update Date: 12/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"A 298 æCi I-125 localization seed was lost in the licensee's pathology department after removal. The seed was confirmed missing on October 24, 2021 when paperwork and inventories confirmed it was not returned to the Nuclear Medicine Department."
MN incident no.: MN210008
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 Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"A 298 æCi I-125 localization seed was lost in the licensee's pathology department after removal. The seed was confirmed missing on October 24, 2021 when paperwork and inventories confirmed it was not returned to the Nuclear Medicine Department."
MN incident no.: MN210008
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: 55647
Rep Org: Tennessee Div of Rad Health
Licensee: ECS Southeast
Region: 1
City: Mt. Juliet State: TN
County:
License #: R-94042-A26
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Mike Stafford
Licensee: ECS Southeast
Region: 1
City: Mt. Juliet State: TN
County:
License #: R-94042-A26
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Mike Stafford
Notification Date: 12/15/2021
Notification Time: 14:08 [ET]
Event Date: 12/14/2021
Event Time: 11:00 [EST]
Last Update Date: 12/15/2021
Notification Time: 14:08 [ET]
Event Date: 12/14/2021
Event Time: 11:00 [EST]
Last Update Date: 12/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following was received from the Tennessee Division of Radiological Health via email:
"A Troxler model 3440 (SN 21556) was run over by a dump truck at a local construction site. Source is in the shielded position within the unit. Gauge is cordoned off from staff. However, the gauge is not operational.
"Corrective actions will be updated with a report within 30 days."
The gauge contains a 40 mCi Am:Be-241 and a 8 mCi Cs-137 source.
State Event Report ID Number: TN-21-116
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following was received from the Tennessee Division of Radiological Health via email:
"A Troxler model 3440 (SN 21556) was run over by a dump truck at a local construction site. Source is in the shielded position within the unit. Gauge is cordoned off from staff. However, the gauge is not operational.
"Corrective actions will be updated with a report within 30 days."
The gauge contains a 40 mCi Am:Be-241 and a 8 mCi Cs-137 source.
State Event Report ID Number: TN-21-116
Non-Agreement State
Event Number: 55648
Rep Org: Environmental Prot. Agency
Licensee: Environmental Prot. Agency
Region: 4
City: Denver State: CO
County:
License #: 05-14892-02
Agreement: N
Docket:
NRC Notified By: Steven Merritt
HQ OPS Officer: Brian Lin
Licensee: Environmental Prot. Agency
Region: 4
City: Denver State: CO
County:
License #: 05-14892-02
Agreement: N
Docket:
NRC Notified By: Steven Merritt
HQ OPS Officer: Brian Lin
Notification Date: 12/15/2021
Notification Time: 15:45 [ET]
Event Date: 12/13/2021
Event Time: 00:00 [MST]
Last Update Date: 12/15/2021
Notification Time: 15:45 [ET]
Event Date: 12/13/2021
Event Time: 00:00 [MST]
Last Update Date: 12/15/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (FAX)
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (FAX)
EN Revision Imported Date: 12/23/2021
EN Revision Text: LOST SURVEY INSTRUMENT
The following information was received from the Radiation Safety Officer (RSO) at the Environmental Protection Agency (EPA), Region 8 via telephone:
On 12/13/21, the RSO received notification reporting a missing shipment containing a Ludlum Model 192 survey instrument. The survey instrument contains a 1 microCi Cs-137 source and was scheduled for calibration at a facility in Sweetwater, TX. The common carrier reported that the incorrect shipping label was placed on the survey instrument's package and sent to an unknown location. The common carrier is conducting an investigation to determine the location of the survey meter. The last location of the survey meter was in Hutchins, TX.
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 Text: LOST SURVEY INSTRUMENT
The following information was received from the Radiation Safety Officer (RSO) at the Environmental Protection Agency (EPA), Region 8 via telephone:
On 12/13/21, the RSO received notification reporting a missing shipment containing a Ludlum Model 192 survey instrument. The survey instrument contains a 1 microCi Cs-137 source and was scheduled for calibration at a facility in Sweetwater, TX. The common carrier reported that the incorrect shipping label was placed on the survey instrument's package and sent to an unknown location. The common carrier is conducting an investigation to determine the location of the survey meter. The last location of the survey meter was in Hutchins, TX.
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: 55650
Rep Org: Tennessee Div of Rad Health
Licensee: Methodist Le Bonheur Healthcare
Region: 1
City: Memphis State: TN
County:
License #: R-79027-H26
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Mike Stafford
Licensee: Methodist Le Bonheur Healthcare
Region: 1
City: Memphis State: TN
County:
License #: R-79027-H26
Agreement: Y
Docket:
NRC Notified By: Andrew Holcomb
HQ OPS Officer: Mike Stafford
Notification Date: 12/15/2021
Notification Time: 15:48 [ET]
Event Date: 12/14/2021
Event Time: 00:00 [EST]
Last Update Date: 12/15/2021
Notification Time: 15:48 [ET]
Event Date: 12/14/2021
Event Time: 00:00 [EST]
Last Update Date: 12/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Young, Matt (R1)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following was received from the Tennessee Division of Radiological Health via email:
"During the removal of I-125 seeds from a patient, only 22 of 23 seeds were recovered. No survey readings above background were discovered in the operating room. It was concluded that the seed was not present in the patient upon operating room entry. Exam rooms visited by the patient were checked and showed no readings above background levels. The seed is thought to have been lost during implant with surgical drape on 12/7/21. The seed information is as follows:
"Manufacturer: BEST
"Model: 2301
"Isotope: I-125
"Activity: 1.6 mCi
"Corrective actions will be updated with a report within 30 days."
State Event Report ID Number: TN-21-117
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 Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following was received from the Tennessee Division of Radiological Health via email:
"During the removal of I-125 seeds from a patient, only 22 of 23 seeds were recovered. No survey readings above background were discovered in the operating room. It was concluded that the seed was not present in the patient upon operating room entry. Exam rooms visited by the patient were checked and showed no readings above background levels. The seed is thought to have been lost during implant with surgical drape on 12/7/21. The seed information is as follows:
"Manufacturer: BEST
"Model: 2301
"Isotope: I-125
"Activity: 1.6 mCi
"Corrective actions will be updated with a report within 30 days."
State Event Report ID Number: TN-21-117
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
Non-Agreement State
Event Number: 55652
Rep Org: U.S. Air Force
Licensee: U.S. Air Force
Region: 4
City: Albuquerque State: NM
County:
License #: 42-23539-01AF
Agreement: N
Docket:
NRC Notified By: Lt Col Christina Peace
HQ OPS Officer: Mike Stafford
Licensee: U.S. Air Force
Region: 4
City: Albuquerque State: NM
County:
License #: 42-23539-01AF
Agreement: N
Docket:
NRC Notified By: Lt Col Christina Peace
HQ OPS Officer: Mike Stafford
Notification Date: 12/15/2021
Notification Time: 20:53 [ET]
Event Date: 12/15/2021
Event Time: 14:38 [MST]
Last Update Date: 12/15/2021
Notification Time: 20:53 [ET]
Event Date: 12/15/2021
Event Time: 14:38 [MST]
Last Update Date: 12/15/2021
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/23/2021
EN Revision Text: LEAKING SOURCE FROM AIRCRAFT RADIUM DIAL
The following is a summary from a phone call with the licensee:
At 1438 MST on December 15, 2021, base personnel at Kirtland Air Force Base identified a potentially leaking radium-226 aircraft dial. The activity contained within the dial and the leak rate were not known at the time of the call. The storage area for the dial has been locked and flagged pending further investigation. Dosimetry for base personnel did not identify any unexpected exposure. The licensee has contacted NRC Regional Inspectors.
EN Revision Text: LEAKING SOURCE FROM AIRCRAFT RADIUM DIAL
The following is a summary from a phone call with the licensee:
At 1438 MST on December 15, 2021, base personnel at Kirtland Air Force Base identified a potentially leaking radium-226 aircraft dial. The activity contained within the dial and the leak rate were not known at the time of the call. The storage area for the dial has been locked and flagged pending further investigation. Dosimetry for base personnel did not identify any unexpected exposure. The licensee has contacted NRC Regional Inspectors.
Fuel Cycle Facility
Event Number: 55666
Facility: Framatome ANP Richland
Region: 2 State: WA
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
NRC Notified By: Calvin Manning
HQ OPS Officer: Thomas Herrity
Region: 2 State: WA
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
NRC Notified By: Calvin Manning
HQ OPS Officer: Thomas Herrity
Notification Date: 12/20/2021
Notification Time: 17:26 [ET]
Event Date: 12/20/2021
Event Time: 09:20 [PST]
Last Update Date: 12/21/2021
Notification Time: 17:26 [ET]
Event Date: 12/20/2021
Event Time: 09:20 [PST]
Last Update Date: 12/21/2021
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel Agreement State
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
O'Keefe, Neil (R4DO)
EN Revision Imported Date: 12/22/2021
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by Framatome ANP Richland via email:
"On December 20, 2021, at 0920 PST, Framatome received notification that a sealed source, which had been removed by a waste broker (Qal-Tek), had failed a leak test.
"The source, an acrylic rod type made in June 1986 and containing at that time 5 mCi of Cs-137, had been stored at Framatome in a shielding pig for many years. Leak tests had been performed on the storage pig as required by Framatome's radioactive materials license, most recently on November 12, 2021. The waste broker performed a confirmatory leak test on the storage pig on November 22, 2021 and removed the source from the Framatome site. All leak tests performed by Framatome and the waste broker indicated that there was less than 0.005 microcurie of removable contamination on the outside of the storage pig.
"The source was removed from its storage pig at the waste broker's facility in a controlled environment at which point a sample of the bare source indicated a removable beta activity of 0.015 microcurie. Upon discovering the leak, the waste broker placed the leaking source in a sealed container and decontaminated the inside of the storage pig. The source will be sealed with epoxy to prevent any further leak; being already in the waste stream, no further issue is anticipated from the source.
"This report is furnished to the NRC, concurrent to one sent to the Washington Department of Public Health."
The licensee has notified the State and NRC Region IV.
* * * UPDATE FROM JAMES KILLINGBECK TO THOMAS KENDZIA AT 1136 EST ON 12/21/21 * * *
The following information is a synopsis of information received from the Washington State Department of Health, Office of Radiation Protection (Agency) via e-mail and phone:
The Agency was notified of this event yesterday as it is stated above with the following additional information. The Washington State license for Framatone, Inc. is WN-I0612, Qal-Tek Associates, LLC NRC license is 11-27610-01, cesium-137 source current activity is about 0.0022 curies (2.2 millicuries).
The Agency submitted an NRC NMED report for this event yesterday. The Agency was determining if the event met reporting requirements for notification of the NRC Headquarters Operations Center (HOC). Today the Agency determined this event was reportable to the NRC HOC as an Agreement State report since it met the criteria of 10 CFR 30.50(b)(2).
Washington state incident number WA-21-026
Notified R4DO (O'Keefe), and NMSS Events Notification group (email).
EN Revision Text: OFFSITE NOTIFICATION
The following information was provided by Framatome ANP Richland via email:
"On December 20, 2021, at 0920 PST, Framatome received notification that a sealed source, which had been removed by a waste broker (Qal-Tek), had failed a leak test.
"The source, an acrylic rod type made in June 1986 and containing at that time 5 mCi of Cs-137, had been stored at Framatome in a shielding pig for many years. Leak tests had been performed on the storage pig as required by Framatome's radioactive materials license, most recently on November 12, 2021. The waste broker performed a confirmatory leak test on the storage pig on November 22, 2021 and removed the source from the Framatome site. All leak tests performed by Framatome and the waste broker indicated that there was less than 0.005 microcurie of removable contamination on the outside of the storage pig.
"The source was removed from its storage pig at the waste broker's facility in a controlled environment at which point a sample of the bare source indicated a removable beta activity of 0.015 microcurie. Upon discovering the leak, the waste broker placed the leaking source in a sealed container and decontaminated the inside of the storage pig. The source will be sealed with epoxy to prevent any further leak; being already in the waste stream, no further issue is anticipated from the source.
"This report is furnished to the NRC, concurrent to one sent to the Washington Department of Public Health."
The licensee has notified the State and NRC Region IV.
* * * UPDATE FROM JAMES KILLINGBECK TO THOMAS KENDZIA AT 1136 EST ON 12/21/21 * * *
The following information is a synopsis of information received from the Washington State Department of Health, Office of Radiation Protection (Agency) via e-mail and phone:
The Agency was notified of this event yesterday as it is stated above with the following additional information. The Washington State license for Framatone, Inc. is WN-I0612, Qal-Tek Associates, LLC NRC license is 11-27610-01, cesium-137 source current activity is about 0.0022 curies (2.2 millicuries).
The Agency submitted an NRC NMED report for this event yesterday. The Agency was determining if the event met reporting requirements for notification of the NRC Headquarters Operations Center (HOC). Today the Agency determined this event was reportable to the NRC HOC as an Agreement State report since it met the criteria of 10 CFR 30.50(b)(2).
Washington state incident number WA-21-026
Notified R4DO (O'Keefe), and NMSS Events Notification group (email).
Non-Agreement State
Event Number: 55653
Rep Org: Lester E. Cox Medical Center
Licensee: Lester E. Cox Medical Center
Region: 3
City: Springfield State: MO
County:
License #: 24-01143-06
Agreement: N
Docket:
NRC Notified By: Kimberly Prescott
HQ OPS Officer: Mike Stafford
Licensee: Lester E. Cox Medical Center
Region: 3
City: Springfield State: MO
County:
License #: 24-01143-06
Agreement: N
Docket:
NRC Notified By: Kimberly Prescott
HQ OPS Officer: Mike Stafford
Notification Date: 12/16/2021
Notification Time: 13:04 [ET]
Event Date: 11/23/2021
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 13:04 [ET]
Event Date: 11/23/2021
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Skokowski, Richard (R3)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
Skokowski, Richard (R3)
ILTAB, (EMAIL)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/23/2021
EN Revision Text: NON-AGREEMENT STATE - LOST Co-57 MARKER SOURCE
The following is a summary of a phone call with Lester E. Cox Medical Center:
On November 23, 2021, the licensee was performing a radiography procedure on a patient's lymph node. The procedure involved the use of a Co-57 marker rod source, approximately 13.1 microCi. During the procedure the shielding cap was removed, reference mark was made, the cap was replaced, and the rod was placed back onto a medical cart. At some point following the procedure the licensee recognized that the source was missing. A search of the lab, linen area, and trash was conducted and did not identify the missing source.
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 Text: NON-AGREEMENT STATE - LOST Co-57 MARKER SOURCE
The following is a summary of a phone call with Lester E. Cox Medical Center:
On November 23, 2021, the licensee was performing a radiography procedure on a patient's lymph node. The procedure involved the use of a Co-57 marker rod source, approximately 13.1 microCi. During the procedure the shielding cap was removed, reference mark was made, the cap was replaced, and the rod was placed back onto a medical cart. At some point following the procedure the licensee recognized that the source was missing. A search of the lab, linen area, and trash was conducted and did not identify the missing source.
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: 55654
Rep Org: Minnesota Department of Health
Licensee: Fairview Southdale Hospital
Region: 3
City: Edina State: MN
County:
License #: 1039
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Licensee: Fairview Southdale Hospital
Region: 3
City: Edina State: MN
County:
License #: 1039
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Notification Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 08/19/2021
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 08/19/2021
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Fairview Southdale Hospital (FSH) reported a missing 8.36 MBq (226 microCi) I-125 localization seed (IsoAid model IAI-125A). The seed was discovered missing on 8/19/2021. Two I-125 seeds were placed in a patient for localization of non-palpable lesions. Both seeds were removed in the operating room, which was confirmed by imaging. The tissue was sealed in a container in the operating room and taken to Pathology. During processing of the tissue, Pathology could only locate one of the seeds. FSH surveyed the operating room and Pathology. The seed was not located. The operating room had been cleaned prior to the survey. It is not known if the seed went missing in the operating room or Pathology. FSH planned to modify their procedure to place the specimen in a Zip-Lock bag before being imaged in the operating room and kept in the bag when transported to Pathology. Also, Pathology will analyze the specimen in a timely fashion so if a seed does go missing, it will have less time to be moved around."
Minnesota event number: 210006
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 Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Fairview Southdale Hospital (FSH) reported a missing 8.36 MBq (226 microCi) I-125 localization seed (IsoAid model IAI-125A). The seed was discovered missing on 8/19/2021. Two I-125 seeds were placed in a patient for localization of non-palpable lesions. Both seeds were removed in the operating room, which was confirmed by imaging. The tissue was sealed in a container in the operating room and taken to Pathology. During processing of the tissue, Pathology could only locate one of the seeds. FSH surveyed the operating room and Pathology. The seed was not located. The operating room had been cleaned prior to the survey. It is not known if the seed went missing in the operating room or Pathology. FSH planned to modify their procedure to place the specimen in a Zip-Lock bag before being imaged in the operating room and kept in the bag when transported to Pathology. Also, Pathology will analyze the specimen in a timely fashion so if a seed does go missing, it will have less time to be moved around."
Minnesota event number: 210006
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: 55655
Rep Org: Minnesota Department of Health
Licensee: Mayo Clinic
Region: 3
City: Rochester State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Licensee: Mayo Clinic
Region: 3
City: Rochester State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Notification Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 03/17/2020
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 03/17/2020
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Mayo Clinic reported the loss of an I-125 localization seed (Best Medical model 2301, lot #49827) that contained an activity of 9.03 MBq (244 microCi). A lesion and the seed were removed from a patient on 3/17/2020. After the lesion was removed from the patient, the surgeon confirmed that the seed was within the specimen with a survey meter. However, the surgeon did not perform a radiograph of the specimen, nor did he inform pathology per procedure that there was a seed to be removed. The seed was noted to be missing by a nuclear medicine technologist on 3/19/2020, which prompted an investigation. All of the remaining lesion tissue was recovered and surveyed, along with the entire pathology laboratory, on 3/20/2020. Mayo Clinic was unable to locate the seed following investigation and determined it was lost. They assumed that the seed was either washed down the sink in the pathology laboratory or incinerated as medical waste. The cause of the incident was concluded to be inadequate training. Corrective actions included developing a new process for selecting a surgeon and radiologist to ensure that qualified personnel are following procedures."
Minnesota event number: 200003
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 Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Mayo Clinic reported the loss of an I-125 localization seed (Best Medical model 2301, lot #49827) that contained an activity of 9.03 MBq (244 microCi). A lesion and the seed were removed from a patient on 3/17/2020. After the lesion was removed from the patient, the surgeon confirmed that the seed was within the specimen with a survey meter. However, the surgeon did not perform a radiograph of the specimen, nor did he inform pathology per procedure that there was a seed to be removed. The seed was noted to be missing by a nuclear medicine technologist on 3/19/2020, which prompted an investigation. All of the remaining lesion tissue was recovered and surveyed, along with the entire pathology laboratory, on 3/20/2020. Mayo Clinic was unable to locate the seed following investigation and determined it was lost. They assumed that the seed was either washed down the sink in the pathology laboratory or incinerated as medical waste. The cause of the incident was concluded to be inadequate training. Corrective actions included developing a new process for selecting a surgeon and radiologist to ensure that qualified personnel are following procedures."
Minnesota event number: 200003
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: 55656
Rep Org: Minnesota Department of Health
Licensee: Fairview Southdale Hospital
Region: 3
City: Edina State: MN
County:
License #: 1039
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Licensee: Fairview Southdale Hospital
Region: 3
City: Edina State: MN
County:
License #: 1039
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Notification Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 12/05/2019
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 12/05/2019
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Fairview Southdale Hospital (FSH) reported the loss of two I-125 seeds (IsoAid model IAI-125A) used for localization of non-palpable lesions. Each seed contained an activity of 11.1 MBq (300 microCi). The seeds were discovered to be missing from their decay-in-storage area while placing a new seed in storage on 12/5/2019. FSH staff decided to count the seeds that were in the storage pig. There should have been 20 seeds, but only 18 seeds were counted. FSH conducted an investigation and determined that the two seeds were lost. Corrective actions included conducting daily radiation surveys of all areas of the breast center hot laboratory."
Minnesota event number: 200001
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 Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Fairview Southdale Hospital (FSH) reported the loss of two I-125 seeds (IsoAid model IAI-125A) used for localization of non-palpable lesions. Each seed contained an activity of 11.1 MBq (300 microCi). The seeds were discovered to be missing from their decay-in-storage area while placing a new seed in storage on 12/5/2019. FSH staff decided to count the seeds that were in the storage pig. There should have been 20 seeds, but only 18 seeds were counted. FSH conducted an investigation and determined that the two seeds were lost. Corrective actions included conducting daily radiation surveys of all areas of the breast center hot laboratory."
Minnesota event number: 200001
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: 55657
Rep Org: Minnesota Department of Health
Licensee: Abbott Northwestern Hospital
Region: 3
City: Minneapolis State: MN
County:
License #: 1007
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Licensee: Abbott Northwestern Hospital
Region: 3
City: Minneapolis State: MN
County:
License #: 1007
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Notification Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 07/26/2019
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 07/26/2019
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Abbott Northwestern Hospital (ANH) reported the loss of a 6.845 MBq (185 microCi) I-125 localization seed (Best Medical International model 2301, lot #48287) from the ANW Piper Breast Center on 7/26/2019. A tissue specimen containing the seed was removed from a patient and transported to pathology. The pathology assistant removed the seed from the specimen and placed it adjacent to the specimen in the workspace. After the pathologist and surgeon examined the specimen, the assistant noticed that the seed was missing. ANH conducted radiation surveys of the surrounding area (staff clothing, shoes, and adjacent hallways), but did not locate the seed. ANH believes that while the pathologist and surgeon were examining the specimen, the seed was bumped into the sink and washed down the drain. Corrective actions included procedure modification and providing additional training to personnel. During subsequent procedures, pathology staff will place the seed into a lead container before the pathologist and surgeon examine the specimen."
Minnesota event number: 190004
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 Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Abbott Northwestern Hospital (ANH) reported the loss of a 6.845 MBq (185 microCi) I-125 localization seed (Best Medical International model 2301, lot #48287) from the ANW Piper Breast Center on 7/26/2019. A tissue specimen containing the seed was removed from a patient and transported to pathology. The pathology assistant removed the seed from the specimen and placed it adjacent to the specimen in the workspace. After the pathologist and surgeon examined the specimen, the assistant noticed that the seed was missing. ANH conducted radiation surveys of the surrounding area (staff clothing, shoes, and adjacent hallways), but did not locate the seed. ANH believes that while the pathologist and surgeon were examining the specimen, the seed was bumped into the sink and washed down the drain. Corrective actions included procedure modification and providing additional training to personnel. During subsequent procedures, pathology staff will place the seed into a lead container before the pathologist and surgeon examine the specimen."
Minnesota event number: 190004
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: 55658
Rep Org: Minnesota Department of Health
Licensee: New Flyer
Region: 3
City: St. Cloud State: MN
County:
License #: General License
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Licensee: New Flyer
Region: 3
City: St. Cloud State: MN
County:
License #: General License
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Notification Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 04/20/2018
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 04/20/2018
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"New Flyer reported the loss of a static elimination device (NRD model P-2021, serial #A2KY665) that contained a 370 MBq (10 milliCi) Po-210 source. While New Flyer was preparing to replace their devices, they discovered that one device was missing. They performed an investigation, which included searching the painters' lockers and totes, but were unable to find the device. The manufacturer was notified. The cause of the event was determined to be lack of procedure. Corrective actions included connecting static elimination devices to dedicated air lines to ensure they will not be misplaced."
Minnesota event number: 180001
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 Text: AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"New Flyer reported the loss of a static elimination device (NRD model P-2021, serial #A2KY665) that contained a 370 MBq (10 milliCi) Po-210 source. While New Flyer was preparing to replace their devices, they discovered that one device was missing. They performed an investigation, which included searching the painters' lockers and totes, but were unable to find the device. The manufacturer was notified. The cause of the event was determined to be lack of procedure. Corrective actions included connecting static elimination devices to dedicated air lines to ensure they will not be misplaced."
Minnesota event number: 180001
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: 55659
Rep Org: Minnesota Department of Health
Licensee: Certainteed Corporation
Region: 3
City: Shakopee State: MN
County:
License #: General License
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Licensee: Certainteed Corporation
Region: 3
City: Shakopee State: MN
County:
License #: General License
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Notification Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 05/11/2017
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 05/11/2017
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK OPEN
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Certainteed Corporation reported that the shutter on a fixed nuclear gauge (Thermo EGS model SCL-1C, serial #UX458) failed to close on 5/11/2017. The gauge contained a 3.7 GBq (100 milliCi) Sr-90 source (Eckert & Ziegler model SIF.D1). The area within 15 feet of the gauge was cordoned off. Certainteed contacted the manufacturer and arrangements were made for Thermo EGS to inspect and service the gauge on 5/12/2017. The cause of the event was determined to be a broken pin on the mechanical plate that controls the on-off indicator light. The pin was repaired and the shutter mechanism was tested and performed properly. The Minnesota Department of Health conducted an onsite visit."
Minnesota event number: 170004
EN Revision Text: AGREEMENT STATE REPORT - GAUGE SHUTTER STUCK OPEN
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Certainteed Corporation reported that the shutter on a fixed nuclear gauge (Thermo EGS model SCL-1C, serial #UX458) failed to close on 5/11/2017. The gauge contained a 3.7 GBq (100 milliCi) Sr-90 source (Eckert & Ziegler model SIF.D1). The area within 15 feet of the gauge was cordoned off. Certainteed contacted the manufacturer and arrangements were made for Thermo EGS to inspect and service the gauge on 5/12/2017. The cause of the event was determined to be a broken pin on the mechanical plate that controls the on-off indicator light. The pin was repaired and the shutter mechanism was tested and performed properly. The Minnesota Department of Health conducted an onsite visit."
Minnesota event number: 170004
Agreement State
Event Number: 55661
Rep Org: Kansas Dept of Health & Environment
Licensee: Western Industries Plastic Products
Region: 4
City: Winfield State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: James Uhlemeyer
HQ OPS Officer: Brian Lin
Licensee: Western Industries Plastic Products
Region: 4
City: Winfield State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: James Uhlemeyer
HQ OPS Officer: Brian Lin
Notification Date: 12/16/2021
Notification Time: 17:52 [ET]
Event Date: 12/09/2021
Event Time: 08:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 17:52 [ET]
Event Date: 12/09/2021
Event Time: 08:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Proulx, David (R4)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 12/23/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST LICENSED DEVICE
The following information was received from the state of Kansas via email:
"An anti-static device has gone missing from the Western Industries Plastic Products facility. The device was leased from NRD, LLC (Lease number 75780, model number P-2031-1000, and serial number A2MJ492). The Safety Manager reported it to NRD, which responded on 12/15/21 to instruct them to contact the state.
"Routinely, the device is attached to a nozzle at one end and a gauge at the other, which connects to a quick-release hose. At the end of the day, it is disconnected by the quick-release connector and placed in the unlocked bottom drawer of a filing cabinet at the end of the assembly line. In the morning, it is reconnected. The assembly line is located in the warehouse portion of the facility, which is used to mold large pieces of plastic for a variety of companies. The device / air nozzle is used to blow out debris created from cutting holes in these large parts.
"At the end of first shift on 12/8/21 at 1600 [CST], the device was put in the bottom drawer of a filing cabinet (unlocked) at the end of assembly line. This was confirmed by interview with the assembly line worker who placed it there. On 12/9/21 at 0800 [CST] a worker at the start of shift went to retrieve it, but the device could not be located. A complete search was made of the facility by the Safety Manager and others from all shifts, searching the entire facility including all cabinets in the work area, the shipping offices, and the docks.
"The facility has not given up looking for the device, but if it is considered lost, they have not decided if they will continue with another radioactive device. If they do, they have stated their intention to use a sign-in/sign-out system and padlock when the device is not in use. "
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 Text: AGREEMENT STATE REPORT - LOST LICENSED DEVICE
The following information was received from the state of Kansas via email:
"An anti-static device has gone missing from the Western Industries Plastic Products facility. The device was leased from NRD, LLC (Lease number 75780, model number P-2031-1000, and serial number A2MJ492). The Safety Manager reported it to NRD, which responded on 12/15/21 to instruct them to contact the state.
"Routinely, the device is attached to a nozzle at one end and a gauge at the other, which connects to a quick-release hose. At the end of the day, it is disconnected by the quick-release connector and placed in the unlocked bottom drawer of a filing cabinet at the end of the assembly line. In the morning, it is reconnected. The assembly line is located in the warehouse portion of the facility, which is used to mold large pieces of plastic for a variety of companies. The device / air nozzle is used to blow out debris created from cutting holes in these large parts.
"At the end of first shift on 12/8/21 at 1600 [CST], the device was put in the bottom drawer of a filing cabinet (unlocked) at the end of assembly line. This was confirmed by interview with the assembly line worker who placed it there. On 12/9/21 at 0800 [CST] a worker at the start of shift went to retrieve it, but the device could not be located. A complete search was made of the facility by the Safety Manager and others from all shifts, searching the entire facility including all cabinets in the work area, the shipping offices, and the docks.
"The facility has not given up looking for the device, but if it is considered lost, they have not decided if they will continue with another radioactive device. If they do, they have stated their intention to use a sign-in/sign-out system and padlock when the device is not in use. "
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