Event Notification Report for December 22, 2021

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 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 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 Imported Date: 12/22/2021

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 Imported Date: 12/22/2021

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 Imported Date: 12/22/2021

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 Imported Date: 12/22/2021

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 Imported Date: 12/22/2021

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 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).