Event Notification Report for December 27, 2021

EN Revision Imported Date: 1/6/2022

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 Imported Date: 1/6/2022

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 Imported Date: 1/6/2022

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 Imported Date: 1/6/2022

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 Imported Date: 1/6/2022

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 Imported Date: 1/6/2022

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 Imported Date: 1/6/2022

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 Imported Date: 1/6/2022

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 Imported Date: 1/6/2022

EN Revision Text: NON-AGREEMENT STATE REPORT - LOST TROXLER GAUGES

The following information was provided by the licensee via phone conversation:

During an NRC inspection, the Testing Engineering and Consultants, Inc. reviewed their materials accountability records and determined two portable Troxler moisture density gauges (s/n 14195 and 14198; 8 mCi Cs-137 and 40 mCi Am-241/Be each) were missing. The two gauges had last been leak tested in January 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

EN Revision Imported Date: 1/6/2022

EN Revision Text: AGREEMENT STATE REPORT - DAMAGE DENSITY GAUGE

The following information was provided by the Pennsylvania Bureau of Radiation Protection (the department) via email:

"On December 16, 2021, the licensee informed the department that a nuclear density gauge had been damaged at a job site. While a technician was carrying the Troxler gauge, they tripped and fell on top of the gauge handle. This broke off the handle about half-way from the top to the gauge. The portable gauge was a Troxler, 3400 series, Serial Number 15717, containing 8 millicuries of Cs-137 and 40 millicuries Am-241:Be. The area was secured, and the Radiation Safety Officer (RSO) called a third party (Applied Health Physics) for assistance. Applied Health Physics and the RSO determined that the source was secured in the shielded position, and gauge was not leaking. Applied Health Physics did site surveys and determined there was no dose to any employees or anyone on the job site. Applied Health Physics secured the handle to the gauge, and it was transported back to Construction Engineering Consultants, Inc. Pittsburgh office. Once at the office the gauge was placed in their office vault and has been taken out of service. It will be held there until it can be sent to the manufacturer for disposal. Applied Health Physics did a leak test on site that day and the sample results showed no evidence of radiological material. There was no exposure to workers or the public."

Event Report ID No: PA210023

EN Revision Imported Date: 1/6/2022

EN Revision Text: AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The following information was provided by the state of Colorado via email:

"During the morning of 12/17/2021, a portable gauge user noticed their truck had been broken into [in Westminster, CO] and a portable gauge was stolen from the truck. The portable gauge is a Troxler model 3430, serial number 32370, containing 9 mCi cesium-137 and 44 mCi americium-241:beryllium. The stolen gauge has been reported to the local law enforcement."
Event Report ID No.: CO210043

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: 1/6/2022

EN Revision Text: AGREEMENT STATE REPORT - CONTAMINATED WORKER

The following is a synopsis of information received from the New Mexico Radiation Control Bureau (NMRCB):

On October 22, 2019, a worker was manually drilling a container with 1080 millicuries of iridium-192 in ceramic tracer beads. The worker was not wearing eye or face shields and a puff of dust from the drilling struck the worker's face and eyes. Immediately after, the worker repeatedly washed their face and eyes. On the next day, a survey of the worker's face/eye area showed 200 mR/hr. Subsequent surveys over the next 103 days showed steadily decreasing amounts, down to 10 mR/hr at 103 days.

On June 23, 2020, the NMRCB reached out to the NRC seeking assistance in determining the individual's dose. Staff from the Office of Nuclear Material Safety and Safeguards (NMSS) and Region IV Division of Nuclear Materials Safety (DNMS) held a call with NMRCB, providing options on how to proceed, including encouraging the individual submit to a full body count. A whole body radiobioassay was performed on July 17, 2020, 272 days after the exposure. The result on the first run was 4.12 nCi and 4.34 nCi on the second run.

A reported dated November 18, 2021, [a contractor] presented results indicating a committed effective dose equivalent (CEDE) to the worker of 1.48 millirem, a shallow dose equivalent (SDE) estimated to be 663 rem, a lens dose equivalent (LDE) estimated to be 11.5 rem, and an effective dose equivalent (EDE) of 3.6 millirem.

EN Revision Imported Date: 1/6/2022

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY DEVICE SAFETY LATCH FAILURE

The following information was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email:

"On 12/17/2021, the licensee notified RHB of an incident in which an INC IR-100 (S/N 7362) radiography exposure device, containing a 54.2 Ci Ir-192 QSA Global source (S/N 55806M), failed to actuate its safety latch plate upon retracting the Ir-192 source to the fully shielded position. The incident occurred on 12/16/2021, at approximately 1900 PST, at the PBF refinery in Martinez, CA. The radiography site was approximately 150 ft. above grade, on temporary staging, and accessed by an adjacent permanent deck. The RSO [(radiation safety officer)] stated that the device was used all day without issue prior to the safety latch plate's actuation failure. The initial personnel during the incident consisted of a radiographer trainer and an assistant radiographer. The radiographer trainer noticed the failure when attempting to 'crank out' after fully retracting the source. After attempting to fully retract the source, the latch plate maintained a visibly depressed position and the source was not fully secured and free to move. The radiography trainer contacted the RSO for further assistance during which an additional radiographer trainer assisted with maintaining security of the barricaded area until the RSO and staff arrived on the site. The RSO stated that he was able to secure the source by flushing the locking mechanism with brake cleaner and that there was no excessive exposure to any personnel involved. RHB will be investigating this incident further."

CA 5010 Number: 121721