Event Notification Report for April 27, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/26/2022 - 04/27/2022
Agreement State
Event Number: 55870
Rep Org: Alabama Radiation Control
Licensee: The University of South Alabama
Region: 1
City: Mobile State: AL
County:
License #: RML 584
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Lloyd Desotell
Licensee: The University of South Alabama
Region: 1
City: Mobile State: AL
County:
License #: RML 584
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/29/2022
Notification Time: 17:58 [ET]
Event Date: 04/27/2022
Event Time: 00:00 [CDT]
Last Update Date: 04/29/2022
Notification Time: 17:58 [ET]
Event Date: 04/27/2022
Event Time: 00:00 [CDT]
Last Update Date: 04/29/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
AGREEMENT STATE REPORT - DIAGNOSTIC RADIOPHARMACEUTICAL MISADMINISTRATION
The following information was received from the Alabama Office of Radiation Control (the Department) via E-mail:
"The Department received a phone call and e-mail on 4/28/2022 from the licensee regarding two patients that apparently received the wrong radiopharmaceuticals on 4/27/2022. The patients' doses appeared to have been inadvertently switched.
"Patient: 1 (male)
"Ordered dose: 10.0 mCi Fluciclovine (Axumin) F-18
"Given: 10.64 mCi FDG F-18
"Patient: 2 (female)
"Ordered dose: 10.0 mCi FDG F-18
"Given: 12.62 mCi Fluciclovine (Axumin) F-18
"It appears that at least one patient received an effective dose over 500 mrem.
"Alabama Radiation Control will provide more information as the investigation continues."
Alabama Event: 22-07
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.
The following information was received from the Alabama Office of Radiation Control (the Department) via E-mail:
"The Department received a phone call and e-mail on 4/28/2022 from the licensee regarding two patients that apparently received the wrong radiopharmaceuticals on 4/27/2022. The patients' doses appeared to have been inadvertently switched.
"Patient: 1 (male)
"Ordered dose: 10.0 mCi Fluciclovine (Axumin) F-18
"Given: 10.64 mCi FDG F-18
"Patient: 2 (female)
"Ordered dose: 10.0 mCi FDG F-18
"Given: 12.62 mCi Fluciclovine (Axumin) F-18
"It appears that at least one patient received an effective dose over 500 mrem.
"Alabama Radiation Control will provide more information as the investigation continues."
Alabama Event: 22-07
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: 55862
Rep Org: Colorado Dept of Health
Licensee: Terracon Consultants, Inc.
Region: 4
City: Colorado Springs State: CO
County:
License #: CO 664-02
Agreement: Y
Docket:
NRC Notified By: Ramon Li
HQ OPS Officer: Brian Parks
Licensee: Terracon Consultants, Inc.
Region: 4
City: Colorado Springs State: CO
County:
License #: CO 664-02
Agreement: Y
Docket:
NRC Notified By: Ramon Li
HQ OPS Officer: Brian Parks
Notification Date: 04/27/2022
Notification Time: 13:19 [ET]
Event Date: 04/27/2022
Event Time: 10:48 [MDT]
Last Update Date: 04/27/2022
Notification Time: 13:19 [ET]
Event Date: 04/27/2022
Event Time: 10:48 [MDT]
Last Update Date: 04/27/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Young, Cale (R4DO)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The following is a summary of information received from the Colorado Department of Public Health and Environment by e-mail:
The licensee reported a damaged Troxler 3430 portable moisture density gauge (SN:24886) containing Am-241/Be (SN:4721079) and Cs-137 (SN:757025) sources. The gauge fell out of the back of a truck onto an interstate highway while in transit. Pieces of the gauge are on the interstate as a result of vehicles running over the gauge and the licensee is attempting to retrieve them. The licensee intends to contact the police to help cordon off the affected area to support retrieval of the remaining pieces and conduct surveys. A search is ongoing and some of the pieces of the gauge have not been accounted for.
CO Incident Number: CO220013
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
The following is a summary of information received from the Colorado Department of Public Health and Environment by e-mail:
The licensee reported a damaged Troxler 3430 portable moisture density gauge (SN:24886) containing Am-241/Be (SN:4721079) and Cs-137 (SN:757025) sources. The gauge fell out of the back of a truck onto an interstate highway while in transit. Pieces of the gauge are on the interstate as a result of vehicles running over the gauge and the licensee is attempting to retrieve them. The licensee intends to contact the police to help cordon off the affected area to support retrieval of the remaining pieces and conduct surveys. A search is ongoing and some of the pieces of the gauge have not been accounted for.
CO Incident Number: CO220013
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: 55863
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: North State Materials
Region: 1
City: Harmony State: NJ
County:
License #: 861245
Agreement: Y
Docket:
NRC Notified By: Karen Flanigan
HQ OPS Officer: Brian P. Smith
Licensee: North State Materials
Region: 1
City: Harmony State: NJ
County:
License #: 861245
Agreement: Y
Docket:
NRC Notified By: Karen Flanigan
HQ OPS Officer: Brian P. Smith
Notification Date: 04/27/2022
Notification Time: 13:26 [ET]
Event Date: 04/27/2022
Event Time: 08:39 [EDT]
Last Update Date: 04/27/2022
Notification Time: 13:26 [ET]
Event Date: 04/27/2022
Event Time: 08:39 [EDT]
Last Update Date: 04/27/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_Events_Notification, (EMAIL)
Young, Matt (R1DO)
NMSS_Events_Notification, (EMAIL)
AGREEMENT STATE REPORT - DAMAGED GAUGE
The following is a summary of information received from the New Jersey Department Environmental Protection (NJDEP) by e-mail:
On 4/27/2022, North State Materials notified NJDEP that an asphalt roller bumped a density gauge (Troxler model 4640-B, serial #77923 with a Cs-137 source up to 9 milliCuries) at a jobsite in Harmony, New Jersey. The incident was caused by heavy equipment operator error. The operator intended to move the roller backwards, but instead moved forward. The damage was limited to the faceplate and the plastic on one corner of the gauge. The licensee surveyed the gauge to confirm the source was properly shielded prior to transporting it to the licensee's storage location in Philipsburg, NJ. A sealed source leak test is pending.
NJ Incident Number: NJ-22-0003
The following is a summary of information received from the New Jersey Department Environmental Protection (NJDEP) by e-mail:
On 4/27/2022, North State Materials notified NJDEP that an asphalt roller bumped a density gauge (Troxler model 4640-B, serial #77923 with a Cs-137 source up to 9 milliCuries) at a jobsite in Harmony, New Jersey. The incident was caused by heavy equipment operator error. The operator intended to move the roller backwards, but instead moved forward. The damage was limited to the faceplate and the plastic on one corner of the gauge. The licensee surveyed the gauge to confirm the source was properly shielded prior to transporting it to the licensee's storage location in Philipsburg, NJ. A sealed source leak test is pending.
NJ Incident Number: NJ-22-0003
Agreement State
Event Number: 55864
Rep Org: Texas Dept of State Health Services
Licensee: University of Texas MD Anderson Cancer Center
Region: 4
City: Houston State: TX
County:
License #: L 00466
Agreement: Y
Docket:
NRC Notified By: Matthew Kennington
HQ OPS Officer: Brian Parks
Licensee: University of Texas MD Anderson Cancer Center
Region: 4
City: Houston State: TX
County:
License #: L 00466
Agreement: Y
Docket:
NRC Notified By: Matthew Kennington
HQ OPS Officer: Brian Parks
Notification Date: 04/27/2022
Notification Time: 17:10 [ET]
Event Date: 04/27/2022
Event Time: 09:15 [CDT]
Last Update Date: 04/27/2022
Notification Time: 17:10 [ET]
Event Date: 04/27/2022
Event Time: 09:15 [CDT]
Last Update Date: 04/27/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_Events_Notification, (EMAIL)
Young, Cale (R4DO)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 4/28/2022
EN Revision Text: AGREEMENT STATE REPORT - TELETHERAPY DEVICE FAILED IN SHIELDED POSITION
The following information was received from the Texas Department of State Health Services (the Agency) via e-mail:
"On April 27, 2022, the Agency received a notification from the licensee that the drive mechanism on their Theratronics T708C teletherapy device failed in the shielded position. The device contains 5,042 Curies of Co-60. The licensee stated that while starting a procedure at around 0915 hours CDT on April 27, 2022, the technician found that the source would not move out from the shield. There were no exposures as a result of this event. The licensee contacted a service company and scheduled a repair. An investigation is ongoing."
TX Incident Number: I-9926
EN Revision Text: AGREEMENT STATE REPORT - TELETHERAPY DEVICE FAILED IN SHIELDED POSITION
The following information was received from the Texas Department of State Health Services (the Agency) via e-mail:
"On April 27, 2022, the Agency received a notification from the licensee that the drive mechanism on their Theratronics T708C teletherapy device failed in the shielded position. The device contains 5,042 Curies of Co-60. The licensee stated that while starting a procedure at around 0915 hours CDT on April 27, 2022, the technician found that the source would not move out from the shield. There were no exposures as a result of this event. The licensee contacted a service company and scheduled a repair. An investigation is ongoing."
TX Incident Number: I-9926