Event Notification Report for August 02, 2022

AGREEMENT STATE REPORT- LOST EXIT SIGNS

The following summary was received from the Colorado Department of Public Health and Environment via email:

The Colorado Department of Public Health and Environment reported four Speclite model TP10 exit signs, containing 6.5 Curies of tritium each, lost by the licensee. The incident occurred June 8, 2022.

CO Event Report ID no.: CO220024


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: 7/28/2022

EN Revision Text: DAMAGED NUCLEAR GAUGE

The following information is a synopsis provided by the licensee via email:

An incident involving a Nuclear Gauge #26 (CPN MC1 DR serial# MD60503240) on a job site (#37: 1564-C) at about 1315 EDT on 07/22/22 in SE Washington, DC 20032. The gauge contained the following sealed sources: 370 MBq (10 mCi) Cs-137 01/17/96 and 1.85 GBq (50 mCi) Am-241/Be 03/27/96.

The gauge was damaged by an excavator while it was under the control of an authorized user (AU). The AU went to their car about 50 feet away to grab some paperwork. The operator of the excavator did not see the gauge, and hit it hard enough to crack its plastic shell. The source rod and electronics were not damaged.

The AU informed an ECS field supervisor about the incident immediately and cordoned off the 15 foot radius of an area around the damaged gauge. The back-up radiation safety officer (RSO), was contacted and came to the site to evaluate the damage. The gauge's plastic case was broken due to the impact, but the sources were in the shielded position. Several surveys were made using a survey meter (RADIATION Alert M4, calibrated on 12/22/21) at one meter distance, and the readings were found to be less than 0.4 mR/hr range.

In addition to contacting the NRC Operations Center on 7/22/22, the Virginia Department of Health was informed at 1755 EDT the same day.

All the pieces of the gauge were placed in a box and it was hauled back to the designated storage area in the Chantilly, VA office around 1700 EDT. After performing a leak test and once an all-clear report is received, the damaged gauge will be returned to the authorized distributor in the area, for them to repair it properly.

All authorized users will be informed about the incident immediately, and this will be discussed in detail at our safety meetings to reiterate and stress the importance of maintaining physical control of gauges when the gauge is not otherwise secured using two independent physical locking systems to prevent unauthorized access or removal.

NON-AGREEMENT STATE REPORT - DOSE ABOVE THE PRESCRIBED DOSE

The following is a summary of a phone call with the licensee:

On 7/14/22, a patient received more dose than the written prescription for delivery to their bone surfaces. The prescription was for 57.5 microCi of radium-223 and the patient received 184.9 microCi. The patient was intended to receive 184.9 micro Ci, however a clerical error resulted in the prescription only listing 57.5 microCi.

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.