Event Notification Report for August 31, 2022

AGREEMENT STATE REPORT - ABANDONED WELL LOGGING SOURCE

The following report was received via email from the Texas Department of State Health Services (the Agency):

"On August 23, 2022, the licensee notified the Agency that a string of well logging tools containing a 1.5 curie cesium-137 source and a 15 curie americium-241 source was lodged downhole in a well in Starr County, Texas. The sources are at 8,772 foot depth. Efforts to remove approximately 1,800 feet of wireline cable from above the tool were unsuccessful. The abandonment plan has been submitted to the Agency and to the Texas Railroad Commission for review. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: I-9950

AGREEMENT STATE REPORT - UNINTENDED DOSE TO FETUS

The following information was provided by the Massachusetts Radiation Control Program (The Agency) via email:

"The licensee ( Dana Farber Cancer Institute) reported by telephone on August 23, 2022, that it discovered on August 22, 2022, that it had administered on August 22, 2022, a radiopharmaceutical (10 millicuries of F-18 FDG) as part of a PET/CT diagnostic procedure to a patient that was unknowingly pregnant resulting in an estimated dose to the embryo/fetus of 20 milli-gray (20 millisievert or 2 rem). The estimated dose is inclusive of both the F-18 PET and CT components of the procedure.

"The reporting requirement is 105 CMR 120.594(B), Report and Notification of a Dose to an Embryo/Fetus or Nursing Child, a by no later than next calendar day of the event telephone report.

"The licensee reported that pregnancy screening questions were answered through an interpreter, stating that the patient was not pregnant and that the result of the PET/CT scan showed that the patient was pregnant.

"The licensee reported that the referring physician and the patient have been notified. The licensee reported that at this time (August 23, 2022) there is no expectation of physical/deterministic harm to the fetus from the dose received.

"The licensee reported that a written report will be submitted to the Agency within 15 days of the telephone report in accordance with 105 CMR 120.594(B)(4).

"The Agency considers this event to be open."

Massachusetts Event Number: 20-5109

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 REPORT - LOST RADIOACTIVE PORTABLE GAUGE

The following information was received via email:

"The Georgia Department of Natural Resources, Environmental Protection Division, Air Protection Branch sent this as notification that a lost portable gauge reported. The incident occurred 8/23/22 around lunch time and was reported to [Environmental Protection Division] (EPD) at [1530 EDT]. The gauge is a Humboldt Model 5001. It is currently unknown which Isotope it contained or its activity (Cs-137 or Am-241). The gauge user was onsite and had placed the gauge on the tailgate of his truck. He left for lunch and when he got to the location, realized he had forgot to secure the gauge in it's transport box. The gauge was no longer on the vehicle. He reported the lost gauge to the local police and went back to look for the gauge. [The driver was unable to locate the gauge]. We (EDP) are following up for more information, but wanted to meet our reporting requirements and inform you of the loss."

The following additional information was obtained from the state in accordance with Headquarters Operations Officers Report Guidance:
The license number, the county, and the worst case scenario activity for the Humboldt Model 5001 gauge (44mCi of Am-241).

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 REPORT - BROKEN SHUTTER

The following information was received from the Texas Department of State Health Services (the Agency) via email:

"On August 24, 2022 the Agency received a report of an equipment failure from a general license acknowledgement (GLA) licensee. A lead plate on the shutter was found to no longer be attached to the shutter. An initial possible cause is that vibrations allowed the lead to go through the screws and become detached. The shutter was removed from service and placed into storage. A lead blanket is covering the gauge and a survey found no elevated readings. The device is approximately 8.5 years old and contains a 200 milli-Curie Cs-137 source. Nobody was believed to have received a significant dose from this issue. The licensee is taking pictures and will try to better determine the cause. The device will be repaired by a service company on August 26, 2022. An investigation is ongoing and further information will be provided per SA-300."

Texas Reference Number: 9951

AGREEMENT STATE REPORT - LOST/RECOVERED RADIOACTIVE SOURCE

The following was provided by the California Department of Public Health (CDPH)/Radiation Health Branch (RHP) via email:

"On August 24, 2022, the Caltrans [California Department of Transportation] RSO [Radiation Safety Officer] notified CDPH/RHB of the theft ( Loss of control) and subsequent recovery of a Caltrans vehicle that contained a locked and shielded Cs-137 sealed source. The 3.7 GBq (100 mCi) Cs-137 sealed source is manufactured by Gammatron, Inc. - model GT-GHP. The sealed source is a component of a Mount Sopris Instrument Company gamma probe logging tool.

"The Caltrans vehicle was parked at [1800 PDT] on August 23, 2022, at a Doubletree hotel in Santa Ana and discovered stolen at [0600 PDT] on August 24, 2022, from the hotel parking lot. The RSO was immediately notified. California Highway Patrol was able to track the vehicle's GPS [Global Positioning System] locator signal to a nearby address where the Santa Ana Police located the abandoned vehicle with the sealed source locked inside. Many other items were stolen from the vehicle. There is an ongoing police investigation."

California Reference Number: 082422