Event Notification Report for September 01, 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

AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION

The following information was received from the South Carolina Department of Health and Environmental Control [the Department] via email:

"At 0905 [EDT] on August 12, 2022, the Department received a call from a representative of the Lowcountry Medical Group to report a contamination event. At about 0830 that same day, the certified nuclear medicine technician (CNMT) prepared to administer a dose to a patient on a treadmill to perform a stress test. While inserting the dose into the IV [intravenous], the cap loosened and the dose was sprayed onto the CNMT. Drops were released onto the treadmill handrails, track, and side. The CNMT decided to complete the treatment rather than to stop the treatment and perform radiation cleanup procedures as listed for the office. The CNMT, while still contaminated, left the room, went down the hall, and grabbed a replacement dose for the patient. This contaminated a hallway that was otherwise an unrestricted area. The CNMT successfully injected the patient with the second dose and completed the test then put the patient on a table to measure his shoes. The CNMT put booties on the patient and released them to go home. The CNMT changed clothes, went home, showered, and returned to the office afterward. The other CNMT remained at the office and cancelled the remaining patients.

"Inspectors from the Department arrived at the location at approximately 1215 to investigate the situation. At the time the inspectors arrived, no cleanup had begun and the contaminated hallway had not been blocked off. The inspectors surveyed the hallway and instructed the CNMTs to block the hallway and begin cleanup procedures. They reviewed the procedures with the staff and made sure that they had the right equipment to perform the cleanup.

"The radioactive material used was Tc-99m [technetium-99m]. The amount of material was 30.7 mCi. The treatment being performed was a nuclear stress test. The office reported that both CNMTs were 0.03 mR/hr (background) after the event. The results of the surveys pre-cleanup were as follows: Treadmill: 20 mR/hr, Floor: 20 mR/hr, Floor behind treadmill: 20 mR/hr."

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 - GAUGE SOURCE EXPOSED TO FIRE

The following information was provided by the Oklahoma Department of Environmental Quality via email:

"On August 5, 2022, at 2240 [CDT] smoke was reported in Coal Bunker D [at the Hugo Plant]. Staff immediately began procedures to extinguish the fire. Coal Bunker D is located directly below Coal Feeder D and this caused thermal heat around the piping which feeds Coal Feeder D. A plug detector, which is a RA-226 source, is mounted around this pipe. By 0600 on August 6, 2022, the Coal Bunker D was down to 120 degrees. The plant staff notified, the WFEC [Western Farmers Electric Cooperative] Radiation Safety Officer (RSO), at 0640 to check the nuclear gauging device (D FDR Top, serial #SE2562, source amount is 2 mCi).

"Upon arriving at the plant, the RSO surveyed the area around the gauge and determined the area was safe. The gauge had received radiant heat from the fire causing the paint to be removed from the gauge. The survey meter read 0.7 mR/hr to 1.0 mR/hr around the gauge which is normal. The RSO also conducted an inhouse leak test check with the survey meter. The background was 0.1 mR/hr and sample was 0.2 mR/hr. WFEC is contacting the manufacturer to determine if further inspection is needed.

"At the time of this notification WFEC believes that no radiation exposure or leaks have occurred."

EN Revision Imported Date: 9/2/2022

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF X-RAY FLUORESCENCE ANALYZER

The following was received from the Illinois Emergency Management Agency via email:

"Agency efforts to annually verify the inventory of registrant's generally licensed devices resulted in a declaration of loss by a registrant, Universal Scrap Metals, 9223657. Specifically, a Niton LLC, x-ray fluorescence analyzer (model XLp-818 PQ, serial number 9690), containing 30.0 mCi of Am-241 could not be located. The device was one of five, and the other four have been verified. On May 31, 2022 the registrant indicated they could not locate the device, but wanted to check several other departments before declaring it lost.

"The amount of americium present, although not representing a significant public safety concern, requires immediate reporting to the US NRC. The registrant failed to notify the Agency of disposal, transfer or loss. This matter will be [tracked until corrective action is provided.]"

Illinois Item Number: IL220021

* * * UPDATE ON 9/01/2022 AT 1655 EDT FROM LLINOIS EMERGENCY MANAGEMENT AGENCY TO KAREN COTTON * * *
The licensee provided new training for personnel and new procedures. The Illinois Emergency Management Agency closed the event.

Notified R3DO (Hills). Notified via email: NMSS Event Notification and ILTAB.

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: 9/2/2022

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"Representatives of Elmhurst Hospital (RML IL-01612-01) contacted the Agency at approximately 1230 CDT today, 6/29/22, to report a Y-90 Theraspheres administration that took place on 6/29/22 (approximately 1000 CDT) which resulted in 100 percent of the dose prescribed not being delivered. The pre and post surveys of the vial and delivery system were nearly identical, supporting the licensee's assertion that no microspheres were delivered. The patient was surveyed post-administration and was at background. While contamination was identified on the draping, it resulted from the disconnection of the delivery system when the administration was halted. No contamination was identified on the patient.

"Microspheres were observed clustered at the hub and none beyond. The licensee claims there were no kinks and the manufacturer's checklist was followed to include agitation/flushing. At this time, it is unclear if the patient and referring physician have been notified, but the licensee is aware of the requirement. The licensee is aware of the 15-day written report requirement. The AU [(Authorized User)] will be back in the office on Friday and understands the Agency will need additional information via a reactionary inspection. The Agency is scheduling a reactive inspection and this report will be updated as information becomes available."

Illinois Item Number: IL220023

* * * UPDATE ON 9/01/2022 AT 1616 EDT FROM LLINOIS EMERGENCY MANAGEMENT AGENCY TO KAREN COTTON VIA E-MAIL* * *
"The Agency conducted a reactive inspection on 7/1/22. At that time, no indications of root cause could be identified. The licensee's written report was received timely and presented no new information. The delivery kit was returned to the manufacturer for assessment when decayed.

"Subsequent information was submitted to the Agency for review. The licensee's written report was received timely. Documentation included Gamma camera images of the administration set up kit and catheter which appeared to show activity in the microcatheter. Based on images reviewed, the Agency cannot rule out that some activity may have been delivered to the patient.

"Due to the contamination, not all of the activity in the waste was able to be accounted for; however, the bulk of activity in the waste indicated that conservatively less than 8.9% of the dosage was delivered.

"Agency inspectors determined the potential root cause as clumping of microspheres between the D and E lines of the administration kit pending investigation/assessment of the administration kit by the manufacturer. The Agency will continue to monitor additional information provided by the licensee.

"This matter may be considered closed."

Notified R3DO (Hills) and NMSS Event Notification via email.

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: 9/2/2022

EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:

"Issue discovered 6/30/2022, during inspection. The licensee did not report to the Agency at the time of occurrence. The dose to patient was evaluated as a result of a wrong dose on 7/8/2022. [On 3/11/2020,] the patient was prescribed 15 mCi of Tc-99m sestamibi/Cardiolite; the patient received 24.28 mCi of Tc-99m MDP [methyl diphosphonate]. The licensee reported that the nuclear medicine technician did not adequately verify dose labeling, and has been retrained in procedures. [This] appears to result in an effective dose of 512.068 mrem, and dose to bone surfaces of 5659.668 mrem."

AL incident no.: 22-10
* * * UPDATE ON 9/01/2022 AT 1634 EDT FROM ALABAMA OFFICE OF RADIATION CONTROL TO KAREN COTTON * * *
"Cause and Corrective Actions (States and licensees' actions) Licensee reported that the nuclear medicine tech was advised to double check dose labels prior to patient dosing. Licensee also stated personnel were unaware of misadministration reporting requirements (misadministration found during Agency inspection). Event closed"

Notified NMSS DAY (Rivera-Cappella) and R1DO (Gray) and via email: NMSS Event Notification

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: 9/2/2022

EN Revision Text: AGREEMENT STATE REPORT - DIAGNOSTIC MISADMINISTRATION

The following information was provided by the Alabama Dept. of Public Health Office of Radiation Control via email:

"[The licensee's] Representative stated that a patient was prescribed 20 milliCuries of sodium pertechnetate (did not state for which type of scan); the patient received 30 milliCuries of sestamibi (intended for a cardiac stress dose). The representative stated that the nuclear medicine tech that administered the wrong dose is new and has been counseled. This nuclear medicine tech will also be subject to increased oversight into the near future. Representative did not state that the patient will experience any side effects, nor if the patient has been counseled. The misadministration appears to result in an EDE of 876.9 mrem; the highest organ/tissue dose appears to be to the gall bladder wall with a dose of estimated 3663 mrem."

Alabama Incident 22-14
* * * UPDATE ON 9/01/2022 AT 1634 EDT FROM ALABAMA OFFICE OF RADIATION CONTROL TO KAREN COTTON * * *
"Cause and Corrective Actions (State's and licensees' actions):
"The tech that administered the wrong dose was still in her orientation/training period. The licensee stated that the tech was counseled and will be under increased monitoring during her orientation period.
"Close-out report"

Notified NMSS DAY (Rivera-Cappella) and R1DO (Gray) and via email: NMSS Event Notification

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: 8/29/2022

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED PORTABLE GAUGE

The following information was provided by the Maryland Department of Environment via email:

"On August 24, 2022, at about 1840 EDT the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via telephone from the Emergency Response Department (ERD) staff that the ECS Mid-Atlantic, LLC, Troxler nuclear moisture/density gauge was run over and damaged by an excavator in the project jobsite at the Grosvenor-Strathmore Metro Station project. MDE/RHP inspector immediately called and contacted the RSO of the licensee and preliminary information about the accident and measures taken. The MDE/RHP inspection team responded on August 25, 2022 and August 26, 2022 went to the licensee office and conducted investigations.

"On the day of the accident, at about 1503 EDT the Technician moved the gauge to the side, on the curb beside the trench, and the excavator operator that moved the arm (bucket) down the trench hit the gauge. The source rod of the gauge was in its safe (parking) position and the top of the gauge was damaged. The Troxler gauge is Model 3440, with device serial number 31969 which contain Cesium - 137 sealed source with estimated nominal activities of 8 milliCuries, and Am-241:Be with estimated nominal activities of 44 milliCuries.

"The gauge was later locked and put into the transportation case and the technician took it to the ECS Mid-Atlantic. Surveys conducted at the surfaces of the gauge are normal; and leak test results are expected. The case has been reported to the Nuclear Material Events Database (NMED) on 8/26/2022."