Event Notification Report for September 23, 2022

AGREEMENT STATE REPORT - DAMAGED GAUGE WITH SOURCE DISPLACEMENT

The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KYRHB) via email:

"KYRHB was notified on 9/14/2022 by the RSO [Radiation Safety Officer] from SME, New Albany, Indiana, that a Troxler 3411-B portable moisture density gauge (Serial Number 13640; Cs-137: 8 mCi; Am-241:Be: 40 mCi) was significantly damaged after it was impacted by a bulldozer at a temporary jobsite. The gauge was in use when the operator of the bulldozer stopped within 8-10 feet of the moisture density gauge. After a brief pause and despite attempts by the authorized user to stop the driver, [the bulldozer] proceeded forward and subsequently impacted the device, resulting in breakage of the notched index rod, and displacement of the entire source rod (Cs-137) from the device minus the lead shielding. The area was cordoned off in a 100-foot diameter circle and the RSO was contacted. The source rod containing the Cs-137 source was successfully reinserted into the device and readings with a GM detector confirmed no residual radioactivity remained after removal of the gauge from the site. The condition of the 40 mCi Am-241:Be source was not determined but the gauge housing did not suffer significant damage. No overexposures are expected from the incident, but dosimetry for the personnel involved has been requested. The damaged gauge will be transported to the company's headquarters in Plymouth, MI for leak testing and final disposition. A follow-up inspection of the licensee is planned as a follow up to this incident."

Kentucky Incident Number: KY 220005

AGREEMENT STATE REPORT - STOLEN GAUGE

The following information was provided by the Kansas Department of Health & Environment (KDHE) via email:

"On 9/16/2022 (morning), a technician with Kansas City Testing and Engineering, LLC, discovered his work truck had been broken into overnight near his home. The truck had been parked across the street from the technician's apartment. The rear passenger window was completely shattered and the Troxler moisture density gauge was missing along with a few hundred dollars of personal property and an estimated one thousand dollars of work equipment. The technician immediately called the RSO [Radiation Safety Officer] of Kansas City Testing and Engineering. Then, the technician filed a police report with local law enforcement. The RSO reported that he had called the Nuclear Regulatory Commission (NRC) to report the incident, but that the NRC had instructed him to report it to KDHE [beforehand]. The RSO also stated he reported the incident to Troxler. Stolen equipment was a Troxler 3440P (Serial Number 77305). According to the license, the sources are an 8 mCi Cs-137 and a 40 mCi Am-241/Be.

"At 1030 CDT on 9/16/2022, the inspector met in person with the technician at a job site. The inspector was informed that the gauge had been locked in the backseat of the truck cab and secured with a chain and a padlock through a metal anchor bracket. The metal anchor bracket had been cut. The gauge, chain, and padlock were all removed from the truck.

"This incident occurred in Missouri and the licensee also holds an NRC radioactive materials license."

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 - MEDICAL MISADMINISTRATION-DIAGNOSTIC

The following information was provided by Alabama Radiation Control via email:

"The licensee reported that a patient was scheduled on 9/16/2022 for a 1-day protocol. The patient was scheduled to receive 36 millicuries of Tc-99m labeled sestamibi/Cardiolite. The patient mistakenly received 36 millicuries of Tc-99m sodium pertechnetate. This matter does appear to meet Alabama's criteria for a misadministration with approximately 1731.6 mrem WB EDE [whole body effective dose equivalent], the highest organ/tissue does appears to be to the wall of the upper large intestine at 7592.4 mrem.

"Alabama Radiation Control will provide more information as the investigation continues."

Alabama Incident No.: 22-17

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.