Event Notification Report for December 01, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/30/2022 - 12/01/2022
Non-Agreement State
Event Number: 56253
Rep Org: Terracon
Licensee: Terracon
Region: 4
City: Olathe State: KS
County:
License #: 15-27070-01
Agreement: Y
Docket:
NRC Notified By: Adam Maier
HQ OPS Officer: Lloyd Desotell
Licensee: Terracon
Region: 4
City: Olathe State: KS
County:
License #: 15-27070-01
Agreement: Y
Docket:
NRC Notified By: Adam Maier
HQ OPS Officer: Lloyd Desotell
Notification Date: 12/01/2022
Notification Time: 17:49 [ET]
Event Date: 12/01/2022
Event Time: 09:30 [CST]
Last Update Date: 12/01/2022
Notification Time: 17:49 [ET]
Event Date: 12/01/2022
Event Time: 09:30 [CST]
Last Update Date: 12/01/2022
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Peterson, Hironori (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Peterson, Hironori (R3DO)
NON-AGREEMENT STATE REPORT - LOST AND RECOVERED RADIOACTIVE SOURCE
The following information is a summary of the information provided by the licensee via telephone and email:
While in transport from Grand Rapids, MI to Franklin, WI, a Troxler moisture density gauge fell off the trailer and into a median of I-94 near Coloma, MI. The gauge was discovered and secured by another company knowledgeable with gauge use until the licensee was able to retrieve it. The licensee has secured and transported the gauge to their office until a service provider can retrieve it. There is no indication that the gauge has leaked. The date the gauge fell off the trailer is unclear at this time. The gauge was in the control of a transportation service beginning 11/30/2022. The Michigan Department of Transportation and Michigan State Police have been notified of the event (complaint number 53-4067-22).
Gauge information:
Manufacturer: Troxler
Model: 3430
SN: 31413
Source Info:
Am241: serial number 47-1397 [nominal 40 mCi]
Cs137: serial number 750-6146 [nominal 8 mCi]
Agreement State
Event Number: 56254
Rep Org: NC Div of Radiation Protection
Licensee: Duke University Medical Center
Region: 1
City: Durham State: NC
County:
License #: 032-0247-4
Agreement: Y
Docket:
NRC Notified By: Ken Bugaj Jr.
HQ OPS Officer: Bill Gott
Licensee: Duke University Medical Center
Region: 1
City: Durham State: NC
County:
License #: 032-0247-4
Agreement: Y
Docket:
NRC Notified By: Ken Bugaj Jr.
HQ OPS Officer: Bill Gott
Notification Date: 12/02/2022
Notification Time: 14:41 [ET]
Event Date: 12/01/2022
Event Time: 00:00 [EST]
Last Update Date: 12/02/2022
Notification Time: 14:41 [ET]
Event Date: 12/01/2022
Event Time: 00:00 [EST]
Last Update Date: 12/02/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Cahill, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the North Carolina Division of Radiation Protection via email:
"The state of North Carolina Radioactive Materials Branch received a report at 1050 EST on December 2, 2022, from Duke University Medical Center (license number: 032-0247-4) of a possible medical event involving a patient receiving Yttrium-90 therapy for treatment of a liver tumor. The treatment had an intended dosage of 91.6 mCi with a delivered dosage of 54.6 mCi resulting in a 40 percent under dosing that did not appear to involve stasis. The patient and the patient's representative were notified at the time of the treatment and the referring physician was notified the morning of December 2, 2022. The licensee is currently investigating the root cause but initially believes it to be caused by equipment failure. The State is currently investigating and will provide more information as it becomes available."
NC Incident No.: NC220015
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 provided by the North Carolina Division of Radiation Protection via email:
"The state of North Carolina Radioactive Materials Branch received a report at 1050 EST on December 2, 2022, from Duke University Medical Center (license number: 032-0247-4) of a possible medical event involving a patient receiving Yttrium-90 therapy for treatment of a liver tumor. The treatment had an intended dosage of 91.6 mCi with a delivered dosage of 54.6 mCi resulting in a 40 percent under dosing that did not appear to involve stasis. The patient and the patient's representative were notified at the time of the treatment and the referring physician was notified the morning of December 2, 2022. The licensee is currently investigating the root cause but initially believes it to be caused by equipment failure. The State is currently investigating and will provide more information as it becomes available."
NC Incident No.: NC220015
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.