Event Notification Report for January 18, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/17/2023 - 01/18/2023
Agreement State
Event Number: 56314
Rep Org: Texas Dept of State Health Services
Licensee: Precision NDT LLC
Region: 4
City: Odessa State: TX
County:
License #: L 07054
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Brian P. Smith
Licensee: Precision NDT LLC
Region: 4
City: Odessa State: TX
County:
License #: L 07054
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Brian P. Smith
Notification Date: 01/18/2023
Notification Time: 16:37 [ET]
Event Date: 01/18/2023
Event Time: 00:00 [CST]
Last Update Date: 01/18/2023
Notification Time: 16:37 [ET]
Event Date: 01/18/2023
Event Time: 00:00 [CST]
Last Update Date: 01/18/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE INTO FULLY RETRACTED POSITION
The following report was received via email from the Texas Department of State Services [the Agency]:
"On January 18, 2023, the Agency was notified by the licensee that one of its radiography crews [working in Midland, TX] was unable to retract a 99.0 curie iridium - 192 [Ir-192] source into the fully retracted and locked position in a QSA 880D exposure device. The licensee stated they were able to retract the source into the exposure device, but it would not lock in the fully retracted position. An individual on the license approved to recover sources went to the site to retract the source. The licensee contacted the manufacturer who was able to provide instructions to the field team on how to return the source to the locked position. The licensee reported no overexposure occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No: I-9981
Texas NMED No.: TX230002
The following report was received via email from the Texas Department of State Services [the Agency]:
"On January 18, 2023, the Agency was notified by the licensee that one of its radiography crews [working in Midland, TX] was unable to retract a 99.0 curie iridium - 192 [Ir-192] source into the fully retracted and locked position in a QSA 880D exposure device. The licensee stated they were able to retract the source into the exposure device, but it would not lock in the fully retracted position. An individual on the license approved to recover sources went to the site to retract the source. The licensee contacted the manufacturer who was able to provide instructions to the field team on how to return the source to the locked position. The licensee reported no overexposure occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No: I-9981
Texas NMED No.: TX230002
Agreement State
Event Number: 56315
Rep Org: OR Dept of Health Rad Protection
Licensee: The Wallace Group
Region: 4
City: Bend State: OR
County:
License #: 91125
Agreement: Y
Docket:
NRC Notified By: Hillary Haskins
HQ OPS Officer: Lloyd Desotell
Licensee: The Wallace Group
Region: 4
City: Bend State: OR
County:
License #: 91125
Agreement: Y
Docket:
NRC Notified By: Hillary Haskins
HQ OPS Officer: Lloyd Desotell
Notification Date: 01/18/2023
Notification Time: 18:13 [ET]
Event Date: 01/18/2023
Event Time: 14:49 [PST]
Last Update Date: 01/18/2023
Notification Time: 18:13 [ET]
Event Date: 01/18/2023
Event Time: 14:49 [PST]
Last Update Date: 01/18/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following is a summary of information provided by the Oregon Health Authority, Radiation Protection Services via email and phone:
The licensee reported a damaged Troxler 3430 portable moisture density gauge. The gauge's cover was found to be cracked in multiple places, including the electronic pad. The source is in the shielded position and readings around the gauge indicate that the shielding is intact. It is unclear how the gauge became damaged but was found near a vibrating plate compactor.
The gauge will be shipped to the manufacturer for repair once a leak test has been performed.
Dose readings at 3 feet from source: 0.12-0.16 mR/hr
Gauge source: 8 mCi Cs-137, 40 mCi Am-241:Be
Oregon Emergency Response System Incident Number: 2023-0140
The following is a summary of information provided by the Oregon Health Authority, Radiation Protection Services via email and phone:
The licensee reported a damaged Troxler 3430 portable moisture density gauge. The gauge's cover was found to be cracked in multiple places, including the electronic pad. The source is in the shielded position and readings around the gauge indicate that the shielding is intact. It is unclear how the gauge became damaged but was found near a vibrating plate compactor.
The gauge will be shipped to the manufacturer for repair once a leak test has been performed.
Dose readings at 3 feet from source: 0.12-0.16 mR/hr
Gauge source: 8 mCi Cs-137, 40 mCi Am-241:Be
Oregon Emergency Response System Incident Number: 2023-0140
Agreement State
Event Number: 56317
Rep Org: WA Office of Radiation Protection
Licensee: MultiCare Health System
Region: 4
City: Tacoma State: WA
County:
License #: WN-M017-1
Agreement: Y
Docket:
NRC Notified By: Boris G. Tsenov
HQ OPS Officer: Lloyd Desotell
Licensee: MultiCare Health System
Region: 4
City: Tacoma State: WA
County:
License #: WN-M017-1
Agreement: Y
Docket:
NRC Notified By: Boris G. Tsenov
HQ OPS Officer: Lloyd Desotell
Notification Date: 01/19/2023
Notification Time: 18:33 [ET]
Event Date: 01/18/2023
Event Time: 00:00 [PST]
Last Update Date: 01/19/2023
Notification Time: 18:33 [ET]
Event Date: 01/18/2023
Event Time: 00:00 [PST]
Last Update Date: 01/19/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Josey, Jeffrey (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following is a summary of information provided by the Washington State Department of Health (DOH), Radioactive Materials Section via email:
The licensee reported that a Y-90 TheraSphere liver treatment was completed in accordance with manufacturer requirements and nothing out of the ordinary was observed. However, during a subsequent step to flush the system with saline, the technician, who is not an authorized user or radioactive material user, noticed bubbles coming up above the vial. Wipe samples of the procedure equipment were counted and showed radioactivity. A second flush of the system was initiated but the same bubbles were observed and therefore the flush was stopped, and the catheter was retracted from the patient. Additional flushes were not attempted. An evaluation showed that the patient received only 33 percent of the intended dose. The activity contained in the wipes and cleaning materials accounted for the balance of the intended dose (66 percent) and was disposed of as waste. DOH has requested additional information regarding potential occupational exposures. The licensee will submit a detailed report.
Washington Incident Number: WA-23-003.
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 is a summary of information provided by the Washington State Department of Health (DOH), Radioactive Materials Section via email:
The licensee reported that a Y-90 TheraSphere liver treatment was completed in accordance with manufacturer requirements and nothing out of the ordinary was observed. However, during a subsequent step to flush the system with saline, the technician, who is not an authorized user or radioactive material user, noticed bubbles coming up above the vial. Wipe samples of the procedure equipment were counted and showed radioactivity. A second flush of the system was initiated but the same bubbles were observed and therefore the flush was stopped, and the catheter was retracted from the patient. Additional flushes were not attempted. An evaluation showed that the patient received only 33 percent of the intended dose. The activity contained in the wipes and cleaning materials accounted for the balance of the intended dose (66 percent) and was disposed of as waste. DOH has requested additional information regarding potential occupational exposures. The licensee will submit a detailed report.
Washington Incident Number: WA-23-003.
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
Event Number: 56340
Rep Org: Texas Dept of State Health Services
Licensee: Tejas Industries
Region: 4
City: Amarillo State: TX
County:
License #: G02342
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Lloyd Desotell
Licensee: Tejas Industries
Region: 4
City: Amarillo State: TX
County:
License #: G02342
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Lloyd Desotell
Notification Date: 02/06/2023
Notification Time: 17:53 [ET]
Event Date: 01/18/2023
Event Time: 00:00 [CST]
Last Update Date: 02/06/2023
Notification Time: 17:53 [ET]
Event Date: 01/18/2023
Event Time: 00:00 [CST]
Last Update Date: 02/06/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSNS (Mexico), - (EMAIL)
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSNS (Mexico), - (EMAIL)
AGREEMENT STATE REPORT - MISSING GAUGE
The following report was received via email from the Texas Department of State Health Services [the Agency]:
"On February 6, 2023, the Agency received information from the licensee that a Peco Controls Gamma 101P device, which was believed to have been removed from a machine and placed into storage on-site [in Hereford, TX] in 2020, was determined on or about January 18, 2023, to be lost/missing. The licensee has confirmed the device is not on any of its premises. The licensee is investigating with its metal waste vendor to see if they can determine if it was disposed of with them. An investigation into this event is ongoing. The licensee holds a General License Acknowledgment from the Agency for this device. More information will be provided as it is obtained in accordance with SA-300."
Device: Peco Controls Gamma 101P (SN: G030860749)
Source: Am-241 100 millicuries (SN: 3904LV)
Texas Incident No: I-9986
Texas NMED No.: TX230004
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
The following report was received via email from the Texas Department of State Health Services [the Agency]:
"On February 6, 2023, the Agency received information from the licensee that a Peco Controls Gamma 101P device, which was believed to have been removed from a machine and placed into storage on-site [in Hereford, TX] in 2020, was determined on or about January 18, 2023, to be lost/missing. The licensee has confirmed the device is not on any of its premises. The licensee is investigating with its metal waste vendor to see if they can determine if it was disposed of with them. An investigation into this event is ongoing. The licensee holds a General License Acknowledgment from the Agency for this device. More information will be provided as it is obtained in accordance with SA-300."
Device: Peco Controls Gamma 101P (SN: G030860749)
Source: Am-241 100 millicuries (SN: 3904LV)
Texas Incident No: I-9986
Texas NMED No.: TX230004
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