Event Notification Report for February 28, 2023

AGREEMENT STATE REPORT - STUCK SOURCE

The following information was received from the state of Ohio via email:

"On Monday 2/20/2023, radiographers from the licensee's Akron, Ohio office experienced a source that would not retract. There were two radiographers working on the job site when they realized that their source was not locking into the safe position. They contacted management at 1013 [CST] and were instructed to move their boundaries out and use physical barriers to prevent unauthorized access. When the licensee's source retrieval team arrived on site, they discussed the situation with the crew and began to form a plan for locating the source.

"The retrieval team located the source in the collimator and then developed a plan for a way to shield and retract the source. The retrieval team made 16 moves to shield the source before attempting retrieval. The source was locked in the safe, shielded position inside the camera at 1510.

"The source retrieval team found that the drive cable connector had broken just above the crimp causing the source and pigtail to become disconnected from the cable. The licensee reports that the connector lot number is FW-21, and it was put into service on 12/18/2022."

Ohio Item Number: OH230001

AGREEMENT STATE REPORT - STUCK SOURCE

The following information was provided by the Texas Department of State Health Services (the Group) via email:

"On February 21, 2023, the Group was notified by the licensee's radiation safety officer (RSO) that a cobalt-60 source was stuck in the unshielded position. The source is used in a teletherapy unit for non-human experimental irradiation. The source is pointed towards the floor. The RSO stated they contacted their service company and was told it is probably caused by low air pressure as air pressure is used to drive the source. The RSO stated the source/unit was located in the basement of the facility. The RSO stated they performed radiation surveys in adjoining rooms and the room above where the exposed source is located, and all dose rates were normal (less than 200 microrem/hr). The service provider will be at the licensee's location on February 23, 2023, to inspect the unit. The access door has been locked and 'Caution' tape has been placed on the door jam. No over exposures have occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9991

* * * UPDATE ON 02/22/23 AT 2049 EST FROM ART TUCKER TO KERBY SCALES * * *

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

"On February 22, 2023, the licensee's RSO notified the Agency that they had just talked with the service company that would retrieve the source and discussed the operation. The job is expected to start at 0830 CST on February 23, 2023. The RSO stated the individual will enter the room wearing a Personal Radiation Dosimeter (PRD), an OSL [Optically Stimulated Luminescence] dosimeter, and an Instadose for exposure monitoring. Alarms will be set on the PRD. The RSO stated they will have a pre-job safety briefing before the technician enters the room and will establish turnback values for the job. The technician will enter the room and rotate the source head to point the source away from them. They will then force the source back into the shield. The service company estimates the technician will receive 500 millirem for the job. The RSO stated the room has video surveillance and will also have audio capabilities. The RSO stated the job is anticipated to take less than 15 minutes. The RSO will notify the Agency when the technician enters the room for the first time and leaves the room when the job is completed. The Agency has requested additional information."

* * * UPDATE ON 02/23/23 AT 1307 EST FROM ART TUCKER TO IAN HOWARD * * *

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

"On February 23, 2023, the licensee notified the Agency that the service company was able to return the source to the fully shielded position by manipulating the systems air pressure. No individual received any significant radiation exposure from the operation. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Roldan-Otero) and NMSS Events Notification via email.

AGREEMENT STATE REPORT - LEAKING EQUIPMENT

The following was provided by the Utah Division of Waste Management and Radiation Control:

"On 2/21/23, at 1700 [MST], the Intermountain Heart Institute, Cardiac Molecular Imaging (CMI) Coordinator reported to the RSO [Radiation Safety Officer] that around 1630 a technologist, removing a Rb-82 generator from service, found liquid radioactive contamination in the bottom of the well chamber of the infusion system.

"A syringe was used to remove the saline from the well of the infusion system and the liquid was placed in the liquid radioactive waste storage. Decontamination procedures were followed. The infusion system well was wiped dry with paper towel(s). All radioactive waste was placed in approved radioactive waste storage. Wipe test(s) were performed. This incident has no impact on patient treatment. All quality control procedures passed while the generator was in use which verifies that patient treatments were within all requirements.

"The manufacturer was contacted for assistance, and it is planned that the generator will be shipped back for investigation. We will follow the manufacturer's instructions for the shipment. A new generator has been placed in the infusion system so that patient care can continue today."

Utah Event Report Number: UT23-0003