Event Notification Report for March 07, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/06/2023 - 03/07/2023
Agreement State
Event Number: 56394
Rep Org: California Radiation Control Prgm
Licensee: Krazan and Associates, Inc.
Region: 4
City: Lancaster State: CA
County:
License #: 8277-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Thomas Herrity
Licensee: Krazan and Associates, Inc.
Region: 4
City: Lancaster State: CA
County:
License #: 8277-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Thomas Herrity
Notification Date: 03/07/2023
Notification Time: 18:36 [ET]
Event Date: 03/07/2023
Event Time: 00:00 [PST]
Last Update Date: 03/07/2023
Notification Time: 18:36 [ET]
Event Date: 03/07/2023
Event Time: 00:00 [PST]
Last Update Date: 03/07/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSNS (Mexico), - (EMAIL)
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSNS (Mexico), - (EMAIL)
AGREEMENT STATE REPORT - THEFT OF MOISTURE DENSITY GAUGE
The following was received from the California Department of Public Health, Radiologic Health Branch via email:
"On Tuesday, March 7, 2023, the Krazan and Associates, Inc. Radiation Safety Officer (RSO) reported the theft of a moisture density gauge, CPN MC-3 (M351208119) containing sealed sources of Cs-137 (10 mCi) and Am-241:Be (50 mCi), Cal OES control number: 23-1630. The theft occurred overnight between Monday and Tuesday, March 6-7, 2023, at the office's equipment storage container located within their fenced in property. The RSO stated that the thief cut a hole in the back fence that borders an open dirt area behind their lot and then cut the lock off of the storage container and opened the doors. This theft was reviewed on security camera footage. They had several gauges in the storage container and other construction equipment, but only this one gauge was stolen. The other equipment was assumed to be too heavy for the thief. The CPN nuclear gauge handle was locked to prevent operation. The gauge was locked in its transport case, and the company had contact information on the gauge and case. Lancaster police were notified. An investigation will be conducted, and a report will be provided when available. The licensee was advised to submit a reward ad in the local paper to aid in the recovery effort. Further information will be provided as it becomes available."
California Event Number: 030723
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 was received from the California Department of Public Health, Radiologic Health Branch via email:
"On Tuesday, March 7, 2023, the Krazan and Associates, Inc. Radiation Safety Officer (RSO) reported the theft of a moisture density gauge, CPN MC-3 (M351208119) containing sealed sources of Cs-137 (10 mCi) and Am-241:Be (50 mCi), Cal OES control number: 23-1630. The theft occurred overnight between Monday and Tuesday, March 6-7, 2023, at the office's equipment storage container located within their fenced in property. The RSO stated that the thief cut a hole in the back fence that borders an open dirt area behind their lot and then cut the lock off of the storage container and opened the doors. This theft was reviewed on security camera footage. They had several gauges in the storage container and other construction equipment, but only this one gauge was stolen. The other equipment was assumed to be too heavy for the thief. The CPN nuclear gauge handle was locked to prevent operation. The gauge was locked in its transport case, and the company had contact information on the gauge and case. Lancaster police were notified. An investigation will be conducted, and a report will be provided when available. The licensee was advised to submit a reward ad in the local paper to aid in the recovery effort. Further information will be provided as it becomes available."
California Event Number: 030723
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
Non-Agreement State
Event Number: 56395
Rep Org: Ascension Providence Rochester Hospital
Licensee: Ascension Providence Rochester Hospital
Region: 3
City: Rochester State: MI
County:
License #: 21-13562-01
Agreement: N
Docket:
NRC Notified By: Michelle Kritzman
HQ OPS Officer: Thomas Herrity
Licensee: Ascension Providence Rochester Hospital
Region: 3
City: Rochester State: MI
County:
License #: 21-13562-01
Agreement: N
Docket:
NRC Notified By: Michelle Kritzman
HQ OPS Officer: Thomas Herrity
Notification Date: 03/08/2023
Notification Time: 12:14 [ET]
Event Date: 03/07/2023
Event Time: 00:00 [EST]
Last Update Date: 03/10/2023
Notification Time: 12:14 [ET]
Event Date: 03/07/2023
Event Time: 00:00 [EST]
Last Update Date: 03/10/2023
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):
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSC (Canada), - (FAX)
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSC (Canada), - (FAX)
LOST SOURCE
The following is a synopsis of information provided by the licensee via phone call:
A vendor was contracted to remove and dispose of outdated medical equipment. The licensee understood that the sources, 114 millicuries total of Gadolinium-153, had been removed from the equipment prior to its removal from the hospital on March 7, 2023. Upon realizing the sources had not been removed, the licensee contacted the vendor. The truck containing the removed equipment was located in Ohio. It is parked and secured in a warehouse. Arrangements were made to maintain a conservative exclusion zone. There is no indication that the sealed sources are damaged. It is believed the sources are safe and locked in the retracted position, but that has not been confirmed. Surface measurements on a similar unit at the licensee show 0.7 mR/hr at the surface.
The licensee has made arrangements for the truck to remain at its current location until the sources are retrieved. The retrieval is planned for March 9, 2023.
* * * UPDATE ON 03/10/2022 AT 1512 EST FROM THE MICHELLE KRITZMAN TO IAN HOWARD * * *
The following is a synopsis of information provided by the licensee via phone call:
At 1505 EST on 3/10/2023, the licensee received a notification that the sources were retrieved. The sources were in a safe and locked position and there was no indication of tampering with the sources. There was no additional exposure to the public or employees.
Notified: R3DO (Ruiz). Notified via email: NMSS Event Notification, ILTAB, and Canada.
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 is a synopsis of information provided by the licensee via phone call:
A vendor was contracted to remove and dispose of outdated medical equipment. The licensee understood that the sources, 114 millicuries total of Gadolinium-153, had been removed from the equipment prior to its removal from the hospital on March 7, 2023. Upon realizing the sources had not been removed, the licensee contacted the vendor. The truck containing the removed equipment was located in Ohio. It is parked and secured in a warehouse. Arrangements were made to maintain a conservative exclusion zone. There is no indication that the sealed sources are damaged. It is believed the sources are safe and locked in the retracted position, but that has not been confirmed. Surface measurements on a similar unit at the licensee show 0.7 mR/hr at the surface.
The licensee has made arrangements for the truck to remain at its current location until the sources are retrieved. The retrieval is planned for March 9, 2023.
* * * UPDATE ON 03/10/2022 AT 1512 EST FROM THE MICHELLE KRITZMAN TO IAN HOWARD * * *
The following is a synopsis of information provided by the licensee via phone call:
At 1505 EST on 3/10/2023, the licensee received a notification that the sources were retrieved. The sources were in a safe and locked position and there was no indication of tampering with the sources. There was no additional exposure to the public or employees.
Notified: R3DO (Ruiz). Notified via email: NMSS Event Notification, ILTAB, and Canada.
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
Event Number: 56400
Rep Org: Ohio Bureau of Radiation Protection
Licensee: Ohio State University
Region: 3
City: Columbus State: OH
County:
License #: 02110250037
Agreement: Y
Docket:
NRC Notified By: Michael Snee
HQ OPS Officer: John Russell
Licensee: Ohio State University
Region: 3
City: Columbus State: OH
County:
License #: 02110250037
Agreement: Y
Docket:
NRC Notified By: Michael Snee
HQ OPS Officer: John Russell
Notification Date: 03/09/2023
Notification Time: 15:36 [ET]
Event Date: 03/07/2023
Event Time: 00:00 [EST]
Last Update Date: 03/09/2023
Notification Time: 15:36 [ET]
Event Date: 03/07/2023
Event Time: 00:00 [EST]
Last Update Date: 03/09/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 3/16/2023
EN Revision Text: AGREEMENT STATE REPORT - MISAPPLICATION OF MEDICAL DOSE RESULTING IN UNDERDOSING
The following information was provided by the Ohio Bureau of Environmental Health and Radiation Protection via email:
"Ohio State University reported a medical event on March 8, 2023. A written directive for 200 millicuries of lutetium-177 (PLUVICTO) to be administered intravenously was signed by an authorized user. The dosage was assayed at 195.57 millicures and was administered to the patient on March 7, 2023. During the administration, the Nuclear Medicine Technologist noted some drips from the tubing. An investigation was initiated and the results on March 8, 2023, indicate the patient received 157.57 millicuries of lutetium-177 (PLUVICTO), 21.5 percent less than the written directive. The investigation will continue to determine the root cause of the medical event and determine corrective actions if applicable."
Reference Number OH 2023-006
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 Text: AGREEMENT STATE REPORT - MISAPPLICATION OF MEDICAL DOSE RESULTING IN UNDERDOSING
The following information was provided by the Ohio Bureau of Environmental Health and Radiation Protection via email:
"Ohio State University reported a medical event on March 8, 2023. A written directive for 200 millicuries of lutetium-177 (PLUVICTO) to be administered intravenously was signed by an authorized user. The dosage was assayed at 195.57 millicures and was administered to the patient on March 7, 2023. During the administration, the Nuclear Medicine Technologist noted some drips from the tubing. An investigation was initiated and the results on March 8, 2023, indicate the patient received 157.57 millicuries of lutetium-177 (PLUVICTO), 21.5 percent less than the written directive. The investigation will continue to determine the root cause of the medical event and determine corrective actions if applicable."
Reference Number OH 2023-006
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: 56397
Rep Org: Colorado Dept of Health
Licensee: Children's Hospital Colorado
Region: 4
City: Aurora State: CO
County:
License #: CO 075-02
Agreement: Y
Docket:
NRC Notified By: Tim Thorvaldson
HQ OPS Officer: Bill Gott
Licensee: Children's Hospital Colorado
Region: 4
City: Aurora State: CO
County:
License #: CO 075-02
Agreement: Y
Docket:
NRC Notified By: Tim Thorvaldson
HQ OPS Officer: Bill Gott
Notification Date: 03/09/2023
Notification Time: 11:16 [ET]
Event Date: 03/07/2023
Event Time: 14:00 [MST]
Last Update Date: 03/09/2023
Notification Time: 11:16 [ET]
Event Date: 03/07/2023
Event Time: 14:00 [MST]
Last Update Date: 03/09/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gupta Sarma, Trisha (NMSS DAY)
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gupta Sarma, Trisha (NMSS DAY)
AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION EVENT
The following information was provided by the Colorado Department of Public Health and Environment (CDPHE) via email:
"At approximately 1400 MST on March 7, 2023, while performing a meta-iodobenzylguanidine (MIBG) infusion of 266 mCi of I-131 in a patient at Children's Hospital Colorado, an unplanned contamination event occurred on the floor of the hot lab. The floor contamination was discovered at approximately 1730 MST on March 7, 2023, by the licensee. The hot lab has been secured from entry. The licensee believes the amount spilled is greater than 5 times the annual limit on intake (ALI). CDPHE will be receiving more information from the licensee. The licensee will be performing bioassay soon and will provide more information at that time."
Colorado Event Report Number: CO 230006
The following information was provided by the Colorado Department of Public Health and Environment (CDPHE) via email:
"At approximately 1400 MST on March 7, 2023, while performing a meta-iodobenzylguanidine (MIBG) infusion of 266 mCi of I-131 in a patient at Children's Hospital Colorado, an unplanned contamination event occurred on the floor of the hot lab. The floor contamination was discovered at approximately 1730 MST on March 7, 2023, by the licensee. The hot lab has been secured from entry. The licensee believes the amount spilled is greater than 5 times the annual limit on intake (ALI). CDPHE will be receiving more information from the licensee. The licensee will be performing bioassay soon and will provide more information at that time."
Colorado Event Report Number: CO 230006
Agreement State
Event Number: 56392
Rep Org: Texas Dept of State Health Services
Licensee: Exxon Mobil Corp
Region: 4
City: Mont Belvieu State: TX
County:
License #: L03119
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Thomas Herrity
Licensee: Exxon Mobil Corp
Region: 4
City: Mont Belvieu State: TX
County:
License #: L03119
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Thomas Herrity
Notification Date: 03/07/2023
Notification Time: 17:21 [ET]
Event Date: 03/07/2023
Event Time: 00:00 [CST]
Last Update Date: 03/08/2023
Notification Time: 17:21 [ET]
Event Date: 03/07/2023
Event Time: 00:00 [CST]
Last Update Date: 03/08/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On March 7, 2023, the Agency was notified by the licensee that the shutter on a Vega SH-F2 nuclear gauge had failed in the open position during routine testing. The gauge contains a 300 millicurie (original activity) Cs-137 source. Open is the normal operating position for the gauge. The licensee has contacted the manufacturer for repairs to the gauge. The licensee stated the gauge does not create an exposure risk to any individual as the gauge is located 300 feet in the air on the side of a vessel. Additional information will be provided as it is received in accordance with SA-300."
Texas event report number: 56392
* * * UPDATE ON 3/8/23 AT 1341 EST FROM THE TEXAS DEPARTMENT OF STATE HEALTH SERVICES TO JOHN RUSSELL VIA EMAIL * * *
"On March 8, 2023, the Agency was notified by the licensee that while performing routine shutter inspections a second gauge shutter was found in the stuck open position. The gauge is a Vega model SHF2C gauge containing a 500 millicurie (original activity) cesium-137 source. Open is the normal operation position for the gauge shutter. The licensee has contacted the manufacturer for repairs. The gauge does not create an exposure risk to any personnel. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Heather Gepford), NMSS Events Notification.
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On March 7, 2023, the Agency was notified by the licensee that the shutter on a Vega SH-F2 nuclear gauge had failed in the open position during routine testing. The gauge contains a 300 millicurie (original activity) Cs-137 source. Open is the normal operating position for the gauge. The licensee has contacted the manufacturer for repairs to the gauge. The licensee stated the gauge does not create an exposure risk to any individual as the gauge is located 300 feet in the air on the side of a vessel. Additional information will be provided as it is received in accordance with SA-300."
Texas event report number: 56392
* * * UPDATE ON 3/8/23 AT 1341 EST FROM THE TEXAS DEPARTMENT OF STATE HEALTH SERVICES TO JOHN RUSSELL VIA EMAIL * * *
"On March 8, 2023, the Agency was notified by the licensee that while performing routine shutter inspections a second gauge shutter was found in the stuck open position. The gauge is a Vega model SHF2C gauge containing a 500 millicurie (original activity) cesium-137 source. Open is the normal operation position for the gauge shutter. The licensee has contacted the manufacturer for repairs. The gauge does not create an exposure risk to any personnel. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Heather Gepford), NMSS Events Notification.
Agreement State
Event Number: 56391
Rep Org: Louisiana Radiation Protection Div
Licensee: Boise Packaging and Newsprint, LLC
Region: 4
City: DeRidder State: LA
County:
License #: LA-28736-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: John Russell
Licensee: Boise Packaging and Newsprint, LLC
Region: 4
City: DeRidder State: LA
County:
License #: LA-28736-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: John Russell
Notification Date: 03/07/2023
Notification Time: 14:38 [ET]
Event Date: 03/07/2023
Event Time: 09:54 [CST]
Last Update Date: 03/07/2023
Notification Time: 14:38 [ET]
Event Date: 03/07/2023
Event Time: 09:54 [CST]
Last Update Date: 03/07/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - SOURCE SHUTTER MALFUNCTION
The following information was received from the Louisiana Radiation Protection Division (the Department) via email:
"On March 7, 2023, Boise Packaging and Newsprint, LLC notified the Department that there was an equipment malfunction. The pivot pin connecting the shutter handle rusted out and failed. The fixed gauge was an Ohmart Model SHRM-B serial number 1301/1830. The source was 80 mCi of Cs-137. A third party licensee was contacted to come out and fix the Ohmart gauge."
Louisiana Report ID: LA20230003
The following information was received from the Louisiana Radiation Protection Division (the Department) via email:
"On March 7, 2023, Boise Packaging and Newsprint, LLC notified the Department that there was an equipment malfunction. The pivot pin connecting the shutter handle rusted out and failed. The fixed gauge was an Ohmart Model SHRM-B serial number 1301/1830. The source was 80 mCi of Cs-137. A third party licensee was contacted to come out and fix the Ohmart gauge."
Louisiana Report ID: LA20230003