Event Notification Report for July 13, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/12/2023 - 07/13/2023
Agreement State
Event Number: 56622
Rep Org: Florida Bureau of Radiation Control
Licensee: Tesla Inc.
Region: 1
City: Tampa State: FL
County:
License #: 1559-1
Agreement: Y
Docket:
NRC Notified By: Monroe Cooper
HQ OPS Officer: Ernest West
Licensee: Tesla Inc.
Region: 1
City: Tampa State: FL
County:
License #: 1559-1
Agreement: Y
Docket:
NRC Notified By: Monroe Cooper
HQ OPS Officer: Ernest West
Notification Date: 07/13/2023
Notification Time: 10:08 [ET]
Event Date: 07/13/2023
Event Time: 00:00 [EDT]
Last Update Date: 07/13/2023
Notification Time: 10:08 [ET]
Event Date: 07/13/2023
Event Time: 00:00 [EDT]
Last Update Date: 07/13/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - LOST SOURCE
The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:
"BRC Orlando was notified on 7/13/23 that a device leased by Tesla Inc., Tampa from NRD, LLC is lost. The device is an ion gun initially containing 10 mCi of Po-210. The licensee, Tesla Inc., did not turn up in a search of the general licensee Laserfiche [content management platform]. BRC has reached out to Tesla Inc. to get further details and have not yet received a response. Tesla Inc. is in the process of applying for a license (1559-1). A BRC Inspector will respond."
FL Incident Number: FL23-105
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 information was provided by the Florida Bureau of Radiation Control (BRC) via email:
"BRC Orlando was notified on 7/13/23 that a device leased by Tesla Inc., Tampa from NRD, LLC is lost. The device is an ion gun initially containing 10 mCi of Po-210. The licensee, Tesla Inc., did not turn up in a search of the general licensee Laserfiche [content management platform]. BRC has reached out to Tesla Inc. to get further details and have not yet received a response. Tesla Inc. is in the process of applying for a license (1559-1). A BRC Inspector will respond."
FL Incident Number: FL23-105
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: 56669
Rep Org: Wisconsin Radiation Protection
Licensee: Aurora Health Care Central, Inc
Region: 3
City: Sheboygan State: WI
County:
License #: 117-1022-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: John Russell
Licensee: Aurora Health Care Central, Inc
Region: 3
City: Sheboygan State: WI
County:
License #: 117-1022-01
Agreement: Y
Docket:
NRC Notified By: Kyle Walton
HQ OPS Officer: John Russell
Notification Date: 08/09/2023
Notification Time: 11:38 [ET]
Event Date: 07/13/2023
Event Time: 00:00 [CDT]
Last Update Date: 08/09/2023
Notification Time: 11:38 [ET]
Event Date: 07/13/2023
Event Time: 00:00 [CDT]
Last Update Date: 08/09/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Peterson, Hironori (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Peterson, Hironori (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Wisconsin Department of Health Services (the Department) via email:
"On August 9, 2023, the Department was notified by the licensee of a yttrium-90 (Y-90) TheraSphere medical event that had occurred on July 13, 2023. The licensee's radiation safety officer performed a records review on August 2, 2023, and identified a written directive indicating a potential underdose to the patient. After confirming that the documentation was correct on August 8, 2023, the licensee determined that a reportable event had occurred.
"The prescribed activity to the patient was 1.07 GBq. The licensee initially calculated a delivered activity of .86 GBq based on pre- and post-administration surveys. The radiation safety officer was not able to replicate this calculation and determined that the delivered activity was approximately .781 GBq. This is a delivered activity of 72.99 percent. Utilizing the TheraSphere worksheet, the licensee calculated that the patient received 73.4 percent of the prescribed dose.
"The licensee will be notifying the patient. There is no anticipated harm to the patient, or exposure to any additional individuals."
Event Report ID No.: WI230006
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 Wisconsin Department of Health Services (the Department) via email:
"On August 9, 2023, the Department was notified by the licensee of a yttrium-90 (Y-90) TheraSphere medical event that had occurred on July 13, 2023. The licensee's radiation safety officer performed a records review on August 2, 2023, and identified a written directive indicating a potential underdose to the patient. After confirming that the documentation was correct on August 8, 2023, the licensee determined that a reportable event had occurred.
"The prescribed activity to the patient was 1.07 GBq. The licensee initially calculated a delivered activity of .86 GBq based on pre- and post-administration surveys. The radiation safety officer was not able to replicate this calculation and determined that the delivered activity was approximately .781 GBq. This is a delivered activity of 72.99 percent. Utilizing the TheraSphere worksheet, the licensee calculated that the patient received 73.4 percent of the prescribed dose.
"The licensee will be notifying the patient. There is no anticipated harm to the patient, or exposure to any additional individuals."
Event Report ID No.: WI230006
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.