Event Notification Report for July 20, 2023

MEDICAL EVENT - DOSE MISADMINISTRATION

The following information was provided by the licensee via phone:

On July 11, 2023, at 1700 EDT, an intravascular brachytherapy treatment was delivered to the wrong treatment site. The original dose of 23 Gy was intended for a different part of the vasculature system. The brachytherapy device made by Best Vascular is a Beta-Catch (model # 5ICW-2) containing 3.62 GBq of Sr/Y-90. Physicians expect that there will be no permanent damage to any of the patient's organs.

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 REPORT - STUCK OPEN SHUTTER

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

"On July 12, 2023, the Agency was notified by the licensee's service company that during routine shutter checks, the shutter on a Vega Americas model SH-F2 [gauge] could not be shut. The gauge contains a 200 millicurie (original activity) Cs-137 source. Open is the normal operating position for the shutter. The licensee has made plans to repair the gauge in the next seven days. The service company stated there is no risk of radiation exposure to members of the general public or radiation workers due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10036

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

FITNESS FOR DUTY - PROHIBITED SUBSTANCE FOUND INSIDE THE PROTECTED AREA

The following information was provided by the licensee via email:

"This report is being made pursuant to 10 CFR 26.719(b)(1).

"At 1111 (PDT) on 7/17/23, a knowledgeable individual received test results from a lab which identified a prohibited substance that was found in the protected area during the recent refueling outage. This prohibited item was found on 5/21/23 in an infrequently accessed area, the condenser bay, and removed from the protected area. The item was old and is surmised to be from construction. Residual ash on the prohibited item tested positive for a prohibited substance.

"The licensee notified the NRC Resident Inspector."

EN Revision Imported Date: 7/21/2023

EN Revision Text: AGREEMENT STATE REPORT - STOLEN DENSITY GAUGE

The following information was provided by the New York State Department of Health (the Department) via fax:

"The licensee reported to the Department that a portable moisture density gauge had been stolen (Humboldt Scientific, Inc., model 5001 EZ, S/N 9909, Isotope: Am-241/Be (S/N: K833-19) & Cs-137 (S/N: Q1676), activity (when new): Am-241/Be 44mCi & Cs-137 11 mCi).

"An authorized user working under the license removed the gauge from the permanent storage location on June 6, 2023, with the intent to store it in a company van overnight to deliver it to a temporary jobsite in the morning of June 7, 2023. At around 0600-0700 [EDT] on June 7, 2023, the authorized user looked outside and did not see the van, so they contacted the New York Police Department and the Radiation Safety Officer. The Radiation Safety Officer indicated that the gauge was stored in the back of the van overnight. The gauge case was locked, and was secured to the floor of the van by chain, so it was stolen along with the van.

"Currently, the location and status of the gauge is unknown. Any updates to this event will be provided as soon as possible."

New York Event number: NY-23-05

* * * UPDATE ON 7/20/23 AT 1716 EDT FROM DANIEL SAMSON TO ADAM KOZIOL * * *

"The Department was notified at 1206 EDT that the vehicle had been located at an auto shop. The Radiation Safety Officer (RSO) was onsite and had to wait for the NYPD to get access to the site and vehicle. At 1445 EDT, the RSO notified the Department that the gauge was found in the vehicle and had not been damaged. It is now in the possession of the licensee and is being returned to the permanent storage location. This incident can be closed."

Notified R1DO (Carfang), NMSS Events, ILTAB, and CNSC (Canada) via email.

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 REPORT - LOST TRITIUM EXIT SIGNS

The following information is a summary of information received from the California Department of Public Health, Radiologic Health Branch via email:

On July 12, 2023, Kaiser Medical Center of Southern California (the licensee) discovered that nine tritium exit signs were missing (Make: Shield, Model: SLX-60, Original activity: 10 Ci, tritium). The missing signs were exit signs at the licensee's parking garage. It has not been determined how the signs went missing after an engineering and security review.

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