Event Notification Report for August 15, 2023

NON-AGREEMENT STATE REPORT - LOST SOURCE

The following is a synopsis of information was provided by Helmuth, LLC via phone call:

During a relocation of Helmuth to a new facility in November 2022, the static removing air nozzle was mistakenly disposed of in the municipal trash. The mistake was not noticed until a new unit was delivered to the new location.

Manufacturer: AMSTAT Industries
Model : P-2021-8101
Serial Number: A2MR173

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

Activity of the nozzle is 10 mCi ( 370 MBq) of Po-210.

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 REPORT - EXTERNALLY CONTAMINATED PACKAGE

The following information was provided by the Defense Health Agency via email:

The licensee made a 10 CFR 20.1906 report of receipt of a shipment of Tc-99m with external contamination present on the "high-tech solution bag." The licensee reported this event due to contamination levels potentially exceeding regulatory limits prior to receipt during transit.

At approximately 0900 (CDT) IonSouth delivered a package to the licensee's facility at Keesler Air Force Base Medical Center's hotlab. The licensee identified that the bag had external contamination present. The licensee performed 300 square centimeter wipes at approximately 1130 (CDT) resulting in 50544 disintegrations per minute (dpm) inside the package and 5920 dpm outside the package. The Radiation Safety Officer (RSO) projected that the contamination level outside the bag was 7917.5 dpm at time of delivery. The package was placed in a plastic bag and secured for decay.

The licensee notified IonSouth to inform them of the contaminated package. The RSO is awaiting additional information from the vendor.

MEDICAL EVENT - UNDERDOSE

The following is a summary of information provided by the licensee via telephone:

During post procedure processing of a Y-90 treatment to a liver, it was realized that only 78.5 percent (0.77 Giga-Becquerel) of the prescribed dose (0.99 Giga-Becquerel), was delivered to the target organ. The remainder of the dose was still in the delivery vial. All of the administered dose was delivered to the target organ. The prescribing physician has been informed. A written report will be forwarded when complete.

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

"On August 8, 2023, the Agency was notified by the licensee's service provider that the shutter on a Vega America SH-F2 nuclear gauge would not close. Open is the normal position for the gauge. The gauge contains a sixty millicurie (original activity) Cs-137 source. The source is mounted in an elevated location that prevents exposures to any personnel. The service provider stated the licensee had just completed maintenance in the vessel where the gauge was mounted and was opening the shutter when they began to feel resistance to movement. The licensee continued to open the shutter and as they reached the open position the screws holding the operating arm in place broke. The operating arm no longer operates the shutter. The licensee will contact a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: 10044