Event Notification Report for August 21, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/20/2023 - 08/21/2023
Non-Agreement State
Event Number: 56693
Rep Org: Alliance Healthcare Services
Licensee: Alliance Healthcare Services
Region: 3
City: State: MI
County:
License #: 47-25570-01
Agreement: N
Docket:
NRC Notified By: Kay Kassel
HQ OPS Officer: Lawrence Criscione
Licensee: Alliance Healthcare Services
Region: 3
City: State: MI
County:
License #: 47-25570-01
Agreement: N
Docket:
NRC Notified By: Kay Kassel
HQ OPS Officer: Lawrence Criscione
Notification Date: 08/23/2023
Notification Time: 09:30 [ET]
Event Date: 08/21/2023
Event Time: 07:00 [EDT]
Last Update Date: 09/05/2023
Notification Time: 09:30 [ET]
Event Date: 08/21/2023
Event Time: 07:00 [EDT]
Last Update Date: 09/05/2023
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), - (EMAIL)
Skokowski, Richard (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), - (EMAIL)
EN Revision Imported Date: 9/6/2023
EN Revision Text: Ge-68 SOURCE MISSING FOLLOWING MAINTENANCE
The following is a summary of information provided by the licensee via phone and email:
The licensee reported two missing Ge-68 sources with an activity of 0.312 mCi per source. The sources were stored on a PET CT mobile imaging unit used throughout the State of Michigan. The mobile unit went for repair to TDC Trailer in Rensselaer, IN. While the unit was at TDC Trailer, the unit needed a structural repair which required items in the camera room to be removed from their designated place. The trailer repairman unbolted the source holder from the floor and moved it to the hot lab and placed it in a radiopharmaceutical dose container. The licensee believes the sources were inadvertently picked up by PetNet Radiopharmacy as part of their routine pick up of empty radiopharmaceutical cases on August 16, 2023.
* * * UPDATE FROM KAY KASSEL TO DONALD NORWOOD AT 1025 EDT ON 9/5/2023 * * *
"There were two rod sources missing from PETCT 142. The medical physicist estimates that the dose resulting from these sources over their lifetime to be 31 mSv at 1 meter from the unshielded sources."
Notified R3DO Skokowski, NMSS Events Notification, and ILTAB 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
EN Revision Text: Ge-68 SOURCE MISSING FOLLOWING MAINTENANCE
The following is a summary of information provided by the licensee via phone and email:
The licensee reported two missing Ge-68 sources with an activity of 0.312 mCi per source. The sources were stored on a PET CT mobile imaging unit used throughout the State of Michigan. The mobile unit went for repair to TDC Trailer in Rensselaer, IN. While the unit was at TDC Trailer, the unit needed a structural repair which required items in the camera room to be removed from their designated place. The trailer repairman unbolted the source holder from the floor and moved it to the hot lab and placed it in a radiopharmaceutical dose container. The licensee believes the sources were inadvertently picked up by PetNet Radiopharmacy as part of their routine pick up of empty radiopharmaceutical cases on August 16, 2023.
* * * UPDATE FROM KAY KASSEL TO DONALD NORWOOD AT 1025 EDT ON 9/5/2023 * * *
"There were two rod sources missing from PETCT 142. The medical physicist estimates that the dose resulting from these sources over their lifetime to be 31 mSv at 1 meter from the unshielded sources."
Notified R3DO Skokowski, NMSS Events Notification, and ILTAB 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
Event Number: 56689
Rep Org: PA Bureau of Radiation Protection
Licensee: Allegheny Health Network, Pittsburgh, PA
Region: 1
City: Pittsburgh State: PA
County:
License #: PA-1659
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Donald Norwood
Licensee: Allegheny Health Network, Pittsburgh, PA
Region: 1
City: Pittsburgh State: PA
County:
License #: PA-1659
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Donald Norwood
Notification Date: 08/22/2023
Notification Time: 13:37 [ET]
Event Date: 08/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 08/23/2023
Notification Time: 13:37 [ET]
Event Date: 08/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 08/23/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EQUIPMENT FAILED TO FUNCTION AS DESIGNED
The following information was received via email from the Pennsylvania Department of Environmental Protection (the Department):
"On August 21, 2023 the licensee informed the Department of a medical event where the equipment failed to function as designed. This is reportable under 10 CFR 30.50(b)(2).
"A patient was scheduled for an intravascular brachytherapy (IVBT) patient treatment using a Beta-Cath Strontium 90 device (s/n 91273) and upon source retraction the source failed to return to the transfer device due to a kink in the catheter. An emergency 'bailout' procedure was performed, with the cardiologist removing the delivery catheter and guidewire from the patient. The delivery catheter was left attached to the transfer device and placed it into the temporary plexiglas 'bailout' box. The patient was surveyed to confirm the source had been removed. The 'bailout' box was visually inspected and surveyed to confirm the source was in the catheter in the box. This box was then transferred to the radiation oncology secure storage area. The device will be returned to the manufacturer for inspection. No overexposures were reported.
"The cause of the event is unknown at this time.
"The Department will perform a reactive inspection. More information will be provided as received."
PA Event Report ID Number: PA230022
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.
* * * UPDATE FROM JOHN CHIPPO TO DONALD NORWOOD AT 1357 EDT ON 8/23/2023 * * *
The following information was received via email from the Department.
"The event type has been changed from a medical event to a Part 30 equipment event.
"The Department has learned that the authorized user said that treatment was complete and the source did not enter the device within 3 seconds so they started emergency removal of catheter from the patient and placed it in the 'bailout' box; total time from end of treatment to the catheter/device in the emergency box was approximately 10 seconds. The kink in the catheter was noted after it and the source were approximately 15 cm from where it entered the patient thus no overexposure or unintended dose.
"Device make, model, serial number: Best Vascular, Inc, A1000 Series Models, Transfer Device s/n 91273.
"Radionuclide: Sr-90; Jacketed Radiation Source Train s/n ZB948 (60 mm source train) (24 sources).
"Source strength(s): 3.13 Gbq (84.6 mCi) total; [3.52 mCi/source * 24 sources]; Assay date 12/3/2003; Activity as of August 21, 2023 = 1.92 Gbq (51.9 mCi) total.
"Dose patient received:18.4 Gray @ 2 mm; (vessel 3.0 mm).
"Dose patient prescribed:18.4 Gray @ 2mm (vessel 3.0 mm)."
Notified R1DO (Gray) and NMSS Events Notification email group.
The following information was received via email from the Pennsylvania Department of Environmental Protection (the Department):
"On August 21, 2023 the licensee informed the Department of a medical event where the equipment failed to function as designed. This is reportable under 10 CFR 30.50(b)(2).
"A patient was scheduled for an intravascular brachytherapy (IVBT) patient treatment using a Beta-Cath Strontium 90 device (s/n 91273) and upon source retraction the source failed to return to the transfer device due to a kink in the catheter. An emergency 'bailout' procedure was performed, with the cardiologist removing the delivery catheter and guidewire from the patient. The delivery catheter was left attached to the transfer device and placed it into the temporary plexiglas 'bailout' box. The patient was surveyed to confirm the source had been removed. The 'bailout' box was visually inspected and surveyed to confirm the source was in the catheter in the box. This box was then transferred to the radiation oncology secure storage area. The device will be returned to the manufacturer for inspection. No overexposures were reported.
"The cause of the event is unknown at this time.
"The Department will perform a reactive inspection. More information will be provided as received."
PA Event Report ID Number: PA230022
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.
* * * UPDATE FROM JOHN CHIPPO TO DONALD NORWOOD AT 1357 EDT ON 8/23/2023 * * *
The following information was received via email from the Department.
"The event type has been changed from a medical event to a Part 30 equipment event.
"The Department has learned that the authorized user said that treatment was complete and the source did not enter the device within 3 seconds so they started emergency removal of catheter from the patient and placed it in the 'bailout' box; total time from end of treatment to the catheter/device in the emergency box was approximately 10 seconds. The kink in the catheter was noted after it and the source were approximately 15 cm from where it entered the patient thus no overexposure or unintended dose.
"Device make, model, serial number: Best Vascular, Inc, A1000 Series Models, Transfer Device s/n 91273.
"Radionuclide: Sr-90; Jacketed Radiation Source Train s/n ZB948 (60 mm source train) (24 sources).
"Source strength(s): 3.13 Gbq (84.6 mCi) total; [3.52 mCi/source * 24 sources]; Assay date 12/3/2003; Activity as of August 21, 2023 = 1.92 Gbq (51.9 mCi) total.
"Dose patient received:18.4 Gray @ 2 mm; (vessel 3.0 mm).
"Dose patient prescribed:18.4 Gray @ 2mm (vessel 3.0 mm)."
Notified R1DO (Gray) and NMSS Events Notification email group.
Agreement State
Event Number: 56687
Rep Org: Florida Bureau of Radiation Control
Licensee: Blue Marlin Engineering
Region: 1
City: Orlando State: FL
County:
License #: 4585-1
Agreement: Y
Docket:
NRC Notified By: Robert Latham
HQ OPS Officer: Karen Cotton-Gross
Licensee: Blue Marlin Engineering
Region: 1
City: Orlando State: FL
County:
License #: 4585-1
Agreement: Y
Docket:
NRC Notified By: Robert Latham
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/21/2023
Notification Time: 18:49 [ET]
Event Date: 08/21/2023
Event Time: 17:51 [EDT]
Last Update Date: 08/22/2023
Notification Time: 18:49 [ET]
Event Date: 08/21/2023
Event Time: 17:51 [EDT]
Last Update Date: 08/22/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE
The following information was provided by the Florida Bureau of Radiation Control (BRC) via telephone and email:
"On 8/21/23 at 1751 EDT, BRC received notification from the Blue Marlin Engineering radiation safety officer (RSO) that a Troxler 3430 Gauge (serial number 76 464, Cs-137 77-17679, Am/Be 78-12867) was reported stolen from a work site in Apopka, FL. The RSO does not know when the loss of control occurred. The device was last used at approximately 1100 EDT on 8/21/23 prior to the authorized user (AU) traveling for lunch. Upon returning from lunch, the AU noticed the device was no longer under his control.
"An initial incident report [is planned] to be submitted by the Florida Department of Health on 8/22/23."
* * * UPDATE ON 8/22/23 AT 0814 EDT FROM MONROE COOPER TO ADAM KOZIOL * * *
"RSO believes device was likely stolen, but states there is a possibility it has been filled into a ditch on the work site. Orange County Police Report: 23-51399."
Florida Incident Number: FL23-128
Notified: R1DO (Gray), NMSS (email), ILTAB (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
The following information was provided by the Florida Bureau of Radiation Control (BRC) via telephone and email:
"On 8/21/23 at 1751 EDT, BRC received notification from the Blue Marlin Engineering radiation safety officer (RSO) that a Troxler 3430 Gauge (serial number 76 464, Cs-137 77-17679, Am/Be 78-12867) was reported stolen from a work site in Apopka, FL. The RSO does not know when the loss of control occurred. The device was last used at approximately 1100 EDT on 8/21/23 prior to the authorized user (AU) traveling for lunch. Upon returning from lunch, the AU noticed the device was no longer under his control.
"An initial incident report [is planned] to be submitted by the Florida Department of Health on 8/22/23."
* * * UPDATE ON 8/22/23 AT 0814 EDT FROM MONROE COOPER TO ADAM KOZIOL * * *
"RSO believes device was likely stolen, but states there is a possibility it has been filled into a ditch on the work site. Orange County Police Report: 23-51399."
Florida Incident Number: FL23-128
Notified: R1DO (Gray), NMSS (email), ILTAB (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
Non-Agreement State
Event Number: 56886
Rep Org: Liveo Research Inc.
Licensee: Liveo Research Inc.
Region: 1
City: New Castle State: DE
County:
License #:
Agreement: N
Docket:
NRC Notified By: John Oikemus
HQ OPS Officer: Karen Cotton-Gross
Licensee: Liveo Research Inc.
Region: 1
City: New Castle State: DE
County:
License #:
Agreement: N
Docket:
NRC Notified By: John Oikemus
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 12/11/2023
Notification Time: 16:50 [ET]
Event Date: 08/21/2023
Event Time: 00:00 [EST]
Last Update Date: 12/11/2023
Notification Time: 16:50 [ET]
Event Date: 08/21/2023
Event Time: 00:00 [EST]
Last Update Date: 12/11/2023
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAMAGED RADIOACTIVE SOURCE CONTAINMENT
The following is summary of information provided by the licensee via email and phone:
On December 11, 2023, the licensee reported that the point level sensor containment attached to a power feeder was damaged and the internal shutter would not close. The licensee noticed issues with the point level sensor on June 28, 2023. On July 6, 2023, a work order was submitted for servicing the point level sensor. On August 21, 2023, the level senor was serviced, and the technician informed the licensee that due to the damage of the containment the unit was non-repairable. The estimated dose to staff from June 28, 2023 to August 21, 2023 is 1.8 mrem. The device was removed from service on October 5, 2023.
Source and Containment Information:
Source: Cs-137
Containment Model Number: FQG60
Serial Number: J8003301141
Activity: 740 MBq/20 mCi
Manufacturing Date: 08/2014
The following is summary of information provided by the licensee via email and phone:
On December 11, 2023, the licensee reported that the point level sensor containment attached to a power feeder was damaged and the internal shutter would not close. The licensee noticed issues with the point level sensor on June 28, 2023. On July 6, 2023, a work order was submitted for servicing the point level sensor. On August 21, 2023, the level senor was serviced, and the technician informed the licensee that due to the damage of the containment the unit was non-repairable. The estimated dose to staff from June 28, 2023 to August 21, 2023 is 1.8 mrem. The device was removed from service on October 5, 2023.
Source and Containment Information:
Source: Cs-137
Containment Model Number: FQG60
Serial Number: J8003301141
Activity: 740 MBq/20 mCi
Manufacturing Date: 08/2014