Event Notification Report for September 26, 2023

EN Revision Imported Date: 9/26/2023

EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCES MISSING IN TRANSIT

The following information was received via email and telephone by the Illinois Emergency Management Agency [the Agency]:

"The Agency was notified the afternoon of August 16, 2023 by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of two radiopharmaceutical packages missing in transit. The last known location was the common carrier facility in Memphis, TN. The carrier informed the licensee that the packages could not be located and are now identified as missing. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. Details of the packages are below:

"Package 1: Shipped on August 11, 2023 to RLS USA, Inc. Sugar Notch in Pittston, PA under tracking number 782355003930. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.5 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received.

"Package 2: Shipped on August 11, 2023 to Cardinal Health in Sarasota, FL under tracking number 782382357185. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.512 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received."

* * * UPDATE ON 9/25/2023 AT 1127 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *

"The licensee advises no updates have become available and the packages are both considered lost. As both have decayed to background, the Agency considers these incidents closed."

Illinois Event Number: IL230018

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 Imported Date: 9/26/2023

EN Revision Text: AGREEMENT STATE REPORT - LOST LESS THAN CAT 3 SOURCE

The following information was received via email from the Illinois Emergency Management Agency and Office of Homeland Security (the Agency):

"The Agency was notified August 24, 2023, by G.E. Healthcare in Arlington Heights, IL to advise a radiopharmaceutical package was missing - presumably in transit. The last known location was the licensee's Arlington Heights, IL facility when it was reportedly given to the [common carrier]. The carrier reports it wasn't scanned at pickup and cannot be accounted for. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.

"The 16 centimeters squared package was labeled Yellow-II (TI of 0.1), UN2915 and contained a single 10mL shielded vial. The activity of In-111 was 1.5 millicuries at the time of shipment, but has since decayed to approximately 0.6 millicuries. It was reportedly offered for shipment on August 21, 2023, for delivery to the customer in West Virginia on August 22, 2023. After failure to arrive, the licensee initiated a search and found the carrier's tracking system states it was never received. The licensee has searched their facility and reviewed inventory and survey records; all of which indicate the package was conveyed to the [common carrier] for transit into commerce. GE Healthcare contacted the customer, (Pharmalogic in Bridgeport, WV) which confirmed that the package had not been received. After several reviews of the package's status and conversations with various [common carrier] personnel, it has been established that the package cannot be located.

"A site visit by Agency inspectors is not planned at this time. This matter will continue to be tracked until an update is available or the package has decayed to background levels."

* * * UPDATE ON 9/25/2023 AT 1127 EDT FROM IEMA TO LAWRENCE CRISCIONE * * *

The licensee advises no updates have become available and the package is considered lost. As the package has decayed to background, IEMA considers the incident closed.

Illinois Item Number: IL230021

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 GENERALLY LICENSED SOURCE

The following information was received from the California Department of Public Health via email:

"On 09/13/23, Tesla Corporation contacted [Radiation Health Branch] RHB to report a lost radioactive source. The lost item was a Po-210, 10 mCi source, model P-2021-Z705, serial number A2MK511, shipped to the facility on 10/05/2021. Based on this information, the current activity is approximately 281.12 microcuries. The source was used to blow dust off of auto body panels and prevent static buildup prior to painting. The employees at the shop could not provide an estimate of when the last time the device was used and believe that the device may have been disposed of in the trash. They have placed internal restrictions on sites ordering tools with radioactive sources. Additionally, they have transitioned into using an anti-static tool that does not utilize a radioactive source."

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 - UNDERDOSE

The following information was received from the Colorado Department of Public Health and Environment via email:

"After completing a Yttrium-90 TheraSpheres treatment, [medical personnel] were measuring the residual Yttrium-90 TheraSpheres and found that the administered dose delivered to the patient was only 313.2 Gray and the prescribed dose was 407 Gray. The total dose delivered was only 77 percent of the prescribed dose. The department is investigating the cause of the event."

Colorado Event Report ID: CO 230032

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 - LOST SOURCE

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

"On May 22, 2023, a general licensee notified the Agency that it had determined on May 9, 2023, that one of their Ronan RLL-1 gauges containing 0.9 millicuries of cesium-137 (10 sealed sources of 90 microcuries each), was lost. The general licensee reported the device had been removed from service February 2022 and placed in storage in a warehouse at one of its sites. A third party was hired for management and control of the warehouse.

"By the end of May 2022, it was discovered the gauge was not in the warehouse. Believing it was still onsite, over the next 12 months the general licensee made repeated attempts, interviews with current and former staff, and more than eight thorough searches of the warehouse and it reached out to the supplier. It did locate the detector that went with the gauge but not the gauge itself. After reporting this to the Agency, the general licensee also rented radiation detectors and searched the warehouse and the area around it. The general licensee reported it believes the gauge is likely to still be at the plant site due to its size, weight, and labeling. Due to design and low activity, the general licensee does not believe any persons have been exposed to elevated radiation.

"To prevent recurrence, the general licensee reviewed and revised its radiation protection manual and refresher training was presented to applicable plant employees. On a quarterly basis going forward, it will verify and document their general license radioactive sources and each of their locations."

Texas Incident Number: 10021
Texas NMED Number: TX230028

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