Event Notification Report for October 04, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/03/2023 - 10/04/2023
Agreement State
Event Number: 56776
Rep Org: Florida Bureau of Radiation Control
Licensee: James Hardie Building Products, Inc
Region: 1
City: Plant City State: FL
County:
License #: GO663
Agreement: Y
Docket:
NRC Notified By: John A. Williamson
HQ OPS Officer: Karen Cotton-Gross
Licensee: James Hardie Building Products, Inc
Region: 1
City: Plant City State: FL
County:
License #: GO663
Agreement: Y
Docket:
NRC Notified By: John A. Williamson
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/04/2023
Notification Time: 14:37 [ET]
Event Date: 10/04/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
Notification Time: 14:37 [ET]
Event Date: 10/04/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LOSS OF CONTROL
The following information was provided by the Florida Bureau of Radiation Control [the Bureau] via email:
"On October 4, 2023, a gamma density gauge (DensityPro Gamma Density System, Model Number 5201A, 20 mCi Cs-137) was discovered in a rejected load of scrap metal at NuCor Steel. The Bureau inspector took custody of the gauge and transported it to Orlando. Upon further cleaning, the description plate revealed a serial and model number. The gauge was determined to belong to James Hardie Building Products (licensee). The licensee will be contacted and further corrective actions will be referred to the materials group at the Bureau."
Florida Incident number - FL23-152
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 [the Bureau] via email:
"On October 4, 2023, a gamma density gauge (DensityPro Gamma Density System, Model Number 5201A, 20 mCi Cs-137) was discovered in a rejected load of scrap metal at NuCor Steel. The Bureau inspector took custody of the gauge and transported it to Orlando. Upon further cleaning, the description plate revealed a serial and model number. The gauge was determined to belong to James Hardie Building Products (licensee). The licensee will be contacted and further corrective actions will be referred to the materials group at the Bureau."
Florida Incident number - FL23-152
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: 56777
Rep Org: Colorado Dept of Health
Licensee: University of Colorado Hospital
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Meghan Cromie
HQ OPS Officer: Ian Howard
Licensee: University of Colorado Hospital
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Meghan Cromie
HQ OPS Officer: Ian Howard
Notification Date: 10/05/2023
Notification Time: 10:14 [ET]
Event Date: 10/04/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/05/2023
Notification Time: 10:14 [ET]
Event Date: 10/04/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/05/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kellar, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Colorado Department of Public Health and Environment (the Agency) via email:
"On October 4, 2023, the radiation safety officer of the University of Colorado Hospital reported a medical event to the emergency response line. The medical event occurred during the administration of a Y-90 TheraSphere treatment that took place that day. The authorized user stated that high back pressure was observed during administration so only 71.2 percent of the prescribed dose was delivered to the treatment area. This is the third medical event (May 18, 2023 - CO230012 and May 24, 2023 - CO230014) with Y-90 TheraSpheres at this facility in the last six months. Different authorized users and IR [Interventional Radiology] technologists were present at each medical event. The Agency is currently waiting for additional information from the hospital and the Agency intends to follow up with an in-person investigation."
Event Report ID No.: CO2300034
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 Colorado Department of Public Health and Environment (the Agency) via email:
"On October 4, 2023, the radiation safety officer of the University of Colorado Hospital reported a medical event to the emergency response line. The medical event occurred during the administration of a Y-90 TheraSphere treatment that took place that day. The authorized user stated that high back pressure was observed during administration so only 71.2 percent of the prescribed dose was delivered to the treatment area. This is the third medical event (May 18, 2023 - CO230012 and May 24, 2023 - CO230014) with Y-90 TheraSpheres at this facility in the last six months. Different authorized users and IR [Interventional Radiology] technologists were present at each medical event. The Agency is currently waiting for additional information from the hospital and the Agency intends to follow up with an in-person investigation."
Event Report ID No.: CO2300034
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.