Event Notification Report for October 05, 2023

AGREEMENT STATE - GREATER THAN ANTICIPATED DOSE TO NON-TARGET ORGAN

The following information was provided by the New Hampshire Radiological Health Section (NHRHS) via email:

"Via telephone on October 9, 2023, the licensee's Radiation Safety Officer reported a medical event associated with use of their Varian BRAVOS high dose rate remote afterloader (HDR).

"During a treatment fraction administered on October 5, 2023, a patient received a dose of 435 centigray (cGy) (435 rad) versus a planned dose of 700 cGy (700 rad) to the target organ (the cervix) and an estimated 586 cGy (586 rad) versus an expected 300 cGy (300 rad) to the rectum (a non-targeted organ). The dose to the non-target organ exceeds 50 percent of the expected value had the procedure been given in accordance with the written directive.

"The preliminary findings indicate the wrong HDR channel had been selected. The patient and physician were notified. No health effects are anticipated as a consequence of this event. When the treatment fractions are completed, the target organ will have received a dose within 20 percent of the written directive.

"The patient and the patient's physician were advised. No negative health effects are anticipated. Treatment fractions will continue to ensure the desired dose to the target area will be provided. The investigation, with possible identification of further corrective actions, is ongoing. More information is anticipated within 15 days.

"Medical Event: Exposure to a non-target organ exceeding 50 percent of anticipated during a fractional treatment. Dose intended to target organ planned / actual: 700 cGy (700 rad) / 435 cGy (435 rad); 62 percent of planned. Dose to non-target organ anticipated / actual: 300 cGy (300 rad) / 586 cGy (586 rad); 95 percent greater than anticipated."

NMED Report Number: NH-23-0002

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 - LOST EXIT SIGNS

The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:

On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Hays Gulch Plant and several walkdowns of the facility, six exit signs were reported as lost. The signs were manufactured by Isolite Corporation, model number: SLX60 (7.5 Ci of H-3 each).

Event Report ID No.: CO230037



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 EXIT SIGN

The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:

On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Crawford Trail and several walkdowns of the facility, one exit sign was reported as lost. The sign was manufactured by Isolite Corporation, model number 2000 (11.5 Ci of H-3).

Event Report ID No.: CO230036


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 EXIT SIGNS

The following is a summary of the information provided by the Colorado Department of Health (the Department) via email:

On October 5, 2023, after months of correspondence between the Department and the Williams Corporation - Parachute Creek Gas Plant and several walkdowns of the facility, eight exit signs were reported as lost. The signs were manufactured by Isolite Corporation, model number SLX60 (8.1 Ci of H-3 each).

Event Report ID No.: CO230038



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