Event Notification Report for November 29, 2023

AGREEMENT STATE REPORT - EQUIPMENT FAILURE

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

"On November 21, 2023, the licensee's radiation safety officer notified the Department that on November 20, 2023, during an intravascular brachytherapy (IVB) procedure, the strontium-90 source train did not reach the dwell position within 15 seconds. When they attempted to retract the source, it would not retract into the fully shielded position in the device, but it was outside the patient. Following established procedures, the delivery system (catheter, source train, etc.) was removed from the patient and placed in the device's emergency box. There were no overexposures to the patient or staff. The licensee used a second device and completed the IVB procedure on the patient. After a short time, the licensee was able to return the source train to the fully shielded position in the device. The manufacturer's representative will be coming onsite to perform an evaluation. The licensee did observe what appeared to be a possible kink in the catheter. More information will be provided as it is obtained in accordance with SA-300.

"Device Information: Best Vascular Novoste IVB model A1000

"Source Information: Source train of 16 strontium-90 sources, current total activity 35.9 millicuries."

Texas Incident Number: 10067

Texas NMED Number: TX230053

AGREEMENT STATE - LOST MOISTURE DENSITY GAUGE

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

"On November 21, 2023, the licensee's radiation safety officer (RSO) advised the Department that one of its technicians had lost a Humboldt 5001EZ moisture density gauge [which contains a nominal activity of 40 mCi of Am-241:Be and 10 mCi of Cs-137]. The technician had finished testing at a temporary job site and then took a phone call. After completing the call, he left the job site with the moisture density gauge sitting on the tailgate. When he realized what had happened, he called the project supervisor who sent workers out to search the testing area and surrounding areas. The technician notified the RSO and started driving back to the site while looking for the gauge. The RSO sent more technicians out to assist in the search and he also notified the local police department. The RSO reported the trigger lock was not on the insertion rod and it was only the gauge that was lost. It was not inside the transport case at the time. Search of the driving route will resume after daylight and the RSO will be checking with other construction workers at this and nearby sites. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 10069

Texas NMED Number: TX230054


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 - POTENTIAL OVEREXPOSURE
The following information was provided by the New York State Department of Health (the Department) via email:

"New York State (NYS) Department of Heath received an email from the radiation safety officer (RSO) of NRD, LLC regarding an employee entering a restricted zone (Silver Recovery) without use of proper personal protective equipment (PPE) and respiratory protection on Sunday, November 19, 2023. Staff at NRD were made aware of this on November 20, 2023, at 1145 EST. The individual entered the restricted area to conduct non-authorized work, which was performed for 20 minutes in a 12 DAC-hr environment based on continual air monitor (CAM) readings at this time. The individual did not wear proper respiratory equipment, nor did they use a personal (lapel) air sampler, which is a PPE requirement for this zone. The individual later donned proper PPE and respiratory protection and continued to work for a total working time of 2 hours. The nature of work that was being conducted is unknown by the Department at this time.

"As the individual did not perform nasal swabs or have personnel air monitoring estimated doses were assumed using the 12 derived air concentration-hour (DAC-hr) environments based on the CAM. The assumptions in preliminary calculations assume a 2-hour working time to be conservative, which shows 24 DAC Hours (2 percent) of intake for the most limiting isotope (Am-241). Individual has been placed on bioassay urine collection and has had authorizations and security removed. NRD will be notifying the Department of these results and more information as it becomes available. This worker has received one bioassay for urinalysis and has been terminated from employment by NRD, LLC.

"NRD, LLC contacted the Radiation Emergency Assistance Center/Training Site (REAC/TS) regarding this event as a precaution to inquire on the potential supply of Diethylenetriamine pentaacetate (DTPA) for chelation therapy. The affected individual involved in this event has apparently refused to cooperate with REAC/TS. The results of this bioassay will be used to determine if an overexposure event has occurred for this individual where possible."

AGREEMENT STATE REPORT - BROKEN GAUGE SHUTTER

The following information was provided by the Iowa Department of Health and Human Services (HHS) via email:

"3M Company in Ames, Iowa, possesses NDC Technologies fixed nuclear gauges for material thickness measurements on their production line. It is being reported that on the morning of November 22, 2023, when beginning production at 0815 CST, a web from the line caught the shutter of an NDC model 103X fixed nuclear gauge, containing 150 millicuries of americium-141, and bent the shutter away from the closed position impacting the function [of the] shutter and not allowing it to fully shield the beam as intended. This was immediately identified by staff and the line was shut down and the radiation safety officer (RSO) was notified. The affected device is installed behind guarding and nobody had access to the beam until the RSO came onsite at 0920 to evaluate the situation. Iowa HHS was notified at 0945. Under the direct supervision and instruction of the RSO, using a radiation survey meter, the licensee (3M Company) fixed the shutter and 3M Corporate Health Physics was notified that the device had been fixed at 1130.

"No overexposures, release, or contamination of radioactive material has occurred because of this incident and Iowa HHS will update this reportable event as more information (cause, corrective actions, radiation doses) becomes available."

NMED item number: IA230003

AGREEMENT STATE - LOST PACKAGE

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"On November 22, 2023, the Agency was contacted by G.E. Healthcare in Arlington Heights, IL (IL-01109-01) to advise of a radiopharmaceutical package missing in transit. The last known location was the Memphis, TN [common carrier] hub where it was scanned on November 21, 2023. The carrier has declared the package lost. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion.

"The subject package is 16 centimeters square, labeled Yellow-II (TI of 0.1), UN2915 and contains a single 10 milli-Liters shielded vial of In-111. The activity was 5.210 millicuries at the time of shipment but has since decayed to approximately 1.56 millicuries. It was offered for shipment on November 17, 2023, for delivery to a customer in Ontario, Canada on November 20, 2023. Upon failure to arrive, the licensee contacted the carrier and was informed the package was currently unaccounted for. Tennessee program officials were notified, and the matter was reported to the HOO [NRC Headquarters Operations Officer]. This report will be updated with any available information."

Illinois Item Number: IL230033

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