Event Notification Report for February 28, 2024

AGREEMENT STATE REPORT - LOST SOURCES

The following information was provided by the New York State Department of Health (NYSDOH) via fax:

"The Radiation Safety Officer for NRD, LLC (NYS Radioactive Materials License number: C1429) contacted the NYSDOH on February 20, 2024, regarding a shipment of 10,000 Americium-241 foils (approximately 0.77microCi per foil) that were shipped and lost via common carrier. The model is A-001. The destination for this shipment was El Paso, Texas.

"On January 22, 2024, NRD, LLC shipped 11 boxes, each box containing 10,000 units of Americium-241. The shipment was picked up by a common carrier through Buffalo, New York, to El Paso, Texas. The client confirmed that only 10 of the 11 shipped boxes were delivered. The Tracking ID (774896057866) indicated that the missing package in question was unaccounted for in/after the Buffalo, New York location. In reviewing the other 10 shipments, stops were made in Buffalo, New York, Binghamton, New York, Fort Worth, Texas and eventually to El Paso, Texas.

"NRD, LLC requested that the common carrier investigate the location of this lost shipment (Case Number C-138364453 Reference-46194) and the common carrier confirmed that they were unable to locate this shipment on February 13, 2024. To date, this shipment is still missing. NYSDOH is actively monitoring this incident and has assigned Incident number 1475 to track this event. NYSDOH has contacted Texas for awareness, as this event involves their client. NRD, LLC will be contacting their client intermittently and monitoring their returned shipments if this package is delivered or returned to sender. In accordance with 10 CFR 20.2201 (d), NRD, LLC, will be reporting any substantive information to the loss of these devices within 30 days of their awareness. Additional information will be reported to NMED once available."

NYSDOH EVENT REPORT ID NUMBER: NY-24-02


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 - DAMAGED MOISTURE DENSITY GAUGE

The following report was received via phone call and email from the Texas Department of State Health Services (the Department):

"On February 20, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that a Troxler 3440 moisture/density gauge was damaged at a temporary job site. The gauge contains a 40 millicurie americium - 241 source and an 8 millicurie cesium -137 source. The gauge operator was setting the gauge up for use when they noticed that a large number of construction equipment was moving into the area. The operator decided to move their truck out of the way and while they were doing so the gauge was struck by a piece of equipment. The RSO stated the gauge case was damaged, but the sources were not damaged. The cesium source was still in the fully shielded position when the event occurred. The RSO stated the gauge was transported back to their facility and a leak test was conducted on the sources. The RSO stated they have contacted a service company and as soon as they get the leak test results back, they will dispose of the gauge. No individual received any significant exposure due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10089
Texas NMED Number: TX240007

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED DOSE

The following report was received via email from the Alabama Department of Public Health, Office of Radiation Control (the Office):

"The Office was notified of the medical event during a licensee inspection between February 6 to February 8, 2024. The licensee reported that during a patient's 3rd treatment on 12/4/2023, dwell positions in part of the high dose rate (HDR) applicator (2 ovoids) were successfully completed. Dwell positions in another part of the applicator (the tandem) were interrupted due to an obstruction. After repeated checks and attempts, dwell positions in the tandem could not be completed. The patient received 100 cGy of the intended 600 cGy for the third treatment on 12/4/2023.

"The licensee examined the applicator, and determined that there appeared to be microfractures in the area of the tandem. The licensee has replaced this applicator, and developed precautionary safety procedures to avoid this matter in the future. The licensee noted that the matter appears to be related to the autoclaving process for applicators. The licensee also revised the patient's treatment course, and the patient was successfully treated during 4th and 5th fractions.

"The licensee used an Elekta Flexitron serial number: FT00306, with an Alpha-Omega model 136147 source, serial number: D85F-2336, 11.86 Ci of Ir-192 on 11/17/2023."

Alabama Incident Number: Pending

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 - DISCOVERY OF AN ORPHAN RADIOACTIVE SOURCE

The following information was provided by the Washington State Department of Health via email:

"Port Townsend Paper Corporation sent an old lead-lined tank to a scrap yard. Unknown radioactivity was then detected in the tank at the scrap yard. The unknown radioactive material was wrapped in lead from the tank by workers at the scrap yard and sent back to Port Townsend Paper Corporation. The Radiation Safety Officer at Port Townsend Paper Corporation measured 0.33 mR/hour on the outside of the lead. The lead and the unknown radioactive material were temporarily stored in an area of the paper mill that is usually unoccupied.

"An inspector from the Washington State Department of Health plans to go to the Port Townsend Paper Corporation in a few days to investigate. It is suspected that the unknown radioactivity is likely to be naturally occurring radioactive material which can build up over time in piping, tanks, etc. at paper mill facilities. All the licensee's sealed sources are accounted for, so the unknown radioactivity is unlikely to be from one of them, but the inspector will check for that possibility."

WA Event Number: WA-24-005