Event Notification Report for May 22, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/21/2024 - 05/22/2024
Non-Agreement State
Event Number: 57135
Rep Org: Karmanos Cancer Institute
Licensee: Karmanos Cancer Institute
Region: 3
City: Detroit State: MI
County:
License #: 21-04127-06
Agreement: N
Docket:
NRC Notified By: Nagaraju Mogili
HQ OPS Officer: Josue Ramirez
Licensee: Karmanos Cancer Institute
Region: 3
City: Detroit State: MI
County:
License #: 21-04127-06
Agreement: N
Docket:
NRC Notified By: Nagaraju Mogili
HQ OPS Officer: Josue Ramirez
Notification Date: 05/22/2024
Notification Time: 14:33 [ET]
Event Date: 05/22/2024
Event Time: 09:30 [EDT]
Last Update Date: 05/22/2024
Notification Time: 14:33 [ET]
Event Date: 05/22/2024
Event Time: 09:30 [EDT]
Last Update Date: 05/22/2024
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Ziolkowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), (EMAIL)
Ziolkowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSC (Canada), (EMAIL)
LOST LUTETIUM-177 SOURCE
The following synopsis was provided by the licensee via phone:
On 5/21/24, a 200 millicurie lutetium-177 (Lu-177) source was delivered to the Karmonas Cancer Institute and was placed in a clean hot laboratory. A physics resident cleaning the hot laboratory placed the box containing the source outside the hot lab on a trash can. A custodian threw the box in the trash at the end of the day. The licensee notified the trash management company and the facility security department. No threat to public health is expected based on source packaging.
The NRC Region 3 inspector was also notified.
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 synopsis was provided by the licensee via phone:
On 5/21/24, a 200 millicurie lutetium-177 (Lu-177) source was delivered to the Karmonas Cancer Institute and was placed in a clean hot laboratory. A physics resident cleaning the hot laboratory placed the box containing the source outside the hot lab on a trash can. A custodian threw the box in the trash at the end of the day. The licensee notified the trash management company and the facility security department. No threat to public health is expected based on source packaging.
The NRC Region 3 inspector was also notified.
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: 57144
Rep Org: Arizona Department of Health Services
Licensee: Mayo Clinic Arizona
Region: 4
City: Phoenix State: AZ
County: Maricopa
License #: 07-448
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Natalie Starfish
Licensee: Mayo Clinic Arizona
Region: 4
City: Phoenix State: AZ
County: Maricopa
License #: 07-448
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Natalie Starfish
Notification Date: 05/24/2024
Notification Time: 16:39 [ET]
Event Date: 05/22/2024
Event Time: 00:00 [MST]
Last Update Date: 05/24/2024
Notification Time: 16:39 [ET]
Event Date: 05/22/2024
Event Time: 00:00 [MST]
Last Update Date: 05/24/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by Arizona Department of Health Services (the Department) via email:
"On May 23, 2024, the Department received notification from the licensee about a medical event involving Y-90 TheraSpheres that occurred on May 22, 2024. A patient was prescribed a dose of 1.304 GBq but was delivered 0.931 GBq, a percent dose delivered of 71.4 percent. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
Arizona incident number: 24-007
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 Arizona Department of Health Services (the Department) via email:
"On May 23, 2024, the Department received notification from the licensee about a medical event involving Y-90 TheraSpheres that occurred on May 22, 2024. A patient was prescribed a dose of 1.304 GBq but was delivered 0.931 GBq, a percent dose delivered of 71.4 percent. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
Arizona incident number: 24-007
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
Event Number: 57150
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: Phillips 66 Co
Region: 1
City: Linden State: NJ
County:
License #: 506897-RAD220001
Agreement: Y
Docket:
NRC Notified By: Jack Tway
HQ OPS Officer: Josue Ramirez
Licensee: Phillips 66 Co
Region: 1
City: Linden State: NJ
County:
License #: 506897-RAD220001
Agreement: Y
Docket:
NRC Notified By: Jack Tway
HQ OPS Officer: Josue Ramirez
Notification Date: 05/30/2024
Notification Time: 12:26 [ET]
Event Date: 05/22/2024
Event Time: 00:00 [EDT]
Last Update Date: 05/30/2024
Notification Time: 12:26 [ET]
Event Date: 05/22/2024
Event Time: 00:00 [EDT]
Last Update Date: 05/30/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was provided by the New Jersey Department of Environmental Protection via email:
"While performing routine 6-month fixed gauge shutter checks, the licensee became aware of a shutter that was stuck partially open. The fixed gauge is located 20 feet above a platform and only accessible to licensee staff via scaffolding. No member of the public has access to this location.
"The shutter is currently in its normal open position. No maintenance activities are scheduled which would require closure of the shutter.
"The licensee has a contract with the manufacturer. They have scheduled them to assess this situation and make any necessary repairs."
Gauge information: Cs-137 sealed source in Ohmart/Vega holder SH-F2 (s/n 0361CG), max activity 300 mCi. Leak test conducted October 2023. No detectable leakage.
NJ Event ID Number: To Be Determined
The following information was provided by the New Jersey Department of Environmental Protection via email:
"While performing routine 6-month fixed gauge shutter checks, the licensee became aware of a shutter that was stuck partially open. The fixed gauge is located 20 feet above a platform and only accessible to licensee staff via scaffolding. No member of the public has access to this location.
"The shutter is currently in its normal open position. No maintenance activities are scheduled which would require closure of the shutter.
"The licensee has a contract with the manufacturer. They have scheduled them to assess this situation and make any necessary repairs."
Gauge information: Cs-137 sealed source in Ohmart/Vega holder SH-F2 (s/n 0361CG), max activity 300 mCi. Leak test conducted October 2023. No detectable leakage.
NJ Event ID Number: To Be Determined