Event Notification Report for August 12, 2024

AGREEMENT STATE - MISSING SHIPMENT

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

"On August 2, 2024, the Department was notified by a Texas licensee that they had shipped 118 millicuries of iodine-125 seeds to a vendor in the state of Florida on July 26, 2024. The package was shipped standard overnight shipping. The Texas licensee reported that on August 2, 2024 the vendor contacted them and requested a status update of the shipment. The Texas licensee looked up the shipping information on the shipper's web site and it only showed that the material had been picked up by the shipper at the Texas licensee's location. The Texas licensee has not been able to get any additional information from the shipper. The Texas licensee has opened a case with the shipper. Additional information will be provided as it is received in accordance with SA-300.

"The licensee reported the iodine-125 seeds involved in this event are not an exposure risk to any individuals."

Texas incident number: I-10118

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.pdfThe following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

AGREEMENT STATE - STOLEN MOISTURE DENSITY GAUGE

The following information was provided by the North Carolina Department of Health and Human Services Radioactive Materials Branch (RMB) via email:

"The licensee reported that around 0800 EDT on August 1, 2024, it was discovered that a break-in had occurred at a construction site. Their portable nuclear gauge (PNG) containing 8 mCi Cs-137 and 40 mCi of Am-241/Be was stolen. The construction site is a locked and secured fenced area with the licensee's Conex box inside that secured area. The PNG was located inside the Conex box, locked inside its own secured steel storage box, secured via chains and locks to the inside of the Conex box. The steel box containing the PNG was also locked with chains and locks.

"The fenced area was broken into and the doors to the Conex box were forced open with a large sheepsfoot roller, allowing the thieves' access to the steel box containing the PNG.

"RMB's investigation is ongoing. A follow-up report will be made to close and complete the record."

NC event number: NC24004

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 - DOSE TO UNINTENDED ORGAN

The following information was obtained from the California Department of Public Health, Radiologic Health Branch, via email:

"University of California at Los Angeles (UCLA) reported a medical event had occurred on Friday, July 26, 2024, during a Y-90 Therasphere liver cancer treatment. Patient SPECT imaging performed on August 1, 2024, showed that all of the Y-90 activity was in the patient's stomach tissue rather than in the intended left lobe of the liver. The licensee reported that the dosage of Y-90 administered was in conformance with the written directive. UCLA is continuing to investigate to determine how the Y-90 Theraspheres ended up in the stomach tissue and will address the cause in their 15-day written report to the Radiologic Health Branch.

"Per the licensee's documentation, a dosage of 0.77 GBq was delivered to the patient, with 0.74 GBq expected to go to the treatment site to result in a dose of 178.9 Gy to the treatment site."

California event number: 5010-080124

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 - LOST STRONTIUM-90 SOURCES

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

"On August 1, 2024, the Agency was advised by the radiation safety officer (RSO) for Eastern Illinois University that twelve strontium-90 button sources were missing from inventory. As the sources had been secured in a locked cabinet, they were likely mistakenly included in a low-level radioactive waste pickup that occurred on July 8, 2024. The RSO was not present for the shipment, nor was the waste pickup coordinated with relevant radiation safety program staff. The sources were identified as missing when the RSO did a sealed source inventory on August 1, 2024. The sources were not itemized on the waste manifest and while this is the most likely disposition, it cannot be verified at this time.

"The twelve sources were 0.5 microcurie Sr-90 button sources when assayed in 1970. All were manufactured by The Nucleus, Inc. as model Sr-90-S-5, with serial numbers 6/2/70-1 through 6/2/70-12. They are now decayed to approximately 0.14 microcuries each and do not represent a radiation safety concern. The Agency has already conducted a reactive inspection. The licensee is assessing the availability of documentation through the waste broker (NAC Philotechnics). Pending that documentation and a response to the Notice of Violation, this matter is considered closed."

Illinois item number: IL240018

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