Event Notification Report for August 30, 2024

UNPLANNED CONTAMINATION INVOLVING MELTING OF SOURCE

The following summary was provided by via phone:

The facility Steel of West Virginia notified the NRC (see National Response Center report #1408695 for additional notifications) to inform them that they potentially melted a Cesium-137 (Cs-137) source during their melting process before shipping scrap metal to another facility in Chicago, Illinois. Radiation detectors indicated positive readings for Cs-137 in the atmosphere at this facility. The source of the material is unknown at this time. Investigation is underway. The state of West Virginia were able to take radiation readings in the facility's bag house and readings were 550 microRem/hour.

The state of Illinois likewise notified the NRC during the discovery of the shipment of bag house dust from the West Virginia steel mill had tripped a portal alarm upon arrival in Chicago. The Cs-137 was identified in the load with the dust surveying approximately 1.7 mR/hour on contact with the truck. The shipment is planned to be returned to West Virginia under a Department of Transportation (US DOT) special permit. West Virginia program staff are on site at the steel mill and confirmed Cs-137 contamination. Early indications are that a load of scrap, received on or about August 15, 2024, contained a Cs-137 source and was melted in the mill's electric arc furnace. The mill staff surveyed QA samples from recent melts and believe that the Cs-137 volatilized as it wasn't identified in finished steel product.

AGREEMENT STATE REPORT - DOSE ADMINISTERED TO WRONG SEGMENT OF LIVER

The following information was received via email from the Virginia Radiation Materials Program (VRMP):

"At approximately 1500 EDT on 8/22/2024, the VRMP was notified by the radiation safety officer (RSO) for Virginia Commonwealth University of a medical event involving a Y-90 TheraSpheres liver treatment. The event occurred on 8/22/24, at 1330 EDT. The written directive prescribed 215 Gy to segment 'A' of the liver and 142 Gy to segment 'B'. During the treatment, the Y-90 dose was administered to the wrong segment of the left hepatic lobe, segment 'A' received dose intended for segment 'B'. The prescribed dose for segment 'A' was 215 Gy (2.072 GBq) and that segment received 114Gy (1.369 GBq), which is less by 47 percent. This was realized immediately, and the procedure was ended without administering the other dose. The authorized user immediately notified the RSO who then notified the VRMP. Per the RSO, the referring physician has been notified and the patient's treatment will continue once appropriate dose calculation can be done. VRMP will follow up with an investigation."

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 - LEAKING SEALED SOURCE

The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:

"On 3/27/24, the Cs-137 dose calibrator source was found to have 635 disintegrations per minutes (dpm) of contamination during the routine weekly swipe. Second set of swipes found 2346 dpm on the inside of the shielded container and 2559 dpm on the outside of the vial. The source was cleaned and swiped again, which brought counts to zero on the inside of the shielded container and 1018 dpm on the outside of the vial. On 4/1/2024, the swipes were counted again and found to be at the same level, showing the contamination to be a long-lived isotope. Since the area where the sealed source resides does not contain long-lived isotopes, it was assumed the source was leaking and was taken out of service and stored under the office of radiation safety's control. On 4/2/2024, Eckert and Ziegler [the manufacturer] was contacted to request instructions on returning the leaking source. Another swipe taken on 7/29/2024 found 17807 dpm and a small fracture was noticed on the vial. This swipe exceeded 5 nano Ci, and the report was made to BRC. Source will be returned to the manufacturer."

Source Information:
Manufacturer: Eckert and Ziegler.
Model: RV-137-200U.
Serial number: 1047-67-4.
Original activity: 197 micro Ci with a calibration date of 7/1/2004.

Florida Incident No.: FL24-076