Event Notification Report for September 06, 2024

AGREEMENT STATE REPORT - MALFUNCTIONING SHUTTER

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

"On September 6, 2024, the Department was notified that the shutter on a Texas Nuclear model 5204 gauge was found stuck in the open position during routine testing. The gauge contains a 4,000 mCi (original activity) Cs-137 source. Open is the normal position for the shutter. The licensee reported there is no risk of additional exposure to members of the general public or radiation workers at the facility due to the failure.
"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10126
Texas NMED Number: TX240027

EN Revision Imported Date: 10/4/2024

EN Revision Text: AGREEMENT STATE REPORT - MISSING GAUGES

The following is a summary of information provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via phone:

In the conduct of their regulatory duties, RHB established a program to collect and store nuclear gauges from closed or abandoned mining sites. This initiative is aimed at preventing improper disposal of nuclear gauges during reclamation operations.

On September 6, 2024, RHB inspected one such coal mining facility located in Helton, KY, in an attempt to recover six fixed Cs-137 level gauges with an aggregate activity of approximately 700 mCi. The storage facility for the gauges was found open and the gauges were missing. The last recorded inventory of the gauges occurred in 2021. Local law enforcement and state emergency operations were notified. It is believed that the gauges were improperly discarded either by the previous owner or by the reclamation company.

RHB will continue to investigate this event and provide updates in accordance with SA-300. No risk to the public is anticipated from this event.

* * * UPDATE ON 9/16/2024 AT 0959 EDT FROM RUSSELL HESTAND TO SAMUEL COLVARD * * *

The following information was provided by Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via email:

"RHB is in the process of repossessing nuclear gauges from abandoned coal mines. In the process of assessing the number and state of each gauge, it was discovered that the building at the [Big Laurel #1 prep plant] was demolished. The storage cabinet located in that building was missing. On September 6, 2024, an onsite investigation of the facility was performed. The storage cabinet was located on the property. The storage cabinet was damaged and the contents of the cabinet (6 gauges with 700 mCi of Cs-137) were missing.

"The last known pictures and inventory from a routine inspection on June 23, 2021, showed the gauges stored in the locked metal cabinet at the warehouse where Big Laurel #1 prep plant, operated by Bledsoe Coal, then Revelation Energy and later under reclamation by Black Mountain Resources, are now gone.

"On September 10, 2024, at 1153 EDT, RHB was notified of a smelter in West Virginia that had their portal monitors alarmed. The load was returned to its origin site located in Hazard, Kentucky. RHB representatives were dispatched to the facility. Upon arrival at the scrapyard facility, two gauges were present. The gauges were compared to the last known inventory at Big Laurel. Both gauges were positively identified as property of said plant. Both gauges were surveyed for removable contamination. All levels for removable contamination were at or below background. The two gauges were then packaged and secured for transport to RHB in Frankfort, Kentucky. RHB has possession of the two gauges.

"On September 13, 2024, RHB was notified that that an additional gauge was found at the recycling yard where the other two gauges were found. RHB personnel will be dispatched on September 17, 2024, to secure the additional gauge. The gauge will be stored at RHB in a secure location."

Notified R1DO (Werkheiser), NMSS Events (email), ILTAB (email)

* * * UPDATE ON 10/03/2024 AT 0938 EDT FROM RUSSELL HESTAND TO NATALIE STARFISH * * *

The following information was provided by Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via email:

"On Friday September 13, 2024, RHB was notified that an additional gauge was found at the recycling yard where the other two gauges were found. RHB personnel were dispatched on September 17, 2024 to secure the additional gauge. The gauge is stored at RHB in a secure location.

"On Thursday September 19, 2024 RHB was dispatched to a recycling center in Hazard Kentucky to retrieve two more gauges. A third gauge was reportedly cut up and disposed. Surveys of the area where the gauge was supposedly cut-up were conducted. Soil Samples were retrieved. Results are still pending, but no increased levels were detected.

"RHB has recovered five gauges. Three were confirmed by serial number to be from Revelation Energy. Two of the gauges no longer have serial numbers. All five are believed to be from Revelation Energy. The unaccounted sixth gauge is believed to have been cut up and sent to waste weeks ago. RHB went to the location where it was cut and took surveys and soil samples. Lab testing revealed only background radiation. It is not believed that the cesium was compromised.
"Five of the six gauges have been through one half life and the sixth has an original assay date of November 2001."

Notified R1DO (Deboer), NMSS Events (email), ILTAB (email)

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 provided by the Florida Bureau of Radiation Control (BRC) via email:

"BRC received notification from the Advent Health Altamonte radiation safety officer of a possible medical event. A patient received a Y-90 TheraSphere treatment, intended for the liver, which migrated to the stomach. The prescribed dose was 250 Gy, and the dose assessment is still being conducted. The facility states a majority of the prescribed dose was received by the stomach. Migration was identified by the patient's physician, and the patient was notified this morning."

Florida incident number: FL-24-082

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 - Y-90 UNDERDOSE

The following information was provided by the New Jersey Department of Environmental Protection (NJDEP) via email:

"The licensee was scheduled to administer a Y-90 SIR-Sphere therapy to a patient. There was a tubing failure, and the administration was suspended. It is estimated that only 59 percent of the prescribed activity was administered. The patient has been re-scheduled. The licensee will follow-up with a full written report.

"The intended Y-90 SIR-Sphere therapy activity was 13.5 mCi, and the administered activity was 7.99 mCi. The target organ was the liver.

"The licensee is investigating. The root cause(s) and contributing factors will be addressed in a full report.

"Follow-up actions are to be determined."

NJ Event Report ID number: To be determined.

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 - MEDICAL UNDERDOSE

The following information was provided by the New York State Department of Health via phone and email:

"Notification was received by email on 9/13/24 from Mt. Sinai Hospital, NYC license number 75-2909-04, of an event that took place on 9/6/24. The event involved treatment of the liver with Y-90 microspheres, and only 40 percent of the intended dose was delivered, which they said was due to stasis. The dose delivered to the left lobe of the liver was 58.8 Gy compared to a prescribed dose of 147 Gy."

NYC Event Number: NYC-24-0913

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.