Event Notification Report for December 18, 2024

EN Revision Imported Date: 12/18/2024

EN Revision Text: AGREEMENT STATE REPORT - SOURCE LOST IN TRANSIT

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

"The licensee reported to NJDEP on December 3, 2024, that a Ge-68 pin source that they sent for disposal has been lost in transit on December 2, 2024. The source is a Eckert & Ziegler model HEGL-0132, with current approximate activity of 0.267 mCi. The shipping container arrived at its destination damaged and empty. The licensee has filed a claim with the shipper. If the source is not located within the 30 days, the licensee will follow-up with a full written report to include root cause(s) and corrective actions.

"This event is reportable under 10 CFR 20.2201(a)(1)(ii)."

New Jersey Event Report ID number: To be determined

* * * UPDATE ON 12/17/24 AT 1421 EST FROM JACK TWAY TO ADAM KOZIOL * * *

"The missing Ge-68 pin source was found by the common carrier, repackaged, and returned to the supplier (Sanders Medical in Knoxville, TN). The source was located and shipped on December 10, 2024. The NJDEP is in possession of evidence of receipt by the supplier.

"This incident is closed."

NMED Report: 240435

Notified R1DO (Lally), NMSS Events (email), and 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

BROKEN RADIOGRAPHY SOURCE CABLE

The following information was provided by the licensee via email:

"On 11/07/2024, a radiographic crew was performing radiographic testing (RT) on a lease in Prudhoe Bay, AK (about 15 minutes from the Prudhoe Bay field station), when they noticed their camera (Sentinel 880 Delta, serial number: D3963, Ir-192 source model # A424-9, serial number: 96639M, 65.9 Ci) did not lock the source into the safe position. After attempting to check the lock with the same result, they initiated the proper notifications to the site radiation safety officer (RSO), management and drill site operator.

"At 1030 YST, the crew contacted management after extending and verifying their boundaries. They were instructed to wait for retrieval personnel and monitor their boundaries. The retrieval personnel consisted of a trained and certified retrieval RSO and experienced retrieval employees.

"The retrieval crew arrived on-site at 1100. The scene was immediately assessed, boundaries verified, dosimetry checked, and no one was over exposed to radiation. A short meeting with the RT crew and retrieval personnel followed. It was determined that the exposure device was hanging about six feet off the ground on ropes attached to a pipe above it, and the collimator was pointing upward of the building where their exposure was being taken. Once the initial information was gathered, a conference call was initiated with offsite RSO, and management began to form a plan for locating the source.

"The collimated guide tube and camera were safely lowered to the floor. Once the collimator was on the floor it was shielded. The team determined that the source may have disconnected. To verify, the crew cranked the cable all the way in to see if they could confirm the connector either came off or broke off into the pigtail. They attempted to unscrew the back of the camera but were unable to loosen one of the screws. It was decided to disconnect the safety connector off the cranks from the crank cable housing unit. In doing so, it was found that the 550 connector had broken. A plan was formulated to retrieve the source.

"The drive cable connector broke on the shoulder of the connector between the ball and the crimp, closer to the crimp. How or why is under investigation with QSA. This prevented the retrieval personnel from removing the drive cable from the camera in their attempts to retract the source. The safety connector of the cranks from the crank housing unit had to be removed before moving forward.

"QSA Global has the equipment involved in this incident and are investigating the cause of the mechanical failure.

"Event exposures:
Radiation worker 1: 50 mR film badge, 211 mR ring finger.
Radiation worker 2: 67 mR film badge, 47 mR ring finger.
Radiation worker 3: 43 mR film badge, minimal reading ring finger.
Radiation worker 4: 68 mR film badge, ring finger not used."

AGREEMENT STATE REPORT - MISSING TC-99M GENERATOR PACKAGE

The following report was received from the Massachusetts Radiation Control Program (the Agency) via email:

"On 12/10/2024, at around 1500 EST, Lantheus Medical Imaging, Inc. (license number 60-0088) was notified that a package containing a 1 Ci Mo-99/Tc-99m generator in a type B package was missing in transit and notified the Agency at 1545 on the same day.

"The reporting requirement is immediate per 105 Code of Massachusetts Regulations (CMR) 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C.

"The Agency considers this event to be open."

Generator Model: Technelite-LEU 37.0 GBq Domestic
Generator Serial Number: B338411A04
Shipped to Southwest Health Systems in Cortez, Colorado.
Deemed lost by common carrier on 12/10/2024. The most recent reported location was Memphis, TN.
Activity: 37 Gbq, Mo-99/Tc-99m
Calibration date: 12/03/2024
Shipped as Yellow III, TI of 1.3

* * * UPDATE ON 12/11/2024 AT 1335 EST FROM ROBERT LOCKE TO JORDAN WINGATE * * *

"At 1318 EST on 12/11/2024, the licensee reported that the missing package had been delivered to its intended destination. The Agency considers this event closed."

Notified R1DO (Jackson), NMSS Events Notification (email), and 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 - STUCK OPEN SHUTTER

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

"The Agency was contacted on 12/10/2024 by representatives for Equistar Chemicals, LP (IL-01737-01) in Morris, IL, to report a fixed gauge shutter stuck in the open position [that was discovered on 12/9/2024]. The gauge is installed on the side of a process vessel and is normally in the open position. The shutter will remain in its normally open position and there will be no vessel entry. There are no changes in radiation levels except [expected levels resulting from] not being able to close the shutter. Entry to [the vessel] requires complete shutdown of the process line, and none are currently scheduled. The manufacturer's representative is on site today, 12/10/2024, to troubleshoot and make appropriate repairs. There are no exposures reported or anticipated as a result of this issue.

"Agency inspectors are coordinating a site visit to determine the root cause and corrective action. The licensee has provided a preliminary assessment that moisture can enter the housing and cause corrosion in the shutter. This report will be updated when additional information is available."

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:

Two tritium exit signs were determined to be lost by the licensee.

Manufacturer: Isolite Corporation
Number of signs: 2
Model: BX-10-BK
Activity: 9.21 Ci each, H-3

The signs were discovered missing during an annual fire inspection on 03/05/2024.

Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))

Colorado Event Report ID Number: CO240030


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 - LOST EXIT SIGN

The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:

One tritium exit sign was determined to be lost by the licensee.

Manufacturer: Isolite Corporation
Number of signs: 1
Model: 880-12-6
Activity: 12.57 Ci, H-3

Notifications: Colorado Regulations Section 4.51.1.1 (10 CFR 20.2201(a)(1)(i))

Colorado Event Report ID Number: CO240031

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 - MEDICAL EVENT

The following is a summary of information provided by the Vermont Department of Health via email:

A patient was prescribed 49.2 mCi of Y-90 TheraSphere microspheres, but received 33.6 mCi. This is a 30 percent difference in the prescribed dose and is reportable in accordance with 10 CFR 35.3045.

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.

CONCURRENT REPORT

The following information was provided by the licensee via phone and email:

"Global Nuclear Fuel - Americas (GNF-A) is making a concurrent report to the NRC for an OSHA (Occupational Safety and Health Administration) reportable event under 29 CFR 1904.39.

"At approximately 1655 EST, on December 16, 2024, the North Carolina Department of Labor was notified that an employee was injured while operating an electric powered pallet jack resulting in a partial amputation of the left thumb soft tissue. The employee was inside the airborne controlled area but was surveyed and free released with no contamination. Root cause investigations and corrective actions were begun. Because the North Carolina Department of Labor was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."