Event Notification Report for December 26, 2024

AGREEMENT STATE REPORT - LOST SOURCE

The following information was received from the Wisconsin Department of Health Services (the department) via email:

"On September 19, 2024, a licensee reported that a package they shipped containing a Co-57 flood source had been lost by a common carrier and its whereabouts are unknown. The package was shipped on September 3, 2024, identified as missing on September 19, 2024, and reported to [the department] on the same day. The source was originally 20 millicuries and was approximately 2.98 millicuries at the time of shipment. [The source] was shipped as an excepted package containing a limited quantity of Co-57. The source serial number is: BM552022201101.

"The department considers this event closed."

WI Event Report ID No: WI240004.

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 - DISCOVERY OF CO-60 SCRAP MATERIAL

The following information was received from the Wisconsin Department of Health Services (WI DHS) via email:

"On October 18, 2024, WI DHS identified Co-60 [material] in a rejected scrap load using a portable radionuclide identification device. The scrap material was determined to be from a nearby manufacturing facility.

"On October 25, 2024, WI DHS performed a site visit at the manufacturing facility where the scrap material originated. Multiple metal castings and a bin of metal swarf were identified as contaminated with Co-60. Exposure rates on contact with most items ranged from approximately 100-200 microR/hr, with the highest reading of approximately 950 microR/hr.

"The manufacturing facility purchased the metal castings from a WI foundry. It was determined that contaminated metal castings were purchased from a single WI foundry that had imported the castings from a foundry in India. The WI foundry only sold the casings to one manufacturing facility. On October 30 and November 27, 2024, WI DHS performed site visits at the WI foundry and confirmed the presence of Co-60 in additional metal castings from the same foundry in India. The WI foundry did not perform any manufacturing processes on the imported items. The WI foundry is continuing to screen items from the India foundry for elevated radiation levels.

"Preliminary dose assessments by WI DHS indicate that public dose limits have not been exceeded at any of the facilities nor while in transportation. No removable contamination has been identified. WI DHS continues to monitor as additional items are identified and a final disposition of the radioactive material is determined."

WI Event Report ID No: WI240005.

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was received from the Arkansas Department of Health, Radiation Control (the Department) via email:

"On 12/18/2024, at 1530 CST, Exploratory Ventures LLC. notified the Department via phone that an IMS-5420-XX profile thickness gauge experienced a stuck open shutter. This gauge contains a 50.5 curie Cs-137 source, Eckert & Ziegler NuX.N27_A, serial number NR-1120-D-101-S, listed in the sealed source and device registry.

"An IMS technician arrived on-site at 1615 and was able to close the shutter at 1630. The gauge was moved from the in-line position to allow the technician to close the shutter; the technician opened the access panel on the gauge and placed an adjustable wrench on the pointer to manually close the shutter. As they started to turn the pointer, the spring of the shutter activated and closed the shutter. The technician closed the access panel then surveyed the area for radiation and found none.

"The gauge is currently locked-out and not in use. It will remain locked-out until an authorized service technician arrives to service the unit. The estimated date of service is pending.

"The investigation is ongoing and the report will proceed in accordance with SA-300."

Arkansas Event Number: AR-2023-005

EN Revision Imported Date: 12/27/2024

EN Revision Text: AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE

The following information was provided by the state of Colorado via email:

"During the morning of 12/17/2021, a portable gauge user noticed their truck had been broken into [in Westminster, CO] and a portable gauge was stolen from the truck. The portable gauge is a Troxler model 3430, serial number 32370, containing 9 mCi cesium-137 and 44 mCi americium-241:beryllium. The stolen gauge has been reported to the local law enforcement."
Event Report ID No.: CO210043

* * * UPDATE ON 12/26/24 AT 1716 EST FROM PHILLIP PETERSON TO TENISHA MEADOWS * * *

The following information was provided by Colorado Department of Public Health and Environment (CDPHE) via email:

"On 12/26/24, CDPHE was notified that a member of the public had taken possession of a portable moisture/density gauge. From photos received by CDPHE, the gauge was likely the gauge stolen from the event number above. However, photos did not include the serial number for the gauge, so it is possible the gauge is from EN56084 / NMED item number 220396.

"Prior to interacting with CDPHE, the member of the public learned that the gauge contained radioactive material and abandoned the gauge outside of their property. The gauge was then picked up by an unknown party and the current location of the gauge is unknown.

"Assistance from the Colorado State Patrol has been requested for this event. CDPHE will provide additional updates as we receive them."

NMED item number: 220009

Notified R4DO (Roldan-Otero), 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

MEDICAL EVENT

The following is a summary of information provided by the licensee via phone:

The licensee's radiation safety officer (RSO) was notified on 12/20/2024, at approximately 1130 CST of a medical event that occurred at Franciscan Health Munster in Munster, IN on 10/28/2024. A patient was prescribed a Y-90 TheraSphere treatment with a prescribed dose of 23.5 Gbq. The calculated administrated dose was 18.32 Gbq. This indicates an approximate 22 percent underdose. The licensee is continuing to investigate.

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.

* * * RETRACTION ON 12/26/2024 AT 0907 EST FROM WALEED AL-NAJJAR TO SAMUEL COLVARD * * *

The following information was provided by the licensee via phone:

The event is being retracted due to the following reasons. The activity initially documented as prescribed corresponded to the quantity requested from the manufacturer. This activity is intended to decay to a specific dose by the time the procedure occurs. On the day of the procedure, the prescribed dose was 110 Gy, while the dose delivered was 89.1 Gy. The difference between these amounts is less than 20 percent, thus not subject to reporting.

Notified R3DO (Nguyen), and NMSS Events Notification (email).