Event Notification Report for April 15, 2025

EN Revision Imported Date: 4/15/2025

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGE

The following is a summary of information provided by the Washington State Department of Health (DOH) via email:

A portable gauge (PG) was ran over by a roller around 0930 PDT. The main body was crushed and the gauge source rod broke off but appeared to be intact.

The PG user used a shovel to pick up the source and placed it in the transport box. The PG user stayed with the PG until the radiation safety officer (RSO) arrived. The RSO confirmed [an] intact source rod and gathered the remaining damaged PG parts into the transport box. It was then transported to the licensee storage location.

The RSO and local fire department did not have a survey meter for radiation and contamination surveys.

Three DOH representatives were sent for radiation and contamination survey data collection. The highest on-contact radiation level on the PG container was 1.7 mR/hr. No indication of contamination outside of the PG container was detected. A direct frisk of the RSO and PG user's hands found no indication of contamination.

DOH will take survey data including wipes and verify they are negative. Once verified, the RSO will contact the manufacturer or a waste broker for PG disposal. A leak test will be performed prior to transport. The damaged PG will remain secured in the transport box until disposal.

Washington state event number: WA-24-016

* * * UPDATE ON 04/14/2025 AT 1911 EDT FROM MARK HERNANDEZ TO IAN HOWARD * * *

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

The leak test was negative prior to shipping the PG for disposal. All corrective actions have been completed by the licensee and the investigation is closed.

Notified R4DO (Drake) and NMSS Events Notification (email)

EN Revision Imported Date: 4/15/2025

EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSURE FROM RADIOGRAPHY SOURCE

The following information was provided by the Washington State Office of Radiation Protection (the Department) via email:

"Radiography was being performed in a tank at the refinery. [A radiation protection boundary was set up around a tank], and the source was secured in the exposure device. One radiographer was outside the boundary and the other radiographer was inside the boundary with another individual (contractor) outside of the tank. The contractor was in a lift moving upwards next to the tank. Unfortunately, due to a miscommunication between the radiographers and the contractor, the two individuals outside the tank and within the radiation boundaries were exposed to the source for 2 minutes.

"The licensee radiation safety officer (RSO) estimates 1.8 R radiation exposure for the 2 minutes duration right outside the tank as a worst-case scenario. The RSO is currently performing a dose investigation of the affected contract personnel and radiographer. The RSO recommended the contactor to receive medical monitoring (blood draw) as a precaution. The Department set expectations for the licensee to send a full detailed report on findings for this incident. More information to follow for this incident report."

Device information:
Isotope: 87 Ci of Ir-192
Manufacturer: QSA Global
Device Model: 880D

Incident number: WA-24-022

* * * UPDATE ON 11/14/2024 AT 1958 EDT FROM JOHN MARTELL TO TENISHA MEADOWS * * *

The following information was provided by the Washington State Office of Radiation Protection (the Department) via email:

"On 11/14/2024, inspectors from the Department will be conducting a reactive onsite visit of the overexposure event which occurred on 11/12/2024. The inspectors will be meeting at the refinery site where the overexposure occurred with the licensee representatives including the RSO to gather information on the event related to what and how the event occurred and to review related records.

"The Department staff will continue to gather information on the event to determine the extent of the exposures, the potential root cause of this incident, any correlation to previous incidents with this licensee, and appropriate corrective actions. This may include potential enforcement actions in addition to the corrective actions. Updates will be provided as additional information is received."

Notified R4DO (Young), NMSS MSST Deputy Division Director (Silberfeld), and NMSS (email)

* * * UPDATE ON 04/14/2025 AT 1827 EDT FROM MARK HERNANDEZ TO IAN HOWARD * * *

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

The total dose received is 1.7 mrem for two individuals on the lift and 4 mrem for the other individual inside the tank. After the reactive inspection and interviews were performed, a violation letter was sent to the licensee for individuals not wearing proper dosimetry in a radiation area and not contacting the emergency response number after discovery of the unmonitored exposure. All corrective actions have been completed by the licensee and the investigation is closed.

Notified R4DO (Drake) and NMSS Events Notification (email)

AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of information provided by the North Carolina Radioactive Materials Branch via email:

On April 4, 2025, Y-90 SIR-spheres therapeutic split dose administration resulted in a patient being underdosed per the written directive. One of three doses administered was 27 percent or less of the prescribed dose. The referring physician and patient were notified on the same day of treatment. The cause of the underdose was a catheter clog or kink. Corrective actions consisted of retraining of personnel.

NC Event Number: 250004

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.

STUCK OPEN GAUGE SHUTTER

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

The licensee discovered a stuck-open shutter during routine checks on a gauge with a normally open shutter. The gauge is a Berthold model LB444 with a 500 mCi Cs-137 source. The area around the gauge has been flagged and there are no concerns about radiation exposure. The manufacturer will be contacted to repair the gauge.

* * * UPDATE ON 04/09/2025 AT 1257 EDT FROM DUSTIN SMITH TO JORDAN WINGATE * * *

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

The licensee has been in contact with Berthold technologies, who will be sending a technician to repair the gauge. A finalized date has not yet been confirmed. Additional information will be provided as it becomes available.

Informed R1DO(Schussler) and NMSS Events Notifications (email).

UNPLANNED CONTAMINATION EVENT

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

During an ongoing inspection, the licensee determined that the following event had not been previously reported.

On March 29, 2024, at approximately 1800 EDT, a rejected batch of individual lead pots containing glass vials of Pluvicto (Lu-177) solution was being logged into the waste room. Each dose of Pluvicto was 5ml with an activity between 7 to 12 GBq.
An individual handling the lead pots accidentally lifted a lead pot by the lid instead of the bottom. The lead pot was taped shut but the tape failed, and the vial was dropped, breaking on the floor of the waste room. The individual's clothes were contaminated but no skin contamination occurred. Based on dosimetry records the individual has a current lifetime exposure of 1 mrem of deep-dose equivalent, 2 mrem of lens dose equivalent, 2 mrem of shallow-dose equivalent, and 11 mrem to the extremity.
The spread of contamination was limited to the radioactive waste room and the individual's clothing. The radiation safety officer secured access to the radioactive waste room for approximately 48 hours while room decontamination efforts were in progress.