Event Notification Report for July 16, 2025

LOST GENERALLY LICENSED SOURCE

The following information was provided by the licensee via phone:

During a recent license renewal inquiry, it was discovered that during the decommissioning of the licensee's deepwater flow line in August 2017 a jumper with a generally licensed meter containing a nuclear source was removed and inadvertently scrapped. This event is under investigation by the licensee.

Roxar Flowmeter
Model number: RFM-SH7950
Source: Cs-137, 30 mCi
General License Number: 725736-16

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 was provided by the licensee via phone:

A planned treatment administering three Y-90 microsphere doses resulted in underdoses of greater than 20 percent for all three doses. The start of the treatment was delayed as the treatment room was not available at the scheduled time. Doses were dispensed assuming a treatment time of 0930 CDT, but actual treatments were delayed until 1118, 1156, and 1244 CDT, respectively. The licensee is also investigating a potential complication in establishing intravenous access to the treatment site (liver).

Actual doses planned and administered were as follows:

First treatment at 1118 CDT: planned 18.9 mCi, actual 14.1 mCi
Second treatment at 1156 CDT: planned 13.8 mCi, actual 10.1 mCi
Third treatment at 1244 CDT: planned 17.2 mCi, actual 12.0 mCi

Initial review by the authorized user has concluded the treatments administered were adequate and no further treatment is planned.

The attending physician and patient are being notified.

An NRC Region III inspector was on-site and has been notified.

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.