Event Notification Report for December 28, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/27/2020 - 12/28/2020
Agreement State
Event Number: 55029
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: Banner University Medical Center - Tucson
Region: 4
City: Tucson State: AZ
County:
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Thomas Herrity
Licensee: Banner University Medical Center - Tucson
Region: 4
City: Tucson State: AZ
County:
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Thomas Herrity
Notification Date: 12/11/2020
Notification Time: 00:57 [ET]
Event Date: 12/11/2020
Event Time: 00:00 [MST]
Last Update Date: 12/11/2020
Notification Time: 00:57 [ET]
Event Date: 12/11/2020
Event Time: 00:00 [MST]
Last Update Date: 12/11/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT- UNDER DOSAGE
The following was received from the state of Arizona via email:
"The Department (Arizona Department of Health Services) received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed a dose of 120 Gy but was delivered 47.6 Gy, a percent dose delivered of 32.5%. The Department has requested additional information and continues to investigate the event.
"The Licensee is: Arizona License Number- 10-044, Banner University Medical Center - Tucson, 1625 N. Campbell Ave, Tucson, Arizona 85719
"Additional information will be provided as it is received in accordance with SA-300.
Arizona Incident: 20-025
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.
The following was received from the state of Arizona via email:
"The Department (Arizona Department of Health Services) received notification from the licensee about a medical event involving Y-90 Theraspheres. A patient was prescribed a dose of 120 Gy but was delivered 47.6 Gy, a percent dose delivered of 32.5%. The Department has requested additional information and continues to investigate the event.
"The Licensee is: Arizona License Number- 10-044, Banner University Medical Center - Tucson, 1625 N. Campbell Ave, Tucson, Arizona 85719
"Additional information will be provided as it is received in accordance with SA-300.
Arizona Incident: 20-025
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
Event Number: 55041
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Sequoia Consultants, Inc.
Region: 4
City: Orange State: CA
County:
License #: 7597-30
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Howie Crouch
Licensee: Sequoia Consultants, Inc.
Region: 4
City: Orange State: CA
County:
License #: 7597-30
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Howie Crouch
Notification Date: 12/18/2020
Notification Time: 20:39 [ET]
Event Date: 12/18/2020
Event Time: 08:30 [PST]
Last Update Date: 12/18/2020
Notification Time: 20:39 [ET]
Event Date: 12/18/2020
Event Time: 08:30 [PST]
Last Update Date: 12/18/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSNS (MEXICO) (EMAIL)
YOUNG, CALE (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSNS (MEXICO) (EMAIL)
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following information was obtained from California Department of Public Health Radiologic Health Branch Brea (RHB Brea) via email:
"On December 18, 2020, at approximately 1100 PST, [the] RSO [(Radiation Safety Officer)] of Sequoia Consultants, Inc., Radioactive Materials License #7597-30, contacted RHB Brea to report the theft of a moisture/density gauge: CPN, MC-3 Elite, serial #30582 (Cs-137 0.370 GBq, Am-241, 1.85 GBq). The gauge had been in a mobile storage unit at a temporary job site at approximate mile marker 20.07, Northbound State Route 99 (Golden State Highway) in Atwater, CA 95301. The storage unit had been broken into and the radioactive gauge was missing. The Authorized User who discovered the missing radioactive gauge at approximately 0830 on December 18, 2020 notified the RSO and then notified the Atwater Police Department, who directed him to contact the California Highway Patrol. A copy of the theft report will be forwarded to the RHB Brea office to be included as part of this report. The RSO will contact local newspapers in an attempt to retrieve the stolen radioactive gauge, as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered."
California 5010 number: 121820
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
The following information was obtained from California Department of Public Health Radiologic Health Branch Brea (RHB Brea) via email:
"On December 18, 2020, at approximately 1100 PST, [the] RSO [(Radiation Safety Officer)] of Sequoia Consultants, Inc., Radioactive Materials License #7597-30, contacted RHB Brea to report the theft of a moisture/density gauge: CPN, MC-3 Elite, serial #30582 (Cs-137 0.370 GBq, Am-241, 1.85 GBq). The gauge had been in a mobile storage unit at a temporary job site at approximate mile marker 20.07, Northbound State Route 99 (Golden State Highway) in Atwater, CA 95301. The storage unit had been broken into and the radioactive gauge was missing. The Authorized User who discovered the missing radioactive gauge at approximately 0830 on December 18, 2020 notified the RSO and then notified the Atwater Police Department, who directed him to contact the California Highway Patrol. A copy of the theft report will be forwarded to the RHB Brea office to be included as part of this report. The RSO will contact local newspapers in an attempt to retrieve the stolen radioactive gauge, as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered."
California 5010 number: 121820
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
Event Number: 55042
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: Froehling and Robertson, Inc.
Region: 1
City: Charlotte State: NC
County:
License #: 060-0353-4
Agreement: Y
Docket:
NRC Notified By: David Crowley
HQ OPS Officer: Andrew Waugh
Licensee: Froehling and Robertson, Inc.
Region: 1
City: Charlotte State: NC
County:
License #: 060-0353-4
Agreement: Y
Docket:
NRC Notified By: David Crowley
HQ OPS Officer: Andrew Waugh
Notification Date: 12/21/2020
Notification Time: 16:27 [ET]
Event Date: 12/19/2020
Event Time: 11:41 [EST]
Last Update Date: 12/21/2020
Notification Time: 16:27 [ET]
Event Date: 12/19/2020
Event Time: 11:41 [EST]
Last Update Date: 12/21/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
ELISE BURKET (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ELISE BURKET (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAMAGED NUCLEAR GAUGE
The following is a summary of information that was received via email:
At 1141 EST, on 12/19/20, an authorized user (AU) for the licensee determined that one of their portable nuclear gauges was damaged. The AU felt the index rod loosen and then break off when he went to retrieve the gauge from its transport case. The gauge had been used the day before at a jobsite and did not experience any accidents. The gauge had not been dropped and was in the possession of the AU at all times during this event. The source remained in the shielded position within the gauge throughout this event.
The AU contacted the radiation safety officer (RSO) and the gauge was transported to an authorized storage location. The RSO took measurements of the outer transport box surface (1 mR/hr) and the gauge surface (5 mR/hr). The gauge was placed into an authorized storage shed and readings at the surface of the shed were non-distinguishable from background.
The gauge was a Troxler 3440 (s/n: 16938) with an 8 mCi Cs-137 source and a 40 mCi Am-241/Be source.
NC event number: NC200023
The following is a summary of information that was received via email:
At 1141 EST, on 12/19/20, an authorized user (AU) for the licensee determined that one of their portable nuclear gauges was damaged. The AU felt the index rod loosen and then break off when he went to retrieve the gauge from its transport case. The gauge had been used the day before at a jobsite and did not experience any accidents. The gauge had not been dropped and was in the possession of the AU at all times during this event. The source remained in the shielded position within the gauge throughout this event.
The AU contacted the radiation safety officer (RSO) and the gauge was transported to an authorized storage location. The RSO took measurements of the outer transport box surface (1 mR/hr) and the gauge surface (5 mR/hr). The gauge was placed into an authorized storage shed and readings at the surface of the shed were non-distinguishable from background.
The gauge was a Troxler 3440 (s/n: 16938) with an 8 mCi Cs-137 source and a 40 mCi Am-241/Be source.
NC event number: NC200023