Event Notification Report for September 03, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/02/2021 - 09/03/2021
Agreement State
Event Number: 55417
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: Arconic Davenport, LLC
Region: 3
City: Bettendorf State: IA
County:
License #: 0162182FG
Agreement: Y
Docket:
NRC Notified By: Randal Dahlin
HQ OPS Officer: Howie Crouch
Licensee: Arconic Davenport, LLC
Region: 3
City: Bettendorf State: IA
County:
License #: 0162182FG
Agreement: Y
Docket:
NRC Notified By: Randal Dahlin
HQ OPS Officer: Howie Crouch
Notification Date: 08/19/2021
Notification Time: 07:19 [ET]
Event Date: 08/18/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/02/2021
Notification Time: 07:19 [ET]
Event Date: 08/18/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/02/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PETERSON, HIRONORI (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PETERSON, HIRONORI (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/3/2021
EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER
The following information was obtained from the state of Iowa via email:
"On August 18, 2021, at approximately 1000 CDT, the DAV-015 #4 shutter was reported to be stuck in the open position. A survey meter measured a background level of 0.02 mR/hr outside of the gauge house, and 0.05 mR/hr inside the gauge house at that time. Locks were changed to the gauge house to prevent entry. The service company, SenTek, was notified and requested to provide service. They are expected to arrive on August 19, 2021, to provide service and repairs. This event will be updated after the service company determines the cause of the failure and the licensee provides a corrective action plan."
The gauge was manufactured by Isotope Measuring Systems, Inc., model number 5221-02, serial number 2332-2336L, and contains 5 Curies of Am-241.
NMED Number: IA210003
* * * UPDATE ON 9/2/21 AT 1522 EDT FROM RANDAL DAHLIN TO JOANNA BRIDGE * * *
The following information was obtained from the state of Iowa via email:
"The SenTek service technician arrived onsite late afternoon on August 18, 2021 and determined that the bolts holding the shutter had sheared and needed to be replaced. All other shutter bolts were inspected and found to be satisfactory. As a corrective action, the licensee is implementing an annual preventative maintenance check to inspect and replace the bolts on all shutters. The licensee's intent is to replace these fixed gauging devices with x-ray tube devices."
The State considers this event closed.
Notified: R3DO (Riemer) and NMSS Events Notification via e-mail.
EN Revision Text: AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER
The following information was obtained from the state of Iowa via email:
"On August 18, 2021, at approximately 1000 CDT, the DAV-015 #4 shutter was reported to be stuck in the open position. A survey meter measured a background level of 0.02 mR/hr outside of the gauge house, and 0.05 mR/hr inside the gauge house at that time. Locks were changed to the gauge house to prevent entry. The service company, SenTek, was notified and requested to provide service. They are expected to arrive on August 19, 2021, to provide service and repairs. This event will be updated after the service company determines the cause of the failure and the licensee provides a corrective action plan."
The gauge was manufactured by Isotope Measuring Systems, Inc., model number 5221-02, serial number 2332-2336L, and contains 5 Curies of Am-241.
NMED Number: IA210003
* * * UPDATE ON 9/2/21 AT 1522 EDT FROM RANDAL DAHLIN TO JOANNA BRIDGE * * *
The following information was obtained from the state of Iowa via email:
"The SenTek service technician arrived onsite late afternoon on August 18, 2021 and determined that the bolts holding the shutter had sheared and needed to be replaced. All other shutter bolts were inspected and found to be satisfactory. As a corrective action, the licensee is implementing an annual preventative maintenance check to inspect and replace the bolts on all shutters. The licensee's intent is to replace these fixed gauging devices with x-ray tube devices."
The State considers this event closed.
Notified: R3DO (Riemer) and NMSS Events Notification via e-mail.
Agreement State
Event Number: 55432
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: BRADKEN-ATCHISON
Region: 4
City: Atchison State: KS
County:
License #: 21-B092-01
Agreement: Y
Docket:
NRC Notified By: David Lawrenz
HQ OPS Officer: Lloyd Desotell
Licensee: BRADKEN-ATCHISON
Region: 4
City: Atchison State: KS
County:
License #: 21-B092-01
Agreement: Y
Docket:
NRC Notified By: David Lawrenz
HQ OPS Officer: Lloyd Desotell
Notification Date: 08/26/2021
Notification Time: 13:16 [ET]
Event Date: 08/26/2021
Event Time: 11:15 [CDT]
Last Update Date: 08/26/2021
Notification Time: 13:16 [ET]
Event Date: 08/26/2021
Event Time: 11:15 [CDT]
Last Update Date: 08/26/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/3/2021
EN Revision Text:
AGREEMENT STATE REPORT - STUCK SOURCE
The following is a summary of information received from the State of Kansas:
The state of Kansas received notification from the licensee that a fixed gauge cobalt-60 radiographic source is not retracting into the camera for storage following a radiographic exposure. The source moves freely to a point but seems to be stopped during movement in the guide tube about halfway back to the camera. Neither the automatic or the manual retrieval systems were able to retract the source any more than about half way. The licensee indicated that at no time were any personnel exposed or in any danger. The source is located in a secured fixed radiographic booth.
The licensee has contacted the supplier of the equipment for assistance.
EN Revision Text:
AGREEMENT STATE REPORT - STUCK SOURCE
The following is a summary of information received from the State of Kansas:
The state of Kansas received notification from the licensee that a fixed gauge cobalt-60 radiographic source is not retracting into the camera for storage following a radiographic exposure. The source moves freely to a point but seems to be stopped during movement in the guide tube about halfway back to the camera. Neither the automatic or the manual retrieval systems were able to retract the source any more than about half way. The licensee indicated that at no time were any personnel exposed or in any danger. The source is located in a secured fixed radiographic booth.
The licensee has contacted the supplier of the equipment for assistance.
Agreement State
Event Number: 55433
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: Asarco Mission Complex
Region: 4
City: Sahuarita State: AZ
County:
License #: 10-017
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Lloyd Desotell
Licensee: Asarco Mission Complex
Region: 4
City: Sahuarita State: AZ
County:
License #: 10-017
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Lloyd Desotell
Notification Date: 08/26/2021
Notification Time: 17:43 [ET]
Event Date: 08/17/2021
Event Time: 00:00 [MST]
Last Update Date: 08/26/2021
Notification Time: 17:43 [ET]
Event Date: 08/17/2021
Event Time: 00:00 [MST]
Last Update Date: 08/26/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/3/2021
EN Revision Text: AGREEMENT STATE REPORT - BROKEN SOURCE HANDLE
The following was received by the Arizona Department of Health Services (the Department) via email:
"The Department received notification on August 26, 2021, from the licensee, that during an inspection on August 17, 2021, to close the source down for a day, the source handle was broken and the shutter was not able to be closed. The licensee taped off the area and called the vendor to come service the gauge. The gauge was removed from service on August 20, 2021. The gauge was a Berthold Density Gauge, Model #LB7440-D-CR, Serial Number B0514, with an activity of 150 mCi of Cs-137. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
Arizona Incident No: 21-005
EN Revision Text: AGREEMENT STATE REPORT - BROKEN SOURCE HANDLE
The following was received by the Arizona Department of Health Services (the Department) via email:
"The Department received notification on August 26, 2021, from the licensee, that during an inspection on August 17, 2021, to close the source down for a day, the source handle was broken and the shutter was not able to be closed. The licensee taped off the area and called the vendor to come service the gauge. The gauge was removed from service on August 20, 2021. The gauge was a Berthold Density Gauge, Model #LB7440-D-CR, Serial Number B0514, with an activity of 150 mCi of Cs-137. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
Arizona Incident No: 21-005
Power Reactor
Event Number: 55444
Facility: Palo Verde
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Mark Bussell
HQ OPS Officer: Brian P. Smith
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Mark Bussell
HQ OPS Officer: Brian P. Smith
Notification Date: 09/01/2021
Notification Time: 03:07 [ET]
Event Date: 08/31/2021
Event Time: 20:50 [MST]
Last Update Date: 09/01/2021
Notification Time: 03:07 [ET]
Event Date: 08/31/2021
Event Time: 20:50 [MST]
Last Update Date: 09/01/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
10 CFR Section:
50.72(b)(3)(xiii) - Loss Comm/Asmt/Response
Person (Organization):
JOSEY, JEFFREY (R4)
JOSEY, JEFFREY (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 9/3/2021
EN Revision Text: LOSS OF SEISMIC MONITORING SYSTEM
"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.
"On 8/31/21 at 2050 [MST], the Seismic Monitoring System was discovered Non-Functional. This constitutes an unplanned loss of emergency assessment capability for an operational basis earthquake. There is currently no seismic activity in the area according to the U.S. Geological Survey.
"The NRC Resident Inspector was notified of the loss of seismic monitoring capability."
EN Revision Text: LOSS OF SEISMIC MONITORING SYSTEM
"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.
"On 8/31/21 at 2050 [MST], the Seismic Monitoring System was discovered Non-Functional. This constitutes an unplanned loss of emergency assessment capability for an operational basis earthquake. There is currently no seismic activity in the area according to the U.S. Geological Survey.
"The NRC Resident Inspector was notified of the loss of seismic monitoring capability."
Agreement State
Event Number: 55437
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Cedar Park Regional Medical Center
Region: 4
City: Cedar Park State: TX
County:
License #: L 06140
Agreement: Y
Docket:
NRC Notified By: Matthew Kennington
HQ OPS Officer: Mike Stafford
Licensee: Cedar Park Regional Medical Center
Region: 4
City: Cedar Park State: TX
County:
License #: L 06140
Agreement: Y
Docket:
NRC Notified By: Matthew Kennington
HQ OPS Officer: Mike Stafford
Notification Date: 08/30/2021
Notification Time: 15:49 [ET]
Event Date: 08/30/2021
Event Time: 11:30 [CDT]
Last Update Date: 08/30/2021
Notification Time: 15:49 [ET]
Event Date: 08/30/2021
Event Time: 11:30 [CDT]
Last Update Date: 08/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/7/2021
EN Revision Text: AGREEMENT STATE REPORT - REMOVABLE CONTAMINATION ON PACKAGE
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On August 30, 2021, a licensee reported to the Agency a package delivered to the licensee containing 39 mCi of Tc-99m had removable contamination on the exterior of the package of approximately 652 dpm/cm^2. The package arrived at about 1045 CDT. The licensee discovered the contamination during the routine package check-in survey at around 1130 CDT. The licensee confirmed that the vial inside the container was intact and that the contamination was only on the exterior of the package. The licensee notified the shipper and carrier of the contamination. An investigation into this event is ongoing."
Texas Incident Number: 9879
EN Revision Text: AGREEMENT STATE REPORT - REMOVABLE CONTAMINATION ON PACKAGE
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On August 30, 2021, a licensee reported to the Agency a package delivered to the licensee containing 39 mCi of Tc-99m had removable contamination on the exterior of the package of approximately 652 dpm/cm^2. The package arrived at about 1045 CDT. The licensee discovered the contamination during the routine package check-in survey at around 1130 CDT. The licensee confirmed that the vial inside the container was intact and that the contamination was only on the exterior of the package. The licensee notified the shipper and carrier of the contamination. An investigation into this event is ongoing."
Texas Incident Number: 9879
Agreement State
Event Number: 55438
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Exxon Mobil Corporation
Region: 4
City: Beaumont State: TX
County:
License #: L 00603
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Mike Stafford
Licensee: Exxon Mobil Corporation
Region: 4
City: Beaumont State: TX
County:
License #: L 00603
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Mike Stafford
Notification Date: 08/30/2021
Notification Time: 17:30 [ET]
Event Date: 08/30/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/30/2021
Notification Time: 17:30 [ET]
Event Date: 08/30/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/7/2021
EN Revision Text: AGREEMENT STATE - STUCK OPEN SHUTTER
The following was received from the Texas Department of State Health Services via email:
"On August 30, 2021, a health physics service contractor reported a stuck shutter for the licensee. During a 6-month inspection check, the shutter was discovered to be stuck in the open position, which is the normal operating position. The contractor reports there will be no additional dose risk to personnel outside of the normal operations. The shutter is a Vega model SH F1B with serial number ov0895 with a 70 mCi Cs-137 source. The serial number for the source and the installation date were not known at the time of the initial reporting but will be given in the report. The contractor indicated the manufacturer would be contacted for repairs or replacement. Additional information will be provided per SA-300."
Texas Incident Number: 9880
EN Revision Text: AGREEMENT STATE - STUCK OPEN SHUTTER
The following was received from the Texas Department of State Health Services via email:
"On August 30, 2021, a health physics service contractor reported a stuck shutter for the licensee. During a 6-month inspection check, the shutter was discovered to be stuck in the open position, which is the normal operating position. The contractor reports there will be no additional dose risk to personnel outside of the normal operations. The shutter is a Vega model SH F1B with serial number ov0895 with a 70 mCi Cs-137 source. The serial number for the source and the installation date were not known at the time of the initial reporting but will be given in the report. The contractor indicated the manufacturer would be contacted for repairs or replacement. Additional information will be provided per SA-300."
Texas Incident Number: 9880
Agreement State
Event Number: 55439
Rep Org: SC DEPT OF HEALTH & ENV CONTROL
Licensee: S&ME
Region: 1
City: Mt. Pleasant State: SC
County:
License #: 324
Agreement: Y
Docket:
NRC Notified By: Andrew M. Roxburgh
HQ OPS Officer: Joanna Bridge
Licensee: S&ME
Region: 1
City: Mt. Pleasant State: SC
County:
License #: 324
Agreement: Y
Docket:
NRC Notified By: Andrew M. Roxburgh
HQ OPS Officer: Joanna Bridge
Notification Date: 08/31/2021
Notification Time: 13:00 [ET]
Event Date: 08/31/2021
Event Time: 12:15 [EDT]
Last Update Date: 09/03/2021
Notification Time: 13:00 [ET]
Event Date: 08/31/2021
Event Time: 12:15 [EDT]
Last Update Date: 09/03/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DIMITRIADIS, ANTHONY (R1)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
DIMITRIADIS, ANTHONY (R1)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/7/2021
EN Revision Text: AGREEMENT STATE - STOLEN TROXLER GAUGE
The following was received from the South Carolina Department of Health and Environmental Control (the Department) via e-mail:
"On August 31, 2021, the Department was notified by the licensee's RSO at approximately 1230 EDT that one of its trucks containing a portable density gauge had been stolen from the side of the road on Meeting Street in Charleston, SC. The gauge was a Troxler Model 3440 s/n 38444 containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be. The licensee stated the police have been to the scene and took a police report. The truck is equipped with GPS and an active investigation is underway."
* * * UPDATE ON 9/3/2021 AT 0730 EDT FROM ANDREW ROXBURGH TO HOWIE CROUCH * * *
The following information was received from the South Carolina Department of Health and Environmental Control via e-mail:
"On August 31, 2021 at 1555 EDT, officers apprehended the suspect that stole the licensee's truck containing Troxler Model 3440 s/n 38444. The gauge was recovered undamaged and a radiation surveys performed indicated that radiation readings were within the limits specified in the SSD [sealed source and device sheet] for this gauge.
"The Department's on-call duty officer performed an on-site investigation on September 1, 2021."
Notified R1DO (Dimitriadis), NMSS Events Resource and ILTAB via 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
EN Revision Text: AGREEMENT STATE - STOLEN TROXLER GAUGE
The following was received from the South Carolina Department of Health and Environmental Control (the Department) via e-mail:
"On August 31, 2021, the Department was notified by the licensee's RSO at approximately 1230 EDT that one of its trucks containing a portable density gauge had been stolen from the side of the road on Meeting Street in Charleston, SC. The gauge was a Troxler Model 3440 s/n 38444 containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be. The licensee stated the police have been to the scene and took a police report. The truck is equipped with GPS and an active investigation is underway."
* * * UPDATE ON 9/3/2021 AT 0730 EDT FROM ANDREW ROXBURGH TO HOWIE CROUCH * * *
The following information was received from the South Carolina Department of Health and Environmental Control via e-mail:
"On August 31, 2021 at 1555 EDT, officers apprehended the suspect that stole the licensee's truck containing Troxler Model 3440 s/n 38444. The gauge was recovered undamaged and a radiation surveys performed indicated that radiation readings were within the limits specified in the SSD [sealed source and device sheet] for this gauge.
"The Department's on-call duty officer performed an on-site investigation on September 1, 2021."
Notified R1DO (Dimitriadis), NMSS Events Resource and ILTAB via 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
Event Number: 55441
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: The University of Texas MD Anderson Cancer Center
Region: 4
City: Houston State: TX
County:
License #: L 00466
Agreement: Y
Docket:
NRC Notified By: Matt Kennington
HQ OPS Officer: Mike Stafford
Licensee: The University of Texas MD Anderson Cancer Center
Region: 4
City: Houston State: TX
County:
License #: L 00466
Agreement: Y
Docket:
NRC Notified By: Matt Kennington
HQ OPS Officer: Mike Stafford
Notification Date: 08/31/2021
Notification Time: 17:02 [ET]
Event Date: 07/12/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/31/2021
Notification Time: 17:02 [ET]
Event Date: 07/12/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/31/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
WILLIAMS, KEVIN (NMSS)
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
WILLIAMS, KEVIN (NMSS)
EN Revision Imported Date: 9/7/2021
EN Revision Text: AGREEMENT STATE - INCORRECT RADIOPHARMACEUTICAL ADMINISTERED
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On August 31, 2021, the Agency received a notification from the Nuclear Regulatory Commission (NRC) stating that a Missouri supplier of radiopharmaceuticals had reported a misadministration that occurred on July 12, 2021, with one of their products at a Texas licensee. The licensee contacted the Agency to report the event shortly after receiving the notification from the NRC. The licensee stated that a patient was to receive 0.041 mCi of Th-227 with enzymes to affect breast cancer but was given 0.041 mCi of Th-227 with enzymes to affect mesothelioma. The event resulted in approximately 6 Gy dose to the liver. The patient refused a post therapy scan and the licensee was not able to confirm that the radiopharmaceutical went to the correct tissue in the body. The mislabeling was discovered by the radiopharmaceutical supplier who then notified the licensee that the drug administered was not correct. The licensee has notified the patient and physician. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 9882
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.
EN Revision Text: AGREEMENT STATE - INCORRECT RADIOPHARMACEUTICAL ADMINISTERED
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On August 31, 2021, the Agency received a notification from the Nuclear Regulatory Commission (NRC) stating that a Missouri supplier of radiopharmaceuticals had reported a misadministration that occurred on July 12, 2021, with one of their products at a Texas licensee. The licensee contacted the Agency to report the event shortly after receiving the notification from the NRC. The licensee stated that a patient was to receive 0.041 mCi of Th-227 with enzymes to affect breast cancer but was given 0.041 mCi of Th-227 with enzymes to affect mesothelioma. The event resulted in approximately 6 Gy dose to the liver. The patient refused a post therapy scan and the licensee was not able to confirm that the radiopharmaceutical went to the correct tissue in the body. The mislabeling was discovered by the radiopharmaceutical supplier who then notified the licensee that the drug administered was not correct. The licensee has notified the patient and physician. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 9882
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: 55442
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Midwest NDT Services
Region: 4
City: Pharr State: TX
County:
License #: L 07043
Agreement: Y
Docket:
NRC Notified By: Arthur L Tucker
HQ OPS Officer: Joanna Bridge
Licensee: Midwest NDT Services
Region: 4
City: Pharr State: TX
County:
License #: L 07043
Agreement: Y
Docket:
NRC Notified By: Arthur L Tucker
HQ OPS Officer: Joanna Bridge
Notification Date: 08/31/2021
Notification Time: 17:53 [ET]
Event Date: 08/31/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/02/2021
Notification Time: 17:53 [ET]
Event Date: 08/31/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/02/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/7/2021
EN Revision Text: AGREEMENT STATE - UNABLE TO RETRACT SOURCE
The following was received from the State of Texas (the Agency) via e-mail:
"On August 31, 2021, the Agency was contacted by the licensee and informed that they could not retract a 70 Curie, iridium - 192 source into an INC IR100 exposure device. The licensee stated they were working at a fab shop and could not retract the source back into the camera. The licensee did not believe a disconnect had occurred. The licensee stated a 2 millirem barrier was in place. The licensee stated they did not have anyone on its license to retract the source and requested the Agency's assistance in location a qualified company to retrieve the source. The licensee stated it contacted the manufacturer and it stated they could not assist them. The Agency provided them with the contact information of another manufacturer. The licensee contacted the other manufacturer, but it did not offer immediate assistance. The licensee told the Agency that one of its radiographers had received the training for retracting sources but was never added to the license. The licensee was given the contact information for the Agency's licensing group to see if the individual could be added to the license for source retrieval. At 1515 [CDT] the licensee reported the licensing group was able to accept the radiographer's training and amended the license for the retrieval. The licensee stated the individual qualified to retrieve the source was leaving for the site to perform the retrieval. The licensee will contact the agency when the source is retrieved. Additional information has been requested. Additional information will be provided as it is received in accordance with SA - 300.
Texas Incident No.: 9881
* * * UPDATE ON 8/31/21 AT 2237 EDT FROM ARTHUR TUCKER TO JOANNA BRIDGE * * *
The following was received from the State of Texas (the Agency) via e-mail:
"The licensee just reported the individual who will perform the recovery has just landed in Midland, Texas and will head to the site. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Josey) and NMSS via e-mail.
* * * UPDATE ON 8/31/21 AT 2351 EDT FROM ARTHUR TUCKER TO BRIAN P. SMITH * * *
The following was received from the State of Texas (the Agency) via e-mail:
"On August 31, 2021 at 2040 CDT the licensee reported that the source had been recovered to the fully shielded position. The individual who performed the recovery received 190 millirem. The licensee stated the exposure device and associated equipment will returned to the storage location and examined. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Josey) and NMSS via e-mail.
* * * UPDATE ON 9/2/21 AT 1548 EDT FROM ARTHUR TUCKER TO JOANNA BRIDGE * * *
The following was received from the State of Texas (the Agency) via e-mail:
"On September 2, 2021, the licensee contacted the Agency to find out where to send the written report. During the conversation the licensee stated, 'just for your information it appears that the connector spring was malfunctioning as the spring did not engage until about halfway depressed. [The licensee] talked with INC corporate [Radiation Safety Officer] (RSO) and the source will be sent to INC for failure analysis.' The Agency asked if that meant that the spring had disconnected and they stated that it had. The Agency stated that the initial report did not reflect that. [The licensee] stated he knew that and that he had misunderstood what the radiographer had told him over the phone. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Josey) and NMSS via e-mail.
EN Revision Text: AGREEMENT STATE - UNABLE TO RETRACT SOURCE
The following was received from the State of Texas (the Agency) via e-mail:
"On August 31, 2021, the Agency was contacted by the licensee and informed that they could not retract a 70 Curie, iridium - 192 source into an INC IR100 exposure device. The licensee stated they were working at a fab shop and could not retract the source back into the camera. The licensee did not believe a disconnect had occurred. The licensee stated a 2 millirem barrier was in place. The licensee stated they did not have anyone on its license to retract the source and requested the Agency's assistance in location a qualified company to retrieve the source. The licensee stated it contacted the manufacturer and it stated they could not assist them. The Agency provided them with the contact information of another manufacturer. The licensee contacted the other manufacturer, but it did not offer immediate assistance. The licensee told the Agency that one of its radiographers had received the training for retracting sources but was never added to the license. The licensee was given the contact information for the Agency's licensing group to see if the individual could be added to the license for source retrieval. At 1515 [CDT] the licensee reported the licensing group was able to accept the radiographer's training and amended the license for the retrieval. The licensee stated the individual qualified to retrieve the source was leaving for the site to perform the retrieval. The licensee will contact the agency when the source is retrieved. Additional information has been requested. Additional information will be provided as it is received in accordance with SA - 300.
Texas Incident No.: 9881
* * * UPDATE ON 8/31/21 AT 2237 EDT FROM ARTHUR TUCKER TO JOANNA BRIDGE * * *
The following was received from the State of Texas (the Agency) via e-mail:
"The licensee just reported the individual who will perform the recovery has just landed in Midland, Texas and will head to the site. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Josey) and NMSS via e-mail.
* * * UPDATE ON 8/31/21 AT 2351 EDT FROM ARTHUR TUCKER TO BRIAN P. SMITH * * *
The following was received from the State of Texas (the Agency) via e-mail:
"On August 31, 2021 at 2040 CDT the licensee reported that the source had been recovered to the fully shielded position. The individual who performed the recovery received 190 millirem. The licensee stated the exposure device and associated equipment will returned to the storage location and examined. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Josey) and NMSS via e-mail.
* * * UPDATE ON 9/2/21 AT 1548 EDT FROM ARTHUR TUCKER TO JOANNA BRIDGE * * *
The following was received from the State of Texas (the Agency) via e-mail:
"On September 2, 2021, the licensee contacted the Agency to find out where to send the written report. During the conversation the licensee stated, 'just for your information it appears that the connector spring was malfunctioning as the spring did not engage until about halfway depressed. [The licensee] talked with INC corporate [Radiation Safety Officer] (RSO) and the source will be sent to INC for failure analysis.' The Agency asked if that meant that the spring had disconnected and they stated that it had. The Agency stated that the initial report did not reflect that. [The licensee] stated he knew that and that he had misunderstood what the radiographer had told him over the phone. Additional information will be provided as it is received in accordance with SA-300."
Notified R4DO (Josey) and NMSS via e-mail.