Event Notification Report for February 21, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/20/2025 - 02/21/2025
Agreement State
Event Number: 57566
Rep Org: California Radiation Control Prgm
Licensee: Mistras Group
Region: 4
City: Bakersfield State: CA
County:
License #: 8120-15
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Karen Cotton-Gross
Licensee: Mistras Group
Region: 4
City: Bakersfield State: CA
County:
License #: 8120-15
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/21/2025
Notification Time: 16:51 [ET]
Event Date: 02/21/2025
Event Time: 00:00 [PST]
Last Update Date: 02/21/2025
Notification Time: 16:51 [ET]
Event Date: 02/21/2025
Event Time: 00:00 [PST]
Last Update Date: 02/21/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY EQUIPMENT
The following information was provided by the California Department of Public Health via email:
"Mistras Group was performing radiography at a temporary job site outside of a water tank. The radiographer was using a manned lift to perform the radiography at the 50-foot level. The Industrial Nuclear Company (INC) IR 100 exposure device number 4435 with an Ir-192 model 32, serial number 003J with 37.3 curies was resting inside an I-beam trough and secured to the tank using magnets. The source crank assembly was 35 feet long. During the eighth exposure, the radiographer felt the magnets holding the exposure device to the tank pull off, and he immediately cranked the radiography source into the exposure device, which fell approximately 45 feet to the ground level. The radiographer returned to ground level and surveyed the exposure device with his survey meter and found that it was at the normal range.
"Upon examination of the radiography equipment, the radiation safety officer discovered that the swedge end of the Ir-192 source pigtail was damaged during the fall. The exposure device will not be used again and will be returned to the manufacturer, INC, for source removal and any needed repairs.
"There was no exposure to any radiography personnel or members of the public."
California 5010 Number: 022125
The following information was provided by the California Department of Public Health via email:
"Mistras Group was performing radiography at a temporary job site outside of a water tank. The radiographer was using a manned lift to perform the radiography at the 50-foot level. The Industrial Nuclear Company (INC) IR 100 exposure device number 4435 with an Ir-192 model 32, serial number 003J with 37.3 curies was resting inside an I-beam trough and secured to the tank using magnets. The source crank assembly was 35 feet long. During the eighth exposure, the radiographer felt the magnets holding the exposure device to the tank pull off, and he immediately cranked the radiography source into the exposure device, which fell approximately 45 feet to the ground level. The radiographer returned to ground level and surveyed the exposure device with his survey meter and found that it was at the normal range.
"Upon examination of the radiography equipment, the radiation safety officer discovered that the swedge end of the Ir-192 source pigtail was damaged during the fall. The exposure device will not be used again and will be returned to the manufacturer, INC, for source removal and any needed repairs.
"There was no exposure to any radiography personnel or members of the public."
California 5010 Number: 022125
Agreement State
Event Number: 57569
Rep Org: NE Div of Radioactive Materials
Licensee: Nebraska Methodist Hospital
Region: 4
City: Omaha State: NE
County:
License #: 010702
Agreement: Y
Docket:
NRC Notified By: Michael Gries
HQ OPS Officer: Brian P. Smith
Licensee: Nebraska Methodist Hospital
Region: 4
City: Omaha State: NE
County:
License #: 010702
Agreement: Y
Docket:
NRC Notified By: Michael Gries
HQ OPS Officer: Brian P. Smith
Notification Date: 02/24/2025
Notification Time: 12:34 [ET]
Event Date: 02/21/2025
Event Time: 09:00 [CST]
Last Update Date: 02/25/2025
Notification Time: 12:34 [ET]
Event Date: 02/21/2025
Event Time: 09:00 [CST]
Last Update Date: 02/25/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following summary was received via phone from the Nebraska Division of Radioactive Materials (DHHS-NE):
At 0830 CST on February 24, 2025, DHHS-NE was notified by the licensee of a medical underdose occurring during the morning of February 21, 2025. A patient received a Y-90 treatment of 47.25 mCi intended for the right lobe of the liver. However, only 74 percent of the intended dose reached the right lobe of the liver. DHHS-NE is continuing to follow up on the event.
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 FROM BRYCE DAVIDSON TO BRIAN P. SMITH AT 1657 EST ON FEBRUARY 25, 2025 * * *
DHHS NE informed the Headquarters Operations Center that upon further review the Y-90 treatment that underdosed the patient involved shunting and therefore is not a medical event. The event thus is not reportable.
Notified R4DO (Roldan-Otero) and NMSS Events Notification (email)
The following summary was received via phone from the Nebraska Division of Radioactive Materials (DHHS-NE):
At 0830 CST on February 24, 2025, DHHS-NE was notified by the licensee of a medical underdose occurring during the morning of February 21, 2025. A patient received a Y-90 treatment of 47.25 mCi intended for the right lobe of the liver. However, only 74 percent of the intended dose reached the right lobe of the liver. DHHS-NE is continuing to follow up on the event.
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 FROM BRYCE DAVIDSON TO BRIAN P. SMITH AT 1657 EST ON FEBRUARY 25, 2025 * * *
DHHS NE informed the Headquarters Operations Center that upon further review the Y-90 treatment that underdosed the patient involved shunting and therefore is not a medical event. The event thus is not reportable.
Notified R4DO (Roldan-Otero) and NMSS Events Notification (email)