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| Event date | Site | State | Event description | Topic | |
|---|---|---|---|---|---|
| ENS 56493 | 20 April 2023 05:00:00 | Minnesota Department of Health | Minnesota | The following information was received from the Minnesota Department of Health (MDH), Radioactive Materials Unit via email: An unlicensed engineering company found a portable nuclear density gauge in their storage garage while cleaning. They state that they have never been licensed and have never acquired a gauge. (The company) estimates that it has been in the garage since the early 1990s without their knowledge. The gauge is currently being stored in the locked garage. The company has been instructed to place a second tangible barrier on the device while (MDH) continues to investigate and discuss next steps. The licensee reported this discovery to MDH on 4/25/2023, and MDH was able to verify the gauge make, model and activity on 4/27/2023. Below is the information we (MDH) currently have: - Company name: Widseth Engineering, Inc. (formerly Floan-Sanders, Inc.) 1600 Central Avenue NE, East Grand Forks MN - Gauge manufacturer: Soiltest, Inc. 2205 Lee Street, Evanston IL - Gauge Model: NIC-5 DT - Gauge Serial Number: 75C047 - Sources (assay date August 1975): Am-241/Be: 60 mCi (decayed to 55 mCi); Cs-137: 10 mCi (decayed to 3.3 mCi) MDH is conducting an investigation and will provide more information in a report within 30 days. MN State Event Report ID No. MN230002 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 | Moisture Density Gauge |
| ENS 56574 | 2 March 2023 05:00:00 | Illinois Emergency Management Agency | Illinois Indiana | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: On March 2, 2023, staff with the Illinois Emergency Management Agency and Office of Homeland Security responded to a load of scrap metal that tripped portal monitors in Indiana and was returned under DOT SP-IN-IL-23-001.The load of scrap originated at B.L. Duke in Forest View, IL. Within that load, a small unidentified radium-226 source was identified. It was estimated to contain approximately 150 microcuries of activity. On June 14, 2023, the licensing division learned of the recovery and began an investigation into the applicability of reporting requirements. There are no discernable markings or serial/model numbers. Activity estimates (based on dose rate) would place the source at approximately 150 microcuries. Aside from this source having significantly less activity, this appears to be a Ra-226 radiography source from the early 30's/40's. As this source does not appear to be exempt, it is likely byproduct material as a discrete source of radium and subject to specific licensure. Therefore, it is being reported as a lost/missing source. The source has been placed into the Agency's orphan source collection program and will be disposed of as low level radioactive waste. Illinois report number: IL230015 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 | Moisture Density Gauge |
| ENS 56065 | 23 August 2022 16:00:00 | Georgia Radioactive Material Program | Georgia | The following information was received via email: The Georgia Department of Natural Resources, Environmental Protection Division, Air Protection Branch sent this as notification that a lost portable gauge reported. The incident occurred 8/23/22 around lunch time and was reported to (Environmental Protection Division) (EPD) at (1530 EDT). The gauge is a Humboldt Model 5001. It is currently unknown which Isotope it contained or its activity (Cs-137 or Am-241). The gauge user was onsite and had placed the gauge on the tailgate of his truck. He left for lunch and when he got to the location, realized he had forgot to secure the gauge in it's transport box. The gauge was no longer on the vehicle. He reported the lost gauge to the local police and went back to look for the gauge. (The driver was unable to locate the gauge). We (EDP) are following up for more information, but wanted to meet our reporting requirements and inform you of the loss. The following additional information was obtained from the state in accordance with Headquarters Operations Officers Report Guidance: The license number, the county, and the worst case scenario activity for the Humboldt Model 5001 gauge (44mCi of Am-241). 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 | Moisture Density Gauge |
| ENS 56207 | 20 July 2022 04:00:00 | New York Department of Health | New York | The following information was provided by the New York State Department of Health (the Department) via fax: On August 16, 2022, the Department was notified of a missing I-125 localization seed (lsoAid I-125, Serial No. 78315 Activity: 0.025 millicurie) at a licensed medical facility in New York. On July 18, 2022, there were two patients, one seed in each of 2 patients was removed. Radiograph of the specimens showed seeds and biopsy clips were present. On July 20, 2022, the Nuclear Medicine technologist was called to retrieve the 2 seeds in a leaded container. Upon further survey, the technologist discovered there was only one seed, and the other was a biopsy clip. The Nuclear Medical Technologist surveyed the pathology lab, including benches, trash and floor but was then informed that the seeds were retrieved from the specimens the day before on July 19, 2022. The laboratory manager, radiology manager and nuclear medicine technologist tracked the path of seeds including the pathology lab, the operating room and hallways. Radioactive trash was also surveyed for radioactivity. The Radiation Safety Office and Medical Physicist were then notified of the missing seed. Corrective actions are in place including: 1. Nuclear Medicine will be notified immediately when a seed is retrieved from a specimen. 2. When retrieving the seed from the specimen, the survey meter must be used to ensure the seed is present. 3. Temporary pathology workers will not work with radioactive seeds. NY Event Report ID: NYDOH-22-06 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 | Moisture Density Gauge |
| ENS 55772 | 7 March 2022 07:00:00 | Arizona Department of Health Services | Arizona | The following information was received from the Arizona Department of Health Services (the Department) via email: The Department received a call from a concerned citizen over 3 potentially radioactive pieces of metal that he found in a toolbox that his father-in-law previously owned. When Department inspectors went onsite, the pieces of metal read between 2-8 mR/hr on contact. The metal pieces were removed by Department staff and are currently in secure storage. Exposures to individuals are unknown at this time and the origin of the metal is unknown. The Department will continue to investigate. Arizona Incident Number: 22-005 | |
| ENS 55771 | 23 February 2022 06:00:00 | Arkansas Department of Health | Arkansas | The following information was provided by the Arkansas Department of Health (the Department) via email: The Agreement State Radioactive Materials Licensee reported to the State of Arkansas, Arkansas Department of Health, on February 23, 2022, that a general licensed device listed on their specific license has tested positive on the leak test results. The Department provided correspondence to the licensee on February 25, 2022. The leaking sealed source was Ni-63, which is used in a Agilent Gas Chromatograph. The Department considers this event to be in process and will submit additional information until this event is closed. State Event Report ID Number: AR-2022-003
The following was received via email from the Arkansas Department of Health: General License Device information: Make: Agilent Technologies Gas Chromatograph, Model 7890A, SN: CN12421187, Detector: G2397A, Source Model: E&Z NER-004P. Source Serial Number: U37072, Original Activity: 13.2 millicuries Ni-63 (May 2020), Current Activity: 13.05 millicuries Ni-63 (as of Discovery Date: January 5, 2022). U37072 Leak test result: 0.0056 microcuries of removable contamination wiped from its inlet/column adapter. Source Serial Number: U38668, Original Activity: 13.2 millicuries Ni-63 (May 2021), Current Activity: 13.14 millicuries Ni-63 (as of Discovery Date: January 5, 2022). U38668 Leak test result: 0.0495 microcuries of removable contamination wiped from its inlet/column adapter. Immediate corrective actions were performed by the Agreement State Radioactive Materials Licensee, as described in Arkansas State Board of Health Rules for Control of Sources of Ionizing Radiation RH-402.c.5. Corrective actions included immediately suspending operations of device, device was tagged-out and taped shut, and properly posted. Proper wipes and surveys were performed indicating no detectable activity. The manufacturer was contacted by the licensee. The sealed sources were transferred to the manufacturer on March 15, 2022. The Agreement State Radioactive Materials Licensee noted that there were no unusual occurrences. The required thirty-day report has been received by the Agreement State Radioactive Materials Licensee. There have been no known radiation exposures to any worker(s) and/or member(s) of the public. The Arkansas Department of Health did not issue any Items of Noncompliance. The Arkansas Department of Health considers this incident closed and will review this information during the next routine inspection. Notified R4DO (Deese), and NMSS Events Notification via email. | |
| ENS 55730 | 4 February 2022 07:00:00 | Arizona Department of Health Services | Arizona | The following information was received from the state of Arizona via email: The Department received a call from a construction project manager who stated that 110-116 tritium exit signs were stolen by a contractor and are being held at his residence in Flagstaff, Arizona. A police report has been filed with the Coconino Police Department. Additional information will be provided as it is received in accordance with SA-300. AZ report no.: 22-001 | Tritium Exit Sign Stolen |
| ENS 55251 | 11 May 2021 05:00:00 | Illinois Emergency Management Agency | Illinois | The following report was received from the Illinois Emergency Management Agency (the Agency) via email: On May 12, 2021, the (Division of Nuclear Safety - Radioactive Material) DNS-RAM section was verbally notified that a reportable equipment failure had occurred on the Agency's JL Shepherd Model 81-12T irradiator the previous day. The equipment failed in the shielded position and no public/staff exposures were reported as a result of the failure. The unit has been taken out of service pending repair by the manufacturer. All security systems required under 32 (Illinois Admin) Code 337 remain unaffected. This equipment and associated calibration activities are operated under a self-issued materials license, IL-01030-01. Additional details on the equipment failure are forthcoming. Initial notification was made within the 24 hour reporting requirement. A written report containing the information in 32 (Illinois Admin) Code 340.1230 is required within 30 days. This report will be updated as information becomes available. Illinois Item Number: IL210016 | |
| ENS 55186 | 1 April 2021 05:00:00 | Minnesota Department of Health | Minnesota | The following was received from the Minnesota Department of Health via email: A medical event has occurred at Essentia Health, Duluth, MN (MN license number 1048). The event occurred on April 1, 2021 and was discovered by the radiation safety officer on April 8, 2021. The licensee reported the event to the state of Minnesota on April 8, 2021. Preliminary details are as follows: A Y-90 Theraspheres procedures with a prescribed dose of 140 Gy administered 173.4 Gy on April 1, 2021. This resulted in a dose (that varied by) greater than 20 percent of prescribed. The event was discovered by the radiation safety officer following a records review and reported to the state of Minnesota within 24 hours of discovery. The licensee is investigating the root cause and the potential for harm to the patient. A report will be submitted within 15 days. The state plans to do an on-site investigation with the licensee. Additional information will be reported following the final report from the licensee and investigation by the state. 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. | TheraSphere |
| ENS 54933 | 5 October 2020 05:00:00 | Minnesota Department of Health | Minnesota | The following is a summary of an email from the state of Minnesota: During a lab reorganization, the licensee determined that a static eliminator (Po-210; 6 mCi; Model NRD P-2063; S/N A2LU743) was lost. The licensee presumes it was mistakenly disposed of as electronic waste and sent to a recycling facility some time in August of 2020. The licensee is examining their program to identify process improvements that would prevent future loss of material. The licensee has notified the recycling facility. 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 | Moisture Density Gauge Static Eliminator |
| ENS 54924 | 30 September 2020 20:00:00 | Mississippi Division of Radiological Health | Mississippi | EN Revision Imported Date : 10/2/2020 AGREEMENT STATE REPORT - VEHICLE RAN OVER PORTABLE MOISTURE GAUGE This is a summary of a call from the state of Mississippi Division of Radiological Health via phone: A portable moisture density gauge, containing 9 mCi Cs-137 and 44 mCi Am-241/Be sealed sources, was run over by a vehicle at a construction site in Clinton, MS. No visible damage of the gauge was identified. The licensee's survey results were normal for a retracted source. The gauge was returned to a local office and the state will also perform a survey once they are on site. There was no exposure to personnel.
The updated report was sent from the state of Mississippi Division of Radiological Health via email: Off Norrell Road, off MS. 1-20 Clinton Mississippi Continental Tire Construction site off-ramp, the gauge user was on a noisy construction site with heavy equipment and ear protection requirements. The gauge user was taking a measurement and the high elevated Rubber Tire Roller used to pack asphalt did not see the gauge user. The gauge user yelled at him trying to get him to stop, but due to the noise and the driver not seeing him, the rubber tire roller ran over edge of Humboldt Moisture Density Gauge model 5001 Ser. No. 9624, only damaging the outer housing. The RSO was contacted, used a survey meter Troxalert Model 01754 calibrated 01/10/2020, and received readings of 6 mR/hr which are consistent with previous readings that indicate the source was in the shielded position. The gauge is at the RSO's office and is being sent to Humboldt for electronics and housing repair and a wipe test. The incident was an accident. No violations could be issued to the licensee due to gauge user being present taking moisture readings and the driver of the rubber tire packer just did not see him. Mississippi Event Number MS-200003 Notified R4DO (Silva), NMSS Events Notification (e-mail) | Moisture Density Gauge |
| ENS 54922 | 29 September 2020 11:30:00 | Ohio Bureau of Radiological Health and Safety | Ohio | The Ohio Department of Health reported the following via email: On September 29, 2020, at 0948 EDT, the licensee reported the theft of a moisture-density gauge from their location, Cincinnati, Ohio. Due to heavy rain the evening of September 28, a technician left the gauge locked in a company truck outside the secure facility instead of moving the gauge inside the secure facility as required. At approximately 0730 on September 29, the locked box containing the gauge was discovered broken into and the gauge and storage container missing. The gauge is a Troxler model 3411-B with a 8 mCi Cs-137 and a 40 mCi Am-241/Be sources. A report was filed with the Cincinnati police. Ohio Item Number: OH200009 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 | Moisture Density Gauge Moisture-Density Gauge Stolen Troxler Moisture Density Gauge |
| ENS 54936 | 28 September 2020 04:00:00 | Pennsylvania Bureau of Radiation Protection | Pennsylvania | The following was received from the Pennsylvania Bureau of Radiation Protection (BRP; the Department) via email: On Sunday afternoon, September 28, 2020, the Department was notified of radioactive material found in a private residence being cleaned-out for an auction sale. BRP staff responded and found several sealed radium-226 sources and small quantities of uranium ore. The initial investigation revealed an additional nearby property also had radioactive material present. Staff inspected that property as well and discovered several more items. Owners of the houses were related and have passed away. HazMat responder's shoes and gloves were surveyed on September 28, with no removable contamination noted. Ambient dose rates were in the microrem to few millirem per hour range around the sources. The houses were secured that evening and further investigation continued through the week. As of October 7, 45 items have been collected. Note, some items contain multiple exempt sources, pieces of rock, or bottles of circa 1920 quack medical tablets with radium-226. These items include: old quack radium consumer products, exempt check sources, vacuum tubes, a military compass, luminous tubes and deck markers, cans of thorium oxide, and various other items containing radium-226, thorium-232, strontium-90, carbon-14, and natural uranium in quantities ranging from less than a microCurie to a few milliCuries (in the case of two radium-226 sources). An empty 5 gallon pail with 'US Radium, Bloomsburg PA' stenciled on the side was found. It is believed this old manufacturer of radium products, and now an EPA Superfund site, is where these items originated from. No exposure to members of the public above the public dose limit of 100 mrem per year are believed to have occurred during discovery and recovery, as the higher activity sources were within lead containers when found. BRP will update this event if more information becomes available. A complete inventory and activity calculations are underway for proper disposal. Event Report ID No: PA200020 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 | Moisture Density Gauge |
| ENS 54915 | 26 September 2020 04:00:00 | Florida Bureau of Radiation Control | Florida | The following was received from the state of Florida via email: A transport vehicle carrying radio-pharmaceuticals was rear-ended at the intersection of County road 39 and State road 62 in Parrish Florida. Duette Fire rescue is on scene with a representative from the pharmaceutical company. The shipping papers indicate 227 mCi of Tc-99m but the driver had already made several stops and may have additional radioactive waste materials not on manifest. Cardinal Health Sarasota has taken custody of all packages. Florida Incident Number: FL20-110. | |
| ENS 54909 | 24 September 2020 13:30:00 | Florida Bureau of Radiation Control | Florida | The following is a summary of information reported by the Florida Department of Health via email: Terracon Consultants reported a Troxler 2440 gauge was stolen from a truck while the truck was parked at a residence in Brandenton, Florida. The gauge was stolen around 0930 EDT on 9/24/2020. The gauge was secured with two chains and two locks by the driver of the truck. The local police department has been notified. The gauge contained a 8 mCi Cs-137 source (S/N: 75-1841) and a 40 mCi Am241:Be source (S/N: 47-15958). Florida Incident Number: FL20-109 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 | Moisture Density Gauge Stolen Troxler Moisture Density Gauge |
| ENS 54906 | 22 September 2020 05:00:00 | Illinois Emergency Management Agency | Illinois | The following information was received via email from the Illinois Emergency Management Agency (The Agency): The Agency was notified on 9/23/20 that a high dose rate afterloader (HDR) administration resulted in a medical event on 9/22/20 at the Western Illinois Cancer Treatment Center in Galesburg, IL. The licensee states no untoward effects are expected of the patient. Agency staff will respond and evaluate on 9/24/20. The Agency was contacted by an authorized medical physicist and radiation safety officer for Western Illinois Cancer Treatment Center in Galesburg (RML IL-01902-01), to report a medical event that occurred the previous day on September 22, 2020. Reportedly, a patient was prescribed a 30 Gy therapeutic dose to the vaginal cuff, to be delivered over a series of (5) fractionated 6 Gy administrations. Two of the 6 Gy administrations had already been performed on 9/15/20 and 9/18/20 without issue. The patient arrived for the third fractionated dose of 6 Gy on 9/22/20. An unnamed nurse was present as well. It is unclear if an authorized medical physicist was physically present at time of administration. Rather than delivering the dose through the vaginal cavity, the HDR applicator was inserted into the rectal cavity. This was not noticed until after the treatment was delivered. Based on the information currently available, the written directive specified a 6 Gy fraction to be delivered to the vaginal treatment area. The dose delivered was 1.46 Gy. This meets the reportable criteria in 32 Ill. Adm. Code 335.1080(a)(1) for an underdose. Additionally, had the administration gone as prescribed; the rectum would have only received (for 50% of the volume) 1.53 Gy per fraction. In this administration, the dose to the rectum (50% of volume) was 3.94 Gy. This also meets the reportable criteria for an overexposure. The format of this report provides data in the context of an overexposure. The language in the written directive will be reviewed, as well as procedures, personnel present, treatment plan and post-plan calculations on September 24, 2020. Reporting timeliness appears appropriate at this time. A written report will be required to the Agency by October 7, 2020. The referring physician has been notified. The patient is being advised today, which at this time appears to be in accordance with applicable regulations. This report will be updated as additional information becomes available. Illinois Item Number: IL200017. 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. | Overexposure Underdose |
| ENS 54903 | 16 September 2020 19:00:00 | Utah Division of Radiation Control | Utah | The following was received from the state of Utah, Division of Waste Management and Radiation Control, via email: At approximately 1300 (MDT), on September 16, 2020, a Nuclear Medicine Technician injected 9.5 mCi of Tc-99 Sestamibi into the wrong patient. The prescribed radiopharmaceutical to be administered was Tc-99m MAA. The dose of Tc-99 Sestamibi was intended for a patient scheduled earlier in the day that did not show up for their appointment. The Nuclear Medicine Technician failed to swap out the Tc-99 Sestamibi for Tc-99m MAA for the 1300 MDT patient. State Event Report No.: Will be provided in a follow up report. 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. | |
| ENS 54904 | 16 September 2020 07:00:00 | Arizona Department of Health Services | Arizona | The following was received from the Arizona Department of Health Services (The Department) via email: The Department received notification from the licensee that a construction vehicle ran over a portable gauge. The gauge is a Troxler 3430, Serial Number 21871, containing approximately 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241:Beryllium. The Department has requested additional information and continues to investigate the event. Arizona Event No. 20-018. | Troxler Moisture Density Gauge |
| ENS 54912 | 16 September 2020 04:00:00 | Ohio Bureau of Radiological Health and Safety | Ohio | The following is a summary of the email received from the State of Ohio: The licensee discovered that one of their Electron Capture Detectors (Model: G2397A; S/N: U23974; Source: Ni-63 0.015 Ci) was leaking during a routine leak test. The source has been transferred for disposal. Item Number: OH200008 | |
| ENS 54905 | 14 September 2020 05:00:00 | Illinois Emergency Management Agency | Illinois | The following is a synopsis of the report received via email from the Illinois Emergency Management Agency (Agency): The Agency was contacted the morning of 9/14/20 by the licensee to report a Yellow-II package containing approximately 61 mCi of Tl-201 had not arrived at its final destination. There is no reason to suspect intentional diversion or criminal activity. The 12 inch x 6 inch x 6 inch package was labeled Radioactive Yellow-II with a transport index of 0.4 and was shipped via a commercial carrier. The package contained six shielded vials of diagnostic radiopharmaceutical liquid thallium-201. It was shipped from the licensee address on Tuesday, 9/8/20 with an assay activity of 225 mCi. The package was expected to arrive at the final destination, but as of 1600 CDT on Friday, 9/11/20, the package had not reported any movement after reaching the commercial carrier hub at Memphis, TN. As a result, the licensee contacted the recipient, as well as the radiation safety officer of the commercial carrier. The licensee contacted the Agency to report the package as lost. The last known location remains as the commercial carrier hub. No updates were available as of 9/21/20. The Tl-201 was shipped in a shielded container and does not represent a significant exposure hazard. The remaining activity as of 9/21/20 is 12 mCi. Unshielded, this dose would give rise to about 1.1 mR/hour at one foot. This quantity of material is over the NRC reporting requirement and is being reported within the required 30 day timeline. Illinois Item Number: IL200015 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 | Moisture Density Gauge |
| ENS 54900 | 14 September 2020 05:00:00 | Texas Department of State Health Services | Texas | EN Revision Imported Date : 10/9/2020 AGREEMENT STATE REPORT - LOST AND FOUND DEVICE The following information was submitted by the Texas Department of Health Services (the Agency) via email: On September 15, 2020, at 1700 CDT, the Agency was notified by the licensee's radiation safety officer (RSO) that one of their technicians had left a Troxler model 4640B density gauges at a job site overnight. The technician had completed their work on September 14, 2020, and left the job site after completing their paperwork, but failed to store the device into their truck. The RSO stated the gauge handle was locked and did not believe any individual would receive an exposure. The RSO stated the device contains two cesium-137 sources, but did not know the activities. The manufacturer's website states the activity to be 8 (+ or - 1) milliCuries. The licensee's license states a device source cannot exceed 9 milliCuries. The RSO stated they had technicians out searching for the gauge. At 1736 CDT, on September 15, 2020, the RSO contacted the Agency and reported the gauge had been recovered. He could not provide any additional information. Additional information has been requested. If during the investigation of this event it is determined that an individual could have been exposed, the Agency will submit an update to this report. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 9797
The following update was received from the Agency via email: On October 7, 2020, the Agency was notified by the licensee that the gauge only had one source and not two as first reported. The licensee stated it thought it had two sources because of the way it calculates the density of the top two inches. The licensee stated it has only one source, but two detectors so it can calculate thin lift density. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Josey) and NMSS Events Notification and ILTAB via email. 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 | Moisture Density Gauge Troxler Moisture Density Gauge |
| ENS 54892 | 9 September 2020 05:00:00 | Iowa Department of Public Health | Iowa | EN Revision Imported Date : 9/25/2020 AGREEMENT STATE REPORT - BROKEN SHUTTER MECHANISM ON FIXED GAUGE The following was received from Iowa Department of Public Health via email: The licensee reported today that during a routine shutter check it was discovered that a shutter on a fixed gauging device had come off of its hinge. The device is located on coal silo 106 outlet at the 163 foot elevation. Due to the location of the device, no personnel can be exposed to the beam. The licensee has contacted a vendor to repair the shutter. This event will be updated once the Agency (Iowa Department of Public Health) receives the written report. The gauge was a Kay-Ray Sensall model 7700-C containing 50 milliCuries of Cs-137. Iowa NMED Number: IA200003
The following information was received from the State of Iowa Department of Public Health via email: The outside vendor arrived on-site September 16, 2020 and found that the right end mounting bracket for the shaft was bent and the shaft was no longer in the mounting bracket. The vendor removed the device and repaired the shutter. The apparent cause of the shutter failure was the source was swung out to where it completely cleared the calibration blocks and then swung back into place. The state considers this event be closed. Notified R3DO (Cameron) and NMSS Events Notifications (email). | |
| ENS 54894 | 9 September 2020 04:00:00 | New York Department of Health | New York | The following was received from the New York State Department of Health via fax: A medical licensee reported that only 30.3 mCi of a prescribed dose of 45.1 mCi of SIRTEX SIR-Spheres was delivered to a patient. The microspheres apparently became clogged in the applicator. A written report is forthcoming. Event Report ID No.: NYDOH-20-03 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. | Underdose |
| ENS 54891 | 8 September 2020 05:00:00 | Texas Department of State Health Services | Texas | The following was received from Texas Department of Health Services (the agency) via email: On September 9, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that on September 8, 2020, one of his crews lost a QSA 880D exposure device containing a 38.1 Curie iridium-192 source. The radiography crew had placed the exposure device on the tailgate of their truck at the licensee's location. The crew drove away from the site with the exposure device still on the tailgate. The device fell off the truck a short distance from the licensee's location. A second crew left the licensee's location a short time (10 minutes) later and found the device on the pavement. The second crew performed a radiation survey of the device and found the radiation levels to be normal and the source was still fully shielded. The second crew returned the device to the licensee's location. The device was inspected and did not appear to be damaged. The licensee has sent the device to the manufacturer for inspection. Additional information has been requested from the licensee. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9798 THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | Brachytherapy |
| ENS 54886 | 5 September 2020 05:00:00 | Texas Department of State Health Services | Texas | The following was received from the Texas Department of State Health Services (the Agency) via email: On September 5, 2020, The Agency was notified by the licensee's site radiation safety officer (SRSO) that a Humboldt EZ 5001 moisture/density gauge was damaged at a temporary job site when a bulldozer struck the gauge. The gauge contains a 40 milliCurie americium-241 source and a 10 milliCurie cesium-137 source. The cesium source was in the shielded position when the event occurred. The operating rod was bent, and the SRSO stated he did not believe the cesium source rod would move. The SRSO stated they performed radiation surveys around the gauge and the highest reading they obtained was 1.3 millirem per hour, which is a normal reading. The SRSO stated they were taking the gauge back to their storage location and would perform a leak test of the gauge. The event did not present an exposure risk to any individual. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 9795 | |
| ENS 54926 | 4 September 2020 04:00:00 | Florida Bureau of Radiation Control | Florida | The Florida Bureau of Radiation Control reported the following via email: The RSO (Radiation Safety Officer) notified the BRC (Bureau of Radiation Control) by mail that a leak test performed on this source (217.6 microCurie Cs-137 e-vial) resulted in greater than 0.005 microCi of the acceptable removable contamination. After determination, the source was sealed within the shielded e-vial container using silicone. The outer shielded container had no removable contamination. The sealed container was then wrapped in plastic. The outer plastic also had no removable contamination. The area was evaluated for signs of removable contamination with no results above background. The licensee intends to dispose of this source through a licensed radioactive waste disposal company. Florida Event Number: FL20-113 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 | Moisture Density Gauge |
| ENS 54884 | 3 September 2020 07:00:00 | California Radiation Control Program | California | The following was received from the State of California Department of Public Health - Radiologic Health Branch (CDPH/RHB) via email: The licensee Radiation Safety Officer reported that the pool water conductivity exceeded 100 microSiemens/cm on 9/3/20. The reason was the loss of operability of the demineralizer pump. The pump has been repaired and is currently operable with declining pool water conductivity, but the pool water is still in excess of 100 microSiemens/cm. CDPH/RHB is continuing to investigate the circumstances surrounding this event. | |
| ENS 54882 | 2 September 2020 04:00:00 | Georgia Radioactive Material Program | Georgia | The following was received from the Georgia Radioactive Materials Program via email: At the end of the administration of Y-90 SIR Spheres (for the treatment of tumors in the right lobe of the liver), the delivery vial (D-Vial) appeared to overfill as the radiologist was attempting to mix the spheres with a 50/50 solution of contrast and 5 percent dextrose/glucose (D5W). The radiologist noticed some clumping and after attempting to gently disperse the Spheres, he gave a couple hard pushes of the contrast/D5W into the D-Vial. At that time, he noticed the leak. He examined the septum and found it to be dry. As a precaution the radiologist put Durabond on top of the septum. Further examination showed that the material leaked out of the sides of the crimped vial top rather than the septum. The procedure was stopped to prevent further contamination. The event occurred while using SIRTEX new SIROS delivery system. The SIRTEX representative was present providing guidance to the radiologist as this was the first time he used the new system. It is estimated that 75 percent of Y-90 SIR-Spheres were administered to the patient (Prescribed Activity: 3.1 GBq (83.7 mCi); Delivered Activity (estimated): 2.87 Gbq (77.7 mCi)). It is likely that the residual activity was over estimated due to contamination of the SIROS delivery dome. The usual waste from the procedure is contained in a 1-liter Nalgene containers and then placed in a Lucite shield for dose rate measurements to determine the residual activity. The Siros delivery dome could not be measured in the same geometry and likely resulted in an increased dose rate and underestimate of the total dose delivered. At this time, the prescribing physician indicated he does not expect any adverse effects for the patient and is awaiting the dosimetry evaluation from the patients PET/CT Scan. Attempts have been made to recreate the event without success. There is speculation regarding the size of the dose and that the number of Spheres may have been a factor (larger than typically administered). Representatives from SIRTEX indicate that this has not been an issue at other sites. Prior and subsequent studies with the new SIROS delivery system were successful with less activity. Further evaluation of the equipment to determine why the vial leaked, will be performed following decay and return the manufacturer. Georgia Incident Number: 30 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. | Underdose |
| ENS 54899 | 1 September 2020 05:00:00 | Texas Department of State Health Services | Texas | The following information was received via e-mail from the Texas Department of State Health Services (the Agency): On September 14, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that they had discovered a medical event (occurred September 1, 2020) involving a Varian high dose rate remote afterloader (HDR) unit had occurred. The RSO reported that a patient was to receive two boost treatments using the HDR unit. While setting up for the second treatment, the licensee noted the length of source catheter tube used in the first treatment was incorrect, therefore only part of the intended target was treated. The RSO stated the patient and physician were both notified of the event and that the current plan is to perform an additional treatment to the area that was under exposed in the first treatment. The RSO stated they did not expect any adverse effects to the patient. The Agency has requested additional information on the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9796 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. | Underdose |
| ENS 54872 | 31 August 2020 05:00:00 | Texas Department of State Health Services | Texas | The following was received from the Texas Department of State Health Services (the Agency) via e-mail: On September 1, 2020, the Agency received a report from the licensee's radiation safety officer (RSO) indicating the shutter on an Ohmart Vega model SH-F1B nuclear gauge was stuck in the open position. Open is the normal operating position of this gauge. The gauge contains a 100 milliCurie (original activity) cesium-137 source. The stuck shutter was found during routine inspections. The licensee has contacted a service provider to repair the gauge. The gauge does not create an exposure risk to any individual. Additional information will be provided in accordance with SA-300. Texas Incident Number: 9791 | Stuck Shutter |
| ENS 54868 | 30 August 2020 15:15:00 | Kentucky Department of Radiation Control | Kentucky | The following information was received from the state of Kentucky via email: The Radiation Safety Officer (RSO) of the Kentucky Radioactive Materials Licensee Geotechnology Inc. (RML #201-189-51), reported the theft of a single CPN MC-1 Elite Series Moisture Density gauge (Serial No: 31113 with sealed source models HEG137, 10 mCi Cs-137, sealed source serial number Q785, and AM1.NO2, 50 mCi AM-241:Be, sealed source serial Number K039/18) from an authorized users vehicle while parked overnight at the user's residence located in Lexington KY. The gauge was secured by 2 chains within the cab of the vehicle, but was stolen from the vehicle along with several other items. No forced entry into the vehicle was noted, but one of the two chains securing the gauge was cut and the second chain was removed by breaking the top handle of the gauge transportation case. A report was made to the Lexington Police Department which is investigating the theft (Case No. 2020145606). The Kentucky Radiation Health Branch, will follow up with an interview with the RSO and authorized user. Reporting Criteria In 10 CFR 20.2201(a)(1)(i) Kentucky Incident No.: 201-189-51 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 | Moisture Density Gauge Stolen |
| ENS 54866 | 29 August 2020 14:00:00 | Texas Department of State Health Services | Texas | The following was received from the Texas Department of State Health Services (the Agency) via email: The licensee notified the Agency at approximately 1315 CDT that one of its company pickups had been stolen and a Troxler model 3440 moisture/density gauge (SN: 37337) was secured in the bed of the truck. The gauge contains 40 milliCurie americium-241 and 8 milliCurie cesium-137 sources. The technician had a late testing and then went to his residence from the job site due to a serious water leak that was occurring there. After fixing the leak, it was late and he fell asleep and did not return the gauge to the licensee's facility. He last saw the vehicle/gauge at approximately 0100. At approximately 0900, he discovered the vehicle, with the gauge, had been stolen. The set of keys to the locks securing the gauge and the insertion rod were in the cab of the truck. Local police were notified. Police will notify the local pawn shops and the licensee will search local buy/sell/trade internet sites for the gauge and other equipment. More information will be provided as it is obtained in accordance with SA-300. Texas Incident # I-9790
The following update was received from the Texas Department of State Health Services via email: The licensee's Radiation Safety Officer notified the Agency at approximately 1847 CDT that he has possession of the gauge and it was back at their facility. He had been called by the San Antonio Fire Department HAZMAT at approximately 1800 that they had been called to a location where the gauge was - the gauge was sitting on the edge of a street next to the curb. The latches on the transport case were unlocked but the gauge and all other equipment were present. The chains and locks that secured the gauge in the bed of the truck were also present. There was no damage to the transport container or the gauge. Technicians put the device through its normal testing procedures and it is fully operational. Any further information will be provided as it is obtained in accordance with SA-300. Notified R4DO (Kellar), and NMSS Events Notification, ILTAB, and CNSNS (Mexico) 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 | Moisture Density Gauge Stolen Troxler Moisture Density Gauge |
| ENS 54865 | 28 August 2020 05:00:00 | Texas Department of State Health Services | Texas | EN Revision Imported Date : 9/1/2020 AGREEMENT STATE REPORT - LOST SHIPMENT OF TRITIUM EXIT SIGNS The following was received from the Texas Department of State Health Services (the Agency) via email: On August 28, 2020, the Agency was contacted by an individual to notify it that they had shipped seven Forever Lite tritium exit signs to a manufacturer in May of 2020 and they have been informed by the transportation company that they do not know where the signs are. The signs are Forever Lite signs, each containing 7.03 curies (original activity) of tritium, manufactured in May 2011. The package was last scanned in Fort Worth, Texas, in May of 2020. The shipper stated that they were told on May 19, 2020 it was to be delivered in Canada. The next update when they followed up they were advised the package was lost and they were trying to locate the shipment and opened a claim. The location where the signs were lost is unknown at this time; therefore, the Agency is making this report for your information. The Agency has requested additional information and clarifications from the shipper. Additional information will be provided as it is received. Texas Incident #: I - 9789 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 was received from the Texas Department of State Health Services (the Agency) via email: After reviewing documents provided by the licensee, the Agency contacted the licensee and confirmed that eight signs were lost and not seven as previously reported. The transportation company's radiation safety officer (RSO) was contacted by the Agency and the RSO stated they do not store the tracking records of shipments in their computer system for very long, therefore they would not be able to review the tracking information for this shipment. The Agency will provide additional information as it is received in accordance with SA-300. Notified R4DO (Deese), NMSS Events Notification, ILTAB, CNSC (Canada), and CNSNS (Mexico) via email. | Tritium Exit Sign Moisture Density Gauge |
| ENS 54873 | 28 August 2020 04:00:00 | Ohio Bureau of Radiological Health and Safety | Ohio | The following was received from the Ohio Dept. of Health via e-mail: During a routine inspection of a generally licensed device a broken spring on the basis weight shutter was discovered. This spring is a fail-safe that closes the shutter in the event of the loss of air pressure. A temporary repair to the spring was made and the shutter was tested. The shutter is now working properly and a replacement spring is on order with a plan to install the spring as soon as possible after it arrives. Until the spring is replaced, the scanner will be taken off-line daily and observations made that the shutter closes. The device contains a 400 mCi, Kr-85 source. No personnel were exposed due to the spring failure. Ohio Item Number: OH200005 Ohio Reference Number: OH2020-037 | |
| ENS 54876 | 27 August 2020 04:00:00 | Ohio Bureau of Radiological Health and Safety | Ohio | The following was received from the Ohio Department of Health: The licensee tried to perform a split dose procedure on the right lobe anterior and right lobe posterior portion of a patient's liver. The prescribed dose was 60 mCi Y-90 Theraspheres (approximately 150 Gy) for each site. The posterior was treated first and then the catheter was moved to the anterior position. Post treatment scans of the patient indicated the posterior received 20 mCi (35 Gy) and the anterior received 100 mCi (180 Gy). The physician believes the catheter slipped after initial placement, resulting in an overdose to the anterior and underdose to the posterior. The licensee will no longer conduct spilt dose procedures. Ohio Item Number: OH200006 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. | TheraSphere Overdose Underdose |
| ENS 54879 | 27 August 2020 04:00:00 | Georgia Radioactive Material Program | Georgia | The following is a synopsis of the event received from the Georgia Radioactive Materials Program: On July 31, 2020, a physician did not follow proper procedure while recording the number of seeds administered to a patient. The physician initially planned on administering one seed but decided to administer two. The physician did remove both seeds from the patient on August 3, 2020. The tracking system for the administered seeds was based on writing the number of seeds administered on a colored bracelet or arm band, which the patient wears while the seed(s) are implanted. It is removed and travels with the removed tissue through the remaining processes at the hospital. In this case, the physician did not revise the number on the bracelet, therefore during the subsequent processes, other hospital staff only looked for one seed to recover from the procedure by-products. One seed was not recovered. There was some discussion between departments prior to August 21, 2020 about the seed. Radiation Safety was not contacted. On August 21, 2020, an Assistant RSO discovered the discrepancy while conducting an inventory, preparing the seeds for return to the seed vendor. Subsequent searches that included the involved staff did not recover the missing seed. After a review of the laboratory processes for analyzing the removed tissue, the hospital staff believes the missing seed was retained in the transport bin and disposed of with that bin in the bio-hazard waste stream. But, this can not be proven. It was demonstrated to not be in the frozen sample that the hospital retained. The hospital declared the seed lost on August 27, 2020. The seeds were I-125 encapsulated in titanium. Model IAI-125A. Activity level calculated to be 145.1 microCuries at time of loss/disposal. The radioactivity is small, and the decay rate high such that this poses a low risk to the public. Based on literature, the RSO states the contact dose, assuming the seed was trapped in clothing (contact) for twelve hours to be 2.66 milliSeverts. The hospital has conducted a root cause analysis, and has revised its procedures and re-trained staff to prelude future loss of radioactive seeds. Incident #: 29 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 | Moisture Density Gauge |
| ENS 54860 | 26 August 2020 14:00:00 | Colorado Department of Health | Colorado | The following information was received from the State of Colorado via email: A Troxler 3400 Series moisture/density gauge, containing 9 mCi Cs-137 and 44 mCi Am-241:Be or 66 microCi of Cf-252 sealed sources, fell out of the back of a pickup truck during transport by the licensee and was recovered by a member of the public, who turned the gauge into the fire department and the fire department returned the gauge to the licensee. Colorado Event Report ID No.: CO200058 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 | Moisture Density Gauge Troxler Moisture Density Gauge |
| ENS 54862 | 26 August 2020 05:00:00 | Texas Department of State Health Services | Texas | EN Revision Imported Date : 9/2/2020 AGREEMENT STATE REPORT - UNABLE TO DETERMINE IF SOURCE IN SHIELDED POSITION ON LEVEL INDICATOR The following information was received via E-mail: On August 26, 2020, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that while making preparations for the coming hurricane, the position of the source rod on a Tracerco, Model T-218-160032 (used for level indication) could not be confirmed. The source rod contains 10 cesium-137 sources of 10 milliCuries each (original activity.) The RSO stated when they return the sources to the shielded position, the control system does indicate the sources are shielded as indicated by a light change on the system console. When the licensee attempted to shield the sources on this day, the light did not change to indicate the sources were shielded. The gauge source rod is operated manually. They tried it a couple of times, but the light still did not change. A survey was performed on the outside of the vessel. The RSO stated there wasn't enough change in dose rate readings with shutter in the open and closed positions to determine whether the sources were shielded based on survey. The RSO stated it may be that the sources are not moving, or it may be that there is an issue within the control system causing the light not to change. They cannot determine at this time which problem is occurring. The RSO is contacting the manufacturer to send someone out after the hurricane. There is no risk of exposure. The RSO stated they will update the Agency once the manufacturer determines the problem. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9787
The following information was received via e-mail: On September 1, 2020, the licensee notified the Agency (Texas DSHS) that on August 31, 2020, a service company came onsite to investigate the shutter problem they had reported, and identified that there was no mechanical issue with the shutter. The problem they had was a failure of the output signal to indicate source position. The source rod was functioning normally. Based on this information, the Agency is retracting this event. Notified R4DO (Deese) and NMSS Events (email). | |
| ENS 54858 | 25 August 2020 07:00:00 | California Radiation Control Program | California | The following information was received by the state of California via email: On 08/25/20, the California Office of Emergency Services contacted the Radiologic Health Branch (RHB) to report potential fire damage to a moisture gauge stored inside a barn located in Napa County, CA. The gauge involved is a CPN International, Inc. Model 503, moisture gauge containing 50 milliCuries of Am-241:Be. The Radiation Safety Officer (RSO) hasn't been to the incident location, however, he confirmed that the barn where the gauge was stored and the adjacent house have been burned down during the wildfire. The gauge is presumed to have been damaged by the fire; however, due to high temperature resistant construction of the source, the source integrity may not have been affected. According to the RSO, the property is located in a remote area in Napa County, and the entrance to the property is secured by two locked metal gates. Access by the general public is not anticipated. The RSO had already contacted the vendor, Instrotek for disposal of the damaged gauge. The RHB will be coordinating with Instrotek and intends to accompany Isotek if Isotek goes to the site. The United States Environmental Protection Agency has also been informed, and it is possible they may be involved in the gauge recovery. California Incident No.: 082520 | |
| ENS 54857 | 24 August 2020 05:00:00 | Texas Department of State Health Services | Texas | The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 25, 2020, the Agency was notified by the licensee's consultant that during routine inspections the shutter on a Vega model SHGL-1 nuclear gauge containing a 2,000 milliCurie (original activity) cesium-137 source was stuck in the open position. Open is the normal position for the shutter. The gauge does not create an exposure hazard to any individual. The licensee's service provider is aware of the failure. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9786 | |
| ENS 54911 | 24 August 2020 04:00:00 | Pennsylvania Bureau of Radiation Protection | Pennsylvania | The following was received from the Pennsylvania Bureau of Radiation Protection via email: On August 24, 2020, the licensee identified a failure of the shutter assembly and indicator on one of its Valmet Multi-Filler Module, Serial Number 0022 containing 20 mCi of lron-55. The shutter had failed closed. The gauge was immediately removed from service. The manufacturer was contacted, and the broken shutter mechanism was removed and replaced on August 26, 2020. The shutter mechanism was then tested and confirmed as operating properly. No exposures were resulted from this event. Event Report ID No.: PA200018 | Stuck Shutter |
| ENS 54854 | 24 August 2020 04:00:00 | New Jersey Radiation Protection and Release Prevention Program | Texas New Jersey | The following is a summary of information received via email: On August 24, 2020, the licensee notified the New Jersey Department of Environmental Protection of two lost sealed sources. The sources had been sent from the licensee's Austin, Texas facility to their Fair Lawn, New Jersey facility, and are reported as missing by the shipper. The two sources were Ni-63 foil sources with an activity of 10 mCi each (S/N: AO-2484 and AO-5478). Each source was in a Life Technology Holdings, model Trace 1300, electron capture detector (S/N: 719420216 and 719420261). The shipper has been searching for the sources, but at this time considers them missing with little likelihood of recovery. The shipper's tracking system indicates that the sources were delivered to the licensee's Fair Lawn facility, but that location has stated they never received the sources. The address to which the sources were reportedly delivered does not exist and the person who reportedly signed for the package is unknown to the licensee. 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 | Moisture Density Gauge |
| ENS 54851 | 21 August 2020 13:00:00 | Texas Department of State Health Services | Texas | EN Revision Imported Date : 9/14/2020 AGREEMENT STATE REPORT - NUCLEAR GAUGE ENGULFED DURING FIRE The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 21, 2020, at 1307 CDT the Agency was notified by the licensee consultant (LC) that a fire was burning on one of its dredges off the coast Corpus Christi, Texas. The LC stated the drudge had a 250 milliCurie (original activity) (Cs-137) source in a Berthold model 7440 nuclear gauge installed on a pipe for density measurement. The LC did not have any other information on the location, but knew the dredge was in between 40 and 50 feet of water. The LC stated that the personnel on board were fighting the fire. The LC stated they believed that the gauge would be engulfed by the fire. The LC stated they would supply additional information once the fire is out and they have a chance to inspect the equipment. At 1553 CDT the LC contacted the Agency and stated the dredge workers were able to take dose rate reading about two feet from the gauge and the reading was 26 millirem per hour. The LC stated that the steel was still too hot to stay very long in the area. The LC stated (when asked) that they believe the fire is out. The LC stated the current priority on the drudge was locating several missing individuals. The LC stated they directed personnel on the drudge to take a contamination survey on the gauge as soon as possible. The LC stated the gauge source serial number was 0025-06. A search of news sources in Corpus Christi, Texas by the Agency found that a barge had struck an underwater natural gas line at a facility in Corpus Christy, Texas. This information was verified by the licensee's LC. The news reports stated the event occurred at about 0800 CDT. The report stated that the Texas Division of Emergency Management and Texas Department of Public Safety personnel are on the ground to provide support, and the Texas Commission on Environmental Quality is monitoring air quality in the area. The United States Coast Guard is assisting in the fire fighting and search for individuals. The name of the dredge involved was provided in several reports. The Agency contacted the LC verified the ship was owned by the licensee. This information was verified by the Agency by reviewing four different news sources. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9784
The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 21, 2020, at 2200 CDT, the Agency was notified by the LC that the dredge has sunk. The dredge is believed to be in 45-50 feet of water on its starboard (stbd) side. The gauge is located on the stbd side of the vessel and the shutter was in the open position. The LC stated that after talking to the radiation safety officer who is at the location the LC stated the dose rate they were able to take earlier today and was reported as 26 mR/hr at 2 feet was 26 mR/hr at 6 feet. A request for the composition of the source material has been made to the manufacturer. The search for four missing persons continues and is the current priority. Notified R4DO (Taylor), NMSS (Jamerson), and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 22, 2020 the manufacturer confirmed the source involved in this event is made of ceramic source material and is double encapsulated. Follow-up phone call to the Agency confirmed that the fire is out and the LC and the RSO are working on a recovery plan. First priority remains the search for the four missing persons. Notified R4DO (Taylor), NMSS (Jamerson), and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services (the Agency) via email: The Agency has contacted the licensee's radiation safety officer (RSO) and received the following information. The RSO stated that before the vessel sank a hazmat crew was able to get eyes on the gauge. The hazmat team stated the gauge did not appear to have been damaged by the fire. The area around the gauge also did not appear to have been damaged by the fire. The RSO stated the current plan is to raise the vessel, survey the gauge, and close the shutter. The RSO stated they would send a written report providing additional information. Notified R4DO (Taylor), NMSS (Jamerson), and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services (the Agency) via email: The Agency contacted the licensee's consultant (LC) on August 24, 2020, and requested an update on the event. The consultant stated he had received a written report completed by the licensee's RSO for his review. The LC stated he is on vacation but hoped to forward it to the Agency today. As of the writing of this update the report has not been received by the Agency. The LC stated they had a contractor in place to retrieve the vessel. Once raised the plan is to inspect the gauge, perform surveys of the gauge, and close the shutter. The raising of the vessel is not scheduled to take place until next week or the week after that due to difficulties getting the needed equipment in place. In addition, the local weather may hamper recovery activities. Notified R4DO (Kellar) and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services (the Agency) via email: On August 25, 2020, the Agency received the following information from the licensee's radiation safety officer: 'We do not have the equipment to do a deep-water survey of the radiation source. T&T our salvage contractor is ordering the equipment to do the survey of the source to insure the safety of their divers because the source has not had an up-close survey since the vessel sunk. We have taken a survey above the water and have not picked up any radioactivity.' The report from the licensee has been delayed while a review is completed. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Kellar) and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services via email: The licensee has confirmed that a member of a hazmat team who was able to inspect the gauge from a small boat next to the vessel prior to it sinking stated the gauge appeared undamaged, the wires leading to and from the gauge appeared to be undamaged, and that painted surfaces in the area of the gauge did not appear to be damaged by heat or the fire. The licensee stated they were unable to locate any pictures of the gauge prior to the vessel sinking. The licensee stated that their salvage contractor is ordering the equipment to do an underwater survey of the source to insure the safety of their divers because the source has not had an up-close survey since the vessel sunk. The licensee stated they have taken a survey in the water above the vessel and have not picked up any radioactivity. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Kellar) and NMSS Events Notifications (email).
The following information was received from the Texas Department of State Health Services (the Agency) via email: On September 11, 2020, the licensee reported the dredge was raised to the surface and the gauge was recovered on the dredge. The gauge was undamaged, and the licensee was able to shutter the source. Dose rates at the gauge were reported as normal. The shutter has been locked closed and the source will be disposed by a contractor. Additional information will be provided via the Nuclear Materials Events Database. Notified R4DO (Warnick) and NMSS Events Notifications (email). | |
| ENS 54852 | 21 August 2020 05:00:00 | Iowa Department of Public Health | Iowa | EN Revision Imported Date : 9/17/2020 AGREEMENT STATE REPORT - BROKEN SHUTTER ON FIXED GAUGE The following was received from the Iowa Department of Public Health via email: On Friday August 21, 2020 the registrant reported to the Iowa Department of Public Health that they had discovered, on that day, a broken shutter handle on a Berthold Technologies model LB 7440 fixed gauging device. The registrant also indicated that an outside vendor had been contacted to repair the handle. This device is located on a barge used for dredging the Mississippi River. There is no threat to the health and safety of the public. This event will be updated in NMED once the required 30 day written report has been received.
Iowa Item Number IA200002. On September 9, 2020, the manufacturer of the device arrived on site and found that the stem that is rotated by the open/close bar on the shield had broken off. The manufacturer's technician replaced the shield, moved the source to the new shield, performed a device shield survey and performed a leak test of the source. The device and the shutter are working properly. The State considers this event closed. Notified R3DO (Feliz-Adorno) and NMSS_Events_Notification (by email). | |
| ENS 54843 | 18 August 2020 07:00:00 | Arizona Department of Health Services | Arizona | The following report from the Arizona Department of Health Services (Department) was received by email: On August 18, 2020, during a routine inspection, the Department discovered that a licensee was in possession of a portable gauge which appeared to be missing its Cs-137 source rod shutter. The gauge was a Troxler Model 3430, Serial# 38482, containing 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241/Beryllium. While performing a survey of the gauge, inspectors recorded an exposure rate of 175 mR/hr over the shutter opening while the handle was in its locked position. The Department has requested additional information and continues to investigate the event. AZ Incident Number: 20-014 | Troxler Moisture Density Gauge |
| ENS 54841 | 18 August 2020 06:00:00 | Colorado Department of Health | Colorado | The following information was received from the Colorado Department of Health via email. The licensee is unable to locate sixteen tritium exit signs that have an activity of 11.5 Ci each. The signs may have been removed by a contractor. 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. | Tritium Exit Sign Moisture Density Gauge |
| ENS 54842 | 14 August 2020 05:00:00 | Alabama Office of Radiation Control | Alabama | The following information was received from the Alabama Department of Public Health via email. On August 14, 2020, the Agency (Alabama Department of Public Health) received e-mail communication from PPG Industries, a general license device registrant in Huntsville, Alabama. The registrant reported that apparently a registered device containing 10 milliCuries of polonium-210 (at assay) was unable to be located for inventory. The registrant reported that the area of use was searched for 3 weeks; the device remains unaccounted for. The device has been reported to the manufacturer (NRD Systems) as lost. Alabama Event No.: 20-19 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 | Moisture Density Gauge |
| ENS 54837 | 13 August 2020 05:00:00 | Texas Department of State Health Services | Texas | EN Revision Imported Date : 8/17/2020 AGREEMENT STATE REPORT - FIRE INVOLVING OIL WELL LOGGING SOURCE On August 13, 2020, the Agency (Texas Department of State Health Services) was contacted by the Nuclear Regulatory Agency (NRC) and notified that they had been contacted by a State of Texas licensee. The NRC still had the licensee on their bridge line and tied the Agency into the call with the licensee. The licensee's radiation safety officer (RSO) reported that one of their well service blending trucks was engaged in a fire. The well is located near Mentone, Texas. The truck has a TN model 5190 nuclear gauge containing a 200 milliCurie cesium - 137 source installed on the piping system. The gauge was purchased in December 2019. At the time of the call (2121 CDT) the fire was still burning, and a fire department was on scene. The RSO believed the fire department was aware of the source. The RSO stated all their personnel had been evacuated from the scene of the fire. There is no way to know the status of the gauge shielding or of the source. The RSO agreed to contact the Agency when the fire was put out, and after completing a survey of the gauge. Additional information will be provided as it is received in accordance with SA-300. TX Incident #: I-9783 Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).
The following retraction was received from the state of Texas via email: On August 14, 2020, the licensee reported that after the fire was extinguished it found that the fire did not reach the gauge or equipment around it. This included electrical wiring and rubber hoses which showed no damage from the fire. A portion of the equipment the gauge was mounted to did have some fire damage. An Agency radioactive material inspector went to the site and performed a dose rate survey on the gauge. Based on this survey, it does not appear there was any damage to the gauge shielding. There was a second gauge at the site, but it was not anywhere near the area of the fire and was not affected. It was also surveyed and did not appear to have had any damage. The dose rates taken on the gauges were similar. Based on this information this event does not meet the reporting criteria and is therefore retracted. The licensee has performed a leak test of the gauge and if the results are greater than the limit it will be reported in accordance with SA-30. Notified R4DO (Proulx), NMSS EO (Williams), IRD MOC (Gott), and NMSS Event Notifications (email). Additionally notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, CISA Central, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email). | |
| ENS 54902 | 11 August 2020 04:00:00 | New York Department of Health | New York | The following information was obtained from the state of New York via facsimile: On September 9, 2020, the Department (New York State Department of Health) was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 251 microCuries) at Roswell Park Cancer Institute in Buffalo, New York. In this incident two seeds were placed into a patient on 8/10/2020 and removed on 8/11/2020. Removal of the seeds from the patient was confirmed by x-ray in the operating suite. The seeds were then sent to the Frozen Section Room for margin check then sent to the Grossing Room in Pathology. After slicing in the Grossing Room, the specimen was x-rayed again and only one seed was visualized. Pathology believed that the seed was in the Frozen Section Room and immediately searched and surveyed both the Frozen Section Room and the Grossing Room, then notified the RSO (radiation safety officer) when the seed was not found. The RSO and an assistant surveyed the OR suite, Frozen Section Room and Grossing Room. Trash from all three locations was surveyed and after three days radioactive waste was surveyed and examined but the seed was still not recovered. In the time between the incident and reporting to the Department, searches and surveys were performed in Surgery, Pathology, Radiation Safety and Environmental Service areas. In addition, trash, regulated medical waste, and radioactive waste were surveyed and inspected. The seed has not been recovered. Ultimate disposition of the source is unknown and it is possible that the source may still be recovered. New York Event Report ID No.: NYDOH-20-04 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 | Moisture Density Gauge |
| ENS 54835 | 11 August 2020 04:00:00 | Pennsylvania Bureau of Radiation Protection | Pennsylvania | The (Pennsylvania) Department (of Environmental Protection (DEP)) received notification from a licensee on August 12, 2020, of a medical event involving Yttrium-90 Sir-Spheres. The licensee believes a patient received only 47% of the prescribed dose. The prescribed dose was 1.44 GBq and the delivered dose is believed to be 0.67 GBq. Preliminary cause is believed to be a clotted catheter. The licensee continues to investigate the event. The patient and referring physician were informed following the procedure. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided. PA NMED Event # PA2000016 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. | Underdose |