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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 54842 | 14 August 2020 05:00:00 | Agreement State | Agreement State Report - Lost Source | 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 | ||
| ENS 54813 | 3 August 2020 22:00:00 | Agreement State | Agreement State Report - Damaged Radiography Camera | The following is a summary of information received from the Alabama Department of Public Health via telephone: On August 3, 2020 at approximately 1700 CDT, the licensee was working at an asphalt plant in Mulga, AL, when one of its radiography cameras was damaged. The source of the radiography camera was being exposed when a magnetic stand, which was attached to the source, fell and crushed part of the guide tube. Multiple efforts to retrieve the source were unsuccessful. The licensee's radiation safety officer (RSO) responded to the scene. The RSO was able to retract the source after cutting part of the guide tube. No un-badged personnel received any dose as part of the event and applicable dosimetry badges have been sent for emergency processing. The camera is being sent to the manufacturer for investigation. Alabama Incident Report No.: 20-16 | ||
| ENS 54728 | 26 May 2020 20:30:00 | Agreement State | Agreement State Report - Possible Administration at the Wrong Treatment Site | The following information was received from the state of Alabama via email: The Alabama Department of Public Health Office of Radiation Control was notified on May 26, 2020, at about 1620 CDT by the Radiation Safety Officer (RSO) of the University of South Alabama Health University Hospital (license 584) of a possible misadministration via HDR (high dose rate) afterloader. The RSO stated that the patient was apparently treated at the wrong treatment site on May 26, 2020 around 1530 CDT; the prescribed dose for the fraction was 700 cGy (treatment course to total 2100 cGy). The licensee is currently working to reconstruct dosimetry at the time of this report, and is unsure of the variance from the prescribed dose. The licensee is authorized to possess an Elekta 136149A02, with a maximum of 12 Ci of Ir-192. Alabama Incident Report No.: 20-09. 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 54715 | 14 May 2020 05:00:00 | Agreement State | Agreement State Report - Broken Shutter Handle | The following information was received via email: The Alabama Dept. of Public Health Office of Radiation Control was notified on May 14, 2020, by a representative of Indorama Ventures Xylenes and PTA, LLC of a broken shutter handle on a fixed gauge. The licensee identified the device as an Ohmart SHRD-1-35, s/n 0018HB, with a Co-60 source of 3000 mCi, manufactured 10/2000. The licensee stated that there were no exposures to individuals as a result of this shutter failure, apparently no radioactive material was released outside the source housing. The device and source are in storage onsite, waiting for disposal. Alabama Incident Report No.: 20-08 | ||
| ENS 54577 | 7 March 2020 06:00:00 | Agreement State | Agreement State Report -- Broken Radiography Camera in Shielded Position | The following is a synopsis of a facsimile that was received from the State of Alabama: On March 9, 2020 at 0825 CDT, the State of Alabama Department of Public Health, Office of Radiation Control, Radioactive Materials Compliance Branch, was notified by licensee Acuren, Inc., that a radiographer attempted to unlock the locking mechanism of an 880D radiography camera and the key broke off in the lock. The licensee stated that the camera is still locked, is now "red-tagged," and is in storage until it can be sent to its vendor QSA for repair. The source was not exposed at the time and it is in the shielded position. Radiation surveys of the device are normal for a shielded position. This event occurred on March 7, 2020. Alabama Event Number: 20-05 The source is believed to be Ir-192. The source strength was not reported. | ||
| ENS 54483 | 16 January 2020 20:45:00 | Agreement State | Alabama Agreement State Report - Patient Received Greater Dose than Prescribed | The following information was received from the state of Alabama via facsimile: On January 16, 2020 at approximately 1445 CST, (the radiation safety officer (RSO)) of Alabama licensee East Alabama Medical Center notified the Alabama Office of Radiation Control (the Agency) that a patient apparently received more dose than prescribed during a treatment via HDR (high dose rate) afterloader on or around Thursday, 1/9/2020. (The RSO) stated that he noted the matter yesterday (1/15/20 at around 1530); he stated that the physician associated with the patient's case confirmed (the RSO's) concerns about the patient's dose. (The RSO) reported that the patient apparently received dose in 1 fraction that was to be administered over 2-3 fractions. The Agency has no further information on this matter as of the date of submission of this memo. Of note, East Alabama Medical Center is authorized to possess and use an Elekta Flexitron model 136149A02 HDR medical irradiator under Alabama license 105, with a maximum of 12 Ci of Ir-192. Alabama Event 20-01 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 51346 | 25 August 2015 05:00:00 | Agreement State | Abandoned Gauge Found in Scrap Metal | The following report was received from the State of Alabama Department of Public Health Office of Radiation Control via fax: On August 25, 2015, Sam Price, Environmental Health & Safety for Nucor Steel, Birmingham, Alabama notified the Office of Radiation Control that a load of scrap received from Covington, Georgia had set off radiation monitors and was reading 11.0 mR/hr and had been identified as Cs-137. Representatives from the Office of Radiation Control investigated the load and confirmed all measurements that were previously taken. The load was segregated and a single fixed type gauge was discovered in the load. The gauge contained only an unreadable general license label which was still attached. No other labels or markings were identified. The shutter appeared intact, but partially open. The gauge has been secured in place and is awaiting pick-up by an appropriate driver being provided by the scrap metal dealer in Covington, Georgia. The State of Georgia has been notified of the incident. As of today (August 26, 2015), 8:45 a.m. CDT, the gauge remains secure in place at Nucor Steel, Birmingham, Alabama. Alabama Incident 15-38 | ||
| ENS 45516 | 17 November 2009 06:00:00 | Agreement State | Agreement State Report - Report of Found Cs-137 Source | The following report was received via facsimile: On the morning of November 17, 2009, the Alabama Office of Radiation Control received a phone call from a representative of US Steel in Fairfield, Alabama advising the Agency (Alabama Office of Radiation Control) of the discovery of radiation levels in a load of scrap metal. The entire load of scrap was set aside and isolated. On the morning of November 20, 2009, a representative of the Office of Radiation Control visited the USA Steel facility in Fairfield to assist in locating and identifying the source of radiation. The source of radiation was identified as a stainless steel rod approximately 12 inches in length and 3/4 inches in diameter. Maximum radiation levels of 150 millirem/hour were noted at close proximity to one end of the rod. Preliminary field analysis identified the isotope as Cs-137. Based on the configuration and isotope, the source of radiation may be a source rod from a moisture density gauge. The source of radiation was isolated and preliminary leak test results in the field indicate that the source is not ruptured. The Alabama Office of Radiation Control is currently investigating where the source of radiation originated. This is all the information that this Agency (Alabama Office of Radiation Control) has at this time and is current as of 10:30 am central time, November 23, 2009. Alabama Incident 09-43. |