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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 42164 | 19 November 2005 08:00:00 | Agreement State | Agreement State Report - Damaged Moisture Density Gauge | The State provided the following information via email: ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention) The licensee called the Washington State Department of Health, Office of Radiation Protection emergency line Saturday November 19, 2005 to report a damaged portable gauge. The Office of Radiation Protection Emergency Response Duty Officer called the supervisor of the Radioactive Materials Section with the information who drove to the incident site to access the situation and monitor for radiation. Radiation readings were normal for a Troxler gauge. The Licensee provided a statement of the event by the operator. In it the operator said when all the contractor personnel left the area for lunch no equipment was running. Thinking everything was OK; the operator walked to her car for lunch and left the gauge in place. The gauge was not in use. When contractor personnel began returning to the site the operator followed. The operator heard equipment start up and was approximately 50 feet away when a moving piece of equipment backed over the gauge. The operator called the company RSO and 911 to notify the local fire department. The area was cordoned off to keep personnel away. The operator then removed the shipping and emergency papers and made calls to the State Department of Health who responded to the scene of the incident. The gauge was taken to the licensee's lab in nearby Fife, Washington before being taken to their licensed storage location in Bellevue, Washington. To prevent reoccurrence, gauge operators have been instructed by the RSO to be with in a few feet of the gauge when it is in an exposed location. The Licensee has suspended for a week without pay the operator in this incident. Notification Reporting Criteria: WAC 246-221-250 Notification of Incidents. Isotope and Activity involved: 8 mCi of Cesium 137, and 40 mCi of Americium 241 Beryllium. Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None expected. Lost, Stolen or Damaged? (mfg., model, serial number) : Troxler, model 3430, serial number 26287. Disposition/recovery: The gauge was placed back in the manufactures transport case and returned to the licensed storage location in Bellevue, Washington. A licensed technical service provider was contacted and the gauge is being held for pick up and disposal by the service provider. Leak test? None reported post incident. Last Leak Test performed on September 8, 2005. Vehicle: (description; placards; Shipper; package type; Pkg. ID number) NA Release of activity? None found. Activity and pharmaceutical compound intended: NA Misadministered activity and/or compound received: NA Device (HDR, etc.) Mfg., Model; computer program: NA Exposure (intended/actual); consequences: NA Was patient or responsible relative notified? NA Was written report provided? NA Was referring physician notified? NA Consultant used? No. |