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ENS 565742 March 2023 05:00:00Agreement StateLost/Abandoned SourceThe 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
ENS 5525111 May 2021 05:00:00Agreement StateEquipment Failed in Shielded PositionThe 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 5490622 September 2020 05:00:00Agreement StateAgreement State Report - Medical EventThe 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.
ENS 5490514 September 2020 05:00:00Agreement StateAgreement State Report - Loss of Yellow Ii Package Containing Approximately 61 Mci of Liquid Tl-201The 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
ENS 5480428 July 2020 05:00:00Agreement StateAgreement State Report- Patient UnderdoseThe following was received from the Illinois Emergency Management Agency (IEMA) via email: KishHealth System in Dekalb, IL (d/b/a Kishwaukee Community Hospital) contacted the IEMA at approximately 1100 CDT on 7/29/20 to report a patient scheduled to receive Y-90 microsphere therapy for hepatocellular cancer received only 58% of the dose prescribed in the written directive. While investigation is ongoing, the reportable underdose is based on licensee's pre and post-administration measurements of the dose vial and waste container, respectively. IEMA staff have contacted the licensee and are seeking additional information on post-administration imaging, status of patient/referring AU notification, the nature of the written directive (i.e., was this a fractionated dose), and the members of the treatment team. These factors, among others, will determine regulatory compliance as well as patient impact. Therefore, this report will be updated as information becomes available. IEMA is dispatching staff today (7/29/20) for a reactionary inspection. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. Illinois item number: IL200013 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 5478414 July 2020 20:30:00Agreement StateAgreement State Report - Gauge Crushed with Source Rod ExtendedThe following was received from the Illinois Emergency Management Agency (IEMA; the Agency) via email: At approximately 1530 CDT on July 14, 2020, the Agency was contacted by the RSO ((Radiation Safety Officer)) /owner of Construction & Geotechnical Material Testing (IL-02179-01) regarding a Troxler 3440 gauge (s/n: 24805; containing 8 mCi of Cs-137 and 40 mCi of Am-241) that was run over and crushed by an operator running a roller on a construction site at 1514 Main Street in Lombard. The RSO reported that operations had stopped and that he needed guidance to get the source rod out. At 1550 CDT, the Agency contacted the licensee for details and to provide guidance. The gauge user was uninjured but the gauge was run over and destroyed. At the time of the incident it was confirmed that the source rod was extended into the ground and a measurement was in process. The gauge user immediately notified personnel in the area and cordoned off the area. The gauge user then notified his RSO, who then notified Troxler (their emergency contact) and IEMA as per their emergency procedures. The RSO immediately went to the scene. He stated that he verified the security of the scene. He did not believe that the source rod was bent. The RSO stated that he was headed back to his office for a survey meter. Agency inspectors reviewed concerns regarding exposure from the Cs-137 source and the possibility of a leaking source with the RSO. Procedures were reviewed for surveys of the area once the gauge was removed to ensure the Cs-137 source had not become dislodged and that the source was not leaking. The Agency offered to dispatch inspectors to assist; however, the licensee had the gauge manufacturer engaged and able to respond. The gauge manufacturer responded to the scene at approximately 1700 CDT and confirmed the source rod was unbent and able to be shielded. Both the Am-241 and the Cs-137 sources were confirmed as present and intact. The gauge was safely repackaged into the Troxler case by Troxler personnel and the TI (Transport Index) confirmed as 0.3. This information was confirmed with pictures sent to the Agency. Troxler personnel performed surveys of the area to confirm the source was removed and that there was no contamination/leakage. Both sources (Cs-137 and Am-241) were placed into the Troxler transport container without incident. Both Troxler and the licensee performed surveys of the site prior to departing and after packaging the damaged source. At 1830, the licensee confirmed background readings at the site and the gauge was transported back to Troxler. The gauge will be leak tested and then shipped to Troxler in North Carolina for disposal. This matter will remain open pending receipt of leak tests, additional gauge information, documentation of disposal, and required written reports. Illinois Item Number: IL200011
ENS 547374 June 2020 06:00:00Agreement StateAgreement State Report - Low Level Radioactive Waste Railcar FireThe following was received from the Illinois Emergency Management Agency (IEMA; the Agency) via email: At approximately 0700 (CDT) on 6/4/2020, the Agency was contacted by the Texas Radiation Control Program to advise that a rail car containing radioactive material had caught fire at the Belt Railway Co. of Chicago (BRC) located 6900 Central Ave., Bedford Park, IL. The Texas program had been contacted by the railway. IEMA staff contacted BRC and was informed that a lidded gondola (car WP-9241) transporting a load of UN2912 LSA-1 was found to be smoldering at approximately 0100 on 6/4/2020. The shipping manifest listed contents as 'solid oxides' with 4.13 mCi of Co-60, Cs-134, Cs-137, U-234, U-235 and U-238. BRC staff agitated the railcar and continued to observe until approximately 0300. At that time, flames had engulfed approximately 10 percent of the car and the Bedford Park Fire/Hazmat team arrived on scene. There is no indication of arson. The fire was monitored and the car separated from an adjacent car also containing LLRW ((Low Level Radioactive Waste)) (WP 9124). At approximately 0630, the fire burned itself out. At 0837, IEMA staff contacted the Response Management Team for the shipper and the General Manager for Alaron/Veolia to get shipping manifests (received 0920). Indications at that time were that the fire was rekindling and soil was added atop the fiberglass lid to help smother. Agency responders arrived on scene at approximately 1040. Bedford Park Fire/Hazmat was on scene as well as the railway's emergency response team. AreaRays had been deployed by the hazmat team and were reporting background exposure rates. Based on conversations with the shipper, the subject load contained un-irradiated zirconium fuel cladding and other debris enroute from Alaron Nuclear Services in PA to Waste Control Specialists in TX. The cladding at one point contained enriched fuel, so there is approximately 1.3 mCi of uranium present (predominately U-234 at a concentration of 41 pCi/gram and U-235 at 3 pCi/g. Load contains approximately 44g of SNM (Special Nuclear Material)). It is believed that the friction due to transport created pyrophoric zirconium dust which reacted with the surrounding building debris and combustible waste. This debris and combustible waste was also contaminated with radioactive material - approximately 0.8 mCi of Co-60, Cs-134 and Cs-137 each. At the time Agency staff arrived, the lid had been covered with soil and only a small amount of smoke was escaping. This was air sampled for any volatile radioactive contaminants by on site IEMA staff. Areas impacted by smoke, including adjacent cars, were wiped to check for surface contamination. On site measurements did not indicate any deviations from background and there is no indication that the radioactive material within the suspect load impacted personnel or the environment. Lab analyses will supplement this assessment. Impacted areas on the ground were surveyed and exposure rate measurements (reportedly maximally 400 microR/hour on contact with the railcar) documented for any first responder dose recreations. Modeling efforts are underway to provide bounding numbers on potential environmental impacts - albeit unexpected. Temperature of the car was recorded as approximately 400 degrees F and falling. Local Fire/Hazmat was still on scene and the shipper's radiological expertise was expected to arrive at approximately 1530. In the initial fire response, approximately 1000 gallons of water was added to the railcar. A hydrant was not accessible. The bulk of this water impacted the fiberglass cover and ran off. This drip line was assessed for contamination and none identified. The car was also moved approximately 2000 feet to distance it from the second car of LLRW. Both sites were evaluated by inspectors and no indications of radioactive contamination identified. Agency staff will continue to monitor the situation, especially if the shipper intends to uncover or repackage the shipment. The incident was reported to the National Response Center under Incident Report 1278842 by the Railway Police Department. Nuclear Regulatory Commission, IEPA and USEPA notified and briefed. This matter is also reportable to the Nuclear Regulatory Commission Ops Center for Emergencies under 32 Ill. Adm. Code 340.1220(c)(4). Item Number: IL200010
ENS 5473230 May 2020 12:00:00Agreement StateAgreement State Report - Damaged GaugeThe following information was received via E-mail: At approximately 1420 CDT on Saturday, May 30, 2020, the Radiation Safety Officer (RSO) for Global Brass and Copper, Inc., d/b/a Olin Brass, IL-01069-01 contacted the Agency (Illinois Emergency Management Agency (IEMA)) to advise that a SU-S3 fixed gauge containing 1 Ci of Am-241 was damaged on a process line. The source assembly was somehow separated from the fixed gauge housing and fell onto surrounding equipment in an unshielded position. Workers immediately withdrew and fire/safety and security staff cordoned off the area with Radioactive Material (RAM) signage. Reportedly, this incident happened at approximately 0700 CDT on the morning of May 30, 2020. The licensee was attempting to contact their consultant and the manufacturer for assistance. Agency staff responded to the facility to assist in securing the source, assess for removable contamination, and to evaluate any potential exposures to workers. IEMA arrived on site at approximately 1600 CDT on May 30, 2020. IEMA evaluated airflow, took surveys, and established a recovery plan with site security/safety and the RSO. Exposure rates were approximately 170 mR/hour at one foot. Exposure rates were approximately background at the RAM signage/cordon. Remote handling tools were used to place the source in a pig owned by the licensee. The source was then secured within the licensee's RAM storage safe. Exposure rates around the properly secured safe were approximately 20 microR/hour. Wipes were taken of the area, the damaged gauge housing, and the process equipment. No removable contamination was identified. Discussions concerning worker proximity and time in place after the source became dislodged indicate no exposures exceeding regulatory limits. IEMA is awaiting a return phone call on June 1, 2020 for additional source details, results of leak tests and availability of the manufacturer to respond and evaluate. Event Report ID No.: IL200009
ENS 5470211 May 2020 05:00:00Agreement StateAgreement State Report - Troxler Gauge Destroyed by BulldozerThe following was received from the Illinois Emergency Management Agency via email: The Illinois Emergency Management Agency (IEMA) communications center was notified at approximately 1942 (CDT) on 5/11/20 by the radiation safety officer for Testing Service Corp., license number IL-01178-01, to advise that a gauge user operating a Troxler model 3440 was struck by a bulldozer. The gauge user is reportedly fine, but the gauge was destroyed. The density gauge, serial number 72404, contains 8 mCi of Cs-137 and 40 mCi of Am-241/Be. Reportedly the source rod remained intact and both sources were identified and recovered into a lead drum. The licensee does possess a Geiger Muller survey meter and reported an external survey rate of 0.4 mR/hour on the outside of the drum (0.0 mR/hour is the reported background). The incident occurred at the southeast corner of Vollmer and Harlem in Matteson, IL. The sources were transported back to the licensee's facility. Agency inspectors are meeting with the licensee at 0700 (CDT) on 5/12/20 to verify the recovery of both sources, perform gross leak tests, advise on appropriate follow-up actions, and perform a site survey in Matteson. The licensee has already been in contact with the manufacturer for advice and instructions for returning the sources. Illinois Event No.: IL200007
ENS 5454321 February 2020 06:00:00Agreement StateAgreement State Report - Stolen Fluorescence Analyzer EquipmentThe following report was received from the state of Illinois via email: The Agency (Illinois Emergency Management Agency) was notified by the Radiation Safety Officer (RSO) of the Illinois Department of Public Health (IDPH) that an XRF (X-ray fluorescence) instrument was stolen the morning of 2/21/20 in Peoria, IL. The RSO was made aware of the theft at approximately 1030 (CST) today. The vehicle had been parked overnight in the driveway of an IDPH employee who works out of the Peoria field office (site #2 on IL license). The gauge was locked in the trunk, in addition to having a lock on the case itself. However, the vehicle had been left running while the user went back into their home to retrieve a laptop, and upon their return they realized the vehicle had been stolen. Peoria Police were notified and informed of the instrument and radiation source in the trunk. The XRF is model XLP303A, serial number 14472; and the source serial number is TR2743. The IDPH will keep the Agency updated if they receive any additional information related to the vehicle or XRF instrument. The theft appears to be incidental to the theft of a vehicle and not an intentional diversion of radioactive material. The sources contained within these devices are IAEA category 5, meaning no one could be permanently injured and the amount of radioactive material, even if dispersed, could not permanently injure anyone. Illinois report no.: IL200006 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 545125 February 2020 06:00:00Agreement StateAgreement State Report - Lost Gauging SourceThe following was sent by the Illinois Emergency Management Agency (IEMA) via email: The Corporate H & S Mgr. (Health & Safety Manager) at PepsiCo/Quaker Oats reported the loss of an ATl-100S/500 microCurie (Sr-90) general licensed gauging source (SN 30056). They were doing leak tests this morning and found that the whole packaging unit had been removed presumably by Dudek Scrap during a remodel some time ago. They are checking on dates and will contact the scrap dealer to try and find it. IEMA inspectors plan to investigate on 2/6/20 to confirm details at the user's site and also will visit the scrap yard to see if the source is recoverable. At the moment this is considered an accidental loss due to poor oversight and is not related to any criminal theft or diversion. Item Number: IL200004 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 5451622 February 2019 06:00:00Agreement StateAgreement State Report - Reportable Equipment FailureThe following information was received via E-mail: A reportable equipment failure occurred on February 22, 2019 at a panoramic irradiator licensee in Libertyville, IL. The equipment failure was not reported to Illinois Emergency Management Agency (IEMA), but identified during a February 6, 2020 routine inspection. The affected equipment has since been repaired and no impacts to health or security were identified. IEMA inspectors conducted a routine inspection at Isomedix Operations d/b/a Steris, Libertyville location, on February 6, 2020. During a review of licensee files, it was determined that on the evening of February 22, 2019, required safety equipment became disabled as a result of the cell flooding. This is reportable, at a minimum, under 32 Ill. Adm. Code 340.1220c2. Inspection findings indicate that on or about 1817 CST February 22, 2019, a coupler on a 2 inch sprinkler line in the maze of the cell broke during processing. The cell consequently flooded and began to flood the warehouse. An emergency console stop was executed at approximately 1821 CST and both racks submerged. At 1824 CST, the pool high water alarm was tripped. Inspector review of the console event log indicates within the next 80 minutes the smoke detector, exhaust fans, collision bar, inside roof plug, low air pressure, high temperature, main panel communications and loss of 110 VAC and 24VDC faults were logged. It was also noted that at 2024 CST on February 22, 2019, the source racks were moved back up. At 2024 CST, the deionizer radiation monitor alarmed. A number of alarms and faults continued until approximately 1121 CST on 2/23/19. Reportedly, up to four inches of water covered the pool and the entirety of the warehouse. The fire department was needed to shut off the main feeding the sprinklers. Inspection findings indicate, at a minimum, high and low water monitors as well as the deionizer radiation monitor were disabled due to the wiring being flooded and shorted in the trough. The wiring for multiple components were replaced and plumbers contracted to repair the sprinkler system the following day. The licensee has moved to a manually initiated dry fire suppression system. Dosimetry was evaluated and no unusual exposures noted. Interviews of staff involved indicate security systems were not impacted. Leak tests were performed on February 22, 2019. This incident remains under investigation. There is no evidence of intentional disruption of safety or security systems. Event Report ID No.: IL200005
ENS 4035224 November 2003 20:15:00Agreement StateAgreement State Report - Dose to Patient Outside Intended Treatment Site

(Radiation Safety Officer (RSO)) for Advocate Lutheran General Hospital called Illinois Emergency Management Agency on 11/24/03 at approximately 1415 to report an event involving a Novoste Intravascular Brachytherapy (IVB) procedure. Hospital RSO stated that at approximately 1100 on 11/24/2003 during an IVB procedure with a prescribed dose of 18.4 gray, the end of the 40mm source train was not visible at the anticipated location at the end of the catheter. The sources were stuck in an apparent kink in the catheter. The source train was immediately retracted into the safe shielded position in the unit. A second attempt was then made but the sources became stuck in the same area and were again immediately retracted.

The procedure was then terminated and an analysis of the event and dose estimates were performed.  An unintended area of the heart was exposed to radiation from the source train for approximately 47 seconds in the first attempt and 10 seconds in the second.  The estimated radiation dose calculated to the wrong area of the heart was estimated to be approximately 5 gray.  Essentially none of the prescribed dose of 18.4 gray was delivered to the intended area of the heart as the source train was retracted before reaching the intended area.

The patient has been notified that there was a problem encountered during the procedure and the physician will notify the patient shortly of the particulars involved with the unintended dose delivered. The physicians do not expect any adverse medical effects from this event. Hospital RSO stated that they will carefully review this event and enhance training for this procedure. Hospital RSO added that he will notify Novoste regarding this event and submit the required written report within 15 days. Illinois Event Report ID: IL030078, License Number: IL -01152-01 Source Information: NOVOSTE Model #A1767, Serial # 91834, Radionuclide: Sr 90, Activity: .0484 Curies