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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 54868 | 30 August 2020 15:15:00 | Agreement State | Agreement State Report - Stolen Moisture Density Gauge | 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 | ||
| ENS 54821 | 6 August 2020 05:00:00 | Agreement State | Agreement State Report - Stuck Shutter | The following is a summary of information received via email: On 8/6/2020, the licensee notified the Kentucky Radiation Health Branch of an event which had occurred on the same day. The shutter control mechanism malfunctioned on a nuclear gauge and the shutter could not be completely closed. The gauge has been taken out of service and no overexposures were reported as a result of this incident. A service provider has been contacted to help repair or replace the damaged gauge. The gauge is a Data Measurement Corporation Model AM-3E containing a 3 Ci Am-241 sealed source. Kentucky Event Report ID No.: KY200003 | ||
| ENS 54676 | 22 April 2020 15:42:00 | Agreement State | Agreement State Report - Gauge System Switch Failure | The following was received from the state of Kentucky via fax: Kentucky Radiation Health Branch was notified on 4/22/20 by a representative from International Paper of a failure of a magnetic reed switch on their Honeywell gauging system. This switch senses when the mass measurement heads are separated and closes the shutter window on the radioactive source. There are two other means of determining whether the heads are out-of-alignment that also trigger the shutter window to close if indicated. Therefore, these additional layers of protection are adequate to protect against a radiation exposure if the heads are separated. International Paper has returned the system to service with the Honeywell recommendation to replace the switch as soon as the replacement part arrives. Per (the representative) of Honeywell, with the understanding that the failed component will be replaced, the customer can continue to keep the scanner under operation with the basis weight sensor. | ||
| ENS 54668 | 14 April 2020 17:15:00 | Agreement State | Agreement State Report - Medical Underdose Event of Y-90 Sirtex | The following is a summary of an email received from the Kentucky Department of Radiation: At the University of Louisville Hospital on April 14, 2020, a patient received two doses (each dose was 0.4 GBq) of Y-90 Sirtex. The first dose was given at 1130 EDT and the second dose started at 1315 EDT. The second dose was started to be administered when a problem developed. While pushing saline into the dose V-vial, pressure built and vented out the top of the vial rather than pushing the spheres via the tubing to the patent as normal. Liquid, and presumably spheres, vented either from the side of the septum or around the needle at this time which is unknown. The administration box contained the leakage and prevented wider contamination. The second dose was not delivered to the patient so the patient received 0.4 GBq of a planned 0.8 GBq treatment. The manufacturer was contacted and the administration was stopped. Most of the intended dose remained in the plexiglass box that is used for shielding during administration. To prevent any contamination everything was kept and confined to the box. 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 54513 | 6 February 2020 12:15:00 | Agreement State | Agreement State Report - Fixed Process Gauge Shutter Malfunction | The following was received from the Commonwealth of Kentucky via email: The KY RHB (Kentucky Radiation Health Branch) was notified via email on 2/6/2020 (1559 EST) by a representative from specifically licensed facility, Big Rivers Electric Corp., that at 0715 on Thursday, 2/6/2020, one fixed gauging device (Kay Ray Model 7062BP, Serial Number 20086), containing 100 milliCuries Cs-137 (source serial No. 17400V; assay date 10/30/1985) had developed a potential problem while the shutter arm was moving freely. Survey results showed that the shutter remained in the shut position. The gauge is mounted on a pipe, and manned entry is not of concern, and the plant personnel have been notified that there is no access allowed to the affected pipe. All operational and maintenance activities will be delayed until the device has been removed for repair by a service provider. The licensee will be contacting a licensed service provider to remediate this situation. This is being reported under 10 CFR 30.50(b)(2). Kentucky Event Report ID No.: KY200001 | ||
| ENS 54477 | 20 August 2019 06:00:00 | Agreement State | Agreement State - Less than Prescribed Dose Received | The following was received from the State of Kentucky via e-mail: The University of Kentucky reported that a patient received less dose than prescribed on 8/20/2019. The patient was prescribed to receive 429.2 MBq (11.6 mCi) of Y-90 microspheres (Sirtex Medical model SIR- Spheres). A microsphere dose of 425.5 MBq (11.5 mCi) was drawn from the unit vial into the administration vial. However, the patient only received an activity of 316.72 MBq (8.56 mCi), which is 26.2 percent less than prescribed, because some microspheres remained in the administration system. Additionally, it was difficult to draw 429.2 MBq (11.6 mCi) from the 7.13 GBq (192.6 mCi) in the unit vial as it represented only a small portion of the whole. The patient and referring physician were notified. Corrective actions included ordering a dose calibrated to more closely provide the activity needed for the date and time of administration. If the activity to be administered is low, the university will ensure that the activity drawn is 10 percent greater than prescribed. More flushes of the system will also be performed in hopes of pushing more of the residual activity into the patient. Kentucky Incident Number - 190008. NMED Item Number - 190442 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. |