Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 54936 | 28 September 2020 04:00:00 | Agreement State | Agreement State Report - Recovered Miscellaneous Radioactive Items | 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 | ||
| ENS 54911 | 24 August 2020 04:00:00 | Agreement State | Agreement State Report - Stuck Shutter | 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 | ||
| ENS 54835 | 11 August 2020 04:00:00 | Agreement State | Agreement State Report - Patient Underdose | 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. | ||
| ENS 54705 | 11 May 2020 04:00:00 | Agreement State | Agreement State Report - Radiation Level on Package Exceeds Dot Limits | The following was received via email: On May 11, 2020 the licensee received a 10 gallon drum that fell outside of the Department of Transportation (DOT) dose rate level limitations. The package came from Cadman Materials, Inc. in Vancouver WA. The material inside is a gauge with a Cs-137 sealed source inside with an activity of 100 millicuries (3700 MBq). The package was shipped as UN2915, Radioactive Material Type A Package with Yellow-II labeling and a Transport Index of 0.1. Upon survey at receipt, the container exhibited dose rates of 3.4 rem/hr on contact, 240 mrem/hr at 12 inches, and 18 mrem/hr at 3.3 feet. The delivering carrier, and the client, Cadman Materials, have been notified. The Pennsylvania Bureau of Radiation Protection will update this event as soon as more information is provided. The event is reportable per 10 CFR 20.1906(d)(2). PA Event Report ID No: PA200012 | ||
| ENS 54696 | 5 May 2020 04:00:00 | Agreement State | Agreement State Report - Medical Event | The following information was received via email: The Department (Pennsylvania Bureau of Radiation Protection) received notification from a licensee on May 5, 2020, of a medical event involving a Varian GammMedplus iX high dose rate remote afterloader (HDR) containing 8.6 Ci of iridium 192. The patient was set to receive 10 fractions (channels) of breast cancer treatment. An error was noted when treatment from the third channel was attempted. The source was retracted back into the safe position upon the error indication. Staff reset the unit and rebooted. The unit functioned normally for the fourth channel. During the fifth channel the machine experienced another fault, but the source did not automatically retract. Staff then attempted two emergency stop procedures; however, both failed. Staff were finally able to manually retract the source after approximately two to four minutes; however, it hasn't been determined if the source was completely retracted into the shielded safe on the HDR due to catheter interference. The patient was quickly disconnected from the catheter, everyone was immediately removed, and the room was secured from entry. No dose is expected outside the HDR room as it is housed within an accelerator vault. The manufacturer has been contacted. The licensee has also requested the log files from the manufacturer for dose reconstruction of those involved. The department is currently in contact with the licensee and will update this event as soon as more information is provided. PA Event Report ID No: PA200011
The following information was received via email: Manufacturer service technicians removed the wire/source from the afterloader on 5/6/2020. Preliminarily, it appears the source became stuck approximately 4 to 5 inches from the shielded park position (inside the afterloader, but outside the shielded safe). Dosimetry badges have been sent for emergency read, results are expected today, and those results are expected to be minimal. The patient and all personnel involved were surveyed after the incident and readings were at background levels. Notified R1DO (Dentel) and NMSS Event Notifications (email).
The following information was received via email: The preliminary dosimetry report indicates three staff members involved in the event. The technologist received 4 mrem whole body dose, the authorized user received 3 mrem whole body dose and the AMP received 3 mrem whole body dose and a 15 mrem dose on their finger dosimeter. No other dose information was received at this time. Notified R1DO (Lally) and NMSS Event Notifications (email). 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 54679 | 5 April 2020 04:00:00 | Agreement State | Agreement State Report - Stuck Shutter on Berthold Radioactive Gauge | The following information was received from the Commonwealth of Pennsylvania via email: On April 5, 2020, a technician reported to the (licensee radiation safety officer) RSO that when a shutter handle on a Berthold LB8010 with 20 mCi Cs-137 was moved to the closed position, the radiation survey indicated reduced radiation, but not the expected level. The shutter was opened and closed again, and radiation levels were lower but not at normal closed position levels. The gauge has been removed from service and is secured onsite in Canton, PA, awaiting a shipping container for return to the manufacturer. The gauge will be returned for repair or replacement. No personnel overexposure has occurred. The Department (Pennsylvania Department of Environmental Protection) will perform a reactive inspection. More information will be provided upon receipt. Pennsylvania Report ID No.: PA200008 | ||
| ENS 54641 | 3 April 2020 04:00:00 | Agreement State | Agreement State Report - Patient Underdose | The following was received from the State of Pennsylvania via E-mail: The (PA DEP Bureau of Radiation Protection) Department received notification from a licensee on April 3, 2020 of a medical event involving Y-90 TheraSphere microspheres. The licensee believes a patient undergoing a multiple lobe injection of the liver received only 62.7 percent of the prescribed dose in one of the lobes. The second lobe is believed to have received the correct dose. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided. The Department will perform a reactive inspection as soon as possible. Pennsylvania Event Report ID No.: PA200007
The following was received from the State of Pennsylvania via E-mail: The patient was prescribed TheraSphere Y-90 Microspheres at 2.47 GBq total with 2.25 Gbq prescribed to the liver because of 9.1 percent lung shunt. The licensee reports total dose 1.536 GBq, and 1.4 GBq to liver. Ultimately only 62.7 percent (75.3 Gy) of the planned dose was able to be administered to segment 6 of the liver. While attempting to administer the Y-90 dose to treat a lesion in Segment 6 of the liver there was significant resistance to flow. The AU evaluated the microcatheter system to ensure that there were no kinks along the catheter course external to the patient or visualized internally under fluoroscopy. The licensee believes the issue came from blockage at or before the 'E' site on the labeled tubing of the administration set, given that when it was disconnected from the microcatheter at that location, they were able to successfully flush the catheter. The patient then had a subsequent segment 7 segmentectomy using tubing from a box set from a different lot number without incident. No adverse effects to the patient are anticipated and the patient and referring physician were notified the day of the event. Notified R1DO (Lilliendahl) and NMSS Events Notification via email. 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 54542 | 20 February 2020 05:00:00 | Agreement State | Agreement State Report - Gauge Failure | The following report was received via email from the Commonwealth of Pennsylvania: During an inspection on February 20, 2020, an above normal reading on a Cesium-137 level gauge source head was discovered. Radiation measurements ranged from approximately 15 to 45 millirem per hour at one foot from the back of the source holder cap. It should be noted this gauge is located 11.5 feet off the ground, in an area with no stationed personnel or foot traffic. The device is a Kayray Model 7062B level gauge (Serial No. 21462) containing 25 milliCuries of Cs-137. The licensee immediately removed the device from service, the area was secured to ensure background radiation levels, and the manufacturer was contacted to initiate either a repair or replacement of the gauge. The area will remain secured until the device is able to be put into service again. PA incident number: PA200005 | ||
| ENS 54497 | 29 January 2020 05:00:00 | Agreement State | Agreement State Report - Stolen Nuclear Density Gauge | The following was received from the Pennsylvania Bureau of Radiation Protection (the Department) via email: On January 29, 2020, the licensee informed the Department that one of their vehicles, with a nuclear density gauge in the trunk, was stolen earlier that day. The licensee has filed a police report. The Department has been in contact with the licensee and will update this event as soon as more information is provided. The gauge is a CPN International, Model MC-1 DR-P (Serial Number: M7077803), with a 10 mCi Cs-137 source and a 50 mCi Am-241/Be source. PA Event Report ID No.: PA200002
The following was received from the Pennsylvania Bureau of Radiation Protection (the Department) via email: At approximately 2250 EST on January 29, 2020 the licensee informed the Department the stolen car had been recovered with the gauge still padlocked in the trunk of the car and secured with a padlocked chain. The employee had started his car and then returned to his house to get his lunch, and the car was stolen during this time. Notified R1DO (Henrion), NMSS Events (email), ILTAB (email), and CNSC (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 | ||
| ENS 54448 | 13 December 2019 05:00:00 | Agreement State | EN Revision Imported Date : 1/10/2020 AGREEMENT STATE REPORT - HIGH DOSE RATE APPLICATOR DISLODGED The following was received from the PA Department Bureau of Radiation Protection (DEP) via fax: On December 16, 2019, the medical physicist for the licensee verbally reported that during an HDR (high dose rate) treatment using a Varian Model VariSource IX with a Tandem & Ovoid applicator, the applicator was found dislodged at the end of the treatment period. This was fraction 4 of 5 planned fractions. It is unknown at this time how long the applicator was not in the planned position or what caused it to move. The prescribed dose was 600 cGy from a 5.126 Ci Iridium-192 source. No further information is available at this time. The DEP will update this event as soon as more information is provided. Event Report ID No: PA190029 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.
The following information was received from the Agreement State via fax: The patient was seen on 12/27/2019, 12/30/2019, and 1/6/2020 for follow-up appointments. Observed skin effects were described as 'moist desquamation' due to the applicator being dislodged from the vaginal canal and positioned against the skin. The patient is being treated with Silvadene topical cream and will be followed up with regular skin checks. Based on the evidence observed, the licensee assumes that the applicator was against the skin long enough to deliver a skin dose in the range of 10-30 Gy. This dose makes the event a potential Abnormal Occurrence. The Department has performed a reactive inspection and continues to investigate the event. Notified R1DO (Schroeder) and NMSS group (via e-mail). | |||
| ENS 44286 | 11 June 2008 04:00:00 | Agreement State | Agreement State Report - Recovered Nuclear Material | The state provided this information via e-mail: It was reported today by (Pennsylvania Department of Radiation Protection) staff, that an orphan radioactive source was found in a lot of equipment and materials that had been acquired years prior from a bankrupt firm. The source is in Lake City, PA, and was inspected today for radionuclide identification, external exposure rates, and possible leakage. The source is in storage and appears to be in a shielded configuration (~ 3 mR/h contact with the device; background outside the storage area), no leakage was detected. (The source is contained in an industrial density gauge.) Information is still being gathered, but it apparently has been in storage for years. It was identified as a Cesium-137 source, activity noted as 100 millicuries (mCi) in 1979, thus, with a 30 year half-life, is now about 50 mCi. BRP is working with the owner and external agencies and organizations (i.e., NRC, DOE and CRCPD) to ensure the source remains secure, and, proper transfer and/or disposal is performed in a timely manner. There are also some records of prior ownership available, which may possibly assist in cost recovery with this abandoned 'generally licensed' (GL) source. An initial NRC 'NMED report' will be filed shortly.
The state provided this information via e-mail: Working with CRCPD, a health physics service provider was hired to take the Oakes Machine Corp density gauge. The cabinet was opened and a KayRay Model 7062P, Cs-137 source housing was found; serial # 7825. It contained an original activity of 100 mCi (May1978). CRCPD has arranged for transfer to another licensed firm, who will recycle or dispose of the source. BRP will submit a NMED report to NRC. Notified R1DO (Summers) and FSME (Mauer). |