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| Entered date | Event description | |
|---|---|---|
| ENS 54315 | 7 October 2019 15:07:00 | The following was received from the Maryland Radiological Health Program via phone and email: On October 2, 2019, at 0825 EDT, the Maryland Department of the Environment Radiological Health Program (MDE-RHP) was contacted via telephone by the Vice President and Office Manager of Engineering Consulting Services Mid-Atlantic, LLC (ECS), Maryland license number MD-03-092-01, that a portable density gauge was missing. The gauge was identified as a Troxler model 3430, S/N 34485, with nominal activities of 10 mCi Cs-137 and 40 mCi Am-241/Be. The last leak test was performed on July 23, 2019. On October 1, 2019, at approximately 1200 EDT, ECS management started to track down the location of the portable density gauge as an internal audit revealed that this gauge was not signed out by the user. Later that afternoon, the gauge user was found at home by ECS management. The user then revealed that his vehicle was in a minor accident in Hanover, MD and the Anne Arundel County police impounded his vehicle with the gauge locked in the trunk. Multiple attempts were made to recover the portable gauge after hours on October 1, 2019 from the impoundment lot but without success. The gauge remained secured in the trunk of the vehicle while within the fenced and secured impoundment lot overnight. The Radiation Safety Officer from ECS recovered the portable density gauge at 0855 hours EDT on October 2, 2019. The gauge was found intact and returned to ECS storage. MDE/RHP will conduct a reactive investigation. Notified R1DO (Dentel), ILTAB and NMSS (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 54294 | 25 September 2019 16:09:00 | The following was received from the Maryland Radiological Health Program via phone and email: On September 23, 2019 at 1520 EDT, the Maryland Department of the Environment Radiological Health Program (MDE/RHP) was contacted via telephone by the Assistant Radiation Safety Officer (ARSO) of Geo-Technology Associates, Inc. that a portable density gauge was missing. The gauge was identified as a CPN model MC-1DR, serial number MD50707960 with nominal activities of 10 mCi of Cs-137 and 50 mCi of Am-241:Be. The last leak test was performed on April 11, 2019. On September 23, 2019 at approximately 1300 EDT, the density gauge was placed in the bed of a pick-up truck by the gauge operator after making measurements starting earlier in the morning for a residential development project known as Fields at Worthington. The area is located near the intersection of Baublitz Road and Worthington Ridge Road, Reisterstown, MD. Work was suspended due to equipment failure on the job site not related to the density gauge. The gauge operator proceeded to drive back to the licensee's office. After driving approximately 1.5 miles from the jobsite, the gauge operator realized that the gauge was not placed in its transportation case and pulled over near Knox Avenue. The gauge was missing from the bed of the pick-up truck. The tailgate was in the down position. The gauge operator called the ARSO at approximately 1330 EDT to report the missing gauge. The ARSO and the construction site manager looked for the gauge in the surrounding neighborhood with no success. The event has been reported to Baltimore County Police. The Case Number is: 192661514. MDE/RHP will conduct a reactive investigation.
The following was received from the Maryland Radiological Health Program via email: On November 2, 2020 at 1040 EST the Maryland Department of the Environment, Radiological Health Program (MDE/RHP) was contacted via telephone by the Assistant Radiation Safety Officer (ARSO) of Geo-Technology Associates, Inc. that the portable density gauge that was missing on September 23, 2019, at the area located near the intersection of Baublitz Road and Worthington Ridge Road, Reisterstown, Maryland was found, dropped at the Baltimore County Waste Central Acceptance Facility (BCWCAF) located at Cockeysville, in Maryland (10275 Beaver Dam Road, Cockeysville, Maryland 21030). The gauge was identified as a CPN model MC-1DR, serial number MD50707960 with nominal activities of 10 mCi of Cs-137 and 50 mCi of Am-241/Be. The rod above the gauge scale was bent and damaged but the source shutter at bottom was found closed and a leak test performed on the same day, November 2, 2020, reported no leakage. The gauge was transferred to an authorized service provider for disposal on November 2, 2020. Notified R1DO (Greives) and NMSS Event Notifications (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 54254 | 3 September 2019 14:36:00 | The following report was received from the Maryland Department of the Environment (MDE) Radiological Health Program (RHP) via email: On August 30, 2019, at 13:10 (EDT), the MDE-RHP was contacted by telephone by medical licensee, MedStar Franklin Square Medical Center nuclear medicine department (MD-05-032-01). An order had been placed by the medical center's Biomedical Department through eBay for a mobile lead shield for a Co-57 flood reference source. Upon receipt of the mobile shield, a Co-57 flood source was discovered inside. Only the mobile shield was ordered. The flood source was identified as an Eckert & Ziegler Feather Lite model MED3709 (S/N 159-062), 10 mCi as of June 1, 2011. The current activity was calculated to be 4.61 microCuries at time of receipt. The medical center's Radiation Safety Officer was notified. The sealed source was leak tested and evaluated using a Capintec Captus 3000 well counter with an efficiency of 37 percent. The leak test result was less than 0.005 microCuries. Eckert & Ziegler was contacted on August 30, 2019. The flood source was sold to Lower Oconne Community Hospital. The Co-57 flood source was originally shipped on April 20, 2011. The community hospital closed on February 14, 2014. The Georgia Radioactive Materials Program was contacted on August 30, 2019 at 1300 (EDT) with preliminary information concerning this sealed source. Georgia radioactive materials license No. 1389 for the community hospital was terminated June 2016. MDE-RHP will further investigate this incident. Eckert & Ziegler will provide a Return Kit for disposal. The source is currently secured in a waste storage room at MedStar Franklin Square Medical Center. 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 54225 | 16 August 2019 16:11:00 | The following was received from the State of Maryland via email: On August 14, 2019, at 1415 EDT, the Maryland Department of the Environment (MDE) Hazardous Materials Division contacted the MDE Radiological Health Program (RHP) concerning a vehicular accident in the south bound lane of State Route 4 near the intersection of Dower House Road, east of Forestville, MD. A Prince George's County HazMat responder contacted MDE/RHP at 1430 EDT to provide details of the accident. The initial transportation accident, as logged in at 1300 EDT, indicated the transport vehicle from Cardinal Health (MD-33-198-01) was transporting two cases of radiopharmaceuticals to two medical facilities in southern Maryland for its 'third run.' A tractor trailer collided with the rear of the transport vehicle at a controlled intersection just after the traffic light turned green. One case contained 3 lead pigs containing Tc-99m totaling 395.67 mCi. The second case contained 2 lead pigs containing Tc-99m totaling 106.90 mCi. The cases were originally marked as White 1, with a Transportation Index of 0. The cases remained fully blocked and braced following the accident. The containers were not compromised. Two senior pharmacist employees from Cardinal Health responded to the scene and took possession of the containers after carefully surveying the cases. The cases went on to be delivered to the intended destination. The Cardinal Health office in Dublin, OH called the National Response Center at 1627 (Incident Number 1255161) to report this accident. MDE was contacted at 1645. MDE will further investigate this incident. |
| ENS 54217 | 13 August 2019 16:15:00 | The following was received from the Maryland Department of the Environment Radiological Health Program (MDE RHP) via phone: On August 12, 2019, at approximately 1330 (EDT) hours, the Maryland Department of the Environment (MDE) Hazardous Waste Enforcement Division contacted the MDE Radiological Health Program (RHP) concerning a vehicular accident that involved a nuclear density gauge. The initial transportation accident, as logged in at 1300 hours, indicated the accident location near the 70-mile marker on west-bound I-70, near Lisbon, MD. The vehicle, identified as a box truck, was carrying a density gauge that was ejected during the accident. The gauge was observed not in its transportation case at time of arrival of Fire/EMS and Maryland State police. The company Radiation Safety Officer from Francis O. Day, Inc. responded to the scene and verified that the source was in the shielded position. The gauge was taken to Northeast Technical Services for evaluation. The gauge was identified as a Troxler model 4640 surface thin-layer gauge, S/N 2399. This gauge has a Cs-137 sealed source with a nominal activity of 8 mCi and was last leak tested on July 14, 2019. The State trooper on scene stated that the vehicle was actually a pickup truck. The transportation case was ejected from the pickup truck along with the truck cap and the driver. The gauge left the confines of the transportation case and came to rest approximately 10 feet from the case. The chain that held the case to the truck bed broke. The driver did not survive the accident. MDE/RHP will further investigate this event. |
| ENS 54171 | 17 July 2019 15:35:00 | The following information was received from the state of Maryland via email: On July 10, 2019, a health physics consultant contacted the Maryland Department of the Environment Radiological Health Program (MDE/RHP) concerning a discovery during a routine audit conducted on July 10, 2019 at a licensed medical facility. A review of incoming Department of Transportation wipe/survey listing reports at the licensed facility (St. Agnes Hospital in Baltimore, MD) indicated that two packages received on June 12, 2019 from the radiopharmacy had high wipe test values recorded at 400,000 dpm per 100 cm2. These values were documented for surface and contents of the packages. Both packages were labeled as White I and had no abnormal outer package surface exposure rate readings. The computer record contained a note stating that, 'dpm verified and Cardinal (Health) notified. Case stored for decay.' The technologists did not notify the Radiation Safety Officer or MDE/RHP. The cases were opened, the doses unpacked, and used. The computer record indicated good condition for each box. One box contained one syringe of Tc-99m Ceretec at 17.25 mCi. The other box contained one vial of Tc-99m sodium pertechnetate at 104.22 mCi, one syringe of Tc-99m macro aggregated albumin at 10.61 mCi, and one syringe Tc-99m Sestamibi at 30.41 mCi. A reactive inspection is planned (by the state of Maryland). Cardinal Health was the radiopharmaceutical provider. The delivery vehicle and the driver were both surveyed on June 12, 2019, with negative results. No other contaminations or any overexposures were identified when the hospital performed surveys of the facility. |
| ENS 53773 | 4 December 2018 15:53:00 | The following was received from the Maryland Department of the Environment via phone: On November 29, 2018, at approximately 2230 EST, an unidentified citizen contacted the Prince William, VA police department stating they observed a suspicious person throw a yellow box out of their vehicle and then exit the commuter parking lot at 12745 Minnieville Road, Woodbridge, VA 22192. The response was coordinated by the Virginia Emergency Response Center and Hazardous Materials Office. The responding officer located the yellow case having a radiation warning label affixed and his PRD (Personal Radiation Detector) (indicated that) a radiation source (was) present. The Virginia Department of Fire and Rescue, Virginia Department of Transportation, Virginia Department of Emergency Management, Virginia State Police, and the FBI responded. Spectral analysis identified Cs-137 with readings of approximately 1.5 mR/hr on contact with the case; typical for a Troxler gauge. The outside lock on the case was cut; a Troxler 3430 gauge with shipping papers were present. The trigger lock was in place. The Virginia Department of Health (VDH) did not have the facilities or capability to take possession of the gauge. The gauge was secured in the Hazardous Materials officer's (HMO) vehicle until other arrangements could be made. On November 30, 2018, at approximately 0930 EST, VDH contacted the lead Prince William County HMO and was told that there was information contained in the shipping container with the gauge that identified the owner. VDH received that information at approximately 1000 EST and determined the owner of the gauge to be a Maryland licensee (Kim Engineering). At approximately 1020 EST, the Director of the Virginia Radioactive Materials Program contacted the Maryland Radiological Health Program (RHP) concerning a recovery of a Troxler gauge at a Virginia Department of Transportation park-and-ride. The device was identified as a model 3430, S/N 67880 having an 8 mCi Cs-137 source (5/14/2013), S/N 77-12674, and a (40mCi) Am-241/Be source, S/N 78-8664. The device was last leak tested on 6/22/2018. An official of the Maryland RHP volunteered to drive to Prince William County, VA to retrieve the gauge. Arrangements were (made with) the Maryland official to meet with the Prince William County HMO. At approximately 1315 EST, the State of Maryland official contacted the VDH to confirm transfer of possession of the Troxler gauge to transport it back to Maryland. The Maryland official informed VDH that the licensee notified RHP that someone had stolen a Troxler gauge from the licensee. Maryland agreed to notify the US NRC Operations Center of this incident. Maryland has scheduled a reactive inspection of the licensee to determine the root cause of the loss or theft.
The following is a summary of the additional information was provided by the Maryland Department of the Environment via email: The activity for the Am/Be source, Serial Number: 78-8664, was tested on 6/22/2018 and was less than 185 Bq (0.005 microCuries). Notified R1DO (Lally), ILTAB (Allston - via email), NMSS_events (via 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 53208 | 13 February 2018 16:00:00 | The following report was received from the Maryland Department of the Environment Radiological Health Program via email: On February 8, 2018, the Maryland Department of the Environment - Radiological Health Program was contacted by Johns Hopkins Medical Institution (MD-07-005-03) of an incident in which one researcher had received a total effective dose equivalent exceeding 5 Rem and likely an extremity dose exceeding 50 Rem. The licensee received results of a researcher's 4th quarter 2017 radiation badge readings. The researcher was conducting tracer studies using PET isotopes C-11 and F-18 in animals. The researcher has been monitored since February 2012 and has frequently used F-18 in similar studies with no problems. Use of PET isotopes in the lab has been halted pending an investigation by the licensee. The Maryland Radiological Health Program will schedule a reactive investigation. The result of the whole-body radiation badge readings (monitoring period Oct 1 - Dec 31, 2017) was: Deep Dose: 12,818 milliRem
Lens of the Eye: 28,280 milliRem
Shallow Dose: 46,206 milliRem
Beta Dose: 33,388 milliRem
The researcher's assigned extremity ring badge was not worn during the 4th quarter of 2017. The licensee will submit a written report as required within 30 days. |
| ENS 53001 | 6 October 2017 13:11:00 | On October 5, 2017, Johns Hopkins Outpatient Center, notified the Maryland Radiological Health Program (RHP) that on October 5, 2017, following a prostate seed implant procedure, the licensee discovered that one (1) seed was unaccounted for. The Pd-103 seed has an activity of approximately 1.5 milliCuries. The number of seeds implanted into the patient was 42 out of 47 seeds ordered. Four (4) seeds remained in the applicator. This left one (1) seed unaccounted for. Two physicists counted 42 seeds implanted, verified on two separate C-arm images. All personnel were scanned with a sodium iodide survey meter as they exited the room. All equipment, tables, waste bags, surgical covers, linens, etc. were scanned multiple times. The floor was systematically and methodically scanned, including the patient's Foley bag, with negative results. The patient will return tomorrow (October 6, 2017) for a follow-up CT and chest x-ray. Radiation Oncology will re-count the seeds. Theragenics Corporation will also be contacted to determine if only 46 seeds were shipped. These seeds are received precalibrated and presterilized. A reactive inspection will be conducted to investigate this event. 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 |