Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 52831 | 28 June 2017 09:49:00 | The following is excerpted from an email from the Maryland Department of the Environment: On 06/28/2017 at 7:15 EDT, the State project engineer (PE) reported that his project trailer had been broken into and a portable nuclear gauge (serial number 062051) was stolen. The equipment was kept stored, with a lock on the outside of the trailer and then locked inside the trailer. The gauge was stored locked in its carrying case. The gauge model number is Troxler 3440. The gauge contains an 8 mCi Cs-137 source and 40 mCi Am-241/Be source. Prince George's County Police Department was notified.
The following report was received via e-mail: The Maryland Department of the Environment (MDE) has reported that the portable nuclear gauge stolen on June 28, 2017 from a Maryland Department of Transportation, State Highway Administration (SHA) Project has been recovered. The gauge was apparently found abandoned on a residential property in District Heights, Maryland and recovered by Prince Georges County Police on July 4, 2017 with assistance from the Prince Georges County Fire/EMS Department's HAZMAT Division. The gauge was not damaged. Inspectors from the MDE's Air and Radiation Administration inspected the gauge, confirmed the device was not damaged and it was returned to the SHA Radiation Safety Officer on July 5, 2017. Notified the R1DO (Ferdas), ILTAB (Tucker), IRD (Grant), and NMSS Resources (via e-mail). 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 52613 | 16 March 2017 09:44:00 | The following report was received from the Maryland Radioactive Materials Division via email: This afternoon (3/15/17), our (Johns Hopkins University (JHU)) JL Shepherd Mark I irradiator malfunctioned. This is a manual model. The source is lifted up into position by a knob that lifts a rod attached to the source. When lifting the knob up, the rod became jammed. The rod is stuck in an up position, slightly past halfway. It will not move up or down. JL Shepherd was called for help. One suggestion was to move the knob slightly from side to side while lifting or lowering. This had no effect. Because this is a manual model not much can be done besides a repair by manufacturer. The technician (at JL Shepherd) said the most likely cause was due to some part (bearing, spring, etc.) falling down into transfer tube causing it to jam. The irradiator's power supply is controlled by computer and is off now. The door latch on the irradiator is locked. The alarming area radiation monitor on the irradiator door is on and functioning. The key to both the irradiator controller and the door latch have been removed from the irradiator room. The irradiator room is locked and monitored by corporate security and a Remote Monitoring System. The irradiator room is only accessible to approved individuals. Because this unit is a self-shielded irradiator, radiation levels outside the unit are minimal, <0.2 mR/hr) even with the source being partially exposed inside. There is no sample inside the chamber. There is no way to physically open the irradiator door due to an electric interlock. The interlock will not function without power and will not function without the rod in the fully down position. A sign has been put on the irradiator, 'Do Not Use'. JL Shepherd was scheduled to visit (the JHU) site to calibrate another irradiator in March. On Thursday we (JHU) will find out when we (JHU) can have a technician here to fix the problem. Source Make: J.L. Shepherd and Associates Source Model: 6810-G Source Serial #: 81Cs-S14 NSTS Source ID Number: 6729 Isotope: Cs-137 Activity: 5329 Ci Activity Date: 02/25/2017 MD Event Report ID No.: 52613 |
| ENS 51651 | 13 January 2016 16:24:00 | This is a preliminary notification by the State of Maryland, Radiological Health Program of a medical event. During both the first and second of four High Dose Rate brachytherapy treatments to one of the patient's lungs occurring on December 15, 2015 and December 21, 2015, the radioactive source was incorrectly placed between 2 and 3 centimeters away from the intended placement location. The radioactive source being used was Iridium 192. The activity level of the radioactive source is unknown at this time. The placement error was discovered during the third treatment on January 13, 2016. The reason for the placement error involved the use of an incorrect connection between the marker and the catheter. The State of Maryland, Radiological Health Program will conduct an investigation on January 18, 2016.
This updated licensee report was received from the State of Maryland via email: On January 12, 2016, while treating the third treatment fraction for an HDR patient with exuberant granulation tissue of the right lung lower lobe bronchus, we (the licensee) found out a discrepancy in our simulation imaging procedure which contributed to a geographic miss of approximately 4 cm. The geographic miss occurred for the patient's 1st and 2nd fractions on 12/15/2015 and 12/21/2015, respectively. The activity of the source was 6.9 Curies on 12/15/2015. In this procedure a dummy marker is normally sent into the catheter and radiographed to mark the dwell source position for treatment. It was found that in previous two treatments the dummy marker was not sent all the way through the catheter because it was used with an adapter piece on. The adapter piece was used with dummy markers in the previous microSelectron afterloader but it is not supposed to be used with the Flexitron afterloader system that we have been upgraded to since August 2014. The patient was treated correctly on 1/12/2016, however, the Radiation Oncologist is stating that no harm was done to the patient from the geographical miss in last two treatments. Since we reported this case to the State (Maryland Department of the Environment) on Wednesday 1/13/2016, we have found two more patients treated with intrabronchial HDR since the upgrade to Flexitron at this center that may have had a geographic miss. Investigation is still under way for these cases. Notified the R1DO (Gray) 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 50770 | 27 January 2015 14:49:00 | The following report was received from the State of Maryland via email: On 1/27/15 at 0830 EST, (Maryland Department of the Environment (MDEP) personnel) discussed preliminary findings (with the licensee) regarding an alleged medical misadministration at the Cancer Center at Gaithersburg with the Medical Physicist and RSO (Radiation Safety Officer). The initial notification came to (the Maryland) RHP (Radiological Health Program) on 1/26/15 at 1600 EST. The incident occurred on 1/26/15 at about 1430 EST at the licensees address at 808 West Diamond Avenue, Gaithersburg, Maryland 20878. The incident involved a skin cancer therapy treatment to the bridge of the nose to a female patient with a Elekta/Nucletron HDR (High Dose Rate). The licensee has done previous skin treatments but this was the first skin treatment performed at the bridge of the nose. (The Licensee) stated no history of previous medical incidents. The written directive was for 3900 centiGray to be delivered over 6 fractions. The first fraction was intended to be 650 centiGray, but the licensee administered 1300 centiGray. Preliminary discussion of root cause indicated that the patient was not fully conscious and in distress with the use of a 3 centimeter diameter applicator and a decision was made to change the applicator size to 2 centimeters. The treatment plan initially determined for the 3 centimeter diameter applicator was mistakenly added to the treatment plan determined for the 2 centimeter applicator. The Medical Physicist says there is no dialog warning on the software to indicate that an addition will occur. The licensee stated that the husband of the patient has been notified. Potential future erythema of the patient skin will be followed. Present at the therapy - Oncologist, Medical Physicist, and Therapist. (The Medical Physicist) stated that the licensee will re-examine all quality assurance oversight for HDR therapies. Preliminary consideration for corrective actions: All new treatment plans will be given new identities (and) the licensee will explore ways to delete previous treatment plans. The licensee is working to have the written report to RHP prior to end of the 1/27/15 business day. (The Medical Physicist) was informed that RHP will investigate the incident. 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 provided by the State of Maryland via email: The female patients age is 67 and the Elekta/Nucletron HDR Model is 105.002 Microselectron 3. The activity of the source is approximately 5.2 Ci. Notified the R1DO (Cahill) by phone and NMSS Events Notification (Email).
This event is retracted because the dose delivered matched the written directive. Due to a software error, the dose was reported as double the actual dose. The patient, doctor and NMED have been notified. Notified the R1DO (Jackson) and NMSS Events Resource (via e-mail) |
| ENS 49986 | 2 April 2014 14:25:00 | The following information was received from the State of Maryland via email: This is a synopsis of an I-125 seed breaking during an implant procedure at GBMC (Greater Baltimore Medical Center). We (GMBC) will be meeting as a team to discuss corrective action and how to avoid something like this happening again. An I-125 implant was performed at GBMC Hospital on Tuesday, April 1, 2014. 78 Bard I-125 seeds, activity 0.319 mCi/seed, were ordered for the procedure, 71 seeds were used, and 70 seeds were confirmed after the procedure on CT evaluation in Radiation Oncology. The unused seeds (7.5 seeds) were returned to Radiation Oncology and recorded as per policy and procedure. The chief physicist and dosimetrist were called to Cysto at approximately 0900 EDT when the case was completed to (the attending physician's) satisfaction. Upon entry of the Cysto room (the attending physician) informed the physics staff that a seed had jammed in the Mick applicator and he had to use force to continue and complete the case. On arrival, the physics staff surveyed the patient 1 meter above the umbilicus and found 1.7 mR/hr reading using Model 14C Geiger counter (Serial number 167038, Calibration date 1/30/14). The patient was removed from the OR and sent to recovery room. Upon additional survey of the room, it was discovered that a seed was fractured, when a portion of the seed was found on the sterile table. At that time, a thorough and complete area survey was performed. The reading was found to be 1.2 mR/hour on the table, trash, and blood drain. (A staff member) was called to bring an additional survey meter (Model 3 Geiger counter Serial number 39484, Calibration date 4/29/13). All contaminated items were collected for proper storage in the hot lab in Radiation Oncology. All staff and personnel involved in the case were thoroughly monitored and cleared using 14C Geiger counter (Serial number 167038, Calibration date 1/30/14). After the removal of the contaminated items the Cysto room was thoroughly monitored and clear of radiation contamination. The patient was then brought down to the Radiation Oncology department where a CT scan was performed to ensure seed count. VeriSeed program was used to confirm that the patient was implanted with 70 seeds. (The Chief Medical Physicist) contacted Bard to discuss the shattered seed. It was suggested that radiation oncology staff be monitored for thyroid uptake. Bioassay studies were thereby performed and the results were found to match background readings. On Wednesday, April 2, 2014, the patient's recovery area was scanned using Model 3 Geiger counter Serial number 39484, Calibration date 4/29/13. A reading of 300 CPM was recorded. The background was also recorded to be 300 CPM. |
| ENS 49635 | 16 December 2013 15:12:00 | The following information was obtained from the State of Maryland via email: At 12:17 PM on December 16, 2013, the Radiation Safety Officer of Maryland Q.C. Laboratories, called (the State of Maryland) to report an incident that occurred today in their radiography vault. She reported that they were performing industrial radiography using a 34.7 Ci Ir-192 source, QSA model A424-9 in a model 880 D camera, when a steel pipe fell on the guide tube preventing the source from retracting into the shielded position. She stated that attempts to retract the source were not successful. She further stated that QSA Global will arrive at the licensed facility tomorrow to recover the source. The source is in a tungsten collimator inside the vault. The assistant radiographer reported 10 mRem on his SRD. For security, Maryland Q.C. locked the door to the vault and will post a 2-man crew at the facility until QSA arrives. Maryland Health Physicist Bob Nelson is on site at this time conducting an investigation. He reports that the dose rates outside the vault are less than 1.0 mRem per hour. * * * UPDATE FROM ALAN JACOBSON TO CHARLES TEAL AT 0937 EST ON 12/17/13 * * * The Maryland Health Physicists conducting the investigation at Maryland QC Laboratories reported on 12/17/2013 at 0930 hours that the source has been safely retrieved and stored in the camera. Notified R1DO (Dimitriadis) and FSME Events Resource via email. |
| ENS 48346 | 26 September 2012 12:56:00 | A Troxler model 3411B moisture density gauge was run over by a front end loader at a construction site in Silver Spring, MD. The area was roped off and the Radiation Safety Officer and the Maryland State Inspector were able to verify that though the control rods were detached, the sources had remained in their shielded positions. The damaged gauge was placed in the transport case and will be taken to a licensed repair facility. This model gauge typically has a 9 mCi Cs-137 and a 44 mCi Am-241:Be source. |
| ENS 47555 | 28 December 2011 12:05:00 | Per the general license requirements stipulated in 10 CFR 31.5 (5), this letter is being sent to report a damaged Forever Lite model SLXTU1GB20 self-illuminating exit sign and the loss of one of its elements. The exit sign is owned by the Johns Hopkins University Applied Physics Laboratory (JHU/APL) and is possessed under a general license issued by the Nuclear Regulatory Commission (NRC). The general license requires the NRC to be notified of any damaged devices. A verbal notification was made to MDE (Maryland Department of the Environment) in a phone call on December 6, 2001 at 1:45 PM. It has been determined that the damaged sign was removed from its mounted location during the demolition phase of a renovation project in Building 13 that started in May 2011. However, it along with three other signs from that project were not brought to JHU/APL's Hazardous Waste Accumulation Site (Building 10A) until Friday, December 2, 2011. The damaged sign was identified Monday, December 5, 2011 at 2:15 PM. It appears that the sign was damaged during removal from its mounted location and the missing element, along with the outer frame, was disposed of in the construction debris earlier this summer. The total estimated tritium activity contained within the missing element is approximately 640 mCi of which about 90% (576 mCi) may be in the form of tritium gas and about 10% (64 mCi) may be in the form of tritiated water vapor. Contamination monitoring did not reveal any tritium contamination. This could be an indication that the tube did not break during the removal of the sign nor when it was caught up in the construction debris. Bioassay sampling of the potentially exposed personnel is unfortunately not possible due to the amount of time that has transpired since the removal of the sign (the most likely time when an exposure could have occurred). However, the possibility of an exposure is extremely unlikely since there is no indication of a broken element. In addition, the nature of a construction work environment and the use of personal protective equipment (work gloves, eyewear, ...) also minimizes the possibility of inhalation, ingestion and puncture wounds which are potential tritium exposure pathways from a broken element. The damaged sign has been doubly sealed in plastic bags and is stored in JHU/APL's Hazardous Waste Accumulation Site awaiting proper disposal. JHU/APL improved its control and oversight of the self-illuminating exit sign after the last damaged sign that was found in June 2007. Based on the current investigation, the following improvements will be made to improve JHU/APL control and accountability of the generally licensed exit signs: --Annual refresher training with revised self-illuminating exit sign handling and control procedures will be provided to all JHU/APL Technical Service Department (TSD) personnel. This will help ensure a greater awareness, particularly among managers and supervisors, of the handling and control requirements. Training up to this point has been provided to maintenance personnel, electricians and others on an as needed basis. --The training will place particular emphasis on the care required to remove these signs and the need to bring them to JHU/APL's Hazardous Waste Accumulation Site in a timely manner. --For better documentation of which signs are being turned in for disposal, a log will be maintained that documents such things as make, model serial number, former mount location (Bldg, Floor ...), person disposing the sign, date disposed, and the general condition of the sign. 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 This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| ENS 46252 | 15 September 2010 10:21:00 | The following report was obtained from the State of Maryland via e-mail: As follow-up to a telephone discussion (on the) afternoon of Sept. 14, 2010 at 1445, (the RSO sent the State of Maryland) this email as a written notification of a presumed lost sealed source containing radioactive material. The telephone notification and this email serve (as) compliance with Section D.1201a, which requires an immediate report of a theft or loss of a source of radiation. The sealed source in question contains Germanium-68, a nuclide of half-life 271 days. This nuclide decays to Gallium-68, which itself then decays (with positron emission) with a half-life of 68 minutes to stable Zinc-68. The annihilation radiation from the positron emission is used for PET scanner quality assurance, as in the case of this source. This sealed source originally contained 500 microCi of Ge-68 on March 1, 2000. The contained activity of the lost source has been computed to be 0.03 microCi (59000 dpm) as of the date of this notice. The exposure rate of a 1 microCi point (unsealed) source is 5.4 mR/hr at 1 cm; therefore, the exposure rate estimated for this sealed line source at 0.03 microCi is about 0.1 to 0.2 mR/hr at 1 cm. A description of the physical source is (as follows). The source was manufactured by IPL (product code HEGL-0109) and is 6 inches in length and 1/8 inches in diameter with steel encapsulation. The source had been stored and not used (due to low activity), and was last inventoried (and leak-tested) on July 22, 2010. An investigation is currently underway to determine the disposition of this source, and will be submitted to the MDE RHP (Maryland Department of the Environment, Radiological Health Program) per D.1201b within thirty days of this notice. The State of Maryland will be conducting a follow-up investigation. 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 44898 | 12 March 2009 08:55:00 | This report is in reference to a lost 13 (inch) Nuclestat ionizer bar that contains Polonium-210. The model number is P-2001-012, and the serial number is A2FS026. (The licensee) entered into a lease agreement for 13 ionizer bars, 2 Nuclecel in-line ionizers, and 1 Nuclecel ion air blower with NRD, LLC to minimize the amount of static present in our operation. On Friday, March 6, 2009, it was reported by (the licensee's) Maintenance Department that an ionizer bar was missing from Winder #23. They were in the process of removing all of the ionizer bars from the winders to return them to NRD, LLC. The security cable was found attached to the winder, but it appeared someone had unscrewed the ionizer bar. All bars were attached to the end of the plastic winders with a steel cable and two screws. Upon investigation, (a licensee representative) found (that) the operators (remembered) the ionizer bar (being) present the week of February 23 - 27th on Winder #23, but they (did) not remember seeing the ionizer bar when (they) returned from a two day shutdown on Wednesday, March 4, 2009. After learning (that) the ionizer bar was missing on March 6th, the Plastic Winding Department was shutdown in the afternoon to search for it. About 15 employees searched the entire building including the trash and the building next door that contains old equipment. On Monday, March 9, 2009, the trash from the trash compactor was dumped in the parking lot, and the department searched through it for the missing ionizer bar. Once it was determined the ionizer bar was still missing, (a licensee representative) reported the lost device to (a State of Maryland representative) on March 9th. The remaining in-line ionizer bars, Nuclecel in-line ionizers and Nuclecel ion air blower will be returned to NRD, LLC to terminate our lease agreement. We will replace them with carbon bars and electronic air ionizers to reduce static in our operation. 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. |
| ENS 44364 | 25 July 2008 10:57:00 | On July 22, 2008, the State of Maryland was informed by the Teletherapy Operations Manager for Neutron Products, Inc. that one of their teletherapy service engineers performing an Alcyon Co-60 source exchange in Brazil had received a potential overexposure. During the source exchange, the engineer's electronic dosimeter alarmed. Immediate actions were taken to properly secure the source. Preliminary dosimetry readings for the service engineer indicated a potential whole body exposure of approximately 5,211 mrem and extremity reading at the right wrist exceeding 10R (off scale high). The service engineer's film badge was sent for immediate processing to Global Dosimetry with expected results available for evaluation by Thursday, 7/24. The results from Global Dosimetry for the service engineer prior to the incident are as follows: Monthly whole body (DDE, mrem) - 13,465 + 92 (Jan. - May) = 13,557 Left wrist (SDE, mrem) - 73,356 + 236 (Jan. - May) = 73,592 Right wrist (SDE, mrem) - 746 + 488 (Jan. - May) = 1,234 Brazilian regulatory personnel were onsite at the hospital at the time the incident occurred and were briefed within one (1) hour by the service engineer.
Per our telephone conversation of today (between the state and the licensee), this is to update our initial verbal and written Twenty-Four Hour Notifications made July 22, 2008 regarding the incident in Sao Paulo, Brazil, and to summarize our employee's written account thereof. On July 21, 2008 at approximately 6:20 pm EDT, Neutron Products employee #502, informed us via telephone that he may have received an over-exposure while performing a source exchange on an Alcyon II teletherapy unit located in Sao Paulo, Brazil. On July 21, 2008, employee #502 and a radiation worker from Brazil were in the process of transferring the expended cobalt-60 source from the Alcyon II unit into Neutron's transfer cask in accordance with Specification P-9, Appendix XI. After engaging the source holder with the removal tool, #502 transferred the source holder from the Alcyon II unit head into the transfer cask. Once the source holder was in the transfer cask, #502 continued making preparations to complete the removal sequence. Employee #502 had completed all the steps of the removal sequence and was in the process of removing the removal tool from the transfer cask, when it was determined by audible alarms and before the tool was completely out of the cask, that the cobalt-60 source was still connected to the end of the removal tool. At that point, #502 reinserted the removal tool back into the cask and repeated the steps again to make sure that the Source was disengaged from the removal tool. Once he was sure that the source was no longer attached to the removal tool, the tool was removed from the cask, and all the covers installed. The transfer cask now contains both the expended and new sources. Immediately after the container was secured, both men read their SRD's and reported their dose as follows: #502: WB-5,211 mrem, Left Wrist-300 mrem, and Right Wrist-off Scale (10R dosimeter); Brazilian Worker: WB-533 mrem, Left Wrist-off scale (10R dosimeter), and, Right Wrist-4,100 mrem. The TLD's were sent via FED-EX to Global Dosimetry Solutions in Irvine, CA, for emergency reading and the results are as follows: #502: Monthly WB DDE-13,465 mrem, Quarterly WB DDE-11,126 mrem, Left Wrist SDE-73,356 mrem, and Right Wrist SDE-746 mrem. Brazilian Worker: Monthly WB DDE-702 mrem, Quarterly WB DDE-1,559 mrem, Left Wrist SDE-3,030 mrem, and Right Wrist SDE-8,542 mrem. Employee #502 will be returning home sometime this weekend. He will not be involved in any radiation work for the remainder of the year. Notified R1DO (Trapp) and FSME (M. Burgess) |