Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 56948 | 5 February 2024 20:26:00 | The following is a summary of information received from the Tennessee Division of Radiological Health via email: A fire on a truck involving a super sack containing low level waste consisting mostly of personal protective equipment and other small items occurred on Interstate 40 in Nashville. The licensee believes there may have been batteries in the sack that could have caused the fire. With the fire out there were no airborne or exposure hazards associated with the material involved. The exposure rates at the trailer were approximately 15 microR/hr. The licensee has dispatched health physicists and a truck with overpack materials to re-pack the load for transport back to their facility in Oak Ridge. No personnel exposures were reported. Tennessee Event Report Identification Number: TN-24-015 National Response Center Incident Report Number: 1390886 |
| ENS 56903 | 20 December 2023 16:12:00 | The following report was received via email from the Tennessee Division of Radiological Health: During a scheduled 3-month shutter check, it was discovered that a gauge shutter was stuck in the open position. No abnormal levels of radiation were detected. The position was in a normal operating position. A vendor field technician has been contacted about the gauge which is an Ohmart/Vega gauge, model SHLG-1, with an isotope of cesium-137, 300 millicuries. Corrective actions as well as additional information will be updated with a NMED report within 30 days. Tennessee Event Report Number: TN-23-089 |
| ENS 56817 | 25 October 2023 17:38:00 | The following information was provided by the Tennessee Division of Radiological Health via email: During a scheduled 6-month shutter check, it was discovered that a gauge shutter was stuck in the open position. The technician took surveys to verify the shutter was stuck in the open position. No abnormal levels of radiation were detected. The position was a normal operating position. A VEGA field technician has been scheduled to arrive onsite on November 7, 2023, to service the gauge. Manufacturer: Ohmart/VEGA Source holder model: SHLM-CR Source serial number: 4259CO Isotope: Cs-137, 37 mCi Corrective actions or reports as well as additional information will be updated with a NMED report within 30 days. Tennessee Event Report ID Number: TN-23-079 |
| ENS 56407 | 10 March 2023 16:43:00 | The following information was provided by the Tennessee Division of Radiological Health via email: The misadministration occurred on 2/27/23 at Methodist Germantown Hospital in the interventional radiology (IR) suite. The procedure was a Y-90 treatment for 2 separate segments. Each segment had a different dose. All documentation and a checklist were appropriately filled out and the doses were documented. The physician was to the point in the procedure to ask for the first dose. The physician asked for the 'First Dose.' The dose was brought to the physician. The dose was verbally read out and (the physician) connected the dose and administered it. The result was a treatment of the small segment, but the large dose was given. Both segments were treated, but the doses were reversed. The doses of Y-90 were as follows: 1st Prescribed Dose 79.95 Gy, Dose Given 474.7 Gy 2nd Prescribed Dose 474.7 Gy, Dose Given 79.95 Gy Corrective actions will be sent with the follow-up NMED report. State Event Report ID NO.: TN-23-013 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 56305 | 10 January 2023 14:32:00 | The following information was provided by the Tennessee Division of Radiological Health via email: During a scheduled source disposal with a Berthold technician, a licensee staff member broke the handle off the gauge when trying to close the shutter. The technician took surveys to verify the shutter was stuck in the open position. The plan from the Berthold technician is to design lead plates to simulate a closed shutter for the device to be shipped offsite. Corrective actions or reports as well as additional information will be updated with an NMED report within 30 days. Manufacturer: Ohmart/Vega Model: SH-F1A-0 Model SN: 3368CN Isotope: Cs-137, 5 mCi State Event Report ID number: TN-23-001 |
| ENS 56224 | 16 November 2022 16:02:00 | The following report was received via email from the Tennessee Division of Radiological Health: Medical Physicist for Holston Valley Medical Center reported that a patient was mistakenly given all fractions of a cervical treatment on November 14, 2022. The patient was scheduled for five 600 centigray (cGy) fractions of Ir-192 for a total of 3000 cGy. The medical physicist misread the prescription and gave the full 3000 cGy in the initial dose. As of November 15, 2022, the patient had not been notified. However, the patient will be returning on November 16, 2022, for the next treatment. Corrective actions or reports will be updated with a report within 30 days." Tennessee Event Number: TN-22-069 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 56042 | 12 August 2022 15:39:00 | The following was reported by the State of Tennessee via email: During weekly checks on the device located on a kiln scrubber sump tank, it was discovered by a Vega (device manufacturer) technician that the shutter would not close on the device. The shutter is in the 'open' position, which is the normal operating position. The technician deemed it to be unrepairable in the field. The licensee is in contact with the manufacturer to have the device removed. Licensee estimates 2-3 weeks before a replacement can be ordered. The device information is as follows: Manufacturer: Ohmart/Vega Model: SH-F1 Isotope: Cs-137, 50 mCi Source Model: A-2102 (originally CDC 700) Source SN: 6648GK Corrective actions or reports will be updated with a report within 30 days." Tennessee State Event Report ID NO.: TN-22-059 |
| ENS 56025 | 1 August 2022 15:44:00 | The following summary was received from the Tennessee Division of Radiological Health via email: At 1015 CDT, on 7/31/2022, a truck containing a density gauge was stolen. The gauge was secured and locked in a company work truck near the 4600 Block of Summer Avenue in Memphis, TN. A report has been filed with Memphis Police Department. The gauge is a Instrotek 3500 Xplorer, (SN: 4492) with 40 milliCuries of Am-241 (Source SN: K481/21) and 10 milliCuries of Cs-137 (Source SN: BG1480). Corrective actions or reports will be updated with a report within 30 days. TN incident no.: TN-22-056 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 55913 | 24 May 2022 13:19:00 | The following was received from Tennessee Division of Radiological Health via email: On May 22, 2022 at 1048 (CDT), molten metal came into contact with the source holder. Damage occurred to the lifting ears of the gauge. The source was not affected by the event. The source and holder are locked away with other gauges with the shutter in the closed position. No elevated readings were detected after the event. NuCor Steel is going to contract with Radiometrix in Ohio to transfer the source to a new gauge. The following is the technical information on the gauge: Manufacturer: Berthold; Model: LB 300 MLT; Gauge SN: 45132-004-10003; Isotope: Co-60, 3.405 mCi; Source SN: 1344-08-09; Source Model: Berthold P 2608-100 Any corrective actions will be updated with a report within 30 days." State Event Report ID Number: TN-22-037 |
| ENS 55801 | 23 March 2022 19:22:00 | The following was received from the Tennessee Division of Radiological Health via email: An in-line fixed gauge was discovered to have a stuck shutter. Licensee attempted to use penetrating lubricant without success. Licensee has contacted VEGA field technician to attempt to unstick the shutter. If technician is unsuccessful, the plan is to immediately replace the gauge. The following is the technical information on the gauge: Manufacturer: Ohmart/Vega Model: SHF1 Gauge SN: (Will be sent with 30-day report) Isotope: Cs-137, 20 mCi (1993) Source SN: 9274GG Source Holder Model: SHF1-45 Corrective actions will be updated with a report within 30 days. State Event Report ID Number: TN-22-020 |
| ENS 55778 | 9 March 2022 10:47:00 | The following information was received from the Tennessee Division of Radiological Health: During a recent inventory at nine different locations of Service King Collision Repair Centers, 9 devices were found to be missing. The units were scheduled for disposal. Upon a search, all nine units were missing. According to company reports, the units were stolen from nine different locations. The nine units were used as static eliminators. It is believed that the static eliminators were stolen by staff. Updated information will be included in a follow-up report. The devices were all NRD model P-2021 containing 10 mCi of Po-210. Following are the license numbers and serial numbers of the devices: GL-1195 (Marysville, TN) / SN A2LU555 GL-1198 (Columbia, TN) / SN A2LV463 GL-1199 (Murfreesboro, TN) / SN A2LV464 GL-1200 (Cool Springs, TN) / SN A2LV465 GL-1201 (Jackson, TN) / SN A2LW322 GL-1202 (Bartlett, TN) / SN A2LW325 GL-1204 (Germantown, TN) / SN A2LW327 GL-1205 (Mt. Moriah, TN) / SN A2LW364 1 unregistered (Nashville, TN) / SN A2L2321 Tennessee Event Report ID No.: TN-22-017 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 55673 | 24 December 2021 14:32:00 | The following was received from the Tennessee Division of Radiological Health via email: A dozer ran over a density gauge at a construction site in Oneida, TN. Source was in the shielded position. Licensee was able to fit gauge back into the case and return to their facility. Corrective actions will be updated with a report within 30 days. The gauge contains a 40 mCi Am:Be-241 and an 8 mCi Cs-137 source. State Event Report ID Number: TN-21-120 |
| ENS 55647 | 15 December 2021 14:08:00 | The following was received from the Tennessee Division of Radiological Health via email: A Troxler model 3440 (SN 21556) was run over by a dump truck at a local construction site. Source is in the shielded position within the unit. Gauge is cordoned off from staff. However, the gauge is not operational. Corrective actions will be updated with a report within 30 days. The gauge contains a 40 mCi Am:Be-241 and a 8 mCi Cs-137 source. State Event Report ID Number: TN-21-116 |
| ENS 55650 | 15 December 2021 15:48:00 | The following was received from the Tennessee Division of Radiological Health via email: During the removal of I-125 seeds from a patient, only 22 of 23 seeds were recovered. No survey readings above background were discovered in the operating room. It was concluded that the seed was not present in the patient upon operating room entry. Exam rooms visited by the patient were checked and showed no readings above background levels. The seed is thought to have been lost during implant with surgical drape on 12/7/21. The seed information is as follows: Manufacturer: BEST Model: 2301 Isotope: I-125 Activity: 1.6 mCi Corrective actions will be updated with a report within 30 days. State Event Report ID Number: TN-21-117 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 55404 | 12 August 2021 14:54:00 | The following report was received from the state of Tennessee via email: Power loss site wide at Energy Solutions. Power was restarted by the utility. However, the power at the Radioactive Materials Solutions (RMS) building did not return. As a result, the ventilation system at the RMS building was not functional. The back up generator failed to function under load of ventilation fans. Currently, the RMS building operations have ceased due to loss of power. An area monitor is in place and showing no signs of elevated activity from air monitoring inside of the building. The contractor was contacted to reestablish power to site. Security patrols have been established to monitor quantities of concern. A follow-up report will be submitted to include corrective actions from the licensee." Tennessee Event Report Number: TN-21-082 |
| ENS 55271 | 22 May 2021 15:49:00 | The following was received from the Tennessee Division of Radiological Health via e-mail: During construction of a commercial business, a Troxler gauge was run over on May 21, 2021. The gauge is still in a shielded configuration and is being securely stored according to plans and procedures until the local field office can respond. The device information is listed below: Manufacturer: Troxler Model: 3440 Serial Number: 33760 Isotopes: Am-241 8 mCi Cs-137 40 mCi Activity Source Serial Number: Am-241 47-29413 Cs-137 750-8896 State Event Report ID Number: TN-21-058 |
| ENS 55100 | 9 February 2021 14:13:00 | The following event summary was received via e-mail from the Tennessee Division of Radiological Health: During a recent inventory at two different locations of Service King Collision Repair Centers, two devices were found to be missing. One location in Memphis, TN, lost the device during a management transition and inventory not being secured (GL-1202). The Antioch location (GL-1201) has a record from the manufacturer of a delivery to the wrong location. Service King is stating they have no proof of delivery and no record of the unit. Original shipment date was 1/20/20. The two units were used as static eliminators. Updated information will be included in a follow-up report. The information for the devices is below: Manufacturer Model Serial# Isotope Activity NRD, LLC P-2021 A2LW322 Po-210 10 mCi NRD, LLC P-2021 A2LW325 Po-210 10 mCi State Event Report ID No.: TN-21-019 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 54982 | 4 November 2020 12:25:00 | The following was received from the state of Tennessee via email: Licensee noticed on 11/2/2020 that a shutter was stuck open on a gauge. The position was confirmed on 11/3/2020. The licensee is in the process of reaching out to the manufacturer to determine the process for repair. The gauge is an Ohmart model SHD with a 50 mCi Cs-137 source (S/N: M-0720). Tennessee Incident Number: TN-20-165. |
| ENS 54949 | 15 October 2020 17:29:00 | The following was received from the state of Tennessee via email: General licensee, Blues City Brewery, reported the loss of 3 gauges after contractor work that involved the movement of the gauges. Blues City reported the loss. It is possible that the gauges could have made it into the local scrap metal stream. From the scrap metal facility, the load that might have included the gauges went to a shredding facility in Alabama. The State of Alabama Radiation Control has been notified in case gauges are discovered at the shredding facility. The gauge is below: Manufacturer Model SN Isotope Activity Industrial Dynamics CI-2GV/3 44 Am-241 300 mCi Industrial Dynamics CI-2GV/3 46 Am-241 300 mCi Industrial Dynamics FT-100 33 Am-241 100 mCi TN event number: TN-20-152
The following update was a summary of an email report received from the state of Mississippi concerning information pertaining to the lost gauges: On October 19, 2020, the Tennessee Division of Radiological Health contacted the Mississippi Division of Radiological Health and the Alabama Department of Public Health Radiation Control concerning three lost gauges from the Blues City Brewery facility. The facility believes the gauges were lost in the July-August timeframe during construction on some of their lines. Blues City Brewery told the contractor to take the gauges to a storage area, but the contractor moved the wrong parts allegedly to the scrap yard. The scrap metal/gauges are believed to have been brokered by an unknown entity and allegedly sent to Iskiwitz Metals at 604 Marble Ave, Memphis, TN 38107. The Tennessee Division of Radiological Health sent someone to look for the gauges and survey for them, but they only found the detector for part of one of the devices. From Iskiwitz, the metal was believed to be sent to a shredder in TN and a scrap yard in Mississippi named Martin Brothers Scrap Metal located at 690 Belmont Rd, Sardis, MS 38666, then allegedly to a smelter in Alabama. Soil samples were taken at the scrap yard in Mississippi, however, readings show only background radiation. The gauges have not been found. Mississippi Division of Radiological Health considers the event closed. Mississippi Event Number: MS-200004 Notified R1DO (Carfang), R4DO (Dixon), NMSS Events Notification (Email), ILTAB (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 54950 | 15 October 2020 17:17:00 | The following was received from the state of Tennessee via email: Energy Solutions experienced a fire in the gas furnace 'Drum Drying Operation' of the Liquid Volume Reduction Facility (LVRF) building, which is a sub building off of the Incinerator building located at the 1560 Bear Creek Road, (Oak Ridge, TN) facility. The drums being processed contained Energy Solutions secondary waste with the following listed source term associated with the containers: C-14 (0.5 mCi), Co-60 (2.2 mCi), Cs-137 (0.96 mCi), Fe-55 (2 mCi), H-3 (4 Ci), and Tc-99 (98 mCi). Estimated 0.03 mrem dose to the public as a result of the event. TN event number: TN-20-155 |
| ENS 54831 | 12 August 2020 10:57:00 | The following information was received from the state of Tennessee via email: An incident took place while processing a liner with water filters and Dry Active Waste (DAW) in it during filter shredding operation in the Filter Shredding area of the Radioactive Material Solutions (RMS) Building on site. The container contained mixed fission and activation products with Co-60 as a primary contaminant. A fire was observed in the steel Final Form Container (FFC) liner through the remote observation. The size of the fire was limited to the container itself. The FFC is a steel liner where the material accumulates and is contained in preparation for sealing for disposal. The filter processing room was accessed via a hatch and a crane was used to seal the FFC. The fire suppression system was activated to cool down the FFC liner. The Oak Ridge Fire Department responded to the site. Since the fire was contained to the FFC liner, the Oak Ridge Fire Department did not enter the building. The area radiation and air effluent stack monitors did not alarm. Samples from air samplers are being analyzed for airborne material. Staff that remained in the building will undergo a bioassay to assess for potential uptake. A follow-up report will be submitted within 30 days. TN Incident No.: TN-20-116 |
| ENS 54823 | 7 August 2020 16:59:00 | The following was received from the Tennessee Division of Radiological Health via email: On August 6, 2020, World Testing radiographers were radiographing at Matrix Drilling in Lewisburg, Tennessee. They were radiographing pipes and one of the pipes (weighing approximately 1000 pounds) rolled onto the guide tube, denting it. They could not crank the source back in. They called the RSO ((Radiation Safety Officer)). The guide tube was curled and making it more difficult to get the source back into the camera. They pulled on the crank to straighten out the guide tube and with enough pressure they were able to get the source past the dent and back into the exposure device. They placed lead on the collimator for additional shielding while working with it. The camera was a Sentinel, Model 880D, Serial number D-1120. The (Ir-192) source serial number was 96522G, with an activity of 44Ci. The source was exposed for approximately 4 hours. All personnel involved were wearing dosimetry. There were no overexposures. Tennessee Event Report ID No.: TN-20-114 |
| ENS 55082 | 22 January 2021 16:51:00 | The following was received from the Tennessee Division of Radiological Health via email: On February 24, 2020, an evaluation was conducted by Radiametrics Technologies and damage to the source holder was noted on (a Berthold model LB300MLT (device serial no: 45132-004-10009) containing 3.405 mCi of Co-60 (source serial no.: 1043-05-08)). The source holder was locked out of service with the shutter in a closed position. A source holder replacement and leak test were performed on December 2, 2020. TN Item No.: TN-20-044 |
| ENS 54683 | 28 April 2020 14:49:00 | The following information was obtained from the state of Tennessee via email: During a recent inventory at two different locations of Service King Collision Repair Centers, two static elimination devices were found to be missing. One location in Chattanooga, TN, lost the device during the transition of closing the repair center. Updated information will be included in a follow-up report. The information for the devices is below: Manufacturer Model Serial# Isotope Activity NRD, LLC P-2021 A2LV457 Po-210 10 mCi NRD, LLC P-2021 A2LU553 Po-210 10 mCi Tennessee Event Report ID No.: TN-20-076 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 54551 | 28 February 2020 10:17:00 | The following was received from the Tennessee Division of Radiological Health via email: During a recent inventory at Blues City Brewery, the environmental health and safety manager discovered that two devices (Industrial Dynamics CI-2GV/3) were missing. Devices had been out of use for 1 - 2 years. Actual activity (of the Am-241 sources) are unknown at this point. The activity will be reported during the follow-up report. Incident Report No.: TN-20-038 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 54395 | 20 November 2019 09:28:00 | The following information was received from the state of Tennessee via email: Patient treated with Lutathera (Lu-177 dotatate) on November 14, 2019. It was determined during her infusion that the Foley catheter was leaking. After the leak was identified, proper decontamination procedures were performed. The patient was instructed upon discharge that there was a chance for potential skin injury. Licensee reported that the estimated skin dose was 7 Gray (Gy). On November 18, 2019, the patient informed her provider that there was skin irritation in the peri-gluteal and peri-labia areas. It was determined that this was skin injury consistent with radiation injury. A follow-up report will be submitted upon receipt of a written report from the licensee. Tennessee Event Report ID No.: TN-19-161 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 54156 | 10 July 2019 15:08:00 | The following report was received from the State of Tennessee via email: On July 8, 2019, technicians at Eastman Chemical were performing procedures that involved securing radioactive sources on the outside of a vessel. One source had rust and corrosion around the shutter mechanism. After 4 hours with lubricant on the mechanism, the shutter was still inoperable. Eastman Chemical contacted the VEGA technician and scheduled a repair appointment for 7/12/19. Manufacturer: VEGA Model #: SHF1B Serial #: (Will be included in follow-up report) Source Serial #: 7386 CP Isotope: Cs-137 (20 mCi) "A follow-up report will be submitted within 30 days. TN Tracking Number: TN-19-090 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 Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9) |
| ENS 53709 | 1 November 2018 10:26:00 | The following information was obtained from the State of Tennessee via email: On 10/31/18, while performing radiography work in Nashville, TN, a radiographer working for World Testing noticed that his survey meter still had elevated readings and that the source had not successfully returned back to the camera. He attempted again to return the source but was unsuccessful. The (Radiation Safety Officer) RSO was notified. After responding and investigating, the RSO was able to retract the source back into the camera. The device information includes the following: Manufacturer: USA Global Model #: A424-9 Serial #: 9269 Source Serial #: 65744G Isotope: Ir-192 (20.1 Ci) A follow-up report will be submitted within 30 days. Tennessee State Event Report ID No.: TN-18-197 |
| ENS 53707 | 31 October 2018 15:57:00 | The following information was obtained from the State of Tennessee via email: On 10/31/18, the Tennessee Division of Radiological Health was contacted via phone by Ludlum Measurements RSO regarding the loss of a licensed source. It appears the source was last seen on 8/10/18. The licensee realized the source was missing on 8/13/18. The licensee has been searching for the source from 8/13/18 to date. The whereabouts of the source are still unknown at this time. Isotope and activity: Am-241, 1.057911 microCi Manufacturer: Eckert and Ziegler Model and Source Serial #: 1637-72-2 A follow-up report will be submitted within 30 days. Tennessee State Event Report ID No.: TN-18-195 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 53541 | 9 August 2018 16:25:00 | The following was received via email from the State of Tennessee Bionomics in Oak Ridge, Tennessee was contracted by a metal recycler in Arkansas to pick up some radioactive material that was rejected by a metals processor. Bionomics made the pickup on August 1st. Upon opening the shipment on August 8th they discovered an orphaned radium source. Current survey information indicates that a contact reading on the device is 22 mRem/hr. The information printed on the device is as follows: Manufacturer: MINE SAFETY APPLIANCES COMPANY Model: BILLION-AIRE ANALYZER Model #: 706P Serial #: 52328 Isotope: Ra-226 (150 microCi) (JULY 1966) (Calculated 147 microCi (August 2018)) A follow-up report will be submitted within 30 days.
The following information was received from the State of Tennessee via email: Bionomics in Oak Ridge, TN was contracted by Tenenbaum Recycling Group (TRG) in Harrison, Arkansas, to pick up some radioactive scrap metals. Bionomics made the pick up on August 1st. Prior to leaving the site, the technician discovered a radium source within the pile of scrap metal scheduled for pick-up. On August 8th, Arkansas was notified by Bionomics and in turn notified the State of TN that a radium device had been picked up and was currently in Oak Ridge, TN at the Bionomics facility. Current survey information indicates that a contact reading on the device is 22 mRem/hr. The information printed on the device is as follows: Manufacturer: MINE SAFETY APPLIANCES COMPANY Model: BILLION-AIRE ANALYZER Model #: 706P Serial #: 52328 Isotope: Ra-226 (150 microCi) A follow-up report will be submitted within 30 days." Tennessee Event Report ID NO.: TN-18-140 Notified the R1DO (Young) and NMSS Events Notifications 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 54003 | 16 April 2019 15:27:00 | The following report was received via e-mail: On January 11, 2018, FHL Industries, LLC, acquired Replogle Hardwood Flooring out of bankruptcy. The new owners were unaware of a generally licensed hazardous testing device from previous ownership. During a search of the facility during April 2018, FHL concluded the device was missing. FHL has no intentions of acquiring another radioactive testing device. Isotope and activity: Am-241, 0.03 mCi; Cm-244, 13.0 mCi Manufacturer: Asoma Instruments Model: 100 SN: 1537 Tennessee Event: TN-18-089 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 53311 | 3 April 2018 11:48:00 | The following information was received via E-mail: On 4/2/18, while conducting an inventory at Aladdin Temp-rite LLC, the licensee discovered that one of their generally licensed devices was missing. The device information includes the following: Manufacturer: Amersham Model: AMCP6 Model #: 103 Serial #: 11070 Isotope: Am-241 (150 mCi) A follow-up report will be submitted within 30 days. State Event Report ID No.: TN-18-064 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 53164 | 11 January 2018 12:05:00 | The following was provided from the State of Tennessee (TN) via email: The event occurred in the licensee's Metal Melt Facility (MMF). (The Radiation Safety Officer) RSO noted that a 4 inch by 4 inch section of a HEPA filter from the HEPA filter bank was missing. According to RSO, filter bank was pulling from area that has not been active since February 2017. Air effluent stack sampling and real time monitoring system did not indicate elevated radiation levels. The damaged filter was replaced. Licensee will forward investigation report to the TN Division of Radiological Health upon completion. Tennessee Event Report Number: TN-18-007 |
| ENS 52880 | 1 August 2017 10:28:00 | The following report was received from the Tennessee Department of Environmental Conservation Division of Radiological Health via email: (A) Yttrium-90 TheraSpheres patient procedure misadministration (occurred) due to (a) 'kinked' delivery catheter. (Approximately) 60 Gray (was) administered of (the) prescribed 120 Gray. (Two) manufacturer representatives were in attendance throughout procedure, 'proctoring' the physician. According to both proctors, the case was performed per manufacturer instructions, but unfortunately, the kinked catheter prohibited the complete dose from being administered. Tennessee Radiological Event No. TN-17-147 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 52277 | 4 October 2016 10:58:00 | The following was received by fax from the Tennessee Division of Radiological Health: While emptying a 55 gallon drum of lead for reuse into a B-12 box, unknown and unsuspected contamination levels in bottom of drum resulted in a contamination of the area to max levels of 2,000,000 dpm/100 cm2 beta. Contamination levels in drum determined to be 2,000,000 dpm/100 cm2 max post event. Pre job surveys identified no elevated contamination levels in top of drum. Isotope and activity are unknown at this time. Isotope is a weak pure beta emitter. Analysis is underway for isotopic determination. (Three) 3 persons with skin contamination were deconned. Bioassays are underway for internal dose assessment. Area is being recovered, however, not within 24 hours resulting in reporting of event. Dose assessments are forthcoming. State Event Report ID No.: TN-16-138 |
| ENS 52068 | 6 July 2016 16:48:00 | The following information was received from the State of Tennessee via email: A licensee reported a generally licensed device as missing. Further details will be reported as the information becomes available. The specifics on the device are as follows: Manufacturer- Industrial Dynamics, Model-FT-50B, Serial-113439, Isotope-Am-241, Activity-100 mCi. State Event Report ID No.: TN-16-098 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 51672 | 21 January 2016 16:23:00 | The following information was obtained from the State of Tennessee via email: On December 6, 2015 at approximately 1300 EST, an exposure device D6032, (880 Delta) containing Source S/N SE4869, 50 Ci of Se-75, fell from its position on top of a flange assembly approximately six feet to the finished floor. Upon impact, the guide tube was crimped preventing the source from being able to return to the camera. The source was able to be returned to the collimator reducing the radiation present. Technicians secured a true two mR boundary and notified plant safety personnel and the RSO. The lead technician onsite was source retrieval certified and took charge of the retrieval process. The source was further shielded in a larger diameter pipe and covered with sand bags to reduce radiation levels. Using a pair of pliers, the technician was able to 're-round' the guide tube opening to allow the source to be returned to the camera. The guide tube, camera and control assembly was taken out of service pending inspection. The guide tube was damaged beyond use; the source 'pigtail' and control cable were inspected and tested using a no-go gauge. The guide tube was removed from service and the control assembly will be sent to the manufacturer for further evaluation (ball end connector). Source retrieval technician received a total dose of 150 mR during the event. Tennessee Report No.: TN-16-012 |
| ENS 51541 | 16 November 2015 15:53:00 | The following was received from the State of Tennessee via email: On November 16, 2015, a neutron soil density and moisture gauge belonging to Terracon Consultants, Inc. was run over by a dump truck. The source was fully retracted at the time of the incident. Initial surveys have indicated that the source remained in the shielded position after the incident. A leak test has been taken and sent off for evaluation. The device was a CPN MCIDR (SN# MD40407363) with 50 mCi of Am-241 Be (Source #7363) and 10 mCi of Cs-137 (Source #7363). The licensee placed the device 'out of service'. On November 16, 2015, the device will remain in shielded storage until Terracon Consultants, Inc. decides what they are going to do with it. A follow-up report will be submitted upon receipt of further information. Tennessee State Event Report ID No: TN-15-168 |
| ENS 51540 | 16 November 2015 15:53:00 | The following was received from the State of Tennessee via email: A fire occurred in an off gas dust collector and particulate filtration system used for ventilation from a process providing oxidation of metal depleted uranium chips. Alarm engaged and fire suppression system engaged. The local fire department responded and reinforced suppression. The fire department departed by 11:20 AM. Initial indications indicate no releases to the environment based on visual indications and stack monitoring systems not alarming. Negative pressure to the building was maintained. Smears taken outside of the building and radiologically controlled area does not indicate any elevated activity outside of the building. Air samples are being pulled and analyzed for workplace and air effluent stacks. Bioassays were being conducted to assess worker and firemen. A follow-up report will be submitted upon receipt of further information. Tennessee State Event Report ID No: TN-15-167 |
| ENS 51539 | 16 November 2015 12:59:00 | The following was received from the State of Tennessee via email: On October 22, 2015, a radiography device belonging to TUV Rheinland Industrial Solutions failed to function properly due to a jammed selector ring; this occurred when the operator attempted to rotate from the connect to the lock position. The source was fully retracted at the time of the incident. The device was a Sentinel 880D (SN# D2620) with 29.4 Ci of Se-75 (Source #SE4627). The licensee placed the device 'out of service'. On October 26, 2015, the device was shipped back to QSA Global for repair. A follow-up report will be submitted upon receipt of further information. Tennessee State Event Report ID No: TN-15-166 |
| ENS 51419 | 23 September 2015 15:26:00 | The following report was received from the State of Tennessee via email: On September 21, 2015, a moisture density gauge, belonging to Professional Services Industries, was run over at the Memphis International Airport. No contamination was reported by the licensee. The rods were still attached and shutter was in the closed position. The gauge was a Troxler Model 3430 (S/N # 31540) containing an 8 mCi Cs-137 sealed source and a 40 mCi Am-241 source in the base of the gauge. The licensee is making arrangements with manufacturer to package and ship the device. A follow-up report will be submitted upon receipt of further information. Tennessee State Event Report ID NO: TN-15-144. |
| ENS 51315 | 12 August 2015 17:14:00 | On July 13, 2015, a load of residential waste set off the radiation alarm at Middlepoint Landfill, in Murfreesboro, TN. The load, originally thought to be personnel medical waste, was set aside to decay. (Tennessee Radiological Health) Division staff returned on July 16, 2015, with a Canberra Inspector 1000 (detector), for identification and to obtain a spectrum for analysis. After review, the material was determined to be Am-241. (Tennessee Radiological Health) Division staff returned to landfill on July 17, to search for item. Separated from residential waste, the item was found to be a NDC Model 100 series backscatter gauge, SN #11755. The activity on the label was 0.93 GBq (25 mCi). The gauge was transported to the (Tennessee Radiological Health) Division field office in a probe down position surrounded by lead bricks; this resulted in dose rate readings to nearest occupant at approximately background levels. The (Tennessee Radiological Health) Division staff monitored the gauge in route to the field office. Upon arrival, the gauge was surrounded by lead bricks and stored in an isolated area with a pre-arrival background level of 6 microR/hr dose rate. The post-arrival dose rate readings were 8 microR/hr. Under reciprocity, NDC Technologies personnel are scheduled to pack and remove the gauge on 8/13/2015, for return to the manufacturer. Tennessee State Event Report ID NO: TN-15-102 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 50612 | 14 November 2014 10:52:00 | The following report was received from the State of Tennessee via email: (Tennessee Department of Environment Conservation) TDEC was notified on 11/13/14, by a representative of (Toxco, Inc. d/b/a Toxco Materials Management Center) TMMC that a fire had occurred (at approximately 0900 EST) in an area in Building B where evaporation of liquid radioactive wastes was being conducted. Four employees attempted to extinguish the fire but were unsuccessful. The City of Oak Ridge fire department responded to the site and extinguished the fire. Four TMMC employees were sent to the local hospital for smoke inhalation related symptoms and are being evaluated for potential intake of radioactive materials. Air sampling of the building and area were performed during the event. The samples are being evaluated for results and consideration of potential impacts. (Tennessee) State inspectors are onsite investigating. The quantity of mixed fission product involved is unknown at this time. (Tennessee Department of Health) DRH inspectors are onsite and detailed information will be forthcoming. State Event Report ID NO: TN-14-211 |
| ENS 53179 | 22 January 2018 15:16:00 | The following was received via email: On 1/19/18, while conducting an inspection at (Roane Medical Center) RMC of a standard diagnostic nuclear medicine program with no written directive, an inspector identified, in review of facility dose records, evidence of an overexposure to a nuclear medicine technician of a dose of 118.425 Rem for period of January 20, 2014 to February 19, 2014. Investigation by the facility subsequently determined that the exposure was not likely a real exposure to the individual. However, facility failed to report the suspected overexposure. Dose was subsequently removed from the individual's dose history based on their investigation. State Event Report ID NO.: TN-18-012 |
| ENS 51727 | 11 February 2016 15:43:00 | The following historical information was received from the State of Tennessee via email: During a routine inspection, it was discovered through review of Toxco Radiological Occurrence Reports that Toxco had an event on June 17, 2013. In the Building A Supercompactor Room, a 55-gallon drum exploded due to an exothermic reaction. The cause was suspected to be the inadvertent packing of nitro-cellulous filters being placed in a waste drum of 3.7 mCi of I-125 contaminated personal protective equipment from Boston Heart Laboratory. The compactor was secured and no indication of radioactive material was discovered in the vicinity beyond the compaction cell. All personnel passed through a personnel contamination monitor without incident. The licensee performed a root-cause analysis determining that Boston Heart Laboratory had packed the nitro-cellulous filters into the waste containers. The licensee isolated two additional 55-gallon drums for return to Boston Heart Laboratory. State Event ID No.: TN-13-195 |
| ENS 51726 | 11 February 2016 15:43:00 | The following historical information was received from the State of Tennessee via email: On March 26, 2013, Kilgore Flares Company and the Division of Radiological Health (DRH) discovered that one of Kilgore's NRD Ionizer devices, model P-2035; S/N A2GK795, was lost. The device contained 40 mCi of Po-210. The device was shipped 10/09/08 from NRD, LLC, located in Grand Island, NY. It was taken out of service in October 2009 when Kilgore renewed the lease for the device. Kilgore was under the impression that the ionizer had been sent back to NRD the previous year. Kilgore did not learn until after the inventory list was sent to DRH February 4, 2013, that NRD had not received them. The device was searched for but could not be located. The boxes that contained the devices sat in the shipping department for some time and this is believed to be where the device came up missing. Kilgore reported that they now keep all devices, being sent back, in the Maintenance Planners office until sealed up for shipping. Kilgore provided a report to DRH on 4/2/13. State Event Report ID No.: TN-13-048 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 50304 | 24 July 2014 13:32:00 | The following was received from the Tennessee Division of Radiological Health via email: During a routine radioactive materials inspection of GEOServices LLC, a Tennessee Division of Radiological Health inspector found a portable moisture/density gauge, Troxler model 3401-B, containing Cs-137 (8 mCi) and Am-241/Be (40 mCi) that had been struck by a tractor at a construction site located somewhere in Knox County TN. The accident occurred in the month of December 2010. The RSO of GEOServices did not contact DRH about the accident. The RSO did not perform any surveys on the damaged moisture/density gauge. The RSO packaged the damaged moisture/density gauge and returned it to GEOServices' licensed storage location. Once the device was discovered by Tennessee Div. of Radiological Health, surveys were performed. Surveys indicated that the sources were not damaged and were not leaking. The device was packaged by the RSO and returned to Troxler for disposal." Tennessee Incident Number: TN-14-110 |