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| Entered date | Event description | |
|---|---|---|
| ENS 56131 | 29 September 2022 15:24:00 | The following information was provided by the California Department of Public Health (CDPH) via email: Twining Inc. reported the theft of a Troxler model 3430 # 30952 portable soils gauge to the Sacramento CDPH office via California OES (Office of Emergency Services) on 9/8/22. The gauge contains two sealed sources: Cs-137, 0.30 GBq (8mCi) and Am-241/Be, 1.48 GBq (40mCi). The theft occurred around 2230 PDT on 9/6/2022, from the gauge operator's home. A police report was made to a deputy with the Riverside County Sheriff's office on the morning of 9/7/2022. The gauge had an airtag attached to it for tracking purposes. On 9/22/2022, Maurer Technical Services, who calibrates these types of soils gauges was contacted by a person who indicated he had this gauge. The caller's name, phone number and address in Riverside were obtained. Maurer Technical verified the gauge's serial number belonged to Twining, Inc. and their office was notified. Staff from Twining's Riverside office went to pick-up the gauge and it was transferred back to the Ventura office, where it was evaluated and leak tested on 9/25/2022 (found to be not leaking). The Riverside County Sheriff's office was informed that the gauge was recovered. Additionally, the Radiologic Health Branch was also notified that the stolen gauge had been recovered. On 9/29/2022, it was discovered that a supervisor at ICE RHB had received the initial notification from the CDPH duty officer, but due to competing demands, failed to forward the report to the RHB South office for follow-up action and reporting to the NRC. CA Event Number: 092222 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 54775 | 10 July 2020 20:18:00 | The following report was received from the State of California via email: On July 10, 2020, the Radiation Safety Officer for the University of California, Los Angeles, notified the Radiologic Health Branch of a Medical Event that occurred with a Varian High Dose Afterloader with an Ir-192 source during an ovarian cancer treatment. The prescribed dose to the intended organ was 24 Gray (2400 rad). Due to an incorrect entry of the catheter length into the treatment delivery system, an unintended dose of 21.8 Gray (2180 rad) was estimated to have been delivered to the large bowel. The dose delivered to the intended organ was initially estimated at 0 Gray (0 rad). The patient and the patient's physician were notified. The licensee's investigation into this medical event is ongoing and will be reviewed further by the California Department of Public Health California 5010 report no: 071020 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 52259 | 23 September 2016 17:57:00 | The following report was received from the California Department of Public Health via email: On September 23, 2016, the Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event. A patient was treated with Nordion TheraSpheres containing yttrium-90 (Y-90) on September 22, 2016. The prescribed dose was 100 gray (Gy) to the left lobe of the liver. Upon completing the dose assessment after the treatment, it was discovered that only approximately 50 percent of the intended dosage of Y-90 was delivered to the patient (left lobe of the liver). The remainder of the Y-90 dosage appears to have remained in the delivery system, primarily in the system waste container. The licensee performed surveys to confirm that the areas surrounding the delivery system and patient were not contaminated. The patient has been notified, and the licensee is investigating to determine the cause of the event. CA 5010 Number: 092316 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 51316 | 12 August 2015 20:20:00 | The following report was received by the State of California via email: On August 12, 2015, (the licensee's), Alternate Radiation Safety Officer, contacted the (State of California Radiologic Health Branch) Brea Radioactive Materials office to report lost Tritium (target sight) sources. After receipt at the (licensee) facility, 18 sources were no longer accountable in the inventory process. (The licensee) noted that, sometime between August 6 and August 10, the loss was discovered by one of the (licensee's) authorized users while performing an inventory of sources in the shipment to ensure that the proper number of sources were received. The lost sources were SRB Technologies, Inc. model AR Tritium (target sights) generally licensed sealed sources (these sources do not have serial numbers) with 0.8 Curies of tritium, for a total of 14.4 Curies. After the missing sources were discovered, SRB Technologies was contacted to determine the number of sources that were supposed to be contained in the package. When SRB Technologies personnel notified (licensee) that the package contained 36 sources, as listed in the included packing slip, (licensee) personnel conducted a search of the facility to find the sources. When the search did not find the missing sources, it was determined that the missing sources were likely to have been thrown away with the packaging in their trash bin, which had already been emptied on the morning of August 7, 2015. The Irvine facility of Waste Management was contacted to determine if it was possible to search the trash bin, but they were told that was not possible and the trash was most likely to have been dumped in a landfill. Once the investigation into the loss of sources was completed on August 12, 2015, the licensee determined the sources to be lost, most likely in a landfill. After the determination that the source were lost was made, (the licensee) then contacted the (State of California) Brea Office to make the official report. California 5010 Number: 081215 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 50669 | 11 December 2014 13:25:00 | The following information was obtained from the State of California via email: On December 10, 2014, the Assistant Radiation Safety Officer of Koury Geotechnical Services contacted the Radiologic Health Branch Brea office regarding a moisture density gauge that was run over by a construction vehicle at a construction site at 6500 Atlantic Avenue in Long Beach. The gauge was a CPN Model MC1-DRP gauge, S/N MD30901675 (10 mCi Cs-137, 50 mCi Am:Be-241). The gauge was in use as the Cs-137 source was extended approximately 8 inches in the soil at the time of the incident. The source rod has been damaged. The electrical body was also damaged but there was no evidence that the protective shield or the Am:Be-241source was damaged. The Long Beach Fire Department was notified and responded to the incident. Fire Department personnel did a visual inspection and radiation survey of the area and noted that the area was secured at least 50 feet from the gauge and noted that the dose rates at this boundary were at background. Long Beach Hazmat then arrived to take control of the area from the Fire Department. After assessing the situation they contacted Los Angeles County Radiation Management to assist in placing the sources in a safe condition. Thomas Gray and Associates (California materials license number 2105) was also contacted to assist in remediating the damaged gauge. The Health Physicist from Los Angeles County, with assistance from the Thomas Gray technician, was able to place the Cs-137 source into the shielded position and verified that the shutter block was in the proper position. A visual inspection of the body was performed and indicated that there was no damage to the shielding. Wipes were taken on the body of the gauge then tested using a survey meter with a geiger-mueller pancake probe. The wipes were at background indicating that the sources were not leaking. An MCA (multi-channel analyzer) was used to verify that both the Cs-137 and AmBe-241 sources were present. The gauge body was placed in the transport case along with the rest of the gauge parts then turned over to the Koury technician to take to Maurer Technical Services (California radioactive license 6163) to be shipped to the manufacturer so that it can be repaired or the sources recycled. The investigation is on-going and any citations will be determined at a later date. CA Report No.: 5010-121014 |
| ENS 50665 | 10 December 2014 15:11:00 | The following information was provided by the State of California via email: On December 9, 2014, the RSO (Radiation Safety Officer) of Geocon, Inc., contacted San Diego County Radiologic Health regarding a gauge that was run over and damaged at a temporary jobsite on December 8, 2014. ICE RAM-South (Inspection Compliance Enforcement Radioactive Material) was notified of the incident and an inspector contacted the RSO. The gauge, a Troxler model 3440, S/N 27309 (8 mCi Cs-137, 40 mCi Am:Be-241), was left unattended by the operator while talking with another worker when a loader ran over the gauge and struck the gauge handle. The damage to the gauge was to the electrical housing and the scalar rod (snapped into two pieces near the gauge body but remained attached at the handle). The Cs-137 source was locked in the shielded position just prior to the incident. The Cs-137 source remained in the shielded position and the source rod and the protective housing containing the Am:Be-241 source were intact after the incident. After the incident, the area was secured and the RSO was contacted. The RSO arrived at the scene and performed a radiation survey (make/model and type not reported). The RSO found that the dose rates were normal for a gauge out of the transport case (dose rate and background not reported). After inspecting the gauge, it was determined that the gauge could be placed in the transport case in its normal position. The RSO then surveyed the transport case and found that the dose rates were normal for a gauge in the transport case (not reported). The RSO was instructed to prepare a report of the incident to be submitted to our office within 30 days. The investigation is on-going and any citations will be determined at a later date. CA Report No: 120914 |
| ENS 49474 | 25 October 2013 21:21:00 | The following Agreement State Report was received via email: On October 25, 2013, at approximately 1430 (PDT), Fazel Barmaki, RSO (Radiation Safety Officer) of Fazel Barmaki, RML 7923-37, contacted (California Radiologic Health Branch) RHB Brea concerning their moisture/density gauge, CPN model MC-3, S/N M321106780 (with 10 mCi Cs-137 and 50 mCi Am-241/Be sources) that had been run over by an excavator and damaged while performing measurements at a construction site at 1186 N Ridgeline Rd., Orange, CA. A (California State) ICE RAM-South inspector arrived at the scene to assess the situation and to verify the integrity of the sources. The inspector observed the scene and was able to determine that the Cs-137 source was in the shielded position and the Am-241/Be source was still in the shielded housing. Wipe tests taken at the scene were surveyed and were found to be at background, indicating that the sources were not leaking. The rest of the gauge was inspected and it was observed that the hand and guide tube had broken off from the housing and the electronics were smashed and broken off of the gauge. Despite the damage to the non-radioactive parts, the shielding appeared to be undamaged, and the housing was placed in the transport case. A survey was performed on the transport case while using a Victoreen CHP-450. The highest dose rate on contact with the transport case was 1.8 mR/hr and 0.3 mR/hr at one foot, with a background of 0.01 mR/hr. These dose rates are consistent with a CPN MC-3 moisture density gauge. The RSO was interviewed by the (California State) inspector who stated that, between taking readings, he was observing the excavator as it was moving while standing near the gauge, making sure to maintain position between the excavator and gauge. While observing the excavator, the excavator made a sudden move toward him and he had to jump out of the way to prevent being run-over and the gauge was run over, causing the damage to the gauge. After checking on the damage, the RSO then immediately contacted RHB to report the incident. Since the radiation surveys indicated the dose rates were consistent with an intact and operational CPN MC-3 gauge and no leakage was indicated by an inspection of the integrity of the shielding and wipe tests at the scene of the incident, the RSO was allowed to return the gauge to their storage location at (in Escondido, CA.), for storage until the gauge can be sent to a service provider or CPN for repair or replacement. The (State's) investigation will be ongoing to determine if licensee will be cited. This is being reported to the NRC Operations Center as a 24 hour report under 10 CFR 30.5(b)(2) since the gauge cannot be locked in the shielded position (due to the source rod being sheared off from the gauge) despite the fact that the Cs-137 source is in the shielded position since it was in the shielded position at the time of the incident. California Report Number: 102513 |
| ENS 45626 | 12 January 2010 16:10:00 | On Saturday, January 9, 2010, the Radiation Safety Officer (RSO) of IESCO, LLC, contacted the California Office of Emergency Services to report that a Selenium 75 (27.5 Curies) industrial radiography source disconnected from the drive cable during radiography operations at the Chevron, El Segundo Refinery. During the first exposure, the source disconnected from the drive cable. This was discovered during the radiographer's confirmatory survey, as required after the source is cranked back in the shielded position. It was discovered that the source was disconnected near the collimator and when the drive cable was retracted, the source would slide back a couple of inches and the pigtail would be caught at a bend in the guide tube, allowing the source to be partially removed from the collimator. The radiographer placed lead shielding over the exposed source to minimize radiation exposure. The radiographer then contacted the RSO. Upon arrival at the site, the RSO disconnected the guide tube from the exposure device and then assessed the situation. He placed more lead shielding on the camera until the dose rate at 6 feet was at 20 Mr/hr. He returned the drive cable to the guide tube, reinserted the drive cable into the guide tube and removed the guide tube from the collimator. The RSO was then able to connect the drive cable to the pigtail and crank it back into the exposure device. The RSO stated that the reading taken from the Direct Reading Pocket Dosimeter (DRPD) of the radiographer was 9 Mr and the DRPD of the RSO was 25 Mr. After inspecting the equipment and interviewing the radiographer and assistant, the RSO concluded that the source disconnect occurred due to dirt on the shutter of the drive cable preventing the cover on the pigtail from closing, preventing a secure connection. The RSO has scheduled a safety meeting to ensure that the radiographers are aware of the issue and instructed how to avoid another incident. Further investigation will be deferred until the 30 day report has been submitted and reviewed. California Report No: 5010-010910 |