Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 44136 | 14 April 2008 10:02:00 | The State provided the following information via email: DRH (Mississippi Division of Radiological Health) received a phone call from Cardinal Health RSO on 4-9-08 about a transportation accident involving one of their transport vehicles and an 18 wheeler on Hwy 49 South near Tchula, MS. The accident happened around 7:00 AM. The Cardinal driver had already made his deliveries to the facilities and only had the return packages (used doses) from the day before. According to RSO, driver hit the rear of the 18 wheeler after he made a sudden stop on the highway. According to RSO, all packages stayed secured and braced and their was no contamination or contents spilled out of the packages. Another driver was in route to location to pick up the other driver and the radioactive packages to return them to the Flowood facility. The material being transported was used doses of Tc-99m and there was no spillage or cleanup required. MS Report No. MS-493-01 |
| ENS 44137 | 14 April 2008 11:22:00 | The State provided the following information via email: On 3-26-08, licensee's RSO notified DRH (Mississippi Division of Radiation Health) of a Iridium-192 HDR treatment misadministration. The reportable event involves the administration of 3 separate fractions for one (1) patient over a six (6) day period. The misadministration was caused by not measuring the catheters. Measurements taken on 3-25-08 of the tandem and ovoid applicators connected to the Varion Varisource HDR indicated that the length of the source wire entered in the treatment planning system should be 128 cm instead of 120 cm. Further inspection of the catheters revealed that the ovoid catheters were correct but the tandem catheter should have been used with a different applicator. The error resulted in the dose being delivered approximately 86 mm inferior to the desired location. The prescribed treatment was for 5 fractional treatments for 600 cGy each (3000 cGy total); however, due to the error only 470 cGy was administered in 3 treatments (26% of the prescribed dose). It was noted during the investigation by DRH that for other problems not associated with the HDR treatments, the patient did not return for the final 2 fractional doses. The dose to the vaginal region inferior to the treatment area received a 1300 cGy overexposure as a result of the error. The Radiation Oncologist does not foresee this patient experiencing adverse health effects as a result of this misadministration. The referring physician and the patient have been notified. MS Report No. MS-08004 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 43570 | 15 August 2007 18:06:00 | The State provided the following information via email: DRH received notification on 8-15-07 from the Washington Dept. of Health, about the possibility of two (2) Industrial Dynamic Models FT-12 (Device Serial # 101942/Source # 318) and FT-50 (Device Serial No. 116158/Source # 3109) each containing 100 millicuries of Americium 241, being (inadvertently) delivered to a company in Mississippi. Washington DOH asked MS DRH to assist. DRH sent inspectors to the Canton, Mississippi location and verified that the sources were in both devices. DRH called Washington DOH and reported that the devices were indeed at that location. DRH called contractor QSA Global for assistance with disposal. QSA will deal directly with company that shipped devices to Mississippi. DRH confirmed both sources were in (the) devices with survey measurements of 0.7 Mr/hr at (the) surface. Mississippi report number - MS 07003
The State provided the following information via email: The Americium sources (2 sources/100 millicuries each) in the Industrial Dynamic Filtec gauges were picked up for disposal by licensed contractor on 8-30-07. DRH will also notify State of Washington DOH about disposal of sources. R4DO (Nease) and FSME (McConnell) notified. |
| ENS 43129 | 29 January 2007 12:31:00 | Following Agreement State Report was received via e-mail Description of Incident: DRH received notification on 1-28-07 from Mississippi Emergency Management Agency (MEMA) about a Troxler Model 3411 M/D gauge, Serial # 9533, that had been reported stolen. The gauge belonged to Aquaterra Engineering. The RSO was contacted and he stated that the gauge had been locked in a tool box. The tool box was not big enough to put the shipping container in it also, so the shipping container was in the bed of the truck. The RSO stated that the lock was cut on the tool box allowing the gauge to be removed. He also stated that the gauge's source rod was locked. Issued press release on 1-29-07. Date of Incident: Sometime between 1-26-07 and 1-28-07 Isotope(s): Cesium-137, 8 millicuries; & Americium-241:Be, 40 millicuries. Describe clean-up actions taken by DRH: None required. List any other actions required of DRH: Licensee will be required to send a written report of stolen gauge within 30 days. List any actions taken to notify NRC, other Agreement States: Notified Meridian, MS, Police Department. Notified Lauderdale County Emergency Management. Notified NRC by E-mail. Notified Alabama Radiation Control by phone. Mississippi Department of Health issued press release. Case Closed: No Record of incident in RAM files: Yes Enforcement action taken: Investigation ongoing. Incident No. MS 07001
Gauge found on 2-5-07 by unidentified citizen in a garbage dumpster. Notified Meridian Police Department & DRH was contacted. DRH sent inspector to pick up device. Device was undamaged and still locked. DRH returned device to owner on 2-6-07. Describe clean-up actions taken by DRH: None required initially. After found device was retrieved by DRH so leak test could be done. No leakage or contamination detected. List radiation measurements taken by DRH: After found device was surveyed and determined normal readings @ 13 Mr/hr surface. List any other actions required of DRH: Licensee will be required to send a report of stolen gauge within 30 days. List any actions taken to notify NRC, other Agreement States: Notified Meridian, MS Police Department. Notified Lauderdale County Emergency Management. Notified NRC by E-mail. Notified Alabama Radiation Control by phone. Mississippi Department of Health issued press release 1-29-07. Case Closed: No 'Record of incident in RAM files: Yes Enforcement action taken: Investigation ongoing R4DO (Nease) & NMSS EO (Greg Morell) notified. E-mailed to ILTAB. 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 42858 | 25 September 2006 12:19:00 | The State provided the following information via email: The Division of Radiation Health (DRH) received notification on 9-22-06 from Mississippi Emergency Management Agency about a traffic accident that occurred at 6:00 AM on Highway 43 North of Picayune, MS. The vehicle was delivering radiopharmaceuticals to area hospitals and clinics. The road was wet due to rain and the driver lost control of vehicle and collided with 2 other vehicles. Several of the shipping containers were ejected from the vehicle and some of the contents were deposited outside the shipping containers. Local sheriff department and fire departments responded to the accident scene. DRH responded to the scene of the accident as well as Cardinal Health personnel. Cardinal Health personnel discovered that no contamination had leaked from the containers and no personnel were contaminated. Vehicle was transporting 6 boxes (ammo boxes used as shipping containers) containing a total of 892 millicuries of Technetium-99m and Xenon-133. Some boxes contained used doses that had already decayed to near background radiation levels. Mississippi Incident Report number: MS 06011 See Louisiana Agreement State Report: Event Number 42855 |
| ENS 42142 | 15 November 2005 16:27:00 | During routine inspection of general licensed devices at Shell Lubricants, it was discovered that the company could not account for two (2) Metorex X-Ray Fluorescence Analyzers. The facility has changed ownership since the last inspection and records were not well maintained of receipt/transfer and leak tests. The licensee conducted a search of the facility after the inspection and did not locate the devices. They also contacted personnel that had been previously employed in the facility as well as the maintenance supervisor, who had no information of the location or disposal of the devices. The Metorex Models were a HEPS X-ray Fluorescence Analyzer, containing a 60 millicurie Curium-244 source, Serial No. 206734, and a LEPS X-ray Fluorescence Analyzer, containing a 40 millicurie Iron-55 source, Serial No. 206777. Describe clean-up actions taken by DRH: After determining all other radioactive devices were accounted for, DRH helped search for the lost devices, but could not locate them. Case Closed: No Enforcement action taken: Investigation ongoing. Licensee cited violations for lost devices and failure to maintain records of receipt/transfer. Also required to send DRH a report about lost devices and corrective actions. Mississippi Report Number: MS-05-004 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 41862 | 22 July 2005 12:47:00 | The following information was received from the State of Mississippi via email: Description of Incident: Received notification 7-20-05 from Mississippi Emergency Management Agency (MEMA) that another State Agency (DEQ) had discovered the abandonment of a AEA Model 680 Cobalt-60 exposure device and a SPEC Model 150 exposure device containing Iridium-192. Division of Rad Health (DRH) personnel responded to location and determined that no devices were missing from the licensed storage facility. It had been assumed from other emergency responders that a overpack (Model 680-OP) for the Cobalt device may have contained radioactive material and was missing from the container. The event generated television and newspaper media attention. DRH personnel explained that the overpack was only used when the device was transported on public roads. All radioactive material was accounted for and secured in the storage area. Also, DRH and DEQ personnel went to Struthers Industries location at the 34th Street facility located in Gulfport, MS, where all radioactive material ( a Model 680 Cobalt 60 exposure device and a Model 660 Iridium 192 device) was accounted for and still secured in the locked storage vault. There was security concerns due to the companies being in bankruptcy and the new owners not knowing about the radioactive devices. DRH had investigated the security of the sources on 6-28-05 and found the sources safe, but met with the president of company who assured DRH he would properly dispose of the devices. On 7-21-05 AEA Technology was contacted to remove the sources. The sources were put in approved overpacks. Leak tests had been performed on the sources and determined that the sources were not leaking. AEA personnel also removed all radiation signs and associated equipment at the 2 locations. DRH personnel did closeout surveys along with AEA personnel to ensure no radioactive sources were left behind. All radioactive material that was licensed by the 2 licenses (MS-750-01 and MS-259-01) were accounted for and removed by AEA personnel. It has not been determined by DRH personnel if devices were abandoned and the investigation is ongoing by DRH personnel. Isotope(s)/Activity: Cobalt 60 (2 devices/sources) @ 23 curies in each device, Iridium 192 (2 devices/sources) @ 5 curies in each device Date of Incident: 7-20-05 Date Reported To DRH: 7-20-05 Describe clean-up actions taken by DRH: After determining all radioactive devices were accounted for, DRH contacted AEA Technology about the removal of the devices. DRH personnel stayed at location until all sources and devices were removed and caution signs and associated radiography equipment was removed. List radiation measurements taken by DRH: Highest readings were @ 30 mR/hr at surface of the Co-60 exposure devices. The readings on the Iridium-192 devices were less than 5 mR/hr. List any other actions required of DRH: Event is under investigation by DRH, EPA, MS DEQ, and FBI. List any actions taken to notify NRC, other Agreement States: NRC Ops Center notified by E-mail 7-22-05; NMED notified 7-22-05 by E-mail. Event was reported to EPA due to other hazardous materials that were discovered at the site. Also investigated by FBI and inquiries made from Homeland Security. Enforcement action taken: Investigation ongoing as to if devices were abandoned or if the owner was still in process of disposing of the devices. |
| ENS 41685 | 10 May 2005 14:38:00 | The State provided the following information via email: During an inspection at Thomas Wood Preserving on April 7, 2005, it was determined that a generally licensed device, Asoma Model LCA x-ray fluorescence analyzer, Serial No. 466, containing 30 millicuries of Curium-244, was missing. The plant manager of the treatment plant stated that the device had been returned to Spectro Analytical, the device distributor, several years ago. (The Division of Radiation Health) DRH contacted Spectro Analytical on May 2, 2005, and learned that they had never received the device from the company. The plant manager stated that he would continue looking for the device and inform DRH if it was located. It is assumed that the treatment plant purchased a new fluorescence analyzer and the other device was put in storage and/or misplaced. Thomas Wood Preserving, holder of General License No. GL-266 was cited violations for failure to secure radioactive material from authorized removal and failure to report the lost device to the Agency. The licensee is also required to provide a written report to DRH in accordance with State Regulations. It is not known when the device was lost or the event occurred. |
| ENS 41210 | 19 November 2004 12:36:00 | The following information was provided via email from the Radioactive Materials Branch Director, Division of Radiological Health, MS State Dept. of Health: On November 18, 2004, licensee's RSO notified Division of Radiological Health/MS State Dept. of Health, of a Iodine-125 therapy misadministration. The prescribed treatment was for 145 gray to the prostate gland; however, due to an error concerning the coordinates, the treatment area was partially missed and resulted in a greater than 10 gray treatment to the rectum. The isotope was Iodine -125, 88 seeds with average activity of .300 millicuries, total activity of 26.8 millicuries. The patient was notified of the error and agreed to have the treatment performed again with no problems occurring. The RSO notified DRH after discussing the error with the authorized user and agreeing on corrective actions to prevent reoccurrence. At the present time, this is all the information we have received. I will update as soon as possible.
The following update information was provided via email from MS State Department of Health: The cause of the misadministration appears to be a misinterpretation to an ultrasound image which resulted in the needle being inserted in the wrong area. This caused a lower dose to be administered to the prostate gland greater than 20 % dose of the prescribed dose. Corrective actions will require a fIuoroscopticimage to verify the coordinates and confirm needle placement. Notified R1DO (Anderson) and NMSS EO (Giitter) |
| ENS 41704 | 17 May 2005 15:19:00 | The State provided the following information via email: During a routine inspection of Chem-Bio Laboratories, Inc. on March 23, 2000, it was determined that a Perkin Elmer Model 330-0119 electron capture detector, previously possessed by the licensee could not be located. The management representative explained that the owner/authorized user had removed that particular source from the device and placed in storage. She stated that she would continue to look for the source. Shortly after the inspector departed the licensee's facility, a call was made to the MSDH-Division of Radiological Health stating that the missing source had been found. During another routine inspection conducted on March 18, 2004, it was discovered that the source was never located. The licensee stated that she called again to inform someone at DRH that she had mistakenly informed the Agency about the source location and the source had never been found. She stated that she has made every effort possible to locate the source, but has not been successful. The licensee also stated that she was aware that a letter should have been sent to our Agency describing the circumstances surrounding the missing source, but failed to do so. Isotope: Nickel - 63 Activity: 15 mCi (millicuries) Date Closed: 4-12-04 State Event Number: MS-04-002 Enforcement action taken: Violations cited for failure to secure radioactive material from unauthorized removal or access and failure to properly report lost source and provide a written report to the Agency. |