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ENS 479945 June 2012 13:14:00The following information was obtained from the state of Florida via email: First quarter 2012 whole body dosimeter badge for a nuclear med tech indicated a 10.5 Rem dose. Badge was recounted and the dose remained the same. Dose is not confirmed by ancillary ring dosimeters. Ring dosimeters indicate a typical 100 mR/month. Because the ring dosimeters do not confirm the badge dose, the consulting health physicist does not think this is a valid dose and the med tech is still working. Florida is investigating. The isotope used by the medical technician is Tc-99, 30 mCi. Florida Incident Number: FL12-049 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 4786024 April 2012 14:03:00The following information was obtained from the State of Florida via email: On April 16, (a licensee) employee notified (the) RSO that his 0-200 pocket detector had gone off scale ten days earlier. His film badge was immediately sent to Rad Detection Services for processing. It was reported to have 25 Rem whole body exposure. This office (Florida Bureau of Radiation Control) was informed on 24 April. The RSO has tried to recreate the scenario but he can't come up with a 4.5 minute exposure scenario. RSO is considering a blood test. Licensee will provide a written report. Florida is investigating. FL Incident No. FL 12-039 The camera involved was an INC IR-100 Model 32, serial number R887, with a 65 Ci Ir-192 source.
ENS 4779030 March 2012 08:07:00The following information was received from the State of Florida via email: Licensee reported a possible medical event on 8 March which was confirmed in a written report received on 22 March. Patient was being treated by Gamma Knife with 8 shots at four sites when the fifth shot was interrupted for a bathroom break. While in the bathroom the patient fell and dislodged the stereotactic frame. The frame was reapplied and treatment plan recalculated. However, the computer did not start the treatment at the correct site resulting in an increase in dose of 22.2% at site 2, 14.8% at site 3 & 15, and 7% at site 4. The doses are well within clinical practice. A conservative dose prescription had been elevated to a moderate prescription. The referring physician and patient have been notified. No medical consequences are expected. The cause is human error. Any further investigation referred to Licensing and Materials. No further action will be taken on this incident by this office. Device: Leksell Perfexion Serial Number: 6130 Florida Incident: FL-12-034 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 4728020 September 2011 08:12:00The following information was received from the State of Florida via email: During a routine inspection, a Co-57 flood source was determined to be missing. Source was accounted for on 18 Aug 11. (A state) inspector surveyed the area and could not locate the source. Licensee believes the source may be at a doctor's office; they will continue to look for it and will notify us (Florida Bureau of Radiation Control) if found. Any further action is referred to (Florida Bureau of Radiation Control) Radioactive Materials (Branch). The Co-57 source strength was reported as 414 microcuries. FL Incident Number: FL11-081 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 469203 June 2011 15:19:00The following information was sent by the State of Florida Bureau of Radiation Control via email: (The licensee's two) fill detectors were bought in the 1990's and were not in use. The fill detectors were stored in a spare room full of scrap metal. The room was cleaned out in early May and the scrap sent to Alpha Metal Recycling, 2392 NW 147 Street, Opa-Locka, Florida 33054. The recycling plant manager said that the load has already been sent overseas to either China, Pakistan or India. Loss of the material was found when the application for license renewal was being filled out. The licensee will send a written report to Radioactive Materials. Any further action is referred to Radioactive Materials. This office will take no further action on this incident. The two fill detector sealed sources each contained 100 mCi of Am-241 and were manufactured by Industrial Dynamics (Fil Tech; Model Number FT50; Serial Numbers 1296 and 126). Florida Incident: FL11-045 THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. 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 469213 June 2011 15:40:00The following information was sent by the State of Florida Bureau of Radiation Control via email: (On June 2, 2011), a patient with over 100 tumors was being treated. One lesion was supposed to get 16 gray, but received only .85 gray. The physicist forgot to adjust for the weight factor. The physicians have been notified. The patient will receive the correct dose during the next visit. The licensee will submit a written report to the Radioactive Materials. Any further action is referred to Radioactive Materials. No further action will be taken on this incident by this office. The patient was undergoing Gamma Knife Stereotactic Radiosurgery using 3073 Ci of Co-60. Florida Incident: FL11-046 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 467191 April 2011 16:24:00The following was received from the State of Florida via email: A patient was scheduled to receive a 150 mCi dose of I-131 for thyroid cancer therapy treatment on 3/31/11. The dose was two 75 mCi capsules. Only one pill was taken. The other pill was discovered sticking on the bottom of the vial on 4/1/11 (capsules are sticky and the label around the vial prevented direct observation of the capsule from the side). Patient was under dosed by 50%. The tech failed to ensure that both pills were taken. The physician has been notified and he will notify the patient. The patient will be redosed to bring the dose up to prescription. The dosing procedure will be changed to require the tech to verify that the vial is empty. Licensee will submit a written report. Any further action on this incident is referred to Radioactive Materials. This office will take no further action on this incident. Florida Incident Number: FL 11-028 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 4627824 September 2010 17:24:00The following report was received via e-mail: During the last radiographic exposure on 9/22/10 the source did not fully retract. The workers did not do a survey and did not have their rate alarms turned on. They noticed that their dosimeters were off scale and discovered the problem. The film badges were processed on 9/24/10 by Landauer and found the assistant radiographer received 0.742 Rem and the lead (radiographer) received 114.4 Rem. Since they were both together this is questionable. Landauer reports the lead's badge shows an uneven surface reading which is an indication it has been damaged by dropping. Licensee calculations show 0.750 REM for both. The lead has been sent for a blood test. Licensee will send a written report. Florida is investigating. The camera contained a 71 Ci Ir-192 source. Florida report number: FL10-101
ENS 4575911 March 2010 15:55:00The following report was received via e-mail: Patient was receiving the 2nd of 14 fractions of 250 centiGray treatments to the ear. The therapist accidently pushed the 'auto radiography' button rather than the 'treatment' button which delivered approximately 9 times the intended dose. The patient and doctor have been notified. No health effects are expected. Licensee will send a written report. Florida is investigating. Isotope: Ir-192, 5.7 Ci Maximum dose received: 2250 centiGray Device: HDR Surface Applicator manufactured by Nucletron Model V2 MicroSelectron Florida Incident Number: FL10-035 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 4529825 August 2009 15:42:00

The following information was received from the State of Florida via e-mail: Licensee reports that a handheld x-ray fluorescence (XRF) analyzer (containing 30 mCi of Am-241) was stolen. The device was last seen when used on 7/5/09. The device was placed in the office of user and was noted missing when it was looked for on 8/11/09 to use for a job. On 8/24/09, after searching through the company office, the licensee determined that it was missing/stolen. The licensee reports that (the device) is password locked. Licensee is considering offering a reward. Licensee will submit a written report. Florida is investigating. Florida incident number: FL09-063

  • * * UPDATE FROM STEVE FURNACE TO ERIC SIMPSON AT 1420 ON 09/01/09 * * *

The following notification was received via phone: The handheld XRF analyzer was found by the licensee stored in a closet onsite. A member of the technical staff had placed the unit in a closet in order to move it out of the area where a cleaning crew was working. The analyzer is a generally licensed item. The State of Florida expects no further actions to be taken concerning this event. Notified R1DO (Dwyer) and FSME (McIntosh). 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. 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 4486820 February 2009 16:53:00The following information was received via fax: Licensee has gone bankrupt, is out of business and has abandoned a PET scanner and associated sealed sources. Sources will be in a pig in the hot lab. Items are in a locked building not accessible to anyone except the landlord. Orlando Inspection office will retrieve sources on Monday. There are 3 Ge/Ga sources (10.65 mCi) and 2 Cs-137 sources (1 x 250 �Ci and 1 x Unknown activity) . FL Incident Report # FL09-019
ENS 4435016 July 2008 16:22:00The following report was submitted by the State via e-mail: Licensee's truck was parked at a fast food restaurant, which happens to be part of the work site, while the employee was inside getting a late lunch. The (Troxler 3440A, S/N 26057) gauge was in its transport box and secured to the bed of the pick up with two cables and two locks. At approximately 3 p.m. thieves using a bolt cutter tried to cut the cables. When they couldn't, they cut the locks and took the gauge. The keys were not with the gauge. Hialeah PD is investigating. A witness provided the make of the car and a partial plate number. Licensee will submit a written report and after 48 hours consider offering a reward for the return of the gauge. Florida is investigating. This gauge contains an 8 mCi Cs-137 source and a 40 mCi Am-141/Be source. Florida report number FL-08-104 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 4424930 May 2008 07:55:00The following was provided by the State via e-mail: Just after 0500 (EDT) two vans carrying medical RAM collided. There were no injuries. All southbound lanes (of Highway 200 in Marion County) were closed while the vehicles were removed. Hazmat determined that there was no damage or spill from the packages. One van had the packages jammed and they couldn't be removed at the scene. That van and driver were transported to Ocala where the packages can be removed. The other licensee is Cardinal Health 414, 3425 SW 42nd Way, Gainesville, FL 32608; license 3452-3, 3B. The licensees maintain possession of all RAM. No further action will be taken on this incident. The isotope was Tc-99m and Thallium, by-product in a liquid form. The activity level is unknown. FL Incident Number: FL08-082.
ENS 4387228 December 2007 11:34:00Doctor ordered iodine (didn't specify isotope) thyroid uptake & scan for a patient. This licensee uses I-123 for this purpose. Patient was incorrectly scheduled for a I-131 (2.2mCi) whole body scan and that was done on 12/17/07. Error was discovered 12/25. Patient & doctor have been notified and no adverse health effects are expected. Licensee will submit a written report. Scheduling personnel will be re-educated to verify an order before scheduling patients for a procedure. The tech will be re-educated to read the script before dosing a patient. Any further action on this incident is referred to Radioactive Materials. Incident Number FL07-205 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 437779 November 2007 17:56:00The State provided the following information via facsimile: At approximately 1530 hours the left rear tire of the pickup truck transporting the camera blew out. Truck rolled on its side (just West of I-4/I-95 intersection on I-4). There were no injuries and no damage to the camera. Company personnel have custody of camera and a truck is being dispatched to retrieve it. Camera will be tested for leakage and functionality before being placed back into service. No further action will be taken in this incident. Camera: Sential Model 424-9 S/N 3688 Source: 29 Curies Ir-192 Florida Incident: FL07-174
ENS 4365421 September 2007 13:06:00The State provided the following information via email: Licensee called 9/21/07, 1:15 AM and reported that a Troxler gauge (model 3411, s/n 10416) is missing. It was last seen on 9/19/07 during the morning inventory in the locked storage locations along with other gauges. It was not present during the evening inventory 9/19/07. No other gauges are missing. Employees started being interviewed by the RSO on 9/20/07. The storage locks have not been tampered with. It was reported missing to the North Miami PD (report # 07-30026) and this office on 9/21/07. Florida is investigating. Isotopes were Am-241/Be (40 mCi) and Cs-137 (8 mCi). Florida Report # FL07-140. 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 432197 March 2007 15:18:00The State provided the following information via facsimile: The gauge was used at a jobsite at 35050 Halls Road, Clewiston, Florida on a Seminole Indian Reservation. After being used on the jobsite, the gauge was placed in a storage trailer. The gauge is a Model 3411B Troxler soil moisture density gauge, serial number 13563. The gauge contained a 8 millicurie Cs-137 source and a 40 millicurie Am-241:Be source. Device was used Friday 03/02/07 and placed in a storage trailer. It was noticed missing when the trailer was opened 03/07/07 (in the morning). The trailer had not been broken into. The Seminole Reservation authorities are investigating. Licensee will submit a written report. (State of) Florida will investigate within the limits of its authority. FL Incident Number: FL07-039 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 4313530 January 2007 16:12:00Following Agreement State Report was received via e-mail Licensee reported loss of gauge. Last seen during 2/06 inventory. Roof over storage area was replaced in 03/06 and all instruments/equipment had to be moved. Repairs were complete in 5/06. The gauge was noted missing in 8/06 inventory. Licensee reports an extensive search was conducted for several months. The loss was reported to this office 1/30/07. Licensee will submit a written report. Florida is investigating." Device Type: Gas Chromatograph Manufacturer: Hewlett-Packard Model Number: 5890 Serial Number: SN L4479 Isotope(s): Ni-63 Activity: 15.8 millicuries in 1988 (13.2 millicuries now) Material Form: Sealed Source Incident Category: Loss of Control - Lost, Abandoned, or Stolen Materials Location Classification: Controlled Area 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 4176410 June 2005 17:33:00The State of Florida reported that a Troxler gauge, Model # 3411B, Serial # 8280, was found in the trunk of a vehicle in which the occupants were being investigated for attempted robbery. The incident location was at a Wal-Mart store in Lake City, Florida. The gauge, which was impounded and placed in Florida's DOT District Office, was found undamaged. The Soil Moisture Density Gauge will remain in a licensed storage area until picked up by the owner. The isotopes used in the gauge are 10 mCi of Cs-137 and 40 mCi of Am-241/Be. Incident Number FL05-093
ENS 417497 June 2005 07:37:00The following information was obtained from the State of Florida Bureau of Radiation Control via e-mail: Searle marker containing Am-241 source was reported missing from Children's Hospital Miami. Device was bought in early 1980's. This source is in a 'storage only' mode and was last seen during the May 2005 inventory. Florida is investigating. The device description is a Searle marker, manufacturer and model unknown, serial number ACM-24, containing 14 milliCuries of Am-241. Florida Incident Number FL05-088
ENS 417568 June 2005 08:08:00The State provided the following information via email: The patient was to receive 2 GigaBecquerel (GBq) (Yttrium-90) from siraspheres. Backpressure from the liver catheter popped the tubing off the 3-way stopcock; approximately 25% of the material was spilled before the tubing could be re-attached. A lower flow rate was used and no further problems were encountered. The spill was contained in the case around the stopcock. Patient received approximately 75% of the material/intended dose. The licensee will send a letter explaining the event. Determination of whether this qualifies as a medical event is the reason for the late NRC notification. Florida continues to investigate. Florida event number: FL05-086
ENS 4107929 September 2004 14:23:00Licensee's case containing gauge (Troxler Moisture Density Gauge, Model 3411-B, Serial Number 18168, 8 millicuries Cs-137, 40 millicuries Am-241:Be) fell out of a truck while driving down the road. A fire truck just happened to be following the truck and secured the gauge. The technician noted loss and returned to the scene. Gauge and case were not damaged. The technician forgot to chain the gauge to the truck after finishing a job. The licensee will submit a written report on this incident.
ENS 4107527 September 2004 11:25:00

Metal ship container was broken into and the gauge was stolen. It was last seen close of business on Friday the 24th and discovered stolen Monday the 27th. The keys were not taken. The Haines City PD has been notified. Owner will offer a $500 reward. Florida is investigating. Incident Location: HWY 27, 5 miles south of I-4 (Polk County near Haines City) Temp work storage site. Troxler: Model number 3430 (containing) 8 millicuries of cesium-137 and 40 millicuries of Am-241/Be. Serial number of the gauge is 27404. License type: Specific; 3L(1).

  • * * UPDATE ON 09/29/04 AT 1514 EDT FROM CHARLES ADAMS TO GERRY WAIG VIA EMAIL * * *

Stolen Troxler gauge & case were recovered undamaged by the licensee this afternoon. The source rod was still locked. A teenage boy claimed the reward and stated that he had found it Saturday night (during the hurricane) beside the side of road which runs along the orange grove right behind the storage container. When his mother saw the radiation sticker she told him to get it out of the house. He then opened up the case and found the contact information and called the licensee. He claimed that the case lock was gone when he found it. Notified R1DO (John Rogge) and NMSS EO (M. Wayne Rogers)

ENS 4105720 September 2004 09:45:00The following information was received via e-mail. The theft occurred at a temporary job site. The shipping container for the moisture density gauge was found to have the hasp pried off and the case and gauge stolen. The gauge was last seen at close of business on September 17, 2004, and discovered stolen on September 20, 2004. The keys were not taken. The police have been notified. The owner is considering offering a reward. The State of Florida is investigating. The moisture density gauge was a Troxler Model 3440 (serial #25279). Source activity is listed at 8 millicuries Cesium-137 and 40 millicuries Americium-241. The Florida Bureau of Radiation Control and the State Warning Point were notified.
ENS 4106021 September 2004 11:17:00The following information was provided to the NRC from the Florida Bureau of Radiation Control via e-mail. A Troxler soil moisture density gauge (Model #3411-B; Serial #8598) was damaged when it was run over by a front end loader. The source rod was broken off and the cesium source was detached from the rod. Investigators searched and recovered the source. The gauge and source will be sent to Troxler for repair. No further action will be taken on this incident. The Troxler source strength is 8 millicuries Cesium-137 and 40 millicuries Americium/Beryllium. There were no personnel exposures.
ENS 4084930 June 2004 17:27:00Radiography was being performed at a steel fabrication shop when it was determined that the source could not be returned to the shielded position. The source was determined to be at the end of the tube. The camera was dragged to an isolated area and a 2 (milliRem/Hr) boundary was established. The crew (2 men) received about 130 (milliRem) exposure. The lab manager was called and responded. The guide tube was disconnected and the source shook from the tube. Using 4 (foot-long) tongs, the source was replaced in the exposure device. The lab manager received 2 Rem exposure during this process. The crank-to-source connections were subsequently inspected with the Amersham go-no go gauge and found acceptable. Subsequent device operations have been faultless. Florida is investigating. The source is 51.6 Curies of Iridium-192. The radiography camera belongs to Certified Testing Laboratories, Inc. of Orlando, FL. The State of Florida incident number is FL04-094.
ENS 4075818 May 2004 16:31:00The following information was received from the State of Florida Bureau of Radiation Control via e-mail: Patient was scheduled to receive a 2 fraction treatment to the breast over a five day period - for a total ten fractions. Prior to the last two fractions the doctor went out of town. The new doctor discovered that the calculated center of the balloon was off by 4 mm. The doctor chose to cancel the ninth & tenth fractions. Subsequent calculations showed the dose received was approximately 19 (to) 35% less than prescribed, depending on axis used relative to the catheter. The patient has been notified. This office was notified the day the last two fractions were canceled on May 14. However, review of events and the dose calculations were not complete until May 18. Licensee will send a written report on this event. Examination of this report will determine future Florida actions. The fraction treatments were delivered using a Mammosite with an Ir-192, 6 Curie source. The maximum dose the patient received was calculated to be 2720 centiGray.
ENS 4026421 October 2003 08:20:00Noveste Beta-Cath System (Model A1767 30mm S/N 86853) was used in a procedure on September 18, 2003. It has not been seen since. This office was notified October 20. This model contains 12 Sr-90 seeds, total activity up to 60 mCi (milliCuries). Florida is investigating. Florida Incident # FL03-192
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