Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 54088 | 24 May 2019 17:43:00 | The following information was obtained from the Commonwealth of Virginia via email: On May 24, 2019, the Radiation Safety Office for the licensee made a preliminary report of an incident which occurred earlier on that day. The technician extended the source rod while using a portable moisture density gauge but was unable to retract it. The technician placed the gauge, with source rod extended, in the bed of his truck and drove back to his office, approximately 15 miles. When he arrived at his office, the other technicians were able to retract the source. A radiation survey confirmed the source was secured in its shield. The Virginia Office of Radiological Health will perform a reactive inspection to investigate this incident. This notification will be updated with additional information determined during the inspection. Virginia Event Report ID: VA 19-001 |
| ENS 53807 | 26 December 2018 14:32:00 | The following report was received from the Commonwealth of Virginia Department of Health via email: On December 26, 2018, the licensee reported a stolen Troxler portable moisture/density gauge. The gauge had been stored at a temporary jobsite (the Lorton Construction Landfill in Lorton, Virginia). It was stolen between December 21, and the start of work on December 26 when it was discovered missing. The Radiation Safety Officer (RSO) contacted the Virginia State Police and the Fairfax County Police Department, the local law enforcement agency. Initial searches near the landfill by the licensee were unsuccessful. The gauge contained a cesium-137 source and an americium-241 source. This report will be updated when the RSO provides additional information, including serial numbers of the gauge and sources and the source activities.
The following update was received from the Commonwealth of Virginia Department of Health via email: The licensee identified the stolen gauge as a Troxler Model 3430, serial number 33748. It contained a cesium-137 source, serial number 750-9405, with a nominal activity of 8 milliCuries (4/19/2002) and an americium-241:beryllium source, serial number 47-29401, with a nominal activity of 40 milliCuries (8/12/1999). There has been no media attention. The licensee may issue a press release regarding the theft. Notified R1DO (Arner), NMSS Events Notification, and ILTAB 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 53687 | 22 October 2018 16:24:00 | The following was received from the Commonwealth of Virginia by email: On October 22, 2018, the RSO (Radiation Safety Officer) for the licensee reported an accident that morning at a construction site near Sterling, Virginia. A roller hit a portable moisture/density gauge with its rear wheels while backing up. The gauge user established an exclusionary area until the RSO arrived to perform an onsite investigation and radiation survey. The RSO reported the plastic housing of the gauge was cracked but the source rod and shielding were intact. Surveys indicated no unusual radiation levels. The licensee contacted a vendor to analyze leak test samples and to determine potential repairs to the gauge. The gauge was a Troxler 3430, serial (number) 30198, with an 8 milliCurie Cs-137 source, serial (number) 750-2497, and a 40 milliCurie Am-241:Be source, serial (number) 47-27175. VA Event Report ID No.: VA-18-007 |
| ENS 52776 | 30 May 2017 16:23:00 | The following information was provided by the Commonwealth of Virginia via email: On May 30, 2017, the licensee reported that the shutter of a fixed gauge failed to close during a routine test of the shutter mechanism. The gauge is a Ronan Model SA1, serial number 1093CK, with a 200 millicurie cesium-137 source (effective May 1995). It is used to measure the level of material inside a process vessel. The gauge is located approximately 10 feet from ground level. It is accessible only by a platform which has been restricted by the licensee. The licensee has contacted the manufacturer to repair or replace the gauge. VA Event Report ID No.: VA-17-007 |
| ENS 52660 | 3 April 2017 16:07:00 | The following information was received from the Commonwealth of Virginia via fax: On March 31, 2017 the licensee notified the Virginia Office of Radiological Health (ORH) that an eye plaque therapy procedure was not performed in accordance with the procedure's written directive. The plaque was installed on the patient's right eye on March 22 and removed on March 31. The source, 38.8 mCi of l-125, delivered a dose of 85 Gy to the right eye. The right eye was the intended treatment location but the written directive incorrectly identified the target organ as the left eye. The disagreement between the written directive and the treatment location meets the definition of a medical event even though the correct target organ was treated. ORH will review the licensee's written report and determine additional actions to be taken. Event Report ID No.: VA-17-004 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 52467 | 29 December 2016 15:40:00 | The following information was received via facsimile: On December 29, 2016, the Office of Radiological Health (ORH) was notified that radiation had been detected on a local law enforcement officer's personal radiation detector at the intersection of Route 123 and the I-95 southbound exit ramp in Woodbridge, Virginia. The Prince William County HazMat unit responded and identified the source as cesium-137 using a radioisotope identifier. The source was present in the grassy knoll in the median of the interchange. ORH and other agencies, including the Virginia State Police, Virginia Department of Emergency Management and FBI, participated in the initial investigation. The Virginia Department of Transportation, which had representatives at the location, has responsibility for this area and has been requested to arrange for mitigation of the source through the services of a radiation consulting company. Radiation levels were measured at about 10 mR/hr at 1.5 feet above the apparent location of the source and between 30 mR/hr and 50 mR/hr at ground level. Based on the radiation levels and the source location, no radiation exposure occurred to members of the public. The source is apparently below ground and will remain isolated and undisturbed until the Virginia Department of Transportation can arrange for the consultant to remove the item, analyze it, and arrange for its disposal. The consultant is enroute and expected to begin mitigation and disposal efforts late this afternoon. ORH is continuing its investigation and will update this notification when additional information is obtained. Virginia Event Report ID No.: VA-16-015
The following update was received from the Virginia Radioactive Materials Program via facsimile: On December 29, 2016, the Office of Radiological Health (ORR) was notified that radiation had been detected at the intersection of Route 123 and the I-95 southbound exit ramp near Woodbridge, Virginia. The Virginia Department of Transportation (VDOT) took mitigation action. VDOT contacted a radiation safety consulting firm which arrived at the scene that evening. A metallic pellet was found after removal of about one inch of soil. The pellet was confirmed to be a cesium-137 source with an activity of about 8 millicuries and a contact exposure rate of 900 milliRoentgen per hour. It was approximately 7 millimeters in diameter and approximately 15 millimeters long. A field leak test of the source and surveys of the area after removal of the source indicated no contamination. The source was placed in a lead shield inside a DOT 7A Type A steel drum overpack. It was sent to the consulting firm's facility for temporary storage pending disposition. This notification will be updated if additional information becomes available. Notified the R1DO (Lilliendahl), NMSS (Henderson), ILTAB (Tucker) and NMSS Events (email). |
| ENS 52286 | 7 October 2016 13:09:00 | The following information was received via facsimile: On October 6, 2016, at approximately 0200 EDT, a loader backed over the licensee's portable gauge during work in Fairfax County, Virginia. The gauge was a Troxler Model 3400, s/n 31366, with an 8 millicurie cesium-137 source, s/n 750-6052, and a 40 millicurie americium-241:Be source, s/n 47-28023. The operator secured the gauge and cordoned the accident area. Radiation surveys by the licensee's Radiation Safety Officer confirmed the sources were in their shielded positions and that no contamination resulted from the accident. The damaged gauge has been shipped to a licensed service provider for repair. Virginia Event Report ID No.: VA-16-014 |
| ENS 52211 | 31 August 2016 13:33:00 | The following report was received via fax: On August 30, 2016, the licensee's Radiation Safety Officer reported that two cap screws used to secure the shutter handle on a fixed gauge (Ohmart Model SH-F2-C; serial number 70929; 1000 milliCuries cesium-137) had sheared off during a routine test of the on-off mechanism earlier in the day. The failure left the shutter in the on or open position. The gauge is used to provide density measurements of product traveling through a stainless steel pipe and is normally left in the on position. Personnel entry into the pipe is not possible, eliminating potential personnel exposure to radiation. The licensee has contacted a licensed service company to repair the gauge. Virginia Report: VA-16-013 |
| ENS 52089 | 14 July 2016 17:24:00 | The following report was received from the Commonwealth of Virginia via facsimile: On July 12, 2016, Sims Metal Recycling, Richmond Virginia, reported to the Virginia Radioactive Material Program (VRMP) that a radioactive source had been found in a shipment of metal. They said the source was a gauge like the one found the previous day in their Petersburg Virginia Facility (see EN #52088). Refer to VA-16-008. VRMP Radiation Safety Specialists performed an onsite review. Labels indicated that the source was a general license device from EG&G Berthold, model not identified, serial number 001095, with a 100 millicurie (September 1990) cesium-137 source, serial number 3023. Maximum radiation levels at contact at the mounting near the shutter were 2 mR/hr, at three feet, maximum levels were less than 0.1 mR/hr. The gauge was placed in a drum in a secured area. Dose estimates by VRMP health physicists indicated no individual was likely to have received more than 1 mrem whole body or 5 mrem extremity dose. On-site tests for leakage indicated no removable contamination. The recycling facility will contact a waste broker to arrange for disposal. The gauge owner was not identified from review of the VRMP general license database. Berthold Technologies USA is reviewing records to identify the owner of the gauge. Virginia Event Report ID No: VA-16-009 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 52088 | 14 July 2016 17:20:00 | The following report was received from the Commonwealth of Virginia via facsimile: On July 11, 2016, Sims Metal Recycling, Petersburg, Virginia, reported to the Virginia Radioactive Material Program (VRMP) that a radioactive source had been found in a shipment of metal. VRMP Radiation Safety Specialists performed an onsite review. Labels indicated that the source was a general license device from EG&G Berthold, model not identified, serial number 001098 with a 100 millicurie (September 1990) cesium-137 source, serial number 3027. The shutter was locked partially open with the opening behind part of the gauge mounting. Maximum radiation levels at contact at the mounting near the shutter were 5 mR; at three feet, maximum levels were less than 0.1 mR/hr. The gauge was placed in a drum using a mechanical hoist and the drum was placed in a secured area. Dose estimates by VRMP personnel indicated no individual was likely to have received more than 1 mrem whole body or 5 mrem extremity dose. On-site tests for leakage indicated no removable contamination. The recycling facility contacted RSO, Inc., a commercial firm, to arrange for disposal. The gauge owner was not identified from review of the VRMP general license database. Berthold Technologies USA is reviewing records to identify the owner of the gauge. Virginia Event Report ID No.: VA-16-008 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 51903 | 3 May 2016 15:41:00 | The following was received from the Commonwealth of Virginia via email: Honeywell International is authorized by general licenses to possess a number of tritium exit signs. It was discovered during an internal physical inventory that eight tritium signs were unaccounted. All were distributed by Safety Shield, Inc., and included one Model L3, s/n T8543, 11.5 curies; one Model XT, s/n S1075, 7.5 curies; and six Model 2040's, s/n 207011 through 207016, 7.5 curies each. The signs were received several years ago. Honeywell was unable to locate the signs despite a search of the facility and additional record review. Honeywell has submitted a procedural change in an effort to better track the remaining tritium signs at the facility. The licensee will keep the agency informed of any additional information. Event Report ID No.: VA-16-002 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 51088 | 22 May 2015 17:08:00 | The following report was provided by the Virginia Department of Health via facsimile: On May 4, 2015, a transportable HDR (high dose rate) unit (Elekta microSelectron Model 106.900, serial number 14514) licensed for use by a Virginia licensee was damaged while being unloaded from its transport trailer. The source activity at the time was approximately 8 curies of IR-192. The damage appeared to be limited to the unit's covers. The licensee contacted Elekta, Inc., (which performs work in Virginia under reciprocal recognition of its Georgia license) and a field service engineer was sent to investigate. The service engineer found the head covers and collar cover were broken and other damages, but tests indicated the unit functioned properly. New covers were ordered. During the following week the source was uploaded into an emergency container while the covers were replaced. After the source was returned to the HDR it was found to be stuck in the safe. A kink was found in the cable and a new source was ordered. A source exchange was scheduled on May 19th, but the source could not be manually unloaded as before. Instead, it had to be removed from the back of the HDR. The frayed cable was cut and the source was placed in the emergency container by the service engineer. The source fell to the bottom of the emergency container and the service engineer could not retrieve it. The container was placed in storage at the Virginia licensee's facility after additional shielding was placed around it to reduce the exposure rate to 200 microR/hour. The dose received by the service engineer as a result of the event was estimated by Elekta, using a worst case scenario, as 327 mrem whole body. The service engineer's dosimeter was sent to the dosimetry supplier for an emergency evaluation. Elekta has contacted the source manufacturer (Alpha-Omega Services) (AOS) to assist in the retrieval of the source from the emergency container and to send it to AOS for further investigation. Elekta will provide additional information as it investigates the event. Virginia Event Report ID No.: VA-15-06 |
| ENS 50414 | 29 August 2014 14:51:00 | The following information was received via facsimile: On August 29, 2014, the licensee made a telephone notification of a medical event which occurred during a skin treatment using a Nucletron microSelecton 106.990 HDR. The Radiation Safety Officer indicated that a decay corrected value for the source activity was used during data entry for the treatment plan. The licensee discovered, after the administration of the treatment fraction, that the software also corrected for decay in determining the exposure time for the fraction. The extra decay correction resulted in a dose approximately twice the prescribed fraction dose of 600 cGy. The licensee has informed the referring physician and held a staff meeting to discuss the circumstances. Any future treatment fractions for the patient will be reviewed and the licensee will review its nine previous skin treatment procedures to determine if additional medical events may have occurred. Additional information, including the administered dose, will be provided by the licensee in its written report. Event Report ID No.:VA-2014-005 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 50325 | 30 July 2014 13:07:00 | The following was received via facsimile: The licensee reported on July 29, 2014, that a portable density gauge had been damaged by a compaction roller at a temporary job site in Loudoun County, Virginia. The gauge was a CPN Model MC with a 10 millicurie Cesium-137 source and a 50 millicurie Americium-241 source. Investigation by the licensee's radiation safety officer indicated there was no damage to the gauge casing and that the sources were in their shields when the accident occurred. The control rod for the Cesium source was slightly bent as a result of the accident, but both sources remained in their shielded positions. The gauge was returned to the licensee's office and a leak test wipe was sent for analysis. The licensee plans to transport the gauge to an authorized repair facility after the leak test results are received. A written report is required within 30 days. Virginia Event Report ID Number: VA-2014-05 |
| ENS 50087 | 6 May 2014 09:26:00 | The following information was received from the Commonwealth of Virginia: The licensee discovered a shutter stuck in the open position during a routine test of a fixed gauge on May 5, 2014. The gauge is a Ronan Engineering Model SA1, serial number M-7299. It is used as a low-level indicator in a pre-dryer vessel and contains a 26.9 milliCurie (decay corrected) cesium-137 source. The licensee indicated that using unusual force to try to close the shutter would likely damage the actuator rod mechanism. The shutter is kept in the open position during operations and does not pose an additional radiation exposure to personnel. The licensee performs radiation surveys at one foot from the gauge surface during routine tests. The maximum reported result for this gauge was 300 microR per hour. The licensee has contacted the manufacturer to repair the gauge. The Agency (Virginia Radioactive Materials Program) will continue to monitor the situation until the shutter is repaired. Virginia Event: VA-2014-004 |
| ENS 50074 | 30 April 2014 15:26:00 | The following information was provided by the State of Virginia via facsimile: On April 24, 2014, the licensee performed a two part therapy procedure using yttrium-90 microspheres (Sirtex SirSpheres). The procedure was to treat the same lobe of the liver via two different arterial pathways. There were no problems with the first injection, but the second injection failed and none of the yttrium-90 was delivered to the patient. The licensee determined that the failure occurred because of a faulty Surefire Medical catheter. The authorized user decided not to repeat the administration of the second dose but will treat the region with an alternate method. The licensee indicated that the prescribed dosage for the first injection was 11.7 millicuries and that 12.7 millicuries (27,500 rem to the target region of the loft lobe) was delivered. The prescribed dosage for the second injection was 8.3 millicuries (to give a dose of 26,200 rem to the targeted region) but no activity was delivered. This resulted in a medical event for the second injection (or fraction) as well as for the entire procedure. VA Event Report ID No.: VA-2014-003
The following information was provided by the Commonwealth of Virginia via facsimile: The licensee submitted a written report on May 9, 2014, which contained additional information from its review of the event. The licensee's review concluded that the failure of the catheter (Surefire Medical, Model SHF-38120-mT) during the second procedure was attributable a kink or fold in a basket on the catheter which resulted in a catheter occlusion. The licensee concluded that the short arterial segment used for the arterial pathway and the acute angle at the arterial origin, along with possible manipulation or patient movement, resulted in a kink or fold as the basket entered the acute angle of the artery. The catheter will be returned after decay of the radioactivity to the manufacturer for examination. The licensee submitted corrective actions for the procedure which include retraining of personnel to use extra care in ensuring the catheter is firmly set and to flush the catheter prior to administration of the microspheres to ensure there is no occlusion. The agency will review implementation of the corrective actions during a future inspection. Notified R1DO (Lilliendahl) and FSME Events Resource via email. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| ENS 48793 | 28 February 2013 16:22:00 | The following was received via fax from the Commonwealth of Virginia: On February 27, 2013, a patient was treated with Y-90 microspheres (SIRTeX SIR-Spheres) for a liver lesion. The prescribed activity was 11.3 millicuries. Measurements of the residual activity in the delivery system indicated only 8.4 millicuries was delivered to the patient, resulting in a total dose differing from the prescribed dose by 25.9 percent. Notifications were made to the referring physician and patient. The licensee will submit a written report of the event within 15 days. VA Event Report: VA-13-0003 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 48260 | 31 August 2012 15:19:00 | The following information was received from the Commonwealth of Virginia via email: On August 31, 2012, the licensee reported that a wire drift error occurred during a high dose rate afterloader procedure on August 31. The patient undergoing a tandem and ovoid treatment was scheduled to receive a fraction dose of 6 Gray. Because of the wire drift error the fraction was terminated prior to completion and the patient received only 0.73 Gray. The licensee has informed the patient and the referring physician. The cause of the error and the patient's revised treatment plan are being reviewed by the licensee. The Virginia Radioactive Material Program will review the circumstances of the event. 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 48249 | 29 August 2012 14:30:00 | The following information was obtained from the Commonwealth of Virginia via facsimile: On August 29, 2012 at 10:30 a.m., the licensee reported that a Troxler Model 3440 portable density gauge was missing. The gauge, in its transport case, apparently fell from the licensee's truck during transport. The licensee notified the local law enforcement and initiated a search for the gauge. At 11:45 a.m., the licensee reported that the gauge had been found by a local resident who called the licensee. The RSO verified that neither the gauge nor the transport case was damaged. The Virginia Radioactive Material Program is investigating the cause of the incident. Virginia Event Number: VA-12-05 |
| ENS 48028 | 15 June 2012 11:44:00 | The Commonwealth of Virginia submitted the following report via facsimile: On June 14, 2012 the licensee reported that the shutter of one of its fixed gauges could not be closed as designed. The gauge is a Ronan Model SA-1 used on a process vessel as a level indicator. It contains a 438 millicurie (decay corrected) cesium-137 source. The problem was discovered during a routine test of the shutter mechanism. The individual who performed the test indicated that forcing the shutter closed, if possible, could damage the control mechanism. The gauge is normally in the open position during operations and the licensee has take extra steps to ensure no entry into the vessel. Ronan Engineering Company, the gauge manufacturer, has been contacted by the licensee and has scheduled a site visit during the week of June 18, 2012. VA Event Report ID: VA-12-002 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 47830 | 13 April 2012 10:07:00 | On April 11, 2012, a technician performing compaction tests using a CPN MC portable moisture density gauge (10 millicuries cesium-137; 50 millicuries americium-241), left the gauge during a test to prepare the next test location 20 to 30 feet away. A compaction roller ran over the gauge and shattered the gauge housing. The technician cordoned off the area and contacted the Radiation Safety Officer. The RSO contacted the Virginia Emergency Operations Center and returned the gauge to its storage area after ensuring the sources were inside their shields. Based on an onsite investigation by members of the Virginia Radioactive Materials Program, it was determined that no individual was likely to have received a radiation dose and that the gauge sources were secured in their shields. The licensee has contacted the gauge distributor to return the gauge. Virginia Report No.: VA-12-001 |
| ENS 49939 | 20 March 2014 17:31:00 | The following was received from the Commonwealth of Virginia via fax: Event description: On March 18, 2014, the licensee identified an error in a dose calculation for high dose rate (HDR) treatments administered to a patient on March 11-12. The initial report from the licensee indicates the patient was administered two out of a total of six prescribed fractionated doses. An error was made in planning the correct dwell position for the two fractions. The administered dose differed from the prescribed dose (was less than) by more than 20 percent. The licensee plans to correct for the underdose during the remaining fractions. The licensee is investigating if the dose to tissues other than the treatment site may have met the definition of a medical event. Virginia Event Report ID No.: VA-14-0002 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 47153 | 15 August 2011 10:51:00 | The following report was received from the Virginia Department of Health via facsimile: On August 12, 2011, the Radiation Safety Officer of American Electric Power, Clinch River Plant, reported a fixed gauge shutter stuck in the open position. The gauge is a Thermo MeasureTech Model 5197 containing 100 millicuries of cesium-137. It is a general license device used to measure levels in a fly ash precipitator hopper. Based on the licensee's lock-out procedures for entry into the hopper, the licensee has been authorized to continue operations. The licensee has contracted a licensed service provider to repair or replace the gauge. The malfunction does not pose a risk of additional radiation exposure to personnel. VA report ID: VA-11-0007 |
| ENS 47296 | 26 September 2011 15:33:00 | The following report was received via facsimile: The Radiation Safety Officer (RSO) for Virginia Tech notified the Virginia Radioactive Materials Program on September 23, 2011 that a leaking source had been identified on June 28, 2011. The source was an 8 millicurie (April 1989) nickel-63 source used in a Varian gas chromatograph. The source was contained in a detector kit model 02-001972-00, serial number A7074. The gas chromatograph was no longer used. While preparing the unit to be surplussed, the RSO identified contamination of 0.07 microcurie in the area where the ECD (electron capture detector) had been installed. The RSO reported that he did not report the leaking source in June because leak tests of the ECD itself showed no continuing leakage. The RSO indicated that the gas chromatograph would be decontaminated and that procedures would be modified to specify the required five-day reporting requirement for a leaking source to prevent recurrence of late reporting. Event Report No: VA - 11 - 10 |
| ENS 46978 | 23 June 2011 14:34:00 | The following was received via fax: During a routine test on June 22, 2011, the licensee determined the shutter on a fixed gauge failed to completely close. The gauge is used to monitor levels in a digester tank and was identified as a Berthold Technologies Model LB 7444, serial number 903-2-92. It contains a 7.8 milliCurie Cobalt-60 source. The licensee has contacted Berthold to repair or replace the gauge. Virginia Report #: VA-11-0002 |
| ENS 46956 | 13 June 2011 16:39:00 | The following report was received via fax: On May 4, 2011 a patient underwent a Y-90 therapy procedure. Two doses were to be administered to the right lobe of the patient's liver. The first dose was terminated when stasis was achieved. The second dose was terminated because of patient pain after 48% of the dose had been delivered. The pain during the second dose was considered most likely due to embolization. The licensee notified VDH (Virginia Department of Health) and requested guidance on whether the circumstances could be due to patient intervention. It was determined by VDH to be a medical event and not excepted because of patient intervention. A conference call was held with the licensee on June 10th and a written report submitted to VDH. The licensee indicated written directives, patient preparation, and pain control methods would be reviewed. 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 46754 | 14 April 2011 13:59:00 | The following was received via facsimile. In January 2011 a patient was administered 1.58 millicuries of (Iodine) I-I31 for a whole body scan. The written directive specified a 2.0 millicurie dosage. The difference was discovered during a routine audit by the licensee's health physics consultant in March 2011. Calculations by the health physicist indicated the difference between the written directive and the administered dose differed by more than 20 percent, that the difference in the effective dose exceeded 5 rem and that the difference in the dose to the thyroid exceeded 50 rem. A report dated March 24, 2011 was received by (Virginia Department of Health) VDH on April 4, 2011. An on-site investigation by VDH was performed on April 8, 2011. The licensee indicated that the quality of the whole body scan was not compromised and that because the administered dose was less than the written directive, there is no radiological hazard to the patient. Virginia Radioactive Materials Program Event Report ID.: VA-11-01 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 45905 | 6 May 2010 15:09:00 | The following information was provided by the Commonwealth of Virginia via facsimile: On May 6, 2010 the licensee reported a missing Troxler portable gauge, Model 3430, Serial Number 36089. The utilization log indicated that a user had returned the gauge to the storage facility on April 23, 2010. On the morning of April 24, 2010 the user found the gauge was no longer in storage and assumed it had been sent for routine maintenance and repair and did not report it missing to the RSO (Radiation Safety Officer) or management. They became aware it was missing on May 6, 2010 while routine leak testing was being performed. The licensee's representative stated that procedures require the gauge to be secured by a chain with padlock inside a locked caged area in a warehouse. The chain was present with the open padlock and there was no reported vandalism or forced entry into the warehouse or caged area. The circumstances regarding the gauge are under investigation by the Virginia Department of Health Radioactive Materials Program. The licensee has contacted the Loudoun County Sheriff's Office and is conducting interviews with the user and other staff to determine if additional information is available. This event is VA report #VA-10-03.
The gauge was found in the trunk of an authorized user's car. The gauge is being returned to its normal storage location and will be secured there. Notified R1DO (Cook), FSME EO (Suber), and ILTAB (via E-mail). THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 45807 | 2 April 2010 12:17:00 | The following information was received from the Commonwealth of Virginia via facsimile: The licensee's portable density gauge (Troxler Model 3430 S/N 038435) was damaged on April 1, 2010 when it was struck by a piece of earth moving equipment. The accident occurred at a commercial construction site in Roanoke County, Virginia. The gauge operator secured the area of the gauge and telephoned the licensee's Radiation Safety Officer who performed an onsite investigation and a radiation survey. The source was in the shielded position at the time of the accident and the survey confirmed that it remained so. There was no damage to the source rod or handle and only minor damage to the gauge trigger and casing. The gauge was returned to the licensee's storage facility. There were no injuries or radiation exposures as a result of the accident. Virginia Event Report ID No: VA-10-02 |