Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 57217 | 9 July 2024 08:40:00 | The following information was received from the state of Nevada via email: Nevada Gold Mines LLC - Goldstrike, (Nevada license) 05-11-13545-01, reported a stuck open shutter on a Berthold LB 7440, serial number 1459. The fixed gauge remains installed pending the arrival of a contractor to replace the failed shutter. Radiation surveys of the installed gauges are as expected for a gauge in service giving 0.11 mR/hour 1 foot back from the gauge (in walkway). Gauge is installed in a location where there is occasional foot traffic, providing no additional exposure mine/mill staff until it can be repaired. Licensee (was) reminded to report the failure to the manufacturer in accordance with the operations and maintenance manual for the gauge. The gauge contains 50 mCi of Cs-137. The state of Nevada considers this event closed. Nevada Item Number: NV240005 |
| ENS 55945 | 15 June 2022 18:04:00 | The following information was received from the State of Nevada via email: At approximately 1350 PDT, the RSO/CEO for IQC Southwest LLC, 00-11-0745-01 notified the Nevada Radiation Control Program (NRCP) that a Portable Nuclear Gauge (PNG) had been stolen from a work site located near the intersection of Sierra Vista and Paradise Road working off of Paradise Road in Las Vegas, Nevada. In addition, Las Vegas Metro Police Department was on scene and taking a report during the Radiation Safety Officers (RSO) notification call to the NRCP. The RSO stated that they had video of the theft as it occurred. An unknown (possibly transient) individual walked through the work site, picked up the gauge and walked off, appearing to hide the gauge with his body while the Authorized User (AU) was getting material from his vehicle. The source rod was not locked when the gauge was taken. The gauge was a Troxler model 4640-B with a 9 mCi Cs-137 source. An incident inspection will be performed June 16, 2022 by the NRCP. Nevada Item Number: NV220006 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 55823 | 5 April 2022 18:37:00 | The following was received from the State of Nevada via email: The patient was prescribed ten (High Dose Rate Brachytherapy) treatments (with a 9.0 curie Ir-192 source). After four treatments, it was discovered that some of the catheters had been incorrectly labeled. This altered the dose distribution resulting in a higher skin dose than anticipated, however the target dose difference did NOT exceed 50 percent from the prescription. The remainder of the patient's treatment was re-planned to compensate for the dose already given. The total doses once complete will be within limits for the skin and the target dose will be within 20 percent of the prescription. All treatments were to the correct patient and correct site. The treatment area for this patient is adjacent to the skin, so the intended prescription would have given a skin max dose of nearly 100 percent of the prescribed treatment dose. For the four treatments given with the incorrectly labeled catheters, the dose to skin is estimated to be 3 times the initially expected dose, exceeding 50 rem. However, the patient's treatment was re-planned to provide additional skin sparing for the remaining treatments while maintaining minimum target coverage to compensate for the dose already given. We estimate the total skin dose from the entire treatment will exceed the initially anticipated skin dose by 41 percent. This total skin dose is still within standard protocol limits, and the written directive has been updated to be inclusive of the initial and new treatment plans and organ at risk (OAR) doses. The patient and referring physician were notified the day the event was discovered before the determination that a medical event took place. Nevada Event Number: NV220002 |
| ENS 55391 | 2 August 2021 14:23:00 | The following information was received from the state of Nevada via email: Authorized user brought a portable nuclear gauge (PNG) up to Reno, Nevada (their license is based out of Las Vegas) to use on job today, August 2, 2021, and stayed the night of August 1, 2021, at the Atlantis, parked in the South East Corner lot. When he went out at 0800 PDT he noticed that the gauge was missing and the chains had been cut. He reported the missing gauge to the (Radiation Safety Officer) RSO and looked around the parking lot, drove the perimeter of the lot and a few blocks around the hotel and did not find the gauge. They notified Reno PD of the stolen gauge and (was notified they) would respond by 0915 PDT (no report number available yet). Atlantis is checking their parking lot security cameras to see if they caught anything on the camera to get a line on the device and fix the time line. Nevada NMED report number: NV210010
The following update was received via email: The PNG is from Terracon Consultants, Inc. Sacramento, California office covered by California RML CA 8064-34, and it entered the State of Nevada without reciprocity authorization or shipping papers of any kind. Updated the reciprocity pull down and the license number. Added the police report number (21-13940). Atlantis Hotel-Casino will provide anything found in their search of security camera footage to Reno Police Department. Notified R4DO (Gepford) and NMSS 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 55233 | 4 May 2021 20:20:00 | The following was reported by the State of Nevada: An authorized user (AU) and portable nuclear gauge were run over by grader while using the gauge. The AU and gauge were blocked from the driver's view by the grader wheel. The AU was exposed to the source for approximately thirty (30) minutes while the source rod was extended. The source rod remained intact however it cannot be pulled back into the shielded position due to the bent source rod. The radiation safety officer (RSO) placed the source rod into a concrete cylinder to limit the dose to responders. Then the gauge and the cylinder were placed in a fifty-five (55) gallon drum. It was sealed and transported back to the storage facility. The licensee is working with Troxler to make arrangements to return the gauge. On contact readings of the transport drum were no higher than 0.6 mR/hr and 0.260 mR/hr at one meter. No contamination was found on the gauge, shipping container or the RSO's hands. The licensee has been requested to ship the AU's dosimeter for immediate processing due to the long exposure. Will update AU exposure once results are received. The AU is expected to recover. Nevada Item Number: NV210006.
The following information was received from the State of Nevada via E-mail: The State of Nevada Radiation Control Program received notification that the authorized user reported in Event Number 55233, that was struck by a grader while using a portable gauge died on May 5, 2021. Nevada Item Number: NV210006. Notified R4DO (Deese), IRMOC (Gott) and NMSS Coordinator (Rivera-Capella). NMSS Events Notification via email.
The following information was received from the State of Nevada via E-mail: This is to follow up from our discussion earlier this morning and I have attached the AU's dosimetry report as requested. Based on the report, exposure did not contribute to his death, and the Nevada Radiation Control Program will not be issuing a press release. As of right now the cause of death remains related to injuries from being struck by the road grader. The radiation dosimetry report for period April 4, 2021 to June 30, 2021 showed 3 mRem. Notified R4DO (Deese); IRMOC (Gott), NMSS (Rivera-Capella), and NMSS Events Notification via email. |
| ENS 54686 | 30 April 2020 19:50:00 | The following information is summarized from the report received from the state of Nevada via email: A patient was scheduled to receive 34 Gy to the treatment site via a Nucletron brachytherapy device containing 444 GBq of Ir-192. The dose was to be received via two fractions-a-day for 5 days. All fractions were delivered as scheduled. During the post-treatment review, it was determined that the delivery device was placed 8 mm proximal to the intended treatment site due to a digitization error in the treatment plan. This resulted in the patient receiving 71 percent of the intended dose. At the time of the report, there were no acute ill-effects on the patient. NMED Report No.: NV200006 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. |