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 Entered dateEvent description
ENS 5504221 December 2020 16:27:00The following is a summary of information that was received via email: At 1141 EST, on 12/19/20, an authorized user (AU) for the licensee determined that one of their portable nuclear gauges was damaged. The AU felt the index rod loosen and then break off when he went to retrieve the gauge from its transport case. The gauge had been used the day before at a jobsite and did not experience any accidents. The gauge had not been dropped and was in the possession of the AU at all times during this event. The source remained in the shielded position within the gauge throughout this event. The AU contacted the radiation safety officer (RSO) and the gauge was transported to an authorized storage location. The RSO took measurements of the outer transport box surface (1 mR/hr) and the gauge surface (5 mR/hr). The gauge was placed into an authorized storage shed and readings at the surface of the shed were non-distinguishable from background. The gauge was a Troxler 3440 (s/n: 16938) with an 8 mCi Cs-137 source and a 40 mCi Am-241/Be source. NC event number: NC200023
ENS 5267513 April 2017 12:23:00

The following information was obtained from the state of North Carolina via email: 1. Essential Details a. Narrative event description (e.g., Event circumstances and details including source radionuclide and activity). RSO (Radiation Safety Officer) discovered gauge missing while doing inventory check on Tuesday, April 11, 2017. It was last checked in the log book on March 8, 2017 when it came back from calibration and leak testing from the manufacturer. b. Report identification number. NC Local NMED 170014 c. Event date and notification date. Event discovered 4/11/2017 and notified on 4/12/2017. d. Licensee/reporting party information (i.e., name license number, and address). NC License #: 092-0104-1 Licensee: NC Department of Transportation Address: 1801 Blue Ridge Rd. Raleigh NC 27607 e. Location (site) of event. f. Whether the event is NRC reportable and the applicable reporting requirement. 10 CFR 20.2201(a)(1)(i) g. Cause and corrective actions (States and licensees' actions). Failure to properly log or check out gauge at time of use. RSO believes that it was checked out to a DOT field office and not properly recorded. They are currently contacting all trainers of gauge users, DOT engineers, and any District Engineers that may have access in order to locate gauge. They are in the process of developing a barcode scan in/out electronic use log to maintain better accountability and knowledge of gauge locations. Final causes/corrective actions are still to be determined. h. Notifications: local police, FBI, and other States; as needed. Upper State DHSR/DHHS (North Carolina Department of Health Service Regulation/Department of Health and Human Services) management notified; working on press release with public information office. i. Indicate if there are any generic implications (i.e., generic issues or concerns). None. 2. Source/Radioactive Material Isotope and activity; manufacturer, model and serial number, and leak test results, if applicable. Nuclear Gauge Make: Troxler Model: 4640-B (thin-lift asphalt) Serial Number: 1628 Type of Source: Cs-137 (8.0 mCi) Source Serial Number: 75-7134 Leak Test Results: Pass (Performed by manufacturer at last calibration).

  • * * UPDATE FROM DAVID CROWLEY TO HOWIE CROUCH (VIA EMAIL) ON 4/13/17 AT 1535 EDT * * *

Gauge was discovered back at the manufacturer's facility. It apparently was checked back into the licensee, but something didn't work appropriately (not regarding RAM sources) and went immediately back to the manufacturer. Gauge was not logged appropriately for being shipped right back out and it was forgotten by the licensee sometime in the last month. Notified R1DO (Jackson) and NMSS Events Resource 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 5165213 January 2016 17:40:00The following report was received from the North Carolina Department of Health and Human Services via email: The RSO (Radiation Safety Officer for International Paper Company), first noticed the missing FNG (fixed nuclear gauge) after the renovation of an older chute and replacement by the new metal chute. The older scrap parts had been taken to Southern Metals in Wilmington, NC scrapyard. The six month inventory was due at the time and the specific date of the inventory check was January 5, 2016. Several rechecks have been made within the storage areas where other gauges are stored and secured and contacts with the metal chute manufacturer, ICBS Group, and the scrapyard have been made, without a trace of the gauge. Source/Radioactive Material: Cs137, 9 mCi; Thermo Measure Tech, source model 57157C Device: Thermo Measure Tech, gauge model 5192 SN# B3195 State inspectors (North Carolina Department of Health and Human Services) will be conducting a reactive on site investigation tomorrow (1/14/2016) to determine causes and if any corrective actions have been implemented. Our Agency (North Carolina Department of Health and Human Services) will also be visiting the scrapyard where old licensee parts were shipped in the event the gauge was sent there by accident. Portal monitors and scrap material will be checked for functionality and presence of heightened radiation, respectively. NC Report ID No.: NC160003 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 514422 October 2015 17:59:00The following report was received via e-mail: A Gamma Knife patient with trigeminal neuralgia was treated to the incorrect side. The intended side was the patient's right, however, the left side was treated. The prescription was 85 Gy @ 100%. The intended volume was approximately only 33.5 cubic mm which corresponds to the 80% isodose (68 Gy). The incorrect treatment location was determined as the patient completed treatment at approximately 1000 EDT. Once the situation was reviewed, discussed and confirmed by those involved with this treatment, the Radiation Safety Officer (RSO) was notified via phone call at approximately 1100 EDT. The RSO stated that he would contact the State to report the event. The patient has already been informed regarding what happened by the attending neurosurgeon, and after a short break, the patient was then treated to the correct side. The correct treatment was completed at approximately 1230 EDT. The attending radiation oncologist notified the referring physician practice at approximately 1400 EDT. Licensee will provide a required report within 15 days. They are still determining corrective actions to prevent reoccurrence. A state inspector will be on-site doing a follow up investigation Monday, 10/5/2015. The treatment isocenter was positioned incorrectly due to human error. More details to be gathered during site visit and investigation by Agency (North Carolina Division of Health and Human Services) scheduled for 1000 EDT, Monday, October 5, 2015. Corrective actions are being discussed by licensee. Note: Licensee radiation team and referring physician do not believe patient will suffer any acute deleterious effects at this time. North Carolina NMED #NC150026 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 5142728 September 2015 17:29:00The following is a summary of information received from the State of North Carolina via email: Eight new Tritium exit signs were reported missing to the State of North Carolina by the licensee. The new signs were placed in a temporary storage location during building renovations. They were discovered missing when the licensee was preparing to return old signs back to the manufacturer for disposal. The licensee believes the new signs were inadvertently discarded as trash. All eight signs were manufactured by Isolite Corporation and each contained approximately 6.22 Curies of Tritium. The serial numbers of the missing signs are: 1203962, 1203964, 1203966, 1203961, 1203900, 1203963, 1203902, and 1203897. North Carolina will be citing the licensee for loss of radioactive material. NC Item Number: NC 150025 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 513704 September 2015 13:00:00The following information was provided by the State on North Carolina via email: On 8/31/15, at approximately 1300 EDT, a NASCO worker operating the #4 Protos cigarette making machine noticed that the nuclear gauge seemed to be malfunctioning. The worker immediately reported this observation to the NASCO RSO. The RSO performed a shutter test and determined that the shutter would not open. (RSO) then turned #4 Protos off and established a no-entry cordoned area around the gauge, the radius of the restricted area was and still is about 20 feet. The RSO next contacted Little Creek Electronics, a North Carolina licensee, for assistance in repairing the shutter. The RSO of Little Creek contacted a health physicist inspector with the NC Radiation Protection Section, on 9/2/15 to ask whether they are authorized to perform this repair. This is how the Agency (North Carolina Radiation Protection Section) learned of this incident. (Little Creek) was not authorized and instructions were given not to perform work on the gauge; the Agency decided to investigate first thing in the morning on 9/3/2015 to get the details straight from NASCO. State inspector visited site on 9/3/15 to perform a health and safety assessment. State inspector determined that licensee had confirmed that shutter is closed and that the associated machinery had been deactivated. Furthermore, the licensee had established a cordoned, do-not-enter area of approximately twenty feet in radius around the affected gauge. The inspector's surveys were consistent with the surveys during the last regular inspection (8/6/15) of this license. NASCO arranged with Automated Control Technologies (ACT), a reciprocal license which handles manufacturing and repair of fixed nuclear gauges. (ACT) should be in to the facility before close of this week. The licensee address and location of the event is 321 Farmington Road, Mocksville, NC 27028. Nuclear gauge is a Accuray TG-5 fixed gauge, model number: S-18, serial number S-4086-H containing a Sr-90 25 milliCi source (assay date 04/2001), and last leak test on 4/23/15 was negative. Report identification number: NMED NC150024
ENS 512926 August 2015 12:22:00The following information was provided by the State of North Carolina via email: Pitt County Memorial Hospital, Inc. dba Vidant Medical Center (License No. 074-1457-1) had a medical event occur yesterday afternoon (08/05/2015). In brief, a patient with a low GFR (Glomerular Filtration Rate) was being treated for thyroid carcinoma. The original plan was to give the patient 50 mCi of I-131, which was received, assayed and ready for the Radiologist's approval. The Radiologist on site was not the original Radiologist who planned the treatment for this patient. The physician onsite felt that with the low GFR (score to indicate kidney function) a lower dose, 35 mCi, would be prudent and a second order was placed with the radiopharmacy. Around 1200 EDT, the dose was received, assayed and ready for administration. The Radiation Safety Representative identified the patient as required and discussed the home-going instructions with the patient prior to the administration. After the patient acknowledged the instructions, the Radiation Safety Representative went to the hot lab, confirmed the written directive, identified an assayed dose with the patient's name on it (of which there were two), failed to confirm the activity on the pig and slip, and administered the dose. The error was not identified until the hot lab nuclear medicine technologist noted that the 35 mCi dose was still in the hot lab. The Radiologist and Radiation Safety Office was notified immediately. As of 1420 EDT, the referring physician was notified and patient was to be notified by the end of the day. At this time, it is not probable that there will be any health impact from the discrepancy. A NC Health Physicist will be doing a reactive inspection before the end of this week. The radiation safety team is conducting an investigation and will be filing a formal report (15-day report) by August 20, 2015. NC NMED Report Identification number: NC150023 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 5127328 July 2015 16:59:00The following report was received from the State of North Carolina (NC) via email: The licensee was performing routine maintenance and leak testing checks on a Berthold fixed nuclear density gauge when they discovered its shutter was stuck in the closed position. This maintenance record was dated for 7/22/2015 and listed that the device needed cleaning, showed signs of mild to moderate corrosion, the shutter failed to open, and replacement was necessary. The closed shutter was verified by a survey meter and its detector response. The (North Carolina) State was notified the following week, on 7/27/2015. The gauge manufacturer, Berthold, had already been contracted to dispose of the source and device. No exposures or radiation safety concerns have resulted from this failed shutter at this time and none are expected. The Berthold Fixed Nuclear Gauge is serial #6625, model# LB7440 with a Berthold source serial #1329, model #D7547, 20 mCi Cs-137 source (as of 5/98). The last leak test performed March 28, 2013, that passed according to Thermofisher (3 year leak test requirement). Berthold will perform another leak test before transporting off site. The cause of the stuck shutter is dirt and corrosion products that appear to be the leading cause of the shutter failing in the closed position. NC will follow up with the licensee to determine if dirt accumulation and corrosion occurred by operating in environmental conditions outside of the manufacturer's intentions. NC State report: NC NMED #150022.
ENS 5117523 June 2015 17:45:00The following was received via email: (The State of North Carolina) is writing to provide notification of a stolen portable moisture/density gauge from a reciprocal license in NC (North Carolina). Below are the current details: The licensee is EAS Professionals, Inc. - SC (South Carolina) Radioactive Material License No. 849. They entered the state under an expired NC reciprocity approval. The gauge was stolen 6/22/15 between 1700 (EDT) and 2230 (EDT) from a hotel parking lot in Greensboro, NC. Licensee contacted SC about the stolen gauge on 6/23/15 at about 0930 (EDT), SC immediately notified NC. The stolen gauge is an InstroTek Model 3500, Serial Number 1360. Sources contained include 11 mCi of Cs-137 and 44 mCi of Am-241/Be. The Greensboro Police Department was called by the licensee and performed an investigation that included taking fingerprints and looking for hotel surveillance footage. There was evidence that bolt cutters were used to free the case from the truck. Another note, there was a separate police report filed for a different vehicle break-in around the same time and hotel location. This suggests the thief did not target the radioactive gauge, but rather a perceived value in the locked up container. NC notified various other local, state, and federal law enforcement agencies. There is no mention of a press release at this time, but (The State of North Carolina) will encourage the licensee to publish a statement and possibly a reward to motivate the device's return. Please do not hesitate to contact (The State of North Carolina) should you have additional questions. (The State of North Carolina) will update NMED with any additional details as they unfold. 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 5014829 May 2014 12:54:00The following report was received via e-mail: Georgia Radioactive Materials Program (GA RMP) received a report yesterday (5/28/2014) of a medical event involving Nordion Y-90 TheraSpheres. The event occurred on 5/27/2014 at Cancer Treatment Centers of America (license #: GA 1632-1) - 600 Parkway North, Newnan GA 30265. GA RMP is tracking this under complaint number: 73962. GA RMP was notified on 5/28/2014 by the facility's RSO. The event was discovered after treatment while verifying dose delivered to dose prescribed. At that point it was noticed that the doctor had prescribed a 20% reduction for the patient than what is considered the treatment standard. The patient received 35.31 mCi of TheraSpheres as opposed to the physician prescribed amount of 26.73 mCi. The activity delivered deviated by ~32%. The dose consequence to the tumor was 65.32 Gy as opposed to the written directive's 49.45 Gy. The tumor was located in the patient's liver. Finally, the patient was notified of the overdose by the physician. The facility determined that the problem occurred in the treatment planning review process. The nuclear medicine technician performed the treatment plan review but verified with the standard treatment dose as opposed to the doctor prescribed dose. The facility is proposing a two person calculation sheet review for a corrective action in the future to avoid these sort of oversights. GA RMP will work with the facility to ensure these actions are sufficient to prevent reoccurrence. It is worth mentioning that other than delivering the wrong dose, there were no complications with the procedure. No shunting issues, unintended organs dosed, equipment malfunctions, or contaminations occurred. No outside agency notifications have been made other than this notification. GA RMP is responding at this time via telephonic investigation unless any additional doubt is raised on this event. We will follow up with more details and information to NMED as they become available. 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 510321 May 2015 19:10:00The following was received from the State of North Carolina via email: During a recent facility inspection at Duke University Medical Center (License# 0247-4), it was discovered that a lost I-125 seed (National NMED Item #140177) was actually found a couple months later still in the patient's breast tissue. The seed was intended for radioactive seed localization (RSL) of a breast lesion and thought to be excised with the targeted tissue during surgery. Events as follows: -Seed was implanted to patient with 213 uCi on 1/23/2014. -Discovered missing by licensee on 2/27/2014. -Reported lost to NC on 3/21/2014. -Found in patient 3/30/2014, no update given to NC. -Removed from patient breast on 4/1/2014. As of 5/1/2015, the licensee maintains that there was only 12.5 rads received to the 250g of breast tissue and not above the 50 rem for medical event reporting. This is currently under investigation by the NC Radioactive Materials Branch as our preliminary numbers suggest the breast tissue dose could be as high as 66 rem in the maximally exposed 100g of tissue. The licensee is not concerned with overall adverse reaction to the patient health due to them receiving a subsequent external beam radiation treatment that deposited between 300-1100 rads to the affected breast. This possible medical event is tied to the former local NMED Incident# NC 140014 where the source was lost, and it is now being tracked by a new local NMED Incident# NC 150010. 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 4991714 March 2014 16:48:00The following information was received from the State of Georgia via email: Event Narrative: A patient was treated with Y-90 microspheres for cholangiocarcinoma. This was a bilateral disease that would require the treatment of both lobes of the liver. Significant tumor burden was in the central (segment IV) and medial sections. The medical team decided to treat the left lobe first as a result. For the first treatment, 54.05 mCi was to be delivered to the left lobe. It had an expected dose of 69.0 Gy to the liver. Due to issues with hepatic arterial anatomy not previously anticipated, the medical team could not properly position the catheter. Because it was a bilateral disease that would eventually require the treatment of both lobes, they decided to move forward with the procedure. Of the calibrated activity of 52.6 mCi, a post-therapy survey of the vial showed 88% of the dose or 46.3 mCi was delivered. A post-delivery Bremsstrahlung scan showed excellent coverage of Segment IV, with some minor coverage in the right lobe due to the arterial anatomy. 21.8 mCi was localized to Segment IV, and the approximate remainder, 24.5 mCi, ended up in the right lobe. There was no significant extrahepatic activity seen. The medical team considered the treatment to be successful due to the patient's bilateral disease. The authorized user intended to treat the right lobe next, and the team reports that the treatment plan will be adjusted to take into account the diseased areas which were treated. There should be no adverse reaction from this initial treatment. Cause and Corrective Actions: Occurred due to an arterial aberration causing a the interventional radiologist to be unable to canulate the artery. The hepatic arterial anatomy was different the day of treatment than the initial shunt study suggested on 5 February 2014. The patient's medical team decided to proceed with the catheter orifice just at the origin of the segment IV hepatic artery. The shunt fractions then resulted differently from the intended treatment for that day. The medical team and RSO are continuing to discuss if any preventative actions can be achieved. Treatment with Y-90 microspheres is reported to be complicated by the degree that the disease and prior treatments have affected liver vasculature. This makes it hard to plan for these scenarios pre-treatment. Generic Implications: Post treatment scans for Y-90 were reported by the licensee not to be a common practice, but they seem vital for determining if a treatment meets reportable limits. Procedure Administered: Bilateral radioembolization of liver with Y-90 microspheres. Intended Dose: 54.05 mCi (69.0 Gy) to left lobe of liver. Actual Dose: 21.8 mCi to Segment IV of left lobe and 24.5 mCi to the right lobe. Patient and Referring Physician Notified: Informed following the procedure's post-delivery Bremsstrahlung scan. 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 4973717 January 2014 12:58:00The following was received from the State of Georgia via email: Licensee's Radiation Safety Officer for PQ Corporation with Georgia Radioactive Materials License GA 976-1 reported to the Georgia Radioactive Materials Program (GRMP) on 1-16-14 that an Industrial Source Holder shutter failed to close (used for level measurements) leaving the source in the exposed position. This was discovered when the licensee was performing a semiannual shutter check and inventory for their gauges and source holders. Once this was discovered by the licensee, the entrances to the unoccupied building where the source holder is located was taped off to prevent any unauthorized entrance to the building. The licensee then contacted Thermo Fisher who will be sending a technician to repair the malfunctioning source holder on 1-28-14. The licensee indicated to the GRMP that the building will remain inaccessible until Thermo Fisher arrives to perform repairs on the source holder. The Licensee will inform the GRMP once the repairs have been completed. Source Holder: TN Technologies, Inc. Model: 5205 Source: Cs-137 Source Activity: 200 mCi Source S/N: B597 Complaint ID: 72888
ENS 4972114 January 2014 15:59:00The following information was received from the State of Georgia via email: On January 13, 2014, NOVA Engineering and Environmental, LLC had a Troxler 3440 gauge stolen out of the bed of the truck. There have been a couple thefts at this site leading up to this incident (2075 Princeton Ave., College Park, Georgia). The truck was parked at an active construction site (new elementary school) and the vehicles are required to park some distance away from the construction. During (the) NOVA gauge operator time at the site he stated he saw the gauge in the bed of the truck and sometime later he left this site to go to another. Upon arrival, he realized the chain had been cut and the gauge box was gone. (The) NOVA RSO confirmed that the gauge box was only secured with one chain and that there was a lock on the box. A police report has been filed and will be available to be viewed in three to five days. At this moment, all gauges are locked in storage at the company's office. Gauges are only allowed to be removed if there is an assignment. Prior to this, the gauge stayed in the bed of the truck and went to all job sites even if there wasn't an assignment for it. A leak test was done on November 27, 2013 and the result report was created on December 13th 2013 by Atlantic Supply with no areas of concern. Gauge Information: Model Number: Troxler 3440 Serial Number: 22661 Isotope: Am-241 and Cs-137 Source serial numbers: 47-18503 (Cs-137) and 75-4417 (Am-241) Activity: 8mCi Cs-137 and 40mCi Am-241 GA Complaint ID: 72861 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
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