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| Entered date | Event description | |
|---|---|---|
| ENS 49493 | 1 November 2013 10:57:00 | The following report was received from the Kansas Department of Health and Environment via facsimile: Initial notification of an overexposure to the extremities of a radiopharmacy nuclear medicine technician at St. Francis Health Center, Topeka, KS, was made by the radiation safety officer. A Landauer report received 10/31/2013 indicated a right hand dosimeter (dose) at 55.85 rem and a left hand dosimeter (dose) at 54.29 rem. Whole body badge (dose) indicated 36 mrem. The tech has been removed from any job duties involving occupational radiation exposure. A more detailed report is being prepared (by the licensee). Kansas Report Number KS130009 |
| ENS 48952 | 22 April 2013 10:13:00 | The following information was received via facsimile from the State of Kansas: We (Frontier El Dorado Refining) attempted to move a source from its drywell, into its source holder. The source seems to be stuck in the drywell. There were no reportable personnel exposures. Because of the position of this source, 2 feet inside a large vessel with 5 (inch) steel walls, it is shielded at least as well as inside its holder. The shutter in question is on an Ohmart/VEGA model SHLM-CR3 source holder S/N 19077661, containing 2 Ci of Cs-137 in a model A2102 sealed source S/N 0586CO. The source is located at approximately 100 feet above the ground. Operations and maintenance personnel were notified of the issue. A wipe sample was collect to check for gross leakage. None was indicated. We (Frontier El Dorado Refining) will contact VEGA Americas (formerly Ohmart/VEGA) to arrange for repairs. Item Number: KS130004 |
| ENS 46328 | 12 October 2010 13:26:00 | One Troxler moisture/density gauge and three thin layer density gauges were transported to InstroTek, Inc. on September 23, 2010. The licensee was later notified that only three Troxler thin layer density gauges had arrived. The licensee searched their loading docks and did not find the missing gauge. InstroTek and R and L Trucking have also performed searches, but did not locate the gauge. The information about the gauge is below: Troxler Model 3440 Nuclear Moisture/Density gauge Serial Number 22504 CS-137, 8 mCi, Serial Number 47-4236 Am-241 Be, 40 mCi, Serial Number 47-18335 KS NMED KS100012
The Troxler Moisture Density Gauge was found at the R and L Trucking Terminal in Wilson, NC (about 40 miles from the intended destination of Raleigh, NC). The gauge is being delivered to InstroTek today (10/14/2010). Notified the R4DO (Haire) 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. 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 46002 | 11 June 2010 17:21:00 | At approximately 1600 CDT local time, a Kansas Licensee, Team Industrial Services Inc., reported that they had a radiography camera source become stuck during source retraction. While they were retracting the source, the stand tipped and resulted in the guide tube being bent such that the source could not be fully retracted. The licensee was able to secure the area easily since the shot was being conducted in a vault. Personnel exited the area and the licensee contacted their corporate RSO in Hammond, Indiana. There is no concern by the licensee of any over-exposure. The State, after talking with the licensee's corporate RSO, authorized recovery by a person on-site who is listed under the NRC license in Indiana. The State is expediting reciprocity paperwork to recognize the source recovery. Kansas # KS-100005. * * * UPDATE FROM DAVE WHITFILL TO STEVE SANDIN AT 1848 EDT ON 6/11/10 * * * At 1725 CDT the source was successfully retracted. Notified R4DO (Powers) and FSME (Mauer). * * * UPDATE FROM DAVE WHITFILL TO BILL HUFFMAN AT 1716 EDT ON 6/14/10 * * * The State of Kansas provided the following additional details on this event via facsimile: Equipment involved: QSA Global model 880D exposure device s/n D3027, Iridium 192 s/n 59219B, 26.6 curies, with associated equipment including drive mechanism, guide tube. And a tungsten collimator. Description of incident: At approximately 3:15 pm, the magnetic stand used during the exposure set up fell at the conclusion of a radiographic exposure and impacted the source guide tube causing it to crimp and preventing the source assembly from returning to the fully shielded position within the exposure device. Actions taken to resolve: The exposures were conducted within a shielded room thereby providing radiation attenuation and enhancing control of the area during incident remediation activities. There were no exposures to unmonitored persons or members of the general public. The Radiographer immediately contacted emergency response personnel within Team Industrial Services, Inc. including the Corporate Radiation Safety Officer. The CRSO performed a preliminary assessment of the event and contacted Kansas Department of Health and Environment. A retrieval plan was developed and discussed with on site personnel. The plan used involved the placement of additional shielding (including available steel and bags of welding flux) at the source location using an overhead crane. This reduced the radiation levels to the point that the radiographer could approach the location of the crimp and remove the crimp by applying pressure using large adjustable pliers (i.e. channel-lock type). He then retracted the source into the fully shielded position within the exposure device, surveyed, and locked the device. The exposure for the complete activity including the radiographic operations was 120 mrem for the radiographer and 75 mrem for the assistant radiographer as registered on their assigned direct reading dosimeters. Corrective Actions taken: The damaged guide tube was immediately removed from service. An inspection of the device and drive assembly, including the drive cable and source assembly, will be conducted to determine if any damage occurred before releasing for continued use. An investigation into the use of the magnetic stand will be conducted to try to determine the problems associated with the use of this type of source positioning device. Notified R4DO (Powers), R3DO (Kunowski), and FSME (Mauer). |
| ENS 46029 | 18 June 2010 17:13:00 | The State of Kansas provided the following information via facsimile: During the course of an inspection performed on 10/31/2007, it was discovered that Tetra-Tech had a gauge damaged in an accident at a temporary jobsite on 8/1/2007. The gauge was leak tested and shipped back to the manufacturer (Troxler) and refurbished and then returned to Tetra-Tech. Tetra-Tech did not notify the State of the damaged gauge and was issued a citation via the Inspection letter dated 11/15/2007. Terra-Tech responded in a letter dated 12/26/2007 and that was accompanied by several pictures of the damaged gauge. Based on the licensee's description and the photos the gauge was only superficially damaged with only a slight dent being visible on one end of the gauge. Had KDHE (Kansas Department of Health and Environment) been notified at the time of the accident on 8/14/2007 and been sent pictures, no response would have been required. The licensee understands, based on their letter, the need to communicate with KOHE regarding future incidents. No further action is required. This item was determined during the State of Kansas IMPEP (Integrated Materials Performance Evaluation Program) inspection conducted the week of June 14, 2010, that this event was reportable under 10CFR30.50(b)(2). An electronic update to the NMED database will follow. KS Event No.: KS070010 |
| ENS 46027 | 18 June 2010 17:13:00 | The State of Kansas provided the following information via facsimile: This event that occurred during the 4th quarter of 2006 at Wesley Medical Center, LLC, was determined during the State of Kansas IMPEP (Integrated Materials Performance Evaluation Program) inspection conducted the week of June 14, 2010, to be reportable under 10CFR2201. An electronic update to the NMED database will follow. Below are details of the event. During an inspection by KDHE (Kansas Department of Health and Environment) of Wesley Medical Center 2/14/2007, a review of the 4th quarter Radiation Safety Committee notes revealed that a brachytherapy source was lost for approximately 45 hours. From the inspector's notes: 'Incident where a Cs-137 brachytherapy source was lost for approximately 45 hours before being found in the sheets in the laundry room by the RSO (Radiation Safety Officer). RSO did not make a determination of exposure to the patient based on conservative and worst case scenarios. Incident was not reported to the State.' The RSO notes read: 'We had one recordable event that has been noted in the HNS system. We had one misplaced cesium 137 brachytherapy source. A patient presented for treatment of cervix cancer and we used low-dose Fletcher Suit system where the cesium sources dwell within the patient for 45 hours. The plan was reviewed and the patient was loaded. On the day of removal, one source was missing when the RSO emptied the tandems. Both physicists searched extensively for the source using a Geiger counter. The source was located on the floor in the laundry capture room for women's health. It was determined that the source never reached its destination in the patient, and that it most likely fell into the bed linens during insertion. One environmental service worker spends approximately five minutes per day having an approximate exposure of 1 mRem from that activity. A member of the public would be limited to 100 mRem of exposure per year and the exposure rate would be approximately 1.2 mRem per hour at 3 meters; some of the walls in the room are cinder blocks which provide some shielding. It was suggested that linen be left in the patient's room during their stay to guard against having an incident such as this in the future.' The licensee was issued a citation for failure to report this as a lost source. Update information provided during the week of June 14, 2010 indicated that the source activity was 37 mCi (15 mg Ra equivalent). KS Event No.: KS100006. |
| ENS 42349 | 20 February 2006 10:03:00 | Between Saturday February 18, 2006 and Sunday morning February 19, 2006, a Troxler (Model 3440, S/N 31113, containing two sources; i.e., 0.3GBq (8 mCi) Cs-137 and 1.48 GBq (40 mCi) Am-241:Be) moisture density gauge was stolen from the operator's residence. The residence was the normal storage location for this gauge. The gauge was stolen along with other equipment from the operator's residence. The event was reported to local law enforcement. Case Number: KS060001 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 41893 | 5 August 2005 14:31:00 | Kansas Department of Transportation workers transited from one worksite to another with a Troxler Moisture Density Gauge in their vehicle. When they arrived at their destination, they discovered that their Model 3440 Troxler Moisture Density Gauge (44 milliCuries Am/Be; 8 milliCuries Cs-137) was missing. Someone noticed a gauge on Fort Riley Blvd in Manhattan, KS, and notified the police and fire department. The DOT personnel had used Fort Riley Blvd to get to the second job site. When emergency personnel arrived at the scene, the gauge was gone. The KS DOT notified local law enforcement. The gauge was in its transportation container and the source was locked. KS Report Number: KS-050016
The Troxler Moisture Density Gauge was found late (2200 - 2300) on 08/05/05 near the location it was reported lost. Kansas Department of Transportation has custody of the gauge and it is not damaged. Notified R4DO (D. Powers) and NMSS (S. Moore) and emailed to TAS (R. Warren). |
| ENS 42503 | 14 April 2006 15:35:00 | The licensee provided the following information via facsimile: 06/03/05: High Bluff Operating, LLC reported The Rosel Company of Liberal, Kansas lost a logging tool downhole in Clark County, Kansas. The logging cable broke, and the tool dropped to a depth of 5866 feet. The tool was 'fished' from the hole, but the density pad broke off the tool and stayed in the hole. An experienced 'fishing tool expert' recommended that cement the possible source in place. (High Bluff) proposes: 75' of red dyed cement on top of the pad with a 'whipstock' device preventing reentry of the hole. Set 5740 feet of production casing to prevent deepening. Post at the wellhead a plaque noting the required Information. 06/04/05: (Kansas) replied to (High Bluff) and concurred with his plan. 11/01/05: (High Bluff) sent in his final report. Correct the final depth to 5856'. Modified the plan of action to be 5710 feet of casing and 146 feet of red dyed cement by Allied Cement. The plaque was still awaiting production and placement. 11/11/05: (High Bluff) reported the plaque was unacceptable, and a new plaque was being made. 03/22/06: Received cd-rom of digital pictures taken of well site, time stamped 03/13/2006. Plaque meets general requirements. Event considered closed. Source: 2 Curie Cs-137, Serial Number CSV-K98 manufactured by Gulf Nuclear Kansas Report Number: KS050022 |