Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 49035 | 15 May 2013 13:49:00 | On April 24, 2013, The Colorado Department of Public Health and Environment (Department) received notification from the Mesa County Landfill located in Grand Junction, Colorado, that a load of trash had alarmed the gate monitor. The roll-off in question came from a residential spring clean-up event sponsored by the city of Grand Junction. That same day, a member of the Department responded to the alarm and the roll-off was moved to a secure location after an initial radiation survey on the outside of the roll-off had been completed. On May 7, 2013, members of the Department examined the contents or the roll-off and a small section of plastic pipe (1 foot length) and a small source bound with tape were identified. It appeared that the source had been taped to the side of the plastic pipe at one time, and the word 'source' was written on the pipe. Using an Identifinder multi-channel analyzer, the isotope was identified as Ra-226. Dose rates were measured at greater than 200 millirem per hour on contact with the source (the limit of the inspector's instrument), and 10 millirem per hour at 1 foot. The dimensions of the source appeared to be approximately 3 mm by 2 cm. The source is currently stored in a secured location. The Department is conducting an investigation, and a press release is being issued to encourage anyone with information about the source to contact the Department.
The following information was received by email: Following the initial event notification on 5/15/13 regarding a found Ra-226 source in Grand Junction, CO, the Colorado Department of Public Health and Environment issued a press release that requested anyone with additional information to please contact the DOH. Several days later a member of the public contacted DOH with a possible lead. Using that information, inspectors were able to trace the source back to a private residence in Grand Junction. On 5/24/13, inspectors visited a house in a residential neighborhood and found additional radioactive materials in the attached garage. However, the inspectors were not permitted to enter the residence. Radioactive materials found included 2 more Ra-226 sources and a half dozen small jars containing an unknown radioactive powder, which appeared to be uranium mill tailings. The radioactive materials were removed by the inspectors and taken to a secure storage location where additional measurements/analysis can be conducted. The elderly female resident at the house told inspectors that her late husband and his business associates manufactured Geiger counters during the uranium boom years. Additional information will follow as it is obtained." Notified R4DO (Azua) and FSME Resources 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 47738 | 13 March 2012 17:39:00 | A radiographer working for High Mountain Inspection was conducting radiography on a pipeline near De Beque, CO. The radiographer failed to secure the camera in his pickup truck when he drove off to the next location. Arriving at his destination the radiographer realized his camera was missing and retraced his steps. The radiography camera with a 26 Curie, Ir-192 source was not located. At 1826 EDT the State of Colorado called and said a member of the public had found the missing camera and called the licensee. The licensee is now in possession of the radiography camera and the source has not been tampered with. The camera is a SPEC, s/n 150. The source s/n is SJ0702. THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 47043 | 11 July 2011 16:50:00 | The following was received from the state via fax: The Colorado Department of Public Health and Environment received notification this date from The University of Colorado Hospital, Colorado License # 828-01, that a patient received the wrong dose of I-131 on July 8, 2011 resulting in a dose that exceeded prescribed by 50 rem and 50% of the dose expected from the administration defined in the written directive. The patient was prescribed 20 mCi of l-131 for Graves disease, but instead received 100 mCi of I-l31, which was intended for another patient. The patient was discharged before the error was discovered. The patient's physician and the patient have been contacted and made aware of the situation. The patient has been given additional instructions regarding contact with family members and members of the public. No other details are available at this time. The Colorado Department of Public Health and Environment has initiated an investigation. 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 46635 | 22 February 2011 15:09:00 | The state of Colorado submitted the following information via e-mail: On 2/21/11, a medical licensee, St. Mary's Hospital in Grand Junction, Colorado (CO License # 14-03), notified the Department that they received a package containing medical isotopes that was externally contaminated in excess of reporting limits. The package originated from NuQuest Pharmacy (CO License # 1022-01) also located in Grand Junction, Colorado. Hospital staff reported that the package, which contained about 50 millicuries of I-131, was intact but had about 1 microcurie of external contamination present. Hospital staff immediately notified the RSO at NuQuest who was able to contact their driver and perform contamination surveys, which were negative. NuQuest's RSO conducted an investigation and reported that the driver, who also works at the pharmacy as a helper, is a new employee. The RSO believes that the new employee must have forgotten to change his gloves after handling some I-131 waste, and touched the package before it was loaded into the vehicle. The RSO stated that he provided additional training to the new employee as a corrective action. Also, as a precaution, the RSO plans to perform a thyroid scan to verify that there was no uptake of I-131 by the new employee. No other details are available at this time. |
| ENS 45787 | 24 March 2010 12:30:00 | The following information was obtained from the State of Colorado via facsimile: The Department received notification on March 23, 2010, of a fetal exposure in excess of 500 milliRem from a PET/CT Scan. The licensee, PET Imaging of Northern Colorado, License No. 1105-0, is located in Fort Collins, Colorado. The licensee reported that on December 14, 2009, a female patient received 17.4 mCi of F-18 and underwent a PET/CT scan. The patient had indicated that she was not pregnant on her medical history questionnaire and told the technologist she was not pregnant prior to the scan. Later, the patient's physician notified the licensee that the patient was indeed pregnant at the time of the scan. A consulting medical physicist calculated the total dose to the fetus from the PET/CT scan as 2.6 Rem (26 mGy). However, the medical physicist did not report the individual dose from the F-18 component alone, and this information has been requested from the licensee. The licensee's authorized user physician reported that the risk of abnormality for the fetus is considered to be negligible per the guidance from the American College of Radiology Practice Guidelines. No other details are available at this time. * * * RETRACTION FROM ED STROUD TO PETE SNYDER AT 1550 ON 4/6/10 * * * The following information was obtained from the State of Colorado via facsimile: Following a full investigation of the incident, the fetal exposure was determined to be below the NRC's reporting requirement of 5 REM. Notified R4DO (Proulx) and FSME EO (VonTill). |
| ENS 45054 | 11 May 2009 15:31:00 | The State of Colorado sent this report in by fax. On 5/7/09, the Department received a request for assistance from a private citizen regarding the disposition of a load of scrap metal that he sent to a scrap metal recycling facility. The load was rejected after it tripped the gate radiation monitor. On 5/8/09, representatives from the Department went to the owner's site to investigate. After sifting through the pile of scrap, a radium source was found. The source, which was approximately 2 inches (in) diameter and 0.25 thick, had a glass face and appeared to be some type of light source. The back of the source was stamped with the following, 'USRC, UNDARK, 22MTTR58, Poison Inside.' The source was reading approximately 35 millirem per hour on contact and 0.3 millirem per hour at one foot. No removable contamination was detected by wipe test. The owner, who was cleaning out an old building on the property, did not know where the source came from. The source is currently being stored inside a locked, empty building on the property pending disposition. No other details are available at this time. |
| ENS 44628 | 4 November 2008 10:42:00 | During a routine inspection at Rocky Mountain Cancer Centers, Colorado License, two fetal overexposures were identified that had not been reported to the Department. The first case occurred on 8/23/05, and involved a PET/CT scan where the patient was injected with 16.3 mCi of FDG (F-18). After the procedure, the patient discovered she was pregnant. The fetal exposure was estimated to be 1.5 rem. The licensee determined the risk of congenital abnormalities to be negligible. The second case occurred on 11/28/06 and also involved a PET/CT scan where the patient was injected with 11.9 mCi of FDG (F-18). After the procedure, the patient discovered she was pregnant. The fetal exposure was estimated to be 1.02 rem. The licensee determined the risk of congenital abnormalities to be negligible. No other details are available at this time. Additional information will be reported through NMED as it becomes available. |
| ENS 44591 | 22 October 2008 14:57:00 | The state faxed the following report We (state) received a phone call today from the RSO of Acuren Inspections (RML- 997-01). On October 21, 2008, a two-man crew was making radiography shots at a field location near the intersection of County Roads 59 and 70, east of Eaton, CO. The incident involved an Amersham 660 camera, with an Ir-192 source with an estimated 24 Ci of activity. While making a shot, the pipe fell and resulted in a kink in the guide tube that prevented the source from being retracted. The crew cranked the source back into the collimator and called the RSO, who responded. Upon arrival, the RSO placed bags of shot over the collimator and used pliers to straighten the guide tube and safely retract the source into the camera. The RSO received a dose of zero mrem. The radiographer had a total dose for the day of 20 mrem, and the assistant had a total dose for the day of 68 mrem. A written report is being prepared by the licensee and will be forthcoming. Incident Report I08-019 |
| ENS 44033 | 5 March 2008 16:14:00 | The State provided the following information via facsimile: A medical licensee notified the Department of a misadministration during a Y-90 microsphere procedure, The problem was identified at the conclusion of the procedure when staff noted that 50% of the Y-90 microspheres were still in the application kit, resulting in a 50% underdose to the patient. The licensee's medical physicist, who is investigating the incident, was unsure if the problem was caused by a faulty injection valve or human error (e.g.. The valve was turned to the wrong position during the procedure). The licensee is Skyridge Medical Center Denver, CO, License 1053-01. No other details are available at this time. The Department has initiated an investigation of this incident.
The NRC has reviewed this event and determined it to be a reportable medical 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 43547 | 3 August 2007 13:25:00 | The State provided the following information via facsimile: This is the initial notification for an incident that was reported to this Department (State of Colorado) on this date. A research licensee reported the loss of a custom source containing approximately 120 microcuries of Am-241. The source, a stainless steel tube approximately 6 inches long and 1 inch in diameter, was manufactured by NRD with model number A001, and was used as an air stream ionization device contained in aerosol and gas-phase measurement instruments. The Am-241 is plated on a foil within the tube. The licensee reported the last known use was in March 2006. However, the licensee moved to a new location in December 2006, and the RSO stated that it is possible the source was lost at that time. The licensee reported that all efforts to locate the source have failed including a search of their former use location. No other details are available at this time. COLORADO Incident #: I07-12 THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| ENS 43496 | 17 July 2007 11:49:00 | The State provided the following information via facsimile: This is the initial notification for an incident that occurred on 7/11/07. A broad-scope licensee reported the loss and recovery of a 50 mCi, Am:Be source from a CPN Model 503DR soil moisture gauge. The gauge was being used as part of an irrigation/moisture study in an agricultural field located about 10 miles south of Sterling, CO. The licensee reported that the source/detector assembly became disconnected from the cable during use, and fell to the bottom of a test hole. The gauge users notified their RSO, and he was able to respond to the scene, retrieve the source, and place it back into the shielded position within the gauge using a remote handling tool. There were no radiation exposures to the gauge users or members of the public, and the RSO estimated his exposure to be less than 20 millirem. The licensee has contacted the manufacturer and is investigating the cause of the problem. |
| ENS 43304 | 16 April 2007 14:49:00 | The licensee provided the following information via facsimile: This is initial notification that the Department is investigating an incident involving licensed radioactive material that was discovered at a (Grand Junction, CO) landfill on 4/13/07. Apparently, a licensee using radioactive materials for subsurface well tracing activities lost control of 4-10 bottles of resin bead waste containing Ir-192. Radiation readings taken on the waste containers indicated about 2 millirem per hour at one meter. The company believed to be responsible for the waste, Protechnics, responded to the scene and removed the material to their facility for decay. So far, there is no indication that any members of the public were exposed to radiation in excess of established limits. An investigation is in progress. |
| ENS 43006 | 22 November 2006 14:17:00 | The State provided the following information via facsimile: A licensee, TSA Systems, Ltd., Colorado License #285-01, notified the Department on this date that a 2.1 microcurie Cf-252 source was missing. The source, manufactured by Isotope Products Laboratories, is a Model A3014 with Serial #B2-833. The licensee's representative stated that they continue to search their facility for the source which is used for instrument response checks and calibrations. No other details are available at this time. The Department has initiated an investigation. 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 42519 | 21 April 2006 14:31:00 | A licensee, Hazen Research, Inc., Colorado license # 77-02, notified the (Colorado Department of Health) that 4 generally licensed Tritium exit signs were accidentally disposed of in the sanitary landfill during a building repair project. Apparently, an electrical contractor disposed of the exit signs in a dumpster after they were removed and replaced with new signs in February or March of this year. The error was discovered on April 6. The signs, Isolite Model: 2040-50G-10BK, were purchased in May of 2001, and contained about 7.5 Ci of Tritium each. No other details are available at this time. The (Colorado Department of Health) has initiated an investigation of this incident. 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 42296 | 31 January 2006 09:19:00 | The State provided the following information via facsimile: The Department received notification at 3:00 pm on 1/30/06, from the RSO at Kumar and Associates, Colorado License # 778-01, that one of their Troxler Model 3430 moisture/density gauges had been stolen from a construction site in Westminster, Colorado. Apparently the technician, who was using the gauge at the construction site, left it unattended for 5 minutes, and discovered it missing when he returned. Local police were notified and responded to the scene. The gauge was found, undamaged, in a field at the construction site a short time later. No public exposures are expected from this incident. The Department is investigating. 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 41950 | 26 August 2005 13:59:00 | The State provided the following information via facsimile: A well logging licensee notified the (Colorado Department of Health) on 8/26/05, that one of their well logging vehicles was involved in a roll-over accident in Colorado on Monday, 8/22/05, resulting in the spill of a small quantity of Scandium-46. No other vehicles or personnel were involved. The licensee, ProTechnics, of Trinidad, Colorado, License Number CO-545-01, stated that the accident occurred in a remote area on state highway 550, south of Ouray, Colorado. Emergency vehicles responded to the scene, and the driver was taken to a local hospital with minor injuries. The licensee sent additional personnel to the site with survey meters, and they assisted with the clean up. They reported that the shipping container was ejected from the vehicle, and broke open. They reported that they were able to clean up all of the spilled material, except for one spot that was reading 15 (millirem per hour) on contact. The spot was located in a remote area, several feet to the side of the road. No other details are available at this time. The Department has initiated an investigation of this incident, and arrangements are being made to perform a confirmatory survey of the area. |
| ENS 41695 | 12 May 2005 17:23:00 | The State provided the following information via facsimile: The Colorado Department of Public Health and Environment received notification on 5/12/05 of a radiography equipment malfunction resulting in a stuck radiography source. The radiography company, Midwest Inspections, located at 325 Walnut Street, Brighton, Colorado, with the Colorado license number 902-01, reported that a radiography crew was unable to retract a radiography source back into the shielded position while working at a temporary job site near Byers, Colorado on 5/11/05. Per the company's RSO, the crew secured the area and contacted him for assistance when they were unable to fully retract the source. He traveled to the site with shielding equipment and was able to free the source and return it to the shielded position. The cause of the problem is reported to be a dent in the guide tube under the 'bend restrictor' where it was not easily visible to the crew. The RSO reported no excessive exposures to the crew, the public or himself (he estimated an exposure of 50 millirem to himself). Initial corrective action was to remove the defective guide tube from service.
This update provides information that was originally contained in EN 41769 which has been deleted and provided as an update to the original report. The State provided the following information via facsimile: The exposure device involved was INC Model IR-100 s/n 4035 with a 38 curie Ir-192 source s/n G862. The RSO attempted to retract the source and encountered the same problem as the crew. The source assembly seemed to hang up as it entered the exit port of the camera. The RSO attached a 0-500 millirem pocket dosimeter to his wrist watch on his left hand to measure any exposure to the hands during the following process. He cranked the source into the collimator and placed (2) 25# lead shot bags over the collimator for shielding. Using a pair of 12 inch channel lock pliers, he disconnected the source tube from the collimator. Keeping the source assembly in the collimator and shot bag shielding, he exposed the drive cable and source pigtail connector. After disconnecting the source pigtail connector and drive cable, he disconnected the exit port end of the source tube from the camera and slid the source tube off of the drive cable. The source tube was replaced with a new one and reconnected to the source assembly. The RSO then retracted the source into the camera. The crew x-rayed the remaining welds while RSO remained on site. The RSO's total whole body exposure was 50 millirem and the dosimeter on his wrist indicated an exposure of 220 millirem. Inspection of the source tube showed a kinked area next to the exit port fitting which apparently would not allow the locking ball on the pigtail assembly to pass back through it. Notified R4DO (Whitten) and NMSSEO (Holahan) |
| ENS 41251 | 10 December 2004 15:35:00 | Colorado Department of Public Health and Environment received a report from a licensee, Ground Engineering Consultants, that they had possibly lost a Model 3440 Troxler Moisture Density Gauge containing an 8 milliCurie Am: Be source and an 8 milliCurie Cs-137 source. The technician transporting the gauge failed to properly secure the gauge in the back of his vehicle. When the technician discovered the gauge missing, he backtracked and found pieces of the gauge on Arapahoe Road in metropolitan Denver. At the time of discovery, the licensee determined that the sources were intact in the shielding base on radiation surveys. Upon further investigation, it was discovered that the Cs-137 source was missing. The licensee and technicians from the State of Colorado are currently searching the area for the lost source. The State of Colorado will provide an update on the results of the search.
Colorado Department of Public Health and Environment (CDPHE) informed the Operations Center that attempts to locate the missing source have proven unsuccessful. CDPHE Public Affairs has issued a press release to inform the public of the missing source and how to proceed if the source was found. CDPHE will provide an update to this event as necessary. Notified R4DO (Smith), NMSS EO (Giitter), HQPAO (Burnell and Brenner). R4PAO (Dricks) and DHS.. |
| ENS 40898 | 27 July 2004 12:42:00 | Yesterday, July 26, 2004, Colorado State University, a Colorado licensee, notified the Department that a source used in one of their panoramic irradiators became stuck in the exposed position during a routine service check. The University's Radiation Safety Officer locked and posted the irradiator room to prevent further entry. The room was designed for irradiator use, so, there is no potential for exposures to staff or members of the public. The maker of the irradiator, JL Shepherd, was notified, and a plan is being developed to manually move the source to the shielded position. Location: Colorado State University, Fort Collins, Colorado License: Colorado # 002-27 Irradiator: JL Shepherd Model #354 Source: Amersham, Cs-137, 21.7 Ci |
| ENS 40935 | 10 August 2004 09:20:00 | The Department (of Public Health for Colorado) received notification from a company that a generally licensed exit sign containing tritium was lost. The company, State Farm Mutual Insurance Company, located in Greeley, Colorado 80638, stated that the sign was discovered missing, in July of 2004. The sign was taken down during a remodeling project in 1996, and was supposedly placed into storage. However, recent attempts to locate the sign have been unsuccessful. A representative from the company stated that they now believe the sign was disposed of at the landfill along with the rest of the construction debris. The sign is a Brandhurst (SRB) Luminexit, Model B100, S/N 552371, that contained about 25 curies of tritium when new (1993). The sign was obtained under the provisions of a general license. |
| ENS 40470 | 23 January 2004 14:36:00 | When film badge dosimetry for December 2003 was processed, it was determined that a radiographer, employed by an inspection firm in Utah but working in Colorado, received an annual radiation dose of 5.035 Rem for the year ending 12/31/03. The radiographer claimed, however, that his film badge had fell on the ground during radiography such that the dose was not actually received. No additional information has been provided at this time. |