Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 48147 | 1 August 2012 13:34:00 | The following was received from the State of North Carolina via email: On July 31, 2012 a portable nuclear gauge owned by ECS of Raleigh (License Number 092-0253-1) was run over and crushed by a tracked dozer. The incident occurred off Caveness Farm Road in Wake Forest, NC. The gauge user stated that he had finished performing density testing for the day and was proceeding to leave the job-site. After exiting the job site and traveling the length of Caveness Farms Road to US Highway 1, he noted that his tailgate was down on his pick-up truck. He exited the truck to close the tailgate and noticed that the gauge was missing. He then traveled back to the job site and retraced his path to his testing location. He then observed the gauge approximately 100 feet from where he had been testing. Upon approaching the gauge he noted that it had been crushed by the dozer. The rod on the gauge was in the safe position with the source being shielded. A trigger lock was not present on the gauge at this time. The ECS RSO was notified and the user instructed the other workers in the area to remain at least 50 feet from the damaged gauge. They did. The ECS RSO arrived on the job site at approximately 3:00 pm. Upon arrival, he surveyed the damaged gauge with survey meter. A reading of 0.4 mrem/hr was noted at approximately 1 meter and a reading of 1 mrem/hr was noted on contact with the source. The RSO interviewed the dozer operator, who said that he did not see the density gauge in his path of travel but felt the gauge under the dozer as he traveled over it. He proceeded to a safe distance and notified his supervisor. He stated that moments later the ECS technician returned to the area of the damaged gauge. The RSO contacted the NC Radiation Protection Section and notified them of the incident. A NC RPS inspector was dispatched to the scene. Troxler Laboratories (gauge Mfg) was also contacted about the incident. When the NC RPS inspector arrived on the job site, he and the ECS RSO surveyed the damaged gauge. Once it was determined the gauge was safe to move, the gauge source rod and shield assembly was placed into the transport case. The rest of the gauge was collected and contained. After the pieces of the gauge were removed from the area where it was damaged, the area was surveyed and no reading over 0.03 mrem/hr were noted. The Inspector indicated that the sources had been recovered and the area was safe to resume work. Survey readings were taken of the transport case after the sources had been placed in the case. The highest reading was 70 mR/hr contact on the outside of the transport case at the end where the damaged source shield was located. The tungsten sliding block was damaged and was loose. Dose rates on the rest of the transport box were in the 0.1 range, with higher doses on the end. Dose at 1 meter (app) from the transport box end where the source was 0.2 mR/hr. At 6:00 pm the gauge was transported back to the ECS office. It arrived at the ECS office at approximately 6:45 pm and was stored in the appointed nuclear gauge storage location. The gauge was marked 'Do Not Use' and ECS technicians were instructed not to move the damaged gauge. ECS will take leak tests on August 1, 2012 and upon being notified of the results of the leak test, Troxler Labs will be notified of our intent to transport the gauge to their RTP location. North Carolina Incident NC 12-43. |
| ENS 47616 | 23 January 2012 16:42:00 | The following report was received from the State of North Carolina via email: A cancer patient undergoing therapeutic radiation treatment for gastric cancer received an exposure to the wrong treatment site. This error occurred using a HDR afterloader device with a radioactive source containing Ir-192. The event occurred after the dosimetrist made an error while correcting a change to dwell position due to catheter migration. The dwell position was mistakenly adjusted out rather than in. Two treatments were made prior to the error being detected. The error resulted in an approximately 4 cm positioning error, which caused the source to stop short of the target so that the total prescribed dose was not delivered. The patient was informed of the event, and received a correct third treatment as well as external beam therapy. Additional information will be provided as it is provided by the licensee. The intended treatment site was a bile duct which was to receive 700 cGy in three (3) fractions. The first two (2) fractions were delivered on 1/5/2012 and 1/12/2012 with the source mispositioned as indicated above. The Regional Inspector for the State of NC is following up. 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 47480 | 28 November 2011 09:17:00 | The following information was obtained from the State of North Carolina via email: On November 18, 2011, the RSO of Research Triangle Institute (RTI), License Number 032-0131-1, performed a leak test on a sealed source. The results of the leak test revealed greater than 0.005 microcuries of removable contamination. The leak test showed 0.00517 microcuries of removable contamination. Subsequent surveys continued to show elevated results. The survey was performed with a Packard 1900 TR liquid scintillation counter, S/N 103761, calibrated Aug. 24, 2011. The source was a Ni-63 Electron Capture source. It had been removed from service and placed in storage in 2008. The source was being leak tested to prepare for disposal. Upon determination that the source was leaking, the RSO double-bagged the source, removed it from storage and segregated it, and contacted the waste broker for instructions on source disposal. The RSO performed contamination surveys of the storage area and the area is clean. Source information: Isotope: Ni-63, Quantity: 11.3 mCi, Mfg: Franklin GNO Corporation, Drawing No: 801-023, Serial Number: 37, Source date: October 20, 1975 The licensee met all reporting requirements for the 5-day notification of a leaking source and is preparing a report with additional information. |
| ENS 47276 | 18 September 2011 13:42:00 | The following information was received via e-mail: On September 7, 2011, the licensee discovered a failure of the locking mechanism of a QSA 880-Delta radiography exposure device. This is a 30-day notification event. Device: 880 Delta. S/N: D7822. During the installation of the 880 camera, it was discovered that the locking mechanism would not return to the 'Stored / Locked' position. While investigating the malfunction, it was determined that possibly one of the springs in the locking mechanism was bad. The manufacturer (QSA Global / Sentinel) was called and the malfunction was explained and it was requested that the camera be sent back for further investigation and correction of the malfunction. This camera did not have a radioactive source in it or attached to the drive cable at the time of the malfunction discovery. This is a brand new 880 Delta camera and has not had a radioactive source in it. The source to be installed in the camera is being stored in a 650L changer, serial number 2168 and secured in (the licensee's) radiography booth. The RSO was the only person in the radiography booth when the malfunction was discovered and no potential exposure occurred. Updates will be provided through NMED. North Carolina Incident Number: NC 11-48 |
| ENS 47000 | 30 June 2011 13:39:00 | The following was provided by the State of North Carolina via e-mail: A Troxler portable nuclear gauge belonging to Kam Engineering Services was run over by a smooth drum roller and has been damaged. The event occurred near the intersection of Normandy Street and Half Street in Fort Bragg, NC. Fort Bragg is under a NRC license and the licensee should be working under reciprocity. The licensee does not possess any survey instruments but they have an agreement to borrow one from Troxler (RTP, NC.) Someone has been dispatched to Troxler to get a meter and to take it back to the accident site. The RSO is on-site and has cordoned off a 20 foot circle around the gauge. The licensee will notify the State of North Carolina when additional survey results are available. The gauge contained 9 milliCuries Cs-137 and 44 milliCuries of Am-241.
The RSO called (the state). The area was surveyed and the dose rate at the 20 ft boundary was 0.02 - 0.04 mR/hr. The RSO worked his way toward the damaged gauge and the readings remained constant. At 1 meter, the reading was still 0.2 mR/hr (Transport Index) On contact, the gauge was about 7 mR/hr. The RSO repositioned the gauge and sent pictures to Troxler. Troxler said it appeared that the tungsten blocks were still in place and there was no damage to the source shielding. The RSO (per Troxler instructions) then placed the gauge in the transport box and locked it. The damaged gauge is being transported to the company office tonight and will be transported to Troxler tomorrow. Notified R1DO(Welling) and FSME(Jackson) Incident NC 11-35. |
| ENS 46865 | 20 May 2011 11:32:00 | The following information was received from the North Carolina Radiation Protection Section via e-mail: On May 18, 2011, an employee of S&ME parked a company truck at his house. The truck had a Troxler 3411B Portable Nuclear Gauge double locked in an aluminum box in the bed of the truck. The next morning, he discovered the truck missing. Company management was notified, who in turn notified Local Law Enforcement and the agency (State of North Carolina). About 15 minutes after the Agency notification. the police determined that the vehicle had been towed. The explanation for the towing of the vehicle was that the vehicle, which was in front of the employees residence, had its wheels on the grass. The vehicle was retrieved from the towing company. The gauge was still locked in its storage box and appeared untouched. Device/Material Info: Troxler 3411B S/N 13772 Cs-137 S/N 50-2590 9 mCi Am-241 S/N 47-9185 44 mCi 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 46602 | 8 February 2011 13:51:00 | The following information was received from the State of North Carolina via email: A patient undergoing a HDR (High Dose Rate) brachytherapy procedure received an under dose on three fractions. The guide tubes were misaligned which resulted in a 5 cm displacement from the source plan. This misalignment resulted in a 59% difference in dose (under dose) to the intended site and an overexposure to other tissue. The patient has received three of ten exposures and the plan will be re-worked to mitigate the under dosage of the intended site. The patient has been notified and they are trying to contact the prescribing physician to notify him. An investigation has been initiated to determine the cause of this event and corrective actions. 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 46389 | 3 November 2010 13:43:00 | The following report was received from the State of North Carolina via email: The patient has persistent small cell lung cancer after chemotherapy, in an area that has received prior external beam radiation therapy, and was symptomatic. Therefore, a course of endobronchial brachytherapy with a high-dose rate unit (HDR) was recommended to the left upper and left lower lobe bronchus where the tumor was present. The treatment prescription was 10 Gy x 2 fractions to the target volume as defined in the planning CT. The first treatment was delivered between 2 to 3 pm, on Oct 22, 2010. Unfortunately, due to errors in defining the starting dwelling positions of the source during the treatment planning, the actual dose was delivered to the wrong location along the catheters. Details of the process are described below. After two endobronchial catheters were placed under bronchoscopy in the OR (operating room), the patient was transferred to Radiation Oncology Department where a CT was obtained for treatment planning purposes. The two catheters were positioned correctly based on CT. In the first step of the treatment planning, the locations of the two endobronchial catheters were correctly identified in the CT images. The direction of the catheters was mistakenly reversed afterwards during the treatment planning, thereby changing the starting position of the HDR source. Therefore, instead of the patient being treated correctly to the identified tumor region in the left-sided airways, she was treated to a position more proximally along the path of the catheters (the larynx area). Although the plan was checked by a number of qualified physicists per operational protocol, the subtle orientation error was missed, both in the plan check and in the delivery check. The wrong treatment was delivered around 2:45 pm. The error was identified by the planning physicists when they were working on another patient case, about one hour after the patient's treatment. A computerized 3-D plan was generated to calculate the actual location and dose delivered due to this error. The estimated dose to the neck region was about 15-20 Gy. The plan delivered to the patient was also delivered on radiochromic film to confirm the location of the delivered dose. The attending physician, clinical director, and the director of physics were all notified immediately after the error was identified and confirmed. The Radiation Oncology Department chair was notified by the clinical director. The Radiation Safety Officer was notified also by the chief physicist. The attending physician reviewed the case and the dosimetry, and immediately tried to contact the patient. After several attempts the patient was reached around 6:00 PM and asked to come back to the hospital immediately for observation and prophylactic treatments. The patient was admitted to hospital around 9:00 PM on the same day (the time required for her to travel back to Duke from her home). Licensee's evaluation of why the event occurred: a. Staff physicists were more focused on dose optimization and missed the catheter's orientation. B The wrong orientation was again missed during the plan and delivery checks. C. In addition to calculation checks, there was no experimental check, i.e. delivering dose to the film to verify the distance. The effect, if any, on the individual(s) who received the administration: The patient was admitted to Duke Hospital immediately after the error was discovered. She remained hospitalized for 4 days during which time she remained relatively asymptomatic. She did not develop increasing hoarseness, shortness of breath, or odynophagia. She underwent fiber optic laryngoscopy 36 hours after her treatment which showed minor edema of the supraglottic larynx but no airway compromise. She received the correct treatment while an inpatient, and after one additional day of observation was discharged home. What actions, if any, have been taken or are planned to prevent recurrence: a. Conducted a root-cause analysis of the event among the physicists. B. A new and more detailed standard operational procedure (SOP) for this type of treatment was generated by the members of the Brachytherapy team. C. The existent HDR Patient QA form was edited to add extra check levels that will prevent this error from happening again. D. A new verification procedure was added to the existent set of verification procedures. It involves the delivery of the treatment on Gafchromic film or alternative imaging device to verify the exact starting point of the treatment. This film will be compared with the plan and will have to be approved by two physicists and the attending for each case. Certification that the licensee notified the individual (or the individual's responsible relative or guardian) and if not, why not: The patient was contacted, was returned to Duke and was admitted for evaluation and management. Log # NC 10-47 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 46071 | 6 July 2010 11:17:00 | The following information was received from the State of North Carolina via email: On 05/05/10, a physician at Iredell Memorial Hospital (NC License 049-0412-2) performed a prostate seed implant procedure. The prescribed dose was 1440 cGray (~1440 REM). After the seeds were implanted, they did a scan and discovered a seed in the urethra. They removed the seed and it was part of a strand of four seeds. On 05/19/10, the patient returned for a follow-up and had an additional strand of three seeds. The patient said the seeds had come out during urination about a week before. The patient went through the post-implant CT scan. On 07/02/10, the post-dose calculations were performed. The D-90 actual dose (dose to 90% of the mass) was calculated as 77% of the prescribed dose. The hospital has made the notification (to the North Carolina Division on Radiation Protection) and is attempting to make the physician and patient notification. A report will be prepared and delivered within 15 days. State Event No.: NC 10-32 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 45342 | 11 September 2009 14:05:00 | '(A) contaminated package (was) received at Mission Hospital from Cardinal Health - Asheville. The RSO (Radiation Safety Officer) of Mission Hospital received a shipment of Tc-99 unit doses from Cardinal Health pharmacy. The exterior of the box was contaminated to (approximately) 180,000 dpm/100 (square centimeters). Upon determination of the contamination, Mission Hospital contacted Cardinal Health pharmacy and they came and picked up the box. Mission Hospital did not open the box. After the box was picked up, a small spot of contamination was found on the absorbent paper that the box had been placed on. Mission Hospital removed the paper, which removed the contamination, and placed it as waste into their decay-in-storage area. This level exceeds the reportability limit of 22,000 dpm/100 (square centimeters) of 15A NCAC (North Carolina Administrative Code) 11.1627; which references 10 CFR 71.87; which references 49 CFR 173.443. 15A NCAC 11.1627(d) requires an immediate notification to the (North Carolina Radiation Protection Section) Agency. North Carolina Incident 09-43. |
| ENS 45257 | 11 August 2009 14:50:00 | The State of North Carolina discovered 2 missing static eliminators containing 500 microCi of Po-210 and 80 microCi of Am-241. The licensee was billed for the annual fees related to these gages and notified the State that they no longer had the gages in their possession. The State sent an inspector to investigate the situation. The inspector discovered that the manufacturing facility had been relocated to Vietnam 3 years ago. When this occurred the licensee believes it is possible that the sources were relocated with the majority of the manufacturing facility assets to the Vietnam location at that time. The State is continuing to follow-up with the licensee to determine disposition of these sources. * * * UPDATE ON 8/13/09 AT 1022 EDT FROM BARNES TO HUFFMAN * * * A representative of the State of North Carolina provided the following additional information about the lost sources: The Am-241 source was manufactured by Pyrotronics. Model number F315A. Serial Number 1000635. Date received - 1971 The Po-210 source was manufactured by Nuclear Products. Model number 2U500. Serial Number Unknown. Date received - 1989 R1DO (Cook) and FSME (McIntosh) have been notified of this update. 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 45253 | 10 August 2009 13:55:00 | The following was received from the state via email: On August 7, 2009, the Agency (State) was notified by the licensee RSO (Radiation Safety Officer) of a possible leaking source discovered during a routine leak test. The source is a 25 mCi Sr-90 source (as of 07/93). The RSO said he is used to seeing approximately 75 dpm on the wipe, but this time the wipe was 323 dpm. Since this level is below the report limit of .005 uCi (11,000 dpm), no report was made. An (State) Agency inspector was in the area and said he would stop in to investigate. The inspector arrived and discovered that the source is leaking. A contact reading using a Ludlum 14C with side window GM (Geiger Muller) was off scale high. The four swipes of the source were checked with the Ludlum 14C with pancake GM probe. The swipes/Q-tips read 0.3, 0.5, 0.7, and 1.1 mr/hr on contact. The Q-tips are contained in individual plastic zip-top bags. A swipe of the source holder did not yield any removable contamination. The background in the area is <0.1 mr/hr. The sources are in the source manipulation/storage room and all sources are in storage. The licensee is planning to terminate their license in the next few weeks and has been in contact with DOE (Department of Energy) to take possession of their sources under the orphaned source retrieval program. The notification is being made per NC Regulations 15 A NCAC 11 .0357(b)(1)(B) an unplanned contamination event involving RAM exceeding 5 times 10 CFR 20.1001 - .2401 Appendix C values (the Appendix C value for Sr-90 is 0.1 microcuries) as well as .0357(b)(2)(A) equipment fails to function as designed when it is required to prevent releases exceeding regulatory limits. This is a 24 hr notification event. The investigation is ongoing and updates will be provided as information is obtained. NC-Report #: 09-35 |
| ENS 45120 | 10 June 2009 09:54:00 | The following information was received via facsimile: The device is a product fill level gauge that was on a line that was being disassembled and cleared out. (Proctor & Gamble) P&G had told the contractor to leave the part of the line with the gauge until Industrial Dynamics (their consultant for radioactive materials) had a chance to remove the device from the package line. However, the device was not removed and the line was sent off for disposal. The device was physically removed from the site on or about May 28, 2009. The Licensee discovered the (device to be missing) on June 9, 2009. The disposed-of material was sent to DH Griffin (a scrap yard) in Greensboro, NC. DH Griffin has been contacted and they are in the process of sorting and searching for the device. They say there is a good chance that the device is still at the scrap yard as the material received from P&G should be in one of two piles still at the yard. (The State of North Carolina) asked P&G if they needed any assistance and (P&G) said no, at this time. The device is an Industrial Dynamics FT-50 Filtec device used to measure the fill level of liquid products. The source is an Am-241, 100 mCi source. Gauge S/N: 110585, Source S/N: 3770. The source was leak tested in Sept. 2006 and it was not leaking at that time. The North Carolina Incident number is NC-09-25.
D.H. Griffin contacted P&G (at) 10:15 am. They informed P&G that they had located the Filtec unit on site. (An employee of P&G) drove to the D.H. Griffin site (and) verified that it was their Filtec unit. The unit is now isolated on a pallet and secured in a warehouse at D.H. Griffin. P&G is in contact with their Industrial Dynamics regional resource to arrange to have the source removed. They will keep (the State) informed as to the progress on the removal of the unit. 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 45288 | 24 August 2009 13:29:00 | On June 1, 2009, licensee personnel were performing radiography when the projector fell on the guide tube while the source was exposed, preventing the source from being retracted into the shield. Licensee personnel tried to retract the source but were unsuccessful. The area was secured and monitored until a source retrieval team could be assembled and arrive on site. On June 2, 2009, the source retrieval team arrived and performed the source retrieval. The damaged guide tube was replaced and tested and the camera operates properly. The radiographer received 325 mRem by dosimeter and the radiographer's assistant received 38 mRem. No overexposure is anticipated. The incident was reported to the Agency within the 30 day reporting time. However, the received report was misplaced until August 24, 2009. Incident Number: 09-40 NMED Number: NC090040 |
| ENS 44979 | 9 April 2009 13:48:00 | The following was received via facsimile: N.C. Radiation Protection Section was notified of a misadministration involving Y-90 microspheres. The licensee reports that the administered dosage was 24 percent less than the prescribed dosage. Licensee reports no equipment malfunction and no leakage of radioactive material from the delivery device. Licensee has notified patient and there are no plans to perform a second administration. Licensee is contacting vendor to assist in investigation. N.C. Radiation Protection has not received any media attention as of this report. No press release has been issued. The North Carolina Event Report ID Number for this event is NC-09-22. 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. |