Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 44080 | 20 March 2008 11:45:00 | The following report was received via email: N.C. Radiation Protection Section was notified 19 March 2008 of two (2) missing polonium-210 static elimination devices. Information on the devices is as follows: 1) NRC Model P-2021-8201, serial no. A2FC364, initially distributed on 22 Jun 2006, initial activity was 10 millicuries, decay-corrected activity (as of 18 March 2008) 0.415 millicuries 2) NRC Model P-2021-8201, serial no. A2FK529, initially distributed on 01 Dec 2006, initial activity was 10 millicuries, decay-corrected activity (as of 18 March 2008) 0.935 millicuries The information will be turned over to the General License Coordinator for further investigation. N.C. Radiation Protection has not received any media attention as of this report. No press release has been issued. Event Report ID No.: NC-08-13 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 43938 | 28 January 2008 15:09:00 | N.C. Radiation Protection Section was notified on 28 January 2008 by the RSO for ECS Carolinas, LLP Charlotte office that one of their portable moisture/density gauges (Humboldt Model 5001) was damaged at a construction site in Charlotte, NC. The gauge contains two sealed sources: (1) Cesium-137, 10 milliCuries (nominal) and (2) Americium-241:Beryllium, 50 milliCuries (nominal). Serial numbers for the gauge and the sources were not immediately available. The RSO responded and performed confirmatory measurements on the device using a hand-held GM survey instrument. The gauge handle was detached from the source rod and index rod and the case has some minor damage. The index remained attached to the gauge and the source rod remained within the shield. The RSO's survey confirmed that the Cesium-137 source is still contained within the shield. The licensee also performed a survey of the area where the gauge was initially struck and readings were at background levels (approx. 0.05 mR/hr). The readings at one meter from the gauge were approx. 0.4 mR/hr (consistent with the TI (Transportation Index)) and at one foot were approx. 2-3 mR/hr. The licensee has been in contact with the manufacturer and has received instructions on packaging and returning the device to Humboldt Scientific (Raleigh, NC). The device has been transported back to the licensee's storage facility and will be returned to Humboldt's Raleigh facility later this week. North Carolina has assigned Event Report ID No. NC-08-03. |
| ENS 43336 | 2 May 2007 09:39:00 | The State provided the following information via facsimile: Patient was scheduled for administration of 30 millicuries of 90Y (Yttrium-90) microspheres. The delivery catheter developed a leak during the administration. Leakage was mostly contained within the Plexiglas box containing the vial of microspheres. There was very minimal contamination outside of the box. Licensee performed bremsstrahlung measurements of the patient and the Plexiglas box. Based on differences, the administered dose was determined to be only 66% of the prescribed dose. Licensee noted that this was the first of a two part administration of the microspheres and the dose at the next treatment will be adjusted to compensate for the 'missing' activity. The device manufacturer (Sirtex) traced the leaky units to one operator who had deviated from the normal assembly procedure. Sirtex destroyed the remainder of that lot number and replaced them with a new, tested lot. NC Event Report ID number: NC-07-02 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. * * * UPDATE FROM C. FLANNERY TO P. SNYDER AT 1436 ON 5/02/07 * * * The NRC's medical events review committee has determined that this report is a medical event. Notified R1DO (Holody) and FSME (Morell) via e-mail. |
| ENS 42270 | 18 January 2006 17:38:00 | The State provided the following information via fax: N.C. Radiation Protection Section was notified on 18 Jan 2006 by the RSO for the Charlotte Mecklenburg Hospital Authority of a misadministration during a manual brachytherapy treatment. The authorized user's written directive called for a temporary implant 'tandem and ovoid' using Cs-137 sources to deliver a total dose of 4883 RAD (approximately 49Gy) over 68 hours, with following source loading in the applicator: Right Ovoid: 1 at 14.6 mgRaEq (milligram Radium Equivalent) (approximately 51.1 mCi or 1891 MBq) Left Ovoid: 1 at 14.6 mgRaEq Tandem: 1 at 11.2 mgRaEq (approximately 39.2 mCi or 1450 MBq), 2 at 14.6 mgRaEq A medical dosimetrist loaded the tandem and ovoid incorrectly. The actual loading of the applicator was: Right Ovoid: 1 at 14.6 mgRaEq (approximately 51.1 mCi or 1891 MBq) Left Ovoid: 1 at 14.6 mgRaEq Tandem: 1 at 11.2 mgRaEq (approximately 39.2 mCi or 1450 MBq), 2 at 24.8 mgRaEq (approximately 86.8 mCi or 3212 MBq) This errant loading of applicator resulted in the patient receiving 6474 RAD (approximately 65 Gy) to the treatment area. The delivered dose was 33 percent more than prescribed. The Cs-137 sources utilized in the procedure were: 3M Model 6503 (14.6 mgRaEq) 3M Model 6502 (11.2 mgRaEq) AEA Technology/QSA Model CDC.T1 (24.8 mgRaEq) The licensee is conducting follow-up investigations and will make a report the Radiation Protection Section within 15 days of the discovery of the event. The report will contain root cause analysis and procedures to prevent recurrence. N.C. Radiation Protection has not received any media attention as of this report. No press release has been issued. Event Report ID No.: NC-06-04 |
| ENS 41806 | 28 June 2005 17:06:00 | The State provided the following information via facsimile: The North Carolina Radioactive Materials branch was made aware of the loss (of) a Po-210 static elimination source from the Energizer facility in Asheboro, NC today. The agency interviewed the Staff Environmental Coordinator this afternoon via telephone. The information for the missing source is as follows: Isotope: Po-210 Activity: 20 millicuries as of 3 March 2004 (decay corrected to 2.38 mCi at time of loss) Make: NRD LLC Model: P-2031-1000 Serial No.: A2DP844 The licensee continues to search for the missing source. North Carolina Radioactive Materials Branch continues to monitor the situation and will dispatch health physicists to investigate as necessary. |