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| Entered date | Event description | |
|---|---|---|
| ENS 50633 | 21 November 2014 17:25:00 | The Department (Colorado Department of Public Health and Environment) was notified via e-mail that a patient discovered she was pregnant after undergoing a PET examination. Dose is estimated to be on the order of 1 - 1.5 rem. A written report is expected within 15 days. No other information is available at this time. Colorado Event Report ID No.: CO14-014-01 |
| ENS 50489 | 24 September 2014 16:37:00 | The following report was received from the State of Colorado via email: Event description: The department (Colorado Department of Public Health and Environment) was notified via phone on 9/23/2014, at approximately 1845 (MDT) by the Radiation Safety Officer (RSO) of Premier NDT Services, Inc. (license # CO 1162-01) that a radiography crew was unable to retract the source assembly to its fully shielded position and secure it in this position at a temporary job site. At approximately, 1900 (MDT) on 9/23, the RSO reported to the department (Colorado Department of Public Health and Environment) that the source had been retracted to it fully shielded position by working the crank back and forth a few times. It was about a quarter turn to get the source into position and have the exposure device lock engage. The source was not fully extended outside of the camera but was in the camera enough to close the outlet port cover. The radiography camera was surveyed and it was determined that the source was in fact in its fully shielded position prior to transporting the camera back to the licensee facility. The department (Colorado Department of Public Health and Environment) visited the licensee facility on 9/24/14, at approximately 0930 (MDT) and interviewed licensee staff including the radiography crew. It was determined that the radiography assistant had not properly surveyed during the approach to the camera to verify that the source was in fact in its fully shielded position and that he disconnected the guide tube prior to realizing that the source was not fully shielded. When he attempted to disconnect the drive cable he realized that the exposure device lock was not engaged properly and the crew retreated to a safe distance. There were two assistant radiographers and a radiographer present and their pocket dosimeters read 10, 9 , and 20 mrem after the event. It appears unlikely that this is an overexposure event. The time in which the crew was in close proximity to the camera with the source out of its secured position was less than 5 minutes total and the time in which the crew member was in contact with the camera was less than a second to disconnect the guide tube and close the outlet port cover and another second when he attempted to disconnect the drive cable. It is suspected that this was a malfunction of the device. The camera (QSA 880 Delta), drive cables, and guide tube are being sent back to the manufacturer for diagnosis. The department (Colorado Department of Public Health and Environment) is preparing a Notice Of Violation for multiple items and is expecting a full report from the licensee within 30 days including dose estimates. Event Report ID No.: CO14-I14-26 |
| ENS 50368 | 14 August 2014 17:16:00 | The following was received from the State of Colorado via email: CDPHE (Colorado Department of Public Health) received telephone notification of an inoperability of the access control system on 8/14/2014 at approximately 1445 (MDT). Colorado State University, a research licensee, reported that a radiation monitor provided to detect the presence of high radiation levels in the radiation room of a panoramic irradiator was alarming when there was no (abnormal) radiation level present. One of the irradiator users noticed the audible alarm when their work was complete and they were leaving the area. The RSO responded and suspected a stuck source. Using a hand held radiation detection instrument, the irradiator door was opened and the irradiator room was entered. As the RSO entered the room there was no indication of radiation levels above what was expected when the source is in its shielded position, and as a result, it was determined that the source was in its shielded position. The room radiation monitor was reset but shortly after again alarmed without any (abnormal) radiation field present. The irradiator has been taken out of service and the monitor has been removed for repair. Colorado event report ID: CO14-I14-22 |
| ENS 50388 | 21 August 2014 10:25:00 | The following report was received from the State of Colorado via email: Event description: The Department (Colorado Department of Public Health and Environment) was notified via e-mail on 8/13/2014, by TestAmerica Laboratories Inc (license # CO 486-03), that a leak test result for a Ni-63 Electron Capture Device (ECD) source had shown counts exceeding 185 Bq. The licensee has removed the source from service, decontaminated the instrument that the ECD was mounted on and sent the unit, containing the source, to the manufacturer for repair and source replacement. The email was sent to the department pursuant to Section 4.58 of the Colorado Regulations. The Department has requested a few additional details regarding specifics of the source (serial Number, manufacturer, etc.) at this time and will populate the NMED database as soon as they are received. Colorado Event Report ID No.: CO14-I14-21 |
| ENS 47216 | 29 August 2011 19:05:00 | The following report was received from the Colorado Department of Public Health and Environment via facsimile: The Colorado Department of Public Health and Environment received telephone notification of a lost Iodine-129 sealed source (~24.8 microCuries; Assay date: 6/1/1992) on 8/29/2011 at approximately 4:00 p.m. The University of Colorado, a research licensee, reported that a campus inspection conducted on 8/12/2011 identified a missing gamma counter calibration source. As of 8/29/2011, all efforts to locate the source have failed. It is suspected that the source was discarded with an entire sample rack that was removed from the counter for disposal at some time within the last six months. The source was used for reference in a gamma counter and was an epoxy sealed type source with a small vial geometry. The licensee will submit a written report with more detail within the next few days. No other details are available at this time. Colorado Report: CO11-I11-13 |
| ENS 45276 | 19 August 2009 15:43:00 | The following report was received from the state via e-mail: A Colorado Specific licensee, Suncor Energy (USA) Inc. (License # 615-02), reported that a fixed nuclear gauge was having shutter problems. The shutter was unable to be returned to a closed position during a routine check. The gauge is an Ohmart Vega Model SH-F2 containing 250 mCi of Cs-137 (serial number M-7105). The licensee plans to have a Ohmart Vega Technician on site within the next few weeks to take a look at the gauge and determine whether or not the gauge can be fixed or (if) it needs to be replaced. The gauge is a flow gauge on a pipe in an oil refinery, and the shutter is normally open during facility operation. The radiological control area is normally maintained in force during operations, and remains in force. No inadvertent exposures are expected to have occurred. |
| ENS 45275 | 19 August 2009 15:10:00 | The following was received from the state via e-mail: This incident was reported by a medical licensee (Centura Health Penrose - St. Francis Health Services License # 197-02) on 08/06/2009. On 22 July 2009, at patient at Penrose Hospital was implanted with 70 Palladium-103 seeds, 2.5 U each on that day. The application was via a Mick applicator, using intra-operative planning with a Variseed planning system. It was noted on the C arm film taken at the completion of the implant that there was some clumping of the seeds in groups. A post implant CT scan was done on 23 July 2009. The results of the computerized dosimetry plan was evaluated on the 5 August 2009 and it was determined that the prostate gland was under dosed, receiving a dose to 90% of the prostate volume (D90) of 36.6% of the prescribed 125 Gy. The AU (Authorized User) written directive listed an expected range of D90 to be 90% to 135%. The discrepancy between actual dose and prescribed falls outside of the 20% tolerance for delivered dose according to (Colorado State Regulation) RH 7.21.1.1 (1). A full report is expected from the licensee within 30 days. 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 43761 | 31 October 2007 10:55:00 | The State provided the following information via facsimile: This is the initial notification for an incident that was reported to this Department on this date. Conam Inspection & Engineering Services, Inc., 6900 East 47th Ave. Unit 200 Denver, CO 80216, a Radiography Licensee (Colorado License # 963-01) provided the Department with the attached Preliminary Incident Investigation report (two pages). Initial details indicate that a radiography source was left unattended and improperly secured on a jobsite for approximately six hours. A member of the job site staff identified the problem and notified the licensee. It appears that this was a result of an ill employee leaving the job site without properly securing the source. An investigation has been initiated by the Colorado Department of Public Health and Environment. No other details are available at this time. The Conam Preliminary Incident Investigation Report follows: Date and time of incident: October 29, 2007 at 11:00 p.m. Location of the incident: Suncor USA in Commerce City, CO. Date and time investigation began: October 30, 2007 at approximately 4:30 a.m. Description of the Incident/Chronology of Verifiable Events: Conam I&ES performed radiography services at Suncor Refinery in Commerce City, CO on October 29, 2007. These services were being performed on a 24 hour basis. An exposure device was maintained on site and transferred from day shift personnel to night shift personnel. On October 29, 2007 the exposure device was not stored properly in the transport vehicle by the day shift radiographer. The day shift radiographer neglected to lock the outer door to the darkroom and the tailgate on the transport vehicle prior to leaving visual surveillance of the transport vehicle. The vehicle was parked on Suncor property approximately 40 feet from the Conam office. The day shift radiographer departed the job site at approximately 6:45 p.m. The night shift radiographer was on site prior to the departure of the day shift radiographer. The night shift radiographer became ill, and left the lob site at approximately 11:30 p.m. The night shift radiographer left the exposure device on site unattended by any approved Conam I&ES personnel. The night shift radiographer did not access the darkroom at any time on site prior to his departure since the radiography assistant was not present that evening. A Suncor representative noticed the darkroom on site without any Conam representation at approximately 4:30 a.m. The Suncor representative locked the darkroom and removed the keys to the vehicle then notified Conam management. Conam management responded at approximately 5:15 a.m. and representation was on site to properly secure the exposure device at 6:15 a.m. There were no exposures to the Public during this time period. List of Contributing Factors: Radiographers failed to follow proper security procedures for securing radioactive materials with IC orders. Proposed Corrective Actions: Conam management had a safety stand down for all radiographic personnel at Suncor. All additional radiographic personnel will have a safety stand down this week. The staff will be reinstructed as to the proper protocol for securing radioactive materials with the IC order. The two radiographers have been suspended from radiographic services at this time. Corrective Action Plan Complete? No If Not, Reason: Corrective action will be completed upon the final outcome of the investigation and the completion of reinstruction to radiographic personnel. |