Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 53482 | 2 July 2018 11:27:00 | The following information was received from the State of Kansas via email: The licensee had an incident with an I-131 patient that resulted in the Iodine Patient room being badly contaminated along with the patient's bed and some other room furniture. The room is secured and removed from service. When the licensee has their Weekday management staff meeting on Monday, they develop a plan to complete the room decontamination and return it to service. The room is removed from clinical service at 2100 today (15 Jan 16). The contamination is contained within the room and there is no risk to Hospital staff or members of the public. No unintended dose to the patient, staff or other personnel. The patient was on a Foley catheter with the urine bag in a roll able pig. She got out of bed and walked around the room and "dragged" the pig. The hose connection inside the pig was damaged and urine spilled inside the pig and some was spilled on the floor. No one was contaminated - skin or clothing ... just the floor. The easily removable contamination / urine is cleaned up and will leave the room to decay for a half-life. That will make clean-up easier and also will reduce dose to those who are involved in the detailed cleanup. The licensee will notify the department when the room is returned to service. 6/28/2018 - Patient administered 159.8 milliCuries Iodine-131 on 1/13/2016. The patient placed on a catheter because they were incontinent, had early Alzheimer's, and was not able to comply with instruction. The patient catheter with urine bag was placed in a 'rollable pig' which was dragged around the room when the patient walked around the room. The hose connection was damaged about the second day and urine spilled in the pig and onto the floor covering, bedding, linens, and absorbent chucks. The patient was released with an estimated 28 milliCuries Iodine-131 remaining on 1/15/2016. The initial room survey indicated high contamination levels. The decision was made to allow the contamination to decay over the weekend to allow for lower exposure to personnel performing the decontamination, and determine the contamination levels, location and a plan to decontaminate the room. The contamination was determined to be confined to the bed (mattress), linens, absorbent chucks and plastic sheeting. Minor contamination was found on the floor under the plastic sheeting. The contaminated items were removed from the room and held for 10 half-lives decay. The floor was surveyed and contaminated spots were decontaminated. The room was returned to clinical service Monday morning 1/18/2016. The time out of service was approximately 60 hours. 6/29/2018 - Integrated Material Performance Evaluation Program (IMPEP) review identified the event had not been reported to the NRC as required. Kansas Item Number: KS160001 |
| ENS 50761 | 26 January 2015 12:30:00 | The following information was obtained from the State of Kansas via email: The Team Industrial office in Wichita was broken into. They have video evidence of attempt to access the licensed material of concern. All material is accounted for. Missing items include UT equipment, computers, vehicle keys (vehicles were not taken), files were ransacked including the sensitive information files. Unknown at this time if sensitive information was taken. Police notified. Kansas Case Number: KS150001
The following updated information was provided by the Kansas Department of Health and Environment via email: The Kansas Department of Health and Environment provided additional detail regarding the event and the items stolen. Radioactive material was not stolen as a result of the break in attempt(s). Local law enforcement and FBI were notified and investigated the event. Additional corrective actions were taken by the licensee to secure sensitive materials and equipment. A reward has not been offered for return of the stolen items. A detailed list of the missing items has been provided to the Wichita police department. Notified R4DO (Vasquez), ILTAB (Wray) and NMSS Events Notification (email). |
| ENS 49839 | 18 February 2014 11:00:00 | The following information was provided by the State of Kansas via email: Industrial radiography equipment failed to function as designed which resulted in a possible source disconnect. The radiography equipment was located at a work site in Winfield, Kansas. The radiography equipment contained a 56 Curie Ir-192 source. The State of Kansas will update the event as more information becomes available. Kansas Item Number: KS140003 |
| ENS 49320 | 4 September 2013 15:07:00 | The following report was received from the Kansas Bureau of Environmental Health via facsimile: During radiography operations on the night of 5 Aug 2013, two employees, a radiographer and an assistant radiographer of Coder Welding & X-ray Service were finishing an 8 hour shift (which is 2nd shift for Alstom), when the source and crank assembly would not operate correctly. At that time, they could only determine that the source had not fully retracted into the camera correctly. After several additional attempts, they concluded a malfunction of unknown causes prevented the source from retracting to a full and locked condition. Following Coder Operating and Emergency protocol, the first action was to secure and maintain a 2mr/hr boundary. A complete survey of the area determined that the original roped and placarded boundaries were still correct and valid. Next the RSO was contacted as well as the assistant RSO. The RSO advised the radiographer to secure and maintain the 2mr/hr boundary and asked if any personnel or workers had been exposed to radiation levels in excess of those in Kansas Radiation Protection Regulations, Part 4 and following, and they stated no. They were advised that the RSO would be on site in 90 minutes to oversee the incident and resolve the situation. While waiting for the RSO to arrive, the two Coder employees decided to extend the roped boundaries an additional 75 feet in addition to the existing roped area and inform Alstom management of the situation. Since this was the end of 2nd shift for Alstom workers, and no Alstom workers were in the area at the time, there was no disruption of production or evacuation needed. Any Alstom employees on site were advised not to enter plant area as a precaution. At no time were Coder or Alstom employees at risk or in danger of overexposure. The RSO arrived on site at approximately 12:15 p.m. and made a radiation survey of the area and boundaries. The RSO found correct actions had been taken and 2mr/hr boundaries were maintained. In fact, 1mr/hr was the highest reading. The RSO then walked up to the crank-out reel and found the radiation level to be 5mr/hr. He concluded that the source was in fact in the tungsten collimator (4.3 hvl (half value integers)) secured on the pipe weld where it was during earlier radiographic operations. Several attempts to return the source to its shielded and locked condition failed, so plans were made to allow for closer inspection of the cables and source tube. At this point, the assistant RSO was contacted and advised to bring additional drive cables and source tube in the event they could be needed. While the radiographer and assistant radiographer maintained security over the boundaries and source, the RSO and several Alstom management, who had arrived on site, went outside to look for suitable shielding that could be brought in. Two one inch plates were chosen for use. The plates were tack welded together and moved to an area where overhead cranes could be used to move into position. This was accomplished by using the remote controls of the crane system so no person would have to be in a high radiation environment. With help from Alstom personnel, the steel plates were directed into place by the RSO next to the source camera, providing additional shielding. It was then possible for the RSO to walk up to the source camera with a survey level of 32mr/hr. It was then possible to inspect the drive cables and look at the source tube for possible causes of the return failure. A small depression was noted some 6 to 7 feet from the camera and cable attachment. Using a hacksaw, pliers, and other tools, the outer cable shielding was removed and the RSO returned to the cable crank, and was able to retract the source into the camera in the full and locked position. During the entire operation the RSO received a whole body dose of 35 mr. Due to the time and distance for the RSO, late arrival of the assistant RSO arrival on site, and the caution taken to resolve the situation, some 3-1/2 hours elapsed from the start to the end. The help and materials provided by Alstom management aided in the safe and satisfactory conclusion of this incident. At this time, it is unknown what might have caused the depression in drive cables or why it suddenly caused a failure to retract situation. Kansas Report Number: KS130006 |
| ENS 49104 | 11 June 2013 10:59:00 | The State of Kansas was notified by the licensee that on 6/9/2013, personnel dosimetry indicated that one assistant radiographer had received a potential overexposure, and two other assistant radiographers had received potential elevated exposure. The licensee reported that the dosimetry had been stored improperly and in close proximity to a location where a source change out had occurred. Corrective actions taken by the licensee include establishment of a controlled dosimetry storage location and additional training of personnel on the use of dosimetry. The individual with the potential overexposure was removed from radiography duties and given alternate work assignments. All three individuals were notified of the dosimetry readings. The dosimeter readings were 5.046 rem, 1.133 rem and 0.633 rem.
The following information was obtained from the State of Kansas via fax: Based on the last dosimetry report (received by the licensee), several employees have received a high dose. The reported doses are Employee 1 - 5046 mR, Employee 2 - 1133 mR, and Employee 3 - 633 mR. The three employees are radiographers assistants acting under one of the 4 licensed radiographers. The three radiographers assistants never worked together on any single job. The only common denominator between the three assistants is that their film badges were stored in the same general area. The licensed radiographers that were assigned to them received no such high dose rates. The three assistants also did not have any off-scale readings from dosimetry nor did they report any unusual incidences. All three also stated they did not believe that they could possibly have received an unusually high dose during that time period based on dosimetry, rate alarm, and survey meter readings. Upon further investigation, it was discovered that the three were leaving their film badges in their (work) uniforms in a controlled area within the shop between shifts. During this time period, radiographic operations were conducted at the shop facility. Additionally, there was a source change conducted by two radiographers in the controlled area of the shop during this time. During times these employees were not working, their (work) uniforms would have been located in the controlled area allowing their badges to be exposed during radiographic operations. In conclusion, there are two possible explanations for the substantial increases in exposure to the three assistants badges. Conclusion one would be that excessive heat and humidity played a role in the increased readings found with the badges. Conclusion two would involve film badges in close proximity to the area where radiographic operations were being conducted with the individuals assigned to those badges being absent at the time, therefore creating an erroneous reading leading to the obvious assumption that the badges alone were exposed, not the individuals associated with these badges being exposed. Corrective action taken at this time: Badges will be stored in the office, (with the proper controls in place) when not being worn. Retraining (was) conducted on the physical properties of the film badge and how badges become exposed through various means. Based on the reading of employee 1's badge, he will not be involved in radiographic operations nor be allowed in the controlled areas near radiation in the shop until a full investigation is completed. The State of Kansas is still investigating this event. Kansas Case No.: KS130005 Notified R4DO (Walker) and FSME Events Resource via email. |
| ENS 47456 | 18 November 2011 13:35:00 | The Kansas Department of Health and Environmental Services provided a notification via facsimile concerning an employee working for a State licensee (PFI LLC) who apparently received an extremity overexposure of 53,010 mrem during the month of September while processing the radiopharmaceutical Fluorine-18. No additional details concerning the circumstance of how the overexposure occurred was provided in the State's report. The Headquarters Operations Officer was unable to contact the originator of the report for additional information. |
| ENS 47324 | 6 October 2011 12:05:00 | The following report was received from the Kansas Department of Health and Environment via facsimile: The licensee attempted to close the shutter (on a process gauge) in preparation for a job. The shutter would not close. There were no personnel exposures (associated with this event). Because of the location (of the gauge), there are no likely exposures due to this failure. The source is located approximately 12 feet above the ground on a tank. Access is by portable ladder. Operations and maintenance personnel were notified. The shutter in question is on an Ohmart/VEGA model SHF1 B-45 source holder (S/N 7294CN) containing 100 milli-Curies of Cs-137 in a sealed source. The manufacturer, (Ohmart) VEGA, has been contacted and is working to schedule their service technician to (make repairs). Sealed Source and Device Registry OH-0522-D-01 02-B states 'Commonly reported device failures associated with this device series includes stuck shutters, shutter handles breaking off, and broken screws. A review of these failures indicate common root cause issues are associated with: operating the devices outside the normal conditions of use; failure to seek appropriate device service when shutters start becoming difficult to operate; shutter binding due to environmental contaminant intrusion into the shutter; and, forcing operation of shutter instead of seeking corrective action. The most commonly involved series is the SH-F2 which is the model typically installed in harsh environmental conditions'. Kansas Report Number: KS110011 |
| ENS 45121 | 10 June 2009 11:31:00 | The following was received from the State of Kansas via facsimile: Case number: KS090005. Kansas Division of Emergency Management reported that the duty officer received a call at 5:29 on 6/9/09 from licensee that a moisture density gauge had been stolen from a job site in Roeland Park, KS, Johnson County, on 6/6/09. The Roeland Park police were notified at 5:12 pm on 6/9/09. (The responding officer) stated he observed the vehicle and chains used to secure the gauge. The chains were rusty and did not appear to have been tampered with (no scrape marks or areas where the rust had been disturbed). The licensee employee stated the gauge transport case was secured by the chains through the handles. KDHE (Kansas Department of Health and Environment) was notified 0905 6/10/09. The gauge was a Humboldt Scientific model number 5001, with sealed sources of 50 mCi Am-241:BE and 11 mCi Cs-137. 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 43751 | 26 October 2007 16:37:00 | The following information was received via fax: Tulsa Gamma Ray was doing some radiography work at the Coffeyville refinery and had a source hang-up on October 23. The Tulsa Gamma Ray RSO was called. He came up from Tulsa and was able to return the source to the shield after about 10 minutes using a rod to push the source. Tulsa Gamma Ray RSO performed an investigation and discovered the radiographer did not properly attach the drive cable to the source assembly. The source was able to be pushed out but did not allow the source to be retracted. The equipment did not fail. The event occurred (due) to human error. The personnel were instructed to properly connect the drive cable to the source assembly and verify the connection by attempting to pull the connection apart. The personnel have been given additional radiation safety training. The camera is an Amersham Model 880B (S/N 1568) containing a 73 Curie Ir-192 source. The RSO received a dose of approximately 150 mrem while reattaching the source. Tulsa Gamma Ray is an Oklahoma licensee (License No. OK-17178-02) performing work in Kansas under reciprocity permit No. 2007-013. The Coffeyville Refinery is located in Coffeyville, KS. Kansas Reference No.: KS070009 |