Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 57038 | 19 March 2024 21:13:00 | The following was received from the Washington State Department of Health (the department) via email: A hospital (Baptist Hospital of Miami, Miami, FL.) shipped unused brachytherapy seeds and GammaTiles back to the manufacturer, who is GT Medical Technologies. The manufacturer surveyed the returned package and measured about 14.6 mR/hour on the outside of the package instead of the typical reading of about 1.5 mR/hour. The manufacturer opened the package and found that the hospital did not follow the written instructions on how to pack return shipments. The top piece of foam packaging was not included in the package. The manufacturer found that, during transportation, two glass vials containing (cesium-131) reference brachytherapy seeds had escaped from their shielded storage container. The glass vials did not break and the seeds were still inside them. It was the unshielded seeds that caused the elevated reading on the outside of the package. The manufacturer notified the hospital, the (common) carrier, and the regulator ((the department)). The department expects to obtain additional information tomorrow about this event, and will provide an updated event report. Washington Event Number: WA-24-008 |
| ENS 56986 | 21 February 2024 21:16:00 | The following information was provided by the Washington State Department of Health via email: Port Townsend Paper Corporation sent an old lead-lined tank to a scrap yard. Unknown radioactivity was then detected in the tank at the scrap yard. The unknown radioactive material was wrapped in lead from the tank by workers at the scrap yard and sent back to Port Townsend Paper Corporation. The Radiation Safety Officer at Port Townsend Paper Corporation measured 0.33 mR/hour on the outside of the lead. The lead and the unknown radioactive material were temporarily stored in an area of the paper mill that is usually unoccupied. An inspector from the Washington State Department of Health plans to go to the Port Townsend Paper Corporation in a few days to investigate. It is suspected that the unknown radioactivity is likely to be naturally occurring radioactive material which can build up over time in piping, tanks, etc. at paper mill facilities. All the licensee's sealed sources are accounted for, so the unknown radioactivity is unlikely to be from one of them, but the inspector will check for that possibility. WA Event Number: WA-24-005 |
| ENS 56879 | 5 December 2023 20:37:00 | The following information was provided by the The Washington State Department of Health via email: The shutter on a fixed nuclear gauge (a Vega Americas Corp. Model No. SH-F1 gauge containing 53 millicuries of Cs-137) was unable to be closed when licensee staff attempted to lock it out. Licensee staff consulted with the manufacturer and, per the manufacturer's recommendation, installed four inches of steel plates in front of the fixed nuclear gauge to shield it. After installation of the steel plates, radiation levels were 0.2 mR/hour. The licensee is planning to replace the entire fixed nuclear gauge, per the manufacturer's recommendation, as the manufacturer has previously replaced the shutter on this gauge. The steel plates will remain installed until the fixed nuclear gauge is replaced. The Washington State Department of Health will gather additional information about this event and will submit an updated event report. An investigation may be conducted. WA Event Number: WA-23-031 |
| ENS 56654 | 3 August 2023 19:19:00 | The following information was provided by the Washington State Office of Radiation Protection via email: During the semi-annual routine shutter tests on a fixed gauge, the gauge was found to be stuck in the 'ON' position. This malfunction did not pose any additional risk to personnel in the 'ON' position; it only inhibited the ability to lock the gauge in the 'OFF' position for maintenance. The gauge manufacturer was contacted, and a service engineer was able to move the source tube assembly to the 'OFF' position by applying lubricant to the handle rod and gently twisting and pulling on it. This event appears to have occurred due to a lack of lubricant on the handle rod, or from the dust conditions that the gauge is located in, resulting in the source tube assembly becoming stuck inside the source housing. Going forward, a few drops of lubricant will be added during the semi-annual shutter checks to prevent the source tube assembly from becoming stuck again. There were no personnel overexposures due to this event. Device/Source Details: VEGA Americas, Inc., model number: HLG-2, serial number: 13570676, containing a 2 Ci (original activity) Cs-137 source. Reference Document Number: WA-23-013. |
| ENS 56310 | 12 January 2023 21:34:00 | The following information was provided by the Washington Office of Radiation Protection via email: This is an event report involving two patients and a technologist (which occurred on 12/14/2022). The first patient was being treated for prostate cancer with the radiopharmaceutical PLUVICTO (lutetium-177 vipivotide tetraxetan). The apparatus that is normally used for administering the radiopharmaceutical was not available due to supply chain issues, so a similar apparatus where the infusion vial would be pressurized was used instead. Unfortunately, the radiopharmaceutical began to leak out of the rubber septum of the vial and into the shielded storage container. As soon as the leak was identified, the pump was stopped and the case was aborted, resulting in the dosage delivered being less than the prescribed dose by more than twenty percent. 200 millicuries had been prescribed, but only 129 millicuries was administered to the patient. There may have been too much pressure in the vial, which forced the liquid out of the pierced septum near the needles. The patient will continue receiving the remainder of their planned treatments. The effects and appropriate response to missing a partial dose will be discussed with the care team and the drug manufacturer. (The typical recommended treatment is 200 millicuries every six weeks for up to six doses.) The licensee will use a different administration method and apparatus that uses a syringe pump instead of a pressurized vial. The second patient was being treated for prostate cancer with the radiopharmaceutical PLUVICTO (lutetium-177 vipivotide tetraxetan). The apparatus that is normally used for administering the radiopharmaceutical was not available due to supply chain issues, so a similar apparatus where the infusion vial would be pressurized was used instead. Unfortunately, radiopharmaceutical began to leak out of the rubber septum of the vial and into the shielded storage container. As soon as the leak was identified, the pump was stopped and the case was aborted, resulting in the dosage delivered being less than the prescribed dose by more than twenty percent. 200 millicuries had been prescribed, but only 121 millicuries was administered to the patient. There may have been too much pressure in the vial, which forced the liquid out of the pierced septum near the needles. Due to a cancellation, on the next day (12/15/2022) a dose of PLUVICTO was available and after consultation with the patient, the nuclear medicine team including other authorized users, and the referring physician, it was agreed to inject a partial dose so that the full 200 millicuries originally prescribed would be delivered. The clinical team agreed on the medical necessity and safety of this fractionated administration. The second infusion was completed without incident and was well tolerated by the patient. At the manufacturer's web site in the prescribing information for PLUVICTO, a few options are given for administering PLUVICTO. None of those options involve pressurizing the vial of PLUVICTO. This does not appear to be a good practice, and appears to have resulted in the leak. Unfortunately, one of the technologists involved in the cleanup of the radiopharmaceutical spills (from the leaking vials) had contamination on his hand that he and radiation safety staff were unable to remove. The Washington State Department of Health has asked for additional details on how the contamination occurred, the radiation readings, and dose estimates, and suggested contacting the U.S. Department of Energy's Radiation Emergency Assistance Center / Training Site for help with dose calculations, decontamination advice, and advice on any additional medical care that the technologist may need in the future because of his radiation dose. Washington Report Number: WA-23-002 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 56183 | 26 October 2022 20:08:00 | The following information was provided by the Washington Office of Radiation Protection via email: A fixed nuclear gauge was mounted to a standpipe about a foot above the floor. The mounting bracket failed. The weld broke from vibration, and the fixed nuclear gauge fell about 1 foot to the floor. The fixed gauge appears to be undamaged. It appears that nobody was working near the fallen gauge, so nobody was exposed to the radiation beam. A radiation survey was conducted by the Radiation Safety Officer (RSO), who closed the shutter, locked out the fixed gauge, and chained and locked the fixed gauge to a support column. The area was flagged off, and is in an area away from where personnel are working. The RSO notified the state regulatory agency, who will be sending a health physicist to investigate. The RSO contacted the gauge manufacturer to have them inspect the fixed gauge, repair the mounting, and reinstall the fixed gauge. Device: Gauge, fixed. Source: Sealed source, gauge. Manufacturer: VEGA Americas, Inc. Model Number: SHLD1. (SS and D registration certificate number OH-0522-D-120-B.) Serial Number: 6023CO. (Manufactured October 2011.) Radionuclide: Cesium-137. Activity: 0.005 curies when manufactured in October 2011. Current activity of 0.004 curies. Reference Document Number: WA-22-019. |
| ENS 55946 | 15 June 2022 20:01:00 | The following information was received via E-mail: The following is preliminary information, and will be updated as the State of Washington learns more about this event: A mechanical incident occurred with the HDR (high dose rate) afterloader unit, and a treatment had to be aborted. It appears that a motor in the afterloader failed. The manufacturer's representative removed the active and dummy wires and is in the process of making the necessary repairs. There does not appear to be any radioactive material contamination in the system. No staff or patients received any excess dose. Plans are to exchange the source and complete all of the needed QA checks so that patient treatments may resume. The equipment involved was a Varian HDR remote afterloader, Model VariSource iX, Serial Number 600501, containing less than 11 curies of Iridium-192. Washington Incident Number: WA-22-016 |
| ENS 57051 | 25 March 2024 18:54:00 | The following information was received from the Washington State Department of Health, Office of Radiation Protection (the Department) via email: Action Towing LLC transported a car to the Schnitzer Steel Industries scrap metal facility, and it triggered the scrap yards radiation detectors. The scrap yard staff measured about 35 micro roentgen/hour on the outside of the car. Officials at Schnitzer Steel Industries contacted the Department which resulted in an evaluation of the concern and issuance of a DOT special permit so that the radioactive car could be returned to Action Towing LLC for proper handling. The Action Towing office manager was informed that the staff had seen some sort of radiation equipment in the car, so the Department requested pictures of the equipment. The pictures showed an old military Geiger-Mueller (GM) survey meter and other items. The Department went to Action Towing to investigate the radioactivity. In addition to the old military GM survey meter, which was not radioactive, the Department found two glass tubes containing radioactive material, which measured about 2 milliroentgen/hour on contact. One of the tubes was labeled as radium-226. The Department took the radioactive tubes for disposal, then surveyed the car and found no elevated radioactivity remaining in the car, and therefore released the car for unrestricted use." WA State Item Number: WA240001 |
| ENS 55677 | 27 December 2021 19:43:00 | The following was received from the state of Washington via email. The patient was scheduled to receive three doses of yttrium-90 microspheres (to the liver), but only the first two doses were successfully administered. However, it appears that only five percent of the final dose was administered, and the rest was caught up in the tubing from the vial. The exact radiation dose administered is not known at this time. The licensee will investigate this event further and provide a written report. Washington State Incident Number: WA-21-027 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 55589 | 17 November 2021 17:26:00 | The following is a synopsis of a report received from the State of Washington, Office of Radiation Protection via email. On Monday, November 15, 2021 a patient undergoing cancer treatment at University of Washington Medical Center received an under dose of Y-90 TheraSpheres. The details of the intended dose to the liver (target organ) are yet to be provided. They will be forwarded when obtained.
The following information was received from the state of Washington State Department of Health via email: The University of Washington Medical Center reported that a patient received less dose than prescribed during a yttrium-90 microsphere (Nordion/BWXT model TheraSphere) liver cancer treatment on 11/15/2021. In this event, the patient was administered two dosages of yttrium-90 microspheres to treat the patient's liver at two different liver treatment sites. One dosage was 51.5 millicuries, which was successfully delivered. The other dosage was 34.1 millicuries, but only 24.2 millicuries (about 69 percent) was successfully administered. The prescribed dose was 13,100 rem, but the dose actually administered was only 9,300 rem (about 29 percent less). It appears that the microspheres that were not successfully administered remained mainly in the catheter since the radiation reading of the catheter and syringe after administration of the yttrium-90 microspheres was about 1 mR/hour instead of the usual reading of 0 mR/hour after administration. This appears to be an event where the catheter was blocked or clogged because of clumping of microspheres in the catheter. Events like these are discussed in 'NRC Information Notice 2019-12: Recent Reported Medical Events involving the Administration of Yttrium-90 Microspheres for Therapeutic Medical Procedures.' A copy of this information notice was sent to University of Washington officials in hopes that it would help them to fully understand this incident and to help them prevent future incidents from happening. WA report no.: WA-21-024 Notified R4DO (Deese) and NMSS via email. 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 55622 | 2 December 2021 21:58:00 | The following was received from the Washington State Department of Health, Office of Radiation Protection, via email: Dosimetry results for the month of October 2021 for one employee showed ring extremity dosimeter readings of 77,156 millirads for one hand and 29,391 millirads for the other hand. The employee was interviewed and it appears that the radiation exposures were received during experiments involving yttrium-90 radiolabeling and injections into mice on October 25-27, 2021. The activity used during the experiments is not known at this time, but they had received a shipment of 40 milliCuries of yttrium-90 just before these experiments. This event is still being investigated by the licensee, but some (preliminary) calculations using the `beta activity to dose-rate' online calculator in Rad Pro Calculator suggest that the high dosimetry results could have been caused if the outside of the employee's ring extremity dosimeters were contaminated with as little as a few thousandths of a microCurie of yttrium-90. This possibility of contamination on the ring extremity dosimeters is also supported by the employee's low whole body dosimeter results for the month of October 2021, which were 0 millirems deep dose, 45 millirems lens dose, and 97 millirems shallow dose. The much lower dosimetry results of a coworker who was working alongside of the exposed employee also suggest that contamination on the ring extremity dosimeters of the exposed employee may have been the cause. The coworker's results were ring extremity dosimeter readings of 6025 millirads on one hand and 889 millirads on the other hand, and whole body dosimeter results of 0 millirems deep dose, 32 millirems lens dose, and 68 millirems shallow dose. Washington Reference Document Number: WA-21-025 |
| ENS 55500 | 30 September 2021 13:59:00 | The following report was received from the state of Washington via email: A pickup truck containing a InstroTek, Inc. Model 3500 Xplorer portable moisture density gauge in the cab was parked overnight at a hotel in Walla Walla, WA. The shipping case was locked and chained to the steering wheel of the pickup truck, and the cab of the pickup truck was locked. During the night, the portable moisture density gauge was stolen. The technician noticed that it was missing at about (0500 PDT). The theft has been reported to the Walla Walla Police Department. Gauge Serial Number: 4233 Radionuclides and Activities: Gamma Source: Cesium-137, 10 millicuries. Source Model Number: Eckert & Ziegler HEG-137. Source Code: HEG-0085. Source Serial Number: BG1234. Neutron Source: Americium-241:Be, 40 millicuries. Source Model Number: Eckert & Ziegler AM1.N02. Source Code: PHI-0161. Source Serial Number K433/20. Date of Latest Leak Test of Sealed Sources: February 24, 2021. 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 54394 | 18 November 2019 19:15:00 | The following information was received from the State of Washington via email: At Selah-Home Ranch, the ranch manager noticed on Sunday morning, November 17, 2019, that someone had broken into the ranch shop building. The doors on the building had been forced open, the locked storage closet inside the building was also forced open, and the lock on a storage locker inside the storage closet was cut. Two CPN International model 503 portable nuclear gauges were stored inside the storage locker in locked storage cases. Both portable nuclear gauges were removed from the ranch shop building by the thief. One CPN International model 503 portable nuclear gauge (serial number H310606212) was found outside the ranch shop building, undamaged and still in its carrying case. The other portable nuclear gauge (believed to be serial number H35066208) is missing and stolen (approximately 50 milliCuries of americium-241/beryllium). The Zirkle Fruit Company is in the process of confirming the serial number of the stolen gauge (Sealed Source and Device Registry Number CA-0208-D-104-S). Zirkle Fruit Company has notified the Yakima County Sheriff. The case number is 19C20517.
The following update was received from the State of Washington via email: The correct serial number of the CPN International model 503 moisture gauge that was stolen is: H371204057. Notified via email the R4DO (O'Keefe), ILTAB, NMSS Events, CNSNS (Mexico). Washington State Event No: WA-19-031 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 54323 | 10 October 2019 15:22:00 | The following information was received via e-mail: A Troxler 3430 portable surface moisture-density gauge, S/N 19274, was damaged when it was hit by an excavator at a temporary job site in Shoreline, Washington. Damage included: the screws had been ripped out of the top shell of the gauge, and the metal base of the gauge was cracked on the side. The gauge operator verified that the source rod was intact and retracted into the safe position, and returned the gauge to the licensee's main office for storage, as directed by his radiation safety officer. A Washington Department of Health inspector surveyed the gauge and verified that the neutron and gamma readings were similar to the radiation profile shown in the sealed source and device registry certificate for the gauge. The inspector checked for removable radioactive material contamination on the outside of the gauge by wiping the crack in the side of the base of the gauge, the seam where the top shell joins with the metal base of the gauge, and the source rod opening and bottom plate. No removable contamination was found. The damaged gauge will be shipped for disposal in the near future. The gauge contained a 40 mCi Am-Be source, S/N 47-14734, and a 4 mCi Cs-137 source, S/N 50-8931. Washington Reference Number: WA-19-028 |
| ENS 53377 | 2 May 2018 19:53:00 | The following information was obtained from the state of Washington via email: Swedish Medical Center (SMC) reported that a patient prescribed to receive 725 MBq (19.59 mCi) of Y-90 microspheres (Sirtex Medical model SIR-Spheres) to the left lobe of the liver, only received 370 MBq (10 mCi). SMC planned a two-artery feed, using 360 MBq (9.73 mCi) per artery per sub lobe. The written directive called for a total of 725 MBq (19.59 mCi) split into two doses. The certified nuclear medicine technologist who drew the dose did not properly review the written directive's instruction to split the total dose into two doses. Instead, the technologist split 370 MBq (10 mCi) into two doses of 190 and 180 MBq (5.14 and 4.86 mCi), respectively. Prior to patient administration, the radiation oncologist also failed to check the drawn doses prior to injecting them. The incident was identified post-injection when the remaining 360 MBq (9.73 mCi) of the original 725 MBq (19.59 mCi) was discovered. The physicians involved believe that the diminished dose may still provide the treatment sought. They will follow up on the patient in six months and will, if deemed necessary, retreat the liver lesions. The referring physician and patient were informed of the incident. SMC's investigation identified several errors: lack of comprehension regarding the dose draw worksheet, miscommunication and failure to review the written directive prior to correcting a dose, and failure to perform a safety pause and properly review the dose to be administered against the written directive prior to administration. Corrective actions included modifying the dose draw spreadsheet, training the nuclear medicine department with regards to the spreadsheet, and modifying the treatment record sheet to include a formal procedural pause prior to administration. The Washington Department of Health, Office of Radiation Protection, did not anticipate conducting an onsite investigation. NMED Item Number: 180058 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 52786 | 2 June 2017 19:59:00 | The following report was received from the State of Washington via email: An operator of a portable moisture/density gauge touched and directly handled the unshielded source. Here is how the event occurred: A worker knelt down next to a portable moisture/density gauge and pulled it up, tilted it back, and stuck his face toward the source rod. He then extended the source rod out of the gauge housing and into the air. He then took his left hand and rubbed the source rod clean with his bare hand. This event was observed by a manager from Oregon Radiation Protection Services, who then reported the event to the Washington State Department of Health for investigation. Incident Number: WA-17-014 The portable moisture/density gauge is a Troxler 3430 containing 0.333 GBq (9 mCi) of Cs-137 and 1.628 GBq (44 mCi) of Am-241/Be. |
| ENS 52038 | 23 June 2016 19:46:00 | The following information was received by the State of Washington via email: The operator of a portable moisture-density gauge temporarily left the gauge unattended at a construction site in Redmond, Washington, and the gauge was run over by the wheel of a roller. The top of the gauge handle was broken off, but both radioactive sources are in safe condition inside the body of the gauge. The gauge operator is maintaining security around the damaged gauge, and has called a nuclear gauge calibration and servicing company to come to the construction site to assess the scene, package the gauge for transport to a safe location, and conduct radiation surveys to verify that there is no radioactive contamination of the construction site and the roller equipment, and to verify that the radioactive sources are undamaged and inside the gauge case. The portable gauge is a Campbell Pacific Nuclear; Model MC-1-DR; Serial Number MD51008063; Sources-Cs-137 (.010 Ci), Am/Be (.050 Ci). Washington Item Number: WA160002 |
| ENS 51879 | 22 April 2016 20:00:00 | The following report was received from the State of Washington via email: On 4/21/2016, the Radiation Safety Officer at University of Washington reported by phone and by email that a Po-210 static ionization source was missing from a lab at the Southlake Union (SLU) Campus. The static ionization source had been placed in a cardboard box in preparation for shipment back to NRD (manufacturer). Someone in the lab thought the box was empty and placed it in the recycling. This was discovered on Monday, and the lab had been searching for it for a couple of days before notifying the Radiation Safety Officer. The immediate report value for Po-210 is 100 microCi and the 30 day report value is 1 microCi. Source information: Isotope: Po-210, Manufacturer: NRD, Model: P-2001, Initial Activity: 5 mCi (May 2015), Current Activity: approximately 1 mCi Device information: Nuclespot - Static Eliminator, Manufacturer: NRD, Model: P-2042-1000, Serial Number: Not reported. The facilities personnel are currently trying to find out from (the recycling company) where the recycling is taken for processing. (The recycling company) picks up recycling from the SLU campus twice a week on Friday and Tuesday. University of Washington Principal Investigator lab informed NRD of the loss. Once their investigation is complete, UW will provide us (WA Office of Radiation Protection) with a written report as required by WAC 246-221-240(2). Incident Number: WA-16-018
The following information was received from the State of Washington via email: WA-16-018 Po-210 static ionization source missing from University of Washington Update and Closure University of Washington submitted their final report on the lost Po-210 static eliminator. University of Washington is a Broad Scope A Licensee. Their (University of Washington) Radiation Safety staff performed a thorough investigation and search for the source. There are a total of six possible routes the source may have taken; all of which end up overseas. Initially, three potential avenues were explored at Recology CleanScapes: 1. If source stayed inside the box with the paper - processed as corrugated cardboard and sent overseas for recycling processing 2. If paper came out of the box and source stayed with paper - processed as mixed paper and sent overseas for recycling process 3. If paper came out of box and source came out of the paper - source would have filtered out into glass recycling stream (includes metal), which is sent to Strategic Materials. The RSO contacted Strategic Materials and identified an additional three possible outcomes for the source, if it made it to the Strategic Materials facility. 4. All incoming material is first passed by a large magnet, if the source housing was ferrous enough the source would have been transferred to a metal recycler. The source model is believed to have an aluminum housing. 5. If the source was not pulled out by the magnet, it was either manually removed by a picker and thrown in the trash, or 6. The source was pulled out by an Eddy Current device and would be in one of the device collection bins. This also would have been thrown in the trash. Staff at both facilities were shown photos of the source and interviewed, and no one had seen or moved the source. Ultimately, it is believed that the source, thoroughly wrapped in in paper, in a corrugated box was processed and sent overseas in a bulk cardboard or mixed paper recycle bundle. The Registry of Radioactive Sealed Sources and Devices - Safety Evaluation of Device (Number: NY 502 D 108 G) for the P-2042 model indicates an maximum external exposure rate of 0.05 mR/hr on contact with the source. This is equivalent to background radiation levels. It should be noted that the principle emission of Po-210 is an alpha particle, so the exposure falls off rapidly with increasing distance from the source. Therefore, the exposure to any individual handling the source would be negligible. Since Po-210 is an alpha emitter, the highest risk would be to a person who ate the radioactive foil. However, this scenario is extremely unlikely due to the fact that the individual would have to first remove the foil from the housing, and then have a desire to eat the foil. Some new additions to the information: Manufacturer: NRD Inc. Device Type: Nuclespot - Static Eliminator Device Model: P-2042-1000 Sealed Source Model Designation: P-2001 Serial Number: A2KG893 NRD Lease Number: 059345 Shipped to UW: 5/21/2015 Original Activity: 5 millicuries Activity when lost: 1 millicurie This source is considered lost and unrecoverable. The assessed health and safety risk is very low. This incident is considered CLOSED. Notified R4DO (Miller) and NMSS Events Notification 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 51855 | 7 April 2016 19:38:00 | The following report was received via e-mail: On April 6, 2016, a portable moisture/density nuclear gauge from Earth Solutions NW, LLC was damaged at a construction site near Monroe, Washington. The technician from Earth Solutions NW, LLC restricted the area around the damaged nuclear gauge and reported the incident using our (Washington Office of Radiation Protection) 206-NUCLEAR emergency number. Our (Washington Office of Radiation Protection) nuclear engineer assessed the condition of the nuclear gauge over the telephone and determined that the nuclear gauge should be safe to transport, so the nuclear gauge was transported to the Snohomish office of Northwest Technical Services, which is the company that typically maintains and calibrates the gauges for Earth Solutions NW, LLC. Northwest Technical Services personnel inspected the damaged nuclear gauge and determined the nuclear gauge is intact, and that both radioactive sources are present in their normal locations inside the nuclear gauge. The cesium-137 source (10 mCi) is attached to its source rod, which is bent a bit, but the source is inside the gauge in its shielded position. The americium-241:beryllium source (50 mCi) is not compromised and is also inside the gauge in its normal position. Based on the professional opinion of Northwest Technical Services personnel, there would not be any radioactive contamination at the construction site where the nuclear gauge was damaged. So, we (Washington Office of Radiation Protection) advised Earth Solutions NW, LLC personnel that it would no longer be necessary to restrict the part of the construction site where the nuclear gauge was damaged. The next steps that will be taken are: 1) Northwest Technical Services personnel will conduct leak tests of the two sealed radioactive sources in the damaged nuclear gauge, to verify that no radioactive materials have leaked from the two sealed radioactive sources. They will send a written report, including photographs of the sealed radioactive sources and the damaged nuclear gauge. 2) The damaged nuclear gauge will be properly disposed of by Northwest Technical Services personnel. 3) Earth Solutions NW, LLC will send us a written report about the incident. Gauge model: CPN-131 from Campbell Pacific Nuclear Washington Incident: WA160001 |
| ENS 53376 | 2 May 2018 19:22:00 | The following information was obtained from the state of Washington via email: Earth Solutions NW (ESNW) reported that a moisture/density gauge (CPN model MC-1-DR, serial #MD60308232) was crushed on 7/2/2013 at temporary jobsite in Mill Creek, Washington. The gauge contained a 1.85 GBq (50 mCi) Am-Be source (model CPN-131, serial #AM8232) and a 0.37 GBq (10 mCi) Cs-137 source (model CPN-131, serial #C8232). The gauge operator had placed the gauge in front of his truck. When asked to move his truck, he forgot about the gauge, moved the truck forward, and crushed the gauge. The source rod was retrieved using a shovel and placed in a bucket of sand. Radiation surveys revealed no radioactive contamination at the jobsite. The source rod and other parts of the gauge were returned to the ESNW facility. On 7/17/2013, Hevly Technical Services (gauge contractor) and Washington Department of Health personnel performed leak tests on the Cs-137 and Am-Be sources. Washington State Public Health Laboratories analyzed the leak test samples and detected no radioactivity. The Cs-137 source rod was reinserted into the gauge body and secured with duct tape. The gauge was then placed into its shipping container. Hevly Technical Services transported the gauge to Qal-Tek Associates (radioactive waste broker) for disposal. To prevent recurrence, ESNW provided additional training to gauge users on proper handling, transporting, storage, and emergency procedures. NMED Item Number: 130311 |
| ENS 48954 | 22 April 2013 19:18:00 | The following was received from the State of Washington via email: Mistras Group, Inc. was conducting industrial radiographic operations at Shell Puget Sound Refinery. After a routine exposure, the radiographer attempted to crank the source back into the camera, but the source became stuck. The source could not make it past a crimp in the guide tube, which was caused earlier when the camera fell on it. The radiography crew moved their restricted area boundaries to increase the size of the restricted area and to provide additional protection to anyone in the area. Fortunately, nobody other than the radiography crew were in that portion of the refinery. The radiography crew and assistant radiation safety officer were able to manually pull the source back into the shielded position in the camera. The highest exposure to any person, as read from a pocket dosimeter, was 10 millirem. Note: This is a preliminary report - we (State of Washington) will obtain additional information from the licensee and provide a more complete report in the near future. Washington Item Number: WA130001
The following information was received via fax: An industrial radiography crew retracted the source, checked to verify that the source was fully retracted and locked, and discovered that it was not. The crew made more attempts to retract the source, but were unsuccessful. They attempted to straighten out the crank assembly, then the radiographic exposure device fell about 46 inches from a pipe onto a platform, after which the drive cable would not move using the crank handle. The restricted area was expanded to the 2 mR/hr line and facility management and the licensee's radiation safety personnel were notified and traveled to the site. The guide tube was moved onto the platform and lead shot bags were placed onto the collimator to provide extra shielding. Licensee radiation safety staff found that the drive cable was hung up in the crank assembly conduit but moved freely in the source tube. So, the staff manually pulled on the drive cable and returned the source to the fully retracted and locked position in the radiographic exposure device. It was discovered that there was a crimp in the crank assembly conduit that kept the drive cable from moving. The highest pocket dosimeter reading was 18 millirem. The radiographic exposure device was sent to the manufacturer for evaluation. Notified the R4DO (Haire) and FSME Event Resources (via e-mail). |