Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 41266 | 15 December 2004 13:55:00 | The following information was received via facsimile: The driver/operator of a company vehicle transported the nuclear moisture density gauge to his residence in Cedar Hill, Texas, rather than return it to permanent storage. The gauge was missing when the operator prepared to leave his residence this morning (12/15/04). The stolen gauge is an older Troxler Model 3401B that was re-built into a Model 3411B, Serial No. 12990 containing two Special Form, sealed sources: Cs-137, nominal 8 millicuries, Serial No. 501337, and Am-241/Be, nominal 40 millicuries, Serial No. 47-8300. The gauge was removed from the company truck by cutting the security chain sometime during the hours of darkness. Both the gauge and the transport container were taken. The licensee is thinking of offering a reward and posting it both in the local newspaper and in advertising on a local news channel. Reward, if offered, will be no questions asked for return of the gauge. Texas Incident No: I-8193
At 2300 on 12/21/04, Dallas Fire Department found the stolen gauge intact in a shopping cart in a shopping center parking lot. The gauge was returned to the Reed engineering group. Notified NMSS (T Essig), R4DO (Spitzberg), TAS (J Foster) (email), and faxed to Mexico. |
| ENS 41255 | 13 December 2004 15:35:00 | On December 10, 2004, (Friday), the Licensee had dispatched operator (deleted), for a job with a Troxler 3440, Serial No. 33733, containing two sealed Special Form sources: 8.0 mCi (nominal) Cs-137, Serial No 750-9391, and 40.0 mCi (nominal) Am-241/Be, Serial No 47-22867. Upon completion of the job the operator was returning to the company office, he decided to stop by the Wal Mart store in Harris County, Texas. Upon returning to his company truck, Ford F150 fleetside, License Plate No. (deleted), he determined that the gauge was missing from the tiedown location. Looking into the bed of the truck he noted that the cable securing the gauge to the truck had been cut and was laying in the bottom of the truck bed near the tailgate, still locked into place. The operator reported the incident to his supervisor and was advised to report the incident to the Harris County Constable's Office - Precinct #4. While he was making the report, Case No 0412101909, the company R.S.O. reported the incident to the Texas Department of State Health Services (DSHS) on-call duty officer. Due to the R.S.O. being at home, he did not have the source Serial Numbers. The source serial numbers were reported to the Agency on Monday afternoon at 1:15 p.m. Licensee is considering offering a reward and announcing the loss to local media. Texas Incident No.: I-8191
A technician from another company was offered the gauge for sale. The technician consulted his supervisor who told him to purchase the gauge. The gauge was determined to be the stolen gauge from Stork. The gauge was intact and was returned to Stork. An update will be provided to the local law enforcement. Notified NMSS (T Essig), R4DO (Spitzberg), TAS (J Foster) (email), and faxed to Mexico. |
| ENS 41034 | 10 September 2004 15:55:00 | Facility suffered a sewer blockage in the Waste Building on the morning of 09/02/2004. Soil waste removed to discover cause of blockage. It was immediately determined that the line was not connected to the sanitary sewer. The line has been in place for 12 years for the disposal of H-3 and C-14 waste. An estimated total of 100 millicuries of these radioactive materials have been disposed during the last 12 years. Maximum soil contamination discovered was measured at 0.1 millirem per hour. No workers or equipment were contaminated. The University immediately let a contract for cleanup of the contaminated soil and repair of the sewer line. The area was placed behind barrier tape and covered with plastic to prevent blowing or erosion. Initially, the soil was removed and barreled by a licensed Texas decontamination firm. A second break in the line was discovered near the building that may require soil removal by covered roll-off container. |
| ENS 40967 | 18 August 2004 15:21:00 | After IVB therapy the source train did not retract due to a kink in the IVB catheter, did not retract to the remote Beta-Cath device. The IVB catheter was immediately withdrawn and placed in the Novoste emergency plexiglass storage safe and then in the IVB storage room. No overexposure was received by the patient or attending staff. Novoste has been notified of the malfunction. The Novoste Beta Cath was returned to the manufacture on August 2, 2004. The IVB manufacturer is Novoste Beth Cath, source Sr-90, 1.71 GBq (46 millicuries). Transfer device Serial No. 92917, and Source train Serial No. ZA543. The device was packaged and returned to the manufacturer on August 2, 2004. This agency did not receive notice of the event within 24-hours Texas Incident No.: I-8155 |
| ENS 40852 | 5 July 2004 09:34:00 | Texas Incident #: I-8136 Event Location: Hidalgo County, Texas(TDH, Public Health Region 11) at the Guerra #25 operated by Edge Petroleum API #: 42-215-33214 On July 4, 2004, the Licensee notified this Agency of the loss of three radioactive sources on a well logging tool-string in Hidalgo County, Texas, at the Guerra #25 well (API # 42-215-33214) operated by the Edge Petroleum Company. The string contained three sources, manufacturer and Serial Nos. are not available at this time. The sources are: 0.8 microcurie Cs-137; 2.5 curie Cs-137; and an 18 curie Am-241/Be. The sources are abandoned in a well with a total depth of 9,034 feet. The top of the tool-string is located at 5,697 feet and fishing attempts have not allowed recovery. A minimum of 200 feet of red tagged cement has been poured to secure the string in place. Negotiations with the Texas Railroad Commission continue for the placement of a deflection device in the well. The Licensee will be ordering a plaque for emplacement on the wellhead. |
| ENS 41135 | 19 October 2004 16:37:00 | A verbal report was received on July 20, 2004, which reported patient doses in excess of 50 Rem to the wrong physical area on treatments involving a Nucletron HDR Microselectron brachytherapy device, Model 080.000, Serial No. 9072. Four patients received wrong doses due to a 7.5 centimeter error in source location from the intended treatment site/plan. Details were vague due to discussion over the phone. A written report would follow. The written report date August 2, 2004, was received by this agency on August 6, 2004. The report failed to give details needed by this agency. An Agency investigator was assigned to investigate this incident on August 6, 2004. The investigation conducted on August 18, 2004, determined that an error in catheter length was entered by two different registered therapists as 920 millimeters versus the default and actual length of the catheter of 955 millimeters. The 75 millimeter or 7.5 centimeter error resulted in two sources: a 12.3 curie (02/16/2004) Ir-192 source, Serial No. D35AO131 and a new Ir-192 source installed on 07/08/2004, Serial No. D35A0605, 10.5 curies being positioned outside of each patients body. The error was discovered after one of the four patients developed skin erythema. The patients were to receive boost treatments of 500 centiGray per fraction from the HDR unit to the prescribed location with the total number of fractions varying from 3 to 7 in the physician's written directive. The patients were all being treated for inter uterine cancer. The patients received fractional treatments with the error which varied from 1-5 fractions. Make-up treatments were required on three of the patients to achieve the correct dosage to the treatment site. Some patients received both correct and incorrect treatments from the same therapists. The error was discovered on July 8, 2004, when one patient complained of tenderness in one leg. The physician determined that the patient had erythema on her leg, several centimeters from the planned treatment site. The physician's investigation determined the error in catheter length on July 14, 2004, and ordered make-up treatment for his patient on July 15, 2004. A total of four female patients, three radiation oncologists, and three radiation therapists were involved in the treatments and required corrective treatments to three of the four patients. The hospital was reluctant to release dose data on the patients due to concerns of HIPAA privacy standards. After explanation of allowable disclosure to this agency, the Licensee provided the data on October 4, 2004. Patient #1 received a non-target tissue dose of 800 rad superficial and 250 rad deep over a three week period. She suffered skin erythema which was treated over a few weeks with rest and a topical ointment. After the erythema was resolved she resumed normal follow-up treatment for her initial disease. Patient #2 received a non-target tissue dose of 400 rad superficial and 150 rad deep over a one week period and exhibited no abnormal reactions. She immediately resumed normal follow-up treatment for her initial disease. Patient #3 received a non-target tissue dose of 1100 rad superficial and 300 rad deep over a three week period. She exhibited no abnormal reactions and resumed normal follow-up treatment for her initial disease. Patient #4 received a non-target tissue dose of 1800 rad superficial and 350 rad deep over a seven week period. She suffered skin erythema and was treated with rest and topical ointment. After the erythema was resolved, she resumed normal follow-up treatment for her initial disease. This is an abnormal occurrence. Texas Incident # I-8145.
The correct catheter length is 995 mm vs. the entered length of 920 mm. A difference of 75 mm or 7.5 cm. Notified R4 DO (Whitten) and NMSS EO (Essig). |
| ENS 40854 | 7 July 2004 13:40:00 | On May 6, 2004, a leak test sample from a Hewlett Packard 5890 Gas Chromatograph, with ECD Model # 19233, was leak tested for source Serial No. L6180 (Nickel - 63, current activity 13.48 milliCuries). The initial leak test resulted in removable activity of approximately 9250 disintegrations per minute (dpm) or 0.0042 microCuries, near leak test limits. A second test was repeated on May 7, 2004, which resulted in 194,000 dpm or 0.087 microCuries of removable activity on the vent tube, which was well above the leak test limit. Minor removable contamination (approximately 100 counts per minute (cpm)) was detected on the interior of the case, the inlet tube sample (approximately 100 cpm), and the vent tube cap (approximately 1750 cpm). The source was confiscated by the University's radiation safety staff to a secure location at the Radiation Safety Office. The last leak test was conducted on December 17, 2003, with results indicating no contamination. The source will be returned to the manufacture or disposed of as radioactive waste. The direct cause of the loss of the source's integrity is not known. The written report was received by this agency May 17, 2004, but was not delivered to Incident Investigation until July 7, 2004. No violations have been cited. This incident was closed July 7,2004. TX Incident number I-8138 |