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| Entered date | Event description | |
|---|---|---|
| ENS 55661 | 16 December 2021 17:52:00 | The following information was received from the state of Kansas via email: An anti-static device has gone missing from the Western Industries Plastic Products facility. The device was leased from NRD, LLC (Lease number 75780, model number P-2031-1000, and serial number A2MJ492). The Safety Manager reported it to NRD, which responded on 12/15/21 to instruct them to contact the state. Routinely, the device is attached to a nozzle at one end and a gauge at the other, which connects to a quick-release hose. At the end of the day, it is disconnected by the quick-release connector and placed in the unlocked bottom drawer of a filing cabinet at the end of the assembly line. In the morning, it is reconnected. The assembly line is located in the warehouse portion of the facility, which is used to mold large pieces of plastic for a variety of companies. The device / air nozzle is used to blow out debris created from cutting holes in these large parts. At the end of first shift on 12/8/21 at 1600 (CST), the device was put in the bottom drawer of a filing cabinet (unlocked) at the end of assembly line. This was confirmed by interview with the assembly line worker who placed it there. On 12/9/21 at 0800 (CST) a worker at the start of shift went to retrieve it, but the device could not be located. A complete search was made of the facility by the Safety Manager and others from all shifts, searching the entire facility including all cabinets in the work area, the shipping offices, and the docks. The facility has not given up looking for the device, but if it is considered lost, they have not decided if they will continue with another radioactive device. If they do, they have stated their intention to use a sign-in/sign-out system and padlock when the device is not in use. 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 53390 | 7 May 2018 18:20:00 | A lung scan was incorrectly performed at Wesley Medical Center in Wichita, Kansas last Friday, the 4th of May. It was reported (to the State) at approximately 1500 (CDT) on 5/7/2018. The DTPA (pentetic acid) dose was supposed to go through a nebulizer, and an MMA (methylmalonic acid) dose was supposed to be injected for perfusion, but they accidentally injected the DTPA instead. The patient was able to go through the scan as normal, but the end result is that 40 mCi of DTPA (what should have been the MMA dose, by (the State's) understanding) were injected instead of 4 mCi (what should have been the DTPA dose). The bladder dose was over 5 rads. A full report has been promised by the licensee tomorrow, which will be forwarded to (the NRC) and entered into NMED (Nuclear Material Events Database). It is unknown if the patient and the prescribing physician have been notified at the time of this report. 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 53109 | 8 December 2017 17:26:00 | The following information was excerpted from an email received from the State of Kansas: The licensee is reporting that an ionizer containing a radioactive source (Model Number P-2063-1000) was lost. The licensee currently has 3 other ionizers of the same model. The device radioactive source was Polonium-210 (SN: A2KT674) with an activity of 31.5 mCi and was last leak tested on 9/20/2016. The device was checked out by the licensee and placed within the secure test floor while testing electrical devices at the Integra Technologies facility. The missing device use was last logged on 8/25/2017. The licensee believes that their maintenance department mistakenly threw the device away. Upon discovering that the device was missing, the licensee searched their facility several times over without finding the device. The prevention for further loss is that the remaining 3 units will be mounted in permanent locations using security screws so they cannot be removed by unauthorized personnel. 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 52985 | 22 September 2017 11:00:00 | The State of Kansas was notified that an Electron Capture Detector Gas Chromatograph (ECD-GC) owned by Occidental Chemical Corporation (OxyChem) was inadvertently disposed of as electronic waste. The contracted waste company, Clean Harbors Wichita, ships waste to the recycler, ERI, in Fresno, CA. OxyChem provided ERI pictures of the missing Varian ECD GC to aid in identification. The missing ECD-GC is a model 3400 (Serial Number A-8080), containing 8 mCi Ni-63 as of 1990. The current activity is calculated as 6.58 mCi. The State of Kansas is providing a courtesy notification to the State of California Radiation Program Office. 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 52928 | 25 August 2017 15:20:00 | The following was received from the State of Kansas via email: During Therasphere setup, a technician forgot to prime the syringe and inserted it into the vial of Y-90. She realized the syringe was not primed, but because the syringe cannot be removed, her attempt at priming it opened the vial inadvertently. It got tracked all over the room and to some extent all around the Interventional Radiology (IR) department. IR is now completely closed. She was put in a bunny suit immediately and sent to emergency to get deconned at the shower. There was no risk of internal contamination due to the rapidity of the decon after the incident. Highest contamination is at 90k on her scrubs. Most of the contamination was on her lead apron. The clothes are currently sequestered and lacking skin contamination, she was sent home. They are currently in the process of cleaning up and recovering to get IR back in business. An investigator will be sent on Monday to gain first-hand knowledge of the incident. The RSO and ARSO were at a conference, arriving home last night, and were not present during the incident. Reporting under 10 CFR 30.50(b) (corresponding to K.A.R. 28-35-184b in Kansas Annotated Regulations), area closed to workers and public for more than 24 hours due to an unplanned contamination. |
| ENS 52864 | 19 July 2017 17:11:00 | The following information was received from the state of Kansas via email: A medical event occurred during a Yttrium-90 TheraSphere treatment of a patient's liver cancer. The patient received approximately 24 percent of the dose prescribed in the written directive. There was no harm to the patient other than the inconvenience of rescheduling the treatment to receive the remainder of the dose. (The licensee is) investigating the event and will submit a report within the required 15 days. With this procedure the vial containing the TheraSpheres cannot be viewed due to being inside a lead pig. Therefore, a digital radiation dosimeter is placed near the delivery device. As the dose is delivered to the patient, the readings drop to or near zero. In this case, the technologists and the physician stated the dosimeter was reading 0.0 at the end of the procedure. (The licensee's) immediate corrective action will be for radiation safety staff to verify the instrument readings when the physician feels the entire dose has been delivered. The prescribed dose or quantity was not provided by the State. Kansas NMED Item Number KS170006 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 52661 | 3 April 2017 16:37:00 | An in-use Troxler gauge was damaged at a construction site on US 83 near Garden City, KS. The gauge, a Troxler model 3430, S/N 28271, contains a 0.3 GBq (8 mCi) Cs-137 source and a 1.48 GBq (40 mCi) Am-241/Be source. The Cs-137 source rod was extended at the time of the incident and could not be withdrawn into the shielded volume. Rad surveys on-site confirmed that both sources were intact (No contamination at the jobsite). The gauge was returned to its case and temporary shielding used to prevent personnel exposure during transport back to the licensee's Ellsworth Office. The licensee will return the gauge to the manufacturer for disposition. Item Number: KS170004 |