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| Entered date | Event description | |
|---|---|---|
| ENS 52139 | 1 August 2016 09:10:00 | The licensee reported a stolen Troxler Model 3430 Moisture/Density gauge, Serial Number 27320 between midnight and 0600 CDT. The Troxler gauge was locked and stored at the licensee's facility. The Topeka Police Department was notified. 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 52108 | 20 July 2016 11:34:00 | The following report was received via e-mail: Yesterday, July 19, 2016, at approximately 1400 (CDT), the state of Kansas was notified of damage sustained to a portable moisture/density gauge. The gauge was a Troxler 3430 #32870 containing 8mCi Cs-137 and 40 mCi AM-241:Be. Building Earth Sciences Inc., under reciprocity (Kansas #2016-052/Alabama lic #1266) was in a field 20 miles South of Dodge City, Kansas. Due to high grass and extreme temperatures, the vehicle caught on fire with the portable gauge located in the bed of the truck. The vehicle and gauge were completely destroyed. At that time, no survey meter was onsite so Terracon was contacted in Garden City to utilize a loaner survey meter. The survey meter brought to the site was not in calibration. Surveys were conducted of the wreckage at one meter at around 1500 that showed approximately 0.2 mR/hr exposure rate from all sides. The Senior Project Manager onsite, had contacted the RSO, located in Alabama, who was already on his way to the site. (The Senior Project Manager) stated that a calibrated survey meter and Type A overpack had already been dispatched from the Building Earth Sciences Inc. Tulsa OK office and would be onsite no later than 1900. (The Senior Project Manager) stated that the wreckage had been fenced off and that he was staying onsite until the meter and overpack arrived. It was at this time that the state of Kansas made the determination not to send anyone out to the site as the overpack coming from Tulsa would be arriving well before anyone from Topeka could get to the site. At 2000 (CDT), July 19, 2016, (the Kansas Department of Health and Environment) received notification of confirmatory (calibrated) survey data of no greater than 0.2 mR/hr at one meter as well as the gauge debris having been placed within the overpack. (Survey meter - Troxalert cal date 8/3/15, serial number13385.) Surveys were also conducted of the truck wreckage after the gauge debris had been placed into the Type A overpack, with no contamination found confirming the integrity of the source remained intact. The overpack was then transported to the Building Earth Sciences Inc. Tulsa, OK, office. The RSO, will be submitting a full written preliminary report and timeline as soon as all information becomes available. NMED entry is forthcoming. |
| ENS 51465 | 12 October 2015 10:55:00 | The following information was received from the state of Kansas via email: At 0843 (CDT) hours, on 10/10/15, a call was received by the State of Kansas Staff Duty Officer (SDO), to the SDO line regarding a radiological 'accident'. The caller, (the licensee technician), stated that he had an accident involving a density gauge, and that the radiation sources had been compromised from their cases (Cs-137 less than 9 mCi, Am/Be less than 44 mCi.) (The State) asked him if this involved radiation which had contaminated the highway, and he stated that it had not. (The licensee) further explained that he had isolated the source rods in a cooler. (The licensee technician) stated that he was wearing his nuclear badge, and had not detected a change in the level of radiation. In response to this, (the State) made a phone notification to the KDEM (Kansas Department of Environmental Management) Response and Recovery Branch Director, KDHE (Kansas Department of Health and Environment) Radiation Control staff, and Johnson County Emergency Management. (The State) then called (the licensee) back to confirm details regarding the accident. According to (the licensee), he started the equipment, and placed it on his truck to let it 'warm up'. (The licensee technician) stated he then forgot the machine, and drove away. When this happened, the machine fell from the truck, and was broken when it hit the ground. (The licensee technician) stated he had not called any first responders about the incident. (The licensee technician) stated he picked up the pieces, and isolated the sources in the cooler. (The licensee technician) stated he would wait for personnel to respond, if needed. (The State) informed (the licensee) that KDHE was requesting that he make notification to them as well. (The licensee technician) was given the contact information, and stated he would do so. Local Response: Johnson County Emergency Management indicated they were planning to coordinate a local response to the scene, to ensure no further action would be needed. At 1038 (CDT), the Kansas Radiation Program Director dispatched two KDHE Radiation Control staff, with instrumentation to the scene with an ETA of 1145. Company (licensee) RSO could not be reached . (The licensee technician's) supervisor arrived on scene. (The licensee technician) was advised by (Kansas Radiation Program Director) to fill the cooler with dirt and/or sand to aid in shielding. 1148, (the licensee technician) reported that Johnson County HazMat surveys were not showing any radiation exposure rate readings above background. As soon as KDHE staff confirm the readings, (the licensee) will transport the device back to their business where it will be stored in a secure location. The licensee already in communication and coordination with Troxler to return the damaged gauge to them. KDHE staff arrived on site. 1202, KDHE staff verified that radiation sources were secured. Swipes taken and analyzed by KDHE staff showed no contamination on container with surveys confirming Johnson County readings. (The licensee technician) was able to contact the (licensee) RSO. Instructions were provided and arrangements made for storing the device in a secure location at (licensee) headquarters. Licensee transported RAM to their headquarters with a follow up report forthcoming. |
| ENS 51435 | 1 October 2015 10:23:00 | The following report was received from the State of Kansas via email: Yesterday afternoon (the State of Kansas) was contacted by (the licensee's), RSO (Radiation Safety Officer) for KU Hospital Authority lic# 18-C801, to report a medical event. On the morning of 9/29/15, a Thera-spheres Y-90 therapy procedure was found to have underdosed the patient by 36%. The details are as follows: A RADose RAD 60R personal electronic dosimeter is attached to the plexiglass 'box' which holds the vial containing the Y-90 Thera-spheres during the procedure. This dosimeter is the only method of detection to ensure that all of the Y-90 material is placed within the patient. In comparison, the Sir-sphere, similar material and procedure, utilizes a contrast to better ensure material is where it's supposed to be. Prior to the procedure, the dosimeter was checked for current calibration and source checked and found to be satisfactory including low battery indicator not active. During this pre-procedure check, the dosimeter exhibited fluctuating readings. A backup dosimeter of the same make and model was searched for but could not be located. The dosimeter was then re-checked and the fluctuations could not be duplicated, thus it was decided to utilize the dosimeter for the procedure. The Y-90 procedure was then completed, with the dosimeter reading at levels that indicated the required Y-90 had been placed within the patient. At this point, the 'waste' from the procedure i.e. vials, tubing, pads is taken back to the hot lab and surveyed to calculate the remaining Y-90. It was discovered that 36% still remained and that the patient did not receive the entire prescribed dose. It was determined that enough of the Y-90 had been administered to the patient to receive a satisfactory therapeutic dose thus another procedure would not be necessary. Exposure to staff was also determined to be negligible due to the nature of the material/shielding/remaining concentration. The RSO stated that the dosimeter was again rechecked and the low battery indicator was active during the check. The RSO made the preliminary assessment that the dosimeter was possibly functioning just above the 'cutoff' point of low battery. The licensee stated that a detailed report is in process and will be submitted within the required time parameters. 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 51238 | 16 July 2015 15:16:00 | The following was received from the Kansas Department of Health and Environment via email: A nuclear density gauge was struck at approximately 0100 (CDT), Thursday, July 16, 2015. At 0132 (CDT), (Kansas Division of Emergency Management) KDEM on duty staff officer, received a call from the Kansas Highway Patrol that a nuclear density gauge had been struck in Wichita. (Kansas Department of Transportation) KDOT was on scene. (KDOT) said the gauge was in use at the time by Cornejo and Sons. The supervisor from Cornejo was on the scene. He said the gauge was completely destroyed. He could see the source plate containing the neutron source and said the source rod was stuck in the car that hit the gauge. (KDEM) had similar incidents in the past and could put the source in 5 gallon bucket of dirt for shielding and transport both sources back to their shop, place in a secure area, and contact Troxler for further instructions. KDOT had a radiation survey instrument on scene and did not detect any unusual readings. At that time emergency response personnel at the scene were not letting anyone approach the debris and the source rod. (Personnel at the scene) confirmed that the Cs-137 source was still intact and that Cornejo could transport both sources back to their shop. (The licensee) recovered the sources and were transporting them back to their shop. On the afternoon of July 16, 2015, (Kansas Department of Health and Environment) confirmed that Cornejo had the source rods secured. (The licensee RSO) stated that they contacted Troxler to begin the source return process i.e. pictures of the source rods as well as leak tests. Kansas Item Number: KS150008 |