Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 54658 | 10 April 2020 14:30:00 | The following is a summary received from the state of Mississippi via phone: The licensee notified the state that during a routine check of an Ohmart gauge (s/n: 1169GK), the shutter would not close. The gauge contains a 10 mCi Cs-137 source (source holder: SHF-1). It is located over a chemical bin and the normal shutter position is open, so there is no additional exposure to employees. An authorized company is scheduled to remove and replace the gauge with an identical model. |
| ENS 54469 | 9 January 2020 12:50:00 | EN Revision Imported Date : 2/7/2020 AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE COULDN'T BE RETRACTED The following was received from the Agreement State via e-mail: RSO reported inability to retract a 40.2 Ci Ir-192 source (Source Model A424-9), (Source Serial No. 89706G) into the Sentinel/QSA 880 Delta exposure device (Serial No. D12297) during the period of 12/31/2019 to 1/1/2020. Licensee notified of 24 hour reporting requirement and to send written 30-day report. Mississippi report number: MS-200001.
The state of Mississippi sent the following update by email: (State Health Physicists) investigated the inability to retract the source, and the RSO reported that corrosion inside the crank cables caused the cable to hang up. The crew followed their emergency procedures and called the RSO. The RSO retracted the source into the fully shielded position and OSL (optically stimulated luminescence) badges were processed showing that no over exposure occurred, and the occupation exposure limits were maintained in compliance. Notified R4DO (Taylor) and NMSS Events Group by email. |
| ENS 54357 | 29 October 2019 12:56:00 | The following information was received via email: Licensee called (the Mississippi Division of Radiological Health) to report a carjacking of one of its drivers carrying two packages of PET doses. The carjacking occurred at approximately 0315 CDT at a gas station in Jackson, MS. The local law enforcement was notified. The vehicle has still not been recovered. Stolen sources were F-18. Source 1 had an activity of 6000.627 mCi at 0149 CDT and source 2 had an activity of 1694.932 mCi at 0151 CDT. Incident Report No.: MS-190004 THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 52914 | 18 August 2017 17:43:00 | The following report was received via e-mail: The licensee's RSO reported a possible medical event for four separate patients, involving a Nucletron Model microSelectron-HDR 106.990 remote afterloading brachytherapy unit. This was noticed during review by the medical physicist. The licensee notified Elekta for confirmation of the software error. The RSO confirmed on 8/18/2017, that two (2) patients were under dosed by more than 20% and the other two (2) patients were being reviewed by the medical physicist. An Elekta Notification was sent out to all MS Radioactive Licensees on 8/17/2017, that possess a Nucletron Model microSelectron-HDR. Source: 12 Ci, Ir-192, Elekta Model 105.002 Mississippi Report: MS-170002
Update: 10/18/2017 Licensee reported four (4) medical events utilizing the tandem and ring applicator model within Elekta's Oncentra Brachy Software version 4.5.2. Licensee written report received, 8/23/2017, for the period between 11/8/2016 and 8/15/2017, stated two of the four patients treated using Nucletron Model microSelectron-HDR 106.990 remote afterloading brachytherapy unit and utilizing the tandem and ring applicator model within Oncentra's Treatment Planning software received a dose less than 20% of the prescribed dose to the treatment site (base of the uterus). All of the treated patients received greater than 50 Rem and 50 percent or more of the dose expected from the administration to unintended tissue (vaginal canal). The written directives called for a prescribed dose of 28 Gy for three patients and 27 Gy for one patient, to be delivered in four (4) separate fractions to the base of the uterus. All four (4) fractions were affected for one patient, three (3) fractions for two patients, and only one (1) fraction for one patient, which received 50 percent or more of the dose expected from the administration. Patient / Estimated Dose Delivered to Treatment Site / Percent of Intended Dose from Written Directive / Affected Number of Fractions / Expected Range of Doses to Unintended tissue / Estimated Dose to Unintended Tissue Patient A / 18.44 Gy / 65.84 % / 4 / 126 cGy and 175 cGy per treatment fraction / > 28 Gy Patient B / 21.78 Gy / 77.7 % / 3 / 126 cGy and 175 cGy per treatment fraction / > 7 Gy per fraction (total > 21 Gy) Patient C / 23.39 Gy / 83.55 % / 3 / 126 cGy and 175 cGy per treatment fraction / > 7 Gy per fraction (total > 21 Gy) Patient D / 26.84 Gy / 99.41 % / 1 / 126 cGy and 175 cGy per treatment fraction / > 14 Gy for one fraction A software error occurs in the Oncentra Treatment Planning Software version 4.5.2, whenever the built-in tandem and ring applicator model is used. The microSelection afterloader step size of a measured source path is 2.5 mm. An override to the default step size of 5 mm (RDStore), from the step size of the measured source path in the planning software occurred. A change in the source position step size, from 2.5 mm to 5 mm was not realized by the licensee for the ring catheter but was implemented for the delivery plan. The dose distribution, prescription point values, and dose volume histogram readouts were all based on a 5 mm spaced tandem and a 2.5 mm spaced ring. When the plans were exported to the treatment unit and delivered, the afterloading brachytherapy unit utilized a source step size of 5 mm for both the tandem and ring applicators, thus a discrepancy between the planned and delivered dose distributions occurred. The licensee has suspended use of the tandem and ring applicator model within the software and will define all catheters for the tandem and ring applicator manually until further notice of Elekta's software correction. The referring physician and patients have been notified. No adverse health effects were noted for the patients due to the medical events. Activity: 12 Ci Licensee Authorization Update: (8.85 Ci - 5.195 Ci) Date of Incident: 11/8/2016 through 8/15/2017 List any other actions required of DRH (Mississippi Division of Rad Health): Licensee notified to send 15-day written report. Elekta Notification, FCA-NU-0004, FCO Reference No. 806-01-BTP-001, was sent out to all MS Radioactive Licensees on 8/17/2017, that possess a Nucletron Model microSelectron-HDR. Licensee's written report received August 23, 2017. DRH conducted a reactive inspection of the licensee on September 1, 2017, to determine the cause and further clarify the medical events. The medical events were discussed with the licensee's RSO's, medical physicist(s), and the chair of Radiation Oncology on September 1, 2017, and again on October 17, 2017 and October 18, 2017, with the licensee's medical physicist. Case Closed: Yes Date Closed: 10/19/2017 Notified R4DO (Vasquez) and NMSS Events Notification 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 52774 | 30 May 2017 10:19:00 | The following report was received from the Mississippi Department of Health via email: Licensee's RSO (Radiation Safety Officer) reported a stuck shutter on a Ronan Model SA8-C10 fixed gauge, Serial No. 1093CP, Source Model CDC.700. This was noticed during preventive maintenance, while performing shutter checks. Licensee notified the manufacturer for service. Isotope: Cs-137 Activity: 200 mCi
The following update was received via e-mail: Licensee reported that the gauge had been repaired by the manufacturer and returned to service. The gauge manufacturer's field engineer reported that the gauge shutter was able to be closed with channel lock pliers before the gauge was removed from the vessel. The field engineer reported that the lead ceiling portion of the shutter cavity was tight against the shutter assembly causing the shutter assembly to bind and not close. The field engineer suspects that water leached in behind the lead and froze, thereby pushing the lead deeper into the shutter cavity. The field engineer removed the expanded lead from hitting the shutter. Once the gauge had its seals replaced, the source holder was reassembled. The gauge was then wiped for removable contamination, surveyed at 30 cm and 12 in, and remounted by the field engineer for continued use. The wipe test was negative (less than 0.001uCi) for removable contamination and all fifteen (15) surveys were less than 1 mR/Hr with the gauge shutter open. Mississippi Report: MS-17001 Notified the R4DO (Farnholtz) and NMSS Resources (via e-mail). |
| ENS 52287 | 7 October 2016 16:58:00 | The following information was obtained from the state of Mississippi via email: Licensee's RSO (Radiation Safety Officer) notified DRH (Mississippi Division of Radiation Health) on 10/7/2016 that a Berthold Model LB7440D level/density gauge had a stuck shutter. The shutter malfunction was discovered while performing a calibration for the gauge. The gauge is located twelve (12) foot off the ground and away from any personnel. The licensee contacted Berthold for repair of the shutter mechanism on 10/7/2016. The gauge serial number is 69-0545, containing 30 mCi of Cs-137; source model P2623-100; source serial number 2762; last swipe tested on 9/30/16. The source was manufactured in September of 1992. Mississippi Report number: MS-16005
The following information was obtained from the state of Mississippi via email: On 10/10/2016, the licensee reported that the gauge shutter was not stuck. Licensee stated the shutter was hard to open and close. The gauge service company was called in to replace the shutter mechanism on the gauge to prevent a possible stuck shutter. Notified R4DO (Gepford) and NMSS Events Resource via email. |
| ENS 51779 | 8 March 2016 15:34:00 | The following report was received from the State of Mississippi via facsimile: The Licensee notified DRH (Mississippi Department of Radiation Health) on 3/7/2016, that an incident had occurred at 2233 (CST on 3/6/16), at the client's site (in Holly Springs, MS). The Licensee's two (2) man radiography crew was performing radiography inside a twelve (12) foot, open end vessel, thirty six (36) feet long, and nine (9) foot off the ground. The radiography camera in use was a Sentinel model 880D, serial No. D1120. During one exposure the guide tube became crimped preventing the source from retracting back into the camera. This was due to the camera falling off the scaffolding to the vessel floor while the radiographer was retracting the source. The resulting action caused the guide tube connected to the camera and magnetic stand to become crimped at the camera connection point. The licensee's radiography supervisor was notified and the restricted area boundary was increased by the two (2) radiographers. Source retrieval was performed by the radiography supervisor with assistance from the radiography crew. A survey was performed using a NDS, ND-2000, SN: 20113, Calibration date: 1/15/2016, at the opposite end of the vessel thirty two (32) feet away from the source revealing a reading of two hundred twenty (220) mR/hr. A decision was made to pull the camera to one opening of the vessel by the camera cranks. The restricted area was then readjusted for two (2) mR/hr. While the camera was being lowered to the ground with a guide rope out of the vessel opening, the guide tube became straight enough to allow for source retraction. The guide tube and magnetic stand hung at the opening of the vessel causing the guide tube to straighten out from the weight of the camera below the vessel opening. The radiographers made another attempt to retract the source with success when the guide tube was straight. Once the camera was on the ground, the Licensee's survey of 46 mR/hr confirmed the source was retracted back into the camera. Doses to the radiography crew and supervisor were all below 60 millirems (mR). Instadose radiation badges were used with the highest dose reported of thirty nine (39) mR to both radiographers. Pocket dosimeters were also used with the highest dose reported by the radiography supervisor of fifty five (55) mR. Licensee's written report was received on 3/7/2016. The camera has been removed from service pending a sealed source and DU wipe test. Implemented corrective actions included adequate lighting at night and tying the camera off when it is used over twelve (12) inches off the ground. The radiography camera contains a 79.9 Ci Ir-192 Source, model A424-9, serial number 28799G. The State of Mississippi instructed the licensee to submit a 30 day written report and considers this case to be closed. Mississippi State Report number: MS-16002. |
| ENS 53211 | 14 February 2018 17:52:00 | The following report was received via e-mail: The general licensee's president said he lost the static eliminator sometime in 2015. The general licensee's president said he used the device once and it did not work well. The general licensee also said the static eliminator must be lost and is probably in the dump somewhere. Make/Model: NRD / P-2021 Serial: A2KD940 Source: Po-210, 10 mCi in April 1995 Mississippi Report: MS-180002 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 49897 | 11 March 2014 14:00:00 | The following was received from the State of Mississippi via email: (The) licensee reported a stuck shutter on an Ohmart Model SH-F2 level gauge, Source Holder Model No. SH-F2-30, during maintenance work to repair the gauge detector. The failure was identified on 3/3/2014 by the licensee while preparing/isolating the gauge for work to be performed on the gauge detector. A Vega Americas service engineer was on site at the time to complete the repair of the shutter mechanism. The shutter failure was identified to be caused from age and oxidation. The gauge contains 200 mCi of Cs-137. Mississippi Event Report Number: MS-14002 |
| ENS 49896 | 11 March 2014 13:40:00 | The following was received from the State of Mississippi via email: (The) shutter on Ohmart SH-F2 fixed gauge, (sealed source Ohmart Model A-2102, sealed source serial number 2597CG, source holder model SHF-2-45) was broken in the 'open' position. Source holder shielded, removed from location and transferred to source storage location where repairs could be made by Vega Americas. After repair, gauge returned to safe operation on 3/7/14. The gauge contains 200 mCi of Cs-137. Mississippi Report Number: MS-14001 |
| ENS 49009 | 7 May 2013 15:05:00 | The following information was received via E-mail: Licensee reported a stuck radiography source that occurred at approximately 2315 CDT on May 6, 2013. Licensee's RSO (Radiation Safety Officer) responded to incident site, increased barricades, maintained perimeter, and notified Chevron RSO. Licensee's source was fully retracted into the shielded position at 0100 CDT (on May 7, 2013). The Licensee's RSO received 20 mR conducting the source retrieval. The incident occurred while performing work at the Chevron Pascagoula Refinery. Mississippi Report Number: MS-13002
The following report was received via e-mail: On 5/6/2013, the Licensee had a two man crew performing industrial radiography at the Chevron Plant. The radiographer was unable to crank the source back into the camera after his third exposure. The source was then cranked back into the collimator. The radiographer repositioned the cranks and tried to retract the source again without success. The radiographer and assistant radiographer extended the restricted area boundary and called the Licensee's night safety officer on site. The Licensee's RSO then notified Mistras Group's CRSO (Corporate Radiation Safety Officer) and plant personnel of the incident. The Licensee's RSO, once on site, discovered from conversation with the radiographer that the drive cable was hitting a melted area of the conduit and not letting the drive cable pass through. The melting of the (black) return conduit of the cranks occurred because it was placed over a non-insulated pipe from the plant's furnace. The Licensee's RSO made the decision to cut the conduit at the melted area of the cranks to save time and reduce exposure while trying to retract the source. This provided clearance for the drive cable to pass through and allowed the source to retract back into the fully shielded position inside the camera. The camera, guide tube, and cranks were surveyed by the RSO upon source retraction. The State (Mississippi) has closed this case. Notified the R4DO (Walker) and FSME Events Resources via email. |
| ENS 48308 | 14 September 2012 16:57:00 | The following report was received from the State of Mississippi via email: On 9-10-2012, the licensee administered 163 mCi of I-131 from an admission order dated 9-6-2012, instead of the prescribed 100 mCi of I-131 from the written directive dated 9-5-2012. The licensee's investigation revealed a misinterpretation of an admission order as a written directive by the nuclear medicine technologist due to inclusion of the authorized user's name and 150 mCi of a radionuclide activity on the admission order. The written directive was never received by the Nuclear Medicine Department. The licensee determined the root cause of the error stemmed from a new communication process by which written directives are conveyed from the authorized user to Central Scheduling and then to the Nuclear Medicine Department. The administered dose is described as not out of line with doses typically prescribed for patients with similar disease and the authorized user indicates an expectation of no adverse effect for the patient. The referring physician and patient were both notified on 9-10-2012 by the authorized user. The licensee is correcting its procedure for written directives and how they are communicated to the Hospital's Nuclear Medicine Department and will submit them for review to DRH. Mississippi Event Report No.: MS-267-01 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. * * * UPDATE FROM MOAK TO SNYDER ON 9/28/12 AT 1656 EDT * * * (The) licensee's inspection revealed the medical event was an isolated incident. The new procedures for communicating written directives were only in place for two (2) months with one (1) I-131 administration during this time. The licensee has since changed back to their old procedures where written directives are communicated directly from the authorized user to the nuclear medicine department. Notified R4DO (O'Keefe) and FSME Event Resource (e-mail). |
| ENS 48244 | 28 August 2012 18:11:00 | The following information was obtained from the state of Mississippi via email: DRH (Mississippi Division of Radiation Health) was notified 8/26/2012 by MEMA, Mississippi Emergency Management Agency, regarding an overturned radiography truck that occurred on Hwy 45 south of Macon, Mississippi. Two Licensee personnel were involved in the wreck with minimal injuries. The camera remained secured in the overpack but separated from the destroyed dark room. Surveys were performed of the overpack and camera by the driver after the wreck. The driver and MS Highway State Patrol Officer waited with the overpack and camera until DRH and the Licensee's ARSO arrived on site to take possession of the camera. MS Report Number: MS 120004
Licensee's leak test reported to DRH was less than 0.005 microCuries. Notified R4DO (Powers) and FSME Events Resources via email. |
| ENS 48243 | 28 August 2012 17:37:00 | The following information was obtained from the state of Mississippi via email: DRH (Mississippi Department of Radiation Health) was notified on 8/27/2012 by Licensee's RSO regarding a stuck source incident that occurred on 8/24/2012 while performing industrial radiography at a temporary job site in Mississippi. The RSO claims the camera (880D) fell onto the guide tube during one of the shots and crimped the guide tube preventing the source from retracting back into the camera. The RSO suspects the technician may have pulled on the cranks while trying to crank back in the source after the shot. This could have then caused the camera to fall onto the guide tube and crimp it. The restricted area boundary was readjusted to one (1) mR/hr, maintained, and the RSO was called by the radiographers at the job site. An ARSO and technician from the company who are trained in source retrieval arrived at the job site and retrieved the source. The camera was wiped and leak tests were submitted for analysis. The Licensee's ARSO received 82 mR and the technician received 8 mR/hr from actions taken during the source retrieval. MS Report Number: MS 120003
The following update was received from the State of Mississippi via email: Test for leakage and/or contamination received from the Licensee was less than .005 microCuries. Notified R4DO (Lantz) and FSME via email. |
| ENS 48008 | 8 June 2012 18:23:00 | The following information was received by e-mail: Licensee notified DRH (Mississippi Department of Radiological Health) about a Ronan X92 Continuous Level Gauge, Serial No. 9479GG with source Holder Model SA1-F37. Licensee suspects the source shutter may not be closing 100% due to elevated readings of 7 mR/hr with the shutter in the closed position. * * * RETRACTION FROM JASON MOAK TO PETE SNYDER ON 6/26/12 AT 1558 EDT * * * This report is retracted based on the fact that the gauge "did not fail to function as designed. No maintenance was performed on the gauge. The service representative did not find a problem with the gauge shutter or radiation fields. Notified R4DO (Clark), FSME (e-mail). Mississippi Incident Number: MS-12002 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 Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9) |
| ENS 46734 | 6 April 2011 17:50:00 | The following was received via e-mail: Licensee's RSO notified DRH (state) by phone on 3-22-11, and by letter received on 3-22-11, of a dislodged source from an Ohmart Vega Model SHLM-BR, fixed gauge Ser. No. 13530993. The source became dislodged from the main rod during the gauge's shutter test and fell into the gauge well. The licensee's surveys around the gauge well were less than 0.5 mR/hr. A gauge representative has been called in to repair the gauge. DRH (state) requested licensee send in manufacturer's service report with the licensee's written 30-day report. The source is 40 millicurie Cs-137, ser. No. 6965GK. Mississippi Incident Number MS-11004.
Licensee was contacted (by the state) on 4/7/11, for further clarification of the location of the source. The licensee's RSO said the source was at the bottom of the well inside a vessel. This would also be the case during normal operations. Surveys were also confirmed by the RSO to be 0.5 mR/hr around the vessel. Licensee's RSO said a new well is being built for the vessel and a service representative has been notified. Source retrieval and replacement of the gauge is scheduled for the middle of April once the new well is built, and the material in the vessel has cooled. Notified R4DO(O'Keefe) and FSME(McIntosh)
The following information was received via e-mail: Licensee submitted a field service report from the gauge service company on 6/9/2011. The service report indicated the roll pin in the rod was sheared and the source carrier fell to the bottom of the well. The service report claimed the roll pin was corroded due to the harsh environment that the source was in. Part of the rod was still attached to the source which was retrieved and inserted back into the source holder. The source was replaced, and the old source has been transferred. Notified the R4DO (Werner) and FSME (Persinko). |
| ENS 46566 | 24 January 2011 15:55:00 | The following information was received by email: DRH (Mississippi State Department of Health) was notified at 0720 (CST), about a transportation accident in Jackson, MS, on Riverside Drive. Cardinal Health Nuclear Pharmacy Services was delivering radiopharmaceuticals to Baptist Hospital and Kings Daughters Hospital. The driver hit an icy patch on the road where a water main had broken. The driver lost control of the delivery vehicle. The vehicle turned over in the median and the driver was trapped. DRH responded at 0730 (CST). The driver was not injured. Packages were dislodged from their protective security rack, that is required to prevent shifting and movement of packages. Radiopharmaceutical packages were surveyed and wiped for contamination. (No contamination was detected.) The packages were picked up by the Radiation Safety Officer so they could be delivered to the hospitals. The pharmacy's vehicle was then released to the wrecker service. DRH closed this case on 12/28/2010. MS Report No.: MS-10010. |
| ENS 46411 | 10 November 2010 15:31:00 | The licensee's RSO notified Department of Radiological Health (DRH) about their missing Varian electron capture detectors on 10/15/10, while conducting their six (6) month sealed source inventory and leak tests. The licensee's Receiving and Property Control Office picked the Varian gas chromatograph, Serial No. 10734, up for disposal from one of the licensee's labs and boxed it for shipment to Creative Recycling Systems, Inc., in Palmetto, Georgia. Creative Recycling Systems received the licensee's recycle trailer on 10/12/10. On 10/15/10, the licensee's property control office contacted Creative Recycling Systems, Inc., and requested notification if the detectors were ever found. Creative Recycling Systems did not find the Varian electron capture detector containing two Ni-63 sources, serial numbers A2115 and T585, and it is assumed that it has been lost at the recycle facility. The licensee did survey a similar Varian device and found that survey readings were very close to background. MS Incident #: MS-10006. 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 46732 | 6 April 2011 16:27:00 | The following information was provided by the State of Mississippi via e-mail: During inspection and review of licensee's gauge service reports, two gauges were discovered to have stuck shutters. Both gauges are Ronan models SA1-F37. Ronan service engineering was called in to repair gauges and determined that on gauge serial # 9473GG, the bottom bushing was found frozen to the shutter shaft. On gauge serial # M4122, the roll pin was broken and the shutter handle was rotated 45 degrees out of alignment. Both gauges were repaired. Both gauges had a Cs-137 source. Gauge #M4122 was 5 millicuries and gauge #9473GG was 200 millicuries. MS Report: MS-11003. |
| ENS 44956 | 2 April 2009 11:25:00 | The following information was received from the State of Mississippi via Email: On 03-23-2009, Licensee's radiographic crew were unable to return the source (Source Model 424-9; SN 51178B; IR-192; 51.3 Ci) to the shielded and safe position while performing NDT radiography (RT) profile inspection at the Chevron Refinery (located in Pascagoula, MS) using a Sentinal Delta 880 radiography camera (D-2549), QSA cranks, and a QSA source tube. The radiography crew increased their barrier, notified the RSO and field operator of the situation. The two technicians maintained the security of their barrier while awaiting arrival of the RSO. Acuren's RSO notified the site manager, supervisor, assistant RSO, Chevron's RSO, and a Chevron company representative. Once a meeting was held to devise a plan for source retraction the source was retracted within one (1) hour. Dose received (by the RSO and the associate RSO) during the retraction of the source was 90 mR and 25 mR, respectively. The (two technician) radiography crew received a dose of 45 mR and 65 mR, respectively. There were not any non-occupational or over-exposures received. Licensee concluded that during the course of the source retraction and investigation, it was determined that the source tube had a crimp in it. The positioning of the source tube during radiographic operations could have been the cause of the hang up, but all equipment was shipped to QSA-Global Inspection to determine if equipment failure contributed to the incident. Licensee stated inspection report from QSA-Global Inspection will be reviewed and sent to DRH (Mississippi Division of Radiological Health). Licensee has implemented safety meetings and additional training before the crew involved can resume radiographic operations, to cover proper equipment use, inspection, safety notification processes, proper inspection techniques, and equipment limitations. DRH received written report from licensee on 04-01-2009. DRH called licensee on 04-01-2009 to verify source activity and ask about licensee's investigation. DRH also requested 24 hr telephone notification from the licensee in the future. MS report number - MS-784-01. |
| ENS 44780 | 16 January 2009 13:16:00 | The following was provided by the State via e-mail: On 1-15-09, DRH was notified by the Forrest County ERC that JANX Integrity Group had an accident with one of their darkroom trucks off Hwy 59 N., in Hattiesburg, MS. The driver for JANX struck a tree off the side of the interstate causing the vehicle to catch fire. The driver then left the scene of the accident. The radiography camera, SPEC-150, SN 150 (Ir-192, 65 Ci), was not discovered until the fire department saw a 'Caution Radiation Area' sign in the bed of the darkroom truck after extinguishing the fire. Surveys were conducted by firefighter personnel for their safety and to pinpoint the location of the radioactive device in the darkroom truck. The Forrest County ERC contacted an industrial radiography company and MS licensee located in Hattiesburg to take possession of the camera and secure it in their storage vault. The radiography camera was retrieved off the darkroom truck and out of its locked storage box by the MS licensee. The radiography camera was surveyed by the MS licensee before being transported to their storage facility. On 1-15-09, JANX retrieved the radiography camera out of storage for transport back to the manufacturer to assess the damage. DRH took surveys of the darkroom truck and the radiography camera. Radiation measurements were as follows: 24 mR/hr at the surface of the camera; 4 mR/hr at 6 inches from the camera; levels were background at the vehicle. DRH coordinated the receipt of radiography camera between JANX and a MS licensee for delivery back to the manufacturer. MS report number - MS 09001
The following was provided by the State via e-mail: On 1-15-09, swipes were taken on the camera and revealed no removable contamination. Leak test results for the source and DU shielding were received from SPEC on 1-23-09 and also revealed no removable contamination. Notified FSME EO (Chang) and R4DO (Farnholtz).
The following was provided by the State via e-mail: On 1-28-09, DRH received the SPEC - 150, Exposure Device S/N 150 Final Inspection Certificate from SPEC. The camera met the requirements contained in 10 CFR 34.20, ANSI N432 1980, USA/9263/B(U)-96 and SPEC's QA Program approval number 102. Notified FSME EO (White) and R4DO (Cain).
The following information was provided by the state via e-mail: Source was Ir-192, 65 Ci, S/N PJ1606, Source Model G-60. Notified FSME EO (Vontill) and R4DO (Powers).
The following information was provided by the state via e-mail: The State of Mississippi has taken enforcement action and cited their licensee with four violations. Notified R4DO (Gaddy) and FSME EO (Vontill).
The following information was provided by the state via e-mail: On 3/5/09 (the State of Mississippi) received a written report from JANX Integrity Group. This incident has been closed on 3/5/09. Notified R4DO (Proulx), and FSME EO (McIntosh). |
| ENS 44625 | 3 November 2008 13:10:00 | On October 21, 2008, Mississippi State Department of Health was notified by Rich Dailey, RSO for Wal-Mart that two (2) exit signs, each containing 11.5 Ci of H-3, were missing from the Wal-Mart store in Hernando, Mississippi. On October 27, 2008, DRH informed the RSO for Wal-Mart that the exit signs were exempt from state regulations but to send in a written notification report. The following devices were reported missing from Wal-Mart: 1. Exit sign form store (#05419) located at 2600 McIngvale Road, Hernando, Mississippi 38632, Serial Number - Unknown, Manufacturer - Isolite, activity - 11.5 Ci of tritium at time of manufacture. 2. Exit sign form store (#05419) located at 2600 McIngvale Road, Hernando, Mississippi 38632, Serial Number - Unknown, Manufacturer - Isolite, activity - 11.5 Ci of tritium at time of manufacture.
The State of Mississippi was notified by a Wal-Mart corporate representative located in Bentonville, AR, indicating that Wal-Mart was unable to account for 307 tritium exit signs (which are general licensed materials) that were used at one time in Wal-Mart stores throughout the State of Mississippi. The Wal-Mart representative informed the State Office that Wal-Mart had exhausted searching for the tritium exit signs and considered them to be lost and/or missing. The State of Mississippi was provided a listing from corporate Wal-Mart of the store locations along with information on the tritium exit sign manufacturers, model and serial numbers and curie content where known. Notified R4DO(Farnholtz), FSME(Burgess), and ILTAB via e-mail. 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. |