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ENS 539804 April 2019 17:36:00The following information was received via e-mail: Louisiana Department of Environmental Quality (LDEQ) was notified of this event on Monday, April 1, 2019. This event occurred in a manufacturing fabrication shop in a fixed shooting bay. On Tuesday, March 12, 2019, the Radiation Safety Officer (RSO) and a radiography trainee were shooting welds at the Steel Forgigs, Inc. (SF) site. The RSO stated the QC/QA (Quality Control/Quality Assurance) safety checks had been performed before the 'radiography work' began. During radiography work of shooting welds and exchanging out pipe to be x-rayed, the trainee proceeded to change out the film on the pipe while the RSO went to retrieve a new piece of pipe. The safety alarm/lights were not flashing and the trainee assumed the source had been retracted into the shielded position. However, the trainee's survey meter saturated and his pocket dosimeter went off scale. The lights and alarm were still not responding. The RSO stated 'I knew the trainee did not exceed the 5 REM exposure limit due to my work experience.' The survey meter was functioning properly when removed from the 'high radiation' field and his pocket dosimeter appeared to function properly when re-zeroed after the off-scale reading. The trainee's personnel monitor was sent to be processed for his personal exposure. The exposure results were 2.488 REM exposure. The equipment involved in the incident was a QSA 880 Delta, s/n D5843, exposure device with a QSA source model A424-9, Ir-192 source, s/n 71973G with an activity of 19 Ci. The internal investigation documented there was no excessive exposure to the trainee. However, the late reporting of the incident, not reporting of the incident by regulatory requirement and no commitment to corrective actions to prevent these events from reoccurring in the future are still outstanding. LDEQ is seeking escalated enforcement actions pertaining to this licensee and NMED incident. Louisiana Event Report ID No.: LA-190005
ENS 537837 December 2018 16:35:00The following was received from the Louisiana Radiation Protection Department (LDEQ/ERSD/Radiation Section) via e-mail: On or about December 3, 2018, (an individual) contacted KLS Physics to inform them he had acquired some sealed sources (check sources) in a bankruptcy liquidation of assets. KLS Physics had provided physics support to HVA (Heart & Vascular Associates, PC) for their Radioactive Materials Program. KLS Physics instructed (the individual) to contact LDEQ/ERSD/Radiation Section to determine how to proceed correcting/solving the situation. LDEQ staff received (the individual's) notification on December 3, 2018. The inventory performed by KLS Physics on December 4, 2018, indicated the five (5) sources are check sources of Cs-137 and Co-57. The activities range from 0.02 microCuries Co-57 to 176 microCuries of Co-57. At this time, the Department has taken possession of three of the sources. LDEQ has assigned this NMED Incident to an investigator. This is a preliminary investigation report. Information will be updated when available. The five sources were abandoned by (the licensee), who is the registered owner of Heart and Vascular Associates, PC. (The licensee's) equipment was sold during a bankruptcy liquidation to pay expenses. The licensed source possession and Regulatory Reporting requirements are (the licensee's) responsibility. LDEQ staff received (the individual's) notification on December 3,2018. He reported the acquisition of the sources to KLS Physics Services. The name was on documents included in the box of equipment. KLS in turn had him contact the LDEQ's Radiation Section. The Department dispatched an inspector to (the individual's) residence to assess the situation. (The individual) only had three of the five sources in question. All three were is their lead pigs and surface readings were minimal. Staff personnel is still attempting to contact (the licensee) about the remaining two sources. The LDEQ reported that the sources that were found had the following activities: 69.35 microCuries of Cs-137, 57.98 microCuries of Cs-137, and 0.01 microCuries of Co-57. The sources that are still missing had the following activities: 176 microCuries of Co-57 and 0.62 microCuries of Cs-137. Louisiana Event Report ID No.: LA-180019 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 535352 August 2018 16:46:00The following information was received from the State of Louisiana via email: On 07/26/2018, (the) Radiation Safety Officer (RSO) for ExxonMobil Chemical Co. (ExMCo) reported a multi-source gauge failure to the Department (Louisiana Department of Environmental Quality), LDEQ by e-mail. On 07/25/2018 during routine annual maintenance and pm (preventative maintenance) checks it was discovered the level/density gauge had several shutters stuck in the open position. Three sources would not retract into the shielded position. However, the remaining four sources are functioning properly. The gauge is a Berthold Technologies USA multi-source device, Model LB 300 IS, utilizing AEA Technologies, Model CKC.P4 sources. There are seven (nominal) 50 mCi Co-60 sources in the device. The sources involved in this malfunction are source #1 s/n 1369-08-02, source #2 s/n 1370-08-02, and source #6 s/n 1374-08-02. All three sources will not retract into the shielded position. The device has a SS&D Registration # TN-1031-D-801-S. Only one device was manufactured and is no longer being manufactured. The manufacturer is Berthold Technologies GmbH & Co. KG, D-75323 Bad Wildbad Germany. The Berthold Model LB300 IS level density gauge is installed on G-Line High Pressure Reactor Vessel, V5300 and G-Line high pressure separator production line. ExMCo engineers and Flowmaster/Berthold engineers & service company have been contacted to fix the problem by repairing the source holders or replace the device with other comparable technology. Event type: The gauge is installed on processes and does not pose a health and safety threat to the general public or the ExMCo employees. The gauge will remain on the operational process until the repair is made to the device. This is considered an equipment failure for reporting requirements. Event Location: ExxonMobil Chemical Co. Baton Rouge Plastics Plant 11675 Scotland Avenue, (Hwy 19) Baton Rouge, LA 70807, Event description: Shutters stuck in the open position or difficult to operate shutters were detected on a level/density gauge installed on processes at ExMCo. A service company has been contacted to make the repair or replace the device. The Department will be provided a final report with corrective actions. The Department was notified and the incident was reported to the NRC Operation Center. The report to the NRC as required by 10 CFR Part 30.50 (b) (2) and required by LAC 33:XV.341.B.2.b. Louisiana Event: LA 180015
ENS 5339710 May 2018 17:20:00The following is a synopsis of information received via E-mail: On 5/9/2018, the Radiation Safety Officer (RSO) for ExxonMobil Chemical Co. (EMCo) reported a device failure to the Louisiana Department of Environmental Quality. On 5/1/2018 during routine annual maintenance and preventive maintenance checks it was discovered that a level density gauge had a shutter stuck in the open position. The gauge was a Ronan Engineering Co. gauge, Model Number SA1-C5 loaded with 100 mCi Cs-137 (10/95). The device s/n is EE815. The source and source holder usually have one s/n for the whole device. A RONAN engineering sales and service company was contacted to fix the problem by repairing the gauge and the shutter to function properly. The gauge is installed on processes and does not pose a health and safety threat to the general public or the EMCo employees. The gauge will remain on the operational process until the repair is made to the device. A service order number was generated by EMCo for the device repair. The shutter was stuck in the open position due to the buildup of grime and corrosive material from the operational environment. This is considered an equipment failure for reporting requirements. Louisiana Event Report ID No.: LA-180008
ENS 5336930 April 2018 12:34:00The following is information received via e-mail: April 19, 2018, (the licensee) called to inquire if one of his facilities had a 'Recordable Event' or if the facility had a 'Reportable Medical Event.' The report and attachments were left in a voice mail at 8:18 pm (CDT). The event occurred under the (Slidell Memorial Hospital) SMH Therapeutic and Diagnostic Radioactive Material License, LA-0783-L02. The event involved 5.4 mCi Tc-99m-Myoview administered to a patient who was scheduled for a lung scan utilizing (approximately) 5.4 mCi Tc-99m-MAA. The technologist depended on the unit dose for 'STAT' used to be MAA and did not verify the unit dose label. This medical event occurred on 04/12/2018. The technologist states that a Myoview cardiac dose was in a pig labelled MAA for a lung scan. The pharmacy pulled the dose records, verified the bar coding and determined the technologist was at error. (The licensee) provided dose calculations for the heart scan dose utilizing 5.4 mCi Tc-99m-Myoview as 0.224 rad effective dose equivalent and highest organ dose of 0.972 rad to the wall of the gallbladder. There were corrective actions (to) retrain the technologist in patient dose verification prior to injection and request their pharmacy change their label fonts to magnification and bolding the unit dose labels. The referring physician and the patient were notified of the error. LDEQ (Louisiana Department of Environmental Quality) considers this incident still open and subject to investigation to determine if this event was caused by the facility personnel or if it is an error caused by the pharmacy personnel. Louisiana Event Report ID No.: LA-180007, T 184299
ENS 5325512 March 2018 13:54:00The following information was received from the state of Louisiana via email: On March 9, 2018, at approximately 3:15 pm (CST), (the RSO of Alpha-Omega Services, Inc.) contacted the Department (Louisiana Department of Environmental Quality) to inform us that (the common carrier) had not delivered an HDR Radioactive Sealed Source to Lancaster General Suburban Hospital (LGSH), Lancaster, PA 17604. Documentation of the Event # 53255 was provided on March 10, 2018. The shipping date from Alpha-Omega Services in Vinton, LA. was 02/26/2018. The source has not been delivered to LGSH. On March 9, 2018, (the RSO) for (the common carrier) communicated to (Alpha-Omega's RSO), they could not locate the source in the tracking system or in the Memphis, TN hub. It needed to be reported as lost or missing to the NRC. On 03/12/2018, the source has not been located. The Ir-192 source is a GammaMed 232, 383 GBq, (10.4 Ci), S/N 24-01-6226-001-020818-12254-81, Transportation Index - 6. Louisiana Event Report ID No.: LA-180004 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 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 5280414 June 2017 16:29:00

The following report was received from the Louisiana Department of Environmental Quality (LDEQ) via email: Event Date and Time: On June 13, 2017, 0730 (CDT) the e-mail was received by LDEQ. The report was for two Elekta Clients under timely renewals who both received Ir-192 sources for HDR (High Dose Rate) units. Neither set of documentation matched the sources it was accompanying. Both sources were manufactured, calibrated and shipped from the A&O (Alpha-Omega Services, Inc.), LA facility on April, 27, 2017. Facility #1: A report of an HDR source being shipped to Texas Oncology PA where the source activity was less than the activity ordered and documented from the source received. The source received was actually 8.98 Ci Ir-192, but the shipping documents and source information listed the source as 11.28 Ci Ir-192. The mis-documented source was returned and a new source with the correct activity and documentation was requested. The source was an exchange source as a replacement source for the Texas Oncology PA, dba Texas Cancer Center Sherman (TCCS), Sherman, TX 75090. TX License # L05019, Amendment #23, Expiration date: January 31, 2016. The licensee is under a timely renewal and on Amendment #31. The Source S/N D36G1424. Facility #2: The report of an HDR source being shipped to New York Oncology Hematology PC (NYOH), Albany, New York, 12206. NYSDH Radioactive Material License No. 5284, Amendment #6, DH Number 09-1113. The HDR source received was 13.88 Ci of Ir-192 on May 10, 2017. The documentation for the source received was 11.01 Ci of Ir-192. This source is being held for decay and will be put into service June 13, 2017. A&O sent a source with incorrect documentation that is in violation NYOH license for activity received and activity installed in the HDR unit. The Source S/N D36G1425. A&O is a source supplier for Elekta HDR units. Elekta's ordering process notifies A&O when sources should be shipped/supplied their licensees. Event Location: The shipments originated from Alpha and Omega Services, Vinton, LA 70668 and were delivered to TCCS, Sherman, TX 75090 and NYOH, Albany, New York 12206. Neither facility received the quantity of radioactive material they ordered and were licensed to receive nor was the documentation for the radioactive material correct. The facilities were licensed each to receive an Ir-192 HDR source. Event type: Calibrating, shipping and delivery of radioactive material in quantities greater than the licensed activities and under documented quantities. The licenses were correct, but the sources shipped were greater than the facility was licensed to receive and/or the documentation accompanying the RAM Ir-192 sources for each HDR units was incorrect. A&O explained that their reference numbers were mixed up during the manufacturing process.

The A&O errors were detected by TCCS and NYOH licensees when they were performing their QC/QA on the active sources prior to patient treatment. The shipments were intact and not damaged. The sources were secure and in the hands of trained radiation safety personnel. Health and safety to the radiation workers and general public was not the issue. The issue was the reference numbers did not match the calibration activities of each source and wrong activities were shipped. Notification: On June 8, 2017, the error, quantities of RAM greater than licensed activity was discovered and reported to A&O. On June 8, 2017, the replacement source was shipped to TCCS. The incident preliminary notification was reported to the LDEQ, Assessment Radiation Section by e-mail on June 13, 2017. Reported to the NRC as LAC 33:XV.340.C. For not reviewing a radioactive material license before transferring radioactive material and LAC 33:XV.328.L.1.C. A permanent label was not affixed to the source or device containing the information on the radionuclide. LA Event Report ID No.: LA-170009

ENS 527303 May 2017 15:57:00The following information was obtained from the state of Louisiana via email: On 05/03/2017, the Assistant Radiation Safety Officer (RSO) for ExxonMobil Chemical received notice that a level density gauge was having difficulty with the operation of the shutters on a gauge installed on a process. During follow-up checks, the one level gauge was found with shutters that were stuck in the open position and the manual operation handle had broken. The report was received by the RSO at approximately 1400 (CDT) on May 02, 2017. The gauge was an Ohmart Corporation Gauge, devices involved, Model Number SHF-2-45. The gauge/device S/N unknown is loaded with approximately 200 mCi of Cs-137 and the S/N 5828GK. The source and source holder usually have one S/N for the whole device. BBP Sales/Service Company was contacted to fix the problem by repairing the gauge or replacing the device. The gauge is installed on processes and does not pose a health and safety threat to the general public or the employees. The source survey revealed the readings were less than 2 mR/hr and proper safety precautions will be taken when personnel enters the area. This is considered an equipment failure with the manual shutter handle device breakage. LA Event Report ID No.: LA-170007
ENS 5248913 January 2017 16:46:00The following report was received from the State of Louisiana via email: Event type: Level density gauge on a process had a shutter malfunction. Eagle was performing their annual operational checks when the malfunction was discovered. The malfunction is the gauge shutter is stuck in the open position on an active process. The gauge Service Company, BBP Sales will make the repair or replacement after the assessment of the device. They discovered the shutters would not close. The Gauge is a RONAN SA1-C-10 device/source holder, S/N 9527GG, loaded with a 200 mCi Cs-137 source. Notifications: LDEQ (Louisiana Department of Environmental Control) was notified by Eagle US 2 in a message on the voice mail system on 1/10/2017. The notice was sent to the Compliance Radiation Assessment Section of LDEQ. The notification was readdressed when Eagle was contacted on 1/12/2017, to get the preliminary information report. Eagle US 2 will send LDEQ a corrective action and a final report no later than 30 days of the corrective action. The Eagle US 2 preliminary written report was received 1/12/2017 at 1457 CST. Event description: On 1/10/2017, Eagle US 2 was performing their annual inventory and operational checks of their licensed devices. During their routine annual maintenance checks, the shutter malfunction was discovered. The gauge shutter would not close. Eagle US 2 called a service contractor, BBP Sales, to evaluate the situation and determine the best course of action to correct the problem. (The contractor) was unable to close the shutter and will determine the course of corrective action. The cause appears to be the corrosive environment where it (the gauge) is installed and used. The source and device with shutter stuck open will remain installed and utilized on the process until the repairs are made. This is not a radiation exposure hazard and does not pose a health and safety situation for the Eagle US 2 employees or the general public. This event is considered closed by LDEQ. This event is being reported to the NRC as required by Regulatory Requirement 10 CFR 30.50(b)(2). Event Report ID No.: LA-17001.
ENS 5179917 March 2016 17:28:00The following was received from Louisiana via email: On 03/16/2016, the RSO for A&O (Alpha Omega) called in a report of a HDR (high does rate brachytherapy) source being shipped to Texas Oncology PA (TOP) in excess of licensed quantities. The source was 12.8 Ci Ir-192 source intended as a replacement source for the Texas Oncology PA Center 3550 Northeast Loop 285, Paris, TX 75460. License # L04664, Amendment #28, Expiration date: February 28, 2025. (The RSO) was enroute to the facility to return the 12.8 Ci Ir-192 source and replace it with an additional 11.2 Ci Ir-192 source. He stated that the 12.8 Ci source was being retrieved and placed in a storage pig/container by the Service Engineer until it could be packaged and returned by common carrier to A&O 03/16/2016. Their intent was to install the 11.2 Ci source so the TOP facility could receive the source and resume patient care. A&O is a source supplier for Elekta HDR units. Elekta notifies A&O when sources should be shipped/supplied their licensees. The error was the wrong source was inadvertently shipped to TOP. The source received by TOP exceeded the licensed activity limit. The sources were Elekta Model 105.002s. The source S/N16-0505 12.8 Ci of Ir-192 was shipped when the source S/N 16-0504 11.8 Ci of Ir-192 should have been shipped. When TOP received the 12.8 Ci source, they knew it was too 'HOT' to treat patients. They called A&O at (1700 EDT) on 03/15/2016 to report the error. The incorrect source, 12.8 Ci of Ir-192 was returned to A&O by common carrier A&O explained that the mix-up was caused by reference numbers that were switched after the sources were calibrated. Louisiana incident # LA-160005
ENS 517632 March 2016 17:06:00The following information was provided by the State of Louisiana via email: On February 1, 2016, a crew from NVI (Nondestructive & Visual Inspection, LLC) was performing radiography at a temporary jobsite located at the Loop Clovelly Facility on Highway 1 in Cutoff, LA. The crew was working in an area only accessible by boat. The crew made some exposures and did not notice the 'crank out' cable became wedged between the boat and the vessel support. The crew set (four) boundaries for the duration of the 'shots'/exposures. When the crew tried to retract the source into the shielded position, it would not (retract) because the 'crank out' tube was crimped, but was still connected to the exposure device. The source assembly remained out of the shielded position. When it was determined the source was not retractable, immediately the crew cleared the area and boundaries were established by distance and for unnecessary exposures. The lead radiographer contacted the RSO and received instructions on how to secure/shield the area from potential/unnecessary exposures. This was after the crew had submerged the source in the water to provide shielding for the source. This was the initial notice and was not received until the source was secured in the shielded position and the event was over. The RSO did the actual retrieval and securing of the source. His direct reading pocket dosimeter reading was 593 mR and the crew's readings were 230 mR and below. The exposure device and associated equipment ('crank out' control and source guide tube) were SPEC 150 exposure device S/N 1764 and a SPEC G-60, S/N WI1508 source. The source was 42 Ci of Ir-192. The equipment, the exposure device and source assembly were brought to SPEC (Source Production & Equipment Company) in St. Rose, LA and was evaluated and passed the quality assurance requirements. The radiography crew was suspended from radiography work until they can be reinstructed in the NVIs' Operation Emergency and Safety Manual. The crew was sent to an Occupational Medicine Facility for blood-work. The test results were within normal limits. This is the corrective action. THIS EVENT IS CONSIDERED CLOSED. NVI, Nondestructive & Visual Inspection, LLC is Departmentally (Louisiana Radiation Protection Division) approved and licensed to perform source retrievals. This is being reported as 10CFR Part 34.101(a). Louisiana Event Report ID # LA-160002
ENS 515196 November 2015 17:14:00

The following report was received from the State of Louisiana via email: On 11/04/2015, the ARSO (Assistant Radiation Safety Officer) for (the licensee) called the LA DEQ (Louisiana Department of Environment Quality) about a hairline crack on the housing of a Berthold level density gauge. The crack was noticed when the annual operational inspections were being performed. The level gauges are required to be inspected by Condition Number 6 of the licensee's radioactive material license. The (gauge is located) in Geismar, LA within the secure boundary the licensee's chemical plant. The fixed gauge is installed on a hopper/drum, but the gauge has not been used as a qc/qa (quality control/quality assurance) device since March 21, 2003, when the device was locked-out. The crack or hairline crack was not detected or documented before the November 2015 annual inspections. The notification to LA DEQ is required by Condition Number 6 of the license. The gauge remained installed on the hopper since 2003, but was not functioning as a gauge during that time. LA DEQ was notified on November 4, 2015, at approximately 1430 CST, that during (the licensee's) annual operational inspections, they detected a hairline crack in the housing of an installed locked-out density measuring device (gauge). The device was a Berthold gauge Model LB 7440D loaded with approximately 60 mCi of Cs-137. On 11/04/2015, the licensee's ARSO called LA DEQ to make a preliminary report about a hairline crack found in a gauge housing/source holder. The crack was at the union of the gauge shielding and the mounting plate of the device.

(A contract company) has been contacted to provide services at (the licensee' facility), for packaging the source to be shipped and for the source disposal. This will be the 'corrective action' and it was speculated the crack possibly happened due to the vibration of the hopper. The source or device is not leaking. The source is not exposed or removed from the shielded position. This appears to be reportable under 10 CFR 31.5(c)(5). The source was not being used/operational when the crack was detected. There is no possible exposure to the plant workers because the gauge is still installed on an elevated process. Surveys were taken of the source/gauge housing and they were in the same range as before noticing the crack. The exposure level is approximately 150 mR/hr. The gauge has been locked-out since March 20, 2003. The shutter remains closed and the gauge does not cause a safety hazard to the plant personnel. The gauge operated in the open direction without a problem. (The ARSO) called and reported the incident to comply with Condition Number 6 of (licensee's) Radioactive Material License. The gauge is a Berthold, model #LB-7440D (originally) loaded with approximately 100 mCi of Cs-137 and received and installed in 1992. The SN for the source is 3029-9-90. The corrective action will be disposal by (the contractor). The Department (LA DEQ) considers this item OPEN until the disposal. The records will be reviewed during a site visit and the next inspection. Louisiana Event Report ID No.: LA 15-0020, T167164

ENS 5149926 October 2015 19:38:00The following report was provided by the Louisiana Department of Environmental Quality via email: On 10/26/2015, (The) RSO (Radiation Safety Officer) / Technical Service Manager for QSA Global notified the LDEQ (Louisiana Department of Environmental Quality) about an incident where a (common carrier) delivered a device containing radioactive material to their facility on Langley Dr., Baton Rouge, LA. When the receipt surveys were being performed, they noticed at one point on the surface they had a reading of 2 R/hr at the surface. It appears that one or more of the pull ties used to secure the shutters on the device broke causing a shift in the shielding. Part of the bracing material minimized the shielding shift. The device in question is a Texas Nuclear level/density gauge, Model # 5210, SN B1110, loaded with (approximately) 733 mCi of Co-60 sealed source. The origin of the shipment was Puerto Ordaz, EDO Bolivar, Venezuela. It came stateside via (common carrier) to Houston, TX and then to the QSA Global facility in Baton Rouge, LA by (common carrier). The shipment arrived (at approximately) 1145 (CDT) on 10/26/2015. The activity is below Cat 2 quantities at (approximately) 733 mCi of Co-60. The device was surveyed and moved to a bunker on the QSA Global site. Re-enactments and calculations will be conducted on 10/27/2015 AM when (the RSO) is present. The LDEQ personnel will be on site for the measurements, calculations and follow-up information (dissemination). This is a preliminary notification of an incident reported to LDEQ (at approximately) 1530 (CDT). After the source was secure, safe and locked in a bunker at the QSA Global Baton Rouge, LA facility. Possible exposure calculations will be determined from the reconstruction of events. The Baton Rouge facility is compliant for the IC (Increased controls) principles and Radiation Safety procedures/aspects for the receipt activities. The Department, LDEQ personnel will be on site for the corrective actions and calculations. The NRC, Region IV, was made aware of this situation on 10/26/2015. Follow-up information will be (disseminated) when available. This is being reported as a preventive and protection action under 10 CFR Part 30.50(a). Information will be updated when available. LDEQ considers this incident still open. Event Report ID No.: LA-150019
ENS 5149323 October 2015 13:06:00

The following information was received from the state of Louisiana via email: On October 19, 2015, the Radiology/Nuclear Medicine Manager, reported that on October 16, 2015 at 1200 hours, a PRN Licensed Nuclear Medicine Tech inadvertently dosed a patient with 25 mCi of Tc-99-MDP. The error was detected shortly after administration. The patient had physician's orders to have a cardiac scan utilizing 25 mCi of Tc-99-Tetrofosmin. The isotope activity was correct. However, the organ uptake tag was incorrect. The error resulted from the Nuclear Medicine Tech not using the patient two identifiers before administering the unit dose. The activity was correct for the unit dose, but the organ uptake tag was different. The facility employees were off and a PRN Tech was filling-in on that Friday. This Tech is used at the facility frequently when an essential employee is absent. He is no stranger to the work environment of the Facility/Licensee. The source was a 25 mCi Tc-99 unit dose. He performed the receipt procedures, unit dose assay, and utilized procedures to administer the isotope, but did not cross-reference the name on the unit dose with the individual who received the injection. This site is a Medical Institution. The unit doses are kept in a locked 'HOT' lab in the Nuclear Medicine Department. KLS Physics Consultants was called in the help with the reporting requirements. The Tech was counselled and retrained in the facility's procedures for patient identification and administration of radioactive materials for human in vivo imaging. 

"The patient will receive the correct unit dose and scan, 25 mCi Tc-99-Tetrofosmin, for a cardiac scan at a later date.

Event Report ID No.: LA-150018, T166800 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 514412 October 2015 16:54:00

The following report was received via fax: An OHMART gauge was discovered with the shutters malfunctioning on a level gauge installed on processes. The shutters were stuck in the open position due to the buildup of grime and corrosive material from the operational environment. This device does not pose a radiation exposure hazard or a threat the work force or the general public. The device will remain in operation on the processes until the repair or replacement. 

"The detected malfunction was discovered during the annual inventory/operational checks.  These checks are required by condition # 7 of the radioactive material license, LA-2316-L01.  The repairs will be made and documentation will be reviewed during the next inspection.

The gauge detected was an OHMART Corp. gauge, Model Number SHF-2. The gauge/device S/N unknown is loaded with approximately 671 mCi of Cs-137 with source S/N 5895GK. BBP Sales was contacted to fix the problem by repairing the gauge or replacing the device. Louisiana Event: LA-150016

ENS 513819 September 2015 15:50:00The following information was provided State of Louisiana via email: On 09/02/2015, the RSO for A&O (Alpha-Omega Services, Inc.) called in a mis-delivery/wrong delivery of 11.6 Ci Ir-192 source intended for the Radiation Oncology Center at Sibley Memorial Hospital (SMH) in Washington, DC. SMH is a client/customer of A&O in association with ELEKTA. SMH purchased and attempted to possess the radioactive source under a license NRC 08-07398-03. A&O packaged the Ir-192 source and addressed it to SMH, Dept. of Radiation Oncology, 5255 Loughboro Road NW, Washington, DC 20016. The source was shipped from the (A&O) Vinton, LA address to SMH on August 31, 2015. However, (common carrier) delivered the source to Howard University Hospital, Cancer Center, 2041 Georgia Avenue NW, Washington, DC 20060 (on September 2, 2015). Common carrier was notified of the delivery error and took possession of the source on September 3, 2015 and delivered to the proper address (SMH) that day. The source shielding and shipping container was intact during the incident. It was not damaged nor was the container opened until it reached the final destination. Source information: Elekta Model 105.002 source: 11.6 Ci Ir-192, Serial Number - D36F5755 LA Event Report ID No.: LA-150015; T165946 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 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 5135728 August 2015 17:12:00The following information was obtained from the State of Louisiana via email: Event date and time: On August 27, 2015, (a licensee employee) reported a lost QC/QA check source utilized to perform the daily constancy on the dose calibrator. He did the daily test at approximately 6:00 a.m. (CDT) with the source. He noticed the source was missing at approximately 1130. His administrator and he used survey meters and searched every possible place where the source could be, but have not located the missing source. (He) reported the source missing to LADEQ Radiation Assessment at 1538 on August 27, 2015. The source is an Atomic Labs 102 microCurie Cs-137 check source. The model number given was #11010170 and the serial number was 356013-0001. The source was last leak tested on April 29, 2015, with no leakage detected. This site is a medical institution. The source was kept in a locked hot lab in the Nuclear Medicine Department. They surveyed the Nuclear Medicine Dept., the Radiology Department and the waste disposal location. KLS Physics Consultants was called in to help with the search and the reporting requirements. Event Location: Ville Platte Medical Center/dba Acadian Medical Center, 3501 Hwy 190, Eunice, LA 70535. The last known location within the facility was during the daily dose calibrator constancy check. Louisiana Event Report ID No.: LA-150014, T165187 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 511408 June 2015 16:35:00The following report was received via fax: The incident happened on June 8, 2015, and was corrected and under the licensee's control by 0840 CDT. It was not reported to the Department (Louisiana Department of Environmental Quality) until 1150 CDT on June 8, 2015. A radiography exposure device was left in a company radiography rig parked at the Baton Rouge Metro Airport. A radiographer was flying out of the Baton Rouge Airport after working a job in the field. The radiographer went through security and boarded the plane departing at 0700 CDT. However, the person who was to retrieve the rig with the camera did not arrive at the airport until 0840 CDT. This means the camera alarm system was left unattended for 1 hour and 40 minutes. The IC alarm system for the radiography rig sounds/alarms to a 'key fob' while in the field. One potential responder was in the air with one alarming device and the other alarming device had not made it to the airport. The radiography rig was parked in a parking lot unattended. The rig and camera were retrieved at 0840 CDT the same morning. The camera was an AEA Delta 880, SN D8086 exposure device loaded with 34 Ci of Ir-192. The camera and the vehicle were locked and secured, but the alarming device was unmanned for approximately 2 hrs. The Radiation Safety Officer called in his report at approximately 1150 CDT on 06/08/2015. The situation did not result in a radiation incident. However, the potential for a radiation incident or security breach was the problem. At this time, LDEQ (Louisiana Department of Environmental Quality) considers this incident still open. The incident is still under investigation and review by the staff. Enforcement and corrective actions will be determined by the out-come of the investigation. The incident was considered under control by MISTRAS and reported after the exposure device was back at the MISTRAS'S Geismar, LA location. Louisiana Report: id No.: LA150009
ENS 5099217 April 2015 17:10:00

The following report was received via e-mail: Installed fixed level gauge on a process. The shutters on a fixed level gauge would not close properly due to a breakage of a shutter pin. The situation is the result of extended usage. The gauge was purchased and put into service in 1985. The problem with the shutter function is considered equipment failure of this device. Corrective action will be to de-install this device and (dispose of it). The gauge will be replaced with a new lower activity source device. The failure is that the shutter blades would not open and close due to a shutter pin breaking. There was no removable radiation released into the environment. The gauge/source holder was 'fixed', and the RSO tagged and posted the broken device. Additionally, all personnel working in the vicinity of the devise were informed of the problem. The RSO advised the employees the radiation exposure levels were in the normal operational range. 

"The gauge was an Accuray Mfg. device, SH302, s/r HS302-S6, approximately 200 mCi of Cs-137 when installed and manufactured in 1985. The source serial number is CS11166.

Louisiana Report: LA150007, T163028

ENS 5099620 April 2015 16:43:00

The following was received from the State of Louisiana via email: A radiography inspection was being performed on a Central Testing crew at the Tri-7 facility in Sulphur, LA. At a point during the inspection, the inspector requested that the crew demonstrate a misconnect/disconnect test on the camera and drive cables in use. The crew stated that the equipment had passed the test before the equipment was put into service for the day. However, during the demonstration, the 'control assembly' on the crankout set functioned in a test failure mode. The control assembly easily slipped into position without the drive cable being attached to the source assembly, 'pigtail.' With this failure, the RSO was contacted and an additional set of crankouts were brought to the jobsite. The crankout was evaluated and it was determined that the control assembly is what failed during the test. The control assembly was replaced on the crankout and it corrected the misconnect/disconnect test failure. This test is to be performed on the equipment daily with use. This is a requirement of LA Radioactive Material License LA-2393-L01A, Condition # 16.

The exposure device was a SPEC Model 150 camera, S/N 1057, loaded with a 63 Ci Ir-192 source, SPEC Model G-60. The associated equipment was manufactured by SPEC, crankout and control assembly, with unknown model and s/ns. When the equipment was replaced, the radiography crew was allowed to resume their work. LA Event Report ID: LA 15-0004

ENS 5091924 March 2015 15:20:00

The following report was received via e-mail: On 02/26/2015, the RSO for Boise Cascade called in a preliminary report (to the Louisiana Department of Environmental Quality) about a shutter missing on a gauge to be 'locked out' during a 24 hour turn-a-round. The shutter is a manual sliding port cover that has to be removed when the gauge is used on the process. The removed shutter is stored by placing it on an adjacent surface until needed. Vibrations on the process had caused the port cover to fall approximately 50 ft. below the storage locations. However, this time the cover could not be located and the gauge could not be locked out. The gauge remained on the process until it could be repaired. 

"On 02/26/2015, a replacement shutter/port cover was ordered from Thermo Measuretech.  The shutter was delivered on 02/27/2015 and installed the same day.  There was no radiation exposure risk to the public or workers.  The gauge is installed on a 50 ft. elevation and the unshielded radiation field is approximately 0.3 mR/hr at 1 ft. from the surface of the device.

The gauge was a Texas Nuclear Device, TN 5192, s/n B3421 containing approximately 100 mCi of Cs-137 when installed during the mid-1980s. 

"The Department (Louisiana Department of Environmental Quality) considers this item closed and the records will be reviewed during the next inspection.

Louisiana Event Report ID No.: LA 15-0005, T162439

ENS 5080510 February 2015 17:17:00

The following information is an excerpt from a report received from the Louisiana Department of Environmental Quality via email: On 02/09/2015, the Director of Regulatory Affairs for QSA Global Notified the (Louisiana Department of Environmental Quality) LDEQ about an incident where the common carrier delivered a 'crate/container' of (Radioactive Materials) RAM to the Baton Rouge, LA address that was intended for Seoul, South Korea. The call was received approximately 9:00 am CST at the Department. The caller stated the shipment was Ir-192 wafers/disc that were to be assembled into radioactive sealed sources. (The Director of Regulatory Affairs for QSA Global) stated he believed the shipment involves Category #1 quantities that should be reported. The delivery error resulted in a partial shipment bound for Asia being delivered to the Corporation's Baton Rouge, LA location. One of the Asia bound containers was 'bound/attached' to the container destined for Baton Rouge location at the Memphis Hub belonging to the common carrier. The other container went on to Asia. The international paperwork would document the partial receipt of the first container and the other when it was delivered. The common carrier was notified of the incorrect delivery. The common carrier was to pick up the Asia container on 02/10/2015 at QSA Baton Rouge facility and take it to the common carrier terminal in Kenner, LA. Then the container would be forwarded to Asia from Kenner, LA.

Three containers, each having radioactive material in excess of Category 1 quantities were being shipped from the QSA Global Burlington, MA facility. Two were addressed to Seoul, South Korea and one was being shipped to Baton Rouge, LA. The labeling on one of the Korean containers was not legible or missing and it was bound to the container going to Baton Rouge, LA. After the delivery was made to Baton Rouge and the shipment was being surveyed/assessed it was learned they had received a wrong container and was in excess of the licensed activity for Ir-192. The Baton Rouge facility was compliant for the IC principles and Radiation Safety procedures/aspects for the receipt activities. The Department, LDEQ, determined that it would grant an emergency verbal activity increase for this situation. This would hold the radioactive material safe and secure until the common carrier could retrieve the excess material. The NRC, Region IV, was made aware of this situation on 02/09/2015, and the circumstances involving the common carrier error. Region IV was told QSA Global Burlington was going to be making the proper notifications/reports to the regulatory agencies. This was the information provided by (The Director of Regulatory Affairs for QSA Global). However, on the morning of 02/10/2015, the NRC Region IV notified LDEQ that a report about this situation could not be located within his agency. (the Director of Regulatory Affairs for QSA Global) was notified and he was unaware the notifications had not been made. He stated he would look into the situation. A call was placed to the Baton Rouge facility around 9:00 am (EST). At that time, it was learned the common carrier was at the Baton Rouge facility to retrieve the container of radioactive material and forward it to South Korea. At this time LDEQ is still waiting on (The Director of Regulatory Affairs for QSA Global)'s explanation for the notifications not being made. A fact finding discussion resulted in a plan of control and containment until the common carrier could take possession of the container. LDEQ considers this incident closed. Louisiana Event Report ID No: LA15004

ENS 5075523 January 2015 14:03:00The following information was received from the State of Louisiana Department of Environmental Quality Assessment Division via fax: On 11/21/2014, Berthold Technologies reported that Morehouse Bioenergies, LLC called to replace a density gauge source, 10 mCi Cs-137, for a gauge they were installing on a process. However, Berthold Technologies had sold and shipped the whole unit to BioEnergies in March 2014. The reorder peaked the interest of Berthold Technologies who notified the LDEQ. Attempts to reach Drax Biomass International, Inc., the radiation responsible company and owners of Morehouse Bioenergies, LLC, were unsuccessful on numerous occasions. Berthold Technologies supplied shipping documents, quarterly distribution records and signed records of receipts for the source/gauge. The record of receipt was signed and transferred back to the construction foreman and the site on March 25, 2014. The location of the source from March to November 2014, is unknown and continues to be a mystery. This site is a wood yard for manufacturing wooden pellets. Its location is in the deep woods of north Louisiana and is only accessible from the state of Arkansas. The scintillation detector has been installed, but the box with the Cs-137 source is nowhere to be found. All communication with Drax Biomass International, Inc. is done by remote access and usually by return phone call. The gauge was a Berthold Technologies unit shielding Model LB 7440-F-CR, Serial Number 37625-11972. The source was 10 mCi of Cs-137 serial number 0038/13. Event Location: The Morehouse Bioenergies, 7070 Carl Road, Bastrop, LA 71220. This was a construction site for a wood pellet plant. An investigator made a site visit, but there was only a person with Haskell Contractors to interview. Event Type: This was a loss of control incident that has not been resolved to this date. The freight company delivered the gauge to the site and it has since disappeared. This incident is considered still open. Louisiana Department of Environmental Quality, Radiation Assessment report number: LA-150003, T160317. 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 5074216 January 2015 18:17:00

The following information was received via E-mail: This event occurred at a permanent shooting cell at the licensee's facility in Amite LA. The RSO was performing the semi-annual leak test on his radiography cameras. One is loaded for use in radiography and the other is essentially considered in storage. He removed the guide tube to swab the port entry and finished the paperwork for the leak test. Later he went to make an exposure and the source extended the length of the drive cable and would not retract into the shielded position. The source was stuck out into the vault shooting bay area. The equipment was an Amersham Model 680-BE, s/n BE 178 loaded with approximately 50 Ci of Co-60, a QSA Global source s/n 45274B. The associated equipment was an Amertest Automatic Exposure Control, Model 957, s/n 67.

This was operator error. The RSO did not reattach the guide tube after performing a leak test at the camera's port. The source was being utilized in a fixed shooting cell/vault when it would not retract. (In order to retrieve the source) the side panel was removed from the camera and a manual source retraction was performed. The source was shielded from unnecessary exposure, ALARA (as low as reasonably achievable), during the source retrieval. Again, this was operator error, not equipment failure. The source is secure from removal and unnecessary exposure. This event is not closed and additional investigation and evaluation will continue. The source is in a safe shielded position and no threat to workers or the general public. Louisiana Event Report ID No.: LA150001

ENS 5061614 November 2014 18:12:00The following was received from the State of Louisiana via email: IRISNDT-LA was transporting a SPEC Model 300 exposure device, S/N 004, loaded with Co-60 greater than Cat. 2 concerns, S/N C 60-49. The exposure device and source were being returned to IRISNDT, 905 GA Ave., Deer Park, TX. Texas License TX L0 6435. They were driving in the flow of traffic when the utility trailer, loaded with the exposure device was rear-ended by a pick-up truck at 1030 (CST). The LSP (Louisiana State Police) and LDEQ (Louisiana department of Environmental Quality) responded as well as the LA RSO and the CRSO who was in town on other business. A field assessment was conducted at the site and then the device was transported to the New Orleans, LA office. Additional evaluations and wipe test were performed and sent for evaluation. It appears that no shielding or radiation containment was compromised. The exposure device is being transported to Source Production & Equipment, the manufacturer, for a more extensive evaluation. All personnel involved with the radioactive source during this incident were T&Red by IRISNDT under their IC security procedures. LA and TX Licenses and other documents were with the device. All radioactive sources are secured at the New Orleans office. No radioactive material was released or determined to be leaking at the time of this preliminary report. The radiography equipment will be transported to a location where an extensive evaluation of the equipment will be conducted. The outward appearance does not indicate there is severe or excessive damage to the exposure device resulting in a radioactive material release. The two carded radiographers involved in the traffic accident were taken for a medical evaluation and released with no serious injuries. Updates will be provided when 'new' information is available." Louisiana incident # LA1400011
ENS 506554 December 2014 15:08:00The following report was received from the State of Louisiana via fax: The source became stuck/lost down a strategic oil reserve cavern belonging to US DOE. Cavern named WH 9A, in West Hackberry field, Cameron/Cameron Parish, LA. STC (the licensee) was logging/taking measurements in/down a strategic oil reserve cavern for the Department of Energy when the 125 mCi source became lost down cavern, STC abandoned in place the Cs-137 source and applied all practical applicable P/A procedures pertaining to a cavern. The source was declared irretrievable November 11, 2014, and requested approval of the information on the plaque. The source is believed to be on the bottom of the cavern at depth of 3,575 ft. Schlumberger, after several 'fishing' attempts, decided to 'cap'/abandon the location and move on. LDEQ (Louisiana Department of Environmental Quality) was notified of the lodged source on October 27, 2014 (approximately) 1720 CDT. At that time, Schlumberger requested direction to abandon the irretrievable source. The request was granted by (LDEQ). On October 27, 2014, STC contacted LDEQ with a preliminary notification reporting that a well-logging source was lost down-hole in a DOE Strategic Oil Reserve Cavern in Cameron Parish, LA. The source, a Gulf Nuclear, 125 mCi Cs-137 source, S/N CSV-129. This incident was reported and will be abandoned and maintained by the requirements of LAC 33: XV. 2051 and 2099, Appendix B. LDEQ considers this event closed. Louisiana Event Report ID No.: LA - 140012 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 5057529 October 2014 14:35:00The following information was provided by the State of Louisiana via fax: On September 12, 2014, LA DEQ (Louisiana Department of Environmental Quality) received a notification from the (licensee) Radiation Safety Officer (RSO). (The RSO) stated a crew was making exposures at a fab shop (in Walker, LA) at approximately 1730 CDT. The exposure device was on an I-beam when the device slid off of the beam onto the front guide tube outlet connection. The radiographer realized the source could not be retracted back into the shielded position. The lead radiographer contacted the RSO and received instructions on how to secure/shield the area from potential/unnecessary exposures. An assistant RSO, was dispatched to the site to perform the retrieval and he arrived approximately 1830 CDT. (The assistant RSO) was able to retract/shield the source when he removed the crimped drive cable. The source retrieval was completed approximately 1920 CDT. The crew members exposures were both less than 30 mrem and the assistant RSO's exposure was less than 100 mrem. The exposure device and associated equipment (crank out control and source guide tube) were shipped to QSA Global for a materials evaluation. The equipment was evaluated and passed the quality assurance requirements for Type B radiography equipment. The male connector on the source guide tube was replaced and was returned to the customer. The equipment involved in the incident and returned to the customer after the repair and evaluation: QSA 880 Delta, s/n D9829. QSA source model A424-9, Ir-192 source, s/n 16863C with an activity of 69 Ci. QSA control model SAN88225R and a Swivel End Stop QSA GST TAN48906. (The licensee) is Departmental (LA DEQ) approved and licensed to perform source retrievals. License No.: LA-15838-Lol, AI#s. 12540; 165525. Louisiana Event Report ID No.: LA-140010
ENS 4931027 August 2013 18:00:00The following report was received via e-mail from the Louisiana Department of Environmental Quality: On 08/27/2013, the RSO for Tulane University Hospital called to notify the Department that their facility had a Medical Event involving (exposure to unintended tissue greater than) 50 Rem. The event was discovered on 08/27/2013 when an application was not able to be applied to the intended tissue. The HDR source had 'dog legged' into the bowel area when it was intended to apply the radiation dose to the cervical area. The films were pulled for the application on 08/22/2013 and revealed that the application had 'dog legged' also. The cervical tissue did not receive the initial intended dose. The HDR (High Dose Rate Brachytherapy Afterloader) unit was a Nucletron Micro-Selectron, loaded with (an) Ir-192 (source). The therapy dose was 8.4 Gray (840 rads) given in fractions. The patient is to receive the entire corrected therapy dose prescribed. This is believed to be (under investigation) a positioning problem and not an equipment malfunction. The patient's physician has been notified. However, the patient was heavily sedated and has not been notified. Updates will be made when additional information is available. Louisiana Report ID: LA-130001 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 489891 May 2013 13:28:00The following information was received via fax: On 04/26/2013, the RSO for IRIS, was notified by one of his radiography crews working at the Marathon Refinery that a source was not retracting into the shielded area of the camera. This incident involved a QSA Global Exposure Device, Model Delta 880, S/N D6458, loaded with an Ir-192 source. Associated equipment was used with the exposure device. The problem occurred when the crew used a magnetic source tube stand as opposed to a non-magnetic support stand. Source retrieval was accomplished by the RSO around 2:53 pm. Using safety equipment, maintaining a 2 mR boundary, and time, the highest exposure received was by the RSO which was 75 mR. The other exposures recorded were from normal work activities. The Department (Louisiana Department of Environmental Quality) was notified after source retrieval was completed.
ENS 488998 April 2013 16:50:00

The following information was provided by the State of Louisiana via email: Event date and Time: On 04/02/2013 (the) RSO for A & O (Alpha-Omega Services, Inc.) called in a mis-delivery of an Ir-192 source intended for Radiation Oncology Center of Nevada (ROCN). ROCN is a client/customer of A & O, but (the common carrier) delivered the source to Cardinal Health (CH). ROCN and CH are both radioactive material licensees and both have facilities in Las Vegas, NV. Event Location: Around the Las Vegas, NV area. The source was intended for ROCN in Las Vegas, NV, but was delivered to Cardinal Health, (also in) Las Vegas, NV. The source delivery occurred in the morning to CH. CH notified ROCN that their source was delivered to CH by (the common carrier). (The common carrier) was notified and picked up the source at 1300 (PDT) and delivered it to ROCN. Event type: Delivery of a radioactive source by the (common) carrier to the wrong licensee. Except during transport, the source was in possession of someone who was a licensee and well trained in radiation safety practices. Notifications: A notification was made to LA DEQ (Louisiana Department of Environmental Quality) Radiation Assessment after the incident was basically over and entirely under control. The notification was made to (a Louisiana representative) located in (the Louisiana) Southwest Regional office. A & O was involved in the recovery of the source by phone after learning of the mis-delivery. The source was delivered to the wrong licensee. CH, the licensee where the source was delivered, was licensed for radioactive material and well trained in the handling of radioactive material.

Event description: (An) Ir-192 source was delivered to the wrong licensee by (the common carrier). When the error was discovered by CH, CH notified ROCN that they were in possession of licensed radioactive material that belonged to ROCN. (The common carrier) was called and they picked up the source and delivered it to ROCN around 1300 (PDT). The source shielding and shipping container was intact during the entire incident. It was not damaged nor was the container opened.

Transport vehicle description: (The common carrier) picked up the source from the A & O facility (in) Venton, LA which was being shipped to a client, ROCN (in) Las Vegas, NV. (The common carrier) delivered the Ir-192 source to the wrong address. The source was delivered to Cardinal Health (CH), (also in) Las Vegas, NV. Event Report ID No.: LA-120015

ENS 488843 April 2013 16:20:00The following information was received from the State of Louisiana via email: On 04/01/2013 (the) RSO for NVI (Nondestructive & Visual Inspection), notified the Department (Louisiana Department of Environmental Quality) that his personnel monitoring processing company, Landauer, notified him that one of his monitors was processed with a result of 108 R exposure. The monitor was assigned to an individual who had been terminated at the beginning of February 2013 for chemical dependency. The individual could not be directly contacted and the monitor was missing for the month of February. The monitor appeared in the cab of a rig truck for radiography. The employee had not been employed or working in a radiation environment for NVI about 2-3 weeks when the monitor surfaced. Attempts were made to make contact with the individual, but (there was) no response. (The RSO) stated that he was trying to reach the individual to provide him with medical assistance. At a minimum, he wanted to do blood work Cytogenetics/Biodosimetry on the individual. This is a possible but, not probable excessive exposure to this individual. At 8:00 AM on 04/02/2013 (the RSO) called to update the Department and stated that the individual returned his call at (11:00 PM) on 04/01/2013 and consented to accept the medical assistance. The employee has not been sick or had any visible signs of radiation sickness. The trip to a physician office and a call to REACTS in Oak Ridge, TN set up the process for Monday April 8, 2013. The process needs fresh blood within 24 hours for the test. At this time, the Department considers this incident pending the outcome of the test. LA Event Report ID: LA-120014
ENS 4874913 February 2013 14:46:00The following information is a synopsis of information received from the State of Louisiana: On 2/6/2013 at 1752 CST, the Iberia Parish Sheriff's Office (IPSO) notified the Louisiana Department of Environmental Quality (LDEQ) that radioactive material had been found in a vehicle which had been towed and impounded by IPSO. LDEQ personnel conducted an investigation on 2/8/2013 at the IPSO. A metal briefcase containing a SenoRx Gamma Finder II survey meter and two calibration sources was found in the impounded vehicle by the IPSO. Survey readings done at a local hospital before LDEQ was called read 0.008 mR/hr for the two calibration sources. The briefcase containing the survey meter and calibration sources was then taken to the IPSO. Description of the first source: Co-57, serial number D-138-21, last calibration date 10/21/2008, activity 11.5242 microCuries. Description of the second source: Co-57, serial number D-139-6, last calibration date 10/22/2008, activity 1.1419 microCuries. The IPSO traced the serial numbers and found that the survey meter and calibration sources belonged to Bard Biopsy Systems in Philadelphia, Pennsylvania. The IPSO confirmed that Bard Biopsy Systems had reported the survey meter and calibration sources stolen from their location in Philadelphia, Pennsylvania in 2009. A report had been filed with the Philadelphia Police Department, District 26, at that time. LDEQ personnel performed a survey on both calibration sources using a Ludlum 14C survey meter. The first source read 0.05mR/hr on the surface and the second source read 0.03 mR/hr on the surface. A background reading of 0 mR/hr was noted during these readings. The Philadelphia PD, District 26 is following up on the stolen equipment. The IPSO will ship the survey meter and sources to the Philadelphia PD. Philadelphia PD will return the survey meter and calibration sources to the owner.
ENS 4863128 December 2012 15:14:00The following information was received from the Louisiana Department of Environment Quality via facsimile: On 11/27/2012, the RSO for BASF called in a preliminary report about a shutter on a fixed level gauge utilized in their processes in the chemical plant. There is no possible exposure to the plant workers because the gauge (is) installed on a remote process (tank inaccessible by plant personnel) and, (consequently), the shutter remaining open and operating (should not be) a problem. . . . The gauge is a Berthold, model #LB-7440D loaded with 150 mCi of Cs-137. (A manufacturer service technician) has been contacted to repair the level gauge. The manufacturer's service tech stated that (the stuck shutter) appears (to be the result of exposure to) the elements. The Louisiana Department of Environmental Quality considers this item closed and the records will be reviewed during the next inspection. Louisianan Incident Number: T145017
ENS 4863028 December 2012 15:26:00The following information was received from the Louisiana Department of Environment Quality via facsimile: On 11/09/2012, the RSO for Phillips 66 called in a preliminary report about (stuck) shutters on fixed level gauges utilized in their processes in the chemical plant. There was no possible exposure to the plant workers because the gauges were still installed on a process (tank in a remote location) and the shutters remaining open was not a problem. . . . The gauges are Omart and Ronan Engineering devices. (A manufacturer service technician) was contacted to evaluate the source holders and determined which devices could be repaired and which ones needed to be replaced. All of the source holders, with the exception of two were able to be freed up for continual use. . . . Two source holders were damaged during the evaluation process. . . .These two sources in their holders will be replaced during the next turn-a-round to reduce down time. . . . The gauges have been in the elements for a prolonged period of time and the shutters malfunctioned due to corrosion in the mechanism of the source holder. All of the sources were evaluated and inspected . . .. The manufacturer's service tech stated that it appears the be from being in the elements. The manufacturer stated that they were looking into finding a modification to shield the shutter mechanism from the elements. The Louisiana Department of Environmental Quality considers this item closed and the records will be reviewed during the next inspection. The gauges involved are: 1) Omart SHLG2-45 2) Omart SR 2 3) Ronan SA1-F37 Louisiana Incident Number T145023
ENS 4863228 December 2012 15:24:00The following information was received from the Louisiana Department of Environment Quality via facsimile: On 11/01/2012, the RSO for Rock Tenn called to report a stuck shutter on a (density) gauge utilized on a process (line) in the paper mill refinery. There was no possible exposure to the mill workers because the gauge is installed on a process (line in a remote location) and, (consequently,) the shutter remaining (open) is not a problem. The gauge is a Berthold, Model LB 7400 Series, loaded with a 50 mCi Cs-137 (source). The gauge has been in the elements for a prolonged period of time and the shutter malfunctioned due to corrosion in the mechanism of the source holder. All of the sources were evaluated and inspected and only one needed repair. The manufacturer stated that it appeared to be from being in the elements. The manufacturer stated that they were looking into finding a modification to shield the shutter mechanism from the elements. The Louisiana Department of Environmental Quality considers this item closed. Louisiana Incident Number: T144358
ENS 483651 October 2012 16:15:00The following information was provided from the State of Louisiana via facsimile: IRISNDT dispatched a radiography crew to Marathon Petroleum on September 5, 2012. The crew set up and began work around 6:30 am. The crew worked with a camera, associated equipment, and a collimator for hours before there was a problem. (At 1045 CDT) the source setup was about 15 feet up above the ground in the pipe rack when the source would not return into the shielded position. After several attempts to retrieve the source, the RSO was notified. The crew was instructed to secure the barricade at the 2 mR distance and maintain observing the area until the RSO could arrive. The RSO arrived and secured the source into the exposure device's shielded position. The equipment, QSA Global Delta 880, s/n# D6460, the source is s/n# 86363B ...Ir-192, last leak tested on 08/07/2012. The investigation concluded a gear in the crank assembly was damaged and it caused the drive cable to jam. The assembly was red tagged and removed from service. Event exposures were 29 mR (Radiographer Trainer), 6 mR (Radiographer Trainee) and 2.4 mR (RSO). Louisiana Event Report ID No. LA1200004.
ENS 4715012 August 2011 16:31:00

The following report was received via e-mail: On July 22, 2011 at 3:00 p.m., (the Louisiana Department of Environmental Quality) received a call from Team Industrial, that there was an attempted break in on a radiography crew's truck, while staying at a hotel in Belle Chasse, LA. It was around 9:30 p.m. on July 21, 2011, when the crew heard the alarm on the truck go off. They came out to see what happened and saw two men take off. There was nothing taken and they called the local law enforcement. However, there was no video surveillance footage available. The crew moved to another hotel with video surveillance in the area of the IR (Industrial Radiography) truck.

The crew came from the Team office in Gonzales, LA.

ENS 4429914 June 2008 19:19:00The State of Louisiana reported the theft of a Thermomeasure Model 5715 1C gauge containing a 100 mCurie CS-137 source (S/N B5633). The gauge was in a truck in a fenced parking area for the licensee (B J Services). The theft was discovered around 0200 CDT on 6/14/08 but the last time the gauge was accounted for was on 6/11/08. The theft has been reported to the police. The State of Louisiana is investigating. 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. Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Less than Cat 3 event. Note: the value assigned by device type "Category 3" is different than the calculated value "Less than Cat 3
ENS 4397911 February 2008 16:44:00

The following information was provided by the State of Louisiana via email: On February 9, 2008 at around 9:00 am, a Model Number AccuSource 1000, with a Model M-19 Iridium-192 High Dose Rate Brachytherapy Source failed to retract automatically while pre-operational acceptance testing was being performed at New York Radiation Oncology Associates, Queens, New York City, New York. The AccuSource 1000 is manufactured by Oncology Systems, Inc. Their license number is LA-11598-L01, amendment# - initial, with an expiration date of July 31, 2012. Agency Interest Number is 147139. Model M-19 Iridium-192 source SSD number is LA-0612-S-115-S. The sources maximum quantity is 12 curies of Iridium-192. Oncology Systems, Inc. according to their license condition number eight, states that 'The licensee shall report to the Department, immediately by phone and written notice with ten (10) days of occurrence of any irregularities pertaining to inability to retract the source to its fully shielded (position), and failure of any component or software (critical to safe operation of the device) to properly perform its intended function under the authority of this license.' This was reported by SPEC who is the manufacturer of the Model M-19 Iridium-192 source. Talking with SPEC, it does not seem that Oncology Systems, Inc. have any personnel located at the 119 Teal Street, St. Rose, LA 70087 location. The source, which was extended approximately 10 cm when it stuck, was manually retracted. There was no reported personnel overexposures, however, the individual's film badges involved in returning the source to the shielded position have been sent out for processing. The City of NY Rad Health Department was notified by the State of Louisiana of this incident.

  • * * UPDATE PROVIDED AT 1512 EDT ON 05/15/08 FROM PENROD TO ROTTON * * *

The State provided the following information via facsimile: The incident involved an OSI AccuSource 1000, lr-192 HDR Brachytherapy unit. The unit malfunctioned, during an initial systems check, resulting in the source disconnecting from the source cable and the source capsule. The source strength was 8.62 curies. The source remained in a shielded position and was shipped back to Source Production & Equipment Company (SPEC), RAM License # LA- 2966-L01, the source manufacturer. No patients were involved and no overexposures were noted. This investigation is still in progress. One area of concern was noted. On February 9, 2008, an Oncology Systems. Inc. (OSI) Field Engineer, was performing quality assurance testing on the AccuSource 1000, lr-192 Brachytherapy High Dose Rate Remote Afterloader (HDR), at the new York Radiology Associates, located in Queens, New York (RAM License # 91-3338-01). Field Engineer first performed a systems and software check on the HDR using a nonradioactivce source. All quality assurance tests passed during this time. He then loaded the HDR with the inner vault/spool cartridge assembly, which had an 8.62 Curie lr-192 sealed source. Field Engineer performed several tests on the HDR unit before running the source cable out, to insure that the inner vault was installed correctly to the outer vault (which is part of the HDR unit). The tests passed. He then extended the source out of vault when a force error sensor was triggered between the vault and the turret. When the force error was triggered this triggered an emergency retraction of the source. During the emergency retraction of the Ir-192 source, the vault door closed on the source tip resulting in a source disconnect and the loss of the top part of the source capsule. The source did retract to the inner vault where it was shielded and did not leave the AccuSource unit. The inner vault/spool cartridge, with the Ir-192 source was packaged in a Type A shipping container, provided by SPEC, held at the facility in a locked room until it could be shipped to SPEC. SPEC received the container on 2/26/2008. The source capsule tip loss was not known until the inner-vault was inspected by SPEC on 03/18/08. Surface readings were 19mR/hr and 0.7mR/hr at one foot away. Survey readings of the package, before it was sent to SPEC, highest survey reading at one foot away from the package was 1.4mR/hr. This was taken at the bottom of the package. The highest reading taken from its side at one foot away was 0.51 mR/hr, similar to the reading at SPEC. Once the package was open, several wipes were performed by SPEC. Two areas above background were noted. The wipe from the tip of the cap/wire where the source capsule was missing (the lr-192 source would have direct contact with this piece) had a wipe count of 327cpm and back end of the cable had a wipe count of 101cpm. Background was 37cpm. Survey readings of the vault were done by SPEC and the department at the time of this investigation. Survey readings on the side of the vault were 200 mR/hr and 100 mR/hr at the end of the vault. The source was located in the inner vault, but the inner vault was not opened at the time of this inspection. The facility wanted the lr-192 source to decay before opening the inner vault. The inner vault was disassembled by SPEC on 03/18/2008. They found the bare lr-192 pellet in the straight exit channel of the front vault slug. The source capsule was not in the inner vault. The shipping package was re-surveyed and the capsule was not found. SPEC immediately notified the department and OSI. Wipe tests of the inside of the vault was performed by SPEC. The highest reading was taken from the center vault slug which was 33,000 nanoCuries. OSI field Engineer was going to the New York Facility during the week of 04/15/2008 to do a survey of the AccuSource and the therapy room to see if the missing capsule can be located. The results have not been received by the department as of 04/23/2008. OSI states that the force error could have been triggered by many reasons and that the cause is unknown. The source became 'stuck' due to the vault door closing partially on the capsule. OSI is in the process of making design and software changes to prevent this problem from occurring in the future." Notified R4DO (Powers) and FSME EO (Tadessee).

ENS 4271921 July 2006 10:02:00A technician who works for the licensee left his vehicle at his residence and then went to have dinner about 30 minutes away. Upon returning to his home and vehicle, the technician found that all equipment had been stolen, including the Troxler moisture/density gauge, model 3430, s/n 32187. The gauge contained 40 milliCi of Am-241/Be and 8 milliCi Cs-137. The licensee had the Troxler chained and locked to the truck bed. The licensee filed a police report with the Opelousas State Police, and will be offering a reward. 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.
ENS 426267 June 2006 09:11:00

The State provided the following information via facsimile: The density/moisture gauge was stolen from the West Gate Tavern's parking lot located at 2725 Mississippi in Metairie, Louisiana, which is in Jefferson Parish. The gauge was stolen sometime between the evening of May 27, 2006 and the morning of May 28, 2006. The theft was reported to the Jefferson Police Department on May 28, 2006. The gauge was a Troxler Model T3440, Serial Number-20980, Source Activity: Cs-137 (8 millicuries, serial # 75-2404; Am-241:Be (40 millicuries), serial # 47-16481. Last leak test was March 17, 2006. (The gauge operator) stopped to have a drink at the tavern on Saturday after performing a job at the Michoud Canal. He did not return the gauge to the Hahnville storage location before visiting the tavern. (The gauge operator) had to have someone pick him up from the tavern and bring him home; leaving the truck and the chained container with gauge in the Tavern's parking lot. When (the gauge operator) returned to the truck on Sunday, May 28, 2006, the gauge container (with the gauge in it) was cut from its chains and was gone. The gauge container was chained and locked, and the gauge itself was locked at the time of the theft. The gauge was properly labeled with caution signs and contact phone numbers. The Department was notified immediately after the discovery of the stolen source. The facility spent countless hours trying to find the gauge. More training was provided to the operator. The facility ordered eight new bolt-in containers to secure the gauges in the bed of the trucks to deter theft. The Radiation Safety Officer stated that he will probably have it put in the newspaper as well. He also stated that he will write a letter to the Department within 30 days with description of the incident including corrective actions. The state generated report number LA060009 for this event. 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.

ENS 4267329 June 2006 08:41:00The State provided the following information via facsimile: Incident: A Metco crew was working at the PPG facility (Lake Charles, LA) the evening of May 24, 2006, when they reported a disconnected source (to the LA Department of Environmental Quality on May 26, 2006). Timeline of events: 1. 6:25 pm - Crew set up to make three exposures in PPG at the area known as the loading dock. 2. 6:45 pm - Crew makes their first exposure. 3. 6:48 pm - The crew retracts the source but the camera does not lock and the survey meter is still giving high readings. 4. 6:50 pm - (Worker 1) and (Worker 2) were notified of the disconnect. 5. 7:05 pm - (Worker 1) and (Worker 2) meet at the Metco shop and leave to go to PPG facility. 6. 7:13 pm - (Worker 1) and (Worker 2) arrive at PPG. 7. 7:20 pm - The source is retrieved. 8. 7:21 pm - The camera and equipment were examined to see where the malfunction occurred and the investigation began. Investigation: After further review of the incident, it was determined that the source was never connected to the drive cable before making an exposure. The crew had performed only one shot when they realized the source did not retract fully. Key Points: 1. A perimeter of 150' was maintained after the disconnect occurred. This was inside of a building that had 1.5' concrete walls. 2. The barrier was kept at 2 mrem/hr after the disconnect occurred. 3. The source remained in the collimator and laid facing the floor until (Worker 1) and (Worker 2) arrived onsite. 4. None of the radiographers present on site received a dose of more than 15 mrem. 5. (Worker 1), who performed the source retrieval, received a total dose of 365 mrem. Exposure Device Manufacturer: Amersham Model No.880 Sigma S/N S1712 Isotope: Ir-192 Source Activity: 91 Ci LA Report ID No.LA060013
ENS 426237 June 2006 07:31:00The State provided the following information via facsimile: (Pathfinder Energy Services (licensee) notified the State of LA that) during drilling operations on 17 May 2006 the drill string became stuck while making a connection. The hole had packed off around the drill string not allowing circulation, up and down movement or rotation of the drill pipe. All reasonable effort was used to attempt to free the drill string. (LADEQ Emergency & Radiological Services Division) was notified on 19 May 2006 that there might be a possibility of needing to abandon the sources over the weekend. He gave a verbal approval to abandon the sources and referred me (licensee) to (LADEQ) to follow up on Monday with the status of the abandonment. (LADEQ) was notified Monday 22 May 2006 that the sources were abandoned at 4:00 AM, 22 May 2006 and given details of the abandonment with the agreement that a formal report would be filed within 30 days of the abandonment. E-mail notification was also sent to Mr. Noble. It became apparent on Sunday 21 May 2006 that the drill string would be lost. A 370 foot cement plug was set above the sources. A total of 22 joints of HWDP (675 feet) were left on top of the radioactive sources to act as a mechanical deflection device to prevent inadvertent intrusion on the sources. A sidetrack well is planned to be drilled after 7 5/8" casing is set at 10,237' from the shoe to the original depth of 10,265 ft TVD. The sidetrack well is planned not to come within 15 ft of the sources. A liner (casing) will be set at completion of the bypass well and cemented in place. Description of Sources: One 1.5 Curie, Cs-137, Doubly Encapsulated, Special Form, Well Logging Sealed Source Serial Number, 5080GW AEAT Model CDC.CY6 One 8 Curie, Am-241/Be, Doubly Encapsulated, Special Form, Well Logging Sealed Source Serial Number: DNS 013 Gammatron Model AN-HP 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source
ENS 426247 June 2006 08:54:00The State provided the following information via facsimile: On May 22, 2006, a package containing 300 (microcuries) of I-123 in two (2) capsules was prepared for shipment at the Cardinal Health Nuclear Pharmacy Services ('Cardinal Health') facility in Dallas, TX. This package was a Type 7A container and was given a Yellow II label. This package was consigned to a contract courier, Tradewind, Inc., for delivery to Cardinal Health in Shreveport, LA. Delivery of this package to Cardinal Health Shreveport was attempted sometime after it closed at 5:00 PM. It was discovered by a parking lot cleaning crew at approximately 11:30 PM that evening. The package had been left behind a dumpster outside the pharmacy and covered with a Tradewind jacket. The cleaning crew contacted the police, who arrived at the scene shortly afterwards and contacted the fire department, who dispatched a HazMat team. The police also contacted our pharmacist on call by using the emergency contact number posted on the outer vestibule door to our pharmacy. The fire and/or police departments took control of the material until a representative from Cardinal Health arrived on site. All radioactive material listed on the shipping paper was present and accounted for. Root Causes: The cause of this event was a failure by the courier, Tradewind, to properly perform their contracted duties. The package in question was left unsecured behind a dumpster. This is not how Tradewind has been instructed to deliver packages to our pharmacy. They have been instructed to deliver radioactive material packages in a designated area (that is appropriately marked) inside the vestibule, in the rear of our building. Tradewind was issued a vestibule key for this sole purpose. The driver who originally arrived to deliver the package did not have the vestibule key. An interview with him revealed that his intent was for another Tradewind driver to arrive later with the key and deliver the package into (licensee's) secured vestibule. Actions Taken to Prevent a Recurrence: Cardinal Health will be working with Tradewind to review training documents required by the DOT and to formulate corrective measures taken to prevent reoccurrence of this type of event. LA Event Report ID No.: LA060008
ENS 4229530 January 2006 16:00:00A representative from the State of Louisiana reported that an X-Ray Fluorescence (XRF) Unit used by the Chalmette Refinery is missing following the devastation from Hurricane Katrina. The building housing the XRF Unit was under 20 feet of water from storm related flooding. The building was gutted in post Katrina restoration without first locating the XRF Unit. The licensee has searched for the unit and declared it missing on 1/30/06. It is believed that the Unit was sent to a landfill with other building wastes. The XRF Unit was a model TN-927 with a 45 mCi Fe-55 source and a 5 mCi Cd-109 source. State Report Number: Pending 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.
ENS 4163325 April 2005 14:23:00Two 1.6 Curie tritium neutron generator tubes licensed for well logging were picked up by FedEx at the licensee's facility in Houma, LA on 04/11/05. The destination was Princeton Junction, New Jersey. On 04/21/05 it was confirmed that the package was lost. The shipment was tracked to different locations within FedEx. No other information is currently available.
ENS 406547 April 2004 21:45:00

While passing a SPEC 150 Industrial Radiography Camera from a boat to an Apache Corporation Petroleum platform in the Gulf of Mexico, the radiography camera fell into the water. The water depth is 60 to 70 feet and is located approximately 50 to 70 miles from the coast of LA. The lost camera was a SPEC 150 S/N 223 with a 24 Curie Ir-192 source S/N 12433B. The radiography camera was in a Type B shipping container. The licensee plans on using divers to retrieve the radiography camera.

  • * * UPDATE 0940 EDT ON 4/12/04 FROM MIKE CIULLA TO S. SANDIN * * *

The LA licensee notified the State of Louisiana (Joe Noble) that the camera was recovered on 4/10/04 at approximately 0930 CDT and has been returned to the manufacturer for evaluation. Notified R4DO (Powers), NMSS (Essig) and TAS (Hahn).

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