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| Entered date | Event description | |
|---|---|---|
| ENS 57173 | 14 June 2024 12:28:00 | The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email: On June 14, 2024, an employee of the licensee reported to police that their vehicle, with a nuclear density gauge secured in the trunk, was stolen earlier that day. Local police are aware of the incident. The DEP has been in contact with the licensee and will update this event as soon as more information is provided. Manufacturer and Model Number: Troxler Electronic Laboratories Model Number: 3440 Serial Number: 35459 Isotope and Activity: Cesium 137, 9 millicuries; Americium 241:Be, 44 millicuries. PA Event Report ID No: PA240012 Surrounding States and the Pennsylvania emergency response team have been notified.
The following is information provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (DEP) via email: On June 24, 2024, the car and gauge were recovered. The gauge was still inside of the vehicle with no damage or evidence of tampering. Survey meter readings of the gauge showed normal levels and it was returned to the licensee. Representatives of the Philadelphia Fire Company accompanied the licensee to retrieve the gauge. Notified R1DO (Jackson), NMSS Events Notification (email), ILTAB (email), CNSC Canada (email) 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 56661 | 5 August 2023 11:07:00 | The following information was provided by the PA Bureau of Radiation Protection (the Department) via email: On August 4, 2023, the licensee, University of Pennsylvania, informed the Department of an under-dose incident involving yttrium-90 (Y-90) TheraSpheres. The event is reportable per 10 CFR 35.3045(a)(1). On August 3, 2023, it was determined that 71.0 percent of the prescribed dose to the target tissue was delivered for the above treatment. The only information relayed to the Department so far was that there were no spills or leaks in the system. The DEP (Department of Environmental Protection) is currently in contact with the licensee and will update this event as soon as more information is provided. The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received. Event Report ID No: PA230021
An administration of Y-90 TheraSpheres occurred with no apparent difficulties. No leaks or spills were identified, as corroborated by post administration monitoring which identified no contamination. However, when the waste was measured it was determined that less than 80 percent (72.6 percent) of the prescribed activity was administered. It is estimated that 21.18 mCi of the 29.18 mCi prescribed dose was administered. The patient and prescribing physician have been informed. No adverse effects to the patient are present nor are any anticipated. Notified R1DO (Dimitriadis) and NMSS (Email). A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| ENS 55640 | 10 December 2021 13:27:00 | The following was received from the Commonwealth of Pennsylvania by email: On December 10, 2021, the Radiation Safety Officer for the licensee verbally reported a patient being treated for vaginal cancer was prescribed a 21 Gy total dose, to be delivered in 3 fractions of 7 Gy each via HDR ((high dose rate)). The first fraction was delivered on October 28, 2021. At some point after that treatment, the patient began experiencing complications from the hysterectomy and ended up going to a different hospital for that issue. The patient did not return to the licensee's facility to complete her treatment. At the other hospital, a different Radiation Oncologist was consulted and was reviewing the patient's treatment and discovered that the treatment in October at the licensee was 3 cm off and the intestine received some fraction of the first treatment dose. It was discovered that the patient required re-suturing of the cervix and that the brachytherapy apparatus (used in the HDR treatment) passed beyond the apex of the vagina. This discovery was made yesterday, December 9, 2021. The licensee's medical physicist is currently calculating dose estimates. The referring physician is also being informed. No further information is available at this time. The Department of Environmental Protection will update this event as soon as more information is provided. PA Event Report ID No: PA210021 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 55511 | 7 October 2021 15:16:00 | The following was received from the Pennsylvania Department of Environmental Protection (DEP) (the Department) via email: The Department received notification from a licensee on October 6, 2021, of a radiography source from a QSA 880 Delta Industrial Radiography device containing a 91 curie Ir-192 source that was unable to retract. The source had been exposed to check a weld and when the radiographer tried to retract the source, the slide would not lock the source in. The radiographer approached the set-up with a meter and noticed the readings were high, so he retreated. The area was roped off and put under surveillance by the Assistant Radiographer and Radiographer. The Radiographer also noticed his direct read dosimeter was off scale and so he remained outside the boundary. His dosimetry will be sent for emergency processing and he will be restricted from radiography work until his results are received. The licensee dispatched a Radiation Safety Officer (RSO) with source retrieval authorization to recover the source. The source was secured later the same morning of the event. The RSO received 60 millirem and his assistant received 20 millirem. The RSO's ring dosimeter will be sent out with the Radiographer badge for emergency processing. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided. Pennsylvania Event Report ID Number: PA210013
The following was received from the Pennsylvania Department of Environmental Protection (DEP) via email: Emergency processing of thermoluminescence detectors for the radiographer and assistant radiographer has been completed. The radiographer received approximately 9.3 rem and the assistant radiographer received approximately 2 rem. The licensee is continuing to monitor the radiographer's hands for erythema, as it was determined that the radiographer handled the guide tube and collimator with the 91 curie Ir-192 source in an unshielded position. Both workers have been put on mandatory leave and the licensee has committed to mandatory re-training of employees. A reactive inspection by the Department was conducted on October 12, 2021, and the licensee has gone through dose reconstruction and event re-enactments to determine how the disconnect occurred. At this time a bent pin on the control cable seems to be the cause of the event. More details will be provided when known. Notified R1DO (BICKETT) and NMSS events Notification group (via email) |
| ENS 55372 | 22 July 2021 13:58:00 | The following was received via an email from the Pennsylvania Bureau of Radiation: The licensee reported that on July 21, 2021, while using a QSA Global Model 880 containing a 135.5 curie source of iridium-192, the source failed to fully retract and lock. The source serial number is 32578M and the camera serial number is D9477. The technicians secured the area by adjusting their 2 mR/hr boundaries to an unshielded source distance and immediately contacted their company (Radiation Safety Officer) (RSO). The licensee then contacted QSA Global who will be onsite on July 22, 2021, to retrieve the source and take the camera and entire crank and assembly mechanism with them for evaluation. The licensee will remain onsite to secure the boundary until QSA arrives. No overexposures have occurred and all proper procedures were followed. The cause of the malfunction remains unknown. More information will be provided when received. Pennsylvania Event Report ID No.: PA210007
The following update was received via an email from the Pennsylvania Bureau of Radiation: QSA arrived on site at approximately 2000 EDT on July 22, 2021, and the source was moved to a locked position in the camera at 2155 EDT. At this time the drive cable is suspected to be the problem. The camera and drive system will be evaluated. Notified R1DO (Gray) and NMSS Events Notification via email. |
| ENS 55337 | 3 July 2021 11:11:00 | The following was received via an email from the state of Pennsylvania: The Department (PA Bureau of Radiation Protection) received notification from a licensee on July 2, 2021 of a medical event involving a Y-90 TheraSphere. The licensee noted 71 percent of the prescribed dose of 30.8 millicuries was administered to the patient. A mechanical blockage occurred in the delivery system preventing spheres from exiting the administration vial. All material was contained in the delivery system, lines, and patient. Area monitoring confirmed that no leak occurred and no contamination of the work area. Nuclear Medicine imaging of the waste confirmed activity concentrated within the vial. The physician and patient have been notified. No adverse effects to the patient are anticipated. The Department is currently in contact with the licensee and will update this event as soon as more information is provided. Pennsylvania Event Report ID No: PA210006 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 53905 | 1 March 2019 13:56:00 | The following was received via fax from the Pennsylvania Department of Environmental Protection: On March 1, 2019, a manufacturer's technician from Sabia Inc. (PA-R0124) notified the Department (Pennsylvania Department of Environmental Protection) of a missing 0.9 microgram (0.5 mCi) Californium-252 source from a Sabia XL5000 analyzer at the Holcim (US), Inc. Whitehall Cement Plant (PA-1336). The manufacturer was performing replenishment of two of seven sources (on February 28, 2019). It was discovered that the analyzer only contained six sources. The analyzer was removed and disassembled, destroying the unit, in efforts to locate the missing source but it was not located. The manufacturer technician surveyed the unit and the area multiple times and did not find the source. The remaining sources have been packaged in a drum for safe storage until shipping can be arranged. The Department will perform a reactive inspection. More information will be provided upon receipt. Pennsylvania Event Report ID No: PA190006 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 53738 | 15 November 2018 11:13:00 | The following was received from the state of Pennsylvania via email: Notifications: On November 14, 2018, the licensee informed the Department (Pennsylvania Department of Environmental Protection) of a failed shutter. It is reportable per 10 CFR 30.50(b)(2). Event Description: The licensee reported that on October 18, 2018, a IRMS Model TG-2 gauge, serial number 00MO397-15, containing 3000 milliCuries of americium 241 did not properly perform following scheduled maintenance. Specifically, the shutter failed to open completely and then would not open at all. The gauge was taken out of service and a service provider was contacted, responded and corrected the problem. The licensee has since contacted the same service provider and, on November 2, 2018, transferred the device for proper disposal. Licensee and service provider survey results indicated no abnormal amounts of radiation in the area before, during or after the event or removal of the device. There were no overexposures related to this event. Cause of the Event: Equipment failure. Actions: The Department will perform a reactive inspection. More information will be provided upon receipt. PA Event Report ID No: PA180020 |
| ENS 48137 | 26 July 2012 15:24:00 | Event Type: A medical event (ME) involving the administration of yttrium-90 SIR-Spheres which is reportable under 10 CFR 35.3045(a)(1)(i). Notifications: On July 25, 2012, the Department's Southeast Regional Office received notification via telephone about this event. Event Description: The patient received 77% of the intended dose. Cause of the Event: Currently under investigation and unknown at this time. Actions: No harm to the patient is expected. The Department (PA Bureau of Radiation Protection) plans to do a reactive inspection. Updates will be provided upon receipt of information. 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. |