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| Entered date | Event description | |
|---|---|---|
| ENS 51942 | 19 May 2016 14:47:00 | |
| ENS 50959 | 6 April 2015 14:22:00 | The following information was received from the Commonwealth of Pennsylvania via email/fax: An 84 curie iridium-192 (lr-192) source being housed in a Source Production & Equipment Company (SPEC) 150 industrial radiography camera could not be retracted back into the exposure device. The source eventually was able to be retrieved without any over exposures to either the workers or the general public.. The cable broke and became dislodged from the gear mechanism within the exposure device itself. The cable was manually pulled to return the lr-192 source to its locked position within the exposure device. It is unknown at this time why the cable broke. PA Event Report ID No.: PA150009 |
| ENS 49855 | 25 February 2014 15:00:00 | The following information was received from the Commonwealth of Pennsylvania via fax: NOTIFICATIONS: Licensee notified the Department (PA DEP Bureau of Radiation Protection) via email and voice message after close of business on February 24, 2014. This event is reportable within 24-hours per 10 CFR 30.50(b)(2). EVENT DESCRIPTION: During the pressure pumping operations at a well fracturing job site, personnel observed an unexpected fluctuation in density readings. The density gauge was inspected and attempts to turn the shutter handle to the closed position caused it to separate from the body of the gauge. It was observed that the roll pin, which attaches the shutter handle to the shutter shaft, had come out causing the shutter handle to separate from the shield housing. The pin was replaced, the handle reattached, and the gauge shutter was closed and locked. No elevated exposure to personnel is anticipated. The gauge was then removed from service, placed into storage, and the manufacturer was notified. Manufacturer: Berthold Model: LB 8010 Serial Number: 10049 Isotope: Cs-137 Activity: 20 mCi Source Serial Number: 0180/08 CAUSE OF THE EVENT: The roll pin, which attaches the shutter handle to the shutter shaft, came out causing the shutter handle to be removed from the shield housing. More information will be forwarded upon receipt of final report. ACTIONS: The density gauge has been removed from operations and is in storage in a Williamsport, Pennsylvania facility. The licensee is working with the manufacturer to investigate the event, make repairs, and determine root cause. The Department plans to do a reactive inspection. PA Event Report ID No: PA140006 |
| ENS 49513 | 7 November 2013 14:40:00 | The following Agreement State Report was received via facsimile: Notifications: The Southeast Regional (SER) Office was contacted by Coatesville Scrap on October 31, 2013 regarding a radiation alarm on an outbound trailer load. The event is reportable within 24 hours per 10 CFR 20.2201(a)(1)(i). Event Description: On Thursday, October 31, 2013, a radioactive source was detected when a radiation alarm sounded on an outbound trailer load. The alarm was caused by a small metal object. It was located, placed in a lead pipe, crimped and moved to a remote area of the scrapyard behind a large steel piece of equipment. A SER inspector was sent to the site to determine the isotope and activity. It was identified as cesium-137 and a measurement on the surface of the lead pipe was 320 mR/hr. On Wednesday, November 6th the activity was estimated at approximate 10 mCi. It was determined that three members of the public were involved in locating the source, however one had the longest contact with the source; approximately 2.5 hours on and off. It took site staff some time to find the material via shoveling through the solid material and metal of the load. When found, the radioactive source was carried by a shovel approximately 150 to 200 feet away. An individual then carried the source by hand to an adjoining property and placed it in a lead pipe, which was crimped. This took approximately 10 to 15 minutes. A whole body dose documented from the uncalibrated dosimetry that was being worn by this individual was 364 micro-roentgens (microR). SER staff estimate a possible 10 rad dose to this individual's hand. Hands and feet of all parties were surveyed, with no contamination found. Caution tape was used to create a boundary to help notify other employees to stay away from the area. Meter readings at the caution tape boundary were approximately 60 microR/hr. CAUSE OF THE EVENT: Loss of control of a Cs-137 sealed source. ACTIONS: The DEP (Department of Environmental Protection) plans a full investigation of this event. The scrap yard has hired a consultant health physicist to assist with this event and Cs-137 source. The DEP will recommend that the individual who handled the source have their hands photographed and be examined by a physician. Event Report ID No: PA130026 |
| ENS 48707 | 30 January 2013 08:17:00 | The following was received from the Commonwealth of Pennsylvania via facsimile: On January 15, 2013, the licensee sent notification via email to the Central Office (PA Bureau of Radiation Protection) about an event that took place on January 14, 2013. This email was received by Central Office (PA Bureau of Radiation Protection) on January 16, 2013. It is reportable within 24 hours under 10CFR30.50(b)(2). During use of the gauge, the density readings were not as anticipated. The electronic technicians replaced the detector with no change in output. Based on the output readings, the suspicion is that the shutter is closed and cannot be opened. The gauge has been taken out of service and stored securely in their Meadville Warehouse. The device is identified as: Manufacturer: Berthold Technologies USA, LLC Model: LB 8010 Serial #: 10185 Source Serial #: 1160/10 Isotope: Cs-137 Activity: 20 mCi The manufacturer is being contacted to investigate and perform repairs if needed. A reactive inspection will be performed by the Department (PA Bureau of Radiation Protection). Event Report No: PA 130002 |
| ENS 48303 | 13 September 2012 12:05:00 | The following event was received from the Commonwealth of Pennsylvania via facsimile: 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 September 12, 2012, an inspector was performing a reactive inspection for a recent event (PA120026) that occurred on August 23, 2012. During the inspection the licensee reported another similar Sir-Sphere event. Event Description: A patient was being treated for disease of the liver with 33.04 millicuries (mCi) of Y-90 and received 25.6 mCi resulting in 77.5% of the intended dose. The treating physician, who also is the referring physician, notified the patient. Cause of the Event: Currently under investigation and unknown at this time. Actions: No harm to the patient is expected. The Department's reactive inspection occurring on September 11, 2012 incorporated this new event and therefore no new inspection is planned. PA Report Number: 120030 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 46818 | 4 May 2011 09:58:00 | The following information was obtained from the State of Pennsylvania via facsimile: It was determined that the remote shutter actuator on a device is inoperable due to foreign material in the shutter mechanism. The device is identified as Texas Nuclear, Model 5197 (Serial No. 81637) with approximately 100 mCi of Cs-137. The cause of the event was equipment failure. The shutter is locked in the closed position and shall remain so until repairs are made. Licensee will notify the Department (Pennsylvania Dept. of Environmental Protection) when licensed repairs are made. PA Event Report ID: PA110009
Upon further investigation it was determined that the remote actuator on the device is inoperable due to a crack in the mechanism that holds the actuator to the gauge. This prevents the shutter from operating as designed by the manufacturer. The device is identified as Texas Nuclear, Model 5197 (Serial No. B1637) with approximately 100 mCi of Cs-137. Notified R1DO (DeFrancisco) and FSME (Diaz-Toro). |