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| Entered date | Event description | |
|---|---|---|
| ENS 51245 | 21 July 2015 20:06:00 | The following report was received from the State of California via email: On 07/21/15, the Sterigenics Corporate RSO (Radiation Safety Officer) contacted (California - Radiologic Health Branch) RHB-Sacramento office, via an email and telephone, to report the following event in accordance with (10CFR)36.83(a)(4). (The licensee's) email stated the following: Last night, at approximately (0011) PDT, at the Sterigenics Hayward Facility (Radioactive materials License 6268-1), the pneumatic cylinder used to raise one of the two source racks (Hoist #1) failed to function as designed. The failure did not cause a stuck source, nor was there any risk of exposure to any individual as a result of this failure. The source did return to the down position in the pool as designed, however, the pneumatic cylinder experienced a failure and a broken flange and is not operable. (The licensee) will review, in detail, the cause of this failure and implement appropriate corrective action including any necessary changes in maintenance and equipment and report these changes to (the State of California) in writing, within 30 days, as required by 10CFR36.83(b). In the interim, the facility will not commence operations until repairs are completed to the hoist and approval to commence operations is granted by the Corporate RSO and Corporate Engineering. (The licensee RSO) further stated that there is no emergency or current issue. A corporate engineer will arrive in San Francisco by (1400 PDT) on 7/21/15, to work on the irradiator. The facility is staffed 24/7 and will notify RHB before resuming any operations. (California) RHB will be following up with the licensee. The irradiator is in safe mode and the licensee will be investigating the reason for the failure. |
| ENS 50738 | 15 January 2015 15:36:00 | The following information was provided by the State of California Department of Public Health - Radiological Health Branch (RHB) via email: On 01/14/15, RHB received an email from the RSO reporting a Medical Event. On 1/7/15 a patient was scheduled for a thyroid uptake scan. Instead of the prescribed dose of 300 microcuries of Sodium Iodide 123, 3.69 mCi (3690 microcuries) of the isotope was administered to the patient. Due to quality of the scan, the error was noted. An initial calculation performed on 1/8/15 indicated target organ (dose) exceeding 50 rem. On 1/9/14, another calculation performed by the consulting physicist using patient's actual measured uptake values, the target organ (dose) was deemed less than 50 rem and it was decided to be non-reportable. On 1/13/15, the chief of Nuclear Medicine reviewed the reference source and contacted the same physicist to review his calculations, and the physicist realized that he made an error in calculations, and informed the facility that the organ dose exceeded 50 rem. On 1/14/15, the Kaiser Medical Physicist confirmed the (dose) to be 53.6 rem to the thyroid, and the RSO notified RHB of the Medical Event. RHB will be following up on this matter." CA Event Report Number: 011415 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 49812 | 10 February 2014 16:53:00 | The following Agreement State report was received via email: (The California Department of Health, Radiologic Health Branch) RHB Richmond received an incident report from the Qualspect Manager, via an email that a radiography camera had been left unattended. On February 9, 2014, between 0030 and 0245 (PST), Qualspect employees were conducting a radiography operation using (a camera containing an) Ir-192 104 Curie (source), camera s/n 4850, at the Valero Benicia Refinery. During the operation a few Qualspect rope (access) employees were in the area, their presence distracted the two radiographers thinking that another radiographer was in the area, so they left to process film. While the film was being processed, the camera was (left) dangling at 2 feet from the floor and unattended. A Valero Benicia Refinery employee discovered the suspended camera and brought it to the Qualspect employees' attention. Shortly thereafter, the Qualspect employees took possession of the camera. The California RHB considers this a major event and is conducting an investigation. There were no personnel overexposures. California Report #021014 Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 48017 | 12 June 2012 14:49:00 | The following report was received via fax: On 06/06/12, the ARSO (Assistant Radiation Safety Officer) at UC Berkeley contacted the RHB (Radiological Health Branch) to report an event that occurred on 06/05/12. This event involved contamination caused by a Cs-137 source that is not a sealed source per manufacturer's statement. This source has a very thin window to permit transmission of betas. This source was used in a vacuum chamber and the contamination occurred and was detected when researchers were changing the flange. The licensee cordoned off a 6' x 10' area within a much larger lab. No floor contamination was detected, however, the bench and some equipment within the cordoned off area are still being cleaned. Access to this area was restricted for over 24 hours. The current activity of the source is 950 microCuries. Applying conservative assumptions to convert the detected contamination counts into activity, the licensee has come up with a total activity on the order of 10 microCuries (summed over the contaminated spots). The licensee notified the RHB within 24 hours, since the area was cordoned off for more than 24 hours, however, the activity detected is minimal per 30295(b)(1)(B) where the involved quantity is less than 5 times the lowest ALI specified in Appendix B 10 CFR 20 incorporated by reference in section 30253. Also, since this is not a sealed source, the reporting criteria for leakage of more than 0.005 microCuries does not apply. Based on these criteria, no reporting is required. California incident: 060612 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 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 43618 | 6 September 2007 18:06:00 | The State provided the following information via email: Two XRF Analyzers possessed under a general license by Engineering Remediation Resources Group (ERRG) were stolen from the cab of a truck parked overnight in San Francisco, California at Grove and Masonic. The serial numbers of the stolen Analyzers are 7497 and 7706. These devices contain 40 mCi of Cadmium-109 each. The police and the company from which the Analyzers were rented, Thermo-Niton in Boston, MA, have been notified. The cases for the Analyzers were found broken open about a block away from the location of the parked truck. All the equipment for the Analyzers was missing as well. The employees of ERRG, a soil gauge licensee (RML# 6739-07), have been retrained on maintaining the security of radioactive material in their possession. ERRG has agreed to offer a reward for the return of the Analyzers in a local newspaper. A 30 day reporting requirement was chosen because of the low exposure rate of Cadmium-109 and the unlikely possibility of opening the devices to get at the radioactive material. The energy of the X-Rays from Cadmium-109 are 22.1 Kev, 24.9 Kev and 88.0 Kev. CA State Report No.: 090407 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. 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 44416 | 15 August 2008 14:38:00 | On August 12, 2008 UC Berkeley requested a meeting with RHB to provide information regarding their findings that they had not maintained adequate control of their SNM. Specifically they were unable to locate 17 grams of elemental uranium enriched to 43% in the isotope of U 235. The reason for the problem was considered to be inadequate material accounting practices for the period since 1978, due to inadequate methodology, apparently records were not maintained for the day-to-day consumption of uranium for research and subsequent discard of uranium that occurred routinely. There were no records to indicate use. Therefore this material is considered as 'material unaccounted for' (MUF) and an ongoing investigation is in progress to determine the disposition of the material between 1994 and 1997. Seventeen grams would equal about 15 pellets the size of a small pencil eraser. The licensee informed NRC HOO of this issue, as information on 8/13/08. The licensee also informed RHB on 8/13/08. The licensee clarified that this was a notification pursuant to 10 CFR 20.2201 at 1700 on 8/14/08 regarding their inability to locate this material. An investigation is ongoing to reconcile the records regarding lost or missing material at UC Berkeley. California Report Number: 081308 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. 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 |