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ENS 5077728 January 2015 18:08:00The following report was received from the State of California via email: On 01/28/15, (the licensee) RSO contacted (the California) RHB (Radiologic Health Branch) to notify (the state) of a damaged nuclear gauge incident that occurred on 01/27/15. The gauge involved was a Troxler Model 3440, S/N 21101 containing 9 mCi of Cs-137 and 44 mCi of Am-241. Gauge user had left the gauge on a wheel barrow and walked away (approximately) 25 feet to look for a foreman. User then noticed a CAT scrapper backing off towards the gauge. His attempt to stop the scrapper failed, resulting in a damaged gauge. After the incident, it was noted that the gauge was intact with damage only to the face plate area. The operator contacted the RSO, and then transported the gauge to Instrotek for further testing. Leak tests performed indicated no contamination. The gauge is still at Instrotek for repairs. California Event: #012815
ENS 5071030 December 2014 16:04:00The following was received from the State of California via email: A CPN Portable gauge containing 10 mCi of Cesium 137 and 50 mCi of Americium 241 was stolen from the technician's residence (Campbell, CA) on December 25, 2014. According to the RSO (Radiation Safety Officer), a police report was filed on December 25th and RHB (California Radiologic Health Branch) was notified on December 26, 2014. RHB North was notified of this theft on December 30, 2014 at 1300 PST. The RSO was requested to provide a reward in the local paper and on Craigslist and to provide RHB North a copy of the Police Report and description of the circumstances as soon as possible, as the RSO was not in the office and did not have access to the pertinent information. Additional information will be forwarded when it is received 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 5040226 August 2014 17:59:00The following was received from the State of California via email: On August 21, 2014, . . . Henkle Aerospace contacted . . . RHB to report that one of their generally licensed fixed gauges (NDC, Model 103, S/N 4331 containing Am-241) had been found at a recycling facility. The recycling facility had contacted the manufacturer of the gauge (NDC) and it was returned to NDC. NDC contacted Henkel to notify them of the gauge was found at the recycling center. The source was intact and NDC has performed a leak test which indicated no contamination. On 08/26/14, . . . Henkel called RHB and provided the following information: The gauge contained 150 mCi of Am-241 (as of late 90s) and it was acquired by Henkle in 2006. This gauge was replaced by a licensed vendor in February 2010, and was set aside to be transferred to the vendor. Eventually, they lost track of the gauge, and it ended up at the recycling center with the rest of the metal Henkel had shipped to the scrap yard. Corrective actions by Henkle: After this incident they have revised their policies and procedures to keep track of the two gauges they currently possess (Sr-90 containing 250 mCi each, GL units licensed by Mahlo). Note: As of now, RHB does not have the information on current activity of the Am-241 source in the gauge. California 5010 #: 082114
ENS 5076426 January 2015 17:20:00The following information was obtained from the State of California via facsimile: On 01/22/15, RHB (California Radiologic Health Branch) was notified of a stolen tritium exit sign from an AMC Theatre in San Jose, CA. The police report No. 142273216 filed by the AMC theatres on 08/15/14 stated the following: 'The management was doing a walkthrough of the building on 08/15/14 at AMC Saratoga 14. In theatre No. 13, the manager noticed one of the exit signs missing.' The model, S/N or the activity of the exit sign is unknown. RHB will be contacting AMC theatres and the Ultimate Lighting Source (vendor) to get further details. California Report Number: 5010-012215 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 5012019 May 2014 14:53:00The following information was provided by the State of California via email: RHB (Radiological Health Branch) Richmond received Hazardous Material Spill Report - Cal EMA (Emergency Management Agency) Control #:14-2601, from Warning Center on May 17, 2014. The report stated that the Silicon Valley Soil Engineering's moisture density gauge manufactured by CPN, model MC-1 DR-P, Serial MD 70803844, was stolen from the transport vehicle on May 16, 2014, at 10:40 a.m. (PDT). The gauge contained 50 mCi of Am-241 and 10 mCi of Cs-137. RHB will be inspecting this licensee to develop more information. 5010 Number (Date Notified): 051914 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 4981611 February 2014 18:03:00The following Agreement State report was received via email: On February 10, 2014, (the California Department of Health, Radiologic Health Branch) RHB Richmond received a call from the MISTRAS Group RSO, indicating that a radiographer had inadvertently left behind a radiography camera when he drove off the parking lot at the Chevron Richmond Refinery. On February 9, 2014, at 1035 (PST) after the radiographer finished radiography using IR100 Camera containing 31 Curies Ir-192, s/n 6614, he left the radiography camera on the bumper of the truck; later, assuming that he left the camera inside the truck, he drove off and the camera fell onto the pavement. According to the radiographer, the camera was left unattended for a short period of time. Later, a Chevron Richmond employee noticed the camera in the parking lot and contacted the Chevron facility Manager. Chevron management contacted Mistras RSO and he drove to the refinery and took possession of the camera. California Report #: 021014 THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL 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 4981711 February 2014 18:40:00The following Agreement State report was received via email: On February 10, 2014, (the California Department of Health, Radiologic Health Branch) RHB Richmond received a call from MISTRAS Group, Inc. RSO, regarding a source disconnect. On February 9, 2014, at 0600 (PST), during radiography at Chevron Refinery, using IR-100 camera, containing 31 Curies, Ir-192, s/n 6614, the source pigtail connector became disconnected from the drive cable. Following good health physics practices, the RSO retrieved and secured the source into the shielded position. Exposures to personnel (were) less than 50 millirem for this event. California Report #: 021114
ENS 4962210 December 2013 18:37:00The California Radiologic Health Branch reported a stolen moisture density gauge from a licensee in Walnut Creek, CA. The gauge was recovered in about 4 hours, in Lafayette, CA, after being abandoned by the thieves. The state assisted local law enforcement in Walnut Creek and Lafayette, CA with the gauge recovery. The gauge was recovered in good condition and there are no known exposures or spread of contamination. The gauge has been returned to the licensee for storage in a secure location. The gauge is a Instro Tek, model 3500 Explorer, Serial #1644, containing 10 mCi Cs-137 and 40 mCi Am/Be-241 sources. California State Report #121013 and Lafayette, CA police report #13-21268. 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 4927813 August 2013 21:56:00

The following Agreement State report was received via email. (The California Department of Public Health / Radiation Health Branch was notified that Stanford University received a package containing Radium 223 from Cardinal Health in Denver, Colorado and the package indicated removable contamination of 400 DPM of technetium 99 on the package. The following information was provided:

The caller stated, that a package was received at the Nuclear Medicine Department and the package had a reading of 400 DPM which exceeds the Dept. of Transportation limits. Caller stated the package has been isolated and secured in the appropriate area and the carrier notified. Caller stated that the package will be at normal readings tomorrow.

Cardinal Health, in Denver, was notified and will investigate this issue. RHB California will report additional information.

ENS 489993 May 2013 13:54:00The following information was obtained from the State of California via email: A female patient was treated with 176.9 mCi of Iodine 131 on 2/20/13. A serum pregnancy test conducted on 2/18/13 came back negative. On 4/22/13, Radiological Associates received a phone call from the patient's endocrinologist informing them that the patient was pregnant. An ultrasound evaluation of the patient performed on 3/18/13 determined that the fetus would have been approximately two weeks old at the time of the Iodine 131 dose administration. The dose to the fetus was determined to be 47 rad, which may meet the requirement for an abnormal occurrence. The (California Radiologic Health Branch) will be reviewing this event. California Event: 5010-050313
ENS 4854528 November 2012 20:40:00

The following is a summary of a report provided by the State of California: On the morning of November 27, 2012 a licensee technician was retrieving a gauge from one of its storage locations when it was noticed that the unit had been broken into and a gauge was stolen. There were six gauges at this location and five of them are accounted for.

A review of the gauge locking system was checked / confirmed. The nuclear gauge had two locks with a third lock/cable around the box. The roll-up door was locked and the gate to the storage facility itself was locked. The lock latch to the storage facility was broken. This was the evidence of forced entry into the unit. The police were notified right away and came out and took a report. The licensee will also be placing a local ad, reporting the stolen gauge and offering a reward for any lead information to the finding of this gauge. The licensee was able to move to another storage unit to secure the remaining five gauges. The licensee also purchased heavy duty chains or cables to wrap through all gauges at this location and other storage locations. Gauge Manufacturer: CPN Model: MC1DR S/N: MD70108564 Source: Cs-137 10 mCi 

               AM-241   50  mCi

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 4846531 October 2012 18:50:00On 10/17/12, the licensee notified RHB (Radiation Health Branch) of an issue related to prostate brachytherapy and questioned if this falls into the category of Medical Event (ME). RHB is currently investigating this matter to evaluate if a ME had occurred. The RSO called RHB for guidance about three permanent prostate seed implants for which post-implant dosimetry showed less than ideal dose coverage of the gland. The RSO reiterated that none of these deviations were a surprise all were expected based on intra-operative experience. In one Iodine-125 case, poor coverage of the lateral base resulted from significant pubic arch interference. In the other two cases, both Palladium-103, poor coverage of the base occurred from vendor failure to disclose an additional unplanned spacer at the end of each seed strand. As stated, the D90 value (minimum dose to 90% of the CT-defined prostate one month following the implant) for the I-125 case was 77% and for the two Pd-103 cases was 68% and 53% of the dose prescribed as a minimum peripheral dose to the ultrasound-defined prostate +margin prior to the implant. The RSO requested RHB read this statement carefully, as it compares apples to oranges 'The RSO will make the case that the post-plan D90 is relevant as an assessment of plan and programmatic quality but is irrelevant for definition of a medical event'. The RSO indicated that the hospital's physicians do not prescribe by D90. What is prescribed is a minimum peripheral dose (MPD) to the ultrasound-defined prostate gland plus planning margin (PTV). A pre-plan is generated to deliver the intended MPD (145 Gy for I-125 monotherapy and 125 Gy for Pd-103 monotherapy) to the PTV. The resulting planned combination of radionuclide, source strength, and number of sources is what is approved, prescribed, ordered, and implanted. Very often, changes are made intra-operatively to account for implantation difficulties and clinical factors (deviation of urethra from predicted path, pubic arch interference, presence of more aggressive disease in a specific part of the gland, etc). In addition, extra seeds are ordered for each case, to be implanted at the discretion of the Authorized User (AU). Extra seeds may be implanted to boost areas of sparse coverage following implantation of planned seeds. Extra seeds may also be implanted to boost areas of known aggressive disease to a dose higher than the initial MPD. It is impossible to mentally arrive at a new dose that might correlate to a D90 on post-implant dosimetry under these conditions. The AU recognizes that this will result in an increase to the D90 on the post-plan but does not alter the dose on the written directive but only the number of sources (in part to of the written directive following implant but prior to release of the patient) to reflect the intra-operative changes. This is because the prescribed dose refers to a MPD for the pre-implant ultrasound prostate volume with margin (as our policy states). It was never meant to correlate with a D90 on a CT-defined prostate volume (which volume may be double the ultrasound-defined pre-implant volume) a month after the implant. As a result of the clinically discretional implantation of extra seeds, many of our D90 results in post-implant dosimetry actually exceed 100% of the prescribed dose. Several even exceed 120% of the 'prescribed' dose, and this is intentional. Nevertheless, the radionuclide, source strength, number of seeds, and duration of implant (permanent) indicated on part 2 of each written directive (the part completed following implantation but prior to release of the patient) correctly reflects what was done, as required by 10 CFR 35.41. The RSO called RHB about these three cases because the dose delivered to parts of these prostate glands was less than intended, an anticipated but initially unplanned result due to known but unplanned and uncontrollable outside factors. The Authorized Users for these cases are still reviewing the clinical data to determine what, if any, additional medical actions will be taken. Note that none of these cases meet the criteria for a medical event as recommended by the Nuclear Regulatory Commission's Advisory Committee on the Medical Use of Isotopes on October 18, 2011 (see attached). These criteria analyze the spatial distribution of seeds within octants of the gland as well as the overall D90 (threshold for which is lowered to 60% of prescription dose, and only in conjunction with failure of the spatial analysis). In each of these cases (and in contrast to what happened in the VA cases), very few seeds (only a few percent) were implanted outside the planning margin of the prostate CTV. Even by the older document the state reference, the May 18, 2011 Prostate Permanent Implant Brachytherapy and Associated Medical Event Questions and Answers from Clarification of Current Guidance for Prostate Permanent Implant Brachytherapy, the hospital assert (as in Case 2) that ' in accordance with NRC regulations, a ME has not occurred, since the delivered activity is equal to the prescribed activity for the treatment site (as defined by the AU). Even though the D90 values differ by more than 20 percent; the AU does not use D90 to prescribe dose, and is therefore, not required to use D90 to perform the regulatory evaluation of the prescribed dose'. CA 5010 Number: 101712
ENS 4802514 June 2012 13:04:00The agreement State of California reported the following via email: On 06/13/12, the RSO at Team Industrial contacted RHB to report a radiography camera incident that occurred on 05/22/12 at the Evergreen refinery in Newalk, CA. The radiographers were using a QSA 880 camera on the second deck of the unit 1 at this refinery. The radiographer cranked the 59 Ci source out into the collimator and after the exposure, he couldn't retrieve the source back into the shielded position. He immediately contacted the RSO. Per RSO's instructions, the radiographer unscrewed the crank assembly and pulled the cable back to retrieve the source into shielded position. There were no exposures to the radiographers, two assistants, and any member of the public. The licensee's Instadose dosimetry indicated 8 mR for the radiographer for the period of 5/18 - 5/22 and 7 mR and 0 mR for the two assistants for the same period. Their pocket dosimeters indicated zero exposure for all three individuals. The crank assembly was sent to QSA and they have indicted that the worn out teeth and bearings of the crank assembly inhibited the normal retrieval of the source. RSO will be providing a detailed report to RHB ASAP. CA 5010 Number: 061312 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 4805829 June 2012 15:59:00

The following was received via e-mail: On 6/28/12 Saint Joseph Hospital personnel were surveying a packing materials used to ship I-125 seeds, for a procedure conducted earlier that day, when they noted elevated readings. Further surveys revealed that the elevated readings were not coming from the packing material associated with the 6/28/12 procedure but from packing material that was used to ship I-125 seeds for a previous procedure, which was in the area of the survey. Surveys of the packing material revealed no loose contamination on the exterior or interior of the box but elevated readings of 2500-350000 cpm and .2 mrem/hr. Receipt and post procedure surveys of the procedure associated with contaminated box did not reveal any abnormal readings. The Saint Joseph RSO assumes the material is I-125 but they do not have the capability to verify this. No loose seeds were found in any of the packing material. The I-125 seeds were accompanied by the manufacturers leak test report which indicated no contamination. The patient, whose procedure was associated with the contaminated packing material, will be evaluated on Monday 7/2/12 to determine if there was any uptake in his urine or thyroid of I-125 as a result of leaking seeds. CA Report Number: 062912 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

  • * * UPDATE ON 7/2/12 AT 1806 EDT FROM EUGENE FORRER TO DONG PARK VIA EMAIL * * *

This is a follow up of an incident, as information only, on Friday, June 29, 2012. Radiologic Health Branch reference would be 5010 #062912. The notification was about contaminated packaging that had contained Best Medical I-125 seeds. A thyroid count was performed on the patient who had the seeds implanted in May. The thyroid count verified that there had been an uptake of iodine by the thyroid. Below is the write up and preliminary dose estimate from the licensee regarding. Based upon this morning's patient measurements, instrument-manufacturer supplied efficiency data, and reference data for dose conversion, we estimate the patient involved received a thyroid uptake of 0.1 mCi of I-125 and a dose to the thyroid of 300 cGy. 1) Conversion of counts per minute (cpm) to activity Two(Pi) counting efficiency for I-125 (per manufacturer) is 133.5% fraction of 2(Pi) solid angle subtended by a 2 inch diameter detector at a distance of 30 cm from the thyroid is 10.13 squared cm / 5654.9 squared cm = 0.00179 overall efficiency = 1.335 x 0.00179 = 0.00239 (190493 - 30) net cpm / 0.00239 x 4.505x10-10 mCi/dpm = 0.0359 mCi present thyroid burden. Back-correcting 60 days to time of implantation (conservatively assuming that all uptake occurred at that time) with 42-day effective half-life, initial uptake given by 0.0359 / 0.3715 = 0.0967 approximately 0.1 mCi 2) Taking the value quoted by Chen et.al. (attached) from NUREG/CR-6345, we assume the dose to thyroid is 780 cGy per mCi of I-125 administered, and this value assumes 25% uptake into the thyroid. Our calculated estimated thyroid burden of 0.1 mCi then gives an estimated absorbed dose of 0.0967 mCi x 780 cGy/mCi / 0.25 (since we measured actual thyroid burden v. amount administered) = 302 cGy approximately 300 cGy (rad) to thyroid. 3) Whole body committed effective dose equivalent (CEDE) from a 300 rad dose to the thyroid (using a thyroid weighting factor of 0.04) would be 12 rem. Notified R4DO (Allen) and FSME (Einberg).

  • * * UPDATE FROM GENE FORRER TO CHARLES TEAL ON 12/19/12 AT 1650 EST * * *

EVENT SUMMARY: While surveying an empty brachytherapy seeds package for return to Best Medical hospital personnel discovered contamination on the interior of the package. Follow up thyroid scans of the patient who was implanted with the seeds associated with the package verified an uptake of I-125 by the patient's thyroid. The initial report to RHB was intended, by the licensee, to be a notification of a Medical Event. REPORTING: This event was reported to the NRC, by phone, on 4/13/12, at 8:50 am via email. HEALTH AND SAFETY: Based on surveys of the packing material all contamination was contained within the package and did not pose a threat to hospital personnel. The estimated dose to the patient's thyroid was calculated to be approximately 330 rad with a CEDE of 12 rem. ADDITIONAL DETAILS: The RSO conducted an investigation of the incident and could not find any indication that there were any irregularities with the implantation procedures. Hospital personnel associated with the procedure indicated to the RHB inspector that there were no irregularities with the procedure. In addition receipt surveys of the package did not reveal any contamination of any of the packaging material. The RSO concluded that the cause of the contamination was due to a manufacturing error. The RSO of Best Medical conducted an investigation of the production of the seeds implanted in the patient. All records at Best Medical indicate that all QC tests of the seeds were done satisfactorily. The RSO concluded that the seeds had been damaged in transit or that Saint Joseph personnel must have damaged the seeds either during the initial surveys or during the implantation. The Best Medical RSO was unable to explain how the seeds could have been damaged and still be implantable. The Virginia Department of Health inspected the Best Medical facility and concluded that all QC testing on the seeds had been completed satisfactorily with no abnormalities noted. After interviewing Saint Joseph and Best Medical personnel RHB personnel concluded that the most logical explanation for the leaking seeds was a manufacturing error, however, without samples from the same lot of seeds implanted available for analysis this can not be proven conclusively. The hospital has changed suppliers for the brachytherapy seeds. In addition they have initiated a procedure where the needles containing the seeds are wiped after they have been removed from the shipping container. ENFORCEMENT ACTIONS: The hospital was not cited for this incident. INVESTIGATION STATUS: This investigation is closed. Notified R4DO (Spitzberg) and FSME Event Resource via email.

ENS 4773412 March 2012 20:18:00

The following information was provided by the State of California via email: On March 12, 2012, the RSO at Consolidated Engineering called the RHB (State of California - Radiological Health Branch) to report two missing moisture density nuclear gauges from their Oakland, CA storage facility, followed by an email (see below) detailing the events: On January 4 and January 5, 2012, as part of our bi-annual inventory, personnel performed an audit on a number of our nuclear gauges as required by our license. The inventory report was submitted to the RSO for review. Additional information was requested by the RSO on some of the gauges as is normal and customary. All of the gauges at that time were present and accounted for and were found to be satisfactory.

On January 26, gauge # 0840 was signed in and out of our Oakland laboratory by one of our senior technicians. He subsequently used a different gauge in the days that followed. As part of my continuing duty to monitor locations and conditions of gauges, it became apparent to me last week that one of our gauges, #0840 was not in its designated storage location. In the course of calling all of our technicians and evaluating all of our storage locations, we called all gauges to be brought into our San Ramon office on Saturday March 10th. A second inventory was performed at that time on all of the gauges on our license. It was noted that gauge #0840 was missing as was gauge #5027, which was also stored in the Oakland location.

We continued to exhaust all records, including sign-in and sign-out logs, report forms and checking with our license repair personnel and have concluded today that these gauges were more than likely stolen out of our Oakland office in January.

Manufacturer Model # Serial No Last documented use of gauge

Troxler 3411B T341 5027 06 January 2012 CPN MC3 M320400840 26 January 2012 The (source) quantities are as follows: CPN, 10 millicuries of Cesium 137 and 50 millicuries of Americium 241 Troxler, 09 millicuries of Cesium 137 and 44 millicuries of Americium 241. California Incident #5010-031212 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 4767116 February 2012 18:03:00The following information was received from the State of California via email: On 02/16/12, the RSO at Testing Engineers (TE) contacted the RHB (Radiological Health Branch) reception desk to report a stolen gauge. She reported that an employee had his truck stolen which also contained his nuclear gauge. The gauge a CPN MC1, S/N MD 20206438 containing 10 mCi of Cs-137 and 50 mCi of Am-241 was stolen yesterday (02/15/12) between 1:00 to 4:15 pm (PST) in a parking lot near the employee's residence . . . (in) Fremont, CA. The gauge was stored inside of its transportation case and placed in the back of the truck with the bed cover locked in place. The transport case was secured with a cable attached to the bed of the truck. The gauge user found the truck stolen around 4:15 pm (PST). The incident was reported to the Fremont police at that time. The gauge user failed to notify the RSO of the stolen gauge until the following day (02/16/12) (in the) morning. On 02/16/12, The TE (Testing Engineers, Inc.) RSO also notified this incident to Operations Emergency Center (report # 120902) and the NRC. 5010 Number (Date Notified): 021612 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 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 4762731 January 2012 14:36:00This information was provided by the State of California by e-mail: The Alternate RSO for Construction Testing & Engineering reported a Troxler 3440, serial number 22426, containing 9 mCi of Cs-137 and 44 mCi of Am-241, was stolen out of the cab of his pickup, which was parked in his driveway. . . sometime last night. The Licensee notified the Manteca Police Department and is working on posting a reward for the safe return of the gauge. CA Report Number: 013112 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 476478 February 2012 13:45:00The following was received from the State of California via email: On January 24, 2012, RHB was informed by the owner of National Analytical Instruments (...) that he had purchased a Varian UV-VIS detector from Golndustry Dovebid back in 06/11/2008 and he subsequently learned this device was contaminated with C-14. The purchase invoice ID is # 2169450, and the following equipment was indicated on the invoice: Varian ProStar 320, s/n 1550, Lot # 143568. The equipment has a Pfizer's asset number 16468. According to (the owner), the equipment came from Pfizer in Ann Arbor, Michigan, and that this laboratory has been owned by the University of Michigan since 2007. On January 24, 2012, the RHB inspector confirmed contamination of the Varian UV-VIS detector. A Thermo Scientific, RadEye B20-ER, s/n 0242 GM, survey meter was used to check for contamination, and contamination was observed with the maximum reading of 25 CPS. On January 26, 2012, in the presence of RHB inspector, the Pfizer San Francisco RSO took surveys, and also confirmed contamination of the Varian UV-VIS detector. The Pfizer RSO also took possession of the contaminated equipment.
ENS 4748428 November 2011 19:52:00The following was received from the State of California via email: During the holiday weekend, November 26, 2011, (a carrier) delivered a source containing 11.35 Ci of Ir-192 to Saint Joseph Hospital in Eureka, CA. There were no radiation safety personnel on site to receive the package and (the carrier) left the package with the receptionist, who is not authorized to receive radioactive material. The package was stored in the shipping and receiving area over the weekend. On Monday, November 28, 2011, the RSO became aware that the package had been sitting unsecured in the shipping and receiving area all weekend and notified the CA/RHB (California Radiation Health Branch). CA 5010 Number: 112811
ENS 4744015 November 2011 19:28:00The following report was received via e-mail: Stuck 37 Curie radiographic source in an INC IR100 camera. The magnet holding the collimator to the tank came loose and fell on the guide tube, kinking the guide tube. Operators placed lead bags on the source and repaired the kink so that the source could be retrieved. The radiographer received 42 mRem. The RSO received 39 mRem and the assistant received 10 mRem. California report number: 5010-111411 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 474001 November 2011 16:06:00

The following information was received by e-mail: On 10/31/11, the ARSO (Alternate Radiation Safety Officer) at TC Inspection informed RHB (California Radiation Health Branch) via email of an incident occurring on 10/26/11 at Valero Refinery in Benicia, CA during one of their radiography operations. The email written by the ARSO is as follows: On October 26, 2011, there was an incident involving RAM material; one of (the licensee's crew was) performing radiography at the Valero refinery when, while cranking out the source, the trainer noticed the crank handle started free-spinning. When he tried to crank the source back in it was still free spinning so the source was stuck out of the shielded position. When the trainer called, (the licensee) advised him to loosen one of the nuts on the crank assembly, pull back the tube and then grab the cable and pull the source back into the exposure device and into the shielded position and that (the licensee was on his way). When (the trainer) did this he noticed that the end of the cable was inside the tube, he was able to grab it with a pair of needle nose pliers and retrieve the source back into the shielded position. Two things happened here, the first; the trainer or assistant (still not sure which one) did not fully connect the guide tube to the camera. This allowed the source and cable to go out of the camera into air, thus allowing the cable to reach the end where the stop at the end of the cable did not stop the cable from coming out of the crank assembly. After further investigation (the licensee) found that the aluminum body of the crank assembly was worn right at the exit hole thus allowing the stop to go through. (The licensee) just did a maintenance inspection on those cranks on 10/1/11 and saw some wear on it but not as much as was there this time. (The licensee has) been in the process of replacing the aluminum body on all of (the licensee's) INC crank assemblies with stainless steel bodies when the techs tell (the ARSO) their cranks are getting hard to crank (That is usually the first sign that the aluminum body is wearing). (The apparent cause of the event is a technician forgetting to connect all of the equipment pieces due to production pressures or) equipment failure. CA 5010 Number: 103111

  • * * UPDATE FROM KEN PRENDERGAST TO CHARLES TEAL ON 11/3/11 AT 1513 EDT * * *

The following was received via email: On the day of the event, the operators pocket dosimeters indicated 10 mR. Camera information: INC IR-100, S/N 4301, with a source activity of 40.8 Ci. The crank assembly has been sent to INC and we'll be visiting INC today. We requested written statements from the trainer assistant. The ARSO already received them and he'll be sending a copy to RHB today. TC was requested to process the dosimetry badges worn by trainer and the assistant. Notified R4DO (Gaddy) and FSME EO (Camper).

ENS 473183 October 2011 18:48:00The following was received from the state via e-mail: On September 27, 2011, RHB (Radiologic Health Branch) was informed by Pacific Nuclear Technology (PNT) that they collected a moisture density gauge that was left on the adjacent office porch of the BSK & Associate office. The gauge was discovered by BSK & Associate's employee, and according to PNT service records, the gauge belonged to J. Yang and Associates. The gauge was delivered to CDPH-RHB on 09/27/11 by PNT. RHB will investigate to determine how the gauge was lost. Mr. Yang terminated his CA License in 2008, but apparently did not relinquish all of his licensed materials. CA 5010 Number: 092711
ENS 4714411 August 2011 15:06:00

The following information was received from the state of California via e-mail: On August 8, 2011, Mr. Todd Rucker, RSO from Pavement Engineering, Inc., notified RHB (Radiation Health Branch) Sacramento that one of their moisture-density gauge operators lost a gauge at their job site on August 6, 2011 at approximately 4:30 am. The gauge had been borrowed from A. Teicher & Son, Inc., License No 4030-34. The gauge was used on a job site on HWY 70 in Yuba County, near the town of Olivehurst, CA. The lost gauge is a Troxler, Model 4640-B, Serial number T464 1793. This model moisture density gauge has an 8 mCi Cs-137 source. California event number: 080611

  • * * UPDATE FROM EPHRIME MEKURIA TO CHARLES TEAL ON 8/17/11 AT 1731 EDT * * *

Pavement Engineering has found the lost gauge. Notified R4DO (Hay), FSME EO (Watson), ILTAB (Johnson), and Mexico via fax. 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 4619320 August 2010 21:00:00The following information was received from the State of California via email: On 08/20/10, the ARSO at Stanford University called and informed RHB (California Department of Public Health - Radiologic Health Branch) of the following: On 8/16/10, it was discovered that one of our Contractors, Vance Brown, lost control of 28 signs they removed from two buildings (Building 05-600 Moore South (row 475) and Building 05-610 Moore North (row 493). The signs were placed into a plastic bin and Vance Brown cannot determine what happened to them. Representatives from Vance Brown and Redwood City Electric, the electrical subcontractor who removed the signs, conducted an investigation to determine the fate of the signs. They determined that while the signs had been removed and stored properly awaiting disposal by EH&S (Stanford University Environmental Health and Safety), they vanished from the secured construction site at an undetermined time between 6/28/2010 and 8/16/10. EH&S met with representatives from Vance Brown and Redwood City Electric on 8/19/10. Several avenues were explored during the meeting. Vance Brown explained that the site was broken into on 7/29/2010 and several tools and other valuables were stolen. Vance Brown filed a police report, but did not notice the signs missing at that time. Vance Brown and Redwood City Electric also questioned their employees, reviewed truck logs, and looked through both construction site storage containers and their off-site warehouses. Stanford EH&S has also conducted an internal investigation to determine if any Stanford employees had picked up the signs. None had. Stanford EH&S also queried the waste hauler used by Redwood City Electric (Quick Light Recycle) who stated they had not picked up the signs. At this time Vance Brown and Stanford EH&S has exhausted potential locations for the plastic bin of 28 tritium exit signs and considers them to be lost and/or missing. California Report No.: 5010-082010 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 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 459087 May 2010 02:39:00The following was received from the State of California via email: On May 5, 2010 the California Radiologic Health Branch (RHB) was informed by the alternate Radiation Safety Officer (RSO) of Chevron USA that they may have lost a Niton, XLP 818, S/N 13354, containing a 30 mCi Am241/Be sealed source. According to the alternate RSO, the Niton XLP was lost and was reported to him by the Material Inspection Group supervisor on April 29, 2010. This incident was not reported to RHB because the licensee was looking for the Niton XLP until the date of this report. CA Report #: 050610 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 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 4558923 December 2009 18:57:00

AGREEMENT STATE - RADIOGRAPHY SOURCE FAILED TO RETRACT

The following was received via email:

The 48 Ci Iridium-192 source in an INC IR-100 radiography camera, sn 6617, failed to retract in that the safety latch popped up prematurely, locking the source in the un-captured position outside of the radiography camera. The radiographer approached and surveyed the radiography camera, depressed the latch, returned to the cranks and returned the source to the safe position. Upon examination of both the radiography camera and the cranks, no damage or excessive dirt was detected that could explain this type of failure. The radiographer and assistant did not pick up any excessive radiation exposure as a result of this incident. Note: the operations manual for this instrument indicates that this type of failure could occur and instructs the user/radiographer in the steps to take to correct the problem. These steps, mentioned above, were taken by the radiographer.

This event occurred at Shell Oil Refinery in Martinez, California.

California report number 122309.

ENS 455467 December 2009 19:48:00The following notification was received via email: On December 7, 2009, CPN Instrotek, California License CA1100-07, reported that a MC-3 gauge was stolen from a delivery truck while it was being transported to CPM Instrotek. The gauge is Serial Number M36046710. The gauge contains 10mCi of CS 137 and 50mCi of Am/Be. This theft was reported by CPN Instrotek on Monday, December 07, 2009 1118 AM by email. The report was made by (the) Radiation Safety Officer (RSO) for CPN Instrotek. (The RSO) reported that CPN Instrotek had received a call on the morning of December 7, 2009 from the transport company that was transporting the gauge from the airport to CPN Instrotek (both in Concord California). The transport company stated that the gauge was stolen from one of their trucks between the evening of December 4th and the morning of December 7, 2009. The truck was locked. The transport company had picked up the gauge at the airport and it was being delivered to CPN Instrotek in Concord. The gauge was being returned to CPN Instrotek for disposal. The loss was reported to local law enforcement. California Event Number: N/A 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 4525811 August 2009 16:09:00The following was received from the state via email: On 08/05/09 during the evening a T.C. Inspection radiographer was performing radiography at the Chevron refinery in Richmond, CA. The job was completed around 8:30 p.m. The radiographer loaded the gear into the truck leaving the locked camera (INC, Model IR100, S/N 7019, 49 Ci activity) at the job site. Approximately 10 to 15 minutes later, Chevron maintenance noticed the exposure device and notified the Chevron fire department. The A T.C. Inspection radiographer who was at the refinery heard the call on the radio and responded to the event location, however, he did not have a survey meter to approach the camera. He noticed that the plug was in and the device appeared to be locked with no key in the lock. They barricaded the area, and kept the camera under surveillance until a survey meter was brought in. The radiographer surveyed the camera and confirmed that the source was in a shielded position and transported the camera to the storage location. The radiographer who left the camera at the job site is no longer employed by T.C. Inspections. CA Report #: 80609
ENS 4525410 August 2009 18:37:00The following was received from the state via email: The source housing from a 6.58 mCi Ni-63 electron capture device (ECD), (Varian Model 02-001972-00, S/N A2296) was inadvertently opened when the detector was removed from a gas chromatograph for storage. The situation was discovered by radiation safety staff, and followed up immediately. Removable contamination was detected on the open interior of the source assembly and on top of the gas chromatograph, but was less than the removable value of 0.005 microcuries. The detector foil was not damaged or accessed. All components of the source assembly were retrieved and will be disposed of as radioactive materials waste or returned to the vendor. CA Report #: 080509
ENS 4516826 June 2009 19:25:00The licensee reported a M/D (moisture density) gauge was stolen from the residence of a Krazan and Associates employee. The gauge was a Troxler 3430 portable moisture density gauge, serial number 35729 containing approximately 8 mCi of Cesium 137 and 40 mCi of Americium 241. The gauge was stolen sometime between 5pm on Thursday, June 25 and 6:00 am on Friday, June 26, 2009. The gauge was stolen from the back of an open pickup bed at the employee's residence in Bakersfield, CA. According to the RSO, the gauge was stored in the locked gauge case that was chained to the vehicle frame. The licensee has reported the incident to the Kern County Police and the Kern County Sheriffs Office. The licensee will also be offering a reward in the local newspaper and on Craigslist." 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 448387 February 2009 17:14:00

On 2/6/09, between the hours of 0200 and 0600 PST, a 3400 series Troxler gauge was stolen from a residence. The gauge was in a camper on the premises of the residence located in Martinez, California. The licensee (Stevens, Ferrone & Bailey Engineering Co.) reported the stolen gauge to the State of California on 2/7/09 at 1300. The density gauge contains approximately 8 mCi of Cesium 137 and 40 mCi of Americium 241. The Sheriff was notified and the licensee plans to offer a reward. This notification is preliminary and will be updated by the state of California as more information is available.

  • * * UPDATE AT 1629 EST ON 2/9/09 FROM PRENDERGAST TO HUFFMAN VIA E-MAIL * * *

(The licensee RSO reported) on 2/7/09 that (a) portable gauge had been stolen early in the morning on 2/7/09. Apparently, one of (the licensee's) employees had transported a Troxler model 3440 portable gauge to his residence (deleted) in Martinez, CA. 94553, after work on 2/6/09. According to (the RSO), the Troxler model 3440 series moisture density gauge (serial number T344-33708 containing 9 mCi of cesium 137 and 44 mCi of Am-241) gauge was stolen from the back of a locked camper shell between 12:00 a.m. and 6:45 a.m. on 2/7/09. (The RSO) stated that the gauge was stored inside a locked camper shell that was backed up to the garage at the employee's residence. The camper shell was broken into, the chains were cut and the gauge was removed from the vehicle. According to (the RSO), the gauge had been covered inside the camper shell to prevent detection. The Martinez Police were also notified and filled out Martinez Police report # 09-513. The (California Radiologic Health Branch) was notified by (the RSO) that a trucker had called (the RSO) at 10:00 a.m. on 2/9/08 to inquire on the reward. The trucker, who did not give his name, indicated that he had found the gauge and case on the side of the road. The anonymous trucker was concerned and stated that he had to notify his management before he turned over the gauge. CA Report #020909 R4DO(Miller), FSME EO (Shaffer), and ILTAB (via e-mail) were notified. 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 447556 January 2009 16:59:00The following information was provided by the State via e-mail: On 01/05/2009, an unlabeled, unmarked package containing 278 mCi of Rubidium-82 for cardiac PET studies was received at (the University of California at San Francisco) UCSF Receiving Department. The package was surveyed with radiation levels of 17 mR/hr at the surface and 0.5 mR/hr at 1 meter. A wipe of the package was negative. The container was not the usual one that UCSF has received for incoming shipments of Rubidium-82. The Receiving Department failed to contact the RSO's office, and instead contacted Nuclear Medicine to take custody of the package. Nuclear Medicine took custody of the package and exchanged the new Rubidium-82 generator for the old one. Nuclear Medicine alerted the RSO on 01/06/09, to the matter. The package insert indicated that the package was distributed by Bracco Diagnostics in Princeton, New Jersey. The UCSF Assistant RSO contacted personnel at Bracco Diagnostics and was subsequently referred to GE Healthcare in South Plainfield, NJ. Personnel at the GE Healthcare facility are investigating the matter and will report back to the assigned State of California inspector. State of California Report No. 1725-5010
ENS 4462031 October 2008 17:31:00

The following information was received from the State of California via email: On 10/30/08 the Vallero Refinery, Benicia, CA, informed the RHB of an incident that happened on 10/02/08 during radiography operations performed by T.C. Inspections at their refinery. On the night shift of October 2, 2008, a radiographer, two assistants, and a technician were performing radiography on Tank # 1795. After cranking the source out, the magnetic stand holding the collimator fell and was suspended by a rope from the top. This left the camera, crank, and collimator dangling from the tank. The collimator was about 40 feet up, the crank was hanging down and accessible from the lowered man-lift, so the radiographer tried to crank the source in, but realized that the source was stuck due to a kink in the guide tube. The radiographer approached the collimator using a man-lift and was able to straighten the guide tube and crank the source into the shielded position. The radiographer was very close to the source for approximately 1 minute. It has taken about 5 minutes from the ground to get the source back into the shielded position. The radiographer's pocket dosimeter was off scale. His dosimeter was processed and the whole body dose indicated 843 Mr.

California 5010 Number (Date Notified): 103008

ENS 4450519 September 2008 15:10:00On September 18, 2008, at 5:00pm, the state received a telephone call from the RSO of Nektar Therapeutics that their Aglent Technology gas chromatograph containing generally licensed source is leaking. This notification is based on the swipe test results report from their swipe test laboratory. Source Serial Number U8663, had a confirmed a positive wipe test result of 137,362 DPM which is a result of 0.0619 micro curies/sample. The RSO stored the gas chromatograph in a secured locked storage room where the storage is posted with 'Caution Radioactive Material'".
ENS 443301 July 2008 15:50:00The state submitted this report via e-mail. Seagate leases static discharging (elimination) devices from a licensed manufacturer, NRD LLC. These static dischargers are Po-210 based alpha emitters. Seagate employees noticed oxidation/discoloration on these static discharges within 2-3 months after installation in their clean rooms. They were concerned about possible flaking of any particulates onto their micro sensitive products and cost of swapping the devices more frequently than every 12 months (lease period). Seagate removed these units from the clean rooms and wipe tested them and sent them for processing to Sterling & Associates. On 6/23/08, the CIH from Sterling & Associates informed Seagate that 4 of the 5 fans exhibiting discoloration, exceeded the limit (0.005 microcuries) 'leaking' with sample results ranging from 0.009-0.01 microcuries. These units included Model # P-2063 with S/Ns A2FD498 (0.02 microcuries), A2FH895 (0.01 microcuries), A2FD505 (0.02 microcuries) & A2FH915 (.009 microcuries). In addition, the remaining 12 fans sampled collectively showed results of 0.3 microcuries. All these 12 units were same Model # P-2063. After the findings, Seagate wipe tested 5 more units (1 brand new, 1 clean looking, & 3 discolored) and the nearby work areas of leaking sources, and the results were non-detect. Seagate notified NRD and all the units that were tested (5+12) were shipped to NRD for further verification. NRD believed that the wipe sampling of the unit, if not done properly might affect the ultra-thin gold encapsulation layer and thereby pick up some imbedded Po-210. 07/01/08 - Per NRD RSO, they still have not received the units from Seagate. He also stated that these units contain a very thin layer of plating and if wipes are not done properly, wipes will pick up imbedded Po-210 indicating contamination. NRD will be wipe testing all the units as soon as they are received and will be calling RHB to notify their findings.
ENS 441841 May 2008 18:59:00The State provided the following information via facsimile: On April 19, 2008, Urban Ore picked up a load of material from 2151 Berkeley Way, which included a gas chromatograph with an ECD (Electron Capture Detector) containing 300 mCi of Tritium. Prior to this, 2151 Berkeley Way had been sold to the University of California at Berkeley (UCB). On April 26, 2008, Urban Ore returned the gas chromatograph to the loading dock of 2151 Berkeley Way. On April 28, 2008, the Richmond Regional Office of RHB (Radiological Health Branch) was notified. On April 28, 2008, at 1330 the UCB RSO, and other representatives from UCB met at 2151 Berkeley Way and identified a Largus Applied Technologies gas chromatograph, with an Electron Capture Detector (ECD), Model 200 within the loading dock containing approximately 150 mCi of Tritium. Smears were taken of this ECD and no contamination was found. The group inspected the parking garage inside the building and found another ECD unit, Valco containing approximately 500 mCi of Tritium and a 0.9 uCi Radium-226 button source. Smears of this ECD identified approximately 8000 dpm of contamination at the open end of small bore exhaust tubing. The ECD reportedly came from room 100C. The Largus unit was moved from the loading to the inside of the building and labeled 'do not remove.' At 1600 on April 28, 2008, the RSO asked that all recycling work be stopped in 2151 Berkeley Way. The RHB was informed of the events of April 28, 2008, at about 1140 on April 29, 2008, which was followed by an email to RHB detailing the above at 1830 on April 29, 2008. On April 30, 2008, RHB has taken custody of the 2 ECDs, and met with the RSOs of UCB and DOL (Department of Labor) and other representatives of CDPH (California Department of Public Health). A strategy for resolving this incident was worked out, and RHB offered full assistance to DOL.
ENS 4409826 March 2008 14:48:00The State provided the following information via email: On March 25, 2008, a Troxler M/D gauge, Model 3411, Serial Number 6520 was stolen from a URS company pick up truck during the evening. According to the RSO, the gauge was stolen from inside a locked container, which was stored in a locked camper shell, within a locked gated garage at the employees residence. The employee had taken the gauge to his residence in preparation for an early morning job. The density gauge was stated to contain approximately 9 mCi of Cesium 137 and 44 mCi of Americium 241. CA Report #032608 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 4401528 February 2008 19:16:00The State provided the following information via email: The Licensee reports that they have 'discovered' residual radiation left in a Nuclear Systems irradiator model 'U' following the removal of the original 5000 Ci of Co-60 by a contractor of the OSRP last summer. The licensee thinks that one of the original 40 capsules that comprised the 8 rods (5 sources/rod) that contained the original 5000 Ci of cobalt 60 in 1958 may have remained in the device following source removal. The sources were removed for disposal last summer as part of the OSRP program to remove old unneeded sources of radiation. CA Report: 022808
ENS 4385820 December 2007 19:03:00The State provided the following information via email: (Deleted) of the City of Santa Rosa City Hall, Facilities Maintenance reported that a single tritium exit sign that was used at the facility located at 520 3rd Street, Santa Rosa, formerly owned by AT&T, and later sold to the City of Santa Rosa, was missing. The single Isolite Tritium Exit sign (S/N A3N1685) was listed on the inventory list but was not located when they took over the facility. (Deleted), the representative of AT&T acknowledged the loss and reported it to RHB on December 12, 2007. The inspector assigned to this issue will visit the facility in the very near future to investigate and determine if any of the Santa Rosa personnel are aware of the location of missing H-3 exit sign. CA Incident Number: 121207 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 4364314 September 2007 18:48:00The licensee completed testing at jobsite and thought he had stowed his moisture density gauge (Troxler model 3340, SN 25752, 8 - 10 mCi Cs-137/ 40 mCi Am-241/Be). He left the jobsite in Shingle Springs, CA, and while in-transit to Elk Grove, CA (via highway 50) the technician heard a thud from outside of the vehicle but did not think anything of it. When the technician arrived at his residence he noticed the truck's tailgate was down and realized the gauge was missing. He backtracked to the jobsite and was unable to locate the gauge on the highway or at the jobsite. The technician notified the RSO, the Elk Grove Police Department and the California Highway Patrol. The State will provide more information as it becomes available. 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 4278418 August 2006 15:17:00The State provided the following information via email: Problems were encountered during a Varian HDR source exchange during the evening of 8/14/06. While attempting to replace the source on a Varian Medical System's VariSource HDR unit, the new active source (Ir-192, 9 curies) got stuck in a transfer tube. Following placement of shielding, the source was freed and placed in the transport pig by noon on 8/15/06. A new source was delivered, and was successfully installed during the evening of 8/16/06.
ENS 4259321 May 2006 18:38:00

The licensee (IsoRx) reported to the State of California that their vehicle was broken into at Modesto, CA and a 2 milliCurie capsule of I-131 was taken. IsoRx is a Nuclear Pharmaceutical company operating in San Francisco, CA. The owner and RSO is on his way to Modesto to investigate this matter. The State of CA told licensee to contact the Modesto police and fill out a report.

  • * * UPDATE PROVIDED FROM KENT PRENDERGAST TO JEFF ROTTON AT 1616 EDT ON 05/22/06 * * *

The initial report from the State of California claimed that the vehicle was broken into in Modesto, CA. That was reported incorrectly and is being revised by the update provided below. The State provided the following information via email: On 5/21/06, the RSO at IsoRx called Kent Prendergast (State of California) to report a theft of about 2 mCi of I-131 capsule from a trunk of a IsoRX vehicle that was parked at Myrtle Street between Park and Larkin in San Francisco. Immediately after the incident, the RSO and (Deleted) (CHP) surveyed a four block area around the theft site with a Ludlum Model 3, (S/N 197096, PR 207476) micro R meter. A thorough survey of the vehicle was also performed. None of the surveys indicated any elevated readings above background. The RSO also conducted a ground search of the area with the pharmacy personnel and spoke with local 'street people' to uncover any information. A reward was also offered for the capsule. RSO filed reports with OES and SFPD. The RSO will be sending a formal report to the RHB regarding the incident. Notified R4DO(Shaffer) and NMSS EO (Burgess) and ILTAB(via 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 injured 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 4237324 February 2006 01:15:00The State provided the following information via email: Based on a July 05 inspection and notification from RML licensing it was determined that Merrvel Engineering had not paid their annual fees and had abandoned their facility. Based on a 2/17/06 visit to the Engineering Office, it was noted that Merrvel Engineering had been evicted based on the Notice Posted on the front door. RHB contacted the Oakland Police and spoke with an (DELETED) who provided the name of the building owner. RHB contacted the building owner, (DELETED) and set up a time to gain entry to the facility and determine of there were any gauges present. On 2/22/06, RHB visited the facility and met owner at the facility to see if (DELETED) may have left any RAM at this facility. A quick survey indicated that RAM was present in a locked and posted cabinet at the rear of the facility. (DELETED), the owner and party that the property had reverted to, after the 14 day eviction proceedings, removed the hinges from the cabinet and a locked CPN gauge case was observed. According to the case placard, the gauge contained 10 mCi of cesium 137 and 50 mCi of americium 241 on 05/14/84. The serial number of the gauge is M14115815. After removal of the gauge surveys of the facility using a Ludlum Model 19 survey meter indicated that no other gauges were present at this facility. All other readings were background or 9 microrem/hr. A copy of the RHB business card was left with (DELETED) who indicated he would tape it to the door, in case (DELETED), came by and had questions. The inspector noted that (DELETED) had abandoned the facility and had not taken his tools, computers, or equipment. So it is suspected that at some point (DELETED) may contact (DELETED) or RHB regarding the Moisture Gauge. The inspector impounded the gauge because it had been abandoned and will transport the gauge to CPN or storage until release by RHB. RHB will continue to try and locate (DELETED) to retrieve back fees and to determine if he possesses any other portable gauges.
ENS 413939 February 2005 19:12:00The following information was obtained from California Department of Health Services, Radiation Health Branch - Berkeley / Region 3 via facsimile: A CPN Model MC-1DRR-P moisture density gauge was run over at a construction site at Valencia Street between 14th and 15th Street in San Francisco, CA approximately at 9:30 am. The gamma source rod was in the extended position at the time of the incident. The source tip rod containing 10 (milliCuries of) Cs-137 was intact but was slightly bent and could not be retracted into the safe position. The 50 (milliCurie) Am-241/Be source was intact as designed. Mr. (DELETED) from CPN was at the site after the incident. A screen leak test performed by Mr. (DELETED) did not indicate any contamination. Gauge was picked up by CPN at the site and held for disposal.
ENS 413764 February 2005 18:53:00The following information was received from California Radiation Health Bureau via facsimile: A Troxler Moisture Density gauge (Serial # 27061) was run over at construction site at Mare Island, Vallejo, CA at 4:30 PM on 2/3/05. According to the RSO, the gauge operator was standing 15 feet from the gauge when a loader operated by Gilotti Construction changed course and ran over the gauge. The gauge was damaged severely and the source rod was bent and removed by the operator from it's protective lead shield. The rod and gauge were stored in a shed and CPN (gauge manufacturer) has been contacted this afternoon and will retrieve the gauge and prepare it for transport to Troxler, Inc. The RSO will be investigating this incident The gauge contains 8 milliCuries of Cs-137 and 40 milliCuries of Am-241. At this time, there does not appear to be any personnel overexposures or spread of contamination due to this event. The State of California has requested that the worker's film badges be immediately processed as a part of the licensee investigation.
ENS 4226818 January 2006 15:30:00The State provided the following information via email: RSO for Earth Consultants, claims his company has broken up and his Alternate RSO has taken their single moisture density gauge. The gauge is a CPN model 503, source model 131 serial number H300305517. This information was first provided in a letter dated 1/21/05 and he has not been able to locate his former ARSO. RHB Richmond has determined that the former ARSO is probably located in Greenfield, CA. RHB will continue its efforts to locate the former RSO and the gauge. RHB Richmond has spoken to the RSO and suggested that he report the gauge as stolen by his former ARSO to the local authorities and request license termination. These gauges typically contain 10 milliCi of Cs-137 and 40 milliCi of Am-241. 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 4086613 July 2004 18:30:00At 1440 PDT on 7/13/04, the California Radiologic Health Branch was notified by the Assistant Radiation Safety Officer for Stacey and Witbeck that their one and only gauge was stolen along with some other goods from a Conex box, container car, which was located at a construction site at Bascomb and SW Expressway in San Jose. The stolen gauge was a Troxler 3440, Serial Number 750-8909 containing 9 millicuries Cs-137 and 44 millicuries Am-241. The gauge was in a locked construction site in a locked Conex box. Bolt cutters and a torch were used to open the Conex box.
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