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| Entered date | Event description | |
|---|---|---|
| ENS 56940 | 30 January 2024 19:48:00 | The following is a summary of information that was provided by the California Department of Public Health, Radiological Health Branch via email: On January 30, 2024, at 1450 PST, the radiation safety officer of Cedars Sinai Medical Center contacted the Los Angeles County Radiation Management office to report a medical underdose event. The underdose occurred during a treatment of Y-90 (yttrium-90) TheraSpheres microspheres for a radioembolization treatment for liver cancer. The prescribed activity was 480 Gy and the administered activity was 227.6 Gy (about 47 percent of the prescription). The underdose was due to an obstruction of the microcatheter used to deliver the Y-90. The patient has been notified. Cedars Sinai Medical Center will conduct an investigation to gain a better understanding of the details of the event. CA event ID number: 013024 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 56472 | 17 April 2023 16:05:00 | The following information was provided by the California Radiation Control Program via email: Industrial Nuclear Company (INC) (located in California) shipped three nominal 103 Curie Ir-192 radiography sources to Miami for export to a customer in Venezuela on 9/27/22. The sources did not reach the Venezuelan customer. The sources were reported missing by INC on 4/10/23 (the sources were never 'lost' as their whereabouts were known to be in custody). The sources have been recovered from a common carrier warehouse in the Miami area by the Florida Radiation Control Bureau and Florida law enforcement on 4/14/23. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: A previous notification of this matter was made to the Headquarters Operations Officer (HOO) by the Florida Radiation Control Program on 4/10/23. On 4/10/2023 at 1300 EDT, the HOO also received a phone call from INC regarding a potentially abandoned radioactive source that was originally intended to be shipped to Venezuela but was in possession of the common carrier in Doral, FL. The state of Florida provided preliminary information on the incident and will provide additional information as it becomes available. 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 55877 | 4 May 2022 20:47:00 | The following was received from the California Department of Public Health, Radiologic Health Branch via email: On May 4, 2022, the Radiation Safety Officer for Eckert & Ziegler Isotope Products, Inc. (EZIP) contacted Los Angeles County Radiation Management regarding two missing sources. Pennsylvania licensee Abington Jefferson Health, located in North Wales, PA, shipped a package on October 21, 2021, and (the common carrier) tracking information indicated the package was delivered to EZIP with no receipt signature on October 22, 2021. Abington Jefferson Health contacted EZIP on November 10, 2021, requesting a receipt for confirmation of the returned sources. The sources were two gadolinium-153 line sources, with approximately 13 millicuries (mCi) each (greater than 1000 times the Appendix C value of 10 microCi). EZIP did not have a record of receipt of the package, and a search of the EZIP facility did not find the sources. The notification to Los Angeles County Radiation Management by EZIP was delayed due to confusion by EZIP regarding whether the package had been returned to Abington Jefferson Health by (the common carrier). 5010 Number: 050422 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 55876 | 4 May 2022 19:31:00 | The following was received from the California Department of Public Health Radiologic, Health Branch via email: The Radiation Safety Officer for UCSD ((University of California, San Diego)) contacted the Radiologic Health Branch regarding the loss of I-125 sealed sources. He also reported the loss to the CA State Warning Center (control no. 22-2532). A medical physicist at the Moore's Cancer Center at UCSD received a box that contained 4 packs of I-125 sealed sources instead of his expectation of 3 packs. The medical physicist removed 3 packs and set the packing box outside for recycling, believing it was empty. The cardboard box was taken away by environmental services staff and has possibly been taken to the on-campus recycling center. The pack contains approximately 6-7 I-125 medical brachytherapy seeds with combined activity of 2.3 millicuries. The seeds are sealed in a shielded, sterile pack. The expected exposure level is close to background radiation level outside of the shielded pack. UCSD sent health physicists to the recycling center to search for the missing package. 5010 Number: 050322 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 55707 | 17 January 2022 15:44:00 | The following report was received from the California Department of Public Health via email: On Monday, January 17, 2022, the licensee's radiation safety officer reported the theft of a CPN MC-1DR (MD30406938) containing sealed sources of Cs-137 (10 mCi) and Am-241:Be (50 mCi), leak tested 4/2021. The theft occurred overnight between Friday and Saturday 1/14/2022 - 1/15/2022 at an authorized gauge user's (AU) residential home. The AU returned home urgently on Friday due to a family member's illness. The AU did chain the gauge case to the door inside the truck cab but failed to lock the truck before entering his home. The AU discovered that the gauge case was missing early Saturday morning while the truck was parked in the driveway of the home. The CPN nuclear gauge handle was locked to prevent operation, the gauge was locked in its transport case, and the transport case was chained to the door inside the truck cab, but the chain was cut and case/gauge was taken, apparently the only item stolen. The gauge and case had a company name and phone number label adhered to it in case of loss or theft. A police report was filed with the Corona police department (22-03047). The licensee will submit a lost/reward ad in the local paper/website and gather additional information for the follow up investigation. California Event Number: 011722 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 55374 | 22 July 2021 20:11:00 | The following was received from the California Radiologic Health Branch (RHB) via email: The licensee reported that on 7/13/2021, they received an externally contaminated package containing two unit doses of F-18 (110 minute T1/2 (half life)). The licensee's receipt survey found the outer surface removable contamination level to be 5,417,497 dpm per 100 sq cm. The inside of the package, including the F-18 vials, were not contaminated. The radiopharmacy courier was informed of the excessive contamination, and the radiopharmacy was contacted. The package radiation levels were acceptable. The package was received from Optimal Tracers (CA-RML 7975). RHB will investigate this matter further, including onsite at Optimal Tracers' facility. 5010 Number: 071921 |
| ENS 56033 | 5 August 2022 15:46:00 | The following information was provided by the licensee via email: During an inspection on 7/26/22, the RSO (Radiation Safety Officer) of Advanced Geotechnical Solutions stated that on March 6, 2021, an Authorized User of radioactive gauges for Advanced Geotechnical Solutions discovered that his SUV had been broken into and the radioactive gauge Troxler, 3430, serial #70783 that he had checked out from the permanent storage site at (REDACTED), had been stolen. The Authorized User had transported the radioactive gauge to his personal residence and left it locked in his vehicle rather than transport it back to the permanent storage location in Escondido. The Authorized User reported the theft to his RSO, and to the San Diego Police Department, and the RSO reported the theft to Cal OES (California Governor's Office of Emergency Services) on 3/7/21, instead of to the Brea, CA office since it was a weekend. The report of the lost gauge apparently did not get to the Brea office, and consequently no investigation was conducted, nor was the theft reported to NRC. The RSO had contacted local newspapers in an attempt to retrieve the stolen radioactive gauge, as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service, but the gauge has not been recovered. The investigation is ongoing, including why the Cal OES report did not get to the Brea, CA, RHB (Radiologic Health Branch) inspection office. 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 55121 | 3 March 2021 20:18:00 | The following is a summary of a report received from the California Department of Public Health (the Department) via email: The Department was notified that a Troxler model 3440, Serial Number 22188 (9 mCi. Cs-137, 44 mCi. Am:Be-241) had been lost when the operator left the worksite believing the gauge was in the bed of the truck. At approximately 1430 PST, the licensee reported the gauge had been located at the work site and returned. The licensee is investigating the event and the Department will review their findings. California Report ID: 5010-030321 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 55047 | 23 December 2020 20:46:00 | The following information was received via email: On December 23, 2020, the Radiation Safety Officer (RSO) for ABI Engineering, Inc. contacted the California Department of Public Health - Radiologic Health Branch to report a moisture density gauge that was lost while transporting the gauge from the worksite in Orange, CA to the office. The gauge was locked in the transport case and placed in the vehicle, a pickup truck with a camper shell. During the short trip back to the office, the driver of another vehicle alerted the licensee's operator that the rear door of the camper shell was open. The licensee's operator then discovered that the gauge was missing, with one end of the chain used to secure the transport case loose. The licensee's operator backtracked to the jobsite in an attempt to find the gauge but did not locate it. The driver then notified the RSO and went to file a police report. Approximately 20-30 minutes after the RSO reported the incident to the Radiologic Health Branch, the RSO received a call from an individual who found the gauge. The gauge will be returned to the licensee. The gauge is a CPN International MC-3 (10 mCi Cs-137, 50 mCi Am-241:Be), S/N M39048766. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health. California 5010 Number: 122320 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 54778 | 14 July 2020 23:51:00 | The following was received from the California Department of Public Health via email: A Troxler moisture density gauge (model 3430, serial # 31716) was reported stolen Monday morning at approximately 0600 PDT from the bed of an employee's vehicle while the vehicle was parked for 1-2 hours outside the employee's residence in Moreno Valley, CA. The gauge contains approximately 0.3 GBq (8 mCi) of Cs-137 and 1.50 GBq (40 mCi) of Am-241. The gauge was reportedly picked up earlier that morning at the licensee's office in Rancho Cucamonga, and left appropriately chained/locked in the back of the vehicle at the employee's residence before leaving for a work location. The theft was reported to the Moreno Valley Police Department (police report #MV201950058 taken by Officer Flores). A reward will be advertised for the return of the gauge. California 5010 NUMBER: 071420 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 53936 | 15 March 2019 11:03:00 | The following report was received from the California Department of Public Health via email: A moisture density gauge was being used at a construction site when it was struck by a backhoe. The gauge operator had visual contact with the gauge, and had been assured by the backhoe operator that the gauge would not be impacted by the backhoe operation. However, that was not the case. The backhoe bucket struck the gauge source rod extension, bending it, and damaging the gauge casing. Due to the damage, the source rod could not be fully shielded and locked in the storage position. CA 5010 Number: 031419 |
| ENS 53880 | 17 February 2019 08:25:00 | The following is a synopsis from information received from the state of California via email. The California radiation protection program was notified by the licensee of a partially depleted, missing Mo-99/Tc-99m generator. The generator was shipped using a commercial carrier on October 31, 2018, from the licensee's California facility to their facility in Arlington Heights, Illinois. Near the beginning of February 2019, the licensee became aware that the generator did not arrive at its destination. The commercial carrier spent the last couple of weeks searching their facilities for the missing generator with no success and has suspended the search and considering the package lost. At the time of shipment, the generator contained 10.35 GBq (280 mCi), greater than 1000 times the 10 CFR 20 Appendix C activity for Mo-99, making it reportable under 10 CFR 20.2201(a)(1)(i). It is housed in a 12.7 kg depleted uranium shield. The package was shipped as a label category Yellow II, with a TI (transportation index) of 0.2. By November 5, 2018, the activity of Mo-99 would have decayed below the 10 CFR 20.2201(a)(1)(i) reporting criteria. By November 23, 2018, the activity of Mo-99 would have decayed below the 10 CFR 20.2201(a)(1)(ii) reporting criteria. 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 53731 | 9 November 2018 18:51:00 | The following was received via fax from the State of California: A wild fire is burning in Butte County where the Feather River Hospital is located. This facility has a small Nuclear Medicine operation with radioactive materials permitted by 10 CFR 35.100, 200, and 300 (Ra-223 only). RHB (California Radiation Health Branch) has not received any notifications from this licensee (nor can the hospital be reached by telephone). Based on news reports, the extent of fire damage to the hospital may be severe. According to the previous inspection reports, the Nuclear Medicine Department should currently possess the following radioactive materials: two Co-57 flood sources (2.6 milliCuries and 2.1 milliCuries as of 11/9/18), and two Cs-137 check sources (96.9 microCuries and 16.7 microCuries as of 11/9/18). The California Department of Health-Radiologic Health Branch (CDPH-RHB) will be following up with the licensee once the area becomes accessible for inspection. This event report is being filed based on the general information that is known currently about the extent of the fire and damage in the town of Paradise, and will be updated as appropriate when more complete information becomes available. CA 5010 Number: 110918
The following retraction was received via e-mail: A CA Department of Public Health-Radiologic Health Branch individual has accessed the fire devastated town of Paradise in northern CA, and has determined that the portion of the Feather River Hospital containing licensed radioactive material was undamaged in the recent wildfire. The radioactive sources were accounted for. Notified the R4DO (Haire) and NMSS (via e-mail). 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 53730 | 9 November 2018 18:20:00 | The following report was received from the State of California via email: On 11/09/18, RSO (Radiation Safety Officer) at Alliance Healthcare Services contacted the California OES (Office of Emergency Services) to report possible loss of control of radioactive materials that are located in one of their mobile PET (Positron Emission Tomography) Coaches stationed at the Feather River Hospital in Paradise, CA, due to a wildfire. A huge wildfire is still burning and spreading in the area and the extent of the damage is unknown, although the town of Paradise is reported to have been evacuated and heavily damaged in the fire. The PET Coach is believed to have contained Cs-137 (210 microCuries), Ba-133 (260 microCuries), and Ge-68 (3 milliCuries). RHB (California Radiation Health Branch) will be following up with the licensee once the area becomes accessible for inspection. This event report is being filed on the information that is known now about the extent of the fire and damage, and will be updated as appropriate when more complete information becomes available. CA 5010 Number: 110918
The event is retracted via e-mail: The CA licensee and Radiologic Health Branch personnel have accessed the fire devastated town of Paradise in northern CA, and have determined that the PET coach and its radioactive material contents were undamaged in the recent wildfire. The radioactive sources were accounted for. Notified the R4DO (Haire) and NMSS (via e-mail). 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 53638 | 3 October 2018 10:57:00 | The following was received via email from the State of California: On October 2, 2018, at approximately 0830 (PDT) the, Radiation Safety Officer (RSO) for Geocon, Inc. contacted (California Radiologic Health Branch) RHB Brea concerning the moisture/density gauge, Troxler, model 3440, serial #33877 (Cs-137, 0.333 gigaBecquerel; Am-241, 1.6 gigaBecquerel) that had been stolen along with a transport vehicle parked in San Ysidro, CA, at approximately 0600 to 0700 (PDT), on Friday morning, September 28, 2018. The authorized user whose truck was stolen did not inform the RSO until 1000 to 1030 (PDT) on Monday, October 1, 2018, of the stolen radioactive gauge. The RSO has contacted local law enforcement in San Diego and is awaiting the completed police report, a copy of which he will send to RHB Brea to be included as part of this report. The RSO will contact local newspapers to attempt to retrieve the stolen radioactive gauge as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. California Notices of Violation will be issued to the licensee for failure to report the loss in a timely manner, and loss of control of the radioactive material. California Report No. 5010-100218 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 53569 | 27 August 2018 18:16:00 | The following information was obtained from the State of California via email: On August 27, 2018, (the licensee's radiation safety officer) RSO contacted the Brea Office of the (California) Radiologic Health Branch to report that a moisture density gauge had been stolen from a gauge operator's truck in Santa Rosa, California. The operator stated that the gauge was stolen sometime between the evening of Saturday, August 25, 2018 and the morning of Sunday, August 26, 2018. The gauge was a CPN model MC-3, S/N M320906734 containing nominally 10 mCurie of Cs-137 and 50 mCurie of Am-241:Be. A report was filed with the Santa Rosa Police Department. California Report Number 5010-082718 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 53513 | 17 July 2018 20:32:00 | The following information was obtained from the state of California via email: On July 16, 2018, the California Office of Emergency Services (OES) contacted RHB (California Radiation Health Branch) to report the recovery of a stolen moisture density gauge. The gauge recovery was reported to OES by the San Jose Police Department. The service truck containing the moisture density gauge was stolen from a private residence sometime over the weekend, and was found by the San Jose Police Department during patrol early on July 16, with the gauge still chained to the bed of the truck. The San Jose Police Department cut the chain and stored the gauge at the station. The moisture density gauge is a CPN Model MC-1DR-P, S/N MD60508312, containing 10 mCi of Cs-137 and 50 mCi of Am-241. The gauge was collected by RHB and put in RHB storage on July 16. RHB will be following up with the licensee concerning adherence to regulatory and license requirements. California report no.: 5010-071618 |
| ENS 53172 | 17 January 2018 19:42:00 | The following information was received from the State of California via E-mail: The California Radiation Control Program (CDPH-RHB) was notified by US CBP (Customs and Border Patrol) on 1/12/18 that a shipping container that had arrived at the Oakland port triggered a radiation detector upon attempting to depart the port. The shipping container contained scrap metal that was later determined to have been rejected at a South Korea port due to radiation detected upon receipt there. The Oakland port CBP personnel detected Cs-137, with a maximum dose rate on the outside of the shipping container of 86 microR/hr (gross). The radiation apparently had not been detected when the container was shipped out of the Oakland port to South Korea. The shipping container was held at the Oakland port by CBP until Tuesday 1/16/18, when it was released to AS Metals with the provision that CDPH-RHB would be present when the container was opened to determine the source of the radiation and subsequent disposition. CDPH-RHB went to a scrap yard site on 1/16/18 and found the source of the radiation was a gauge that was labeled (in handwriting as the original gauge label was missing) as containing 100 mCi of Cs-137. The gauge shutter was locked in the closed position. Dose rates were measured as approximately 40 mR/hr contact and 3 mR/hr at one foot distance, and the radioactive material was confirmed to be Cs-137. The apparent generally licensed gauge, which appeared very old, is being held in secure storage by AS Metals pending an attempt by CDPH-RHB to identify the general licensee who lost control of the gauge. This may be difficult due to the missing original label on the gauge, and because AS Metals has not been able to determine how or where they came into possession of the gauge. California 5010 Number: 011618 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 52969 | 14 September 2017 16:38:00 | The following information was received from the State of California via email: On September 14, 2017, (The RSO) of Southwest Calibration & Training notified the RHB Brea office that United Inspection & Testing, Inc., RML # 4788-33, had a Troxler, 3411B, serial #6644 radioactive gauge run over and damaged. On September 14, 2017, RHB Brea contacted (The RSO) of United Inspection & Testing, Inc. (The RSO of United Inspection & Testing, Inc.) informed our office that the radioactive gauge had been run over by a backhoe on the afternoon of September 13, 2017 at approximately 1400 (PDT), at the intersection of Banana Street and Daurin Street at a construction site in Fontana, CA. As a result of the accident the radioactive gauge had the handle broken off. The RSO was able to return the Cs-137 source to its shielded position, but it could not be locked in the shielded position due to the damage to the gauge. The authorized user of the gauge was also struck by the backhoe and died of his injuries. (The RSO of the United Inspection & Testing, Inc.) retrieved the gauge from the accident site and transported it to Southwest Calibration & Training to be inspected. (The RSO) of Southwest Calibration & Training reported that the Troxler radioactive gauge read 0.9 mR/hr at 1 foot. The gauge was extensively damaged and may not be repairable. California 5010 Number: 091417 |
| ENS 52075 | 8 July 2016 20:53:00 | The following report was received from the California Department of Public Health, Radiation Health Branch (RHB) via email: RHB North was informed by the Radiation Safety Officer of UC (University of California) Davis Medical Center, of a Medical Event that took place on July 7, 2016. The Medical Event involved a SirSphere case. The patient received 29 per cent more than the prescribed dose. The physicians working on the case as well as the referring physician and the patient have been notified. There are no expected negative impacts on the patient. Prescribed dosage: 13.5 mCi. Administered dosage: 17.4 mCi. The apparent reason of the misadministration is that the CNMT (Certified Nuclear Medicine Technologist) miscalculated the dosage required. 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 51365 | 3 September 2015 08:05:00 | The following report was received from the California Department of Public Health Radiologic Health Branch via email: On November 11, 2014, an individual associated with the Orange County Science Education Center obtained two small metal cylinders that had caught his eye that were on a shelf at a metal recycling center (DBW Metals Recycling, Anaheim, CA). The metal recycler's analysis of a cylinder showed 96.76% Zirconium with 2% Nb and some Mo, Cr, Pd, Mn, BI, FE, Ni, & Cd. On August 14, 2015, the member of the public donated one of the Zirconium metal cylinders to the Geology Department at the California Institute of Technology. The location of the second Zirconium metal cylinder is unknown at this time. On August 21, 2015, the California Institute of Technology determined the zirconium metal cylinder was radioactive. The cylindrical metal item measured 3.3 cm D x 5 cm L and weighed 290 gm. The (State of California) Radiation Safety Office subsequently analyzed the item using a Germanium detector and determined it contained approximately 20 gm of U-238 and 8 gm of U-235 (28.6% enrichment). No fission products were detected, and only minor surface contamination was found (removable surface contamination <30 DPM over entire item. GM (Geiger Muller) meter survey results are as follows: 48,000 cpm on contact (mostly beta); 1 mrem/hr on contact; and 0.03 mR/hr at 1 foot (background of 0.02 mR/h). The Radiation Safety office believes the item is a portion of an unirradiated uranium fuel element. The Brea Office (State of California Radiation Health Branch) will follow-up under this 5010 to investigate the current location of the 2nd similar item and to ensure it is properly possessed, and will also investigate from whom the metal recycler received the two SNM (special nuclear material) items (what licensee apparently lost control of these SNM items). LA County also has a 5010 (090215) associated with this event to ensure that CalTech properly possesses the SNM and makes required reports. California 5010 Number: 090315
The following information was provided by the State of California via email: After a discussion with the private party who received the SNM item from the local metal recycling facility, it appears that there is no second similar item. Rather the second item had significantly different visual characteristics. The individual indicated he no longer has the second item. (State of California) will attempt to verify the metal composition of the 2nd item with the metal recycling facility. The private party who received the SNM item from the recycling facility is associated with the Science Education Center of California, not the Orange County Science Education Center. The SNM item is not clad in zirconium or anything else, rather the SNM item is a mixture of zirconium and enriched uranium, with some other metals in significantly smaller amounts, and perhaps additional non-metals. The Caltech RSO indicated that he had not performed as good of an analysis as he would have liked to have done, and emphasized that the values he provided for the U-238 and U-235 weights were both approximate values, leaving the U-235 enrichment better represented as between 21-28 percent. Notified the R4DO (Warnick), ILTAB (English) and NMSS Events Notification group via email.
The following information was provided by the State of California via email: Personnel from Los Alamos National Laboratory (LANL) were contacted to assist in evaluation of the apparent SNM item recovered from a metal recycler. The LANL personnel determined that the item did not contain SNM. Rather the item contained approximately 30-35 grams of unenriched processed uranium. Notified the R4DO (Drake), ILTAB (English), CNSNS (Mexico) and NMSS Events Notification group 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 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 49264 | 11 August 2013 23:26:00 | The following information was obtained from the State of California via email: The California Department of Public Health received the following information from the licensee: Please be advised that during a survey of the location seven missing exit signs were discovered in the exit corridors. Having been stolen prior to site survey we are unable to provide the specific manufacturer or serial number of the stolen units. A police report was filed (case: 13705804) within the jurisdiction of San Diego with the San Diego Police Department. The state of California has also been notified. |
| ENS 44834 | 6 February 2009 13:26:00 | The following information was received from the State of California via email: On February 5, 2009, (the Radiation Safety Officer (RSO) for the) City of Hope/Beckman Research Institute, contacted LA County Radiation Management regarding a misadministration that occurred at approximately 6:00 pm on February 4, 2009. The incident involved HDR treatment of the wrong site. Using HDR, a patient was scheduled for groin sarcoma therapy treatment. The treatment planning comprised of administration of approximately 4000 cGy to the tumor. The dose is to be administered in 10 fractions of 400 cGy/fraction; 2 fractions per day for 5 days. Six catheters to be administered/fraction. Per (the RSO), an error was made in the interpretation of the CT data, and therefore, the wrong distance was calculated. On February 4, 2009, the first day of the treatment, the catheters administered went to the body, past the tumor site, then to the outside of the thigh. (The RSO) stated that there was no dose administered to the tumor. All the dose was administered to the skin of the thigh. The patient had two treatments, and received approximately 800 cGy to the skin of the thigh. "A written report will be submitted by the licensee within 15 days. Based on the current report of 800 rad to the wrong treatment site (skin), this medical event does not meet the criteria for an Abnormal Occurrence (see SA-300, Appendix section 6.3.IV). CA 5010 Number: 020509 A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient. |