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| Entered date | Event description | |
|---|---|---|
| ENS 55183 | 8 April 2021 19:47:00 | The follow was received from the Wisconsin Department of Health Services (Wisconsin DHS) via email: On April 8, 2021, the licensee's (Radiation Safety Officer) RSO reported a missing QSA global model 880 D exposure device containing a 28.9 Ci selenium-75 source. The package was shipped Monday April 5, 2021 via (the common carrier) from Neenah, WI to another Acuren location in Kingsport, TN. The package was shipped `overnight' with the intent to be delivered on Tuesday April 6, 2021. The package was reported delayed by (the common carrier) at Memphis, TN facility during the week. Then package arrived on Thursday April 8, 2021, damaged and without the shipped contents. Package weight information gathered as (the common carrier) handled the packaged indicates that the package contents were separated before final delivery, the exact location is unknown at the time of this report. The licensee is in contact with (the common carrier) and device manufacture QSA to locate the device and source. Wisconsin DHS will monitor efforts to locate the device and coordinated with other jurisdictions as necessary. Event Report No.: WI210002 THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 52565 | 18 February 2017 13:04:00 | The Wisconsin Department of Health was notified by phone at 5:30 PM on February 17, 2017 that the licensee has lost components of a radio-synthesis device containing approximately 70 Ci of Hydrogen-3 and 20 grams of Depleted Uranium in the form of uranium tritide (UT3) discs. More than three years ago, the licensee had packaged the material and placed it into a metal drum while a disposal option was to be determined. The drum was stored in a restricted area near the licensee's incineration facility. A week ago the licensee was preparing to repackage the material in order to transfer it for final disposal. The drum was found to be empty when opened. The licensee has search all facilities used for radioactive material storage and reviewed disposal records; but has been unable to account for the material. At this time the licensee suspects that the material was incorrectly disposed of in either a non-hazardous waste stream or incinerated within the last three years. The department has started an investigation to determine the most likely disposal pathway and the exposure impact. Site visits and updates will (be) perform(ed). Event Report ID No.: WI170003
The licensee has performed a preliminary investigation and concluded that it is unlikely the loss of material was malicious. The licensee has already begun an impact assessment for the potential incineration of material, and Wisconsin DHS has coordinated with the licensee on what actions need to take place going forward. Inspectors will be performing an on-site inspection to further gather information. Notified R3DO (Jeffers) 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 47363 | 21 October 2011 11:13:00 | The following was received from the state via fax: The on-duty State Response Coordinator (SRC) for the Wisconsin Department of Health Services (DHS) received a phone call at approximately 3:30 am that a moisture density gauge had been struck by a motor vehicle. The incident occurred at a road construction site near 1221 Northport Drive, Madison, WI. The gauge was in use with the operator in contact with it, when a car veered out of traffic into the construction lane. The operator was forced to jump out of the path of the vehicle, leaving the gauge. The vehicle struck the gauge, shattering the housing. The source rod with the Cesium-137 source detached from the housing. The Americium/Beryllium source remained within the housing. The SRC and licensee's RSO responded to the scene to supervise source recovery. The Cesium source was leak tested in-situ and determined to be intact. Surveys were performed in the affected area, with no contamination detected. A portion of the housing designed to hold the retracted Cesium source rod was found partially intact. The Cesium source was placed within the cavity and securely taped. The housing assembly was placed in the transport container for transport back to a licensed service provider for assistance with disposal. The driver who struck the gauge has yet to be located by the police. The licensee will be submitting a 30 day written report concerning this event. Event Report ID Number: WI110017 |
| ENS 47254 | 9 September 2011 16:26:00 | Wisconsin Department of Health Services (DHS) received notification by phone call from the licensee on September 8, 2011 about a medical event involving I-125 permanent prostate seed implants. During a standard review conducted September 7, 2011 of a post seed implant report the Authorized Medical Physicist determined that the dose delivered differed from the prescribed dose by 20% or more. Specifically it was found that only 76% (110 Gy) of the prescribed dose was delivered to 90% of the CTV for an implant completed on July 22, 2011. The licensee had established the dose based criteria that by post-operation CT, prostate D90 values are < 80% or >130% for classifying medical events. The licensee has notified the Authorized User, referring physician and will notify the patient during a scheduled examine the week of September 11, 2011. There is no expected immediate harm to the patient and the Authorized User and referring physician will discuss with the patient to determine if supplemental radiation (implant or external beam) will be done. DHS conducted an investigating of this medical event on September 9, 2011 by sending a special inspection team. The preliminarily conclusion after reviewing the licensee's procedures and discussion with the Authorized User and Authorized Medical Physicist is that the under dose was directly caused by edema of the prostate, i.e. post implant procedure swelling. Wisconsin Event Number: WI110014 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 46949 | 10 June 2011 17:17:00 | The following information was provided by the State via facsimile: On June 10, 2011, the licensee's Radiation Safety Officer reported the identification of two medical events involving a HDR (High Dose Rate) Partial Breast Treatment using SAVI applicators. For both patients, treatment was delivered twice a day for five consecutive days in May 2011. It was determined later that the distance as determine by use of a Varian VariSource check ruler was incorrect. The check wire was blocked approximately 4.5 cm from the end of the lumen. The preliminary results from re-planning indicates that in both cases the most distal half of the applicator was under dosed at least 20 percent and the proximal half received approximately 200 percent more dose than what was prescribed. The patients will be notified by the referring physician. The licensee has suspended SAVI treatments until the root cause can be identified. Further updates will be made through NMED. The State of Wisconsin Department of Health Services will conduct a special inspection at the licensee's location. Wisconsin Report No: WI 110006 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 46836 | 10 May 2011 14:28:00 | The following information was received via facsimile: On May 5, 2011, the Licensee's Radiation Safety Officer reported via phone message that the shutter mechanism on an installed fix gauge failed to close. The gauge is an Ohmart model SHRM-3 with a 500 mCi Cesium-137 source. This malfunction was discovered during routine maintenance testing. No persons were exposed to radiation as a result of the malfunction. The Licensee has restricted access to the area and has scheduled repairs to be done by the manufacturer. DHS plans to perform a follow up inspection within the next 6 months. Wisconsin Event Report # WI-110004. |
| ENS 46910 | 1 June 2011 17:03:00 | The following information was received by fax: On May 31, 2011 the Department (Wisconsin Radiation Protection Section) received notification via email from the licensee's RSO that the licensee had reported a portable nuclear gauge stolen from their storage location in Lodi, WI (Columbia County). The Department called the licensee for additional information on June 1, 2011. The gauge was a Seaman model R-50 roofing gauge containing a maximum of 40 mCi of Americium-241:Be. In the call the licensee stated that on May 1, 2011 they had discovered their storage location had been broken into, their security barriers to the gauge had been defeated, and their portable nuclear gauge had been removed from the premises. Law enforcement had been notified on May 1, 2011 and investigated the theft. The gauge was recovered on May 28, 2011 in Madison, WI and had already been returned to the licensee at the time this conversation took place. The Department performed a reactive inspection on June 1, 2011, and confirmed that the gauge was recovered in good condition and placed in secure storage. The Department is waiting for additional information regarding this theft from both the Madison Police Department and the Columbia County Sheriff's Office. |
| ENS 45984 | 7 June 2010 15:07:00 | The following information was received from the State via facsimile: On June 7, 2010 a representative of West Short Pipe Line Company notified Wisconsin Radiation Protection Section of a stuck shutter. This was discovered during a routine six-month shutter check. The device is a Ronan SA1 containing 500 mCi of Cs-137. The general licensee performed a radiation survey and radiation levels were normal. Licensee also performed routine leak test, results are pending. Normal operation for the device is with the shutter open. The device is located in a restricted area that is fenced off. The nearest personnel access point is 600 ft away from the device. The licensee will contact the manufacturer for service. The Radiation Protection Section will continue to monitor the situation and will request information concerning the cause of the stuck shutter. Wisconsin Report No: WI100007 |