Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 51420 | 23 September 2015 15:59:00 | The following report was received from the Commonwealth of Virginia via email: On September 22nd at 1749 EDT. (The Commonwealth of Virginia Department of Health) received a call from the Virginia Emergency Operations Center, stating that the RSO (Radiation Safety Officer) from WRA (the licensee, Whitman, Requardt & Associates) was calling to report a missing gauge. (Virginia Department of Health) contacted the (licensee's) RSO who then informed (Virginia Department of Health) that one of their gauges was lost in shipment. (Virginia Department of Health) requested the RSO send an email detailing the event. On August 12th, WRA shipped a Troxler 3411B gauge (S/N: 5374), containing 9 mCi of Cs-137 and 44 mCi of Am-241, to Northeast Technical Services (NETS) for calibration. On September 1st, WRA was contacted by NETS that the calibration was completed and the gauge was being shipped back. On September 15th, WRA contacted NETS to say they had not received the gauge. On September 22nd, NETS contacted WRA to inform them that (the common shipper) was unable to locate the gauge and considered it to be unlikely recovered. NETS supplied (Virginia Department of Health) with the tracking number which indicated the gauge was picked up on September 1st, sent to the York, PA facility, then the Greencastle, PA facility. The results then say on September 2nd, the gauge was sent to the Winchester, VA facility and unloaded. On September 23rd, (Virginia Department of Health) contacted the (common shipper's) facility in Winchester, VA and spoke with the site manager. The manager stated that the gauge was not on the truck when it arrived at this facility on September 2nd, and that an 'All Points Bulletin' (APB) was submitted. (Virginia Department of Health) then contacted the Greencastle, PA facility and spoke to the OS&D/Customer Service Representative regarding the loss of this gauge. (Virginia Department of Health) discussed what actions had been taken to locate the gauge and supplied them with an email containing pictures of the transportation case and the gauge. At 1458 EDT on September 23rd, an APB from the Greencastle, PA facility was created and submitted to (the common shipper's) staff. They have checked the truck that was used on September 1st, and the gauge was not found in the truck. They are speaking with the driver of this truck and showing him pictures of the gauge and case. Currently, (the common shipper) is looking through the Greencastle, PA facility and contacting the Pittsburgh, PA facility regarding the gauge. The Greencastle OS&D/Customer Service Representative stated they will provide daily updates regarding the search. The Pennsylvania RMP (Radioactive Materials Program) has been notified and made aware of this event. The Virginia RMP will provide updates as they become available. There is no public health or safety impact at this time. Commonwealth of Virginia Event Report ID No.: VA-15-11
On September 24th, it was discovered that the portable gauge was delivered to another Virginia licensee who also had sent a portable gauge to NETS for service. The gauge was returned to (common carrier) who is shipping it back to NETS to inspect. The gauge will then be sent to WRA. The investigation at (Common Carrier) is on-going with regards to how it was delivered to the wrong licensee. Notified R1DO (Welling). Notified ILTAB (Johnson) and NMSS_Events_Notification 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 51466 | 13 October 2015 11:03:00 | A prostate brachytherapy implant using I-125 performed at Fauquier Hospital on 6/25/2015, resulted in a dose distribution having a D90 percent of 97Gy as measured on post implant CT done on 8/12/15. The written directive prescribed a D90 percent of 145Gy. The implanted dose of 97 Gy is 66.9 percent of the intended 145 Gy. The patient was notified and is being monitored to determine if additional treatment is required. The final determination was not made until 10/8/15 and Fauquier notified VRMP (Virginia Radioactive Materials Program) by email on 10/8/15. A telephone conversation was held on 10/13/15 regarding the 15 day written report. VRMP will review the report and determine whether an inspection will be performed. Virginia Report ID: VA-15-14 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 50850 | 25 February 2015 16:49:00 | The following information was received from the Commonwealth of Virginia via email: While performing testing at a temporary jobsite in Alexandria (VA), the portable moisture/density gauge (CPN MC1DR, Serial # MD40907569) was run over by a bulldozer. The sources were in the shielded position and the shielding integrity was not damaged. A survey of the gauge was performed by the licensee and readings observed were between 1 and 2 mrem/hr on contact. The gauge was packaged and returned to the office where a wipe test was taken and the analysis was performed by the manufacturer/distributor with results showing no contamination. The gauge is being returned to the manufacturer/distributor. The VRMP (Virginia Radioactive Materials Program) is reviewing the licensee's report and corrective actions. The gauge contains two (2) sources; 50 mCi Am-241/Be and 10 mCi Cs-137. Virginia Event Report ID # VA-15-03 |
| ENS 50679 | 15 December 2014 14:41:00 | The following report was received from the Commonwealth of Virginia via email: On Saturday, December 13th (2014), a CPN MCIDR moisture/density gauge was run over at a temporary jobsite in Leesburg, Virginia (Battlefield Parkway and Sycolin Road). The licensee's authorized user was performing a test and walked about 20 feet away from the gauge. The general contractor's bulldozer operator did not see the gauge because the bulldozer blade was raised, which obstructed his view when driving the bulldozer up the slope. The gauge was completely destroyed with the source in the transmission position. The authorized user contacted the construction testing services manager who then contacted the radiation safety officer. Both individuals arrived on scene and were able to retract the source into the shielded position using a pair of pliers. A radiation survey was performed at 1 meter indicating a reading of 0.4 mrem/hr. The gauge was then placed into the transportation case and returned to storage where a wipe test was performed. The wipe test has been sent to a licensed service provider for analysis and if no contamination is present, the gauge will be returned (pending final resolution). The licensee submitted an incident report, which is under review by the (Virginia) Radioactive Materials Program. The incident and suggested corrective actions will also be re-examined during the next inspection. Event Report ID No.: VA-14-25 |
| ENS 50638 | 25 November 2014 15:31:00 | The following was received via email: A patient arrived for a rest/stress imaging procedure on 11/24/14. The rest dose was written to be 8 mCi Tc-99m, and the stress dose was written to be 24 mCi Tc-99m. The patient received the rest dose as written and the scan was performed. The patient was then to receive the 24 mCi stress dose, but instead received a 5 mCi stress dose (same drug, but only 21% of the intended activity) that was intended as the rest dose for another patient. Once the error was discovered, the patient was informed of the error and sent home with the intention of rescheduling the procedure at a later date. The licensee will submit the 15 day report to VRMP (Virginia Radioactive Materials Program) at which time the corrective actions will be reviewed and verified during their next inspection. Virginia Incident #: VA-14-23 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.
This report is being retracted, because it does not meet 10CFR35.3045 criteria. Notified R1DO (Noggle) and NMSS Events Notification via email. |
| ENS 50433 | 8 September 2014 16:37:00 | The following information was received via email: A Y-90 TheraSphere liver therapy procedure resulted in delivered doses to the liver and lungs that differed from the prescribed dose. The revised Lung Shunt Fraction (LSF) value was used to recalculate the actual radiation dose to lungs and LT liver lobe. The results are that the lungs received 34.5 Gy (instead of 3.7 Gy) and the LT liver lobe received 67 Gy (instead of 117 Gy). Also, it is calculated that the LT liver lobe was implanted with a Y-90 activity dose of 0.82 GBq (22.2 mCi) while the lungs received a Y-90 activity dose of 0.69 GBq (18.64 mCi) since the patient was implanted with 1.50 GBq (40.53 mCi) of Y-90. The patient's family was notified. UVA staff are meeting to analyze the root cause of the event. RMP (Virginia Radioactive Materials Program) staff will review UVA's findings and determine what further actions are necessary. Virginia Event Report ID No.: VA-2014-16 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 49755 | 22 January 2014 15:58:00 | The following information was received from the Commonwealth of Virginia by email: Event description: On January 20th the Radioactive Materials Program (RMP) received a call from Simms Metal Recycling in Petersburg, that a load of scrap metal being received set off the radiation monitoring detector. A DOT exemption form was completed and the scrap load returned C&C Cullet, Inc. in Ashland, where it originated from. They dumped the scrap load and found the item using a survey meter, which indicated 87 microrem/hr. Pictures were sent to the RMP and upon review concluded that the device was a liquid scintillation analyzer. The RMP contacted the manufacturer, Perkin Elmer, and began a conversation regarding the analyzer. The analyzer is secured at C&C Cullet, Inc. as an investigation is ongoing to determine the serial number and owner of the analyzer. It is believed to contain an 18 mCi source of either Ba-133 or Ni-63. There are no health or safety impacts as the source is secured in the analyzer. Virginia Event: VA-14-01
The following was received from the Commonwealth of Virginia via email: On Tuesday January 28th, the source was removed by the manufacturer for disposal. The company will try to ascertain a serial number from the source to determine the General Licensee whom the device was provided to. Notified R1DO (Burritt) and FSME Event Resource via email.
The following was received from the Commonwealth of Virginia via email: On Tuesday January 28th, the source was removed by the manufacturer for disposal. The source serial number (432228) was ascertained by the manufacturer which allowed for tracking to Virginia State University (VSU) as the recipient of the device. The source activity was incorrectly stated at 18 mCi in the initial report, the actual activity is 18 microcuries (uCi) of Ba-133. An investigation was performed by VSU in regards to when and how the device was disposed of. VSU stated the device was given to the Department of General Services (DGS) as surplus equipment in 2012 and was then subsequently sold as scrap metal. The RMP will contact DGS and discuss the proper disposal methods of radioactive material. Notified R1DO (Welling) and FSME Event Resource 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 49577 | 25 November 2013 13:53:00 | The following was received from the Commonwealth of Virginia via email: An individual (non-radiation worker) performing a pipe inspection on a Norfolk Dredging barge received a dose from a Vega America Model SR-2 fixed gauge source while crawling through the pipe. Initial dose estimates to the individual are that he received 146 mrem. Norfolk Dredging sent an e-mail to the Virginia Radioactive Materials Program on Saturday the 23rd and discussions were held on Monday the 25th. Norfolk Dredging is working on an event report to submit, and the RMP will perform an investigation with the licensee. Virginia is providing the event report as the barge is home based in Virginia and is registered as a General License. The barge was operating at a temporary jobsite in New York. The New York State Program and NRC Region 1 was notified of the event. Virginia Report Number: VA-13-10 |
| ENS 49670 | 20 December 2013 14:57:00 | The following information was submitted by the Commonwealth of Virginia via email: On November 25th, the Virginia Department of Health Radiological Duty Officer received a call from the General Electric (GE) service provider representative that a PET/CT machine at Rockingham Memorial failed. The representative responded and found that the source holder was open exposing the source. The representative troubleshot the holder and found that the gripper was not functioning properly. The source was removed and the coach was sent back to Wisconsin for service at GE's facility. The Virginia Radioactive Materials Program has been working with GE regarding the cause for the failure. At this time, GE is reviewing service reports to evaluate whether this is an isolated incident. The unit was repaired and returned to Rockingham Memorial. Virginia Event Report ID: VA-13-12 |
| ENS 49669 | 20 December 2013 14:57:00 | The following information was submitted by the Commonwealth of Virginia via email: On October 9th, the PET/CT unit reported a problem with the pin source holder indicating the holder was open. The licensee closed the scan room door and contacted General Electric (GE) service provider to provide emergency service. On October 10th, a GE representative investigated the unit and found the source holder cable was broken. A new cable was ordered and replaced on October 11th. The source was replaced, and the unit was tested and placed back in service. The Virginia Radioactive Materials Program has been working with GE regarding the cause for the failure. At this time, GE is reviewing service reports to evaluate whether this is an isolated incident. Virginia Event Report ID: VA-13-11 |
| ENS 49255 | 9 August 2013 10:40:00 | The following report was received via fax: An employee of GET (Geotechnical Environmental Testing) went home with a Troxler 3430 portable gauge in the bed of his work truck. The employee mishandled charcoal embers after cooking dinner on a grill, which caused the bed of the truck to start on fire. A neighbor noticed the fire and called 911 . When the fire trucks arrived, the employee discovered it was his truck on fire and talked with the VA Beach fire personnel. He stated that a portable gauge containing radioactive material was in the bed of the truck. The VA Beach hazmat team was contacted and arrived on scene. The fire was extinguished and surveys were performed by the hazmat team indicating 1 mR/hr, a normal. reading for a secured gauge. The GET employee began to contact management regarding the situation. The VA Beach GET RSO was on vacation so the North Carolina GET RSO responded and also performed surveys when he arrived. Survey readings indicated the sources were in their shielded position. The RSO was able to package the damaged gauge into another transportation case and return it to the VA Beach office. GET has contacted Troxler and has sent a swab for leak test analysis. The gauge will be returned to Troxler after verification of the sources not leaking. There is no threat to public health or safety from this event. The Virginia RMP (Radiological Materials Program) will be performing an investigation and inspection. Media attention: Yes, two local news stations ran a story this morning on the incident. VA Report ID: VA-13-06 |
| ENS 49242 | 6 August 2013 11:04:00 | The following information was received from the Commonwealth of Virginia via facsimile: On August 5, 2013, an Authorized User (AU) was conducting density testing for asphalt placement for a parking lot using a CPN MC-1-DR. The AU had just performed a density test and set the gauge on the adjacent asphalt approximately 5 feet from the joint for the hot asphalt. The AU stepped to the joint to tell the asphalt roller operator that density values were low. As the AU stepped back, he heard a tandem axle truck backing up. As he stepped to pick up the gauge, he realized the rear tandem axle tire was about to strike the gauge. By the time he pulled the gauge handle, the rear tire rolled over the gauge. He pulled the gauge away from between the rear tandem axle tire and the center axle tire. He then set the gauge down. A survey of the damage gauge was performed by the RSO and the sources were verified to be in their shielded position. The gauge was returned to the shop for shipment to CPN. There was no adverse effect to public health and safety from this event. VA Event Report ID Number: VA-13-05 |
| ENS 49243 | 6 August 2013 11:04:00 | The following information was received from the Commonwealth of Virginia via facsimile: On Thursday, August 1st, a shipment was being received by B&W from QSA Global, Inc. During the receipt survey, readings indicated 5.4 mrem/hr in the cab of the truck. The sources were received and leak tests were performed indicating no leakage. B&W contacted the Virginia Radioactive Materials Program (RMP) who then contacted the Massachusetts RMP. B&W also reported the event to the NRC Operations Center on August 1st. A discussion to retract the event as this shipment occurred under the Virginia license was held on Friday 8/2 but the final determination was not made until Monday 8/5 to retract the NRC report. A decision was agreed upon for the Virginia RMP to report the event to the NRC Ops Center. The Massachusetts RMP contacted QSA Global, Inc. A preliminary investigation indicates that a QSA Global, Inc. employee did not perform the proper survey before the sources were shipped. The (contract carrier) consultant was contacted and made aware of this event. The (contract carrier) has begun an investigation into the event. There was no adverse effect to public health and safety from this event. Media attention: Yes VA Event Report ID Number: VA-13-04
The following retraction was submitted by the Commonwealth of Virginia via email: On August 1st, a shipment from QSA Global using (a common carrier) was received at Babcock & Wilcox. During the receipt, a survey indicated readings >2 mrem/hr in the cab. An investigation was performed by the Massachusetts Radioactive Materials Program, during which they spoke with QSA and (the carrier). Based upon this investigation, it has been determined that the shipment was not an exclusive shipment and all DOT regulations were met. This event is being retracted based upon the investigation results. Notified R1DO (Joustra), NMSS EO (Bjorkman), Fuels Group (via email) and FSME Events Resource (via email). |
| ENS 51957 | 25 May 2016 15:55:00 | The following information was received from the Commonwealth of Virginia by email: Event description: On May 23, 2016 a Virginia Radioactive Material Program (VRMP) inspector performed a routine unannounced inspection of Superior Paving Corporation. The inspector discovered that on April 20, 2012, two Troxler Model 4640-B Portable Gauges (serial numbers 1384 and 845) containing 8 mCi of Cs-137 each, were damaged by fire. The fire burnt the storage box which contained the two gauges. The transport containers and plastics on the gauges were melted. However, according to the Radiation Safety Officer statement, the integrities of the sources were intact. On May 10, 2012 the two gauges were transported by the licensee to North East Technical Services (NETS) for disposal. A transfer record was available for review. The licensee will provide the agency (VRMP) a detailed report for review. There was no public health exposure or environmental release from this event. Virginia Event Report: VA-16-005 |
| ENS 47174 | 19 August 2011 15:42:00 | The following information was obtained from the State of Virginia via fax: On August 7, 2011, the licensee's RSO received notification of an incident. A patient was treated for bronchial/trachea carcinoma using temporary brachytherapy employing a HDR delivery system. Subsequent to treatment, it was realized that dwell positions were misrepresented on the approved treatment plan. Reconstruction of the applicator position led to the conclusion that dose to organs or tissue other than the treatment site received more than 50 Rem and more than 50% of the expected dose. Licensee notified Virginia Department of Health on August 17, 2011. Referring physician was notified on August 17, 2011. Physician is meeting with patient on August 19, 2011. Licensee indicated organs at risk and health effects to patient are under development. Virginia Report ID: VA-11-08
The following update was received from the State of Virginia via email: On August 31st the licensee report was received. The report indicated the cause was human error during data loading into the delivery system. An error was received and in order to clear the error the source position spacing was changed. The report detailed the licensee's dose calculations to the surrounding organs and tissue. The estimated maximum amount received by the larynx was 2.332 Gy which was 581% over the expected dose of 0.42 Gy. A subsequent licensee response on September 1st detailed the dose to the lungs. The dose to the lungs did not differ between expected and delivered. The patient has had two follow up visits and shows no adverse effects. A positive tumor effect was observed by the referring physician. Notified R1DO (DiPaolo) and FSME (Hsueh). 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 42401 | 9 March 2006 15:15:00 | The State provided the following information via email: On Friday, March 3, 2006 at 6:45 am a vial containing 890 mCi of Tc-99m Cardiolite ruptured while in a heating block. Two employees entered the area immediately, visually confirming the rupture through a window in the heating box and with a survey meter. The employees unplugged the heating box and shut the door. They returned 15 minutes later after the heating box and vial had cooled. The heating box was cleaned and waste was placed in a lead shielded container for decay. No individuals were contaminated. Wipes were taken each day until 3/07/06 when contamination levels were reduced to 2-3 times background. This event will be followed up by DHFS on the next inspection. Media attention: None Wisconsin Event Report ID No. 35 |
| ENS 41696 | 13 May 2005 10:29:00 | The State provided the following information via facsimile: The RSO contacted the DHFS, Radiation Protection Section on May 12, 2005 to report a damaged shutter on a fixed gauge at their facility. The gauge is a Berthold Model LB7400D containing 350 mCi of Cs-137, SN DW954A. The licensee discovered the problem when they were preparing to do some maintenance work on the gauge. The detector was giving erroneous readings. The licensee observed higher radiation levels (12 Mr/hr on contact with the source holder) with the shutter in the 'closed' position than the 'open' position, (6 Mr/hr on contact with the source holder.) The licensee assumed that the shutter had failed. Berthold has been contacted and will provide a service visit on May 17 or 18. The gauge is in the same configuration as in operations. Access is restricted by a fence around the area, including a lock with keypad entry. The inspector who recently visited the licensee confirms that access is restricted. The gauge is on Line 5 at the Superior Terminal, Enbridge Pipeline. The licensee will send the required report following the service visit.
Wisconsin Radiation Protection Section would like to retract event number EN41696, Enbridge Pipeline, LLC. After reviewing the in-question housing, Berthold states that there is nothing wrong with the source housing. It appears to be an error on the licensee determining if the shutter was open or closed. Notified NMSS (M. Burgess) and R3DO (P. Louden) |
| ENS 41620 | 21 April 2005 15:05:00 | The following information was provided by the State via facsimile: On Wednesday, April 19, 2005 while loading a Pd-103 seed into the Mick applicator, the applicator jammed. When the operating room technician attempted to get the seed loose, the seed broke. This spread a small amount of radioactive contamination onto the table, which was cleaned up by the RSO and dosimetrist. The applicator was found to be contaminated. It was put in a plastic bag, placed behind lead shielding and locked in the Nuclear Medicine hot lab. The activity of the Pd-103 seed was 1.578 mCi (millicuries). According to the licensee, there was no overexposure, contamination, or intake of radiation by anyone present in the operating room. The patient was treated, as per the prescription after borrowing a Mick applicator from another hospital. The licensee notified DHFS on April 20, 2005. The licensee also contacted their consultant and their MIC applicator distributor regarding the event. A replacement applicator is being sent and the contaminated applicator will be allowed to decay before servicing. The licensee has developed, an action plan for this event based on possible causes: 1. Look into the possibility of having the MIC applicator on a preventative maintenance schedule. 2. Change the sterilization procedure such that central supply does the cleaning of the applicator, not the OR technician. 3. Set up a 'core' group of OR technicians who are involved in their procedure, and document their education. A voluntary MedWatch form was sent in to the FDA. Wisconsin Radiation Protection Section plans on investigating this event. State Event Report ID # 24. |