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| Entered date | Event description | |
|---|---|---|
| ENS 56792 | 13 October 2023 12:06:00 | The following information was provided by the Maryland Department of the Environment Radiological Health Program (MDE/RHP) via email: On October 11, 2023 at 1558 EDT, the Maryland Department of the Environment Radiological Health Program was contacted via phone from the Radiation Safety Officer (RSO) of Testing Technologies, Inc. (TTI), and reported that a source disconnect had occurred on 10/10/2023, at about 1000 EDT while working at College Park, Maryland. TTI has an active authorization and reciprocity recognition to practice industrial radiography in Maryland with US NRC license (number 45-25007-01). TTI has a Virginia (Maryland reciprocity license number 94-031-01) and an NRC license; and they are also authorized to retrieve sources. The radiography device was QSA Global, Sentinel 880, device serial number D6011, which contains 50 Ci of Ir-192. The incident occurred when the TTI radiographer was taking images of a pipe in the well and while cranking back at finishing, the source became stuck at about the half-way position. The radiographer was aware that the source disconnection from the tube had happened and the source was lodged in a 14 feet deep hole. The radiographer later retrieved the source. The radiographer reported the incident to the TTI RSO. The RSO reported that there was no exposure to the public. A dose of 40 mrem was received by the radiographer. MDE/RHP will finalize a reactive investigation. |
| ENS 56806 | 20 October 2023 12:49:00 | The following information was provided by the Maryland Department of the Environment (MDE) via email: At 1520 EDT on August 31, 2023 a troxler gauge containing a 9 mCi Cs-137 source and a 44 mCi Am-241 source was struck by a dump truck at a construction site in Clarksburg, Maryland. The gauge was licensed to, and being operated by, ECS Mid-Atlantic, LLC (MD-21-037-01). The display and source guide handle was damaged but the part of the gauge containing the sources was not. The sources' shielding was not damaged. The source rod was successfully retracted by the Radiation Safety Officer (RSO) and several surveys of the area were performed by the RSO confirming only background radiation levels. At the time, the gauge was returned to the licensee's storage facility and tested for source leakage. MDE was notified and requested that the gauge be tested for leakage and the RSO's dosimetry be read. Leak tests later showed no leakage of radioactive material and the RSO's dosimetry read a minimal dose. At this time, the gauge has been repaired by the manufacturer and returned to service. |
| ENS 56591 | 26 June 2023 13:25:00 | The following information was provided by the Maryland Department of the Environment via telephone: On 6/26/23 at 1116 EDT, the licensee was working at Howard University in Washington, D.C. when a Niton XLp 300 (lead base paint analyzer containing a maximum of 50 mCi of Cd-109) was stolen out of a vehicle. The Howard University and Washington, D.C. police were notified of the vehicle break in. 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 56470 | 14 April 2023 18:29:00 | The following information was provided by the Maryland Department of the Environment (MDE) via email: On 04/14/2023 at 0951 (EDT), the MDE discovered an unsigned, undated report from the University of Maryland Medical Center, Baltimore, MD, that a medical misadministration had occurred on 02/28/2023. (After) contacting a health physicist and the Radiation Safety Officer (RSO) (at the University of Maryland), they confirmed that the event had actually occurred. A dose of 104.73 mCi of Ludotadipep (Lu-177) was being administered to a patient as part of a phase 1 clinical trial to treat metastasis. During the procedure, catheter infiltration (catheter movement) occurred resulting in a significant portion of the dose remaining in the upper left arm. The study sponsor was informed. Subsequent gamma scans showed that within 24 to 48 hours the dose had migrated to the intended treatment site. MDE is following up with the RSO and medical staff to confirm that the actual dose delivered to the treatment site was within 20 percent of the dose prescribed in the written directive. The University of Maryland staff has determined that an unintended dose estimated at 157 Rem had been delivered to the upper arm tissue. As of 04/14/2023, no ill effects have been observed, and the patient has been scheduled to resume subsequent treatment. This event is being reported under 10CFR 35.3045 (a)(1)(ii) B `. a dose that exceeds 50 Rem to an organ or tissue from administration of a radioactive drug containing byproduct material by the wrong route of administration'.
The following information was provided by the Maryland Department of the Environment (MDE) via email: (The MDE) has been informed that the NRC medical team has reviewed this event notification and determined that this is not a reportable event under 10 CFR 35.3045. The medical team determined that, although not explicitly named as such, this event notification describes an extravasation. Extravasations are currently exempted from medical event reporting due to Commission policy, however this may change in the near future. Please note that the NRC does not consider extravasations as 'wrong route of administration,' as stated in 10 CFR 35.3045(a)(1)(ii)(B). On May 19, 2023, the patient's physician at (University of Maryland Baltimore) (UMB) confirmed to (the MDE) that this event can be considered as an extravasation. Notified R1DO (Jackson), NMSS (Rivera), and NMSS Events Notification via email. 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 56268 | 9 December 2022 15:53:00 | The following event was received from the state of Maryland via email: On December 8, 2022 a UMD (University of Maryland) campus-wide power outage occurred and the panoramic irradiator source rack failed to automatically return to the fully shielded position. Operators responded and while remaining outside of the shielded vault, they manually lowered the sources to the fully shielded position. Shielding remained intact. Radiation levels in the irradiator area are at normal levels and the sources are secured in a safe and legal manner. The irradiator will not be operated until an investigation has been conducted and determined that the irradiator can be operated as normal. There was no risk for exposure to staff or members of the public. Operators are unloading the source rack and investigating to ensure that the sources will automatically return to the fully shielded position when power is lost. |
| ENS 56249 | 30 November 2022 18:11:00 | The following information was received from the state of Maryland via email: A Maryland Department of the Environment (MDE) radioactive materials inspector was performing a close-out survey in support of license termination. The facility is no longer operating with radioactive materials (RAM) and some essential staff are gone. The inspector found that three Cf-252 sources for installed gauges had been changed out. The licensee was unable to provide records for the disposal of the old sources, which are no longer present, the new sources were accounted for. The sources of concern are: Cf-252; serial # FTC-CF-Z3384; 5.2 Ci Assay date missing. Installed October 2009. Decay corrected activity to November 2022 = about 165mCi or less Cf-252; serial # FTC-CF-Z3383; 5.2 Ci Assay date missing. Installed October 2009. Decay corrected activity to November 2022 = about 165mCi or less Cf-252; serial # FTC-CF-Z3930: 5.2 Ci Assay date missing. Installed October 2009. Decay corrected activity to November 2022 = about 165mCi or less Total Activity: about 495 mCi or less The licensee is continuing the search for records of these sources. It does not appear to the licensee that an exposure could result to persons in unrestricted areas. The licensee believes that the sources were sent to ThermoFisher Scientific and is attempting to confirm. MDE is providing this precautionary notification pursuant to 10 CFR 2201(a)(1) using the best available information on the radioactive sources.
Updated activities for sources of concern and results of search for the sources are as follows: Cf-252; serial # FTC-CF-Z3384; 10.8 mCi on 25 September 2010. Decay corrected activity November 2022 = 445 microcuries Cf-252; serial # FTC-CF-Z3383; 10.8 mCi on 25 September 2010. Decay corrected activity November 2022 = 445 microcuries Cf-252; serial # FTC-CF-Z3930: 10.8 mCi on 25 September 2010. Decay corrected activity November 2022 = 445 microcuries Total Estimated Current Activity: 1.335 mCi The licensee is continuing to search for disposal records for these sources or the sources themselves. It does not appear to the licensee that an exposure could result to persons in unrestricted areas. The supplier, ThermoFisher Scientific, has confirmed that they do not have the sources. The waste disposer, RAM Services, is attempting to confirm their possession or the possibility that the sources remain in the gauge housing. MDE is providing this precautionary notification pursuant to 10 CFR 2201(a)(1) using the best available information at the time. This report principally revises source activities using information from the supplier and continuing efforts of the supplier and waste disposer. Notified R1DO (Cahill), NMSS Events Notification, and ILTAB via email.
An MDE radioactive materials inspector was performing a close-out survey in support of license termination. The facility is no longer operating with RAM and some essential staff are gone. All RAM sources had been reportedly removed and disposed. The inspector found that three Cf-252 sources from three installed process gauges had been replenished in the past. Each gauge contained one Cf-252 and one Cs-137 source; the Cs-137 are not normally replaced because of their long half-life. The licensee was unable to provide records for the disposal of the three old Cf-252 sources which were no longer present; the three new Cf-252 sources were accounted for. The sources of concern are: Cf-252; serial # FTC-CF-Z3384; 10.8 mCi on 25 September 2010. Decay corrected activity Nov 2022 = 445 microCuries Cf-252; serial # FTC-CF-Z3383; 10.8 mCi on 25 September 2010. Decay corrected activity Nov 2022 = 445 microCuries Cf-252; serial # FTC-CF-Z3930: 10.8 mCi on 25 September 2010. Decay corrected activity Nov 2022 = 445 microCuries Total Estimated Current Activity: 1.335 mCi The licensee and vendors continued to search for disposal records for these sources or the sources themselves. At no time did it appear to the licensee that an exposure could result to persons in unrestricted areas. A precautionary Event Report was made on 11/30/22 and updated on 12/01/22. On 12/02/2022 the waste disposer, RAM Services, confirmed by serial number that they have possession of the three old and three new Cf-252 sources in a neutron-shielded container in a secure, licensed facility in Wisconsin. The sources had been removed and misidentified when the gauges were de-sourced for license termination. The intended sources to be removed were three Cs-137 sources; these sources are presently unaccounted for and believed to be remaining in the gauges. The sources are: Cs-137; serial # CZ-2586; 30mCi on 10/01/2010. Decay corrected activity 12/01/2022 = 22.68 mCi Cs-137; serial # 0950/08; 30mCi on 10/01/2010. Decay corrected activity 12/01/2022 = 22.68 mCi Cs-137; serial # 0949/08; 30mCi on 10/01/2010. Decayed corrected activity 12/01/2022 = 22.68 mCi Total Estimated Current Activity: 68.04 mCi It appears that the disposer had removed sources without actually verifying the serial numbers, isotopes, and activities of the sources, contrary to the records that were submitted. The source slots in the gauges are not visible and sources are moved remotely. The disposer will investigate and confirm or locate the three Cs-137 sources 12/05-12/09/2022. This is an update to the precautionary notification made 11/30/2022 pursuant to 10CFR 2201(a)(1) using the best available information currently available. Notified R1DO (Cahill), NMSS Events Notification, 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 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 |