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| Entered date | Event description | |
|---|---|---|
| ENS 52393 | 23 November 2016 11:21:00 | The following report was received via e-mail: On 10/28/2016, GA-PAC (Georgia Pacific) was shutting down this process to perform routine annual maintenance. In the process of securing the radiation sources from becoming a radiation exposure hazard, it was discovered that the gauge shutter would not close. GA-PAC called a service contractor, BBP Sales, to evaluate the situation and determine the best course of action to correct the problem. (BBP Sales) was unable to close the shutter and determined the source holder would have to be replaced. Further evaluation determined one of the pins holding the shutter had sheared off and would have to be replaced, not repaired. The sources and device with shutter failure will remain installed until the replacement source and device are received. The failed device will be sent for disposal when replaced. This is not a radiation exposure hazard and does not pose a health and safety situation for the GA-PAC employees or the general public. The gauge is a RONAN C-10 device/source holder, S/N 9830GG, loaded with a 2,000 mCi Cs-137 source. The manufacturing date was 1994. This event is considered to be closed by LDEQ. This event is being reported to the NRC as required by Regulatory Requirement 10 CFR Part 30.50(b)(2). Louisiana Event: LA-160016 |
| ENS 44518 | 25 September 2008 16:07:00 | On September 17, 2008, at 3:20 a.m. the Radiation Safety Officer for Georgia-Pacific called the answering service for radiation incidents after hours. He stated that the screws on a Honeywell Measurex unit, model 4201 had backed out and a shielding plate fell off leaving a 1 Ci Kr-85 source exposed. He stated that the operator had roped off the area around the paper machine to prevent access and exposure. The operator described the time and distance to the source and it was determined that any exposure would have been minimal. Honeywell International, license LA-10814-L01 was contacted for servicing and packaging of the unit. The service tech was to be at the facility September 17, 2008 around 4:00 p.m. because he was traveling from out of state. The facility will follow up with a report and additional information concerning this incident. Louisiana Incident: LA0800019 |
| ENS 44476 | 9 September 2008 09:46:00 | The following was provided by the state via facsimile: On August 19, 2008, Hi Tech Testing reported an overexposure to an industrial radiographer. On August 17, 2008, two industrial radiographers noticed that their pocket dosimeters were 'off scale'. Their film badges were sent to Landauer for emergency processing and it was determined that one of the radiographer's dose for August 2008 was 3.719 rem. Adding this to the year to date dose for this radiographer gave the radiographer a year to date dose of 5.776 rem for 2008. Hi Tech Testing investigated the incident and determined that the radiographers were not using a survey meter or performing a proper survey after each exposure. The following corrective action was taken for this incident: The radiographer that had the excessive exposure has had his employment with Hi Tech Testing terminated. Hi Tech Testing also had a mandatory company safety meeting concerning this incident. Louisiana report number - LA0800017 |
| ENS 44369 | 28 July 2008 11:20:00 | This report was received from the state by facsimile. On July 25, 2008, TEAM Industrial Services reported that a source was stuck in the guide tube and could not be returned to the shielded position. The industrial radiography camera involved is a AEA 880 Delta with serial number D2847. The source involved is an AEA source with serial number 45020B that is 49.8 Ci of Ir-192. While the source was in the collimator, the stand that was being used to x-ray welds fell on the guide tube. The radiographers attempted to return the source to the shielded position but could not. The radiographers then returned the source to the collimator and set up a 1 mr/hr boundary around the source. They called the Radiation Safety Officer for TEAM. TEAM contacted QSA Global to retrieve the Ir-192 source. The source was retrieved on July 25, 2008 at 5:30 PM. The guide tube and stand have been taken out of service. The camera and crank-outs are being sent to QSA Global to be inspected. Event Report ID: LA0800016 |
| ENS 44264 | 4 June 2008 13:36:00 | The State provided the following information via facsimile: On June 3, 2008, a Cardinal Health delivery vehicle carrying nuclear medicine doses was involved in a vehicle accident. Some of the ammo boxes containing the syringe pigs opened, however the syringe pigs remained intact. No radioactive material was spilled or leaked during this accident. Louisiana Report: LA0800012 |
| ENS 44259 | 3 June 2008 12:08:00 | (On the morning of May 29, 2008), a Pulsed Neutron Generator (Source #183619) belonging to Baker Hughes Oilfield Operations, Inc. dba Baker Atlas, containing approximately 900 millicuries of Tritium (H-3) was lost into the waters of the Mississippi River. The events were as follows: A commercial hotshot carrying two complete Pulsed Neutron Tools was dispatched to the Hilcorp dock in Cocodrie, La., from the Baker Atlas facility in Broussard, La. at approximately 3 A.M. this morning (5/29/08). The tools arrived at the Hilcorp dock at approximately 5 A.M.. The shipment was verified by the Hilcorp dock dispatcher and loaded onto a Hilcorp contracted Crew Boat. Note: there were no Baker Atlas employees included in the transport of this shipment. The Baker Atlas crew was already at the rig when this equipment was ordered. The shipment arrived at Hilcorp S/L 3090 #7, in the Little Pass field at approximately 7 A.M.. At arrival, the Hilcorp company representative noted that the aluminum tubes containing the Baker atlas downhole tools were not strapped down and were extended over the rail of the boat. The Hilcorp representative alerted the Baker Atlas crew, who conducted an inventory of the equipment and found that one tube containing both the upper section and lower section (containing the 900 milliCurie H-3 source) of a Pulsed Neutron Generator Tool was missing. The Hilcorp representative dispatched the crew boat back to the dock to conduct a visual search of the route and dock, but nothing was found. Due to the weight and density of the equipment, it is most likely that the tube (and tools in it) sank to the bottom of the river. Note: the rig is approximately 20 nautical miles from the dock. The customer (Hilcorp) has accepted financial responsibility for this loss and does not believe that a search for the missing equipment would be cost effective. The State of Louisiana considers this event closed. Louisiana DEQ Event Report ID: LA0800011 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. Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Less than Cat 3 event. Note: the value assigned by device type "Category 3" is different than the calculated value "Less than Cat 3 |
| ENS 44266 | 4 June 2008 14:05:00 | On May, 7, 2008, Wal-Mart reported six broken Tritium Exit Signs (TES). Three TES were located at a store in Baker, LA and three were located in a store in Baton Rouge, LA. Wal-Mart has hired Shaw Group, Inc. for its company-wide program to inventory and manage TES. Shaw Group performed decontamination of the affected stores and shipped the broken TES to a licensed source disposal facility. All the TES were located in non-public areas of the stores. LA Event Report: LA0800013 |
| ENS 44177 | 29 April 2008 15:03:00 | This incident was originally reported in Event Notification #44159 by the licensee due to the uncertainty of the location of the potential overexposure. The State provided the following information via facsimile: On April 23 2008, (DELETED) (RSO) with Global X-Ray & Testing (GXT) reported an excessive exposure on an industrial radiographer's badge. Landauer contacted GXT and reported that a badge had a reading over 1000 rads. The radiographer in question was interviewed by (DELETED) and a LA Department of Environmental Quality inspector. The radiographer was very shocked to hear of the excessive exposure. He was asked if anything unusual occurred during the month. The radiographer did not think anyone exposed the badge intentionally. The radiographer did state that he could not find his badge one morning on a job that occurred on March 20 - 24, 2008. The radiographer had a physical and blood work performed. The physical included CBC and total Lymphocyte count. The blood work came back within normal limits. This incident is still under investigation by the Louisiana Department of Environmental Quality. Louisiana Report: LA080008 |
| ENS 44040 | 6 March 2008 15:29:00 | Received the following information from the State of Louisiana via facsimile: The licensee, Louisiana Heart Hospital in LaCome, LA., submitted a High Exposure Report to the State concerning one of their physicians. The physician's exposure by badge was 5,244 mrem for the 2007 calendar year. The cause of the overexposure was attributed to high workloads in the Cardiac Catherization Labs during the period. Corrective actions taken include double badging the individual, including the addition of a waist badge beneath his lead apron, using additional shielding/distance and using special equipment such as pull-down lead shields. Additionally, the licensee will review the individual's exposure quarterly to adjust workload and/or corrective actions. |
| ENS 44019 | 29 February 2008 11:09:00 | The following information was received from the State of Louisiana via fax: On February 28, 2008, TEAM Industrial Services reported that an industrial radiographer's personnel monitoring badge received an excessive exposure of 10 rem. The industrial radiographer left his badge in the work truck while he was not performing radiography for a few days. The truck was parked next to a tank that was being x-rayed. According to TEAM, this exposure was just to the badge and not to the radiographer. According to TEAM, the actual exposure to the radiographer is 67 mrem. This incident is under investigation and further information will be forwarded once available. LA Event Report ID: LA 080006 |
| ENS 44011 | 27 February 2008 16:15:00 | The State provided the following information via facsimile: On February 27, 2008, Circle Inc. discovered that a Troxler nuclear gauge with a 9 mCi source of Cs-137 (s/n 50-9134) and a 44 mCi source of Am-241 (s/n 47-14943) was missing from a construction site on the levee near Nicole and Lapalco in Westwego, LA. The incident is under investigation and additional information will be forwarded once it is received. Louisiana Event Report: LA080004 THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. |
| ENS 44018 | 29 February 2008 10:39:00 | The following report was received via email: A Louisiana Department of Transportation and Development (DOTD) van was involved, in an accident while carrying a Humboldt 5001 soil moisture density gauge. The gauge contained 10 mCi of Cs-137 (s/n9733GQ) and 40 mCi of Am-241 (s/nNJ03934). The Louisiana State Police notified LA DEQ of the accident and stated that the overpack was not breached and that readings at the surface were 0.9 mR/hr. The gauge and overpack were inspected at the DOTD district laboratory that was 0.5 miles from the accident. The overpack was in overall excellent condition except for a small hole (approximately 1 inch in circumference) which had been punched through the exterior wall but did not puncture the interior wall of the overpack. The overpack and gauge were surveyed by a DEQ inspector and recorded readings of 0.2 mR/hr at 1 meter which, correspond to the transportation index. A leak test has been sent off for the gauge and the results are pending. Will update with further information when it becomes available. LA Event Report ID No.: LA080005 |
| ENS 43980 | 12 February 2008 16:15:00 | The State provided the following information via facsimile: On February 8, 2008, Waste Management reported a leaking source. On February 7, 2008, an e-mail from Suntrac was opened. This e-mail contained information on two leak tests that were performed on two sealed radioactive check sources. One of the sealed sources had removable activity that was above 0.005 uCi. A 5 mCi source of Cs-137 had a removable activity of 0.0084 uCi. This source has been taken out of service. Waste Management will contact Suntrac for disposal of the source. The source was identified as 'Orange #2' and a serial number was not known. LA Report ID LA080003 |
| ENS 43890 | 10 January 2008 12:44:00 | The agreement state submitted the following information via e-mail: On January 10, 2008, CONAM reported an accidental, excessive exposure to an industrial radiographers badge. The badge reading for the month of November 2007 was 11,592 millirem. At the end of his shift, the radiographer put his personnel monitor in his work bag. The shift that came in after him used his work bag and had the bag next to the radiography camera during exposures. The licensee believes that this exposure was to the badge and not to the radiographer. The licensee will be sending a written report within 30 days. (The State of Louisiana) will forward new information when it is received. Louisiana Event Report ID: LA070032 |
| ENS 44189 | 6 May 2008 11:42:00 | The State provided the following information via facsimile: An overexposure was discovered during a routine compliance inspection of Accurate NDE & Inspection on March 25, 2008. This overexposure was not reported to the Louisiana Department of Environmental Quality. An industrial radiographer received a dose of 7819 mrem for the calendar year 2007. The licensee has been cited for the overexposure and for not reporting the overexposure. This overexposure is being investigated by the LA Department of Environmental Quality. LA Report ID No.: LA08009 |
| ENS 43841 | 14 December 2007 08:36:00 | The Agreement State of Louisiana submitted the following information: On Monday November 19, 2007, Cardinal Health Nuclear Pharmacy delivered an isotope dose labeled incorrectly. The dose delivered, was labeled Tc-99m Mertiatide (Mag-3) assayed at 5.1 milliCuries at 9:13 AM. The dose ordered was for a Renal Scan scheduled for 9:30 AM. After injection of the ordered dose, subsequent imaging revealed accumulation of radiopharmaceutical in the liver and spleen. The target organ for Mag-3 is the kidneys. The images would suggest Tc-99m Sulfur Colloid as the agent delivered. This information was reported by the facility that received the dose. The facility also notified Cardinal Health. This matter is under investigation by Louisiana DEQ. This report refers to Louisiana event identification number: LA070030. 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 43842 | 14 December 2007 10:49:00 | This information was received via email Eustis Engineering reported an incident that occurred on November 15, 2007. At 8:00AM on this date a Troxler gauge model number 3440 with serial number 25934 was hit by a bulldozer. This gauge has a 8.0 mCi source Cs-137 and a 20 mCi source of Am241:Be. The bulldozer that hit the gauge was operated by James Construction at the Marathon GME Refinery construction site. The technician called the Eustis Engineering office immediately after it occurred. Mr. (deleted), the Eustis RSO, was dispatched to the site. The RSO arrived at 9:30AM and conducted a survey using a Trox Alert survey meter. At 30 feet away the meter reading was 0.1 Mr. At 2 feet away the meter reading was 0.2 Mr. A leak test was conducted by Gamma Tron on November 15, 2007 after the incident with the results being less than 0.005 uCi (microCuries) of removable contamination. Event Report ID No.: LA070031. |
| ENS 43731 | 19 October 2007 09:55:00 | The following information was received from the Louisiana Department of Environmental Quality via fax: On September 24, 2007, a customer called the pharmacy to inform them that a Tc-99m mertiatide prescription for renal imaging showed no renal distribution and instead showed only liver distribution. After an investigation by the licensee, it was determined that the error occurred in the pharmacy and all customers who could have been affected by the event were notified. Only one of the patients was injected. The radiation dose to the patient involved was minimal. Procedures not followed is the root cause of this incident. The corrective actions for this incident include retraining on policy and procedures regarding compounding doses. Event Report ID No.: LA070028
This event (EN43731) has been reviewed and determined to not meet the definition of a medical event. Notified R4DO (Proulx) and FSME EO (Flannery). |
| ENS 43609 | 30 August 2007 11:22:00 | The licensee provided the following information via facsimile: A portable gas chromatograph with a 15 mCi source of Ni-63 was lost during Hurricane Katrina when the levees broke. This is a General License device. LDEQ was not notified of this loss until August 13, 2007. LA Event Report - LA070025 THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. |
| ENS 43554 | 8 August 2007 09:55:00 | The following information was provided by the State via facsimile: On 8/1/07, one of Integrity Inspection Solutions crews was setting up for radiographic operations at a temporary job site. While connecting the crankout to the exposure device, the source connector assembly broke. Due to this happening before the first exposure on the job, there was no source disconnect. Another crankout was available and the job was completed. The crankout manufacturer could not be determined. The crankout will be sent to an authorized agent for repair. The crankout was used with a SPEC 150 camera. LA Event Report ID No.: LA070023 |
| ENS 43521 | 25 July 2007 14:17:00 | The State provided the following information via facsimile: During a routine maintenance inspection it was noted that the control assembly (of the radiography camera) would not project or retract the drive cable. After an investigation, it was found that 2 of 4 'small gear housing' screws were interfering with the gear teeth of the large gear. The two screws that interfere with the operation of the large gear only interfere when they are loose in the housing. Since the outside of the small housing is where the handle for the controls is kept, the screws inevitably come loose over time and use. Since the screws are applied in the housing there is no way to tighten the small housing screws with out disassembling the control arm assembly. A small design change is needed on these 4 small housing screws to prevent a source from stuck out in the shielded position. Equipment involved: SPEC 150, (no serial number provided), Source: Ir-192 (no source strength provided), Control assembly: SPEC 'Red-Red' conduit control. |
| ENS 43480 | 11 July 2007 15:59:00 | The licensee provided the following information via facsimile: A facility in Twin Falls, Idaho was shipping a 6 Ci Ir-192 HDR source back to Alpha & Omega Services for disposal. The carrier was FedEx. When the package arrived at Alpha & Omega and was opened, it contained a helicopter part and not a source. Will update when information is available. Event Report ID No: LA070018 See also Event Notification #43484
The following information was received via fax: This source was never lost. The facility did not follow their SOPS and log in the shipment from FEDEX. The source was in the facility the entire time. Notified R4DO (Pick) and FSME (Wastler). 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. Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Category 3 event. Note: the value assigned by device type "Category 2" is different than the calculated value "Category 3 |
| ENS 43469 | 3 July 2007 09:29:00 | Christus St. Francis Cabrini hospital called and reported an over exposure on a treatment using an HDR (High Dose Rate system). The HDR system delivered a dose 40% more than what the treatment plan called for to the patient. The overexposure for the treatment was reported as 1400 cGy. This is all of the information we have at this time. An investigation has started for this incident. LA report number - LA070017 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 43482 | 12 July 2007 07:53:00 | The licensee provided the following information via facsimile: Agreement State Agency: Louisiana Department of Environmental Quality Event Report ID No.: LA070020 License No.: LA-5694-L0IA Licensee: Ohmstede Event date and Time: June 25, 2007 Event Location: Sulphur, LA Event type: Equipment Notifications: LA DEQ Event description: Ohmstede sent an Amersham 660B camera serial number B1072 to QSA Global for a source exchange. Before a new source was put into the camera, QSA Global discovered that the camera had a cracked S tube. The camera has been removed from operation and is in storage. |
| ENS 43481 | 12 July 2007 07:12:00 | The State provided the following information via facsimile: Agreement State Agency: Louisiana Department of Environmental Quality Event Report ID No.: LA070019 License No.: LA-7396-L01 Licensee: Oceaneering International, Inc Event date and Time: May 2007 Event Location: Houma, LA Event type: Overexposure Notifications: LA DEQ Event description: Oceaneering received a notification from Landauer that one of Oceaneering's employees was over exposed for the month of May 2007. The dose that was reported for this employee was 5467 mrem (deep), 5677 (eye), and 5892 (shallow). This incident will be investigated and DEQ will forward new information once it is received. Transport vehicle description: N/A |
| ENS 43459 | 29 June 2007 12:28:00 | The licensee provided the following information via facsimile: Oceaneering reported an over exposure to one of the industrial radiographers. The RSO received a notification from Landauer of an over exposure to the licensee's employee. This employee received a dosage on his May 2007 badge of 5549 mrem (deep) and a year to date dosage of 5788 mrem. The RSO is going to discuss this issue with the employee and send the LDEQ additional information. Once the additional information is received, it will be forwarded to the NRC. Louisiana Event Number - LA070016 |
| ENS 43432 | 19 June 2007 14:37:00 | The State provided the following information via facsimile: Description of Event - A customer called the (Cardinal Health) pharmacy on Wednesday, May 16, 2007 to report that the late injection of Tc-99m sestamibi, a heart imaging agent, showed no heart uptake on the film. Instead there was only soft tissue uptake. The activity dispensed and injected matched the prescription. The next day the patient was brought back to the department and the image indicated that the dose injected was Tc-99m medronate, a bone imaging agent. Investigation and Root Causes - A large dose of Tc-99m sestamibi was ordered at 0600 calibrated for 1400. A biliary dose was also ordered at the same time. These were the only two doses drawn at that time. After notification by the hospital, an investigation revealed that the activity and volume remaining in the sestamibi vial plus the volume and activity dispensed matched the total volume and activity of the prepared kit (after correction for decay). The concentration for the sestamibi kit is normally 30% greater than for a bone imaging kit. Since the volume was correct, no flags were detected during dispensing. It is not Cardinal Health policy to test used syringes due to blood borne pathogen hazards. No other clients that were dispensed doses from the same vial reported errors in imaging. From this analysis, Cardinal Health can find no errors on its part to account for the imaging error. Actions Taken to Prevent a Recurrence - Cardinal Health has protocols in place to prevent dispensing errors of the type described above. Since the error cannot be attributed to Cardinal Health, corrective action is unnecessary. LA event Report ID No.: LA070015 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 43411 | 6 June 2007 12:36:00 | The following report was received from the Louisiana Department of Environmental Quality (LA DEQ) via fax: (A) field inspection was performed on a field crew for METCO. (While) performing the inspection a misconnect test was performed. The crank outs had a serial number of MST 225 manufactured by AEA Technologies and the camera was an Amersham 880 Sigma with serial number S1712. This misconnect test failed. The crank outs were removed (from) operation and taken back to the shop. The problem was located on the crank out and was repaired. A misconnect test was then performed with the same camera and an additional camera and it passed the test. METCO stated that they will pay closer attention to damage and wear and tear on equipment. LA Event Report ID No.: LA070014 |
| ENS 43352 | 8 May 2007 15:40:00 | The State provided the following information via facsimile: (A licensee representative) with Nondestructive and Visual inspection notified the Louisiana Department of Environmental Quality on May 4, 2007 of an overexposure. The indicated exposure from the badge reading is 5123 mrem. Additional information will be forwarded once it is received. Louisiana Event Report ID No.: LA070011
Upon further investigation, it has been determined that there were two separate incidents where employees of Nondestructive & Visual Inspections, LLC may have exceeded the annual dose limit of 5 rem. The first incident was the original basis for the above initial notification. "The worker involved) is an industrial radiographer, certified by the State of Louisiana. (The worker) . . .was employed by NVI, LLC from April 30, 2005 until March 29, 2007, at which time he was terminated for violating company policies. (The worker) did not turn in his March 2007 TLD badge. In February 2007, (the worker's) lifetime dose equivalent, while employed at NVI, LLC was 5117 millirems. His year to date dose equivalent for 2007 at this time was 132 millirems. His year to date dose equivalent for 2006 was 2535 millirems. This dose includes a calculated dose for the month of December 2006 for a badge that according to (the worker) was lost. On May 1, 2007, NVI, LLC received an exposure notification from Landauer for (the worker's) December 2006 TLD badge of 3156 millirems. This put his year to date dose equivalent for 2006 at 5691 millirems, which exceeds the annual dose limit for radiographers. The lost badge was apparently found and returned to Landauer by mistake. There is no way to determine what dose the badge had been exposed to during the four months that it was unaccounted for. (NVI, LLC) has tried on numerous occasions to reach (the worker) by phone to discuss this matter with him. (NVI, LLC) has been unsuccessful in attempts (to reach him) so far. The second incident involves another (worker). (The worker) is an industrial radiographer trainee, certified by the State of Louisiana.. . . .(The worker) has been employed by NVI, LLC, since April 1, 2005. On May 4, 2007, (NVI, LLC ) received an exposure notification from Landauer. (The worker's) dose for the month of March 2007 was 5363 millirems. His year to date dose equivalent for 2007 is 5514 millirems. (NVI, LLC) notified (the worker) immediately and informed him that he could not perform radiography. (NVI, LLC) met with (the worker) the same day and discussed the overexposure. (The worker) stated that there was no way possible that he could have receive such a dose. He stated that at no time did he ever go offscale or have any type of incident or accident while performing his duties during the month of March 2007. . . .(The worker) is still employed by NVI, LLC and has been reassigned to perform other NDT methods that do not include radiography. R4DO (Bywater) and FSME (Morell) have been notified. |
| ENS 43254 | 22 March 2007 12:00:00 | The State provided the following information via facsimile: On March 5, 2007 there was a malfunction with a Troxler gauge. After performing a moisture/density test, the technician squeezed the release handle, pulled up the rod, and walked away from the test location. While walking towards the truck, an assistant told the technician that he had dropped something. When the technician looked, (he) realized that the object that had fallen was the bottom piece on the Troxler gauge rod. The technician told the assistant to stay away from the broken piece. The technician then carefully picked up the piece with a shovel from the truck and placed it on the tailgate. A brief observation of the broken rod was taken by the technician to assure that the (source) pellet was still in place and not dropped on the ground. He then noticed that the weld on the rod was the main cause of the problem. At this time the technician immediately staked out the area and called his equipment manager - a repair technician (redacted) with Gamma-Tron, and his Supervisor (redacted). He then shoveled the broken rod into the containment box were the gauge was located. It was locked and secured as he transported it to the company equipment container were it was placed and double locked for safety. A sign was placed at the container to keep other employees from disturbing the gauge. All of the previously mentioned personnel were contacted and made aware of the situation. On March 6, 2007, (the technician) from Gamma-Tron placed the source back into the safe position. (The technician from Gamma-Tron) assured the facility that the radioactivity was controlled. (The technician) then took the gauge to QSA Global so the unit could be disposed of properly. LA report number LA070008 |
| ENS 43201 | 28 February 2007 12:07:00 | The following information was provided by the state via facsimile: Description of Event: On February 14, 2007, a customer called to report that the Thallium-201 Chloride dose they ordered was only 2.9 mCi instead of the 4.0 mCi requested. Thallium-201 Chloride is an imaging agent used for myocardial perfusion imaging or parathyroid and tumor imaging. Another TI-201 dose was sent to the customer to account for the incorrect activity. An investigation revealed that the pharmacist who dispensed the dose had selected the incorrect setting on the dose calibrator when assaying the dose at the pharmacy. The dose calibrator was set on Tc-99m instead of TI-201, resulting in an incorrect assay. Root Causes: The root cause of this event was an error by the pharmacist while assaying the dose. By not double-checking that the dose calibrator was on the correct setting, an incorrect assay was recorded. Actions Taken to Prevent a Recurrence: In an effort to prevent a recurrence of this event, the pharmacist will be sure to check that the correct isotope settings are in place on the dose calibrator for the dose being assayed. Additionally, checking the volume on the dose label will help reinforce that the pharmacist has checked which dose is being assayed and if the isotope setting is correct. LA Event Report ID No.: LA070003
The State of Louisiana is retracting this report following a review which concluded that their reporting criteria was not met. Notified R4DO (Shannon) and FSME (Morell). |
| ENS 43200 | 28 February 2007 11:49:00 | The following information was provided by the state via facsimile: On 02/05/07, the licensee notified the Louisiana Department of Environmental Quality that one of its Electron Caption Detectors (ECD) had a removable activity above 0.005 microcuries as a result off a recent "wipe test". The ECD is a Agilent Technologies, Inc. model number: 19233-69570, serial number YA353 with an estimated activity of 15 millicuries of Ni-63. Leak test results from a test performed on 01/26/07 were 0.024 microcuries. The wipe test results were reported to the licensee on 02/02/07. On 02/07/07 an onsite inspection was performed by licensee corporate personnel. On 02/07/07 the ECD was returned to the manufacturer's location in Wilmington, DE for disposal. LA Event Report ID No.: LA070002 |
| ENS 43230 | 12 March 2007 15:17:00 | This Agreement State report was received from the State of Louisiana via facsimile. Bayou Inspection Services reported an overexposure (of) two employees. (Deleted) received an annual dose of 5055 mR. (Deleted) received an annual dose of 5330 mR. Radiation Safety Officer stated he talked to both employees and told them they must do a better job of protecting themselves from exposure to radiation. Event Report ID No.: LA070004 |
| ENS 42855 | 22 September 2006 14:44:00 | A Cardinal Health vehicle from the Slidell, LA location was carrying 1214 mCi of Tc-99 and 40 mCi of Xe-133 to a Mississippi facility when it was involved in an accident on Highway 43 in Mississippi. Cardinal Health notified the appropriate authorities in Mississippi. Emergency Response in Mississippi took control of the vehicle. Louisiana event report ID number: LA060017 See Mississippi Agreement State Report: Event Number 42858. |
| ENS 42905 | 13 October 2006 16:05:00 | The following information was received via fax: Event Report ID No.: LA060019 Event Date and Time: September 21, 2006 Event Location: East Baton Rouge Parish Event Type: Abandonment down hole Notifications: LA DEQ Event Description: Schlumberger abandoned two sealed radioactive sources down hole. The AEA 63 GBq Cs-137 source, serial number A2371, was abandoned at a depth of 18,887 feet. The Gamatron 592 GBq Am-241:Be source, serial number G4040, was abandoned at a depth of 18,855 feet. Many attempts were made to retrieve the sealed sources from 9/7-21/06. The sealed sources are covered with Premium cement and a cement retainer was set at 18,246 feet. A whipstock was placed on top of the cement retainer at 18,246 feet. An abandonment plaque will be placed on the well. |
| ENS 42987 | 13 November 2006 09:50:00 | The state provided the following information via fax: Precision Energy Services abandoned a 2 Ci source of Cs-137 (serial number 06926B) down a hole at a depth of 3064 feet. The tool string got stuck on September 20, 2006. The first attempt to retrieve the stuck tool string succeeded in retrieving the Am/Be neutron source but also caused the tools to break apart. The section of the tool string with the Cs-137 source was stuck at a depth of 3064 feet. Red-dyed cement plug was set with open-ended drill pipe at 3060 feet to 2860 feet. Production casing was run and cemented at 2850 feet, with float shoe, 41 feet of cement filled shoe joint, and float collar. The deflection device was dropped on the float collar and 20 feet of red-dyed cement was dumped on the device on November 1, 2006. An identification plaque will be placed on the well. |
| ENS 42735 | 27 July 2006 16:50:00 | The State provided the following information via facsimile: Non-Destructive & Visual Inspection (NVI) reported an excessive exposure to an industrial radiographer on July 27, 2006. (NAME DELETED), RSO, was called by Landauer (dosimetry service) with an exposure of 11,792 mrem for the month of June 2006 for (NAME DELETED). (The RSO) is conducting an investigation into the excessive exposure and will supply further information once it is available. (The radiographer) told (the RSO) that he could not remember when he would have received such a high dose. Additional information will be provided to the NRC from the State of Louisiana as it becomes available. Louisiana Event Report ID No.: LA-060016 |
| ENS 42709 | 17 July 2006 15:31:00 | The State provided the following information via facsimile: While performing NORM (naturally occurring radioactive material) remediation at an old Texaco site at the end of Hwy 23 in Venice, LA, a radioactive source was uncovered. Production Management Industries (PMI) was dipping out mud out of a canal when, the scoop of mud had a high reading. The scoop was set aside in a restricted area. It was thought to be NORM pipe until the survey meter used on NORM material pegged. They also noticed that the piece of metal giving off radiation was about two inches long. Then it was believed to be a sealed source. Mr. (Redacted) was called about the situation. Mr. (Redacted) told them to set it aside until he got there. Once Mr. (Redacted) was on site they took a survey of the source with a different survey meter. The reading at contact was 30 mR/hr. It was 100 microR/hr at 3 feet and 20 microR/hr at 10 feet. Mr. (Redacted) performed a wipe test on the source and it did not appear to be leaking. Mr. (Redacted) then put the source in a 5 gallon drum and put dry cement around the source. The reading at the drum after this was 1.9 mR/hr. He then put the drum in the generator room where it could be locked up and secure. American Radiation Services is going to pick up the source from Venice on July 17 for disposal. All the employees that were around the source are radiation workers and were wearing personnel monitoring. No excessive exposures are expected. No one picked up the source by hand. Louisiana Report Number LA0600014 |
| ENS 42688 | 6 July 2006 15:15:00 | The State provided the following information via facsimile: Global X-Ray had a source disconnect at the McDermott Fabrication Facility in Amelia, LA on June 12, 2006. The radiographers were performing routine radiography on some welded pipe sections. After several exposures, the radiographers began having trouble with the crankout. The radiographers realized that the source had not come back to the shielded position at the end of the exposure. The radiographers followed Global X-Ray & Testing Operating and Emergency Procedures. The radiographers reset their boundaries to a 2 mR/hr level and maintained surveillance and called the office. The source was found in the source guide tube. The source was retrieved and returned to the exposure device with minimal exposure during retrieval. Both the exposure device and controls were sent to SPEC for evaluation. It appears that there was enough wear on the control adapter and the drive cable connector to allow a disconnect. Global ruled out a source misconnect being the problem due to the fact that the film that was exposed prior to the crank out trouble was developed and came out just as it should. There were no excessive exposures to the radiographers. The radiographers dosimeters read 10-12 mR and 35-40 mR. The retrieval process produced an exposure of 85 mR. The device that was involved with the disconnect is a SPEC 150 camera with serial number 139. The source in the camera was an 82 Ci (Curie) source of Ir-192 manufactured by SPEC with model number G-60 and serial number ND-1002. LA Event Report Number: LA060012 |
| ENS 42868 | 29 September 2006 15:29:00 | The following information was received via fax: During an inspection of the Sewerage and Water Board of New Orleans it was discovered that a Hewlett-Packard Gas Chromatograph, model number 18713A, with 15 mCi of Ni-63 foil could not be located. According to the inventory, it was placed into storage in 1995, but it could not be inventoried in December 2005 due to Hurricane damage to the storage facility. The facility tried to locate the GC around June 2006, but could not locate the unit. The facility failed to notify the Louisiana Department of Environmental Quality of the missing GC and has been cited. This incident is under investigation. The NRC will be notified of any additional information once it is received. Event Report ID No.: LA060018 THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| ENS 42628 | 8 June 2006 18:14:00 | Louisiana Agreement State Report was faxed to the NRC Operation Center. National Inspection Services reported on June 6, 2006 that a trainee, (deleted), received an excessive exposure. The film badge for (deleted) had an exposure of 5.879 Rem for the March 2006 wear period. This individual is no longer working for National Inspection Services. His employment ran from February 23, 2006 to April 26, 2006. The facility is performing an investigation and will report their findings to the Louisiana Department of Environmental Quality. (Deleted), Radiation Safety Officer, stated that the daily pocket dosimeter records do not reflect an excessive exposure. Event Report ID No.: LA060011 |
| ENS 44368 | 28 July 2008 10:46:00 | This report was received from the state by facsimile. Exxon Mobil Chemical Company had an incident occur in August of 2005 and did not report the event. The event was discovered while an inspector was performing a reciprocity inspection on Ronan Engineering at Exxon on July 9, 2008. Ronan was contacted to package a nuclear gauge for transport and disposal. In August 2005, Exxon had a problem with a ThermoMeasure Tech 'SA-10' device that contained four 1000 mCi sources of Cs-137. The sources were QSA model CDC.93 with serial numbers 4421GN, 4424GN, 4425GN, and 4426GN in a rod configuration. In August 2005, the sources could not be returned to the shielded position to perform a shutter check. The facility returned the sources to the normal detent position for operation and continued to use the gauge. Ronan Engineering determined that the sources were encountering friction from the vessel source well. The vessel source well is part of the vessel and not part of the Ronan gauge. The gauge and sources were safely returned to the source holder, locked out, surveyed and leak tested on July 11, 2008. The gauge was shipped to ThermoMeasure Tech on July 11, 2008 for disposal. Event Report ID: LA0800015 |