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ENS 5722210 July 2024 16:32:00The following is a summary of information provided by the New Jersey Department of Environmental Protection (NJDEP) via email: Kennedy Memorial Hospital University Medical Center (the licensee) was scheduled to administer a Nordion TheraSphere therapy (116 mCi of Y-90) to a patient. The target organ was the right hepatic lobe of the liver. There was a tubing failure in the delivery system and the administration was suspended. It is estimated that only 2.62 mCi (17 percent) of the prescribed dosage was administered. The patient and referring physician were notified. The patient has been re-scheduled for treatment. No release of licensed material or contamination was reported. The licensee will follow-up with a full written report. The licensee is sending the equipment that failed to the manufacturer for detailed analysis. 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 5641215 March 2023 13:17:00

The following information was provided by the New Jersey Department of Environmental Protection (DEP) via email: While receiving treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6135, the patient's treatment had to be suspended. During the administration of the treatment, after the conclusion of a prescribed shot, but before completion of the full treatment, the unit displayed an error that could not be resolved by licensee personnel and required a service technician. The treatment was consequently suspended. The service technician identified a worn sector drive as the cause of the malfunction. The dose administered versus the dose prescribed is still under discussion. The licensee will follow-up with a full report. NJ Event Report ID number: NJ-23-0001

  • * * UPDATE ON 3/16/23 AT 1513 EST FROM RICHARD PEROS TO BILL GOTT * * *

Additional information has been obtained related to the initial notification provided on 3/15/23. The dose administered to the patient was only approximately 2.9 percent of the dose prescribed. The prescribed dose was 15 Gy. The unit malfunctioned after only 3 of the planned 13 shots was completed. 14.5589 Gy still needed to be administered out of the 15 Gy when the malfunction occurred. This incident therefore does qualify as a medical event as per 10 CFR 35.3045(a). Notified R1DO (Bickett) and NMSS Events Notification. 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 562658 December 2022 17:40:00The following report was received from the New Jersey Department of Environmental Protection (NJDEP), via email: The licensee had scheduled two patients who were each to receive 200 mCi of Lu-177. One patient was to receive 200 mCi of Lu-177 Lutathera, while the other was to receive 200 mCi of Lu-177 PSMA. The PSMA patient was mistakenly administered the Lutathera, while the Lutathera patient was mistakenly administered the PSMA. Licensee is working with Radiation Safety Officer on steps needed to prevent recurrence. NJDEP Actions: Will conduct on-site visit if warranted. 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 561424 October 2022 15:56:00The following was received from the state of New Jersey via email: While treating a patient with a gamma-knife icon unit, there was an apparent activation of the emergency stop. No one admits to touching the emergency stop button, but the sources retracted, the unit doors remained open, and the table functions were frozen. One of the authorized medical physicists (AMP) entered the room and manually retracted the table from the unit, as per emergency procedures. The licensee reported that this is the protocol when the emergency (red) console button is pushed. The AMP and one of the authorized users (AU) helped the patient off the table. The couch lever was pushed back into place and the unit was reset so the doors would close. The AMP observed the treatment time at the back of the unit. The AMP repeated the sector position check of the unit without incident. The licensee contacted the device manufacturer, Elekta, about the incident. They reported that Elekta informed them it was acceptable to proceed and complete the patient treatment. They then resumed and completed the patient's treatment without further incident. The events were documented in the patient's record. The manufacturer sent a service technician to the licensee the next day (i.e., today, October 4, 2022) to inspect the unit, make any needed repairs and check the log files. After review of the logs, the AMP and Elekta believe patient movement triggered the incident. The dose to the AMP and AU was estimated to be 0.134 mrem. This was not a medical event, since the planned treatment was completed.
ENS 5591727 May 2022 15:54:00The following report was received via e-mail from the New Jersey Radiation Department and Release Prevention Program (the Department): The Radiation Safety Officer of Rutgers University informed the Department that one H-3 (Tritium) exit sign cannot be found and is considered lost. The exit sign was last inventoried in October 2021 and was noticed to be missing in April 2022. After extensive investigation/searching, the licensee considers the sign lost. The Exit sign in question is an Isolite H-3 Exit sign, model 880-126R10BA, S/N H138883, originally containing 7.59 Ci of H-3. Rutgers will forward a written report within 30 days concerning the loss and their investigation. 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 5560724 November 2021 14:23:00The following report was received via email from the New Jersey Department of Environmental Protection: While conducting the routine spot check prior to patient treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6114, the unit's shutter doors failed to close during the "Emergency Off" button test. The licensee's authorized medical physicist (AMP) followed emergency procedures and entered the room to manually close the doors. The doors closed, but the AMP decided to try again with the same result. The AMP carried a handheld survey meter with them each trip. Their calculated total exposure for their trips based on the exposure rate was 0.575 mR. There was no patient involvement. The unit is secured and Elekta is in the process repairing the unit. The licensee will follow-up with a full report.
ENS 5561529 November 2021 16:20:00The following information was received from the state of New Jersey Department of Environmental Protection: The Radiation Safety Officer of Rutgers University informed the New Jersey Department of Environmental Protection that one sealed source device, with an installed source, cannot be found and is considered lost. The source in question is a Ni-63, electron capture detector source, serial number U1739, to be used in Agilent HP Gas Chromatograph, Model # HP6890, serial number US10204036 electron capture detection device. The source contained 15 mCi of activity. The device was present during the licensee's April, 2021 inventory. When the current inventory was being conducted, the device could not be found. The licensee stated that the lab where the device was located had a burst pipe in June, 2021. It is believed that the device was mistakenly discarded in July, 2021, as part of the clean-up. Rutgers will forward a written report within 30 days." 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 5531617 June 2021 18:07:00The following was received from the New Jersey Department of Environmental Protection (DEP) via email: On June 16, 2021, the DEP was notified that family members were cleaning out the home of a deceased relative, and discovered an item marked "radioactive." The DEP responded on June 17, 2021. The item in question appeared to be some sort of tile, or piece of rock, and was identified as containing Ra-226. There was some removable activity on this item. It was re-wrapped in the lead sheeting it was found in and placed in a plastic bucket, sealed, labelled, and secured in a safe location in the basement (where it was originally discovered), pending proper disposal. The on-contact reading was 4 mR/hr.
ENS 5531517 June 2021 18:07:00The following was received from the New Jersey Department of Environmental Protection (DEP) via email: On Tuesday evening, June 15, 2021, the DEP was notified that a member of the public had come to the Mountain Lakes police HQ to report that he had in his possession some radioactive material that he had obtained 60 years ago when he worked for Westinghouse as an engineer. The material was reported to be "Nuclear Reactor grade U-238 with 5 percent U-235 enriched". The citizen further stated that the material is wrapped in lead foil and placed in a lead pipe with the ends pinched over. The material allegedly consists of three or four rejected pellets, approximately 3/8 inch diameter. These were rejected because of dimensional irregularities. They are allegedly doughnut shaped with a hole in the center. They were reportedly to be used in Westinghouse nuclear reactors/steam power. The citizen stated that the material in question has been stored for decades in a lead pipe, sealed off at the ends, and then tightly wrapped in lead sheeting. It was also clearly labelled with the word "Radioactive" and then placed inside a large can, which has been securely stored in the citizen's garage for several decades. DEP personnel responded to the citizen's home on June 17, 2021. The material was found stored as the citizen had previously described. The container was not opened. There was no detectable removable contamination on the outside of the container. The material was returned to the garage where it will be secured pending proper disposal.
ENS 5485424 August 2020 16:36:00The following is a summary of information received via email: On August 24, 2020, the licensee notified the New Jersey Department of Environmental Protection of two lost sealed sources. The sources had been sent from the licensee's Austin, Texas facility to their Fair Lawn, New Jersey facility, and are reported as missing by the shipper. The two sources were Ni-63 foil sources with an activity of 10 mCi each (S/N: AO-2484 and AO-5478). Each source was in a Life Technology Holdings, model Trace 1300, electron capture detector (S/N: 719420216 and 719420261). The shipper has been searching for the sources, but at this time considers them missing with little likelihood of recovery. The shipper's tracking system indicates that the sources were delivered to the licensee's Fair Lawn facility, but that location has stated they never received the sources. The address to which the sources were reportedly delivered does not exist and the person who reportedly signed for the package is unknown to the licensee. 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 5453521 February 2020 10:30:00The following was received from the state of New Jersey via email: A local Police Department informed (NJ Department Radioactive Materials Program) that a suspicious package was discovered behind a deli/apartment building. Hazmat officials responded. The package was identified as the transport container for a portable moisture density gauge. Labeling on the container identified the gauge as a CPN International, Inc., MC Series Portaprobe, serial number M380404223. The labeling further stated that the gauge contained a Cs-137/Am-241/Be source. The listed activities were 10 mCi of Cs-137 as of 11/19/97 and 50 mCi of Am-241/Be as of 6/6/97. The shipping container appeared intact, with appropriate cautionary labeling. The highest exposure rate reported was 0.9 mR/hr at two feet from the container. The licensee reportedly told officials on the scene that they were out of business and could not explain how the device got to the location where it was found. Due to the lack of security that allowed the device to be moved to the location where it was found, we were not confident that the licensee would be able to secure the item if it was returned to them. The hazmat team secured the device overnight at their office location. The device will be secured pending completion of the investigation and subsequent proper disposition of the device. The State of New Jersey Department of Environmental Protection's Bureau of Environmental Radiation was notified.
ENS 5394318 March 2019 14:09:00The following was received from the state of New Jersey by email: The Pennsylvania Department of Environmental Protection informed the New Jersey Department of Environmental Protection that a load of scrap metal from the John Blewett company in Howell, New Jersey set off the radiation alarm at Sims Metal Management in Morrisville, Pennsylvania. Sims rejected the load and it was returned to Blewett in Howell via a U.S. DOT special permit. Once returned to Blewitt, the load was dumped and what appeared to be the instrument panel from a World War II era plane was found to be the cause of the elevated readings. Based on readings taken at the site, it is estimated that the panel contains 61 microCi of Ra-226. The highest reading seen was 12.5 mR/hr on contact. Some of the glass covering over a gauge was broken. A gross wipe test indicated removable contamination was present. Those individuals who had touched the panel were checked for contamination or advised to check. The area where the panel had been originally placed was also checked, with slightly elevated readings discovered. All surfaces were cleaned to background levels, as well as the area where the panel had been originally secured. The panel and all items involved in the clean-up were placed in a five-gallon bucket and will be secured pending proper disposition through a waste broker.
ENS 5387413 February 2019 13:29:00The following was received from the state of New Jersey via e-mail: While receiving treatment with an Elekta Leksell Gamma Knife Perfexion unit, serial number 6016, the patient's head may have slipped forward in the stereotactic frame by two millimeters. This was not noticed until after the treatment was completed. The licensee is not sure when the slippage occurred. If the movement occurred during treatment, the dose received would have been 50 percent of the prescribed dose. The authorized user and authorized medical physicist are in discussions with the Radiation Safety Officer concerning the matter. The licensee will follow-up with a full report. 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 5384725 January 2019 10:37:00The following was received from the State of New Jersey via email: While a dosage of samarium-153 Quadramet was being administered to a patient, no one noticed that there was a crack in the locking assembly of the IV tubing connection. As a result, when the material was being administered, most of it leaked out of the assembly, rather than being administered to the patient. This resulted in the patient receiving only 2.35 mCi of the prescribed dosage of 58 mCi. This caused a reportable underdosage. The physician has been informed and all the necessary involved persons involved have been supplied with this information. The licensee will follow-up with a full report. 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 5369224 October 2018 10:45:00The following was received from the State of New Jersey via email: A reciprocity licensee informed (New Jersey Department of Environmental Protection Radioactive Materials Program) that during a routine preventive maintenance and source exchange of a (high dose rate) HDR unit at a hospital, the sealed Ir-192 source was found to be leaking. Upon discovery of the leakage, the source exchange was halted. The sealed source is a model 105.002 Ir-192 source manufactured by Alpha Omega Services, Inc. for use in an Elekta HDR microSelectron model 106.990, serial number 10362. The wipe test revealed the presence of 190 Bq on the check cable and 183 Bq on the source cable. Checks of the transfer tubes were within regulatory limits. Checks on the applicators used and the indexer cap are being conducted. The source is secured in its shielded position within the HDR unit. Exposure levels are normal for a shielded source. The unit itself is secured in its routine storage location. There are no HDR patient treatments scheduled for the next two weeks. This should be sufficient time for the levels of contamination to decay to below regulatory limits. At that time, the source exchange will proceed. A phone call and follow-up e-mail was made to the State of New Jersey Department of Environmental Protection's Bureau of Environmental Radiation.
ENS 5268618 April 2017 10:17:00The following information was received from the State of New Jersey via facsimile: The RSO (Radiation Safety Officer) for this cardiology office called to report a lost/missing Cs-137 dose calibrator vial source. Control of this facility was recently transferred to a medical center. When the new RSO visited the cardiology office to become familiar with it, it was discovered that the Cs-137 source was missing. The source, as listed on the cardiology office's inventory, contained 199.04 uCi (microCuries) of activity as of its calibration date of 9/1/2005. The decayed source would contain approximately 152.2 uCi (microCuries) of activity as of the date of this notification. The manufacturer and model # of the source were not immediately available. The RSO will follow-up with a written report within 30 days. 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 5172811 February 2016 15:38:00The following information was received from the State of New Jersey via fax: One of the hospital's authorized medical physicists reported that a patient was due to receive a therapeutic treatment from the center's HDR (High Dose Rate) unit. During administration of the fraction, there was a device malfunction. The source was safely returned to the shielded position, but the patient did not receive the prescribed dose for the fraction. There was an underdose. The patient and the patient's physician have been informed. The unit is a Nucletron MicroSelectron Model 106.990. Additional details will be forthcoming from the hospital. 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 516365 January 2016 16:13:00The following was received from New Jersey via fax: The hospital's Radiation Safety Officer reported that a patient was due to receive a therapeutic treatment of Y-90 SIR-Spheres. The prescribed dose was 10.5 milliCuries to the left lobe of the liver. The dose administered was only 65% of the prescribed dose. Approximately 3.2 milliCuries remained in the vial after the administration was completed. The patient was underdosed and has been informed. Additional details will be forthcoming from the hospital. 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 513673 September 2015 16:09:00The following information was provided by the State of New Jersey via email: At approximately 1145 (EDT) on Thursday, September 3, 2015, the licensee's Administrator/Radiation Safety Officer was contacted (by the State of New Jersey) to discuss several issues related to the re-location of their office. One of the issues raised was the location of several dose calibrator vial sources and gamma-camera flood sources that were last known to be in the possession of the licensee. The licensee had not provided confirmation that the sources had been moved during their office re-location or had been disposed of properly. The licensee stated that their consulting physicist was taking care of the sources. When informed that the consultant had been contacted and did not know the location of the sources, the licensee stated then they did not know where they were either. As such, the sources are considered lost. Of the sources unaccounted for, only the above listed Cs-137 vial source was of sufficient activity to warrant a report. The vial source in question is a North American Scientific, Inc., model MED 3550, serial # 28809, 205.6 microCi as calibrated on 10/1/02. 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 4920318 July 2013 09:30:00The following information was obtained from the State of New Jersey via email: At 11:30 a.m. (EDT) on July 16, 2013, a patient was being treated for three lesions with an Elekta Leksell Gamma Knife Perfexion unit, serial number 6016, at Cooper Health System in Camden, New Jersey. The prescribed total dose for all three lesions was 58 Gray. The first two lesions were treated as planned without incident. During treatment of the third lesion, treatment was interrupted because of mechanical failure. A 'Sensor Failure' error occurred, which caused the patient couch to retract and the shielding doors to close. An Elekta service engineer was called and no other treatments were attempted after the 'Sensor Failure'. Treatment of the third lesion was to be re-scheduled. It is estimated that only 44.8 Gray out of the prescribed dose of 58 Gray was actually delivered, which is an underdose of greater than 20%. 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 491808 July 2013 14:37:00The following information was obtained from the State of New Jersey via email: At approximately 1:30 p.m. (EDT) on Monday, July 8, 2013, the consulting health physicist for Hopewell Radiology Group called to inform the NJDEP's RMP (New Jersey Department of Environmental Protection Radioactive Materials Program) that a sealed vial source originally containing approximately 209 uCi of Cesium-137 on June 1, 2001, was found to be leaking. The source was manufactured by Eckert & Zeigler and has a serial number of 747-33-46. A routine semi-annual leak test of the source revealed the presence of 0.067 uCi of removable contamination, which exceeds the limit of 0.005 uCi. The source has been removed from service and is secured at the licensee's location. The licensee is arranging for appropriate disposal.
ENS 488138 March 2013 12:54:00A patient was treated with a Varian GammaMed plus iX HDR unit on March 7, 2013. The prescription dose was 700 cGy per fraction for 2 fractions, with a prescription dose of 800 cGy for a third fraction. The first two fractions were delivered to the patient as planned, the first fraction on February 26, 2013 and the second on February 28, 2013. The third fraction was to be delivered via tandem and ovoid. The planned tandem dose of 613 cGy was successfully delivered, and the source returned to its shielded position. However, prior to delivery of the ovoid dose of 187 cGy, the HDR unit displayed an error message of 'Electronics Defective error.' The staff could not correct the error. The manufacturer was notified and a service technician arrived later in the day to correct the problem. The remaining portion of the fraction was cancelled for the day and re-scheduled. The fractionated dose delivered differed from the prescribed fraction by 23.37%. The Varian service technician arrived later in the day and replaced the unit's indexer board, cleaned the indexer belt, tested a spring for tightness and re-set the wheel on the belt. The unit then functioned properly. 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 4773713 March 2012 11:22:00The following information was received from the State of New Jersey: A patient was treated with a Nucletron microSelectron 106.990(v3) HDR unit on March 12, 2012. The prescription dose was 600 cGy per fraction for 5 fractions. The fractional treatment planned was for a total of 14 dwell positions in two different catheters: six dwell positions in the ring to be treated on HDR Channel 1 and eight dwell positions in the tandem to be treated on HDR Channel 3. After all appropriate QA, the patient treatment was started with Channel 1 being the first set of dwell positions treated. At the completion of the Channel 1 treatment, the HDR unit gave an error stating that there was a 'Possible incomplete source retraction in Channel 2.' Even though all radiation indicators did not detect the presence of radiation, and even though the licensee was not using Channel 2, immediate emergency procedures were implemented. The emergency stop was activated and the room was entered with a survey meter to verify that there was no elevated radiation present. All indications were that the source was retracted properly and that there was no danger to the patient or the staff. The error displayed on the treatment screen indicated that it was possible that dust was on the optocoupler, thus causing the fault. However, the error could not be cleared by using the reset button. Nucletron was immediately contacted. Nucletron support personnel attempted to walk the licensee through some steps that may have cleared the error, but they were unsuccessful. Therefore, the remaining part of the patient's treatment was aborted. Nucletron scheduled one of their service engineers to respond to the licensee's facility to repair the unit. The authorized user informed the patient that the complete treatment was not delivered due to the machine malfunction and that the authorized user would determine what action to take on the future fractions. The patient and the treatment room were surveyed prior to release. No elevated readings were observed. The patient received 120 cGy (versus the prescribed dose of 600 cGy). The deviation from the written directive was documented in the patient's chart. 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 4689225 May 2011 16:53:00The following information was received via email: At approximately 3:30 p.m. on Wednesday, May 25, 2011, the radiation safety officer (RSO) of Nuclear Diagnostic Products of Philadelphia called to inform the (New Jersey Department of Environmental Protection's Radioactive Materials Program) NJDEPs RMP that a sealed rod source containing approximately 2.68 microCuries of cobalt-57 was unaccounted for at their facility. The source had been returned to the licensee by one of their customers for disposal. The source was secured at their location prior to being shipped for final disposal. In the interim, the room where the source was being secured was painted and materials were moved to a different room while the painting activities occurred. The painting activities began about three weeks ago. When the removed materials were returned to the room after the painting was concluded recently, the source could not be found. A search was conducted by the licensee, but, to date, the source cannot be located. The licensee believes the box that contained the source was either inadvertently placed in the garbage for routine disposal or the source was placed into a sharps container for incineration with biohazard materials. The licensee will continue to look, but informed us of the matter after what they believe is a comprehensive search. 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 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
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