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ENS 5062018 November 2014 09:32:00The following information was obtained from the State of New York via facsimile: A radioactive source or I-125 seed used for localization in breast surgery was misplaced by the Pathology Department at Roswell Park Cancer Institute (DOH# 2923). This event occurred on Thursday, October 9, 2014 and the source was officially determined to be lost on November 4, 2014. Two breast localization seeds (I-125) were not extracted from a specimen on October 9, 2014 by a Clinical Pathology Fellow. The Pathology department did, however, receive written documentation that the seeds were removed from the patient and they were sent with the specimen to the Pathology Department. The seeds were not returned to Nuclear Medicine per Institute Policy. An extensive search and survey was conducted of Pathology, Nuclear Medicine and Environmental Services areas. One of the two seeds was discovered in trash removed from the Pathology department. Further search and surveys of these areas were repeated but to no avail. Trash and regulated medical waste were surveyed and inspected. Over the course of the next few weeks, Radiation Safety surveyed and explored all radioactive waste in an effort to locate the lost source. Aforementioned search and surveys were again conducted without discovery of the missing seed. It was believed that the missing source would eventually be located in Institute trash or more likely Institute radioactive waste. All Institute trash and waste is surveyed for radioactive material. The radioactive waste may be stored in various short and long-term storage locations. Unfortunately, the seed was never found and officially declared lost on November 4, 2014. Corrective Action and Recommendations: 1. The incident was reviewed and discussed with pertinent Pathology staff. A training oversight was discovered and Pathology Department Fellows are now trained to anticipate radioactive seeds in breast surgical specimens and to remove them prior to surgical specimen evaluation. (Required Corrective Action) 2. Radiation Safety and Environmental Services have emphasized the importance of monitoring all trash and regulated medical waste during the annual in-service conducted on August 6, 2014 and again on October 29, 2014. (Required Corrective Action) 3. Any further information regarding this matter will be communicated to the Bureau of Environmental Radiation Protection, NYS DOH (New York State Department of health). (Required Corrective Action) New York State Event Report Number: NY-14-05 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 4958727 November 2013 10:58:00The following information was received by facsimile: Reported to NYS DOH (New York State Department of Health) on 11/12/2013. A patient received two seeds for right breast radioactive seed localization when only one was intended. The patient had two marker clips, a cylinder clip marking a benign biopsy site and a coil clip marking a papilloma. It was intended for her to only receive one seed placed at the papilloma site, but the benign site was marked with a 0.252 mCi iodine-125 seed. A second seed (0.251 mCi) was then placed to mark the correct site. The unintended dose from the 0.252 mCi seed in place for 2 days was 0.61 Gy @ 0.5 cm. Root cause analysis is ongoing. Event Report Identification Number: NY-13-06 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 494012 October 2013 09:52:00The following information was received from the New York State Department of Health (NYS DOH) via facsimile: The source was a seed source for Breast Localization Procedures. The medical procedure occurred on July 12, 2013. A tissue specimen was removed from a patient. The localization seed was identified and removed from the specimen post-surgery. The seed was not returned to the Nuclear Medicine Department per institute policy, which initiated a facility search for the missing RAM (radioactive material). Immediate actions included conducting extensive facility area surveys for several weeks. The source was declared officially lost on August 29, 2013. The root cause involved a failure to follow the facility policy. The seed was allowed to become lost, after it had been properly identified. Corrective actions involve an incident review with the pertinent staff and an in-service refresher training for all staff. The facility has been informed by NYS DOH that this event should have been reported immediately on July 12, 2013. Manufacturer, Best Medical International, Inc., Model No. 2301 I-125, Activity, 140 microCuries. New York State Report ID No. NY-13-05 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 4914524 June 2013 11:06:00The following was received from the State of New York via fax: The RSO of NYS (New York State) Licensee C2274 called to report a moisture/density (Troxler Model 4640-B 'thin layer') gauge was damaged at a worksite in Far Rockaway, NY. The source (8 mCi of 137 Cs) was in the safe position when it got damaged and the source is within the unit as determined by survey meter readings. The operator was about 5 ft. away from the gauge when it was run over by a roller. The RSO visited the site took measurements to confirm the source was still in the gauge. He called the QC Resources and took a leak test measurement. He is awaiting the results before shipping the gauge to QC Resources. A written report is forthcoming. New York State Event Report: NY-13-03
ENS 489922 May 2013 13:31:00A prostate seed implant procedure was terminated after the insertion of 2 needles. Only 5 of 106 intended seeds were implanted (1.55mCi of 32.86mCi). The patient's anatomy (pubic arch) presented interference to the placement of needles/seeds for proper dose distribution. The patient will now be treated with external beam IMRT (intensity modulated radiation therapy) once post implant CT and dose assessment have been performed in approximately 3 weeks. The patient and referring physician have been notified. The facility notified NYS DOH (New York State Department of Health) same day, written report with corrective actions has been received. To prevent recurrence the urologist will verify during planning volume study that there are no anatomical obstructions to needle placement. Report No. NY-13-02 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 4893016 April 2013 13:32:00The following information was received by facsimile: A patient for axillary node dissection with radioactive seed localization had an 8.33MBq 123 I (Iodine) seed placed at tumor site under ultrasound guidance by radiologist. The surgeon successfully removed the tumor and lymph node, however the seed had migrated deeper into tissue and was not removed. The surgeon determined that the new seed location prevented safe extraction due to scarring from previous node removal, mastectomy and reconstructive, surgery. NYS DOH (The New York State Department of Health) received verbal notice within 24 hours and written notice within 15 days. The patient, referring physician, medical oncologist, and radiologist have all been notified. A localized dose at 0.5 cm from the seed of 22.9Gy was calculated, negligible dose at 6 cm. As a corrective action the facility will no longer use radioactive seed localization for axillary node lesions. (Licensee) Policy updates and staff notifications are to be evaluated during the next routine inspection. Event Report Identification Number: NY-13-01 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 4843423 October 2012 11:51:00The following report was received from the State of New York via fax: The Radiation Safety Officer for Materials Testing Lab, Inc. (NYS license no. C2274) called to report that a moisture density gauge (Troxler Model 4640, serial no.1003) was stolen around 9 a.m. today. The New York City Police Department was immediately called but as of 10:45 a.m. they have not responded. The gauge contains 40 mCi of Am-241/Be and 8 mCi of Cs-137. Materials Testing Lab staff are canvassing the area and posting reward flyers with a picture of the gauge. (The RSO) will keep NYS DOH informed of any significant changes to the situation. No press release has been issued at this time. New York City radioactive material program has been notified. NYS DOH Incident: #991 Event Report ID No. NY-12-02 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 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 4791210 May 2012 10:25:00The following information was received from the State of New York via fax: As required by 10NYCRR16.15(a)(1)(ii), Callanan Industries in Ravena, NY called to report a stolen gauge. The gauge is a BSI Instruments model NW-201 gamma gauge. It contains 0.3 mCi of Cesium 137 in sealed form. The gauge was removed from its location above a conveyor line and stored in a container in a warehouse in 2011. At some point in October of 2011 several items of copper were stolen from that warehouse. It is now believed that the gauge was also stolen at that time. Callanan Industries will submit a written report as required under 16.15(a)(2). NYS BERP (Bureau of Environmental Radiation Protection) will review recent reports of scrap metal yard monitor trips. Local police have been notified. A press release has not been issued. A reward has not been offered. NYS BERP internal tracking number for this incident is #970. NY Event Report ID No. NY-12-01 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 473961 November 2011 11:11:00The following information was received by facsimile: NYS Incident 935 - On 10/31/2011 a NY radioactive materials licensee reported a diagnostic misadministration which occurred on 10/13/2011 and discovered on 10/28/2011. A patient undergoing diagnostic imaging of the thyroid using Iodine-123 was administered 4.21 mCi instead of the intended 400 uCi. The estimated dose to the patient's thyroid is 58 rem. This is a preliminary 24 hour notification report. The facility is performing an investigation and root cause analysis. Telephone communications with the facility (and the State of New York) are ongoing. The facility is required to submit a written report within 15 days. New York Event: NY-11-25 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 4699427 June 2011 15:50:00

The following was received via fax: Fairway Testing Co. license no. C2322, called 6/27/11 to report that a Troxler model 3411 s/n 4363 portable density gauge was stolen from a company vehicle on Sunday, June 26. The device contained 8 mCi Cesium 137 and 40 mCi of Americium 241/Beryllium. The employee worked late on Friday, June 24 and did not have access to the permanent storage location since the building is locked after 5:00 p.m. The driver took the vehicle to his residence on Brookside Drive in Stony Point, Rockland County and parked it in his driveway. The device was in its transport container, which was doubly chained to the bed of the pickup truck. On Sunday morning, the employee observed that the container was still in the bed of the pickup before he left his residence for the day in a family vehicle. When he came home that night he did not check the vehicle. On Monday morning, he realized that both chains were cut and the transport box along with the device was stolen. Other items were also stolen from the vehicle which leads to speculation that the perpetrators were not specifically after the density gauge. The local police were notified and a police report has been initiated. The licensee has thirty days to send a written response and to notify the NYS DOH (New York State Department of Health) of any substantial development in the case. NY State Event #: NY-11-11

  • * * * UPDATED AT 1431 EDT ON 7/20/11 BY S. SANDIN * * * *

The following update was received from NY DOH via fax: On 7/5/11, DOH was notified via fax that a load of scrap metal tripped the alarm at Gerdau Ameristeel in Sayreville, NJ. The load was returned to the originator (Teplitz in Nanuet, NY) and then to Orange County Metal recycling (OCMR) in Middletown, NY. OCMR staff identified, isolated and secured the source of the trip and contracted Co-Physics to characterize. In cooperation with DOH, Co-Physics contacted Troxler with model and serial numbers from the item and identified it as the cesium source from the stolen gauge. Fairway Testing and Stony Point Police have been notified. Fairway Testing is aware of its responsibility for proper disposition of the source. The Am-Be source is still unaccounted for. A search of Teplitz is underway. No Reward offered. No Press Release issued. Notified R1DO (Dentel), FSME (White) and Canada via fax. 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 4694510 June 2011 12:01:00The following information was provided by the State via facsimile: The RSO called to report a leaking Ni-63 sealed source in a gas chromatograph. The leak test result was 0.04 microCuries of removable contamination at ECD (Electron Capture Device) inlet. The RSO contacted the manufacturer, Agilent, about this event and they will be making a site visit to investigate. The system was shut down and isolated. The defective detector will be sent back to the manufacturer. There is no apparent cause. The system is only a year old and is used carefully. All other areas surveyed & swiped were negative for contamination. Event #: NY-11-10
ENS 4689025 May 2011 16:33:00The following information was received via fax: Event location: 401 South Oyster Bay Road. Plainview, NY, 11803 (On) 7/15/10, (Bed Bath and Beyond) BBB reported that Shaw Group, Inc. visited Bed Bath and Beyond to package their tritium exit signs for removal. They discovered two signs with letters that did not illuminate. Neither sign showed evidence of damage to the tubes. Both signs were packaged and secured in an electrical room. On June 15, 2010, a Shaw Representative took surveys of the floor and space where the sign was located. All results were below 1000 dpm per 100 square centimeters. Bed Bath & Beyond plans to send the damaged signs to Shield Source, Inc (SSI) and will provide a report within 30 days of the transfer of the damaged signs. A letter received (on) July 30, 2010, showing that the lights were returned to Shield Source, Inc. Incident is closed. New York Event Report ID Number: NY - 11 - 07
ENS 4688925 May 2011 16:33:00The following information was received via fax: Event location: 3064 Route 50, Saratoga Springs, NY, 12866 A tritium exit sign was found damaged on March 31, 2010, at Bed Bath & Beyond in Saratoga Springs. On April 6, 2010, Shaw Environmental Group was granted reciprocity to survey, decontaminate and package the broken sign. All measurements were found to be below MDA. The broken sign was shipped to Shield Source, Inc, a tritium light manufacturer based in Canada. Written report (was) received (on) 4/29/2010. Bed Bath and Beyond has implemented and communicated protocols to its stores for the proper handling of (Tritium Exit Signs) TES. It has also inventoried all of the TES at its sites across the U.S. to re-establish the accuracy of its records and to track the location of TES for proper accounting and handling. This incident is closed. New York Event Report ID Number: NY - 11 - 06
ENS 4688825 May 2011 16:33:00The following information was received via fax: Event location: Utica Compression Station, 1103 Higby Road, New Hartford, NY, 13417 (On) 4/23/10, Dominion Resources called to inform (New York State Department of Health) that one tritium exit sign was found missing after some demolition work at their Utica, NY facility. A written report (was) received (on) 4/29/10. During a company wide effort to inventory all tritium exit signs it was discovered that one was missing at their Utica facility. An investigation ensued, and it was determined that during July of 2009, the entire wall on which the exit sign was located was removed during remodeling. The exit sign was likely disposed of in a 30 cubic yard roll-off container owned by Waste Management and is likely in the local AVA landfill. Dominion is reinforcing and enhancing established processes and programs for handling tritium exit signs. This event will be incorporated into training and lessons learned. All other signs at the facility are accounted for, (and) this incident is closed. New York Event Report ID Number: NY - 11 - 05 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 470201 July 2011 13:15:00The following information was received via fax: On 12/9/2008, the RSO reported that a recent source inventory showed three (Po-210 Static Eliminators) missing from their last known use location. Calculations estimate that they contain less than 10 micro Curies of Po-210 each. Efforts to locate the missing units are continuing. Training is being conducted to prevent recurrence. On 3/22/2010 the RSO reported that the three missing Po-210 static eliminators were located in July 2009. No reward offered. No press release issued. Incident Closed New York Event: NY-11-21 New York Incident: 664
ENS 4689125 May 2011 16:33:00The following information was received via fax: Event location: 14 Parker Hall, 3435 Main Street, Buffalo, NY, 14214 The RSO at (SUNY at Buffalo) called on 08/21/08 to report a leaking nickel 63 sealed source located in a HP gas chromatograph unit. Location of unit is Farber Hall room 2128. Apparently on Monday, August 11, 2008, the researcher was cooking 'stuff' in the oven portion of the unit. Product exploded in the oven and spilled over into the other parts of the unit and landed on the sealed source compromising integrity. Contamination was found in the oven of the unit. SUNY EH&S (State University of New York Environment, Health and Safety) staff performed decontamination of the unit until <100 dpm. No contamination was found outside of the unit. SUNY EH&S staff also surveyed the rooftop of the building as the unit is vented and no contamination was found. SUNY EH&S (gave) the researcher until Friday, 08/29/08 to submit his report of the incident to EH&S. NYS staff visited (SUNY at Buffalo) on 08/26/08 and interview (an individual) who reported that the leak was found during the routine leak testing. When the swipe came back high, he re-swiped the unit and noticed a white powder all over the oven and inside the tubing. (When) asked, the researcher stated that she had dried a silica gel in the oven on 08/11/08. Apparently, the foil cover blew off of the beaker, and the silica gel went all through the machine via an inlet port possibly 'sandblasting' the foil compromising its integrity. Swipe testing by liquid scintillation showed contamination on inlet and outlet and no contamination on the housing or outside the machine. EH&S has decontaminated the machine as much as possible and taken it out of service. EH&S has also contacted the manufacturer of HP 5890. Manufacturer states there is no way to clean it and the machine should be scrapped. EH&S plans to take out the source, scrap metal parts that are not contaminated and hold remaining pieces until a disposal option is available. Written report (was) received (on) 9/11/2008 . The unit (is) to be handled as indicated above, and additionally, all researchers will be in-serviced on keeping the inlet to the foil capped when using ovens for other than GC (gas chromatograph) analysis. Incident is closed. New York Event Report ID Number: NY - 11 - 08
ENS 470181 July 2011 13:15:00The following report was received via fax: 06/11/08 the RSO (Radiation Safety Officer) called to report the inadvertent disposal of a Beckman Liquid Scintillation Counter instrument with the 30 micro-curie source still in place. He was not consulted in March 2008 when the Beckman was removed by a commercial waste hauler. The waste hauler was called to determine the disposition of this instrument. On 07/07/08 the report was received from the RSO. The RSO reported that at this time (several months after pick-up) the waste contractor was unable to provide any information on the whereabouts of this instrument. No reward was offered. No press release was issued. Incident Closed. New York Event: NY-11-19 New York Incident: 617 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 4688725 May 2011 16:33:00The following information was received via fax: Event location: 800 Phillips Road, Webster, NY 14580 Reported to (New York State Department of Health) NYS DOH (on) 11/17/2008. Twelve NRD static eliminators containing polonium 210 were inadvertently thrown out in March 2008. The total activity of all twelve sources would have been 334 microCuries in March 2008. They were most likely sent to Genesee Scrap and Tin Baling Co., Inc., at 80 Steel Street in Rochester as part of a large roll-off of assorted scrap. Attempts to locate the missing devices were fruitless. NRD has been contacted with the serial number information. A written report received from Xerox November 17, 2008. Procedures have been modified to prevent recurrence. Xerox will inventory their sealed sources two times a year to prevent other losses. NRD has been instructed to send correspondence to Xerox RSO regarding shipment of devices instead of the Xerox end user. Incident Closed. New York Event Report ID Number: NY - 11 - 04 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 470161 July 2011 13:15:00The following report was received via fax: Two static eliminators were thrown out during relocation of the process line to another building. NRD (The static eliminator vendor) has been notified in case units are recovered at the landfill. No press release issued. No reward offered. New York Event: NY-11-18 New York Incident: 579 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 470131 July 2011 13:15:00The following information was received via fax: 351 microcuries of P-32 was lost (on 11/9/07). The isotope was checked in, delivered and signed for at the research lab on 11/9/07. When lab personnel went to use the isotope, they could not locate it. Radiation safety staff searched dumpsters, garbage cans, and the lab, but could not locate the vial of P-32. It is possible it was put out as garbage by mistake. The RSO contacted the garbage removal contractor. Written report received on 11/16/07. Although the licensee could not determine the precise circumstances that caused the source to be lost, the corrective action appears to be adequate. No press release was issued. No reward offered. The incident will be reviewed during the next routine inspection. Incident closed. New York Event: NY-11-17 New York Incident: 575 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
ENS 470121 July 2011 13:15:00The following information was received via fax: On 10/29/07, the portal monitor at Nucor Steel alarmed from a load originating at Eastman Kodak. The load contained structural demolition debris. An Exploranium GR-135 identified the source as Radium-226 with a max reading of 210 uR/hr. Eastman Kodak has been notified for follow-up. New York Event: NY-11-16 New York Incident: 571
ENS 470081 July 2011 11:19:00The following report was received via fax: On 10/25/2007, (the New York State Department of Health) received a call from a radiation oncology manager to report a therapy misadministration involving a gamma knife due to a machine malfunction, couch failure. The physicist and the neurosurgeon had to go in and manually pull the couch out. The physicist's badge was read on an emergency basis and showed DDE of 1 mRem and SDE of 2 mRem. The neurosurgeon did not have his badge on when he went in. The facility has treated about 125 patients in 4 years with the gamma knife unit, according to field notes from the inspection done in February 2007 and is close to the 5 year service requirement. The facility had planned to treat 10 lesions in the brain but stopped after 3 lesions were treated due to couch failure. The rest of the lesions were not treated with radiation. The patient had already received whole brain irradiation and received additional chemotherapy after the gamma knife procedure. Service performed: couch repaired. Policy & Procedure regarding film badge use reviewed during next routine inspection. This event is closed. New York Event: NY-11-15 New York Incident: 570 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 470061 July 2011 11:19:00The following report was received from the state via fax: On 6/5/07, the NRC (Nuclear Regulatory Commission) called to report a Troxler gauge for sale on E-Bay. The gauge was listed as a Troxler 4640-B which contains a source of up to 9 mCi Cs-137. The seller listed the item as being in NY so the NRC contacted NYS DOH (New York State Department of Health). After reviewing the item description it appeared to match an item that had been reported as stolen. E-Bay was notified as well as the NYPD. The item was delisted from the auction site and the seller was contacted by the NYPD to recover the device. The gauge for sale was determined to be one reported stolen from a licensee on 6/9/03. The gauge was recovered on 6/5/07 from a garage in Valley Stream, NY by NYPD with assistance from Nassau Co. PD and FBI. The licensee took possession of gauge on 6/6/07 from NYPD. The gauge (was) sent for maintenance and inspection prior to (being) returning to service. The NRC was notified. New York Report: NY-11-14 New York Incident: 544
ENS 470091 July 2011 13:19:00The following report was received via fax: On February 07, 2007 the RSO called to report a missing ECD (Electron Capture Device) detector. Apparently the entire GC (Gas Chromatograph) was discarded as obsolete equipment in the November / December 2006 timeframe. The RSO is looking into the disposition which he believes was a dumpster / roll-off that went to the Port of Albany. Fortunately Ni-63 has a low health and safety risk compared to other common isotopes. The date of occurrence has been estimated as 11/30/2006. The date of discovery is 01/31/2007. No press release issued. No reward offered. Better training and inventory instituted as corrective action. Actions evaluated during next routine inspection. Incident closed. New York Event: NY-11-12 New York Incident: 504 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 470191 July 2011 13:15:00The following report was received via fax: The licensee submitted a written report June 11, 2008 documenting the loss of 31 mCi of tritium and 0.6 mCi of carbon-14 which had been discovered missing in May 2008. In September 2004, an incoming scientist brought the materials with him to Wadsworth. Since he was not an authorized. user, the RSO placed the material in a freezer in the chemical storage room. In May 2008 the RSO discovered the materials missing and initiated a thorough investigation. Unfortunately the disposition of the materials remains unknown. The RSO has implemented corrective actions which include; better inventory practices, increased vigilance over materials in long term storage with an eye towards proper disposal, and no 'general' storage of materials. No reward offered. No press release issued. Incident Closed New York Event: NY-11-20 New York Incident: 619 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
ENS 4689526 May 2011 14:29:00The following information was provided by the State of New York via email: A patient was prescribed 11 mCi of Iodine-131 for hyperthyroidism but received 7 mCi. Discovered during routine NYS DOH (New York State Department of Health) inspection on 10/18/2007. DOH staff reviewed a memo from the physicist to the RSO discussing the event, but their concern was only that the expiration date on the capsule was 12/28/04 (consultation with the pharmacy after the fact indicated that it was still acceptable to us this dose). A 'left-over' capsule from the previous week (15 mCi on 12/27/2004) with activity of 7 mCi on 01/01/2005 was administered to a patient who was prescribed 11 mCi with the permission of the RSO. Additional dose was ordered and an additional 4 mCi was administered the following day so they RSO did not think it was a misadministration. Follow-up letter from RSO concluded that there was no adverse effect on the patient. Corrective actions included changing procedures and staff training on proper course of action to take in the future and incident reporting requirements. Incident is closed. New York Report Id No.: NY-11-09 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 470041 July 2011 11:19:00The following information was received from the State of NY Bureau of Environmental Radiation Protection via fax: The state received notification 03/06/2007 that static eliminators were lost sometime around 8/3/2001. SMSC (Standard Microsystems) suspects that they were inadvertently shipped to Delta Design because they were placed inside Delta Flex Handlers and were not visible from the outside. Delta Design presumes that the sources were scrapped sometime after 2001. The activity of the Polonium-210 at that time was less than 45 microcuries. The written report from SMSC indicates that 5 NRD static eliminators, model P-2042, s/n SP101713 thru SP101717, each containing 5 milliCuries on 3/9/1998 were disposed. Decay corrected activity of each foil is less than 1 nanocurie. No further action is warranted. New York Incident: 519 New York Event: NY-11-13 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
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