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| Entered date | Event description | |
|---|---|---|
| ENS 57190 | 24 June 2024 17:46:00 | The following information was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Department) via email: On June 24, 2024, the Department was notified that on June 4, 2024, an I-125 seed for breast localization was not recovered during routine tissue processing of the tissue sample at the grossing bench or within the histology lab. The seed was verified in the tissue sample at the time of removal from the patient through both survey of the patient and a radiograph of the tissue sample. The seed was most likely disposed of either in the biohazard waste or in the non-biohazard waste. Upon discovery of the lost source, a survey of the lab with a low energy gamma detector was performed in an attempt to locate the source. The source was not found. Exposure to the public is expected to be very low or minimal. The low energy X-rays associated with I-125 decay are likely to be attenuated due to overlying waste, minimal time around the waste, and the given low exposure rate associated with the source. The material is encapsulated. Utah Event Report ID: 240004 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 56762 | 27 September 2023 19:33:00 | The following information was provided by the Utah Division of Waste Management and Radiation Control (the Division) via email: During a routine radioactive materials inspection on September 27, 2023, the Division was informed that a gauge was damaged by a piece of equipment which cracked the gauge's casing in May of 2023. The incident was not reported to the Division by the licensee as they believed the event was not reportable. The Division is waiting for additional information pertaining to the incident and will provide an update once the information is received. Utah Event Report ID number: UT 230007 The following additional information was obtained from the Utah Division of Waste Management and Radiation Control in accordance with Headquarters Operations Officers Report Guidance: The location is listed as 'Unknown' since the location where the portable gauge was in use when it was damaged is currently unknown but will be provided once that information is received.
The following information is a summary of an email provided by the Utah Division of Waste Management and Radiation Control (the Division): After review of additional information provided to the Division by the licensee, it was determined that the gauge only received minor damage to the gauge casing. All equipment of the gauge necessary for safety worked as intended. Therefore the event was not reportable and requested by the Division to be withdrawn. Notified R4DO (Kellar), NMSS Events (email). |
| ENS 55555 | 2 November 2021 22:06:00 | The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email: The licensee was at a temporary jobsite and stepped away from their vehicle. An unknown man ran up to the vehicle and stole the truck and its contents. At the time the truck was stolen, a Moisture Density Gauge containing licensed material was secured in the bed of the licensee's truck in its transportation case. The licensee notified the police and has begun actions to recover the gauge. The Division is waiting for additional information from the licensee. Utah Event Report ID Number: UT 210006
The following information was received via e-mail: At the time of this notification (UT 210006) we did not have information pertaining to the gauge. Please see the following gauge information. Model: Instrotek 3500, Serial Number: 3823, Cs-137: 11 mCi, Am-241: 44 mCi. The licensee has recovered the stolen gauge. The gauge was still locked and chained in the transport vehicle in it's transport package and had not been tampered with. The Division will update and send the NMED report once the event is closed. Notified R4DO (KOZAL), NMSS Events Notification group (email), and ILTAB (email). THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 55014 | 30 November 2020 18:13:00 | The following was received from the state of Utah via email: The licensee indicated that while conducting an inventory of their radioactive devices it was discovered that a small Static Control Device (SCD) was missing containing an estimated 16.27 mCi, Po-210 source, manufacturer: NRD, model: 1U400. The source was licensed and distributed under a general license. The licensee believes the SCD may have been disposed of as lab waste, been moved to a different location within the building, or was inadvertently added to a field project kit that has not been located. The current location of the device is unknown. Event Report ID No.: UT 200002 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 53466 | 21 June 2018 18:12:00 | The following was received from the state of Utah via E-mail: On June 21, 2018 at 1335 MDT, Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (DWMRC), received written notification from the Church of Jesus Christ and Latter-Day Saints that on June 21, 2018 four tritium exit signs were discovered to having been sent to the landfill for disposal. The licensee will continue to investigate the incident and will submit a written report to the DWMRC. Utah Event Report ID No: UT180004. |
| ENS 53458 | 15 June 2018 16:55:00 | EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT The following was received from the State of Utah via email: The licensee informed the State of Utah they are evaluating a potential medical event. A patient was implanted with 54 Pd-103 seeds in the prostate under ultrasound guidance. Per standard practice, the patient returned for a CT scan to verify the placement of the seeds. The CT scan revealed that 32 of the seeds had been implanted outside of the prostate. In addition, only 51 seeds were located, likely the result of 3 seeds being passed via stool. They believe that several additional seeds are in the rectum and will be passed following an enema. Utah Event Report ID No.: UT180003
The following update was received from the State of Utah via email: The licensee reported a medical event involving a patient treated for prostate cancer. The treatment included implanting 54 Pd-103 brachytherapy (seeds) (Theragenics, Theraseed) containing a total activity of 4 GBq (108.167 mCi), in the patient's prostate for a prescribed therapeutic radiation dose of 12,500 cGy (rad). The prostate gland only received approximately 1,000 cGy (rad). The seeds were implanted on June 14, 2018 under ultrasonic guidance. On June 15, 2018, the patient returned to the facility for a post implant CT scan. The scan showed that the implanted seeds, although in an appropriate pattern, were placed outside the intended target. The Licensee's Radiation Oncology group determined that an additional quality assurance review was warranted. The State performed a reactive inspection during the week of June 15, 2018. The cause was determined to be human error. An unintended dose to the rectum of approximately 18,677 cGy (rad) was received, where no dose was anticipated. Corrective actions included changes to the prostate brachytherapy protocol to incorporate an additional step to ensure the medical physicist and authorized user clearly identifies the prostate gland and the surrounding anatomy. The treatment will be cancelled if the prostate gland and surrounding anatomy cannot be visualized adequately. Notified R4DO (Deese), INES Coordinator (Milligan), and NMSS Event Notifications via email. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| ENS 52970 | 15 September 2017 08:15:00 | The following report was received by email: On September 14, 2017, the licensee discovered that two exit signs containing H-3 were missing. The licensee searched their facility and asked individuals about the location of the exit signs, but were unsuccessful in finding them. The licensee then notified the DWMRC (Department of Waste Management and Radiation Control) of the missing signs. The licensee will continue to investigate the incident and will submit a written report to the DWMRC. Manufacturer: Forever Light Model: unknown Serial #: 281280 and 281278 Acquired by the licensee in 2005 (activity 11.21 Ci) Utah Event Report ID No: UT170006 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 52816 | 21 June 2017 13:51:00 | The following State of Utah report was received by email: The licensee delivered a 500 cGy fraction of HDR (High Dose Rate) brachytherapy to a site adjacent to the intended target. This treatment was a supplemental boost to external beam radiotherapy, and the mistreated volume was included in the target volume of the external beam plan. The State of Utah was notified of the event on June 21, 2017 by electronic mail opened at 1125 MDT. Utah Event Report ID No: will be provided in follow up report.
The following information was received via e-mail: The licensee name needs to be changed from 'University of Utah, Radiological Health Department' to 'Jordan Valley Medical Center, LP'. Notified the R4DO (Gaddy) and NMSS Events Notification via e-mail. 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 52673 | 11 April 2017 14:28:00 | The following information was received from the State of Utah via email: (University) Radiological Health personnel responded to an incident involving a damaged tritium exit sign at the University Guest House. It was determined the damaged exit sign was leaking tritium and the licensee notified the (Utah) Division of Waste Management and Radiation Control. This incident report is the initial notification of the NRC Operations Center. Utah Event Report: UT170003 |
| ENS 52164 | 9 August 2016 18:41:00 | The following was received from the State of Utah via email: On July 19, 2016, the licensee (University of Utah) was performing a 6-month inventory of the H-3 exit signs, when the individual performing the inventory noticed that one of the signs was missing. The licensee left a message with the University's facilities management office to see if the sign was removed by them. On August 4, 2016, the licensee was informed by the (facilities) management group that they had not removed the sign. The licensee then determined that the sign was missing and presumed stolen. The licensee notified the DWMRC (Division of Waste Management and Radiation Control) of the missing sign on August 9, 2016. The licensee will continue to investigate the incident, and will submit a written report to the DWMRC. The DWMRC will possibly perform an investigation on August 10, 2016. Manufacturer: Safety Lite Corporation Model: unknown Serial #: 025297 Activity on manufacture date: 20 Ci of H-3 Utah Event Report Number: UT160003 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 51598 | 10 December 2015 19:43:00 | The following information was received from the State of Utah via email: The licensee stopped and parked their truck in Cottonwood Heights, Utah. Licensee personnel stepped away from the truck but left it unlocked and running. An unknown man ran up to the vehicle and stole the truck and its contents. At the time the truck was stolen, a Troxler Moisture Density Gauge containing licensed material was secured in the bed of the licensee's truck in its transportation case with the source rod locked (gauge and source information listed below). The licensee notified the police and has begun actions to recover the gauge (Cottonwood Police Department, Case Number 15x7206). Troxler Moisture Density Gauge: Gauge Serial Number: 12386 Source Information: CS-137 (8.7 mCi) S/N: 50-0529 Source Information: Am241: BE (40.0 mCi) S/N: 47-7684 This incident is still being investigated (by the State of Utah). Utah Event Report ID No.: UT150009 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 50547 | 17 October 2014 11:54:00 | The following information was provided by the State of Utah via email: Event Description: The licensee failed to properly secure a moisture density gauge in a locked transportation case before leaving a temporary jobsite in a pickup truck. The device fell out of the truck onto the road. The licensee has not been able to locate the device. The local law enforcement agency has been notified. The event location was 900 East and 5200 South, Murray, Utah. The device is a Troxler Model 3440, Serial number - 69079. This device contains 8 mCi of Cs-137 and 40 mCi of Am-241. UT Event Report ID No.: UT140004 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 50342 | 5 August 2014 11:28:00 | The following information was received via E-mail: The Assistant Radiation Safety Officer (ARSO) of Mistras reported to the Division of Radiation Control (DRC) that a radioactive source could not be returned to the shielded position in a radiography camera. The radiography technician failed to connect the guide tube to the stiff extension they were using to make superimposed exposures. When the technician cranked out the source, he cranked the cable past the assembly gear and could not retrieve the source. The technician then roped off the area of the incident to ensure individuals did not enter a high radiation area, and informed personnel at the refinery that an incident had occurred. The ARSO was then contacted and informed of the situation. The ARSO arrived on the scene of the incident and performed surveys near the exposure device to determine what the high and low levels of radiation were. The ARSO selected a spot where he could reach the radiography camera's crank handle that was in an area with a dose rate of 4 mR/hr. The ARSO used a hack saw to cut the crank handle off of the guide tube. Once the crank handle was removed, the ARSO pulled the guide cable to retract the source back into the camera's shielded position. The camera was then surveyed and returned to the licensee's storage facility. No personnel involved in the incident received exposures in excess of the regulatory limits. On May 30, 2014, at approximately 5:00 pm (MDT) the DRC inspectors arrived at the Mistras's facility. The inspectors interviewed personnel involved in the event and collected statements. The inspectors took photographs of the exposure device, collimator, and performed surveys of the camera. The inspectors confirmed that the radioactive sealed source was stopped in the camera's shielded position. Radiography exposure device information: Model INC-100, S/N 4419. The radiography camera contains a 68 Curie Ir-192 source. The event took place at the Chevron refinery located at 2351 North/1100 West, Salt Lake City, Utah. Utah Event Report ID No.: UT140002.
The following event update was received from the Utah Department of Environmental Quality, Division of Radiation Control via email: No personnel involved in the incident received exposures in excess of the regulatory limits. On May 30, 2014, the day after the incident, DRC inspectors interviewed personnel involved in the event and collected statements. The inspectors took photographs of the industrial radiography exposure device and performed surveys of the device. The inspectors confirmed that the radioactive sealed source was stopped in the device's shielded position. Notified R4DO (Campbell) and FSME Events Resource via email. |
| ENS 49555 | 18 November 2013 18:05:00 | The following was received via facsimile from the Utah Division of Radiation Control: The Operations Manager of Hales Sand and Gravel reported to the Division of Radiation Control that one of the licensee's gauge operators was at a temporary job site to perform soil moisture density measurements on November 14, 2013. After taking a moisture density measurement, the gauge operator left the gauge sitting on the ground while he walked away to talk to the roller operator. The gauge was left in the backing up path of Hales Sand Gravel's grader (heavy equipment) and was run over. After everyone was cleared out of the area, the Radiation Safety Officer of Jones & Demille Engineering was contacted to provide a survey instrument. At the time of the incident the radioactive sources were in the safe shielded position. After the gauge was run over, the gauge was broken into two pieces; the source rod was separated from the shielding block but was still in one piece. Upon arrival, the Radiation Safety Officer verified that the radioactive sources were still intact and attached to the source rod. The Radiation Safety Officer added additional shielding to the source rod to prevent the sources from becoming detached. The Radiation Safety Officer then put the damaged gauge and its pieces into the transportation container. After the gauge was loaded in the truck and removed from the job site, the Radiation Safety Officer performed a survey of the area the accident occurred at to verify that no contamination was present. No contamination was found, and the gauge was returned to its storage area in Elsinore, Utah. On November 15, 2013, the Division of Radiation Control's inspector arrived at Hales Sand and Gravel's facility at approximately 1230 (MST). The inspector interviewed personnel involved in the accident and collected statements. The inspector took photographs of the damaged gauge, collected wipe tests, and took surveys of the damaged gauge. The inspector also visited the site of the accident to perform a contamination survey. No readings were distinguishable from background. Gauge information: Troxler 3430, s/n 31986 Event Report ID Number: UT 130004 |