Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 56575 | 15 June 2023 09:10:00 | The following information was provided by the Georgia Department of Natural Resources (the State) via email: On June 12, 2023, (the licensee) notified the State that they had discovered a stuck shutter on one of their fixed gauges (Ohmart Corp 4/2000 containing 100 mCi of Cs-137) that morning. The (licensee) had a service vendor repairing the handle of the gauge, and when they went to shut the shutter it wouldn't shut. They attempted to lubricate the shutter to get it to move, but it still would not close. It was determined that the issue will not cause undue exposure or risk to personnel. The vendor is sourcing the parts required for repair. As soon as the part is delivered, they will return to the site and replace the mechanism. Until then, the gauge will remain on the pipe with a notice attached to it, informing personnel of the issue to not interact with the gauge. Georgia Incident Number: 66 |
| ENS 56528 | 19 May 2023 12:23:00 | The information below was provided by the Georgia Department of Natural Resources via email: During a routine sealed source inventory check, Cardiac Consultants of Central Georgia, LLC, license GA 1629-1 discovered that one of their Cs-137 vials (S/N 1615-4-2) appeared to display signs of moisture within. This source's current activity is 0.15078 mCi. A wipe test was then performed. Results of the wipe test confirmed that this source was leaking. The area surrounding the source was surveyed and wipe tested as well. No sign of contamination was discovered. The leaking source has been contained and is secured in the licensee's hot lab in an appropriate shielded container. The licensee waits for a hazardous waste disposal quote before properly disposing. This incident occurred on May 11, 2023, and the licensee reported to the State on May 15, 2023. The State is waiting for the licensee to provide a copy of leak test results for the source of concern and confirmation of source disposal. GA Incident Number: 65 |
| ENS 56240 | 25 November 2022 15:04:00 | The following information was received from the Georgia Radioactive Materials Program via email: We received an emailed report of a misadministration, where there was over 50 percent deviation of the prescribed dose. The patient received only 10 percent of the (redacted) prescribed fractioned dose due to equipment malfunction. The patient is scheduled to receive the remainder of the dose at a later time. The licensee will conduct a thorough investigation and provide a formal report as soon as possible. We are still pending the source activity information and event date. We will update as more information comes in. Georgia incident no.: 61
The following is a synopsis developed from information provided by the Georgia Radioactive Materials Program via email: Was source able to be retracted to safe position? Yes Manufacturer and Model number of HDR: Elekta's Flexitron Serial number: 00625 Source activity (8.9 Ci); Prescribed dose (750 cGy); Delivered dose (12.7 cGy) Root Cause: Equipment failure. Assessment by Elekta's field service engineer determined that the Flexitron selector assembly should be recalibrated including lubrication of all brackets on the assembly. Corrective Action: Recalibration. Following recalibration of the Flexitron selector assembly, the treatment unit functions correctly. Spot checks performed by physics confirmed normal operation of the treatment unit. The treatment unit reentered clinical service the following day and this patient was successfully treated on 11/21/22 for their third fraction and they finished treatment on 11/23/22. Notified: R1DO (Cahill). Notified via email: NMSS Event 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 56065 | 24 August 2022 12:51:00 | The following information was received via email: The Georgia Department of Natural Resources, Environmental Protection Division, Air Protection Branch sent this as notification that a lost portable gauge reported. The incident occurred 8/23/22 around lunch time and was reported to (Environmental Protection Division) (EPD) at (1530 EDT). The gauge is a Humboldt Model 5001. It is currently unknown which Isotope it contained or its activity (Cs-137 or Am-241). The gauge user was onsite and had placed the gauge on the tailgate of his truck. He left for lunch and when he got to the location, realized he had forgot to secure the gauge in it's transport box. The gauge was no longer on the vehicle. He reported the lost gauge to the local police and went back to look for the gauge. (The driver was unable to locate the gauge). We (EDP) are following up for more information, but wanted to meet our reporting requirements and inform you of the loss. The following additional information was obtained from the state in accordance with Headquarters Operations Officers Report Guidance: The license number, the county, and the worst case scenario activity for the Humboldt Model 5001 gauge (44mCi of Am-241). 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 55829 | 7 April 2022 16:58:00 | The following was received from the State of Georgia, via email: Graphic Packaging International called us this afternoon to report a missing gauge. The gauge is a Berthold Model LB7441 S/N 2212 and is believed to be about 41 milliCuries. It is unknown to us at this time if the source is Cobalt-60 or Cesium-137. The last leak test was conducted on December 13, 2021. The licensee says that the gauge was installed on a part of the line that they haven't used in a long time. The Radioactivity Safety Officer (RSO) went to that part of the line to clean the tags and discovered that entire end of the line was gone. They have been having demolition work done, so it is his belief that the gauge was in the demolition. The demolition company is Grey Wolf. We are following up with the licensee and the company for more information and will keep you informed. Georgia item number: N/A 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 55382 | 28 July 2021 13:36:00 | The following was received via email from the Georgia Radioactive Materials Program: During a routine 6 month leak test, a sealed source Cs-137 vial (0.035 milli-Curie) failed the leak test. (Leak Test Results: less than 0.005 micro-Curie.) Damage was detected on the vial and the source was immediately placed back into its shielded container and sealed with tape. All potentially contaminated items such as gloves were triple bagged, sealed, and labeled and placed in a shielded storage container in the hot lab. Area surveys and wipe tests were conducted and no contamination was found. The licensee is obtaining quotes for disposal and will follow up when the source has been disposed of. Georgia Incident Number: 44 |
| ENS 55309 | 16 June 2021 10:14:00 | The following was received from the Georgia Radioactive Materials Program (Agency) via email: Hurst Boiler Welding Company used (a common carrier) to ship a source changer back to QSA Global. It was shipped on May 19, 2021, and officially declared lost on 6/14/21. Hurst Boiler reported the loss to (the Agency) on 6/16/21. The licensee intended to ship a source changer back to QSA global via (a common carrier) on 5/19/2021. After approximately 14 days without a confirmation of receipt. The licensee contacted (the common carrier) on 6/14/21, who confirmed the source had been lost. The Radiation Safety Officer (RSO) then contacted (the Agency) on 6/16/21. When speaking with the RSO by phone, he stated the source changer contains an Ir-192 source (Serial # 9887G Model SC-800). The source activity when shipped (5/19/21) was 8.3 Ci and as of 6/16/21 it has decayed to 6.3 Ci. The most current leak test was performed on 8/31/21. The RSO was advised to provide a written report and submit all supporting documents as soon as possible. Georgia Incident #41
The source has been retrieved in North Carolina. The following e-mail was received from the North Carolina Department of Health and Human Services in regards to finding the lost source: (The common carrier) confirmed with our staff this morning that the shipment was located in Durham, NC. It had been delivered to an incorrect shipping warehouse. (The common carrier) will be picking it up from that location later today and getting it back on route to the vendor in Massachusetts. The error was discovered by reviewing video footage and noticing it being loaded to the truck bound for Durham. Notified R1DO (Lilliendahl), NMSS Events Notification (E-mail), and ILTAB (E-mail) THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 54662 | 13 April 2020 12:21:00 | The following was received from the state of Georgia via email: An Iodine-125 seed (assayed at 69 microCuries on March 24, 2020 (Best Model 10172-11, Double wall titanium encapsulated, Serial Number: 49802A20)) used for breast lesion localization was shipped within a tissue specimen from Piedmont Fayette Hospital to Piedmont Atlanta and then lost into the ordinary solid waste stream, rather than being recovered and placed in decay-in-storage at Piedmont Fayette, as is the standard procedure. The seed was implanted in a patient with a breast lesion at Piedmont Fayette on March 24, 2020. The lesion containing the seed was successfully removed in surgery and sent to the pathology lab on March 30, 2020. The presence of the seed in the specimen was verified in pathology by Neoprobe measurement. There was no pathology physician assistant present that day and the pathologist was not notified. A lab staff member arranged for all specimens to be shipped to Piedmont Atlanta. The specimens, including the one containing the seed, were shipped by MedSpeed courier service that same day. At the Atlanta campus, the specimen with the seed was processed by the normal procedure on April 1, 2020. The histotechnologist there removed what he thought was a marker or a clip and discarded it in the regular waste bin. The waste containing the seed was removed from the Atlanta campus (in a bag of solid waste) and transported to the (Pine Ridge Regional Landfill) by the waste disposal company's normal procedure on or around April 2, 2020. (The Radiation Safety Officer (RSO)) was notified by phone on April 3, 2020 and searches of all relevant areas at Piedmont Atlanta were performed by staff using a GM survey meter with pancake probe as well as with a Sodium Iodide scintillator probe that day. No evidence of radiation or the seed was found in any location. The proper course of action that should have been taken in order to prevent this situation is as follows: The pathologist at Fayette should have been notified that there was a specimen with a radioactive seed. The pathologist would have removed the seed and the pathology staff would have contacted Nuclear Medicine to retrieve the seed and place it in decay-in-storage. Seeds should not leave the Fayette Campus. In (the RSO's) estimation, it is unlikely that any occupationally exposed worker or member of the public received any significant exposure or exceeded any dose limit. All staff in pathology have been educated on the circumstances that led to this incident. The procedure has been updated to clarify what actions should be taken if a specimen with a seed arrives in pathology when no pathology physician assistant is present. Knowledge of this procedure has been added to the competency checklist for pathology employees. 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 |