Semantic search
Jump to navigation
Jump to search
| Start date | Report date | Site | Reporting criterion | System | Event description | |
|---|---|---|---|---|---|---|
| ENS 57381 | 14 October 2024 22:33:00 | The Dow Chemical Company | Agreement State | The following report was received from the Texas Department of State Health Services (the Department) via phone and email: On October 14, 2024, the Department was notified by the licensee that while preparing to lock shut the Ronan model SA1 nuclear gauge, the shutter would not close. The gauge contains a 10 millicurie cesium-137 source. The licensee reported 'open' is the normal position for the shutter. The licensee reported access to the tank, where the gauge is used to monitor, has been posted no entry. The licensee reported a service contractor has been contacted to assist in getting the gauge repaired. The licensee stated no additional exposure is expected to its employees or members of the general public due to this event. Additional information will be provided in accordance with SA-300. Texas Incident Number: 10136 NMED Number: TX240036 | ||
| ENS 57371 | 9 October 2024 19:49:00 | Tbd | Agreement State | The following report was received via email from the Maryland Department of the Environment (MDE): On October 9, 2024, at 1549 EDT, the MDE emergency response center received a telephone report of a suspected stolen soil density gauge was captured by police. The report came from the Prince George's County Police to get guidance on the subject. MDE has called the Prince George's County Police contact person and are waiting for a response. Details about the gauge are not yet available. This report is based on 10 CFR 20.2201(a)(1)(i) because soil density gauges have a typical activity of 9 mCi of Cs-137 and/or 44 mCi of Am-241. An investigation will be conducted and follow up reports are to be expected. 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 57374 | 9 October 2024 05:00:00 | Dunn Construction | Agreement State | The following information was received from the office of Alabama Radiation Control via email: This report is connected to NMED item 140245, Nuclear Regulatory Commission Event Notification Number 50082 (Damaged Moisture Density Gauge, May 2, 2014), and Alabama Incident number 14-14. Alabama Radiation Control received an email from Troxler Electronic Laboratories on October 9, 2024. The licensee returned the gauge involved in this incident to Troxler in July of 2022. The device was retrieved for service this month. The Troxler representative reported that the cesium-137 source was not present at servicing. The americium-241/beryllium source was present and is being prepared for disposal. We are investigating with the licensee, transportation department contacts, and others. Model: CPN MC-3 Serial Number: M30129990 Activity: Nominal activity of 10 millicuries cesium-137 and 50 millicuries of americium-241/beryllium. 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 57375 | 9 October 2024 04:00:00 | University of Pennsylvania | Agreement State | The following information was provided by the Pennsylvania Bureau of Radiation Protection (the Bureau) via email: On October 10, 2024, the licensee informed the Bureau of a medical event involving a treatment with TheraSpheres. It is reportable per 10 CFR 35.3045. On October 9, 2024, a patient was receiving a (Y-90) TheraSphere treatment. Only 32.7 percent of the prescribed activity (15.975 mCi) was administered to the patient. The physician and the patient were informed on October 9, 2024, following the treatment. It is suspected that the cause was an occlusion within the catheter which prevented the proper flow of fluid and TheraSpheres into the patient. The official cause is still under investigation. The Bureau will perform a reactive inspection. More information will be provided as received. Pennsylvania Event Report ID: PA240019 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 57368 | 8 October 2024 05:00:00 | Bayport Polymers Llc | Agreement State | The following report was received via phone and email from the Texas Department of State Health Services (the Department): On October 8, 2024, the Department was notified by the licensee that the shutter on a Vega model SH-F2 nuclear gauge containing a 200 millicurie (source) (original activity) was stuck in the open position. Open is the normal operation position of the shutter. The licensee reported there is no risk of additional radiation exposure to members of the general public or radiation workers due to this on/off mechanism failure. The licensee reported that the current plan is to dispose of the source. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10133 Texas NMED Number: TX240033 | ||
| ENS 57364 | 4 October 2024 16:44:00 | Qsa Global | Agreement State | The following information was provided by the Massachusetts Radiation Control Program (the Agency) via phone and email: On 10/4/2024, at 1244 EDT, QSA Global, Inc. (license number 12-8361) was notified that a package containing a 109.1 Ci Ir-192 sealed source in a type B package was missing in transit and notified the Agency at 1315 EDT on the same day. The following information was provided at the time of notification: Isotope: Ir-192 Source Serial Number: 97855M Form: Sealed source Activity (at time of shipment): 109.1 Ci Container Model Number: 650L Container Serial Number: 1063 Transportation Index: 0.6 Shipping Date: 9/13/24 Last Known Location: (Common carrier) hub in Memphis, TN The reporting requirement is immediate and is required by 105 Code of Massachusetts Regulations (CMR) 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C. The Agency considers this event to be open. The following additional information was obtained from the Agreement State in accordance with Headquarters Operations Officers Report Guidance: The last physical scan was on 9/17/24, at 1403 EDT, in Memphis, TN. The recipient reached out to the common carrier on 10/1/24 asking to track the package. The response from the common carrier was that they were experiencing high volume and the package was waiting to be cleared in customs. The recipient followed up again on 10/4/24, at 0928 EDT, asking for an update, and received an update at 1108 EDT stating that they could not locate the package. The Agency has contacted the State of Tennessee regarding this event. Notified DHS SWO, FEMA Ops Ctr, CISA CWO, USDA Watch Officer, HHS Ops Ctr, DOE Ops Ctr, EPA Emergency Ops Ctr, FDA EOC (email), DHS Nuclear SSA (email), FEMA National Watch Center(email), CWMD Watch Desk (email).
The following information was provided by the Massachusetts Radiation Control Program (the Agency) via email: At 1108 EDT on October 8, 2024, the missing package was delivered undamaged to the intended recipient. The Agency considers this event closed. Notified R1DO (Arner), IR (Grant), NMSS (Fisher), ILTAB (Brown), INES (Smith), NMSS Events Notification. Notified DHS SWO, FEMA Ops Ctr, CISA CWO, USDA Watch Officer, HHS Ops Ctr, DOE Ops Ctr, EPA Emergency Ops Ctr, FDA EOC (email), DHS Nuclear SSA (email), FEMA National Watch Center(email), CWMD Watch Desk (email). THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 53440 | 3 October 2024 19:14:00 | Geotechnical Consultants, Inc. | Agreement State | The following report was received from the Ohio Bureau of Environmental Health and Radiation Protection via email: The Licensee had a truck with a CPN Model MC1DR gauge in it, stolen at approximately (1330 EDT) on 5/31/18 from a convenience store in southeast Columbus. The gauge contains 10 mCi of Cs-137 and 50 mCi of Am-241 sealed sources. The truck and gauge were recovered by police several hours later. The Licensee got the truck and gauge back about (2100 EDT) that evening. The gauge case had been opened, but the gauge did not appear to be damaged. The Licensee is taking the gauge to Cline Technical Services (a licensed service provider) to have it checked out as a precautionary measure. An ODH (Ohio Department of Health) inspector (will be visiting the) licensee location on Monday, 6/4/18. Ohio Item Number: OH180004 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 57355 | 30 September 2024 07:00:00 | Leighton And Associates | Agreement State | The following information was provided by the California Radiologic Health Branch (RHB) via email: RHB was notified on 9/30/24 that Los Angeles (LA) County Radiation Management recovered an InstroTek CPN MC-1 Elite number 31069 (containing nominally 50 mCi Am-241/Be and 10 mCi Cs-137 sources) from an apartment complex in Long Beach, CA. Long Beach Fire and Police Department responded to a call from the apartment complex management that the transportation box was left in their parking garage for approximately a week. An LA County health physicist verified that the box did contain a moisture density gauge, which is owned by Leighton and Associates according to transportation paperwork found inside the unlocked transportation case. The Cs-137 source rod was locked in the shielded location. The gauge was removed from the property and secured in a storage locker. RHB contacted the company radiation safety officer, who was unaware that the gauge was missing. Follow-up investigation is in process to determine how and when the gauge went missing and why the licensee was unaware that it was missing. California 5010 Number: 093024 | ||
| ENS 57354 | 29 September 2024 05:00:00 | Syngenta Crop Protection, Llc | Agreement State | The following information was provided by the Louisiana Radiation Protection Division via email: This event is considered an equipment failure with open shutters. The failure occurred while Syngenta Crop Protection was performing their required license condition shutter checks on August 29, 2024. There were two nuclear gauges that failed the shutter operational checks. The two nuclear gauges are in the failed open shutter position. The first gauge is a Texas Nuclear series 5100, model 5189 and serial number 51, with a source activity of 25 mCi (Cs-137) and the second gauge is a RONAN Engineering, model SA1-F37 and serial number 6268CM, with a source activity of 2000 mCi (Cs-137 and Co-60). Syngenta Crop Protection is planning to bring a third party to work on or replace the nuclear gauges. BBP Sales will be the third party. Syngenta Crop Protection plans on having BBP Sales out to the facility as soon as possible. LA Event Report ID Number: LA20240010 | ||
| ENS 57348 | 27 September 2024 09:00:00 | Cardinal Health | Agreement State | The following information was provided by the Texas Department of State Health Services (the Department) via email: The Department was notified at 0815 (CDT) on September 27, 2024, by the licensee, that one of their courier vehicles had been involved in a vehicle accident on I-35 North, between Denton and Valley View, Texas. The accident resulted in the death of a driver of an 18 wheeler but was not related to the presence of radioactive material (RAM). The courier driver was injured with a broken leg and was transported to the hospital with non-life threatening injuries. The roadway was shut down for several hours due to diesel fuel, oil, and debris from the collision. There was no radiological involvement as part of the closure. The shipment was six `ammo' boxes containing 10 doses of F-18. Five of the containers were located in the courier vehicle and transported to a nearby hospital. The packages were surveyed on arrival at the hospital by hospital staff and placed in a secure area to await the licensee's personnel. The five packages were subsequently retrieved by the licensee. The sixth package was ejected from the transport vehicle and was not transported to the hospital with the other five packages. The licensee retrieved and surveyed (the sixth) package at the accident scene. There was no contamination or release of RAM. The investigation (by the Department) continues. Texas Incident Number: TBD | ||
| ENS 57352 | 26 September 2024 19:00:00 | Ctl/Thompson, Inc. | Agreement State | The following information was provided by the Colorado Department of Public Health and Environment (the Department) via email: On 09/26/2024, the Department was notified by the CTL/Thompson, Inc. radiation safety officer (RSO) that a possible incident with a moisture density gauge occurred at a job site in Granby, CO. The RSO stated he had no further information to provide (about the event). The Department compliance lead spoke with the RSO over the phone and identified the assistant RSO (ARSO) over that job site. (When contacted) the ARSO stated that a technician was driving on a job site when the incident occurred. The latches were closed on the transportation case, but not fixed with locks since additional testing was going to be performed. While driving over the uneven terrain of the job site, the truck jostled causing the tailgate to open and the transportation case flipped over towards the edge of the truck bed. The latches on the transport case released and caused the gauge (Troxler model 3430, 8 mCi Cs-137, 40 mCi Am-241/Be) to come out and land on the ground, resulting in damage to the gauge. Colorado Event Report ID: CO240024 | ||
| ENS 57350 | 26 September 2024 07:00:00 | Banner University Mc - Phoenix | Agreement State | The following information was provided by the Arizona Department of Health Services (The Department) via email: The Department received notification from the licensee of a lost I-125 seed used for localization. A patient was implanted with two, approximately 0.050 mCi I-125, seeds on September 20, 2024, with the placement of the seeds verified by x-ray. The patient returned to the hospital on September 26, 2024, to have the tissue, including the seeds, removed. The seeds were then sent to pathology where only 1 seed was found. The operating room and patient were surveyed but the seed was not located. The Department has requested additional information and continues to investigate the event. Arizona License Number- 07-478 Additional information will be provided as it is received in accordance with SA-300. 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 57356 | 26 September 2024 05:00:00 | Bard Brachytherapy, Inc. | Agreement State | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: On September 26, 2024, the radiation safety officer at Bard Brachytherapy, Inc. (the licensee) notified the Agency of a contamination event within a restricted area presumably resulting from the receipt of leaking Pd-103 brachytherapy seed or seeds. Seventy-one (71) Pd-103 seeds (solid/sealed sources, Theragenics Corp. Model 200 TheraSeed), each with an approximate activity of 1.6 mCi, were received on September 26, 2024, from Theragenics Corporation for loading into a Mick applicator. No contamination was noted on the incoming package and the (transportation information) on the package label was verified. As a result, no exposures to the carrier or members of the public are anticipated. However, upon working with the Pd-103 seeds within the restricted area, personnel surveys evidenced contamination on PPE. At the time of notification, the process of assessing the extent of contamination and decontaminating had begun. Personnel surveys had been performed and indicated contamination on clothing/shoes, with no skin contamination reported. Agency staff performed a reactive inspection on September 27, 2024. Inspectors verified that contamination was limited to the restricted area (loading room) and that no contamination to the skin was identified. The licensee is working to quantify the contamination and assess any potential skin dose to workers. At this time, Agency staff do not anticipate any occupational exposures in excess of regulatory limits as a result of this incident. No public exposures resulted from this incident and all contamination was limited to restricted areas. All 71 seeds had been placed in secured storage and radiation safety staff had successfully cleaned contaminated areas (floor, bench top, equipment, chairs) and had placed contaminated clothing (shoes, lab coats, gloves, a shirt, a pair of jeans) for decay-in-storage. Regarding reportability, the licensee committed (to Illinois) to performing leak tests of the sources once assembled. Therefore, (Illinois-specific) reporting requirements apply. There may not be an equivalent NRC requirement. There was no limit on contamination within the restricted area exceeded by the licensee. It is unlikely the potential for uptake of more than one annual limit on intake (greater than 3 seeds) would have been feasible within 24 hours. Therefore, unless there is a reportable occupational exposure, this matter may not be NRC reportable. Regardless, the incident will be shared with Georgia program staff as well. This report will be updated with the information obtained from the licensee's written report. Illinois item number: IL240022 | ||
| ENS 57337 | 24 September 2024 05:00:00 | East Texas Testing Laboratory, Inc | Agreement State | The following information was provided by the Texas Department of State Health Services (the Department) via phone and email: On September 24, 2024, the Department was notified by the licensee that on September 21, 2024, one of its technicians lost a Troxler model 3440 moisture density gauge. The gauge contains a 40 millicurie Am-241/Be source and an 8 millicurie Cs-137 source. The technician had completed work at a temporary job site and placed the gauge on the back of the pickup truck they were using. The technician failed to place the gauge in the transport container. The technician failed to secure the gauge in the truck. The technician drove off the job site and after a short distance realized they had failed to secure the gauge. The technician stopped and found the gauge was no longer in the truck. The technician stated he looked for the gauge but did not find it. The licensee stated the technician brought the empty transport box back to the storage location and left it. The licensee stated that on September 24, 2024, they went to the storage location to use the gauge and found the box was empty. The licensee contacted the technician who stated they had lost the gauge on Saturday. The licensee stated the Cs-137 source rod was not locked in the shielded position. The license stated they will contact the local sheriff office and notify them of the lost gauge. Since the Cs-137 rod was not locked in the shielded position, they can not say with any certainty that the lost sources would not create an exposure risk to any individual. Texas Incident #: 10131 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 57341 | 24 September 2024 04:00:00 | Memorial Sloan Kettering Cancer Center | Agreement State | The following information was provided by the New York State Department of Health via phone and email: Notification was received by phone call on 9/24/24 and email on 9/26/24, from Memorial Sloan Kettering Cancer Center, NYC license number 75-2968-01, of an event that took place (or was discovered) on 9/24/24. They say the event involved a Y-90 microsphere procedure with a dose to a site other than the treatment site that exceeded 0.5 Sv and was 50 percent or more in excess of the dose expected. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The unintended dose was to the stomach and duodenum. The estimated excess dose to the affected tissue was 99 Gy. This information is tentative pending further investigation. NYC Event Number: NYC-24-0924 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 57377 | 23 September 2024 05:00:00 | Northwestern Memorial Healthcare | Agreement State | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: The Agency was contacted on October 10, 2024, by Northwestern Memorial Healthcare in Chicago, IL, to advise of a suspected TheraSphere device failure. There was no associated medical event, nor any contamination resulting from the equipment failure. Reportedly, on September 23, 2024, during the administration of Y-90 TheraSpheres, the treatment was immediately halted by the authorized user (AU) following infusion of 3 mL of saline through the system due to observation of excessive air bubbles present in the outlet line. Both the (authorized medical physicist) (AMP) and the AU noticed what appeared to be flakes in the bottom of the 'V' vial and possible microspheres in the outlet line. The source vial and attached microcatheter were removed following standard procedures. The licensee followed the standard protocol and determined that the patient received 42.18 Gy of the prescribed 45.48 Gy. No follow up or medical action was required of the patient. No contamination of staff, patient, or the area was identified. Staff were interviewed to determine possible causes of the leak, with no deviations from the protocol noted. No initial defects in the administration kit were noted, however, after concluding their investigation, the licensee made the determination of a reportable equipment failure on October 9, 2024. The investigation remains ongoing, and a report was sent by the licensee to the manufacturer on October 9, 2024. This matter is reportable under 32 Illinois Administrative Code 340.1220(c)(2). NMED number: IL240023 | ||
| ENS 57335 | 23 September 2024 05:00:00 | Acme Environmental, Inc. | Agreement State | The following is a summary of information that was provided by the New Mexico Radiation Control Program via phone and email: During the weekend, Acme Environmental, Inc. (the licensee) was burglarized. An XRF lead paint analyzer, model Heuresis Pb200i, containing 5 mCi of Co-57 was stolen, along with numerous other items. The licensee notified the police, and the police are actively investigating. 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 53441 | 21 September 2024 09:30:00 | Calcasieu Refining Co. | Agreement State | The following information was received via E-mail: On May 31, 2018, during a turn-around at Calcasieu Refining Co., lockout and tagout procedures were not performed for two fixed gauges. Two non-radiation workers were over-exposed for the limit of 2 mR/hr. External radiation exposures are currently estimated at between 20 to 40 millirem whole body. The two sources were 50 mCi Cs-137 sources in Ohmart Vega Model SH-F1 gauges with serial numbers 70012 and 69998. This event was reported by the facility on June 1, 2018. LA Event Report ID No.: LA20180010 | ||
| ENS 53436 | 19 September 2024 10:03:00 | Universal Pressure Pumping, Inc. | Agreement State | The following information was received via E-mail: On May 31, 2018, the Department (PA DEP Bureau of Radiation Protection) was notified by the licensee that a malfunction of a roll pin on a shutter handle occurred at a temporary jobsite in Eighty Four, Pennsylvania. It is initially reportable per 10 CFR 30.50(b)(2). A roll pin, which holds the shutter handle to the shutter shaft on a Berthhold Model LB 8010 in-line density gauge containing 20 milliCuries of cesium-137 became sheared off during an attempt to move the shutter to the open position, rendering the gauge unusable. The gauge is currently being stored at their Punxsutawney, PA location. The shutter is in the closed position and the gauge is out of service awaiting repair from the manufacturer. There was no other damage to the gauge. No overexposures have occurred. Radionuclide: Cs-137 Manufacturer: Berthold Model: LB 8010 Serial Number: 10485 Activity: 20 mCi The cause of the event has been attributed to normal wear and tear on the gauge. A reactive inspection is planned by the Department. PA Event Report ID No: PA180013 | ||
| ENS 57332 | 18 September 2024 16:15:00 | Keller, Schleicher, And Mcwilliam | Agreement State | The following information was provided by the Florida Bureau of Radiation Control (BRC) via email and phone: On September 18, 2024, at 1345 EDT, BRC received call from the licensee's radiation safety officer (RSO), that an employee noticed their soil moisture density gauge (containing 10 mCi of Cs-137 and 50 mCi of Am-241:Be) was missing from the back of their pick-up truck at 1215 while traveling between job sites. The employee left a job site at the intersection of Triton and Roma in Port Saint Lucie and noticed the gauge missing at the intersection of Kanner Hwy and I-95. The employee called their supervisor at 1230, who in turn called the RSO at 1330. The employee admitted that the gauge case was not chained to truck, but that the gauge was secure in the case which had two locks on it. The employee retraced their route several times, but could not locate the gauge. BRC will assign an inspector to respond. Device Information: Device type: soil moisture density gauge Manufacturer: CPN Model Number: MC-DR Serial number: MD40107276 Florida incident number: FL24-092
On September 25, 2024, at 1440 EDT, BRC was notified that the gauge had been returned. A worker on the job site returned the gauge in its case on September 25, 2024. The gauge was intact. A latch on the case was broken off, but the other latch was intact with a lock on it. Notified R1DO (Dimitriadis), NMSS (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 57327 | 16 September 2024 14:30:00 | Alpek Polyester Usa, Llc | Agreement State | The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email: On September 16, 2024, at 1415 EDT, the Department was notified by Alpek Polyester (the licensee) that while performing semi-annual shutter checks the licensee discovered that two gauges (model: Berthold LB 300 IRL) had cables that were malfunctioning, and that the sources were unable to be retracted to the shielded and locked position. One gauge contains a 6 mCi (original activity) cobalt-60 source and the other contains a 2.5 mCi (original activity) cobalt-60 source. Currently the cobalt sources are 1.07 mCi and 0.044 mCi, respectively. These sources were placed into service on September 17, 2011. On September 17, 2024, the department on-call duty officer met the licensee's radiation safety officer at 0900 EDT to perform a visual inspection and radiation survey of the gauge. The highest radiation measured was 0.5 microR/hr. The licensee has contacted a licensed vendor to schedule the repair of the drive cables. | ||
| ENS 53444 | 16 September 2024 14:29:00 | Dignity Health At St. Joseph'S Hospital And Medical Center | Agreement State | Below is a summary of multiple emails received from the State: At 1530 hrs. MST on 6/5/18, the State was notified that a patient was undergoing high dose rate treatment (HDR) when the Nucletron HDR applicator malfunctioned. The treatment plan was to deliver the intended fraction using thirteen dwell points but the HDR applicator failed at dwell point 9 of 13. The vendor, Elekta, was notified and they repaired the applicator. The written directive was modified and the patient will be able to complete the treatment. | ||
| ENS 57323 | 15 September 2024 05:00:00 | Basf Corporation | Agreement State | The following information was provided by the LA Department of Environmental Quality, (LDEQ) via email: The LDEQ was notified on September 16, 2024, of a stuck shutter on a nuclear gauge. While the licensee was trying to isolate the T220B tower for maintenance on September 15, 2024, the shutter handle on an Ohmart Vega SHS1 nuclear gauge with a 50 mCi Cs-137 source broke leaving the shutter in the open position. The licensee's gauge vendor was contacted and on September 16, 2024, the nuclear gauge was removed and put into storage. Louisiana event report ID: 20240009 | ||
| ENS 57317 | 11 September 2024 05:00:00 | Equistar Chemicals Lp | Agreement State | The following information was provided by the Texas Department of State Health Services (the Department) via email: On September 11, 2024, the Department was notified by the licensee that the shutter on a Ronan model SA-1 gauge containing a 50 millicurie Cs-137 source, was found stuck in the open position during routine testing. Open is the normal position for the gauge. The licensee reported that there is no risk of additional radiation exposure to members of the general public or radiation workers due to this on/off mechanism failure. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-10129 | ||
| ENS 57316 | 10 September 2024 05:00:00 | Exxon Mobil Oil Corp | Agreement State | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: On September 11, 2024, the Agency was contacted by a representative for the Exxon Mobile refinery in Channahon to advise of a fixed gauge containing 20 mCi of Cs-137 (sealed source) had a reportable equipment failure. Specifically, on September 10, 2024, during routine shutter checks, the handle that operates the shutter broke off, leaving the gauge in the open position. The gauge is mounted to a production vessel which is full of commodity. There were no exposures, and due to the vessel being in use, personnel exposure is not a concern. The manufacturer has been contacted for repairs. The licensee met the notification requirements. This report will be updated with the source serial number and verification of repair and replacement upon receipt. Illinois Event Item Number: IL240021 | ||
| ENS 57315 | 9 September 2024 16:07:00 | Cooper Health System At Camden | Agreement State | The following information was provided by the New Jersey Department of Environmental Protection (NJDEP) via email: On September 9, 2024, during a routine inspection of the licensee, information for the exit sign was provided to the radiation safety officer (RSO). The inspectors asked for the sign's location and for the facility contact listed to be updated if necessary. After the inspection, follow up emails and searches of the facility led to the determination that the sign could not be located. The sign's manufacturer was contacted to confirm whether or not the sign might have been returned. SRB Technologies (the manufacturer) confirmed that the sign was not assigned a return number, and that paperwork for its return was not submitted. After additional follow up with the RSO, and final search of the facility, it was determined that the sign has been lost. New Jersey Event Report ID number: To be determined. Additional information: The lost exit sign contained approximately 9210 millicuries of tritium (H-3). 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 57311 | 6 September 2024 05:00:00 | Acend Performance Materials Texas | Agreement State | The following information was provided by the Texas Department of State Health Services (the Department) via email: On September 6, 2024, the Department was notified that the shutter on a Texas Nuclear model 5204 gauge was found stuck in the open position during routine testing. The gauge contains a 4,000 mCi (original activity) Cs-137 source. Open is the normal position for the shutter. The licensee reported there is no risk of additional exposure to members of the general public or radiation workers at the facility due to the failure. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 10126 Texas NMED Number: TX240027 | ||
| ENS 57312 | 6 September 2024 05:00:00 | Coal Mining Facility | Agreement State | The following is a summary of information provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via phone: In the conduct of their regulatory duties, RHB established a program to collect and store nuclear gauges from closed or abandoned mining sites. This initiative is aimed at preventing improper disposal of nuclear gauges during reclamation operations. On September 6, 2024, RHB inspected one such coal mining facility located in Helton, KY, in an attempt to recover six fixed Cs-137 level gauges with an aggregate activity of approximately 700 mCi. The storage facility for the gauges was found open and the gauges were missing. The last recorded inventory of the gauges occurred in 2021. Local law enforcement and state emergency operations were notified. It is believed that the gauges were improperly discarded either by the previous owner or by the reclamation company. RHB will continue to investigate this event and provide updates in accordance with SA-300. No risk to the public is anticipated from this event.
The following information was provided by Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via email: RHB is in the process of repossessing nuclear gauges from abandoned coal mines. In the process of assessing the number and state of each gauge, it was discovered that the building at the (Big Laurel #1 prep plant) was demolished. The storage cabinet located in that building was missing. On September 6, 2024, an onsite investigation of the facility was performed. The storage cabinet was located on the property. The storage cabinet was damaged and the contents of the cabinet (6 gauges with 700 mCi of Cs-137) were missing. The last known pictures and inventory from a routine inspection on June 23, 2021, showed the gauges stored in the locked metal cabinet at the warehouse where Big Laurel #1 prep plant, operated by Bledsoe Coal, then Revelation Energy and later under reclamation by Black Mountain Resources, are now gone. On September 10, 2024, at 1153 EDT, RHB was notified of a smelter in West Virginia that had their portal monitors alarmed. The load was returned to its origin site located in Hazard, Kentucky. RHB representatives were dispatched to the facility. Upon arrival at the scrapyard facility, two gauges were present. The gauges were compared to the last known inventory at Big Laurel. Both gauges were positively identified as property of said plant. Both gauges were surveyed for removable contamination. All levels for removable contamination were at or below background. The two gauges were then packaged and secured for transport to RHB in Frankfort, Kentucky. RHB has possession of the two gauges. On September 13, 2024, RHB was notified that that an additional gauge was found at the recycling yard where the other two gauges were found. RHB personnel will be dispatched on September 17, 2024, to secure the additional gauge. The gauge will be stored at RHB in a secure location. Notified R1DO (Werkheiser), NMSS Events (email), ILTAB (email)
The following information was provided by Kentucky Department for Public Health and Safety, Radiation Health Branch (RHB) via email: On Friday September 13, 2024, RHB was notified that an additional gauge was found at the recycling yard where the other two gauges were found. RHB personnel were dispatched on September 17, 2024 to secure the additional gauge. The gauge is stored at RHB in a secure location. On Thursday September 19, 2024 RHB was dispatched to a recycling center in Hazard Kentucky to retrieve two more gauges. A third gauge was reportedly cut up and disposed. Surveys of the area where the gauge was supposedly cut-up were conducted. Soil Samples were retrieved. Results are still pending, but no increased levels were detected. RHB has recovered five gauges. Three were confirmed by serial number to be from Revelation Energy. Two of the gauges no longer have serial numbers. All five are believed to be from Revelation Energy. The unaccounted sixth gauge is believed to have been cut up and sent to waste weeks ago. RHB went to the location where it was cut and took surveys and soil samples. Lab testing revealed only background radiation. It is not believed that the cesium was compromised. Five of the six gauges have been through one half life and the sixth has an original assay date of November 2001. Notified R1DO (Deboer), NMSS Events (email), 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 57340 | 6 September 2024 04:00:00 | Mt. Sinai Hospital | Agreement State | The following information was provided by the New York State Department of Health via phone and email: Notification was received by email on 9/13/24 from Mt. Sinai Hospital, NYC license number 75-2909-04, of an event that took place on 9/6/24. The event involved treatment of the liver with Y-90 microspheres, and only 40 percent of the intended dose was delivered, which they said was due to stasis. The dose delivered to the left lobe of the liver was 58.8 Gy compared to a prescribed dose of 147 Gy. NYC Event Number: NYC-24-0913 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 57309 | 6 September 2024 04:00:00 | Virtua Our Lady Of Lourdes Hospital | Agreement State | The following information was provided by the New Jersey Department of Environmental Protection (NJDEP) via email: The licensee was scheduled to administer a Y-90 SIR-Sphere therapy to a patient. There was a tubing failure, and the administration was suspended. It is estimated that only 59 percent of the prescribed activity was administered. The patient has been re-scheduled. The licensee will follow-up with a full written report. The intended Y-90 SIR-Sphere therapy activity was 13.5 mCi, and the administered activity was 7.99 mCi. The target organ was the liver. The licensee is investigating. The root cause(s) and contributing factors will be addressed in a full report. Follow-up actions are to be determined. NJ Event Report ID number: To be determined. 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 57308 | 6 September 2024 04:00:00 | Advent Health Altamonte | Agreement State | The following information was provided by the Florida Bureau of Radiation Control (BRC) via email: BRC received notification from the Advent Health Altamonte radiation safety officer of a possible medical event. A patient received a Y-90 TheraSphere treatment, intended for the liver, which migrated to the stomach. The prescribed dose was 250 Gy, and the dose assessment is still being conducted. The facility states a majority of the prescribed dose was received by the stomach. Migration was identified by the patient's physician, and the patient was notified this morning. Florida incident number: FL-24-082 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 57306 | 4 September 2024 20:00:00 | S And Me, Inc. | Agreement State | The following information was provided by the North Carolina Department of Health and Human Services, Division of Health Service Regulation, Radioactive Materials Branch (the Department) via email: The licensee reported that around 1600 EDT on September 4, 2024, their portable nuclear gauge (PNG) was run over by another vehicle at a construction site. The PNG is a Troxler 3440 (serial number 25787), containing 8 millicuries of Cs-137 (serial number 20-2119) and 40 millicuries of Am-241/Be (serial number 41-9543). The licensee dispatched their recovery team immediately. They were able to retract the source rod back into the PNG with the source block closed. Readings taken around the gauge indicated no readings in excess of transportation index requirements. Additional surveys of the work area indicated the source was intact and in the safe position. The PNG was then transported to the manufacturer for repair. The Department's investigation is ongoing and this report will be followed up on to close and complete the record. NC Event Number: NC240005 | ||
| ENS 57303 | 3 September 2024 05:00:00 | Dewpointer Repair | Agreement State | The following information was provided by the Illinois Emergency Management Agency (the Agency) via telephone and email: On September 3, 2024, the Division of Radioactive Materials was notified that an Alnor Instruments dew point measurement device was located at a metal recycling facility in Bellwood, IL. The instrument was recovered by Agency staff and there was no indication of removable contamination. The device contains a 7 microcurie radium-226 foil that was manufactured and distributed by an Illinois specific licensee. An authorized service provider was contacted to assist in tracking down the original owner. The device was intact and no public exposures are anticipated as a result of this incident. If unable to locate the owner, this device will be incorporated in the Agency's orphan source recovery program and properly disposed of as low level radioactive waste. Updates to this report will be made as they become available. Illinois report number: IL240020 | ||
| ENS 57299 | 1 September 2024 05:00:00 | Nextier Completion Solutions Inc | Agreement State | The following information was provided by the Texas Department of State Health Services (the Department) via email: On September 2, 2024, the Department was notified by NexTier Completion Solutions Inc (the Licensee) that the handle on a Berthold model LB 8010 density gauge had broken off the gauge while at a well site. The gauge shutter was in the open position when the failure occurred and could not be closed. The gauge contains a 20 millicurie cesium-137 source. The gauge was removed from the truck, wrapped in lead blankets, placed in an overpack, and transported to the Licensee's storage area. The Licensee reported there were no overexposures due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas incident number: I-10125 | ||
| ENS 57357 | 30 August 2024 15:45:00 | Mistras Group | Agreement State | The following report was received via email from the California Radiologic Health Branch (RHB), The Mistras Group's radiography crew was working at a temporary job site (inside a tank) on Friday, August 30, 2024. During the first exposure for the day at 0845 (PDT), the radiographer extended the source assembly and then felt the crank mechanism spin freely, causing the inability to retract the source assembly into the shielded position (a critical component failure). Emergency procedures were implemented; both radiographers extended their controlled radiation area boundary and monitored the area while the radiation safety officer (RSO) was notified at 0852. Source recovery personnel from Mistras Group's Torrance Lab arrived at 1040 to evaluate the situation. A recovery plan was discussed and implemented by the recovery radiographer. He entered the tank, opened the crank assembly, and determined the drive cable was not inside the housing. He opened the exposure side of the crank assembly and saw the end of the drive cable. He was able to retract the source assembly drive cable until the source assembly latched and locked inside the exposure device. This was accomplished at 1105. The RSO made a telephone notification to RHB at 1801 to report the event, but it went to voice mail, so he left his name and phone number. However, the voice mail was not forwarded and the RSO did not follow-up the next week to determine if his voice mail was received. A 30-day written notification of the event, per 10 CFR 34.101 was sent to RHB and received on September 28, 2024. Radiation exposures did not exceed 5 mrem for any involved personnel." California Report Number: 093024 | ||
| ENS 57301 | 30 August 2024 07:00:00 | Nmg Geotechnical, Inc. | Agreement State | The following information was provided by the California Radiologic Health Branch via email: The RSO and Vice President of NMG Geotechnical, Inc. notified the California Radiologic Health Branch that two moisture density gauges had been stolen over the weekend (August 30 - Sept 2, 2024) from a locked trailer at their jobsite. Other construction equipment was also stolen. Thieves removed security bars from a window to enter and exit the trailer. The two gauges were secured within separate locked cabinets inside the trailer, inside their locked transportation cases that has company name and contact number affixed. The Troxler model 3411, number 12325 contains 8 millicurie of Cs-137 and 40 millicurie of Am-241/Be sealed sources. The CPN MC-3 Elite contains 10 millicurie of Cs-137 and 50 millicurie of Am-241/Be sealed sources. A trigger lock on the CPN gauge was not engaged and the Troxler did not have a trigger padlock. Irvine Police Department was notified of the theft. Maurer Technical Services was also notified. NMG Geotechnical will post a reward for information leading to the return of the stolen equipment. California 5010 Number: 090324 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 57294 | 27 August 2024 05:00:00 | Weaver Consultants Group North Centra, Llc | Agreement State | The Illinois Emergency Management Agency (the Agency) provided the following information via phone and email: Weaver Consultants Group North Centra, LLC (the licensee) notified the Agency of a source rod stuck open on a Troxler 3440 portable density gauge (8 mCi Cs-137, 40 mCi Am-241/Be). The licensee confirmed that the incident took place on August 27, 2024. The source rod was stuck out 3 inches. The (licensee's) consultant came to the jobsite to pick up the gauge for repair the same day. The consultant confirmed that they were able to retract the rod once back at their facility. The gauge is pending repair. Agency staff will be on-site August 28, 2024, to perform a reactionary inspection. Updates will be provided as they become available. Illinois Item Number: IL240019
The following is a summary of information provided by the Illinois Emergency Management Agency (the Agency) via email: Agency staff conducted a reactive inspection at the site where the gauge failed to function as designed on August 28, 2024. Gauge use was observed and the gauge user was interviewed. It is believed the compacted clay hardened and prohibited retraction of the source rod. Inspection and repair by the licensed consultant evidenced no damage or obvious defects. Notification was timely and a proper written report was received. No occupational or public exposures are anticipated from this incident. Barring any further developments, this matter is considered closed. Notified R3DO (Hills) and NMSS (email). | ||
| ENS 57290 | 26 August 2024 15:45:00 | Universal Engineering Sciences | Agreement State | The following was reported by the Florida Department of Health, Bureau of Radiation Control (BRC), via email: The BRC received notification from Universal Engineering Sciences of a Troxler gauge being hit by a passing car. The Troxler gauge was being standardized by a technician when a passing car made contact with the device. The source rod was retracted at the time and has not been exposed. The only identified damage was a crack in the plastic near the LCD screen. Device Type: Soil Moisture Density Gauge Manufacturer: Troxler Model Number: 3430 Activity: 8mCi of Cs-137, 40 mCi of Am-241/Be Florida Incident Number: FL24-077 | ||
| ENS 57289 | 26 August 2024 14:00:00 | Epic Engineering | Agreement State | The Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) reported the following via email: On August 26, 2024, an Epic Engineering gauge user was at the gym from 0700-0800 MDT. While at the gym, a Troxler nuclear density gauge was locked in the bed of the company truck. When the user returned to the truck after completing their workout, the company truck had been stolen along with the nuclear density gauge. The local police department has been contacted. The Division was notified by the company owner later that morning. Utah Event Report ID: UT 24-0007 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 57292 | 26 August 2024 05:00:00 | Protech Llc | Agreement State | The following information was provided by the Texas Department of State Health Service (the Department) via email: On August 27, 2024, the Department was notified by the licensee that one of its crews was working at a job site with a QSA 880D exposure device containing a 48 curie Iridium - 192 source. The crew was working in a shooting bay surrounded by concrete walls. While performing an exposure, the camera fell 18 inches from the pipe it was on, onto the guide tube, crimping the tube and preventing the crew from retracting the source into the camera. The radiographers drove the source back into the collimator and isolated the area. The radiographers contacted the radiation safety officer (RSO). The site RSO (SRSO) responded to the location. The SRSO added additional shielding to the collimator. The crimped section of the guide tube was removed, and the source was successfully retracted to the fully shielded position. The event was resolved in less than 2 hours. No individual received an exposure that exceeded any limit. Device Type: QSA Model Number: 880D Activity: 48 Ci of Ir-192 Texas Incident Number: 10122 Texas NMED # TX24024 | ||
| ENS 57293 | 26 August 2024 04:00:00 | Piedmont Athens Regional Med Center | Agreement State | The following is a summary of information provided by the Georgia Radioactive Materials Program (the Program) via email: The radiation safety officer (RSO) at Piedmont Athens Regional Medical Center notified the Program on August 26, 2024, that an incident occurred with Y-90 underdose. The catheter line became kinked during the procedure and the dose given was more than 20 percent below the planned dose. The RSO will send an official written report to the Program within 15 days. Georgia Incident Number: 86 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.
The following information was provided by the Georgia Radioactive Materials Program (the Program) via email: The Program received the official written report from the licensee radiation safety officer (RSO) on September 12, 2024. The RSO stated that one dosage was successfully delivered. The second dosage was not fully delivered due to a kink in the catheter. Prescribed dosage: 15.68 mCi and 16.76 mCi Y-90 microspheres Administered dosage: 5.39 mCi and 16.87 mCi Y-90 microspheres Notified R1DO (Werkheiser), NMSS Events Notification (email). | ||
| ENS 57286 | 22 August 2024 17:30:00 | Virginia Commonwealth University | Agreement State | The following information was received via email from the Virginia Radiation Materials Program (VRMP): At approximately 1500 EDT on 8/22/2024, the VRMP was notified by the radiation safety officer (RSO) for Virginia Commonwealth University of a medical event involving a Y-90 TheraSpheres liver treatment. The event occurred on 8/22/24, at 1330 EDT. The written directive prescribed 215 Gy to segment 'A' of the liver and 142 Gy to segment 'B'. During the treatment, the Y-90 dose was administered to the wrong segment of the left hepatic lobe, segment 'A' received dose intended for segment 'B'. The prescribed dose for segment 'A' was 215 Gy (2.072 GBq) and that segment received 114Gy (1.369 GBq), which is less by 47 percent. This was realized immediately, and the procedure was ended without administering the other dose. The authorized user immediately notified the RSO who then notified the VRMP. Per the RSO, the referring physician has been notified and the patient's treatment will continue once appropriate dose calculation can be done. VRMP will follow up with an investigation. 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 57281 | 20 August 2024 20:30:00 | Iges Ingenieros Dba Geostrata | Agreement State | The following summary was provided by the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (DWMRC) via phone and email: The licensee (IGES INGENIEROS, L.L.C. DBA GEOSTRATA) contacted the DWMRC to report that a portable gauge, Troxler 3430 model, with a 8 mCi Cs-137 and a 40 mCi Am-241/Be source, fall off the back of a truck. Once the licensee noticed the gauge was missing, they returned to the scene and found the damaged gauge. Although the gauge was in pieces, the sources were intact and there was no apparent leakage identified. Swipe tests were taken and the results are pending. Utah event report ID number: UT 240006 | ||
| ENS 57276 | 20 August 2024 18:30:00 | Leonard Lawson Cancer Center | Agreement State | The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email: KY RHB was notified on August 20, 2024, by a representative from Leonard Lawson Cancer Center (of the following:) The date of discovery is August 20, 2024 at 13:30 EDT. There were two medical events for the same patient receiving Ra-223 dichloride. In each of the two cases, the patient was under dosed. The authorized user physician and the patient have been notified of the medical events. (The first dose is being tracked under a different NRC Event number. See EN 57275) The second dose was administered on August 7, 2024, with a prescribed dose of 89.2 micro Ci and an administered dose of 45.53 micro Ci with a difference of 53.9 percent. The written directive procedure is to measure the dose in the dose calibrator and then administer the dose. The medical physicians deviated from the written directive procedure and adjusted the dose based of the following calculation: Volume to administered equals (Body weight in kg x 1.35 micro Ci/kg)/(decay factor x 27 micro Ci/ml). The concentration provided in the formula is different than the concentration for each dose. The concentration for the second dose was 18.12 micro Ci/ml. Also, this formula was taken from an old Bayer document from 2013. The current Bayer document provides the following formula. Volume to administered equals (Body weight in kg x 1.49 micro Ci/kg)/(decay factor x 30 micro Ci/ml). The problem is the document does not instruct one to use an actual concentration for the patient specific dose. The two reasons for the medical events are: 1) The medical physicist did not follow the written directive procedure. He added the volume calculation step. 2) The Bayer documentation does not instruct you to use the actual concentration for the patient specific dose. The incident remains under evaluation and investigation for corrective actions. 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 57275 | 20 August 2024 18:30:00 | Leonard Lawson Cancer Center | Agreement State | The following information was provided by the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB) via email: KY RHB was notified on August 20, 2024, by a representative from Leonard Lawson Cancer Center (of the following:) The date of discovery is August 20, 2024 at 13:30 EDT. There were two medical events for the same patient receiving Ra-223 dichloride. In each of the two cases, the patient was under dosed. The authorized user physician and the patient have been notified of the medical events. The first dose was administered on July 9, 2024, with a prescribed dose of 91.2 micro Ci and an administered dose of 72.46 micro Ci with a difference of 20.5 percent. (The second dose is being tracked under a different NRC Event number. See EN 57276) The written directive procedure is to measure the dose in the dose calibrator and then administer the dose. The medical physicians deviated from the written directive procedure and adjusted the dose based of the following calculation: Volume to administered equals (Body weight in kg x 1.35 micro Ci/kg)/(decay factor x 27 micro Ci/ml). The concentration provided in the formula is different than the concentration for each dose. The concentration for the first dose was 19.17 micro Ci/ml. Also, this formula was taken from an old Bayer document from 2013. The current Bayer document provides the following formula. Volume to administered equals (Body weight in kg x 1.49 micro Ci/kg)/(decay factor x 30 micro Ci/ml). The problem is the document does not instruct one to use an actual concentration for the patient specific dose. The two reasons for the medical events are: 1) The medical physicist did not follow the written directive procedure. He added the volume calculation step. 2) The Bayer documentation does not instruct you to use the actual concentration for the patient specific dose. The incident remains under evaluation and investigation for corrective actions. 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 57318 | 20 August 2024 04:00:00 | Artazn, Llc | Agreement State | The following information was provided by the Tennessee Division of Radiological Health via email: On August 20, 2024, during a routine calibration of a Global Gauge SS3A, employees at Artazn, LLC were unable to get stable readings. A Global Gauge technician arrived on August 22, 2024, and discovered that the shutter on the gauge was partially stuck open even though operator panel was showing everything as normal. The maximum exposure to workers was calculated to be 3.7 mrem. The available device information is as follows: Manufacturer: Global Gauge Model: SS3A Serial Number: 8376LV Isotope: Am-241, 1000 millicuries Corrective actions or reports will be updated with a report within 30 days." Tennessee Event Report ID Number: TN-24-068 | ||
| ENS 57277 | 19 August 2024 04:00:00 | 3M Corporation | Agreement State | The following information was provided by the Tennessee Division of Radiological Health via email: It was discovered on August 19, 2024, that three (3) fixed gauges had shutters that were open without commands to open from the PLC terminal. The area was unoccupied at the time. The facility radiation safety officer (RSO) did not indicate any physical damage to the devices. The event occurred again on the morning of August 20, 2024. No exposure was noted since the gauges were operating in a normal capacity. The RSO had the shutters closed and took the gauges out of service. The gauges were also locked out to prevent reoccurrence. The gauge manufacturer has been contacted for troubleshooting the occurrence. The available device information is as follows: Manufacturer: Mahlo America, Inc. Model: 11-200933 (source holder) Isotope: Kr-85, 260 mCi (as of March 28, 2019) Source SN#: AN-3035, AN-3036, AN-3037 Corrective actions will be updated with a report within 30 days. Tennessee Event Report Number: TN-24-060 | ||
| ENS 57273 | 16 August 2024 13:00:00 | Ecs Mid Atlantic Llc | Agreement State | The following information was provided by the Virginia Department of Health, Office of Radiologic Health (RMP) via email: At approximately 1100 EDT on 8/16/2024, RMP was notified of an incident involving a portable nuclear gauge. At approximately 0900, at a deep trench construction site in Fairfax, a CPN International gauge model MC-1, containing 10 mCi Cs-137 and 50 mCi Am-241, was dropped approximately 15 feet when a rope pulley system slipped. The authorized user notified the radiation safety officer (RSO) who arrived on site and then they notified the RMP. Per the RSO, the gauge fell onto dirt at the bottom of a trench. The device landed flat onto the base of the gauge. The gauge functions and is operational. The rod handle was retracted and locked at the time, and the source remained retracted in the shielded position. The RSO obtained survey readings of 0.4 mR/h at 1 meter from the gauge. The gauge was placed in its transportation box, secured in the back of a pickup truck, and transported back to the licensee's office for secure storage. A leak test was obtained and analysis indicates there is no leakage. The gauge will be sent for assessment by an authorized dealer. RMP will follow up with an investigation. Event Report ID No.: VA240004 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 57269 | 9 August 2024 07:00:00 | Giles Engineering Associates, Inc. | Agreement State | The following information was provided by the California Department of Public Health, Radiologic Health Branch (RHB) via email: The radiation safety officer for Giles Engineering contacted the RHB in Sacramento to report a lost/stolen CPN portable nuclear gauge, model MC-1, serial number MD71003961. This gauge contains two radioactive sealed sources: 370 MBq (10 mCi) of Cs-137 and 1.9 GBq (50 mCi) of Am-241. The loss / theft occurred about on Friday August 9, 2024, while in Palm Springs at a job project. The CPN (brand) gauge was secured in the rear of the company pickup truck, locked inside the locked case. The gauge operator got stuck in deep sand at the job site, so he removed the security chain to get pulled out. He failed to re-secure the portable gauge to the pick-up truck and noticed it was missing while he was stopped at a local gas station. A police report was filed with Palm Springs police department. Maurer Technical Services and Instrotek were also notified. California 5010 Number: 081224 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 57267 | 7 August 2024 14:45:00 | Kleinfelder | Agreement State | The following information was provided by the Maryland Department of the Environment (MDE) via email: This report is made in accordance with 10 CFR 30.50 (b)(2). At 1045 EDT on 8/7/2024, an Instrotek 3500 nuclear density gauge (serial number 566), containing a 10 mCi Cs-137 source and a 40 mCi Am-241 source, was struck by site equipment (skid steer) during asphalt placement operations in Syracuse, NY. The gauge was licensed to, and being operated by, Kleinfelder, a Maryland licensee (MD-05-248-01) and used in New York under reciprocity arrangement. The base plate of the gauge was damaged, but there was no observable damage to the source rod and it was retracted to the safe position at the time of the accident. Kleinfelder contracted a third party to complete a survey and no elevated levels of radiation were detected. The gauge was then transported to the Kleinfelder office, located in Mechanicsburg, PA, and tested for source leakage. MDE was notified on 8/8/2024 at 1258 EDT and requested that the gauge be tested for leakage. Leak tests later showed no leakage of radioactive material. At this time, the gauge is returned to the licensee storage in Maryland and (placed) out-of-service. The State of New York also reported this event on August 8, 2024, under EN 57266. |