Semantic search
| Start date | Report date | Site | Reporting criterion | System | Event description | |
|---|---|---|---|---|---|---|
| ENS 38415 | 22 October 2001 04:00:00 | Bowser-Morner, Inc | Agreement State | Bowser-Morner, Inc (State of Ohio licensee) reported the theft of a Troxler moisture/density gauge (model 3430, serial 31270) containing a 1.44 GBq (38.9 mCi Am-Be sealed source and a 0.28 GBq (7.7 mCi) Cs-137 sealed source. The gauge was stolen from the back of a truck parked at an employee's residence in Toledo, Ohio. The gauge was stolen in the time period between the evening of 10/20/01 and the morning of 10/22/01. The handle of the gauge case had been pried off, leaving the handle and locked chain. The licensee notified the Toledo and Oregon, Ohio police departments.
On 09/12/2003, the Troxler moisture density gauge was found in an abandoned building in Toledo, Ohio by the police. It has been returned to the licensee. The gauge was still inside the case and locked. The licensee will perform a leak test of the gauge then will start using it again. Mike Snee is with the Ohio Bureau of Radiation Protection. R3DO (Lanksbury) & NMSS EO (Doug Broaddus). | ||
| ENS 39014 | 24 June 2002 14:35:00 | Aea Technology Qsa Inc. | Agreement State | The State Agency was informed by the licensee they received the shipment from England on 12/5/01, checked the outer cardboard container for damage, and resent the shipment to their customer, Knolls Atomic Power Laboratory in New York. The package was received 12/6/01 or 12/7/01. At Knolls, the radiation safety staff received the shipment and confirmed the outer package was undamaged and delivered it to the end user in the Chemistry Department. The user opened the package on or around 5/20/02. Knolls Atomic informed AEA they believe the seal on the inner plastic container was intact, but that the final container, a flame-sealed glass container, appeared to have been opened and the contents removed, in addition, AEA was informed that the Federal Bureau of Investigation (FBI) was notified.
The State provided the following information via email: The following information is provided to close NMED Item Number 020624: Material was shipped to the Knolls Atomic Power Laboratory (KAPL) and received there on or around 12/6 or 12/7/2001 and not opened until Mid-May of 2002. Investigation by AEA Technology QSA, Inc. (AEA) and KAPL revealed that the shipment arrived at the laboratory intact with no apparent damage; when later opened it appeared that the materials had been used. Based upon the condition of the shipping containers when they arrived at KAPL it appears likely that the vials were used at the customer location, apparently without their knowledge. Notified R1DO (Finney) and NMSS (Flannery) | ||
| ENS 39137 | 19 August 2002 07:00:00 | Urs Corporation | Agreement State | The licensee reported the theft of a Campbell Pacific Nuclear moisture/density gauge (model MC-1DRP, serial number MD01005902). The gauge contained a 1.85 GBq (50 (millicuries)) Am-Be source and a 0.37 GBq (10 (millicuries)) Cs-137 source. An authorized user had been working at a temporary job site for two weeks. On Sunday, August 18 at 8:00 p.m. the authorized user parked his pick-up truck in the parking lot of a local motel in Centralia. The gauge was in back under the locked canopy, but visible. The gauge box was locked but not secured within the bed of the truck. When the authorized user went out to his truck at 6:00 a.m. on Monday the 19th the gauge was gone. The back window of the canopy had been forced open. Nothing else was missing from the truck (not much else of value was in the truck). The theft was reported to the Centralia police and to the licensee's RSO. The RSO notified the Department.
The following information was received from the State via email: On Friday February 4, 2005 an employee of another engineering firm noticed the gauge at a garage sale in Centralia, Washington. The employee noted the gauge ID specifics and had his RSO contact the gauge manufacturer for information. When informed by the manufacturer that it had been stolen, the employee was able to involve the police and secure the gauge. The individual responsible for the garage-sale was subsequently arrested. The owner, URS Corporation was notified and is presently having the gauge serviced and leak tested by a licensed technical service provider. They plan to retake ownership when this work is completed. Notified R4 DO (J. Whitten) and NMSS EO (W. Reamer) | ||
| ENS 39201 | 18 September 2002 05:00:00 | Building And Earth Sciences | Agreement State | The writer received a call from (an employee) of Building and Earth Sciences at approximately 9:00 AM on September 19, 2002. The employee reported that a Troxler Model 3430 gauge (S/N 30199) had been stolen sometime during the night of September 18, 2002, from their truck working under reciprocity in Memphis, Tennessee. The gauge had been left chained in the back of the truck overnight at ( . . . . . ). The chain had been cut, and the gauge taken. The licensee's employee had contacted both the State of Tennessee and had filed a report with the local police. The licensee is continuing their investigation, and considering additional methods to expedite recovery of the gauge. Contact the Headquarters Operations Officer for additional information.
The State provided the following information via email: (Mississippi) DRH (Division of Radiological Health) received a phone call from Desoto County (MS) EMA (Emergency Management Agency) on 12-20-07 about a Troxler Model 3430 moisture/density gauge ( Serial # 30199 ) that was found by a member of the public in the woods. The moisture/density gauge had been stolen on September 19, 2002, (NRC Event No. 39201) in Memphis, Tennessee, while Building & Earth Sciences was working under reciprocity of their Alabama Radioactive Material License AL-1266. The theft was originally reported to Alabama Radiation Control, Tennessee Division of Radiological Health, and the Memphis Police Department. The gauge was picked up by Mississippi Division of Radiological Health on 12-21-07 and returned to our office where it was leak tested and stored. Building & Earth Sciences was contacted and is going to pick the gauge up on 1-3-08. No leakage was detected. Notified the R1DO (Conte) and FSME EO (Flannery). | ||
| ENS 39739 | 7 April 2003 05:00:00 | Am Engineering And Testing, Inc. | Agreement State | The following information was obtained from State of Florida Bureau of Radiation Control via e-mail: On 4/05/03, a truck transporting a load of hazardous chemicals and two Troxler moisture density gauges was involved in an early morning accident. As a result of the accident, the truck caught fire and burned up. It was not known until 4/07/03, when a copy of the bill of lading was obtained, that the truck was carrying radioactive material. The Troxler gauges were being returned to the licensees from Troxler, Inc. after being calibrated. The gauges have not yet been located. Florida is investigating.
On 4-5-03 a truck fire destroyed two Troxler gauges (FL03-058, PNO-II-03-005). Only one was found. Today the other has been located. The trucking company which carried the gauges apparently took the remains of the truck to their location in Lakeland Florida after the accident in 03. They just tried to send that metal to a scrap dealer and it set off the radiation alarm. Investigation by a hired consultant found the burned out remnants of the gauge. Swipes show no leakage. The licensee will take possession and arrange with Troxler for disposal. Notified Reg 2 RDO (Widman), NMSS EO (Essig) and Reg 1 RDO (Cobey) | ||
| ENS 40035 | 30 July 2003 04:00:00 | Wheelabrator | Agreement State | On 7/28/03 Wheelabrator became aware that a TN (Texas Nuclear) Level Gauge, Cs-137 100 mCi (milli Curie) (Model Number: 5197) SN # B728 (SS&D No. TX634D119B) had gone missing. Plant was in shutdown and work was being performed on the associated hopper. The gauge was removed not following standard procedure. A search of the premises was conducted with negative results. A consultant was hired, and located the gauge in a scrap metal pile on the morning of 7/30/03. The shielding was partially melted away, it was surmised that the gauge may have passed through the boiler. The consultant performed radiation surveys and placed the gauge in a metal container in the storage area. The manufacturer was contacted, arrangements will be made to return the gauge. Cause description: Gauge removed from frame to accommodate work taking place on hopper (steel replacement). Precipitating factor: Not secured in storage area; typically used a secure holding area prior to shipping/installation. State Event Number: MA 03-0023 Wheelabrator is located at 100 Salem Turnpike, Saugus, MA.
On July 30, 2003, gauge was located: casing intact, Pb (Lead) shielding melted. Secured, survey. Leak test results SAT, dose assessment for members of public SAT, shipped to (manufacturer), and staff was re-trained. Notified R1DO (Henderson) and NMSS EO (Broaddus). | ||
| ENS 40056 | 23 June 2003 20:30:00 | University Of Kentucky | Agreement State | On June 23, 2003 at 3:30 PM the (University of Kentucky) radiation safety office received a call from an AU (Authorized User) in the Dept. of Biology, because a shipment of I-125, triiodothyronine, 100 microcuries, had not been received. Upon review of the records it was found that the package had arrived on June 18, 2003, and had measured 10 (millirem)/hr at the surface, 0.1 (millirem)/hr @ 1meter, and no external contamination. The Radiation Safety Office shipping paper record shows the I-125 package was included for delivery to room 109, Research Building 3, on June 19. The required signature of receipt for the package was not obtained. With the DOT shipping labels removed, the greatest likelihood is that the package was put into the ordinary trash. A thorough search of the Radiation Safety Office facilities and vehicles was conducted on June 23. On June 24, the authorized user's lab was searched, including use of a low energy NAI (Tl) detector, as well as all labs where deliveries were made on June 19. No trace of the package or contents has been found. It was concluded that the highest probability was that the package entered the normal waste stream and went to a landfill. Once in a landfill, the I-125 will be sequestered from any contact, and will be essentially non-radioactive in 1.65 years. Assuming worst case scenarios, the dose rate to the torso would be about 10 (millirem)/hr or less, and would have to be held against the body continuously by a single individual for 10 hours to produce a dose in excess of 100 (millirem). Additionally there is no indication or likelihood of intentional or accidental ingestion of the contents since this is not intended for human use. However, if the entire 100 microcuries were ingested by a single individual, as sodium iodide, the thyroid dose would be 78 rem, and the effective dose would be 2.4 rem. While no thyroid dose information has been found for the triiodothyronine form, the effective dose from ingestion of 100 microcuries would be 17 (millirem). Surveys are conducted on a continual basis, if the package did not go to a landfill it would likely be found during monthly use area surveys or quarterly supervisory surveys. No NOV was issued based on the corrective actions taken by licensee to correct deficiencies prior to report completion. | ||
| ENS 40062 | 12 August 2003 04:00:00 | Kewell, Llc | Agreement State | Overnight, August 12, 2003, unknown persons entered the licensee's facility and stole various office equipment including copiers, computers and a Niton analyzer containing radioactive material. The Niton Analyzer is a model XLi or XLp series device which contains 30 millicuries of Am-241. The Licensee, Kewell, LLC, reported the theft to the local law enforcement. Media attention: None Georgia Event Report No: GA-2003-241 | ||
| ENS 40079 | 30 June 2003 16:45:00 | Wa Dot | Agreement State | Licensee: WA State Dept. of Transportation (WA DOT), South Central Region City and state: Yakima, Washington License number: WN-L065-1 Type of license: Portable Gauge Date of event: 30 June 2003 Location of Event: near Walla Walla, Washington ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention) On 30 June 2003, at about 9:45 AM, an errant motorist entered a coned-off lane and ran over a Troxler, Model 3430, moisture/density gauge, Serial Number 24671. The gauge contained two sealed sources, one of about 8 millicuries of Cesium 137 and the second of about 40 millicuries of Americium 241/Beryllium. The accident happened just north of Myra Road on State Route 125 near Walla Walla, Washington. An errant motorist drove past a WA DOT road flagger holding a stop sign. The motorist entered a lane that had been coned-off. The motorist proceeded to drive down the restricted lane and ran over the gauge while it was being used to test for compaction. The gauge operator saw the approaching vehicle and attempted to stop it by waving his hands and yelling as the vehicle approached. The motorist, a senior, was apparently oblivious to the lane restriction. After the gauge was hit, it wedged under the vehicle and was dragged for approximately 90 feet down the road until the motorist finally became aware of the problem and stopped. The cause was inattention or inability to understand that the road conditions had changed. It appears that age of the driver contributed to the cause of the event. The need to make any corrective action was deemed to be unnecessary. The gauge operator was operating per procedure and was only feet away from the gauge as it performed the test. The lane was restricted from travel by flagger and cone. The incident destroyed the gauge. Impact with the vehicle caused the Cesium 137 source to be drawn back into its shielded position. Although pieces of the gauge housing, electronics and mechanisms were scattered along the 90-foot section of road that the vehicle traveled after impact the gauge, the sources were still attached to their respective parts of the gauge. Subsequent leak tests were negative. DOH was not able to do an on site investigation due to the excessive distance to the event site and excessive time it would have taken to get staff to the site and clear the incident. The licensed RSO, a person trained to respond to events of this nature and having experience with similar events, went to the scene to give direction. The RSO performed surveys and an evaluation that allowed trained WA DOT personnel to release the area. The gauge parts were placed into the Troxler transportation box, a gravel/dirt mix was used to lower dose-rate readings to below a usual reading for an intact gauge, and the box was transported by trained WA DOT personnel to the WA DOT Headquarters facility for further evaluation, leak testing and disposition. WA DOH personnel performed an investigation of events and the gauge at WA DOT Headquarters after the gauge arrived. WA DOH staff inspected the gauge parts including the sources, evaluated the circumstances of the event, reviewed the report information, and consulted with WA DOT staff regarding procedure, equipment and their plan to return the gauge to Troxler. Once WA DOH staff determined that sources were not leaking and the material was safe to be returned to Troxler, it was sent to Troxler via normal method. There was no media attention. What is the notification or reporting criteria involved? 10 CFR 30.50(B)(2) and 20.2201 - After reviewing the incident file and the Handbook on Nuclear Material Event Reporting in the Agreement States , we determined that a 24 hour notification should have been sent to NRC. This did not occur; consequently we are now submitting this completed report, although late. Activity and Isotope(s) involved: 8 millicuries of Cesium 137 and 40 millicuries of Americium 241/Beryllium Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) No members of the public received exposure in any amount. Calculation, survey readings and previous experience with similar gauge events indicate that WA DOT radiation worker staff only received exposure that is associated with usual gauge operations. Dosimetry reports will be evaluated upon receipt from the dosimetry processor. Lost, Stolen or Damaged? (mfg., model, serial number) Troxler, Model 3430, Serial Number 24671 was destroyed (damaged). Disposition/recovery: The gauge was returned to Troxler for disposal. Leak test? A leak test was performed on each source. They were found to be negative. Vehicle: (description; placards; Shipper; package type; Pkg. ID number) The gauge transportation vehicle was not involved in the event. Release of activity? There was no release of activity. Activity and pharmaceutical compound intended: N/A Misadministered activity and/or compound received: N/A Device (HDR, etc.) Mfg., Model; computer program: N/A Exposure (intended/actual); consequences: N/A Was patient or responsible relative notified? N/A Was written report provided? The licensee provided a written report, dated 7 July 2003. Was referring physician notified? N/A Consultant used? No | ||
| ENS 40085 | 19 June 2000 19:00:00 | Fred Hutchinson Cancer Research Center | Agreement State | Exposure (intended/actual): consequences: Actual exposure received was Licensee: Fred Hutchinson Cancer "Research Center City and state: Seattle, Washington License number: WN-L042-1 Type of license: Medium Broad License Date of event: Reported by licensee on 19 June 2000, (indicated overexposure for the wear period between 5 April to 4 "May 2000). Location of Event: Seattle, Washington ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention) On 19 June 2000, the licensed RSO reported that their dosimetry badge provider (Landauer Inc.) had notified them that one of the Fred Hutchinson employees had apparently received an exposure of 317,791 millirem of high energy gamma radiation. This employee performs animal studies involving irradiations using both a Linac and a Cobalt 60 irradiator (a J.L. Shepherd Model 285, Serial Numbers 625 & 626). The RSO immediately started an investigation of the reported overexposure. The RSO discovered that the individual's dosimetry badge had been lost during the second week of April 2000 for a period of about one week. An unknown person, via the inter-office mail system, returned it to the individual the next week. The employee was unable to recall any situation that would have lead to an exposure of any amount greater then the usual for the work performed over that time period. Several circumstantial events as well as actual occurrences seem to indicate that the exposure was probably only received by the dosimetry badge. These were: first, the employee indicated that the dosimetry badge had been lost during the second week of April 2000, for a period of about one week. Second, only the Cobalt 60 irradiator was in operation during that period; the Linac was out of service then. Third, since several groups share use of the irradiator, the badge conceivably was found, in the irradiator room, by one of those people and returned in the inter-office mail system. Lastly, the employee never experienced any radiation related illnesses. The reported exposure of 317,791 millirem was removed from the employee's exposure history and replaced with a 20 millirem exposure (average monthly exposure for previous 12 months). No DOH on-site investigation was made or media attention was noted. What is the notification or reporting criteria involved? 10 CFR 20.2202 (a)(1) significant . After reviewing our incident files and the Handbook on Nuclear Material Event Reporting in the Agreement States , we determined that an immediate notification should have been sent to NRC. This did not occur; consequently we are now submitting this completed report, although late. Activity and Isotope(s) involved: 518 terabecquerels (1400 curies), cobalt 60. Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) The initial notification indicated that one worker (employee) had been overexposed. The event did not involve a member of the public. The Landauer report indicated that an employee had received a whole-body exposure of 317,719 millirem of high-energy gamma radiation. No consequences will be realized since the exposure was later determined to only involve the dosimetry badge. The employee's exposure history was revised to indicate a 20 millirem exposure for that period of wear. Lost, Stolen or Damaged? (mfg., model, serial number) The employee's dosimetry badge was lost for a period of about one week. Disposition/recovery: Badges were to be used by placing them into a pouch for individuals using the irradiator devices. Leak test? N/A Vehicle: N/A Release of activity? None Activity and pharmaceutical compound intended: N/A Misadministered activity and/or compound received: N/A Device (HDR, etc.) Mfg., Model; computer program: J.L. Shepherd Model 285 irradiator. Exposure (intended/actual): consequences: Actual exposure received was estimated to be the usual, average amount of 20 millirem for that wear period. Was patient or responsible relative notified? N/A Was written report provided? Yes, from licensed RSO dated 21 July 2000. Was referring physician notified? N/A Consultant used? No Washington State Event Report # WA-00-023. | ||
| ENS 40087 | 5 August 2003 17:00:00 | Source Production And Equipment Co. | Agreement State | Louisiana Radiation Protection Division received the following information on August 6, 2003 from Source Production and Equipment Co., located in Saint Rose. On August 5, 2003 a Hot Cell operator discovered material on the floor that was reading a high radiation level. He believed the source was a form of contamination which he attempted to clean up with his hand and a swipe. It was later discovered the same day that the source was a iridium-192 wafer that had inadvertently been released from the Hot Cell (the caller said that it took them fours hours to find out how the wafer got out of the Hot Cell). The persons radiation badge was sent in for a reading on August 6, 2003. Whole Body dose to the person from the badge was 157 millirems. Hand exposure calculation is still being investigated but the exposure to his hand ranges from 20 Rem to 700 Rems. Two weeks after the incident the person hand does not show any clinical indication to exposure to a high dose of radiation (no reddening). This event is under investigation. The size of the iridium-192 wafer is approx. 0.1 inches in diameter, 0.01 inches in thickness with a total activity of 7.6 curies. NRC Region 4 was notified of this event by Louisiana Radiation Protection Division. Called did not have the licensee's license number or the State of Louisiana event number. | ||
| ENS 40088 | 18 August 2003 16:00:00 | Rush North Medical Center | Agreement State | A patient was undergoing an intravascular brachytherapy procedure using a Novoste 40 mm. Sr-90 system with a prescribed dose of 23 gray. Due to difficulties retracting the source train to its shielded position, the exposure time was 5.09 minutes (one minute longer than the planned 4.09 minutes). Preliminary estimates indicate that the delivered dose exceeded the prescribed dose by approximately 25 percent. Novoste was notified and a Novoste representative went to the medical facility to investigate. The Novoste system will be sent to Novoste in Georgia for analysis. The licensee continues to investigate and refine the dose calculations and will submit the required written report as soon as possible. Illinois assigned event number: IL030064. | ||
| ENS 40090 | 31 July 2003 19:00:00 | Stl Seattle | Agreement State | STATUS: new & closed Licensee: STL Seattle (STL) City and state: Tacoma, Washington License number: R-0158 (a General Licensee) Type of license: N/A - receipt of generally licensed gas chromatography cells from manufacturer or equivalent. Date of event: July 31, 2003 - date of licensee notification letter to DOH (date of actual event is unknown). Location of Event: Severn Trent Laboratories Inc., dba STL Seattle. 5755 8th Street East, Tacoma, Washington 98424 ABSTRACT: STL Seattle sent DOH notification dated July 31, 2003 of a lost GC detector cell, foil source. The letter was received August 4, 2003. In the letter STL Seattle reported a missing 555 megabecquerel (15 millicurie), Nickel 63, foil source, Serial Number A5447 that was assumed to have been in a Varian ECD cell. The cell had been sent to a DOH specific licensee that is licensed for GC repair work. A technician at the GC-repair licensee discovered the missing foil source. The GC-repair licensee notified STL of the missing source. STL performed a thorough search of the lab but could not find the missing foil. DOH contacted both STL and our GC-repair licensee after receipt of the letter. The Operations Manager at STL, (DELETED), who was the event reporter, could not initially be contacted. DOH did reach him for discussion two weeks later. DOH contacted our GC-repair licensee shortly after receipt of the notification. The GC-repair RSO mentioned that the ECD cell received from STL was an older cell that looked like it had never been used. The cell showed severe corrosion, which indicated that this cell had been in storage for a long time. The cell came in a box and was broken. The GC-repair RSO stated that the foil in these cells could fall out or removed easily, if the cell had been opened or if the ceramic portion of the cell was broken. This cell had a broken connector when received by the GC-repair licensee. The GE-repair RSO said that the cells can become loose in the Varian device and can break at the ceramic connector, which may have happened when someone attempted to remove it from the GC device. A tool is needed to remove the source from a cell in normal condition. The GC-repair RSO said that the cell didn't look like it had been tampered with in a purposeful manner. The GC-Repair RSO contacted (DELETED) when it was determined that the source was missing. They discussed the event in detail and (DELETED) was reminded, per the terms of GL device receipt requirements that they were not allowed to perform activities involving removal of sources. (DELETED) had recently taken over the program at STL Seattle. (DELETED) was further reminded of his record keeping responsibilities and the other limitations of receipt of GL GC detector cells. When DOH talked with (DELETED) he confirmed that he had spoken with the GC-repair RSO and had been made aware that the source was missing after the cell had been received. The cell had not been used for a few years. A person, no longer employed by STL Seattle, was thought to have worked on the cell. He had not worked for the company in over a year. (DELETED) thought that any work done on the cell would have been a year or two previous to this individual leaving. He did not know if this work had included removing the foil from the cell. (DELETED) stated that when he had been informed of the missing radioactive source, staff at STL performed a search of the lab. He stated that they have a Geiger counter, but were not able to find the source. DOH re-informed (DELETED) that they are not licensed to perform source work on cells, (DELETED) agreed. He stated that this won't happen again . (DELETED) stated that STL management oversight of lab activities had recently been improved. DOH issued an item of noncompliance to STL that was categorized as a Violation, for their failure to keep licensed radioactive material secure. DOH did not perform an on site investigation and no media attention was noted. What is the notification or reporting criteria involved? 10 CFR 20.2201(a)(1)(ii) 30 days. Activity and Isotope(s) involved: 555 megabecquerel (15 millicurie), Nickel 63. Overexposures? Likely N/A but was unable to be determined. This is a lost source: Manufacturer Varian Associates Inc., Model- 02-001972-0, Serial Number 5447. Disposition/recovery? STL was several times reminded of their responsibilities and limitations. Leak test? N/A Vehicle: N/A Release of activity? Loss of 555 megabecquerel (15 millicurie), Nickel 63, foil source. Activity and pharmaceutical compound intended: N/A Misadministered activity and/or compound received: N/A Exposure (intended/actual); consequences: exposure, if any, is unknown; consequences are unlikely. Was patient or responsible relative notified: N/A Was written report provided? Yes Was referring physician notified? N/A Consultant used? No | ||
| ENS 40093 | 9 August 2003 05:00:00 | Oklahoma Testing Labs | Agreement State | The following information was reported to the Operations Center by Oklahoma Department of Environmental Quality: On August 19, 2003, the licensee RSO (Radiation Safety Officer) conducted a biweekly inventory of his gauges and discovered that one of them was missing. Upon investigation he discovered that the gauge, a Troxler 3411B, S/N 6322, was last used on August 8, 2003. The next day, the technician who used the gauge took the gauge out to his truck and, preparing to go to a jobsite, loaded the gauge into the toolbox bolted to (the) bed of the truck. He left the tool box unlocked while he helped another worker unload, then discovered the gauge was missing when he returned. He had since decided not to work that day. He did not report this to anyone because he assumed that the other worker had taken the gauge out on the job with him. The licensee has contacted the police and has prepared a press release offering a reward for return of the gauge. According to the licensee, the gauge contained 281.2 Mega Becquerels of activity (7.6 milliCuries) as of 5/15/83. The gauge was not in its transport case and the gauge plunger was apparently unlocked when stolen." The Troxler contained an Am: Be source, S/N CAA-2493 and a CS-137 source, S/N CC-3452. Oklahoma Department of Environmental Quality is considering issuing a press release to its border states. The licensee will be offering a reward for the return of the gauge. The Oklahoma Department of Environmental Quality has notified NRC Region 4 (Linda McLean). | ||
| ENS 40102 | 25 August 2003 16:30:00 | Phelps-Dodge, Inc. | Agreement State | At approximately 9:30 AM MST August 25, 2003, the Agency was informed by the Licensee that they had discovered a source had disconnected from a rod in the Process Leaching Vessel. The source contains 3 Curies of Cobalt 60 as of October 2001. The licensee has made measurements and determined the radiation levels outside the vessel are not excessive. The device is a ThermoMeasure Tech Model 5031 L SN B43. Even though the source is disconnected, because it is trapped within a sealed source guide tube, it is still secure from inadvertent removal. The estimated date for full repair is October 21, 2003. Repair will be made by the device manufacturer. The Licensee has agreed not to drain the vessel without Agency notice and approval. The Agency continues to investigate this incident. The Agency is: ARIZONA RADIATION REGULATORY AGENCY. First Notice: 03-13 | ||
| ENS 40112 | 26 August 2003 00:30:00 | Longview Inspections, Inc. | Agreement State | The following report was received via fax from the Arizona Radiation Regulatory Agency: On August 25, 2003, at approximately 5:30 PM, while making an exposure at valve #14 (Iverton Rd. and Contractors Way in Tucson, Arizona) the source assembly unintentionally disconnected from the drive cable in the end of the six foot collimating guide tube. The exposure device being used was an INC - IR100, SN-4015, containing a 61 Curie IR-192 source, Model #87703, capsule #08809B. A 35 foot set of NDT (Non Destructive Testing) drive cables and a NDT guide tube were being used. The source was removed from the guide tube and collimator, reattached to the drive cable and cranked back into the exposure device, plugged, locked, and the drive cables removed. Pocket dosimeters indicated that whole body exposures were approximately 30 mR (millirem) and a hand exposure to the individual recovering the source was calculated to be 200 mR. The exposure device and drive cables are being sent back to AEA in Baton Rouge, LA to determine the cause of the disconnect. | ||
| ENS 40116 | 27 August 2003 14:15:00 | Mountain Enterprises | Agreement State | At approximately 9:15 A.M. (on 08/27/03), ( ) the Area Manager of Ashland, KY called and advised ( ), RSO, that ( ) had his truck stolen with a Troxler 3440 gauge (s/n 14782) in it. He also indicated that the Ashland Police Department had been notified along with all other local police departments. Mountain Enterprises offered a $1000 reward for the return of the gauge, and also provided two employees to assist in the search for the gauge. At 1:30 P.M. the Ashland Police Department called and said that they found the truck in a yard at 2513 Newman St. The gauge was still locked in the bed of the truck and the case was still locked with the source locked in place. A survey was performed that showed the source to still be inside. The police said that another vehicle was stolen a block away so the indication is that the truck and gauge were stolen for the transportation and not for the gauge. The gauge will no longer be stored overnight anywhere but at the plant. KY Item Number: KY030003. This event is closed by the State. | ||
| ENS 40120 | 27 August 2003 07:00:00 | Cornerstone Geotechnical Inc. | Agreement State | Subject: Event Report # WA-03-034 ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention) The license's representative, (...), reported that sometime between the evening of 27 August and the morning of 28 August that a Troxler, Model 3411B, moisture density gauge, Serial Number 13050, was stolen out of the trunk of the operator's transport vehicle parked outside the operator's residence in Everett, Washington. A police report was filed on 29 August and a reward posted. The operator violated several DOH requirements that contributed to the theft to the device. DOH requires that portable gauge licensees prohibit operators from taking gauges to residences if the work site is within 50 miles of the primary storage location. The gauges must be returned to that location. This didn't happen. Also DOH requires two independent layers of protection to keep the transport box, with secured gauge inside, secured to the vehicle. The licensee had not been using the two-layer method. And, gauges are not allowed to remain in the transport vehicle overnight as did happen. The licensee will be cited for at least 3 violations as a result of the event. A full report provided by the licensee, should be in the office, by the week of 1 September. This report will be updated after that. No media attention noted at present. Corrective actions will be discussed with the licensee. What is the notification or reporting criteria involved? 24-hour Activity and Isotope(s) involved: 370 megaBq (10 millicuries) Cesium 137 and 1850 megaBq (50 millicuries) Americium 241/Beryllium. Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) N/A Lost, Stolen or Damaged? STOLEN (mfg., model, serial number) noted above Disposition/recovery: pending Leak test? Unknown Vehicle: (description; placards; Shipper; package type; Pkg. ID number) Unknown Release of activity? N/A Activity and pharmaceutical compound intended: N/A Misadministered activity and/or compound received: N/A Device (HDR, etc.) Mfg., Model; computer program: N/A Exposure (intended/actual); consequences: N/A Was patient or responsible relative notified? N/A Was written report provided? Pending Was referring physician notified? N/A Consultant used? N/A | ||
| ENS 40128 | 27 August 2003 15:30:00 | Tobey Hospital | Agreement State | Upon receiving a package (small gray suitcase) of bulk Techneticum-99m (75 millicuries), a technician at Tobey Hospital detected high surface contamination readings on the case. The case was not open and showed no damage. Hospital staff isolated the case until the shipper could arrive. The shipper, Mallinckrodt, arrived at the hospital and performed their own tests on the package. There were two "hot spots" detected: one 3.5 to 4.0 millirem/hr on contact on the plastic auxiliary pouch, and one 0.3 to 0.4 millirem/hr on the side of the suitcase. Upon opening the package, a survey of the Tc-99m pig and inside foam showed almost no contamination. The driver of the delivery truck and the vehicle were immediately surveyed and showed no detectable activity. Surveys of the hospital lab and the lab where the suitcase was packed both showed no evidence of contamination. At this time, it is uncertain as to where the contamination originated. The package has been isolated and will be allowed to decay to background before the case is returned to service. | ||
| ENS 40132 | 4 September 2003 11:00:00 | Professional Service Industries | Agreement State | At approximately 0600 CDT on 9/4/2003, a 1999 Nissan Altima belonging to an employee of Professional Services Industries (PSI) was stolen while parked at his residence in Pass Christian, MS. The vehicle had a Troxler Moisture/Density gauge Model 3411B, serial number 18549, locked in the trunk. The gauge contained the following isotopes: Cs-137, 8 millicuries, serial number 50899, and Am-241/Be, 40 millicuries, serial number 4714005. The local PSI office is located in Gulfport, MS. Local Law Enforcement was notified of the stolen vehicle and gauge.
The stolen vehicle was located in downtown Gulfport, MS. The gauge was found intact and was transported back to the office for a leak test. It appeared that the gauge was not touched. Notified R2DO (P. Fredrickson). | ||
| ENS 40136 | 4 September 2003 15:00:00 | Little Company Of Mary Hospital | Agreement State | On September 4, 2003, two patients were scheduled for prostate brachytherapy implants. The first was suppose to be implanted with Iodine 125 and the second with Palladium 103. In anticipation of these procedures both the Palladium 103 and Iodine 125 were brought to the surgical suite. The first implant procedure was started and after two strands of Palladium 103 had been implanted it was discovered that an error had been made because the patient was scheduled to be implanted with Iodine 125. The treatment plan had been performed for Iodine 125. The decision was made to continue with the implanting of the Palladium 103 after a new treatment plan was performed. Based on the new plan the appropriate number of Palladium 103 seeds were implanted delivering the prescribed dose. Initial report from (DELETED) was that the patient was scheduled for 7:30 AM, so the event most likely occurred around 8:00 AM. Specific details will be included in his full report to follow. Because the treatment planning equipment was already in the surgical suits, the new plan could be developed with little delay. Specific time frame delays to follow in the full report. The second patient, scheduled for Palladium 103 was in the same day surgery suite and had not been prepped nor given an IV. He was rescheduled for another day, as they did not have enough Palladium 103 for both patients. | ||
| ENS 40137 | 4 September 2003 05:00:00 | Hbc/Terracon | Agreement State | A nuclear gauge was stolen during the night from a pickup truck parked at a residence. The chain and lock were cut and the gauge was taken. We are unaware of whether other items were taken. The technician became aware the gauge was missing when he arrived at a jobsite at about 5:30 am on 09/05/2003. The field service manager looked around the neighborhood and at local pawn shops but did not locate the gauge. The Licensee is considering a public announcement and the offering of a reward. The Agency is investigating the incident. The gauge is a Troxler 3430, serial # 17272, with 39.2 milliCuries of Am-241 (serial # 47-12694) and 6 milliCuries of Cs-137 (serial # 50-6643). | ||
| ENS 40141 | 8 September 2003 16:30:00 | Northridge Hospital | Agreement State | The following was received via fax from the California Radiation Control office: At about 9:30 a.m. on 09-08-03, an Ir-192 source (4.6 Ci (Curie)) failed to retract following a patient treatment. The source became stuck in the transfer tube. The physicist started his stopwatch, entered the room and attempted to manually retract the source. Manual retract failed. The physicist called the physician, who was waiting outside the room. The physician entered the room and disconnected the apparatus from the patient and dropped the transfer tube into a lead pig. The physicist and physician moved the patient out of the room. The physicist stopped the watch and it showed that 2 minutes had elapsed. The physicist surveyed the patient and obtained no measurement above background. The physicist re-entered the room and performed a radiation survey, and found the hot spot along the transfer tube to be in the pig. The pig measured 10 mR (millirem) /hr at 3 feet. The room was locked and posted until arrival of the manufacturer's representative, who also was unable to make the source retract. The manufacturer's representative placed the transfer tube into a shipping container and shipped it back to the manufacturer for further investigation. Doses to the patient, physicist and physician were estimated as follows: patient skin dose (10cm from source for 2 minutes) = 9 rem; physicist for 2 minutes = 45 mrem (millirem); physician 125 mrem (millirem) whole body and 15 rem extremity. The device used was a Nucleotron MicroSelectron HDR (High Dose Rate) model number 31324 (Serial Number D36A4476). The malfunction of the device is under investigation. | ||
| ENS 40144 | 10 September 2003 18:15:00 | S.T.A.T.E. Testing, Llc | Agreement State | Abstract: The agency received a call at 13:40 on September 10, 2003, from (DELETED) RSO of S.T.A.T.E. Testing, LLC (License Number IL-01015-01). He reported that, at approximately 13:15, this afternoon, a Troxler Model 3440 moisture density gauge, serial number 22737, (containing 8 mCi of Cesium-137 and 40 mCi of Americium-241/Beryllium), was stolen from the back of a locked truck (Ford F-150) parked on the street at 63rd and Racine in Chicago. According to the technician in charge of the gauge, (DELETED), the source rod was locked in the shielded position and the device itself was contained in a locked D.O.T. Type A transport container with Radioactive -Yellow II transport labels on it. The licensee stated that he would notify the police next. We suggested that he provide the police with photographs of such a type A container and the device itself. We also recommended that he consider a press release or other means to get the word out to the public, in case it is abandoned and later found. In addition to the written report required by our regs, we instructed (DELETED) to keep us informed of any developments in this case. We also provided him with the number to our Dispatch Center, if it happens to be recovered during off-hours. This event was reported to the NRC Operations Center at 1759 hrs e.s.t. and assigned NRC Event No. 40144. Illinois Item Number: IL030067 | ||
| ENS 40149 | 11 September 2003 19:00:00 | Atl Inc. | Agreement State | The following information was provided via facsimile: On September 11, 2003, and prior to 6:00 AM, a soil density moisture gauge was stolen from the back of a pickup truck located at (Deleted), Mesa, AZ. The gauge is a Troxler Model 4640, Serial Number 2443 and was contained in a yellow shipping container. It was reported that the gauge was originally chained and locked in the rear of the pickup bed and the chain and lock were missing. This Agency was notified and the Mesa Police are investigating. The company is offering a $500.00 for information leading to the recovery and return of the gauge. The initial investigation indicates that several violations may have occurred. The Agency and licensee's will continue to investigate this occurrence and report further. The U.S. NRC, FBI, Mexico, and the states of Colorado, Nevada, Utah, New Mexico and California are being informed of the incident. | ||
| ENS 40154 | 9 September 2003 07:00:00 | Unknown | Agreement State | At 4:30 pm on 9/9/03 the radiation alarm pegged at off scale at the Keller Canyon Land fill from a load of trash from the Contra Costa Transfer Station. The facility's Bicron probe indicated (off scale) on the drivers side of the truck. The passenger side probe was fluctuating above normal but not off scale. (DELETED), the Operations Manager informed RHB Berkeley of the radiation alarms and that Contra County Environmental Health had also been notified. Based upon this conversation it was determined that the truck will be secured in a restricted area and access will be restricted and warning tape and signs will be used. Arrangements were made to visit the facility on 9/10/03 to determine the cause of the radiation alarms. The facility was visited on 9/10/03 and after surveys it was determined the source of the radiation alarms was cesium 137. The maximum reading on side of the dump truck was 2.5 milliRem/hr and 0.7 mRem at one meter using an Eberline RO 20 Calibrated 4/03. A Bicron Fieldspec was also used and it was determined that radiation was from cesium 137 based upon the 662 kev gamma photon. The truck was moved to an isolated area and the driver using hydraulics pushed the load out as while surveys were conducted to indicate when the source of radiation had left the truck. Based upon the identification of cesium 137 a sealed source was suspected. After the surveys indicated the source of the radiation was on the ground, rakes and wood were used to move the trash to identify the location of the source. Following surveys and raking, a small one inch cylinder or rod was identified as the source of the radiation readings. The source resembled the end of a moisture density gauge source rod. Based upon surveys it was calculated that the source contained about 8-10 milliCuries of cesium 137. Using tools the rod was placed in a lead pig and transported to CPN for further investigation. The investigation will try to determine if the rod was cut or broken off the source rod and if the serial number on the source can be used to locate it's previous owner. Surveys of the load and truck using a Ludlum Survey meter with a pancake G-m model 44-9 probe indicated their was no contamination from the source. CPN will also perform a leak on the source. Troxler and Pacific Nuclear were also contacted to see if there were any unusual requests for a new source rod in the last six months. Both companies indicated they were not aware of any such requests. Further information will be provided following this investigation. The engraved source capsule serial number is CDCW 556, 9290. This information has been reported to Troxler, Rancho Cordova, who will report it to the RSO, Troxler, North Carolina, where source/gauge/customer files are kept. | ||
| ENS 40155 | 30 July 2003 05:00:00 | Raba-Kistner Consultants, Inc. | Agreement State | A Troxler Model 3411, Serial No 10540, containing two sealed sources: 1.48 GBq/40mCi (+/- 10%), Am-241:139, Serial No. 46-1962 and 0.30 GBq/8 mCi (+1-10%), Cs-137, Serial No. 40-7974, was stolen from an employee's truck at his residence. The cable securing the case had been cut and the case pried open with the gauge, calibration (standard) block and gauge paperwork removed. A police report was submitted to the San Antonio Police Department. Texas Incident No.: I-8051 | ||
| ENS 40160 | 15 September 2003 21:52:00 | Utah Valley Regional Medical Center | Agreement State | A patient was administered 15 millicuries of I-131 sodium iodide rather than 4 millicuries for a post-ablation scan. The administrative dosage differed from the prescribed dosage by more than 20% of the prescribed dosage. | ||
| ENS 40169 | 16 September 2003 05:00:00 | Chicago Prostate Cancer Center | Agreement State | The following was received via email from the State of Illinois: On 9/16/2003, the agency was contacted by (DELETED) RSO at the Chicago Prostate Cancer Center in Westmont, IL (IL-02015-01). He indicated that on 9/11/2003, a package of unused radioactive seeds was being prepared to be returned to Amersham Health/Medi Physics in Arlington Heights, IL. At that time they noted that the package contained only 6 'strands' of sources whereas the paperwork for receipt on 9/4/2003 indicated 7 'strands' of sources to be present. The I-125 seeds are contained in a special rigid plastic carrier. This carrier has a marketing name of 'rapid strand'. Each 'strand' contains ten I-125 seeds in a rigid plastic holder which is then placed in a stainless steel holder with an opening at one end. When the seeds are in the holder, radiation readings are at or very near background levels of radiation. This holder has been sterilized at Medi Physics and as a result it is placed in a sealed pouch until it is ready to be used in the operating room. A full description with some diagrams can be found at http://www.hsrd.ornl.gov/sources/pdf/01360338.pdf. The package containing the six strands of seeds was picked up by Federal Express and returned to Medi Physics on 9/17/2003. (DELETED), RSO of Medi Physics participated in the inspection of the package to be sure that the problem was not just an administrative error. His inspection did not turn up the missing 7th strand. An inspection of previously used shipping containers from this site that had been returned to Medi Physics did not result in the recovery of the missing strand either. (DELETED) also had production perform an accounting check as well to see if perhaps only 6 strands had been originally shipped as a mistake. The check showed no outstanding seeds or strands from that lot that could not be accounted for, or shipped to another client as a result of a substitution. An agency inspector also visited the Chicago Prostate Cancer Center in Westmont on 9/17/2003 and attempted to locate the strand through radiation monitoring. He was not successful in recovering the strand. As a result, one strand containing a total activity of 5.94 (milliCuries) mCi (10 seeds with 594 micro Curie each) is missing. The licensee will continue its attempts to locate the missing seeds and will keep the agency updated with its efforts. The licensee was also advised that a written report is due to the Agency in 30 days. | ||
| ENS 40180 | 17 September 2003 20:00:00 | Arizona Oncology Services | Agreement State | At approximately 1:00 PM September 17, 2003 the Agency was informed of a medical event. The reporting individual indicated that in the course of treating a breast cancer, a saline filled balloon was used to aid in positioning the HDR source, Iridium 192, approximately 9.589 curies. Starting September 15, 2003, a series of 10 fractional treatments was prescribed. Between each, an ultra sound image was made to assure the continued proper placement of the source. The ultra sound technician indicated all was ok for all treatments. After the series was completed, the balloon was deflated for removal and the physician then noted that the balloon had ruptured. A review of the retained ultra sound images indicated (that) starting with treatment 7 the balloon was deflated. The doses were recalculated and the tissue dose was 40 (percent) higher than prescribed. The adjacent skin dose was calculated to be 266 cGy (centigray) rather than the 175 cGy (centigray) as originally calculated. The licensee has proposed corrective measures to prevent a recurrence of this event. The balloon manufacturer has been informed of this event. The patient has been informed of the event. The medical review indicates some additional fat necrosis and possible inflammation may occur. It will be reviewed as a part of the patient follow up. | ||
| ENS 40188 | 22 September 2003 05:00:00 | Schlumberger Tech Corp | Agreement State | (The) Company (Schlumberger Technology Corporation) has decided to abandon two sources downhole. Recovery operations have failed and sources will be cemented in place today. Two sources consist of: One (1) AEA Technology, Cs-137, 1.7 curie sealed source, Model GSJ, Serial No 180; and (1) Schlumberger Am-241/1Be, 16 curie sealed source, Model NSR-F, Serial No. 2355. Sources are stuck in the well, Recovery has not been possible. Source will be cemented in place at 11,755 feet and 11,742 feet respectively by 200 feet of red dyed cement with whipstock place as a deterrent to future drilling. Schlumberger is in the process of ordering a wellhead placard for placement on the wellhead. Texas Incident No.: I-8056. | ||
| ENS 40190 | 22 September 2003 10:00:00 | A.G.I. Geotechnical, Inc. | Agreement State | The RSO reported by phone to Radiologic Health Branch (RHB), Granada Hills, that one of its portable nuclear gauges had been stolen the night of 9/21/03, between 2330 and 0630 (PDT), from the RSO's vehicle which was parked in a back parking lot at his apartment complex in Glendale, CA. The gauge is a CPN, Model MC-2, S/N M21073950, containing Cs-137 and Am-241 sealed sources, special form, 10 (millicuries) and 50 (millicuries), respectively. Apparently, the RSO took two gauges home on 9/21/03 to drop one off at a job site for another operator and one for his use at another job site the next day. The RSO stated he stored the two gauges in the bed of his vehicle, locked down and concealed with a tarp. The morning of 9/22/03, the RSO found that one of the two gauges (his) was missing. The second gauge was not taken but had its case damaged. It seems that a 'hammer-like' tool also kept in the vehicle was possibly used to break in. Note that this is the 2nd reported theft of a nuclear gauge for this licensee this year. The last one was reported stolen on 6/19/03 and then recovered on 7/7/03. The RSO had already notified the Glendale Police Department and his company management. The RSO will be providing a written report shortly. | ||
| ENS 40193 | 23 September 2003 17:00:00 | Arviso Engineering Inc | Agreement State | On 23 September 2003, the licensee notified the Agency that a Humboldt Scientific moisture/density gauge, serial number 1136, had been run over by a roller at a construction site in the vicinity of interstate 8 and Avenue 3E in Yuma. The source was in the backscatter position at the time; however, the licensee was able to retract the source into its shielded position. A leak test is being performed. The Agency will continue to investigate. The gauge contains approximately 10 millicuries of cesium 137 and 40 millicuries of americium-beryllium. The NRC and Governor's office are being notified of this event. | ||
| ENS 40201 | 26 September 2003 17:00:00 | Computalog | Agreement State | A 5 curie AM-241/Be sealed source was found leaking during a routine leak test on September 26, 2003. The removable contamination was 0.081 microcuries. The source is a Gulf Nuclear model 71-1 serial # 71-1448B. The source was transported during September 2003 from the Licensee's Edinburg, TX site to the Ft. Worth site. The contamination was confined to the inside of the transport container and the source housing. A second source that had been stored as a companion in the same down hole storage in Edinburg also had a small amount of contamination on it (399 dpm found, below the 11,000 dpm limit). Therefore, the Edinburg downhole site will be checked by the Licensee for contamination. The storage facility in Edinburg has been taken out of service and off limits until proper surveys are made. An update will be provided when more information is available Transport vehicle description: Computalog company vehicle Texas Incident No: I-8059. | ||
| ENS 40218 | 2 October 2003 04:00:00 | Sinai Hospital | Agreement State | On 10/02/03, a patient with suspected hyperthyroidism was undergoing treatment at Sinai Hospital in Baltimore, MD. During administration of an uptake diagnostic test, the patient was given a dose of 80 microcuries of I-131 versus the prescribed dose of 8 microcuries. Preliminary investigation indicates that hospital policy is to have technician dose measurement verified by another technician and approved by supervision until the technician shows proficiency at this task. It is unclear at this time whether the technician followed this protocol. The prescribing physician has been notified and has notified the patient. Follow-up tests will be performed on the patient, but no increase in physiological effect on the patient is expected.. Maryland Department of Radiation Health is planning to contact the Hospital Radiation Safety Officer. | ||
| ENS 40219 | 2 October 2003 04:00:00 | Nodarse | Agreement State | Troxler moisture density gauge, model #3430, serial #32804 was stolen from the rear of licensee employee's truck parked at residence in Tampa, FL between the hours of 11 PM EDT 10/02/03 and 11 AM 10/03/03. The locked chain securing gauge box was broken. The gauge contained 40 (milliCuries) of Am-241/Be and 8 (milliCuries) of Cs-137. Tampa Police, Florida Department of Emergency Management and the NRC Region 2 have been informed. The licensee posted a notice offering a reward in the Tampa newspaper. Florida Incident # FL 03-181
Troxler was notified by a pawn shop owner in Tampa on 8 October that they had bought the gauge. Troxler notified the State of Florida. The owner and police were notified and the gauge was retrieved. It was undamaged. The police have a good lead on the thieves. Licensee will be forwarding a copy of the police report to the State of Florida. Notified R1DO (Bellamy) and NMSS EO (Hickey). | ||
| ENS 40220 | 3 October 2003 22:00:00 | Stork Sw Laboratories | Agreement State | The following information was received from Texas Department of Health, Bureau of Radiation Control via facsimile: Troxler model 3440, serial # 31623 8 (millicuries) Cs-137 source, sn (serial number) 7506418 40 (millicuries) Am-241/Be, sn 4728354 A technician removed the gauge from the back of the pick up truck to wash the truck. The gauge was placed outside the wash bay. The gauge was stolen while the technician was busy washing the truck. The gauge was locked inside the storage container. Some tools were inside. No other items were stolen or left unattended. The licensee notified the local police. The incident was reported to the Agency by the Beaumont site RSO. The Agency is investigating the incident. Texas Incident Number I-8060. | ||
| ENS 40235 | 9 October 2003 04:00:00 | Thelen Associates, Inc. | Agreement State | The Ohio Bureau of Radiation Protection was notified on 10/9/03 that a CPN Model MC portable moisture density gauge, S/N MD20606630, was stolen from an employee's vehicle parked overnight at his residence. The gauge contains two (2) sources; 9.7 millicuries Cs-137 and 49.8 millicuries Americium-241/Beryllium. The theft was discovered earlier this morning and reported to the State at 1259 EDT. The State is dispatching a field investigator for followup. The licensee informed the local Police Department of this incident. | ||
| ENS 40236 | 8 October 2003 07:00:00 | Sacred Heart Medical Center | Agreement State | This is notification of an event in Washington state as reported to the WA Department of Health, Division of Radiation Protection. STATUS: New (this is an preliminary notification due to the lack of required information at this point in time). Licensee: Sacred Heart Medical Center City and state: Spokane, Washington License number: WN-M031-1 Type of license: Medical Date of event: 8 October 2003 Location of Event: on campus (OR) ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention) The licensee was implanting a source train of I-125 seeds for a lung cancer treatment and during that implant decided the source train in use was longer than necessary. They decided to clip the unwanted part of the train but snipped a source rather than the space between the sources. What is the notification or reporting criteria involved? Leaking source, possibly. If not, no notification is required, if so, then a possible overexposure to the patient (thyroid). Activity and Isotope(s) involved: Iodine-125 therapy seed(s). Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) None, with the possible exception of the patient. Lost, Stolen or Damaged? (mfg., model, serial number): This was an Iodine-125 seed, part of a source train of such seeds which was damaged when the licensee attempted to shorten the train but cut through a seed instead of the interstice desired. Disposition/recovery: No loss of seeds. Leak test? Licensee is performing one ASAP but as of this writing there are no results. Vehicle: (description; placards; Shipper; package type; Pkg. ID number): N/A Release of activity? Unknown at this time, if the seed is not leaking, then 'no'. If the seed is in fact leaking then the potential exists for release of material inside the patient. Activity and pharmaceutical compound intended: N/A, the proper nuclide and activity was delivered to the intended treatment site. Misadministered activity and/or compound received: N/A, this was not a misadministration. Device (HDR, etc.) Mfg., Model; computer program: N/A, no device involved. Exposure (intended/actual); consequences: No unplanned exposure, unless the source turns out to be leaking. Was patient or responsible relative notified? Unknown at this time. Was written report provided? Not yet, but it will be. Was referring physician notified? Yes, referring MD notified by oncologist. Consultant used? No. This is WA Event Report # WA-03-043.
New (this is an updated notification). ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH on-site investigation; media attention) The licensee was implanting a source train of 31 (Iodine-125) seeds for a lung cancer treatment along the lining of the pleura and during that implant decided the source train in use was longer than necessary. They decided to clip the unwanted part of the train but snipped two source(s) rather than the space between the sources. The licensee administered large quantities of SSKI within one hour of breaching the seeds. The current plan is to continue administration of SSKI in amounts of at least 0.5ml daily for at least the next two weeks. What is the notification or reporting criteria involved? MISADMINISTRATION via leaking source. Activity and Isotope(s) involved: Iodine-125 therapy seed(s). A total of two seeds with an activity of 0.729mCi each according to the licensee. Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence) None, with the possible exception of the patient. The primary handler has received thyroid bioassay with negative results. The licensee is expecting results of the pleural fluid sample taken from the patient soon, and will attempt thyroid bioassay of the patient at the 72-hour exposure interval. Lost, Stolen or Damaged? (mfg., model, serial number): These are Iodine-125 seeds, part of a source train of such seeds which were damaged when the licensee attempted to shorten the train but cut through two seeds instead of the interstice desired. The manufacturer is MPI, the model is the 'Oncoseed' 'Rapid Strand'. The licensee will include an enlarged version of the product insert with their written report. Disposition/recovery: No loss of seeds although remains of the two leaking sources are properly stored awaiting decay/disposal. Leak test? Leak test results from the soak test (four hours in plain water) showed 'significant leakage' according to the licensee, and they are assuming a worst-case scenario basis of one entire seed leaking and one-half the second seed leaking. Release of activity? Yes, it is assumed on a worst-case basis that the entire contents of one seed and fifty percent of the second seed has or will leak. Misadministered activity and/or compound received: This was a misadministration by definition because the sources are determined to have leaked. Exposure (intended/actual); consequences: Exposure is limited to the patient only. The licensee will attempt to quantify through both calculation and bioassay the extent of patient/thyroid exposure. Physicians involved expect little or no adverse effects at this point, assuming the SSKI works as expected. Was patient or responsible relative notified? Yes. Rev 1. 1530 hrs, 9 October 2003 Notified R4DO(Bill Johnson) and NMSS(Holonich). | ||
| ENS 40237 | 9 October 2003 22:00:00 | Western Technologies, Inc. | Agreement State | At approximately 2:15 PM (MST) October 9, 2003 the Agency was informed by the Licensee that a truck carrying a moisture-density gauge had been involved in a single vehicle accident and the driver is dead. The reporting individual indicated that they were informed of the accident by the Department of Public Safety. The accident occurred on AZ Highway 260 between Bridgeport and Camp Verde. The moisture-density gauge is a Troxler Model 3440, SN 27494. The device contained 40 mCi Be:Am-241 and 8 mCi Cs-137 (mCi=millicuries). The device remained in the transporting box inside a locked steel box in bed of pick up. The Licensee is trying to retrieve (it) from law enforcement for storage and leak test. (It is) Currently in an impound yard in Mayer, AZ. Agency continues to receive information regarding this fatality. The Agency is unaware of any press coverage regarding radioactive materials. The U.S. NRC is being notified of this event. AZ First Notice: 03-19
The leak test was negative. It appears the driver was not wearing his seat belt. Notified NMSS (D. Broaddus) and R4DO (G. SANBORN) | ||
| ENS 40238 | 9 October 2003 05:00:00 | Wisconsin Public Serv Corp | Agreement State | The Wisconsin Department of Health and Family Services reported that on 10/9/03 it was discovered that a general licensed gauge used on the coal conveyor at the Wisconsin Public Services Corporation Pulliam coal-fired power plant in Green Bay, WI was removed without properly closing the shutter and left in a public area on 9/25/03. The gauge contains a 50 milliCuries Cs-137 source. The device was subsequently recovered and properly shuttered on 10/09/03. Wisconsin Public Services Corporation issued on 10/09/03. Fixed Gauge Manufacturer: Texas Nuclear Source S/N: B2920 The RSO (Radiation Safety Officer) took readings in the direction of the open shutter; at 8 feet (4 to 5 Mr/hr) and at 3 feet (10 Mr/hr). Wisconsin Department of Health and Family Services, Radiation Protection Section staff will perform an investigation the week of 10/13/03.
The Wisconsin licensee notified the State of Wisconsin that there was an error in the original report related to gauge make, model, serial number and source strength. The new detailed information is as follows: ThermoMeasureTech Model # 5200, Ser. # B2011, Source Activity 20 mCi (milliCuries). Notified R3DO (Madera) and NMSS (Holonich). | ||
| ENS 40239 | 10 October 2003 04:00:00 | Unknown | Agreement State | This is to inform you that North Carolina Radiation Protection Section has discovered a fixed nuclear gauge that was scrapped and is now being held by a North Carolina scrap dealer from Gastonia, NC. Radioactive Materials Branch Incident 03-13 has been open pending further investigation of a device, originally described as an X-Ray head, having been found in a returned scrap load sent to a South Carolina scrap steel processor and returned under a CRCPD exemption. A Section representative performed a field inspection on October 9, 2003 on the undetermined item being held in secure isolation at the scrap-yard since its discovery in March 2003. At present our investigation has determined that: - Device is a Fixed Nuclear Gauge. K-Ray model 7107-6. This device is inactive per the SS&D registry sheet and is considered for both GL (General Licensing) and Specific Licensing. - Contains isotope Cs-137 in the amount of 50 millicuries. Reference year from gauge label is March 1983. - Highest general area (about 1(meter)) dose rate is approx 0.1 (millirem per) hr with 200 (millirem per) hr on contact. It is unknown whether the shutter is open or closed but dose rates when compared to SS&D (Sealed Source & Device) information for the general model indicate it may be open. - Labeling has been painted over and also appears as if a deliberate attempt had been made to destroy the device identification labeling & serial number(s). Corrective Actions So Far: Surveys and leak tests have been performed. Analysis on wipes is pending but source does not appear to be leaking. Device has been re-secured. Verbal direction has been given to the State Line Manager on its necessary security and continued isolation from the scrap yard workers and other members of the public. Additional steps are being taken to determine if any significant exposures could have been received by anyone at State Line who spent time nearby or who may have handled the device since its return to them. If/when significant additional information becomes available it will be passed along to you. | ||
| ENS 40240 | 10 October 2003 13:00:00 | Greater Kelly Development Authority | Agreement State | A hangar formerly used by the U.S. Air Force was under re-construction for transformation to a corrosion control facility. The unlicensed facility had been contaminated by radium during use as a paint shop during 1922-1929, and as a paint removal facility during later years. Supposedly this facility has been deed recorded as a site of contamination with Ra-226 (Radium-226). The facility is not Licensed by the State of Texas. At this time it is unclear if this facility was released for unrestricted use when turned over to the Greater Kelly Development Authority. This Agency can find no record of the site contamination. Contractors from the Boeing Corporation were working on the facility to be remodeled to a corrosion control facility. Digging around the foundation (slab) they hit a 2-inch galvanized pipe that was contaminated with radium-226. Background levels at the facility were measured at 10,000 counts per minute and after the incident at 10 times that level. An Agency inspector will be on site for soil sampling. It is estimated that 10-20 Boeing employees may have come in contact with the material. Urine analysis has been ordered by the contractor for personnel suspect of working in the contamination. Initial reports from both Greater Kelly Development Authority and the Boeing Corporation have been received - but are inconclusive. The Texas Commission on Environmental Quality, the EPA, and the U.S. Air Force have been notified. | ||
| ENS 40241 | 10 October 2003 19:30:00 | Coastal Engineering And Testing Co | Agreement State | The South Carolina Department of Health and Environmental Control was notified on October 10, 2003, at 7:45 pm (EDT) by Coastal Engineering and Testing, Co. that a Troxler Model 3430 gauge, s/n 33695 was stolen from the back of a company pickup truck while at a temporary jobsite in Charleston, SC. The gauge contained an Am: Be (Americium: Beryllium) source with an activity of 44 mCi (millicuries) and a Cs-137 (Cesium-137) source with an activity of 9 mCi (millicuries). The licensee has called the local police department to file a report. The licensee in its official report will provide further information to the Department. | ||
| ENS 40264 | 20 October 2003 04:00:00 | Florida Medical Center | Agreement State | Noveste Beta-Cath System (Model A1767 30mm S/N 86853) was used in a procedure on September 18, 2003. It has not been seen since. This office was notified October 20. This model contains 12 Sr-90 seeds, total activity up to 60 mCi (milliCuries). Florida is investigating. Florida Incident # FL03-192 | ||
| ENS 40267 | 21 October 2003 13:10:00 | Raven Inspection & Testing, Inc. | Agreement State | Texas Incident No.: I-8065 Event date and time: 10/21/03, discovered approx. 8:10 cst Event location: Humble, TX storage shed Event type: Stolen radiography camera Notifications: The licensee notified the local police, BRC, and other radiography companies in the area. Event description: SPEC Model 150 exposure device, sn #0336, 32 Ci (Curies), Ir-192 source, model G-20, sn #KF1204 The licensee arrived at work this morning, found the security gate wide open, the lock cut on the storage shed, the lock cut on the vault and the camera missing. The only thing taken was the camera, all other equipment was still in place and the darkroom was still locked. The licensee had only one camera. The camera was used on a job yesterday and secured after use. There are about 60 other storage sheds located within the fence. The only one broken into was the licensee's storage shed. Other radiography companies in the area were contacted by the licensee, also the local police were notified. The incident has not received any media attention. The Agency (BRC) is investigating the incident. Transport vehicle description: None reported Media attention: None reported. | ||
| ENS 40269 | 22 October 2003 19:30:00 | University Of Texas At Austin | Agreement State | Event location: RLM Building Vault Room 2.306, J.J. Pickel Research Campus, The University of Texas at Austin, Austin, TX. Event description: While performing an exhaustive inventory of sources for possible recovery in the DOE Source Recovery Program it was determined by visual survey a 5 millicurie, Am-241, sealed-source was missing. The source was probably procured in the 1960's and has been indicated as in storage since the late 1980's. The last leak test that was currently available was dated 04/19/88. The source is suspected of being manufactured by the Monsanto Company and is listed as Serial No. M-376. No information on Model is available. The source is indicated as being sealed in 1-inch pipe. The RSO reports that the source has evidently been confused for years with another source that is indicated on storage records as CNS-1. However, he feels relatively sure that it is not the same source. Records indicated that the source was transferred to storage 11/27/84 and may have last been seen on 04/19/88. A visual and instrument survey of the last known storage facility did not locate the source. The RSO believes that the source may have been disposed of with Radium sources but there is no indication on shipment manifests. The previous RSO has been contacted and reportedly cannot recall details about the specific source. Transport vehicle description: Not applicable Media attention: None Texas Incident No.: I-8066 | ||
| ENS 40275 | 23 October 2003 12:30:00 | Drash Consulting Engineers, Inc | Agreement State | A Troxler gauge, Model 3241C, serial # 2547 with a 100 millicurie Am-241/Be source serial # 558906 was stolen from the back of gauge operator's pickup truck. The truck was parked at the gauge operator's residence overnight. The lock, chains, and broken handles from the gauge case remained on the back of the truck. Only the gauge and case were taken. TX Bureau of Radiation Control, Local police, states surrounding TX, and Mexico have been notified. Texas Incident # I-8067. | ||
| ENS 40279 | 18 October 2003 06:00:00 | Longview Inspection | Agreement State | Radiographic exposure device (Camera) was left unsecure on the tailgate of a company pickup truck before departing Licensee's local site enroute to the work site at: Huntsman Polymers, 2400 South Grandview Avenue, Odessa, Texas 79766. The Radiographer Trainer, (deleted), and his Trainee enter into conversation with another company employee and failed to block and brace the device or to secure the device to their truck. They drove out of the shop area and onto the street in front of the office. Approximately 100 yards from the office, the device fell off the tailgate and onto the service road. Approximately 10 minutes later, an NDT customer enroute to the Licensee's facility came by and noticed the camera in the road. He recovered the device and transported it to the Licensee's Odessa office. The crew was notified by cell phone and returned to the shop. The camera is an Industrial Nuclear Company, Model IR-100 exposure device, Serial No. 4318, containing 80 curies of iridium 192. The camera was surveyed for external damage and radiation at the shop. No external damage was noted and the results of the radiation survey revealed radiation levels that were the same as when the device had initially been surveyed that day. The exposure device was taken to a safe location, attached to associated equipment and operated to determine if the device had suffered internal damage. No damage was noted as the device operated perfectly. The device was leak tested. Results of this test have not been returned to the company as of October 27, 2003. As corrective action both the Radiographer Trainer and the Trainee have received a written warning under the Licensee's disciplinary policy. Both individuals will be required to participate in several radiation safety programs and be re-tested. The Trainee will be require to attend another 40-hour radiation safety class in December 2003. The Licensee is being cited for: failure to physically secure radioactive material; and failure to make an immediate (24-hour) notice to this Agency. In addition, the Radiographer Trainer will also be cited for failure to secure the device. Escalated Enforcement actions have been recommended which will include assessment of an Administrative penalty for the Licensee. | ||
| ENS 40291 | 1 January 1993 06:00:00 | Big Red Keno Lottery | Agreement State | The following was received from the State of Nebraska via facsimile: Four signs with 8.5 curies of tritium were installed at Big Red Keno Lottery in 1991 during a remodeling project. The main entrance to the building was moved in about 1993. The original main entrance doorway was closed except for a small door which was not a fire exit. They believe the sign to the original entrance was removed at that time. No one knows where the sign went. After doing an inventory requested by this Agency, the facility discovered the sign missing and we were notified. The lost sign is a sealed source, manufactured by Safety Light Corporation, Model Number 880-12-5-12, Serial Number C17089. The probable disposition of the sign is the city landfill. Nebraska event report ID number NE-03-0005 |