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| Entered date | Event description | |
|---|---|---|
| ENS 45150 | 23 June 2009 11:06:00 | On 15 Jun 2009 a fixed gauge fell off a digester blow line, about 4 feet onto a grating platform. Licensee staff working in the area noticed the gauge and alerted their supervisor and radiation safety officer. After ensuring the shutter was closed and the source (CS-137; .4092 Ci) was still present, the device (containing its source) was moved to a secure location. Licensee performed wipe surveys to check for leaking / contamination. Meter surveys confirmed the presence of the source, and also the absence of elevated dose rates. There is concern that the welds failed that attached the device to the mounting on the pipe. The manufacturer (Ohmart Vega) has been notified and will assist in arranging return of device (containing its source) and further assessment of cause of failure. The manufacturer uses same model (SR-1A) and serial (#6339) for both source and device. The Washington State incident number is WA-09-034. |
| ENS 45234 | 29 July 2009 11:40:00 | The following report was sent from the State of Washington via email: On 22 July, 2009 (the Washington State Office of Radiation Protection) received a report of a missing XRF device. On 20 July, 2009, an employee at Cole & Associates, failed to report to work and has yet to contact employer's office as to their whereabouts. The employee has not been seen nor heard from. The employee was performing inspections at the Veterans Hospital in Tacoma, Washington, the employee's home town. The employee had in their possession a Thermo Fischer Scientific Niton XL 309 X-ray Fluorescence (XRF) device, serial number U2615TRO459, with an 14 millicurie Cadmium-109 source dated 11/15/2008. The XRF device is used exclusively for lead analysis in paint. Thermo Fisher Scientific has been notified and will alert the licensee if anyone turns in the unit in to them. A report was also filed with the Kent police. Washington Report WA-09-049. Cadmium-109 has a half life of 462 days. 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. |
| ENS 45272 | 18 August 2009 12:33:00 | On 19 June 2009, TTM Technologies in Redmond was contacted as part of a routine check of their inventory of generally licensed devices. It was discovered at this time that the facility was closing and that the gauges and static eliminators had been sent to TTM Technologies facilities in other states. TTM Technologies has since tracked down as many of the missing devices as possible. Those facilities that have received sources have been informed of the reporting requirements and regulations surrounding those generally licensed devices. NRD, Inc. was contacted to see if any of the remaining unaccounted for sources had been returned to them. They have not been. The remaining missing sources are being reported as lost. This report lists eight devices/sources. A ninth device/source (exactly the same as number 8 except for the serial number) is being included here instead. This device/source is serial number A2CK423. Seven of the nine devices/sources are Po-210 static eliminators and have gone through more than ten half-lives. The other two devices are sources of Pm-147 in beta backscatter gauges and have gone through approximately 8 half-lives. It is therefore concluded that the missing sources are of little threat to human health and safety. Source of Radiation: Source Number: 1 Form of Radioactive Material: SEALED SOURCE Radionuclide: PM-147 Source Use: OTHER Activity:0.9E-3 Ci 0.0333 GBq Manufacturer: OXFORD INSTRUMENT Model Number: GM-1 Serial Number: 75125P Source Number: 2 Form of Radioactive Material: SEALED SOURCE Radionuclide: PM-147 Source Use: OTHER Activity:0.6E-3 Ci 0.0222 GBq Manufacturer: OXFORD INSTRUMENT Model Number: GM-1 Serial Number: 65986P Source Number: 3 Form of Radioactive Material: SEALED SOURCE Radionuclide: PO-210 Source Use: STATIC ELIMINATOR Activity:0.05513 Ci 2.03981 GBq Manufacturer: NRD, INC Model Number: P-2001 Serial Number: A2EA910 Source Number: 4 Form of Radioactive Material: SEALED SOURCE Radionuclide: PO-210 Source Use: STATIC ELIMINATOR Activity:0.05513 Ci 2.03981 GBq Manufacturer: NRD, INC Model Number: P-2001 Serial Number: A2BM653 Source Number: 5 Form of Radioactive Material: SEALED SOURCE Radionuclide: PO-210 Source Use: STATIC ELIMINATOR Activity:0.05513 Ci 2.03981 GBq Manufacturer: NRD, INC Model Number: P-2021 Serial Number: A2DY847 Source Number: 6 Form of Radioactive Material: SEALED SOURCE Radionuclide: PO-210 Source Use: STATIC ELIMINATOR Activity:0.010 Ci 0.37 GBq Manufacturer: NRD, INC Model Number: P-2021 Serial Number: A2CE789 Source Number: 7 Form of Radioactive Material: SEALED SOURCE Radionuclide: PO-210 Source Use: STATIC ELIMINATOR Activity:0.010 Ci 0.37 GBq Manufacturer: NRD, INC Model Number: P-2021 Serial Number: A2BM653 Source Number: 8 Form of Radioactive Material: SEALED SOURCE Radionuclide: PO-210 Source Use: STATIC ELIMINATOR Activity:0.010 Ci 0.37 GBq Manufacturer: NRD, INC Model Number: P-2021 Serial Number: A2CK423 Corrective Actions: 1 Personnel received additional training. Washington state reporting requirement WAC 246-221-240 Washington Report No: WA090061 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. |
| ENS 45599 | 30 December 2009 19:02:00 | The following was received via email: A fixed gauge licensee operating a paper mill in Camas, Washington, reported that the shutter mechanism of an Ohmart Vega fixed gauge, Model Number SH-F1B-0, containing a 100 mCi sealed source of Cesium 137 failed to close during a routine six-month shutter check. The Radiation Safety Officer reported the gauge is mounted on a vertical section of six-inch piping and is still functioning correctly as a density meter. The device is not part of any lockout or confined space entry permit and there is currently no safety hazard potential for exposure to radiation associated with the failure of the shutter mechanism. The environment where the gauge is mounted is susceptible to messy process conditions which allows water and lime-mud to accumulate on the fixed gauge. This appears to have contributed to the failure of the shutter mechanism. The manufacturer's representative was called by the licensee and has scheduled a visit to the facility to make corrective repairs. Report #: WA090097
On February 25, 2010, service representatives from Ohmart Vega replaced the shutter mechanism with a new shutter closing this incident. Notified R4DO (Cain) and FSME EO (McIntosh). |
| ENS 45996 | 9 June 2010 18:36:00 | The following information was received via e-mail: On June 8, 2010 at approximately 9:45 am, a patient scheduled for a 30 mCi TC-99m Myoview cardiac scan was mistakenly administered a 27.1 mCi Tc-99m Medronate bone dose. The mistake was discovered shortly after the administration of the dose when the technician noticed the name on the dose did not match that of the patient. The bone scan patient and cardiac patient had very similar sounding last names, which contributed to the error. The patient was notified of the error when he returned for his cardiac scan 45 minutes after injection. The actual bone scan patient was sent home without any scan and was not injected with any dose because they caught the error before he arrived for scanning. Event No.: WA 100041 |
| ENS 48068 | 3 July 2012 17:26:00 | The following was reported from the state via e-mail: During a routine six-month inventory, the licensee was unable to locate four (4) sealed sources, of which one has an activity that exceeds exempt quantities. The last known person using the sources was contacted on June 5, 2012 to determine if they were in his possession. He indicated that the previous x-ray RSO had found them and returned them to the source locker. However, the former x-ray RSO indicated that in-fact he did not locate the sources. Management and the materials RSO was notified and an investigation was initiated. All staff members were questioned and asked to check around their work areas. The assistant RSO checked all devices, pigs, the source cabinet and surveyed the entire facility, including shipping and receiving, with a micro-R survey meter. None of the sources were located on any disposal or transfer records. The sources were used in a prototype instrument called Plombix, designed to operate with an exempt source in the shape of a washer, and were used only for in house experiments. The missing sources were designed for this prototype instrument and do not fit all other instruments at this facility. Washington Department of Health corrective action is pending. The Assistant RSO indicated that sufficient controls are not in place to maintain control of sources stored outside the source locker, and that a single company source custodian will be assigned for all sources. Source Number: 1; Source/Radioactive Material: SEALED SOURCE M & D; Radionuclide: CD-109, 0.000000194 Ci, 0.000007178 GBq; Manufacturer: ISOTOPE PRODUCTS LAB; Model Number: MISC-IND; Serial Number: 1112-35. Source Number: 2; Source/Radioactive Material: SEALED SOURCE M & D; Radionuclide: CD-109, 0.000064 Ci, 0.002368 GBq; Manufacturer: ISOTOPE PRODUCTS LAB; Model Number: MISC-IND; Serial Number: D1-472. Source Number: 3; Source/Radioactive Material: SEALED SOURCE M & D ; Radionuclide: CO-57, 0.000005 Ci, 0.000185 GBq; Manufacturer: ISOTOPE PRODUCTS LAB; Model Number: RFQ482-3; Serial Number: C9-333. Source Number: 4; Source/Radioactive Material: SEALED SOURCE M & D; Radionuclide: CO-57, 0.000000122 Ci 0.000004514 GBq; Manufacturer: ISOTOPE PRODUCTS LAB; Model Number: MISC-IND; Serial Number: 1096-28. Reference Number: WA-12-047 THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |