Semantic search
| Start date | Report date | Site | Reporting criterion | System | Event description | |
|---|---|---|---|---|---|---|
| ENS 40293 | 3 November 2003 20:00:00 | Georgia Pacific, Inc. | Agreement State | A Troxler Model 3440 Moisture Density Gauge, S/N 34418 (8 millicurie Cs-137; 40 millicurie Am-241/Be) was stolen from the back of a pickup truck sometime between 2000 PST 11/02/03 and 1200 PST 11/03/03 at an employee's apartment complex in Tualatin, OR. The gauge was locked in its case and the case was chained to the truck at the time of the theft. The licensee notified the Tualatin, OR police department. The State Dept. of Radiation Protection will be issuing a press release.
The Troxler Gauge was found behind a discount store and reported to the Tualatin, OR police on 11/17/03 at 1800 PST. The gauge was retrieved by the Oregon State Department of Radiation Protection. The gauge is intact. Notified R4DO (Kennedy) and NMSS (Hickey). | ||
| ENS 40300 | 6 November 2003 00:30:00 | Terracon, Inc. | Agreement State | At approximately 1700 MST on 11/5/03, a technician using a CPN model MC-3 moisture density gauge was told to relocate her vehicle on the jobsite at 8247 Shaffer Place in Littleton, CO. The gauge contains 10 millicuries of Cs-137 and 50 millicuries of Am-241, with serial number M380804502. The technician placed the gauge inside its orange transport box in the back of her truck, but she left the tailgate open, and did not chain the box to the bed of the truck. The technician left the jobsite at approximately 1730 MST to return to the main office 25 miles away. Shortly before arriving at the main office, the technician realized that the truck bed was open and the transport box (and gauge) were not in the truck. The technician turned around and re-traced her route back to the jobsite, but was unable locate the gauge. The technician reported the missing gauge to the Radiation Safety Officer (RSO) at 1830 MST. The RSO, along with other supervisors, retraced the route to the jobsite and searched for the gauge, which was not found. The licensee notified the Colorado Department of Public Health and Environment (CDPHE) at 0530 MST on 11/6/03. The CDPHE informed the licensee that a written report is required within 30 days. The licensee notified local law enforcement officials regarding the lost gauge, and issued a press release offering a reward for information leading to its recovery. | ||
| ENS 40304 | 28 October 2003 06:00:00 | Chemsyn Science Labs | Agreement State | Licensee reported via phone call of potential overexposure of two employees to carbon-14. The licensee indicated initial calculations showed approximately 2.5 Rem exposure. Licensee followed up the phone call on November 7, 2003, after receiving urinalysis results. The initial calculations indicated internal whole body exposure to carbon-14 of 7976 milli Rem and 8976 milli Rem for two employees. The 252 milliCuries carbon-14 was in a mixture of 221 micro liter benzene in a flame sealed glass ampoule which was being readied for shipment to a customer. The ampoule was wiped for contamination and placed on a counter outside of the fume hood for approximately 2 hours. Initially the ampoule was thought to be in the fume hood. The ampoule was found to be leaking and 59 milliCuries of carbon-14 remained in the ampoule. The resultant loss into the lab was 193 milliCuries of carbon-14. This is a preliminary report to be updated as information is received. Person 1 received 7.976 Rem internal (CEDE) occupational. Person 2 received 8.976 Rem internal (CEDE) occupational. | ||
| ENS 40307 | 10 November 2003 06:00:00 | Southwest Research Institute | Agreement State | On October 30, 2003, during a routine inventory of sources, it was discovered that a Nickel-63 electron capture source that had been in storage since January 23, 1996, was missing. An exhaustive search of source storage areas did not locate the source. However, upon questioning employees that had access to the source storage area, one employee recalled that the source in question had been picked up by a Health Physics Technician from the manufacturer, it was believed during the year 1998. The manufacturer denies having the source picked. A search of paperwork is ongoing to locate a transfer document, if one exists. | ||
| ENS 40312 | 10 November 2003 08:00:00 | Construction Testing & Engineering , Inc. | Agreement State | The State of California was informed at 1900, November 9, 2003 that Construction Testing & Engineering had reported the theft of one of their Troxler gauges (Model 3440, S/N 24168). The theft occurred on Friday November 7, 2003, and was reported to Sacramento County Sheriff. The sheriff detectives indicated that they would be questioning the operator who had possession of the gauge at the time it was stolen. An onsite inspection/investigation will be conducted. The licensee RSO indicated that the theft had been on the local television news Monday morning along with photographs of the stolen device, and a reward for its recovery. Subsequent to the initial report, the gauge was reported by an unknown party to be in a ditch in an area north of Sacramento. Sheriffs, Hazmat, and other agencies responded and the gauge was recovered without incident. California Incident Report # 111003. | ||
| ENS 40323 | 14 November 2003 06:00:00 | No Frills Supermarket | Agreement State | The State of Nebraska reported that one of their licensees could not account for 12 tritium exit signs during their annual inventory check. The signs were manufactured in 05/87 and 11 contained 25 curries each of tritium and 1 contained 50 curies. All activities were measured at date of manufacture. Remodeling of the store occurred during the period between the previous inventory check and the current inventory. The licensee has contacted the general contractor, but the location of the exit lights is still unknown. They may have ended up in the landfill. | ||
| ENS 40334 | 15 November 2003 08:00:00 | Nv Department Of Transportation | Agreement State | The Nevada Department of Transportation notified the Nevada Division of Rad Health on 11/17/03 that on 11/15/03 a Troxler 4640B, s/n 2361 was stolen out of a field lab trailer. The gauge was secured in the trailer, but the thief was able to defeat the locks and barriers. The gauge contained 8 millicuries of Cs-137. Notifications were made to the local police, the FBI and other states of the stolen gauge. | ||
| ENS 40337 | 17 November 2003 08:00:00 | Swedish Medical Center | Agreement State | The licensee's RSO reported on 18 November 2003, that a patient, at Swedish Medical Center, Providence Campus, was scheduled to receive an intravascular Brachytherapy procedure that involved the use of a NOVOSTE Beta-Cath device. The device, Serial Number ZB638, employed a total activity of 2907 Megabecquerels (78.56 millicuries) of Strontium 90/Yttrium 90, in a sealed source-train, Serial Number 91837. The cardiologist was unable to insert the source-train for the treatment because, as reported by the RSO, it was into a small artery and the routing did not follow a direct path. This resulted in a 143 second, 13.78 Gray (1378 Rad), exposure to healthy patient tissue. The source-train was partially inserted into the patient when the cardiologist experienced difficulty. A 143 second exposure time elapsed before the cardiologist withdrew the source-train even though medical center procedure requires the sources to immediately be withdrawn once a problem is understood. The delay apparently occurred as the cardiologist first worked to fully insert the source-train and then discussed correcting the problem with the oncologist. The cause of the exposure was failure to follow established procedures. The cardiologist has been suspended from further licensed activities until the details of the event are fully understood. It is anticipated that no health affects to the patient will be realized as a result of the exposure. A DOH staff health physicist will pursue additional details of the event. There is no media attention at this time. Patient and referring physician were notified. | ||
| ENS 40339 | 18 November 2003 21:00:00 | Golder Associates Inc | Agreement State | A portable Troxler Model 3411B S/N 6581, was run over by a bulldozer on 11/18/03. The probe was intact and was returned to inside of the gauge housing and moved to a secure location to be leak tested and transported back to the office awaiting recommendations from Troxler. The gauge contained 40 millicuries Am-241 and 8 millicuries Cs-137. A second licensee, Englehard #Ga178-1, was also involved. | ||
| ENS 40341 | 18 November 2003 20:00:00 | Atl Inc | Agreement State | The Arizona Agency was informed on 11/19/03 @ 1230 of a stolen moisture density gauge which was taken when the pickup truck it was in was stolen. The gauge was a CPN Model MC3, S/N M390404988 containing 10 millicuries of Cs-137 and 40 millicuries of Am:Be-241. Avondale, AZ police are investigating (report # 0327274) the incident. A press release will be issued and the licensee will notify the FBI, States of CA, NV, NM, CO and the Country of Mexico.
The Phoenix Police Department recovered the truck on 12/16/03. The driver door indicated a forced entry and the ignition switch key area was damaged. As of 12/17/03, the licensee reported the only item missing is the CPN moisture/density gauge. Other equipment, including cement testing equipment, was not removed from the truck. The Licensee issued a press release offering a reward for the recovery of the gauge. The release was not carried by the media. The Agency has an active investigation into the circumstances surrounding the loss of this device. The FBI, States of California, Nevada, New Mexico, Colorado, and the country of Mexico are being notified of this event. Notified R4DO (P. Harrell), and NMSS EO (J. Hickey). | ||
| ENS 40352 | 24 November 2003 20:15:00 | Illinois Emergency Management Agency | Agreement State | (Radiation Safety Officer (RSO)) for Advocate Lutheran General Hospital called Illinois Emergency Management Agency on 11/24/03 at approximately 1415 to report an event involving a Novoste Intravascular Brachytherapy (IVB) procedure. Hospital RSO stated that at approximately 1100 on 11/24/2003 during an IVB procedure with a prescribed dose of 18.4 gray, the end of the 40mm source train was not visible at the anticipated location at the end of the catheter. The sources were stuck in an apparent kink in the catheter. The source train was immediately retracted into the safe shielded position in the unit. A second attempt was then made but the sources became stuck in the same area and were again immediately retracted. The procedure was then terminated and an analysis of the event and dose estimates were performed. An unintended area of the heart was exposed to radiation from the source train for approximately 47 seconds in the first attempt and 10 seconds in the second. The estimated radiation dose calculated to the wrong area of the heart was estimated to be approximately 5 gray. Essentially none of the prescribed dose of 18.4 gray was delivered to the intended area of the heart as the source train was retracted before reaching the intended area. The patient has been notified that there was a problem encountered during the procedure and the physician will notify the patient shortly of the particulars involved with the unintended dose delivered. The physicians do not expect any adverse medical effects from this event. Hospital RSO stated that they will carefully review this event and enhance training for this procedure. Hospital RSO added that he will notify Novoste regarding this event and submit the required written report within 15 days. Illinois Event Report ID: IL030078, License Number: IL -01152-01 Source Information: NOVOSTE Model #A1767, Serial # 91834, Radionuclide: Sr 90, Activity: .0484 Curies | ||
| ENS 40363 | 15 November 2003 08:00:00 | Nevada Department Of Transportation | Agreement State | The State of Nevada provided the following information via facsimile: Date notified of event by licensee or non-licensee: November 17, 2003 Radionuclide, activity Cesium 137.8 millicuries Any exposures (indicate short and long-term effects): Unknown Sealed source, device, etc. (make, model #, serial #): Troxler 46408, S/N 2361 Leak test information, if applicable: Unknown Persons involved, consequences: Unknown Cause and contributing factors: Gauge was secured, according to procedures, in the licensee's field lab trailer. Thief defeated locks and barriers to break into storage closet and remove gauge. Gauge case and source rod were padlocked at the time of gauge theft. Licensee corrective actions: None, source was properly secured at the time of theft Provide status through resolution (update record when found): Gauge recovered on November 26, 2003 by a person wanting to remain anonymous. Gauge delivered to State regulatory agency and will be returned to licensee. Notifications, local police, FBI and other States; as needed: Henderson, NV Police Dept., Nevada Highway Patrol, Nevada Division of Emergency Management, and lastly, Nevada Radiological Health Section Identify any possible generic safety concerns: None Potential for others to experience the same event: Slight Note: This EN is actually an update to EN 40334. | ||
| ENS 40365 | 30 November 2003 06:00:00 | Baker Hughes Oilfield Operations | Agreement State | Texas Incident No.: I-8079 Event Report ID No.: 40365 Event location: Newfield Exploration Company Well: Cotton Whitehead 2501 Valverde County, Texas Notifications: Texas Department of Health, Bureau of Radiation Control; Texas Railroad Commission, NRC Operations Center; NMED; NRC Region IV Event description: Late Friday evening, November 28, 2003, a logging source string became stuck in the customer's well. After several fishing attempts without success, it was decided to abandon the sources downhole. The sources will be cemented in place with the top most point covered by a minimum of 100 feet of red dyed cement. A deflection device will be place above the source string. A plaque has been ordered for installation on the wellhead. The source string held three sources: one Am-241/Be source manufactured by NSSI, Model DA-5, Serial No 27942, with an activity of 4.5 curies; one Cs-137 source manufactured by AEA, Model CDC.CY4, Serial No. 2907GW, with an activity of 2 curies; and a second Cs-137 source, manufactured by Gammatron, Model GT-GHP, Serial No. Z-194, with an activity of 0.8 curie. | ||
| ENS 40369 | 1 September 2003 08:00:00 | Applied Materials, Inc | Agreement State | During major construction, five out of eight exit signs were discovered missing in September 2003. Each exit sign contained 20 Curies Tritium as of 12 years ago. As of today each sign contains about 10 Curies Tritium. These exit signs are Generally Licensed devices and were manufactured by Fisher. The owner investigated and interviewed several employees within the last 30 days and advised them that if they find the signs they should bring them to him. As of today, the signs have not been recovered. The owner also reported that the facility brought about 100 dumpsters to the facility for inspection of debris and that the exit signs were not picked-up with the debris. | ||
| ENS 40374 | 3 December 2003 23:00:00 | Bayou Inspection Services | Agreement State | An IR-100 industrial radiography camera, serial number 4470, Spec model G40F, with a 33 curie Ir-192 source, serial number KG2801, was reported lost while being transported by the licensee from a work-site to the licensee's office. On December 3, 2003 at approximately 1700 CST the licensee, Bayou Inspection Service, 318 Degravelle Road, Amelia, LA was transporting the radiography camera from a work-site located at 1081 Highway 70, Pierre Port, LA to the Amelia, LA address, a distance of approximately 20 miles. Upon arrival at the office, the camera was noticed missing from the pickup truck being used to transport it from the worksite. The route of travel was from the work-site on Highway 70, through Morgan City, and to the Amelia exit on Highway 90 . The licensee notified the State of Louisiana of the event on 12/04/03 at 0940 CST and has notified local law enforcement along the route of travel.
The Louisiana Radiation Protection Division reported that, at approximately 1500 CST on 12/11/03, the radiography camera was turned in to the licensee at his facility in Amelia, LA by a private citizen. The citizen found the camera along the side of Highway 70 in Belle River, LA on 12/03/03. The licensee performed a leak check of the source and no leakage was found. Notified R4DO (D. Graves), NMSS EO (T. Essig), and DHS Ops Center (E. McDonald) | ||
| ENS 40376 | 4 December 2003 05:00:00 | State Of Florida | Agreement State | The following information was received via facsimile and telephone conversation: Loss of Control - Lost, Abandoned, or Stolen Materials Incident Location: Suspected Florida Department of Transportation (FDOT) job site at US1 just north of North Bridge Road, St. Lucie, Florida in unrestricted area. Incident Description: POC (Point of Contact) reported he looked for gauge in the bed of transport truck this AM. Gauge was not in carrying case. He believes he left the gauge at the job site on 4 Dec. He has the locks for the transportation case and the box attached to the truck bed and they were intact. The gauge handle was locked and he has the keys. He had a crew in Ft. Pierce make a futile search for the gauge at the work site. He called the Ft. Pierce PD (Police Department) and they had no reports of a gauge being found. This office requested a press release and reward for the return of the gauge be issued and the gauge be reported lost or stolen to the Ft. Pierce PD. Further investigation of this incident will be by the Radioactive Materials section. The subject gauge is a Troxler model 3440, serial number 20515, 40 milliCuries Am-241:Be, 8 milliCuries Cs-137 moisture density gauge licensed to the FDOT. Florida incident number FL03-217.
(On August 13, 2008,) a scrap truck tripped portal alarm (at a metal recycling facility - Trade Mark Metals). (The scrap metal container) was rejected and returned to owner. (Redacted information) (The scrap metal) owner found what appear(ed) to be a bus door opener handle (as the) source (of the radioactivity). An investigator (from the State) was dispatched to survey the source. The remaining load was accepted by Trade Mark Metals. (The) 'Handle' (was determined to be) a part of a soil moisture density gauge (containing the CS-137 source and) originally belonging to Florida DOT, and reported stolen 05-Dec-03. Incident number FL03-217, original NRC Event number 40376 (see above). Other parts of the load were surveyed for the Am-241/Be source, (however) no radiation (was) found emitting neutrons (and no other parts of the gauge found). (The original gauge) owner (DOT) will take control of item and properly dispose of. No further action will be taken on this incident (by the State). The State indicated that the CS-137 source was undamaged and the source serial number used to trace the original owner. Followup State Report is FL08-121 Notified R1DO (Powell); FSME (Burgess); and ILTAB (Whitney via e-mail). | ||
| ENS 40377 | 3 December 2003 06:00:00 | Texas A&M University | Agreement State | The following is taken from a facsimile received from Texas Department of Health (TDH), Bureau of Radiation Control: Event Description: A 30 microcurie cesium-137 source located in a scintillation counter was found with 430,000 cpm counts on a swab leak test conducted by a serviceman. No contamination was found outside the source assembly. Texas Incident No. I-8024 The Licensee's report to TDH was also faxed to the NRC and is identified, in part, below: On December 3, 2003, the Radiological Safety Officer at Texas A&M University (TAMU) was notified by a service representative of Beckman Coulter that a Cs-137 source contained within a liquid scintillation counter was leaking. After obtaining information from the service representative, the RSO then made a telephone notification to the Texas Department of Health-Bureau of Radiation Control, informing Ms. Helen Watkins of the situation. This letter is a written notification of the leaking sealed source, in accordance with TAC 289.202 (ddd). The following information identifies the liquid scintillation counter and specifies of the source: Location: Chemistry Bldg., Room 2516 Manufacturer: Beckman Model: LS 6000 SE S/N: 7060437 Source: Cs-137 Activity: 30 uCi (microcuries) The device user, a professor at TAMU, noticed that the device was not operating properly and contacted Beckman for service. The service representatives performed diagnostics on the device including a smear (cotton swab) of the plastic sphere source. The swab was counted with a result of approximately 430,000 cpm (counts per minute). No parts have been removed from the device, but the intention is to replace the source, source housing, and source elevator. These components will then be returned to Beckman. Repair parts have been ordered. The device has been removed from service with signage indicating 'No Usage' and 'Contact Radiological Safety.' In addition, Environmental Health and Safety Department (EHSD) personnel performed contamination surveys on the device, the service representatives, and within the room. No contamination was detected. | ||
| ENS 40383 | 8 December 2003 08:00:00 | Ndc Infrared Engineering | Agreement State | Licensee reported that several months ago, four (4) 'sensor units' on fixed GL (General License) gauges it manufactures were involved in a fire at one of their customer sites in Painesville, Ohio. The RSO did not know the exact date of the fire. The sealed source used in these units is the AEA, AMC, P1, 150 milliCurie Am-241. Two of the units appeared burned and the other two appeared undamaged. The licensee had the customer do wipes on these which were negative. Then the units were shipped back to the licensee where they are now. On 12-08-03 the RSO was disassembling the worst-looking one in preparation for shipment back to the source manufacturer, AEA Technology. Wipes were done. The RSO detected elevated readings up to 200 cpm (background is 2-3 cpm) from the burned area of source S/N 4382LX mounted on probe sensor S/N 2851 using a Ludlum Model 12 alpha meter. Per the RSO, sources have been secured and contained pending further instructions. RSO indicated surveys were done of work area and personnel and no contamination was detected. The State is initiating an investigation and will send an inspector to the licensee for surveys. The State reported that the gauge is a model # 103. | ||
| ENS 40385 | 9 December 2003 06:00:00 | Waste Control Specialist | Agreement State | On December 10, 2003, (the licensee's RSO at) Waste Control Specialist reported a fire involving radioactive material that occurred on December 9, 2003. There was no excessive exposure to individuals nor was there any off-site airborne release. The waste processing company believes reactive metals (lithium, sodium, potassium) oxidized in water to start the fire. Packing materials were placed in a shredder that feeds into a hopper containing mixed waste. The system is closed with HEPA filters in place. Vibrations from the hopper may have resulted in the ignition. The material burned for about 20 seconds and was extinguished. When more materials were poured into a mix pan, the fire reignited and again was quickly extinguished. According to the Licensee's preliminary calculations, the affected or burned radioactive material exceeded the reportable quantity of five times an ALI (annual limit on intake). The total radioactive material in the mix pan was under 50 microcuries. The shredder contained about 2.4 microcuries. There were 12 to 14 radionuclides involved. The Licensee will send a detailed written report within 30 days to include specifics on radionuclides and activities. The most serious consequence was the unplanned fire. The building is pressurized and the smoke from the fire was pulled through HEPA filters and a monitored exhaust system. The workers wear PPE (personal protective equipment) and airlines with protection factors of 1000. Texas Incident # I-8024.
The following information was provided in a letter dated 1/6/2004 from Waste Control Specialists (WCS) to the Texas Department of Health: On December 9, 2003 at approximately 1400 hrs a small fire occurred in the Permacon building at our facility located 30 miles West of Andrews, Texas. This fire occurred in the hopper beneath the waste shredder. There was a small quantity of untreated water reactive radioactive waste (WP-019224) that caught fire after passing through the shredder above. Two employees at the scene quickly extinguished the fire within the hopper using hand-held halon fire extinguishers. The hopper was pulled from underneath the shredder and then the waste was put into the mix pan where it re-ignited. It was extinguished by dropping water on the materials using the prentice arm. The personnel who were in the immediate area were wearing anti-contamination clothing and respiratory protection equipment in accordance with the Radiation Work Permit. The air sample that was being collected at the time of the incident indicated approximately 85% of the DAC for Th-228. The respiratory protection equipment used has a protection factor of 1000. There was no significant internal or external radiological exposure to personnel. The radioactive distribution of the material involved is enclosed. Additionally, the licensee provided the following information to the State in response to a question about any action the licensee may have taken to prevent a reoccurrence of a fire. The licensee stated the following in an email to the State: WCS issued a Stop Work Order on December 9, 2003. The Stop Order included a corrective action of 'Evaluate the treatment methodology for reactive metals prior to receipt of new shipments of reactive metals for processing.' WCS will not receive any new shipments of reactive metals for processing until such time that a different treatment methodology is developed to process these wastes without subsequent ignition of waste materials. Notified R4DO (L. Howell) and NMSS EO (L. Kokajko) | ||
| ENS 40387 | 24 November 2003 06:00:00 | Lexington Clinic | Agreement State | On 11/24/03 a patient was administered a thyroid uptake dose of 0.98 millicuries. The prescribed dose was 0.015 millicuries. The misadministration apparently occurred due to the prescription order being made incorrectly with no subsequent verification. The patient and the patient's physician were notified on 11/26/03. No adverse effect to the patient occurred as a result of the misadministration. | ||
| ENS 40390 | 12 December 2003 16:00:00 | Gallett And Associates | Agreement State | On 12/12/03 at 1100 ET, a licensee's pickup truck was stolen with a moisture density gauge locked in the bed of the truck. The truck was parked at a construction site on Northside Drive in downtown Atlanta, GA. The gauge is a CPN Model MC Porta-Probe, Serial Number MD60703301. The gauge contained two sources: 50 milliCuries Am241/Be and 10 milliCuries Cs-137. The licensee has reported the theft to the Atlanta Police Dept. and the Atlanta Field Office of the FBI. | ||
| ENS 40392 | 10 December 2003 06:00:00 | Novartis | Agreement State | The State of Nebraska was notified by letter dated December 10, 2003 of 4 (four) unaccounted for exit signs during an inventory conducted by the licensee, Novartis Consumer Health Inc., 10401 Highway 6, Lincoln, NE 68517. The signs, identified by the licensee as item numbers 4, 5, 8, & 10, are believed to have been lost during various renovations to licensee facility buildings occurring over a period of years. The licensee is unable to confirm the exact time or disposition of the signs but does not suspect theft. The make, shipping date, model number, serial number, and activity level of the exit signs are as follows: Item numbers 4 and 5: NRD, shipped last quarter 1984, model T4002, serial number 6988/6989 respectively, each containing 19.9 curies tritium. Item number 8: SRB, shipped 02/10/88, model B100, serial number 64174, containing 17.2 curies tritium. Item number 10: SRB, shipped 02/08/88, model B100, serial number not identified, 15.5 curies tritium. The State of Nebraska will not assign this event an incident number and considers this event to be closed. | ||
| ENS 40395 | 15 December 2003 08:00:00 | Ge Company Vallecitos Nuclear Center | Agreement State | On December 16, 2003, GE Vallecitos contacted RHB-Sacramento office to report that a shipment of 2.1 Ci (Curies) of Xe-133 to the University of Alabama has not arrived at its destination. On the same day, RHB-Berkeley office contacted the GE Vallecitos RSO, C.W. Bassett and the EHS leader, D.W. Turner and learned the following: On December 12, 2003, GE Vallecitos sent a shipment of 2.1 Ci of Xe-133 to the University of Alabama via Fedex. On December 15, 2003,one of the Vallecitos technicians noticed that the shipment had not arrived at its destination in Alabama. They contacted Fedex immediately (name deleted) and the tracking database indicated that the shipment supposedly left Oakland Friday. As of December 16, 2003, Fedex was unable to locate the final destination of the shipment. GE Vallecitos had contacted the University of Alabama and confirmed that they have not received the Xe-133 shipment. Per RSO, the current estimated activity (as of 12/16/03) of the Xe-133 shipment is 1.2 Ci (Curies).
The following information was received via email: This lost shipment was found Friday 12/19/03 at the Fed Ex warehouse facility in Memphis, TN. It has been shipped to it's original destination, the University of Alabama. Notified R1DO (R. Lorson), R2DO (T. Decker), R4DO (L. Smith), NMSS EO (F. Brown) | ||
| ENS 40398 | 17 December 2003 19:30:00 | Ninyo & Moore | Agreement State | On 12/16/03 at approximately 1230 MST, a soil moisture density gauge was stolen from the rear of a technician's pickup truck while he was stopped for lunch at 23rd Street and Indian School. The gauge was contained in a yellow transport case and is a Troxler Model 3430, Serial Number 33308. The gauge contains approximately 10 millicuries of Cesium-137, and 40 millicuries of Americium-241. The theft of the gauge was reported to the Arizona Radiation Regulatory Agency at approximately 1325 MST. The licensee issued a press release offering a $500.00 reward for the recovery of the gauge. The Arizona Radiation Regulatory Agency and the licensee will continue to investigate this occurrence and report further. The FBI, States of CA, NV, NM, CO, and the country of Mexico are being notified of this event.
After working hours on 08/27/04, the (Arizona Radiation Regulatory) Agency was notified by the licensee, that a non-employee had contacted them and returned the missing Troxler Model 3430 gauge. The FBI, States of CA, NV, NM, CO and the country of Mexico are being notified of the recovery. Notified R4DO (Jones), NMSS (Brach), and Mexico (V. Gonzalez). | ||
| ENS 40399 | 17 December 2003 06:00:00 | Guidant Corporation | Agreement State | The following is taken from an email received from the State of Texas, Department of Health: This is a Texas agreement state incident being forwarded based on a 5 day report requirement for a leaking source. (Incident 8083) The Licensee reporting the incident is Guidant located in Pearland, TX, L05178. More information is anticipated. This is a preliminary report. Today a returned P-32 (Phosphorus-32) source wire was received at our Pearland facility. This facility is authorized for radioactive material use under license number L05178. The source wires we manufacture are registered with the TX-BRC as TX-1070-S-101-S. These source wires are sent to our user sites (hospitals) and returned to Pearland for decay and disposal. The active portion of the source wire was wiped during the receipt survey. Approximately, 8.0 nCi (nanocuries) of activity was removed at that time. The source wire was stored for investigation at that time. A later wipe showed removable activity of approximately 0.5 nCi (nanocuries). We will continue to investigate the source wire to determine if the wire is leaking or if the contamination was from another source. | ||
| ENS 40400 | 18 December 2003 06:00:00 | Shop Go Stores | Agreement State | The State of Nebraska reported that one of their licensees could not account for 17 missing tritium exit signs. The signs were manufactured in 07/84 and each sign contained 21 curies of tritium at the time of manufacture. Three major renovations have taken place in the store since that time and the licensee believes that is when the signs were lost. Store records indicate that 11 new signs were purchased in 1994. A search of the store did not find any of the missing signs. The State of Nebraska considers this issue closed. | ||
| ENS 40409 | 4 December 2003 06:00:00 | Central Arkansas Radiation Therapy Institute Inc | Agreement State | A medical misadministration resulting from an I-125 permanent prostate seed implant procedure was reported to Arkansas Department of Health, Radiation Control and Emergency Management on December 19, 2003. The licensee reported that the misadministration, resulting from a December 4, 2003 implant procedure, had been identified during the patient's post-implant CT study on December 18, 2003. The brachytherapy misadministration involves an underdose to an intended treatment area as well as a radiation dose delivered to an unintended area. This event is still under investigation by the licensee and the Department. | ||
| ENS 40412 | 22 December 2003 06:00:00 | Guidant Corporation | Agreement State | The following information was received via facsimile: Houston licensee received an IVB (Intravascular Brachytherapy) source wire back from a hospital. Source wire was determined to be leaking upon leak test. Leaking Source, P32 IVB, approximately 85 millicuries of P-32. Leaking IVB source returned by unknown hospital in Lafayette, Louisiana to the manufacturer. Texas Incident Report I-8086. | ||
| ENS 40413 | 22 December 2003 18:00:00 | Southwest General Health Center-Ireland Cancer Center | Agreement State | On 12/23/2003 at 1600 hours EST the licensee notified the Ohio Department of Health, Bureau of Radiation Protection, of the following information regarding a patient undergoing intravascular brachytheraphy treatment: On December 22, 2003 during a treatment with a Novoste Beta-Cath 3.5 French IVB System, the source did not travel the entire way to the treatment site and was 3 centimeters proximal to the treatment site. The immediate cause of the event was a small kink in the delivery catheter which kept the source train from traveling to the correct site, even though the kink was not substantial enough to affect the flow of sterile water used to send/retrieve the sources. The error was discovered the next day during medical physics quality checks and reported to Ohio Department of Health, Bureau of Radiation Protection. An investigation will be performed the week of December 29, 2003. The dose to the unintended site was identified as 1840 rad (18.4 Gy) from a 0.05378 curie, Sr-90, sealed source. The attending physician has been notified. The intravascular brachytheraphy unit is a Novoste, model TDA-1040, serial number 91828. The Ohio Department of Health, Bureau of Radiation Protection reference number for this event is 2003-126. | ||
| ENS 40416 | 27 December 2003 08:00:00 | Geosoils Inc | Agreement State | GeoSoils, Inc., reported that a CPN nuclear gauge (Model MC3, S/N M390104771) was stolen on 12/27-28/03 from a locked jobsite trailer located at Cajalco Road and Wood Road in Riverside, CA. The gauge was in its transportation case, which was chained to the floor of the trailer. The chain was cut and the gauge and its transportation case stolen. The local Sheriffs Department was notified and a police report was taken (Police Report No. PCR03361015). A newspaper ad will be placed as soon as possible offering a reward for return of the gauge. | ||
| ENS 40420 | 31 December 2003 20:00:00 | Simpson Tacoma Kraft, Llc | Agreement State | |||
| ENS 40427 | 2 December 2003 06:00:00 | Vulcan Chemicals | Agreement State | A Kay-Ray Model 7063P gauge with serial number 12349 and a 500 milliCurie source of Cs-137 was not accounted for during the last Radiation Source Survey. The device has been stored in a locked warehouse with limited access since 1984. It was stored in a secured wooden crate with proper labeling. A search was conducted and interviews performed. As of December 2, 2003 the device has not been found. An email from Thermo Electron Corporation states that the source has decayed to 316.366 milliCurie. Vulcan also notified all of its scrap metal contractors to be on alert for the device. | ||
| ENS 40430 | 5 January 2004 14:16:00 | The Methodist Hospital | Agreement State | Novoste Strontium-90 Intravascular brachytherapy (IVB) source (remote afterloader) was discovered missing on January 5, 2004. Source was last seen but not used on December 17, 2003. Reported by phone by RSO. Source is a small handlheld device - Manufacturer: Novoste, Model: BethCath, Serial No. 92607; Source train Serial No. ZB-520; Original Activity 55.62 millicuries; current activity (date of discovery) 54.64 millicuries; Calibration date: 04/11/2003; Last leak test 10/29/2003. Received at the hospital on November 4, 2003. Last used in a patient on December 5, 2003 (first and last use). Last seen on during a functional test on December 17, 2003 in the Fondren Building, Room F1099 (near cath lab) at the Licensee's main site 6565 Fannin Street, Houston, Texas. The source was not used that day. Two other sources of different activity and length remain in storage. The room and cath lab have been search 4 times by the Licensee's staff. Trash has been surveyed. Hospital staff has been notified of the missing equipment.. Texas Incident No.: I-8089. | ||
| ENS 40439 | 7 January 2004 08:00:00 | Sabia, Inc | Agreement State | During an inspection of the licensee facility by RHB (State) on 1/7/04, a potential radiation problem was indicated by a high neutron radiation level above a shield assembly used to store Cf-252 neutron sources. Directly above the shield, the neutron dose rate was measured as approximately 5 rem/hr using a rem-ball. This area was not controlled as a high radiation area, nor were controls effective at the time of the inspection to preclude unrestricted access to the room. On the roof, directly above the shield assembly, the neutron dose rate was measured as approximately 25 mrem/hr, in an area of approximately 1 square foot. The roof area was not controlled as a restricted area. (Both neutron measurements were made by the licensee because of the lack of neutron survey instrumentation by the RHB inspector.) The licensee was directed to remeasure the neutron dose rate on the roof because it was inconsistent with the room dose rate, to add shielding to reduce the roof dose rates, and to provide high radiation area controls to the room containing the stored neutron sources. The second measurement of the roof dose rate found 250-260 mrem/hr in the highest area (approximately 1 square foot). The licensee representative reported he had incorrectly read the instrument scale during the previous measurement. Polyethylene sheets and a container of hydrogenous material were placed on the top of the shield assembly to act as temporary neutron shielding. This reduced the neutron dose rate directly above the shield assembly to 8-10 mrem/hr, and the roof dose rate to less than 2 mrem/hr. Locks were installed on the doors accessing the laboratory area where the Cf-252 sources are stored. The licensee is in the process of constructing a permanent safe storage inside of this shield assembly, with additional shielding to conservatively ensure that individuals in unrestricted areas won't exceed 100 mrem/year dose (and unrestricted area dose rates will be less than 2 mrem in any hour). The shielding design will ensure that the shielding cannot be removed by an unauthorized person and accidentally recreate the high radiation area and unrestricted area dose rate problems. This construction is expected to be completed by 1/15/04. The state (RHB) will continue to investigate this matter to evaluate the potential for exposures to personnel as a result of the elevated dose rates and lack of access controls. No personnel overexposures, worker or public, are known to have occurred at this time. | ||
| ENS 40445 | 11 January 2004 02:00:00 | Schlumberger Technology Corp | Agreement State | On 01/12/04, the State of California received a report from Schlumberger Technology of an incident that occurred about 1800 PST on 01/10/04. A 1.3 curie Cs-137 source fell off of its tool. A rig hand picked up the source with his fingertips thinking it was the base of a lightbulb. A Schlumberger crew member told the worker to leave it on the deck. The source was recovered with the source handling tool, and returned it to the shielded container. Touching exposure was estimated to be 20 mrem with calculations based on maximum touching time of 10 seconds. Whole body exposure was estimated to be 2.9 mrem with calculation exposure based on beginning at 6 feet from the source and closest distance at 2.5 feet for maximum of 2 minutes. The source has exposure characteristics of 2 mrem/hr at 200 inches (min) from shielded (dovetail) end, and 2 mrem/hr at 680 inches (max) from the non-shielded end. | ||
| ENS 40460 | 19 January 2004 06:00:00 | Bowling Green Medical Center | Agreement State | A medical event occurred on 1/19/04 at the Bowling Green Medical Center located in Bowling Green, Kentucky. Specifically, an inner vascular Brachytherapy treatment was planned. The catheter ran outside the body through an external valve which was inadvertently partially shut resulting in no dose to the target area. As a result, the doctor administering the treatment received .736 gray at his fingertips. Also, the patient received .736 gray to the thigh area. The source involved was 43.14 curies of strontium-90. There was no significant adverse health effects from this event. A review was initiated by the licensee to determine the cause and to initiate corrective actions. | ||
| ENS 40461 | 16 January 2004 06:00:00 | Industrial Services Of America | Agreement State | On 1/16/04, the radiation detectors alarmed at the North American Stainless scrap yard, located in Ghent, Kentucky, when a truck entered the scrap yard. The scrap yard radiation detectors indicated 42 microrem per hour. The truck was not accepted and sent back to its origin. The scrap material in the truck came from Industrial Services of America. Investigation determined that a piece of a fixed gauge caused the radiation alarms to set off. Apparently, the gauge went through a shredder. On-contact radiation readings were 35 millirem/hour with the shutter closed and 58 millirem/hour with the shutter open. This was considered a loss of radioactive material and further review will be performed to try to determine the owner of the gauge. | ||
| ENS 40464 | 16 January 2004 21:10:00 | Hillcrest Hospital | Agreement State | On 11/20/03 a 19 year old female patient received 140.1 millicuries I-131 for thyroid carcinoma as prescribed. At the time she was unaware and had completed the required forms indicating she was not pregnant. On 12/5, 12/8 and 12/11/03 quantitative tests confirmed that she was pregnant. The results were provided to her endocrinologist who recommended that a fetal dose calculation be performed. The hospital was notified and their consultant informed the endocrinologist that the fetus would have received 19.6 rads. The Endocrinologist sent the results to the Center for Human Genetics at University Hospital in Cleveland where as assessment was performed that the pregnancy could safely continue. The Ohio Bureau of Radiation was informed on 1/16/04 and submitted the information to the NRC Region III office. NRC Region III (Lynch) recommended making a telephonic notification due to the incident meeting the criteria of an AO even though Ohio is not required to conform with the revised reporting requirements for a period of three years (October 2005) after the final rule is issued. Hillcrest Hospital has implemented pregnancy testing for child bearing age female patients receiving radiation therapy. | ||
| ENS 40466 | 21 January 2004 06:00:00 | Amersham/Medi Physics | Agreement State | The Director of Nuclear Regulatory Assurance of Amersham/Medi Physics (IL-01109-01) called late yesterday to report that a package of small activity sources intended for medical use had not arrived at its intended destination. The details are as follows: On January 9, a package containing sixty-six sealed iodine-125 sources was sent from the Arlington Heights, IL facility intended for the St. John's Riverside Hospital in Yonkers, New York. The sources are stainless steel encapsulations of I-125, each originally 0.942 millicuries of activity. The total activity at the time of packaging was 62 millicuries. The sources are about the size of a grain of rice and designed for implantation in cancerous tumors of the prostate gland via a needle. The package was shipped in a standard 'Type A' box and had a surface dose rate of less than 0.5 millirem/hr. The package was due to arrive in Yonkers on the 12th of January for a treatment on the 14th. As part of Medi Physics customer service, a routine call to the client revealed that the package had not arrived as of the end of the day on the 12th. When the carrier, Federal Express, was queried by the licensee, Federal Express claimed that the package had been accidentally set aside at their Newark, New Jersey facility with some other packages and would be delivered the next day. Additional tracking by Medi Physics on subsequent days showed that the package never left the Federal Express sorting facility in Newark, New Jersey. To date, efforts by Medi Physics and those reported by Federal Express have not located the missing package. As of this time, the activity of each source is 810 microcurie for a total package activity of 53.5 millicuries. Although in the past such packages have been located and recovered and returned to Medi Physics by the carrier, the extended length of time from the date of expected delivery to now is unusual. Both Medi Physics and Federal Express have indicated they will continue monitoring this situation. The U.S. NRC Region III Liaison Officer has been made aware of the situation and has indicated he will contact his U.S. NRC Region I counterpart to advise him of the situation. Form of Radioactive Material: SEALED SOURCE Radionuclide: I-125; Source Use: BRACHYTHERAPY; Activity: 53.5E-3 Curies Manufacturer: MEDI+PHYSICS, Model Number: 6711; Serial Number: NA
Federal Express has located the package containing sixty-six sealed iodine-125 sources in Newark, NJ. Federal Express is in the process of returning the package back to Amersham/Medi. Notified R1DO (Anderson), R3DO (Lanksbury) and NMSS EO (Kokajko). | ||
| ENS 40470 | 31 December 2003 07:00:00 | Utah Inspections | Agreement State | When film badge dosimetry for December 2003 was processed, it was determined that a radiographer, employed by an inspection firm in Utah but working in Colorado, received an annual radiation dose of 5.035 Rem for the year ending 12/31/03. The radiographer claimed, however, that his film badge had fell on the ground during radiography such that the dose was not actually received. No additional information has been provided at this time. | ||
| ENS 40471 | 22 January 2004 22:20:00 | Lfr, Inc. | Agreement State | The Radiation Safety Officer (RSO) who works for LFR Inc. of Braintree, MA reported his personal pick up truck stolen while on an errand at a gas station-mart in Providence, RI. His pick up truck contained a 4 x 2 foot case which contained his Niton XL series Xray florences gauge (Serial # U-472) which contains about 14 millicuries Cd-109 byproduct material. He left his pick up truck unlocked, and keys on seat, while he went into mart for purchase. RI state police were notified of theft, and they reported theft to MA state police at approx 5:17 PM (ET) on 1/22/04. MA state police in turn notified a MA radiation control officer at home at approx. 5:30 PM who then notified his MA Radiation Control Supervisor. At 9:39 on 1/23/04 AM, the supervisor notified the RI Radiation Program by e mail that theft had occurred. A MA radiation control officer, called the RSO at approx. 10:30 AM and 1:50 PM and was told vehicle had not been recovered yet. The RSO was asked to fax MA RCP a copy of police theft report and copy of RI radioactive license, and to call us if vehicle is recovered. The RSO lives in RI. The RSO said he would perform a leak test if tester is ever recovered. MA sent email to RI Radioactive Materials Program at 2:45 PM with status. Immediate notification requirement means complete investigation is pending. | ||
| ENS 40479 | 23 January 2004 23:30:00 | Taylor Forge Engineered Systems | Agreement State | On 1/26/04, about 8:00 am (CST), (Kansas Department of Health and Environment) KDHE staff retrieved a phone message from the Assistant Radiation Safety Officer (ARSO), of Taylor Forge Engineered Systems, Inc (TFES). The ARSO called on 1/23/04, Friday, about 10:20 pm, stating that one of their radiographers may have received an exposure greater than 5 Rem. This was the initial phone call stating that an unusual event may have occurred. Around 5:30 pm, on 1/23/04, a radiographer was performing radiographic operations in the middle bullpen cell, using a Co-60, 62.1 curie source. According to the radiographer, the gamma alarm malfunctioned, thereby the lights, bells and alarms weren't working. He entered the vault to try and determine the cause of the malfunction, but failed to retract the source, resulting in a possible overexposure to himself. The radiographer was in the area about 10 - 15 minutes. The radiographer contacted the ARSO later that evening and related the above events. On 1/26/04, about 8:00 am, KDHE staff retrieved a phone message from the Radiation Safety Officer (RSO). The RSO called on 1/24/04, Saturday, about 7:00 am, stating that one of their radiographers had received an overexposure greater than the 5 Rem limit. This was the official 24 hour emergency notification. The radiographer's chirping alarm rate meter and pocket ion chambers (PICs 200 mrems / 500 mrems) were found to be off-scale. The radiographers film badge was overnighted to Landauer dosimetry services for processing. The radiographer has been relieved of his duties as they relate to IR. Preliminary dose calculation estimates, from the RSO, are that radiographer received between 15 - 30 rems whole body and up to 87 rems to the hand. TFES is currently investigating the incident and is trying to recreate the above mentioned conditions (using a dummy source) to determine what happened. KDHE is currently investigating the incident. We will provide updates when they occur. Source: Cobalt 60, 62.1 Curies Manufacturer: AEA Technologies Model Number: TECHOPS A-424-14 Serial Number: S/N 2899 Device: Manufacturer: AEA Technologies Model Number 660-B Serial Number: S/N B-234 | ||
| ENS 40488 | 28 January 2004 06:00:00 | J.K. Display Inc. | Agreement State | On January 28, 2004 a letter was received by Wisconsin's Radioactive Materials Program, dated January 26, 2004 from state licensee J.K. Display, Inc., 8300 W. Parkland Court, Milwaukee, WI 53223. The letter informed the department that the company could not locate one of the two NDR, Inc., P-2021 Nuclecel-Ionizer air gun devices that it had in its possession.. The missing/loss P-2021 device, serial # A2CL456 was leased from NDR, November 2002 with an activity of 10.0 mCi of Po-210. The static eliminator gun was last used in July of 2003 because it was broken and unusable. Apparently, the connections between the air-hose and device leaked, reducing the gun's ability to produce ionized air. The device was placed in the shop on a shelf for return to NDR, Inc. at termination of the lease. Polonium-210 has a half-life of 138 days, therefore, if the assay date of November 2003 is accurate, the source has gone through approximately three (3) half-lives. The Po-210 source at this point should have an activity of approximately 1.275 mCi. The licensee has done an exhaustive search of the shop and offices for the device, but it cannot be located. The most likely possibility, according to the company, is an employee threw out the device. Corrective actions taken by the company are to instruct their six employees to identify the device(s) and their location at all times and to isolate and store unused device(s) in a secure location. | ||
| ENS 40511 | 10 February 2004 05:00:00 | Ma Radiation Control Program | Agreement State | A load of waste or recycle materials that had been transported to Covanta Haverhill, Inc (a waste-to-energy facility) in Haverhill, MA had a radiation measurement of 0.13 mrem/hr when it entered the facility. The driver of the truck was told to return the load back to its origin, BFI facilities, in Peabody, MA without any stops. Once at the origin of the shipment, the load is to be isolated until mitigation by a consultant. A report detailing material identification and disposition shall be submitted to the MA Radiation control Program. | ||
| ENS 40514 | 4 February 2004 17:00:00 | Cardinal Health, Inc. | Agreement State | TDRH was notified on 02/11/04 of a spill involving I-131 at the Cardinal Health pharmacy in Chattanooga, TN. This event occurred during the afternoon on 02/04/04. An employee was transferring a stock bottle containing 97 millicuries of I-131 from the glove box to the fume hood. The employee dropped the lead pig and the contents of the vial were spilled. Two employees cleaned the area for approximately 20 minutes. Air samples were collected and bioassays of the workers were performed. The room was immediately closed off and access by personnel limited to once a day to collect air sampling media. The initial bioassay results were above the licensee's action limits but below regulatory limits. As of 02/10/04, bioassays results were below the licensee's action limits. The initial air sample collected 18 hours after the spill indicated a stack concentration of 6.5E-08 microcuries/ml. The area will remain restricted, under negative pressure, with fume hoods running. TDRH was notified by the Senior Manager of Health Physics from the corporate office in California. A written report from the licensee will be submitted within 30 days. This incident is reportable under 1200-2-5-.141(c)1(i) of" State Regulations for Protection Against Radiation". Event Report ID No: TN-04-013 Media attention: None
The correct license number is R-33111. The correct reference in 'State Regulations for Protection Against Radiation' should be 1200-2-5-.141 (2) (c) 1. (i). | ||
| ENS 40520 | 14 February 2004 18:00:00 | Universal Engineering Services | Agreement State | At approximately 1300 hours on 2/14/04, the technician returned home for lunch in the company truck with a Troxler Model 3430, S/N 30167, gauge containing two sources, i.e., 8 millicuries Cs-137 and 40 millicuries Am-241/Be, locked in its case in the truck bed. The chain securing the case was cut and the Troxler stolen. The technician has the key which locks the source in the retracted position. The Miami Police Department and the Florida State Warning Point were notified. The company will issue a press release and reward for the return of the gauge. Florida Incident No. FL04-116.
The Troxler gauge was found next to a garbage dumpster located on a grocery store parking lot. The gauge was still in its case and had not been damaged. Miami HAZMAT came to the scene and took radiation readings of the gauge in its case. Radiation readings were 2 millirem/hr (expected value). The gauge has been returned to its assigned owner. R1DO ( Jim Trapp) & NMSS EO (Gary Janosko) notified. | ||
| ENS 40526 | 4 February 2004 06:00:00 | Irwin Industrial Tool Company | Agreement State | The licensee reported that upon an inventory check in early February 2004, two general licensed self-luminous exit signs were missing and are currently unaccounted for. The two units were purchased from SRB Technologies, Inc (serial #'s 18132 and 16138) containing 24 curies of activity each as assayed in May of 1985. These exit signs were purchased and installed in 1985 and were removed and held in storage since 1990. The licensee has concluded that the exit signs were unintentionally disposed of or misplaced and thrown away during a clean-up of inventory from their change of ownership to Newell Rubbermaid Inc. Efforts of locating and recovering these units have been unsuccessful. The remaining five signs were placed in a single container and stored in a locked fireproof cabinet for subsequent transfer to their respective manufacturers for proper disposal. | ||
| ENS 40532 | 19 February 2004 22:50:00 | Soil Testing And Engineering, Inc | Agreement State | At 3:50 PM (MST) on 19 Feb 04 - The Department received telephone notification of a stolen gauge by Larry W. Chisman, the RSO for Soil Testing and Engineering Inc. The theft occurred between 11:30 AM and 2:00 PM (MST) on 19 Feb 04 in a parking lot at 314 W. Bijou, Colorado Springs, Colorado. The gauge was locked within its orange transport case which was locked within a Suburban. The windows were reported to be intact and it is unknown how entry to the vehicle was gained. The stolen gauge is a CPN Model MC-2, serial number M21084026. The gauge contains 10 milliCi of Cs-137 and 50 milliCi of Am-241:Be. The incident was reported to local police on the day of the theft.
This text update was reported as EN#40544 on 02/24/04 at 14:51 EST. EN#40544 has been retracted because it was a duplicate of this event notification. A Campbell Pacific Nuclear (CPN) Density Gauge, Model MC2, serial number M21084026 was stolen from the backseat of a privately owned Chevy suburban at approximately 1300 CST on 2/19/04. The gauge contains 10 millicuries of Cs-137, and 50 millicuries of Am-241/Be. The gauge case inside the truck was not locked, but was blocked to prevent movement. Several other items were also stolen from the truck including a cellphone, wallet, and briefcase. The licensee reported the theft to the Colorado Springs Police Department, Case No. 04-6892, shortly after the theft was discovered. Police are investigating credit card and cellphone usage to try and track down the perpetrators.
The Colorado Department of Health reported that Local Law Enforcement located the lost gauge, and it was returned to licensee, Soil Test and Engineering. The gauge source is intact and the licensee is leak testing the instrument as requested by the Agreement State. Notified R4DO (Sanborn) and NMSS (Brown).
The stolen gauge was found intact and not damaged between two storage units in its transport box in Colorado Springs, CO. on 2/26/04. Notified NMSS EO(Essig) and Reg 4 RDO(Graves) | ||
| ENS 40542 | 20 February 2004 05:45:00 | Joseph M. Keyzers | Agreement State | The Wisconsin Radiation Protection Section was notified of a fire involving radioactive materials on February 19, 2004 at 23:45. The item was a NDC Model 104P Portable Mass Gauge containing 25 millicuries of Am-241. Members from the Wisconsin Radiation Protection Section responded to the location of the fire in Wisconsin Rapids on Friday, February 20, 2004. Wisconsin Rapids Police Department controlled access to the scene and allowed no one to enter until personnel arrived from the Radiation Protection Section. A survey was performed at the location using sodium iodide detectors. The gauge was located under 3 to 4 inches of fire debris. The gauge was emitting 30 millirem/hour on contact with the source opening. Wipe test of the gauge and surveys of the surrounding area confirmed the source was intact. The gauge was damaged severely by the fire. Initial investigation into the fire by the Wisconsin Rapids Police Department indicated that the fire was set by two to three individuals to cover up an apparent robbery at the residence. These individuals have been apprehended. The licensee used the gauge at temporary job sites in Wisconsin to measure drainage profiles on paper lines at paper mills. | ||
| ENS 40543 | 28 January 2004 19:00:00 | Altru Health System | Agreement State 10 CFR 35.3045(a)(1) | On 1/28/04, the patient was to receive a total dose of 50.4 Grays to the 'vaginal cuff' region using a 6 Curie Ir-192 sealed source. The dose was to be administered using a Microselectron Remote Afterloader HDR manufactured by Nucletron, serial number 31021. The plan was to administer 3 radiation treatments using a catheter that is 1500 millimeters (mm) long. The treatment planning software system uses a default value of 995 mm for the catheter length. When preparing the treatment plan for the first of the 3 planned radiation treatments, the medical physicist did not notice that the catheter length in the treatment plan was incorrect (995 mm instead of the actual 1500 mm catheter that would be used). When the radiation oncologist and the medical physicist were doing a pretreatment review and ensuring that the important parameters of the planned treatment were correct, they did not check the catheter length in the treatment plan to ensure that it was correct. The first radiation treatment was conducted, but instead of the radiation source traveling approximately 1500 mm in the catheter and providing radiation treatment to the 'vaginal cuff' region on the patient, it traveled only about 995 mm, and never entered the patient's body. When the medical physicist began to plan the second of the three radiation treatments, he noticed the error in the treatment plan for the first treatment. The radiation oncologist notified the patient on the same day the error was discovered. The records of all patients previously treated by this medical physicist and radiation oncologist were reviewed to determine if a similar error had occurred during any other high dose rate remote afterloader treatments, but no other errors of this type were found. To prevent future errors, both the medical physicist and the radiation oncologist have reviewed the treatment planning software and have agreed on a program of formal cross checking of the pretreatment printout that would include verifying that the catheter length specified in the treatment plan is correct. |