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 Entered dateEvent description
ENS 4883921 March 2013 09:13:00The licensee notified the Department (Ohio Department of Health) on March 20, 2013 of a medical event that occurred on March 19, 2013 involving a Y-90 SIR-Sphere patient treatment. The delivery system became clogged and delivered only 3.2 mCi (13%) of the 24.3 mCi prescribed activity. The cause of the event is under investigation. The licensee plans on retreating the patient. Ohio Item Number: OH130002 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
ENS 500149 April 2014 14:28:00

The following information was received from the Ohio Bureau of Radiation Protection via email: The corporate RSO for Acuren Inspection made an immediate telephone notification under OAC (Ohio Administrative Code) 3701:1-38-21(B)(1) (same as 10 CFR 20.2202(a)(1)) to the Ohio Department of Health Bureau of Radiation Protection at 1320 (EDT on) April 9, 2014, to report a radiographer overexposure at a temporary job site in Marietta, OH. The event happened about 1100-1130 (EDT) this morning. The initial estimates regarding the male radiographer is that he may have received a 15 Rem whole body exposure and an estimated 3000-5000 Rem to the hand. The radiographer's whole body dosimeter is being sent off for immediate processing. The radiographer has been sent for medical attention. REAC/TS (Radiation Emergency Assistance Center/Training Site) was contacted by the licensee who gave REAC/TS the contact information for the attending physician of the radiographer. The radiographer was working with an 88 Ci Ir-192 source at the time. The radiographer supposedly had all his dosimetry and a survey meter at the time of the incident. The corporate RSO and a local (RSO) are both enroute to the temporary job site. Sequence of events: The radiographer had sat down and was chatting while waiting for an exposure to complete. At the end of the shot time, he had assumed that the other radiographer had retracted the source and proceeded to set up for the next shot. When he noticed that the other radiographer was not present he went back and checked to find that the source had not been cranked back. The (State of Ohio) Department will have an inspector on scene in the morning to investigate the incident and also to observe and review the incident reenactments. Ohio event report number 2014-007.

  • * * UPDATE FROM KARL VON AHN TO CHARLES TEAL ON 4/10/14 AT 1530 EDT * * *

On April 10, 2014, the (State of Ohio) Department performed an onsite inspection and observed the licensee perform a reenactment of the incident scenario. It was determined that the radiographer did not handle the end of the source tube with the source in it and did not receive the initially assumed hand dose. The whole body deep dose is still expected to be about 15 Rem. The hand dose is expected to be on the order of the whole body dose, about 15 Rem. During the reactive inspection, the (State of Ohio) Department found that the radiographer's alarming rate meter had a dead battery, and the survey meter was not functional and had not been checked that day. The Assistant Radiographer was trailing the radiographer approximately one and a half minutes in entering the shielded bunker, and it was the assistant radiographer's alarming rate meter and survey instrument that identified the presence of the exposed source. The source collimator was not being used in the bunker, and so the 89 Ci Ir-192 source was not shielded. Notified R3DO (Pelke), FSME Duty Officer (McIntosh), and FSME Event Resource.

  • * * UPDATE FROM KARL VON AHN TO CHARLES TEAL ON 4/11/14 AT 1234 EDT * * *

The Acuren Inspection Services RSO has provided the Department (State of Ohio) with the following updates: (1) The radiographer's whole body dosimeter reading was 836 mRem. (2) Based on the dose estimates from the scene reenactments, Acuren will assign the radiographer a whole body dose of 13 Rem, and an extremity dose of 6.5 Rem. (The radiographer's chest was much closer to the source than his dosimeter was.) (3) The radiographer will be under continued medical surveillance and REAC/TS will remain involved. Notified R3DO (Pelke), FSME Duty Officer (McIntosh), and FSME Event Resource.