Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 55980 | 7 July 2022 16:03:00 | The following was received from the state of Oregon via email: On June 29, a deviation on the length of the transfer tube was identified where the tube was found to be 2.9 centimeters longer than the vendor's specification (122.9 cm vs. 120 cm). This tube is used specifically with Channel 1 of the afterloader ((source: 10 Ci Ir-192; model: VS2000; s/n: 02-01-0235-001-031622-11038-12)) with a tandem and ring (T and R) applicator. Treatments therefore will be 2.9 centimeters shorter than the programmed distance for treatments and involving 1.5-2 cm of unintended tissue which shall exceed 50 rem and quite probably 50 percent to the location. The transfer tube length was last measured on July 27, 2020 and the licensee noted that the tube "measured length appeared to reflect the specified length by the manufacturer at the time." Because of this, the licensee believes they may have under-dosed some of their T and R patients using this transfer tube with Channel 1 of the afterloader. The licensee has already indicated two T and R treatments where this may be the case, May 13 and June 22, and is putting together a list of all cases since the most recent tube length verification in 2020. Oregon Report ID Number: 22-0031 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 55941 | 14 June 2022 02:39:00 | The following information was received from the Oregon Health Authority via e-mail: The following is a report of a medical event corresponding to Subpart M, 35.3045(a)(1)(iii) for a high dose rate afterloader (HDR) dose to the skin other than the treatment site that exceeds 50 rem and 50% of expected dose to the location. Description of event: A patient was scheduled for two HDR (Varian GammaMed Plus iX) treatments, one each for two separate lesions located on the patient's lower right leg. The first lesion treatment (5100 cGy total; 17 fractions @ 300 cGy ea) was performed in February without incident. The first fraction of 500 cGy for the second lesion was performed on June 7th. The second treatment was scheduled for June 10th, however, during set-up and after drawing a circle on the patient's leg to help align the second lesion and monitor positioning during treatment, the patient informed the physicist that after the first fraction on June 7th, he noticed the circle had been drawn at that time around the first lesion treated in February. Treatment staff immediately alerted the patient's physician. Images from the patient's treatment on June 7th were compared to the February treatment and found to be the same location as the first lesion. The physician stated there is no adverse effect to the patient since the dose went to the site of the previous February treatment that was 'well tolerated' by the patient and 'the additional one HDR fraction of 500 cGy is likely of benefit to the patient.' The patient's written directive was updated to reflect an additional fraction to be given to the second lesion. Cause and corrective actions: The licensee is still gathering information but from the preliminary data received, verification of the treatment site was not performed for the June 7th fraction and former treatment plan location was used. No corrective actions have been submitted at this time. Concerns: Verification of treatment site may not be robust enough in separating separate treatment sites that are close together. Only through patient notification was this event identified. Awaiting further information/explanation from licensee." Oregon Report Identification Number: 22-0028 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following updated / revised information was received via E-mail: Description of event: The patient was scheduled for two treatments, one each for two separate lesions located on the patient's lower right leg. The first lesion treatment (5100 cGy total dose; 17 fractions @ 300 cGy ea) using beam therapy (SBRT) was performed in February without incident. The second lesion was not present during this treatment but appeared shortly after. On June 7th, the first fraction of 500 cGy (4000 cGy total dose; 8 fractions at 500 cGy ea) was performed. The second treatment was scheduled for June 10th, however, during set-up and after drawing a circle on the patient's leg to help align the second lesion and monitor positioning during treatment, the patient informed the physicist that after the first fraction on June 7th, he noticed the circle had been drawn at that time around the first lesion treated in February. Treatment staff immediately alerted the patient's physician. Images from the patient's HDR fractionated dose on June 7th were compared to the February external beam treatment and found to be the same location. The physician stated there is no adverse effect to the patient since the dose went to the site of the previous February treatment that was "well tolerated" by the patient and "the additional one HDR fraction of 500 cGy is likely of benefit to the patient". The patient's written directive was updated to reflect an additional fraction to be given to the second lesion. Cause and corrective actions: Facts to note: - The second lesion was not present during the February external beam treatment. - The written directive for the HDR treatment plan for the second lesion stated it was "lateral" than the "more medial" first lesion. Both were within approximately 1.5 inches of each other. - The patient positioning for external beam was supine and for the HDR, prone. This event occurred due to human error. The licensee failed to note the change in patient positioning from supine to prone while using photos of the treatment area resulting in `visual flip' of image nor confirm treatment site from the written directive. A contributing factor is the proximity of the two lesions and another is that the second lesion was not present during the February external beam treatment. Stated corrections are to add a pretreatment step for multiple lesions close to each other that include: - Asking the patient to point to the site to be treated. - Verification by including more images of the body (hand or foot) along with the lesions to better identify the site and orient treatment personnel. Source: Irridium-192 Activity: Approximately 4.8 Ci Model: Gammamed 232 Serial number: 24-01-0285-001-020422-15242-99 Leak test date: March 17, 2022. Notified R4DO (Azua) and the NMSS Events Notification E-mail group. |
| ENS 55524 | 15 October 2021 10:53:00 | The following was received from the Oregon Health Authority, Radiation Protective Services (Oregon RPS) via email: On October 8, 2021, during a low-level radioactive waste (LLRW) broker's visit to an Oregon scrap metal site to package and ship accumulated radioactive materials to a LLRW site, a fixed gauge was found among the items in storage. The technician notified the broker's office of the discovery and the broker notified Oregon RPS on October 11, 2021 at 1120 (PDT) hours. The gauge shows some wear with the gauge shutter lever broken but the shutter appears intact and closed with the source inside. Information on the gauge/source is as follows: Manufacturer: Ohmart Model 3340 Serial number: 70453 Source: Cs-137 Activity: 50 mCi Source holder: SR-1A Source manu: 3M Source model: 4F6S Source serial: S-601 Highest dose rate at contact: 70 mrem/hour (at collimated end) Highest dose rate at 1 ft: 18 mrem/hour Highest dose rate at 1 m: 2 mrem/hour The gauge was placed shutter-side down in a secured metal storage vault on site. Dose rate on the surface of the gauge measured at less than 2 mrem/hour. The licensee is in contact with the manufacturer to arrange disposal of the gauge. The gauge was originally installed in 1981 at a silver mining mill located south of Ely, NV. There were four additional gauges installed at the Nevada site at that time. RPS has contacted the Nevada Agreement State Radiation Control office and that office is investigating. Oregon State Event Report No: OR-21-0051 THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 55424 | 23 August 2021 15:20:00 | The following is a summary of information received from the State of Oregon: Licensee miscalculated and administered more radiation to a patient's spine than the prescription allowed. Radiation dose to the patient was intended to be 800 centigray but the actual dose delivered exceeded this by 21%. Oregon Emergency Response System Incident Number: 2021-2250 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following is a synopsis of information received via e-mail from the state of Oregon via e-mail: After obtaining direct information from the responsible party, the radiation dose above the prescribed 800 centigray was from an x-ray generating device and is therefore a nonreportable event to NRC but is being investigated at the State (Oregon) level. This is not a reportable event to the NRC. Notified R4DO (KOZAL) and NMSS Events (by email). |
| ENS 54243 | 28 August 2019 16:35:00 | The following is a summary of information received from the State of Oregon via phone call: On August 28, 2019, at 1102 PDT, the Oregon Department of Health and Radiation Protection received a report from the R.S. Davis Scrap Yard, that a moisture density gauge was found in a 55 gallon drum that was crimped at the top so the gauge will not fall out. The gauge is a CPN MC-3 Porta Probe with a 10 mCi Cs-137 source and a 50 mCi Am/Be 241 source. The scrap yard employed a contractor to take radiation readings and perform a swipe test of the gauge. The gauge housing appears to be damaged but the source housing seems intact. The contractor was unable to inspect the bottom of the gauge inside the drum. The following was measured: A reading of 13 mR/hr on contact at the side A reading of 200 mR/hr on contact at the bottom A reading of 3 mR/hr one foot from the side Swipe Test results were less than background The State of Oregon Radiation Inspector believes the gauge is damaged because normal radiation readings for a similar gauge at one meter would be 0.4 mR/hr. The State of Oregon will be conducting an investigation of this event. The gauge is currently under the control of the scrap yard. Oregon Event Reference Number: 19-0037. THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 53926 | 11 March 2019 13:55:00 | The following is a summary of the phone call with the state of Oregon: On March 5, 2019, the licensee realized that a 9.4 Curie Ir-192 industrial radiography source was missing when the scheduled shipment was not received on March 4, 2019. Last known location was Memphis, TN on March 1, 2019.
The following report was received via e-mail: On March 11 at 11:38 AM (PDT), the licensee (OWL) emailed and stated that the lost package and source have been found after an extended telecon (1 hour) with the carrier. No location given in email but a statement that (the common carrier) had held the shipment because they needed a copy of the shipping papers to send it on to its destination (QSA in Baton Rouge, LA). OWL emailed a copy of the shipping papers to (the common carrier) and the package was released to continue on to QSA. On March 12 at 9:15 AM (PDT), (the state of Oregon) contacted the licensee (OWL) by phone. The package and source were found by (the common carrier) in their Memphis, TN shipping center. (The common carrier) did not have shipping papers for the package when received in Memphis and placed it into their 'Overgoods' department where 'lost dangerous goods' are taken and held if there is a paperwork issue preventing a shipment from continuing on its way. The package in this case was released on March 11th as previously indicated and arrived at QSA in Baton Rouge at 10:02 AM (CDT). Notified the R4DO (Groom), and NMSS Events Resource and ILTAB (via e-mail). THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9) |
| ENS 53171 | 17 January 2018 16:45:00 | On January 15, 2018 a medical event occurred at the licensed facility in which a patient received a prescribed dose less than 80 percent of the target dose to the liver. The dose was delivered via Y-90 microspheres. The State will investigate this medical event.
On January 15, 2018, a patient was prescribed a dose of 130 Gy (2.789 GBq) for the left lobe of the liver involving two dose vials of Y-90 MDS Nordion TheraSphere microspheres. The first dose vial was administered without issue. The second dose vial was then primed and prepped as normal, however, a train of bubbles was noted in the line between the dose vial and the patient prior to administration. Due to the proximity of gastric artery relative to point of administration and the possibility that the bubbles could cause the flow to reflux into this artery (which could permanently damage the stomach), the AU (Authorized User) determined the best course of action was not to administer the second dose vial. The therapy procedure was then halted and rescheduled to complete on Thursday, January 18th. The administered dose was 84.9 Gy (1.760 GBq) to the left lobe of the liver. The dose was therefore 65% of the prescribed dose, a 35% difference. The difference between the prescribed and administered dose to the liver is 45.1 Gy (4510 rem). Therefore, the dose administered exceeds +/- 20% of prescribed dose and differs from the prescribed dose by more than 50 rem to an organ (liver). The referring physician has been notified as well as the patient. This event was reported to the Oregon Agreement State program on January 16, 2018. The licensee has removed all Y-90 therapy tubing sets from the same lot number for return and analysis by the vendor. Tubing sets from a different lot number were provided to interventional radiology for future cases. Notified R4DO (Proulx) and NMSS Events Resource (email). State Event Report ID No.: OR-18-0001 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 53088 | 22 November 2017 15:22:00 | Eye plaque brachytherapy was being performed using I-125 seeds with a prescribed dose of 85 Gray. After the dose, the Iso-dose curve was noted to be different from the brachytherapy plan i.e. the dose was deeper than expected. Investigation revealed that a new model plaque was used which differed from the previous model. This resulted in an underdose with 65 Gray actually administered. Oregon Report: 17-0073 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 50991 | 17 April 2015 12:43:00 | On 4-15-15 the patient was to receive a fractionated dose of 4 Grays to the 'vaginal cuff' region using a 10.175 Curie Ir-192 source. The dose was to be administered using a Varian Model VariSource 200t remote HDR (High Dose Rate) afterloader, serial number 600349. The plan was to administer 6 radiation treatments using a cylinder applicator and holder, the treatment length intended to be 5 cm. Imaging was done after placement of the cylinder prior to treatment to verify location, however, post-treatment imaging showed that the cylinder applicator had come loose from the holder and shifted 3 cm. This was the first of the six fractions. Hospital staff physicists are currently working to determine the delivered dose to the target and why the shift occurred. Physician notification has not been verified at this time. The patient has been notified. 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 50868 | 5 March 2015 17:38:00 | On March 4, 2015, the licensee notified the State of Oregon that they discovered that their Elekta Leksell Gamma Knife was off target by approximately 1.87mm. This was allegedly due to maintenance performed in early January 2015, that resulted in a misaligned couch. Since the misalignment, eight patients have undergone gamma knife surgery. The licensee Medical Physicist is currently evaluating each case to determine whether an underdose/overdose occurred to any of the patients. The Elekta Leksell Gamma Knife is licensed for up to 6.6 kCi of Co-60. The State of Oregon will update this report as more information becomes available. 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 50648 | 2 December 2014 17:15:00 | The following information was received via email: The licensee reported a medical event at 0958 PST involving a patient treated for vaginal cancer. The treatment involved an Ir-192 high dose rate afterloader (HDR) source at 5.369 Curies activity (December 2nd) delivered to the vaginal vault via a 3 cm single-channel cylinder for a prescribed dose fraction of 400 cGy (rad). Instead, a 5 cm single-channel cylinder was used that delivered a 700 cGy dose (rad), or 75 percent (300 cGy) above the prescribed dose. The licensee stated that an afternoon patient's treatment plan was being reviewed on the console while the morning patient was being prepped for treatment and the patient subsequently treated with the other patient's plan. The licensee failed to verify the patient's identification before starting the treatment. The cause is therefore determined to be human error. The licensee stated that the patient was scheduled for three fractionated doses at 400 cGy (rad) each for a total dose of 1200 cGy (rad). This was the 2nd fraction so the total dose delivered to the patient is currently 1100 cGy (rad). The licensee performed a biological effective dose (BED) calculation and that the final effective dose is within 4 percent and 10 percent of the intended dose in terms of short/long term effects and the final fraction dose will most likely not be administered. The licensee notified the patient's physician who will notify the patient of the error. The licensee will submit a formal report to Oregon RPS including corrective actions to prevent recurrence. 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 50228 | 26 June 2014 12:28:00 | The following information was received by facsimile from the State of Oregon: Event Description: OR Radiation Protection Services (RPS) was notified by facsimile on June 24, 2014 at 0813 (PDT), by Schnitzer Steel Industries, 12005 N. Burgard Way (Portland, Oregon) of one cesium-137 fixed gauge received in a truckload of scrap from Idaho that triggered their site entry detectors. RPS personnel investigated, found the gauge housing to be severely crushed, shutter damaged and partially open. One side of housing is split but compressed together. Identification plate still attached and mostly legible and given as follows: Manufacturer: Texas Nuclear; Model: 5197; Gauge housing serial number: B7951; Source: Cesium-137; Activity: Currently 65 mCi according to Thermo Fisher Scientific. Gauge is being stored in secured metal bin in restricted and remote area on company site. Highest exposure reading at bin surface measured at 1.48 mR/hour. Schnitzer personnel reported 60,000 microR/hour (60 mR/hour) at approximately 4 inches from split side of gauge housing surface when first discovered. Schnitzer personnel (one person) used shovel and 4 foot steel rod with hook to move gauge from truck to storage bin on June 23rd. Estimated dose to company person from reconstruction of gauge move is 1.50 mrem based on a 6/25/14 exposure measurement. No other company employees received a dose from this device and RPS personnel did not receive any appreciable dose. RPS personnel took contamination wipes of gauge housing and found no evidence of exterior contamination after analysis. The manufacturer, now Thermo Fisher Scientific, was contacted and found the gauge was originally sold to a Martell, California company, Wheelabrator Martell, Inc., on August 23, 1996. Thermo added the last contact for leak test services was December, 1999. RPS is currently investigating further to trace gauge history since 1999 as well as location in Idaho where truck originated. The gauge will not be returned to the manufacturer according to Thermo and classified as waste. A waste broker will be contacted by Schnitzer for packaging and disposal. RPS will be monitoring this process. Oregon State Incident: OR-14-0028.
State of Oregon provided clarification of source activity and exposure estimate. Notified the R4DO (Allen) and FSME Resources via email. THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 47991 | 4 June 2012 16:45:00 | On June 1, 2012, the licensee reported a lost Ni-63 electron capture detector (ECD) to the state of Oregon. The source is an Agilent Technology model 19233, serial number L5286 and was used in a gas chromatograph (GC) device. The source was obtained in April of 2006. The last time the source was known to be in possession of the licensee was during a 6-month wipe test performed on November 1, 2011. The gas chromatograph was sent to Far West Fiber Metal Recycling around the first of the year and it is possible the source was in the machine at the time of disposal. The licensee will continue to search for the source. The state of Oregon will follow-up with the licensee.
The following update was received from the State of Oregon Radiation Protection Services via facsimile: Inspection/investigation at TestAmerica Analytical Testing Corporation (TAATC) site performed on June 14, 2012. Missing ECD device not located, believe to have been housed inside a gas chromatograph (Hewlett-Packard model 5890, serial number 3033A30613) that was turned over to Far West Fiber Metal Recycling on December 5, 2011. All other ECD devices (25) were accounted for during the inspection. Discussion with Far West on June 4, 2012 indicates that metal items received are held for downstream customers for two weeks and then turned over to them for stripping/smelting. Far West had no record of receipt of the GC/ECD or which customer it may have gone to. Checks were made with local firms (Schnitzer Steel and Metro Metals) but no record of the GC/ECD unit receipt was located. TAATC continued to search for ECD unit for several months but it was not found. Believe ECD was smelted with GC at this time. Cause of this event due to management deficiency. RSO was moved to new position in November 2011 and out of room where ECD unit located and was training replacement person to perform some R50 duties (6-month leak testing/inventory) for ECD's. Missing ECD was housed in GC unit that was not used for 4 years and GC was used for spare parts. An employee of TAATC not listed on the materials license and unfamiliar with GC/ECD's removed 3 GC units from the room on December 5th and delivered to Far West Fiber for recycling, including the GC unit that normally housed the ECD in question. The other GC's did not house ECD's. The RSO and his trainee were unaware of the missing ECD until June 1, 2012 during routine 6-month leak testing nor was the RSO aware of the GC transfer since RSO works in a different area on site and do not routinely monitor ECD locations anymore. No other actions available at this time. The State of Oregon is closing this event. Notified the R4DO (Gaddy) and e-mailed FSME Events Resource. OREGON NMED REPORT NUMBER 120345 THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 49204 | 19 July 2013 12:00:00 | The following was received from the State of Oregon via email: On February 17, 2011 at 0800 PDT, OR Radiation Protection Services was notified by phone by (the licensee), HazMat Resource Coordinator, a representative of the Oregon Office of the State Fire Marshal (OSFM) regarding a missing Smith's Detection model APD2000 ECD device (s/n 1276) containing 10 mCi of Nickel-63 (source s/n is the same as device, 1276). There were no equipment problems noted. The device was stored at Hazmat Team 7, stationed in Redmond, Oregon. The team was disbanded in late 2008 and the device was believed returned to the Salem, Oregon main OSFM office in early 2009. During equipment inventory in September (no date given, 1-30th supplemented), 2010, the device was discovered missing. OSFM personnel wrote a memo dated Sept. 2010, and addressed 'MEMO to File' stating the device was missing and that this was reported to Oregon RPS. No record of the memo having been received was found in RPS records for the license (The licensee) stated that the remaining seventeen APD2000 units in possession were to be disposed of through the CRCPD's SCATR program sometime in the next 2 months. An incident report was started by OR RPS on this date (February 17th) for the missing device/radioactive source. On April 8, 2011, the seventeen APD2000 units were shipped by waste broker (Thomas Gray and Associates) to affiliate company EMC in Turlock, CA. On May 26, 2011 during regular equipment inventory at the Corvallis, Oregon Hazmat team 5B office, the missing APD2000 was located at the back of a storage cabinet. The device was removed and brought to Salem and (the State was) contacted for disposal of this device through the CRCPS SCATR program. A leak test was taken June 7th and analyzed June 8th showing detection less than .005 microCurie for Ni-63. On June 15, 2011, the device was transferred to Thomas Gray and Associates for disposal and the license terminated on July 1, 2011. On July 16, 2013, a review was performed of this incident and it was discovered that it was not reported to the US NRC HOO as per the NRC's Reporting Material Events (SA-300), Appendix A. The specific requirement is 10 CFR 20.2201(a)(1)(ii) which states, in part, that reports of missing licensed material > 10X Appendix C value and still missing is to be reported (30 day requirement). The report was written and submitted via e-mail to the HOO on July 19th. State Event Number: OR-11-0007 Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 46245 | 10 September 2010 17:29:00 | The following information was received via facsimile: Jeld-Wen Wood Fiber of Oregon located in Klamath Falls possesses 5 fixed gauges at their wood door manufacturing facility. In late December 2009, the Radiation Protection Services (RPS) office (State of Oregon) received a phone call from (the Jeld-Wen) Maintenance Manager, who talked to (the) RPS Licensing Manager and stated that he wished to report that there were two gauges at their facility that were having shutter mechanism problems. (The Maintenance Manager) stated he would elaborate on the issue in an email. On February 22, 2010, (the Maintenance Manager) emailed (the RPS Licensing Manager) and stated that the gauge with the broken shutter mechanism (Ronan, model SA-8, serial M2119, 20 mCi Cs-137, high level indicator gauge, installed 12-15-88) was operating in the open shutter position and unable to close. (The Maintenance Manager) stated that the licensee had manufactured a 1.5" thick shutter (by approximately 8 inches wide by approximately 1 meter long) that fits between the gauge and the vessel it is attached to. He also stated that this gauge is in a restricted access area that is roped off and the closest area of worker frequency is 20 feet away. (The Maintenance Manager) stated that the other gauge with the 'sticking' shutter (Ronan, model GS-200, serial 3401, 50 mCi Cs-137, digester level indicator, installed 12-15-88) is closable and is also operating. He stated that he would be scheduling a repair for the 50 mCi gauge and would be evaluating whether a replacement will be needed for the 20 mCi gauge. On March 15, 2010, (the Maintenance Manager's) email to (the RPS Licensing Manager) was given to (an RPS employee) in radioactive materials licensing. From (the RPS Licensing Manager's) email, another staff member may be working on this incident. (The RPS employee) phoned (the Maintenance Manager) and found that this was an event possibly not entered into the system but he would check with materials inspectors to see if that was the case. (The Maintenance Manager) stated that he was scheduling for repair of the 50 mCi gauge and possibly the 20 mCi gauge but not sure of the latter. (The Maintenance Manager) also stated that he would be submitting an amendment request naming him as Radiation Safety Officer. On May 21, 2010, (the RPS employee) requested an update on the repairs/actions by the licensee for the two gauges. No response was received. On June 9, 2010, (the Maintenance Manager) phoned (the RPS employee). He stated that the company did not have the fiscal ability to replace the 20 mCi gauge and asked if the company could continue operating the gauge for approximately 2 more years. (The RPS employee) stated that the SS&D sheet would have to be reviewed as well as an onsite inspection of the gauge. On June 23, 2010, (the RPS employee) reviewed the SS&D for the 20 mCi device. For a 500 mCi Cs-137 source, exposure rates with the shutter open were listed as 43 mR per hr at 2 inches, 4.3 mR per hr at 1 foot, and 0.6 mR per hr at 1 meter. At 4 percent of maximum activity allowed, the 20 mCi source located in a restricted access area using 1 meter distance should give an exposure rate of approximately 300 microR per hr maximum. It was also determined that an inspection would be made of the facility in Klamath Falls in late July (in order) to verify exposure rates around the gauge with the shutter open. On July 27, 2010, an inspection of the facility was performed by (another employee of RPS). (This other RPS employee) determined exposure rates around the 20 mCi gauge to be approximately 100 microR per hr at 1 meter. (This other RPS employee) also noted that the gauge is located at or below the catwalk that accesses that area. The licensee was allowed to continue operation with the shutter. (The other RPS employee) also discovered that the 50 mCi gauge with the sticking shutter was not actually sticking but merely hard to open and close due to residue/resin buildup. The licensee cleaned the residue off and covered the shutter mechanism and gauge with a metal canopy to prevent future buildup. Vendor work on this gauge was not performed as the licensee corrected the issue internally. Management approval for the modified shutter of the 20 mCi gauge will be sought at this time. (The Maintenance Manager) noted also during the inspection that the issues with the two gauges had been known by the licensee for approximately 2 years and was only then being reported because he was to become the new RSO and thought it should be. On September 10, 2010, a review of this incident was performed and it was found that the NRC HOO had not been notified. A copy of open NMED events for Oregon was also reviewed and no mention of this incident was found. NRC was notified of the incident at this time. Oregon RPS management has not made a final decision on the 20 mCi gauge with the broken shutter mechanism.
On October 1,2010, (the owner of) an Oregon-licensed fixed gauge service vendor company (RS&S Calibration LLC), Oregon license ORE-91083) contacted the Oregon Radiation Protection Services (RPS) office by email stating that he had cleaned and oiled the shutter mechanism on the gauge with the shutter stuck open (Ronan model SA-8, s/n M2119) and the unit is working properly. The handle is broken yet and (the vendor owner) stated that the customer is going to order a new handle. On October 25, 2010, Daryl Leon of RPS emailed the site RSO, Rob Reifel to determine status of handle repair. Mr. Reifel emailed that he was still trying to get a quote on the part and asked if his site maintenance personnel can manufacture a new handle. He also added that (the repair vendor) indicated he (Reifel) should use one provided by the manufacturer. Mr. Leon responded by email stating that the part should be obtained from the manufacturer since safety evaluation of the device was performed with parts originally from the manufacturer and a locally-manufactured part would not suffice. Mr. Reifel indicated that he would 'push harder' to get this done. On November 8, 2010, Mr. Reifel emailed Mr. Leon stating that the handle was fixed and that the fix was performed November 4,2010. This event is ready for closure for the HOO and NMED (incident 100458) Notified R4DO (Pick) and FSME EO (Villamar). |