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| Entered date | Event description | |
|---|---|---|
| ENS 51569 | 27 November 2015 19:33:00 | The following information was provided by the State of Utah via email: At approximately 2100 MST on November 26, 2015, two radiographers, working for QTI (Quality Testing and Inspection), were completing radiography operations (at a job site in Provo, UT for Dragon Manufacturing). When the exposure was completed, the source was withdrawn to the camera but was not fully retracted into the shielded position when the locking mechanism was engaged. The radiographers could not move the source or cable. The source was secured, personnel exited the affected area and the radiographers notified the Radiation Safety Officer (RSO). Temporary lead shielding was placed over the affected camera. Licensee personnel waited in low dose areas until the RSO arrived at the site. Licensee personnel maintained visual control of the affected area. After performing radiation surveys of the camera, the RSO withdrew and inserted the source into the source changer. The RSO locked the source inside the source changer and transported the radiography equipment to the Licensee's facility. The source changer, camera and associated cables were removed from service and transported to the licensee shop. Radiation exposures (from self-reading dosimetry) to the licensee personnel were approximately 10 mRem. The RSO's dosimeters indicated an exposure of approximately 40 mRem. More information will be provided in coming days. The licensee notified the State of Utah at 1200 MST on 11/27/2015. The camera was a model IR 100, serial number -4122, which contained a 93 curie Ir-192 source, serial number - Z825. UT Event Report ID No.: UT 150006 |
| ENS 51520 | 6 November 2015 20:24:00 | The following report was received from the State of Utah via email: On 11/5/15, a 66 year-old male patient was scheduled to receive a TheraSphere infusion. The patient required a TheraSphere vial dose of 1.94 GBq Y-90 (order was for 5.5 GBq dose calibrated on 11/1/15 to deliver 1.94 GBq on 11/5/15) to treat the left hepatic lobe of the liver to a dose of 125 Gy for hepatocellular carcinoma. It was not until the Nuclear Medicine technologist returned to the In-Patient 'hot lab' to finish her calculations and make her final measurements after the procedure that she determined that the patient received a TheraSphere vial dose of 1.502 GBq instead of the prescribed vial dose of 1.94 GBq. (22.5 percent of the dose remained in the administration system.) The Nuclear Medicine Coordinator notified the Radiation Safety Officer and the authorized user. The Authorized User notified the patient. Also, the manufacturer's representative was notified. This incident is currently under investigation. Utah Event Report No.: UT150005 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 State of Utah (Division of Waste Management) has received additional information, from the licensee, indicating that the actual underdose to the patient was < 5% and does not meet the reportability criteria. Therefore, this event is being retracted. Notified the R4DO (Farnholtz) and NMSS Events Notification via email. |
| ENS 51111 | 1 June 2015 18:49:00 | Loss of control of source: Data Control Device (DCD) containing a 500 microCurie Po-210 source was transferred from the Utah State University campus by an unnamed researcher. The source was removed and was transported to a city in India. The RSO (Radiation Safety Officer) is currently making efforts to locate the researcher in India and verify the source is under his control. This event occurred on 5/29/2015 and was reported to the state at 1300 MDT on 6/1/2015. Utah Report: UT150002 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 50892 | 13 March 2015 19:29:00 | The following is a synopsis of information received from the State of Utah: Two workers entered a confined space to perform work near a fixed gauge. One of the workers remained in the area for 9 minutes and the other remained in the area for 90 minutes. It was later determined that the fixed gauge shutter had not been closed. Surveys conducted by the licensee to measure dose rates in the area where the workers had been present indicated dose rates ranging from 0.5 mR/hr to 4 mR/hr. Utah inspectors performed confirmatory measurements that indicated dose rates between 0.97 mR/hr and 2.2 mR/hr. Utah Event ID Number: UT150001 |
| ENS 50657 | 5 December 2014 17:15:00 | The following report was received from the State of Utah via email: A portable gauge was run over by a compactor at a construction site (located at the University of Utah Business Loop Parking Garage). The gauge was damaged and required disassembly to withdraw the source. The source was withdrawn to the shielded position. Leak test wipes were taken and sent to a laboratory for analysis. The (Licensee) RSO (Radiation Safety Officer) placed the gauge inside the transport case. The RSO verified transport index readings were normal. The RSO transported the gauge to the licensee's facility and stored it until the leak test results were verified to be below 0.005 microcuries. Additional information and photographs will be forthcoming. Utah Event Report ID: UT140005 |
| ENS 50403 | 26 August 2014 18:29:00 | The following was received from the State of Utah via email: (The licensee was unable) to retract and secure a radiographic source to its fully shielded position. (The) licensee's RSO was able to disassemble the locking mechanism and retract the source. The exposure device was then locked and the source verified to be in the fully shielded position. There were no overexposures as a result of this event. Event Report ID No.: UT140003 |
| ENS 50048 | 22 April 2014 10:25:00 | The following information was received from the State of Utah via fax. The Utah Division of Radiation Control (DRC) was notified at 1:38 p.m. MST on Wednesday, August 13, 2013 of an incident where a church chapel was destroyed by fire. The fire had occurred three months earlier on May 13, 2013. No one noticed the radiation symbol mixed with the trash until a representative of the church, watching the residue being shoveled from the chapel. He noted the radiation symbol stuck to the remains of the melted sign. The DRC contacted the church representative and was informed of the details of the fire. The DRC Radioactive Materials Section Manager was notified of the incident. Notification to the NRC was completed on January 24, 2014. The tritium sign was melted by the high heat of the fire. There were no remaining identifiable components. The debris from the sign was mixed with other burnt materials and the trash had been shoveled into waste containers. The church representative said there was nothing recoverable in the fire's residue. The EXIT sign (Model B-100) was manufactured by SRB Technologies in 2005. The sign was designed to operate for 20 years using 18.9 curies of tritium. The estimated activity of tritium remaining inside the sign when it was destroyed was approximately 12 Curies. Utah Event Report ID No.: UT140001 |