Event Notification Report for June 22, 2009

RADIOGRAPHY CAMERA TEMPORARILY LOST

On June 22, 2009, the licensee placed an INC IR-100 radiography camera on the tailgate of his work truck. The radiography camera contained a 54 curie Ir-192 source. The camera was not secured on the truck and the tailgate remained in the open position. When he arrived at the job site 25 minutes later he realized the camera had fallen off the truck. In order to look for the camera, the licensee proceeded back along the same route he had taken to the work site. The licensee noticed a police vehicle travelling on the same remote rural road. He stopped the police vehicle for assistance and discovered that the police officer had coincidentally just recovered the camera from a passerby. A passerby had found the camera on the road and contacted the police. The camera was not damaged. There was no personal exposure as a result of this event. The camera was out of the licensee's possession for approximately one hour.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy.

AGREEMENT STATE REPORT INVOLVING A POTENTIAL PERSONNEL OVEREXPOSURE DUE TO EQUIPMENT MALFUNCTION

The State of California provided the following information via email:

"During a teletherapy treatment of a cat on 6/22/09, an apparent malfunction of the MDS-Nordion Model C-146 teletherapy device resulted in the radiation beam not terminating at the end of the treatment. Two entries into the treatment room were apparently made with the radiation beam on, one by a technologist (who wore dosimetry), and one by a veterinarian (who did not wear dosimetry). The veterinarian was exposed to the beam when he removed the cat from the treatment table. The technologist reportedly did not enter the beam. The technologist's dosimetry was submitted to the dosimetry vendor for emergency evaluation.

"The veterinarian indicated that he was aware of the location and size of the radiation treatment beam when he removed the cat, and only his lower arms entered the beam. The beam was approximately 70 R/minute at the treatment site. The veterinarian estimated his time in the beam at one and one-half to two minutes. A re-enactment will be conducted as soon as the veterinarian returns to the office from a trip he is on the rest of the week.

"A state inspector arrived at the licensee facility at 0630 on 6/24/09 to investigate this event. The licensee has suspended use of the teletherapy device pending the results of the onsite investigation."

California 5010 Number: 052309

* * * UPDATE FROM ROBERT GREGER TO VINCE KLCO (VIA EMAIL) ON 6/29/09 @ 1919 * * *

"The current best estimate for the dose to the veterinarian has changed to less than one rem (both whole body and extremity). This is based on an on-site re-enactment of the event today that confirmed a significantly lower exposure time and dose rate for the event than was originally believed to have existed. "

Notified FSME (Foster) and R4DO (Powers).

LOST AMERICIUM-241 SOURCES DUE TO AIRCRAFT CRASH

On June 22, 2009, an F-16 crashed in a remote area in the Great Salt Lake test range in the area of the Utah and Nevada borders near Hill AFB. The aircraft was carrying a Sniper Laser Targeting Pod with two Am-241 sources each with an activity of 4 microcuries (8 microcuries total). Following investigation of the crash site and aircraft remnants, the licensee has determined that the sources are lost. The licensee has previously notified NRC Region IV (Browder) of this occurrence.


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.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source