Event Notification Report for June 15, 2012

AGREEMENT STATE REPORT - BURST VIAL OF Tc99m IN NUCLEAR PHARMACY

The following information was received via email:

"On Friday, June 15, 2012, at approximately 0230 Mountain Daylight Time (MDT), a nuclear pharmacy licensee located in Grand Junction, Colorado, had a vial containing approximately 1.9 Ci of liquid Tc99m burst and likely volatilize following placement on a heating block as part of compounding activities for preparation of cardiac imaging (Sestamibi) radiopharmaceuticals. The pharmacist, who also serves as the Radiation Safety Officer (RSO), notified the Colorado Department of Public Health and Environment (CDPHE) Radioactive Materials Unit on-call duty officer several hours later at approximately 1000 MDT on Friday, June 15.

"Following the initial notification to CDPHE, a secondary phone interview of the pharmacist was conducted. It was determined that the burst container resulted in contamination of the pharmacist, compounding area (generator room), and areas within the main pharmacy. The pharmacist was the only person in the facility at the time of the incident. Other staff - primarily courier personnel - arrived after the incident, and provided some assistance but reportedly did not enter the pharmacy lab area. As a result of the ruptured vial, radiation survey instruments in the laboratory became contaminated, which required the licensee to borrow instrumentation from a local hospital licensee. Sometime following the incident, the pharmacist initiated limited decontamination activities of himself (glove and lab coat removal/exchange) and the area. The pharmacist reportedly continued with the preparation of some radiopharmaceutical materials following the incident. Additionally, following gross decontamination activities at the pharmacy, the pharmacist left the licensee facility to shower and change clothing at his residence.

"During phone interviews with the licensee, CDPHE requested that the pharmacist obtain a urine sample, prepare for the return and processing of personal dosimeter badges and arrange for a back-up pharmacist. The pharmacist was directed to not conduct work involving radioactive material, pending further evaluation of internal and external dose.

"In response to the incident, CDPHE dispatched the on-call duty officer from the Denver office to the Grand Junction area on Friday afternoon. (NOTE - Grand Junction, Colorado is approximately 5.5 hours drive time from the Denver CDPHE office). CDPHE staff met with the licensee pharmacist/RSO on the morning of Saturday, June 16, 2012 to evaluate the situation and perform surveys of potentially impacted areas and personnel. A whole body scan of the pharmacist was conducted at a local hospital nuclear medicine department in the later morning of Saturday, June 16. Personnel surveys of the pharmacist and the scan did not indicate the presence of radioactive material. Further details and information are being gathered.

"No members of the public were believed to have been exposed above public dose limits as a result of the incident, and radioactive materials are believed to be contained within the lab area, with the exception of minor contamination discovered near the back door to the pharmacy.

"The Department continues to investigate the incident and is gathering additional information."


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

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

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

"On Friday, June 15, 2012, at approximately 3:15 p.m. MDT (Mountain Daylight Time), a portable gauge licensee (Kumar and Associates, Inc.; Colorado License No. 778-01, Amendment 14) based in Denver, Colorado notified the Colorado Department of Public Health and Environment (CDPHE) Radioactive Materials Unit on-call duty officer that a gauge being used on a construction site had been damaged by heavy equipment earlier in the day (~2:15 p.m. MDT). The licensee reported that heavy equipment backed up and rolled over the gauge and the gauge technician was unable to retrieve or move the gauge in time. According to the licensee, and based on visual observation, the source capsule area at the end of the rod appeared intact and not significantly damaged as a result of the incident. Neither the source nor source rod were separated from the body of the gauge. The source rod, however, could not be retracted back into the shielded position and was transported back to the licensee facility in that manner.

"The gauge involved was a Troxler model 3440 (gauge serial number 32754), currently containing approximately 6.2 mCi (decayed from 3/1/2001 assay date) of Cs-137 (serial #750-8100) and 40 mCi (5/28/99 assay date) of Am-247:Be (serial #47-28951).

"At the time of the notification by the licensee to CDPHE at approximately 3:15 pm MDT, the gauge had already been returned to the licensee's facility. CDPHE requested that a leak test be performed on the gauge sources before any further actions are taken and that the licensee consult with a licensed repair facility or manufacturer for proper shipment of the damaged gauge.

"Additional information and an incident report from the licensee is pending."

AGREEMENT STATE REPORT - DAMAGED TROXLER

The following information was obtained from the State of Tennessee via Email:

"On June 15, 2012, Building and Earth Sciences contacted the Division of Radiological Health to report that their Troxler Moisture Density Gauge model 3430 (SN#37366) which contains 8 mCi of Cesium-137 and 40 mCi Americium-241:Beryllium had been hit by a bull dozer at a jobsite in Sevierville, TN. The gauge was visually inspected, and it was determined that the source rod was retracted and inside the gauge but the sliding block was not in place. The survey meter indicated an exposure level of 100 mRem/hr within 1 meter of the base of the gauge in its case. After speaking with Troxler, the RSO replaced the sliding door and held it in place with duct tape. This reduced the dose rate to 18 mR/hr. The gauge was secured into a truck bed and was returned to their licensed facility in Birmingham, AL. Upon arrival in Birmingham, a leak test was conducted and sent for analysis. Once the results were returned, they obtained a return authorization to ship the gauge to Troxler."

Tennessee Event: TN-12-164

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

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FAILURE

The Commonwealth of Virginia submitted the following report via facsimile:

"On June 14, 2012 the licensee reported that the shutter of one of its fixed gauges could not be closed as designed. The gauge is a Ronan Model SA-1 used on a process vessel as a level indicator. It contains a 438 millicurie (decay corrected) cesium-137 source. The problem was discovered during a routine test of the shutter mechanism. The individual who performed the test indicated that forcing the shutter closed, if possible, could damage the control mechanism. The gauge is normally in the open position during operations and the licensee has take extra steps to ensure no entry into the vessel. Ronan Engineering Company, the gauge manufacturer, has been contacted by the licensee and has scheduled a site visit during the week of June 18, 2012."

VA Event Report ID: VA-12-002

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

FIXED NUCLEAR GAUGE FELL FROM MOUNTING BRACKET DUE TO RUSTED THROUGH MOUNTING BOLTS

On the morning of 6/15/12, a fixed level monitoring gauge at the licensee's Merom Generating Station (coal fired facility), fell from its mounting bracket into a cable tray. The gauge, a Kay-Ray Model 7062P, S/N 9242Q, containing an estimated 50 mCi Cs-137 source (original activity - 100 mCi approx. 30 years ago) was not in service at the time, i.e., its shutter was closed, did not result in any personnel exposures. The licensee intends to have the instrument reinstalled using an outside contractor licensed to perform the work.

The licensee contacted R3DO (Dickson).

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