Event Notification Report for January 16, 2015

AGREEMENT STATE REPORT - POTENTIAL RADIOGRAPHER EXCESSIVE EXPOSURE

The following report was received from the State of Louisiana via email:

"Event Date and Time: 01/16/2015, around [1515 CST] a radiography crew was working at the ExxonMobil Refinery on Scenic Highway, Baton Rouge, LA. The event was reported [about 1645 CST] on January 17, 2015, by a phone call from [an individual] who represented himself as the Corporate RSO. He stated he drove down on January 17, to evaluate and investigate this incident. He reported this incident appears to be a Human Error Potential Excessive Exposure.

"Event Location: ExxonMobil Refinery 4999 Scenic Highway. Baton Rouge, LA 70805. A temporary jobsite for Acuren Inspection.

"Event type: This is a potential excessive exposure involving a radiographer attempting to breakdown a radiography exposure setup. He attempted to disconnect the guide tube from the exposure device and the source was not locked in the shielded position. It was noticed that the locking device was red after the guide tube was handled to disconnect it from the exposure device.

"Notifications: LA DEQ [Department of Environmental Quality], Assessment, Radiation by direct phone call to our after hours answering system. The notification came in around [1645 CST] on January 17, 2015.

"Event Description: The radiography crew was making exposures on lower level equipment at the ExxonMobil Refinery. The crew was utilizing [about] 38 Ci of Ir-192. The crew attempted to breakdown/disconnect the equipment after the exposures. The guide tube would not disconnect. The 2nd hand of the crew manipulated the drive cable that returned the source into the shielded position. A quarter turn on the crank shielded the source.

"The radiographer and his equipment were checked. His pocket dosimeter was off scale, but he claims his Alarm Rate Alarm meter did not alarm. A second check of the Alarm Rate Meter revealed the unit did alarm, but it was a weak alarm.

"Estimated dose calculations were done for his whole body and extremities. His whole-body estimated dose was 3.3 Rads and his extremity dose was estimated at 206 Rads to his hands. These were calculated on a one minute exposure where a .5 minute is more realistic. The exposed radiographer was taken to Core Occupational Medicine for examination, x-rays and blood work. He is being monitored and examined every other day. At this time he has been asymptomatic for an excessive radiation exposure. The Licensee is conducting reenactments.

"This incident is not considered closed by the Department [LA DEQ]. The investigation findings will be updated when they become available.

"The equipment was all QSA equipment loaded with 38 Ci Ir-192. This appears to be an operator error exposure.

"The source is secure from removal and unnecessary exposure. This event is not closed and additional investigation and evaluation will continue. The source is in a safe shielded position and no threat to workers or the general public.

"Transport vehicle description : N/A This was at a temporary job site inside the ExxonMobil Refinery located in Baton Rouge, LA."

License Numbers: LA-7072-L01, AI 126755

Louisiana Event Number: LA1500002

MOISTURE DENSITY GAUGE IN TRUNK OF STOLEN CAR

The licensee reported that a technician had a Troxler moisture/density gauge, Model #3430 (Serial #19531), locked in the trunk of his car. The technician's brother took the car for a "joy ride" and the car was reported to the Fairfield police as stolen. The brother was pulled over by the police roughly 1/2 hour later. The gauge was recovered undamaged and still locked in the trunk of the car. The licensee reported that they lost possession of the gauge for no more than 1/2 hour and that the brother probably did not intend to steal the gauge. The gauge contains 27mCi of Cesium 137 and 132 mCi of Americium 241. The Fairfield police, bomb squad, and the local FBI responded to the event.

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 - MEDICAL UNDERDOSE

The following report was received via e-mail:

"Memorial Sloan-Kettering Cancer Center reported that a pediatric male patient only received 64.38 MBq (1.74 mCi) of I-124 labeled monoclonal 8H9 on 1/16/2015, instead of the prescribed 120.25 MBq (3.25 mCi). The patient had been diagnosed with pontine glioma. The incident occurred because the infusion process along the gauze at the site of the catheter connector leaked. The leak was not obvious on visual inspection. The cause was determined to be a procedure problem. Corrective actions included generating a new procedure and improvements to radioactive material labeling and handling."

NMED: 150094

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.