Event Notification Report for August 30, 2019

AGREEMENT STATE - RADIOGRAPHY CAMERA SOURCE UNABLE TO RETRACT

The following was received from Kentucky Department of Health Radiation Branch (KY RHB) via email:

"KY RHB was notified by telephone on 9/3/19 that at approximately 1230 EDT on 8/30/19, while performing radiography in a pipe rack, radiographers were unable to retract a 38.7 Curie Ir-192 (AEA/QSA A424-9, Serial No. 82580G) source into the exposure device (QSA 880D Serial No. D11651) using the crank mechanism. During the retracting process the cover plate on the drive became loose, enabling the internal drive cable to depart the gear system in the handle of the drive cable mechanism.

"Since the issue with the drive cable could not be repaired, the incident became a retrieval situation, and the crew made appropriate notifications to the Radiation Safety Officer, manager and on-site contact. The crew established a new 2 mR boundary as required and confirmed that the area was secure. The drive cable was removed from the handle, and the source was manually retracted into the exposure device. The source was secured in the exposure device at 1435 EDT. During the 2-hours while the source was exposed, there were no overexposures to the public.

"The radiographer and assistant received exposures of 80 mR and 130 mR respectively and the manager received an exposure of 5 mR. It was determined that the root cause of the incident was that the crew did not properly inspect the equipment before commencing non-destructive testing activities. It was discovered that the drive cable handle was missing four of the six screws that secure the cover plate on. This caused the drive cable to slip off the gear and partially lift the cover plate. The drive cables were immediately taken out of service and replaced with properly functioning equipment."

Event Report ID No.: KY190009

AGREEMENT STATE REPORT - MOBILE LEAD SHIELD SHIPPED WITH SOURCE INSIDE

The following report was received from the Maryland Department of the Environment (MDE) Radiological Health Program (RHP) via email:

"On August 30, 2019, at 13:10 [EDT], the MDE-RHP was contacted by telephone by medical licensee, MedStar Franklin Square Medical Center nuclear medicine department (MD-05-032-01).

"An order had been placed by the medical center's Biomedical Department through eBay for a mobile lead shield for a Co-57 flood reference source. Upon receipt of the mobile shield, a Co-57 flood source was discovered inside. Only the mobile shield was ordered. The flood source was identified as an Eckert & Ziegler Feather Lite model MED3709 (S/N 159-062), 10 mCi as of June 1, 2011. The current activity was calculated to be 4.61 microCuries at time of receipt. The medical center's Radiation Safety Officer was notified. The sealed source was leak tested and evaluated using a Capintec Captus 3000 well counter with an efficiency of 37 percent. The leak test result was less than 0.005 microCuries.

"Eckert & Ziegler was contacted on August 30, 2019. The flood source was sold to Lower Oconne Community Hospital. The Co-57 flood source was originally shipped on April 20, 2011. The community hospital closed on February 14, 2014. The Georgia Radioactive Materials Program was contacted on August 30, 2019 at 1300 [EDT] with preliminary information concerning this sealed source. Georgia radioactive materials license No. 1389 for the community hospital was terminated June 2016.

"MDE-RHP will further investigate this incident. Eckert & Ziegler will provide a Return Kit for disposal. The source is currently secured in a waste storage room at MedStar Franklin Square Medical Center."

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 - MISSING PORTABLE GAUGE

The following is a summary of information received from the Department of Environmental Quality (DEQ) via email:

At about 0910 [CDT] on 8/30/19, DEQ received a call from W2 Engineering, Oklahoma license OK-32142-01. W2 Engineering holds an Oklahoma license for portable gauges and is based in Oklahoma City. [W2 Engineering] reported that it had lost contact with one of the technicians who had been driving one of the company's vehicles with a Humboldt portable gauge (s/n 8700) in it. The last known location for [the technician] (and presumably the gauge) was at 0856 [CDT] Thursday when [the technician] made a purchase at Perry, Oklahoma. [The technician] had not made contact since then, nor had [the individual] responded to numerous messages and efforts to contact. [W2 Engineering] now considers the gauge out of the licensee's control. [W2 Engineering] has advised the [Oklahoma Highway Police], and they say the vehicle is not known to be in any of their impound yards. [W2 Engineering] has filed a report with Oklahoma City police, and a police officer is on site taking the report now.

This report is based on an initial phone notification, and more information will be added when it becomes available.


* * * UPDATE FROM MIKE BRODERICK TO DONALD NORWOOD AT 1717 EDT ON 9/1/2019 * * *

The following information was received via E-mail:

"The gauge missing from W2 engineering has been recovered along with the vehicle in Blackwell, Oklahoma. More details will be provided as they become available."

Notified R4DO (Drake) and the NMSS Events Notification E-mail group.

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 - LOST TRITIUM EXIT SIGNS

The following information is a synopsis of an email received from the state of Colorado:

The licensee has reported that they are unable to locate three tritium exit signs. Each exit sign has an activity of 10 Ci. The current service manager states that it is possible the previous owner may have taken the signs.

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