Event Notification Report for June 01, 2000

I-131 OVERDOSE - MEDICAL MISADMINISTRATION/AGREEMENT STATE EVENT -

A female patient at Allen County Hospital, Iola, KS, was given 100 microcuries of I-131 for an thyroid uptake measurement during a diagnostic study instead of the prescribed 50 microcuries. The cause of this medical misadministration event was due to the hospital hot lab delivering two capsules of 50 microcuries each; one to be given to the patient and the other to be used as a standard. The patient was mistakenly given both capsules. This overdose poses no adverse medical effects to the patient. The patient's doctor has been informed. The doctor plans to inform the patient. The hospital is determining corrective actions.
(KS Case #KS-00-0011).

SOURCE ASSEMBLY, CONTAINING 24 CURIES OF IRIDIUM-192, BECAME DETACHED FROM ITS DRIVE ASSEMBLY

While checking a radiographic exposure device manufactured by AEA Technology, the source assembly became detached from its drive mechanism. The licensee was checking the swage end, the locking mechanism, of the exposure assemble when the assembly failed. The swage connection had a crack and this caused the swage connection to fail, becoming detached. The Assistant Radiation Safety Officer (ARSO) cleared the room and made several trips into the room to place lead shielding over the source assembly. After the source assembly was covered with lead, the ARSO took radiation surveys around the room to make sure radiation levels were within acceptable limits. The ARSO spent the night guarding the entrance to the room to prevent anyone from entering. AEA Technology was notified of this event on 06/01/00 and they are sending a retrieval team out on 06/02/00 to retrieve the source. The source model number is 424-9.

The ARSO was the only one to be exposed and he received 78 millirems as indicated by his pocket dosimeter.

The source, Iridium-192, was originally manufactured on 12/17/99 with a strength of 114.5 curies. The present strength of the Iridium-192 source is 24 curies (half life of Iridium-192 is 74.2 days).

Tri State Consultants' main office is located in Pittsburgh, PA.

SHUTTER ON SCANNER DISABLED ON CONVEYOR LINE

A small piece of lead fell off the inside of a shield for a sealed beam source which prohibited the full closure of the shutter on the source. There was no exposure to personnel and repairs will be made by Philip Morris. This was discovered on 6/1/00 during a normal inventory of sources. It wasn't known to be reportable until today. The scanner is used to monitor cartons for missing packs of cigarettes. It is manufactured by Industrial Dynamics, model FT14, with two 100 mCi Am-241 sources.

The company also notified NRC Region 2 (Orysia Bailey)

AGREEMENT STATE REPORT OF RADIOGRAPHER OVEREXPOSURE FROM TWO YEARS AGO

"On April 29, 2002, the department completed its investigation into a reported radiography incident that may have occurred in June 2000. After a review of all available information, the department cannot definitively eliminate the possibility that an industrial radiographer received a radiation burn while performing industrial radiography at a temporary jobsite near Channahon, Illinois. The radiographer was using an 81.2 Ci lr-192 source while performing radiographs on 8-inch pipe welds. The radiographer alleges that after cranking the source back in, he approached the area without looking at his survey meter. He set the meter behind the camera and knelt down in front of the camera, He changed out the film and then changed out the band and numbers for the next shot. He then disconnected the guide tube and saw 4-6 inches of the drive cable. He looked over at the survey meter and saw that it was pegged. He then immediately went to the controls and cranked the source fully into the camera. He performed a survey of the area and saw that the source was shielded properly. He looked at his alarming rate meter and saw that the battery indicator showed low battery. His self-reading pocket dosimeter showed off-scale. What happened after that is even more unclear but the radiographer continued working for the rest of the day. The radiographer did not report the incident to the RSO nor did the other radiographer on the two certified radiographer team. In fact, the other radiographer denies knowing anything about the reported incident. The allegedly overexposed radiographer states that after one or two weeks, he noticed a red area, about the size of a nickel, on his leg. He stated that it was a red area with what appeared to be white scar tissue in the center. It was not until May or June of 2001 that he realized that it may have been a radiation burn. During August or September 2001 his condition apparently worsened and the area would not heal. In early January 2002 the Radiation Safety Officer finally became aware of this matter, and notified the department on January 15, 2002. In early January 2002 the radiographer was apparently examined by a physician. The radiographer stated that the physician took a biopsy and the diagnosis was either sarcoma or radiodermatitis. A preliminary report was provided to the department by the licensee on January 16, 2002. The department recommended the licensee seek assistance from the REAC/TS Center in Oak Ridge, which they did. The information pertaining to this incident was provided to REAC/TS by the licensee and REAC/TS concluded that the medical condition could be attributed to the event in June 2000. After thoroughly reviewing all the information available and scheduling interviews for involved out of state personnel, the department conducted interviews and time in motion studies on February 25, 2002. Subsequent to the interviews and time in motion studies, careful review was performed as well as additional clarifying information was requested and reviewed. Finally on April 29, 2002, the department concluded that it could not definitively eliminate the possibility that this industrial radiographer received a radiation burn while performing industrial radiography at a temporary job site near Channahon, Illinois in June 2000. The radiographer underwent skin grafting on February 26, 2002, and was released after several days. The radiographer currently remains under medical surveillance and reports that the graft was less than successful. The licensee has been issued a Notice of Violation and will take appropriate actions to prevent a recurrence. The radiographer may be subject to additional department enforcement action related to his industrial radiographer certification resulting from this event."