Event Notification Report for September 04, 2024

AGREEMENT STATE - DAMAGED RADIOGRAPHY EQUIPMENT

The following information was provided by the Texas Department of State Health Service (the Department) via email:

"On August 27, 2024, the Department was notified by the licensee that one of its crews was working at a job site with a QSA 880D exposure device containing a 48 curie Iridium - 192 source. The crew was working in a shooting bay surrounded by concrete walls. While performing an exposure, the camera fell 18 inches from the pipe it was on, onto the guide tube, crimping the tube and preventing the crew from retracting the source into the camera. The radiographers drove the source back into the collimator and isolated the area. The radiographers contacted the radiation safety officer (RSO). The site RSO (SRSO) responded to the location. The SRSO added additional shielding to the collimator. The crimped section of the guide tube was removed, and the source was successfully retracted to the fully shielded position. The event was resolved in less than 2 hours. No individual received an exposure that exceeded any limit."

Device Type: QSA
Model Number: 880D
Activity: 48 Ci of Ir-192
Texas Incident Number: 10122
Texas NMED # TX24024

AGREEMENT STATE - MEDICAL UNDERDOSE

The following is a summary of information provided by the Georgia Radioactive Materials Program (the Program) via email:

The radiation safety officer (RSO) at Piedmont Athens Regional Medical Center notified the Program on August 26, 2024, that an incident occurred with Y-90 underdose. The catheter line became kinked during the procedure and the dose given was more than 20 percent below the planned dose.

The RSO will send an official written report to the Program within 15 days.

Georgia Incident Number: 86

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.

EN Revision Imported Date: 9/4/2024

EN Revision Text: AGREEMENT STATE - MOISTURE DENSITY GAUGE SOURCE ROD STUCK OPEN

The Illinois Emergency Management Agency (the Agency) provided the following information via phone and email:

"Weaver Consultants Group North Centra, LLC (the licensee) notified the Agency of a source rod stuck open on a Troxler 3440 portable density gauge (8 mCi Cs-137, 40 mCi Am-241/Be). The licensee confirmed that the incident took place on August 27, 2024. The source rod was stuck out 3 inches. The [licensee's] consultant came to the jobsite to pick up the gauge for repair the same day. The consultant confirmed that they were able to retract the rod once back at their facility. The gauge is pending repair.

"Agency staff will be on-site August 28, 2024, to perform a reactionary inspection. Updates will be provided as they become available."

Illinois Item Number: IL240019

* * * UPDATE ON 09/03/2024 AT 1524 EDT FROM GARY FORSEE TO ROBERT THOMPSON * * *

The following is a summary of information provided by the Illinois Emergency Management Agency (the Agency) via email:

Agency staff conducted a reactive inspection at the site where the gauge failed to function as designed on August 28, 2024. Gauge use was observed and the gauge user was interviewed. It is believed the compacted clay hardened and prohibited retraction of the source rod. Inspection and repair by the licensed consultant evidenced no damage or obvious defects. Notification was timely and a proper written report was received. No occupational or public exposures are anticipated from this incident. Barring any further developments, this matter is considered closed.

Notified R3DO (Hills) and NMSS (email).

AGREEMENT STATE - STUCK OPEN SHUTTERS

The following information was provided by the Texas Department of State Health Services (the Department) via email:

"On August 28, 2024, the Department was notified by the licensee that during a record review, it was discovered that on November 22, 2023, during routine testing, two gauge shutters had failed in the open position and were not reported to the Department. The gauges were both Vega [model] SHLG-1 gauges. One gauge contained a 1 millicurie Cs-137 source and the other a 500 millicurie Cs-137 source. Open is the normal operating position for the gauges. The licensee reported that there is no additional risk of radiation exposure to members of the general public or the licensee's workers. Additional information will be provided as it is received in accordance with SA-300"

Texas Incident Number: 10124
Texas NMED Number: TX240025