ENS 41182
ENS Event | |
|---|---|
08:00 Nov 5, 2004 | |
| Title | Agreement State Report Due to Loss of Iodine-125 Calibration Seeds |
| Event Description | On Monday morning, 8 November 2004, the licensee reported a loss of 16 Iodine-125 calibration seeds, Amersham Model 6711, total of 193 mega Becquerel (5.216 milliCi), packaged in 2 vials. The vials contained 6 and 10 seeds respectively. Each vial was inside a lead shield.
The missing calibration seeds had been received on 5 November. They arrived in the same package as medical therapy seeds. The licensee's medical physicist removed the therapy seeds and placed them into secured storage assuming that the calibration and therapy seeds were all contained in the vials the physicist was removing. However, the calibration seeds were reported by the vendor to have been in additional vials associated with the foam packing material. The cardboard package and packing foam is routinely sent to the licensee's recycle center once the licensed material has been removed. This probably happened (including the calibration seeds) some time shortly after the physicist opened the package on 5 November. On 8 November, the medical physicist realized the calibration seeds were not with the therapy seeds. The physicist reported their loss to the licensee's Radiation Safety Officer. Licensee staff surveyed the receipt area, the recycle center as well as the corridors connecting the areas and other likely spots. The lost material has not been located. The waste material had apparently been removed from the facility on 7 November. It is likely the lost material went to the landfill on 7 November. The licensee is still investigating. The licensee will send the department a formal report when their investigation is complete. Contributing factor: The licensee failed to perform an acceptable package receipt survey. Corrective actions: Will be addressed during the department's investigation. No media contact: None yet. WA Event Report # WA-04-066 |
| Where | |
|---|---|
| University Of Washington Seattle, Washington (NRC Region 4) | |
| License number: | WN-C001-1 |
| Organization: | Wa Division Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+99.17 h4.132 days <br />0.59 weeks <br />0.136 months <br />) | |
| Opened: | Arden C. Scroggs 11:10 Nov 9, 2004 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Nov 9, 2004 |
| 41182 - NRC Website | |
University Of Washington with Agreement State | |
WEEKMONTHYEARENS 561932022-10-25T07:00:00025 October 2022 07:00:00
[Table view]Agreement State Leaking Sealed Source ENS 559442022-06-14T07:00:00014 June 2022 07:00:00 Agreement State Agreement State Report - Lost Then Found I-125 Seed ENS 556772021-12-23T08:00:00023 December 2021 08:00:00 Agreement State Underdosing of Patient with YTTRIUM-90 Microspheres ENS 551922021-04-09T07:00:0009 April 2021 07:00:00 Agreement State Patient Underdose ENS 540132019-04-15T07:00:00015 April 2019 07:00:00 Agreement State Agreement State Report - Leaking Intravascular Brachytherapy Device Identified ENS 518792016-04-20T07:00:00020 April 2016 07:00:00 Agreement State Agreement State Report - Missing Static Ionization Source ENS 518492016-03-31T07:00:00031 March 2016 07:00:00 Agreement State Agreement State - Package Containing 40 Millicuries of Ni-63 Reported Missing ENS 511762015-06-19T07:00:00019 June 2015 07:00:00 Agreement State Agreement State Report - Medical Under Dose ENS 495402013-11-12T08:00:00012 November 2013 08:00:00 Agreement State Agreement State Report - Radioactive Material Unaccounted for ENS 469312011-03-31T01:00:00031 March 2011 01:00:00 Agreement State Agreement State Report - Extremity Overexposure During Laboratory Work ENS 411822004-11-05T08:00:0005 November 2004 08:00:00 Agreement State Agreement State Report Due to Loss of Iodine-125 Calibration Seeds 2022-06-14T07:00:00 | |