ENS 42255
ENS Event | |
|---|---|
06:00 Jan 5, 2006 | |
| Title | Leaking Sealed Source Due to Improperly Packaged Material |
| Event Description | The State provided the following information via email:
On January 11, 2005 the Division learned of an event involving a leaking sealed source that was intended for the therapeutic treatment of prostate cancer. On January 5, 2006, the Chicago Prostate Cancer Center (CPCC) in Westmont, IL (IL-02015-01) received four packages [which] contained sources that had been loaded into [an] applicator as well as 'loose seeds' for reference and potential application. One of the four packages contained 10 sealed sources of Cs-131 and 42 additional sources (actual activity of 3.8 milliCi, each) [were] pre-loaded into treatment applicators by Anazao Health of Tampa Florida via IsoRay, Inc of Richland Washington who manufactured the sources. Although the outer packaging was shown to be free from contamination, once the cardboard outer container was opened, and the secondary lead container was opened, a seed was visually detected on the outer lead container. The seed was also notably damaged. Associated contamination was subsequently found on the secondary container, and the primary lead container as well as a second 'seed' of Cs-131 that had been trapped and bent within the primary lead container. Although all the sources were accounted for, none of the 10 seeds were contained within the innermost glass vial as its lid was not engaged with the vial. Cs-131 is a very low energy gamma emitter (33 KeV) with a half life of 9.7 days. The form of Cs involved is bound to a non-volatile, insoluble material. The Division discovered that the CPCC had experienced widespread contamination within the source preparation area as a result of the damaged sources and the failure to don proper protective gloves. The affected surfaces and items had been subsequently decontaminated and set aside as waste by the staff that was present on January 5, 2005. Contamination levels ranged from 1,000 cpm to 5,000 cpm as measured by their Geiger counter and rate meter. Items which had been touched by the medical physicist who had not been wearing disposable gloves were found to be contaminated. One of the assisting staff members experienced contamination on their hand that was later completely decontaminated. A Division representative was dispatched from the West Chicago offices to the facility shortly after we were notified, to determine the effectiveness of the decontamination effort, the extent of contamination that may have remained and to interview the Radiation Safety Officer [redacted]. The inspector's initial investigation today showed that contamination was limited to the source handling room which is a restricted area and that indeed all the sources were accounted for and secured. She also obtained the verbal report from [the RSO]. The only remaining contamination she was able to find were two spots on a counter of approximately 1,000 cpm - 2,000 cpm and the containers which were involved. The inspector returned to the facility on the following day to interview the responsible physicist, and the assisting technician. Gamma spectroscopy performed on samples of the contaminated items indicate the presence of Cs-131 rather than any of the other nuclides used by the facility. The Division is continuing its investigation and is acquiring additional information from the licensee. The Division has been in contact with the State of Washington regarding this matter. A formal report is due from the licensee within the next 30 days. This event was reported to the U.S. NRC Operations Center on January 12 and assigned event number 42255. |
| Where | |
|---|---|
| Chicago Prostate Cancer Center Westmont, Illinois (NRC Region 3) | |
| License number: | IL-02015-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+179.53 h7.48 days <br />1.069 weeks <br />0.246 months <br />) | |
| Opened: | Daren Perrero 17:32 Jan 12, 2006 |
| NRC Officer: | Arlon Costa |
| Last Updated: | Jan 12, 2006 |
| 42255 - NRC Website | |
Chicago Prostate Cancer Center with Agreement State | |
WEEKMONTHYEARENS 422552006-01-05T06:00:0005 January 2006 06:00:00
[Table view]Agreement State Leaking Sealed Source Due to Improperly Packaged Material ENS 401692003-09-16T05:00:00016 September 2003 05:00:00 Agreement State Agreement State Report -- Missing Iodine-125 Seeds 2006-01-05T06:00:00 | |