ENS 42876
ENS Event | |
|---|---|
13:30 Oct 4, 2006 | |
| Title | Washington Agreement State Report - Two Damaged Shipping Packages Containing Cesium-131 Cancer Therapy Seeds. |
| Event Description | Event sent to NRC Headquarters Operation Center via e-mail.
ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention): At 6:30 am, 4 October, the Spokane FedEx Terminal Manager discovered a flattened lead cap. A partial label on the cap indicated it came from one of two packages containing IsoRay, Cesium 131, therapy seeds. A second package was found crushed but essentially intact; the seeds in this package were all present and apparently undamaged. Scraps from the first box were found on the runway and other pieces on the floor of a tug (airport vehicle used to move cargo). It is thought the damage was caused when the boxes were caught between moving pieces of the cargo loading equipment. The actual incident appears to have happened 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> earlier (about 6 pm, 3 October). Dayshift FedEx staff had apparently placed the damaged packages on the floor on the passenger side of the tug cab. Four WA Department of Health, Health Physicists responded to the scene at about 8:00 am, 4 October. IsoRay also dispatched a team of three HP technicians arriving at noon with equipment including a decontamination kit. WA Department of Health staff were able to retrieved three of the sixty-three seeds that were in the one shredded package. Several areas of contamination were also found. Measurement on the floor of the tug's passenger side was reading 150 Mr/hour with an Eberline RO2 ion chamber. Radiation measurements on the crushed pig lid were about 25 Mr/hour with an RO2 and a contamination measurement of about 400 cpm with a GM instrument. Contamination reading on the crushed box was about 300 cpm with the GM instrument. A spot on the tarmac was found reading about 12 Mr/hour with an RO2. The undamaged stainless steel pig reads about 5 Mr/hour with an RO2. Night shift personnel were asked to return to the facility. No personnel contamination had been found at the writing of this report. WA Dept of Health and IsoRay staff continue to look for the remainder of the packaging and seeds. No news media attention yet. Notification Reporting Criteria: 10 CFR 30.50(b)(1) Isotope and Activity involved: 330 mCi, 12.2 Gigabecqerals of Cesium 131. Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): Exposures to be determined. Lost, Stolen or Damaged? (mfg., model, serial number): 3 of 63 missing seeds recovered, contamination found in tug, packaging and on the runway. The remainder of the activity is still being sought. Sealed Source and Device Registry: WA-1220-S-101-S Disposition/recovery: WA Dept of Health and the manufacturer staff are still on the scene to assist in recovery of seeds. Leak test? The seeds are leak tested prior to packaging and were within limits. Vehicle: (description; placards; Shipper; package type; Pkg. ID number) Airport tug, N/N FedEx air bill # 730 235 322 954. Release of activity? Three seeds found in the tug. Contamination found in the tug, on packaging and on the runway. Activity and pharmaceutical compound intended: N/A Misadministered activity and/or compound received: N/A Device (HDR, etc.) Mfg., Model; computer program: N/A Exposure (intended/actual); consequences: N/A Was patient or responsible relative notified? N/A Was written report provided? Not yet Was referring physician notified? N/A Consultant used? No." Washington Incident Report - WA-06-053
The State provided the following update in the text of their original report via email: This is notification of an event in Washington State as reported to and investigated by the WA Department of Health, Office of Radiation Protection. STATUS: update / close Licensee: IsoRay, City and State: Facility in Richland, Washington License Number: WN-L0213-1 Type of License: Manufacturer and Distributor (of cancer therapy seeds) Date of Event: 3 October 2006 (reported 4 October 06). Location of Event: Spokane International Airport, FedEx Terminal, Spokane Washington. ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, Dept. of Health (DOH) on-site investigation; media attention): At 6:30 am, 4 October, the Spokane FedEx Terminal Manager discovered a flattened lead cap in the plane loading area. A partial label on the cap indicated it came from one of two packages containing IsoRay, Cesium 131, cancer therapy seeds. A second package was found crushed but essentially intact; the seeds in this package were all present and found to be undamaged. Scraps from the first box were found on the runway and other pieces on the passenger side floor of a 'tug' (airport vehicle used to move cargo containers). It is thought the damage was caused when the boxes were caught between moving pieces of the cargo loading equipment. The actual incident appears to have happened 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> earlier (about 6 pm, 3 October 06). Dayshift FedEx staff had apparently placed the damaged packages on the floor on the passenger side of the 'tug' cab but this was unable to be verified. Four WA Department of Health, Health Physicists responded to the scene at about 8:00 am, 4 October. IsoRay also dispatched a team of three HP technicians arriving at noon with equipment including a decontamination kit. WA Department of Health staff returned Thursday, Friday and Monday to continue the investigation. WA DOH was not able to find any additional material except that found October 4. These finds amounted to three seeds and a minor amount of contamination in the tug and on the loading surface. WA DOH spent 16 FTE days looking for the material and interviewing FedEx staff. Night shift personnel were asked to return to the facility. No personnel contamination was found. All parts of the complex within the FedEx secured area (buildings and property) and public areas adjacent to the FedEx secured property were searched. IsoRay personnel decontaminated the tug and loading surface. Took control of the three recovered seeds found in the tug and took all of the damaged packaging including the second package (damaged but intact) and its contents. Measurement on the floor of the 'tug's' passenger side was reading 150 mR/hour with an Eberline RO2 ion chamber. Radiation measurements on the crushed pig lid were about 25 mR/hour with an RO2 and a contamination measurement of about 400 cpm with a GM instrument. Contamination reading on the crushed box was about 300 cpm with the GM instrument. A spot on the tarmac was found reading about 12 mR/hour with an RO2. The outside of the undamaged stainless steel pig measurers about 5 mR/hour with an RO2. Some product is transported in a lead container and some in stainless steel. The missing material was in lead; the material in the damaged second package was in stainless steel. WA Dept of Health and IsoRay staff were on site for a total of 4 days. WA DOH spent approximately 16 FTE days looking for the remainder of the packaging and material. Nothing additional was able to be located. There was a local television media news story. Notification Reporting Criteria: 10 CFR 30.50(b)(1) Isotope and Activity involved: 330 mCi, 12.2 Gigabecqerals of Cesium 131. Cesium 131 has about a 9.2 day half-life. Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): The investigation indicates it unlikely that personnel received any significant radiation exposure. However, this could not be substantiated since facility individuals were not forthcoming with information that could be used to make an exposure determination. Lost, Stolen or Damaged? (mfg., model, serial number): 3 of 63 missing seeds recovered, contamination found in tug, packaging and on the runway. The remainder of the material was not able to be located. Sealed Source and Device Registry: WA-1220-S-101-S Disposition/recovery: WA DOH has indicated to FedEx management that hazardous materials transportation handling procedures should be revised and staff refresher training should be performed. Leak test? The seeds are leak tested prior to packaging and were within limits. Seeds from the damaged second package were found to be undamaged. Vehicle: (description; placards; Shipper; package type; Pkg. ID number) Airport tug, N/N FedEx air bill # 730 235 322 954. Release of activity? Three seeds found in the tug. Contamination found in the tug, on packaging and on the loading runway. Activity and pharmaceutical compound intended: N/A Misadministered activity and/or compound received: N/A Device (HDR, etc.) Mfg., Model; computer program: N/A Exposure (intended/actual); consequences: N/A Was patient or responsible relative notified? N/A 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. |
| Where | |
|---|---|
| Isoray Richland, Washington (NRC Region 4) | |
| License number: | WN-L0213-1 |
| Organization: | Wa Division Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+7.53 h0.314 days <br />0.0448 weeks <br />0.0103 months <br />) | |
| Opened: | Arden C. Scroggs 21:02 Oct 4, 2006 |
| NRC Officer: | John Mackinnon |
| Last Updated: | Oct 26, 2006 |
| 42876 - NRC Website | |
Isoray with Agreement State | |
WEEKMONTHYEARENS 520092016-06-14T07:00:00014 June 2016 07:00:00
[Table view]Agreement State Agreement State Report - Lost and Found Brachytherapy Seeds ENS 517092016-02-04T08:00:0004 February 2016 08:00:00 Agreement State Agreement State - Lost Shipment of Cs-131 Brachytherapy Seeds ENS 448892009-02-19T08:00:00019 February 2009 08:00:00 Agreement State Improperly Packaged Radioactive Material ENS 439552008-02-01T08:00:0001 February 2008 08:00:00 Agreement State Agreement State Report - Depleted Cesium-131 Seeds Lost from Damaged Package During Shipment ENS 428762006-10-04T13:30:0004 October 2006 13:30:00 Agreement State Washington Agreement State Report - Two Damaged Shipping Packages Containing Cesium-131 Cancer Therapy Seeds. 2016-06-14T07:00:00 | |