ENS 43061
ENS Event | |
|---|---|
05:00 Dec 1, 2006 | |
| Title | Lost Vial Containing Phosphorus-32 |
| Event Description | This is a report of the loss of licensed material in accordance with 10CFR20.2201.
1. The licensed material consisted of a single packaged vial of Alpha-Adenosine Triphosphate (a-ATP) which contained 250 microcuries (9.25 MBq) of Phosphorus-32 (Half-life=14.3 days). The product is supplied by GE Healthcare, product number PT10160. The volume of the product was 25 microliters. 2. On December 1, 2006 a box containing three separate shielded vials of the product described in (1) above was delivered to a technician in the Clinical Research Center, 5th floor, Room 3288. Some time later, the Authorized User [AU] unpacked the box, but only retrieved two of the three product packages from the dry ice within the Styrofoam chest, because the third package was below the remaining dry ice. The AU then defaced the radioactive materials labels on the delivery box and placed the box containing the remaining vial for pickup as regular trash. The AU did not discover the error until December 4, 2006, too late to attempt retrieval from the regular trash dumpster. 3. The disposition of the material is to the regular trash stream through the Montgomery Country, MD refuse transfer station in Rockville, MD. 4. We have no reason to believe that this loss of licensed material resulted in exposure to anyone. The P-32 labeled ATP is in a very small volume of liquid, shielded by a sturdy Lucite plastic vial shield, encased in a sealed vinyl plastic outer containment. Furthermore, that assembly was in a thick-walled Styrofoam box within the cardboard delivery box. It is highly unlikely that, during the process of transport to, and through the transfer station that the P-32 would have leaked out of containment. 5. No action was taken to recover the material due the circumstances of loss and the time between loss and discovery of the loss. 6. No procedures have been modified as a result of this incident. The package insert clearly delineated to the AU that there were 750 microcuries of Alpha-ATP-32 in the shipment, in accordance with what the AU ordered, indicating that three items should have been retrieved from the dry ice. The loss was the result of human error. 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 | |
|---|---|
| National Institute Of Health Bethesda, Maryland (NRC Region 1) | |
| License number: | 19-00296-10 |
| Organization: | National Institute Of Health |
| Reporting | |
| 10 CFR 20.2201(a)(1)(ii) | |
| Time - Person (Reporting Time:+512.53 h21.355 days <br />3.051 weeks <br />0.702 months <br />) | |
| Opened: | Robert Zoon 13:32 Dec 22, 2006 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Dec 22, 2006 |
| 43061 - NRC Website | |
National Institute Of Health with 10 CFR 20.2201(a)(1)(ii) | |
WEEKMONTHYEARENS 430612006-12-01T05:00:0001 December 2006 05:00:00
[Table view]10 CFR 20.2201(a)(1)(ii) Lost Vial Containing Phosphorus-32 2006-12-01T05:00:00 | |