ENS 43553
ENS Event | |
|---|---|
20:20 Aug 3, 2007 | |
| Title | Missing Source During Inventory |
| Event Description | Licensee conducted radioactive source inventory on 08/03/07 at 1620 and discovered one Am-241 sealed source containing 50 microcuries was not in its assigned storage location. It's normal storage location is in a storage locker inside of a square enclosure built of shielding bricks. On 08/07/07 the source was located in the storage locker behind its normal storage location. Facility procedures will be modified to prevent reoccurrence.
The following information was provided by the licensee via fax: (i) Description of source: Americium-241 source (AM-241-587), 50 microcuries on October 1, 1995, manufactured by Isotope Products Laboratories, model number: PHR-241-50U, A2 capsule. (ii) A description of the circumstances under which the loss or theft occurred: On August 3,2007 (Friday), the Radiation Protection Office (RPO) staff conducted a quarterly radiation source inventory in Building 2, room W102A's storage locker. During the inventory, radioactive source Am-241-587, a 50 microcurie source, was not readily visible in the locker. The RPO staff noted that the source sign out sheet had not been filled out showing that the source had been moved out of the room. The RPO staff contacted the Authorized User and told him that they were not able to locate the source in the locker and told him that he needs to check with anyone that may have been using the source to see if they know of its whereabouts. The RPO staff notified the RSO (who was out of the office) by email at 4:17 p.m. that the source had not been located during the inventory. On August 6, 2007 (Monday), the RSO, upon reading the email sent by the RPO staff, reviewed the requirements of 10 CFR 20.2201 and misinterpreted the value listed in Appendix C and followed the notification requirements listed in 10 CFR 20.2201(ii), which allowed for 30 day notification. The RSO went to room W102A and reviewed the status of the locker. It was noted that all the sources were now being maintained on the bottom of the locker behind lead bricks. On April 17, the last time the inventory was completed by the RPO, the sources were stored on different shelves to help segregate the authorized user's sources from each other. After looking inside the locker and throughout room W102A and W102 the source was not sighted. On the morning of August 7, the RSO instructed the RPO staff to go back and search the locker and remove all of the leads bricks surrounding the sources to ensure that the source in question was not there. At around 8:30 am, upon removing all of the bricks it was found that radioactive source Am-241-587 had gotten pushed up against the back of the locker behind the lead bricks. This apparently had taken place when the sources had been moved to the bottom shelf behind the lead bricks by the researchers. On the morning of August 8, the RSO, while writing the report for this event, noticed that he misread the Appendix C value for Americium-241 and an immediate notification to the NRC based on 10 CFR 2201(a)(i) was required. The RSO then made an immediate notification to the NRC Operations Center at 9:49 a.m. (iii) A statement of disposition, or probable disposition, of the licensed material involved; Radioactive source Am-241-587 had been in the locker throughout this whole process and never was missing, but had been improperly stored by the authorized users when they reconfigured the way the sources are stored in the radiation locker. (iv) Exposures of individuals to radiation, circumstances under which the exposures occurred, and the possible total effective dose equivalent to persons in unrestricted areas; Room W102A is a restricted area and since the source had been in a shielded configuration throughout this whole event, no individuals received any exposure in unrestricted areas. (v) Actions that have been taken, or will be taken, to recover the material; The source was found inside the authorized locker behind bricks that had been set up by the researchers. (vi) Procedures or measures that have been, or will be, adopted to ensure against a recurrence of the loss or theft of licensed material: - A Radiation Safety Officer Notice will be sent to all users of radioactive sources to inform them of this event and explain the importance of notifying the RPO of any changes to the way in which radioactive sources are being stored in their areas. -Modifications will be made to the current Standard Operating Procedures (SOP) used by the RPO staff for performing quarterly source inventories, which will expand the Notifications section to ensure that staff members get in direct contact with the RSO when a source on the inventory is not located. - Appropriate staff will be trained on all modification to the procedures. Notified R1DO (Summers) and FSME EO (McConnell). 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| Where | |
|---|---|
| Nasa Goddard Space Flight Center Greenbelt, Maryland (NRC Region 1) | |
| License number: | 19-05748-02 |
| Organization: | Nasa Goddard Space Flight Center |
| Reporting | |
| 10 CFR 20.2201(a)(1)(i) | |
| Time - Person (Reporting Time:+109.48 h4.562 days <br />0.652 weeks <br />0.15 months <br />) | |
| Opened: | Dan Simpson 09:49 Aug 8, 2007 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Aug 8, 2007 |
| 43553 - NRC Website | |
Nasa Goddard Space Flight Center with 10 CFR 20.2201(a)(1)(i) | |
WEEKMONTHYEARENS 435532007-08-03T20:20:0003 August 2007 20:20:00
[Table view]10 CFR 20.2201(a)(1)(i) Missing Source During Inventory 2007-08-03T20:20:00 | |