ENS 43955
ENS Event | |
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08:00 Feb 1, 2008 | |
Title | Agreement State Report - Depleted Cesium-131 Seeds Lost from Damaged Package During Shipment |
Event Description | The State provided the following information via email:
The Licensee reported by phone that at 2:30 PST today a package of returned and depleted implant seeds containing Cs-131 with a 9.7 day half-life was found damaged upon receipt with some of the contents missing. The package was to have contained 15 seeds that were returned from a customer on the east coast. When the package arrived, the licensee upon receipt inspection noted the package had a hole in it that had been repaired with tape. The receipt inspection also detected higher than expected dose rates at slightly less than 1 mr/hr contact with the package. The package was taken to a controlled area suitable for bio-hazard work and opened by the RSO. The package was opened and discovered with loose seeds in the box. 11 seeds were recovered, 4 seeds are missing. An Isoray facility survey was performed between the receiving area and the controlled area where the package was opened. No additional seeds were located. The sender of the package is being contacted as well as the RSO for FedEx. Highest dose rate on contact with a single seed was 1 mr/hr. The seeds were reported to have aged seven half-lives as of this day and at 1/100th of original strength. The Licensee will update our office [the State of Washington] with additional information when it comes available. The State does not know who originated the shipment or the initial strength of the CS-131 before the seven half-life decay. Washington State Report Number: WA-08-007
The shipment originated from Geisenger Health in Danville, PA, and was shipped by FedEx. The original strength of the seeds was nominally 4 to 5 millicuries each, or 14 to 20 for the four missing seeds. At seven half-lives, the strength would be approximately 1/100th of the original strength, or 40 to 50 microcuries. R4DO (Mike Shannon), FSME EO (Larry Camper), ILTAB (Matt Hahn), and R1DO (Christopher Cahill) informed.
The receipt inspection detected higher than expected dose rates at ~1.7 mR/hr contact with the package. Detailed Carrier Information from with delivery route and timeframe. Jan 29, 2008: 4:15 PM - Picked up in Montoursville, PA. 7:51 PM - left Montoursville, PA. 11:46PM - Arrived FedEx location in Newark, NJ. Jan 30, 2008: 8:38 AM - Departed FedEx location in Newark, NJ. 10:41AM - Arrived FedEx location in Memphis, TN. 3:36 PM - Departed FedEx location in Memphis, TN. 6:35 PM - At sort facility in Spokane, WA. 8:49 PM - At local FedEx facility in Spokane, WA. Jan 31, 2008: 9:52 AM - On FedEx vehicle for delivery Pasco, WA. 11:46AM - Delivered. R4DO (Dale Powers), FSME EO (Michelle Burgess), ILTAB (Jim Whitney), and R1DO (Glenn Dentel) informed. 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 | |
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Isoray Richland, Washington (NRC Region 4) | |
License number: | WN-L0213-1 |
Organization: | Wa Division Of Radiation Protection |
Reporting | |
Agreement State | |
Time - Person (Reporting Time:+11.33 h0.472 days <br />0.0674 weeks <br />0.0155 months <br />) | |
Opened: | Arden Scroggs 19:20 Feb 1, 2008 |
NRC Officer: | Bill Huffman |
Last Updated: | Feb 11, 2008 |
43955 - 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 | |