ENS 44261
ENS Event | |
|---|---|
16:30 Jun 3, 2008 | |
| Title | |
| Event Description | The following information was received from the State of California Radiologic Health Branch [RHB] via email:
On Tuesday, June 3, 2008, RHB was notified by NRC Region IV of an incident involving a California licensee. A package had been shipped by the California licensee to an Illinois licensee. The package should have contained 23 iodine-125 seeds used for brachytherapy, with activities of approximately 0.425 millicuries each. Upon receipt, the outer package was undamaged, but was reading 460 millirem/hour on contact. When the package was opened, the inner shielded container was open and some of the seeds were out of the shielded container, and at the bottom of the shipping container. The IL licensee could only account for 19 of the 23 seeds. They notified the IL radiation control program, and contacted [the carrier]. The IL licensee has surveyed the delivery truck, and the loading dock. They are in the process of surveying the [carrier's] terminal at Chicago's O'Hare airport. The California licensee that made the shipment is a small surgical center. Based on the information from IL, the package was not prepared for shipment in accordance with the instructions provided by the IL licensee, and vibrations during the shipment appear to have caused the shielded container to open during the shipment, releasing some of the seeds. RHB will be investigating the root cause of this incident and corrective actions with the California licensee. CA Incident Number 5010-060308
As of 1:02 pm PDT, we [RHB] received notification from the IL radiation control program that their licensee found the four missing I-125 seeds at the licensed facility in IL, among other packages received that morning. All seeds are now accounted for. California will continue to investigate the root cause of this incident. Notified R4DO (Whitten) and FSME EO (Chang). 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 | |
|---|---|
| Cypress Surgery Center Visalia, California (NRC Region 4) | |
| License number: | 7342-54 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-2.8 h-0.117 days <br />-0.0167 weeks <br />-0.00384 months <br />) | |
| Opened: | Barbara Hamrick 13:42 Jun 3, 2008 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Jun 3, 2008 |
| 44261 - NRC Website | |
Cypress Surgery Center with Agreement State | |
WEEKMONTHYEARENS 442612008-06-03T16:30:0003 June 2008 16:30:00
[Table view]Agreement State California Agreement State Report - Lost I-125 Brachytherapy Seeds 2008-06-03T16:30:00 | |