ENS 44882
ENS Event | |
|---|---|
05:00 Feb 4, 2009 | |
| Title | Lost Nickel-63 Source |
| Event Description | Description of the material involved, including kind, quantity, and chemical and physical form: GE Vapor Tracer 2 detection system (SN 07024933861). Approx. 8 mCi Nickel-63 (#09-3896).
Description of the circumstances under which the loss occurred: On 29 Jan 09, during a routine semi-annual audit, the Andrews Air Force Base (AAFB) Radiation Safety Officer (RSO) identified the missing device used by the Aerial Port Squadron (APS). The device was used to screen luggage for explosives/narcotics. A review of records indicated the device was sent to the Defense Reutilization and Marketing Service (DRMS) through base supply by the user on 1 Jul 08. On 4 Feb 09, the RSO contacted the USAF Radioisotope Committee (RIC) to report the event. NOTE: The RSO is a member of the Bioenvironmental Engineering (BE) office. An investigation shows the APS (user) contacted the BE office on 24 Jan 08 and received instructions for disposing of the device via the DRMS. A technician from the BE office certified the device did not contain any hazardous material and would be suitable for turn-in to the DRMS. On 25 Jan 08, an officer from the BE office (not the RSO) sent a letter to the user affirming the technician's assessment. The technician and officer had no knowledge the device contained radioactive material (RAM). No RAM warning labels were visible on the exterior surface of the device. During the investigation of the loss of material, the RSO found the RAM warning label was located under the battery pack and not visible. Being unfamiliar with the device, the technician evaluated it for chemical hazards (and found none) but didn't consider radiological aspects. After review of all transfer/receipt and inventory documents over a span of three years, the RSO found no evidence that another event of this type had occurred at AAFB. This is an isolated event. Air Force Instruction 40-201, Managing Radioactive Material in the U.S. Air Force, expressly prohibits GLDs from being sent to the DRMS. A statement of disposition, or probable disposition, of the material involved: The investigation by the RSO revealed the device left AAFB and traveled to DRMS at FT Meade, MD and then to the DRMS at Mechanicsburg, PA. It was sold to a de-manufacturing contractor, Global Investment Recovery, where it was shredded for scrap. The scrap was sold through the DRMS scrap sales partner, Government Liquidation, LLC. It could not be tracked further. Exposures of individuals to radiation, circumstances under which the exposures occurred, and the possible total effective dose equivalent to persons in unrestricted areas: Nickel-63 is a pure beta emitter with a 100 year half life. The ingestion annual limit on intake (ALI) is 9 millicuries (mCi). Ingestion of the source would not exceed the ALI and the committed effective dose equivalent (CEDE) would be less than 5 rem. The (Class D) inhalation ALI is 2 mCi. Using the EPA's inhalation dose conversion factor of 3.1 millirem/microCuries, the CEDE for 8 mCi of Ni-63 (Class D) is 25 rem. The size of the source is approximately that of a pencil eraser. It is unlikely an industrial shredder could have pulverized it to such an extent so as to present an inhalation hazard. The possible total effective dose equivalent to persons in unrestricted areas is presumed to be less than 1% of the ALI. Actions that have been taken, or will be taken, to recover the material: The RSO tracked the device from AAFB (1 Jul 08) to the DRMS at Fort Meade, MD and to the DRMS at Mechanicsburg, PA (7 Aug 08). It was shredded by Global Investment Recovery, the DRMS de-manufacturing contractor and sold as scrap through the DRMS scrap sales partner, Government Liquidation, LLC. It could not be tracked further. Procedures or measures that have been, or will be, adopted to ensure against a recurrence of the loss of material: The RSO has determined the root cause of the event to be inadequate training. The users of the device and the BE office did not, collectively, possess information about GL material. The RSO had not shared his knowledge about the material with the BE office. The following corrective measures have been taken: Photographs of GLDs will be taken and provided to the BE staff, the users, base supply and DRMS. If warning labels are considered to be inadequate, new labels will be affixed to GLDs to alert individuals that RAM is present. The RSO, working with BE staff, has initiated awareness training for users of GLDs. Such will be conducted annually. Users will be required to possess binders in which to maintain information about their devices (e.g., safety data sheets, owner's manuals, policy, pictures, inventory, leak test results, contact numbers, etc.). The RSO has informed management of the event. Lessons learned will be passed down to targeted audiences. Andrews AFB instructions will be evaluated for gaps in policy and strengthened as necessary. The means for purchasing and transferring GLDs back to the manufacturer will be addressed in detail. The RIC Secretariat has contacted the GE Radiation Safety Officer regarding the placement of the radiation warning label. The RIC Secretariat informed Ms. Rachel Browder, NRC Region-IV, about the loss of a GLD on 10 Feb 09. 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 | |
|---|---|
| Usaf Andrews Afb, Maryland (NRC Region 1) | |
| License number: | 42-23539-01 |
| Organization: | Usaf |
| Reporting | |
| 10 CFR 20.2201(a)(1)(ii) | |
| Time - Person (Reporting Time:+559.87 h23.328 days <br />3.333 weeks <br />0.767 months <br />) | |
| Opened: | Lt Col Craig Adams 12:52 Feb 27, 2009 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Feb 27, 2009 |
| 44882 - NRC Website | |
Usaf with 10 CFR 20.2201(a)(1)(ii) | |
WEEKMONTHYEARENS 517832016-02-17T14:00:00017 February 2016 14:00:00
[Table view]10 CFR 20.2201(a)(1)(ii) Lost Am-241 Check Source ENS 448822009-02-04T05:00:0004 February 2009 05:00:00 10 CFR 20.2201(a)(1)(ii) Lost Nickel-63 Source 2016-02-17T14:00:00 | |