ENS 45176
ENS Event | |
|---|---|
15:30 Jun 30, 2009 | |
| Title | Agreement State Report - Potential Worker Overexposure |
| Event Description | The following information was received via facsimile:
A worker was working in a hot cell when a F-18 [radio-isotope] was mistakenly delivered to the hot cell. [The] initial estimated worker dose [was] 100 Rad extremity dose and 20 Rad to the whole body (upper arm). The dosimeter has been sent to Landauer for immediate processing. [The] worker has been taken off Rad work and is being monitored" A Commonwealth of Massachusetts investigation is pending.
The following report was received via e-mail: On 6/30/09, 1.6 Curies of Fluorine-18 was mistakenly delivered to a shielded vial within the cyclotron facility hot cell while a worker was performing routine maintenance within the hot cell. Delivery was intended for a different hot cell. The total worker exposure time was less than 3 minutes. The worker was removed from radiation work and dosimeters were sent out for immediate processing. Same day notification was made from the licensee to the Agency [Massachusetts Radiation Control Program]. The licensee submitted an independent consultant written report, dated 7/8/09, to the Agency [Massachusetts Radiation Control Program] on 7/27/09. The worker's effective dose equivalent was conservatively determined to be not more than 0.170 Rem, the maximum extremity not more than 26.9 Rem, and the eye dose equivalent not more than 1.2 Rem. These dose values were assigned to the worker. The worker was returned to radiation work with cumulative dose closely monitored. Licensee's formal descriptions of cause, contributing and precipitating factors, and corrective actions are pending. The Agency [Massachusetts Radiation Control Program] considers this situation to still be OPEN. Notified the R1DO (Cook) and FSME (McIntosh).
The following update was received via e-mail: 9/16/09 Update: A subsequent on-site Agency inspection was performed. On 8/27/09, the licensee submitted report of cause, contributing and precipitating factors, and corrective actions. Cause: Pre-event re-configuration of transport tubing during an earlier calibration effort was not returned to original configuration and operators were not aware of the routing change. Precipitating and Contributing Factors: Licensee procedures related to use of personnel dosimeters, functioning survey instruments, and hot cell door closure, were not followed. Corrective Actions: Licensee to implement procedural changes and retraining of staff. The Agency considers this situation to be closed. Notified the R1DO (Jackson) and FSME (McIntosh). |
| Where | |
|---|---|
| Brigham And Women'S Hospital Boston, Massachusetts (NRC Region 1) | |
| License number: | 44-0004 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1.95 h0.0813 days <br />0.0116 weeks <br />0.00267 months <br />) | |
| Opened: | Tony Carpenito 17:27 Jun 30, 2009 |
| NRC Officer: | Vince Klco |
| Last Updated: | Sep 17, 2009 |
| 45176 - NRC Website | |
Brigham And Women'S Hospital with Agreement State | |
WEEKMONTHYEARENS 470382011-05-01T04:00:0001 May 2011 04:00:00
[Table view]Agreement State Agreement State Report- Underexposure ENS 461162010-06-03T04:00:0003 June 2010 04:00:00 Agreement State Agreement State Report - Potentially Lost Radioactive Material ENS 451762009-06-30T15:30:00030 June 2009 15:30:00 Agreement State Agreement State Report - Potential Worker Overexposure 2011-05-01T04:00:00 | |