ENS 51799

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v t e ENS Event
05:00 Mar 15, 2016
Title	Agreement State Report - Radioactive Source Shipment in Excess of Licensed Quantity
Event Description	The following was received from Louisiana via email: On 03/16/2016, the RSO for A&O [Alpha Omega] called in a report of a HDR [high does rate brachytherapy] source being shipped to Texas Oncology PA (TOP) in excess of licensed quantities. The source was 12.8 Ci Ir-192 source intended as a replacement source for the Texas Oncology PA Center 3550 Northeast Loop 285, Paris, TX 75460. License # L04664, Amendment #28, Expiration date: February 28, 2025. [The RSO] was enroute to the facility to return the 12.8 Ci Ir-192 source and replace it with an additional 11.2 Ci Ir-192 source. He stated that the 12.8 Ci source was being retrieved and placed in a storage pig/container by the Service Engineer until it could be packaged and returned by common carrier to A&O 03/16/2016. Their intent was to install the 11.2 Ci source so the TOP facility could receive the source and resume patient care. A&O is a source supplier for Elekta HDR units. Elekta notifies A&O when sources should be shipped/supplied their licensees. The error was the wrong source was inadvertently shipped to TOP. The source received by TOP exceeded the licensed activity limit. The sources were Elekta Model 105.002s. The source S/N16-0505 12.8 Ci of Ir-192 was shipped when the source S/N 16-0504 11.8 Ci of Ir-192 should have been shipped. When TOP received the 12.8 Ci source, they knew it was too 'HOT' to treat patients. They called A&O at [1700 EDT] on 03/15/2016 to report the error. The incorrect source, 12.8 Ci of Ir-192 was returned to A&O by common carrier A&O explained that the mix-up was caused by reference numbers that were switched after the sources were calibrated. Louisiana incident # LA-160005

ENS 51799 +/-
Where
Alpha-Omega Services, Inc. Vinton, Louisiana (NRC Region 4)
License number:	LA-10025-L01
Organization:	Louisiana Radiation Protection Div
Reporting

Agreement State
Time - Person (Reporting Time:+60.47 h2.52 days <br />0.36 weeks <br />0.0828 months <br />)
Opened:	Joe Noble 17:28 Mar 17, 2016
NRC Officer:	Daniel Mills
Last Updated:	Mar 17, 2016
51799 - NRC Website
v • d • e

v t e Emergency Notification System
Alpha-Omega Services, Inc. with Agreement State
WEEKMONTHYEAR2023-03-30T05:00:00 [Table view]
[ENS list for Alpha-Omega Services, Inc.]

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