ENS Event | |
|---|---|
07:00 Jun 14, 2016 | |
| Title | Agreement State Report - Lost and Found Brachytherapy Seeds |
| Event Description | The following was received from the State of Washington via email:
[A common carrier] lost 252 IsoRay Cesium-131 brachytherapy seeds intended for four patient implants. On Friday, 6/9/2016, radioactive materials licensee, IsoRay (WN-L0213-1) sent four orders of cesium-131 brachytherapy seeds. The four orders contained a total of 252 seeds at a total air kerma activity level of 522.8 U. The total apparent activity is approximately 1 Ci (the actual activity is between 1 - 2 Ci). The absorbed dose from the 252 seeds would be approximately 52,280 rad (522.8 Gray). Early Tuesday morning, 6/14/2016, the Memphis hub of [the common carrier] informed IsoRay that they were unable to locate these packages, and they would not be delivered on time as contracted. They were scanned in and out at both the Pasco and Spokane airports. The Spokane flight to Memphis arrived, but [the common carrier] could not locate them. IsoRay notified the state of the loss of radioactive material that same day. On 6/15/2016, IsoRay notified the state that [the common carrier had] found the missing shipments and are returning them to IsoRay. They were not delivered to the intended physicians. There are no details yet on how they became misplaced. IsoRay has scheduled a senior management meeting with [the common carrier's] Priority Alert team to trouble shoot the missing shipments. This incident is one of several incidents in which [the common carrier] played a role within the last 4 months. Incident Number: WA-16-027 |
| Where | |
|---|---|
| Isoray Richland, Washington (NRC Region 4) | |
| License number: | WN-L0213-1 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.73 h1.489 days <br />0.213 weeks <br />0.0489 months <br />) | |
| Opened: | Anine Grumbles 18:44 Jun 15, 2016 |
| NRC Officer: | Dong Park |
| Last Updated: | Jun 15, 2016 |
| 52009 - 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 | |