ENS 52804
ENS Event | |
|---|---|
12:30 Jun 13, 2017 | |
| Title | Agreement State Report - Incorrect Source Shipment |
| Event Description | The following report was received from the Louisiana Department of Environmental Quality [LDEQ] via email:
Event Date and Time: On June 13, 2017, 0730 [CDT] the e-mail was received by LDEQ. The report was for two Elekta Clients under timely renewals who both received Ir-192 sources for HDR [High Dose Rate] units. Neither set of documentation matched the sources it was accompanying. Both sources were manufactured, calibrated and shipped from the A&O [Alpha-Omega Services, Inc.], LA facility on April, 27, 2017. Facility #1: A report of an HDR source being shipped to Texas Oncology PA where the source activity was less than the activity ordered and documented from the source received. The source received was actually 8.98 Ci Ir-192, but the shipping documents and source information listed the source as 11.28 Ci Ir-192. The mis-documented source was returned and a new source with the correct activity and documentation was requested. The source was an exchange source as a replacement source for the Texas Oncology PA, dba Texas Cancer Center Sherman [TCCS], Sherman, TX 75090. TX License # L05019, Amendment #23, Expiration date: January 31, 2016. The licensee is under a timely renewal and on Amendment #31. The Source S/N D36G1424. Facility #2: The report of an HDR source being shipped to New York Oncology Hematology PC (NYOH), Albany, New York, 12206. NYSDH Radioactive Material License No. 5284, Amendment #6, DH Number 09-1113. The HDR source received was 13.88 Ci of Ir-192 on May 10, 2017. The documentation for the source received was 11.01 Ci of Ir-192. This source is being held for decay and will be put into service June 13, 2017. A&O sent a source with incorrect documentation that is in violation NYOH license for activity received and activity installed in the HDR unit. The Source S/N D36G1425. A&O is a source supplier for Elekta HDR units. Elekta's ordering process notifies A&O when sources should be shipped/supplied their licensees. Event Location: The shipments originated from Alpha and Omega Services, Vinton, LA 70668 and were delivered to TCCS, Sherman, TX 75090 and NYOH, Albany, New York 12206. Neither facility received the quantity of radioactive material they ordered and were licensed to receive nor was the documentation for the radioactive material correct. The facilities were licensed each to receive an Ir-192 HDR source. Event type: Calibrating, shipping and delivery of radioactive material in quantities greater than the licensed activities and under documented quantities. The licenses were correct, but the sources shipped were greater than the facility was licensed to receive and/or the documentation accompanying the RAM Ir-192 sources for each HDR units was incorrect. A&O explained that their reference numbers were mixed up during the manufacturing process. The A&O errors were detected by TCCS and NYOH licensees when they were performing their QC/QA on the active sources prior to patient treatment. The shipments were intact and not damaged. The sources were secure and in the hands of trained radiation safety personnel. Health and safety to the radiation workers and general public was not the issue. The issue was the reference numbers did not match the calibration activities of each source and wrong activities were shipped. Notification: On June 8, 2017, the error, quantities of RAM greater than licensed activity was discovered and reported to A&O. On June 8, 2017, the replacement source was shipped to TCCS. The incident preliminary notification was reported to the LDEQ, Assessment Radiation Section by e-mail on June 13, 2017. Reported to the NRC as LAC 33:XV.340.C. For not reviewing a radioactive material license before transferring radioactive material and LAC 33:XV.328.L.1.C. A permanent label was not affixed to the source or device containing the information on the radionuclide. LA Event Report ID No.: LA-170009 |
| 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:+27.98 h1.166 days <br />0.167 weeks <br />0.0383 months <br />) | |
| Opened: | Joe Noble 16:29 Jun 14, 2017 |
| NRC Officer: | Dong Park |
| Last Updated: | Jun 14, 2017 |
| 52804 - NRC Website | |
Alpha-Omega Services, Inc. with Agreement State | |
WEEKMONTHYEARENS 564442023-03-30T05:00:00030 March 2023 05:00:00
[Table view]Agreement State Radioactive Source Lost in Shipment ENS 550702021-01-15T21:30:00015 January 2021 21:30:00 Agreement State Lost Source in Transit ENS 550222020-12-04T06:00:0004 December 2020 06:00:00 Agreement State Lost High Dose Rate Source While in Transit ENS 532552018-03-09T21:15:0009 March 2018 21:15:00 Agreement State Louisiana Agreement State Report - Lost Iridium-192 Source ENS 528042017-06-13T12:30:00013 June 2017 12:30:00 Agreement State Agreement State Report - Incorrect Source Shipment ENS 525352017-02-06T08:00:0006 February 2017 08:00:00 Agreement State Agreement State Report - Transportation Posting Inaccuracy ENS 517992016-03-15T05:00:00015 March 2016 05:00:00 Agreement State Agreement State Report - Radioactive Source Shipment in Excess of Licensed Quantity ENS 488992013-04-02T07:00:0002 April 2013 07:00:00 Agreement State Agreement State Report Involving a Mis-Delivered Shipment of Radioactive Material 2023-03-30T05:00:00 | |