ENS 53804
ENS Event | |
|---|---|
08:00 Dec 19, 2018 | |
| Title | En Revision Imported Date 1/18/2019 |
| Event Description | EN Revision Text: AGREEMENT STATE REPORT - RADIOACTIVE SOURCE FAILS LEAK TEST
The following report was received via e-mail: A routine leak test at the Swedish Cancer Institute found a leaking Cs-137 e-vial source in the Physics Lab. The initial leak test was taken 12/19/2018 and analyzed on 12/20/2018. It revealed an activity of approximately 10 nanoCuries, and additional confirmation tests found contamination above the regulatory threshold for a leaking source. The source was immediately removed from service, contained within multiple non-permeable barriers, and placed into a larger pig while it is being held for disposal. Surveys of the original storage pig and the hot lab where the source was utilized found no removable contamination and there was no personnel contamination detected. The RSO [Radiation Safety Officer] was notified of the positive results the morning of 12/21/2018 and provided notification to DOH [Washington State Department of Health] at 1114 PST on 12/21/2018.
The following report was received via e-mail: A leaking sealed source was discovered at The Swedish Cancer Institute during periodic leak tests performed by the health physics staff. The source (MED3550 Gamma Reference Standard, SN 11345, Cs-137, initial activity 209.6 micro-Ci, reference date 8/1/2001) was used in the A Level Physics Lab as part of routine radiation oncology operations. The source was initially received by Swedish 12/6/2007. The sample was collected on 12/19/2018 using an alcohol wipe, and analyzed on 12/20/2018 using a Ludlum 261 single channel analyzer coupled with a NaI well detector. The system was set to detect the 662 keV photon energy for Cs-137, with a calculated efficiency of 11.71 percent. The result of the wipe test analysis was a removable activity of 9.92 Nano-Ci, above the 5 Nano-Ci threshold for a leaking source. After the RSO was notified of the positive result on 12/21/2018, the source was immediately removed from service, contained within multiple non-permeable barriers, and placed into a lead pig. The pig is currently being stored in the Radiation Safety Office Lab awaiting disposal. Wipes of the A Level Physics Lab source storage cabinet and all surfaces of the pig used to house the source when it was in service yielded no detectable removable contamination. After reviewing the final report of the licensee, this event is now closed as of 1/3/2018. DOH will verify that the source has been disposed of during the next routine inspection of the licensee. Washington Event Report ID: WA-18-031 Notified R4DO (Drake) and NMSS Event Notification (e-mail). |
| Where | |
|---|---|
| Swedish Medical Center Seattle, Washington (NRC Region 4) | |
| License number: | WN-M008-1 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+55.92 h2.33 days <br />0.333 weeks <br />0.0766 months <br />) | |
| Opened: | Andrew Halloran 15:55 Dec 21, 2018 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Jan 17, 2019 |
| 53804 - NRC Website | |
Swedish Medical Center with Agreement State | |
WEEKMONTHYEARENS 569302024-01-19T20:00:00019 January 2024 20:00:00
[Table view]Agreement State Y-90 Microsphere Misadministration ENS 540222019-04-23T07:00:00023 April 2019 07:00:00 Agreement State Washington Agreement State Report - Lost and Found Radioactive Material ENS 538042018-12-19T08:00:00019 December 2018 08:00:00 Agreement State En Revision Imported Date 1/18/2019 ENS 537942018-12-15T07:00:00015 December 2018 07:00:00 Agreement State Agreement State Report - Medical Misadministration ENS 533772018-01-23T18:30:00023 January 2018 18:30:00 Agreement State Agreement State Report - Patient Received Dose Less than Prescribed Dose ENS 435352007-07-17T17:00:00017 July 2007 17:00:00 Agreement State Agreement State Report - Six Lost Palladium - 103 Seeds ENS 415012005-03-17T20:00:00017 March 2005 20:00:00 Agreement State Argeement State Medical Event ENS 410782004-09-24T07:00:00024 September 2004 07:00:00 Agreement State Agreement State Report ENS 403372003-11-17T08:00:00017 November 2003 08:00:00 Agreement State Patient Received an Overdose During a Brachytherapy Procedure 2024-01-19T20:00:00 | |