ENS 54013
ENS Event | |
|---|---|
07:00 Apr 15, 2019 | |
| Title | Agreement State Report - Leaking Intravascular Brachytherapy Device Identified |
| Event Description | The following report was received from the Washington State Department of Health via email:
UW [University of Washington] Radiation Safety (RS) conducts semi-annual sealed source leak test during the months of April and October. After analyzing a leak test for a Sr-90 Intravascular Brachytherapy (IVB) device it was found to be leaking. Details provided by the University of Washington radiation safety office are as follows: 'The results of the sample's analysis were reviewed and it was discovered that a sample for one of the IVB source trains indicated contamination at 3737 cpm. A second sample of both IVB source trains was obtained. The sample for the 40 mm source train indicated 177 cpm and the sample for the 60 mm source train indicated 7998 cpm. The RS staff member discussed the contamination with the Radioactive Materials Compliance Manager (RMCM) and the Radiation Safety Officer (RSO). It was then discovered that the leak test procedure specified in the Novoste Beta-Cath User's Manual was not performed correctly. A swab of the water sample obtained during the leak test was analyzed rather than the whole 5 ml of water. The RS staff member performed another leak test of both IVB source trains, and analyzed the 5 ml water samples (The results are provided below). The IVB device was placed out of service and removed from Radiation Oncology. The RS staff member contacted the RSO at Best Vascular who requested the sources and items used for the leak testing be returned to Best Vascular for investigation. 'Radiation Safety counted the 5 ml water samples using one of their liquid scintillation counters (LSC) [Packard Tricarb 2900TR - S/N 426395]. Using an efficiency of 100 percent for Sr-90 (Beckman Coulter's Isotope Booklet for Liquid Scintillation Counters - 2002) the activity calculated was: '40 mm source train: 396 counts / min (decays / 1 counts)(min / 60 sec)(Bq*sec / decays) = 6.6 Bq '60 mm source train: 17429 counts / min (decays / 1 counts)(min / 60 sec)(Bq*sec / decays) = 290 Bq 'The activity level of the 60 mm source train leak test sample exceeded the limit of 185 Bq. The contamination in the leak test for the 40 mm source train is believed to be a result of cross contamination from the 60 mm source train leak test.' WA Event Report ID No.: WA-19-013 |
| Where | |
|---|---|
| University Of Washington Washington (NRC Region 4) | |
| License number: | C001 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+104.13 h4.339 days <br />0.62 weeks <br />0.143 months <br />) | |
| Opened: | Tristan Hay 15:08 Apr 19, 2019 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Apr 20, 2019 |
| 54013 - NRC Website | |
University Of Washington with Agreement State | |
WEEKMONTHYEARENS 561932022-10-25T07:00:00025 October 2022 07:00:00
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