ML20082P521

Advises That on 910805,two Shipments Made from Univ W/ Incorrect Radionuclides & Activities Listed on Shipping Papers & Package,Per 10CFR71.5.Person Responsible for Discrepancy Counseled & Restrictions Imposed

ML20082P521
Person / Time
Site:	University of Missouri-Columbia
Issue date:	09/04/1991
From:	Mckibben J, Reilly W MISSOURI, UNIV. OF, COLUMBIA, MO
To:	Office of Nuclear Reactor Regulation
References
NUDOCS 9109100359
Download: ML20082P521 (4)

Text

Research Reactor Facihty II ne u en en cwt,a Mn.wun ac t 1 UNIVERSITY OF MISSOURI-COLT lMBIA

""QQyfy September 4,1991 Director of Nuclear Reactor Regulation US Nuclear Regulatory Commission Mail Statiar PI-137 Washington, DC 20555

REFERENCE:

Docket 50-186 University of Missour; Research Reactor License R 103

SUBJECT:

Report of Deviation from 10 CFR 71.5 incorrect Radionuclide listed on a Type A Package

Dear Sir:

On August 5,1991 the University of Missouri Research Reacte (MUluD made two shipments with the incorrtet radionuclides and activities listed in the shipping : apers ar.d,n the package.

10 CFR 71.5 requires licensees to follow the Department of Transr W. ion regulations, Chapter 49 of the Code of Federal Regulations, in shipping radioactive materials. These two shipments did not meet the requirements of 49 CFR 172.203 and 172.403. The error resulted from the tro samples being inadvertently switched in the MURR hot cell. Chapters 10 (NRC) and 49 (DOT) of the Code of Federal Regulations do not require a formal report in this situation, but we are providing a description and eur corrective actions fcr your iaformation. We called Mr. Alexand'r Adams, NRC. Washington D.C., on August 7 and Mr. Andrew Dunlop, NRC - Region 111, on August 9 to describe this discrepancy and volunteered to file this report within 30 days.

As a esult of the report to Mr. Dunlop, Mr Mark Mitchell and Mr. Paul Pelke, Region 111, visited MURR on August 21 to investigate the discrepancy and the MURR shipping program.

DISCREPANCY Activated rock samples intended for NASA-Johnson Space Center were mistakenly ent to Mallinckrodt Medicallabeled as Re 186,11 Ci. The Re-186 shipment intended for Mallinckrodt Medical was sent to NASA-Johnson Space Center labeled as Na 24,16 mci (primary activity in the aluminum foil around the rock samples) Both were Type A shipments and they were both properly labeled with dose rates and transport indices (TD. The rocks (shipped as Re-186) were properly labelled as a Yellow Ill shipment and the Re-166 (shipped as rocks - Na-24) was properly labelled as a Yellow H shipment. MURR verified that both Mallinckrodt and NASA licenses were authorized to receive the intended isotopes prior to shipmcnt. The Mallinckrodt NRC license also authc,rized them to receive the isotope and activity in the mistaken shipment to them, but the NASA license did not authorize NASA to receive the Re-186 shipment.

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September 4,1WI Page 2 NASA discovered their rock samples were not in the package shipped to them when it was opened on August 6. Personnel at NASA momentarily removed the plastic bag containing a sealed quartz vial (Re-186) from its shipping pig and recognized the sample was not their expected samples i;.

scaled quartz vials wrapped in aluminum foil. They immediately reinserted the bag into the shipping pig. NASA informed MUltR of the discrepancy at approximatelv 11:00 a.m. and refo,ed receipt of the material which they secured under NASA health physica control. The NASA and Mallinckrodt shipping pigs had been in the hot cell with five other containers for MURR in house researchers, and those Ove samples had been properly received by the researchers on August 5. It was concluded that the NASA and Mallinckrodt samples had been switched. We immediately called Mallinckrodt Medical to inform them of the discrepancy and found that they had opened the overpack but had not openrd the sealed shipping can contained in the MURR Type A package.

The discrepancy was caused by an error in loading shipping pigs in the hot cell. During later steps in processing for shipment, smface and Tl radiation readings were made. The magnitudes of the readings were nat sufUciently discrepant to suggest that the contents were the wrong radionuclides, and, based on those readings, the shipping label designations were correct for the actual mnterial in each package.

RECOVERY The MURR llealth Physics Manager remained in close contact with the NASA Radiation Safety Omcer after we were informed of the discrepancy. Based on MURR measurements of another Re.

186 sample that had a similar irradiation history and was sealed in a quartz vial as was the Re.186 at NASA, the MURR llealth Physics Manager estimated the dose for a 30 second exposure at 4 inches from the Re-186 via! at 8.00 a.m. on August 6 to be approximately 970 mrem, about 959 due to beta radiation. Using this dose information, NASA's RSO made r.n assessment of extremity dose to their own personnel. NASA obtained immediate processing of the whole bady Glm badges of the person who opened the package and another person in the vicinity. The readings on both whole body badges were minimal (below 10 mrem).

We dispatched a certified shipper and a QA inspector (who is also a Certi6ed llealth Physicist) to NASA on August 8 to retrieve the Re-186 under a MURR Radiation Work Permit. Since the required eqt.ipment to prepare MURR Type A shipments is not portable, we had sent a Type B container to NASA to use in the retrieval. Mallinckrodt Medical needed to have the Re 186 by August 9 for treatment of a patient, so the Re-186 was sent by MURR frem NASA to Mullinckrodt Medical as a Type A shipment made in a Type B container. Repackaging of the Re 186 vial by MURR personnel required that the vial was out ofits shielding (handled with forceps and behind a leaded glass shield) for approximately 35 seconds. During this repackaging, MURR personnel wore whole body Glm badges, and TLD wrist and ring badges. All dosimetry badges registered minimal.

MURR also sent a shipper to Mallinckrodt Medical on August 8, and he brought the activated rocks back to MURR.

ANALYSLS Samples to be irradiated at MURR and shipped go through the following process. Irradiation targets are placed in aluminum cans or capsules which are welded shut and leak tested. Small

Septc mber 4,1991 Page 3 targets that are loaded in capsules are then placed into " host" cans which are welded shut and leak tested. Next the cans are placed in irradiation positions for specified periods and then removed to

- reactor pool storage paitions when irradiations are complete. They are removed from the pool, under health physics supervision, and transported it. transfer casks to the hot laboratory or hot cell for opening, processing, and preparation for shipment.

In keeping with the principles of ALARA, samples to be processed in the hot cell are transferred in groups to reduce the number of transfers and openings of the hot cell. Prior to moving the transfer cask into the hot cell, the required shipping pigs are marked and pheed in the hot cell.

The transfer cask is then placed inside the hot cell, opened, and the cans are removed. As far as possible, decanning, processing, and loading for shipment are completed on the contents of an irradiatian can before another can is opened. I!ost cans contain multiple irradiation capsules.

some of which are shipped and some of which are loaded into another host can for further irradiation. Special care is exercised to identify the capsules and ensure that they reach their l

proper destination.

i A double verification of each irradiation capsule prior to opening in the hot cell had been instituted in September 1990 as a result of a shipment of Pd-103 which was destined for Theragenics Corporation but was shipped to htallinckrodt hiedical. In that instance, the discrepancy was discovered by h1URR and the package was returned prior to opening. The Alallinckrodt hiedical NRC license did authorize receipt of the Pd.103 material.

l Processing may include a determination of the activity using a shielded Capintec inside the hot cell. The sample is then loaded into a plastic bag preplaced inside the shipping pig. Tops are

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manually placed on the pigs afl.er the hot cell is opened under health physics supervision, and surface dose rates and external contamination assessments are made.

I The shipping pigs for Type A shipments are then transported to a shipping preparation area where each is placed in a can and sealed. Contact and one foot dose rate readings are taken and recorded

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lI on each can for information for the receiver. The sealed can is placed in an identified expanded j

polystyrene overpack which is strapped, and the overpack is placed in an identified shipping j

container (box) which is strapped and sealed. Contact dose rates are read and recorded at the top, bottom, and all sides of the shipping container and the TI is measured to determine the proper

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shipping label (i.e White I, Yellow II, Yellow Ill).

Procedures were followed on August 5, but human error in not properly identifying each shipping pig resulted la switching the placement of the samples between the containers.

i Due to che number of shipments being handled at MURR, the stalling for this area was reviewed i

during June and July 1991. The decision was made to increase the number and qualification level i

of the staff. The group is being increased from four personnel (one Reactor Services Supervisor, j

one Laboratory Technician, and two Laboratory Assistants) to five personnel (one Reactor j

Services Supervisor and four Laboratory Technicians). The steps to complete this change were in

-i progress when the August 5 shipping event occurred. Currently, the shipping group consists of the

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Reactor Services Supervisor and three Laboratory Technicians, and we are interviewing l

l candidates to fill the open position.

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Septemler 4,1991 Pa;;c 4 CORRECTIVE ACTIONS The immediate corrective action consisted of noti 0 cation of Mallinekrodt Medical and retrieval of the shipments described above, review and revision of processing and shipping procedures, and personnel actions.

- The initial procedure review was performed August 7, and interim revised procedures were used for processing and shipping after that date. The main thrust of the procedure review was to identify potential ste;::, where samples could be accidentally switched. The revised procedures included requir ng recorded double checks (two person verification) for these sample handling i

steps that hr.d a potential for misidentifying the shipment, and improving the identifying marks on the shipping pigs.

The following personnel actions were taken:

All processing / shipping personnel were informed of the misshipments, reminded of the importance of correct processing and shipping, and trained in the revised procedures The person responsible for the discrepancy was counseled by the person's supervisor and some restrictions were imposed on the person's work duties Long term corrective actions will consist of follow up on immediate actions on procedures and personnel. Procedures, to include procedures for target preparation and irradiation, will be reviewed, revised if necessary, and finalized.

Evaluation of the person responsible for the August 5 shipping discrepancy will continue to determine further action to be taken, if any. Iliring actions will be completed, and new personnel will be indoctrinated and trained.

Sincerely, hf/fhs William F. Reilly Assistant Director, Fiscal / Reactor Services g [J / p %[%s Reviewed and Approved:

V J. Charles McKibben Associate Director xe: NRC Region III Reactor Advisory Committee p onsin H tem Reactor Safety Subcommittee form punt srArt or nissem Isotope Use Subcommittee BOCtE COLNTY t

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