Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56444 | 30 March 2023 05:00:00 | Agreement State | Radioactive Source Lost in Shipment | The following information was received from the Louisiana Department of Environmental Quality via email: On February 17, 2023, the (Alpha-Omega) Radiation Safety Officer (RSO) shipped a high dose rate (HDR) source through (a common carrier) for shipment to Radiation Oncology, Elk Grove Village, IL 60007. The shipment's last known location was the (common carrier's) Memphis Hub. Alpha-Omega contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section to report that a HDR Ir-192 source was lost in transit with (a common carrier) on March 30, 2023. The source serial number is 02-01-1027-001-021523-11023-87. The activity of the Ir-192 source on 2/17/23 was 400 GBq when it was shipped. The current activity on 3/31/23 is 7.292 Ci (269.8 GBq).The (common carrier's representative) in Dangerous Goods Administration stated that, '(the common carrier's) position is that an exhaustive manual search was completed and the parcel is no longer in our control.' Louisiana Event Report ID No.: LA20230006 THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 55070 | 15 January 2021 21:30:00 | Agreement State | Lost Source in Transit | The following was received from the State of Louisiana, Department of Environmental Quality: On January 05, 2021, (the Radiation Safety Officer) (RSO) dropped off seventeen sources to the common carrier for shipment to various locations. Alpha-Omega contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section (at 1530 CST on 1/15/21) to report that a High Dose Rate (HDR) Ir-192 source was lost in transit with the common carrier. The source was being shipped to Mid-Columbia Medical Center, The Dalles, OR. The source serial number is D36R0392. The activity of the Ir-192 source on 1/5/21 was 10.568 Ci (391.016 GBq) when it was shipped. The current activity on 1/15/21 is 9.626 Ci (356.162 GBq). The common carrier does not show this source being tracked or received. LA Event Report ID No.: LA 20210001 THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9) | ||
| ENS 55022 | 4 December 2020 06:00:00 | Agreement State | Lost High Dose Rate Source While in Transit | The following was received from the state of Louisiana via email: On December 04, 2020, Alpha-Omega Services RSO contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section to report that a High Dose Rate (HDR) Ir-192 source was lost in transit with the commercial carrier. The source was being shipped to Stanford University Medical Center, 820 Quarry Road, Palo Alto, CA 94304. The source serial number is 02-01-2922-001-111120-11438-41. The activity of the Ir-192 source was 11.44 Ci (423.22 GBq) on November 13, 2020 when it was shipped. The source was last tracked in the commercial carrier Memphis, TN Hub on November 14, 2020 at 06:07 am CST. Louisiana Incident Number: LA20200011 THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9) | ||
| ENS 53255 | 9 March 2018 21:15:00 | Agreement State | Louisiana Agreement State Report - Lost Iridium-192 Source | The following information was received from the state of Louisiana via email: On March 9, 2018, at approximately 3:15 pm (CST), (the RSO of Alpha-Omega Services, Inc.) contacted the Department (Louisiana Department of Environmental Quality) to inform us that (the common carrier) had not delivered an HDR Radioactive Sealed Source to Lancaster General Suburban Hospital (LGSH), Lancaster, PA 17604. Documentation of the Event # 53255 was provided on March 10, 2018. The shipping date from Alpha-Omega Services in Vinton, LA. was 02/26/2018. The source has not been delivered to LGSH. On March 9, 2018, (the RSO) for (the common carrier) communicated to (Alpha-Omega's RSO), they could not locate the source in the tracking system or in the Memphis, TN hub. It needed to be reported as lost or missing to the NRC. On 03/12/2018, the source has not been located. The Ir-192 source is a GammaMed 232, 383 GBq, (10.4 Ci), S/N 24-01-6226-001-020818-12254-81, Transportation Index - 6. Louisiana Event Report ID No.: LA-180004 THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9) | ||
| ENS 52804 | 13 June 2017 12:30:00 | Agreement State | Agreement State Report - Incorrect Source Shipment | 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 | ||
| ENS 52535 | 6 February 2017 08:00:00 | Agreement State | Agreement State Report - Transportation Posting Inaccuracy | The following report was received from the State of Louisiana via email: Event description: On February 6, 2017, LDEQ (Louisiana Department of Environmental Quality) was notified by Alpha-Omega, Inc., that the facility had received three 'EMPTY' Nucletron V2 containers from a Mexico site then transported to the United States, Alpha-Omega Services, Inc., Vinton, Louisiana, 70668. When inspected, two of the containers had Ir-192 sources in them, Model 105.002. Container 2785C6 had source D36F3728, 25 mCi of Ir-192, a QSA Global source. Container 2053C6 had source D36P3481, 351 mCi of Ir-192, an Alpha-Omega, Inc. source. Event Report ID No.: LA-170002. | ||
| ENS 51799 | 15 March 2016 05:00:00 | Agreement State | Agreement State Report - Radioactive Source Shipment in Excess of Licensed Quantity | The following was received from Louisiana via email: On 03/16/2016, the RSO for A&O (Alpha Omega) called in a report of a HDR (high does rate brachytherapy) source being shipped to Texas Oncology PA (TOP) in excess of licensed quantities. The source was 12.8 Ci Ir-192 source intended as a replacement source for the Texas Oncology PA Center 3550 Northeast Loop 285, Paris, TX 75460. License # L04664, Amendment #28, Expiration date: February 28, 2025. (The RSO) was enroute to the facility to return the 12.8 Ci Ir-192 source and replace it with an additional 11.2 Ci Ir-192 source. He stated that the 12.8 Ci source was being retrieved and placed in a storage pig/container by the Service Engineer until it could be packaged and returned by common carrier to A&O 03/16/2016. Their intent was to install the 11.2 Ci source so the TOP facility could receive the source and resume patient care. A&O is a source supplier for Elekta HDR units. Elekta notifies A&O when sources should be shipped/supplied their licensees. The error was the wrong source was inadvertently shipped to TOP. The source received by TOP exceeded the licensed activity limit. The sources were Elekta Model 105.002s. The source S/N16-0505 12.8 Ci of Ir-192 was shipped when the source S/N 16-0504 11.8 Ci of Ir-192 should have been shipped. When TOP received the 12.8 Ci source, they knew it was too 'HOT' to treat patients. They called A&O at (1700 EDT) on 03/15/2016 to report the error. The incorrect source, 12.8 Ci of Ir-192 was returned to A&O by common carrier A&O explained that the mix-up was caused by reference numbers that were switched after the sources were calibrated. Louisiana incident # LA-160005 | ||
| ENS 48899 | 2 April 2013 07:00:00 | Agreement State | Agreement State Report Involving a Mis-Delivered Shipment of Radioactive Material | The following information was provided by the State of Louisiana via email: Event date and Time: On 04/02/2013 (the) RSO for A & O (Alpha-Omega Services, Inc.) called in a mis-delivery of an Ir-192 source intended for Radiation Oncology Center of Nevada (ROCN). ROCN is a client/customer of A & O, but (the common carrier) delivered the source to Cardinal Health (CH). ROCN and CH are both radioactive material licensees and both have facilities in Las Vegas, NV. Event Location: Around the Las Vegas, NV area. The source was intended for ROCN in Las Vegas, NV, but was delivered to Cardinal Health, (also in) Las Vegas, NV. The source delivery occurred in the morning to CH. CH notified ROCN that their source was delivered to CH by (the common carrier). (The common carrier) was notified and picked up the source at 1300 (PDT) and delivered it to ROCN. Event type: Delivery of a radioactive source by the (common) carrier to the wrong licensee. Except during transport, the source was in possession of someone who was a licensee and well trained in radiation safety practices. Notifications: A notification was made to LA DEQ (Louisiana Department of Environmental Quality) Radiation Assessment after the incident was basically over and entirely under control. The notification was made to (a Louisiana representative) located in (the Louisiana) Southwest Regional office. A & O was involved in the recovery of the source by phone after learning of the mis-delivery. The source was delivered to the wrong licensee. CH, the licensee where the source was delivered, was licensed for radioactive material and well trained in the handling of radioactive material. Event description: (An) Ir-192 source was delivered to the wrong licensee by (the common carrier). When the error was discovered by CH, CH notified ROCN that they were in possession of licensed radioactive material that belonged to ROCN. (The common carrier) was called and they picked up the source and delivered it to ROCN around 1300 (PDT). The source shielding and shipping container was intact during the entire incident. It was not damaged nor was the container opened. Transport vehicle description: (The common carrier) picked up the source from the A & O facility (in) Venton, LA which was being shipped to a client, ROCN (in) Las Vegas, NV. (The common carrier) delivered the Ir-192 source to the wrong address. The source was delivered to Cardinal Health (CH), (also in) Las Vegas, NV. Event Report ID No.: LA-120015 |