Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 57193 | 25 June 2024 05:00:00 | Agreement State | Broken Brachytherapy Seed | The following information was provided by Illinois Emergency Management Agency, Radioactive Materials Branch (the Agency) via email: The Agency was contacted on 6/25/24 by Bard Brachytherapy in Carol Stream, IL to advise that they received a package which contained an applicator device with a broken brachytherapy seed. The applicator device was found to be contaminated and was placed in the licensee's hood for decontamination, recovery, and proper disposal. The licensee indicated there was no staff or area contamination as a result. The South Carolina licensee, having shipped the seed, similarly reported no contamination or adverse impacts. Due to the condition of the damaged seed, the radionuclide (Pd-103 or I-125) as well as the model and lot number are still pending. The activity remaining is likely beneath 0.5 mCi. This matter is reportable under 32 Ill. Adm. Code 340.1220(c)(1) and was transmitted to the NRC. Updates will be provided as they become available. Bard Brachytherapy is a manufacturer and distributor of brachytherapy seeds (IL-02062-01). Their client, West Hospital in Charleston, SC, returned the damaged seed in proper packaging. There is no indication of a public health or contamination concern. Illinois Report #: IL240015 THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 57127 | 13 May 2024 05:00:00 | Agreement State | Lost Brachytherapy Seed | The following was provided by the Illinois Emergency Management Agency (the Agency) via email: The Agency was contacted on 5/13/24 concerning one lost iodine-125 brachytherapy seed with an activity of approximately 0.267 millicuries. On 5/13/24, Bard Brachytherapy received a package from Northside Hospital - Gwinnett (Lawrenceville, GA), and initially identified a total of seven of the nineteen iodine-125 brachytherapy seeds were missing. Five seeds were found shortly thereafter in the packing material. The common carrier was called to return to the Bard facility and an additional seed was located within the delivery vehicle. Additional searches of the local Schaumburg, IL (common carrier) hub and OHare airport facility were unsuccessful in locating the final seed. The Agency was notified that the final seed was considered lost. The package is reported as having left Lawrenceville, GA and then Norcross, GA before arriving at the Schaumburg, IL facility. Reportedly, the package had no indication of damage from transit. The cause of the loss seed appears to be inadequate packaging when shipped. Illinois event number: IL240013.
The licensees written report was received 5/22/23 and provided no additional information. Exposures to the carrier and other members of the public are not expected to exceed reportable limits. Due to the small size and the proximity required to accumulate a reportable exposure, this incident is not expected to result in public exposures exceeding regulatory limits. The Illinois licensee followed reporting timelines and package receipt procedures. Provided no new information becomes available that would allow identification of the seed, reasonable search efforts have been undertaken and this matter is considered closed. Notified R3DO (Ziolkowski), R1DO (Carfang), NMSS Events Notification (email), ILTAB (email). THIS MATERIAL EVENT CONTAINS A Less than Cat 3 LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 56341 | 6 February 2023 06:00:00 | Agreement State | Lost Brachytherapy Seeds | The following information was provided by the Illinois Emergency Management Agency, Division of Nuclear Safety, Radioactive Material Branch (DNS-RAM) via email: DNS-RAM was notified on 2/6/23, by Bard Brachytherapy (IL-02062-01) that a package of radioactive brachytherapy seeds was lost while in the care of a common carrier. The package was shipped on 2/3/2023, from the licensee's facility in Carol Stream, IL to Centrum Radiotherapie in Kortrijk, Belgium. Total package activity at the time of shipment was 65.62 millicuries of I-125 (ninety STM-1251 seeds, each at 0.430 millicuries). DNS-RAM is currently seeking updated information on the last reported location of the package - which is believed to have been in South Africa. This does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. Updates will be provided as they become available. Illinois Event Number: IL230003
The following information was provided by the Illinois Emergency Management Agency, Division of Nuclear Safety, Radioactive Material Branch (DNS-RAM) via email: Licensee advised this morning that the package has been located. Updates will be provided as they become available. Notified R3DO (Szwarc), NMSS Events Notification, and ILTAB (email).
This matter is considered closed. THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 56181 | 25 October 2022 05:00:00 | Agreement State | Lost Shipments | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: The Agency received a phone call from the Radiation Safety Officer at Bard Brachytherapy (IL-02062-01) on 10/25/2022 indicating the loss of three packages containing Iodine-125 brachytherapy seeds. The information for each package is as follows: 1) Ninety (90) I-125 brachytherapy seeds, accounting for a total activity of 40.23 mCi (0.447 mCi per source) at shipment. 2) Ninety (90) I-125 brachytherapy seeds, accounting for a total activity of 43.65 mCi (0.485 mCi per source) at shipment. 3) Seventy-five (75) I-125 brachytherapy seeds, accounting for a total activity of 50.4 mCi (0.672 mCi per source) at shipment. The packages appear to have been lost at a (common carrier facility) in Memphis, TN. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion. DETAILS: On 10/20/2022, Bard Brachytherapy shipped three packages to Gwinnett Hospital in Lawrenceville, GA. The anticipated delivery date for all packages was 10/24/2022. Bard Brachytherapy was notified by (the common carrier) via email on the morning of 10/25/2022 that all three packages were lost. The common carrier is continuing its search. Additional information will be provided as it becomes available. Illinois Item Number: IL220040
The following information was received via email: The following updated information is being provided regarding Event Number 56181: All three packages identified in the notification were located at the (common carrier facility) in Memphis, TN the evening of October 25, 2022. All three packages are expected to be delivered to their final destination on October 26, 2022. Notified R1DO (Dentel), R3DO (Feliz-Adorno), ILTAB and NMSS Events Notification email group. THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 56145 | 30 September 2022 05:00:00 | Agreement State | Lost Shipment | The following was received from the Illinois Emergency Materials Agency (the Agency) via email: The Agency received a phone call from the Radiation Safety Officer at Bard Brachytherapy (IL-02062-01) on 10/5/22 indicating the loss of a package containing (10) ten I-125 brachytherapy seeds, accounting for a maximum estimated activity of 7.29 mCi (0.729 mCi per source). The package appears to have been lost at the (common carrier) warehouse in Vermont. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion. DETAILS: On 9/30/2022, Bard Brachytherapy shipped two boxes to the University of Vermont Medical Center in Burlington, VT. One of the boxes, which contained (10) ten I-125 brachytherapy seeds did not arrive with the shipment. (The common carrier) initially reported that it was still in the VT warehouse. (The common carrier) reportedly conducted a search yesterday and did not find the package and notified Bard Brachytherapy this morning that it was lost. Illinois Item Number: IL220038
The following information was provided by the Illinois Emergency Management Agency via email: Licensee advised the common carrier located the package and confirmed delivery. This matter is considered closed. Notified R3DO (Betancourt-Roldan) and R1DO (Ferdas). Notified via email: NMSS Event Notification and ILTAB THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 56083 | 31 August 2022 05:00:00 | Agreement State | Lost I-125 Brachytherapy Seeds | The following information was provided by Illinois Emergency Management Agency, Radioactive Materials Branch (the Agency) via email: The Agency received a partial report via email from the licensee on September 1, 2022, indicating the potential loss of two brachytherapy seeds, accounting for a maximum estimated activity of 1.05 millicuries. The licensee has conducted an investigation and although the package appeared undamaged; believes the seeds may have been lost in transit from Atlanta Medical Center in Atlanta, GA. Requests for clarification and the nuclide (either I-125 or Pd-103) have not yet been returned. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion. While incomplete, this incident has the potential to be reportable and will be communicated to the United States Nuclear Regulatory Commission Headquarters Operations Officers today. On August 8, 2022, Bard Brachytherapy received a package from the Atlanta Medical Center. The package contained sources that were outside of the primary container and were lodged in the packaging foam. The shipping box looked undamaged from the outside, but three of the four primary containers were loose or open inside. The licensee counted the sources in the package and found 28. The return sticker included in the box from Atlanta Medical Center listed that 30 sources should have been returned. Surveys were conducted of the packaging material, the receiving and returns processing areas, and the path between to verify that the unaccounted-for sources were not in the Illinois facility. The counts were verified with the shipper and the licensee confirms two brachytherapy seeds (likely I-125) were most likely lost in transit. Illinois Incident Number: IL220031 THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 56099 | 23 August 2022 05:00:00 | Agreement State | Loss of I-125 Brachytherapy Seed | The following information was provided by Illinois Emergency Management Agency (The Agency/IEMA) via email: The Agency received a phone and email report from Bard Brachytherapy (licensee) on September 2, 2022 indicating the loss of a single I-125 brachytherapy seed, accounting for a maximum estimated activity of 0.75 millicurie. The licensee's investigation leads them to believe the seed remains within their Illinois facility and the loss of accountability is a function of either operator or documentation error. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion. Agency inspectors are conducting a reactionary inspection the week of September 12, 2022 for this incident and the loss reported September 1, 2022. While not representing a significant public safety concern, the quantity requires reporting to the US NRC HOO (Nuclear Regulatory Commission Headquarters Operations Officer) within 30 days. DETAILS: On August 23, 2022, staff at Brad Brachytherapy in Carol Stream, IL notified their manager of a missing brachytherapy seed. An investigation was opened and the counts compared against orders processed from this lot. Surveys were conducted of the workstations, the lab and the dumpster; yielding no identification of the seed. Reviews of paperwork, inventory records and orders also failed to indicate the location of the source. No customers have reported the receipt of an extra source. While the licensee believes the loss can be attributed to operator or documentation error; no root cause or corrective action was provided. An IEMA inspection team will seek this information in the reactionary inspection. Illinois Incident Number: IL220032. THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 56011 | 29 June 2022 05:00:00 | Agreement State | Lost Sources | The following information was provided by the Illinois Emergency Management Agency (Agency) via email: The Agency received a report from the licensee on 7/16/22, indicating the potential loss of (4) brachytherapy seeds, accounting for a maximum estimated activity of 1.02 mCi. The licensee has conducted an investigation and believes the seeds were likely lost or miscounted during patient implant and prior to shipment from a medical facility. Requests for clarification and the nuclide (either I-125 or Pd-103) have not yet been returned. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion. DETAILS: On June 29th, 2022, the licensee received a package from a hospital in California (CA). The package contained a source that was outside of the primary container but was found in the corner of the shipping box. The shipping box, reportedly, appeared undamaged from the outside, but the inside lacked appropriate packing materials to cushion the pewter containers. This package was then opened, and all the sources were counted. The hospital sent return fax paperwork saying that the package had six containers from different orders with a total of 218 sources. After fully disassembling all sources from their cartridges, the licensee's staff counted 214 sources. This count at 214 was reverified multiple times by multiple associates. Surveys were also conducted of the licensee's receiving area and returns processing area, as well as, the path in between to verify that the unaccounted-for sources were not in the facility. The hospital staff was contacted to verify the number of sources returned. They responded confirming their records showed they returned 218 sources from six orders but explained that the returned items were packed by other associates prior to their involvement and did not reopen the containers to recount the sources during the shipping process. REPORTABILITY: At this time the (4 missing) seeds cannot be attributed to implant, loss in shipment or loss at the CA facility; and is therefore being reported as lost under 32 Ill. Adm. Code 340.1210. It is unclear if the licensee met the reporting window since we are awaiting information on the nuclides involved. The Agency is making notification within 24 hours of becoming aware of the report (email wasn't retrieved until 7/21/22, due to staff absence and the automated reply was not heeded by the notifying party). Additional information will be provided as it becomes available. Illinois Event Number: IL220026 THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 55951 | 16 June 2022 21:00:00 | Agreement State | Shipment Lost Then Found | The following was received from the Illinois Emergency Management Agency (IEMA) via email: Representatives for Bard Brachytherapy contacted IEMA at close of business on 6/16/22 to report a shipment of I-125 brachytherapy seeds in route from their Carol Stream, IL facility to Tortola in the British Virgin Islands could not be accounted for after a flight change in Miami, FL. The shipment consisted of two overpacks: One containing five boxes with 350 seeds and a cumulative activity of 241 mCi, and one containing four boxes with 385 seeds and a cumulative activity of 265 mCi. The licensee shipped the packages on 6/7/2022 to O'Hare airport where they were received (and) placed on a commercial flight to Miami. After arrival at Miami, the packages missed two different flights scheduled for Tortola. After an inquiry by the licensee, the carrier reported the package could not be immediately accounted for. The incident was reported to IEMA shortly before 1600 CDT and then notification was received at 1627 CDT that the packages were located. This matter is considered closed. There were no breaches to packages reported and no resulting public exposures. The packages remained incident to transportation and secure. Due to the activity involved (A > 1000x the value in Appendix C to 10 CFR Part 20), the loss is immediately reportable under 32 Ill. Adm. Code 340.1210 and 10 CFR 20.2201(a)(1)(i). Unlike missing shipments of lesser activity, a review of SA-300, Appendix A reporting requirements doesn't give the same caveat that the package must still be missing at the time of reporting. Illinois # IL220020 THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 53873 | 13 February 2019 06:00:00 | Agreement State | Agreement State Report - Report of Loss of Brachytherapy Seeds | The following was received from the State of Illinois via e-mail: The agency (Illinois Emergency Management Agency) was notified the morning of 2/13/19 by Bard Brachytherapy, IL-02062-01, in Carol Stream to advise that a package of (34) I-125 brachytherapy seeds arrived with no obvious damage, but (5) of the (34) seeds were unaccounted for. Facility staff were immediately alerted of the issue when (the common carrier) opened the dock door and meters alerted to elevated radiation readings. (2) seeds were identified by the licensee staff outside of the package on the floor. Package wipes were taken and there is no indication of removable contamination. Each of the seeds has a current activity of 0.346 mCi and would have an exposure rate of approximately 0.6 mR/h at one foot. There is currently no reason to suspect any malicious intent or deliberate diversion of package contents. The five unaccounted for seeds contain an aggregate activity of 1.73 microCuries as of 2/13/19. The (common carrier) driver's vehicle was surveyed by licensee staff. Additionally, it was determined that the driver picked the package up at O'Hare airport, went to the (common carrier's) hub and then directly to Bard. Licensee staff are coordinating with (the common carrier) and are currently en route to the hub to perform surveys. Additional details will be provided as they become available. This matter remains open. Illinois Item Number: IL190008 THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 42984 | 10 November 2006 06:00:00 | Agreement State | Shipment of Iodine - 125 Seeds Lost in Transit | The State provided the following information via email: On November 10, 2006, (a representative) of Bard Brachytherapy, Inc. (IL-02062-01) called to report that they had been advised by their customer, that a package intended for Milton Hospital, Milton, Massachusetts did not make it to its destination. The package had been offered to their courier, Airnet, the previous evening for next morning delivery. Using the company's package tracking system, it was determined that the shipment (DELETED) had been transferred from Airnet, to the American Airlines' O'Hare Airport Air Freight Hub in Chicago, IL., but no record of its departure existed. Physical searches of the airport facility by the carriers' staff did not immediately locate the package containing the radioactive material. The shipment consisted of 2 leaded pigs of I-125 sealed sources. One pig held 73 'seeds' with an activity of 66 milliCuries, the second held 80 'seeds' with an activity of 72 mCi. The two packages had been combined into an 'over pack' with a total activity of approximately 134 milliCi of I-125. The package was identified as a 'limited quantity' package with a dose rate of less than 0.5 milliR/h at the surface of the container. The box was approximately 15x12x12 inches in size. As of 17:30 CST the package remains missing. The customer, Milton Hospital, notified their local regulatory authority, the Massachusetts Department of Public Health, Radiation Control Program to advise them of the situation. Due to the quantity of I-125 involved, the U.S. NRC Operations Center was advised of this event. As a result, U.S. NRC event number 42984 was assigned. Bard is continuing to work with their courier and the carrier to locate the package. At this time American Airlines believes it is still in possession of the package as it does not show the airbill tracking number (DELETED) as arriving at any of its domestic hubs. The radioactive material involved is encapsulated in medical grade stainless steel and is approximately the size of a 0.5 cm length of pencil lead. It is used as a permanent implant to treat cancer of the prostate. Due to the energy of I-125, it posses a very limited external exposure hazard, and then only at very close distances of less then a foot. (The Bard representative) promised to keep the Agency informed of developments as they occurred by contacting the Agency's radiation duty officer. Illinois Report No: IL060058
The package has been located at the airport in Boston, MA. The package is intact and is being returned to the originator in Illinois. Notified the R3DO (Cameron), NMSS (McConnell), and ILTAB (English via E-mail). THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. | ||
| ENS 41159 | 29 October 2004 05:00:00 | Agreement State | Agreement State Report | On October 29, the radiation safety officer (RSO) for Bard Brachytherapy, Mr. Ed Zduenk called the Division to report an excessive radiation level from a package that they had received. Federal Express had delivered a container that was shipped by Northwest Hospital, Randallstown, Maryland on October 26, 2004. The maximum measured radiation level on the surface of the package was 500 milliRem/h. At a distance of 3 feet, the measured radiation level was indistinguishable from background. After verifying that the package was intact and undamaged, the RSO proceeded to take measurements in the delivery vehicle. No elevated radiation levels were noted. With the package repositioned in the vehicle as described by the driver, additional measurements were made. There were no elevated readings detected on the exterior of the truck nor at the driver's position. As such, the RSO estimated the driver's exposure to be minimal from handling the package and briefly working at the rear of the delivery vehicle. The carrier was subsequently contacted with this information as well. After the package was accepted and moved to a safe location at the facility, additional measurements were taken. The maximum dose rate measured at 1 foot was 10 milliRem/h and at 2 feet was 2 milliRem/h. The container was expected to have 112 sealed sources of I-125 with an actual activity of 0.476 milliCurie each for a total of 53.3 milliCurie. After the package was opened and its contents inventoried, it was determined that all of the sources were accounted for. When the package was opened, the RSO observed that the lid of the interior primary shielded container was not in its expected position. Although some of the sources remained in the shielded container, the other sources were only in their shielded applicator. No sources were 'loose' in the box. Considering the shipper, the state of Maryland was notified of this event. This item is still open pending investigation to determine the cause of the event. IL report number IL040068 |