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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 45109 | 30 May 2009 04:00:00 | Agreement State | Agreement State Report - Lost Shipment of I-125 Brachytherapy Seeds | On Saturday May 30, 2009 the Virginia Radioactive Materials Program received notification from Best Medical International, Inc. that a shipment of I-125 Brachytherapy seeds had been lost in transit by Fed-Ex. A follow-up telephone conversation on June 1, 2009 revealed the following: On Friday May 22, 2009, a shipment of 70 I-125 seeds was prepared for shipment to the University of New Mexico - Albuquerque for patient implant on Friday May 29, 2009. The source strength was 30.3 mCi at the time of shipment. On May 26, 2009, Best Medical noticed that the shipment had not been received by the University and contacted Fed-Ex. Fed-Ex initiated a search for the material. Best Medical contacted Fed-Ex on May 27th and was told that Fed-Ex could not find the shipment. The patient's treatment has been postponed.
The State of Virginia has clarified the original report it made to the NRC to note that the shipment was inadvertently directed to Windsor Locks, CT instead of Memphis TN. Specifically, the State reports the following update: Further conversations on Wednesday, June 3 revealed the following: On Tuesday, June 2, 2009 Fed-Ex found the I-125 package in Windsor Locks, CT. The package was shipped back to Best Medical and received on June 3, 2009. According to Fed-Ex, the I-125 package was not placed in the shipping container for Memphis, TN. The package had an incorrect URSA (routing) label (and) the package was then sent from Springfield, VA to Windsor Locks, CT (instead). The R1DO (Perry) and FSME EO (McIntosh) have been notified. 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. |