Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56635 | 25 July 2023 01:45:00 | Agreement State | Loss of Control (Lost Then Found) of Radioactive Material | The following is a synopsis of information received from Oregon Health Authority, Radiation Protection Services (RPS): At 1845 PDT this evening a caller contacted the Oregon Emergency Response System (OERS) to report a yellow package with a radioactive placard that was found in a parking lot at their location. RPS followed up on the OERS report (Incident Number: 2023-1825) and it appears that an employee from Weston Solutions, an EPA contractor, discovered a box with a Yellow II DOT label in the middle of a parking lot outside of their warehouse in Portland. The box appeared structurally sound and intact. The caller had a survey meter on-site (a Ludlum 2241 with pancake probe) and measured approximately 11,000 cpm at 1 inch away from the package. The employee called 911 and the police notified the National Response Center and sent officers to respond. The police inspected the package and discovered it belonged to Cardinal Health. Cardinal Health Nuclear Pharmacy, a licensee, shares a parking lot and occupies an adjacent warehouse to Weston Solutions. The police then hand-carried the box to the Cardinal Health building. A representative from Cardinal Health (police verified credentials) accepted the package and took it inside their facility. RPS called Cardinal Health Nuclear Pharmacy Services and spoke with the on-call pharmacist / RSO of the facility. At the time of the call she was on-site at the pharmacy to investigate the situation after being contacted by the employee that accepted the package from the police. The pharmacist / RSO explained that she had immediately leak tested the package and the readings were typical. The box was labeled as containing I-131. There was no sign of a breach or disturbance to the package. The package was then transported to a locked storage vestibule and the pharmacist / RSO then notified the courier of the misplaced material. The courier used to transport the radionuclides to the nuclear pharmacy was PNW Trade Winds. RPS called and spoke with the lead courier to gather more information about the circumstances that could have led to losing the package. The lead courier had spoken with the driver involved and their best guess is that while the driver was segregating packages for the different delivery locations at his vehicle, he must have dropped a box and it landed underneath the vehicle. All the material that was supposed to arrive at Cardinal Health was accounted for, so the driver was not aware of the missing package. The driver most likely would not have realized it was lost until performing a physical inventory at a subsequent location. As far as timing, the lead courier explained that the driver had left Cardinal Health at approximately 1800 PDT and the package was discovered by Weston Solutions at 1820 PDT. When talking with the Weston Solutions employee, he had mentioned that they were in the parking lot area at 1745 PDT and did not see the package at that time, confirming the timeline. Therefore the material was in the parking lot for only about 20 minutes before it was discovered. RPS Incident Number: 23-0035
The following information was received from RPS via email: This letter (from Cardinal Health to RPS) serves as the written report concerning an incident involving the loss of radioactive material as it relates to Oregon radioactive materials license ORE-90509, pursuant to OAR 333-102-0350(3)(b). On July 23, 2023 at 1845 PDT, a caller contacted the state emergency response system to report a package was discovered in their parking lot with a radioactive material label in Portland, OR. The package was labeled Cardinal Health. Cardinal Health's Portland nuclear pharmacy (ORE-90509) shares a parking lot with the location that reported the package. The police delivered the package to Cardinal Health, where it was then secured by a Cardinal Health employee. The package was inspected and wipe tested by the site radiation safety officer, with no contamination, damage, or breach found. The package contained 1 mCi worth of I-131 capsules that had been packaged for delivery to a separate Cardinal Health location in Seattle, WA. The package was transferred to PNW Trade Winds, a contract courier, upon receipt at the airport for transportation to Cardinal Health's Seattle location. PNW Trade Winds reported that the package was likely dropped when segregating packages for different delivery locations. The driver reportedly left the licensee at approximately 6:00 pm, the package was discovered at 1820 PDT. With this timeline the package was left unattended for approximately 20 minutes before it was discovered. In response to this event Cardinal Health has inquired with PNW Trade Winds to review the corrective actions taken on their part. PNW Trade Winds reported that the driver has reviewed their triple check policy and has been placed on three months' probation. During the first month of their probation they are required to call their manager at each stop to review the delivery and verify the remaining packages in the vehicle. Notified R4DO (Dixon) and the NMSS Events Notification and ILTAB email groups. | ||
| ENS 51688 | 27 January 2016 05:00:00 | Agreement State | Agreement State Report: Radiation Overexposure to External Whole Body | The following was received from the State of Florida via email: Tampa inspection office (State of Florida Bureau of Radiation Control) conducted a routine inspection on January 22, 2016. Searching their records (the inspector) found that (one) employee had exceed the annual limit of 5 Rem per year (not including the month of December). (The employee) had nine high exposure investigative reports recorded in the last year. The report also noted that the RSO (Radiation Safety Officer) failed to take any action to mitigate more exposure to ionizing radiation. The RSO will be required to submit a report. The BRC (State of Florida Bureau of Radiation Control) will request a safety inspection of the facility paying particular attention to (the employee) daily duties and make recommendations to reduce exposure. The BRC would also suggest additional unannounced inspections to insure improvement to their adherence to regulations. Isotope: F-18 Activity: 16.5 MeV Cyclotron Material Form: Particle Accelerator External Whole Body exposure Maximum Dose Received: 5.2 Rem/year (excluding December) Florida Incident Number FL16-016. | ||
| ENS 51056 | 8 May 2015 10:40:00 | 10 CFR 20.2201(a)(1)(ii) | Stolen Radiopharmaceuticals | The following event occurred in Kansas City, MO. The corporate office of Cardinal Health Nuclear Pharmacy was notified that a vehicle being used to deliver material to the VA (Veterans Affairs) Hospital in Kansas City, MO had been stolen at approximately 0540 CDT on 5/8/2015. Inside the vehicle were two packages, each containing Tc-99m. The maximum combined activity of the Tc-99m in the two packages was less than 250 millicuries. Both VA security and the Kansas City, MO police were notified. VA security is reviewing security videos for possible leads. The Kansas City, MO police case number is 15-31091.
The following information was received via E-mail: The vehicle was located in Overland Park, KS by the police in Overland Park. Cardinal Health Kansas City sent drivers to retrieve the vehicle. It is now back at the Cardinal Health Kansas City nuclear pharmacy as of 0935 CDT on May 8, 2015. Packages containing radioactive materials in the vehicle with tamper resistant seals are intact and unopened." Apparently the vehicle was stolen by a patient of the VA Hospital. The identity of this individual was able to be confirmed. Notified R3DO (Skokowski), ILTAB (Wray), and NMSS Events Notification.. 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 42855 | 22 September 2006 05:00:00 | Agreement State | Agreement State Report | A Cardinal Health vehicle from the Slidell, LA location was carrying 1214 mCi of Tc-99 and 40 mCi of Xe-133 to a Mississippi facility when it was involved in an accident on Highway 43 in Mississippi. Cardinal Health notified the appropriate authorities in Mississippi. Emergency Response in Mississippi took control of the vehicle. Louisiana event report ID number: LA060017 See Mississippi Agreement State Report: Event Number 42858. | ||
| ENS 42665 | 25 June 2006 22:00:00 | Information Only | Flood Damage to Nuclear Pharmacy | On the evening of 06/25/06, the Regional Director arrived at the facility and determined that the pharmacy had been under at least six feet of water at some time during the day. The Regional Director notified the building landlord and the company RSO. After their arrival and the flood waters receded, they conducted a physical inspection of the pharmacy and the radioactive materials. Initial inspection discovered no missing or damaged radioactive material. The licensee is presently completing a detailed inventory. Several doors and windows have been replaced to provide security to the facility. The licensee will update this report when it determines if any specific 10 CFR reporting criteria have been met. |