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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 57063 | 29 February 2024 05:00:00 | Agreement State | Agreement State - Lost Package | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: On March 4, 2024, the Agency received a notification from G.E. Healthcare in Arlington Heights, IL to advise of one missing radiopharmaceutical package at the Memphis, TN (common carrier) hub. The package contained one vial of I-123 with 14.268 mCi at the time of shipment. G.E. Healthcare was notified on March 4, 2024 by (common carrier) in Memphis, TN that a radiopharmaceutical package was missing with no indication of the contents being separated from the package. The package was originally shipped out of G.E. Arlington Heights, IL facility on February 29, 2024. The lead shielded package contained 14.268 mCi of I-123 in one 10 mL vial at the time of shipment. The destination was Spokane, WA. The last measured activity was 0.094 mCi. The last scan was at the (common carrier) hub in Memphis on February 29, 2024 and (common carrier) confirmed the package could not be found on March 4, 2024. This matter will continue to be tracked until an update is available or the package has decayed to background levels. As of April 3, 2024, the licensee indicates there are no changes to the status of the package or contents of the package. The package content has decayed to background levels. This does not pose a threat to the health and safety of the public. Provided there are no changes, this matter is considered closed. Item number: IL240007 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 56947 | 2 February 2024 06:00:00 | Agreement State | Lost/Missing Source | The following information was received from the Illinois Emergency Management Agency (the Agency) via email: The Agency was notified 2/2/24, by G.E. Healthcare in Arlington Heights, IL, (RML IL-01109-01) to advise two radiopharmaceutical packages were missing at the Memphis, TN, (common carrier) hub. The first package contained two shielded vials of iodine-123 (I-123), accounting for 66.8 mCi at the time of shipment. The second package contained 1.0 mCi of indium-111 (In-111); but was located in the (common carrier) facility damaged with the contents missing. (Common carrier) staff advise they are actively searching the facility. The first radiopharmaceutical package containing two vials of I-123 (and believed to be intact) was shipped 1/29/24 from Arlington Heights, IL, to Nuclear Diagnostic in Budd Lake, NJ. It was last reported at the (common carrier) hub in Memphis, TN, on 1/29/24. The second package believed to be damaged and within the (common carrier) facility was shipped 1/13/24 from Arlington Heights, IL, to RLS USA in Pittston, PA. Missing is a vial of In-111 Oxyquinoline Solution within a 6-mm thick lead-shielded container. The current activity is estimated to be 19.0 microcuries. If unshielded, this vial would present an exposure rate of approximately 1 millirem per hour at three inches. GE Healthcare has been provided photos and a description of the container and inner product. (Common carrier) staff are currently surveying with radiation detection equipment. Illinois Item Number: IL24004 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 56890 | 14 December 2023 06:00:00 | Agreement State | Agreement State - Lost Package | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: On December 14, 2023, the Agency was contacted by G.E. Healthcare in Arlington Heights, IL (IL-01109-01) to advise of a radiopharmaceutical package missing in transit. The last known location was the Memphis, TN (common carrier) hub where it was scanned on December 12, 2023. The carrier has declared the package lost. This package does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. The subject package is 16 centimeters square, labeled Yellow-II (TI of 0.1), UN2915 and contains a single 3 mL shielded vial of In-111. The activity was 5.210 millicuries at the time of shipment but has since decayed to approximately 1.154 millicuries. It was offered for shipment on December 8, 2023, for delivery to a customer in Clovis, CA on December 11, 2023. Upon failure to arrive, the licensee contacted the carrier and was informed the package was currently unaccounted for. Item Number: IL230035 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
As of 1/11/2024, the package is now back at the pharmacy and in storage for decay. The package did eventually arrive at its intended location but was then sent back to the pharmacy. The inner packaging was damaged but the vial containing radioactive material was undamaged. This matter is now considered closed. Notified R3DO (Orlikowski), and NMSS via email. | ||
| ENS 56712 | 1 September 2023 05:00:00 | Agreement State | Missing Packages | The following information was provided by the Illinois Emergency Management Agency (the Agency) email: The Agency was notified after hours on September 1, 2023, by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of three radiopharmaceutical packages missing in transit. This is in addition to the four previously reported missing shipments (See EN56682, EN56697, and EN56701). All three were shipped on August 24, 2023, and marked as 'missing' by the common carrier on September 1, 2023. The last known location was the (common carrier) Indianapolis transfer hub on August 24, 2023. Indiana contacted the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS) and reported at least two of these packages were located in an Indiana landfill and were recovered by their responders. (One of the two packages recovered from the landfill is for a previous event, See EN56701). This investigation is ongoing. The radiopharmaceutical packages were offered for shipment on August 24, 2023, for delivery to three customers (Nuclear Medicine Associates in Redding, CA; Cardinal Health in Southfield, MI; and RLS USA INC - New Orleans in Harahan, LA). The Nuclear Medicine Associates package contained three 14.3 mCi vials of I-123; the Cardinal Health package contained one 4.1 mCi vial of In-111 and the RLS package contained one 4.1 mCi vial of In-111. Activities are those at time of shipment. Information available at this time indicates the Nuclear Medicine Associates package and at least one other package containing In-111 (see EN56701) were located at a landfill by State of Indiana officials. NMED report number: IL230023 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 47608 | 14 January 2012 06:00:00 | Agreement State | Agreement State Report - Missing Then Recovered Thallium-201 Source | On January 17, 2011 the licensee's radiation safety officer called (the state) to advise that a portion of a shipment of radiological material to be used for medical purposes had not arrived at its intended destination. A package containing two doses of Thallium-201 of nominally 20 milliCi each was picked up by the Texas licensee, Pan Handle Nuclear, on January 14, 2012 in Amarillo. However, the package showed signs of repaired damage and when inspected, the third dose of Thallium-201 was missing from the package. The manufacturer was alerted on the morning of January 16th and they subsequently contacted the carrier, regarding the package. HazMat Personnel from (the shipping company) conducted a trace of their facilities associated with the transfer which resulted in the missing vial being identified as 'found' in the Memphis 'Over goods' holding area. Apparently, the package had become damaged early in the morning on January 14th during the shipping process such that one of the three vials had escaped the packaging. The damage to the package was noted and repaired, however an accurate count of the contents was not conducted and, contrary to standing instructions from the manufacturer, the package was forwarded to the intended recipient rather than being returned to the manufacturer. The 'missing' vial was subsequently found on the same day later that morning, some hours after the package was processed through the Memphis hub. The vial was identified as hazardous based on the trefoil which appeared on the shielded and intact container and the manufacturer's name. It was isolated and placed into an over pack that same day. The slightly damaged, but intact shielded container was then returned to the manufacturer as of January 18, 2012 after it was determined to be the 'missing' third vial. Surveys of the returned vial conducted by the manufacturer showed that there was no external contamination on the shielded vial, there was no damage to the vial and all the expected material remained present. Illinois Item Number: IL 12004 | ||
| ENS 41521 | 24 March 2005 06:00:00 | Agreement State | Missing Shipment of 105 Brachytherapy (I-125) Seeds Totaling 66 Millicuries | GE Healthcare, also known as Medi Physics, reported that a package of radioactive material had not been received as expected by Northwest Arkansas Medical Center in Springdale, Arkansas. The package, which contains 105 brachytherapy seeds, was to be delivered on Monday March 21, 2005. The seeds contain approximately 0.63 milliCi of activity each, with a total package activity of 66 milliCi. The maximum radiation level on the surface of the package is less than 0.5 milliR/hr. The material was sent via FedEx on Friday March 18 and received at the FedEx facility in Tulsa, Oklahoma on March 19. No further information has been logged since. Medi Physics' customer service group has begun their investigation. The Arkansas Division of Radiation Control has been advised of the situation. IL report number: IL050022
The State of IL, Division of Nuclear Safety, called to indicate the missing package containing 105 brachytherapy seeds was located in the Fed Express facility in Arkansas. The package, which was estimated to be found about 11:30 EST on 3/25/05, was intact and in its original condition. The licensee believes the missing package was in the possession of Fed Ex at all times, with no third party intervention. The brachytherapy seeds are being returned to G.E. Healthcare to determine that all seeds are accounted for and to further investigate how the package was lost within the Fed Ex system. Notifications were given to R3 (Kozak), NMSS (Moore), and TAS (Sandler). |