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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 50902 | 26 February 2015 05:00:00 | 10 CFR 20.2201(a)(1)(i) | Molybdenum-Technetium Generator Lost During Shipment | A Mo-Tc Generator was sent to Baptist Hospital in Miami, Florida. The generator was used for approximately 2 weeks before being shipped back on 1/18/14. It was picked up by the common carrier on 1/19/14. The Mo-Tc generator did not make it back to the Mallinckrodt facility. A search was initiated at the Mallinckrodt facility and Baptist Hospital. When the Mo-Tc generator could not be located, it was declared missing on 2/26/15. The generator is approximately 65 lbs. total and contains 8.1 mCi of depleted uranium-238. The shield was stamped with the number 2116. 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 49695 | 6 January 2014 14:13:00 | 10 CFR 20.2201(a)(1)(i) | Molly-Tech Generator Lost Source During Shipment | The Mo-Tc Generator (Mallinckrodt Tracking number 2241132 on box and generator, and DU (Depleted Uranium) number 4283 stamped on DU shield) was offered for shipment on 27DEC13 to courier (common). The generator was sent to customer Pharmalogic MT Inc in Missoula, Montana. The customer did not receive the generator and contacted Mallinckrodt (on December 28, 2013). A search was conducted and on 06JAN14, (common carrier) informed Mallinckrodt that they believe they did not have the generator of concern at any of their sites. Typical shipment routing is from Maryland Heights, Missouri to St. Louis Lambert airport to Memphis, Tennessee. After Memphis we (Mallinckrodt) are not aware if a second stop occurs prior to arrival in Missoula, Montana. Mallinckrodt conducted an onsite search and was not successful at finding the generator. At time of shipment, the generator activity was 11 curie of Mo-99, and 8.1 mCi of depleted Uranium-238. The shipping box read 10.9 mR/hr on contact with the outer surface. Estimated on contact exposure rate levels on the outside of the generator at time of shipment was 180 mR/hr. At time (06JAN14) of declaration of the generator being lost, the activity levels were estimated to be 882 mCi of Mo-99, 882 mCi of Tc-99m, and 8.1 mCi of depleted U-238. Estimated exposure rate levels were 0.9 mR/hr on the outside surface of the shipping box, and 14 mR/hr on the outside surface of the generator. This event was also reported to Ken Lambert (Voice Mail), NRC Sr. Health Physicist in Region III. During shipment pickup on December 27, 2013 by the common carrier , the package did not get properly scanned into the common carrier tracking system, and no shipping Bill of Lading, Air Way Bill number, or shipping documentation of any sort was provided to the shipper and was attributed to a new common carrier employee.
On 27DEC13 (Day of initial event), another generator that day was shipping to Cardinal Health in Pompano Beach, Florida. Numerous changes were made to generator orders over the holiday due to reduced pharmacy needs. This particular customer has their standing order for their generator flown on American Airlines on a standing order basis every Friday. Any other orders they want would ship (common carrier). They made changes to their generator for the 27th which resulted in this particular order defaulting to their (common carrier) routing. When the generator for Pompano Beach was processed on the 27th their routing for this generator was (common carrier). When a generator is routed (common carrier) the DG (Dangerous Goods) statement and the label will generate automatically when it is processed at the drop station which is what happened here. The technician noticed that this particular order goes American every Friday and changed the order to ship with the airline. The (common carrier) paperwork was not pulled and another technician mistakenly put the (common carrier) label on the Missoula, MT generator. We know this by looking at the history of the order for Pompano Beach. It shows it being processed as a (comon carrier) order but the route being changed to ship with American. The generator then shipped down to the (common carrier) facility in Pompano Beach where it remained until Friday 10JAN14 when it was reported to Mallinckrodt. Notified R1DO (Rogge), R3DO (Skokowski), R4DO (Kellar) and FSME Events Resource via 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 |