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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 42770 | 4 June 2002 04:00:00 | Agreement State | Agreement State Report - Defective Packaging of Radioactive Material Shipment | The State provided the following information regarding a previously unreported event via facsimile: On June 4, 2002, the surface and 1 meter radiation dose rates from a package containing 8 curies of phosphorus-32 (P-32) was found to be 1 R/hr at the surface and 4 milliR/hr at 1 meter. The package had a Yellow II label affixed which has a surface dose rate limit of 50 milliR/hr and a dose rate at 1 meter of 1 milliR/hr per Massachusetts regulation 120.775(A)(1). There was no removable contamination on the package hence the inner container appeared to be intact. However, the inner container appeared to be loose in the packaging rather than in the fixed geometry as evidenced in other similar packages in the same shipment. The package dose rate at the surface is greater than 0.2 R/hr but less than 0.01 R/hr at 1 meter hence the package exceeded the requirements of a Yellow III. In summary the defective packaging resulted in a radiation field at the surface of the package in excess of the limit for a common carrier and the Yellow II label on the package. The licensee has suspended all shipments from this supplier until the investigation of the package failure is complete. The root cause investigation of this event by the licensee has been postponed until September with the approval of the Massachusetts Radiation Control program pending decay of the radioactive material and adherence to the Perkin Elmer Life Sciences ALARA policy. A preliminary investigation concluded that persons handling the package during shipment would not have received a significant radiation dose because of the limited area of the package in excess of Yellow Il limits and the limited time of handling package by transportation personnel. UPDATE Excessive radiation field is due to seepage of radioactive material from cracked glass vial. There is a metal cap used to seal the vial. The metal cap is fastened using a hand operated crank. This tool can be mishandled resulting in over-tightening of the cap and causing the glass to crack. This vial, cap and tool are provided by Perkin Elmer and the firm is familiar with this potential failure mode. Root cause: improper training or supervision of operator of capping tool. Licensee informed vendor that supplies the glass vial and have discontinued using this vendor. This event is closed by the state |