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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56077 | 17 December 2021 07:00:00 | Agreement State | Lost Radioactive Source | The following information was provided by Oregon Health Authority, Public Health Division, Radiation Protection Services via email: On December 17, 2021, while conducting a semi-annual inventory of radioactive material in possession, a Broad Scope A - Academic licensee found that a gas chromatograph (GC) containing one electron capture device (ECD) missing. The previous inventory was performed in May 2021 and most recent leak test performed in March 2021. (note: after March the lab was shut down during September 2021 for asbestos abatement and ECD marked as `in storage') Upon checking with the device custodian, the GC/ECD device was picked up in July 2021 by the campus surplus property group by request from the custodian for disposal. The device custodian verbally told the surplus property personnel taking the device that it contained radioactive material which they verbally acknowledged, stating they would contact Radiation Safety to remove it. However, this was not done. The licensee performed extensive searches of the lab where the device was housed, surplus property warehouse and campus metals scrap yard with negative results. It is possible the device/source was shipped to a local scrap metals dealer but after contacting the dealer this could not be confirmed. Cause and corrective actions: Primarily, the department in possession of the GC/ECD failed to notify the Radiation Safety Office of the intent to dispose of the device prior to contacting the Surplus Property Office as required by the licensee's Radiation Safety Manual. Secondarily, the Surplus Property Office personnel do not have the training to identify a device that potentially contains radioactive material and minimal, if any, radiation safety training. This resulted in loss of possession of a radioactive source with human error as the cause. Corrective actions include (1) an information bulletin was sent to departments that possess radioactive materials confirming radioactive material control procedures and responsibility for material unless explicitly cleared by Radiation Safety, (2) expanded safety instruction and meeting with surplus personnel to discuss GC/ECD's and other radiation hazards that may come to surplus, and (3) additional placarding of GC/ECD's, X-ray machines, (Liquid Scintillation Counters) LSC's, and sealed sources. Concerns: For many years, the licensee has relied on their rules contained in their Radiation Safety Manual regarding possession/security of radioactive material that are initially reviewed/acknowledged by the departments involved. The subsequent semi-annual inventories also include an acknowledgement of these rules by the department audited. Offering a device containing radioactive material for removal without first contacting the Radiation Safety Office is a violation of these rules. Surplus property personnel receive minimal, if any, radiation safety instruction and none regarding possession/security of radioactive material since the signage and sources are normally removed from the device(s) by the Radiation Safety Office prior to disposal. In addition, surplus property personnel were informed verbally of the radioactive material that was inside the device but failed to contact the Radiation Safety Office. These concerns have been adequately addressed by the licensee's corrective actions. Source: Nickel-63 Activity: 8.7 mCi (nominal 10 mCi on 4-5-01) Manufacturer: Shimadzu Model: VS2000 Serial number: C10893200343 Leak test date: March 24, 2021 Oregon Report Identification Number: 21-0061 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 |