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STATUS: new & closed Licensee: STL Seattle (STL) City and state: Tacoma, Washington License number: R-0158 (a General Licensee) Type of license: N/A - receipt of generally licensed gas chromatography cells from manufacturer or equivalent. Date of event: July 31, 2003 - date of licensee notification letter to DOH (date of actual event is unknown). Location of Event: Severn Trent Laboratories Inc., dba STL Seattle. 5755 8th Street East, Tacoma, Washington 98424 ABSTRACT: STL Seattle sent DOH notification dated July 31, 2003 of a lost GC detector cell, foil source. The letter was received August 4, 2003. In the letter STL Seattle reported a missing 555 megabecquerel (15 millicurie), Nickel 63, foil source, Serial Number A5447 that was assumed to have been in a Varian ECD cell. The cell had been sent to a DOH specific licensee that is licensed for GC repair work. A technician at the GC-repair licensee discovered the missing foil source. The GC-repair licensee notified STL of the missing source. STL performed a thorough search of the lab but could not find the missing foil.

DOH contacted both STL and our GC-repair licensee after receipt of the letter. The Operations Manager at STL, (DELETED), who was the event reporter, could not initially be contacted. DOH did reach him for discussion two weeks later. DOH contacted our GC-repair licensee shortly after receipt of the notification. The GC-repair RSO mentioned that the ECD cell received from STL was an older cell that looked like it had never been used. The cell showed severe corrosion, which indicated that this cell had been in storage for a long time. The cell came in a box and was broken. The GC-repair RSO stated that the foil in these cells could fall out or removed easily, if the cell had been opened or if the ceramic portion of the cell was broken. This cell had a broken connector when received by the GC-repair licensee. The GE-repair RSO said that the cells can become loose in the Varian device and can break at the ceramic connector, which may have happened when someone attempted to remove it from the GC device. A tool is needed to remove the source from a cell in normal condition. The GC-repair RSO said that the cell didn't look like it had been tampered with in a purposeful manner. The GC-Repair RSO contacted (DELETED) when it was determined that the source was missing. They discussed the event in detail and (DELETED) was reminded, per the terms of GL device receipt requirements that they were not allowed to perform activities involving removal of sources. (DELETED) had recently taken over the program at STL Seattle. (DELETED) was further reminded of his record keeping responsibilities and the other limitations of receipt of GL GC detector cells. When DOH talked with (DELETED) he confirmed that he had spoken with the GC-repair RSO and had been made aware that the source was missing after the cell had been received. The cell had not been used for a few years. A person, no longer employed by STL Seattle, was thought to have worked on the cell. He had not worked for the company in over a year. (DELETED) thought that any work done on the cell would have been a year or two previous to this individual leaving. He did not know if this work had included removing the foil from the cell. (DELETED) stated that when he had been informed of the missing radioactive source, staff at STL performed a search of the lab. He stated that they have a Geiger counter, but were not able to find the source. DOH re-informed (DELETED) that they are not licensed to perform source work on cells, (DELETED) agreed. He stated that this won't happen again . (DELETED) stated that STL management oversight of lab activities had recently been improved. DOH issued an item of noncompliance to STL that was categorized as a Violation, for their failure to keep licensed radioactive material secure. DOH did not perform an on site investigation and no media attention was noted. What is the notification or reporting criteria involved? 10 CFR 20.2201(a)(1)(ii) 30 days. Activity and Isotope(s) involved: 555 megabecquerel (15 millicurie), Nickel 63. Overexposures? Likely N/A but was unable to be determined. This is a lost source: Manufacturer Varian Associates Inc., Model- 02-001972-0, Serial Number 5447. Disposition/recovery? STL was several times reminded of their responsibilities and limitations. Leak test? N/A Vehicle: N/A Release of activity? Loss of 555 megabecquerel (15 millicurie), Nickel 63, foil source. Activity and pharmaceutical compound intended: N/A Misadministered activity and/or compound received: N/A Exposure (intended/actual); consequences: exposure, if any, is unknown; consequences are unlikely. Was patient or responsible relative notified: N/A Was written report provided? Yes Was referring physician notified? N/A Consultant used? No