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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 52565 | 17 February 2017 23:30:00 | Agreement State | Agreement State Report - Missing Tritium Source and Depleted Uranium Disks | The Wisconsin Department of Health was notified by phone at 5:30 PM on February 17, 2017 that the licensee has lost components of a radio-synthesis device containing approximately 70 Ci of Hydrogen-3 and 20 grams of Depleted Uranium in the form of uranium tritide (UT3) discs. More than three years ago, the licensee had packaged the material and placed it into a metal drum while a disposal option was to be determined. The drum was stored in a restricted area near the licensee's incineration facility. A week ago the licensee was preparing to repackage the material in order to transfer it for final disposal. The drum was found to be empty when opened. The licensee has search all facilities used for radioactive material storage and reviewed disposal records; but has been unable to account for the material. At this time the licensee suspects that the material was incorrectly disposed of in either a non-hazardous waste stream or incinerated within the last three years. The department has started an investigation to determine the most likely disposal pathway and the exposure impact. Site visits and updates will (be) perform(ed). Event Report ID No.: WI170003
The licensee has performed a preliminary investigation and concluded that it is unlikely the loss of material was malicious. The licensee has already begun an impact assessment for the potential incineration of material, and Wisconsin DHS has coordinated with the licensee on what actions need to take place going forward. Inspectors will be performing an on-site inspection to further gather information. Notified R3DO (Jeffers) and NMSS Events Notification group 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 | ||
| ENS 44917 | 19 March 2009 05:00:00 | Agreement State | Agreement State Report Involving Improperly Packaged Material | The following information was received from the State of Wisconsin via fax: On March 19, 2009 the department received a telephone notification that UW-Madison had received a Yellow II package that exceeded the limits of the external radiation levels permitted for this type of package. The RSO stated that the contents are two sealed sources of Cs-137 with a combined activity of 52 millicuries. The package was not delivered to the Radiation Safety Officer, but was shipped directly to the University calibration lab on March 18, 2009 and received about 3:30 pm. Alarms went off at the loading dock and the calibration lab when the package was delivered. The (transportation index) TI on the package stated 0.2, however, the radiation levels at one meter were 20 mR/hr. The highest reading on contact was 0.9 R/hr. The licensee wipe tested the package and found no removable contamination. The package has been placed in a secured area and has not been opened. The RSO has contacted the shipper's contact person at LAC + USC and the courier. The package is approximately 10 inches x 10 inches x 10 inches in size. The State of Wisconsin will continue to monitor the situation, provide assistance as needed to address any jurisdictional issues, and perform independent dose assessments as the public dose limit may have been exceeded. Wisconsin Event Report ID No.: WI09004
The following information was provided as an update via fax: On March 19, 2009 the department received a telephone notification that UW-Madison had received a Yellow II package that exceeded the limits of the external radiation levels permitted for this type of package. The RSO stated that the contents are two sealed sources of Cs-137 with a combined activity of 52 millicuries. The package was not delivered to the Radiation Safety Office as required, but was shipped directly to the University Calibration Lab on March 18, 2009. It was received and signed for at the Wisconsin Institute for Medical Research (WIMR) loading dock at around 9:00 am and delivered to the calibration lab at 9:52 am. An area monitor in the lab shipping/receiving room alarmed when the package was delivered. A student worker immediately notified the Technical Director of the UW Calibration Lab. The Director used a meter to identity the package and noted that the exposure rate on one package exceeded 50 mR/hr on contact. The package was placed on a cart and transported to a secure location. The TI on the package stated 0.2, however, the radiation levels at one meter were 20 mR/hr. The highest reading on contact was 0.9 R/hr. The package was approximately 10 inches x 10 inches x 10 inches in size. The licensee conducted a thorough wipe test and confirmed that there was no removable contamination on the outside of the package. He then left a message for UW Safety. The call was returned about noon and the Safety Office staff arrived around 2 pm. The RSO and Assistant RSO concluded that the two sealed sources were outside of the lead shielded container due to the high radiation readings on contact with the package. The RSO called the shipper's contact person named on the shipping papers at LA County, University of Southern California and the courier. The individual who had prepared the package stated that the package must have been opened either in transport or by the Calibration Lab. The UW-Madison RSO emphatically stated that the package had not been opened. The State of Wisconsin was notified on the morning of March 19, 2009 and made an immediate notification to the NRC Operations Center. Contact was established with the California jurisdiction for the shipper/licensee in order to facilitate contact with the licensee's radiation safety office. The State of Wisconsin inspector made arrangements to be present on the morning of March 20, 2009 to monitor and video the package opening. On March 20, 2009, the Director of the UW Radiation Calibration Laboratory carefully opened the package and conducted multiple wipe tests to assure there was no contamination inside the package. The package contained an open lead pig. The sources were loose in the box. One source was located under the bottom of the styrofoam tray and one source was stuck in the styrofoam tray. There were multiple problems with the packaging, markings and shipping paperwork. The main problems were that the lead pig was not adequately taped shut and the inner packaging was not sufficient to hold the pig in place, thus, the pig moved about in the package. It does not appear that this was an approved shipping container. The sealed sources were wipe tested and were not leaking, however, the Director would like to take a closer look at the sources to assure that they were not damaged. The State of Wisconsin will continue to monitor the situation, provide assistance as needed to address any jurisdictional issues, and perform independent dose assessments as the public close limit may have been exceeded. Notified R3DO (Ring) and FSME (Camper). | ||
| ENS 44429 | 19 August 2008 05:00:00 | Agreement State | Agreement State Report - Fire in Research Laboratory | This information was received from the state via fax: The afternoon of 8/19/2008 DHS (Department of Health Services) staff became aware a fire had occurred at a licensee facility the previous evening. Reports indicated the local fire department and hazardous materials teams had responded to a fire in a molecular biology lab on the campus of the University of Wisconsin - Madison. The fire was extinguished within 15 minutes. Reports also indicated the Hazardous Incident Team used instruments to rule out the presence of any radioactive materials. Although no contamination was detected, fire equipment was rinsed with water to remove any reside from the fire. DHS contacted the licensee. The licensee indicated staff members from radiation safety had responded to the incident the next morning. The research lab performs molecular biology research using P-32. The safety department staff performed surveys of the fire scene and identified areas of contamination on the floor. The areas had been decontaminated. Initial information from the licensee indicates approximately 0.5 to 0.7 millicuries of P-32 in waste containers was involved. The licensee did not report the incident to DHS. DHS inspectors were dispatched to investigate. | ||
| ENS 44353 | 14 July 2008 05:00:00 | Agreement State | Agreement State Report - Medical Event Due to Dose Less than Prescribed Dose | The following report was received from the State of Wisconsin via facsimile: On 7/14/2008, a patient was simulated and treatment planning performed for High Dose Rate (Ir-192) partial breast irradiation to the right breast using a Contura (SenoRx) balloon. The authorized user prescribed a dose of 3.65 Gy per fraction x 9 fractions for a total dose of 32.85 Gy to the Planning Target Volume. After the planning was done, the length of each of the five catheters was measured by the Nucletron Source Position Simulator. The readings were found to be 1154 each. The treatment file in the High Dose Rate treatment console was modified from its default value of 1500 to 1154 and patient was treated. The patient was treated in the High Dose Rate machine located in Room 'A'. On 7/15/08, the patient was scheduled to be treated in the High Dose Rate machine located in Room 'B'. Since the sources are different in activity, total time check was performed, at which time, the medical physicists also compared the measured lengths with a second patient under treatment with the Contura balloon in Room 'B'. At this point they noted the difference in the measured lengths between the two cases. The medical physicist checked the Source Position Simulator and noticed that there was an obstruction at the 1154 reading. The review of the actual delivered dose during the first fraction revealed that the source did not enter the patient's body and thus the negative impact was mitigated. A small region of the skin surface received some radiation dose, but the clinical impact is insignificant. The incident was immediately reported to the primary Radiation Oncologist and the Authorized User. The licensee states that no long-term, permanent side effects are anticipated as a result of the medical event. Due to the licensee's investigation of the Source Position Simulator revealing that a welded junction in the cable of this measuring device was kinked, it was immediately replaced with a new one. The licensee has also developed a new Quality Assurance form which will be exclusively used for Contura balloons and which incorporates the expected length for the five catheters. Department of Health Services (DHS) staff have been dispatched to investigate this incident. Wisconsin Report Number: WI080017 A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. | ||
| ENS 41576 | 8 April 2005 14:30:00 | Agreement State | Potential Medical Event Involving a Therapeutic Administration of Yttrium-90 | The licensee provided the following information via facsimile (licensee text in quotes): On Friday, April 8, 2005 at approximately 8:30 a.m., the Wisconsin Radiation Protection Section (RPS) received notification from the University of Wisconsin, Madison, WI (license number 25-1323-01) of a potential medical event involving a therapeutic radiation dose from a Yittrium-90 Zevelin treatment in which the delivered dose may have differed from the prescribed dose by more than 0.5 Sv (50 rem) and by 20% or more of the prescribed dose. (HFS 157.72 (1) (a) 1.) On Tuesday, April 5, 2005, a physician at the University of Wisconsin Hospital and Clinics, Madison, WI administered a 48 mCi dose of Y-90 Zevalin to a patient. Based upon patient weight and platelet count, the intended dose should have been 28 mCi. The dose was dispensed as a unit dose by a nuclear pharmacy and administered as received. There is no indication of a written directive. The error was not discovered until Thursday, April 7 during a licensee review of records. The licensee is investigating the incident. The ordering physician has been notified HFS 157.72 (1) (a) 1. requires a licensee to report an event in which the administration of radioactive material or resulting radiation results in 'A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem), 0.5 Sv (50 Rem) to an organ or tissue or 0.5 Sv (50 rem) shallow dose equivalent to the skin and the total dose delivered differs from the prescribed dose by 20% or more'. DHFS, RPS staff plan to investigate. |