Semantic search

Jump to navigation Jump to search
 Entered dateEvent description
ENS 4938124 September 2013 15:53:00The following was received by the Commonwealth of Massachusetts via fax: On 8/22/2013, Brigham and Women's Hospital (BWH) was involved in a discrepancy in the contents of a shipment of I-125 brachytherapy seeds. The shipment was labeled to contain 71 seeds (as ordered), plus 4 seeds to be used for QC purposes. Upon opening, in preparation for administration, a count of the sources revealed only 70 of the 71 expected therapy seeds. Immediate recount and subsequent survey & investigation of the area, packaging and container showed no indication of the presence of the 71st seed. There was also no evidence of contamination detected. BWH does not believe the 71st seed was delivered. Meanwhile, the supplier, Bard Brachytherapy, Inc.'s (BBI) investigation indicates that the 71st seed was shipped to BWH. The expected 71st seed was a Bard Brachytherapy, Inc., model 125I containing 0.561 mCi (with an apparent activity of 0.330 mCi), with a reference date of 8/17/2013. 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 4886629 March 2013 13:46:00The following information was received via facsimile: The Radiation Safety Officer (RSO) called to report that the quarterly whole body dosimeter for her technician recorded 993 mrem deep, 21,900 mrem to the lens, and 58,000 mrem shallow dose. The technician's finger ring dose was negligible. The technician & RSO have worked for years injecting three to ten cats with I-131 on a monthly basis (approximately 3 mCi per cat) and neither have ever approached such high radiation doses. It is suspected that the dosimeter has malfunctioned or was inadvertently contaminated with I-131. The licensee has requested that the dosimeter manufacturer re-analyze the dosimeter. The Massachusetts Radiation Control Program is investigating.
ENS 455427 December 2009 11:47:00The following information was received from the Commonwealth of Massachusetts via facsimile: On 9/11/09 a package containing 1 mCi of P-32 was received by the licensee Radiation Safety Office, (who then) opened the package to confirm RAM (radioactive material) was in the box, surveyed the package, and then delivered (the package) to the research lab. The research lab signed for the package. One week later the research lab reported to the RSO that the package did not contain the ordered P-32. A search of lab, adjacent labs, and waste removed from the lab did not locate the missing radioactive material. MA Docket Number: 10-8699 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 This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source
ENS 4362610 September 2007 12:46:00The State provided the following information via facsimile: Licensee received routine shipment of Am-241 button sources from supplier in China - Shenzhen CIC in Shenzhen, China on August 15, 2007. Shipment was sent via China Air from China to New York, and then transported by air to Boston. In Boston, it is then trucked via Ground Control and arrived at the licensees facility in Burlington, MA. The licensee estimates the package was sent from China sometime after July 25, 2007. The excepted package (UN2911) was damaged when it arrived at the licensees' facility. At this time the licensee confirmed there was no contamination nor high radiation levels from the package. This package is normally not opened as it is forwarded to a customer for use in smoke detectors. On August 31, 2007, before forwarding the package, the licensee opened the package to verify its contents. The licensee discovered that 2 vials from the package were missing. Each plastic vial contains 500 Am-241 button sources, each 0.8 microCi nominal activity, for a total of 0.4 milliCi total in each vial. The licensee immediately notified their transport broker and their agent in China. 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source
ENS 4343119 June 2007 14:41:00This Agreement State report from the Commonwealth of Massachusetts was received via facsimile: Cat moved (kicked) during I-131 injection resulting in a couple of drops on veterinarian gloved hands, exam table, and floor. Contaminated Area subsequently mopped which seemed to spread more than clean the area. Contaminated area covered with plastic and access was restricted for more than 24 hours. Inside the room, the highest measurements on the floor, with a Ludlum 44-88 GM, was 12 Mr/hr on one spot, and 2-5 Mr/hr in all other floor areas - all measurements are at 1 cm. There was no personal contaminations and one small spot on a technicians sweatshirt sleeve which measured 15 mR/hr at 1 cm. With the 44-88 GM. All thyroid measurements indicate no internal intake of I-131. Event type Description: Contaminated Area restricted for more than 24 hours. Cause of Description: Cat moved (kicked) during I-131 injection resulting in a couple of drops on veterinarian gloved hands, exam table, and floor. Contributing Factor: Contaminated Area subsequently mopped which seemed to spread more than clean the area. Docket No.: 06-7113
ENS 433341 May 2007 13:37:00The State provided the following information via facsimile: Licensee received Type A package containing 100 millicuries of Na-22 from Los Alamos National Lab. External Radiation measurement of the package on contact was 360 mrem/hr. The TI on the package was listed as 7 (the licensee measured a TI of 8.5). Package was shipped on April 30, 2007 and flown to Boston Logan Airport by Fed Ex, after which it was trucked by Fed Ex to the licensee site at 331 Treble Cove road in Billerica, MA. The licensee has informed Fed Ex of the external radiation measurements.
ENS 4277515 August 2006 14:33:00The State provided the following information via email: Licensee received an 'empty' lead pod with exterior contamination of 1.3 E-5 microCi/cm2. Contamination identified as Cs-137. Shipment came from Thermo Electron, 1410 Gillingham Lane, Sugarland, Texas via Conway Trucking. Licensee informed Conway Trucking of the contamination.
ENS 4277315 August 2006 13:24:00The State provided the following information regarding a previously unreported event via facsimile: S-35 (7 mCi) package was shipped via FedEx, from PerkinElmer in Boston, MA on 1/30/06. FedEx tracking indicates 1) the package was picked up from PerkinElmer in Boston, MA; 2) the package left the FedEx South Boston station; 3) the package arrived at FedEx Hub in Memphis, TN; 4) the package had an In-transit scan to Montreal on 1/31/06. There were no package scans after that. PerkinElmer Canadian Customer Service reported the customer did not receive the package. PerkinElmer asked FedEx several times to locate the package. PerkinElmer receiving department did not receive the package as a return and verified with the customer, again, that the package was not received. FedEx was unable to locate the package. PerkinElmer declared the package as lost on February 12, 2006, and reported to the Agency (MA Radiation Control Program) by phone on March 10, 2006. A written report was received to the Agency on April 10, 2006. Corrective action: PerkinElmer advised FedEx that all radioactive shipments require a Proof of Delivery; this issue has been escalated to FedEx Dangerous Goods Administrator; and a letter was sent to FedEx explaining the requirements of delivering radioactive packages. 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.
ENS 425629 May 2006 08:48:00The following information was received from the state via fax: Cause Description: During Clean-Out of Deceased Dermatologist, the family discovered a box with Ra-226. About 11/1/2005: (Deleted) contacted the Boston Regional (Office) of the EPA to dispose of Ra-226 discovered at family home. EPA recommended to (Deleted) that it would be cheaper if he disposed of the Ra-226 directly via a waste broker. EPA suggested Radiac Environmental Services of Brooklyn, NY. 11/17/2005: Radiac (Environmental Services of Brooklyn, NY) visited the Milton, MA residence and estimated that the amount of Ra-226 was about 2.9mCi. In addition, Radiac placed the box of Ra-226 sources into a 5-Gallon DOT Type A steel drum with a ring bolt closure, placed a security seal was placed over the ring, and labeled the drum with yellow/magenta radioactive label. (Deleted) was going to Florida for the winter. 4/27/06: The EPA informed the Mass. Radiation Control Program about the Ra-226 in Milton, MA. Corrective Actions: Material to be disposed of by licensed broker - Radiac Environmental Services of Brooklyn, NY - during the week of May 8, 2006.
ENS 423833 March 2006 14:30:00The Commonwealth of Massachusetts submitted the following report via e-mail: A shipment of 23 devices was scheduled for delivery to a customer in Georgia. AIT Worldwide Logistics, the contract freight forwarder, acknowledged receipt of the 23 devices on September 14, 2005 from GE Ion Track. On Sept. 19th, 2005, when the truck checked into the forwarder's final distribution hub, the shipment was noted to be 2 devices short. The freighter forwarder conducted searches of its distribution centers, and was unable to locate the devices. GE Ion Track performed a thorough search of their Wilmington, MA facility and the devices were not located. GE Ion Track's and its subcontractor's database showed that the devices had not been transferred to another customer or recipient. GE Ion Track discovered that these sources were missing on January 24, 2005 and made notification to the Massachusetts Radiation Control Program on January 30, 2006. The customer in Kuwait and Georgia compared the shipping list to what they received and it was determined that the two missing devices are: 1) Vapor Tracer 2, serial number 120014, source number 09-13171 2) Itemizer 3, serial number 20566, source number 09-13480 Each device contained an 8 mCi source of Ni 63 in a foil form, model NER 004 manufactured by Isotope Products Laboratories. GE Ion Track has concluded that the devices were lost in shipment. As a preventative measure, freight forwarders and transport companies will be asked to verify quantity before accepting shipment from GE Ion Track. MRCP will be visiting the licensee on Monday March 6, 2006 for investigation. The missing sources were originally reported in a lost voice mail message to the Massachusetts Radiation Control Program on 1/30/2006. The state verified the loss on 3/3/2006. 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. This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source
ENS 4114322 October 2004 15:26:00Patient scheduled to receive template-guided transperineal prostate interstitial brachytherapy for clinical localized prostate cancer was to receive 72 I-125 seeds, instead received 47 seeds resulting in underexposure of greater than 20%. The cartridges carrying 15 seeds each were loaded into a 'Mick' applicator. Transrectal ultrasound was used for localization of the prostate and implant needles; fluoroscopy was used very little during the procedure to minimize staff exposure. As each seed was injected into the prostate, it was recorded both on paper and in computer system and final tabulation was 77 seeds were implanted. However, x-rays taken after the procedure showed only 47 seeds had been implanted, although distribution appeared satisfactory.
ENS 4277415 August 2006 13:24:00The State provided the following information regarding a previously unreported event via facsimile: The Agency (MA Radiation Control Program) received a report on 6/23/03 of a misadministration; ie., The wrong area of the scalp was treated during a treatment for a superficial scalp cancer. The wrong area of the scalp was treated because of a malfunction with the source position simulator. The misadministration was not noticed during the treatment period of May 12, 2003, thru June 5, 2003. It was discovered on June 23, 2003 while doing a similar procedure. After the source position simulator malfunction was detected, all cases that used this same device were reviewed and it was determined that only the last patient treatment was affected by this malfunction. Corrective actions were implemented to ensure this event will not happen again. Corrective action 1. Licensee reviewed all cases that involved the same device and determined that the only patient affected by this malfunction was the last one treated before discovery. 2. All HDR treatments involving variable length catheters will have the length of the catheters measured by 2 independent means. 3. The HDR manufacturer was notified of the problem encountered with the catheter measuring device.
ENS 4277215 August 2006 10:01:00The State provided the following information regarding a previously unreported event via facsimile: By letter dated 1/28/03, Level 1, Inc. notified the Agency (MA Radiation Control Program) of the loss of a GL device. The device was an NRD air deionizer model number P-2021-0101, serial number 109646 which was shipped to the licensee on March 3, 1999. The device was used to de-ionize air during their clean-room assembly process. The device was taken out of service in March of 2002. When units are taken out of service the licensee stated that the devices are stored in a cabinet. The licensee discovered that the device was lost when they sent back all devices (30) in the program that were beyond their usefulness. They had 31 and could not account for one device when they were going to send the devices back. The device was discovered to be lost in December 2002. They have tried unsuccessfully to locate the device. They believe that it may still be in their facility and will continue to locate it. In order to prevent future losses, the licensee has implemented a Preventive Maintenance (PM) Program and have included all air deionizers as part of the PM program. The PM program will consist of a computer program that tracks all devices that are to be accounted for in the company for maintenance. The GL devices will be added to the list. The devices had 10 millicuries of Po-210 loaded in March of 1999. With the 138.38 day half life of Po-210, the device contains about 6 microCuries at this time. The safety significance is low for this lost device. Corrective action In order to prevent future losses, the licensee has implemented a Preventive Maintenance Program and have included all air deionizers as part of the PM program. The PM program will consist of a computer program that tracks all devices that are to be accounted for in the company for maintenance. The GL devices will be added to the list. EVENT CLOSED BY STATE. 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.
ENS 4276915 August 2006 10:01:00The State provided the following information regarding a previously unreported event via facsimile: A fire, which started in garage/storage facility, at a golf course construction site near the summit of a former city landfill was allowed to burn for two days by the local fire department. However, during the fire and immediately after the proximity of the device storage shed was disclosed by the licensee to the local authorities, the City of Quincy Fire Department summoned the Agency (MA Radiation Control Program) to the scene. At the scene the Agency representative was able to overview the situation, to take measurements and to advise the fire officials that the radiological device in the nearby stage shed was neither an immediate or imminent health or safety hazard. On the third day, the Agency representative (and) the licensee Radiation Safety Officer (RSO) were allowed by the Fire Chief to enter the separate device shed with instrumentation and to retrieve the device. The device was located with appropriate instrumentation, separated from the rubble and stored securely elsewhere on-site. Surveys were subsequently conducted to release the remains of the storage shed. The manufacturer of the device was engaged by the licensee to come to the job site to confirm recovery of both Cesium-137 and Am-241:Be sealed sources; to conduct appropriate leak testing and leak test analyses; and to package, mark and label the 55 gallon drum for shipment to the manufacturer's headquarters. Leak test results disclosed no apparent leakage of material from either sealed source. These sources were packaged on August 22, 2002, and the shipment was secured on-site in a vault pending completion of attendant paperwork, obtaining the certificate of compliance for the shipping container, and arranging for the transportation pickup of the hauler. Event closed by state.
ENS 4277015 August 2006 10:01:00The 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
Retrieved from "https://kanterella.com/Special:Ask/-5B-5BOriginated-20by::Mike-20Whalen-5D-5D-20-5B-5BCategory:ENS-20Notification-5D-5D/-3FEntered-20date/-3FEvent-20description/mainlabel%3D/order%3Ddescending/sort%3Dstart-20date/offset%3D0/format%3Dtable/searchlabel%3DOpened:/default%3DOpened*:"