Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 56148 | 6 October 2022 10:16:00 | The following information was provided by the MA Department of Public Health (the Agency) via email: On 10/05/2022, at 1230 (EDT) , a telephone report was received by the Agency that two discs, each measuring 1.5 inches in diameter and each determined to be containing 0.024 mCi Ra-226 (0.048 mCi total), were found within a load of residential trash picked up in Milton, MA. Each disc measured 6 mR per hour at 3 inches from surface. The discs reportedly did not have any identifying information or markings (no manufacturer name, no date, no serial number) other than 'poison inside'. The discs were placed in secure storage until proper disposal is arranged and completed. The discs are currently presumed to have been inadvertently and unknowingly abandoned by owner. Investigations by the Agency and by Covanta Braintree Transfer Station are ongoing. The Agency considers this matter still open. MA Event Number: to be announced (TBA) 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 56034 | 5 August 2022 16:56:00 | The following information was received from the Massachusetts Radiation Control Program (the Agency) via email: Licensee reported employee weekly finger ring exposure exceeding 50 rem (67.569 rem for wear period, 7/4/22-7/10/22) a situation reportable within 24 hours per 105 CMR 120.282 (B) (1) (c). The other finger ring dosimeter worn by the subject employee received 31.509 rem exposure for same wear period. Exact cause of exposure not yet known. Licensee investigation ongoing. Licensee, a radiopharmaceutical manufacturer/distributer, stated that subject employee does perform work involved with F-18 radiopharmaceutical manufacturing operations. The Agency considers this matter still open. MA Event Number: 20-5102
On August 17, 2022, An Agency investigation was performed at the PETNET facility. The inspector determined that the root cause of the event was insufficient training of staff. The licensee submitted sufficient corrective actions to prevent recurrence. The Massachusetts Radiation Control Program considers this incident closed. Notified R1DO (DeFrancisco) and NMSS (email). |
| ENS 56029 | 4 August 2022 11:27:00 | The following information was received from the Massachusetts Radiation Control Program (the Agency) via email: On 8/3/2022 at 1444 EDT, the licensee reported (to the agency (MA Department of Public Health Radiation Control Program)) a medical event for Sirtex Wilmington LLC SIR-Spheres Y-90 microspheres (SS&D MA-1229-D-101-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more. A portion of a two-site Y-90 16.2 mCi microsphere therapy treatment delivered to the patient liver on 8/2/22 remained in the delivery system causing delivery of 12.7 mCi Y-90 of the prescribed 16.2 mCi. The error was discovered the next morning during final post-treatment calculations. The administered dose to the treatment area differed from the prescribed dose by 21.6 percent. The licensee stated that the cause, including possible equipment malfunction, has not yet been determined. The prescribing physician and referring physician have been notified. The physician is to notify the patient (not yet confirmed). The licensee stated no negative health effects to the patient due to the situation. No additional Y-90 therapy treatment is expected due to this situation. The licensee stated that all Y-90 was accounted for. The licensee is to submit a written report within 15 days of discovery date. This is a next day reportable medical event per regulation. Investigation is ongoing. The agency considers this event docket to still be open. MA Event Number: TBD 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 56030 | 4 August 2022 16:06:00 | The following information was received from the Massachusetts Radiation Control Program via email: QSA Global reported via telephone at 1400 EDT on 8/4/2022 (to the agency (MA Department of Public Health Radiation Control Program)) that a 6/30/2022 shipment from Australia, containing thirty-two Ir-192 sealed sources totaling 134 Ci and two Se-75 sealed sources totaling 8.38 Ci, was missing in transit. The shipment departed from Sydney, Australia (SYD) via Qatar Airways on or about 7/1/2022 and arrived at Chicago O'Hare International Airport (ORD). QSA Global stated last known (scanned) location was at ORD on 7/20/2022. QSA Global was informed that shipment was missing at 1345 EDT on 8/4/2022. This shipment included three 34x34x40 cm, RQ UN2916, Yellow-II, Type B packages containing Ir-192 with a Transport Index of 0.3 DIM, two 49x49x53 cm, RQ UN2916, Yellow-II, Type B packages containing Ir-192 with a Transport Index of 0.2 DIM, and one 25x21x43 cm, RQ UN2916, Yellow-II, Type B package containing Se-75 with a Transport Index of 0.1 DIM, at time of shipment. QSA updated last known location by later stating that the shipment was picked up in Chicago by Forward Air Corporation trucking company on 7/21/22 and arrived in Boston on 7/25/22 (current last known location is Forward Air facility in Boston). This situation is an immediately reportable event per regulation. Search for the missing shipment by Forward Air Corporation is ongoing. The agency currently considers this docket to still be open. MA Event Docket Number: TBD Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, and EPA EOC and via E-mail: FDA EOC, Nuclear SSA, FEMA National Watch Center, and CWMD Watch Desk.
The following was received from the Massachusetts Radiation Control Program via email: Shipment discovered on loading dock at carrier (Forward Air Corporation) facility in Boston 8/4/22. Receiver licensee (QSA Global Inc.) reported receipt of shipment on 8/5/22 and confirmed all six individual package seals were observed to be intact. Notified internal: R1RDO (Henrion), IR MOC (Crouch), and ILTAB (MacDonald), and via email: NMSS (Williams), INES (Smith), NMSS Events Notification, and ILTAB. Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, and EPA EOC and via E-mail: FDA EOC, Nuclear SSA, FEMA National Watch Center, and CWMD Watch Desk. THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf |
| ENS 55606 | 24 November 2021 13:49:00 | The following was received from the Massachusetts Radiation Control Program (the Agency) via email: On 11/17/2021, 1113 EST, the licensee reported 3 packages containing radioactive material were not received at PerkinElmer facility in Groningen, Netherlands. Extensive searches were conducted in Boston, Amsterdam and Zurich. The packages were destined to arrive in Zurich on November 13, 2021. The 3 packages, each with a Transport Index 0.1, were shipped, along with 20 other excepted packages, from Logan International Airport in Boston, MA on 11/12/2021. The transfer of the packages was planned in the following sequence: Logan International Airport, Boston - Zurich - Amsterdam - Groningen, The Netherlands. All 23 packages were received in Zurich on November 13. Only 20 of the 23 packages were recorded as received in Amsterdam. The 3 missing packages were positively identified as the packages labeled as Yellow II with a TI of 0.1 each. The 3 packages contained the following radioactive material: Package 1 had 3 vials of P-32 with total activity of 1.5 mCi, Package 2 had 1 vial of I-125 at 0.160 mCi, and Package 3 had 1 vial of P-32 at 0.800 mCi. Each package was 25 cm x 15 cm x 13 cm in dimension and constructed of white cardboard with Styrofoam packing in shielded vials. A shipping manager at PerkinElmer, Inc., Boston, was first notified via email at 0719 EST on November 17 that the package was not received by the PerkinElmer facility in Groningen, Netherlands. The Radiation Safety Officer was first notified around 0900 EST. On November 19, the licensee notified the Agency that the 3 packages were found in Zurich. The Agency considers this matter closed. " Massachusetts Event Number: 23-4724 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 54838 | 14 August 2020 17:03:00 | The following email was received from the Massachusetts Radiation Control Program (the agency) via email: On August 5, 2020, InviCRO reported receiving in error on same day a White I package of 140 mCi Lu-177. Receipt survey recorded a package surface dose rate of 0.2 mRem/hr. The received package activity exceeded their license radioactive material possession limit of 125 mCi. Package held by licensee in secure storage until activity falls below license limit (Lu-177 half-life is 6.7 days). The intended activity as requested by the licensee was 60 mCi. Package ordered through Radiomedix in Texas who forwarded order to supplier (ITM Medical isotopes GmbH) in Germany. Package sent from Germany arrived in (common carrier) US facility and directly forwarded to customer without going through Texas. Agency contacted (common carrier) and Texas Department of State Health Services. Apparent cause was (common carrier) accidentally switching labels/paperwork on two similar Lu-177 packages. The package originally intended for InviCRO was forwarded to a customer licensed in Indiana. Indiana customer (Endocyte) notified by Radiomedix. All US parties identified above are aware of incident. Radiomedix continuing its internal investigation. Agency left detailed voicemail messages (including circumstances, package receipt date and activity) at Indiana Department of Homeland Security and Indiana Department of Health. Agency determined this to be a 30-day reportable event and considers this event currently still open. MA Event Number: 20-4230 |
| ENS 54722 | 20 May 2020 21:34:00 | The following is taken from the Massachusetts Radiation Control Report abstract: PerkinElmer reported on May 20, 2020, that one UN2910 package, Transport Index 0.0, shipped from the licensee's Billerica, Massachusetts facility via a common carrier, containing 5.73 mCi I-125, was reported missing by the carrier on May 20, 2020. The last known location of the package was at the Atlanta, Georgia, airport on May 15, 2020 (when the carrier reported to the licensee that the package was still being held in place awaiting transfer). The package, measuring 10x6x6 inches and weighing approximately 2 kg, was one of a 22-package shipment destined for a customer in the Netherlands. The package was left behind in Atlanta on May 6, 2020, due to external package damage and the other twenty-one packages continued to the customer. There was no reported external package radioactive contamination or loss of radioactive material. The licensee continues to work with the carrier to locate package. No significant public health and safety concern exists based on the package radiation measured at background levels. This situation is an immediately reportable event per regulation. The Agency (Massachusetts Radiation Control Program) currently considers this docket to still be OPEN. 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 53971 | 3 April 2019 12:25:00 | The following was received from the Commonwealth of Massachusetts via e-mail: On 4/2/19, 1430 EDT, the licensee reported a medical event involving Nordion TheraSpheres (SS&D NR-0220-D-131-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more. A portion of a two-vial Y-90 62 mCi (13 mCi and 49 mCi vials) microsphere therapy treatment delivered to the patient's liver on 4/2/19 was stuck in the catheter causing delivery of approximately 37 mCi Y-90. This was discovered immediately after treatment. The administered dose to the treatment area differed from the prescribed dose by approximately 40 percent. The licensee stated that the primary cause was an equipment malfunction. The first vial of 13 mCi was delivered fully, but only 24 mCi of the second vial containing 49 mCi was actually administered to the patient. The prescribing physician, referring physician and patient have been notified. The licensee stated that there were no negative health effects to the patient due to the situation. No additional Y-90 therapy treatment will be required. Corrective actions will include removal of the suspect equipment (catheter) and return of said equipment to the manufacturer for evaluation. A larger diameter catheter will be used during future therapy treatments. The licensee will submit a written report within 15 days of the discovery date. Agency on-site investigation is pending. This is a next day reportable medical event per regulations. Investigation ongoing. Agency considers this event docket to still be OPEN. 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 53701 | 29 October 2018 10:48:00 | The following was received via email from the Commonwealth of Massachusetts: Massachusetts Radiation Control Program was notified this morning by S.W. Cole Engineering (MA Radioactive Materials License 48-0689) of Taunton, MA, that InstroTek Model 3500 Xplorer Series portable moisture density gauge, containing 11 mCi Cs-137 and 44 mCi Am-241, was stolen yesterday (Sunday, 28 October 2018) from a temporary job site in Fall River, MA. Local Police, State Police and FBI have been notified.
Notified by the Commonwealth of Massachusetts that at 2130 EDT on 11/1/18, the Commonwealth was notified by the FBI that the subject gauge was recovered during the course of a criminal investigation. The gauge is currently in the possession of the Swansea, MA Police Department. The Commonwealth will coordinate with the licensee to take possession of the gauge on 11/2/18. The gauge appears to be undamaged and there is no evidence of tampering. The licensee will be conducting a leak check and inspection of the gauge once they regain possession. Notified R1DO (Schroeder), ILTAB (Davis), and NMSS Events Notification (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 53233 | 28 February 2018 14:33:00 | The following information was received via E-mail: QSA Global reported via telephone on 2/28/2018 that a package shipped via (a common carrier) on 2/19/2018 (shipping documents prepared on 2/16/2018), containing two Model A424-9 Ir-192 industrial radiography sealed sources within a Model 650L source changer, was reported as missing via telephone by (the common carrier) at 1030 EST on 2/28/2018. (The common carrier) trace was already initiated and in progress, and tracking indicates last known package location was (the common carrier) hub in Memphis, TN. This was a RQ UN2916, Yellow-III, Type B package with a Transport Index of 1.9 at time of shipment. Package dimensions were 26x22x34 cm. Source changer SN 263. Sources - SN 63782G (111.6 Ci on 2/14/2018) and 73783G (108.0 Ci on 2/14/2018). This situation is an immediately reportable event per regulation. The search for the missing package is ongoing. Agency (Massachusetts Radiation Control Program) currently considers this docket to still be OPEN. Package Origin: Burlington, MA, USA Intended Destination: Bogota, Columbia Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC. Notified External via E-mail: FDA EOC, NuclearSSA, FEMA NRCC SASC, FEMA National Watch Center, DNDO-JAC.
QSA Global reported to the Agency that the package was received at its intended destination on 2/26/2018. Agency considers this event to still be OPEN. Massachusetts Radiation Control Program updated Tennessee Division of Radiological Health. Notified R1DO (Bickett), NMSS EO (Rivera-Capella), ILTAB (English), IRD MOC (Pham), and NMSS Events (email). Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC. Notified External via E-mail: FDA EOC, NuclearSSA, FEMA NRCC SASC, FEMA National Watch Center, DNDO-JAC.
The following was received from the Commonwealth of Massachusetts via email: QSA Global provided a 30-day written report received by the Agency on 3/9/18. Agency telephone discussions with QSA Global and (the common carrier) were held on 3/12/18. The following information is provided in order to report previously unreported details: (1) QSA Global confirmed that the 650-L Source Changer is itself a Type B package and was not shipped in an overpack container and therefore was the shipping container, (2) (the common carrier) indicated, as a corrective action, this situation would be included in the lessons learned portion of annual refresher training presented to (the common carrier) employees. In this case, although QSA Global had contact with the international customer on 2/21/18 and 2/23/18, the customer did not follow-up to inform QSA Global when the item actually arrived on 2/26/18 (two days before it was reported to Agency as missing by QSA Global on 2/28/18). Agency considers this event to be CLOSED. Massachusetts Radiation Control Program updated Tennessee Division of Radiological Health. NMED number: 180099 Massachusetts Event: 15-3140 Notified R1DO (Jackson), NMSS EO (Rivera-Capella), ILTAB (Ahern), IRD MOC (Pham), and NMSS Events (email). THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web. |
| ENS 52680 | 14 April 2017 14:38:00 | The following information was obtained from the Commonwealth of Massachusetts via email: Licensee reported one leaking sealed source (Model A3901-2, S/N P4-892, 6 mCi, Co-57) and one contaminated sealed source (Model A3901-2, S/N P4-898, 6 mCi, Co-57). These were among ten sources received from manufacturer individually wrapped in plastic ziplock bags. Leak test results for the other eight sources indicated that they were free of contamination. Leak test result for SN P4-892 was reported as 5.04 times the 0.005 microCurie wipe test limit and the leak test result for SN P4-898 was reported as 23 percent of the 0.005 microCurie limit. Leak test wipes were taken on 4/10/17 and analyzed on 4/11/17. Licensee reported the subject sources were not taken out of their respective bags and did not come into contact with anything other than the leak test swab. Initial survey of the outside of the transport package, and subsequent surveys of gloves worn during the leak testing, work area surfaces, inside the lead pig that contained the plastic bags, and outside the ten individual plastic bags indicated no other contamination present other than the interiors of the two plastic bags containing the two suspect sources and the sources themselves. P4-892 was returned to Eckert and Ziegler for analysis. P4-898 was re-wiped for analysis by licensee's leak testing consultant service. Agency (Massachusetts Radiation Control Program) considers this event docket to currently be OPEN. |
| ENS 51192 | 30 June 2015 12:17:00 | The following information was received from the Commonwealth of Massachusetts via email: Worcester Polytechnic Institute reported on 6/30/15 that a shipment of one Selenium-75 (1 curie) and two Ytterbium-169 (1.76 curies together) brachytherapy sealed sources arrived as an empty package (no radioactive material was within the package). The received Yellow-II labeled cardboard package was visibly damaged and resealed with clear shipping tape. Survey of the received package determined background radiation readings. Carrier, shipper and various government agencies have been contacted. Search for missing items is ongoing. Radiation from the unshielded sources expected to be approximately 1 R/hr at one meter distance. Agency (MA Radiation Control Program) to perform on-site investigation in Worcester today . HOO NOTE: Also reported by the common carrier to the National Response Center on 6/29/15 (Incident Report # 1121358) and by the State of Louisiana (EN # 51191).
The following update was received from the Massachusetts Radiation Control Program via email: Agency (Massachusetts Department of Public Health - Radiation Control Program) (MADPH-RCP) conducted investigation at receiving licensee facility on 6/30/15. Agency also conducted radiation surveys on 7/1/15 at the three carrier facilities in Massachusetts through which the package passed. No sources were identified and all radiation readings were at background levels. The three sources have been described by shipper as titanium capsules approximately 5 mm long and 1 mm diameter. Each source may still be individually contained within an approximate 1.5 inch tall glass vial with teal-colored plastic screw-on cap, each vial with white label taped to outside of vial describing the contents. The receiving licensee ordered a 0.2 curie Se-75 source (same physical description) and it is unknown at this time which Se-75 activity amount (0.2 or 1 curie) was shipped. Notified the R1DO (Dimitriadis), ILTAB (Johnson) and NMSS Events (via Email)
The following update from the Massachusetts Radiation Control Program was sent via email: The shipper (i.e. SPEC) provided clarification that, contrary to the activities identified in shipping papers, one Yb-169 source was actually approximately 1.74 curies, another Yb-169 source was actually approximately 1.77 curies and the third source, Se-75 was approximately 207 millicuries. The sources continue to be missing. Notified the R1DO (Cahill), ILTAB (Johnson) and NMSS Events (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 50192 | 12 June 2014 09:50:00 | The following information was obtained from the Commonwealth of Massachusetts via email: On 6/11/14, licensee reported to Agency (Commonwealth of Massachusetts) a potential dose exceeding the adult occupational shallow dose equivalent to the skin or extremities limit of 50 rem. Licensee reported situation occurred during March-April 2014 dosimeter wear period and involved employee working with Y-90 in hot cell. Licensee reported extremity ring badge pierced through the employee's glove resulting in contamination of ring badge. March-April 2014 extremity ring exposure reading of 52,480 mRem. Year-to-date extremity ring exposure at 53,400 mRem. The year-to-date whole body badge exposure is at 51 mRem. Licensee reported corrective actions identified and implemented to reduce likelihood of recurrence. Consultant hired to review dose assessment and assist in completing 30-day written report. No other details from the licensee at this time. The Agency inspector will conduct a site visit. The Agency is awaiting a 30-day written report by the licensee. The Agency considers this event to still be OPEN. Event Docket #: 18-1343 |
| ENS 50003 | 7 April 2014 11:30:00 | The following information was received from the Commonwealth of Massachusetts via email: On Saturday, 4/5/14, licensee left voice mail notification for this Agency (Massachusetts Radiation Control Program) of the same day determination of two potential leaking or contaminated sealed sources that had been taken out of long-term storage and intended to be shipped for eventual disposal. Notification received by Agency on Monday, 4/7/14. Follow-up contact with licensee by Agency on 4/7/14. The source was returned to storage pending licensee contact with manufacturer. Licensee reported leak lest results are preliminary in nature and were determined by licensee to be above background. There was no evidence of contamination beyond the source itself. Five-day written report from licensee to follow. Additional Reference: NMED Item Number TRA Manufacturer: Eckert & Ziegler / IPL Model #: SIF.D1 Manufacture date: 3/2004 (0.100 Ci) Serial #: MI318 / MC915 Isotope: Sr-90 Isotope activity (Ci): 0.078 (4/2014) Leak test result (microCi): 0.002 (preliminary) / 0.0007 (preliminary)
The Licensee's written report was received by the Agency on 4/10/14. The Licensee confirmed that leak test results were unchanged from the earlier report. With this new information, the Agency determined that this is not a reportable event because results were below the reportable level of 0.005 microcuries. The Agency considers this matter to be closed. Notified the R1DO (Burritt) and FSME Events Resource via email. |
| ENS 49520 | 8 November 2013 13:43:00 | The following was received via email: On 11/8/13, a licensee shipper informed this Agency (MA Radiation Control Program) that on 11/2/13 the licensee receiver survey of a package containing one patient dose of Fluorine-18 (F-18), indicated removable surface contamination exceeding 49 CFR 173.443 levels. The receiver notified the shipper on 11/2/13. The shipper reviewed the outgoing package survey, as well as routine facility and personnel surveys for 11/2/13, and determined there were no contamination issues. Transports are made via courier vehicles. The shipper retrieved the empty subject package on 11/4/13 during a normal delivery run. F-18 has a half-life of less than two hours. The receiver did use the contained dose for patient administration as intended on 11/2/13. On 11/8/13, this Agency attempted to contact the receiver to confirm specific contamination results obtained by the receiver's package survey. The licensee receiver has not yet responded to this Agency's inquiry so specific results are not yet known at the time of this report. The Agency considers this matter to be OPEN pending results of ongoing Agency investigation.
11/14/13 information from the receiver confirmed exclusive use shipment was used. With the new information, the Agency (Massachusetts Radiation Control Program) determined this is not a reportable event because 49 CFR 173.443 contamination limits to be applied should be ten times higher than limits applied previously. The receiver's removable contamination survey results no longer exceed limits. Notified R1DO (Bower) and FSME Events Resource via email. |
| ENS 49016 | 9 May 2013 14:18:00 | The licensee reported to the state that a ionizing static dissipater, licensed under a General License (GL) and used on lines for clearing small parts of dust, was lost. The device is Model: NRD P-2021-8101 with Serial Number: A2HN439 and contained a Po-210 with an up to a 10 mCi source, on 1/18/12, which has decayed to approximately 0.9 mCi as of 5/9/13. The licensee has properly returned all other devices for destruction from the facility. The State has initiated an investigation and will assign an event number as new information is obtained.
The following update was received via e-mail: The agency (Massachusetts Radiation Control Program) conducted a site visit on 5/29/13. The general licensee implemented a search through facilities and determined the missing device may have been inadvertently dispositioned during recent building renovations and subsequent departmental reorganizations and relocations. The missing device was last used in 2012. The general licensee is seeking to terminate GL registration due to GL devices having been phased out and replaced with non-RAM (radioactive material) equipment. All other GL devices were accounted for and have already been dispositioned. The missing device component is a small metallic cylindrical object 0.5 inches in diameter and 2.7 inches in length. The agency considers this event to be CLOSED. Massachusetts Event Docket #17-0766 NMED Item #130233 Notified the R1DO (Holody) and FSME Event Resources (via e-mail). 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 48815 | 12 March 2013 13:10:00 | The following information was received by email: On 2/4/13, a scrap metal load shipped by Southern Recycling from Millbury, MA, was rejected by Audubon Metals of Henderson, KY, for triggering the site's radiation detectors. The highest net radiation reading was 10 microR/hr. The vehicle returned to Millbury where, on 2/6/13, one device (described as a WWII "Blackout Button" measuring ~1.75 inch diameter and containing ~10 microCuries Radium-226) was located and removed from load by an independent consultant and isolated in secure storage for further processing. The remaining load re-shipped to Henderson without further incident. On 2/13/13, the device was removed, packaged and shipped to a proper disposal site by a third-party waste broker. The original owner was not determined. The Agency (MA Radiation Control Program) considers this matter closed. SCRAP Docket #: 14-0613 |
| ENS 48589 | 13 December 2012 17:05:00 | The following was received from the Commonwealth of Massachusetts via email: On 12/13/12, licensee notified this Agency of the 12/12/12 determination of a potential leaking or contaminated sealed source that had been received from an out-of-state vendor. The source being returned to vendor for further analysis. There was no evidence of contamination beyond the source itself." The Agency considers this matter to be OPEN pending receipt of written report. The sealed source contained 0.040 Ci of Cd-109. The manufacturer is Eckert and Zeigler, model XFB-3, with serial number TR2463.
The following was received from the Commonwealth of Massachusetts via email: The Vendor/Manufacturer reported to licensee in a letter dated 1/7/13 that, per wipe and soak tests conducted in accordance with ISO 9978:1992 (Radiation protection -- Sealed radioactive sources -- Leakage test methods) the source is not leaking and removable activity initially found originated from the capsule's surface. The vendor/manufacturer also wrote that the incident was assigned to the vendor/manufacturer's internal corrective and preventive action program. Notified R1DO (Newport) and FSME Event Resource via email. |
| ENS 47867 | 26 April 2012 14:02:00 | The following information was obtained from the Commonwealth of Massachusetts via email: On 4/5/12, (the) licensee reported as missing a 1.78 GBq (48.1 mCi) Thallium-201 package that was shipped from its site on 3/12/12, was scanned in at the carrier's Nashville, TN, transportation hub on 3/13/12 and reported to the licensee as missing by the carrier on 3/13/12. Licensee in communication with the carrier in ongoing effort to locate missing package. After a reasonable search time had passed, licensee reported missing package to this Agency (MA Radiation Control Program). Last known location was in Nashville, TN. The subject radioactive material is 7 ml of liquid solution held within a vial inside a lead pig inside a sealed plastic container inside a styrofoam insert within a corrugated cardboard box. Subject radioactive material has a 73 hour (~3 days) half-life and has decayed well past 10 half-lives since its original shipping date. Licensee remains in communication with carrier in ongoing effort to locate missing RAM and has requested return of package to licensee if found. The Agency considers this event to be CLOSED. 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 47423 | 9 November 2011 14:16:00 | The following information was provided by the state via email: On 11/9/11 (EST), the licensee reported to the Agency (Massachusetts Radiation Control Program) that a portable moisture density gauge had been damaged by a construction vehicle at a temporary job site. The source rod was bent and extended outside of the shielded gauge body so that it could not be returned to the closed position. The extended rod was left within the measuring hole so that the surrounding soil could provide shielding. A 15-plus-foot radius area was segregated around the damaged gauge. The licensee's radiation safety officer and radiation safety consultant were en route to the site to conduct and oversee the source recovery operation at the time of this report. The Agency (Massachusetts Radiation Control Program) considers this event to be open and ongoing. Manufacturer: Humboldt Scientific Inc, 5001 Series; Isotopes: Cs-137/ .011 Ci; Am-241/ .044 Ci.
The following report was received via e-mail: The consultant and licensee submitted follow-up reports. An authorized gauge user was attending to the gauge and could not get the attention of the driver of the vehicle being driven in reverse just before gauge damage occurred. The source rod retracted into the gauge body successfully and the gauge was returned in its transport case to the licensee's facility on 11/9/11. A post-retrieval survey determined no residual contamination in the area. Personnel dosimeters worn during retrieval indicated minimal personnel exposure. The licensee presented employees retraining related to construction site safety on 11/10/11. Leak test results indicated no sealed source leakage. The gauge was returned to manufacturer for repairs. Manufacturer : Humboldt Scientific, inc. Model Number : 5001 EZ Serial Number : 3544 Cesium-137 Source Serial Number : 9433GQ Americium-241 Be Source Serial Number : NJ03832 The Agency considers this event to be CLOSED. Notified the R1DO (Dentel) and FSME (McIntosh).
The following information was received via e-mail: The Cesium-137 source is an AEA Technology/QSA Model CDC.805, Capsule Type X8. The Americium-241 source is an AEA Technology/QSA Model AMN.V997, Capsule Type X1. The Agency still considers this event to be CLOSED. Notified FSME (McIntosh) and R1DO (Powell). |
| ENS 45695 | 12 February 2010 10:45:00 | The following was received from the Commonwealth of Massachusetts via e-mail: On 2/12/10, licensee reported to this Agency (Commonwealth of Massachusetts) the 2/11/10 discovery of a medical event that occurred on 2/10/10. The situation (was) described as two treatment fraction underdoses, delivered on the same day to the same patient, that differed from the prescribed dose, per fraction, by more than 50%. Initial indication (is) that (the) event was caused by (an) equipment software bug. Two fractions of 0.4 Gy were delivered on the first day of treatment. The prescription was for two treatments of 4 Gy per fraction per day for two days and one final 4 Gy treatment on the third day. (The) prescribing physician and equipment manufacturer (were) notified. This is a preliminary report; investigation (is) ongoing; more information to follow. The Agency considers this event OPEN and ONGOING.
(The) equipment manufacturer found the software issue to be 'reproducible' and therefore may be classified as a 'potential' (patient) safety issue. (The) suspect portion of software will not be used again until (the) program (is) debugged and documented to be correct. (The) suspect portion of the software had not been used in the past by the licensee; no previous patients were affected. The device has been identified as a Nucletron HDR V3, and the software program is named Oncentra. Event docket #02-8893. Notified R1DO(T. Jackson) and FSME EO(McIntosh)
The equipment manufacturer published a customer information bulletin describing the problem. The licensee submitted a formal follow-up report to this Agency (Commonwealth of Massachusetts) on 2/25/10. The licensee wrote that since the underdose could be made up there will be no effect on the treatment outcome. There is no radiation morbidity. Patient underdose on 2/10/10 was 90%. The Agency considers this matter to be closed. Notified R1DO(Caruso) and FSME EO(Kock). 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 45176 | 30 June 2009 17:27:00 | The following information was received via facsimile: A worker was working in a hot cell when a F-18 (radio-isotope) was mistakenly delivered to the hot cell. (The) initial estimated worker dose (was) 100 Rad extremity dose and 20 Rad to the whole body (upper arm). The dosimeter has been sent to Landauer for immediate processing. (The) worker has been taken off Rad work and is being monitored" A Commonwealth of Massachusetts investigation is pending.
The following report was received via e-mail: On 6/30/09, 1.6 Curies of Fluorine-18 was mistakenly delivered to a shielded vial within the cyclotron facility hot cell while a worker was performing routine maintenance within the hot cell. Delivery was intended for a different hot cell. The total worker exposure time was less than 3 minutes. The worker was removed from radiation work and dosimeters were sent out for immediate processing. Same day notification was made from the licensee to the Agency (Massachusetts Radiation Control Program). The licensee submitted an independent consultant written report, dated 7/8/09, to the Agency (Massachusetts Radiation Control Program) on 7/27/09. The worker's effective dose equivalent was conservatively determined to be not more than 0.170 Rem, the maximum extremity not more than 26.9 Rem, and the eye dose equivalent not more than 1.2 Rem. These dose values were assigned to the worker. The worker was returned to radiation work with cumulative dose closely monitored. Licensee's formal descriptions of cause, contributing and precipitating factors, and corrective actions are pending. The Agency (Massachusetts Radiation Control Program) considers this situation to still be OPEN. Notified the R1DO (Cook) and FSME (McIntosh).
The following update was received via e-mail: 9/16/09 Update: A subsequent on-site Agency inspection was performed. On 8/27/09, the licensee submitted report of cause, contributing and precipitating factors, and corrective actions. Cause: Pre-event re-configuration of transport tubing during an earlier calibration effort was not returned to original configuration and operators were not aware of the routing change. Precipitating and Contributing Factors: Licensee procedures related to use of personnel dosimeters, functioning survey instruments, and hot cell door closure, were not followed. Corrective Actions: Licensee to implement procedural changes and retraining of staff. The Agency considers this situation to be closed. Notified the R1DO (Jackson) and FSME (McIntosh). |
| ENS 43319 | 25 April 2007 13:07:00 | The State provided the following information via email: On 3/27/07, licensee reports being unable to locate a single Bard STM 1251 prostate seed containing 0.35 millicuries of Iodine-125 (60-day half-life) soon after a 130-seed (120 stranded seeds and 10 single seeds) medical procedure. This single titanium cylindrical capsule measures 0.8 mm (~0.03 inch) in diameter and 4.5 mm (~0.18 inch) in length (see Sealed Source Registry No. IL-1074-S-101-S). The last known location of the seed was in an operating room within the licensee's facility in Springfield, MA. The licensee conducted an extensive search of its facilities as described in its written report dated April 9, 2007. The licensee assumes the seed is lost at this point in time. In order to prevent recurrence, the licensee implemented updated seed counting and inventory control procedure changes and assignment responsibilities. Cause description: Inconsistent use of seed well container. All 10 single seeds were placed in one well instead of placing one seed in each of ten wells within container. Corrective action: Updated seed counting, inventory control procedure changes, and assignment responsibilities. Massachusetts Event Docket Number: 04-6969 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 42803 | 25 August 2006 10:52:00 | The State provided the following information via facsimile: On 8/7/06, licensee reports being unable to locate two NRD Model P-2021 In-Line Ionizers (S/N A2EJ536 and S/N A2EJ538) each containing up to 10 millicuries of Polonium-210 (138-day half-life). These stainless steel cylindrical items measure 0.5 inches in diameter and just under 3 inches in length. The items were purchased from NRD LLC of Grand Island, NY, in April 2005 (see Sealed Source Registry No. NY-502-D-107-G). The last known location of the items was in a stock storage area at the licensee's former facility in Woburn, MA. The licensee relocated operations from Woburn to Wilmington, MA, in September 2005. The licensee assumes the items were lost, and possibly disposed, during the Woburn facility cleanup and relocation effort. The licensee does not believe the items were stolen. In order to prevent recurrence, the licensee implemented a specific device use log and assigned an employee to be responsible for device inventory. The licensee's search and investigation is ongoing. 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 42741 | 31 July 2006 08:56:00 | The State provided the following information via facsimile: On 7/13/06, licensee reported ( to State of MA) that a Raid-M-100 Hand-Held Chemical Agent Monitor (S/N 22653301851) containing up to 100 Mbq (2.7 mCi) of Nickel-63, shipped by licensee employee on 6/5/06 from Anchorage, AK, via United Parcel Service was reported as being not yet received at the licensee's Billerica, MA, site on 6/14/05. A second package, containing work related non-radioactive items, that had been shipped at the same time was received on 6/8/06. The device was in the custody of UPS at the time of the loss. UPS tracking system indicates the package was scanned in AK. Per the licensee, UPS reported on 6/19/06 and on 6/29/06 that its internal investigation had not yet found the missing item. Licensee filed incident report with Anchorage Police Department. The UPS missing package investigation is ongoing. The site of the event and last known location was UPS, 200 West 34th Avenue, Anchorage, AK. MA Report 7/31/06, Docket # 07-6484
Informed the Canadian government of above event via e-mail. 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 41542 | 29 March 2005 12:46:00 | The State provided the following NMED information: On 1/18/05, the licensee reported to the Agency a teletherapy misadministration that occurred on 1/17/05. The situation was described as 'the treatment field was displaced by six cm when the therapist set the central axis of the field at the tattoo marking the bottom of the field'. An area of 15 cm x 6 cm (treatment site) received dose when the plan called for that tissue to receive no dose. The dose was one day's treatment of 180 cGy. The treatment monitor units and energy were correct, the error was entirely an issue of field placement. The Regulation Code cited is 105 CFR 120.502 (4) (a). The intended dose to the patient was 180 cGy, however, only 90 cGy was given to the wrong treatment site (15 cm x 6 cm area). Per the treating physician, no corrective action is needed. The hospital retrained staff to ensure confirming proper positioning of therapy prior to treatment. Event type Description: MD2 - Wrong Treatment Site. Cause description: The therapist did not correctly align the treatment field with the patient's treatment alignment tattoo. The Agency considers this event closed.
The following information was provided by the State via facsimile (State text in quotes): The device used to deliver the radiation treatment was a LINEAR ACCELERATOR. Notified R1 DO (Noggle) and NMSS EO (T. Essig)
Based on a discussion with the NMSS EO (T. Essig) and the State (T. Carpenito), this notification is retracted because the device used to deliver the radiation treatment is not regulated by NRC. Notified R1 DO (Noggle) and NMSS EO (T. Essig) |