ENS 45226: Difference between revisions
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| event date = 07/15/2009 EDT | | event date = 07/15/2009 EDT | ||
| last update date = 08/11/2009 | | last update date = 08/11/2009 | ||
| title = Agreement State Report Involving | | title = Agreement State Report Involving the Loss of a Californium-252 Source | ||
| event text = On 07/24/09 the State of North Carolina was notified by Duke University that a Cf-252 source could not be located during a mid-July inventory of their TUNL facility. | | event text = On 07/24/09 the State of North Carolina was notified by Duke University that a Cf-252 source could not be located during a mid-July inventory of their TUNL facility. | ||
The following information is a portion of an email forwarded by the State of North Carolina: | The following information is a portion of an email forwarded by the State of North Carolina: | ||
Latest revision as of 21:11, 1 March 2018
ENS Event | |
|---|---|
04:00 Jul 15, 2009 | |
| Title | Agreement State Report Involving the Loss of a Californium-252 Source |
| Event Description | {{#Wiki_filter:On 07/24/09 the State of North Carolina was notified by Duke University that a Cf-252 source could not be located during a mid-July inventory of their TUNL facility.
The following information is a portion of an email forwarded by the State of North Carolina: "TUNL staff today formally reported the loss of a Californium-252 source: (1) Source description: 3.4 microcuries of Cf-252 with an active layer of 8 mm diameter on the platinum backing 15 mm in diameter, 0.2 mm thick. The source was inside an ionization chamber, which was purchased in 1995 from Physikalish-Technische Bundesanstalt, Berlin with an initial activity of 5.17 MBq (86 microcuries; T� = 2.645 y) (2) Circumstances: A physical inventory of TUNL sources during mid-July determined that this source was missing. A search of the TUNL facility failed to locate this source. Although the investigation is continuing, TUNL staff have concluded that the source is lost. (3) Disposition or probable disposition of lost source: This source was incorporated into a piece of equipment (ion chamber) composed of a metal tube with several smaller metal tubes (vacuum lines) coming off of it. TUNL staff suspect that this piece of equipment containing the source may have been left with other scrap items shipped off site for disposal as radioactive waste during the Fall of 2008. However it is quite possible that this ion chamber and the source inside are still somewhere inside the TUNL facility. TUNL staff have been instructed to report if they happen upon it. (4) Possible radiation exposure: None under any reasonably probable scenario. (5) Actions taken to recover the material: TUNL staff conducted a search of the TUNL facility; the investigation into this incident is ongoing. (6) Steps taken to prevent a recurrence: TUNL staff are developing and implementing a series of measures to tighten control over TUNL radioactive sources. The development of these policies and procedures is still underway." The RSO at the TUNL facility said the lost source is a target foil used in the TUNL linear accelerator (032-247-A1), and it was stored at TUNL. The loss occurred under the Duke University broad scope academic license 032-0247-1 and not the TUNL license. No manufacturer, make, model, or serial number reported at this time (16:45 7/24/09). North Carolina Incident ICD 09-30
The following information is a portion of an email forwarded by the State of North Carolina: The source was found at approximately at 1:30 PM on Monday, July 27, 2009 in room K101 of the Keck Building. The source was on a table among an assortment of other research equipment. The area where the source was found is a radiation controlled area and is not accessible to the general public. Combining the circumstances of the discovery of the source with details of our search for the source and a review of our source checkout logs, we conclude that the source has likely been mixed with research equipment in the same research area where it was discovered since the summer 2008. Findings: The loss of inventory control of this source and our failure for timely discovery was due to three contributing factors: (1) improper removal of the source from its storage location, (2) a clerical error in the quarterly source inventories and (3) our practice of using source checkout log sheets to augment physical inspection in our quarterly inventories. Our radioactive materials (RAM) inventory control is based on proper checkout of sources by completing entries on a sign-out/in sheet for each usage and quarterly RAM inventories. Normally failures to properly sign out/in sources are caught in the quarterly inventories. However, because of our practice of augmenting the physical inspection in our quarterly RAM inventory check with information on the sign-out/in log sheets, it is possible for this check to fail due to either logging errors on the sign-out/in sheets or clerical errors made in reviewing the sheets for inventory assessment. In this rare event, both occurred. During the September 2008 inventory check, the most recent entries for this source on the sign-out/in sheets were overlooked and earlier entries were used that indicated that the source was in use by a student. We have no reason to believe the source was not in use at TUNL because he was not present at the July 2008 accelerator scheduling meeting when a faculty member mentioned that the source wasn't in the storage safe, and [the professor] forgot to alert him of the potential problem with this source. Also contributing to this oversight that delayed discovery of the problem was our policy of allowing source usage without time limitations; it is not unusual for a source to be used by an individual for several quarters. Corrective Actions: This unfortunate event has caused us to review our practices in managing the RAM inventory at TUNL. Based on our findings, the following actions will be taken to reduce risk of loss of control of any items in our RAM inventory in the future: 1. We will discontinue the use of information from the checkout log sheets to augment physical inspections in the quarterly inventories. In the future, all sources will be physically inspected. For sources that are permanently embedded in equipment, the seal on the equipment where the source is installed will be inspected and the presence of the source will be checked with particle detectors whenever practical; 2. Open ended source usage will be discontinued source usage will be limited to a duration of one week; 3. The number of people with authorization to checkout sources will be more restrictive - Only TUNL faculty members, research scientists, post docs and selected technical staff members will be allowed to check out radioactive sources (graduate students, undergraduate students and visitors will no longer be allowed to checkout radioactive sources); 4. Substantial consequences will be imposed on individuals who do not properly checkout sources - failure to sign out radioactive sources properly will put research groups at risk of losing their privilege to use radioactive sources in the TUNL inventory; 5. Security in the area around our main source storage will be increased - the main area for radioactive materials storage at TUNL will be monitored with video cameras to record removal and return of radioactive sources; and 6. The radioactive materials in the TUNL inventory will be sorted into categories according to the reporting requirements by the State: high, medium and low. We are investigating technologies for electronic inventory control on the materials in the high and medium reporting categories. Notified R1DO (Cook), FSME EO (Mauer), and ILTAB via e-mail. 252 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 }}[[Event description::Description::{{#Regex_clear:On 07/24/09 the State of North Carolina was notified by Duke University that a Cf-252 source could not be located during a mid-July inventory of their TUNL facility. The following information is a portion of an email forwarded by the State of North Carolina: "TUNL staff today formally reported the loss of a Californium-252 source: (1) Source description: 3.4 microcuries of Cf-252 with an active layer of 8 mm diameter on the platinum backing 15 mm in diameter, 0.2 mm thick. The source was inside an ionization chamber, which was purchased in 1995 from Physikalish-Technische Bundesanstalt, Berlin with an initial activity of 5.17 MBq (86 microcuries; T� = 2.645 y) (2) Circumstances: A physical inventory of TUNL sources during mid-July determined that this source was missing. A search of the TUNL facility failed to locate this source. Although the investigation is continuing, TUNL staff have concluded that the source is lost. (3) Disposition or probable disposition of lost source: This source was incorporated into a piece of equipment (ion chamber) composed of a metal tube with several smaller metal tubes (vacuum lines) coming off of it. TUNL staff suspect that this piece of equipment containing the source may have been left with other scrap items shipped off site for disposal as radioactive waste during the Fall of 2008. However it is quite possible that this ion chamber and the source inside are still somewhere inside the TUNL facility. TUNL staff have been instructed to report if they happen upon it. (4) Possible radiation exposure: None under any reasonably probable scenario. (5) Actions taken to recover the material: TUNL staff conducted a search of the TUNL facility; the investigation into this incident is ongoing. (6) Steps taken to prevent a recurrence: TUNL staff are developing and implementing a series of measures to tighten control over TUNL radioactive sources. The development of these policies and procedures is still underway." The RSO at the TUNL facility said the lost source is a target foil used in the TUNL linear accelerator (032-247-A1), and it was stored at TUNL. The loss occurred under the Duke University broad scope academic license 032-0247-1 and not the TUNL license. No manufacturer, make, model, or serial number reported at this time (16:45 7/24/09). North Carolina Incident ICD 09-30
The following information is a portion of an email forwarded by the State of North Carolina: The source was found at approximately at 1:30 PM on Monday, July 27, 2009 in room K101 of the Keck Building. The source was on a table among an assortment of other research equipment. The area where the source was found is a radiation controlled area and is not accessible to the general public. Combining the circumstances of the discovery of the source with details of our search for the source and a review of our source checkout logs, we conclude that the source has likely been mixed with research equipment in the same research area where it was discovered since the summer 2008. Findings: The loss of inventory control of this source and our failure for timely discovery was due to three contributing factors: (1) improper removal of the source from its storage location, (2) a clerical error in the quarterly source inventories and (3) our practice of using source checkout log sheets to augment physical inspection in our quarterly inventories. Our radioactive materials (RAM) inventory control is based on proper checkout of sources by completing entries on a sign-out/in sheet for each usage and quarterly RAM inventories. Normally failures to properly sign out/in sources are caught in the quarterly inventories. However, because of our practice of augmenting the physical inspection in our quarterly RAM inventory check with information on the sign-out/in log sheets, it is possible for this check to fail due to either logging errors on the sign-out/in sheets or clerical errors made in reviewing the sheets for inventory assessment. In this rare event, both occurred. During the September 2008 inventory check, the most recent entries for this source on the sign-out/in sheets were overlooked and earlier entries were used that indicated that the source was in use by a student. We have no reason to believe the source was not in use at TUNL because he was not present at the July 2008 accelerator scheduling meeting when a faculty member mentioned that the source wasn't in the storage safe, and [the professor] forgot to alert him of the potential problem with this source. Also contributing to this oversight that delayed discovery of the problem was our policy of allowing source usage without time limitations; it is not unusual for a source to be used by an individual for several quarters. Corrective Actions: This unfortunate event has caused us to review our practices in managing the RAM inventory at TUNL. Based on our findings, the following actions will be taken to reduce risk of loss of control of any items in our RAM inventory in the future: 1. We will discontinue the use of information from the checkout log sheets to augment physical inspections in the quarterly inventories. In the future, all sources will be physically inspected. For sources that are permanently embedded in equipment, the seal on the equipment where the source is installed will be inspected and the presence of the source will be checked with particle detectors whenever practical; 2. Open ended source usage will be discontinued source usage will be limited to a duration of one week; 3. The number of people with authorization to checkout sources will be more restrictive - Only TUNL faculty members, research scientists, post docs and selected technical staff members will be allowed to check out radioactive sources (graduate students, undergraduate students and visitors will no longer be allowed to checkout radioactive sources); 4. Substantial consequences will be imposed on individuals who do not properly checkout sources - failure to sign out radioactive sources properly will put research groups at risk of losing their privilege to use radioactive sources in the TUNL inventory; 5. Security in the area around our main source storage will be increased - the main area for radioactive materials storage at TUNL will be monitored with video cameras to record removal and return of radioactive sources; and 6. The radioactive materials in the TUNL inventory will be sorted into categories according to the reporting requirements by the State: high, medium and low. We are investigating technologies for electronic inventory control on the materials in the high and medium reporting categories. Notified R1DO (Cook), FSME EO (Mauer), and ILTAB via e-mail. 252 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 }}| ]] |
| Where | |
|---|---|
| Duke University Durham, North Carolina (NRC Region 1) | |
| License number: | 032-0247-1 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+228.58 h9.524 days <br />1.361 weeks <br />0.313 months <br />) | |
| Opened: | James Albright 16:35 Jul 24, 2009 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Aug 11, 2009 |
| 45226 - NRC Website | |
Duke University with Agreement State | |
WEEKMONTHYEARENS 525602017-02-11T05:00:00011 February 2017 05:00:00
[Table view]Agreement State Agreement State Report - Leaking Uranium-235 Source with Contamination in Public Areas ENS 525002017-01-19T18:00:00019 January 2017 18:00:00 Agreement State Agreement State Report - Incorrect Drug Delivered to Patient ENS 452262009-07-15T04:00:00015 July 2009 04:00:00 Agreement State Agreement State Report Involving the Loss of a Californium-252 Source ENS 428382006-09-11T10:30:00011 September 2006 10:30:00 Agreement State Agreement State Report - Fire in a Laboratory Containing Nuclear Materials 2017-02-11T05:00:00 | |