Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 46497 | 20 December 2010 10:34:00 | The following was received via email from the Commonwealth of Massachusetts: Licensee reported not receiving 400 Ci Mo-99/Tc-99m shipment from supplier on schedule (arrival originally expected for 12/18/10). Licensee is in communication with supplier and carrier(s) in ongoing effort to locate missing package. Last known location, per IRE (shipper), was Frankfurt, Germany. At 12/20/10, 8:30 AM ET, licensee received verbal confirmation confirming the shipment is still on the ground in Germany. Licensee has requested more definitive confirmation from its source(s). The Agency (Commonwealth) considers this event still OPEN.
The licensee stated that photographic evidence has been received confirming the shipment is still on the ground in Germany. The shipment will be returned to the supplier. The Commonwealth of Massachusetts considers the event to be closed. Notified R1DO (Perry), FSME (Burgess), and ILTAB (Whitney)
The Massachusetts Event Docket Number for this event is 12-9422. Notified R1DO (Perry), FSME (Villamar), FSME (Lewis) and ILTAB (Johnson) all via E-mail. 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 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 46577 | 31 January 2011 13:59:00 | The following was received via email: On 1/13/11, the licensee reported to the agency (Massachusetts Radiation Control Program) a potential dose exceeding the adult occupational total effective dose equivalent limit of 5 rem. The situation causing this event occurred during late December 2010, when a number of emergency repairs within a cyclotron were conducted over several days. The potential for overexposure was suspected on 1/5/11. A dosimeter exposure readings report of the (Optically Stimulated Luminescence OSL) was received by the licensee from the dosimeter service, after quick read, on 1/13/11. Affected individual's annual TEDE reported at 5457 mrem. Exposure (1596 mrem) obtained by official (OSL) dosimeters worn during cyclotron repair operations differed significantly from exposure (620 mrem) obtained by electronic dosimeter worn simultaneously during cyclotron repair operations. Electronic dosimeters are used by individuals for real-time readings during the repair operations. The licensee removed affected individual from any potentially high exposure operations. Investigation ongoing. Intermediate and draft reports have been received. Awaiting final written report by licensee. The Agency considers this event to still be OPEN. Massachusetts Event # 01-9454. Notified R1DO (Dwyer) and FSME (McIntosh).
Subsequent on-site agency inspection performed. Licensee submitted follow-up report (on) 2/28/11. Cause Description: Misinterpretation of licensee's pre-existing policy restricting workers when YTD (year-to-date) annual exposures approach in-house limits and over-reliance on real-time electronic dosimeters worn specifically during potentially high exposure operations. Precipitating factor: Over-reliance on real-time electronic dosimeters worn specifically during potentially high exposure operations. Corrective Action: Licensee to implement policy re-write to minimize subjective misinterpretations, change full-time dosimeter exchange frequency to obtain more current year-to-date exposure totals, replace current job-specific dosimeters with different type of dosimeter better suited to monitor type of work involved, apply administrative correction factors to readings of job-specific dosimeters to obtain more conservative real-time results. The individual (involved in this event was) removed from potentially high exposure operations during investigation and re-instated several weeks later on 3/3/11. Although the Agency considers this specific situation to be closed, it will be revisited during future inspections. The report did not state whether an over exposure actually occurred. Notified R1DO (Dimitriadis) and FSME (McIntosh).
The Massachusetts Radiation Control Program determined the individual received a dose of 5457 mrem. Notified R1DO (Dimitriadis) and FSME (McIntosh). |
| ENS 48710 | 31 January 2013 15:25:00 | The following information was received from the Massachusetts Radiation Control Program via email: General licensee requested termination of GL registration G0038 on 9/13/12 noting that the registered material (two electron capture detectors (ECD)) had been shipped to another organization. Upon Agency (MA Radiation Control Program) inquiry, the receiving organization confirmed receiving only one ECD. The shipper stated the missing ECD had been physically removed from its original gas chromatograph several years earlier and was last known to be in a small cardboard box that was assumed to have been segregated during a lab cleanup and subsequently included in an overall lab equipment transfer to the receiving organization. Upon further investigation and review, the shipping organization stated on 12/20/12 that the ECD may have been inadvertently dispositioned during the lab cleanup. The ECD is a small metallic cylindrical object approximately less than one inch in diameter and four inches in length. The Agency considers this event to be closed. The electron capture detector is a Hewlett Packard Model G1223A (Serial Number K0118). The source contained less than 15 mCi Ni-63. MA Event #: 130131. 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 49530 | 12 November 2013 16:20:00 | The following information was obtained from the Commonwealth of Massachusetts via email: On 11/12/13, licensee reported 10 mCi spill of medical Tc-99m (6-hour half-life) liquid during patient administration. Report based on the licensee's need to restrict access to the area of the spill for more than 24 hours. Licensee reported there was no occupational exposure to workers. Spill cleanup action was performed by licensee but enough residual contamination remained for licensee to restrict access to contaminated room until 10 half-lives (approximately three days) of radioactive decay have passed. Licensee will submit written follow-up report within 30 days. The Agency (Massachusetts Radiation Control Program) considers this matter to be OPEN pending results of ongoing investigation.
The Agency (Massachusetts Radiation Control Program) agrees with recent USNRC determination that this is not a reportable event, because it meets one but not all three of the requirements contained in 105 CMR 120.142 (B)(1) or 10 CFR 30.50 (b)(1). Notified R1DO (Bower) and FSME Events Resource via email. |
| ENS 50335 | 1 August 2014 11:22:00 | The following information was obtained from the Commonwealth of Massachusetts via email: On 9/12/12, a scrap metal load shipped by ECO Recycling of Brockton, MA, was rejected by Metal Recycling of Providence, RI, for triggering the site's radiation detectors. The highest vehicle radiation reading was < 0.2 mR/hr. The vehicle returned to Brockton where, on 9/13/12, one device (described as an Alphatron ionization vacuum gauge containing approximately 500 microCuries Radium-226 manufactured by National Resources of Newton, MA approximately 40 years ago) was located and removed from the load by an independent consultant and isolated in secure storage on-site in Brockton for future disposition. The consultant indicated < 0.5 mR/hr readings in accessible areas near the storage container. The original owner not determined. The device continues to be secured at Brockton site as of 8/1/14. The Agency (Massachusetts Radiation Control Program) considers this event to still be OPEN. Event Docket #: 19-1408
The following information was received via e-mail: 9/12/14 Update - Agency conducted on-site inspection 8/1/14. No significant change to previously reported information. Agency (Massachusetts Radiation Control Program) review ongoing. The Agency considers this matter to still be OPEN. Notified the R1DO (Ferdas) and FSME Event Resources (via e-mail).
The following was received from the Commonwealth of Massachusetts via email: ECO Recycling in process of soliciting / collecting quotes from waste brokers for proper disposal. Agency review ongoing. Agency considers this event to still be OPEN. Notified R1DO (Bower) and FSME Events Resource via email.
The following was received from the Commonwealth of Massachusetts via email: ECO Recycling continuing process of soliciting / collecting quotes from waste brokers for proper disposal. Agency review ongoing. Agency considers this event to still be OPEN. Notified R1DO (Gray), FSME Events Resource, and NMSS Events Resource via email.
ECO Recycling arranged for source to be removed by registered waste broker. Upon Agency (State of Massachusetts) contact and inquiry, waste broker confirmed source pick-up scheduled for third week in January 2015. Agency considers this event to still be OPEN. Agency will close this event when source is removed from Brockton site. Notified R1DO (Rogge) and NMSS Events Notification via email. |
| ENS 50422 | 3 September 2014 11:25:00 | The following was received from the Commonwealth of Massachusetts via email: On 9/3/14, Agency (Commonwealth of Massachusetts) determined, through inventory reconciliation, the general licensee is missing eleven Model 2021 Nuclecel Ionizers each originally containing up to 10 mCi Po-210. Agency further determined that six devices contained material with calculated current activity well below the immediate report level (0.1 mCi for Po-210), three devices contained material with calculated current activity of 0.12 mCi, and two devices contained material with calculated current activity of 0.77 mCi. The Agency did not receive specific lost source notification from the licensee. No other details from the licensee at this time. The devices are designed to be rugged, require no special handling procedures, and intended for use in neutralization of static charge in environmental tests. The current exposure rate for each device is expected to be considerably less than the initial maximum exposure rate of less than 0.2 mR/hr. Agency inspector to conduct site visit. Agency considers this event to still be OPEN and Agency review is ONGOING The devices were manufactured by NRD Inc., Model P-2021, three were manufactured 4/13/12, and two were manufactured 4/10/13. The serial numbers are A2JB491, A2JB496, A2JB500, A2JM622, and A2JM624. The sources were Po-210 10 mCi each.
The following was received from the Commonwealth of Massachusetts via email: Agency initiated inspection 9/3/14. Licensee written report received 9/22/14. Two devices were subsequently found by licensee during search within facility. Agency (Commonwealth of Massachusetts) determined that all nine devices still missing will each individually have, on 10/17/14, calculated activities below the immediate report level (0.1 mCi for Po-210). Notice of Violation to be issued related to loss of control of licensed material and not immediately reporting missing licensed material. Causes and corrective actions included in this update. Agency considers this event to be CLOSED. Notified R1DO (Bower), ILTAB and FSME Events Resource via email.
The following was received from the Commonwealth of Massachusetts via email: Notice of Violation (NOV) issued 10/16/14. In response to NOV, licensee included report that another of the missing devices was found. Additional licensee corrective actions not previously reported included retraining of employees and implementing a monthly device inventory check. Licensee to also systematically phase out its use of said device. Agency (Commonwealth of Massachusetts) still considers this event to be CLOSED. On 10/26/14, the licensee reported another device previously reported missing was found: SN A2JB491, NRD Model P-2021, 10mCi, 4/13/12 Manufactured and Assay Date." Notified R1DO (Jackson), ILTAB and NMSS Events Notification 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 54643 | 6 April 2020 15:52:00 | The following is summarized from an e-mail received from the Commonwealth of Massachusetts: The licensee reported on 4/6/20 that three UN2915 White I label packages, shipped from Germany via common carrier, each containing 21.14 Ci Sulfur-35, did not arrive on 3/29/20 as expected. Upon inquiry on 3/31/20, the common carrier informed the licensee that the packages arrived at JFK Airport, NY, and had not yet been forwarded. The common carrier informed the licensee on 4/6/20 that the three packages could not be located within its system, all flights were cancelled from JFK to Boston due to the COVID-19 situation, and affected freight would be forwarded via ground. The licensee continues to work with the common carrier to locate the packages. There is no significant public health and safety concern due to the package radiation levels being at background.
The following was received from the Commonwealth of Massachusetts via email: The licensee (PerkinElmer) on 4/9/2020 reported to this Agency (the Massachusetts Radiation Control Program) that three packages previously reported as missing were found in (the common) carrier's warehouse at JFK Airport in NY. The licensee stated that the packages were reportedly intact, unopened and undamaged. The licensee stated that the packages are expected to be ground transported to licensee in Boston for arrival on 4/10/2020. The licensee stated that a comprehensive incoming package survey will be performed on packages upon arrival at licensee facility. This Agency considers this event to still be OPEN until licensee confirmation of package arrival in regulatory-acceptable condition. Notified R1DO (Lilliendahl), NMSS Event Notifications, and ILTAB via email.
The following was received from the Commonwealth of Massachusetts via email: The licensee (PerkinElmer) on 4/10/2020 reported to this Agency that three subject packages were received at the licensee's facility on the afternoon of 4/10/20. The licensee performed an incoming package survey and determined the outside of the packages were not radioactively contaminated, there was no physical damage to the packages, and the inner packaging and contents remained intact. The Agency expects this event to remain OPEN until all details, including action docket numbers, are compiled and relevant documentation is completed. Notified R1DO (Lilliendahl), NMSS Event Notifications, and ILTAB via email.
The following was received from the Commonwealth of Massachusetts via email: Carrier corrective action includes retraining of employees. Agency considers this event to be CLOSED. Massachusetts Event Number: 16-4134. NMED Item Number: 200171 Notified R1DO (Arner), NMSS Event Notifications, and ILTAB 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 54966 | 22 October 2020 12:47:00 | The following was received from the Commonwealth of Massachusetts (the Agency) via email: QSA Global reported via telephone at 1100 EDT on 10/22/2020 that a package shipped via common carrier on 10/9/2020, containing two Model A424-9 Ir-192 industrial radiography sealed sources within a Model 650L source changer, was reported as missing via telephone by common carrier at 0926 EDT on 10/22/2020. Common carrier trace already initiated and in progress, and tracking indicates last known package location was common carrier hub in Memphis, TN. This was a RQ UN2916, Yellow-II, Type B package with a Transport Index of 0.5 at time of shipment. Source changer SN 2238. Sources SN 11393M (65 Ci) and 11394M (33.1 Ci). This situation is an immediately reportable event per regulation. A search for the missing package by common carrier is ongoing. Agency currently considers this docket to still be OPEN Intended recipient is Gilligan Engineering Services, Prudhoe, Northumberland, Great Britain.
The following update was received from the Agency via email: The licensee/shipper (QSA Global Inc.) on 10/23/20 reported to this Agency that the missing package was reported by the carrier as found in the carrier's Memphis, TN hub facility on 10/23/20. The package is being returned to the licensee/shipper for inspection. Agency expects this event docket to remain open until all details, including action docket numbers, are compiled, licensee's 30-day written report is received, and all relevant documentation is completed and reviewed. Notified R1DO (Young) and NMSS Events Notification, NMSS Regional Coordinator (Rivera-Capella), and ILTAB via 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.pdf |
| ENS 55280 | 27 May 2021 22:11:00 | The following was received from the Massachusetts Radiation Control Program via email: At 1551 EDT on May 27, 2021, the Massachusetts Radiation Control Program received a phone call from the Radiation Safety Officer (RSO) of Thermo Scientific Portable Analytical Instruments, License Number 55-0238. The RSO stated that a source was removed from the licensee's manufactured device that was sent to them for servicing. During this receipt procedure, a wipe sample taken on the device resulted in positive contamination. The Nickel-63 source was found to be leaking and the wipe test indicated a removable contamination level of 0.0728 microcurie. The limit for reporting the activity is 0.005 microcurie. Further information will be forthcoming as the event is under investigation.
The following update was received from the Massachusetts Radiation Control Program (MRCP) via email: The licensee notified the MRCP at 1202 (EDT) on May 28, 2021 to correct and update its earlier report. The sealed source isotope of interest is Iron-55 (Fe-55), not Nickel-63 as reported earlier, and the source activity is 20 millicuries. (The) Source was contained within an X-ray fluorescence device Model XLi 969, SN 5249. The customer had shipped the device to the licensee for decommissioning rather than service/repair. The accompanying leak test result prior to shipment was negative for contamination. Wipe survey results for areas within the licensee's facility where the device had been were negative for contamination. End of update. Notified R1DO (Bower) and NMSS Events Notification
The following update was received from the MRCP via email: The only update to this event is the MA docket number as referenced in the subject above (MA Event Docket 17-4568). There are currently no other updates to this event at the moment. MA Event Docket: 17-4568 Notified R1DO (Lilliendahl) and NMSS Events Notification |
| ENS 55557 | 3 November 2021 12:08:00 | The following information was received from the Commonwealth of Massachusetts via email: On November 2, 2021, 3:00 PM (EDT), licensee reported medical event under license 60-0160 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 Y-90 5 mCi microsphere therapy treatment delivered to patient liver on November 2, 2021 remained in the delivery system causing delivery of approximately 3.67 mCi Y-90 of the prescribed 5 mCi. The error was discovered immediately after treatment. Administered dose to treatment area differed from prescribed dose by approximately 27 percent. Licensee stated the cause, including possible equipment malfunction, has not yet been determined. Prescribing physician, referring physician and patient have been notified. Licensee stated no negative health effects to patient due to situation. No additional Y-90 therapy treatment would be required due to this situation. Licensee stated all Y-90 was accounted for. Licensee stated 5 mCi prescription was unusually small compared to previous procedures (range 9-to-39 mCi with 15 mCi being the most prescribed dose). Licensee to submit written report within 15 days of discovery date. This is a next day reportable medical event per regulation. Investigation ongoing. Agency considers this event docket to still be OPEN. Report by Anthony Carpenito, 11/3/2021. |