ENS 56099
ENS Event | |
|---|---|
05:00 Aug 23, 2022 | |
| Title | Loss of I-125 Brachytherapy Seed |
| Event Description | The following information was provided by Illinois Emergency Management Agency (The Agency/IEMA) via email:
The Agency received a phone and email report from Bard Brachytherapy [licensee] on September 2, 2022 indicating the loss of a single I-125 brachytherapy seed, accounting for a maximum estimated activity of 0.75 millicurie. The licensee's investigation leads them to believe the seed remains within their Illinois facility and the loss of accountability is a function of either operator or documentation error. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion. Agency inspectors are conducting a reactionary inspection the week of September 12, 2022 for this incident and the loss reported September 1, 2022. While not representing a significant public safety concern, the quantity requires reporting to the US NRC HOO [Nuclear Regulatory Commission Headquarters Operations Officer] within 30 days. DETAILS: On August 23, 2022, staff at Brad Brachytherapy in Carol Stream, IL notified their manager of a missing brachytherapy seed. An investigation was opened and the counts compared against orders processed from this lot. Surveys were conducted of the workstations, the lab and the dumpster; yielding no identification of the seed. Reviews of paperwork, inventory records and orders also failed to indicate the location of the source. No customers have reported the receipt of an extra source. While the licensee believes the loss can be attributed to operator or documentation error; no root cause or corrective action was provided. An IEMA inspection team will seek this information in the reactionary inspection. Illinois Incident Number: IL220032. 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 |
| Where | |
|---|---|
| Bard Brachytherapy Carol Stream, Illinois (NRC Region 3) | |
| License number: | IL-02062-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+415.42 h17.309 days <br />2.473 weeks <br />0.569 months <br />) | |
| Opened: | Gary Forsee 12:25 Sep 9, 2022 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Sep 9, 2022 |
| 56099 - NRC Website
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Bard Brachytherapy with Agreement State | |
WEEKMONTHYEARENS 571932024-06-25T05:00:00025 June 2024 05:00:00
[Table view]Agreement State Broken Brachytherapy Seed ENS 571272024-05-13T05:00:00013 May 2024 05:00:00 Agreement State Lost Brachytherapy Seed ENS 563412023-02-06T06:00:0006 February 2023 06:00:00 Agreement State Lost Brachytherapy Seeds ENS 561812022-10-25T05:00:00025 October 2022 05:00:00 Agreement State Lost Shipments ENS 561452022-09-30T05:00:00030 September 2022 05:00:00 Agreement State Lost Shipment ENS 560832022-08-31T05:00:00031 August 2022 05:00:00 Agreement State Lost I-125 Brachytherapy Seeds ENS 560992022-08-23T05:00:00023 August 2022 05:00:00 Agreement State Loss of I-125 Brachytherapy Seed ENS 560112022-06-29T05:00:00029 June 2022 05:00:00 Agreement State Lost Sources ENS 559512022-06-16T21:00:00016 June 2022 21:00:00 Agreement State Shipment Lost Then Found ENS 538732019-02-13T06:00:00013 February 2019 06:00:00 Agreement State Agreement State Report - Report of Loss of Brachytherapy Seeds ENS 429842006-11-10T06:00:00010 November 2006 06:00:00 Agreement State Shipment of Iodine - 125 Seeds Lost in Transit ENS 411592004-10-29T05:00:00029 October 2004 05:00:00 Agreement State Agreement State Report 2024-06-25T05:00:00 | |