ENS 56635
ENS Event | |
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01:45 Jul 25, 2023 | |
Title | Loss of Control (Lost Then Found) of Radioactive Material |
Event Description | The following is a synopsis of information received from Oregon Health Authority, Radiation Protection Services (RPS):
At 1845 PDT this evening a caller contacted the Oregon Emergency Response System (OERS) to report a yellow package with a radioactive placard that was found in a parking lot at their location. RPS followed up on the OERS report (Incident Number: 2023-1825) and it appears that an employee from Weston Solutions, an EPA contractor, discovered a box with a Yellow II DOT label in the middle of a parking lot outside of their warehouse in Portland. The box appeared structurally sound and intact. The caller had a survey meter on-site (a Ludlum 2241 with pancake probe) and measured approximately 11,000 cpm at 1 inch away from the package. The employee called 911 and the police notified the National Response Center and sent officers to respond. The police inspected the package and discovered it belonged to Cardinal Health. Cardinal Health Nuclear Pharmacy, a licensee, shares a parking lot and occupies an adjacent warehouse to Weston Solutions. The police then hand-carried the box to the Cardinal Health building. A representative from Cardinal Health (police verified credentials) accepted the package and took it inside their facility. RPS called Cardinal Health Nuclear Pharmacy Services and spoke with the on-call pharmacist / RSO of the facility. At the time of the call she was on-site at the pharmacy to investigate the situation after being contacted by the employee that accepted the package from the police. The pharmacist / RSO explained that she had immediately leak tested the package and the readings were typical. The box was labeled as containing I-131. There was no sign of a breach or disturbance to the package. The package was then transported to a locked storage vestibule and the pharmacist / RSO then notified the courier of the misplaced material. The courier used to transport the radionuclides to the nuclear pharmacy was PNW Trade Winds. RPS called and spoke with the lead courier to gather more information about the circumstances that could have led to losing the package. The lead courier had spoken with the driver involved and their best guess is that while the driver was segregating packages for the different delivery locations at his vehicle, he must have dropped a box and it landed underneath the vehicle. All the material that was supposed to arrive at Cardinal Health was accounted for, so the driver was not aware of the missing package. The driver most likely would not have realized it was lost until performing a physical inventory at a subsequent location. As far as timing, the lead courier explained that the driver had left Cardinal Health at approximately 1800 PDT and the package was discovered by Weston Solutions at 1820 PDT. When talking with the Weston Solutions employee, he had mentioned that they were in the parking lot area at 1745 PDT and did not see the package at that time, confirming the timeline. Therefore the material was in the parking lot for only about 20 minutes before it was discovered. RPS Incident Number: 23-0035
The following information was received from RPS via email: This letter [from Cardinal Health to RPS] serves as the written report concerning an incident involving the loss of radioactive material as it relates to Oregon radioactive materials license ORE-90509, pursuant to OAR 333-102-0350(3)(b). On July 23, 2023 at 1845 PDT, a caller contacted the state emergency response system to report a package was discovered in their parking lot with a radioactive material label in Portland, OR. The package was labeled Cardinal Health. Cardinal Health's Portland nuclear pharmacy (ORE-90509) shares a parking lot with the location that reported the package. The police delivered the package to Cardinal Health, where it was then secured by a Cardinal Health employee. The package was inspected and wipe tested by the site radiation safety officer, with no contamination, damage, or breach found. The package contained 1 mCi worth of I-131 capsules that had been packaged for delivery to a separate Cardinal Health location in Seattle, WA. The package was transferred to PNW Trade Winds, a contract courier, upon receipt at the airport for transportation to Cardinal Health's Seattle location. PNW Trade Winds reported that the package was likely dropped when segregating packages for different delivery locations. The driver reportedly left the licensee at approximately 6:00 pm, the package was discovered at 1820 PDT. With this timeline the package was left unattended for approximately 20 minutes before it was discovered. In response to this event Cardinal Health has inquired with PNW Trade Winds to review the corrective actions taken on their part. PNW Trade Winds reported that the driver has reviewed their triple check policy and has been placed on three months' probation. During the first month of their probation they are required to call their manager at each stop to review the delivery and verify the remaining packages in the vehicle. Notified R4DO (Dixon) and the NMSS Events Notification and ILTAB email groups. |
Where | |
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Cardinal Health Nuclear Pharmacy Portland, Oregon (NRC Region 4) | |
License number: | 90509 |
Organization: | Or Dept Of Health Rad Protection |
Reporting | |
Agreement State | |
Time - Person (Reporting Time:+-25.28 h-1.053 days <br />-0.15 weeks <br />-0.0346 months <br />) | |
Opened: | Thomas Pfahler 00:28 Jul 24, 2023 |
NRC Officer: | Donald Norwood |
Last Updated: | Aug 23, 2023 |
56635 - NRC Website | |
Cardinal Health Nuclear Pharmacy with Agreement State | |
WEEKMONTHYEARENS 566352023-07-25T01:45:00025 July 2023 01:45:00
[Table view]Agreement State Loss of Control (Lost Then Found) of Radioactive Material ENS 516882016-01-27T05:00:00027 January 2016 05:00:00 Agreement State Agreement State Report: Radiation Overexposure to External Whole Body ENS 428552006-09-22T05:00:00022 September 2006 05:00:00 Agreement State Agreement State Report 2023-07-25T01:45:00 | |