ENS Event | |
|---|---|
05:00 Jan 8, 2021 | |
| Title | HDR Source Not Fully Secured in Transport Pig |
| Event Description | The following information was received from New Jersey Department of Environmental Protection (the Agency) via email:
On January 11, 2021, the Agency was notified by the licensee that during a vendor source exchange of the center's radiation oncology Iridium-192 remote afterloader source (approximately 5.2 Curies at time of incident), the service engineer, noted the failure of the source to be fully secured in its transport pig bucket. This was discovered because the service technician's personal monitor and the in-room monitor both indicated the presence of radiation. The service technician promptly left the vault, closed the door, notified the physicist on site, and the room was secured from further entry. This engineer, another service engineer, the vendor RSO and source recovery team then worked to fully secure the source as per their source exchange procedure. The estimated doses received during the incident are 52.8 mrem and 39.9 mrem to the service engineers involved in securing the source. Their dosimeter readings will be available in the future. No patients or hospital staff were exposed. The vendor will supply the hospital with a full report on the incident, including possible cause. Equipment/device involved, Isotope and activity, manufacturer, model and serial number, leak test results as applicable: Varian Medical Systems, VariSource ix HDR, serial number VS-321, Ir-192, 5.2 Ci (at time of incident), manufactured by Alpha Omega Services, model VS2000, serial number 02-01-2823-001-101420-11593-17. New jersey Incident No.: N/A Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9) |
| Where | |
|---|---|
| Ocean Medical Center Brick, New Jersey (NRC Region 1) | |
| License number: | 457842 |
| Organization: | Nj Rad Prot And Rel Prevention Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+100.73 h4.197 days <br />0.6 weeks <br />0.138 months <br />) | |
| Opened: | Richaard Peros 09:44 Jan 12, 2021 |
| NRC Officer: | Solomon Sahle |
| Last Updated: | Jan 12, 2021 |
| 55061 - NRC Website | |
Ocean Medical Center with Agreement State | |
WEEKMONTHYEARENS 550612021-01-08T05:00:0008 January 2021 05:00:00
[Table view]Agreement State HDR Source Not Fully Secured in Transport Pig 2021-01-08T05:00:00 | |