ENS 58044
ENS Event | |
|---|---|
18:18 Nov 18, 2025 | |
| Title | Lost Sources |
| Event Description | The following information was provided by the Illinois Emergency Management Agency (Agency) via phone and email:
The Agency was contacted on November 17, 2025, to advise of four missing I-125 brachytherapy seeds with an activity of approximately 0.23 millicuries each. Three seeds remain missing with the most likely disposition being lost in transit from the Georgia shipper to the Illinois [common carrier] hub. The root cause appears to be poor packaging by the shipping licensee. On November 17, 2025, Bard Brachytherapy, Inc. received a package from Northside Hospital - Gwinnett (Lawrenceville, GA) with return shipping information indicating that there were twenty-four seeds being returned. Upon examination, ten were sealed inside their original packaging, nine were found loose inside the box, and one was found in the parking lot outside of the delivery door. Four sources remained unaccounted for when the Agency was contacted. [The common carrier] was called to return to the Bard facility, but surveys failed to identify any additional seeds within the delivery vehicle. Additional surveys were conducted at the local [common carrier] hub and on the truck that transported the package from O'Hare airport. The licensee was able to locate one additional seed at the [common carrier] hub, underneath a receiving conveyor belt, leaving three (3) seeds unaccounted for. The package is reported as having left Lawrenceville, GA on November 12, 2025. The package had no indication of damage from transit. The Georgia program will be notified. A similar incident was reported on May 13, 2024, as a result of inadequate packaging of seeds for transport by the same Georgia licensee. Agency outreach to O'Hare is still pending for additional surveys. A detailed listing of stops prior to delivery is also being sought. The brachytherapy seeds are classified as a Category 5 source, described by the IAEA as the least likely to be dangerous to a person. At the estimated activity, the exposure rate at one foot would be just under 0.5 mR/hour. Due to the small size as well as the proximity and duration of exposure required; it is highly unlikely any public exposures would exceed regulatory limits. The Illinois licensee followed reporting timelines, package receipt procedures, and performed all reasonable search efforts. Agency staff are pursuing additional avenues to attempt recovery of the sources. This report will be updated with any information available. IL incident number: IL250045
The following information was provided by the Illinois Emergency Management Agency (Agency) via email: Agency inspectors performed a reactive inspection at O'Hare airport on November 19, 2025. Search efforts located one of the three missing seeds, which will be returned to the Illinois licensee for disposal. Two I-125 brachytherapy seeds, containing approximately 0.23 mCi each, remain missing. A detailed listing of stops was obtained from the carrier but proved logistically impractical to fully survey (approximately 63 locations). Given the very low likelihood of public exposures exceeding any regulatory limit, the Category 5 classification of the sources, and high likelihood the remaining sources are out of state; the Agency is considering this matter closed. Notified R3DO (Orlikowski) (email), NMSS Events Notification (email), and ILTAB (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 |
| 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:+-6.1 h-0.254 days <br />-0.0363 weeks <br />-0.00836 months <br />) | |
| Opened: | Gary Forsee 12:12 Nov 18, 2025 |
| NRC Officer: | Jordan Wingate |
| Last Updated: | Nov 19, 2025 |
| 58044 - NRC Website
Loading map... {"minzoom":false,"maxzoom":false,"mappingservice":"leaflet","width":"350px","height":"250px","centre":false,"title":"","label":"","icon":"","lines":[],"polygons":[],"circles":[],"rectangles":[],"copycoords":false,"static":false,"zoom":6,"defzoom":14,"layers":["OpenStreetMap"],"image layers":[],"overlays":[],"resizable":false,"fullscreen":false,"scrollwheelzoom":true,"cluster":false,"clustermaxzoom":20,"clusterzoomonclick":true,"clustermaxradius":80,"clusterspiderfy":true,"geojson":"","clicktarget":"","imageLayers":[],"locations":[{"text":"\u003Cb\u003E\u003Cdiv class=\"mw-parser-output\"\u003E\u003Cp\u003E\u003Ca class=\"mw-selflink selflink\"\u003EENS 58044\u003C/a\u003E - \u003Ca href=\"/Bard_Brachytherapy\" title=\"Bard Brachytherapy\"\u003EBard Brachytherapy\u003C/a\u003E\n\u003C/p\u003E\u003C/div\u003E\u003C/b\u003E\u003Cdiv class=\"mw-parser-output\"\u003E\u003Cp\u003ELost Sources\n\u003C/p\u003E\u003C/div\u003E","title":"ENS 58044 - Bard Brachytherapy\n","link":"","lat":41.93156944444444,"lon":-88.11291666666666,"icon":""}],"imageoverlays":null} | |
Bard Brachytherapy with Agreement State | |
WEEKMONTHYEARENS 580442025-11-18T18:18:00018 November 2025 18:18:00
[Table view]Agreement State Lost Sources ENS 579352025-09-08T05:00:0008 September 2025 05:00:00 Agreement State Contamination Detected in Shipping Vial ENS 576972025-05-07T05:00:0007 May 2025 05:00:00 Agreement State Missing Packages ENS 571932024-06-25T05:00:00025 June 2024 05:00:00 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 2025-09-08T05:00:00 | |