ENS 47358
ENS Event | |
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04:00 Oct 10, 2011 | |
Title | Loss Of Control Of An I-125 Brachytherapy Seed |
Event Description | On October 10, 2011, North Carolina Radiation Protection (NCRP) received a call from the Radiation Safety Officer (RSO) at Marion L. Shepard Cancer Center in Washington, NC, informing them that on September 26, 2011, while working with I-125 brachytherapy seeds for calibration, they had discovered the loss of one of the seeds. The lost seed was a 0.346 mCi brachytherapy seed that had been received on September 23, 2011. According to the RSO, they had made every effort to locate the seed but could not find it. At that time, it was believed that the seed must have gone behind an un-movable counter in the hot lab at the hospital nuclear medicine department. The well counter they use is kept at the cancer center and taken to the hospital's nuclear medicine department when needed to assay the seeds.
According to North Carolina section .1645 of the rules, this amount did not require immediate phone notification but does require notification within 30 days by phone and a written report within 30 days of the phone notification. On October 19, 2011, NCRP received a call from the State of Wisconsin to notify them that a licensee at the University of Wisconsin had received a well counter from NC that contained a brachytherapy seed. It has not been the policy of the Cancer Center licensee to survey a well counter prior to shipment, since it should not contain any radioactive material, but in the future, well counters will be surveyed. The well counter belonging to the licensee was sent to Wisconsin for calibration and will be shipped back to the Marion L Shepard Cancer Center. No personnel exposures occurred during this event. North Carolina Incident: 11-56 Wisconsin Item Number: WI 110066 (This item received via North Carolina) 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 | |
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Marion L Shepard Cancer Center Washington, North Carolina (NRC Region 1) | |
License number: | 0311-2 |
Organization: | Nc Div Of Radiation Protection |
Reporting | |
Agreement State | |
Time - Person (Reporting Time:+245.92 h10.247 days <br />1.464 weeks <br />0.337 months <br />) | |
Opened: | Sheila Nelson 09:55 Oct 20, 2011 |
NRC Officer: | John Shoemaker |
Last Updated: | Oct 20, 2011 |
47358 - NRC Website | |
Marion L Shepard Cancer Center with Agreement State | |
WEEKMONTHYEARENS 473582011-10-10T04:00:00010 October 2011 04:00:00
[Table view]Agreement State Loss of Control of an I-125 Brachytherapy Seed 2011-10-10T04:00:00 | |