ENS 56083
ENS Event | |
|---|---|
05:00 Aug 31, 2022 | |
| Title | Lost I-125 Brachytherapy Seeds |
| Event Description | The following information was provided by Illinois Emergency Management Agency, Radioactive Materials Branch (the Agency) via email:
The Agency received a partial report via email from the licensee on September 1, 2022, indicating the potential loss of two brachytherapy seeds, accounting for a maximum estimated activity of 1.05 millicuries. The licensee has conducted an investigation and although the package appeared undamaged; believes the seeds may have been lost in transit from Atlanta Medical Center in Atlanta, GA. Requests for clarification and the nuclide (either I-125 or Pd-103) have not yet been returned. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion. While incomplete, this incident has the potential to be reportable and will be communicated to the United States Nuclear Regulatory Commission Headquarters Operations Officers today. On August 8, 2022, Bard Brachytherapy received a package from the Atlanta Medical Center. The package contained sources that were outside of the primary container and were lodged in the packaging foam. The shipping box looked undamaged from the outside, but three of the four primary containers were loose or open inside. The licensee counted the sources in the package and found 28. The return sticker included in the box from Atlanta Medical Center listed that 30 sources should have been returned. Surveys were conducted of the packaging material, the receiving and returns processing areas, and the path between to verify that the unaccounted-for sources were not in the Illinois facility. The counts were verified with the shipper and the licensee confirms two brachytherapy seeds (likely I-125) were most likely lost in transit. Illinois Incident Number: IL220031 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 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+36.6 h1.525 days <br />0.218 weeks <br />0.0501 months <br />) | |
| Opened: | Gary Forsee 17:36 Sep 1, 2022 |
| NRC Officer: | Ian Howard |
| Last Updated: | Sep 1, 2022 |
| 56083 - NRC Website | |
Bard Brachytherapy with Agreement State | |
WEEKMONTHYEARENS 563412023-02-06T06:00:0006 February 2023 06:00:00
[Table view]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 2023-02-06T06:00:00 | |