Event Notification Report for August 28, 2009

AGREEMENT STATE REPORT - RADIOLOGICAL CONTAMINATION IN AN UNCONTROLLED AREA

"On August 28, 2009, the [State] Agency was notified by the licensee that while performing radiological surveys in response to a shipping event, access to an area of their facility not normally controlled for radiological reasons was isolated due to the presence of radioactive contamination. The licensee believes that the radionuclide involved is Curium (Cm) - 244. The licensee is continuing their investigation and cleanup activities. The [State] Agency will provide updates when available."

Texas report # I-8661

* * * UPDATE ON 09/02/09 AT 1436 EDT FROM ART TUCKER TO TEAL * * *

"NSSI became aware of our contamination problem as a result of the shipment of an empty transport container in support of the DOE Offsite Source Recovery Program (OSRP) which operates from Los Alamos. The NSSI facility is used by OSRP as the primary consolidation facility for the Program.

"NSSI shipped an empty 30 gallon 6M transport container to Penn State University at University Park, PA on August 20, 2009 by [a delivery company]. An attempt was made by the [delivery company] to deliver the package on August 24, but it was refused. The drum was accepted the morning of August 25, 2009.

"On receipt, contamination was noted on the lid with another spot on the pallet and on the banding holding the drum to the pallet. OSRP personnel were at the site and confirmed the contamination. [The delivery company] was also notified and arrangements were made to survey the delivering vehicle. No contamination was found on the truck.

"NSSI was notified midday and began to make measurements to determine if the contamination could be from the NSSI facility or whether it occurred during transit. NSSI tracked the drum back to its origination point in the NSSI facility and was able to confirm that the area immediately surrounding where the drum had been stored was contaminated. Further surveys and wipes showed activity across the storage area floor. Trace contamination was also found on the pallet banding equipment and on the OSRP source inspection and documentation table. Other spots of low contamination were found on a fork lift and a drum cart that was used to move the transport container that went to Pennsylvania. These areas were decontaminated so the equipment could be utilized.

"As the radionuclide has not yet been identified, decontamination is being limited to small spots on the concrete outside the Longhorn building and on equipment or shields that may have been removed from the contaminated area.

"NSSI has decided to delay any decontamination activities pending identification of the nuclide. Time will be required to get air sampling set up and operating and to coordinate with the decontamination personnel.

"At the moment, the radionuclide, quantity, and physical/chemical form involved has not been specifically identified. Surveys tell us the radioactive material is an alpha emitter. Gamma spectrum tells us that the nuclide is not Am-241. Long term gamma spectrum counts of wipes collected also tend to indicate the absence of Pu-238 and Pu-239 as there is always some Am-241 present with these nuclides. Liquid scintillation identifies the alpha energy as being higher than the 5.4-5.5 MeV from Am-241, the 5.4-5.5 MeV for Pu-238 and the 5.1-5.2 for Pu-239. Polonium 210 would also appear to be excluded as it's alpha energy is only 5.3 MeV. In addition, NSSI handles almost no Po-210. At this time, the primary suspect at this time is Curium-244 which has an alpha energy of 5.7-5.8 MeV. We do expect to have nuclide confirmation within a few days as the State of PA and Los Alamos both have samples for evaluation.

"At this point, we do not have any indication of personnel radiation exposure. We will be talking with Los Alamos internal dose assessment people early next week.

"Until we have nuclide information and further evaluate the contamination present in the restricted area, the involved area will remain closed to all NSSI personnel. NSSI is currently in the process of contacting the decontamination experts that assisted NSSI several years ago with an Am-241 contamination incident. We expect to be ready to start the decontamination process within the next 2-3 weeks."

See also EN #45321 for the Pennsylvania report on the same event.

Notified R4DO (Farnholtz) and FSME (McIntosh).

AGREEMENT STATE REPORT - BRACHYTHERAPY PATIENT RECEIVED MORE THAN PRESCRIBED DOSE

The following information was received via NMED report #090706:

"Hardin Memorial Hospital reported that a patient received 26.9% more dose than prescribed during prostate seed implant procedure on 8/28/09. The patient received I-125 brachytherapy seeds with a total activity of 1.26 GBq (34.054 mCi) instead of the prescribed 0.99 GBq (26.825 mCi). It is believed that the medical physicist calculated dose to the prostate using air kerma instead of milliCurie. All physicians and the patient have been notified of the mistake."

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.