Event Notification Report for June 14, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/13/2016 - 06/14/2016
EVENT NUMBERS
52009
Agreement State
Event Number: 52009
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: ISORAY
Region: 4
City: RICHLAND State: WA
County:
License #: WN-L0213-1
Agreement: Y
Docket:
NRC Notified By: ANINE GRUMBLES
HQ OPS Officer: DONG HWA PARK
Licensee: ISORAY
Region: 4
City: RICHLAND State: WA
County:
License #: WN-L0213-1
Agreement: Y
Docket:
NRC Notified By: ANINE GRUMBLES
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/15/2016
Notification Time: 18:44 [ET]
Event Date: 06/14/2016
Event Time: 00:00 [PDT]
Last Update Date: 06/15/2016
Notification Time: 18:44 [ET]
Event Date: 06/14/2016
Event Time: 00:00 [PDT]
Last Update Date: 06/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - LOST AND FOUND BRACHYTHERAPY SEEDS
The following was received from the State of Washington via email:
"[A common carrier] lost 252 IsoRay Cesium-131 brachytherapy seeds intended for four patient implants. On Friday, 6/9/2016, radioactive materials licensee, IsoRay (WN-L0213-1) sent four orders of cesium-131 brachytherapy seeds. The four orders contained a total of 252 seeds at a total air kerma activity level of 522.8 U. The total apparent activity is approximately 1 Ci (the actual activity is between 1 - 2 Ci). The absorbed dose from the 252 seeds would be approximately 52,280 rad (522.8 Gray). Early Tuesday morning, 6/14/2016, the Memphis hub of [the common carrier] informed IsoRay that they were unable to locate these packages, and they would not be delivered on time as contracted. They were scanned in and out at both the Pasco and Spokane airports. The Spokane flight to Memphis arrived, but [the common carrier] could not locate them. IsoRay notified the state of the loss of radioactive material that same day.
"On 6/15/2016, IsoRay notified the state that [the common carrier had] found the missing shipments and are returning them to IsoRay. They were not delivered to the intended physicians. There are no details yet on how they became misplaced. IsoRay has scheduled a senior management meeting with [the common carrier's] Priority Alert team to trouble shoot the missing shipments.
"This incident is one of several incidents in which [the common carrier] played a role within the last 4 months."
Incident Number: WA-16-027
The following was received from the State of Washington via email:
"[A common carrier] lost 252 IsoRay Cesium-131 brachytherapy seeds intended for four patient implants. On Friday, 6/9/2016, radioactive materials licensee, IsoRay (WN-L0213-1) sent four orders of cesium-131 brachytherapy seeds. The four orders contained a total of 252 seeds at a total air kerma activity level of 522.8 U. The total apparent activity is approximately 1 Ci (the actual activity is between 1 - 2 Ci). The absorbed dose from the 252 seeds would be approximately 52,280 rad (522.8 Gray). Early Tuesday morning, 6/14/2016, the Memphis hub of [the common carrier] informed IsoRay that they were unable to locate these packages, and they would not be delivered on time as contracted. They were scanned in and out at both the Pasco and Spokane airports. The Spokane flight to Memphis arrived, but [the common carrier] could not locate them. IsoRay notified the state of the loss of radioactive material that same day.
"On 6/15/2016, IsoRay notified the state that [the common carrier had] found the missing shipments and are returning them to IsoRay. They were not delivered to the intended physicians. There are no details yet on how they became misplaced. IsoRay has scheduled a senior management meeting with [the common carrier's] Priority Alert team to trouble shoot the missing shipments.
"This incident is one of several incidents in which [the common carrier] played a role within the last 4 months."
Incident Number: WA-16-027