United States Nuclear Regulatory Commission - Protecting People and the Environment

ACCESSION #: 9608070003

                          William Beaumont Hospital
                                  Royal Oak

License Number 21-01333-01: Notification of a Minor Radioactive Spill and
Possible Defect
Licensee: William Beaumont Hospital, 3601 W. Thirteen Mile Rd, Royal Oak,
Michigan 48073
Date/Time of Discovery:  April 29, 1996 at 10:00 a.m.

A.   Description of Event

A spill of 60 millicurie of Tc-99m HMPAO occurred at 10:00 a.m. on April
29, 1996 in the Radiopharmacy of the Nuclear Medicine Department.  The
Radiopharmacy technologist had prepared the radiopharmaceutical kit
inside the lead vial shield.  The top of the lead vial shield screws into
a threaded brass ring located inside the body of the lead vial shield.
The technologist picked up the lead vial shield by its top and the brass
ring came loose from the body of the lead vial shield.  This caused the
body of the lead vial shield containing the kit vial (with 60 millicurie
of Tc-99m HMPAO) to drop onto the floor.  The technologist's shoes,
stocking and pants were contaminated and promptly removed.  No skin
contamination was detected.  The spill was contained and decontaminated.
An area of residual contamination was shielded with lead foil and covered
with absorbent paper for decay.  The RSO was notified immediately, and a
Spill Report will be completed when the contamination is reduced to
background levels.

B.   Cause of the Spill

Although the integrity of each vial and elution shield are routinely
checked by the Radiopharmacy staff, with defective components repaired or
replaced, the fact that this particular brass ring was loose was not
known prior to the spill.  The Radiopharmacy technologist picked up the
vial shield by its top only in order to transport it to the quality
control bench.  The weight of the body of the lead shield (i. e., lead
pig) coupled with the loose brass ring caused the spill to occur.  The
lead kit vial shield involved in this spill was several years old and of
an older design than currently available vial shields.  All lead shields
become malleable and more susceptible to loss of their structural
integrity over time and with high frequency of use.

C.    Corrective Actions

The manufacturer of the lead vial shield was notified by the RSO on April
29, 1996.  The manufacturer redesigned the lead shield in October 1994.
In the new design, the brass ring is cemented inside the body of the lead
shield with epoxy to prevent it from coming apart.  All vial shields
designed before October 1994 will be returned to the manufacturer.  The
manufacturer will replace them with the newly designed vial shields.  As
part of our routine quality control, each kit and elution vial shield
will be checked for structural integrity monthly by the Radiopharmacy
staff to prevent this event from recurrence.  The Nuclear Medicine staff
has been instructed to transport the lead vial shields by the body of the
shield, and not just the top.

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D.   Reporting Requirements

This event is being reported to NRC Operations as a possible defect
regulated by 10 CFR 21.21 "Notification of failure to comply or existence
of a defect and its evaluation."

This section required licensees to notify the NRC Operations Center (301-
816-5100) by telephone and within 30 days after making the telephone
report, in writing.  Notification that is required for a defect should be
made as follows:  (i) initial notification by fax is the preferred method
to NRC Operations Center at (301) 816-5151 within two days following
receipt of information of a defect or by telephone; and (ii) written
notification within 30 days.

Report Prepared by:

Cheryl Culver Schultz, M.S.
Radiation Safety Officer


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