ENS 52009

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v t e ENS Event
07:00 Jun 14, 2016
Title	Agreement State Report - Lost and Found Brachytherapy Seeds
Event Description	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

ENS 52009 +/-
Where
Isoray Richland, Washington (NRC Region 4)
License number:	WN-L0213-1
Organization:	Wa Office Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+35.73 h1.489 days <br />0.213 weeks <br />0.0489 months <br />)
Opened:	Anine Grumbles 18:44 Jun 15, 2016
NRC Officer:	Dong Park
Last Updated:	Jun 15, 2016
52009 - NRC Website
v • d • e

v t e Emergency Notification System
Isoray with Agreement State
WEEKMONTHYEAR2016-06-14T07:00:00 [Table view]
[ENS list for Isoray]

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ENS Notification