Event Notification Report for February 23, 2023

AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIALS

The following information was provided by the Wisconsin Radiation Protection Section (the Department) via email:

"On March 21, 2023, the licensee, PPD Development, LLC, reported a loss of control of radioactive material to the Department. On February 23, 2023, the licensee discovered that eight shipments were sent to a hazardous waste vendor in Nebraska for disposal, and the waste inadvertently contained carbon-14 radiolabeled pharmaceutical samples used for research and development. The eight shipments occurred between July 26, 2019, and October 27, 2022. In total the amount of carbon-14 that was improperly disposed of was 3.88 millicuries. The largest single shipment contained 1.19 millicuries of carbon-14. The licensee immediately contacted the recipient and determined that the waste had already been incinerated. The State of Nebraska has been notified. The Department performed a reactive inspection, and the investigation is ongoing."

WI Event Report ID No.: WI230005

* * * UPDATE ON 4/20/23 AT 1250 EDT FROM MEGAN SHOBER TO ADAM KOZIOL * * *

"On April 19, 2023, the Department became aware that of the eight referenced shipments inadvertently containing carbon-14, only four shipments were sent to a hazardous waste vendor in Nebraska. The other four shipments were sent to a hazardous waste vendor in Arkansas and incinerated. The State of Arkansas has been notified."

Notified R3DO (Orth), NMSS Events, and ILTAB

AGREEMENT STATE REPORT - FAILED SHUTTER

The following information is a summary provided by the Illinois Emergency Management Agency via email:

During a routine inspection on May 17, 2023 at Flexsys America, L.P. in Sauget, IL, an inspector identified a February 2022 equipment failure involving a fixed gauge that resulted in a stuck-open condition of the shutter (300mCi Cs-137 sealed source, model A-2102, serial number 3654CP). This incident was reportable to ONS-RAM within 24 hours under 32 Ill. Adm. Code 340.1220(c)(2). No personnel exposures occurred as a result. Corrective action was taken with repairs to the mechanism performed by the manufacturer and the gauge was returned to operable condition. The initial reporting requirement was not met by the licensee and will be addressed through inspection correspondence. This matter was reported to the NRC within the required timeframe.

Illinois report number: IL230010

AGREEMENT STATE REPORT - LEAKING SOURCE

The following information was obtained from the Ohio Bureau of Radiological Protection via email:

"On 2/17/2023, the licensee's [Alternate Radiation Safety Officer] ARSO entered the radioactive material storage room where a technician was opening the housing on a device containing a Kr-85 source.

"Upon the initial attempt to withdraw a bolt of the device housing, an area radiation monitor began to alarm. The ARSO and the technician took a second reading with a Victoreen 451 [radiation detector] to confirm that it was Kr-85 gas leakage and exited the room. A radiation survey meter indicated that there was no contamination on either person. Removable swipes of the area outside of the room also were indicative of no contamination. The entry door was sealed and access restricted until additional information was available.

"Follow-up entries were completed by the ARSO on 2/20/2023 and 2/21/2023 using 1 meter by 1 meter grids to identify specific areas of testing for removable contamination. Radiation and contamination survey results identified no readings above background. The licensee did not report results of any personnel testing or estimates of uptake.

"The licensee is investigating the cause of the Kr-85 leak. [Ohio Department of Health] ODH will travel to the site to conduct an investigation on 02/28/2023."

Ohio Item Number: OH230003

AGREEMENT STATE REPORT - LOST/MISSING GAUGE

The following was received from the state of South Carolina via email:

"The South Carolina Department of Health and Environmental Control was notified on 02/23/23 at 1546 [EST] via telephone that a Humboldt Model 5001 device (serial number 4686) portable moisture density gauge was lost or missing. The Humboldt Model 5001 device contains a maximum activity of 11 millicuries (407 MBq) of Cs-137 and 44 millicuries (1628 MBq) of Am-241:Be. The licensee is reporting that the Humboldt Model 5001 device was lost or missing while in transit via a common carrier. The Humboldt Model 5001 device was picked up by the common carrier at a temporary jobsite in South Carolina on 01/18/23 and was intended to be delivered to the manufacturer in Raleigh, NC. The licensee is reporting that the Humboldt Model 5001 device was delivered to a common carrier facility in Durham, NC on 01/19/23. The licensee is reporting that the Humboldt Model 5001 device has not been delivered to the intended destination and the licensee is reporting that the common carrier has indicated that the shipment cannot be located.

"This event is under investigation by the South Carolina Department of Health and Environmental Control."

* * * UPDATE ON 2/24/23 AT 1112 EST FROM SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL TO KAREN COTTON * * *

"The South Carolina Department of Health and Environmental Control was notified on 02/24/23, at 1056 EST via telephone that the Humboldt Model 5001 device (serial number 4686) has been found by the common carrier and retrieved by the licensee from the common carrier facility in Durham, NC.

"This event is still under investigation by the South Carolina Department of Health and Environmental Control."

Notified R1DO (Carfang), NMSS Events Notification, and ILTAB

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

EN Revision Imported Date: 4/19/2023

EN Revision Text: AGREEMENT STATE REPORT - POTENTIALLY DAMAGED GAUGE

The following information was provided by the Illinois Emergency Management Agency (IEMA) via email:

"At 1730 CST on 2/23/2023, the IEMA was contacted by the radiation safety officer (RSO) for Rubino Engineering to advise of a portable moisture/density gauge involved in an accident at a temporary jobsite. Reportedly, a Troxler 3400 series gauge was in use at a construction site in Maple Park, IL when it rolled down an embankment and was struck by a skid steer. The licensee's technician remained on scene and assessed minor damage to the case. The source rod was not extended at the time of the accident. Both sources were reported as intact and the area secured until the RSO could arrive within an hour with a survey meter. No exposure concerns were reported or anticipated. The RSO arrived on site approximately an hour later to assess, survey, package, and return the device to safe storage. The IEMA advised that they were available to respond if contamination was suspected or if there were complications in retrieving and returning the sources to storage. At approximately 1900, the RSO advised IEMA that the device had been returned to storage. Surveys of the device and source holders were consistent with an undamaged device.

"On 2/24/2023, IEMA inspectors initiated a reactionary inspection to verify the presence of both sources, assess for removeable contamination, advise on proper return of the unit to the manufacturer, determine root cause of the incident and evaluate compliance with IEMA regulations. Updates from that inspection, as well as specifics on the device serial number and sources will be provided once available."

Illinois Item Number: IL230005

* * * UPDATE ON 4/18/23 AT 1326 EDT FROM IEMA TO SAM COLVARD* * *

"On 2/24/23, IEMA inspectors performed a reactionary inspection and verified the presence of both sources. An assessment for removeable contamination was performed with negative results. Inspectors advised on the proper return of the unit to the manufacturer and verified the package TI [Transport Index]. No items of non-compliance were identified as the licensee met license and regulatory requirements. The root cause was determined as ill-advised placement of the gauge on filter fabric (near the edge of a hill) which got pulled by a skid steer while backing at the bottom of the hill causing the gauge to tumble down the hill in the path of the backing skid steer.

"The licensee advised that corrective actions included advising gauge users regarding placement of gauges near any edge while at a field site and discussion on modification of field use procedures to place the gauge back in the transport container during lapses between testing.

"This matter may be considered closed pending satisfactory sealed source leak test results from the manufacturer upon return of the gauge to Troxler and the licensee's required written report per 340.1230(b)."

Notified R3DO (ORTH), and NMSS Events Notification (E-mail).