Event Notification Report for April 20, 2023

EN Revision Imported Date: 4/20/2023

EN Revision Text: AGREEMENT STATE REPORT - INDIVIDUAL EXPOSED TO RADIOACTIVE MATERIALS

The following event was received by the New York State Department of Health [the Department] via email:

"On 8/15/22, the Radiation Safety Officer of NRD, LLC notified the Department that an individual may have been exposed to radioactive materials. At approximately 1145 EDT, the continuous air monitoring system located in the Rolling Room area of the Isotope Production Lab triggered an alarm. All associates immediately exited the lab per established protocol. Nasal smears were collected and accounted for all six lab personnel. With exception of one individual, all other personnel's nasal smear results were below the facility's 500 dpm [disintegrations per minute] threshold. One individual produced a nasal smear reading of 725 dpm in the left nostril and 781 dpm in the right nostril. This employee was instructed to blow their nose twice and a second nasal smear test was performed. The nasal smear readings were 27 dpm and 30 dpm respectively. Blank samples that were counted along with the nasal smears were 39 dpm and 7 dpm respectively.

"The effected individual was removed from working with radioactive material and has begun a 24-hour bioassay collection. A root cause investigation into the cause of the air alarm and the positive nasal smear is underway. The air monitor filter paper was replaced and the activity displayed on the continuous air monitor system returned to normal levels, indicating that the cause of the alarm was a very short duration event."

New York Event Number: NYDOH-22-4

NMED Number: 220369

* * * UPDATE ON 4/19/23 AT 1054 EDT FROM DANIEL SAMSON TO ADAM KOZIOL * * *

The following update was received by the New York State Department of Health (NYSDOH) via fax:

NYSDOH contacted Radiation Emergency Assistance Center/Training Site (REAC/TS) to independently review the nasal smear readings. The review revealed a likely overexposure to one worker who was advised to seek medical treatment. Further site investigation identified a defective machine utilized in producing smoke detectors with americium-241 foil. The worker with the overexposure had been using that machine and had to repeatedly open the fume hood to keep the machine operational.

"NYSDOH took administrative action to halt licensee production activities, require modification to radiation safety program, enhance oversight of the licensee through increased inspection frequency, provide specific conditions requiring immediate notification, requirement of an independent safety analysis and adoption of recommendations from these findings, and multiple follow-up site visits by inspection staff to verify progress and status of decontamination and corrective actions."

The investigation showed that several workers had elevated doses and one worker had exceeded occupational dose limits in 10 CFR 20.1201 for Committed Dose Equivalent (CDE) to bone surfaces (56 rem). It was found that the licensee had failed to calculate CDE and committed effective dose equivalent (CEDE) from collected bioassay data from 2019 to the date of the incident. NYSDOH requested the licensee utilize a consultant certified health physicist third-party evaluation of all collected bioassay data for all workers. The one worker with the overdose from this incident was found to have consistently exceeded the occupational dose limits for CDE to bone surfaces for calendar years 2019 (115 rem), 2020 (51 rem), and 2021 (51 rem). Additionally, one previous worker that left employment of the licensee in 2022 received 76 rem CDE to bone surfaces. NYSDOH is following up on the computational methods used by the consultant to clarify and potentially modify the internal doses calculated.

Additionally, significant Am-241 contamination was found on floors, tables, walls, light fixtures, and specific equipment. Further directed corrective actions include replacement of equipment, improvement to the air monitoring systems in the labs, implementation of a respiratory protection plan, enhancement of emergency response plans, restructuring of management and organizational structure of the company, hiring of additional radiation safety technicians, enhancement of training and personnel monitoring programs, and modification to proprietary work procedures to prevent recurrence. NYSDOH and licensee are discussing further investigation and corrective actions.

Notified R1DO (Arner), NMSS (Rivera-Capella), NMSS Events Notification

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER (REPAIRED)

The following information was provided by the Ohio Department of Health via email:

"On 3/3/23, the general licensee discovered a generally licensed device [used for package content measuring] with a failing source shutter, or the 'open-close' mechanism, was likely failing in the open position during scheduled internal routine inspection. The receiver portion of the device demonstrated radiation readings were present in the bridge opening when the shutter should have be closed and reading no presence.

"The manufacturer was contacted and the device was taken out of service per the manufacturer's advice regarding the regulations. On 3/21/23, the manufacturer arrived on site, repaired the shutter device, and conducted a survey of the device to ensure the shutter was closing properly after repairing. The survey after the repairs, showed that even with the shutter open, outside the direct beam, annual radiation levels would be less than 100 mrem per year.

Device Manufacturer: Heuft
Device Model: 45US
Device Serial Number: 9KG005979
Source Model: AMC.25
Source Serial Number: 2097LQ containing 40 mCi of Am-241 assayed 3/28/2000

"Note: Initial report made on 4/7/23, by manufacturer to Illinois Agreement State program which passed along to Ohio program. When contacted by Ohio on 4/11/23, the general licensee expressed they were unaware of the requirement to report. General licensee was instructed as to the requirements and they submitted report on 4/12/23."

Ohio Event Item Number: OH230006

AGREEMENT STATE REPORT - LEAKING SOURCE

The following information was provided by the Utah Division of Waste Management and Radiation Control (DWMRC) via email:

"The University of Utah contacted the DWMRC to report that they had found that an Isotope Products Laboratories, Cs-137 Resin Vial Source, Source Number 988-97-3 with an assayed activity of 208.9 microcuries (assay date May 1, 2004), was leaking.

"A routine quarterly leak test was taken of the sealed source. When counted with a PerkinElmer 2480 Wizard2 radiation detector, the wipe showed an elevated reading. The wipe results showed 4531 cpm (background 32 cpm). The technologist who performed the wipe contacted the licensee's Radiological Health Department. The technologist was told to count the wipe in the well counter (Biodex AtomLab 500). The well counter on the Cs-137 channel showed there was 0.6 microcuries with a 0.3 microcuries background on the sample for a leak test result of 0.3 microcuries. Since there was no obvious leak in the resin vial, the licensee suspected it had been contaminated with short lived radioisotopes. The source was doubly bagged and isolated in storage until the next day when it was again verified to be above background. On April 11, 2023, it was retested. The leak test was performed with both an alcohol pad and a gauze pad. The results of these samples were counted with the PerkinElmer instrument, but not the well counter. The result of the wipes was 4248 cpm and 7303 cpm respectively (PerkinElmer 2480 Wizard2 radiation detector for both tests was 32 cpm). This showed it was not a short-lived isotope and the source was leaking.

"The individual stated that when he performed the wipe test on April 11, 2023, he heard the plastic vial crack and the crack opened while the wipe was being taken but returned to a 'closed position' when the wipe was completed. He immediately returned the wipe to the baggies and put it in storage. Since the wipes taken verified the original assessment was correct, the licensee stated that the source would be placed with their waste and disposed in their normal waste shipments to a licensed radioactive waste disposal site.

"After the initial finding on April 4, 2023, radiation surveys of the area and equipment were conducted to verify that no contamination was present. No contamination was found, and the area and equipment were released for use.

"The licensee stated that the vial appeared to be slightly yellowed around the crack and believes the plastic may have cracked due to radiation fatigue. The licensee had ordered two of these sources in 2004. The other source was in use at one of the licensee's other medical facilities but was removed from service and will be disposed of with the leaking source as a precaution."

Utah Event Report ID Number: UT 23-0004

UNACCOUNTED FOR TROXLER MOISTURE GAUGE

The following information was provided by the licensee via phone and email:

"While finishing the renewal of our license, I was not able to account for one device found in a 2016 inventory, the number of devices matched the number of devices listed on our 2016 license.
"Both the license and inventory from 2016 listed 10 devices, I could only account for 9 devices.
"On the 11th of April, documentation was found in our property management system that listed the device as transferred to an outside agency, agency is unknown.
"The last leak test preformed on this device was in 2013, so the condition of the shielding in 2016 is not known, when it was transferred.
"The missing device is a Troxler model 3411 device serial number is 13760.
"The device contains two sources americium-241 with 44 millicuries at 1.480 giga becquerels (SN 47-9073), and cesium-137 with 9 millicuries at 0.296 giga becquerels (SN 50-2578)"

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.pdfThe following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

OFFSITE NOTIFICATION FOR SEWAGE DISCHARGE

The following information was provided by the licensee via phone and email:

"At 1905 [EDT], a security force member discovered what appeared to be a sewage leak along the gravel roadway northwest of the gatehouse entrance. The affected area was approximately 12' X 15'. The water was slowly bubbling up from the ground about 20' along one of our access roads.
"Large absorbent spill containment barriers were placed at the scene to minimize the incident. Water usage was stopped within our facility, and sewer pumps isolated. The Maine State Department of Environmental Protection (DEP) was notified of the incident (DEP spill # 23-0004705). The area was inspected at approximately 2130 [EDT], and water discharge was no longer observed.
"Maine Yankee site management is currently in the process of contacting contractors to resolve the issue.
"The site is safe and secure. The concrete cask heat removal system is operable, and the temperature monitoring system is functional."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee notified Region 1 personnel.

RCS PRESSURE BOUNDARY DEGRADED

The following information was provided by the licensee via email:

"At 1112 EDT on 4/15/23, it was determined that the [reactor coolant system] RCS pressure boundary does not meet ASME Section XI, Table IWB-341 0-1, `Acceptable Standards,' due to through wall leak of the flux mapper seal table guide tube H-6. Corrective actions have been scheduled. `This event is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(A).

"A follow-up review of the condition revealed that 10 CFR 50.72 notification was applicable within 8 hours of the time of discovery on 04/15/23.

"The NRC Resident Inspector has been notified."