Event Notification Report for May 15, 2023

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was received from the New York State Department of Health (NYSDOH) via email:

"The New York State Department of Health conducted a routine inspection of lnficon, Inc. on May 5, 2023, and were made aware of Ni-63 (2.4 mCi) source that exceeded the 0.005 microcurie leak testing threshold and is considered leaking. Information on the source is below:

Make: NRD, LLC
Model: N1001 (SSDR: NY-0502-S-103-U)
Serial Number: INF739
Date of Sample Collection: 4/27/2023
Leak Test Result: 1.82E-2 microcuries
Analysis Report Date: 5/2/2023

"In accordance with lnficon's license, this source was obtained for secondary manufacturing and assembly into Micro Argon Ionization Detector (MAID) cells. lnficon detected this leaking source immediately following assembly prior to distribution in accordance with all regulatory requirements and the conditions of their license. Once it was determined that this source was leaking, personnel were notified, and the device was immediately quarantined. lnficon conducted removable contamination surveys around the device in question, however, they do not believe that any personnel or equipment may have been contaminated from this leaking source. Wipe test results are pending to date. As this is the second leaking source reported by lnficon (See NY-23-01 notification for the first leaking source notification), lnficon has hired an external consultant to review and audit their assembly process. This audit has been scheduled and lnficon has agreed to submit the findings of this audit to New York State Department of Health.

"Following the results of these wipe tests, the facility plans to dispose of this source and equipment. New York State Department of Health is in continued discussion with lnficon regarding next steps for this event.

"No further information on the device, source or incident is available at this time. Any updates to this event will be provided as soon as feasible. This incident is tracked under Incident No. 1436 by NYSDOH.

"New York State report no.: NY-23-03"

AGREEMENT STATE REPORT - STUCK SOURCE

The following information was provided by the Texas Department of State Health Services (the Department) via email:

"On May 5, 2023, the Department received a notification of a source retrieval incident. A team of radiographers was working at a fab shop late at night using a QSA Delta 880 camera with a 45 curie selenium-75 source. While the source was out, a small pipe fell onto the guide tube and crimped the line. The radiographers were unable to retract the source back into the camera and pushed it back out to the collimator. They then watched the barrier that was at slightly less than 2 mR/hr until the RSO [Radiation Safety Officer] arrived. The RSO, who is authorized on Texas license for source retrieval, then placed lead filled bags on the source that was still within the collimator. He then proceeded to uncrimp the line, and after the 5th attempt, he was able to retract the source back into the camera. The two radiographers did not receive additional dose, but the RSO who retrieved the source did receive 108 mrem. No one else was present because of the late hour. A survey of the camera was performed after the retrieval with no change compared to before the incident.

"Further information will be provided per SA-300."

Texas Incident Number: 10015
NMED Number: TX230020

AGREEMENT STATE REPORT - TWO SOURCES INVOLVED IN A FIRE

The following information was provided by the Texas Department of State Health Services (the Agency) via email:

"On May 5, 2023, the Agency received a phone call from the licensee's service provider who reported that yesterday (May 4, 2023) Shell Chemical LP in Deer Park, Texas, had a fire and explosion. Two nuclear gauges both containing 20 millicurie cesium-137 sources may have been involved in the event. The licensee has not been able to inspect the gauges due to structural safety concerns therefore the condition of the of the two gauges is unknown. The two gauges are located very close to each other. The licensee hopes to get eyes on the two gauges tomorrow or Monday. The gauges do not present an exposure risk to any individual.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident number: I-10016

NMED number: TX230021

* * * UPDATE ON 5/8/2023 AT 1338 EDT FROM ART TUCKER TO BRIAN LIN * * *

The following information was provided by the Texas Department of State Health Services (the Agency) via email:

"On May 8, 2023, the Agency was notified that the licensee has not been able to inspect the gauges. The licensee is still working on isolating hydrocarbon gasses that are being released in the area. There is a concern that the fire could reignite. The licensee does not know when they will be able to access the area. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Werner) and NMSS Events Notification via email.

* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD ON 5/10/2023 AT 1256 EDT * * *

The following information was provided by the Agency via email:

"On May 6, 2023, the Agency received a phone call from the licensee's service provider who reported that yesterday (May 5, 2023) Shell Chemical LP in Deer Park, Texas, had a fire and explosion.

"On May 10, 2023, the Agency was notified by the licensee's service provider (SP) that the licensee was able to use a drone to inspect the area of the fire. The SP stated that they were able to see one of the gauges which was still located in the same position it was in before the fire. The second gauge could not be located due to all the debris in the area. The SP stated the gauges original position was on a pipe six feet above the ground. They believe the pipe may have fallen to the ground and the gauge went with it. The SP stated the licensee did perform a radiation survey outside the exclusion area in the area where the gauges are located, and the readings were background. The SP did not know how close they would have been to the gauges. The licensee is making plans to enter the area, but the weather is causing delays as they have to shut down outside activities anytime there is lightning within 10 miles of the plant. The SP stated they did not have a date or time when they will be able to access the gauges. The SP stated they have discussed how they will conduct contamination surveys and radiation surveys once they gain access to the area. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Werner) and NMSS Events Notification via email.

* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD ON 5/11/2023 AT 1729 EDT * * *

The following information was provided by the Agency via email:

"On May 6, 2023, the Agency received a phone call from the licensee's service provider who reported that yesterday (May 5, 2023) Shell Chemical LP in Deer Park, Texas, had a fire and explosion.

"On May 11, 2023, the Agency was contacted by the licensee's service provider (SP). The SP stated the licensee had made an entry into the area affected by the fire and was able to visually inspect the gauges from an unknown distance. One gauge (unknown which one) was free of soot and was still the same color as it was before the fire. The other gauge had soot on it. The gauge that was mounted 6 feet off the ground on a pipe was observed in the same location as it was before the fire and had not been knocked to the ground with debris as previously thought. The dose rates in the areas the individuals were in were reported as background. The licensee plans to reenter the area tomorrow afternoon and perform radiation surveys and take swipes on the gauges. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Werner) and NMSS Events Notification via email.

* * * UPDATE ON 5/13/23 AT 1916 EDT FROM ART TUCKER TO ADAM KOZIOL * * *

The following information was provided by the Agency via email:

"On May 6, 2023, the Agency received a phone call from the licensee's service provider who reported that yesterday (May 5, 2023) Shell Chemical LP in Deer Park, Texas, had a fire and explosion.

"On May 13, 2023, the licensee reported both sources had no removable contamination and they have both been safely removed and placed in a low occupancy and secure temporary storage location. The licensee reported the gauge shielding had been degraded and the gauges were wrapped in lead before they were placed in the storage location. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Werner) and NMSS Events Notification via email.

AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was provided by the LA Department of Environmental Quality (the Department) via email:

"[On] May 6, 2023, Shell Chemical LP notified the Department that a fixed gauge has a stuck shutter in the open position. [Gauge information:] Vega Model SHF1 serial number: N0416 with Cs-137 50 mCi, source serial number: N/A.

The facility has contacted BBP Sales to come out on Monday, May 8, 2023. The facility is planning to replace the nuclear gauge housing because of corrosion."

Event Report ID No.: LA20230008

AGREEMENT STATE REPORT - LIQUID RADIOACTIVE CONTAMINATION

The following information was provided by Utah Department of Environmental Quality, Division of Waste Management and Radiation Control [the Division], via email:

"The Division was notified of the incident at 7:38 AM on May 8, 2023, by email from the Utah Department of Environmental Quality's duty officer who was on call on Saturday May 6, 2023.

"Information received from the on-call duty officer: The Radiation Safety Officer reported a radioactive material (rubidium-82) release of an unknown amount due to a leaking generator. She said that Cardiac Molecular Imaging found liquid in the bottom of a well chamber of the infusion system. Proper decontamination procedures were followed, the liquid was placed in radioactive waste storage, a wipe test was done, and everything was cleaned up. She said this has happened before. There was no impact to patient treatment. The generator will be shipped back to the manufacturer for investigation. The incident has been contained and there is no immediate threat.

"This appears to be the exact same issue that we notified the NRC for the UT23-0002 and UT23-0003 incidents.

"The Division will investigate this matter and update the record upon completion of the investigation."

Utah Event Report ID No.: UT23-0005