Event Notification Report for April 12, 2024

EN Revision Imported Date: 4/12/2024

EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE
The following information was provided by the New York State Department of Health (the Department) via email:

"New York State (NYS) Department of Heath received an email from the radiation safety officer (RSO) of NRD, LLC regarding an employee entering a restricted zone (Silver Recovery) without use of proper personal protective equipment (PPE) and respiratory protection on Sunday, November 19, 2023. Staff at NRD were made aware of this on November 20, 2023, at 1145 EST. The individual entered the restricted area to conduct non-authorized work, which was performed for 20 minutes in a 12 DAC-hr environment based on continual air monitor (CAM) readings at this time. The individual did not wear proper respiratory equipment, nor did they use a personal (lapel) air sampler, which is a PPE requirement for this zone. The individual later donned proper PPE and respiratory protection and continued to work for a total working time of 2 hours. The nature of work that was being conducted is unknown by the Department at this time.

"As the individual did not perform nasal swabs or have personnel air monitoring estimated doses were assumed using the 12 derived air concentration-hour (DAC-hr) environments based on the CAM. The assumptions in preliminary calculations assume a 2-hour working time to be conservative, which shows 24 DAC Hours (2 percent) of intake for the most limiting isotope (Am-241). Individual has been placed on bioassay urine collection and has had authorizations and security removed. NRD will be notifying the Department of these results and more information as it becomes available. This worker has received one bioassay for urinalysis and has been terminated from employment by NRD, LLC.

"NRD, LLC contacted the Radiation Emergency Assistance Center/Training Site (REAC/TS) regarding this event as a precaution to inquire on the potential supply of Diethylenetriamine pentaacetate (DTPA) for chelation therapy. The affected individual involved in this event has apparently refused to cooperate with REAC/TS. The results of this bioassay will be used to determine if an overexposure event has occurred for this individual where possible."


* * * UPDATE ON 4/11/24 AT 1404 EDT FROM DANIEL SAMSON TO KAREN COTTON * * *

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

"An individual (employed by NRD, LLC) did not wear proper respiratory equipment, nor did they use a personal (lapel) air sampler, which is a personal protective equipment (PPE) requirement for this zone. The individual later donned proper PPE and respiratory protection and continued to work for a total working time of 2 hours. The nature of work was discovered to be the removal of an induction furnace from within a glovebox previously used for precious metal recovery/recycling. The work performed was planned to be performed by NRD, LLC later in the week using pre-approved protocols and procedures. However, the individual in question decided to perform the work on the weekend without following required approved safety protocols and without the knowledge of NRD, LLC.

"Nasal swabs were not collected for the individual in question. However, a single bioassay (24-hour cumulative urine sample) was collected following NRD, LLC's awareness of the event. The 24-hour cumulative urine bioassay analysis showed undetectable levels of Am-241 and Po-210- the two target isotopes of concern during this incident. Noteworthy to the analysis of this data, only one bioassay sample was collected as the individual was terminated shortly after NRD, LLC's awareness of this event. NRD, LLC contacted REAC/TS (Radiation Emergency Assistance Center/Training Site) regarding this event as a precaution to inquire on the potential supply of DTPA (Diethylenetriamine pentaacetate) for chelation therapy. The affected individual involved in this event had apparently refused to cooperate with NRD, LLC or REAC/TS. No doses of DTPA or other chelation agents were administered to the individual following this event. However, provided the assumed intake by this individual, clinical intervention was not likely necessary.

"New York State Department of Health (NYSDOH) performed an unannounced reactive inspection on 12/13/2023 and 12/14/2023 to investigate the circumstances leading to and following this event. Since the bioassay data showed undetectable levels of both Am-241 and Po-210, a comparison to air sampling data was also conducted. Information provided (security camera footage) compared with ambient air concentration data on a continual air monitor (CAM) indicates that the average air concentration was approximately 12 DAC-hrs (assuming Am-241, most limiting ALI) for the 20-minute duration in which this individual was performing work without PPE. This would constitute approximately 100 mrem CDE to the bone surfaces for Am-241 (approximately 0.2 percent Annual Limit CDE for Am-241 to the Bone Surfaces). Since the CAM was placed next to the location where this work was conducted, a rough/conservative estimate to determine potential dose incurred by the individual assumes that there was a uniform distribution of aerosolized Am-241 in an environment 6x higher for the worker than what was recorded near the CAM based on prior lapel air sampling data for performing this type of work. From performing this work without PPE, it would be estimated that this individual could have approximately 600 mrem CDE to the bone surfaces for Am-241 (approximately 1.2 percent Annual Limit CDE for Am-241). Based on information provided and observed, this would expect to be an overly conservative assumption, as the individual appeared to minimize hands-on work during the 20-minute duration without PPE. Expected doses incurred from this intake, if any, would be expected to fall well below 600 mrem CDE to the bone surfaces-based observations by NYSDOH staff performing the reactive investigation. This is further reinforced by the single 24-hour bioassay sample, which provides some additional confidence that these estimates may be overly conservative.

"Following this event and investigation, NYSDOH made numerous attempts to contact the individual in question. All attempts by NYSDOH to contact this individual were unsuccessful.

"The reactive inspection performed by NYSDOH resulted in observations of noncompliance and notices of violation issued to NRD, LLC. NRD, LLC has and will continue to implement corrective actions following this event. NYSDOH will be evaluating all corrective actions on the next inspection.

"Given the lack of information available at the time of original notification, NYSDOH opted to report this information out of an abundance of caution in the event this individual in question may have received in intake, caused an event leading to excessive airborne or surface contamination, or participated in an event which may have met the reportability criteria to NMED. Given the information provided, NYSDOH has closed Incident No. 1464."

Notified R1DO (DeFrancisco), NMSS Day Coordinator (Roberts), and NMSS Events Notification (email)

AGREEMENT STATE - LOST PACKAGE

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

"On March 4, 2024, the Agency received a notification from G.E. Healthcare in Arlington Heights, IL to advise of one missing radiopharmaceutical package at the Memphis, TN [common carrier] hub. The package contained one vial of I-123 with 14.268 mCi at the time of shipment.

"G.E. Healthcare was notified on March 4, 2024 by [common carrier] in Memphis, TN that a radiopharmaceutical package was missing with no indication of the contents being separated from the package. The package was originally shipped out of G.E. Arlington Heights, IL facility on February 29, 2024. The lead shielded package contained 14.268 mCi of I-123 in one 10 mL vial at the time of shipment. The destination was Spokane, WA. The last measured activity was 0.094 mCi. The last scan was at the [common carrier] hub in Memphis on February 29, 2024 and [common carrier] confirmed the package could not be found on March 4, 2024. This matter will continue to be tracked until an update is available or the package has decayed to background levels.

"As of April 3, 2024, the licensee indicates there are no changes to the status of the package or contents of the package. The package content has decayed to background levels. This does not pose a threat to the health and safety of the public. Provided there are no changes, this matter is considered closed."

Item number: IL240007

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

AGREEMENT STATE REPORT - LOST SOURCE

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

"Annual self-inspection request was sent to all generally licensed entities on February 15, 2024. This registrant e-mailed back on February 21, 2024, indicating that he was no longer associated with the company, the company was no longer in business in Illinois, and the radioactive material was lost. The company was sold and the radioactive material was sold with the other assets. However, the sources were in place as recently as January 3, 2020, when they submitted their last self-inspection.

"The registration had three 10 mCi nickel-63 (Ni-63) sealed sources on their inventory. After continued research, the Agency was unable to track down the sources. The Agency contacted the manufacturer, Shimadzu, who did not have any records of any service work on the 3 sources or disposal paperwork. The new company could not be found. These sources do not pose a health or safety risk to the public. Pending any new information, this matter is considered closed."

Illinois Item Number: IL240005

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

STUCK SHUTTER

The following information was provided by the licensee via phone:

The radiation safety officer (RSO) was showing a new employee the nuclear gauges when they noticed that a gauge was missing a handle. The handle opens and closes the shutter. The RSO believes the shutter may be stuck in the open position. The gauge was manufactured by Burthold in 1995 with model number 7440 and serial number 2964 containing 50 millicuries of Cs-137. There is no additional exposure to plant personnel or the public due to the position of the shutter. Burthold has been contacted for maintenance.

AGREEMENT STATE REPORT - STUCK WELL LOGGING SOURCE

The following information was provided by the Louisiana Radiation Protection Division (the Division) via email:

"On April 4, 2024 at approximately 1619 CDT, the president and radiation safety officer (RSO) of Roke Technologies USA, Inc. [was] working under Louisiana reciprocity when they reported to the Division that at approximately 1400 CDT, two QSA Global 3.0 Ci well logging sources of Americium-241:Be (Model AMN.CY3) contained in the licensee's custom made proprietary logging tool became stuck in tubing at a depth of approximately 1,965 feet. The well, Ronald Richard et ux No. 1, is in Opelousas Field, St. Landry Parish, Louisiana. The E-line holding the logging tool, rated at 3,150 lbs., pulled out of the rope socket on the logging head after the subcontractor logging crew, Verde Services, LLC (Verde) of Laurel, MS, attempted to pull out the tool. The licensee's plan is to meet Verde's braided line truck that is arriving on site at 0800 CDT on April 5, 2024. The braided line is much stronger than the E-line and this truck has a greater pulling strength than the E-line truck. The licensee has high confidence that they will be able to recover the tool as they are also equipped with a fishing neck for the 1-11/16-inch tool which faces upward inside the 2-3/8-inch tubing. The RSO is remaining on site until the tool and sources are recovered. The RSO will follow up with a status report tomorrow morning."

FITNESS FOR DUTY

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

"A non-licensed employee supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.

"The NRC Senior Resident Inspector has been notified."