Event Notification Report for June 10, 2024

EN Revision Imported Date: 9/17/2024

EN Revision Text: AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION

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

"NYSDOH received an email from the radiation safety officer of NRD on 6/11/2024 to indicate that a non-routine bioassay was started for an employee due to hand contamination. The employee's hand was decontaminated with soap and water and a whole-body frisk and nasal swabs were conducted. The whole-body count and nasal swabs were less than background.

"[After NYSDOH inquiry, the licensee subsequently reported that] the incident occurred on 6/10/2024 at 1630 EDT and was identified when the employee was leaving the facility. As a standard procedure implemented by license condition, the employee was frisking hands and feet for potential removable contamination. It was discovered upon frisking that the employee had 758 disintegrations per minute of suspected Am-241 on the palm of their left hand when leaving the facility. This amount of alpha skin contamination is 63 times the incident levels established on the license.

"[The employee] was transferring contaminated personal protective equipment (PPE) bags into a B25 [shielded waste] container. [The employee is believed to have] incorrectly doffed gloves. No other individuals had contamination present. A survey was performed of the area showing no contamination in excess of background levels on the surfaces, including the external surface of the B25 container.

"NRD is still performing an investigation, reporting their findings, and providing NYSDOH with bioassay data for this employee.

"It is unclear if this event truly meets the reportability criteria by 10 CFR 20.2203(a)(3)(i) or (ii), however, NYSDOH wishes to voluntarily report this event in the event [it is reportable,] regardless of applicability. NYSDOH will provide updates as appropriate regarding this incident."

NYSDOH Incident Number 1489

* * * UPDATE ON 9/16/2024 AT 1624 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * *

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

"Following the original notification, the worker in question's bioassay result indicated that no Am-241 or Po-210 in excess of this individual's baseline concentrations were present (all 'undetected'). Additionally, this worker's dosimeter did not record any dose received (dose received was below detection limits). This event did not meet the reportability criteria by 10 CFR 20.2203(a)(3)(i) or (ii), however, NYSDOH voluntarily reported this event regardless of applicability.

"As a corrective action, this worker was retrained by the licensee in proper use of PPE, including procedures to properly don and doff PPE. As this was the second event within the past month involving a hand contamination, the licensee also provided additional educational signage for reminding staff on proper PPE usage, training videos and hands-on demonstrations during annual refresher training. Furthermore, additional contamination equipment was purchased to improve monitoring capabilities of staff involved with handling radionuclides.

"NYSDOH has accepted these corrective actions and will evaluate the implementation of these actions on the next inspection. NYSDOH has closed this event."

Notified R1DO (Werkheiser), NMSS (email).

EN Revision Imported Date: 7/26/2024

EN Revision Text: LOST RADIOACTIVE SOURCE

The following is a summary of information obtained from the licensee in accordance with Headquarters Operations Officers report guidance:

At 0415 CDT, on 6/10/2024, the Radiation Safety Officer's (RSO) truck, which contained a Troxler 3440 nuclear gauge (serial number 66812), was stolen (loss of control). The RSO left the truck running with the keys in the ignition and the nuclear gauge secured inside when an individual decided to get in the drivers seat and drive away. When the RSO realized the truck was stolen, they immediately contacted Missouri local law enforcement. The nuclear gauge contains 44 mCi of Am241:Be.

* * * UPDATE ON 6/10/2024 AT 1032 EDT FROM LARRY BRADSHAW TO IAN HOWARD * * *

The following is a summary of information obtained from the licensee in accordance with Headquarters Operations Officers report guidance:

At 0902 CDT, on 6/10/2024, the truck was located and returned to the RSO with the Troxler gauge secure in its locked case. There was no indication of tampering with the case or the locks used to secure the Troxler gauge.

* * * UPDATE ON 7/25/2024 AT 1838 EDT FROM LARRY BRADSHAW TO ERNEST WEST * * *

The following is a summary of information obtained from the licensee in accordance with Headquarters Operations Officers report guidance:

After reviewing security footage, it was determined that the truck was not left running, but the keys were left in the ignition which allowed the truck to be started.

Notified R3DO (Feliz-Adorno)


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 was received from the Texas Department of State Health Services (the Department) via email:

"On June 11, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that a 40 millicurie americium-241/beryllium (Am-241/Be) source from a Troxler 3430 moisture/density gauge could not be located. The gauge did not pass the standardization test, and was later sent to the service provider. On June 10, 2024, the service provider informed the RSO that the gauge was inspected, the cap that held the Am-241/Be source in place was no longer screwed in, and the source was missing. Radiation surveys were conducted at the facility but were unable to locate the Am-241/Be source. RSO contacted the service provider and requested a facility survey. The RSO will be interviewing their technicians and reviewing use records for the gauge in an attempt to locate where the source could have fallen out of the gauge. An exposure risk to an individual was not reported. Additional information will be provided as it is received in accordance with SA-300."

TX Incident Number: 10109

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