ENS 56368
ENS Event | |
|---|---|
06:00 Jan 17, 2023 | |
| Title | Occupational Dose Limit Exceeded |
| Event Description | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
The Agency received written correspondence on February 16, 2023, indicating a worker at a Romeoville, IL nuclear pharmacy (Sofie, RML IL-02074-01) received a whole body dose that exceeded the occupational limits in 32 Ill. Adm. Code 340.210. The exposure occurred over the course of 2022 and no adverse health impacts are anticipated. Specifically, the information provided indicates a quality control production associate received 5,090 millirem over the course of 2022, exceeding the occupational limit of 5,000 millirem. The licensee has conducted an investigation and believes the cause is related to both a management deficiency and equipment issues. New duties assigned in July of 2022 resulted in increased exposure which was apparently not reviewed and/or assessed at a frequency sufficient to limit occupational dose. Additionally, dose delivery equipment reportedly failed at some point in 2022, resulting in the use of equipment with insufficient shielding. The licensee identified corrective action as more frequent dosimetry exchange, repair of equipment (timeline unspecified) and reassignment of duties. This is a reportable incident under 32 Ill. Adm. Code 340.1230 and was reported to NRC the same day (2/16/23). The licensee provided timely notification. In the next week, IEMA inspectors will perform a reactionary inspection to assess the adequacy of the licensee's investigation and corrective action, compliance with Agency regulations and root cause determination. Illinois Event Number: IL230004
The following information was received via email: On March 3, 2023, Agency inspectors performed a reactionary inspection. The root cause of failing to provide adequate monitoring of occupational exposures was confirmed. This was compounded when delivery equipment failed and alternate procedures were utilized. The subject employee who exceeded the annual occupational dose of 5,000 mrem (5 rem) was reported as having received 5,090 mrem. However, during the inspection, inspectors discovered that from February 14, 2022, through April 25, 2022, the employee was wearing visitor dosimetry, which wasn't added to the individuals dosimetry report. It was added to her Form 5 by the RSO which was completed on February 20, 2023. The total exposure was 5,781 mrem for this individual. It was also noted that as a result of not adding the visitor badges to the individuals report the employee first exceeded the annual occupational dose at the end of October, 2022, having reached 5,057 mrem. Additional violations regarding employee dosimetry were noted and are being assessed at this time. However, they are not expected to result in another occupational exposure. The Agency has requested dosimetry records for all licensee staff working under the alternate procedures. Updates will be provided as they become available. otified the R3DO (Havertape) and the NMSS Events Notification email group. |
| Where | |
|---|---|
| Sofie Romeoville, Illinois (NRC Region 3) | |
| License number: | IL-02074-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+729.92 h30.413 days <br />4.345 weeks <br />1 months <br />) | |
| Opened: | Gary Forsee 15:55 Feb 16, 2023 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Mar 6, 2023 |
| 56368 - NRC Website | |
Sofie with Agreement State | |
WEEKMONTHYEARENS 569232023-12-11T06:00:00011 December 2023 06:00:00
[Table view]Agreement State Potential Overexposure ENS 563682023-01-17T06:00:00017 January 2023 06:00:00 Agreement State Occupational Dose Limit Exceeded ENS 555432021-10-25T14:45:00025 October 2021 14:45:00 Agreement State Agreement State - Contaminated Package 2023-12-11T06:00:00 | |