ENS 56869

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v t e ENS Event
05:00 Nov 19, 2023
Title	Potential Overexposure
Event Description	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 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />. 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 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />. 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, LLCs 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, LLCs 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)

ENS 56869 +/-
Where
Nrd, Llc Grand Island, New York (NRC Region 1)
License number:	NYSDOH C1391
Organization:	New York State Dept. Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+79.28 h3.303 days <br />0.472 weeks <br />0.109 months <br />)
Opened:	Daniel Samson 12:17 Nov 22, 2023
NRC Officer:	Karen Cotton-Gross
Last Updated:	Apr 11, 2024
56869 - NRC Website
v • d • e

v t e Emergency Notification System
Nrd, Llc with Agreement State
WEEKMONTHYEAR2025-03-07T04:00:00 [Table view]
[ENS list for Nrd, Llc]

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