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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 52916 | 18 August 2017 18:00:00 | 10 CFR 30.50(b)(1) | Unplanned Contamination Event - Broken Flame-Sealed Glass Ampoule | The purpose of this communication is to provide additional details surrounding the circumstances that led to the identification of unplanned contamination in one of the laboratories designated as a restricted area under the US NRC license SNM-362. As indicated verbally during the initial report at 1207 EDT, and required by 10 CFR 30.50(b)(1), this event is described as having a broken flame-sealed glass ampoule that resulted in contamination of the lead-shielding storage area on top of the countertop and other surfaces within room C11 in building 245 of the NIST Gaithersburg, MD campus. This was discovered at approximately 1400 EDT on 8/18/2017. The ampoule contained a well-characterized solution of Am-241 with an activity of approximately 47 MBq (most restrictive ALI (Annual Limit on Intake) is 0.006 uCi) and is registered in our database as being in a solution of nitric acid. The initial report requirements of 10 CFR 30.50(b)(1)(i) through (iii) are satisfied by the phone notification and supplemented by this communication and attachments. Additional information regarding corrective actions taken and planned, as well as evaluations and/or assessments, will be provided to our Project Manager and Region I in the near future and the required written report will be provided within the required 30 days. After reporting event #52916, at the direction of the Radiation Safety Officer and with the support of the NIST Senior Management, multiple efforts will continue to evaluate the extent of the condition and a Stop Work Order will be issued effective today for all other laboratories at NIST Gaithersburg that store similar ampoules until the extent of condition is evaluated and/or mitigated. Extensive surveys of the area and air monitoring have confirmed that the contamination is isolated to portions of room C11. Access has been restricted to room C11. The licensee notified NRC R1 (Ullrich) and NRC HQ PM (Naquin) regarding this event.
The licensee received three bioassay results from personnel exposure to the contaminant. Two of the bioassays were negative. The third bioassay indicated the exposed individual received 9.1 REM whole body with 87 REM to the bone surface of the target organ. Additional bioassays are being performed. The licensee notified R1 (Ullrich and Jackson) and HQ (Naquin). Notified R1DO (Dentel), NMSS (Rivera-Capella), and NMSS Events Notification (email).
The purpose of this communication is to provide additional details regarding Event # 52916 as results of radiological surveys, interviews, and bioassays are obtained. As indicated verbally during the NRC Ops Center phone update today at 18:38 EDT, new survey and interviews information have led us to believe that ingestion was a possible pathway for the individual that had a positive bioassay. Given the difference in the intake retention fraction (IRF) for ingestion versus inhalation pathway, we have performed additional calculations of the previous bioassay results. These calculations have identified the potential for a total effective dose equivalent of 25 rem or more. Given the potential for dose of 25 rem or more, consultation was done with the REAC/TS team. Additional bioassays and medical evaluation will be performed. A courtesy notification was provided earlier today to R1 (Ullrich) and HQ (Naquin). Notified R1DO (Dentel), NMSS (Collins) and INES Coordinator (Rivera-Capella), INES National Officer (Milligan) via email. | ||
| ENS 52900 | 14 August 2017 18:54:00 | 10 CFR 20.2201(a)(1)(i) | Material Identified Lost After Inventory | The NIST (National Institute of Standards and Technology) determined that 24.9 microCuries of Cf-252 is being considered lost after performing an examination of inventory records. The missing material was identified during a leak test conducted on Wednesday August, 9, 2017. After identification of the missing material, NIST performed a physical inspection of all laboratories and examined physical inventory records. NIST has identified that there is a potential for this material to have been shipped to the Department of Energy and is still awaiting a response to verify that information. NIST has performed a courtesy notification to the NRC R1 (Ullrich) and PM (Naquin) regarding this incident.
The purpose of this communication is to provide additional details surrounding the circumstances that have led to location of the Cf-252 source reported as missing under 10CFR20.2201(a)(i) at 14:54EDT on 8/14/2017. A call to the Ops Center was made today at 16:31EDT. The purpose of the call was to retract Event #52900 after successfully locating the source with NIST unique identifier number RS75-0086 (known by the Department of Energy as NS-86). The source was located inside a restricted area, the same room where the empty storage container was located. After reporting event #52900, at my direction as Radiation Safety Officer and with the support of NIST Senior Management, multiple efforts were started to investigate the probable disposition of the source (also as directed by 10CFR20.2201(b)(iii)). During those efforts, all records for shipments of Cf-252 were reviewed and colleagues at the DOE were contacted to exhaust the possibility that the material had been transferred out of NIST. Having no record of the source departing the facility, a new round of radiological surveys was started of the restricted facilities where the source had been previously authorized. After removal of all other neutron-emitting shielding containers from the immediate area, a residual field of neutron radiation was detected. This seemed indicative of the presence of a source. At this time it was observed that a radioactive source was outside of the storage containers. This source is/was of very small dimensions (approximately one inch in diameter). The source matched the description and nearby was found the hazards information tag that corresponded to RS#75-0086. Given that the source was always in a restricted area with low-occupancy, we have determined that no hazards to individuals have resulted from this source misplacement. Notified ILTAB (Ahern), R1DO (Gray), and NMSS Events Resource (via e-mail). 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 | ||
| ENS 52185 | 15 August 2016 20:15:00 | 10 CFR 70.50(b)(2) | Irradiator Safety Equipment Failure | The NIST (National Institute of Standards and Technology) irradiator has several Cs-137 sources used to calibrate instruments. During a calibration process, a 3.6 Ci source did not return to its shielded position. The event occurred in a portion of the building where such events are expected, therefore there were no health or safety consequences to employees, public or the environment. Licensee corrective actions include manually installing a lead plug into the beam port (opening) of the irradiator. The licensee is contacting the manufacturer in order to assist with troubleshooting and repairs. The irradiator (Model 81-12; JL Shepherd; S/N 7132) is currently in a safe and stable configuration. It is noted that the irradiator is NOT a Part 36 irradiator. |