ENS 56045: Difference between revisions
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| NRC officer = Howie Crouch | | NRC officer = Howie Crouch | ||
| event date = 08/15/2022 11:45 EDT | | event date = 08/15/2022 11:45 EDT | ||
| last update date = | | last update date = 04/19/2023 | ||
| title = Individual Exposed to Radioactive Materials | | title = Individual Exposed to Radioactive Materials | ||
| event text = The following event was received by the New York State Department of Health [the Department] via email: | | event text = The following event was received by the New York State Department of Health [the Department] via email: | ||
| Line 21: | Line 21: | ||
The effected individual was removed from working with radioactive material and has begun a 24-hour bioassay collection. A root cause investigation into the cause of the air alarm and the positive nasal smear is underway. The air monitor filter paper was replaced and the activity displayed on the continuous air monitor system returned to normal levels, indicating that the cause of the alarm was a very short duration event. | The effected individual was removed from working with radioactive material and has begun a 24-hour bioassay collection. A root cause investigation into the cause of the air alarm and the positive nasal smear is underway. The air monitor filter paper was replaced and the activity displayed on the continuous air monitor system returned to normal levels, indicating that the cause of the alarm was a very short duration event. | ||
New York Event Number: NYDOH-22-4 | New York Event Number: NYDOH-22-4 | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/ | NMED Number: 220369 | ||
* * * UPDATE ON 4/19/23 AT 1054 EDT FROM DANIEL SAMSON TO ADAM KOZIOL * * * | |||
The following update was received by the New York State Department of Health (NYSDOH) via fax: | |||
NYSDOH contacted Radiation Emergency Assistance Center/Training Site (REAC/TS) to independently review the nasal smear readings. The review revealed a likely overexposure to one worker who was advised to seek medical treatment. Further site investigation identified a defective machine utilized in producing smoke detectors with americium-241 foil. The worker with the overexposure had been using that machine and had to repeatedly open the fume hood to keep the machine operational. | |||
NYSDOH took administrative action to halt licensee production activities, require modification to radiation safety program, enhance oversight of the licensee through increased inspection frequency, provide specific conditions requiring immediate notification, requirement of an independent safety analysis and adoption of recommendations from these findings, and multiple follow-up site visits by inspection staff to verify progress and status of decontamination and corrective actions. | |||
The investigation showed that several workers had elevated doses and one worker had exceeded occupational dose limits in 10 CFR 20.1201 for Committed Dose Equivalent (CDE) to bone surfaces (56 rem). It was found that the licensee had failed to calculate CDE and committed effective dose equivalent (CEDE) from collected bioassay data from 2019 to the date of the incident. NYSDOH requested the licensee utilize a consultant certified health physicist third-party evaluation of all collected bioassay data for all workers. The one worker with the overdose from this incident was found to have consistently exceeded the occupational dose limits for CDE to bone surfaces for calendar years 2019 (115 rem), 2020 (51 rem), and 2021 (51 rem). Additionally, one previous worker that left employment of the licensee in 2022 received 76 rem CDE to bone surfaces. NYSDOH is following up on the computational methods used by the consultant to clarify and potentially modify the internal doses calculated. | |||
Additionally, significant Am-241 contamination was found on floors, tables, walls, light fixtures, and specific equipment. Further directed corrective actions include replacement of equipment, improvement to the air monitoring systems in the labs, implementation of a respiratory protection plan, enhancement of emergency response plans, restructuring of management and organizational structure of the company, hiring of additional radiation safety technicians, enhancement of training and personnel monitoring programs, and modification to proprietary work procedures to prevent recurrence. NYSDOH and licensee are discussing further investigation and corrective actions. | |||
Notified R1DO (Arner), NMSS (Rivera-Capella), NMSS Events Notification | |||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2023/20230420en.html#en56045 | |||
}} | }} | ||
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Revision as of 07:30, 20 April 2023
| 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:+19.5 h0.813 days <br />0.116 weeks <br />0.0267 months <br />) | |
| Opened: | Daniel J. Samson 11:15 Aug 16, 2022 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Apr 19, 2023 |
| 56045 - NRC Website | |