ENS 56045
ENS Event | |
|---|---|
15:45 Aug 15, 2022 | |
| Title | Individual Exposed to Radioactive Materials |
| Event Description | The following event was received by the New York State Department of Health [the Department] via email:
On 8/15/22, the Radiation Safety Officer of NRD, LLC notified the Department that an individual may have been exposed to radioactive materials. At approximately 1145 EDT, the continuous air monitoring system located in the Rolling Room area of the Isotope Production Lab triggered an alarm. All associates immediately exited the lab per established protocol. Nasal smears were collected and counted for all six lab personnel. With exception of one individual, all other personnel's nasal smear results were below the facility's 500 dpm [disintegrations per minute] threshold. One individual produced a nasal smear reading of 725 dpm in the left nostril and 781 dpm in the right nostril. This employee was instructed to blow their nose twice and a second nasal smear test was performed. The nasal smear readings were 27 dpm and 30 dpm respectively. Blank samples that were counted along with the nasal smears were 39 dpm and 7 dpm respectively. 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 NMED Number: 220369
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. 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. Additionally, Am-241 contamination was found in worker vehicles, shoes and homes. These unrestricted areas were immediately remediated to background levels. Notified R1DO (Arner), NMSS (Rivera-Capella), NMSS Events Notification |
| 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 20, 2023 |
| 56045 - NRC Website | |
Nrd, Llc with Agreement State | |
WEEKMONTHYEARENS 571852024-06-10T20:30:00010 June 2024 20:30:00
[Table view]Agreement State Unplanned Contamination ENS 571842024-05-08T04:00:0008 May 2024 04:00:00 Agreement State Unplanned Contamination ENS 569812024-01-26T05:00:00026 January 2024 05:00:00 Agreement State Lost Sources ENS 568692023-11-19T05:00:00019 November 2023 05:00:00 Agreement State Potential Overexposure ENS 560452022-08-15T15:45:00015 August 2022 15:45:00 Agreement State Individual Exposed to Radioactive Materials ENS 539742019-04-01T04:00:0001 April 2019 04:00:00 Agreement State Agreement State Report - Possible Internal Overexposure 2024-06-10T20:30:00 | |