ENS 45439
ENS Event | |
|---|---|
05:00 Oct 14, 2009 | |
| Title | Agreement State Report Involving a Radiography Camera Source Disconnect |
| Event Description | Received a call from State of Texas concerning an incident that occurred 10/14/09 at a temporary jobsite in Texas (location unknown). The company (not identified in the call) is located in Pasadena, TX. The State of Texas representative said that the Radiographer failed to follow procedures and connect the guide tube before cranking out the source. The source subsequently struck the wall and disconnected. The company RSO who is qualified for source retrieval recovered and secured the source. His extremity dosimetry indicated 57 mrem with a whole body dose of about 90 mrem. Details of the incident including licensee name and license number will be provided by update.
The following information was received by e-mail: On October 15, 2009, the Agency [State] was notified by the licensee that on October 14, 2009, they experienced a source disconnect while using an Amersham model 660 radiography camera containing a 45.3 curie Iridium (Ir) 192 source. The Radiation Safety Officer (RSO) stated that two radiographers were setting up for their first shot of the day. The guide tube they had was too short, so one of the radiographers connected an additional guide tube to the end of the existing guide tube, while the other radiographer prepared to perform the shot. Neither of the radiographers attached the guide tube to the camera. They then cranked the source out of the camera to perform their first shot. This caused the source to be pushed out of the camera, onto the floor of the shooting bay, and against the wall of a shooting bay. The camera operator felt that he had cranked the source out farther than it should have traveled for the shot and stopped cranking the source. He then tried to return the source to the camera. When the radiographer retracted the drive cable, the source was left loose on the shooting bay floor. The radiographer approached the shooting area with his dose rate meter and found the dose rates were elevated. The radiographer then secured the area and notified the RSO, who is specifically authorized on the license for source retrieval. The RSO developed a strategy to reconnect the source, and then successfully cranked the source back into the camera. No one involved with this event received an exposure exceeding any regulatory limit. The RSO stated that their investigation into the event determined that the root cause for the event was the failure of the two radiographers to follow procedure. He also noted a failure of the two radiographers to communicate adequately. The RSO stated that they will retrain all of their radiographers regarding their procedures for the proper connecting and disconnecting of equipment to their exposure devices. He also stated that this training would be repeated in their annual training in 2010. Texas Incident: I-8678 Notified R4DO(Cain) and FSME (McIntosh). |
| Where | |
|---|---|
| Fugro Consultants Inc. Pasadena, Texas (NRC Region 4) | |
| License number: | 4322 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+37.07 h1.545 days <br />0.221 weeks <br />0.0508 months <br />) | |
| Opened: | Ray Jisha 18:04 Oct 15, 2009 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Oct 16, 2009 |
| 45439 - NRC Website | |
Fugro Consultants Inc. with Agreement State | |
WEEKMONTHYEARENS 530642017-11-09T06:00:0009 November 2017 06:00:00
[Table view]Agreement State Agreement State Report - Damaged Moisture Density Gauge ENS 521582016-08-06T19:30:0006 August 2016 19:30:00 Agreement State Agreement State Report - Lost Moisture Density Gauge ENS 454392009-10-14T05:00:00014 October 2009 05:00:00 Agreement State Agreement State Report Involving a Radiography Camera Source Disconnect ENS 444722008-09-08T12:30:0008 September 2008 12:30:00 Agreement State Agreement State Report - Stolen Troxler Moisture Density Gauge 2017-11-09T06:00:00 | |