ENS 46489
ENS Event | |
|---|---|
06:00 Dec 10, 2010 | |
| Title | Agreement State Report - Radiography Camera Locking Device Failure Resulting in Personnel Exposure |
| Event Description | On December 17, 2010, the Agency [Texas Department of Health Services] was notified by the licensee that on December 10, 2010, the locking device on QSA model 880 camera containing 97 curies of Iridium (Ir) 192 failed to activate. The radiography crew (group A) had completed operations at one site near Lufkin, Texas, and was moving to a new location at the same site. The radiography camera with the cranking device and guide tube still attached were placed in the dark room of the radiographers' truck. The licensee stated that a survey was conducted to verify the source was in the fully shielded, locked position. As the radiographer was driving to the new location, he passed about 5 feet from another group of radiographers (group B) from the same licensee. As group A passed by group B, group B's dosimeters alarmed. Group B stopped group A and told them that their alarms had gone off. Group A went to the camera, picked up the crank for the camera, and found that the source had moved from the locked position approximately one quarter of a turn. The radiographer cranked the source back to the fully shielded position and secured the camera for transportation.
The radiographers did not inform the licensee of the event until December 16, 2010. At that time, the licensee began an investigation of the event, including reenactments of the event to determine how much dose the radiographers had received. During the investigation, it was discovered that both radiographer's self reading pocket dosimeters had been read after the camera was secured and were reading off scale. The licensee determined that radiographers 'A' were eight feet from the source while they were driving and would have been exposed to the source for approximately 10 minutes. A dose estimate of 1,700 millirem was made for both individuals. The thermoluminescent dosimeters for radiographers 'A' have been sent to the processor for reading. The licensee stated they expected the readings by late Monday December 20. The licensee stated that several pieces of radiography film were lying on the seat of the truck when the event occurred. The film was developed and indicated that it had been exposed to approximately 1,700 millirem. The licensee stated that neither radiographer would have received enough exposure to exceed any limit. The licensee stated that no member of the general public was exposed to any radiation as a result of this event. The licensee has not inspected the camera. The licensee stated that the camera is out of service and is currently stored in their storage facility. Additional information has been requested of the licensee. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #I-8803
On December 23, 2010, the Agency [Texas Department of Health Services] performed an on-site investigation at the licensee's facility. The investigation determined that the camera did not fail to operate properly, but that the operator failed to fully retract and lock the source in place.
This event was initially reported as a failure of the locking device on a radiography camera. The investigation into the event determined that it was caused by operator error and not a failure of the equipment to operate as designed. Notified R4DO(Howell) and FSME(McIntosh). |
| Where | |
|---|---|
| H&H X-Ray Services Inc. Lufkin, Texas (NRC Region 4) | |
| License number: | 02516 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+181.27 h7.553 days <br />1.079 weeks <br />0.248 months <br />) | |
| Opened: | Art Tucker 19:16 Dec 17, 2010 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Feb 1, 2011 |
| 46489 - NRC Website | |
H&H X-Ray Services Inc. with Agreement State | |
WEEKMONTHYEARENS 464892010-12-10T06:00:00010 December 2010 06:00:00
[Table view]Agreement State Agreement State Report - Radiography Camera Locking Device Failure Resulting in Personnel Exposure 2010-12-10T06:00:00 | |