ENS 46577
ENS Event | |
|---|---|
05:00 Jan 13, 2011 | |
| Title | Agreement State Report - Potential Dose Exceeding Annual Occupational Dose Limit for Adults |
| Event Description | The following was received via email:
On 1/13/11, the licensee reported to the agency [Massachusetts Radiation Control Program] a potential dose exceeding the adult occupational total effective dose equivalent limit of 5 rem. The situation causing this event occurred during late December 2010, when a number of emergency repairs within a cyclotron were conducted over several days. The potential for overexposure was suspected on 1/5/11. A dosimeter exposure readings report of the [Optically Stimulated Luminescence OSL] was received by the licensee from the dosimeter service, after quick read, on 1/13/11. Affected individual's annual TEDE reported at 5457 mrem. Exposure (1596 mrem) obtained by official [OSL] dosimeters worn during cyclotron repair operations differed significantly from exposure (620 mrem) obtained by electronic dosimeter worn simultaneously during cyclotron repair operations. Electronic dosimeters are used by individuals for real-time readings during the repair operations. The licensee removed affected individual from any potentially high exposure operations. Investigation ongoing. Intermediate and draft reports have been received. Awaiting final written report by licensee. The Agency considers this event to still be OPEN. Massachusetts Event # 01-9454. Notified R1DO (Dwyer) and FSME (McIntosh).
Subsequent on-site agency inspection performed. Licensee submitted follow-up report [on] 2/28/11. Cause Description: Misinterpretation of licensee's pre-existing policy restricting workers when YTD [year-to-date] annual exposures approach in-house limits and over-reliance on real-time electronic dosimeters worn specifically during potentially high exposure operations. Precipitating factor: Over-reliance on real-time electronic dosimeters worn specifically during potentially high exposure operations. Corrective Action: Licensee to implement policy re-write to minimize subjective misinterpretations, change full-time dosimeter exchange frequency to obtain more current year-to-date exposure totals, replace current job-specific dosimeters with different type of dosimeter better suited to monitor type of work involved, apply administrative correction factors to readings of job-specific dosimeters to obtain more conservative real-time results. The individual [involved in this event was] removed from potentially high exposure operations during investigation and re-instated several weeks later on 3/3/11. Although the Agency considers this specific situation to be closed, it will be revisited during future inspections. The report did not state whether an over exposure actually occurred. Notified R1DO (Dimitriadis) and FSME (McIntosh).
The Massachusetts Radiation Control Program determined the individual received a dose of 5457 mrem. Notified R1DO (Dimitriadis) and FSME (McIntosh). |
| Where | |
|---|---|
| Massachusetts General Hospital Boston, Massachusetts (NRC Region 1) | |
| License number: | RCN01762 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+440.98 h18.374 days <br />2.625 weeks <br />0.604 months <br />) | |
| Opened: | Anthony Carpenito 13:59 Jan 31, 2011 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Mar 4, 2011 |
| 46577 - NRC Website | |
Massachusetts General Hospital with Agreement State | |
WEEKMONTHYEARENS 560292022-08-02T19:30:0002 August 2022 19:30:00
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