ENS 47400
ENS Event | |
|---|---|
19:00 Oct 26, 2011 | |
| Title | Agreement State Report - Equipment Malfunction |
| Event Description | The following information was received by e-mail:
On 10/31/11, the ARSO [Alternate Radiation Safety Officer] at TC Inspection informed RHB [California Radiation Health Branch] via email of an incident occurring on 10/26/11 at Valero Refinery in Benicia, CA during one of their radiography operations. The email written by the ARSO is as follows: On October 26, 2011, there was an incident involving RAM material; one of [the licensee's crew was] performing radiography at the Valero refinery when, while cranking out the source, the trainer noticed the crank handle started free-spinning. When he tried to crank the source back in it was still free spinning so the source was stuck out of the shielded position. When the trainer called, [the licensee] advised him to loosen one of the nuts on the crank assembly, pull back the tube and then grab the cable and pull the source back into the exposure device and into the shielded position and that [the licensee was on his way]. When [the trainer] did this he noticed that the end of the cable was inside the tube, he was able to grab it with a pair of needle nose pliers and retrieve the source back into the shielded position. Two things happened here, the first; the trainer or assistant (still not sure which one) did not fully connect the guide tube to the camera. This allowed the source and cable to go out of the camera into air, thus allowing the cable to reach the end where the stop at the end of the cable did not stop the cable from coming out of the crank assembly. After further investigation [the licensee] found that the aluminum body of the crank assembly was worn right at the exit hole thus allowing the stop to go through. [The licensee] just did a maintenance inspection on those cranks on 10/1/11 and saw some wear on it but not as much as was there this time. [The licensee has] been in the process of replacing the aluminum body on all of [the licensee's] INC crank assemblies with stainless steel bodies when the techs tell [the ARSO] their cranks are getting hard to crank (That is usually the first sign that the aluminum body is wearing). [The apparent cause of the event is a technician forgetting to connect all of the equipment pieces due to production pressures or] equipment failure. CA 5010 Number: 103111
The following was received via email: On the day of the event, the operators pocket dosimeters indicated 10 mR. Camera information: INC IR-100, S/N 4301, with a source activity of 40.8 Ci. The crank assembly has been sent to INC and we'll be visiting INC today. We requested written statements from the trainer assistant. The ARSO already received them and he'll be sending a copy to RHB today. TC was requested to process the dosimetry badges worn by trainer and the assistant. Notified R4DO (Gaddy) and FSME EO (Camper). |
| Where | |
|---|---|
| Tc Inspection, Llc Rodeo, California (NRC Region 4) | |
| License number: | CA 5299-07 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+141.1 h5.879 days <br />0.84 weeks <br />0.193 months <br />) | |
| Opened: | Kent Prendergast 16:06 Nov 1, 2011 |
| NRC Officer: | Vince Klco |
| Last Updated: | Nov 3, 2011 |
| 47400 - NRC Website | |
Tc Inspection, Llc with Agreement State | |
WEEKMONTHYEARENS 474002011-10-26T19:00:00026 October 2011 19:00:00
[Table view]Agreement State Agreement State Report - Equipment Malfunction 2011-10-26T19:00:00 | |