ENS 50701
ENS Event | |
|---|---|
09:00 Dec 23, 2014 | |
| Title | Texas Agreement State Report - Source Disconnected on a Radiography Camera |
| Event Description | The following information was obtained from the State of Texas via email:
On December 23, 2014, the licensee notified the Agency [Texas Department of State Health Services] that one of its radiography crews, who was performing radiographic operations at one of its licensed sites in Houston, Texas, had experienced a source disconnect. After completing an exposure, the radiographers cranked the 79 curie cobalt-60 source back into the SPEC300 exposure device. However, as they started to walk toward the end of the guide tube, their survey meter and alarming rate meters indicated the source was still in the guide tube. They moved their boundaries back, secured the area, and called their supervisor. The licensee's radiation safety officer and two employees who are approved on the license for source retrieval responded to the site. They found that the source assembly (pigtail) cable had broken a couple of inches back from the source. The source was retrieved from the guide tube and placed back inside the exposure device. A survey confirmed the source was in the shielded position. The licensee is sending the exposure device and all associated equipment from this event to the manufacturer for evaluation. No member of the public received any exposure and there were no overexposures to any of the radiographers or source retrieval team. An investigation into this event is ongoing. More information will be provided in accordance with SA-300 as it is obtained. Texas Incident No: I-9263
The following report was received from the State of Texas via email: On January 27, 2015, the Agency received a copy of the manufacturer's inspection report for this device. The report stated the source pigtail had been repaired once before in January 2012. The repair involved placing a splice on the pigtail about 3.75 inches from the source to repair a section of severely frayed cable. The manufacturer's report states that this pigtail failure occurred immediately behind this connection. The report states that the connector did not fail, but the cable broke due to cable fray or abrasion. The report states the crimped sleeve on the connector created a section of the source assembly that cannot flex. This causes the cable adjacent to the connector to flex more than is typical in a normal (unrepaired) cable. This repeated local extreme flexures combined with a potential abrasion eventually resulted in the failure. The manufacturer's report also states the manufacturer inspected the inside of the camera's s-tube. This inspection found an area where the tube was slightly crushed causing a small flange area that could potentially cause the pigtail to become snagged or damaged. The report states the pigtail connector body and piston showed significant wear indicating the device was used extensively. The manufacturer stated all other spliced cobalt sources in service with a similar splice installed by them would be inspected. The manufacturer stated they believed there was only one additional camera in service with similar splice. The manufacturer's report states it is investigating a different design of splice used on the cable to prevent this problem in the future. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Campbell) and NMSS Events Notification via email. |
| Where | |
|---|---|
| Texas Gamma Ray, Llc Pasadena, Texas (NRC Region 4) | |
| License number: | L-05561 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+3.52 h0.147 days <br />0.021 weeks <br />0.00482 months <br />) | |
| Opened: | Karen Blanchard 12:31 Dec 23, 2014 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Jan 27, 2015 |
| 50701 - NRC Website | |
Texas Gamma Ray, Llc with Agreement State | |
WEEKMONTHYEARENS 507012014-12-23T09:00:00023 December 2014 09:00:00
[Table view]Agreement State Texas Agreement State Report - Source Disconnected on a Radiography Camera ENS 414902004-10-31T06:00:00031 October 2004 06:00:00 Agreement State Agreement State Report - Unexplained Exposure Dose 2014-12-23T09:00:00 | |