ENS 52345
ENS Event | |
|---|---|
05:00 Nov 2, 2016 | |
| Title | Agreement State Report - Radiography Camera Source Did Not Retract Causing Dosimeter Alarm |
| Event Description | The following report was received from the Texas Department of State Health Services via email:
On November 3, 2016, the Agency [Texas Department of State Health Services] was contacted by the licensee's radiation safety officer (RSO). The RSO was reporting that two radiographers had experienced a radiation dose causing pocket dosimeters to go off scale. The crew were working at a temp job site on a power plant. The camera had a 36 curie Ir-192 source. The crew could not hear the alarming rate meters due to excessive noise. The radiographers noticed the source had not retracted completely into the camera while trying to disconnect the guide tube to move the camera to another location. The radiographer reported to the RSO that the source was retracted immediately after finding the source extended. The time reported to the RSO with the source exposing the radiographer was less than 3 minutes. The pocket dosimeters were checked outside the area and found off scale. The RSO stopped all work, requested radiographers return to the shop and he checked the camera to find no defects. The RSO has sent the monitoring badges in for processing and is in the process of completing an investigation to determine exposure dose. A complete report will be provided by the RSO. Updates will be provided in accordance with SA 300 guidelines. Texas Incident #: I 9437
On November 3, 2016, the Agency received a call stating that a radiography crew had experienced an incident on November 2, 2016. The crew had been working at a Power Plant near Franklin, Texas when they experienced an incident involving a possible overexposure. The radiographers were working in a noisy area with all monitoring devices on their person. They had performed several exposure shots and were completing the last shot on a pipe before moving the camera to the next weld area. The radiographer had cranked in the source and both walked to the weld to discuss the next shot position. They were about five feet from the camera and behind the camera which was partially shielded by conduit and piping. Then one radiographer walked to the camera and using the quick disconnect, disconnected the guide tube. When he did this he noticed he source protruding from the camera about six inches and yelled at the other radiographer to get back away from the area. Both ran to the crank, one grabbed the survey meter and the other then cranked in the source, about a turn and half on the crank to secure the source in the camera. The source was in the camera. Both checked their alarming rate meters which were alarming and the pocket dosimeters were off scale. They called the RSO and then packed up their equipment for the day. An incident report was completed at the power plant before leaving the site. Once back at the radiography headquarters the badges were collected and mailed for processing. Both radiographers were interviewed by the RSO and then suspended until monitoring results were received. The RSO calculated the dose to be 1593 mrem for the one radiographer's hand dose. "Monitoring badge results were reported to the Agency on November 10, 2016, with a whole body dose of 309 mrem and a whole body dose of 317 mrem. The annual dose for both radiographers was provided with results of 2053 mrem and 2761 mrem. The November badges had been worn for two days when the incident occurred. "A re-enactment investigation was conducted on November 29, 2016, due to limited details on the report provided by the RSO and the calculations appeared to be short in dose. The investigation and interviews with the radiographers on November 29, 2016, revealed the dose to the hand, foot, gonads, knee, and whole body were slightly higher dose but still under the limits for an overexposure. We had calculated the dose to the hand to be approximately 29 rem instead of 15.9 rem reported by the RSO. The distance of the hand dose was provide by the RSO at 4 inches, during the re- enactment, a smaller distance of one half inch during the time the radiographer removed the guide tube was more accurate. His hand passed directly over the source when he pulled the guide tube over the source when it was extended from the camera. The shorter distance increased the dose, however was still under the 50 rem limit for an overexposure. The radiographer has not experienced any redness, blisters or soreness to his hand. He has been viewing his hands daily and has not notice any radiation burn or injury. During the investigation his hands were viewed and no noticeable damage was seen (26 days after the incident). "The cause of the incident was not retracting the source completely into the shielded position and not using a survey meter to ensure the source was shielded. The two radiographers had changed positions during this job. One usually worked the crank and the other collected the film. Neither radiographer heard the alarms on the rate meters due to the noise. Both radiographers commented during the investigation, that they weren't using the meter like they should and it was their fault for not doing the required survey. Violations were cited to company and radiographers. Notified R4DO (Kellar) and NMSS Events Notification via email.
The following information was received from the State of Texas via email: [The Texas Department of State Health Services] would like to retract NRC event 52345. At the initial reporting from the regulated entity, it was believed two radiographers had received an overexposure from a non-retractable source. After further investigation, it was not a non-retractable source, such as equipment failure. It was human error and the source was retracted by the radiographer. There was no equipment failure. It was operator error and the dose that both radiographers received was not over the reporting limits. Please retract this event. Summary: On November 3, 2016, the Agency was contacted by the licensee's radiation safety officer (RSO). The RSO was reporting that two radiographers had experienced a radiation dose causing pocket dosimeters to go off scale. The crew were working at a temp job site on a power plant. The device was a Spec 150, serial 1500, Spec source G60, serial XG2601 with of Ir-192 with 36 curies of activity. The monitoring badges were sent for processing with results of 317 and 309 mrem doses. The annual dose for both radiographers was below the 5 rem limit. The calculations for the extremity dose (hand, foot, and knee) were below the 50 rem overexposure limit. The annual dose for both radiographers was provided with results of 2053 mrem and 2761 mrem. A re-enactment investigation was conducted on November 29, 2016 due to limited details provided by the RSO. The dose was calculated at 29 rem to the extremities which is under the limit 50 rem for reportable event. The cause of the incident was not retracting the source completely into the shielded position and not using a survey meter to ensure the source was shielded. To prevent recurrence, the company had a meeting (training) with employees stressing the importance of safety, following procedures, and being aware of surroundings. One violation cited to the company and each radiographer." Notified the R4DO (Kramer) and NMSS Events Notification via email |
| Where | |
|---|---|
| Intertek Asset Integrity Management Inc Longview, Texas (NRC Region 4) | |
| License number: | 06801 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31.6 h1.317 days <br />0.188 weeks <br />0.0433 months <br />) | |
| Opened: | Irene Casares 12:36 Nov 3, 2016 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Apr 10, 2017 |
| 52345 - NRC Website | |
Intertek Asset Integrity Management Inc with Agreement State | |
WEEKMONTHYEARENS 535182018-07-20T05:00:00020 July 2018 05:00:00
[Table view]Agreement State En Revision Imported Date 8/15/2018 ENS 523452016-11-02T05:00:0002 November 2016 05:00:00 Agreement State Agreement State Report - Radiography Camera Source Did Not Retract Causing Dosimeter Alarm 2018-07-20T05:00:00 | |