ENS 54258
ENS Event | |
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16:30 Aug 30, 2019 | |
Title | Agreement State - Radiography Camera Source Unable to Retract |
Event Description | The following was received from Kentucky Department of Health Radiation Branch (KY RHB) via email:
KY RHB was notified by telephone on 9/3/19 that at approximately 1230 EDT on 8/30/19, while performing radiography in a pipe rack, radiographers were unable to retract a 38.7 Curie Ir-192 (AEA/QSA A424-9, Serial No. 82580G) source into the exposure device (QSA 880D Serial No. D11651) using the crank mechanism. During the retracting process the cover plate on the drive became loose, enabling the internal drive cable to depart the gear system in the handle of the drive cable mechanism. Since the issue with the drive cable could not be repaired, the incident became a retrieval situation, and the crew made appropriate notifications to the Radiation Safety Officer, manager and on-site contact. The crew established a new 2 mR boundary as required and confirmed that the area was secure. The drive cable was removed from the handle, and the source was manually retracted into the exposure device. The source was secured in the exposure device at 1435 EDT. During the 2-hours while the source was exposed, there were no overexposures to the public. The radiographer and assistant received exposures of 80 mR and 130 mR respectively and the manager received an exposure of 5 mR. It was determined that the root cause of the incident was that the crew did not properly inspect the equipment before commencing non-destructive testing activities. It was discovered that the drive cable handle was missing four of the six screws that secure the cover plate on. This caused the drive cable to slip off the gear and partially lift the cover plate. The drive cables were immediately taken out of service and replaced with properly functioning equipment. Event Report ID No.: KY190009 |
Where | |
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Mistras Group Louisville, Kentucky (NRC Region 1) | |
License number: | 201-736-05 |
Organization: | Kentucky Dept Of Radiation Control |
Reporting | |
Agreement State | |
Time - Person (Reporting Time:+161.98 h6.749 days <br />0.964 weeks <br />0.222 months <br />) | |
Opened: | Aj Bhattacharyya 10:29 Sep 6, 2019 |
NRC Officer: | Caty Nolan |
Last Updated: | Sep 6, 2019 |
54258 - NRC Website
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Mistras Group with Agreement State | |
WEEKMONTHYEARENS 554682021-09-13T07:00:00013 September 2021 07:00:00
[Table view]Agreement State Radiography Device Malfunction ENS 542582019-08-30T16:30:00030 August 2019 16:30:00 Agreement State Agreement State - Radiography Camera Source Unable to Retract ENS 539702019-04-01T07:00:0001 April 2019 07:00:00 Agreement State Lost Then Found Category 2 Radiography Exposure Device ENS 475912012-01-04T15:30:0004 January 2012 15:30:00 Agreement State Agreement State Report - Radiography Camera Not Properly Secured 2021-09-13T07:00:00 | |