ENS 58062

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v t e ENS Event
06:00 Nov 24, 2025
Title	Extremity Exposure Exceeding Limits
Event Description	The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email: The Agency was contacted the morning of November 26, 2025, by Mistras Group, Inc., to report a radiography overexposure that occurred on 11/24/25. Reportedly, a trainee stood over a collimated, exposed 37 Ci Ir-192 source for an unreported period of time, before also grabbing the collimator (containing the exposed source) in his right hand and positioning it for the next shot. After checking the camera and recognizing the incident, he continued to work for ten additional shots, and the following day, before reporting the incident. Based on the report, the lead radiographer also failed to properly supervise and/or report the matter. The trainee was not wearing his dosimetry/alarming rate meter or referring to his survey meter throughout the incident. The radiographer reports symptoms consistent with an acute exposure to his right hand [sunburn, skin erythema, and tingling in the hand] and is being directed to medical treatment this morning. Oak Ridge Associated Universities (REAC-TS) was contacted by the licensee the evening of November 25, 2025, for direction on appropriate medical treatment. The trainee has been removed from all work for, at a minimum, exceeding his occupational exposure limits. The Agency has requested updates on medical assessment and is coordinating a full re-enactment with involved personnel for an accurate dose assessment at the beginning of next week. Agency staff, using the limited data available at this time, estimate an exposure in excess of 50 R but likely less than 250 R to the right hand. The source was in a 4 half-value layers tungsten collimator which the trainee states was pointed down. Based on the licensee's description, exposures to the groin and feet are estimated to be less than 50 R. Time/motion studies will allow refinement of these estimates. Based on the description of the exposure, this incident likely has a 24-hour reporting requirement, which the licensee failed to meet. Results of the time/motion study and refined dose estimates will be used to determine if the incident meets the criteria for an abnormal occurrence. Updates will be provided as they become available. Illinois item number: IL250048 * * UPDATE FROM GARY FORSEE TO BRIAN P. SMITH AT 1644 EST ON DECEMBER 2, 2025 * * * The following is an update received from the Illinois Emergency Management Agency (the Agency) via phone and email: Agency inspectors completed a reactive inspection on Dec. 2, 2025. Based on a re-enactment of the incident, statements collected and time-motion studies, Agency staff do not believe the radiographer received a dose in excess of regulatory limits (50 rem). Inspector observations and inspection findings indicate a likely dose of 30 rem to the radiographer's right hand and an additional 1 rem to other portions of the skin. After repeated observations of the trainee's handling and securing of the collimated source, it was determined the guide tube was being held rather than the collimated (shielded) source. As a result, the exposure rate used for dose calculations was changed (increased) to that of an unshielded 37 Ci source at a distance of 1.25 inches. After ten recorded re-enactments, the act of picking up and securing the collimator to the pipe consistently resulted in an exposure to his right hand with a duration of 5-7 seconds. It would take an exposure of approximately twice this duration to result in a 50 rem dose to his extremity (11.7 seconds). Exposures to feet, groin, whole body and eyes were also calculated. In aggregate, the skin dose from this incident is estimated to be equal to or less than 31 rem. Total annual extremity exposure is also estimated to be less than the annual limit. Whole body dose for this incident is estimated to be less than one hundred millirem (15 second exposure, 14 inches away from shielded source at 0.31 R/hour). Prior to this incident, the individual's annual whole-body dose was 131 millirem; however, the trainee admitted to not wearing dosimetry. While lab results are pending, there was no appearance of deterministic effects (skin reddening/erythema). This incident will remain open pending the licensee's written report. If their investigation supports inspector findings, this incident may be retracted. Agency address of noncompliance with administrative rules will proceed concurrently. Notified R3DO (Hills), NMSS (Fisher), IRMOC (Grant) and NMSS _Events via email.

ENS 58062 +/-
Where
Marathon Martinez Renewable Fuels Burr Ridge, Illinois (NRC Region 3)
License number:	IL-01225-22
Organization:	Illinois Emergency Mgmt. Agency
Reporting

Agreement State
Time - Person (Reporting Time:+54.97 h2.29 days <br />0.327 weeks <br />0.0753 months <br />)
Opened:	Gary Forsee 12:58 Nov 26, 2025
NRC Officer:	Robert A. Thompson
Last Updated:	Dec 2, 2025
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v • d • e

v t e Emergency Notification System
Martinez Refining Company with Agreement State
WEEKMONTHYEAR2025-11-24T06:00:00 [Table view]
[ENS list for Martinez Refining Company]

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