IR 07100020/2012003
| ML20203D437 | |
| Person / Time | |
|---|---|
| Site: | 03017129, 07100020 |
| Issue date: | 12/11/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20203D420 | List: |
| References | |
| 30-17129-97-02, 30-17129-97-2, NUDOCS 9712160194 | |
| Download: ML20203D437 (16) | |
Text
._ _
_
_-
,
... -
_, _
__
____ _ -. __,.
_,._._,m.___
.. -. _
-
.
.
-
=.
...
ERCLOSURE
' "
U.S NUCLEAR REGULATORY COMMISSION
'
REGION IV1 i
NMED item No.
970989 P
Ddeket No.:
030-17129 i
License No.:
50-19202-01
Report No.:
030-17129/97-02 Licensee:
CTI Alaska, Inc.
. Facility; CTI Alaska, Inc.
Location:
Anchorage, Alaska
Dates:
October 20, inrough December 3,1997 Inspector:
Emilio M. Garcia, H salth Physicist (Materials)
Approved by:
D. Blair Spitzberg, Ph.D.
Chief, Nuclear Matarlais Inspection and Fuel Cycle /Cecommissioning Branch ATTACHMENT:
Supplemental Inspection Information
.
I t
9712160194 971211
[DR ADOCK 03017129 PDR
.,
..-
-
.
- -
-
- - -
- -
-
- -
-
._..
. _ _ _ _. _ _ _. -... _
.. _ _..
_
_.. _._..
x
., -
-
-2.
.
EXECUTIVE SUMMARY -
,
. CTI, Inc Anchorage, Alaska -
NRC Inspection Report 030-17129/97-02 L
This special, announced inspection was conducted to review the circumstances surrounding a i radiography event _which occurred on October 16,1997, when a radiographer and two other individuals approached an exposure device with the source in the exposed positioni The.-
inspection focused on the sequence of events and the direct and contributing causes.' Doses received b,v_all individuals involved in the event were 65 millirem or less.
Radioaraohv Event
.
.On October 16,1997, a radiographer working as a field crew leader of a real time
-
radiography crew and his assistant approached a pipe crawler which housed an Amersham.865 radiographic exposure device containing a 7,115 TBq (192.6 curie)
iridium-192 source, The source was in the beam port, or exposed position. At the time of his approach and unknown to the radiographer, the radiographer's survey meter was not functioning properly. Nolse from the pipe crawler initially obscured the signal from
the worker's alarming rate meter. When the rate meter alarm was detected, the
'
- .
individuals left the vicinity of the source. No individual was exposed to the direct beam (Sections 1 and 4).
Direct Cause The direct cause of this event was the failure of the radiographer and the field crew
-
leader to determine the position of the source before approaching the exposure device.
-
The field crew leader failed to communicate with the radiographer operating the system to determine the location of the source before approaching the device (Section 4.5).
.
Contributina Causefs)
I A contributing cause of the event was the failure of the field crew leader to conduct a
-
survey with an operable survey meter (Section'4.5).
"
The failure to immediately hear.the alarm signal generated by the rate alarm meter
.
increased the dose received (Section 4.5).
. A factor leading to the event. was the relative inexperience of the field crew in real-time
.
radiography (Section 4.5 ).
,
1.'
.f'
.
-.
. -
.
_ _, _ _ _
..
. _ -.
-. _
, _.
...
-....
-
.
.L '
-
_k,_
'
'
.
3-
"
- Consequences The licensee assigned a dose of 65 millitera to the radiographer's assistant and
-
- 60 millirem to the radiographer. No exposures above regulatory limits were received.
No ill effects on the personnel involved were observed and none were expected (Section 4.5).
>
Reaulatory Isgues An apparent violation was identified involving failure to conduct a survey when
approaching a radiographic exposure device with an operable radiation survey instrument as required by 10 CFR 34.49 (Section 4.6).
An apprent viol 6 tion was identified involving failure of a radiographer to confirm that.a
radiography eource was in the shielded position before approaching a radiography exposure device as required by licensee procedures (Section 4.6).
'
,
k
.
a 1g 4.-
Report Details
=1 Background and Puipose of the inspection (87103)
.
- At 3:30 p.m. (PDT) on October 17,1997, the licensee's former radiation safety' officer
"
notified the Region IV Walnut Creek Field Office of a radiography' event that had occurred the previous afternoon at the British Petroleum Exploration (BPX)- Prudhoe Bay project in the North Slope of Alaska. The licensee's initial report was supplemented with additionalinformation provided to NRC Region IV staff during a subsequent telephone calllater in the day.
The licensee reported that on October 16,1997, while conducting radiography on pipes at Prudhoe Bay, Alaska, a radiographer and an assistant approached an exposure device when they heard a noise which they believed indicated that the device was going to fall from the pipe. The device was positioned on top of a pipe, approximately 8 feet above the ground, to perform radiography, Both the rdiographer and the assistant approached the device while the shutter was !a the open position. The exposure device l
contained a 7.04 terabecquerel (TBq) (190-curie) iridium-192 (Ir-192) source. Both individuals retreated when the assistant heard his alarm ratemeter alarming. The radiographer's 0 200 milliroentgen (mR) dosimeter was off-scale and the assistant's read 78 mR. The incident was promptly reported to the licensee's radiation safety officer (RSO). The radiographer's film badge was express mailed to the licensee's vendor for immediate processing. A preliminary re-enactment of the incident produced an estimate of one rem for the maximum whole body dose to the radiographer. This estimate was based on the estimated 15 20 seconds that the radiographer was within approximately 3
'
feet of the device. The licensee did not consider the event to be reportable to the NRC under the reporting requirements of 10 CFR Parts 20 and 34.
Based on the information described above, the inspector was dispatched to the licensee's offices in Anchorage, Alaska on October 20,1997, to conduct a reactive inspection of licensed activities with primary emphasis on the circumstances surrounding the reported radiography event.
Overview of Licensed Program (87103)
2.1 Insoection Scoce The inspector reviewed the conditions of the license, inspection reports 030-17129/97-01 and 030-17129/96-01, the licensee's response to these reports, and interviewed the former_RSO to gain an overview of the licensee program before the incident.
, 2.2 Observations and Findinas-The license issued to CTI authorizes the use of Ir-192, cobalt-60, and gadolinium-153 -
special form sources iri several models of radiography exposure devices, including the
_
Amersham Model 865. The Amersham Model 865 (865) is licensed for up to 7.4 TBq
r ~~ -
,
-5-(200 curies) of Ir-192. CTI is licensed to use these devices for industrial radiography at temporary job sites under NRC jurisdiction and to store the materials at licensee's facilities in Anchorage, Fairbanks, and Kenai, Alaska. The current license amendment is number 26, issued on October 2,1995. CTI's corporate office is located in Anchorage at the address specified in the license.
The last routine inspection was conducted on July 15-22,1997. No cited violations were identified during this inyection. Two licensee identified and corrected non cited violations (NCVs) were noted.
The previous inspection was conducted on January 17 to July 2,1996. It was a special inspection to review the inadvertent exposure of a radiographer and potential malfunction of a radiographic exposure device. This inspection identified two Severity Level 11 problems involving six violations and the NRC asse* sed a $13,000 civil penalty. An additional Severity Level IV violation was also identified. The corrective actions for these violations had been reviewed during the July 15 22,1997, inspection and these items were considered closed. One violation involved the failure of a radiographer to perform an adequate survey with an operable radiation survey instrument.
The company president and the RSO primarily worked at CTI's corporate headquarters in Anchorage, Alaska. However, most of the company's radiographic work was at oil production facilities on the North Slope of Alaska. On the Alaskan North Slope, CTI liad three major project sites: ARCO-Prudhoe Bay, ARCO-Kuparek, and BPX - Prudhoe Bay.
CTl employed about 70 radiographers and 35 assistants, most of whom were assigned to projects on the Alaskan North Slope.
2.3 Conclusions The licensee operates a large radiography program in Alaska. An escalated enforcement action. including a $13,000 civil penalty, was issued to the licensee in 1996 for violations relating to an inadvertent exposure of a radiographer and potential malfunction of a radiographic exposure device. The licensee had taken the corrective actions committed in the response to the violations identified.
Equipment Description and Opera' ion (87103,83822)
3.1 Insp3r' ion Scooe The inspector reviewed the licensee's procedures and interviewed !icensee personnel to gain an understanding of the equipment and methods used when performing real time radiography. The inspector also reviewed the NDS RA-500 Personal Rate Alarm Operation Manual, the NDS internal procedure for the calibration of the NDS RA-500 Personal Rate Alarm meter, and interviewed the president of NDS and the licensee's radiation instrument technician regarding the calibration and alarms for the NDS RA400 Personal Rate Alarm meter.
- - - - - -
-
-
-
-
..
-
-
.
-5-(200 curies) of Ir.192. CTl is licensed to use these devices for industrial radiography at temporary job sites under NRC jurisdiction and to store the materials at licensee's facilities in Anchorage, Fairbanks, and Kenai, Alaska. The current license amendment is number 26, issued on October 2,1995. CTl's corporate office is located in Anchorage at the address specified in the license.
The last routine inspection was conducted on July 15-22,1997. No cited violations wera identified during thls iropection. Two licensee identified and corrected non-cited violations (NCVs) were noted.
The previous inspection was conducted on January 17 to July 2,1996. It was a special inspection to review the inadvertent exposure of a radiographer and potential malfunction of a radiographic exposure device. 'Ihis inspection identified two Severity Level ll problems involving six violations and the NRC assessed a $13,000 civil penalty. An additional Severity Level IV violation was also identified. The corrective actions for these violations had been reviewed durbg the July 15-22,1997, inspection and these items were considered closed. One violation involved the failure of a radiographer to perform an adequate survey Mth an operable radiation survey instrument.
The company president and the RSO primanly worked at CTl's corporate headquarters in Anchorage, Alaska. However, most of the company's radiographic work was at oil production facilities on the North Slope of Alaska. On the Alaskan North Slope, CTl had three major project sites: ARCO-Prudhoe Bay, ARCO-Kuparek, and BPX - Prudhoe Bay.
CTI employed about 70 radiographers and 35 assistants, most of whom were assigned to projects on the Alaskan North Slope.
2.3 Conclusions The licensee operates a large radiography program in Alaska. An escalated enforcement action, including a $13,000 civil penalty, was issued to the licensee in 1996 for violations relating to an inadvertent exposure of a radiographer and potential malfunction of a radiographic exposure device. The licensee had taken the corrective aedons committed in the response to the violations identified.
Equipment Description and Operation (87103,83822)
3.1 Insoection SepAq The inspector reviewed the licensee's procedures and interviewed licensee personnel to gain an understanding of the equipment and methods used when performing real time radiography. The inspector also reviewed the NDS RA-500 Personal Rate Alarm Operation Manual, the NDS internal procedure for the calibration of the NDS RA-500 Personal Rate Alarm meter, and interviewed the president of NDS and the licensee's radiation instrument technician regarding the calibration and alarms for the NDS RA 500 Personal Rate Alarm meter.
.
-
-
-
-
,
-6-3.2 Observations arid Findings in Amersham Model 865 (865) radiographic exposure devices, the source never leaves the exposure device. The source can be in one of two positions, the beam port position
- or the shielded storage position. The source is attached to a piston in the actuating cylinder. When the cylinder is pressurized, the pistor' moves the source from its shielded storage position to the beam port. In this exposed position. the emergent beam is 60'
wide and 30' high. Shielding built in the beam limiter reduces radiation intensity by a factor of 10,000 in all other directions. When the air precsure is reduced, a spring moves the source to the shielded position.
The licensee used the 865 in what the licensee terms real-time radiography (RTR). This process involved placing the 865 on a crawler device that moves along the length of a pipe to be radiographed. The radiographic information was collected by an imager on the mposite side of the pipe, The crew for RTR consisted of four individuals: (1) the system operator, a radiographer working inside a truck who controls the source position; (2) the crew leader, a radiographer working outside and providing radiological controls on the restricted area and bounding unrestricted area; (3) an assistant radiographer; and (4)
a helper. The system operator and crew leader were in communication by radio.
The licensee's RTR utilized the crawler which was a four-wheeled cart that held the 865 and from which the imager was suspeaded. The system operator, who was located inside the back of a truck, controlled the movement of the crawler by directing it to move forward, reverse, or stop. The system operator observed the pipe in a video monitor displaying the image generated by the suspended imager. The imager was illuminated by radiation from the source. If the source was moved to the fully shielded position, the system operator could no longer see the position of the crawler. The system operator controlled the position of the source. The licensee's procedure for the 865 required that the source be in the fully shielded position before approaching the 865. The crawler had built in sensors to keep it aligned on the pipe. It was the job of the field crew, consisting of the crew leader, and the assistant and helper, to relocate the crawler assembly from one pipo segment to the next. Pipe segments were separated and supported by vertical support members (VSMs). Occasionally, a crawler would have problems driving in a straight line. In such cases, the system operator had to stop the crawler and make it back up and try again. If the crawler was very much out of alignment, the field crew might have to physically move it back into alignment. An electmnics maintenance technician was available to assist with persistent problems with the crawler, the imager, or other parts of the system. The RTR crew referred to the crawler position by comparing it to an analog clock. If the source beam was pointed toward 6:00 o' clock, the crawler was properly aligned.
The licensee used RA-500 personal alarm ratemeters manufactured by NDS Products, Inc. The former corporate RSO told the inspector that he had bought these units because, at the time, hey had the loudest alarm signal. The calibration procedure for the RA-500 contained in the manufacturer's manual stated in part, "The instrument is calibrated by placing the unit in a 450 rr,R/hr cesium-137 (Cs-137) radiation field, if
-
- -
-
-
-
-
-
-
-
- - -
-.
,
.
<
.
necessary, adjust the potentiometer until a crackling chirp is heard. Move the unit toward the radiation field, the alarm should become a continuous tone."
The licensee's calibration procedure called for placing the instrument at a distance of 29.8 cm from the licensee's Cs 137 calibration source. At this position the radiation field is 4.5 mSv/hr (450 mrem /hr) and the instrument should chirp intermittently. If it did not, the potentiometer was to be adjusted. The instrument was then moved to 26.9 cm at the 5.5 mSv (550 mrem /hr) dose rate and checked for a constant chirping %' ally the instrument was moved to 19.0 cm and checked for a loud steady tone. M esults were recorded in a calibration certificate form. This procedure appeared to meet tr.a manufacturer's recommendation.
3.3 Conclusions The licensee's procedure for the 865 required that the source be in the fully shielded position before approaching the 865.
In RTR the individual re3ponsible for placing the source in the fully shielded position is not the individual who approaches the source holder and conducts the radiation surveys.
Therefore communication between these two individuals is criticai for the safety of those who will approach the source holder and work in its immediate vicinity.
Sequence of Events (87103)
4.1 Insoection Eggpg The following sequence of events is based on interviews with the individuals present ouring the incident, interviews with other CTI employees, review of available records, and the licensee's October 27,1997 report on the incident.
4.2 Qbservations and Findinas The crew leader for the work at BPX M Pad on October 16,1997, had joined CTI
.
as a trainee in June 1995. Initially he worked as a member of an RTR crew but within a few weeks was transferred to a manual radiography crew. He worked on manual radiography until September 29,1997. He had received an initial 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> of training at the time of his hiring and subsequently at least an additional 120 hours0.00139 days <br />0.0333 hours <br />1.984127e-4 weeks <br />4.566e-5 months <br /> of formal radiography training. This individual was certified as a radiographer on March 18,1997. He returned to work in RTR on September 29, 1997 as a crew leader.
During the week of September 29,1997, this crew leader worked with an
.
assistant who the crew leader said "had lots of experience with the crawler."
During the week of October 6.1997, the assistant who had helped the crew
.
leader during the previous week rotated out and the crew leader now felt he had e
-
.
- -.
-.
.
-
-
-.
,
.
.
,
-8-responsibility for maintaining the crawler in operating condition. His new assistants had little experience with the crawler. The crew tecder stated that he had put a list together of things he needed to do to get the crawler to run smoothly.
.
During the week of October 13,1997, one of the assistants was replaced by a
.
new hire with no experience. The system operator in the truck and the other assistant were the same as the previous week. Throughout this week, the crew-experienced problems with the crawler not staying in proper alignment and trying to " drive off the pipe." The electronics maintenance technician had replaced several components in the crawler to try to correct the problem.
On Oct.16,1997, the crew began the day at about 7 a.m The weather was not
.
particularly unusual but there were some snow flurries. The crew was assigned to do RTR work on the BPX project Pad M, Pipe 22 (M22). The exposure device used was an Amersham Model 865, Serial Number (SN) 20, with an Ir-192 special form source of 7.04 TBq. SN 0319. The 865 was attached to a pipe crawler. The crew was wearing rate alarm meters, pocket dosimeters, and film badges. They had two INC Model 2 radiation survey meters, SNs 900265 and 900378.
The crew stated they had equipment problems during the moming. The crawler
.
was not staying aligned properly on the pipe and the batteries in the survey meter being used by the crew leader were not making contact, thus rendering the survey meter inoperable. The crew leader would have to take the survey meter apart and tighten the battery contacts. The work was going slow. The system operator often had to stop the crawler, back it up, and then move it forward again to try to make it go straight.
At about noon the crew broke for lunch and noted that the tires on the crawler
.
were low on air. They contacted the electronics maintenance technician who came out and put air in the tires. The crew leader changed survey meters with the system operator. The crew checked their pocket dosimeters and they all read zero.
From about 3:30 p.m. to 3:45 p.m. the crew ran a scan on segment M506 and all
.
went well. The crew moved the crawler to segment M507. Pipe M22 was the third pipe in from a group of pipes coming from Pad M. The pipes were suspended about 8 feet above ground and supported by vertical support members (VSMs). The segment number corresponded to the number marked on the VSM.
The pipe crawler began to drive off center and the two wheels on the left side
.
came off the p;pe causing the 30-degree collimated radiation beam to point toward the 4:00 o' clock position instead of the normal 6:00 o' clock position.
.
- - -
-
.
- -
- -
-
-
f
.
.
.g.
The crew leader contacted the system operator by radio and told him that the
.
crawler was going off the pipe.
The system operator responded, indicating that he could see the crawler was
.
moving off the pipe. The system operator stoppegl the crawler and considered what to do next while the source remained in the exposed pocition. This was normal since he used the radiation detected by the imager to be able to "see" the orientation of the crawler. He thought about it for a while.
After a minute or so the crew leader and the assistant approached the crawler.
.
The crew leacer did not check with the sy3 tem operator to verify that the source was in the fully shielded storage position, as was their normal practice. He assumed that the system operator had brought the source in since sometime had passed with nothing happening.
The crew leader approached the crawler from the left and used the VSM as
.
shielding. He had the survey meter, SN 900378, in his left hand. This instrument was last calibrated on October 6,1997. The crew leader glanced at the survey meter as he passed the VSM and noted that the instrument read zero. His rate alarm meter, an NDS RA-500 SN 5312, was on his belt on his left ride. The pocket dosimeter and film badge were on his belt on the right side.
At about the same time, the assistant approached the crawler by following and
.
walking below the pipe. He did not have a survey meter. His rate alarm meter, an NDS RA-500 SN 6141, was on his right chest pocket, ar.d his pocket dosimeter and film badge were in this left chest pocket.
As the crew leader reached the area below the crawler, he placed his survey
.
meter on the ground. He noticed that it still read zero. He did not conduct a survey of all sides of the exposure device, but the exposure device was at least 8 feet off the ground. He then looked at the crawler trying to assess what to do next. The crawler was making a loud screeching noise. The assistant reached the vicinity of the crawler about the same time as the crew leader. The helper was also approaching the crawler but was some distance back from the assistant.
The assistant realized that they would need a ladder, so he turned to get one. He
.
then heard his rate meter alarming. He immediately alerted the crew leader and both promptly left the vicinity of the source. As he was leaving, the crew leader picked up his survey meter and tapped on the side. The survey meter was on the X1 scale. The meter needle started to move but did not peg off-scale. The crew leader then noticed that his alarm ratemeter was alarming. The crew leader later estimated that he stood approximately 3 feet frora the 865 and the assistant 6 feet. Total time for both at these distances was about 20 seconds.
The crew leader contacted the system operator by radio and confirmed that the
.
source was in the exposed position. After requesting and confirming that the
f
'
.-.
.
- .
-
i source was moved to the shielded position,l the field crew gathered and checked -
their pocket dosimeters._ They found that the crew leader's was off scale, the assistant's read 78 millirem, and the helper's read 18 millirem.
The crew gathered at the truck, informed the system operator of the problem and
.-
contacted their supervisor. The supervisor told them to stop work, collect their equipment, and return to the dispatch location.
The former corporate RSO was notified by the supervisor, and directed that the-
.-
crew leader's film badge be returned to the dosimetry company for immedicte evaluation end that his survey meter, rate alarm meter, and pocket dosimeter be returned to the company's office in Anchorage for evaluation.
On October 17,1997, the crew leader and the system operator underwent urine
.
drug tests. Drug use was not identified.
On October 17,1997, the survey meter rate alarm meter and pocket dosimeter
.
were received in Anchorage. The survey meter had some internal condensation but was operational. The survey meter was sent to the manufacturer for further evaluation. The rate alarm meter was functional and alarming at the set point.
The pocket dosimeter was functional.
On October 17,1997, the former RSO and the safety and training officer -
.
interviewed the crew leader. The possibihty that the crew leader's pocket dosimeter could have been bumped and knocked off scale was discussed.
At 3:30 p.m. PDT on October 17,1997, the former corporate RSO not!6ed the
.
Walnut Creek Field Office (WCFO) of the incident. At the time of the notification, the licensee did not consider the incident a reportable event.
\\t 12.55 p.m. Alaska Daylight Time on October 20,1997, the crew leader's film
.
badge was reported by the dosimetry company as reading 60 millirem.
Later that afternoon following consultation with the inspector, the former corporate
.
RSO directed that the assistant's film badge be returned to the dosimetry company for immediate evaluation and that his alarm ratemeter be returned to the company's office in Anchorage for evaluation.
The assistant's alarm ratemeter was functional and alarming at the set point. On
.
. October 23,1997, the dosimetry company reported the assistant's film badge as reading 65 millirem for the first 16 days of October.
On October 24,1997, the survey meter manufacturer reported that the survey
.
meter had been evaluated and no problems were identified.
.
i
..-
.. -.
,.~ -
_.
,.
. - -.
- - ~. -. ~
- ---
e
- .
<
.
That afternoon, the crew leader's hearing was evaluated. No problems were
'
.
identified.
On October 27,1997, the licensee submitted a written report to the WCFO.
.
4.3 Observations and Findinos by the Licenste The licensee's written report concluded the following:
1.
The crew leader failed to verify that the source was retracted before approaching the crawler.
2.
The crew leader was never in the primary radiation beam.
3.
The crew leader probably did not hear h.e alarm rate meter bscause he was never in the primary radiation beam, the instrument was alarming at the lower intermittent mode, and the high pitch noise from the vrawler obscured the alarm.
4.
It is conceivable that the failure of the survey meter to respond was due to the batteries not making contact with the terminals.
5.
The incident was due to a miscommunication or lack of communication between the crew leader and the system operator regarding the retraction of the souce to the fully shie!ded position.
6.
The film badge readings will be the doses assigned to the individuals involved in the incident.
4.4
' Licensee's Corrective Actions The licensee's written report identified the following corrective actions:
Desiccant packets will be placed in all survey meters, to facilitate absorption of i
.
'
moisture.
The second curvey meter will be required to be used ?:y the RTR crew on the
.
outside instead of being kept with the radiographer in the truck.
A radiation beacon will be installed on the crawler / exposure device assembly
.
which will include an alarm and a flashing beacon activated at 50 mr/hr.
The crew leader will be given annual refreshar trainir.g before returning to work.
.
The ciew leader will be sent to a doctor for hearing evaluation.
.
Both radiographers were drug tested. Drug use was not identified.
.
.
I
.
.
12-4.5 Observations and Findings by the NR_C The direct cause of this event was the failure of the crew leader to determine the position of the source before approaching the exposure device. The crew leauer fa led to communicate with the radiographer operating the system to determine the position of the source. He assumed that the source was in the fully shielded position and proceeded to approach the source.
An inoperable survey meter contnbuted to the incident. Had the crew Irader had an operable survey meter, he would have detected the increased radiation levels as he approached the crawler. The crew leader should have also realized that a survey meter reading zero is probably indicative of an inoperable instrument.
The failure to immediately hear the alarm signal generated by the rate alarm meter increased the doses received. Further, the alarm signal generated was obscured by the sound made by the stuck crawler.
Another factor leading to the event was the relative inexperience of the crew leader in RTR and his focus on fixing the problems with the crawler. The crew leader had been working in this position for less than 3 weeks and his axperience with RTR was for only a few weeks as a trainee in 1995 when he first joined the company. He was not familiar with the licensee's procedure or, the use of 865.
Neither the crew leader nor the assistant entered the primary radiation beam. The licensee's assigned dose of 65 millirem to the radiographer's assistant and 60 millirem to the radiographer appeared reasonable. No doses above regulatory limits were received.
No ill effects on the personnel involved were observed and none were expected.
4.6 Regulatory issues Two apparent violations of NRC requirements were identified 10 CFR 34.49 requires, in part, that the licensee conduct a survey of the radiographic exposure device after each exposure when approaching the device with a calibrated and operable radiation survey instrument that meets the requirements of $ 34.49. The failure of the crew leader to perform a si'rvey of the radiograohic exposure device with an operable radiation survey instrument was identified as an apparent violation of 10 CFR 39.49 (03017129/9702-01).
The licensee's procedure for the operation of the 865 is described in Part 11, Section 9 of CTI's ' Radiation Safety Progiam* manual. This procedure was submitted to the NRC by letter dated August 31,1995, and is incorporated by reference in License Condition 17.
Step 9.5 6 of the procedure states:"At the conclusion of the exposure time, retum the source to the chielded storage position by moving the control switch to the OFF position.
Note that the source position indicator indicates the source is retracted." Step 9.5.7
-
.
{
.
E.
.
-13-states, in part, " Approach the exposure device with the survey meter and survey the device on all sides." The failure of the crew leader to determine that the source had been 'eturned to the shielded storage position at the conclusion of the exposure time, before he approached the exposure device, was identified as an apparent violation of License Condition 17 (03017129/9702-02).
Exit Meeting (87103)
A preliminary site exit briefing was conducted on October,24,1997, with the former corporate RSO, On December 3,1997, a firal exit briefing was cor. ducted telephonically with company president and the corporate RSO to review the specific findings as presented in this repor _
_
.
_
_
.
_ _.
....
.
ATTACHMENT PARTIAL LIST OF PERSONS CONTACTED Ocensee
' George Haugen, President Sandy Watson, Former Corporate Radiation Safety Officer (RSO) (deceased)-
Jeff Arveson, Corporate Radiation Safety Officer (RSO)
Keenan Remele, Safety and Training Steve Ziegler, Radiation Instrument Technician
. Randy Watkins, North Slope Operations Manager Kit Coleman, Systems Engineer
,
Wade Ray, Electronics Maintenance Technician
Jayson Ray, Radiographer (RTR System Operator)
Raymond Todd Reekie, Radiograoher (Crew I.eader)
Shane Sanger, Radiographer's Assistant
,
Donald Odis, Radiographer's Helper-
.
NDS Productt fr'c.
- Noel Smith, President INSPECTION PROCEDURES (IP) USED IP 87103 Inspection of incidents at Nuclear Materials Facilities IP 83822 Radiation Protection ITEMS OPENED. CLOSED. AND DISCUSSED Opened 030-17129/9702 01 APV Failure to conduct a survey when approaching a radiographic exposure device with an operable radiation survey instrument.
030-17129/9702-02 APV Failure of a radiographer, radiographer's assistant and
,
radiographer's helper to confirm that a radiography source was in the stored position before approaching a radiography exposure device.-
,
Closed
'
none Discussed none
.
- _
_
_
_
{3
-
,
.-
.=
-
l LIST OF ACRONYM 3 USED APV
- Apparent violation ADT
- Alaska Daily Saving Time J
BPX,.
British Petroleum Exploration - Prudhoe Bay -
'
-cm Centimeter Cs 137.
EA Enforcement Action IP Inspection Procedure Ir-192 tridium 192 mR.
Milliroentgen mR/hr Milliroentgen per Hour
mrem /hr Millirem per Hour mSv/hr Millislevert per Hour
.
~ NCVs'
no cited violations
,
NMED Nuclear Material Events Database
'PDT Pacific Daily Saving Time RSO Radiation Safety Officer j
,
RTR Real Time Radiography
!
SN Serial Number
!
"
TBq-Terabecquerel i
WCFO Walnut Creek Field Office
865 Amersham Model 865 Radiographic Exposure Device
.
.
.,
!
,
.
>
..
- . ;
.u
. -..
-.
.L