ML19114A081
| ML19114A081 | |
| Person / Time | |
|---|---|
| Issue date: | 04/11/2019 |
| From: | Patricia Milligan Office of Nuclear Security and Incident Response |
| To: | |
| G.R-Capella NMSS/MSST/MSEB 415.5944 | |
| References | |
| EN535994 | |
| Download: ML19114A081 (1) | |
Text
Posted by: Patricia Milligan, Nuclear Regulatory Commission (NRC), United States of America INES EVENT RATING FORM Page 1 of 1 INES Event Rating Form (ERF)
Version 1 Sender's Name:
Patricia Milligan Sender's Organization:
Nuclear Regulatory Commission (NRC) (United States of America)
Event
Title:
Overexposure to Radiographer Event Date:
2019-04-11 Location / Facility:
Alabaster, Alabama / Vital Inspection Professional Event Country:
United States of America Event Type:
Radiation Source INES Rating:
2 - Incident (Final)
Rating Date:
2019-04-17 Impact on people and the environment Release beyond authorized limits?
No Overexposure of a member of the public?
No Overexposure of a worker?
Yes Impact on the radiological barriers and controls at facilities Contamination spread within the facility?
No Damage to radiological barriers (incl. fuel damage) within the facility?
No Degradation of Defence In-Depth?
No Other information Person injured physically or casualty?
No Is there a continuing problem?
No Event Description A radiographer working in the permanent shooting room at one of the licensees facilities, cranked out a 2.48 TBq (67 Ci) Ir-192 source for an exposure and did not crank the source back into the exposure device before setting up for the next exposure. Upon badge processing, it was determined that the radiographer received an exposure of 81.49 mSV (8.149 rem). The calculated exposures to the left hand and right hand were 396.84 mSv (39.684 rem) and 93.38 mSv (9.338 rem), respectively. The radiographer is being monitored by a medical physician. The primary cause of the incident appears to be human error. In addition to not cranking the source back at the end of the exposure, the radiographer failed to observe the radiation actuated visible alarm; bypassed the audible alarm feature of the shooting room; and failed to observe his survey meter upon entry into the shooting room.
All safety features were operating properly at the time of the incident. The dose received by the radiographer exceeds the U.S.
statutory limit for whole body dose of 0.05 Sv (5 rem). NRC EN53994 Rating Justification A Level 2 is warranted for exposure of a worker in excess of statutory annual dose limits. See Section 2.3.1 INES Users Manual 2008 Edition (IAEA-INES-2009) http://www-pub.iaea.org/ MTCD/publications/PDF/INES-2009_web.pdf Press Release Attached:
No Technical Document Attached:
No Further Information on Web:
Contact Person:
Patricia Milligan Affiliation:
Nuclear Regulatory Commission (NRC)
Email:
Patricia.Milligan@nrc.gov Telephone:
0013012873739 Organization on Web: