ML19295B371
| ML19295B371 | |
| Person / Time | |
|---|---|
| Issue date: | 09/11/1980 |
| From: | James O'Reilly NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | MATERIAL TESTING LABORATORIES, INC. (FORMERLY MATERIA |
| References | |
| NUDOCS 8010080082 | |
| Download: ML19295B371 (1) | |
Text
'o UNITED STATES
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NUCLEAR REGULATORY COMMISSION n
E REGION 11 d'f o
101 MARIETTA ST., N.W., SUITE 3100 ATLANTA, GEORGIA 30303 In Reply Refer To:
RII:JPO NATERIALS TESTIN' LABORATORY OF LAB 2706 WYOMING AVENUE NORFULK
__ _ VA 23502 NRC LIC. 8I ca5W 71.51-0_1; Gentlemen:
The enclosed Bulletin 80-22 is sent to you for action.
If there are any questions related to the requested actions, please contact this office.
Sincerely, e e-P. O'Reilly irector
Enclosures:
1.
IE Bulletin No. 80-22 w/ encl 2.
List of Recently issued It Bulletins e
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8006190050 UNITED STATES IEB 80-22 NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMEh"I WASHINGTON, D.C.
20555 September 11, 1980 IE Bulletin No. 80-22: AUTOMATION INDUSTRIES, MODEL CONNECTORS 200-520-008 SEALED SOURCE Description of Circumstances:
An accident recently occurred in the State of C lif that resulted in several serious overexpos ornia (an Agreement State) a The accident involved the use of an Automation I dures (see enclos source pigtail to drive cable connection n ustries (AI) Model 200-520-008 manufacturer as its " quick disconnect" type of connThe connector is identified by the the manufacturer.several models of cobalt-60 and iridium-192 sourc ector a
- 1) that will permit separation of the eye from thThe connection is a simpl at right angles to each other without any furthere hook when they are o(riented n see Fig.
result of the design, a disconnection may occur a positive action. As a Since the Automation Industries Modelcranked out of the exposure d authorized to contain up to 120 curies of i200-520-008 e tube being attached.
sealed-source assembly is creates a potential for a serious exposure. ridium-192, a source disconnection A disconnect is very unlikely to occur if proper users of Automation Industries sealed sources cont iprocedures are followed by However, due to the large number of overexposur a ning the " quick disconnect".
determined that continued use of the Automation I dgraphy procedures, the NRC has connector with its Model can constitute a hazard to the public healthsealed-source an ustries " quick disco 200-520-008 ssembly or other assemblies As a result,
, safety or interest.
distribution of the AI Modelthe NRC has ordered Automation Industries t 200-520-008 sealed scontinue sealed-source assembly that uses the " quick disco-source assembly or any other Additionally, the NRC will not accept new pplic tinnect" type of connector.
use the Al Model 200-520-008 a
" quick disconnect".
or other sealed-soerceons for authorization to pigtail assemblies from service as licensees exchangIn effect, this w sources.
and Special arrangements should be made for removine their diminished activity connectors that are attached to longer lived sources g from service chose such as cobalt-60.
The removal from service of the " quick disconnect" t require that those drive cables having the matching ype of connector will modified.
open hook connector be Actions To Be Taken by Licensees disconnect" connector is used, all licensees authTo assure th ment in which the AI " quick materials under 10 CFR Part 34 shall perform the follorized to use byproduct owing:
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1 7903020542 SSIftS:6830 UNITED STATES NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT WASHINGTON, D.C.
20555 August 16, 1979 IE Circular No. 79-16 EXCESSIVE RADIATION EXPOSURES TO MEMBERS OF THE GENERAL PUBLIC AND A RAD 10GRAPHER Description of Circumstances:
During radiographic operations using 40 curies of iridium-192, the source became disconnected unbeknownst to the radiographer--he did not use his survey instrument. Af ter the radiographer left the facility, an employ 6e of the customer for which radiography was performed, saw the source and, not knowing what it was, picked it up and placed it in his hip pocket.
He carried it about for approximately two hours, later giving it to his super-visor to examine. While making a determination that it was something which belonged to the radiographer, and while waiting for the radiographer to pick up the source, nine employees of the radiographer's customer were exposed. The source was also left with a secretary who was instructed to contact the radiographer.
The radiographer returned, examined and took the source assurring the customer's employees that there was no problem, stating that the source was a " detector".
On the evening of the event, the employee who had put the source in his pocket became nauseous and went to a hospital for treatment.
At that time a blister was found on his buttock. The initial diagnosis and treatment evas for an insect bite.
Thirty one days after this initial treatment the indi-vidual was hospitalized for treatment of the injury to his buttock.
At that time the individual asked the physicians if there could be any connection of the injury to the radiography that had been performed at his place of work one month previously. An investigation followed which disclosed the above information, The individual who had carried the source in his pocket remains under medical care following surgery.
The attending physician does not consider the exposure to be life threatening.
Neither does amputation appear necessary.
The localized dose is estimated to be 1.5 millicn rem at skin surface, 60,000 rem at I cm depth and 7,000 rem at 3 cm depth.
Estimated whole body doses to other individuals ranged from 1 to 60 rem.
Hand doses ranged to 5,000 rem.
The radiographer received estimated doses of 14 rem to the whole body and 50 rem to the hands.
These are serious radiation overexposures.
However, another important aspect of the case, second only to the physiological effects of the e>,posures, is the radiographer's apparent disregard for the health and safety of the exposed individuals and for his own personal safety. The radiographer's failure to inform the involved individuals and to report the event to responsible management within his own and the customer's company is a serious disregard for safety and denied the exposed individuals early medical attention.
IE Circular No.19-16 August 16, 1979 Page 2 of 3 The primary cause of this incident was the failure to perfonn a radiation survey, a comon underlying cause in radiation overexposures in the radiography industry. The number of radiation overexposures experienced in the radiography industry over the past several years has been higher than for any other single group of NRC licensees. To inform radiography licensees of HRC's concern for these recurring overexposure incidents, NRC staff representatives met with licensees in a series of five regional meetings during the period December 1977 throught March 1978. The main purposes of the meetings were to express NRC's concern for the high incidence of overexposures, and to open a line of communication between the NRC and radiography licensees in an effort to achieve the common goal of improved radiation safety. A written sumary of those meetings was published by the NRC in NUREG-0495, "public Meeting on Radiation Safety for Industrial Radiographers".
A copy of that docume'it was mailed to each NRC radiography licensee and to other companies which sent representatives to the meetings.
The remarks prosented by the staff and subjects discussed at those meetings included, among others, ways and means of incorporating safety into radiography operations, and case histories of overexposure Incidents, with highlights of the causes and possible preventions.
In a discussion of the causes of over-exposures, a presentation of statistics at the meetings showed that the failure of the radiographers to perfonn a radiation survey after each radiographic exposure was by far the most prevalent cause. While these surveys are required by regulation in 10 CFR 34.43(b), they are also the most basic, fundamental and common-sense thing to do when dealing with radiation levels inherent in a typical radiography operation. Failure to perform the surveys indicates a lack of train-ing intensive enough to pennanently instill in radiographers the extreme importance Some of the case of surveys for protection of both themselves and other people.
histories discussed in NUREG-0495 resulted in painful radiation injury to hands and fingers, with eventual loss of one or more fingers in some cases.
Notice to Radiography Licensees:
NRC licensees authorized to use byproduct material under 10 CFR Part 34 are requested to take the following acticns:
1.
Review the event described in this Circular (and the other case histories in NOREG-0495) with all of your radiographic personnel at an early date; discuss and emphasize:
the extreme importance of radiation surveys in assuring protection a.
of thtmselves and of other people, and b.
the importance of reporting promptly any unusual events or circumstances to responsible management.
2.
Review your training to assure that appropriate emphasis is placed on the subjects in item 1 in both initial and refresher training courses.
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IE Circular No. 79-16 August 16, 1979 Page 3 of 3 3.
Review your internal audit program to assure that appropriate emphasis is placed on these same subjects. particularly the requirenent for auditors to observe radiographic operations to assure the proper coadu;t of radiation surveys.
No written response to this Circular is required.
If you need additional information regarding this subject, please contact the Director of'the appropriate NRC Regional Office.
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IEB 80-22 September 11, 1980 RECENTLY ISSUED IE BULLETINS Bulletin No.
Subject Date Issued Issued To 80-22 Automation Industries, Model 9/11/80 All radiography 200-520-008 Sealed-Source licensees Connectors 79-26 Boron loss from BWR 8/29/80 All BWR power Revision I control blades facilities with an OL 80-20 Failures
' Westinghouse 7/31/80 To each nuclear Type W-2 opring Return power facility in to Neutral Control Switches your region having an OL or a CP 80-19 Failures of Mercury-7/31/80 All nuclear power Wetted Matrix Relays in facilities having Reactor Protective Systems either an OL or a CP of Operating Nuclear Power Plants Designed by Combus-tion Engineering 80-18 Maintenance of Adequate 7/24/80 All PWR power reactor Minimum Flow Thru Centrifugal facil. ties holding OLs Charging Pumps Following and to those PWRs Secondary Side High Energy nearing licensing Line Rupture Supplement 2 Failures Revealed by 7/22/80 All BWR power reactor to 80-17 Testing Subsequent to facilities holding OLs Failure of Control Rods to Insert During a Scram at a BWR Supplement 1 Failure of Control Rods 7/18/80 All BWR power reactor to 80-17 to Insert During a Scram facilities holding OLs at a BWR 80-17 Failure of Control Rods 7/3/80 All BWR power reactor to Insert During a Scram facilities holding OLs at a BWR 80-16 Potential Misapplication of 6/27/80 All Power Reactor Rosemount Inc., Models 1151 Facilities with an and 1152 Pressure Transmitters OL or a CP with Either "A" or "D" Output Codes 80-15 Possible Loss Of Hotline 6/18/80 All nuclear facilities With Loss Of Off-Site Power holding OLs