ML19340C867
| ML19340C867 | |
| Person / Time | |
|---|---|
| Issue date: | 11/24/1980 |
| From: | James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.) |
| Shared Package | |
| ML19340C864 | List: |
| References | |
| NUDOCS 8012170859 | |
| Download: ML19340C867 (1) | |
Text
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- o-UNITED STATdS MIE 4 W 8T N
NUOfJ.AR HEGULATORY COMMISSION 34 2 E 'AEGION lli D[ 8, 799 ROOSEVELT ROAD RV ,o CLEN ELLYN, ILLINOIS 60137 f($4 MJs \\, na 3 O ~ ~..., - CONSUMERS PonER COMPANY 212 WEST M.lCI).IGAN AVENUE JACKSON ~~ NRC'LIC. 31 2g.g8606-03 = S11BJECT: IE BULLETIN 80-22: S'T0MATION INDUSTRIES, MODEL 200-520-008 SEALED SOURCE CONNECT 01G Gentle =en: l f.0V The above bulletin was sent to all radiography licensees on September w v58 '#,,g 24, 1980. The bulletin may not have clearly s'tated thae '. respons. was required of all recipients whether or not they were using the above acntioned connectors. If you have not responded to this bulletin as yet, please do so i= mediately.- h s ~ -- Sincerely, James G. Kep r Director Enclosure : 'IE Bulletin 80-22 12xyoQ'1 80
55]N5 No: 6820 Accession No.: 8005190050 IEB 80-22 UNITED STATES NUCLEAR REGULATORY COMMISSION OFFICE Or INSPECTION AND ENFORCEMENT 1 WASHINGTUN, D.C. 20555 September 11, 1980 IE Bulletin No. 80-22: AUTOMATION INDUSTRIES, MODEL 200-520-008 SEALED-SOURCE CONNECTORS Description of Circumstances: An accident recently occurred in the State of California (an Agreement State) that resulted in several serious overexposures (see enclosed Circular 79-16). i The accident involved the use of an Automation Industries (AI) Model 200-520-008 l source pigtail to drive cable connection. The connector is identified by the manufacturer as its " quick disconnect" type of connector and is used with several models of cobalt-60 and iridium-192 source assemblies distributed by the manufacturer. The connection is a simple hook and eye connection (see Fig.
- 1) that will permit separation of the eye from the hc.ok when they are oriented at right angles to each other without any further positive action.
As a result of ths design, a disconnection may occur any time the source assembly i, cranked out of the exposure device without the guide tube being attached. Since the Automation Industries Model 200-520-008 sealed-source assembly is authorized to contain up to 120 curies of iridium-192, a source disconnection creates a potential for a serious exposure. A disconnect is very unlikely to occur if proper procedures are followed by users of Automation Industries sealed sources containing the " quick disconnect". However, due to the large number of overexposures that occur in the radio-graphy industry due to the failure to follow proper proceduies, the NRC has determined that continued use of the Automation Industries " quick disconnect" connector with its Model 200-520-008 sealed-source assembly or rm - assemblies can const:tute a hazard to the public health, safety or interest. --- I-. As a result, the NRC ha s ordered Autoaation Industries to discontinue distribution of the AI Model 200-520 *)08 sealed-source assembly or any other l sealed-s'ource assecbly that uses the quick disconnect" type of connector. Additionally, the NRC will not accept new applications for auti:orization to use the AI Model 200-526 008 or other sealed-source assemblies using the "qu.ick disconnect". In effect, this will remove such iridium-192 source and pigtail assemblit:s from service as licensees exchange their diminished activity sources. Special arrangements t nould be made for removing from service, those connectors that are attached to longer lived sources such as cobalt-60. The removal from service of the " quick disconnect" type of connector will require that those drive cables having ^.he matching open book connector be modified. ~ Actions To Be Taken by Licensees To assure the safe operation of radiography equipment in which the AI " quick l disconnect" connector is used, all licensees authorized to use byproduct materials under 10 CFR Part 34 shall perform the ft.11owing:
iEE. 80-22 Septerber 11, 1980 Page 2 of 2 .' (1) Determine the number of Al Moo.1200-520-008 and other assemblies ir pur inventory that have the " quick disconnect" connector and establish a disposal schedule. Your schedule for iridium-192 sources should be no longer than your usual exchange schedule for diminished activity sources. Your exchange schedule for connector modification for cobalt-60 sources should be accomplished as soon as is conveniently possible. However, you shculd complete your disposal or modification by September 1,1981. (2) In the interim, a warning mark or tag should be placed on each radio-graphic device in which AI " quick disconnect" type assemblies are being used. (3) This matter should be reviewed with all radiographers. They should be cautioned of the disconnect possibility and be informed of the method used to identify equipment as marked in accordance with Item (2) above. (4) Review and modify operating, maintenance, inspection and handling procedures as appropriate to preclude this type of accidental disconnect. NOTE: You may want to contact the manufacturer for assistance in determi..ing cppropriate proce' dural changes or fixes to preclude a disconnect. (5) Discuss with the radiographers the ic;portance of making adequate surveys and the need for_following procedures. A report of your actions for each of the above numbered items shall be submitted to the director of the appropriate regional office within 30 days i frN,the date of this Bulletin. A copy of the report shall ako be sent to the Director, Division of Fuel Facility and Materials Safety inspectiea, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, blashington, D.C. 20555. Approved by GAO, B180225 (R0072); approval expired July 31, 1980. (Application 'for renewal pending before' GAD).-Approval was given7nder a bitinket Eeirsn'ce specifically for identified generic prob 1, ems. - l
Enclosures:
1. IE Circular No. 79-16 2. Figure 1 D 9 fP e w N l
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Accessions No. 7933020582 551NS:GB30 UNITE 0 STATES NUCLEAR REGULATORY. COMISSION. OFFICE OF INSPECTION AND ENFORCEMENT WASHINGTON, D.C. 20555 August 16, 1979 / IE Circular No. 79-16 EXCESSIVE RADIATION. EXPOSURES TO ME!GERS OF TE. GENERAL PUBLIC AND A RAD 10GF.APHER - Description of Circumstances: turing radiographic operations using 40 curies of iridium-192, the cource became. disconnected' unbeknownst to the. radiographer--he did not use his-survey. instrument.. After the radiographer left the fa_ility, an employee of the customer for which radiography was. perfcTued, saw the source end, 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-tisor to exa nine. Uhile 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 radiographerf s customer were exposed. The source was also lef t with a secretary who. was-instructed to contact the radiographer. The radiographer. returned, examined and took the source assurring the customer's employees that ther,e was no problem, stating that;the source was a " detector". On the evening of the. event, the.employce who. had put.the source in his pocket becane nauseous and went-to a hospitalt for' treatment. At that time a blistcr was found on his buttock. The initik1 diagnosis and treatment was for en insect bite. Thirty one days af ter this initial treatment the indi-vidual was hospitalized for treatment of.the 16 jury 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 beentperfortned. at.his place.of work ene month previously.. An investigation followed which. disclosed the above - information. l 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 docs' amputat.;on appear necessary. The localized dose is estimated to be 15 million rem at skh nurface, 60,r'JO rem at 1.cm depth and 7;000 rem at 3' cm depth. Estimated wnole body doses.to other individuals ranged from 1.to 60 rem. Hand doses ranged to l 5,000. rem. Therradiographer receivedrestimated doses of 14 rem to the whole byy and 50 rem to the hands. ( These are serious radiation overexposur'es. However, another important aspect cf the case, second only to the physiological effects of the exposures, is the radiographer's spparent disregard for the. health and safety of the exposed individuals and for his own personal safety.; The radiographer's failure to l inform the involved. individuals and to report the event to responsible management within his own and the customer'st company is a serious disregard for safety and deniad the exposed individuals early. medical attention. D"J n m L@
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IE' Circular No. 79-16 August 16, 1979 Page 2 of 3 The primary cause of this incident was the failure to perform a radiation surrey, a corrnor. underlying cause in radiation overexposures in the radiography The nu:ser of radiation overexposures experienced in the radiography industry. industry over the past.several years bas been higher than for any other single group of NRC licensees. To inforn radiography, licensees of HRC's com:ern for these recurring overexpcsure incidents,. NRC staff representatives met with licensees in a series,of five regional meetings during the period December 1977 throught 7: arch 1978. The main purpose:.of the meetings were to express NRC's concern for the high incidence of overexposures, and to open a line of cc:::nanication between the NRC and. radiography ; licensees in an effort to achieve the conraon goal of improved radiation safety. A written sumary of those meetings uas. published by the NRC in NUREG 0495. *Public Meeting on Radiation Safety for Industrial Rhdiographers". A copy of that docunant was mailed to each HRC radiography licensee and to other companies which sent representatives to the meetings. The remarks presented by the staff and subjects, discussed at those meetings included, amono others, ways and means.of incorporating safety into radiography operations, and case histories of overexposure. incidents, with highlights of the ccuses and possible preventions. In a discussion of the causes of over-expusures, a. presentation of statistics at.the meetings showed that the. failure of the radiographers to perform a radiation survey af ter each radiographic txposure was by far the most prevalent cause.. While these surveys are required oy regulation in 10 CFR 34.43(b), they are also the most basic, funda:nental and corn:en-sanse thing to do when dealing with r:adiation levels inherent in a typical radiography operation. Failure to perfcrm:the surveys indicates a lack of train-ing intensive enough.to permanently instill in radiographers the extrme importance of surveys for protection of both themselves and other people. Some of the case histories discussed in NUREG-04,95 resulted.in painful radiation injury to hands and fingers.with eventaal loss.of one:or more fingers in some cases. "Nof. ice:to Radiographf Cicensees: ERC licensees authorized to use byproduct material under 10 CFR Part 34 are rcquested to take the following actions: Review the event described in thisicircular (and the other case histories 1. in NUREG-0495) with all of your radiographic. personnel at an early date; discuss and emphasize: the extreme im;>artance of radiation sorveys in assuring protection a. of themscives and of other peopler, and. b. the Ir portance of reporting promptly any unusual events or circumstances to responsible :nanagement. Review your training to assure that appropriate emphasis is, placed 2. en the subjects in item I in both initial'and refresher training courses. ,( em LL c.2RRL ~-
~. = II Circular ! o. 79-16 August 16. 1979 Page 3 of 3 3. Review your ir.ternal audit progra:r to assure that appropriate ex.phasis is placed on these same subjects, par.ticu7arly the requirement for auditors to observe radiographic operations.to assure the proper conduct of radiation surveys. No written response to thi! Circular is required.: If you ncad additional infomation regarding this subject, please contact the Directos of'the appropriate NRC Regional Oifice. y e 9. 3 1 b .}}