ML20148B455
| ML20148B455 | |
| Person / Time | |
|---|---|
| Issue date: | 12/24/1996 |
| From: | Steven Baggett NRC |
| To: | NRC |
| Shared Package | |
| ML20148B295 | List: |
| References | |
| SSD, NUDOCS 9705130100 | |
| Download: ML20148B455 (9) | |
Text
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From: Steven Baggett To: BWS1, DAB, MLB5, JWL, TWR, KBR, TSK, CXB4 l Date: 12/24/96 6:14am
Subject:
Some information on the Region IV guide tube issue a
Per region IV, a radiographer had punched through the end of two guide tube end caps on sepearate occasions. On in early 1996 and the second one during december 1996.
According to the licensee the guide tubes meet the new equipment requirements.
- Amersham in LA. had examined the first punch through and treated as an isolated incident. Region IV was going to work with Burlington to get some additional ]
i information.
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! We may need to get involved with Region I to 9et the issue resolved. ,
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af the source guide tuce). The radiographer stated that ne completed two more
'evo:utions in case he nac m:scounted and when he had still felt no resistance, he dec:ced to retrac: the source. Slight resistance in turning the crank was noted by
- he radiographer ic lowing the first revoiution (as the source was retracted), but the rad ngrapher was ab!e to fuity retract the source. Fo3owing a survey of the exposure device to determine that the source was in the fully retracted and shielded position, the radiographer exarntried the guide tube and realized that the tip of the source stop was missing. The damaged guide tube was removed from service and Globe's radiation safety officer (RSO) was informed of the incident. Based on subsequent evaluation it appeared that the slight resi/tance felt by the radiographer during the retraction of the source capsule may have been the connection mechanism between the source pigtail and the drive cable travelling back into the damaged source stop.
Had the pigtail connection failed at that point, the source pigtail would have fallen into the header unit being radiographed. The only access to the source pigtail would have been through the small holes on the header unit, and this would have made a retrieval of the source very difficult.
Following notification of the incident, the RSO visually examined the failed equipment and attempted to identify any obvious characteristic which might explain the failure.
The RSO did not identify any surface defects on the guide tube or source stop, so he radiographed the failed source stop and three additional source stops. The RSO noted during interviews with the inspectors that there had been a slight modification of the source stop pieces in recent years. According to the RSO, Amersham stopped producing source stops with a rounded outside dimension and is now producing {
cnorce stops with a pointed outside dimension. The failed piece was manufactured 1 l _ ,,,.
the three additional source stops x-rayed, two were pointed and one l
.y . . 1e RSO determined that the wall thickness of the " shoulder" of one O 0 yle source stops was 1.00 millimeters (0.039 inches) thick. The
- stop appeared to have f ailed in the vicinity of the " shoulder" area.
, ,- all thickness of the other two source stops was 2.00 millimeters
~ ' ' - 'w t both the ends and sidewalls. According to information provided to
"" '" ' "t ersham, the minimum wall thickness for an aluminum source stop ,
u'.t.~ sxible guide tube should be no less than 1.57 millimeters (0.062 l inches). l l
On December 11,1996, the RSO contacted a Tulsa area Amersham representative ;
and informed him of his findings. The Amersham representative indicated to the RSO that he would forward this information to Amersham and that the RSO could expect to receive a follow-up telephone call from Amersham in the near future. The representative also asked the RSO to forward the failed piece to Amersham and stated that a replacement guide tube and source stop would be provided. (As of January 22,1997, Amersham representatives had not contacted the Globe RSO regardin'g this incident.)
On December 12.1996, the Globe RSO informed Region IV staff of the inciAlent by telephone. At this time, the RSO also notified Region IV staff that a similar event
t1AR-14-97 FR1 09:25 NRC R IV FAX NO. 8608188 P.01, ,.Q
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DATE/ TIME: _ 03/14/97 PRIORITY:
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MESSAGE TO: Michelle Burtess. T-8-F5 hESSAGE FROM: Linda Howell. DNMS. RIV NUMBER OF PAGES: 11 PLUS TRANSMITTALSHEET ;
TELECOPY NUMBER: 301/415-5369 VERIFICATIONNUMBER: x5868 CONTACT:
TRANS MTITAT INSTRUCTIONS / ATTACHMENT (Sh Copy of Globe X-Ray 96-03 report attached.
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DISPCSITIO.N_1 Transmitted & Verified by: Return to Originator Place in Mail
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MAR-14-97 FRI 09:26 NRC R IV FAX NO. 8608188 P.02 w tso sraits NUCLEAR REGULATORY COMMISSION 4 .f
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Gwew S. 0:run President G.cce X Ray Services. Inc.
844' South Jnion Street Talse, Ok;ahoma 74132
SUBJECT:
NRC INSPECTION REPORT 030 08719!96 03
Dear Ms. Ozmun:
On January 22.1997. the NRC completed an inspection at Globe X-Ray Services, Inc.'s (Globe) f acihties. This special. announced inspection was conducted in response to notification made by Globe regarding the failure of two source guide tubes. Specifically, the source stop attached to the guide tubes failed and allowed the source capsule to travel outside of the guide tubes. A telephonic exit briefing was subsequently conducted with -
Mr. Ken Swanson of your staff on January 16,1997. The inspection also included a review of photographs provided by Globe to the NRC subsequent to the telephonic exit.
Copies of the photos received on January 22,1997, are included as attachments to the enclosed report. The enclosed report presents the scope and results of that inspection.
As noted in the enclosed report, the equipment manufacturer was notified of the incident on December 11,1996 and you subsequently made telephonic notification to the NRC on December 12,1996. NRC Region RIV personnel discussed the reporting requirements specified in 10 CFR Parts 21 and 34 with Globe representatives at that time. A written report documenting this incident was subsequently provided to the NRC by letter dated January 6,1997. NRC staff have also discussed these incidents with the guide tube.
manuf acturer whose review of this matter is ongoing.
During the course of this inspection, the inspectors reviewed the circumstances relating 'o the reported equipment f ailure. This review included the selective examinations of procedures and representative records, interviews of personnel, and examination of the damaged equipment. The inspection determined that an appropriate level of oversight had been provided for licensed activities and that activities had been conducted in accordance with applicable NRC regulations and the conditions of your license. Examination of the damaged equipment and review of information provided by the manufacturer indicated that the source guide tubes used by Globe met the performance requirements for radiography equipment identified in 10 CFR 34.20. The inspectors also noted that use of radiographic j
exposure devices and ancillary equipment was consistent with the manufacturer's instructions.
No violations were identified; therefore, no response to this letter is required, in accor' dance with 10 CFR 2.790 of the NRC's " Rules of Practice, a copy of this letter and its enclosure will be placed in the NRC Public Document Room !DDR).
0
. MAR-14-97 FRI 09:26 NRC R IV FAX NO. 8608188 P.03 4
C-?c.e X Pav 5e vices. 'r c. 2-Should you have any questions concerning this letter or tna enclosed inspection report, clease certact Mr. Jeffrey Cruz at (317; 860 81 :4 cr f.1s Unaa Hovvell et
- 8171850 8213.
Sincerely, 4 f. Q$ 1
$r Ross A. Scarano, Director Division of Nuclear Materials Safety Docket No. 030-08719 License No.: 35-15194-01
Enclosure:
NRC inspection Report 030-08719/96-03 cc w/ enclosure:
Oklahoma Radiation Control Program Director 1
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MAR-14-97 FR1 09:26 NRC R IV FAX NO. 8608188 P.04 l
Gicce X Rav Serv:ces. !nc. +
e E-Mail report to Document Control Desk (DOCDESK) l bec to DCD (IE07) bec distrib. by RIV:
RIV Regional Administrator CLCain JJHolonich, NMSS (T-7J9)
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- LLHowell l FAWenslawski !
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Steve Baggett, NMSS (T-8F5) l
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DOCUMENT NAME: G:\NMIS.0\JC\08719 REP.JXC To receive copy of document, indicate in box: "C": Copy wmout encJosures "E" = Copy we enclosures "N" = No copy l RIV:NMi&FC/DB C:NMi&FC,/QB ADD:DNMS AD:DNMS JCruz j (_, LLHowell g FAWenslawskf/CLCair(Lt 03/7/97 03/1/97 fit 03/;l/97 0341/97 s OFFICIAL RECORD COPY
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! EfJCLOSURE f
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! U.S. NUCLEAR REGULATORY COMMISSION 1
. REGION IV
- - Docket No. 030-08719 i
4 i License No. 35 15194 01 ;
,9 '
s Report No.- 030-0871'9/96-03 .
Licensee: Globe X-Ray Services, Inc.
l-Facility: Globe X-Ray Services, Inc.
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Location: 8441 South Union Street Tulsa, Oklahoma l
- l. 5202 West Channel Road Catoosa, Oklahoma Dates: December 16,1996 through January 22,1997 4
4 Inspectors: Mark R. Shaffer, Senior Radiation Specialist
! Jeffrey Cruz, Radiation Specialist l Approved By: Linda L. Howell, Chief Nuclear Materials inspection and 4
l Fuel Cycle / Decommissioning Branch l I
ATTACHMENTS:
1
! Attachment 1: Supplemental inspection information Attachment 2: Photographs of Source Guide Tube 1
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- EXECUTIVE
SUMMARY
i
' Giobe X Ray Services, Inc.
NRC Inspection Report 030-08719.96 03 This inspection was conducted in response to the licensee's report that a source guide tube failed during radiographic operations. The inspection included a review of the activit:es relating to use of ancillary radiographic equipment, administrative aspects of the licensee's radiation safety program, and interviews of licensee personnel.
I Eouioment and Instrumentation
- Globe X Ray Services, Inc. (Globe) reported the failure of two source guide tubes during radiographic operations to the NRC on December 12,1996. The first incident occurred during the first calendar quarter of 1996; the second incident occurred on December 2,1996. These equipment f ailures permitted the source capsule to travel outside of the guide tube.
- The inspection determined that an appropriate level of oversight had been provided for licensed activities and that activities had been conducted in accordance with i applicable NRC regulations and the conditions of the license, it appeared that use of ' I radiographic exposure devices and ancillary equipment was consistent with the manuf acturer's instructions and that the f ailure of the source stops did not result from any actions taken by or f ailures on the part of Globe personnel. .
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MAR-14-97 FRI 09:27 t1R0 R IV FAX t10. 8608188 P.07 3
Report Detads 1 Organization and Scope of the Licensee Program (87100,83822,87103)
Globe is autnorized under NRC License 3515194-01 to use byproduct materialin industrial l
radiographic equipment. Licensed activities had been pnmarily performed in exposure bays at permanent field locations maintained by Globe in 8roken Arrow, Port of Catoosa, and i Tulsa, Oklahoma. Globe also performed radiography at temporary job sites throughout the l state of Oklahoma. The licensee possessed both cobalt-60 and iridium-192 sources for l
use in radiographic exposure devices and a cecium '37 scurce for calibrating survey meters. The cobalt-60 and iridium-192 sources had been used in Amersham Model 680 and Model 660 exposure devices, respectively. The cesium-137 source had been used in a Amersham / Technical Operations Model 726 calibrator. At the time of the inspection, Globe employed 15 individuals as radiographers and 2 individuals as radiographers' assistants. Giobe personnel performed industrial radiography on a daily frequency.
2 Equipment and Instrumentation (87100,83822. 87103) j l
2.1 Inspection Scope This portion of the inspection included interviews with licensee personnel, a review f of licensee records, and the examination of the licensee's radiography equipment. l 2.2 Observations and Findinos ,
On December 2,1996, a radiographer conducting radiographic operations at the Globe exposure bay at GEA Rainey Corporation facility, Port of Catoosa, Oklahoma, experienced a f ailure of an Amertest Model 48906 guide tube during the first exposure of the day. Specifically, the aluminum source stop attached to the guide tube ruptured, allowing the iridium-192 source capsule to travel out of the end of the guide tube. The source capsule was an Amersham Model A424-9 (Serial Number (S/N] A9902) with an activity of approximately 72 curies at the time of the incident.
The radiographer had been using the source capsule with an Amersham Model 6608 exposure device (S/N B1644) to radiograph a box header manuf actured for use within an air cooled heat exchanger unit. The unit is constructed in a cubic shape with multiple small holes machined intp two of six sides. The two sides with holes are opposite from one another (end plates). The source guide tube was inserted into the unit through a hole in one of the end plates. The dimensions of the holes,38.00 millimeters (1.500 inches) in diameter, prevented the radiographer from utilizing a collimator.
The radiographer stated that he first realized that there wss a problem when he not!ced that he had completed the usual number of revolutions of the drive cable control mechanism required for the source to reach the source stop (approximately eight and a half revolutions when using a seven foot guide tube) and had not encountered the expected resistance (indicating that the source had reached the end
MR-14-97 FRI 09:28 NRC R IV FM NO, 8608188 P.09
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had occurred dunng ine trst Quarter of 1996. Tne RSO stated that a second Globe radiograprer was ennducang rad:ographic coerations usmg Amersham equipment and experienced the same type of failure of the 2% rec ston. Tne RSO could not recall tne exact date of this ncicent, but he was sure tna!:: tco involved the Amersham Mocet 660 equipment and an Amersham Mode! 48906 guice tube. The RSO stated that at the ::me of the earfier incident, he considered the faliure to be nothing more th.'in an esclated oddity because he had never observed this type of failure before.
Amersham was notified of the f ailure in early 1996; however, the RSO did not l
discuss that incident with the NRC (Note: in both instances the radiographers were '
aole to rettr ct the source back to its fully snielded position.) However, following the second incident in less than 1 year, the RSO became more concerned that these ;
f ailures may be evidence of a possible equipment defect. This concern prompted the l RSO to perform radiograpns of the source stops and notify to the NRC. The RSO stated that prior to 1996, he had never known of a similar incident.
The RSO stated that he had not initially considered failure of a source stop to be reportable pursuant to the provisions of 10 CFR 34.30. Therefore, he did not report the first incident in early 1996 within 30 days of its occurrence. However, following ,
the second incident and discussions with Globe management, the RSO reviewed the regulations again and determined that this type of incident may be reportable to the NRC. The RSO subsequently notified the NRC of the December 2 incident and reviewed with NRC staff the previous incident that occurred earlier in 1996. The
? RSO and licensee management also indicated that following their review of the regulations and discussions with Region IV staff, they had a better understanding of the types of incidents which might be reportable under 10 CFR 34.30. The failure to report the incident that occurred during the first quarter of 1996 was identified and corrected by the licensee and is being treated as a non cited violation, consistent with Section Vll B.1 of the NRC Enforcement Policy (030-08719/9603-01).
On December 16,1996, a telephonic interview of the radiographer involved in the incident on December 2,1996, was conducted. The radiographer stated that the radiographic equipment utilized on December 2,1996, had not been used in any unusually harsh environments and appeared to be in satisfactory condition during his daily equipment check. The radiographer also noted that since the failure occurred during the first shot of the day, the equipment could not have been damaged between the time of equipment check and the time of the exposure. An on-site interview of the radiographer was conducted on January 13,1997. The radiographer appeared knowledgeable of Globe's Operating and Emergency Procedures and no deficiencies were observed during the field site inspection. The radiographer also stated that in his 17 years as a radiographer, he had never experianced a similar equipment f ailure.
The inspectors conducted independent discussions concerning guide tube maintenance with the RSO and radiographer involved in the incident on December 2, 1996. Both of the individuals stated that no maintenance beyond that recommended by the manuf acturer was performed on the source stops. They indicated that it was
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tiAR-14-97 FRI 09:29 I4RC R IV. FAX t40.' 8608188 P.10-I i
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i common practice to place a ;ayer of tape around tne rucoer zed covering of the guide tube to protect the coverir'g from scratches and cuts. The tape was ended prior to ,
reaching the aluminum source stop connection. Tre mspectors' review of equipment maintenance records found no evidence that Globe personnel had performed any l maintenance on source stops which may hava caused them to fail. !
2.3 Conclusions i
i
! The inspection determined that an appropriate level of oversight had been provided
! for licensed activities and tnet activities hac been conJucted in accordance with applicable NRC regulations, and the conditions of the license. It appeared that the use of radiographic exposure devices and ancillary equipment was consistent with the manuf acturer's instructions and that +he f ailure of the source stop did not result. ,
i from any actions taken by or failures on the part of Globe X-Ray Services, Inc. I personnel.
l A non-cited violation was identified involving the Itcensee's failure to provide a
. written report to the NRC within 30 days of the failure of a component (critical to safe operation of the device) to properly perform its intended function. Specifically, j following the failure of source stop during the first quarter of 1996, no written report
, was received by the NRC.
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.. 1 ATTACHMENT 1 l 1
PARTIAL LIST OF PERSONS CONTAC TEQ l
\
(Lgensee T. Ozmun. Vice President D. Poner. Vice President K. Swanson, RSO R. Peters, Radiographer R. Budgick, Radiographer INSPECTION PROCEDURES USED l
Licensed Materials Programs j 87100 l 83822 Radiation Protection 87103 Inspection of incidents at Nuclear Materials Facilities l
)
ITEMS OPENED, CLOSED, AND DISCUSSED Opened l
030 08719/9603 01 NCV Failure to provide a written report to the NRC within 30 )
days of the occurrence of a failure of a component !
(critical to safe operation of the device) to properly perform its intended function. ,
Closed :
None Discussed i
i None UST OF ACRONYMS USED
_. NCV Non cited Violation' NRC ' Nuclear Regulatory Commission F RSO Radiation Safety Officer
2 i . MAR-14-97 FRI 09:29 LIRC R IV FAX F10. 8608188 P.12 i
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- View 1 of Termination Tube with damaged Source Stop
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of " e source guide tube). Tne radiographer stated inat ne completed two more
<ecutions in case ne had rmscounted and when he had still felt no resistance, he dec:ced to retract the source. Slight resistance :n turning the crank was noted by the rad:ographer fe:iowing the first revoiution ias the source was retracted), but the rad cgrapher was ab!e to fu:ly retract the source. Fodowing a survey of the exposure cev:ce to determine that the source was in the fally retracted and shielded position, the radiographer examined the guide tube and realized that the tip of the source stop was missing. The damaged guide tube was removed from service and Globe's radiation safety officer (RSO) was informed of the incident. Based on subsequent evaluation, it appeared that the slight resist ance felt by the radiographer during the retraction of the souice capsule may have been the connection mechanism between the source pigtail and the drive cable travelling back into the damaged source stop.
Had the pigtail connection f ailed at that point, the source pigtail would have fallen into the header unit being radiographed. The only access to the source pigtail would have oeen through the small holes on the header unit, and this would have made a retrieval of the source very difficult.
Following notification of the incident, the RSO visually examined the failed equipment and attempted to identify any obvious characteristic which might explain the f ailure.
The RSO did not identify any surf ace defects on the guide tube or source stop, so he radiographed the f ailed source stop and three additional source stops. The RSO noted during interviews with the inspectors that there had been a slight modification of the source stop pieces in recent years. According to the RSO, Amersham stopped producing source stops with a rounded outside dimensiun and is now producing source stops with a pointed outride dimension. The failed piece was manufactured with a point. Of the three additional source stops X rayed, two were pointed and one was rounded. The RSO determined that the wall thickness of the " shoulder" of one of the pointed style source stops was 1.00 millimeters (0.039 inches) thick. The damaged source stop appeared to have f ailed in the vicinity of the " shoulder" araa.
The minimum wall thickness of the other two source stops was 2.00 millimeters (0.079 inches) at both the ends and sidewalls. According to information provided to the NRC by Amersham, the minimum wall thickness for an aluminum source stop attached to a flexible guide tube should be no less than 1.57 millimeters (0.062 inches).
On December 11,1996, the RSO contacted a Tulsa area Amersham representative and informed him of his findings. The Amersham representative indicated to the RSO that he would forward this information to Amersham and that the RSO could expect to receive a follow-up telephone call from Amersham in the near future. The representative also asked the RSO to forward the f ailed piece to Amersham and stated that a replacement guide tube and source stop would be provided. (As of January 22,1997, Amersham representatives had not contacted the Globe RSO regarding this incident.)
On December 12.1996, the Globe RSO informed Region IV staff of the incident by telephone. At this time, the RSO also notified Region IV staff that a similar event
go gob t GLOBE X-RAY SERVICES, INC.
8441 SOUTH UNION TULSA. OKLAHOMA 74132
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~ a c os ism o, 1-6-97 f( AA$ s$ 1892 U.S. NUCLEAR REGULATORY COMM DIRECTOR, OFFICE FOR ANALYSIS AND EVALUATION OF OPERATIONAL DATA.
SUBJECT:
Possible Equipment Defect Amersham Model 48906 Guide Tube Equipment, Amersham Model 660B Camera S,N. B1644 Source Model 424-9 Iridium 192 72 Ci. S.N.A9902 On December 2,1996 a technician performing radiography experiance a failure of Amersham Model 48906 Guide Tube.
The end of the source stop broke off, there fore allowing the source capsule to travel thru the source stop and into the part the technician was radiographing. Noticing the source traveled to far by the number of revolutions of the cranking mechanism, the technician immediately cranked the source back in to the camera. Luck with him he did not experiance a source hang up when the source connector traveled back thru the end of the source stop.
After surveying the camera an making sure the source was in the j safe position, the technician examined the guide tube noticing the j end of the source stop was missing, He than removed the guide tube and retrieved another one, and continued working, Later he brought in the failed guiMe tube to get another one to replace it.
I Ken Swanson RSO, Being quite concerned that this was the ,
second guide tube failure of this kind for year 1996, I had never j experianced this kind of failure to any of Amershams equipment in the past. After examining several guide tubes, and not being able to determine if anything was wrong with them, I decided to radiograph some of the source stops with an x-ray machine, My findings where quite sh6cking, some of the source stops aluminum material uns Imm thich or less at the shoulder of the tapered end.
On December 11,1996 I notified Amersham representative of my findings, that there was possible a equipment defect.
On December 12,1996 I notified NRC at the Region IV office and talked to Linda Howell Chief, Nuclear Materials Inspection Branch. and reported my findings of a possible equipment defect.
On December 16,1996 Inspector Jeff Cruz and Inspedtor Mark Shaffer arrived at Globe X-Ray Services Inc, to examine the failed guide tube, and radiograph of source stops.
At she sugestion of Mark Shaffer a leak test was performed on camera s.n. B1644 for possible damage to capsule. Leak test report indicated there was no leak or contaimnation.
Sincerly, Ken Swanson RSO W O e f h fY' "
Globe X-Ray Services Inc.
' 8441 So. Union Tulsa Ok, 741:
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FOR PRODUCT COMPLAINTS:
DEVICE MODEL #: SERIAL #:
SOURCE MODEL #: SERIAL *: CURIES:
\ l CONTROL MODE'. AND LENGTH: COLLlMATOR MODEL:
- OF GUIDE TUBES & TYPE: Y[7dh REMOVABLE STOP7 YES NO CORRECTfVE ACTION: RESP. OEPT.:
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. ERSHAM CORPORATION l
RETURNED MATERIAL EVALUATION REPORT l Ff. 1 of 1 Model:489 Source Model:NA RMA Number: 670 RMA Category:II Serial No:NA Source Serial No:NA Notification Date:25 Jan 96 Customer: Date Equipment Received: 9 February 96 Globe X-Ray j l
Tulsa, OK Notification By: Dave Potter l
CUSTOMER DESCRIPTION OF PROBLEM: l Customer states that the end stop of their source guide tube came off and allowed source to exit out the end of the guide tube. Customer was able to ,
return source to stored position using normal operations.
1 1
EVALUATION OF PROBLEM: ,
1 Upon receipt the guide tube was visaally inspected and was found to have several layers of white tape over the source stop and the guide tube. The ;
outer housing of the guide tube was split in 2 locations revealing the inner metal winding. The guide tube appears to be broken behind the sources top connection, this is secured with black tape. The source stop had the end worn off and it appears that the source stop has been subject to wear from the outside due to use. The cause of the failure was due to excessive wear of the j
source stop and not to any design or manufacturing defect, J
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CORRECTIVE ACTION:
Customer should inspect for excessive wear on other guide tubes.
Quality Assurance Evaluator: b*/ Dates lh/b/I l
/
RA/QA Manager Engineering Manager: Regulatory: Facility Manager:
Date: \NS h Date: $ , g Date: hN Date:h Sign:( Sign: !
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