ML20236K280
| ML20236K280 | |
| Person / Time | |
|---|---|
| Issue date: | 04/21/1986 |
| From: | Kerr G NRC OFFICE OF STATE PROGRAMS (OSP) |
| To: | Heltemes C NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| Shared Package | |
| ML20236K265 | List:
|
| References | |
| FOIA-87-377 NUDOCS 8708070064 | |
| Download: ML20236K280 (12) | |
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fiEh0",ATUM FOR: C. J. lleltenes, Jr., Director l
Office for Analvsis end Evaluation of Operational Data FROM: G. Wayne Kerr, Director Office of State Prograns
SUBJECT:
INPUT FOR ABf 0RML OCCURREf1CE REPORT, IST 00ARTER,1985 In response to your April 7,1986 request we are subnitting the ,
- f. following Agreement State A0R's for the subject report:
- 1. Texas - B.F. Inspection Services ,
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- 2. Texas - Basin Industrial X-Ray
- 3. California - Tarco Steel 4 California - Boothe-Twining With respect to the Scripps !!aspital incident, there is a serious discrepancy between estimates provided by two consultants on the radiation dose rcsulting f rom the misadministration. The State has requested its consultant to provide an explanation of the reasons for i the differences. HRC is to receive a copy of the consultant's repartr and at that tine a decision should be possible on whether to conside .
the inc.ideit an A0R.
Or n' 52.;;ne d W G. Mayne Kert G. Wayne Kerr, Director Office of S+. ate Prograns
Enclosures:
As stated Distribution:
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ABNORMAL OCCURRENCE DESCRIPTION RADIATION BURN TO AN INDUSTRIAL RADIOGRPAHER Date and Place - On April 20, 1984, an individual employed by BF Inspection Services in Midland, Texas received an exposure that resulted inThe a radiation burn while performing radiography in Seminole, Texas. .
Licensee failed to notify the Bureau of Radiation Control of the incident after it knew the radiographer had received a radiation burn. The burn was reported by Permian Industrial X-ray, present employer of the irdividual, to the Agency on November 8,1985, when the radiographer had an apparent reoccurrence of the wound.
Nature and Possible Consequences - The radiographer and assistant arrived at the job site at c:00 a.m. and used a 90 curie iridium-192 source to x-ray pipe in a pipe rack until 11:00 a.m.. The job was being performed by
- Conam Inspection, and BF Inspection had been subcontracted to assist on the 1 f.
job.
The radiographer worked on the pipe rack removing exposed film ard placing new film on the weld to be x-rayed. The assistant worked the crank out. ,
~ The radiographer did not have a survey instrument with him. He deperded on the assistant to tell him when the radiation levels decreased on the survey meter kept at the crank out.
At approximately 10:00 a.m., the radiographer took the exposed film to the central processing facility. When this film was developed, it was darker than it should have been and appeared to be exposed longer than necessary.
- At 11
- 00 a.m., the radiographer decided to stop work and go to lunch. At this time he locked the radiographic . device, removed the guide tube and put .
the dust cover on the front of the device. No survey was performed on the s
radiographic device or guide tube at this time. The equipment was placed i in a bucket used to transport equipment on the pipe reck and left there :
during lunch.
Prior to leaving the job site, the radiographer went to the job supervisor.
The radiographer was informed that it appeared that he needed to decrease exposure time and was asked for any other exposed fil m. The his radiographer told the supervisor that he would bring the remaining exposed j film for developing after lunch.
When the crew returned from lunch, the radiographer decided to quit for the day, since he could not determine the cause of the film being overexposed.
The equipment was moved from the bucket to the back of the truck. The radiographer carried the guide tube ar.d crankout in his left hand and the radiographic device in his right hand. When the radiographer disconnected l the crankout from the radiographic device, he discovered that the source was not connected to the drive cable. The radiographer then looked at his j pocket dosimeter and found that it was discharged Oeyond its range. He ;
then asked the assistant to look at his dosimeter and was informed that it was not discharged beyond its range. The assistant radiographer was l instructed to check the radiation level and he told the radiographer that l l
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he had a reading of 90. (The radiographer and the assistant,did not l
j remember what scale the survey meter was set on.) We radiographer, shook the !
J guide tube and heard something rattling. He carried the guide tube, still l
l zolled up, and the radiographic device to a large concrete slab
' approximately 60 feet from the truck. The guide tube was unrolled and when he shook it, the source fell out. The radiographic device was placed on top of the source and the radiographer went back to the truck. He then I
approached the device with the crankout ard passed the drive cable through the radiographic device. We device was then moved behind the connector )
end of the source pigtail and the pigtail and the drive cable were !
connected. We source was returned to its shielded position and locked in ,
place.
When the crew left the job site, the radiographer notified the job supervisor of the disconnect. The supervisor instructed the radiographer
- that he should notify his radiation safety officer (RSO) of the disconnect :
M- ard to leave his fi-Im for processing. We supervisor stated that when this film was developed, it appeared that it may have been fogged.
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-- When the radicerapher returned to the office, he found that the RSO was gone for the weekend and did not attempt to notify him of the disconnect until Monday, April 22.
On Morday, the RSO and the radiographer inspected the equipment. According to the radiographer, nothing was found to be wrorg with the equipment. The radiographer stated that he turned in his and his assistant's film badges for immediate processing. At this time, the radiographer did not I
. demonstrate any symptoms of a radiation injury.
Approximately five to seven days af ter the disconnect, the thumb, irdex and middle fingers of both the radiographer's hands became red and swollen. 1 i
me radiographer was seen by a doctor ard the three blood tests performed :
were within normal limits. The medical expenses were paid for by BF Inspe-tions. After a period of approximately two months, the radiographer's hards appeared to heal.
Coring the first week of tbvember 1985, the radiographer was working for another company and the middle and index fingers of his lef t hand became zed ard swollen. He again went to see a doctor. He notified his employer of the injury, m e campany RSO then notified the Agency of the injury.
Based on statements by the radiographer, Agency investigators calculated his exposure from carrying the equipment to the truck and recovering the source. The radiographer may have received up to 29,390 rem to his left hand and 47.2 rem for his whole body exposure.
During the Agency's investigation, several items of disagreement arose.
While the radiographer stated that he turned in his and his assistant's film badges, the RSO for BF Inspection Services stated that he asked for j
the badges and was informed that they were in the truck used at the job site. The RSO instructed the radiographer to give him the film badges but did not follow up when he did not receive the badges. The question also arose as to whether there wa. an equipment malfunction. According to the i
radiographer, there was no equipment malfunction. The RSO stated during the investigation that toe connector on the drive cable was worn and caused the disconnect.
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When questioned concerning the cause of the disconnect, the radiographer stated that the only conclusion he could reach is that he did not connect )
the source pigtail to the drive cable when he assembled the device.
Cause or Causes - The apparent cause of the disconnect is that the source pigtail was not correctly connected to the drive cable when the equipment was set up. The exposure and subsequent burn resulted when the radiographer did not follow the Licensee's Operating Procedures or the .
Texas Regulations for Control of Radiation, and failed to perform a survey 0- of the radiographic device or guide tube between radiographs, when the : l equipment was secured for lunch, or at the end of the day. The radiographer also failed to follow the Licensee's Emergency Procedures for a source 4
~ disconnect.
Actions Taken To Prevent Recurrence _
Licensee - At this time, the Licensee's response to the Agency's compliance letter was not satisfactory as to what actions it has taken to prevent l
occurrence of this type of accident. The Licensee's initial report of the
! incident did not address calculations of the radiographer's exposure, nor i .
measures taken to prevent a recurrence.
~ l Agency - The A,ency has cited the Licensee for 14 items of non-compliance with the Texas Regulations for Control of Radiation and is undertaking Escalated Enforcement. The investigation of this incident is continuing in an attempt to obtain additional information. j 3
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ABNORMAL OCCURREtCE DESCRlWION l'
RADIATION BURN TO AN INDUSTRIAL RAD 10GRAPHER Date and Place - On November 9, 1985, an individual employed as an ,
l assistant radiographer by Basin Industrial X-ray in 03 essa, Texas, received a 129 rem whole body exposure and a radiation burn to his left hand. The Licensee failed to notify the Bureau of Radiation Control of the incident. ; l Another Licensee informed the Agency on November 26, 1985, that an incident had occurred involving Basin IMustrial X-ray.
Nature and Possible Consequences - The radiography crew was performing work !
(. at Fabricators Contractors, Inc., during the evening of November 9,1985. .
We assistant radiographer was shooting the welds and the radiographer waf, developing the exposed film. At approximately 11:30 p.m., the assistant a radiographer noticed that his survey meter, placed approximately two feet in f ront and to the right of the radiographic device, was off scale after the source was supposed to have been returned to its shielded position. He then checked his pocket dosimeter and found it was discharged beyond its range. He notified the radiographer, who was unsuccessful in his attempt 4
l to return the source to its shield using the crankout. The radiographer I
checked his pocket dosimeter ard found that it was not discharged beyond its limit. He then notified the local supervisor, who was acting as the ' l l
local radiation safety officer. We radiographer was instructed to isolate 1 i the area and wait for the supervisor. l f
he supervisor did not retrieve the source but instructed the radiographer l in the procedures. The first action was to remove the crankout from the ;
radiographic device. At this time it was found that the drive cable had '
bgoken just behind the connection with the source pigtail. The )
j radiographer then removed the guide tube from the device with a pair of 12 :
inch channel lock pliers. Using the pliers and holding the guide tube at arms length he carried it to an open area of the shop and shook the source out of the guide tube. Using the pliers, the pigtail was placed in the device source end first. We pigtail was then reversed using the pliers (
i and pushed in with the dust cap. When the connector end of the pigtail i exited the lock box it was locked in place. After the source retrieval, it was found that the radiographer's pocket dosimeter had been discharged beyond its range of 200 millirem. t The equipment was loaded in a truck and the three employees proceeded to the Licensee's f acility. Af ter arriving at the f acility, the supervisor !
notified the company's radiation consultant of the disconnect and that the !'
employees' pocket dosimeters had been discharged beyond their limits. We i supervisor was instructed to return both badges for immediate processing and to serd the assistant radiographer for a blood test. We blood sample l taken at this time was within normal limits.
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On November 29, 1985, the assistant radiographer met with an Agency representative. At this time, the individual's lef t hand had redness f rom the wrist to the base of the little finger. _On December 2, 1985, the I individual had a blister from the wrist to the base of the little finger on his left hand.
On December 6,1985, the Agency contacted the radiation safety officer l (RSO) and requested the film badge results. The Agency was informed that the film badge had been sent in for routine processing an3 the results were not available. The Licensee was instructed to contact its film badge l
supplier and to have the radiographer's and assistant's film badges immediately processed. When the assistant's film badge was processed, it indicated an exposure of 129.000 rem. When asked about the radiographer's exposure, the RSO stated that he did not have his badge processed with the assistant's. The Agency again instructed the RSO to have the radiographer's film badge immediately processed. The radiographer's -
exposure was determined to be 28.000 tem. :
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Based on statements made by the assistant radiographer and a re-enactment of the incident , Agency investigators calculated the exposure to the ,
l radiographer to be 129.299 rem whole body, and 304,875 rem to his left :
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, The Agency's investigation found that the individual had not received j radiation safety training or formal training in industrial radiography from j the Licensee. It also appeared that the individual had f alsified his application stating that he had previous experience. .
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- When asked why the Licensee did not report the incident to the Agency, the ,'
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RSO stated that he did not realize the severity of the incident, since he .
had not been provided the full details by the radiography crew. The RSO ,
knew that the assistant radiographer's pocket dosimeter was discharged beyond its range but did not return his film badge for immediate :
processing. We Licensee failed to perform a detailed investigation of the incident when it appeared that there could have been a serious radiation exposure. The RSO also informed the Agency that he did not know that the drive cable had broken. When asked by Agency investigators, the RSO stated that he could not locate the broken crank-out cable.
Cause or Causes - We apparent causes of the exposure and burn appear to be that the Licensee permitted an individual to perform the functions of a radiographer without providing the proper safety training, and that the individual failed to perform surveys between radiographs.
Actions Taken To Prevent Recurrence Licensee - The Licensee has started tighter controls on its initial training program and hiring procedures.
Agency - The Agency has citied the Licensee for items of non-compliance with the Texas Regulations for Control of Radiation In addition, a complaint has been issued to'the Licensee, notifying him that the Agency intends to revoke the License. The investigation of this incident is continuing in an attempt to obtain additional information.
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DEte and Place ,
On May 23, 1985 two 20 cubic verd roll boxes being transported to the hazardous waste site at Kettlemen Hills, CA, set of f the radiatio alarms at ,
the weigh station at Newhall, CA. The trucks were returned to the crisinator of the shipment at the direction of the Cali fornia Highway Patrol (CFP) on advice of the Radiologic Health Branch (RFB) . The licensee voluntarily ceased operat, ions upon notice by the C W of the incident at the )
weish station. The f urnace was turned of f and operations began to 90 to a i
cold shut down. Shipments of product steel were suspended. l O* . }
i On May 24, 1985 Inspectors from the Department of Occupational Health and 4 Safety ~ (DOSH) conducted an initial survey of the roll boxes and the facilities of Tamco Steel Company at Ontar io, CA. The survey indicated contam i nat ion .was limited to flue dust, slas piles, bas house (containing flue dust) and associated duct ins, in addition to surfaces of the furnace itself. Samples were collected and sent for analysis. Direct radiation
- ievels ranged from D.03 mR/hr to 15 mR/hr. Analysis of the samples indicated , .
cesium contamination ransins f rom 2.0 Pci/sr to 4 Uci/sr.
On May 25, 1985 Tamco had a contractor on site to begin a thorough survey and develoo a clean un plan. The initial plan for decontami nat ion was developed with the RFB. A planned incremental decontamination program began on May 30, 1985 Priority was given to operational equipment and facilities. Clearance inspections conducted by the State followed the progress of the decontamination effort.
On Aunust 1, 1985 the State Compliance Inspection Team completea its finai survey. The RFB issued a departmental letter dated October 8, 1985 which released the facilities and eauipment for unrestricted use.
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" Na t ur_e a nd P,_ nobs > IE E9"5esvenc32 Y *
. Because of its ch2mical form the essium uns removzd from work occa in the oi l .1 throvsh floe dust ductins and the waste slag, Workers in the furnace crea a.nd bas house, most likely to receive internal contamination by inhalationofairbornedustcontainingcesiumweresenttotheUni)yersityof -
l California at Los Anseles where detail examination was conducted. The' examination did not detect any contamination of the workers.
Cause gr Causes The Tamco Steel Company processes scrap steel purchased from various suppliers throughout California, Nevada s and Ar i zona s into construction -
p, rebar. The scrap is segregated by metal type and sent directly to the ,
melting furr. ace without inspection. The device or source of the l s
.- -- coprox i, mate l y 1.5 curies of cesium was brought in to the scrapyard undetected and sent to the furnace as a part of a routine melt. Scrap metal
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dealers as a ncrmal practice do not screen for radioactive material.
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Actign Taken to Prevent Recurrenge i
Tamco Steel installed low-level radiation monitors at the sete to check scrap steel coming into the facilities and product shipments leaving. They :
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olso physically survey all scrap steel before it is placed in the furnace. (
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f ABNORMAL OCCURRENCE DESCRIPTION INDUSTRIAL RADIOGRAPHY OVEREXPOSURE Date and Place - A serious radiation accident occurred at the a temporary job site of Boothe-Twining Inc. in the Kern River ~ oil field in Bakersfield, California on August 23, 1985. This accident involved a radiation overexposure to the wholebody and radiation injury to the hand of a Boothe-Twining employee, (Subject A). The employee at the time of the accident was conducting industrial radiography at the company's field site named above, utilizing a 46 Curie Iridium-192 source contained in a radiographic projector.
Nature and Possible Consequences At the time of the accident, radiography was being conducted by Subject A using a 46 Ci radiography source. Subject A had four years experience as a radiographer with Boothe-Twining and prior to joining -
- Boothe-Twining, he worked as an automobile mechanic.
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When the source " crank out" met with great resistant.e, Subject A approached and manually readjusted the camera to reduce the kink in the 1
- guide tube. During this action his hands grasped the lock box and guide tube connector. At the completion of this readjustment, Subject A moved away from the camera and observed that his 200mr pocket dosimeter read off scale.
It turned out that Subject A had failed to: (a) crank the Iridium-192 source completely back into the shielded position inside the radiographic projector, (b) survey upon approaching the camera, and (c) .
. lock the source out of service. Subject A did not report his dosimeter was off-scale but reported a pocket dosimeter reading of 119mr to his ,
supervisor. His film badge was sent in for reading approximately 7 days after the accident after symptoms of high dose to the left hand were manifested cnd reported to management. Subject A was seen by and :
continues to be under the care of a physician. In addition, Doctor :
Reynolds F. Brcwn is participating as the Department's medical consultant.
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l Subject A was accompanied at the work site by his helper, Subject B, who s was acting as an assistant radiographer. She was only indirectly involved in actual performance of radiography, and registered no excessive dose. She kept back from the shooting area but had observed most of Subject A's movements during the accident. ;
1 An investigative pnel was convened pursuant to the Statement of Purpose and Delegation Ore.r dated October 16, 1985, to determine the causes of the radiation accident, establish the nature and extent of radiation exposure and any injury and to recomend corrective action to prevent 7
future recurrence of such accidents.
Cause or Causes l The radiographer failed to adhere to established radiation safety and i
operating procedures. - The radiographer did not assure that the
. radiography source was returned to the safe shielded position with the crank and did not perform a radiation survey on his approach to the camera and therefore had no warning that the source was out.
Failure of management to comunicate forcefully its intolerance of deviation from established safety procedures, particularly the failure to survey while approaching the radiographic . projector. The Investigative Panel found that such deviation was common practice with Subject A, and that management knew of it. Had Subject A used his survey instrument as required he would have detected early on, that the source was out, in an unsafe position.
Instruction of radiographer and specifically Subject A was found to be ,
unacceptable in that; (a) There was failure to convey the crucial safety i problem to the employee, i.e., that the performance of field radiography constitutes a serious hazard and therefore requires strict adherence to, safety procedures; (b) The licensees' attempted requirement that J. employees attend refresher training on their own time is unenforceable -
and contrary refresher for providing to State labor law.toThe training thelicense licensee, assigns the not the responsibility) employee; (c
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Semi-annual refresher training consisted of infrequent safety " bull
- sessions" with no structure and no record other than the fact of the bull session; (d) Radiographer were not checked out on equipment prior to use. General operating procedures were available to radiographer, however, no step-by-step operating, radiation safety and emergency procedures were provided that were specific to the make and model of projector used.
Responsibility for the radiation safety program; although vested in the
- RSO of the license, was in fact abrogated by the president of the ,
company. In his own testimony to the Investigative Panel, the President accepted this responsibility and authority, but did very l little to implement the program and clearly would not delegate to ,
l others. In the current case, he prevented the RSO from conducting the ;
- investigation. To compound the situation, the compliance history and the President's testimony clearly illustrated his failure to comprehend' the Company's direct responsibilities for the employee hand burn and for the numerous overexposure. He maintained that the accident was the employee's fault.
The Radiation Safety Officer asserted that the conduct of training and management audits was his safety assignment, but his heavy responsibilities in sales, customer relations and quality assurance often took precedence.
Management audits of Subject A's work as a radiographer were not conducted as required by licensee condition and records were not maintained. ,
Records for August 23, 1985 of the inspection and maintenance of the Gama Century projector involved in the accident were reviewed. These suggest that the equipment was in good functioning cor.dition, yet the investigative panel discovered that the lock could be actueted over the drive cable, thus locking the source outside the shield.
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The compliance history of Boothe-Twining is unacceptably poor. The company was found to be at fault and cited, in the serious overexposure / injury of an employee, in a 1981 radiography accident.
Since then re. peat and serious violations have continued, necessitating i an office compliance conference on July 5. 1985. In spite bf agreements arising out of that conference, the compa continued to fatl to provide adequate training and audits of employees so that there is a clear and unambiguous understanding of the seriousness of the performance of field radiographer and the need therefore to follow required safety procedures. For example, in July,1986 Subject A received a wholebody dose of 2 rem. The report of this did not stimulate an appropriate response by management.
failure of the radiation safety. officer to conduct job site management i L audits at frequencies promised and to provide comprehensive refresher )
[' training for radiographer is contrary to license conditions. Refresher !
training for radiographer is required to include review of: (1) j radiation s.afety and operating procedures, while (2) stressing changes :
in such procedures and (3) measures to be taken to avoid excessive )
exposures.
I ,A_ctions Taken to Prevent Recurrence l Licensee - A Notice of Violation was idsued to the licensee by the l Division of Occupational Safety and Health on December 11, 1985. The '
l , testimony of company employees ir cluding management affirmed that the violatfora did in fact occur. The response also outlined corrective action to prevent recurrence of these violations. , :
L The licensee's response to be matter of management audits was judged to be inadequate. The licem ee was provided additional opportunity to
- develop an-internal audit program to assure that radiographer and radiographer's assistants comply with Department regulations and license conditions, and the compey's operating and emergency procedures. i !
I Agency - The State held an enforcement; conference with the licentee. A' ! ,
consent agreement will be signed between the Director of the State i' Department of Health Services and the licensee. The licensee will be placed on a 3 year probation with provisions for suspension if serious noncompliance occurs within that period. The license will be amended to require a full time radiation safety officer and will detail the officer's duties. ,
, The State investigation panel concluded that if the radiographer had been wearing a functional pocket radiation alarm, the radiographer would have had ample warning that the source was not in its proper shielded position. The panel further agreed that the introduction of pocket radiation alarms into the practice of industrial radiographer is now imperative. Reliability had improved as a result of demand by the nuclear power industry so that the pocket alarm can reasonably be expected to withstand field service, provided radiographer are given '
appropriate instruction in the use of these devices. Instruction will also be necessary to prevent use of the radiation alarm as a substitute for quantitative assessment by radiation survey meter of radiation t J
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fields in conducting radiation surveys. The introduction of pocket radiation alams is expected to reduce the frequency of excessive exposures and minimize the incident of injuries by giving radiographer timely warning of exposed sources. [
California will consider adopting regulations which would require use of appropriate pocket radiation alarms for all radiographer and radiographer's assistants. This requirement would supplement and not in ,
any way displace the present requirement for use of a survey meter in I conducting required radiation protection surveys for industrial l l radiography.
l California will consider promulgating regulatory requirements and f i otherwise encouraging the development of a radiographic projector with ]
) an integral warning system built into the device to indicate in l- unambiguous fashion the safe, intermediate or unsafe position of the i
- source. This may be done by announcing proposed legislative -
l- requirements to authorize only devices with this feature, starting in '
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