Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56773 | 2 October 2023 20:30:00 | Agreement State | Disconnected Radiography Source | The following information was provided by the New Mexico Radiation Control Bureau via phone: On October 2, 2023, at 1430 MDT, a radiography camera source became disconnected from its cable while still inside the guide tube during operations at a fabrication facility in Loving, NM. The device was described as a QSA D880 Model A424-9 camera with a 79.7 Ci iridium-192 source, serial number: 76167M. The licensee reconnected the source and secured the source inside the device in the shielded position by 2100 MDT. There were no public or occupational overexposure related to the source being disconnected from its control cable. | ||
| ENS 56768 | 30 September 2023 05:00:00 | Agreement State | Radiography Source Stuck Unshielded and Recovered | The following was received from the Louisiana Department of Environmental Quality (the Department) via email: On September 30, 2023, Acuren Inspection, Inc. notified the Department that an industrial radiography camera failed to retract the source after an exposure. The industrial radiography camera was a Century 330 QSA Cobalt camera. The serial number of the camera is P30078. The radiation source is a Cobalt-60 with an activity strength of 52.2 curie. The source serial number is 59740G. The source was cranked back out the end of the source guide tube with a collimator. The facility where this event occurred is in St. Martin, Louisiana. Only the two man radiography crew was present at the site during the event, which occurred between 0300 (CDT) and 0350. A source retrieval was performed, resulting with the source in a shielded condition in the radiography camera. The individual performing the source retrieval received only 1 millirem. Louisiana Event Report ID No.: LA20230010 | ||
| ENS 56604 | 30 June 2023 21:50:00 | Agreement State | Missing Radiography Camera | The following information was provided by the New Mexico Environment Department via phone and email: Acuren Inspection, Inc., New Mexico Radioactive Materials License IR-448, reported a missing source of licensed material, a lost gamma camera for industrial radiography with an unknown total quantity of radioactivity. The device was lost between the cities of Carlsbad and Jal, New Mexico on Highway 128 around mile marker 38 on June 30, 2023, at approximately 1550 MDT. Crews are actively looking for the missing device. The licensee is licensed for gamma cameras with sources of iridium-192 not to exceed 150 curies and selenium-75 not to exceed 100 curies. A request for further information from the licensee as events develop has been made. Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, and EPA EOC and via E-mail: FDA EOC, Nuclear SSA, FEMA National Watch Center, and CWMD Watch Desk.
The device was recovered in Kermit, Texas on July 3, 2023, and reported to the State of New Mexico at approximately 1220 (MDT). Notified internal: R4DO (Drake), NMSS (email), NMSS (Williams), ILTAB (email), ILTAB (MacDonald), IRMOC (Crouch), INES (Smith), CNSNS (Mexico) (email). Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, and EPA EOC and via E-mail: FDA EOC, Nuclear SSA, FEMA National Watch Center, and CWMD Watch Desk. THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 55935 | 11 June 2022 12:47:00 | Agreement State | Armed BREAK-IN at Licensed Facility | The following is a summary of information received from the Colorado Department of Public Health and Environment by e-mail: Two armed individuals broke into the Colorado location for Acuren Inspection, Inc. The licensee described this event as part of a chain of local break-ins. The individuals were able to access the vault which contained the radiography cameras but were unsuccessful in accessing the radiography cameras stored within a secure container in the vault. It appears that no radioactive materials were accessed or removed in any way from the licensee's storage area. LLEA (Denver Police) was dispatched and responded to the facility. According to the (National Source Tracking System) (NSTS), as of June 11 the licensee is currently in possession of six Ir-192 sources, ranging from 98 curies to 24 curies. CO Event Report ID No.: CO220016 | ||
| ENS 55791 | 12 March 2022 06:00:00 | Agreement State | Radiography Source Failure to Retract | The following information was provided by the Oklahoma Department of Environmental Quality via email: Today we received a report of an industrial radiography equipment failure which occurred on March 12, 2022. The licensee is Acuren Inspection, Inc. (OK-32148-01). The incident was caused by the failure of the drive cable. Acuren is licensed to perform source recoveries and the source was eventually retracted into the camera safely. The crew's dosimeters have been sent for processing. Pocket dosimeter readings indicate the dose received due to this incident was approximately 135 mR. We will provide details of the equipment involved when we receive them from the licensee. | ||
| ENS 55366 | 20 July 2021 20:30:00 | Agreement State | Radiography Camera Source Disconnect | The following synopsis was received from the Louisiana Department of Environmental Quality (the department) via phone: The department was notified that the licensee was performing radiography shots with a QSA 880D (s/n #: D11621) at the pipeline just outside Ringgold, LA. When attempting to retract, the drive cable connector came off, leaving the 73 Ci Ir-192 source (s/n: 31880M) in the collimator. The Radiation Safety Officer (RSO) was notified and arrived to retrieve the source. The RSO covered the source with bags of lead shot and replaced the drive cable. The source was disconnected from the source cable and retrieved with tongs. The two radiographers received 30 and 29 mrem. The RSO received 189 mrem. Since the pipeline is in an isolated area, there were no other workers or member of the public around. | ||
| ENS 55183 | 8 April 2021 05:00:00 | Agreement State | Source Lost During Shipment | The follow was received from the Wisconsin Department of Health Services (Wisconsin DHS) via email: On April 8, 2021, the licensee's (Radiation Safety Officer) RSO reported a missing QSA global model 880 D exposure device containing a 28.9 Ci selenium-75 source. The package was shipped Monday April 5, 2021 via (the common carrier) from Neenah, WI to another Acuren location in Kingsport, TN. The package was shipped `overnight' with the intent to be delivered on Tuesday April 6, 2021. The package was reported delayed by (the common carrier) at Memphis, TN facility during the week. Then package arrived on Thursday April 8, 2021, damaged and without the shipped contents. Package weight information gathered as (the common carrier) handled the packaged indicates that the package contents were separated before final delivery, the exact location is unknown at the time of this report. The licensee is in contact with (the common carrier) and device manufacture QSA to locate the device and source. Wisconsin DHS will monitor efforts to locate the device and coordinated with other jurisdictions as necessary. Event Report No.: WI210002 THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 55019 | 2 December 2020 22:40:00 | Agreement State | Radiography Source Stuck within Source Guide Tube | The following information was received via E-mail: Acuren Inspection, Inc. contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section on December 3, 2020, concerning an industrial radiography source that had been stuck within the source guide tube. The crew was using a QSA Global model - 880D, serial number - 14783, with an Ir-192 source, with source serial number - 11512M, with an activity of 41 Ci (1,517 GBq). On December 2, 2020, around 1640 CST, the source became stuck outside the camera in the source guide tube while performing radiography operations (when an equipment stand fell on the source guide tube leading it to become crimped). There were no excessive radiation exposures. The industrial radiography crew's pocket dosimeters did not go off scale. A source retrieval team was sent out and had the source returned back into the camera by 2000 CST on December 2, 2020. The event occurred at Enbride Venice Facility in Venice, LA. Louisiana Event Report ID No.: LA20200010 | ||
| ENS 52997 | 2 October 2017 05:00:00 | Agreement State | Agreement State Report - Radiography Source Disconnected While Working in the Field | The following report was received from the Texas Department of State Health Service via email: On October 2, 2017, the Agency (Texas Department of State Health Services) was notified by the licensee that one of its radiography crews had experienced a source disconnect while working at a field site. The radiography crew was using a QSA 880D exposure device containing a 75 curie iridium-192 source. The radiographers had completed a shot and as they approached the exposure device their alarming rate meters alarmed. The radiographers retreated to the end of the crank out device and attempted to retract the source. The source could not be retracted. The radiographers contacted their radiation safety officer (RSO) who responded to the scene. The RSO was able to drive the source into the collimator and place shielding over the source. The RSO inspected the drive cable and found that the drive cable had pulled out of the drive cable connector to the source pigtail. The RSO connected a new crank out device to the source and was able to retract the source into the fully shielded position in the camera. The RSO stated he inspected the drive cable at the connection and it appeared the cable had been stretched. The RSO stated the connector had obvious crimp marks on it. The RSO stated the equipment would be returned to the manufacturer for inspection. No individual received an overexposure due to this event. No member of the general public received any exposure from this event. The Agency has requested additional information from the licensee. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #:I 9515 | ||
| ENS 52759 | 15 May 2017 05:00:00 | Agreement State | Agreement State Report - Potential Excessive Exposure of Radiographer | The following information was received from the Wisconsin Radiation Protection Section via email: On May 15, 2017, radiographers with Acuren Inspection, Inc. were performing radiography on a boiler at Verso Paper in Wisconsin Rapids, WI. They were utilizing an approximately 90 Ci Se-75 source, with a 17.5 HVL (Half Value Layer) collimator to perform shots through the boiler wall. The assistant radiographer would position a panel on the inside of the boiler wall and then move to the far side of the boiler. The main radiographer would then position the collimator for multiple shots from the outside of the boiler. They were in contact via radio. At approximately 7:45 p.m., following a shot, the main radiographer approached the collimator with his survey meter. As he approached, he realized the source had not yet been cranked in, and began walking back to crank it in. At that time, he was contacted via radio by the asst. radiographer. Setting down his survey meter, he had a 30-40 second conversation. Following the conversation, he forgot what he had been in the process of doing, and approached the collimator without his survey meter, and positioned it for the next shot. Turning to walk back, he spotted his survey meter on the ground halfway to the crank, remembered he had yet to crank it in, and realized he had been exposed. He was wearing a functioning alarming rate meter that did not alarm. Acuren notified the state approximately three hours after the event on the evening of the 15th of the possible overexposure. The radiographer initially estimated he had held the source 10 seconds, and Acuren calculated this would result in approximately a 680 Rad dose to the hands. The radiographer was wearing a direct reading dosimeter on his chest which read 100 mR. Other whole body dosimetry is being processed. Following the event, the licensee had the radiographer do a mock performance 3 times. These indicated he held the collimated source approximately 3-5 second in each hand. QSA global is currently performing an independent dose calculation and the radiographer has been removed from duty. The radiographer is not currently experiencing any symptoms of acute radiation exposure. The department has dispatched inspectors to perform a site inspection. Wisconsin Event Report ID No.: WI-170007
The following update was received from the Wisconsin Radiation Protection Section via email: Wisconsin DHS (Department of Health Services) performed a site investigation on May 17, 2017. On the night of the event, there were approximately eight individuals supporting radiography at the temporary jobsite. Two individuals were performing radiography and the rest of the individuals were securing the boundaries. One radiographer was overexposed; no one else on the crew received an elevated dose due to the event. There was no exposure to members of the public. Inspectors confirmed that all radiography equipment (survey meters, alarming rate meters, etc.) was available and operational. The licensee determined that the radiographer held the collimator in his hands in a way that exposed his fingers to the uncollimated beam for several seconds on two separate occasions (once for each hand). The licensee contracted with a third-party to perform a dose assessment. The assessment shows a hand exposure of 176 rem per hand. DHS is evaluating these results. The radiographer's whole body badge was read by the dosimetry provider and showed a 152 millirem dose. This is consistent with the previously reported 100 mR direct-reading dosimeter exposure for May 15. Both the whole body badge and direct-reading dosimeter were located in the radiographer's left front shirt pocket. Wisconsin DHS is continuing to monitor the licensee's response, including medical follow-up of the affected individual. Notified R3DO (Cameron), NMSS Events, NMSS (Rivera-Capella), and NSIR (Milligan) by email.
The following information was received from the State of Wisconsin via facsimile: The source activity on the date of the incident was 96 curies. Notified R3DO (Kunowski), NMSS Events, NMSS (Rivera-Capella), and NSIR (Milligan) by email. | ||
| ENS 52314 | 20 October 2016 05:00:00 | Agreement State | Agreement State Report - Unable to Retract Radiography Camera Source | The State of Texas provided the following report via email: On October 21, 2016, the Agency (Texas Department of State Health Services) was notified by the licensee that one of its radiography crews were unable to retract a 71 curie iridium-192 source into a QSA 880D radiography device. The radiographers had placed the guide tube stand on a wooden box to complete an exposure when, during the exposure, the stand fell off the box and landed on the guide tube crimping it enough that the source would not pass by it. The radiographers contacted the licensee's radiation safety officer who sent a team of individuals to recover the source. The recovery team placed lead shielding over the source and was able to remove the crimp enough to retract the source back into the exposure device. No one involved in the event received an exposure that exceeded any limit. No member of the general public was exposed due to this event. Additional information on this event will be provided in accordance with SA-300. The event location was Exxon Mobil in Beaumont, TX. Texas Incident #: I-9433. | ||
| ENS 52308 | 19 October 2016 06:00:00 | Agreement State | Agreement State Report - Radiography Camera Source Disconnect | The following was received from the State of Colorado via email: The radiography source disconnect occurred on 10/19/2016 at a metal fab yard in Berthoud, CO. No members of the public are believed to have been exposed to radiation from the incident at this time. The source isotope was Ir-192 with an activity of 40 Ci. The source was successfully retrieved by the licensee. The licensee reported the following dose estimates for those involved in the incident. Radiation Safety Officer: 50 mR Radiographer: 28 mR Assistant: 10 mR A written report from the licensee is pending; and will be followed-up by a formal investigation. Event Report ID No.: CO16-I16-23 | ||
| ENS 51839 | 30 March 2016 04:00:00 | Agreement State | Agreement State Report - Radiography Camera Stuck Source | The following information was received from the State of Ohio by email: On March 30, 2016 at approximately (1250 EDT) the Bureau of Environmental Health and Radiation Protection (BEHRP) received a phone call from licensee's RSO that an industrial radiography crew working on a water tank construction job in Groveport, Ohio had a source stuck in the guide tube of a QSA Model 880D camera and were unable to retrieve the back into the camera. The source in use was 75 Curies of Iridium-192. The incident occurred at approximately (1225 EDT). The stuck source was discovered after a shot time had ended and the radiography crew attempted to crank the source back in to the camera. The radiography crew conducted surveys of the area and moved boundaries out 2 mR/hr or less. The cause of the stuck source was due to a magnetic stand becoming dislodged during radiography operations, which fell onto the guide tube, crimping it, and preventing retraction of the source.
A BEHRP inspector was immediately dispatched to the job-site and arrived there at approximately (1320 EDT). The inspector met with the licensee's customer and reviewed the actions taken by the radiography crew to establish new barriers and prevent access to the site. The licensee's trained retrieval personnel dispatched to the site arrived a short time later. After a thorough review of the incident and work area, the licensee's response team was able to retrieve the source, which was completed at approximately (1600 EDT) that afternoon. The maximum dose received by any individual involved in the recovery effort was 50 mR. The camera and guide tube will be returned to manufacturer for repair. QSA Global Camera,Serial Number-D8042; Source Serial Number-29222G. Ohio Event- OH160002 Notified the R3DO (Pelke) and the NMSS Events Notification via email. | ||
| ENS 51803 | 2 March 2016 17:30:00 | Agreement State | Agreement State - Radiography Camera Source Unable to Be Retracted | The following was received from the State of Louisiana via email: On March 17, 2016, Acuren Inspection, Inc. notified LDEQ (Louisiana Department of Environmental Quality) during a telephone discussion, about a source retrieval on March 2, 2016, but did not use our 24-hour hotline number for these types of notifications within the regulatory guidelines prescribe time limits of 24 hours. The event occurred at Exxon Mobil Baton Rouge, 4045 Scenic Hwy., Baton Rouge, LA. "The source could not be retracted due to a crimped guide tube. The total amount of Ir-192 for the industrial radiography camera was 64.7 Ci. The camera was: QSA Global: 880D, S/N: D4022, Curies: 64.7, Source S/N: 27719G. Louisiana Event Report Identification Number: LA160006 | ||
| ENS 50745 | 16 January 2015 21:15:00 | Agreement State | Agreement State Report - Potential Radiographer Excessive Exposure | The following report was received from the State of Louisiana via email: Event Date and Time: 01/16/2015, around (1515 CST) a radiography crew was working at the ExxonMobil Refinery on Scenic Highway, Baton Rouge, LA. The event was reported (about 1645 CST) on January 17, 2015, by a phone call from (an individual) who represented himself as the Corporate RSO. He stated he drove down on January 17, to evaluate and investigate this incident. He reported this incident appears to be a Human Error Potential Excessive Exposure. Event Location: ExxonMobil Refinery 4999 Scenic Highway. Baton Rouge, LA 70805. A temporary jobsite for Acuren Inspection. Event type: This is a potential excessive exposure involving a radiographer attempting to breakdown a radiography exposure setup. He attempted to disconnect the guide tube from the exposure device and the source was not locked in the shielded position. It was noticed that the locking device was red after the guide tube was handled to disconnect it from the exposure device. Notifications: LA DEQ (Department of Environmental Quality), Assessment, Radiation by direct phone call to our after hours answering system. The notification came in around (1645 CST) on January 17, 2015. Event Description: The radiography crew was making exposures on lower level equipment at the ExxonMobil Refinery. The crew was utilizing (about) 38 Ci of Ir-192. The crew attempted to breakdown/disconnect the equipment after the exposures. The guide tube would not disconnect. The 2nd hand of the crew manipulated the drive cable that returned the source into the shielded position. A quarter turn on the crank shielded the source. The radiographer and his equipment were checked. His pocket dosimeter was off scale, but he claims his Alarm Rate Alarm meter did not alarm. A second check of the Alarm Rate Meter revealed the unit did alarm, but it was a weak alarm. Estimated dose calculations were done for his whole body and extremities. His whole-body estimated dose was 3.3 Rads and his extremity dose was estimated at 206 Rads to his hands. These were calculated on a one minute exposure where a .5 minute is more realistic. The exposed radiographer was taken to Core Occupational Medicine for examination, x-rays and blood work. He is being monitored and examined every other day. At this time he has been asymptomatic for an excessive radiation exposure. The Licensee is conducting reenactments. This incident is not considered closed by the Department (LA DEQ). The investigation findings will be updated when they become available. The equipment was all QSA equipment loaded with 38 Ci Ir-192. This appears to be an operator error exposure. The source is secure from removal and unnecessary exposure. This event is not closed and additional investigation and evaluation will continue. The source is in a safe shielded position and no threat to workers or the general public. Transport vehicle description : N/A This was at a temporary job site inside the ExxonMobil Refinery located in Baton Rouge, LA. License Numbers: LA-7072-L01, AI 126755 Louisiana Event Number: LA1500002 | ||
| ENS 50239 | 29 June 2014 21:25:00 | Agreement State | Agreement State Report - Inability to Retract Radiography Source to Its Fully Shielded Position | The following information was obtained from the Commonwealth of Pennsylvania via fax and email: Event type: Inability to retract radiography source to its fully shielded position. Notifications: The Department's (Pennsylvania Department of Environmental Protection) Central Office was informed of this event on June 30, 2014. This event is reportable within 24-hours per 10 CFR 34.101(a)(2) and 10 CFR 30.50(b)(2). Event Description: A radiographer and his assistant were performing radiography above ground. During an exposure, the magnet holding the guide tube and collimator in place disengaged and the tube fell between some conduit below. This caused a (sharp) bend in the guide tube (which caused) the source to become lodged in place and un-retractable. The RSO was notified. The area was roped off to prevent unauthorized access and a retrieval team was called in to address the situation. At 5:35 am on June 30, 2014 the retrieval team notified the RSO that the source had been fully retracted. Dosimeter readings indicate no workers were exposed above regulatory limits as a result of this event. All badges are currently being sent for emergency readings. Manufacturer: QSA Global Model: 880 Delta Serial Number: 14678C Isotope: lr-192 Activity: 70.2 Ci Cause of the Event: Undetermined at this time Actions: The camera and all associated equipment used during this event were removed from service and are currently being sent to the manufacturer for evaluation. The department plans a full reactive inspection. More information will be sent upon notification. PA Event Report ID No: PA140013 | ||
| ENS 50014 | 9 April 2014 15:30:00 | Agreement State | Agreement State Report - Radiographer Overexposure | The following information was received from the Ohio Bureau of Radiation Protection via email: The corporate RSO for Acuren Inspection made an immediate telephone notification under OAC (Ohio Administrative Code) 3701:1-38-21(B)(1) (same as 10 CFR 20.2202(a)(1)) to the Ohio Department of Health Bureau of Radiation Protection at 1320 (EDT on) April 9, 2014, to report a radiographer overexposure at a temporary job site in Marietta, OH. The event happened about 1100-1130 (EDT) this morning. The initial estimates regarding the male radiographer is that he may have received a 15 Rem whole body exposure and an estimated 3000-5000 Rem to the hand. The radiographer's whole body dosimeter is being sent off for immediate processing. The radiographer has been sent for medical attention. REAC/TS (Radiation Emergency Assistance Center/Training Site) was contacted by the licensee who gave REAC/TS the contact information for the attending physician of the radiographer. The radiographer was working with an 88 Ci Ir-192 source at the time. The radiographer supposedly had all his dosimetry and a survey meter at the time of the incident. The corporate RSO and a local (RSO) are both enroute to the temporary job site. Sequence of events: The radiographer had sat down and was chatting while waiting for an exposure to complete. At the end of the shot time, he had assumed that the other radiographer had retracted the source and proceeded to set up for the next shot. When he noticed that the other radiographer was not present he went back and checked to find that the source had not been cranked back. The (State of Ohio) Department will have an inspector on scene in the morning to investigate the incident and also to observe and review the incident reenactments. Ohio event report number 2014-007.
On April 10, 2014, the (State of Ohio) Department performed an onsite inspection and observed the licensee perform a reenactment of the incident scenario. It was determined that the radiographer did not handle the end of the source tube with the source in it and did not receive the initially assumed hand dose. The whole body deep dose is still expected to be about 15 Rem. The hand dose is expected to be on the order of the whole body dose, about 15 Rem. During the reactive inspection, the (State of Ohio) Department found that the radiographer's alarming rate meter had a dead battery, and the survey meter was not functional and had not been checked that day. The Assistant Radiographer was trailing the radiographer approximately one and a half minutes in entering the shielded bunker, and it was the assistant radiographer's alarming rate meter and survey instrument that identified the presence of the exposed source. The source collimator was not being used in the bunker, and so the 89 Ci Ir-192 source was not shielded. Notified R3DO (Pelke), FSME Duty Officer (McIntosh), and FSME Event Resource.
The Acuren Inspection Services RSO has provided the Department (State of Ohio) with the following updates: (1) The radiographer's whole body dosimeter reading was 836 mRem. (2) Based on the dose estimates from the scene reenactments, Acuren will assign the radiographer a whole body dose of 13 Rem, and an extremity dose of 6.5 Rem. (The radiographer's chest was much closer to the source than his dosimeter was.) (3) The radiographer will be under continued medical surveillance and REAC/TS will remain involved. Notified R3DO (Pelke), FSME Duty Officer (McIntosh), and FSME Event Resource. | ||
| ENS 49912 | 12 March 2014 05:00:00 | Agreement State | Texas Agreement State Report - Potential Overexposure to a Radiographer'S Hand | The following information was received from the State of Texas via email: On March 13, 2014, the Agency (Texas Department of Health) was notified by the licensee's Site Radiation Safety Officer (SRSO) that one of its radiographer trainees may have received an overexposure while performing radiography at a field site on March 12, 2014. The radiographers were using a QSA880D camera containing a 69 curie iridium - 192 source. At 2100 hours (CDT), the radiographers had completed a shot and the trainee went to the camera to disconnect the guide tube from the camera. The trainee stated while attempting to disconnect the guide tube he observed the reading on the dose rate meter had gone back up. The trainee backed away from the camera and the source was returned to the fully shielded position. It is unknown at this time where the source was located in the guide tube. The SRSO stated the trainee may have been in contact with the guide tube for as long as 15 seconds. The SRSO stated the radiographer trainer was near the trainee during the event. The SRSO stated the trainee's self-reading dosimeter was off scale. The SRSO did not know if the trainee's alarming rate meter was alarming at the time of the event. The SRSO stated he was not at the licensee's facility when he contacted this Agency, but he was returning to the facility. The SRSO stated he would provide additional information as soon as they had a chance to interview the individuals involved. The Agency contacted the licensee's Corporate Radiation Safety Officer who stated they were on their way to the company's facility to do reenactments and preliminary dose assessments. The SRSO stated the trainee's dosimetry had been collected and will be sent for processing. No other individual received an exposure due to this event. The Agency contacted the Radiation Emergency Assistance Center/Training Site (REAC/TS) and informed them of the event. REAC/TS agreed to provide the licensee with assistance when requested. Additional information will be provided as it is received in accordance with SA-300. Texas Incident # I-9167
The Agency was contacted by the licensee's Corporate Radiation Safety Officer (CRSO) at 1700 (CDT) on March 13, 2014 and provided with additional information on the event. The CRSO stated they had interviewed the radiographers involved in the event and discovered a second radiography trainee was involved. The CRSO stated the three individuals were shooting welds on a tank. The two radiography trainees were inside the tank in a man lift basket operating the camera. The camera would hang on the side of the tank. The radiography trainees would place the collimator to perform the shoot and then back off from the camera the distance of the control cables, approximately 35 feet, and operate the camera. The trainer was in a man lift outside the tank placing film. The CRSO stated the camera had been retrieved from the wall of the tank and placed in the basket with them while they waited to set up for the next shoot. The radiography trainees stated they were in the basket for as long as 15 minutes, with the source not fully shielded. The radiography trainee who tried to remove the guide tube stated he had difficulty removing the guide tube, so the 10 to 15 second estimate for the time he spent trying to remove the guide tube was accurate. The radiography trainee stated when they retracted the source to the fully locked position, it took about one quarter turn of the crank handle to fully retract the source. During the interviews with the radiographers, it was discovered that the radiography trainee who attempted to remove the guide tube was not wearing any personnel monitoring devices. He had left them in the truck. The other radiography trainee was wearing their dosimetry, but failed to turn the alarming rate meter on. The CRSO stated the dosimetry will be sent to their dosimetry (lab) for processing. The CRSO stated they had contacted REAC/TS for assistance. They have taken the radiography trainee who attempted to remove the guide tube to the hospital for blood samples to be provided to REAC/TS. The radiography trainee will be taken to a medical facility again on March 14, 2014. The Agency contacted the CRSO at 0700 (CDT) on March 14, 2014, and asked the condition of the radiography trainee's hand. The CRSO stated they were not aware of any issues with the individual's hand. The Agency discussed the previous event in Texas with similar circumstances. The consultant for the licensee working with the CRSO was also the consultant in the previous event and is providing the licensee with information gained in that event. The licensee currently plans to have the Site RSO to manage the health aspects of this event. The CRSO will manage the investigation of the event. The CRSO stated the former Division of Nuclear Materials Safety Director for NRC Region IV will meet them in La Porte on March 14, 2014, to help with the reenactment. Notified the R4DO (Farnholtz), FSME EO (McIntosh) and FSME Resources via email.
On March 15, 2014, the Agency (Texas Department of Health) was notified by the licensee that based on the reenactment of the event, they have calculated the exposure to the hand of the radiography trainee to be 3,680 rem. The calculation is based on the trainee's hand being 0.5 centimeter from the source for 10 seconds. The licensee reported the whole body deep dose equivalent was 6.0 rem for the trainee. The licensee stated they examined the trainee's hand today and did not see any visual effects of the exposure. The licensee stated the trainee has not experienced any pain in his hand. The licensee stated they will continue to monitor the trainee's hand. The licensee stated they are still corresponding with REAC/TS. The badge for the second trainee in the basket was read by the dosimeter processor and reported to be 3.327 rem. The licensee stated based on the reenactment they believed the reading to accurately reflect the individual's exposure. Notified the R4DO (Farnholtz), FSME EO (Dudes), FSME Resources via email.
On April 20, 2014, the Agency was notified by the licensee they had completed their investigation into the exposure to the radiographer who had come into contact with the guide tube while the source was not shielded. The investigation determined that the source was located at a distance of six inches from the hand of the radiographer when he contacted the guide tube. Interviews with the radiographer who retracted the source determined that the crank out handle had been rotated almost one full turn to retract the source, not one-quarter turn as initially reported. The error in the initial report was due to the radiographer who returned the source to the fully shielded position not having a clear understanding of the term he used as English is not his primary language. Based on that information, the calculated dose to the radiographer's hand is 4.0 rem for the event. The calculated whole body dose to the radiographer was calculated to be 12.0 rem TEDE (Total Effective Dose Equivalent). The hand and TEDE dose calculated by this Agency are consistent with the numbers assigned by the licensee. Additional information will be provided as it is received in accordance with SA-300. Notified the R4DO (Azua), FSME EO (McIntosh) and FSME Resources via email.
On May 20, 2014, the Agency received a copy of the NRC Form 5 for the radiography trainee. The Form 5 listed the TEDE dose for 2014 as 12.369 rem and the SDE Max Extremity dose as 15.680 rem. Also, the reporting criteria was changed to match the exposure reported by the licensee. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Gepford) and FSME (McIntosh) via email. | ||
| ENS 45171 | 26 June 2009 15:30:00 | Agreement State | Agreement State Report - Difficulty Retrieving Radiography Source | The following report was received via facsimile: Licensee contacted Ohio Department of Health at approx. 3:45 PM on 6/26/09 to report an incident which occurred earlier that day involving the inability to retrieve a radiography source at a job site near Dayton, Ohio. The incident involved a QSA Global Model 880D camera with a 85 Ci Ir-192 source. At approximately 11:30 AM and after several unsuccessful attempts to retrieve the source, the radiography crew secured the area around the source and contacted a trained source recovery individual at their Cincinnati office for assistance. This person arrived at the job site at approx. 12:20 PM and assessed the situation. The recovery person determined that a flange had fallen on the guide tube during the previous shot, which crushed the guide tube and prevented source retrieval. The shot involved a 90-degree bend on a six-inch pipe and the flange was a scrap piece of material found on site that the crew had used to hold the guide tube in place during the shot. It was further determined that the set-up used by the crew for the shot was not very stable, which contributed to the falling of the flange onto the tube. The recovery person was able to retract the source into the camera at approximately 12:45 PM. The licensee determined that there was no exposure to the public or radiography crew as a result of this incident. The radiography crew was reminded to ensure the stability of future shot setups before exposing the source. The guide tube was replaced and work continued. Ohio report number: OH090006 |