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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 43761 | 30 October 2007 05:00:00 | Agreement State | Agreement State Report - Radiography Source Unattended for Six Hours | The State provided the following information via facsimile: This is the initial notification for an incident that was reported to this Department on this date. Conam Inspection & Engineering Services, Inc., 6900 East 47th Ave. Unit 200 Denver, CO 80216, a Radiography Licensee (Colorado License # 963-01) provided the Department with the attached Preliminary Incident Investigation report (two pages). Initial details indicate that a radiography source was left unattended and improperly secured on a jobsite for approximately six hours. A member of the job site staff identified the problem and notified the licensee. It appears that this was a result of an ill employee leaving the job site without properly securing the source. An investigation has been initiated by the Colorado Department of Public Health and Environment. No other details are available at this time. The Conam Preliminary Incident Investigation Report follows: Date and time of incident: October 29, 2007 at 11:00 p.m. Location of the incident: Suncor USA in Commerce City, CO. Date and time investigation began: October 30, 2007 at approximately 4:30 a.m. Description of the Incident/Chronology of Verifiable Events: Conam I&ES performed radiography services at Suncor Refinery in Commerce City, CO on October 29, 2007. These services were being performed on a 24 hour basis. An exposure device was maintained on site and transferred from day shift personnel to night shift personnel. On October 29, 2007 the exposure device was not stored properly in the transport vehicle by the day shift radiographer. The day shift radiographer neglected to lock the outer door to the darkroom and the tailgate on the transport vehicle prior to leaving visual surveillance of the transport vehicle. The vehicle was parked on Suncor property approximately 40 feet from the Conam office. The day shift radiographer departed the job site at approximately 6:45 p.m. The night shift radiographer was on site prior to the departure of the day shift radiographer. The night shift radiographer became ill, and left the lob site at approximately 11:30 p.m. The night shift radiographer left the exposure device on site unattended by any approved Conam I&ES personnel. The night shift radiographer did not access the darkroom at any time on site prior to his departure since the radiography assistant was not present that evening. A Suncor representative noticed the darkroom on site without any Conam representation at approximately 4:30 a.m. The Suncor representative locked the darkroom and removed the keys to the vehicle then notified Conam management. Conam management responded at approximately 5:15 a.m. and representation was on site to properly secure the exposure device at 6:15 a.m. There were no exposures to the Public during this time period. List of Contributing Factors: Radiographers failed to follow proper security procedures for securing radioactive materials with IC orders. Proposed Corrective Actions: Conam management had a safety stand down for all radiographic personnel at Suncor. All additional radiographic personnel will have a safety stand down this week. The staff will be reinstructed as to the proper protocol for securing radioactive materials with the IC order. The two radiographers have been suspended from radiographic services at this time. Corrective Action Plan Complete? No If Not, Reason: Corrective action will be completed upon the final outcome of the investigation and the completion of reinstruction to radiographic personnel. |