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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 45662 | 22 January 2010 06:00:00 | Agreement State | Agreement State Report - Radiography Source Disconnect | On January 26, 2010, (The Texas Department of Health) was notified by the licensee that a source disconnect had occurred on January 22, 2010. A radiographer was cranking a 26 curie iridium (Ir) - 192 source from the camera when he began having difficulty driving the source. He decided to retract the source back into the camera when the source disconnected at the drive cable. The source was driven into the collimator at the end of the guide tube. The radiographer contacted his Radiation Safety Officer (RSO) and informed him of the event. An individual qualified for source retrieval was sent to the location. The source was returned to the camera, and the camera was returned to the licensee's facility. The individual performing the source retrieval received 120 millirem as indicated by his pocket dosimeter. The RSO stated that the failure appeared to be caused by a failure of the connector on the drive cable. The RSO stated that it was a result of normal wear on the device. (The Texas Department of Health) has requested copies of the last three maintenance records for the device. The source serial number is QH2505 manufactured by Spec. The camera serial number is 1203. Additional information will be provided as it is received. Texas Incident #: I - 8706 | ||
| ENS 44902 | 5 March 2009 21:45:00 | Agreement State | Source Disconnect from Radiography Camera Drive Cable | The Agency (State) was notified (at 1645 CDT) by the licensees RSO that they had a source disconnect and that the source was later retracted. The event involved an INC IR-100 camera containing a 94 curie Ir-192 source. The source was in use for about one week, about 6 jobs. A local Texas inspector went to the site to investigate the event. The licensee later notified the Agency (State) that in this case, the connector crimped fitted on the source pig tail had separated from the source drive cable. The two individuals who returned the source to the camera housing received 425 millirem by self reading dosimeter for one worker, and between 750 and 800 millirem calculated for the other worker. The RSO stated that neither worker exceeded the annual DDE limit. TLD's for the workers involved have been sent to their processor and the results should be back on 3/9/09. The State of California has been informed of the event. On March 13, 2009, the RSO notified the Agency (State) that the radiography camera had been packaged and will be returned to the manufacturer today. Texas Incident # I-8614 UPDATE FROM ART TUCKER VIA EMAIL TO JOHN KNOKE AT 1237 0N 04/14/09 (The State) received exposure reports for two workers involved in the source retrieval. The support individual received 299 millirem DDE, and the individual who actually retrieved the source received 502 millirem DDE, and 425 millirem calculated to the hand. Notified FSME (Angela McIntosh) and R4DO (Jack Whitten)
Report received via e-mail: The (State of Texas) received the following information from the manufacturer of the source device: (The) license, Industrial Nuclear Company (INC), was notified by Desert Industrial X-ray that there had been a source disconnect of 97 curies, source S/N-N597 on March 5, 2009. Source and connector was received at Industrial Nuclear Co, Inc on March 13, 2009. Upon inspection of source connector (on) S/N- N597 that was received from Desert Industrial X-ray, INC found no evidence (of) physical damage. The cable appeared to have some stretching but not any more than would be expected after the pull test. Dimensions were performed on all previous inspected source assembly components and found to be within design limits. All INC source connector assemblies in inventory (from the same manufacturing date) were re-load tested and all passed. INC has to date never had a Source Connector come off in pre-inspection or after it was put in use. INC has not been able to discover just how this might have happened. In the report the licensee stated the connector crimp failed. INC has tried to recreate this event but (has) had no success in doing so. The licensee said the source had been in use for one week (and) if the source connector crimp was bad it should had failed on the first day. The licensee has not reported any additional problems associated with their exposure devices. Notified R4DO (Lantz) and FSME EO (McIntosh) | ||
| ENS 44962 | 25 November 2008 05:00:00 | Agreement State | Agreement State Report - Radiography Camera Malfunction | The following information was received from the State of Texas via Email: On November 25, 2008, the Agency was notified by the licensee that a source disconnect had occurred while using an INC IR - 100 radiography camera containing an 80 curie Iridium -192 source. While the licensee was collecting information on this event, they received a phone call informing them that the source involved with the event had failed the latest leak test performed on it. A source recovery team was sent to the location and returned the source to the radiography camera. A second leak test was taken on November 26, 2008. The company performing the analysis of the leak test informed the licensee that both the first and the second test were both within acceptable limits. The first test had been misinterpreted. The disconnect was determined to have caused by a worn connection in the pigtail. The pigtail was sent to the manufacturer for repair. All exposures to individuals involved in this event were well below applicable limits. This file is closed. "This event was reported within 24 hours of the event using the NMED reporting system and not to the HOO (NRC Headquarters Operations Officer). Failure to properly report this event was determined after a review was conducted of all radiography related events reported in the State of Texas from September 1, 2006 to March 31, 2009. This review was initiated in response to the State of Texas Incident Investigation Program (IIP) determining that they had failed to correctly interpret the requirements for reporting this type of event. The state used 10 CFR 34.101 to report these events, and not 10 CFR 30.50(b)(2), due to conflicting interpretations of NRC rules requiring reporting. In an effort to prevent a reoccurrence of this, each member of IIP was required to read Information Notice 2001-03, Incident Reporting Requirements for Radiography Licenses, dated April 6, 2001. In addition, the IIP database has been changed to clarify the reporting requirement and bring it in line with the NRC requirements. Texas Incident Number: I - 8583
Upon request of the State the reference to 10 CFR 30.50(b)(a) was changed to 10 CFR 30.50(b)(2). | ||
| ENS 43822 | 4 December 2007 03:00:00 | Agreement State | Agreement State Report - Lost Radiography Camera | The licensee's radiography team left the temporary jobsite with their SPEC 150 radiography camera on the tailgate. The camera contained a 24 Curie Ir-192 source. The licensee drove approximately 15 miles down the road prior to remembering the gauge was on the tailgate. It was then noticed that the camera was no longer in the truck. The licensee team is retracing their route in search of the camera and will be contacting the Tarrant County Sheriff's Department to aid in the search. The licensee is not sure if the camera had been secured properly prior to driving down the highway. The route taken was from Tinsley Lane to North Business 287 in Saginaw, TX towards Justin, TX in Tarrant County. Notified NORTHCOM and Mexico via email. Texas Report TX-07-43822
The SPEC 150 radiography camera was recovered at 0633 CST. A member of the public found the camera and placed it in the back of his private vehicle. Upon hearing about the lost source on the local news this morning, the citizen turned the camera over to the Fort Worth Fire Department. The camera appears intact and undamaged. Texas Department of Health is responding to the fire department to conduct a survey and inspection of the camera. No overexposures are expected. Notified DHS (Haselton), DOE (Parsons), FEMA (Burckart), USDA (Watts), HHS (Garcia), EPA (Johnson), Mexico (via email), NORTHCOM (via email), R4DO (Hay), FSME EO (Burgess) and ILTAB (Sandler). 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. |