Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 54989 | 2 November 2020 20:30:00 | Agreement State | Possible Misconnect of Radiography Source | The following information was received from the State of Kansas via email: On November 3, 2020, at 1100 CST, the Kansas Department of Health and Environment (KDHE) was notified that the Desert NDT LLC radiography crew experienced a possible misconnect at 1430 CST on November 2, 2020, at a job site in Liberal, KS. The two crew members performed an exposure using the Delta 880 exposure camera containing an Iridium-192 source with 51.9 curies (1902 GBq). After the exposure the crew noticed that they did not hear the source click back in place in the camera. Through surveys, the crew noted abnormally high readings at the front of the exposure device. The crew ensured 2 mR boundaries were appropriately set and that all personnel was clear of the area. The crew then called their radiation safety officer (RSO) explaining the problem. The site RSO from the Perryton, Texas (location) was notified to assist with the possible misconnect. The RSO arrived onsite at 1545 CST on the same date and was able to assess possible reasons for the disconnect and devised a plan to retrieve the source. After reducing the radiation area to a manageable level, he was able to disconnect the Source Guide Tube from the device to be able to remove it from the radiation area and inspect the device for further inspection and investigation as to why the disconnect had occurred. After disconnecting the controls from the device it was determined that the Assistant Radiographer had not connected the drive cable to the pig-tail of the source assembly creating a 'Misconnect.' Once the reason for the misconnect was discovered, the RSO replaced the controls on the device and moved forward with the retrieval and was able to connect the drive cable to the source and retract it into the shielded position. The RSO stated that he completed the retrieval at 1610 CST on November 2, 2020. There was no exposure to the general public or any other individuals other than the three crew members. The closest area for any member of the public to be exposed was at a roadway approximately 300 feet away. The RSO, who was authorized to perform source retrieval, received an exposure of 45 mR to his hands and 20 mR to his trunk. Surveys were taken using a ND-2000 survey meter, serial number 54261, and calibration date of July 28, 2020. The RSO wore a model 883 pocket dosimeter and alarm rate meter (ARM) model RA-500, serial number 71037, and calibration date of February 11, 2020. Landauer whole body badges were also worn during the retrieval process. KDHE staff will be performing a reactive inspection of this licensee on the next entry into Kansas and will provide additional details after that inspection. Kansas Incident Number: KS00006. | ||
| ENS 54377 | 6 November 2019 06:00:00 | Agreement State | Texas Agreement State Report - Unable to Retract Radiography Source | The following information was obtained from the state of Texas via email: On November 7, 2019, the licensee's radiation safety officer (RSO) notified the Agency (Texas Department of State Health Services) that at approximately 2000 CST on November 6, 2019, one of their industrial radiography crews had been unable to retract a 113 Curie iridium-192 source (model 702, SN: TT2307) into a QSA 880 Delta exposure device (SN: D7727) at a temporary job site in Sonora, Texas. The RSO stated the drive cable had broken at the ball stop. Source retrieval was performed by authorized employees. The initial radiographers' and another of the licensee employee's self-reading pocket dosimeters read 13 and 14 mR. The two authorized source retrievers' self-reading pocket dosimeters had readings of approximately 300 mR. All dosimetry badges are being sent for immediate processing. There were no other persons in the area so there was no risk of exposure to any member of the public. The RSO and staff will examine the crank assembly and drive cable when it gets to their location on November 8, 2019. The RSO also plans to send the crank assembly/drive cable for evaluation by a third party service/repair company. The exposure device was tested multiple times using a different set of cranks following the retrieval and it operated properly. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident No: 9723 | ||
| ENS 54093 | 29 May 2019 05:00:00 | Agreement State | Agreement State Report - Source Drive Cable Disconnected | The following report was received from the Texas Department of State Health Services via email: On May 29, 2019, the agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that one of their crews had suffered a source disconnect at a field site location. The exposure device being used was a QSA 880D device containing a 58.8 Curie Iridium - 192 source. The RSO stated two individuals approved for source retrieval, retrieved the source, and that no over exposures occurred due to the event. The RSO stated that during the retrieval it was found that the drive cable broke near the connector. The crank out device has been taken out of service and will be sent to the manufacturer for inspection. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 9683 | ||
| ENS 53679 | 20 October 2018 05:00:00 | Agreement State | Agreement State Report - Radiography Source Failure to Retract | The following information was received via E-mail: On October 20, 2018, the agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that one of its radiography crews was unable to return an 80 curie iridium-192 source to the fully shielded position in an INC IR 100 exposure device. The RSO stated that the event occurred near Pecos, Texas. The RSO stated that the radiographers had established a 2 millirem boundary. An individual listed on their license responded to perform the source retrieval. The location where the event occurred was remote and the event did not present an exposure risk to any individual. The RSO stated that there are very few people at the site. Once the individual who was sent to retrieve the source arrived, they inspected the exposure device and guide tube. The inspection discovered the radiographers had bent the guide tube to get it through some pipes and the angle of the bend was what had prevented the source from being retracted. The guide tube was straightened and the source was retracted to the fully shielded position at 2100 hours. The guide tube was inspected and did not have any damage. The RSO stated that no overexposures had occurred. Texas Incident Number: 9622 | ||
| ENS 53641 | 2 October 2018 05:00:00 | Agreement State | Agreement State Report - Damaged Radiography Source | The following was received via email from the State of Texas: On October 3, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that one of their radiography crews had reported they could not retract a 22 Curie Iridium-192 source into a SPEC 150 exposure device. The crew was working at a remote job site (in Carrizo Springs, TX). The exposure device was sitting on a pipe rack. During an exposure (not the first one) the device fell off the pipe rack, hitting the guide tube, and crimping the tube to a point where the source could not be retracted back into the device. The crew contacted the RSO and a retrieval team was sent to the location. The source was positioned in the collimator and covered with bags of lead shot. The retrieval team was able to cut the protective coating off of the guide tube and, using a pair of pliers, reshape the guide tube until the source could be retracted to the fully locked position. No member of the general public received an exposure from this event. The highest dose received by an individual responding to this event was 40 millirem. Texas Incident: I-9616 | ||
| ENS 53549 | 11 August 2018 05:00:00 | Agreement State | Agreement State Report - Unable to Retract Source | The following information was received from the State of Texas via email: On August 12, 2018 at approximately 1135 (CDT)., the licensee notified the Agency (Texas Department of State Health Services) that one of its radiography crews had experienced a source disconnect. The event occurred on August 11, 2018, at approximately 1200 (CDT) at a temporary job site near Whitsett, TX. The device involved was an INC IR-100 (SN: 6792) containing a 91 curie iridium-192 source (SN: ZH0109). The crew had set up the device and performed a procedure shot and everything functioned properly. They performed the first shot of the job and the source would not retract into the device--it felt as though it had stuck on something. After a second unsuccessful attempt, the source was cranked back out into the collimator, boundaries set, and an authorized person came to the site and performed the retrieval. The drive cable and source were both new. There was no observable cause for the failure. The device and associated equipment will be sent to the manufacturer for evaluation. Per readings from all three individuals' self-reading pocket dosimeters, there were no overexposures. The source retriever's dosimetry badge is being sent for processing. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300.
The following update information was received from the State of Texas via email: Clarification: The source assembly (never disconnected) from the drive cable. (The licensee was) unable to retract it back into the exposure device. Notified R4DO (Deese) and NMSS Events Notification Group via email. Texas Incident: I-9606 | ||
| ENS 53487 | 3 July 2018 05:00:00 | Agreement State | Agreement State Report - Source Disconnect | The following information was received from the State of Texas by email: On July 4, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that one of their crews has experienced a source disconnect. The crew was using a QSA 880D exposure device containing a 70 Curie Iridium - 192 source. The licensee did not have a lot of details on the event, but stated the source had been recovered and that no over exposures had occurred. The licensee stated the connector ball on the drive cable was tested after the event and failed the test. The RSO stated they would provide additional information on July 5, 2018. Additional information will be provided as it is received in accordance with SA-300. Texas Incident- I-9591 | ||
| ENS 53439 | 31 May 2018 05:00:00 | Agreement State | En Revision Imported Date 7/12/2018 | EN Revision Text: AGREEMENT STATE REPORT - FAILURE OF RADIOGRAPHY SOURCE TO RETRACT The following information was received via E-mail: On June 1, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee that a radiography crew was unable to retract a 50 Curie Iridium-192 source into an INC 100 exposure device. The crew was working in a remote area in West Texas when they could not get the source to go past the inlet nipple of the exposure device. After a few attempts, the crew contacted the licensee and an individual authorized to recover sources was sent to the site. The licensee did not have specific information on how the source was retracted, but stated it took the individual about 45 minutes to recover the source. The source was returned to the fully shielded position. The exposure device and source were returned to the licensee's storage area and will be sent to the manufacturer for inspection. The licensee stated the exposure device was surveyed and radiation levels were normal. The licensee reported that one individual's 0 - 200 millirem self-reading dosimeter did go off scale. The individual's OSL dosimeter has been sent to the licensee's dosimetry processor for reading. The licensee stated it calculated the individual's dose to be 400 millirem based on an interview with the individual. The licensee stated no individual involved received an exposure that exceeded any limit. No member of the general public received an exposure from this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9578
The following information was received from the State of Texas via email: On June 1, 2018, the licensee reported one of its crews were unable to retract a 50 curie iridium - 192 source to the fully shielded position. The licensee's written report received June 29, 2018, stated one of the radiographers had disconnected the guide tube from the exposure device and saw the source was not in the shielded position. The licensee stated the radiographer would have been in contact with the guide tube for 3-5 seconds. The individuals badge was sent for processing and had a reading of 312 millirem DDE. The licensee's initial calculation for the exposure to the individuals hands was 450 millirem. The Agency questioned the dose assessment to the hand. On July 11, 2018, the licensee's radiation safety officer stated they have contacted a service company to perform the dose calculations for the individuals hands. Pictures of the individuals hands taken on July 11, 2018, show no adverse effects from the exposure. Notified the R4DO (Pick) and the NMSS Events Group via email. | ||
| ENS 52824 | 23 June 2017 05:00:00 | Agreement State | Agreement State Report - Possible Dose Exceeding Limits Received | The following information was received via E-mail: This event occurred at a field site in or near Orla, Texas. On June 23, 2017, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that an event had occurred involving one of their radiography crews. The RSO stated while performing radiography operations at a field site, a radiographer had approached a SPEC 150 exposure device (camera) containing an 81 Curie iridium-192 source to disconnect the guide tube. After reaching down to disconnect the guide tube, the radiographer noticed the guide tube was not completely attached to the camera and their exposure device (ND 2000 dose rate meter) was pegged high on the times ten scale. The source was then fully retracted to the fully shielded position. The radiographer stated his hand was in close proximity to the guide for about 10 seconds. The radiographer stated his self-reading dosimeter was reading 52 millirem after the event. The RSO stated the radiographers were on their way back to their office. The RSO stated the TLD badges for radiographers would be sent in for reading by their dosimetry processor. The RSO stated the radiographers would be interviewed and the licensee would inform the Agency on Monday, June 26, 2017, what their investigation revealed. The RSO did not have any additional information. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9496
The following information was received via E-mail: On June 27, 2017, the Agency contacted the licensee and inquired on the status of the radiographer exposed during this event. The licensee's radiation safety officer (RSO) stated they have not seen any changes in the appearance of the radiographer's hands. The RSO stated the radiographer has not felt any discomfort in his hands. The RSO stated a blood sample will be sent to Radiation Emergency Assistance Center/Training Site (REAC/TS) in Oak Ridge, Tennessee, for analysis. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Vasquez), NMSS Events Notification and NSIR (Milligan) by email. | ||
| ENS 52671 | 8 April 2017 05:00:00 | Agreement State | Agreement State Report - Radiography Camera Source Fails to Retract Properly | The following information was provided by the State of Texas via email: On April 9, 2017, the Agency (Texas Department of State Health Services) was notified by the licensee's Radiation Safety Officer (RSO) that on April 8, 2017, one of his crew was unable to retract a 95 curie iridium-192 source into a Spec 150 exposure device (at a work site 2 miles inside the Texas border near Jal, NM). The RSO stated that after the first exposure for the day, the radiographers noted they could not lock the source inside the exposure device. The radiographers established a two millirem per hour boundary and evacuated two trailers that were inside the two millirem per hour barrier. The RSO stated the people were in the trailer for five minutes before the radiographers had them leave the area. The radiographers contacted the site RSO who responded to the scene. The site RSO found the guide tube had separated from the front of the exposure device. The site RSO was able to retract the source into the fully shielded position. The RSO stated they believe that sand had built up in the guide tube to camera connection which prevented the guide tube connector to fully seat in the connection. The RSO stated his initial calculations indicated no member of the general public exceeded any exposure limits. No licensee personnel exceeded any exposure limit from this event. Additional information will be provided as it is received in accordance with SA-300." Texas Incident #: I-9478 | ||
| ENS 52037 | 22 June 2016 05:00:00 | Agreement State | Agreement State Report - Radiography Camera Component Failure | The following information was received from the State of Texas by email: On June 23, 2016, the licensee notified the Agency (Texas Department of State Health Services) that a radiography camera had failed to lock in position after retracting the source. The ball stop moved about 3/16 of an inch causing the camera to not lock in position after the source was retracted into position. The licensee's radiation safety officer (RSO) obtained the following information about this component failure. The camera was a delta 880 source serial number S7340 at an activity of 52.6 curies. No overexposures were reported to the RSO. An investigation into this event is being conducted by the RSO. The camera has been secured and is located at one of the licensee's sites. Updates will be provided as obtained in accordance with SA300. Texas Incident: I-9415 | ||
| ENS 51000 | 22 April 2015 02:45:00 | Agreement State | Agreement State Report - Radiography Truck Accident Resulting in a Fatality | The following information was received by the State of Texas via email: On April 21, 2015 at 2209 (CDT) hours, the Agency (Texas Department of State Health Services) was contacted by Andrews County Emergency Management (ACEM). They informed the Agency that an accident had occurred 12 miles south of Andrews, Texas, on highway 385, which involved a radiography truck. The Agency contacted ACEM chief who stated he was at the scene of a three vehicle accident which included a truck from Desert NDT. The driver was killed in the accident and the truck cab had separated from the frame. He stated the dark room had separated from the truck bed. He stated a person from the Andrews County WCS (Waste Control Specialist) was there and had performed a radiation survey and measured a dose rate of 15 millirem 10 feet from the truck. He stated the licensee had been contacted. He stated they had taken care of the survivors and had backed out of the area until the licensee's radiation safety officer arrived on the scene. He stated they had not seen the shipping papers, only the radiation symbol on the truck. I asked him to have the licensee contact the Agency as soon as they arrived on site. The licensee's (Desert NDT) RSO arrived at the scene at 2223 hours and contacted the Agency. He stated his priority was to locate the source. He agreed to call the Agency as soon as he had control of the source. At 2240, the RSO contacted the Agency and stated he had control of the source. The iridium source was inside a INC 100 radiography camera and the RSO believed the activity was between 20 and 26 curies. He stated the camera did not appear to be damaged. He stated the dark room had separated from the truck and split into two pieces. The camera was located still in its transport box in a section of the darkroom. He stated the dose rate on contact with the camera was 16 millirem an hour and 0.4 millirem at 1 foot. The dose rate at 1 meter was not distinguishable from background. He stated no individual at the scene would have received an exposure to radiation that would have exceeded any limits. The RSO stated he was taking the source back to the licensee's office for storage. The RSO stated they would send the exposure device to the manufacturer for inspection. Additional information will be provided as it is received in accordance with SA-300. Texas Incident: I-9305
The following information was received by the State of Texas via email: The licensee's corporate radiation safety officer contacted the Agency (Texas Department of State Health Services) and informed them that two radiographers were killed in this event. He stated the source activity was only 13 curies. He stated that local law enforcement in Andrews, Texas will not release any details of the accident until their investigation is completed. Additional information will be provided as it is received in accordance with SA-300. Notified the R4DO (Drake), IRD MOC (Gott) and the NMSS Events Notification via email. | ||
| ENS 50637 | 24 November 2014 06:00:00 | Agreement State | Agreement State Report - Radiography Camera Stuck Source | The following was received via email: On November 25, 2014, the Agency (State of Texas) was notified by the licensee that on November 24, 2014, an INC IR100 radiography camera, Serial # 4374 with an Iridium-192 source, Model 32, Serial #W951, Activity - 1887 GBq (51 Ci) failed to operate properly at a field site. While the source was being cranked out, the drive cable went too far when the stopper in the pistol grip failed, resulting in the inability to reengage the drive cable and retrieve the source back into the camera. The licensee's RSO responded to the scene to inspect and retrieve the source. No individual received any significant additional exposure due to this event. The RSO received the highest dose of 23 mrem. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9256 | ||
| ENS 50634 | 21 November 2014 06:00:00 | Agreement State | Agreement State Report - Radiography Camera Failed to Operate Properly | The following was received via email from the State of Texas: On November 21, 2014, the Agency (Texas Department of State Health Services) was notified by the licensee that an INC IR100 radiography camera, serial #4386, with an iridium-192 source, model 32, serial #W957, activity - 1554 GBq (42 Ci) failed to operate properly at a field site. The technician had an indication that the source was fully inside the camera when the flag indicator changed, however they were unable to disconnect the drive cable from the pig tail. The pig tail was not fully inside the camera. The licensee's RSO (Radiation Safety Officer) responded to the scene to inspect and retrieve the source. (The RSO) moved the source to another camera. The (RSO determined the) locking mechanism had worn out on the camera. No individual received any significant additional exposure due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Report: # I 9255 | ||
| ENS 50552 | 20 October 2014 05:00:00 | Agreement State | Agreement State Report - Radiography Camera Source Retraction Failure | The following information was received via facsimile: On October 20, 2014, the Agency (Texas Department of State Health Services) received notice that there had been a radiography source retraction failure at a temporary field site. A pipe had fallen from a stand onto the guide tube, causing a crimp. The source was retrieved by squeezing the crimp with pliers several times, allowing retraction. The individual performing the retrieval received 198 mR according to a pocket dosimeter. The camera was an INC IR-100 (sn 6832) with an Ir-192 source at 44 Ci (sn W644 ). Additional information will be supplied as it is received in accordance with SA-300. This event occurred at a field site in Encinal, Texas. Texas Incident #: I-9245 | ||
| ENS 50503 | 1 August 2014 05:00:00 | Agreement State | Agreement State Report - Locking Mechanism Failure | The following information was received via facsimile: On October 2, 2014, during a complaint investigation, the Agency (Texas Department of Health Services) confirmed allegations that on August 1, 2014, one of the licensee's industrial radiography crews had experienced a mechanical failure on an INC Model IR-100 exposure device that contained a 34 curie Iridium-192 source. Following the last exposure of the day, the source failed to retract into the locked and secure position within the device. The locking mechanism had tripped while the ball stop was outside the lock. The source was inside the s-tube but not in the locked position. The source could not be cranked out of the guide tube either. The key was removed and the radiographer was unable to unlock the camera when the key was re-inserted to retract the source. The radiographer was able to manipulate the locking mechanism so that the lock reset and the source was fully retracted. The licensee reported that its investigation (had determined) no one had exceeded any dose limits as a result of this event. The licensee did not believe it was a reportable event and did not notify the Agency. The exposure device was cleaned and returned to service by the licensee. Further information will be reported in accordance with SA-300 as it is obtained. Texas Incident #: I-9241 | ||
| ENS 49999 | 4 April 2014 05:00:00 | Agreement State | Agreement State Report - Camera Source Disconnect | The following information was received by facsimile from the State of Texas: On April 14, 2014, the Agency (Texas Department of State Health Services) was notified by the licensee's Corporate Radiation Safety Officer (CRSO) that one of their radiography crews had experienced source disconnect while using an INC IR 100 exposure device. The device contains a 70 curie iridium - 192 source. The CRSO stated the radiographers had completed a shot and noted the dose rates on the camera had not returned to normal after retracting the source. The radiographers increased the barriers around the exposure device and contacted their supervisor for assistance. The CRSO stated the source had been recovered by an individual listed on their license to retrieve sources. The CRSO stated he did not believe any individual received an exposure which exceeded any limits. The CRSO stated no member of the general public received any exposure. The CRSO stated he had just learned of the event and was beginning his investigation and would provide the Agency with additional information as it was obtained. This Agency will provide additional information as it is received in accordance with SA-300. Texas Incident: I-9178 | ||
| ENS 48693 | 22 January 2013 06:00:00 | Agreement State | Agreement State Report - Radiography Camera Source Disconnect | The following information was provided by the State of Texas via email: On January 22, 2013, the Agency (State of Texas) was notified by the licensee's Radiation Safety Officer (RSO) that a radiography crew performing radiography operations at a field location experienced a source disconnect. The crew was using an INC IR 100 exposure device containing a iridium - 192 source. The crew had performed nine or ten exposures and was moving the camera to the next location when they discovered the source was still in the guide tube. A source recovery team was sent to the location and the source was returned to the exposure device and locked in the fully shielded position. The RSO did not know how the crew discovered the source was still in the guide tube. The RSO stated that the self reading dosimeter of the radiographer who moved the exposure device was reading off scale and that his personnel dosimeter was being sent to the dosimetry processor for immediate processing. The RSO stated that the radiographer did not perform a post exposure radiation survey prior to moving the camera and that the radiographer stated that their alarming dosimeter did not alarm. The RSO stated that he did not know how long or how close the radiographer was to the source while they were moving the exposure device. The RSO stated that the radiographer has been removed from all duties involving exposure to radiation. The RSO stated that no other individual received an exposure of concern. The RSO stated that the device would be returned to the manufacturer for inspection. The licensee is conducting an investigation into the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9035
The following information was received via fax: On January 25, 2013, the RSO stated the dosimetry processor reported the dose received by the individual who relocated the exposure device was 791 millirem DDE (deep dose equivalent). The RSO stated that their investigation into the event is ongoing. Additional information will be provided as it is received in accordance with SA - 300. Notified the R4DO (Okeefe) and FSME Events Resource. |