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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 50694 | 17 December 2014 20:55:00 | Agreement State | Agreement State Report - Radiography Camera Source Disconnect | The following report was received from the State of New Jersey via fax: A source disconnect occurred during normal radiography operations. The exposure device was a SPEC 150 containing 29 Ci of lr-192. The operators immediately adjusted perimeter barriers and notified their RSO. A source retrieval team arrived in an hour and were able to successfully return the source to its shielded position within another hour. No overexposures were received. Direct reading dosimeters showed no exposure to the radiography team, and a dose of 33 mR and 5 mR were received by the source retrieval two-person team. The event was reported to be caused by operator error in failing to assure that the source tube was securely connected to the camera. | ||
| ENS 46908 | 31 May 2011 15:45:00 | Agreement State | Agreement State Report- Damaged Radiography Source Retrieval Guide Tube | The following information was received by fax: Radiographers set up a shot on a 2 inch diameter pipe which was laying in jackstands. They were working with a SPEC 150 exposure device containing a 42 Ci Iridium-192 sealed source. The jobsite was a large laydown yard in an industrial setting. The pipe fell from the stands and hit the guide tube. The guide tube was hit about 2 inches from the exposure end, and attempts at retracting the source were unsuccessful. The radiographers re-established boundaries and contacted the local (Assistant) RSO (ARSO) from the new boundary at approximately 1200 (EDT). The ARSO is authorized to perform source retrieval for JANX. (The licensee) maintained surveillance while awaiting his arrival. The ARSO arrived onsite at 1240 (EDT), assessed the situation and interviewed the crew. He noted that the source tube appeared to have 2 crimps. The ARSO was in contact with the Corporate RSO in Michigan during the operation. The ARSO used lead blankets to shield the source and surveyed. Survey revealed need for more shielding that was delivered to the site by (1345 EDT) and acceptable dose rate was achieved. He proceeded to remove the crimped section from the guide tube, observed that the drive cable was unaffected, connected the tube together with tape, and was able to retract the source into the exposure device. The event concluded by (1520 EDT). The licensee will be making a full report with corrective actions within 30 days of the occurrence. New Jersey Event: NJ 11003 | ||
| ENS 45829 | 9 April 2010 04:00:00 | Agreement State | Radiography Camera Source Not Fully Retracted | The following information was received via email: Radiographer failed to fully retract Se-75 source into QSA Model 880 camera while on a job site in Stratton, Ohio. No additional information regarding device or source is available at this time. Radiographer did not 'bump check' the source after retraction to make sure that the source was locked in the camera. He stated that he was using a survey meter as he approached the camera, but it slipped from his hand during his approach and fell to the ground. He stated that he did not verify proper operation after picking up the meter. He was approaching the camera from the rear and stated that he had not observed any reading on the meter. As the radiographer disconnected the guide tube, he noted that the source cable was still sticking out of the camera with the source. He stated that he turned the crank handle about 3/4 of a turn, at which time the source was retracted. The radiographer stated that he could not hear his alarming rate meter due to loud noise in the power plant where the work was being done. The radiographers pocket dosimeter (0 - 200 Mr) was reported as having gone off-scale. The licensee has estimated a whole body exposure of 1.8 R and an extremity dose to the radiographer's hand of between 3 R and 20 R. The licensee has shipped the radiographer's dosimeter for rush processing and expects to have results late Monday (4/12/10) or Tuesday. ODH (Ohio Department of Health) will conduct an investigation. NOTE: This report is being made as a precaution until the actual dose received by the radiographer is confirmed. Ref: OH 2010-013 * * * UPDATE FROM STEPHEN JAMES TO PETE SNYDER AT 0950 ON 4/15/10 * * * The following information was received via email: 1. Camera was a QSA Model 880 Delta, S/N D6162. 2. Source was a QSA Se-75 source, 73 Curies on 4/9/10, S/N 2739. 3. Extremity exposure was to right hand. 4. The radiographer's dosimeter was processed and indicated a whole body dose (shallow) dose of 0.563 Rem for April 2010, through April 9, 2010. This is approximately four times higher than the radiographer received in March 2010 (0.147 Rem). 5. ODH (Ohio Department of Health) will investigate the week of April 19 to recreate event and verify dose estimates and events leading to the exposure. NOTE: As of the current information, the exposure received by the radiographer would not require reporting of the event. Final determination will be made upon completion of investigation by ODH. Notified R3DO (Orth) and FSME (McIntosh). * * * UPDATE FROM STEPHEN JAMES TO CHARLES TEAL AT ON 7/8/10 AT 1128* * * ODH investigation and recreation of event indicate that the radiographer did follow proper procedures and was exposed to (the) source for less than one (1) minute total. (The) radiographer had (a) stopwatch used for timing shots and he had failed to shut off the stop watch until he had removed himself from area of source, at which time the stopwatch indicated 5 minutes since the shot began. This exposure does NOT require notification and no further action to be taken at this time. | ||
| ENS 45288 | 1 June 2009 04:00:00 | Agreement State | Agreement State Report - Radiography Source Stuck Outside Camera | On June 1, 2009, licensee personnel were performing radiography when the projector fell on the guide tube while the source was exposed, preventing the source from being retracted into the shield. Licensee personnel tried to retract the source but were unsuccessful. The area was secured and monitored until a source retrieval team could be assembled and arrive on site. On June 2, 2009, the source retrieval team arrived and performed the source retrieval. The damaged guide tube was replaced and tested and the camera operates properly. The radiographer received 325 mRem by dosimeter and the radiographer's assistant received 38 mRem. No overexposure is anticipated. The incident was reported to the Agency within the 30 day reporting time. However, the received report was misplaced until August 24, 2009. Incident Number: 09-40 NMED Number: NC090040 | ||
| ENS 44780 | 15 January 2009 06:00:00 | Agreement State | Agreement State - Fire Involving Radiography Camera | The following was provided by the State via e-mail: On 1-15-09, DRH was notified by the Forrest County ERC that JANX Integrity Group had an accident with one of their darkroom trucks off Hwy 59 N., in Hattiesburg, MS. The driver for JANX struck a tree off the side of the interstate causing the vehicle to catch fire. The driver then left the scene of the accident. The radiography camera, SPEC-150, SN 150 (Ir-192, 65 Ci), was not discovered until the fire department saw a 'Caution Radiation Area' sign in the bed of the darkroom truck after extinguishing the fire. Surveys were conducted by firefighter personnel for their safety and to pinpoint the location of the radioactive device in the darkroom truck. The Forrest County ERC contacted an industrial radiography company and MS licensee located in Hattiesburg to take possession of the camera and secure it in their storage vault. The radiography camera was retrieved off the darkroom truck and out of its locked storage box by the MS licensee. The radiography camera was surveyed by the MS licensee before being transported to their storage facility. On 1-15-09, JANX retrieved the radiography camera out of storage for transport back to the manufacturer to assess the damage. DRH took surveys of the darkroom truck and the radiography camera. Radiation measurements were as follows: 24 mR/hr at the surface of the camera; 4 mR/hr at 6 inches from the camera; levels were background at the vehicle. DRH coordinated the receipt of radiography camera between JANX and a MS licensee for delivery back to the manufacturer. MS report number - MS 09001
The following was provided by the State via e-mail: On 1-15-09, swipes were taken on the camera and revealed no removable contamination. Leak test results for the source and DU shielding were received from SPEC on 1-23-09 and also revealed no removable contamination. Notified FSME EO (Chang) and R4DO (Farnholtz).
The following was provided by the State via e-mail: On 1-28-09, DRH received the SPEC - 150, Exposure Device S/N 150 Final Inspection Certificate from SPEC. The camera met the requirements contained in 10 CFR 34.20, ANSI N432 1980, USA/9263/B(U)-96 and SPEC's QA Program approval number 102. Notified FSME EO (White) and R4DO (Cain).
The following information was provided by the state via e-mail: Source was Ir-192, 65 Ci, S/N PJ1606, Source Model G-60. Notified FSME EO (Vontill) and R4DO (Powers).
The following information was provided by the state via e-mail: The State of Mississippi has taken enforcement action and cited their licensee with four violations. Notified R4DO (Gaddy) and FSME EO (Vontill).
The following information was provided by the state via e-mail: On 3/5/09 (the State of Mississippi) received a written report from JANX Integrity Group. This incident has been closed on 3/5/09. Notified R4DO (Proulx), and FSME EO (McIntosh). |