Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 50094 | 7 May 2014 03:00:00 | Agreement State | Radiography Source Tube Crimped Preventing Source Retraction | On May 7, 2014, the Agency (Texas Department of State Health Services) received notice that a source retraction failure had occurred on May 6, 2014 around 10 o'clock PM. The camera was a QSA Global 880D (sn D11607) with a 46 curie iridium-192 source (sn 12764C). The guide tube had fallen off of the guide tube stand and crimped. The source was retrieved by the licensee by uncrimping the guide tube. No overexposures resulted from this event. The guide tube was removed from service. All other parts are removed from service pending inspection by the licensee. Texas Incident Report: I-9190 | ||
| ENS 48967 | 23 April 2013 05:00:00 | Agreement State | Agreement State Report - Failure of Radiography Source to Fully Retract | The following information was received from the State of Texas via E-mail: On April 24, 2013, the Agency (Texas Department of State Health Services) was notified by the licensee that they were unable to fully retract an Iridium-192 source into a QSA model 660 radiography device. The radiographers attempted to retract the source several times, but were unable to get the device to lock the source in the fully shielded position. The radiographers contacted the Radiation Safety Officer who responded to the location along with the licensee's Source Retrieval Supervisor. The supervisor attempted to retract the source and on the second attempt, dose rates indicated that the source was fully shielded, but the device's locking device had not tripped. The supervisor inserted the source shipping plug into the device to secure the source in place. The source crankout device was dismantled and they discovered the connector on the end of the drive cable had separated from the drive cable. The crankout device has been shipped to the manufacturer for inspection and repair. The crankout device was placed in service by the licensee on April 11, 2013. The exposure device was inspected by the licensee and found to operate normally. No significant exposure was received by any individual involved in this event. Additional information will be provided in accordance with SA-300. Texas Incident #: I-9074 | ||
| ENS 48420 | 17 October 2012 05:00:00 | Agreement State | Agreement State Report- Unable to Retract Radiography Camera Source | The following information was received by email: On October 18, 2012, the Agency (Texas Radiation Branch) was notified by the licensee that on October 17, 2012, a radiographer was unable to retract a (source) into the QSA 880F exposure device. The guide tube for the device was damaged during radiography operation in the fixed facility when a part fell on it, crimping the guide tube to a point where the source could not pass through it. The licensee stated that they were able to repair the guide tube enough to retract the source and lock it in the exposure device. The licensee stated that no over exposure occurred from the event and no member of the general public received any exposure from the event. Additional information will be provided as it is received in accordance with SA 300. Texas Incident: I-8998 | ||
| ENS 47676 | 17 February 2012 06:00:00 | Agreement State | Agreement State Report Involving Potential Radiographer Overexposure | The following information was received from the State of Texas via email: On February 17, 2011, the Agency (State of Texas) was notified by the licensee of an overexposure event involving one of their radiographers. The radiographer was working in a shooting bay at the licensee's facility using a QSA D880 radiography camera serial number D7293 containing a 37 curie iridium 192 source. The radiographer entered the shooting bay to setup for their next shoot. They stated that they carried their dose rate meter with them but did not pay attention to the reading. The radiographer completed the setup and left the shooting bay. The radiographer attempted to crank the source out, but discovered that the source was already cranked fully out. The radiographer cranked the source back to the fully shielded position and notified their Radiation Safety Officer (RSO) of the event. The RSO questioned the radiographer and found that the radiographer had spent approximately 3 minutes within 10 inches of the source, and about 3 minutes at 3 feet from the source during the setup. Initial calculations by the licensee indicated that the radiographer may have received as much as 20 rem TEDE from the event. The RSO stated that the radiographer did not have to relocate the source to perform the shot so they do not believe there is any extremity dose involved. The RSO also stated that the electrical breaker that supplied power to the shooting bay had been opened therefore the alarm did not function. The RSO stated that they were going to review security video to determine who opened the breaker. The radiographer has been removed from all work involving exposure to radiation and their personal monitoring device will be sent to the licensee's processor. The Agency provided contact information for the Radiation Emergency Assistance Center/Training Site to the RSO. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-8934
On February 24, 2012, the licensee reported that after two reenactments of the event, the licensee now believes that the total exposure time to the radiographer to be 2 minutes and 30 seconds. The licensee was also able to use the radiographer's cell phone records as the radiographer was talking on their phone while setting up the shot. The distance for the radiographers TEDE dose was determined to be 12 inches. The licensee now estimates that the TEDE dose for the radiographer was 8.1 rem. The radiographer has provided three blood samples for evaluation. All three samples were determined to be normal. The radiographer's doctor is consulting with (name redacted) REAC/TS. Additional blood samples are scheduled in the future. The licensee determined that the power breaker to the alarming area radiation monitor was opened by a coworker who believed the breaker only supplied power to a ventilation fan. The operation of the alarm had been verified at the beginning of the start of that shift. Notified R4DO (Deese) and FSME EO (O'Sullivan). | ||
| ENS 47339 | 10 October 2011 12:00:00 | Agreement State | Agreement State Report - Misalignment in the Crankout Device | The following was received via fax: On October 11, 2011, the Agency (state) was notified by the licensee that on October 10, 2011 while performing radiography operations in one of their shooting bays, they were unable to retract an 89 Curie Iridium - 192 source into a SPEC model 150 camera. The licensee used their video surveillance cameras to verify that nothing had fallen on the guide tube to prevent movement of the source. No obstructions were observed. A technician approved for source retrieval inspected the camera and associate equipment and determined that the crankout being used was not working correctly. The crankout was disassembled and the drive cable was pulled by hand until the source returned to the fully shielded and locked position. The licensee inspected the crankout device and found that there was a slight misalignment between the drive cable and the gear. The device was adjusted, tested and operates smoothly. The crankout device will be sent to the manufacturer for further evaluation. No additional exposure was received by any individual during this event. Texas Incident No. I-8890 | ||
| ENS 46834 | 19 April 2011 05:00:00 | Agreement State | Agreement State Report - Stuck Radiography Camera Source | The following information was received via facsimile: On May 10, 2011, the Agency (Texas Department of Health) received written notification from a licensee that on April 19, 2011, at approximately 12:45 p.m. while performing radiographic operations on a tank, a radiographer found he was unable to retract a 58.6 Curie Iridium (Ir) -192 source into to a QSA Model 880D radiography camera. The radiographers working with the camera immediately repositioned the restricted area barricade to ensure that the barricade was set at less than 2 millirem per hour. The radiographers contacted their office and two source retrieval supervisors immediately proceeded to the jobsite. The Site Radiation Safety Officer was contacted and went to the location. The source retrieval team arrived at the secured barricaded area at 1:40 p.m. The radiographers maintained visual surveillance to ensure no members of the public had entered the area. The exposure device was adjacent to the tank's exterior; secured by a magnetic plate lifter, and located approximately 40 feet above ground. The exposure device was removed from the tank using a JLG lift and lowered to the ground. The guide tube was removed from the front of the camera and it was discovered that the source pigtail was sticking out of the front of the camera about one and a half inches. The source was manually retracted to the shielded position and locked in place. A radiation survey of the camera found the readings to be normal. No one exceeded any exposure limits and there was no exposure to any member of the general public. The camera was transported to the licensee's facility and inspected. The camera has been returned to the manufacturer for inspection and repair. The investigation into this event is on going. Additional information will be provided as it is received in accordance with SA-300. Texas Incident # I-8843. | ||
| ENS 45144 | 10 June 2009 07:35:00 | Agreement State | Agreement State Report - Unable to Retract Radiography Source | The following information was obtained from the State of Texas via email: On June 10, 2009, at approximately 2:35 a.m. while performing radiographic operations at GE Oil & Gas, two radiographers found they were unable to retract the radioactive material into the shielded position. They had made approximately 13 radiographic exposures prior to the malfunction. One of the radiographers contacted an approved Source Retrieval Supervisor, who was at the jobsite grading film. The Source Retrieval Supervisor immediately went to the area where the radiographic operation was located, assessed the situation and ensured the barricaded area was at less than 2 mR/hour. He determined the source was located within the collimator, but would not retract by normal means. The source tube was positioned with a fairly sharp bend which he felt may have put the drive cable in a bind, so he ran to the exposure device and repositioned it to reduce the source tube's bend. This action had no effect. The Source Retrieval Supervisor contacted the Site Radiation Safety Officer (RSO) by phone and reported the situation. They agreed that the Source Retrieval Supervisor should attempt to return the source to the exposure device by hand pulling the drive cable. After obtaining tools, the Source Retrieval Supervisor and one of the radiographers approached the crankout assembly, disassembled the crankout, and pulled the drive cable to return the source to the shielded position. After ensuring the source was in the exposure device, the crankout was further disassembled so that it could be disconnected from the source pigtail, the exposure device was locked and the source tube removed. The Source Retrieval Supervisor then called the RSO at approximately 3:00 a.m. to report the successful source retrieval. There were no members of the public in the immediate area. Pocket dosimeter reading for Source Retrieval Supervisor: 10 mR at start of retrieval operation, 15 mR at finish. Pocket dosimeter reading for Radiographer Aiding in Source Retrieval: 15 mR at start of retrieval operation, 15 mR at finish. Pocket dosimeter reading for Other Radiographer: 0 Equipment involved: Exposure device: Spec-150, s/n 0181 Source: QSA Global, 969, s/n 52911B, 35.8 curies Source tube: NDT Repair & Supply, 7', serial number B13-2 Crankout: SPEC, 35', s/n 0603 Texas Incident No. I-8641 | ||
| ENS 44535 | 29 September 2008 18:00:00 | Agreement State | Agreement State Report - Potential Overexposure to Extremities | A radiographer working for METCO was performing radiography operations at CB & I Fabricators in Houston TX. He was moving the radiography camera (a SPEC 150 with a 85 curie Ir-192 source) from one location to another. He removed the nipple off the front of the camera to test the guide tube and his dosimetry started alarming. He observed that the source had come out of the camera about 1/2 inch. At the same time, he inadvertently dropped the camera plug. He picked up the plug and unsuccessfully made two attempts to push the source back in with the plug. He then left the front of the camera and went around and turned the crank and got the source back into the shielded position and then inserted the plug. He then notified appropriate personnel. METCO sent his dosimetry off and the results came back with a whole body exposure of 946 millirem on October 1. The RSO discussed the details of the event with the radiographer and reenacted the event to attempt to estimate the radiographer's hand exposure because to the close proximity of the source to the hand during the event. Based on the time and distance of the source to the hand, it was estimated that the exposure to the radiographer's right hand may be somewhere between 66 and 282 rem. METCO has called in a consultant to get a more accurate assessment of the exposure to the hand. The radiographer's work for the rest of the year has been suspended. His hand does not exhibit any eurythemia. No information is available on whether blood work or medical study will be obtained. Texas will wait for the licensee's final report before it completes and independent investigation of the event. Texas Report I-8569
The following information was received from the State of Texas via email: The licensee provided the final dose estimate for the individual involved in this event. The licensee used conservative times established in several reenactments of the event, NCRP publications, and the source manufacturers information to calculate the dose estimate. The estimate to the individual's right hand is 233.71 Rem SDE. The State of Texas calculated the dose to be 235.65 Rem SDE. This individual's TEDE dose was measured at 2.762 Rem for the 2008 calendar year. Notified FSME (Burgess) and R4DO (Deese). | ||
| ENS 44959 | 28 January 2008 05:00:00 | Agreement State | Agreement State Report - Radiography Camera Malfuntion | The following information was received from the State of Texas via Email: On January 28, 2008, the Agency was notified by the licensee that a radiographer was doing work in one of their shooting bays when a 35.7 curie Iridium -192 source would not retract into the radiography camera. The radiographer used an installed video camera to look into the room and saw that the component he was working on had fallen and crimped the guide tube attached to the camera. The source was cranked to the end of the guide tube, and two attempts to straighten the guide tube and retract the source failed. A source retrieval supervisor then entered the room and placed lead bags over the end of the source guide tube and placed a lead sheet over the lead bags. The supervisor attempted to reshape the section of the guide tube that had been damaged using a hammer. This also did not work. Finally, the supervisor cut the damaged section of the guide tube out and the source was then retracted to the camera. The reported exposure for this event was 15 millirem. The radiographer received additional instruction on proper set up and operation of a radiography camera. 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 Report: I - 8604
Upon request of the State the reference to 10 CFR 30.50(b)(a) was changed to 10 CFR 30.50(b)(2). | ||
| ENS 44963 | 5 January 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 February 5, 2008, the Agency was notified by the licensee that one of their crews had contacted their office and informed them that the guide tube on their camera had detached from the camera housing and a 91.4 curie Iridium (Ir) 192 source could not be retracted into the camera. The crew was instructed to maintain surveillance of the area until the source recovery team got to their location. Once there, the source recovery team determined that the source drive cable was no longer in the gear housing. They then cut the drive cable housing about one foot from the gear housing. The drive cable was located, and they manually pulled the cable and returned the source to the shielded position. The cause of the failure was determined to be a build up of material in the threads of the camera where the guide tube connected to it. This prevented the guide tube from adequately threading into the camera and allowing the guide tube to separate from the camera during use. The camera was inspected and cleaned. All cameras of similar design were also inspected. No other cameras were found to have the same problem. This event 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 Report: I- 8480
Upon request of the State the reference to 10 CFR 30.50(b)(a) was changed to 10 CFR 30.50(b)(2). | ||
| ENS 44961 | 18 October 2007 05:00:00 | Agreement State | Agreement State Report - Inability to Retract Radiography Source | The following information was received from the State of Texas via Email: On November 9 2007, the agency was notified by the licensee of an event that occurred while they were performing radiography operations at a remote location. The licensee reported that the guide tube on a radiography camera containing a 75 curie Iridium (Ir) - 192 source was damaged, preventing them from being able to retrieve the radiation source back into the camera. The radiographer contacted the licensee's main office and was instructed to monitor the area and restrict access until the source retrieval supervisor arrived at the location. The supervisor was able to remove the crimp in the guide tube, allowing them to sufficiently retract the source into the camera. No exposures were received that exceeded regulatory limits. The licensee is redesigning their holder to prevent this from occurring in the future and provided additional training to their personnel. This event 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 Report: I-8454
Upon request of the State the reference to 10 CFR 30.50(b)(a) was changed to 10 CFR 30.50(b)(2). | ||
| ENS 43644 | 15 September 2007 03:00:00 | Agreement State | Agreement State Report Involving Potential Overexposures During Industrial Radiography | At approximately 2200 hrs. on 9/14/07 during radiography work at a jobsite in Vidor, TX (30 miles north of Beaumont), two radiographers noticed that their pocket dosimeters read off-scale high (range 0- 200 m R). They were using a 94 curie Co-60 camera (QSA model 943, A424-14, S/N36391B) to take radiographic shots of a 6 inch thickness steel ladle and had just changed the film in the holder which was located about 7 inches from the exposed source behind the steel ladle. It appeared that the source had not retracted into its shielded volume. A specialist in source retrieval was brought to the jobsite and the source successfully returned to its stowed position. During retrieval the specialist's pocket dosimeter also went off-scale high (range 0-5 R) at which time he switched to a higher reading dosimeter (range 0-20 R) completing the task with an indicated dose of 13 R. The State of Texas was notified of the incident at 1804 hrs. on 9/15/07 and confirmed that the licensee was sending the individuals dosimetry off for emergency reading. Further, the State contacted REAC/TS (Radiation Emergency Assistance Center/Training Site) who recommended that these individuals be immediately medically examined with followup blood chemistry tests, i.e., CBC (complete blood cell), performed the following day to document any cytogenic changes. The State will conduct an investigation to determine the cause of the overexposures.
The State provided the following information via email: The two workers 200 mR dosimeters were off scale and it appears that they were working with the source not fully retracted as a crimp in the source tube was noted approximately 1.5 feet from the camera. A ladder was used to enter the ladle from one side and the source was positioned on the opposite side with a magnetic hold on device. It has been conveyed that the hold on device fell off at some time and damaged the source tube restricting the full retraction of the source for two shots with a survey being taken on the second shot and thus the source being discovered in the exposed position. The source retrieval was difficult apparently requiring the source to be fully extended so that the source tube could be manually stripped from the drive cable. This took reportedly 12 one minute maneuvers, lead shot bags used when possible." Blood was drawn Saturday and twice Sunday for CBC the results of which are to be faxed to REACTS. On Monday blood will be drawn with heparin/lithium for transport to REACTS for cytogenic analysis. Our inspector in the area is to conduct a recreation on the event today and more details will follow in a formal report. Texas report number I-8444 Notified R4DO (V. Campbell) and FSME EO (Morell), and IRD Manager (Blount) | ||
| ENS 43411 | 8 May 2007 05:00:00 | Agreement State | Agreement State Report Involving Equipment Failure of Radiography Camera | The following report was received from the Louisiana Department of Environmental Quality (LA DEQ) via fax: (A) field inspection was performed on a field crew for METCO. (While) performing the inspection a misconnect test was performed. The crank outs had a serial number of MST 225 manufactured by AEA Technologies and the camera was an Amersham 880 Sigma with serial number S1712. This misconnect test failed. The crank outs were removed (from) operation and taken back to the shop. The problem was located on the crank out and was repaired. A misconnect test was then performed with the same camera and an additional camera and it passed the test. METCO stated that they will pay closer attention to damage and wear and tear on equipment. LA Event Report ID No.: LA070014 |