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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 52349 | 3 November 2016 04:00:00 | Agreement State | Agreement State Report - Failure of Source to Retract to Safe Position | The following report was received from the Illinois Emergency Management Agency via email: On Thursday, November 3, (2016) the licensee's Corporate RSO (Radiation Safety Officer) called to advised that one of their crews experienced a source retraction problem while at a temporary jobsite. Radiography shots were being taken with a nominal 60 Ci Ir-192 source at the Wood River Refinery, Wood River, IL. During a shot around 1230 (EDT) that afternoon it became obvious that the source would not retract using normal means. The crew contacted the local facility radiation safety officer to advise him of the event. The local radiation safety officer responded to the site within 30 minutes to discover that a portion of the drive cable assembly had been laid across a bare spot on a pipe that was otherwise insulated. The heat from the uninsulated section of pipe had caused the return side, cable housing coating to melt, forming an obstruction that the return cable could not pass. The RSO, having retrieved a source from a similar predicament in the past was able to quickly and efficiently cut the return side cable guide tube creating an open path for the cable and bypass the obstruction. The source was then able to be returned to the safe position without undue effort. The matter was resolved within an hour. The drive cable equipment has been removed from service. The camera was inspected and tested and put back into service. The direct ion storage dosimeter for the facility RSO was immediately analyzed at the end of the event and a dose of 3 mR was noted. Doses for the crew members were similarly analyzed and both found to be less than 30 mR since the last read which was performed at the end of the previous month. As the area being radiographed was on an overhead scaffold, no other personnel were in the work area at any time during the event other than the radiographers who maintained vigilance over the scene. A preliminary report with supporting photos was received the next day. Based on that report, an immediate investigation was not conducted at that time. Device: Radiography Exposure Device Manufacture: QSA Global Equipment Serial Number: D10972 Source Serial Number: 32867G Model Number: 880-D Radionuclide: IR-192 Activity: 2168.2 GBq Illinois Item Number: IL16011 | ||
| ENS 51180 | 25 June 2015 13:30:00 | Agreement State | Agreement State Report - Lost Radiography Camera During Transit | The following information was received from the State of Louisiana via email: Event date and time: On 06/25/2015 (at 0930 CDT, the licensee Radiation Safety Officer) called the Radiation Section of LDEQ (Louisiana Department of Environmental Quality) to report a lost/missing radiography camera. The camera was to be loaded on a rig truck and (to) be transported to a temporary site. The crew and site RSO had been looking for the camera since it was discovered missing at 0830 (CDT). A radiography exposure device was left on the bumper of a rig truck and not secured in the vault/overpack on the truck. The crew left the yard on Highway LA #30 and headed to I-10 and then East on I-10. About 5 miles down I-10, the crew remembered that they had not secured the camera in the rig truck. They stopped and found the camera missing. They backed tracked I-10 to LA # 30 and back to the office. They did not locate the missing camera. The LA State Police was notified in addition to LDEQ. The Radiation Section (of LDEQ) was notifying the staff and dispatching a Radiation (Environmental Scientist) individual to respond. The media put out an alert of the missing camera. Homeland Security, QSA Global, and the Ascension Parish Sheriff responded and were aiding in locating the lost camera. They were combing the area on ATVs and utilizing sensitive radiation detection instruments. At about 1130 (CDT) the LDEQ was given an update by (the licensee Radiation Safety Officer) which only includes responding agencies and the Site RSO for contact. About 1150 (CDT) the NRC Region IV was notified of the incident (Latisha Hanson) and given a preliminary notification and told the (NRC Operations Center) was being notified. Event Location: A rig truck was dispatched from TIS at 37568 Hwy # 30, Gonzales, LA down LA #30 to Interstate-10. The rig went east on I-10 for about 5 miles when the crew remembered that the camera had not been secured in the rig. The crew check the back of the rig and backed tracked the I-10 to LA #30 route. The camera was not located. Notifications were made. Event type: Loss of control over an exposure device. A QSA 880 Delta exposure device S/N 4586. The exposure device was loaded with about 30 Ci of Ir-192, QSA source Model # 84-9. The Category II, Quantity of Concern was released or lost into the general public. The radioactive exposure device was released into the general public by the two individuals not following the TIS's (Team Industrial Services) Radiation Safety Procedures or the IC (Increased Controls) Security Procedures. The exposure device was released to the general public unsupervised and not in direct control of an authorized company representative. Event description: The equipment was a QSA 880 Delta exposure device S/N D4586. The source was about 30 Ci of Ir-192, model # 84-9. At this time LDEQ consider this incident still open and updates will be given when available. Transport Vehicle: This was a TIS company crew truck being dispatched to a temporary jobsite. Media attention: News Media was alerted and reporting agencies were notified. Louisiana Event: LA150010 Notified DHS SWO, FEMA, USDA, HHS, DOE, DHS NICC, EPA, FDA(email), Nuclear SSA (email) FEMA National Watch Center (email), DNDO-JAC (email). 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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The following information was received from the State of Louisiana via email: The exposure device was recovered at about 7:00pm (CDT) on 06/25/2015. Device QSA/AEA Technologies, Model Delta 880, S/N 4586 Source QSA/AEA Technologies, Model A424-9, S/N 166306; 48.2 Ci Ir-192 Recovered (approximately) 1.5 (Miles) on LA 61 east of US I-10 east. It was on the side of the road in a wet-muddy ditch area. (The device was found) by backtracking the trucks GPS device. A health and safety survey was conducted and the shielding appeared to be intact. The exposure device was loaded on to another Team Industrial vehicle, blocked and braced, and returned to the vault at the highway LA-30 address. The device and source were leak tested and analysis was performed on the test. A QSA Global representative stated it appears the device (DU) and the Ir-192 source were not leaking or compromised. With the exception of corrective actions and enforcement issues the department, LDEQ (Louisiana Department of Environmental Quality), considers this incident closed. Notified R4DO(O'Keefe), IRD MOC(Grant), ILTAB (Wray), and NMSS Events Resource (via email). Notified DHS SWO, FEMA, USDA, HHS, DOE, DHS NICC, EPA, FDA(via email), Nuclear SSA (via email) FEMA National Watch Center (via email), DNDO-JAC (via email). | ||
| ENS 50844 | 23 February 2015 06:00:00 | Agreement State | Agreement State Report - Damaged Guide Tube on Radiography Camera Preventing Source Retraction | The following information was received from the State of Wisconsin via email: The Wisconsin Radiation Protection Section received notice from the licensee's Corporate Radiation Safety Officer (RSO) that a radiography crew working at a temporary jobsite on February 23, 2015 had a source become stuck during radiography operations. The crew was using an Ir-192 source in a QSA Global 880 Delta camera. While the source was cranked out in the collimator, a pipe fell on the guide tube and crimped the tube such that the radiographers were unable to retract the source. Two radiographers who are trained in source retrieval were dispatched to the jobsite. They cut out a one-inch section of the guide tube and were able to retract the source into the camera. As indicated by pocket dosimeters, radiation doses received by the radiographers were beneath regulatory limits. The Wisconsin Radiation Protection Section will follow up with the licensee after receiving its 30-day written report. Additional updates will be provided through NMED. The licensee is sending the camera drive cable to the manufacturer for evaluation and has disposed of the damaged guide tube. Wisconsin Event Report ID No.: WI150004 | ||
| ENS 50572 | 28 October 2014 04:00:00 | Agreement State | Agreement State Report - Radiography Camera Source Can Not Be Retracted | The following information was received from the Commonwealth of Pennsylvania via email: The Department's (PA Department of Radiation Protection) Southwest Office informed the Central Office of this event on October 28, 2014. This event is reportable to the Department within 24-hours per 10 CFR 30.50(b)(2), and within 30 days as per 10 CFR 34.101(a)2. While radiographing a pipe in the field, a crew had an incident where the camera fell and crimped the guide tube, and the source could not be retracted. The area was immediately secured after the event, and recovery operation initiated. The recovery was completed within two hours. Using long handled pliers under lead sheets, the licensee was able to un-crimp the guide tube and retract the source back into the camera. The readings with the lead sheets in place were in the range of 10 to 15 milli-roentgen per hour (mR/h). Electronic dosimetry readings of those involved with the recovery were provided to the Department (Radiation Protection), with no whole body results above 40 mR. Camera Information: Model: AEA / QSA 880 Delta Serial#: D12920 Source Information: Model: AEA / QSA A424-9 Serial #: 11088G Isotope: lr-192 Activity: 99 Ci CAUSE OF THE EVENT: The camera was not tied down to the pipe, it slid off the supporting structure, fell, and crimped the guide tube. ACTIONS: The licensee was able to un-crimp the guide tube and retract the source back into the camera. The Department plans a reactive inspection. PA Event Report ID No.: PA140022 | ||
| ENS 50107 | 6 May 2014 04:00:00 | Agreement State | Agreement State Report - Radiography Camera Source Disconnect | The following information was received from the State of Ohio via email: Licensee contacted BROP (Bureau of Radiation Protection) at approximately 2:30 PM on 5/6/14 to report that a radiography crew experienced a source disconnect during radiography operations earlier in the day. After completing the 3rd shot of the day a radiographer attempted to crank the source back into the camera. The drive cable appeared to crank back in but reading on the survey meter indicated that the source was still outside the camera, apparently in the area of the collimator. Licensee personnel attempted to crank the cable in and out several times in an attempt to retract the source, but were unsuccessful. The area was secured and monitored by licensee personnel pending further retrieval efforts. The corporate RSO was contacted, who dispatch two trained source retrieval personnel to the location. During evaluation it was determined that the drive cable had broken near the male connector. Licensee personnel were able to unlock the camera, feed the broken drive cable through the camera, and retrieve the source into the shielded position. Retrieval was accomplished at approximately 6:30 PM that evening. A new drive cable was connected to the camera and the radiographers were able to continue operating the camera with the new drive cable without incident. The two licensee retrieval personnel recorded doses of 20 mRem and 40 mRem on their pocket dosimeters. The licensee is having the broken drive cable returned to their corporate office for examination to determine the cause of the break. Licensee is preparing a written report on this incident. The Radiography Camera involved is a QSA Model 880D, Serial number D8378 containing 46.1 Curie Ir-192 source. The sealed source is model number A424-9, serial number 12727C. The incident occurred at the Kensington, OH site. State of Ohio Reference No.: 2014-010 Corrective actions included obtaining a new cable. Repairs were made without an engineering change to the system. State of Ohio submitted the NMED Item Number: OH140006 on 05/07/14. | ||
| ENS 50042 | 16 April 2014 05:00:00 | Agreement State | Agreement State Report - Radiography Camera Failure of Source to Retract to Safe Position | The following was received from the State of Illinois via email: On Wednesday at midday, the Regional Radiation Safety Officer (RSO) for the licensee's South Roxana, IL area was called by their two man crew working at the WRB Refinery in Roxana, IL. The crew reported that following a sixth 'shot' on an elevated tank from an overhead platform, the source to the radiography camera would not retract into the safe position. The source had previously been 'run out' to a distance of just over 7 feet into a collimator, and although the crank and assembly rotated freely without notable restriction through two ninety degree turns, the source would not enter the camera. The crew reported that the guide tube had not been affected during the previous shots and noted that the equipment had regularly passed the routine maintenance inspection prior to that day. The Regional RSO assembled his emergency response equipment kit and arrived at the site approximately 30 minutes later. The crew had maintained a perimeter and advised responsible site safety personnel of the matter with instructions to ensure the affected area was to remain off limits until the situation was resolved. The Regional RSO inspected the guide tube and set up and like the crew was unable to retract the source. Calls were then placed to the company's regional management and to the Illinois Emergency Management Agency to advise of the situation. The set up was disassembled and the collimated end point placed into a shielded configuration using bags of lead shot so that the full length of the guide tube could be more closely inspected. Minor dents and obstructions of the guide tube were noted and although when corrected by the Regional RSO, would still not allow the source to be safely returned. With the help of the radiography crew, the camera and guide tube assembly was subsequently moved to a more accessible lower platform by the Regional RSO to allow for additional inspection and to create a more direct path. The source however would still not retract into the camera. Dose rates with the source in the collimator were measured as 390 millirem at 8 feet and 695 millirem at 6 feet which was the closest distance the Regional RSO remained in. Additional support from the regional office was requested to thoroughly patrol the boundaries of the area as it appeared additional time was going to be required and the camera would need to be lowered further to gain better access for potential repairs. While additional equipment was being collected from the regional office, the manufacturer was advised of the situation and consulted. The manufacturer suggested the issue may lie with the drive cables from the reserve crank end and they would likely have to be disconnected from the source cable. When the additional equipment arrived, the crank housing was disconnected from the camera following the manufacturer's suggestion and from a distance, the cable was manually retracted. The source subsequently was returned to the shielded and locked position with no further difficulties. The total time for recovery was approximately two and a half hours. Later, close inspection of the drive crank assembly showed that the reserve section of the crank had been subjected to heat or burned such that the exterior plastic covering had melted along approximately 3 inches of its length. Upon testing, this damaged section prohibited movement of the cable past this point. It's surmised that the crank assembly may have come to rest against an uninsulated section of the piping while taking shots that morning at the refinery that led to the burning/melting of the protective covering over the braided cable which led to the inability to retract the source. A check of the Regional RSO direct reading dosimeter showed less than 80 millirem as a result of the recovery operation. Members of the radiography crew received a total dose for the day of less than 100 millirem. The camera was last inspected by the manufacturer on March 14, 2014 and the manufacturer's associated equipment on February 4, 2014 by the Regional RSO. The associated equipment is being returned to the manufacturer for evaluation and repair/replacement. Illinois event # IL14007 | ||
| ENS 48417 | 16 October 2012 05:00:00 | Agreement State | Agreement State Report - Radiography Camera Source Disconnect | The following report was received from the State of Texas Radiation Branch via facsimile: On October 17, 2012, the Agency (Texas Radiation Branch) was notified by the licensee that on October 16, 2012, a radiography source had disconnected from the drive cable during radiography at a field location. The radiographers were using a SPEC 150 exposure device (redacted). The radiographers had completed an exposure and as they were surveying the exposure device, the radiographer noted that the dose rates at the front of the device were higher than expected. The radiographers contacted their Radiation Safety Officer. A source recovery team was sent to the location and the source was recovered without incident. The licensee read the Instadose dosimeters for the individuals involved in the event and no over exposures occurred. No additional exposure to a member of the general public occurred due to this event. The licensee was not able to determine the cause for the disconnect. The exposure device and the crank-out device the radiographers were using are being sent to the manufacturer for inspection. Texas Incident #: I-8994 | ||
| ENS 48025 | 22 May 2012 07:00:00 | Agreement State | Agreement State Report - Camera Source Fails to Retract | The agreement State of California reported the following via email: On 06/13/12, the RSO at Team Industrial contacted RHB to report a radiography camera incident that occurred on 05/22/12 at the Evergreen refinery in Newalk, CA. The radiographers were using a QSA 880 camera on the second deck of the unit 1 at this refinery. The radiographer cranked the 59 Ci source out into the collimator and after the exposure, he couldn't retrieve the source back into the shielded position. He immediately contacted the RSO. Per RSO's instructions, the radiographer unscrewed the crank assembly and pulled the cable back to retrieve the source into shielded position. There were no exposures to the radiographers, two assistants, and any member of the public. The licensee's Instadose dosimetry indicated 8 mR for the radiographer for the period of 5/18 - 5/22 and 7 mR and 0 mR for the two assistants for the same period. Their pocket dosimeters indicated zero exposure for all three individuals. The crank assembly was sent to QSA and they have indicted that the worn out teeth and bearings of the crank assembly inhibited the normal retrieval of the source. RSO will be providing a detailed report to RHB ASAP. CA 5010 Number: 061312 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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 46750 | 12 April 2011 14:35:00 | Agreement State | Agreement State Report - Fire in Portable Darkroom | The following information was received from the state via email: On 4/12/2011, at 10:35AM the corporate RSO for TEAM Industrial Services informed the PA DEP Bureau of Radiation Protection (BRP) of a temporary job site fire which occurred earlier in the day. This event type is 'An unplanned fire... damaging any licensed material or any device, container, or equipment containing licensed material' which is reportable under 10CFR30.50(b)(4). A fire occurred in the portable darkroom which was housed within the bed of a pickup truck at the job site. A QSA Model 880 Delta radiographic exposure device containing approximately 75 curies of Iridium-192 (Ir-192) was stored in its metal over-pack inside the darkroom. The metal over-pack sustained significant fire damage, however, the radiographic exposure device was undamaged with the exception of a melted plastic handle. Surveys revealed radiation levels to be in the normal range and consistent for the source being in the locked position. It appears that the Ir-192 source was undamaged by the fire, however, the housing and source will be returned to the manufacturer for examination. Early indications are that an electrical problem started the fire. An immediate reactive inspection occurred on 4/12/11. BRP responded, examined the damaged truck and confirmed radiation surveys and measurements taken by the licensee. The camera was taken out of service and will be returned to QSA for inspection once a suitable shipping container is received. Further details (from the State) will be reported as received. PA Event Report No. PA110007 | ||
| ENS 46430 | 21 November 2010 18:00:00 | Agreement State | Agreement State Report - Source Disconnect and Retrieval | The following information was provided by the State of Texas via email: On November 22, 2010, the (Texas Department of Health Services) Agency received notification from the licensee that it had experienced a source disconnect yesterday, November 21, 2010 at approximately 1200 CST. The licensee stated that a two person radiography crew was working at a refinery near Alvin, Texas when they experienced a source disconnect. The radiographers were using a QSA Global device (Model: 660-B) that housed a 67 curie, Selenium (Se) - 75 source. According to the licensee, the radiographers had made 24 exposures and on the 25th exposure, the source disconnected from the drive cable. The radiographers were able to crank the cable back into the camera, but the source remained out. The radiographers contacted their Site Radiation Safety Officer (SRSO). The SRSO, who is authorized to retrieve sources, traveled to the site and returned the source to the camera at approximately 1700 CST. The radiographers at the site waited for the SRSO to arrive while verifying the 2 millirem per hour boundary, and keeping constant security on the radioactive material. According to the licensee, the highest exposure measured by the radiographers' pocket dosimeters was that of the SRSO, whose dose was measured to be 45 millirem for the event. The licensee stated that they were unsure why the source disconnected from the drive cable. However, the licensee has contacted the manufacturer, and will send the entire set-up (camera, guide tube, drive cable, etc) to the manufacturer for inspection and repair. TX: I-8798 | ||
| ENS 46316 | 3 October 2010 05:00:00 | Agreement State | Agreement State - Radiography Source Failed to Retract | On October 4, 2010, the Arkansas Radiation Control Program was notified by Team Industrial Services, Arkansas license number ARK-0344-03320, involving the failure of a radiography source to retract into the camera. The radiography crew involved in this incident was based in Sulphur, Louisiana. On October 3, 2010, radiography work was being conducted in Fulton, Arkansas using a rented SPEC-300 Camera, serial number 017, containing a 27 Curie SPEC G-70 source, serial number GE2503, both manufactured by Source Production and Equipment Company. The source was last leak tested on 10/1/2010. A J-Tube manufactured by QSA, owned by the licensee, was also employed in the radiography work. The source was cranked out of the SPEC-300 and the radiographer was unable to retract the source back into the camera. The radiography crew contacted the RSO and the crew attempted to safely straighten out the guide tube. After realigning the guide tube, the source was retracted into the camera. After the source was determined to be safely stored in the camera, the crew returned to the office to determine the cause of the inability to retract the source. SPEC was also notified. At this time, no overexposures have been reported by the licensee. The Radiation Control Program is awaiting a written report on the incident from the licensee. Report #: ARK-0344-03320
The following report was received from the State of Arkansas via e-mail: The (Arkansas Department of Health (ADH)) received a written report in accordance with RH-1801.k of the Arkansas Regulations describing the event, root cause and exposure information. The SPEC G-70 source is a Cobalt-60 source. During the initial exposure, it is believed that the source did not reach the end of the J-Tube and was temporarily 'hung up' at the connection between the guide tube and J-Tube. The radiography crew re-verified the controlled area boundaries and made notifications. After consulting with the local RSO for the radiography crew and the Corporate RSO an attempt was made to 'straighten' the guide tube to decrease the likelihood of any binding of the crank-out/source and the guide tube. After the utilization of a 'long pole' the source was able to be retracted and locked into the exposure device. Surveys were made and the exposure device was transported to the office of the radiography crew. The total time the source was exposed was 60 minutes. Inspections of the exposure device, guide tubes, crank out, and source revealed all were in proper working condition. SPEC has stated that the J-Tube utilized is not approve for use with the device and that no J-Tubes are approved for use with the SPEC-300 and G-70 Co-60 source configuration. Total exposure from the direct reading pocket dosimeters: lead radiographer 90 mRem; radiographer A, 12 mRem; and radiographer B, 8 mRem. There were no exposures above the annual limit to any members of the public due to this event. It appears that the root cause of the event was incompatibility of the J-Tube and source. The State of Louisiana has been notified of this event and the written report will also be forwarded. The (ADH) considers this event closed. Notified R4DO (Campbell) and FSME EO (Einberg). | ||
| ENS 45818 | 7 April 2010 05:00:00 | Agreement State | Agreement State - Radiography Truck Involved in Auto Accident | On April 7, 2010 at approximately 1430 CST the Incident Investigation Program was notified by the licensee's Radiation Safety Officer (RSO) that one of the licensee's trucks carrying a camera with a 24 curie Iridium (Ir) 192 source had been involved in a car accident around 1300 CST that same day. The RSO stated that the radiography truck had collided head on with a tractor-trailer on a highway approximately 8-10 miles east of Kosse, Texas. One of the radiographers was fatally wounded and the other was rushed to the hospital. Consequently, no one was able to perform a survey to verify the source was intact in the camera as well as secure the camera. The RSO stated that the Robinson County Emergency Management Coordinator was on the scene along with police and fire personnel, as well as Texas Department of Transportation. The RSO stated that none of the emergency personnel responding were equipped with a radiation survey meter to verify the source locale. The RSO stated that the Site Radiation Safety Officer was en route to the scene to perform a survey and retrieve the camera, but he was almost two hours away. The Emergency Management Coordinator had cordoned off the area around the radiography camera. I contacted an Agency investigator who was near the area performing field work, and he agreed to go by the location and perform a survey because he could be there within 45 minutes. At approximately 1630, the investigator arrived on the scene and performed his survey. The investigator stated that it appeared the source was still housed in the camera and that the highest dose rate was 2.2 millirems/hour near the camera. The site RSO arrived on the scene, and the investigator briefed him on the survey. The information was passed to the RSO and he agreed to submit a report to the Agency. Texas Incident #: I-8728 | ||
| ENS 45385 | 25 September 2009 19:00:00 | Agreement State | Agreement State Report - Source Disconnected from Radiography Camera | The following agreement state report was received via e-mail: On September 25, 2009 (at approximately 14:45 MDT), the Colorado Department of Public Health and Environment was notified by the RSO for Team Industrial Services that a source disconnect had occurred within the prior 1-2 hours at a temporary jobsite located in Rifle, Colorado. The source remained disconnected at the time the RSO made the notification to the Department as no personnel working in the area were trained for source recovery operations. Once the radiographer in charge at the jobsite realized that a disconnect had occurred and the source could not be returned to the radiography device, the source was cranked/pushed out to the collimator to provide additional shielding. The RSO reported that the radiographer and radiographer assistant involved in the source disconnect had received approximately 1 mrem up to and including the time of the source disconnect. According to the RSO, the temporary jobsite was located adjacent to an oil or gas drilling rig site, but radiography operations were located at a sufficient distance so as not to impact other non-radiography personnel (members of the public) working in the vicinity. Additional (licensee) radiography crews working in the Rifle, CO area were dispatched to the jobsite where the disconnect had occurred to provide additional support and access control. On September 26, 2009 (at approximately 11:08 am MDT), the licensee notified the Department that the source recovery had been successfully completed by the RSO at about 1:30 am MDT that morning. The personnel involved in the source recovery - including the RSO - had received approximately 8 mrem each based upon pocket dosimeter readings. The event involved a radiography device containing 35.6 curies of Ir-192. The source had been in use for several months and the source was nearing the end of its useful life. The radiography device involved in the disconnect was a Sentinel Delta 880 (Serial #D4309) containing approximately 35.6 Ci of Ir-192. The Ir-192 source was a Model 424-9, Serial #53922B. The Department (Colorado Department of Health) recommended to the licensee that the device and source be returned to the manufacturer for further evaluation. The licensee is expected to submit a written report to the Department within 30 days of the incident. Colorado Incident #I09-19 | ||
| ENS 44493 | 16 September 2008 05:00:00 | Agreement State | Radiography Camera Source Failed to Return to Safe Position | On September 12, (the) RSO for Team Industrial Svcs. called to advise that an irregularity had occurred during a routine radiography shot (deleted). A radiography crew had been working at the Archer Daniels Midland facility in Decatur, Illinois to perform a panoramic shot within a 5 inch thick steel vessel. Following the shot, the 100 Ci Co-60 source failed to return to the safe position within the camera. The crew called their local RSO, (deleted) and requested assistance. During (the local RSO's) travel to the site, the crew secured the Fabrication Shop where the vessel was located. (The local RSO's) first actions at the site were to confirm the area was secured and the appropriate barriers were in place such that exposures to any other individuals remained below regulatory limits for members of the public. (Prior to the work beginning, the area had been evacuated and remained that way during the duration of the event). The shot was described as a 'panoramic, horizontal shot at ground level that did not require support equipment.' The lead radiographer's pocket dosimeter at the time of the notification showed a total of 50 milliR for that day's activities. Preliminary evaluation by the crew suggested the source had become disconnected in that the expected number of 'cranks' on the drive cable exceeded the number necessary to return the source to the camera from the 14 foot length guide tube with extension and there was no evident increase in radiation exposure rate as had been expected from the camera. The manufacturer of the equipment/source, QSA Global, was contacted immediately and had been asked to be on 'standby' in the event their assistance for a source recovery is necessary. Team Industrial Services is authorized to perform source retrievals and has adequate procedures/equipment for that activity for when they choose to attempt a recovery on their own. Later, (the corporate RSO) reported that (the local RSO) confirmed the source disconnect at the scene by separating the guide tube from the camera and cranking the drive cable back to the camera. Additional lead and steel shielding was brought into the area via a remote overhead crane in the Fabrication Shop to allow for more direct observation. Dose rate at the camera location was measured as 200 milliR/h unshielded. With a leaded barrier, the dose rate was brought down to 100 milliR/h at the camera. The dose rate was further reduced by extending the crank assembly an additional 15 feet away from the camera. Based on technical instruction from QSA Global's expert, source recovery was attempted by modifying the connector on a drive cable that was then attached to the crank and threaded back through the camera. Team (Industrial Services) imposed a conservative 200 milliR total dose limit for the recovery operation and 500 milliR/h dose rate limit for area occupancy during (the local RSO's) attempts. After 2 hours of attempts to recover (the source) were unsuccessful, the maximum exposure received at that point was 60 milliR. Over twenty attempts took place however, positive connection with the source 'pigtail' could not be confirmed. A reevaluation of the arrangement suggested that the extension guide tube should be removed and the overall guide tube length be made more straight by remotely partially withdrawing the main guide tube from the vessel. Following those changes and a break, another attempt was made which was successful. The source was secured within the camera and no immediate damage to the source was evident from a field wipe test which showed background levels of radiation. The maximum recorded exposure to recovery personnel was approximately 140 milliR as measured by DRD. All associated equipment was returned to Team Industrial's permanent storage facility in Roxana, IL that same night by 23:00. Plans are to return the source with camera, drive cable and guide tubes to the manufacturer for further analysis as to a potential cause of the event. The radiography crew reported that prior to the days events, routine checks showed the equipment was in properly operating condition. They further insist that a 'misconnect' where the drive cable was not properly connected to the source did not occur in this case. The licensee has been advised that a 30 day report to the Agency is required. This item will remain open pending receipt of that report and the analysis of the manufacturer as to the state of the returned equipment. Illinois Report Number: IL080051 | ||
| ENS 44369 | 25 July 2008 05:00:00 | Agreement State | Agreement State Report - Radiography Camera Malfunction | This report was received from the state by facsimile. On July 25, 2008, TEAM Industrial Services reported that a source was stuck in the guide tube and could not be returned to the shielded position. The industrial radiography camera involved is a AEA 880 Delta with serial number D2847. The source involved is an AEA source with serial number 45020B that is 49.8 Ci of Ir-192. While the source was in the collimator, the stand that was being used to x-ray welds fell on the guide tube. The radiographers attempted to return the source to the shielded position but could not. The radiographers then returned the source to the collimator and set up a 1 mr/hr boundary around the source. They called the Radiation Safety Officer for TEAM. TEAM contacted QSA Global to retrieve the Ir-192 source. The source was retrieved on July 25, 2008 at 5:30 PM. The guide tube and stand have been taken out of service. The camera and crank-outs are being sent to QSA Global to be inspected. Event Report ID: LA0800016 | ||
| ENS 44145 | 17 April 2008 05:00:00 | Agreement State | Radiography Camera Malfunction | This "incident occurred on April 15, 2008 at about 8:20 PM at a new (non-nuclear) power plant under construction. Team Industrial Services was performing industrial radiography on Unit 1. The radiography was being performed on elevation 807 on a header approximately 4 foot off of the roof of the boiler. According to statements from the crew, they had exposed the source on their first shot of the pipe weld, and approximately 15 seconds into the shot they heard what they thought was the guide tube and collimator faillng off the pipe to the roof of the boiler. They then went to retract the source back into the exposure device and encountered an obstruction preventing the source from being retracted into a secured position in the exposure device. They attempted (to retract the source) three times with no success. The industrial radiographer contacted the facility radiation safety officer and advised him that he had a source he could not retract back into the exposure device. The industrial radiographer extended the radiation safety boundaries above and below the area. The Radiation Safety Officer (RSO) advised (the radiographer) that he was on his way to the site. The RSO arrived at the site at approximately 9:00 PM. At this time an initial assessment was made and a decision was made to bring in two more trained technicians to assist with boundary control and retrieval of the sealed source. After arrival of the extra technicians, a plan for retrieval was discussed with all technicians, including the Corporate Radiation Safety Officer. The industrial radiographer stated that his pocket dosimeter had gone 'off scale.' This means that he could have received a dose of at least 200 millirems of radiation. At this time he was advised that he would not be assisting with the retrieval but he continued to assist with boundary control. The licensee has estimated that the industrial radiographer received 630 mR. At approximately 11:35 PM, the shielding of the source and attempt to repair the guide tube commenced. Four lead shot bags were placed over the end of the guide tube where the sealed source was known to be. The radiation levels were reduced to 15 millirems per hour at five feet from the source under the lead shot bags. The RSO then approached the guide tube with a pair of pliers, located the distortion in the guide tube and rounded it with the pliers. He then returned to the crank assembly and retracted the source successfully back into the exposure device. The RSO is estimated to have received 32 mR from conducting the repair. A determination was made that there was not an equipment failure, it was a result of the guide tube falling from the pipe to the roof of the boiler that damaged the guide tube resulting in the obstruction. Boundaries were maintained throughout the incident to ensure that at no time any member of the general public could enter the incident area. DHFS plans to investigate this incident on the next inspection (to be conducted in the near future). | ||
| ENS 44019 | 28 February 2008 06:00:00 | Agreement State | Agreement State Report - Overexposed Personnel Monitoring Badge | The following information was received from the State of Louisiana via fax: On February 28, 2008, TEAM Industrial Services reported that an industrial radiographer's personnel monitoring badge received an excessive exposure of 10 rem. The industrial radiographer left his badge in the work truck while he was not performing radiography for a few days. The truck was parked next to a tank that was being x-rayed. According to TEAM, this exposure was just to the badge and not to the radiographer. According to TEAM, the actual exposure to the radiographer is 67 mrem. This incident is under investigation and further information will be forwarded once available. LA Event Report ID: LA 080006 | ||
| ENS 43504 | 18 July 2007 15:00:00 | Agreement State | Agreement State Report - Defective Radiography Camera | The licensee provided the following information via email: Licensee notified (Ohio) Bureau of Radiation Protection (BRP) at approximately 11:00 AM on 7/18/07. Licensee reported that an Ir-192 radiography source in the guide tube of a radiography camera could not be fully retracted. Source is housed in an Amersham Model 660B camera (Serial number: B1558). Source activity is 86 curies. Source was being used at a temporary job site in East Palestine, Ohio. Radiography crew was from licensee's Pennsylvania office. Source was being used in a building away from customer's main production facilities, in a make-shift chamber behind 3 foot concrete block walls. Area has been secured by licensee personnel, roped off, with boundaries established to ensure no exposure to non-radiological workers or members of the public. Licensee stated that no over exposure licensee personnel are expected as a result of this occurrence. QSA Global has been contacted by licensee to assist with source retrieval. Information current as of 11:45 AM, 7/18/07. UPDATE: Ohio BRP Duty Officer received call from QSA Global requesting waiver of 3-day notification for reciprocity work to enter Ohio and retrieve stuck source. Permission was granted. QSA Global rep stated that they would not be on-site until Thursday, 7/19. Information current as of 5:00 PM, 7/18/07. UPDATE: BRP Duty Officer contacted Licensee rep at temporary job site to discuss security of the camera and source. Licensee stated that boundaries are being maintained at the site and that the licensee would have a two-man crew (radiographer and assistant) on site throughout the night until QSA Global arrived to effect repairs. Information current as of 5:30 PM, 7/18/07. UPDATE: BRP Duty Officer spoke with licensee personnel Thursday morning, 7/19/07. Licensee had crews in attendance at the site throughout the night to maintain security of temporary job site. Licensee stated that the radiography camera had been maintenenced and resourced approximately two weeks ago. After discussions with the manufacturer the licensee suspects that a spring clip at the connecting nut may have dislodged, causing the nut to become misaligned and preventing the source from retracting. QSA Global is expected on site at approximately 1:30 PM on today (7/19/07). Information current as of 9:25 AM, 7/19/07. Equipment is being returned to manufacturer for repair or disposal. Ohio Notice: OH070004 | ||
| ENS 42619 | 2 June 2006 14:30:00 | Agreement State | Agreement State Report - Personnel Overexposure | The State provided the following information via facsimile: On June 1, 2006, a radiographer technician and an assistant from Team Industrial Services, Inc. performed multiple radiography exposures. After the 19th exposure, the radiographers reported "slightly more friction and resistance" when performing exposures at an elevated location. Approximately at 09:30, the final exposure was performed at an elevated location, the source was retracted with the fore noted additional resistance, and the "crank handle was rotated to the shielded position. No abnormal operation was noted and the lock plunger came up to the locked position. However, a survey of the exposure device is required by Team Industrial Services' Operating and Emergency procedures, the NRC and the LA DEQ (Louisiana Department of Environmental Quality). No survey was performed." The radiographers then had difficulty disconnecting the source tube and control assembly. The camera was placed in the truck. The truck was then driven to the control room, to the OSI trailer, and to the shop. The radiographers then went to lunch. After lunch, the radiographers went to their shop, unloaded the camera and realized the source pigtail was not in the camera. The calculated worst case dose to Control Room personnel was 0.38 milliRem, to OSI trailer personnel was 20.7 milliRem, an inhabited office near the OSI trailer was 10.83 milliRem, and a second inhabited location near the OSI trailer was 29 milliRem. "At no time during the sequence of events did any unmonitored personnel approach the truck. Team Industrial Services, Inc. calculated the worse case dose for the technician as 13 Rem and the actual TLD dose was 1.1 Rem. The calculated worse case dose for the assistant was 14.5 Rem and the actual TLD dose was 2.2 Rem. These TLD doses included previous doses received in May. The licensee is performing radiation blood analysis on the two radiographers. Source: Ir-192, 40.5 Curies. Louisiana Report: LA060010 |