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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55879 | 3 May 2022 04:00:00 | Agreement State | Malfunctioning Shutter | The following was received from the state of Pennsylvania (the Department) via email: On May 4, 2022, the licensee informed the Department of an equipment malfunction. The licensee reported that on May 3, 2022 a QSA Global Model 880 containing a 37 Curie source of Iridium-192 malfunctioned. The camera's serial number is D15520 and the source serial number is 36110M. During the course of radiographic operations, the automatic lock slide that secures the source failed to completely close. While the source was completely retracted, secured, and verified using a survey meter, the camera was not fully functioning as intended. The licensee contacted with QSA Global, who suspect a spring malfunction. The camera was sent back to QSA for evaluation and repair. There were no overexposures because of this event. PA Event Report No: PA220015 | ||
| ENS 55372 | 21 July 2021 04:00:00 | Agreement State | Radiography Source Failed to Retract | The following was received via an email from the Pennsylvania Bureau of Radiation: The licensee reported that on July 21, 2021, while using a QSA Global Model 880 containing a 135.5 curie source of iridium-192, the source failed to fully retract and lock. The source serial number is 32578M and the camera serial number is D9477. The technicians secured the area by adjusting their 2 mR/hr boundaries to an unshielded source distance and immediately contacted their company (Radiation Safety Officer) (RSO). The licensee then contacted QSA Global who will be onsite on July 22, 2021, to retrieve the source and take the camera and entire crank and assembly mechanism with them for evaluation. The licensee will remain onsite to secure the boundary until QSA arrives. No overexposures have occurred and all proper procedures were followed. The cause of the malfunction remains unknown. More information will be provided when received. Pennsylvania Event Report ID No.: PA210007
The following update was received via an email from the Pennsylvania Bureau of Radiation: QSA arrived on site at approximately 2000 EDT on July 22, 2021, and the source was moved to a locked position in the camera at 2155 EDT. At this time the drive cable is suspected to be the problem. The camera and drive system will be evaluated. Notified R1DO (Gray) and NMSS Events Notification via email. | ||
| ENS 55158 | 12 February 2021 04:00:00 | Agreement State | Radiography Source Failed to Retract | The following was received by email from the Commonwealth of Pennsylvania: The licensee reported that on February 12, 2021 while using a QSA Global Model 880, Serial # D15520, containing a 128 Curie source of iridium-192, the source failed to fully retract and lock. The technicians secured the area by adjusting their 2 mR/hr boundaries to an unshielded source distance and immediately contacted their company designee. Once on scene, the designee surveyed the scene and device and found elevated readings. Working the crank handle back and forth several times he was able to return the source to the secured and locked position. The device was taken back to the licensee's storage vault in Williamsport, PA for inspection. The cause of the incident is believed to be cold temperature and freezing of the lock mechanism. The Radiation Safety Officer (RSO) subsequently investigated the incident and found that neither the radiographer nor the assistant radiographer had been performing proper radiation surveys during the workday which would have identified the lock failure sooner. As a result, the radiographer received a dose of 876 mR. We are still awaiting a dose on the assistant radiographer. Corrective actions include retraining all radiography employees to follow proper procedure. Also, both the radiographer and assistant radiographer are no longer employed by the licensee. PA Event Report ID No: PA210003 |