The following is a synopsis of information received via E-mail:
On March 22, 2018, LA-DEQ (Louisiana Department of Environmental Quality) received an on-line notification that CAN USA Inc. had an incident where a radiography source was irretrievable during operations at a temporary jobsite at the Phillips 66-Alliance Refinery in Belle Chase, LA.
The crew stated they had made an exposure and were performing their post-job survey when the survey meter indicated the source was not in the shielded position. The radiography crew realized the source could not be retracted back into the shielded position and called the assistant RSO (Radiation Safety Officer) for radiation safety assistance.
The assistant RSO arrived at the jobsite at 0615 CDT. The assistant RSO covered the source in the guide tube with lead shot bags to reduce the exposure during the retrieval operation. It was determined that the guide tube had disconnected from the exposure device. The guide tube was reconnected, the source was returned to the shielded position, and an investigation into this incident begun. The assistant RSO completed the retrieval work at approximately 0645 CDT. The assistant RSO's direct read pocket dosimeter had an exposure of approximately 60 mR.
The exposure device and associated equipment (crankout control and source guide tube) were taken to the CAN USA facility for further evaluation. The equipment is a QSA Global Model 880 Delta exposure device, S/N D9222, utilizing a 70.7 Ci Ir-192 source, S/N 63452-G. An internal investigation continues into this irretrievable source incident.
Louisiana Event Report ID No.: LA-180005
- * * UPDATE AT 1730 EDT ON 3/29/18 FROM JOE NOBLE TO JEFF HERRERA * * *
The following update was submitted by the Louisiana Department of Environmental Quality via email:
Updated information:
A source retrieval has developed into a situation involving, licensed activities, equipment QC/QA practices and personnel qualifications.
QSA Global Delta 880, S/N D9222; source [approximately] 70 Ci of Ir-192 s/n 63452-G
Associated Equipment: 3rd party, drive cable and source guide tube. (not Amersham/QSA Global manufactured equipment)
The connector did not appear to be compatible with the exposure device source assembly in the Delta 880 device. (excessive use)
A misconnect/disconnect test was not performed on the source assembly and 3rd party associated equipment (drive cable and guide tube).
Assessment and Evaluation: the exposure device and associated equipment were transferred to QSA Global, Baton Rouge, LA then to QSA Global Burlington, MA.
CAN USA Inc. was not licensed to perform source retrievals nor did they contact a 'qualified licensed radiation service' company to perform the source retrieval. The Corporate RSO, [deleted] was available by telephone. There was no site/assistant RSO trained or qualified to perform the source retrieval.
Disconnect happened on a 15 foot elevated catwalk [at] an Aromatics Extractor unit # 1797. The facility, Phillips 66-Alliance, [deleted]. Phillips 66-Alliance Contact: [deleted], EHS Officer
Personnel:
CAN USA:
Two Radiography Instructors were directly involved in the source retrieval.
Two Carded Radiographers were working with the equipment when it disconnected on the first exposure.
Provided Pocket Dosimeter readings 'provided' were 8 mR, 30 mR, 40 mR and 70 mR.
Landaure whole body badges immediately processes for three individuals, with the Maximum exposure 290 mrem. The acting site RSO, [deleted] whole body badge is 'lost' in the system.
The individuals involved in the source retrieval are having cytogenetic/chromosomal blood sample analysis by REACTS Medical Dosimetry Dept./ORISE.ORAU; results pending.
Analytical Stress Employees.
Three non-radiation workers were evacuated from the vicinity of the disconnected source and evaluated by blood sample analysis.
SWAT Specialty Welding and Turnaround:
One non-radiation worker was evacuated from the vicinity of the disconnected source and evaluated by blood sample analysis.
The Departmental [Louisiana Department of Environmental Quality] investigation is still incomplete depending on assessment, evaluation and analysis results.