Information Notice 1991-23, Accidental Radiation Overexposures to Personnel Due to Industrial Radiography Accessory Equipment Malfunctions

Accidental Radiation Overexposures to Personnel Due to Industrial Radiography Accessory Equipment Malfunctions

ML031190662
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Crane
Issue date:	03/26/1991
From:	Cunningham R Office of Nuclear Material Safety and Safeguards
To:
References
IN-91-023, NUDOCS 9103200074
Download: ML031190662 (8)

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

WASHINGTON, D.C. 20555

March 26, 1991 NRC INFORMATION NOTICE NO. 91-23: ACCIDENTAL RADIATION OVEREXPOSURES TO

PERSONNEL DUE TO INDUSTRIAL RADIOGRAPHY

ACCESSORY EQUIPMENT MALFUNCTIONS

Addressees

All Nuclear Regulatory Commission (NRC) licensees authorized to use sealed

sources for industrial radiography.

Purpose

This information notice is being issued to alert licensees to recent

radiography incidents involving both extremity and whole body overexposures

of radiographers. These occurred during industrial radiographic operations

as a result of:

(1) not surveying a radiographic exposure device and source

guide tube after each exposure; or (2) using either a magnetic or non-magnetic

stand for applications that applied stresses exceeding the limits of the stand.

It is expected that licensees will review this notice, distribute it to

responsible staff, and consider actions, as appropriate, to avoid similar

problems. However, suggestions contained in this information notice do not

constitute any new NRC requirements, and no written response is required.

Description of Circumstances

The following cases are recent events reported to NRC that have resulted in

radiation overexposures to radiographers and radiography assistants as a

result of improper handling of radioactive sealed sources and inattention

to radiation safety procedures.

Case 1:

A radiographer had been performing exposures of welds at the base

T a 300,000 gallon waste storage6tank, with a radiography camera equipped

with a 14-foot guide tube. A tungsten collimator had been positioned on the

end of a guide tube that was clamped to a stand that was magnetically attached

to the tank wall. After cranking out the 80-curie iridium-192 (Ir-192) source

for an exposure approximately 10 feet above the base of the tank, the radiogra- pher heard the collimator fall. After straightening out the guide tube, the

radiographer fully retracted the cable, and consequently thought that the

source was in the shielded position of the camera. Subsequently, the radiogra- pher removed his dosimetry, picked up a survey instrument, walked up to the end

of the source guide tube and removed the collimator, without observing the meter

reading.

As he was unscrewing the nozzle of the guide tube, the source fell-to

the ground. The radiographer immediately left the area, and notified the proper

authorities. Exposure estimates to the radiographer, based on source activity

and exposure time estimates, are 8.9 rem whole body, and 1070 rem to the right

hand.

IN 91-23 March 26, 1991 Case 2: A radiographer and his assistant were performing radiographic

exposures of welds on a 48-inch diameter tank.

After the sixth exposure, the radiographer left the immediate area to load film in a belt. While the

radiographer was away, the assistant set up the seventh exposure and cranked

out the source. The assistant had turned the crank about two or three times

when he saw that the magnetically mounted stand, that held the guide tube

near the exterior of the tank, had fallen.

When the stand fell, the assistant's

personnel dosimeter (chirper) began to alarm, so he quickly cranked the source

back into the shielded position. Because his chirper stopped alarming, he

thought that the source was in the shielded position, so he did not survey

the area (the licensee later reported that the chirper was found to be

malfunctioning due to a shorted ground wire). Instead, he walked over to the

tank, repositioned the magnetic stand and source guide tube with his right

hand, and returned to the camera to proceed with the exposure. When he cranked

out the 50-curie Ir-192 source, he noted that his chirper did not alarm, so he

looked at his pocket dosimeter and noticed that it was off scale high. When

the radiographer returned, the assistant told him what had happened and that

his pocket dosimeter had gone off scale. The assistant told the radiographer

that he did not think he had received an overexposure, but that he thought his

pocket dosimeter was off-scale because he had bumped it earlier. The radiographer

and his assistant continued to work and did not inform the Radiation Safety

Officer of the incident until the assistant's hands showed clinical signs of

radiation injury.

From reenactments, clinical observations, and calculations, the overexposure to the assistant radiographer's hand was estimated to be

between 1500 and 3000 rem. The attending physician stated that amputation of

one or more fingers could be necessary. The whole body dose to the assistant, as measured by his TLD, was 365 millirem.

Case 3:

This radiographic operation involved the use of an 80-curie Ir-192 source. After completing two radiographs of a pipe weld, an assistant

radiographer disassembled the equipment in order to move the exposure device

to another location. While doing this, he removed the source guide tube and

draped it around his neck so that his hands would be free to carry the

remaining equipment approximately 50 feet.

As he removed the guide tube from

around his neck, he noticed that the sealed source fell from the tube to the

ground.

The assistant notified the radiographer, who telephoned the company

owner and, following his direction, successfully retrieved the source to a

shieldeG position within the exposure device.

The radiographer's film badge

was immediately sent for processing (the assistant radiographer was not wearing

a dosimeter and was immediately sent to a hospital for a medical examination).

The cytogenetic studies revealed equivalent whole body doses of 17 rem for the

radiographer and 24 rem for the assistant.

The assistant developed an area of

redness on the left side of his neck, which later showed signs of more

significant damage to skin tissue in an area approximately 10 centimeters in

diameter. The physician determined that the observed effect corresponded to

an overexposure to the skin of 5000-7000 rem. There were no medical effects

observed for the radiographer.

IN 91-23 March 26, 1991 Discussion:

All licensees are reminded of the importance of ensuring the safe performance

of licensed activities, in accordance with NRC regulations, requirements of

their licenses, and accepted health physics practices. The aforementioned

cases illustrate: the lack of radiation surveys following the retraction of a

sealed source; failure to wear a direct reading pocket dosimeter and either a

film badge or TLD; failure to personally supervise an assistant radiographer

while using radiographic exposure devices; the improper use of a magnetic or

non-magnetic stand that cannot hold the weight of the intended equipment

(such as a 12-pound collimator); the necessity of consistently following

standard operating and, when necessary, emergency procedures; and the need to

understand the significance of radiation doses that result from the misuse of

large radiographic sources. Sealed sources for radiography are capable of

delivering significant unintended exposures to radiographers, assistants, and

members of the general public, when source management procedures are not

followed.

Although it might seem obvious that common sense would prevent radiation

workers from picking up highly radioactive sources or guide tubes that might

inadvertently contain a dislodged radiographic source, the number of

unplanned radiation exposures of this type indicates that "common sense'

cannot be counted on, in such a situation. Licensees are responsible for

ensuring the safe performance of licensed activities in accordance with NRC

regulations and the terms of their licenses. In so doing, licensees should

not only provide adequate training, but should also exercise close supervision

over their employees, to ensure compliance with procedures and with NRC or any

other applicable requirements. All'workers should understand the consequences

of improperly handling a radiographic source containing large quantities of

Ir-192. Such improper handling can cause a significant, undesired, radiation

dose to both the whole body and extremities, and can easily result in the

amputation of several fingers, the development of a tumor, or death.

No written response is required by this information notice.

If you have any- questions about this matter, please contact the appropriate regional office

or this office.

Richard E. Cunningham, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Cynthia G. Jones, NMSS

(301) 492-0629 Attachments:

1. List of Recent NMSS Information Notices

2. List of Recent NRR Information Notices

Attachment 1

IN 91-23

March 26, 1991 LIST OF RECENTLY ISSUED

NMSS INFORMATION NOTICES

Information

Date of

Notice No.

Subject

Issuance

Issued to

91-16

91-14

91-03

91-02

Unmonitored Release Pathways

from Slightly Contaminated Re- cycle and Recirculation Water

Systems At A Fuel Facility

Recent Safety-Related Inci- dents at Large Irradiators

Management of Wastes Contam- inated with Radioactive

Materials ("Red Bag" Waste

and Ordinary Trash)

Brachytherapy Source Management

Requirements for Use of

Nuclear Regulatory Comm- ission-(NRC-)Approved

Transport Packages for

Shipment of Type A Quanti- ties of Radioactive Materials.

Fitness for Duty

Denial of Access to

Current Low-Level Radio- active Waste Disposal

Facilities

Effective Use of Radiation

Safety Committees to

Exercise Control Over

Medical Use Programs

03/06/91 All fuel cycle facilities.

03/05/91

All Nuclear Regulatory

Commission (NRC) licensees

authorized to possess and

use sealed sources at

large irradiators.

01/07/91 All medical licensees.

01/07/91

All Nuclear Regulatory

Commission (NRC) medi- cal licensees author- ized to use byproduct

material for medical

purposes.

12/31/90

All registered users

of NRC-approved

packages.

12/24/90

All U.S. Nuclear

Regulatory Commission

(NRC) and non-power

reactor licensees.

12/5/90

All Michigan holders

of NRC licenses.

11/6/90

All NRC licensees

authorized to use

byproduct material

for medical purposes.

90-82

90-81

90-75

90-71

Attachment 2

I'

N 91-23

.

March 26, 1991 LIST OF RECENTLY ISSUED

NRC INFORMATION NOTICES

Information

Date of

Notice No.

Subject

Issuance

Issued to

91-22

91-21

91-20

90-43, Supp. 1

91-19

91-18

90-25, Supp. 1

91-17

91-16 Four Plant Outage Events In- volving Loss of AC Power or

Coolant Spills

Inadequate Quality Assurance

Program of Vendor Supplying

Safety-Related Equipment

Electrical Wire Insulation

Degradation Caused Failure in

A Safety-Related Motor

Control Center

Mechanical Interference with

Thermal Trip Function in GE

Molded-Case Circuit Breakers

Steam Generator Feedwater

Distribution Piping Damage

High-Energy Piping Failures

Caused by Wall Thinning

Loss of Vital AC Power with

Subsequent Reactor Coolant

System Heat-Up

Fire Safety of Temporary

Installations or Services

Unmonitored Release Pathways

from Slightly Contaminated

Recycle and Recirculation

Water Systems at A Fuel

Facility

03/19/91

All holders of OLs or

CPs for nuclear power

reactors.

03/19/91

All holders of OLs or

CPs for nuclear power

reactors and all

recipients of NUREG-004(

"Licensee Contractor an(

Vendor Inspection Statu!

Report" (White Book).

03/19/91

All holders of OLs or

CPs for nuclear power

reactors.

03/13/91

All holders of OLs or

CPs for nuclear power

reactors.

03/12/91

All holders of OLs or

CPs for pressurized

water reactors (PWRs).

03/12/91

All holders of OLs or

CPs for nuclear power

reactors.

03/11/91

All holders of OLs or

CPs for nuclear power

reactors.

03/11/91

All holders of OLs or

CPs for nuclear power

reactors.

03/06/91

All fuel cycle

facilities.

OL = Operating License

CP = Construction Permit

IN 91- March , 1991 Discussion:

All licensees are reminded of the importance of ensuring the safe performance

of licensed activities, in accordance with NRC regulations, requirements of

their licenses, and accepted health physics practices.

The aforementioned

cases illustrate: the lack of radiation surveys following the retraction of a

sealed source; failure to wear a direct reading pocket dosimeter and either a

film badge or TLD; failure to personally supervise an assistant radiographer

while using radiographic exposure devices; the improper use of a magnetic or

non-magnetic stand that cannot hold the weight of the intended equipment

(such as a 12-pound collimator); the necessity of consistently following

standard operating and, when necessary, emergency procedures; and the need to

understand the significance of radiation doses that result from the misuse of

large radiographic sources.

Sealed sources for radiography are capable of

delivering significant unintended exposures to radiographers, assistants, and

members of the general public, when source management procedures are not

followed.

Although it might seem obvious that common sense would prevent radiation

workers from picking up highly radioactive sources or guide tubes that might

inadvertently contain a dislodged radiographic source, the number of

unplanned radiation exposures of this type indicates that "common sense"

cannot be counted on, in such a situation.

Licensees are responsible for

ensuring the safe performance of licensed activities in accordance with NRC

regulations and the terms of their licenses.

In so doing, licensees should

not only provide adequate training, but should also exercise close supervision

over their employees, to ensure compliance with procedures and with NRC or any

other applicable requirements.

All workers should understand the consequences

of improperly handling a radiographic source containing large quantities of

Ir-192.

Such improper handling can cause a significant, undesired, radiation

dose to both the whole body and extremities, and can easily result in the

amputation of several fingers, the development of a tumor, or death.

No written response is required by this information notice.

If you have any

questions about this matter, please contact the appropriate regional office

or this office.

Richard E. Cunningham, Director

Division of Industrial and

Cynthia G. Jones, NMSS

(301) 492-0629 Attachment:

1. List of Recent NMSS Information Notices

2. List of Recent NRR Information Notices

Editor/NMSS

EKraus

3/06/91

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OFFICIAL RECORD COPY

INRADIO

IN 91- March

, 1991 Discussion:

All licensees are reminded of the importance of ensuring the safe performance of

licensed activities, in accordance with NRC regulations, requirements of their

licenses, and accepted health physics practices.

The aforementioned cases

illustrate: the lack of radiation surveys following the retraction of a sealed

source; failure to wear a direct reading pocket dosimeter and either a film

badge or TLD; failure to personally supervise an assistant radiographer while

using radiographic exposure devices; the improper use of a magnetic or

non-magnetic stand that cannot hold the weight of the intended equipment (such

as a 12-pound collimator); the necessity of consistently following standard

operating and, when necessary, emergency procedures; and the need to understand

the significance of radiation doses that result from the misuse of large

radiographic sources.

Sealed sources for radiography are capable of delivering

significant unintended exposures to radiographers, assistants, and members of

the general public, when source management procedures are not followed.

Although it might seem obvious that common sense would prevent radiation workers

from picking up highly radioactive sources or guide tubes that might inadvertently

contain a dislodged radiographic source, the number of unplanned radiation

exposures of this type indicates that "common sense" cannot be counted on, in

such a situation.

Licensees are responsible for ensuring the safe performance

of licensed activities in accordance with NRC regulations and the terms of

their licenses.

In so doing, licensees should not only provide adequate training, but should also exercise close supervision over their employees, to ensure

compliance with procedures and with NRC or any other applicable requirements.

All workers should understand the consequences of improperly handling a radiographic

source containing large quantities of Ir-192.

Such improper handling can cause

a significant, undesired, radiation dose to both the whole body and extremities, and can easily result in the amputation of several fingers, the development of

a tumor, or death.

No written response is required by this information notice.

If you have any

questions about this matter, please contact the appropriate regional office or

this office.

Richard E. Cunningham, Director

Division of Industrial and

Cynthia G. Jones, NMSS

(301) 492-0629 Attachments:

1. List of Recent NMSS Information Notices

2. List of Recent NRR Information Notices

Editor/NMSS

EKraus

3/06/91

• See previous concurrence

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OFFICIAL RECORD COPY

INRADIO

IN 91- March , 1991 Discussion:

All licensees are reminded of the importance if ensuring the safe performance of

licensed activities, in accordance with NRC regulations, requirements of their

licenses, and accepted health physics practices. The aforementioned cases

illustrate: the lack of radiation surveys following the retraction of a sealed

source; failure to wear a direct reading pocket dosimeter and either a film

badge or TLD; failure to personally supervise an assistant radiographer while

using radiographic exposure devices; the improper use of a magnetic or

non-magnetic stand which cannot hold the weight of the intended equipment (such

as a 12-pound collimator); the necessity of consistently following standard

operating and, when necessary, emergency procedures; and a need to understand

the significance of radiation doses that result from the misuse of large

radiographic sources. Sealed sources for radiography are capable of delivering

significant unintended exposures to radiographers, assistants and members of

the general public, when source management procedures are not followed.

Although it may appear obvious that common sense should prevent radiation

workers from picking up highly radioactive sources or guide tubes that may

inadvertently contain a dislodged radiographic source, the number of unplanned

radiation exposures of this type indicates that "common sense" has not been

effective. Licensees are responsible for ensuring the safe performance of

licensed activities in accordance with NRC regulations and the terms of their

licenses.

In so doing, licensees should not only provide adequate training, but

should also exercise close supervision over their employees to ensure compliance

with procedures and with NRC or any other applicable requirements. All workers

should have a clear understanding of the significance of improperly handling a

radiographic source containing large quantities of Ir-192. Consequently, the

potential for causing a significant, undesired radiation dose to both whole body

and extremities are great, and can easily result in severe radiation consequences:

the amputation of several fingers, the development of a tumor, or death.

No written response is required by this information notice. If you have any

questions about this matter, please contact the appropriate regional office or

this office.

Richard E. Cunningham, Director

Division of Industrial and

Cynthid G. Jones, NMSS

(301) 492-0629 Attachments:

1. List of Recent NMSS Information Notices

2. List of Recent NRR Information Notices

Editor/NMSS

EKraus

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OFFICIAL RECORD COPY

INRADIO