ENS 55667
ENS Event | |
|---|---|
03:00 Dec 17, 2021 | |
| Title | Radiography Device Safety Latch Failure |
| Event Description | The following information was received from the California Department of Public Health, Radiologic Health Branch (RHB) via email:
On 12/17/2021, the licensee notified RHB of an incident in which an INC IR-100 (S/N 7362) radiography exposure device, containing a 54.2 Ci Ir-192 QSA Global source (S/N 55806M), failed to actuate its safety latch plate upon retracting the Ir-192 source to the fully shielded position. The incident occurred on 12/16/2021, at approximately 1900 PST, at the PBF refinery in Martinez, CA. The radiography site was approximately 150 ft. above grade, on temporary staging, and accessed by an adjacent permanent deck. The RSO [(radiation safety officer)] stated that the device was used all day without issue prior to the safety latch plate's actuation failure. The initial personnel during the incident consisted of a radiographer trainer and an assistant radiographer. The radiographer trainer noticed the failure when attempting to 'crank out' after fully retracting the source. After attempting to fully retract the source, the latch plate maintained a visibly depressed position and the source was not fully secured and free to move. The radiography trainer contacted the RSO for further assistance during which an additional radiographer trainer assisted with maintaining security of the barricaded area until the RSO and staff arrived on the site. The RSO stated that he was able to secure the source by flushing the locking mechanism with brake cleaner and that there was no excessive exposure to any personnel involved. RHB will be investigating this incident further. CA 5010 Number: 121721 |
| Where | |
|---|---|
| Marathon Martinez Renewable Fuels Benicia, California (NRC Region 4) | |
| License number: | 4886-48 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+90.87 h3.786 days <br />0.541 weeks <br />0.124 months <br />) | |
| Opened: | Kamani Hewadikaram 21:52 Dec 20, 2021 |
| NRC Officer: | Mike Stafford |
| Last Updated: | Dec 20, 2021 |
| 55667 - NRC Website
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Martinez Refining Company with Agreement State | |
WEEKMONTHYEARENS 571702024-06-04T17:34:0004 June 2024 17:34:00
[Table view]Agreement State Agreement State Report - Stuck Source ENS 564882023-04-25T04:00:00025 April 2023 04:00:00 Agreement State Damaged Radiography Camera ENS 559712022-06-16T07:00:00016 June 2022 07:00:00 Agreement State Lost Shipment ENS 558722022-05-02T05:00:0002 May 2022 05:00:00 Agreement State Radiography Source Disconnect ENS 557172022-01-28T05:00:00028 January 2022 05:00:00 Agreement State Radiography Camera Equipment Failure ENS 556672021-12-17T03:00:00017 December 2021 03:00:00 Agreement State Radiography Device Safety Latch Failure ENS 530332017-10-19T16:05:00019 October 2017 16:05:00 Agreement State Agreement State Report - Whole Body Monitor Exceeded the Annual Occupational Exposure Limit ENS 527042017-04-20T17:30:00020 April 2017 17:30:00 Agreement State Agreement State Report - Unsecured Radiography Camera ENS 521992016-08-24T05:00:00024 August 2016 05:00:00 Agreement State Agreement State Report - Potential Radiographer Overexposure ENS 521102016-07-18T23:05:00018 July 2016 23:05:00 Agreement State Agreement State Report - Radiographer Unplanned Exposure ENS 516412015-12-19T06:00:00019 December 2015 06:00:00 Agreement State Agreement State Report - Human Error Prevents a Radiography Source from Retracting ENS 516082015-12-11T22:38:00011 December 2015 22:38:00 Agreement State Agreement State Report - Unattended Radiographic Exposure Device ENS 503422014-05-30T00:30:00030 May 2014 00:30:00 Agreement State Agreement State Report - Failure of Source to Retract ENS 498162014-02-09T18:35:0009 February 2014 18:35:00 Agreement State Agreement State Report - Radiography Camera Left Unattended ENS 498172014-02-09T14:00:0009 February 2014 14:00:00 Agreement State Agreement State Report - Radiography Camera Source Disconnect ENS 496362013-12-14T08:00:00014 December 2013 08:00:00 Agreement State Agreement State Report - Stuck Radiography Source ENS 490092013-05-06T05:00:0006 May 2013 05:00:00 Agreement State Agreement State Report - Stuck Radiography Source 2024-06-04T17:34:00 | |