ENS 49912
ENS Event | |
|---|---|
05:00 Mar 12, 2014 | |
| Title | Texas Agreement State Report - Potential Overexposure To A Radiographer'S Hand |
| Event Description | The following information was received from the State of Texas via email:
On March 13, 2014, the Agency [Texas Department of Health] was notified by the licensee's Site Radiation Safety Officer (SRSO) that one of its radiographer trainees may have received an overexposure while performing radiography at a field site on March 12, 2014. The radiographers were using a QSA880D camera containing a 69 curie iridium - 192 source. At 2100 hours0.0243 days <br />0.583 hours <br />0.00347 weeks <br />7.9905e-4 months <br /> [CDT], the radiographers had completed a shot and the trainee went to the camera to disconnect the guide tube from the camera. The trainee stated while attempting to disconnect the guide tube he observed the reading on the dose rate meter had gone back up. The trainee backed away from the camera and the source was returned to the fully shielded position. It is unknown at this time where the source was located in the guide tube. The SRSO stated the trainee may have been in contact with the guide tube for as long as 15 seconds. The SRSO stated the radiographer trainer was near the trainee during the event. The SRSO stated the trainee's self-reading dosimeter was off scale. The SRSO did not know if the trainee's alarming rate meter was alarming at the time of the event. The SRSO stated he was not at the licensee's facility when he contacted this Agency, but he was returning to the facility. The SRSO stated he would provide additional information as soon as they had a chance to interview the individuals involved. The Agency contacted the licensee's Corporate Radiation Safety Officer who stated they were on their way to the company's facility to do reenactments and preliminary dose assessments. The SRSO stated the trainee's dosimetry had been collected and will be sent for processing. No other individual received an exposure due to this event. The Agency contacted the Radiation Emergency Assistance Center/Training Site (REAC/TS) and informed them of the event. REAC/TS agreed to provide the licensee with assistance when requested. Additional information will be provided as it is received in accordance with SA-300. Texas Incident # I-9167
The Agency was contacted by the licensee's Corporate Radiation Safety Officer (CRSO) at 1700 [CDT] on March 13, 2014 and provided with additional information on the event. The CRSO stated they had interviewed the radiographers involved in the event and discovered a second radiography trainee was involved. The CRSO stated the three individuals were shooting welds on a tank. The two radiography trainees were inside the tank in a man lift basket operating the camera. The camera would hang on the side of the tank. The radiography trainees would place the collimator to perform the shoot and then back off from the camera the distance of the control cables, approximately 35 feet, and operate the camera. The trainer was in a man lift outside the tank placing film. The CRSO stated the camera had been retrieved from the wall of the tank and placed in the basket with them while they waited to set up for the next shoot. The radiography trainees stated they were in the basket for as long as 15 minutes, with the source not fully shielded. The radiography trainee who tried to remove the guide tube stated he had difficulty removing the guide tube, so the 10 to 15 second estimate for the time he spent trying to remove the guide tube was accurate. The radiography trainee stated when they retracted the source to the fully locked position, it took about one quarter turn of the crank handle to fully retract the source. During the interviews with the radiographers, it was discovered that the radiography trainee who attempted to remove the guide tube was not wearing any personnel monitoring devices. He had left them in the truck. The other radiography trainee was wearing their dosimetry, but failed to turn the alarming rate meter on. The CRSO stated the dosimetry will be sent to their dosimetry [lab] for processing. The CRSO stated they had contacted REAC/TS for assistance. They have taken the radiography trainee who attempted to remove the guide tube to the hospital for blood samples to be provided to REAC/TS. The radiography trainee will be taken to a medical facility again on March 14, 2014. The Agency contacted the CRSO at 0700 [CDT] on March 14, 2014, and asked the condition of the radiography trainee's hand. The CRSO stated they were not aware of any issues with the individual's hand. The Agency discussed the previous event in Texas with similar circumstances. The consultant for the licensee working with the CRSO was also the consultant in the previous event and is providing the licensee with information gained in that event. The licensee currently plans to have the Site RSO to manage the health aspects of this event. The CRSO will manage the investigation of the event. The CRSO stated the former Division of Nuclear Materials Safety Director for NRC Region IV will meet them in La Porte on March 14, 2014, to help with the reenactment. Notified the R4DO (Farnholtz), FSME EO (McIntosh) and FSME Resources via email. On March 15, 2014, the Agency [Texas Department of Health] was notified by the licensee that based on the reenactment of the event, they have calculated the exposure to the hand of the radiography trainee to be 3,680 rem. The calculation is based on the trainee's hand being 0.5 centimeter from the source for 10 seconds. The licensee reported the whole body deep dose equivalent was 6.0 rem for the trainee. The licensee stated they examined the trainee's hand today and did not see any visual effects of the exposure. The licensee stated the trainee has not experienced any pain in his hand. The licensee stated they will continue to monitor the trainee's hand. The licensee stated they are still corresponding with REAC/TS. The badge for the second trainee in the basket was read by the dosimeter processor and reported to be 3.327 rem. The licensee stated based on the reenactment they believed the reading to accurately reflect the individual's exposure. Notified the R4DO (Farnholtz), FSME EO (Dudes), FSME Resources via email.
On April 20, 2014, the Agency was notified by the licensee they had completed their investigation into the exposure to the radiographer who had come into contact with the guide tube while the source was not shielded. The investigation determined that the source was located at a distance of six inches from the hand of the radiographer when he contacted the guide tube. Interviews with the radiographer who retracted the source determined that the crank out handle had been rotated almost one full turn to retract the source, not one-quarter turn as initially reported. The error in the initial report was due to the radiographer who returned the source to the fully shielded position not having a clear understanding of the term he used as English is not his primary language. Based on that information, the calculated dose to the radiographer's hand is 4.0 rem for the event. The calculated whole body dose to the radiographer was calculated to be 12.0 rem TEDE [Total Effective Dose Equivalent]. The hand and TEDE dose calculated by this Agency are consistent with the numbers assigned by the licensee. Additional information will be provided as it is received in accordance with SA-300. Notified the R4DO (Azua), FSME EO (McIntosh) and FSME Resources via email.
On May 20, 2014, the Agency received a copy of the NRC Form 5 for the radiography trainee. The Form 5 listed the TEDE dose for 2014 as 12.369 rem and the SDE Max Extremity dose as 15.680 rem. Also, the reporting criteria was changed to match the exposure reported by the licensee. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Gepford) and FSME (McIntosh) via email. |
| Where | |
|---|---|
| Acuren Inspection, Inc. La Porte, Texas (NRC Region 4) | |
| License number: | 01774 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.53 h1.439 days <br />0.206 weeks <br />0.0473 months <br />) | |
| Opened: | Art Tucker 15:32 Mar 13, 2014 |
| NRC Officer: | Howie Crouch |
| Last Updated: | May 20, 2014 |
| 49912 - NRC Website | |
Acuren Inspection, Inc. with Agreement State | |
WEEKMONTHYEARENS 580092025-10-27T05:00:00027 October 2025 05:00:00
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