The following information was summarized from an email received from the state of Kansas:
[The licensee RSO] (DBI) reported to the KDEM [Kansas Division of Emergency Management] 24-hour number that they had a potential over exposure during a radiography operation.
The radiographer was in the process of setting up the last shot of the day. While returning to the crank, the radiographer was radioed by the refinery's QC person. At the same time, he was adjusting the collimator, which had shifted. The QC person called over the radio 'come on' which the radiographer's assistant (on the same radio channel) took to mean to crank out the source. When the radiographer felt the vibration of the source being cranked out, he dropped the collimator, exited the area immediately, and got the source retracted.
Preliminary worst case calculations indicated a possible extremity over exposure. The radiographer's badge was sent in for processing and the report came back with 33 mR for the period since April 9. With this information, the extremity dose will be recalculated to determine the actual exposure to the individual.
PQT Services Inc. and REAC/TS consulted on the incident. The worst case scenario is that the radiographer could have received a dose from 50 - 100R to the hands. Pictures of the radiographers were inspected for signs of radiation burns. No signs at this time. The plan is to continue to monitor his hands until June 20, 2015. Both PQT Services and REAC/TS agree that this should be a sufficient time to assure the safety of radiographer. The radiographer's annual dose was DDE 262 mR.
Root cause of incident was determined to be weakness in the communication procedures established between personnel during radiographic operations. A visual 'ALL CLEAR' confirmation from the radiographer setting up the exposures must be made with the person operating the exposure device before the source is exposed.
All DBI Inc. employees have been notified of this incident and the importance of a visual confirmation prior to exposing the source. This has been implemented in DBI's protocol.
This event is considered closed.
Item Number: KS150004