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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 52027 | 20 June 2016 14:30:00 | Agreement State | Agreement State Report - Radiography Camera Source Disconnect | The following was received from Minnesota via email: On June 20, 2016 at 0930 (CDT) Midwest Industrial X-Ray, Inc. (License number 1086-89) had a source disconnect event. Their Radiation Safety Officer notified the Minnesota Department of Health (MDH) of the event at 0925 (CDT) on June 21, 2016. Initial details: - The event happened on a jobsite in Lakeville, MN. - The Camera was a QSA 880 Delta. - Source was 47.5 curies of I-192. - The cause has been initially determined to be a worn drive cable. The licensee stated that the drive cable passed the go-no-go test prior to hooking up. - They were able to retrieve the source and get it back in the shielded position. - All equipment was inspected after the retrieval. - The faulty drive cables were brought back to the licensee's corporate office in Fargo, ND for repair. - Pocket dosimeter readings following the retrieval were: 41 mrem, 20 mrem, 11 mrem, and 10 mrem. The licensee is in the process of preparing a written report that will be submitted within 30 days as required. MDH will continue to investigate this event. MDH Inspectors will be on-site at the licensee's office in Albertville MN on June 23, 2016 to perform a follow-up inspection. | ||
| ENS 47933 | 16 May 2012 06:00:00 | Agreement State | Agreement State Report - Radiography Camera Crankout Gears Locked with Source Exposed | On Wednesday May 16, 2012 at 1900 MDT, two Midwest Industrial X-Ray, Inc. radiographers had a reportable incident involving a radioactive material exposure device. The exposure device involved was a SPEC 150 SN:386 loaded with an Ir-192 sealed source model G-60 SN: TC1301. The activity level on 5/16/12 was 56 Ci (2072 GBqs). A SPEC Double Gear Control Assembly with red conduit was used for the drive cable. The radiographers had made previous exposures during the day without incurring any equipment malfunction. At approximately 1900, the radiographers had 'cranked out' the source to make an exposure and upon retraction were unable to retract the source. The radiographers removed the cover plate of the control assembly and manually pulled the drive cables in order to retract the source back into the locked and shielded position. The sealed source was exposed for approximately 3 minutes. Caution Radiation Area cones were posted at 95 ft. from the source and no persons were inside the 2mR/hr zone. The drive cable was disconnected and no further exposures were made that day. The exposure device was inspected and was found to be in good working condition. Corrective Actions: A set of SPEC single gear control assembly, yellow conduit drive cables were brought to the radiographers to replace the malfunctioning drive cables. The set of malfunctioning drive cables will be sent back to SPEC and traded in for a set of single gear control assembly/yellow conduit drive cables.
Source Production & Equipment Company (SPEC) was unable to replicate the failure using the returned gears. They did note that the gears offered a large amount of resistance, had impurities and that the drive cable was out-of-tolerance. Notified R4DO (Lantz) and FSME Events via email.
The final closeout report of event notification 47933 was provided. Notified R4DO (Miller) and FSME Events via email. | ||
| ENS 43638 | 15 May 2007 05:00:00 | Agreement State | Agreement State Report - Inability to Retract Radiography Camera Source | The State provided the following information via email: The licensee reported the inability to retract an Ir-192 radiography source (model G-60, serial #OA2910) that contained an activity of 1.45 TBq (39.12 Ci) into a SPEC exposure device (model 150, serial #456). The radiographers had attached the guide tube to a ladder within a tank at the Absolute Energy Ethanol Plant located on the Iowa/Minnesota border. Halfway through a shot, a gust of wind blew the ladder over, which crimped the guide tube such that the source could not be retracted. The radiographers located the source in the guide tube and covered it with sandbags. The crimped guide tube was then reformed using a hammer and the source was successfully retracted. A new guide tube was shipped to the jobsite and the damaged guide tube was destroyed. The two radiographers received exposures of 1.1 and 1 mSv (110 and 100 mrem) from the incident. The licensee submitted a written report to the Iowa Department of Public Health on 6/13/2007, but failed to provide the required 24-hour notification. The State of Minnesota performed an audit of the licensee on 7/12/2007 and it was determined that the incident occurred in Iowa. The root cause of the incident is the failure to properly secure the ladder per company policy. Corrective actions taken by the licensee included terminating the lead radiographer involved and providing additional instruction to all radiographers on the policy to secure ladders used as guide tube stands. Iowa report number: IA070002 |