Stichting Laka

Event Report Forms (ERFs) are filed to the IAEA. Sometimes there are multiple event reports, updating the rating, the event description. Here you only see the latest event report

ERF send date: Thu, 08-06-2006
ERF description: On June 6, 2006, the State of Louisiana notified the Nuclear Regulatory Commission (NRC) that two individuals conducting radiographic activities may have received an effective dose in excess of NRC's annual occupational limit of 50 millisievert (mSv) or 5 rem.

According to the licensee, a radiographer and a radiographer's assistant were using a radiographic device containing approximately 1.5 TBq (41 Ci) of Ir-192, and during the conduct of radiographic activities, the radiographer stated that the source assembly appeared to have slightly more resistance when exposing and returning the source to the shielded position. Two additional exposures were made and no abnormal conditions were observed, however, during the last exposure the radiographer again noticed abnormal resistance within the first two revolutions of the crank assembly. Subsequent to the exposure, the radiographer cranked the source to what he believed was the shielded position based on the device lock plunger returning to the locked position. The radiographer unsuccessfully tried to remove the source crank assembly for a period of approximately five minutes. The radiographer and assistant subsequently disconnected the source guide tube and returned the components to the truck, with the radiographer carrying the device in his right hand and the crank assembly and guide tube in his left hand.

After eating lunch, another individual noticed that the source pigtail was not in the exposure device. A reenactment by the licensee determined that the radiographer and radiographer's assistant may have received an effective dose of approximately 135 and 145 mSv (13.5 and 14.5 rem) respectively. An analysis of the dosimeters revealed that the radiographer and radiographer's assistant received a monthly effective dose of 1.1 and 2.2 rem respectively. The licensee sent the individuals' blood for cytogenetic analysis.

The State of Louisiana is conducting a reactive inspection to review the licensee's analysis and to determine the root cause of the event.

Note: Neither the radiographer or radiographer's assistant used a survey instrument to evaluate the source location/position nor did the individuals have their required alarming rate meter turned on. Additionally, the radiographer and radiographer's assistant's direct reading dosimeters were determined to be off scale.
ERF rating date: 08-06-2006
ERF contact person: Cynthia Jones
ERF address: Washington, DC USA
ERF affiliation: United States Nuclear Regulatory Commission

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