recent u.s. events regarding industrial radiographic operations

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Recent U.S. Events Regarding Industrial Radiographic Operations U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION Protecting People and the Environment

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Page 1: Recent U.S. Events Regarding Industrial Radiographic Operations

Acuren Temporary Jobsite InspectionJune 28, 2011

Buffalo, Wyoming

Recent U.S. Events Regarding Industrial Radiographic

Operations

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

Page 2: Recent U.S. Events Regarding Industrial Radiographic Operations

Industrial Radiography Events Reported to IAEA-Information obtained from IAEA Nucleus-

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

Page 3: Recent U.S. Events Regarding Industrial Radiographic Operations

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

Does the United States have more radiography overexposures than any

other country?

According to the 18th World Conference on Nondestructive Testing, Radiation Safety Practices of Industrial Radiography License Holders in South Africa, April 2012, the following was discovered:

During interviews with registered radiation workers, it was found that some had exceeded statutory dose limits without the mandated investigations, reports, and corrective actions.

Page 4: Recent U.S. Events Regarding Industrial Radiographic Operations

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

Out of the 14 events reported to IAEA that occurred in the United States from 2011-2014:

INES Rating 1 : 1 event

INES Rating 2 : 12 events

INES Rating 3 : 1 event

Page 5: Recent U.S. Events Regarding Industrial Radiographic Operations

EVENT 1

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Protecting People and the Environment

Page 6: Recent U.S. Events Regarding Industrial Radiographic Operations

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

Radiographer trainee removed guide tube after an exposure and saw the iridium source protruding two inches out of the exposure device. He tried to push the source back into the device with his index finger, and then went to the crank assembly and fully retracted the source.

September 12, 2011: Port Lavaca, Texas

INES Rating : 3

Page 7: Recent U.S. Events Regarding Industrial Radiographic Operations

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

Seven days later he went to the hospital for painful blistering to his thumb and index finger. Estimated extremity exposure was over 38 Sv; whole body dosimeter was processed and revealed 14.1mSv.

September 12, 2011: Port Lavaca, Texas (cont’d)

INES Rating : 3

Page 8: Recent U.S. Events Regarding Industrial Radiographic Operations

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

2 Months After Overexposure

1 Month After Overexposure

Page 9: Recent U.S. Events Regarding Industrial Radiographic Operations

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

3 Months After Overexposure

Amputation Required 21 Months Later

Page 10: Recent U.S. Events Regarding Industrial Radiographic Operations

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

September 12, 2011: Port Lavaca, Texas

The cause of this event was determined to be human error

The radiographer trainer and assistant’s stories conflicted

The radiographer’s “trainer” status was revoked by the regulatory authority

All other radiographers in the company received additional training

Page 11: Recent U.S. Events Regarding Industrial Radiographic Operations

QUESTIONS ON EVENT 1 ?

Page 12: Recent U.S. Events Regarding Industrial Radiographic Operations

EVENT 2

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Protecting People and the Environment

Page 13: Recent U.S. Events Regarding Industrial Radiographic Operations

MARCH 12, 2014: LA PORTE, TEXAS

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

A radiographer and two assistant radiographers (trainees) were shooting in a large tank; the two assistants were inside of the tank performing radiography while the radiographer was outside of the tank placing film. When one of the assistants tried to remove the guide tube, he realized the source was still inside of it.

Page 14: Recent U.S. Events Regarding Industrial Radiographic Operations

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

MARCH 12, 2014: LA PORTE, TEXAS The trainees had not retracted the source when they thought they did.

Trainee A was not wearing any dosimetry at all.

Trainee B was wearing dosimetry, but failed to turn on his alarming rate meter.

Page 15: Recent U.S. Events Regarding Industrial Radiographic Operations

MARCH 12, 2014: LA PORTE, TEXAS

Trainee A received a TEDE of 120 mSv, and 150 mSv to his handTrainee B received a TEDE of 33 mSv

Causes of the event were:• Survey meter not used after each exposure• Alarming rate meters not used or inoperable• No direct supervision of trainees by the

radiographer• Improper connection of drive cable to source

assembly

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

Page 16: Recent U.S. Events Regarding Industrial Radiographic Operations

QUESTIONS ON EVENT 2 ?

Page 17: Recent U.S. Events Regarding Industrial Radiographic Operations

EVENT 3

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Page 18: Recent U.S. Events Regarding Industrial Radiographic Operations

MARCH 24, 2012: PASADENA, TEXAS

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Protecting People and the Environment

Radiographers were working at a refinery, performing radiography using scaffolding. When the radiographer completed the first shot, he disconnected the guide tube from the camera, wrapped the guide tube around his neck, and climbed back down the scaffolding.

Page 19: Recent U.S. Events Regarding Industrial Radiographic Operations

MARCH 24, 2012: PASADENA, TEXAS

When he reached the bottom, he noticed that the exposure device locking mechanism was still unlocked. He removed the guide tube from around his neck and performed a radiation survey and found that the source was still in the guide tube.

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

Page 20: Recent U.S. Events Regarding Industrial Radiographic Operations

MARCH 24, 2012: PASADENA, TEXAS

The source had become disconnected during the first exposure

The final assigned dose to the radiographer was 290 mSv

It was determined that the drive cable broke just behind the connection to the source assembly, due to corrosion

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

Page 21: Recent U.S. Events Regarding Industrial Radiographic Operations

Causes of the event included:

• Failure to perform daily equipment checks

• Failure to maintain radiography equipment in good working order (lubrication, cleaning)

• Failure to perform radiation surveys

• Failure to ensure exposure device was locked prior to disassembly

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Protecting People and the Environment

Page 22: Recent U.S. Events Regarding Industrial Radiographic Operations

QUESTIONS ON EVENT 3 ?

Page 23: Recent U.S. Events Regarding Industrial Radiographic Operations

In all of these events, it is believed that a poor safety culture was partially to blame

From the IAEA’s Nuclear Safety Review 2013:

• Periodic, independent safety culture assessments are of key importance to maintain a strong defense in depth strategy

• Although this statement was used with regards to nuclear power plants, the same holds true to regulators of the industrial radiography profession

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment

Page 24: Recent U.S. Events Regarding Industrial Radiographic Operations

IN SUMMARYThe United States continues to have the highest number of reported radiation overexposures for industrial radiographers

WHY? More industrial radiography is performed in the U.S.? Events are not reported to authorities in other countries? Reporting requirements are different? Training requirements in the U.S. are different?

What are your thoughts?

U.S.NRC UNITED STATES NUCLEAR REGULATORY COMMISSION

Protecting People and the Environment