Incident at Miller Steam Plant, Quinton, AL

RADIOGRAPHY INCIDENT AT THE MILLER STEAM PLANTDavid TurbervilleAssistant DirectorOffice of Radiation Control

Introduction1INCIDENT DETAILSDate and Time: March 17, 2015 @ 9:15 pmLocation: Alabama Power Miller Steam PlantLicensee: Vital Inspection Professionals, Inc. (VIP)INC IR-100Ir-192 76 CiFour Radiographic PersonnelOff-Scale Dosimeters

The industrial radiography incident occurred on the evening of Tuesday, March 17, 2015. The location of the event was at the Miller Steam Plant in West Jefferson, AL. The licensee was Vital Inspection Professionals, Inc. who has had a radioactive material license with the State of Alabama since 1993. The incident involved four radiographic personnel (one radiographer and three radiographers assistants). The exposure device involved was an INC model IR-100 with 76 Ci of Ir-192 on the night of the incident.2

INITIAL CALLOff-Scale DosimetersLandauer OSL had been sent in for Emergency ProcessingOne radiographers assistant was not wearing dosimetryLicensees Initial Dose EstimatesRadiographer 4 RemRadiographers Assistant A 50 milliremRadiographers Assistant B 28 RemRadiographers Assistant C 45 RemThe initial call to the AL Office of Radiation Control was made the next morning by the licensees RSO. The preliminary information indicated that the crew had conducted two exposures in a boiler at the steam plant. At the conclusion of those shots, the radiographer noted that his 200 mR pocket was off-scale. One of the radiographers assistants pocket dosimeter was off-scale also and another read 50 millirem. The RSO advised the Office of Radiation Control that one of the radiographers assistants was not wearing any dosimetry at the time of the incident. The RSO did dose reconstruction estimates based on his interviews with the four individuals and estimated a high exposure of 45 Rem to Radiographers Assistant C. The whole body badges for the three personnel that had their badges were sent to Landauer for emergency processing.3

LANDAUEREMERGENCY PROCESSING PersonnelBadgeInitial Est.Radiographer11.232 Rem4 RemRadiographers Asst AM50 mRemRadiographers Asst B5 Rem28 RemRadiographers Asst CNo Badge45 Rem

On the afternoon of March 19th, the badge results from the emergency processing done by Landauer were received by the licensee with the radiographer receiving the greatest exposure at 11.232 Rem. Radiographers Assistant C which the RSO had identified as having the greatest estimated exposure was the individual that was not wearing any dosimetry at the time.

The licensees estimates and the badge exposure results from Landauer did not match.

4REAC/TSComplete Blood Counts with DifferentialBaseline and Follow-upSlit Lamp Eye ExamVisual ExamOccupational Health PhysicianCytogenetic Biodosimetry

Because of the circumstances, the AL Office of Radiation Control recommended, and the licensee concurred, that REAC/TS in Oak Ridge be consulted for medical evaluation of the radiography personnel, specifically Radiographers Assistant C.

5AGENCY INVESTIGATIONMarch 25-26, 2015Miller Steam PlantInterview of Alabama Power and Southern Co.Scene of the IncidentLicensees FacilityInterviewsEquipmentReconstruction of the Incident

An investigation of the incident details was conducted by the Office of Radiation Control Assistant Director and the Radioactive Materials Compliance Branch Director on March 25 and 26, 2015. This investigation included: interviews with Alabama Power and Southern Company representatives; a review of the incident location; interviews with licensee management and the individuals involved in the incident; a review of the equipment involved in the incident; and a reconstruction of the incident.6Interviews at Miller Steam PlantSafety RepresentativesMiller Steam PlantAlabama Power CompanySouthern Company

Incident LocationWithin the Boiler

The interviews at Miller Steam Plant involved safety representatives from Miller Steam Plant, Alabama Power Company and Southern Company. Their representatives had questions concerning the incident including possible exposure to additional personnel, the Agencys enforcement policies and their role in the incident.

The Agency representatives had hoped to view the actual location within the boiler where the incident occurred but were not allowed due to safety concerns.7Interviews at the Licensees OfficesManagement

Job Foreman

Radiographic Personnel

After the Agencys visit to the steam plant, the licensee then met with the licensee representatives at their offices in Alabaster. The goal was to interview appropriate personnel to get a better understanding of the circumstances leading up to the incident and the incident itself. The individuals interviewed included management personnel, the job foreman in charge on the day of the incident and the four personnel involved in the incident. With the exception of the management personnel, all other individuals were interviewed separately.8

MARCH 17, 2015 9:00 9:30 PMTwo 35 Second Exposures

Panoramic Exposures

10-12 Films Per Exposure

Two Superheat Loop Piping (Pipe Loops 11 & 12)

Based on the interviews conducted by the AL Office of Radiation Control, the crew was responsible for two sets of exposures on pipe loops 11 and 12 at the 9 pm shooting window. They were conducted panoramic shots without a collimator to radiograph both sets of pipe. The film was set up by the radiographer and the camera was set up by radiographers assistant B. Once set up was complete, the first shot was cranked out by radiographers assistant A for 35 seconds. Radiographers assistant A cranked the sealed source back in at the conclusion of the exposure. 9SUPERHEAT LOOP PIPING

The items being radiographed were superheat loop tubes located within the boiler. The radiography crew was looking for obstructions in the bottom of the tubes. 10AFTER THE FIRST EXPOSURE

The radiographer, followed by radiographers assistants A and B, approached the exposure device and performed the required survey with his survey meter. No abnormal readings were noted. The radiographer then placed the survey meter behind the camera because there was not enough room on the scaffold at the front of the exposure device. The radiographer then proceeded to remove the exposed film and place the second set of film for the second shot. Radiographers assistant A and B positioned themselves on each side of the exposure device assisting the radiographer. After about ten minutes, radiographers assistant C (who was working with another crew) arrives to provide guidance to the radiographer on film placement. After the radiographer completes the set-up for the second shot, the radiographer, with radiographers assistants A and B return to the crank handle for the second exposure. Radiographers assistant C returns to his crew. The second exposure is conducted and the exposure device is broke down and returned to the licensee storage trailer on site without anyone noticing their pocket dosimeter is off-scale. Upon return to the trailer, the radiographer and radiographers assistant B notice their pocket dosimeters are off-scale. The Job Foreman is notified and the RSO is then notified later that evening.11

PROBLEMSSurvey meter malfunctionRadiographer did not verify the source was in the fully shielded positionSurvey meter placed behind exposure deviceAlarming ratemeters did not warn personnelPersonnel failed to wear dosimetryTime constraintsWho pushed down the safety plate for the second shot?From the interviews, the Agency identified a number of items that were contributing factors and/or questions that were never answered. Equipment failure and human errors were identified as major factors in the incident.12PERSONNELJob Foreman His First Time in this PositionRadiographer LA Radiographer CardHired Fall of 2014Radiographers Assistant ALA Trainee CardHired as Area Monitor Radiographers Assistants B & CLong Time EmployeesQualified Radiographers Assistants

This was the first experience for the individual identified as the foreman being the lead foreman for the job. According to the licensee, he was requested by the customer specifically.

The radiographer was hired in the fall of 2014 to work an outage for the licensee as the licensee needed extra personnel during that time. He continued to be employed by the licensee when the Miller Steam Plant job came up. Radiographers assistant B was hired as an area monitor with the radiographer in the fall of 2014. She did have a current Louisiana trainee card and an expired Louisiana radiographer card. According to the RSO, she was not hired as a radiographers assistant. At the request of the customer, the job foreman assigned her to work in the boiler on the day of the incident.

Radiographers assistants B and C were long-time employees for the licensee that had participated in the licensees radiation safety training and were qualified as radiographers assistants.13INC IR-100Certified Type B PackageAutomatic Positive Locking Safety Latch PlateLast Leak Tested 2/16/2015Last DU Check 2/3/2015

The exposure device involved in the incident was an INC model IR-100 which has an automatic positive locking safety latch plate. The sealed source was last leak tested February 16, 2015 and the device was last checked for depleted uranium contamination to verify s-tube integrity on February 3, 2015. No issues were identified with this exposure device as part the investigation.14SURVEY METERNDS ND-2000

Cal 1/19/2015 by NDS Products

The survey meter in use at the time of the incident was a NDS model ND-2000 that was calibrated by NDS Products on January 19, 2015.15SURVEY METERIntermittent Electrical Short

Weak Batteries

After the incident, the licensee identified an electrical short in the survey meter causing the meter to intermittently not respond to radiation . Also the licensee identified that the batteries were weak.16ALARMING RATEMETERSRadiographer Yes

Radiographers Assistant A - ?

Radiographers Assistant B Dead Batteries

Radiographers Assistant C - No

After the incident, the radiographers alarming ratemeter was found to be operational. The investigation by the AL Office of Radiation Control could not conclude with certainty that radiographers assistant A was wearing an alarming ratemeter. The alarming ratemeter used by radiographers assistant B had dead batteries and was not operational at the time of the incident. Radiographers assistant B was aware of this but continued to conduct radiography. Radiographers assistant C was not wearing an alarming ratemeter. 17RADIOGRAPHER

A reconstruction of the incident was conducted by the AL Office of Radiation Control with assistance from the licensee at the licensees facility. The radiographer was approximately 18 inches from the front of the exposure device for approximately 10 to 12 minutes as he removed film. He was then approximately 62 inches from the front of the exposure device for about 6 to 8 minutes as he placed film for the second exposure.18RADIOGRAPHERS ASSISTANT A

Radiographers assistant A was stationed on one side of the exposure devices approximately 22 inches from the camera for approximately 8 to 10 minutes.19RADIOGRAPHERS ASSISTANT B

Radiographers assistant B was stationed on the other side of the camera approximately 30 from the camera for approximately 16 to 18 minutes.20RADIOGRAPHERS ASSISTANT C

Radiographers assistant C was practically leaning on the exposure device for approximately 6 to 8 minutes.21AGENCYS DOSE ESTIMATESAssumptionsWorst-Case ScenarioNo ShieldingTime Out of Shield 18 MinutesDistances Approximated

From the interviews and reconstruction, the Office of Radiation Control performed dose estimate calculations. A number of conservative assumptions were made due to the lack of information made available. A worst case scenario with the sealed source assumed to be out of the exposure device was used in the calculations. The time out of the shield was assumed to be the entire 18 minutes between the first and second exposure. The distances were approximated based on statements by the four personnel involved in the incident. 22

AGENCYS DOSE ESTIMATESInitial EstimatesRadiographer30 RemRadiographers Assistant A11 RemRadiographers Assistant B13 RemRadiographers Assistant C483 Rem (Rt. Hip)Based on the reconstruction and time estimates, the AL Office of Radiation Control performed its own dose estimates with specific attention paid to radiographers assistants A and C who were not wearing dosimetry at the time of the incident. 23REACTIVE INSPECTIONConducted on March 31, 2015Reviewed paperwork in regards to the incidentReviewed Training RecordsIdentified 7 Apparent Violations

A reactive inspection of the licensee was performed on March 31, 2015. The inspection focused on daily records during the incident and training records. From this reactive inspection, the AL Office of Radiation Control identified seven apparent violations. 24NOTICE OF VIOLATIONIssued April 13, 2015

7 Apparent Violations

Consideration of Civil Penalty

Enforcement Conference

A Notice of Violation and Consideration of Civil Penalty was issued on April 13, 2015. The apparent violations identified two severity category II violations, three severity category III violation and two severity category IV violations. The first five violations were specific to the incident and the last two apparent violations identified a weakness in the licensees training program. 25APPARENT VIOLATIONSOverexposure of Radiographic PersonnelInadequate Personnel Dosimetry ProgramFailure to Use an Operable Survey MeterFailure to Maintain Supervision of Radiographers AssistantsFailure to Secure Sealed Source in Shielded PositionFailure to Provide Refresher TrainingFailure to Conduct Practical Exam

Four of the seven violations identified were specific to the incident. The Overexposure of Radiographic Personnel was identified as a Severity Category II with the condition that the violation would be upgraded to a Severity Category I if it is determined that personnel received exposures greater that 25 Rem. The license would also be subject to suspension and/or revocation if this occurred. 26FAILURE TO MAINTAIN SUPERVISION OF RADIOGRAPHERS ASSISTANT3 Radiographic Exposure Devices3 Radiography Crews2 Qualified Radiographers

The violation Failure to Maintain Supervision of Radiographers Assistant was identified in interviews during the investigation. The Agency found that radiographers assistant C was conducting radiography approximately 50 feet away with a crew of two other radiographers assistants. According to statements, the radiographer involved in the incident was suppose to be providing personal supervision of that crew while they conducted radiography. The third crew working at that time was on a floor above with a qualified radiographer providing oversight. 27REAC/TS RESULTSReceived April 14, 2015

Results All were less than 20RADs

The licensee consulted with REAC/TS in Oak Ridge, TN. Their doctors recommended for all four personnel, CBC with differential, slit lamp eye exam, a visual exam of their body. This was done through an occupational health physician at the University of Alabama at Birmingham. Blood samples were delivered to REAC/TS and they conducted cytogenetic biodosimetry testing on all four individuals.

The results received from REAC/TS determined that all four individuals received less than 20 RADs.28

ENFORCEMENT CONFERENCEMay 1, 2015Licensees Response to the Notice of ViolationCorrective MeasuresCommitment to Field AuditsReview of Dose EstimatesAgency ActionsCivil Penalty ConsiderationCoordination of Field AuditsInformation Notice to LicenseesAn enforcement conference was held with the licensee on May 1, 2015. At this conference, the licensees planned corrective measures were discussed. The licensee committed to an enhanced training program for its employees and additional field audits for management. The Agency discussed its plan for issuance of a civil penalty; plan coordination of additional field audits by radioactive material inspectors and committed to sending information notices to radiography licensees.29CIVIL PENALTY ORDERBase Civil Penalty $10,000 per Violations (Severity II and Severity III)FactorsSeverity LevelsCompliance HistorySmall Entity statusOrder $469.90

Violations that are severity category III or higher are subject to civil penalties. The base civil penalty is $10,000 per violation. This amount is decreased based on the violation severity level and other factors including the licensees compliance history and if they qualify as a small business entity. Because of all of these factors, the total civil penalty was $469.90 which was paid by the licensee. 30LICENSEES ACTIONSHired a Safety Consultant

40 Hour Radiation Safety Training

Field Audits

Reviewed Dose Estimates

Since then, all of the licensees radiographers and radiographers assistants have had to re-take the 40 hour radiation safety training. The licensees management has conducted multiple unannounced field audits of radiography crews. The licensee has also hired a safety consultant to provide oversight of their entire safety program including radiation safety. 31AGENCYS ACTIONSObserved the Licensees Training

Field Audits

Information Notices

Reviewed Dose Estimates

Since the incident, the AL Office of Radiation Control has observed the licensees training program and performed field audits in coordination with the licensees management. The AL Office of Radiation Control issued two information notices after the incident. One information notice stress the need to wear all personnel monitoring equipment assigned as required by the rules. The second information notice clarified the Agencys position on the requirements for supervision of a radiographers assistant during radiographic operations. 32LICENSEES FINAL DOSE ESTIMATESRadiographer11.43 Rem

Radiographers Assistant A9.06 Rem

Radiographers Assistant B4.49 Rem

Radiographers Assistant C0 Rem

In their letter dated May 19, 2015, the licensee presented three scenarios that they considered possible. Their final conclusion was that sometime between the first and second exposure, the radiographers assistant C recognized that the safety latch plate had not engaged so she went back to the handles to crank the source back to the fully shielded position. The licensee believes that this occurred prior to radiographers assistants C arrival.

The Agency reviewed the licensees scenario and although it was found their assumptions may be plausable, there was no evidence presented at the time of the investigation to conclude that radiographers assistant C cranked the sealed source back into the fully shielded position prior to the second exposure.

33AGENCYS FOLLOW-UP DOSE ESTIMATES ASSUMPTIONSSource within the exposure device

Not in the fully shielded position

Approximately 3 to 5 inches from fully shielded positionFrom all information made available, the Agency performed additional calculations to determine dose estimates of the personnel. The Agency concluded that the source was cranked in at the conclusion of the first exposure but did not return to the fully shielded position or was pushed back out approximately three to five inches from the fully shielded position. This caused the radiographer to be exposed to a direct beam of radiation while he removed and placed the film. The three radiographers assistants had the benefit of some DU shielding as they were not in the direct beam.34AGENCYS FINAL DOSE ESTIMATESRadiographer11.232 Rem

Radiographers Assistant A3.33 Rem

Radiographers Assistant B5 Rem

Radiographers Assistant C17.09 RemUsing the assumptions that the sealed source was within the exposure device but not in the fully shielded position, the Agency performed its own dose estimates. We assumed that the source was approximately three to five inches outside the fully shielded position so we used the DU shielding thickness at that point to estimate the exposures of radiographers assistants A and C. For the radiographer and radiographers assistant B, the Landauer badge results were used for dose estimates.35FINAL CONCLUSIONIs that how it really happened?

Final Dose Estimates AssignedRadiographer 11.232 Rem (from Badge Report)Radiographers Asst. A 5 Rem Radiographers Asst. B 5 RemRadiographers Asst. C 20 Rem

The final dose estimates assigned to the individuals involved in the incident were conservatively estimated based on the information provided by the Landauer report and REAC/TS. All four personnel were determined to exceed the annual occupational limit.36WHY DID IT HAPPEN?Time Constraints

Equipment Malfunction

Human Error

Staff Turnover

Poor Management Oversight

A number of contributing factors were identified in the investigation of the incident. Time constraints played a major role as the radiographer only had a 30 minute window to get the job done. The survey meter and possibly the alarming ratemeter did not function properly to alert the crew of the exposed device. The radiographer in charge failed to verify if the survey meter was operating properly, failed to verify if the sealed source had returned to its fully shielded position at the conclusion of the first shot and failed to ensure that his crew was wearing all of their personnel monitoring.

Another factor to consider was the death of their long time radiation safety secretary in October of 2013. The young lady succumb to cancer at the age of 48 and was an instrumental part of why the licensee had a good compliance history. Management failed to recognize the void left by her death and did a poor job of addressing this issue. 37LESSONS LEARNEDTime constraints will always be an issueThe customer is not always right An operable survey meter is always your best line of defenseA malfunctioning alarming ratemeter gives the same indication as a safe readingChanges in personnel can greatly affect a programShort term memory loss is a common trait after an incident Field audits are necessaryThe licensee along with the AL Office of Radiation Control identified a number of lessons learned to better enhance its programs for the future. 38THANK YOU!For more information contact:David Turberville, Assistant DirectorAlabama Office of Radiation Controldavid.turberville@adph.state.al.usMyron Riley, DirectorRadioactive Materials Compliance Branchmyron.riley@adph.state.al.us (334) 206-539139