1. David Turberville Assistant Director Office of Radiation Control

2. INCIDENT DETAILS Date and Time: March 17, 2015 @ 9:15 pm Location: Alabama Power Miller Steam Plant Licensee: Vital Inspection Professionals, Inc. (VIP) INC IR-100 Ir-192 76 Ci Four Radiographic Personnel Off-Scale Dosimeters

3. INITIAL CALL Off-Scale Dosimeters Landauer OSL had been sent in for Emergency Processing One radiographer’s assistant was not wearing dosimetry Licensee’s Initial Dose Estimates Radiographer – 4 Rem Radiographer’s Assistant A – 50 millirem Radiographer’s Assistant B – 28 Rem Radiographer’s Assistant C – 45 Rem

4. LANDAUER EMERGENCY PROCESSING PersonnelBadgeInitial Est. Radiographer11.232 Rem4 Rem Radiographer’s Asst AM50 mRem Radiographer’s Asst B5 Rem28 Rem Radiographer’s Asst CNo Badge45 Rem

5. REAC/TS Complete Blood Counts with Differential Baseline and Follow-up Slit Lamp Eye Exam Visual Exam Occupational Health Physician Cytogenetic Biodosimetry

6. AGENCY INVESTIGATION March 25-26, 2015 Miller Steam Plant Interview of Alabama Power and Southern Co. Scene of the Incident Licensee’s Facility Interviews Equipment Reconstruction of the Incident

7. Interviews at Miller Steam Plant Safety Representatives Miller Steam Plant Alabama Power Company Southern Company Incident Location Within the Boiler

8. Interviews at the Licensee’s Offices Management Job Foreman Radiographic Personnel

9. MARCH 17, 2015 9:00 – 9:30 PM Two 35 Second Exposures Panoramic Exposures 10-12 Films Per Exposure Two Superheat Loop Piping (Pipe Loops 11 & 12)

10. SUPERHEAT LOOP PIPING

11. AFTER THE FIRST EXPOSURE

12. PROBLEMS Survey meter malfunction Radiographer did not verify the source was in the fully shielded position Survey meter placed behind exposure device Alarming ratemeters did not warn personnel Personnel failed to wear dosimetry Time constraints Who pushed down the safety plate for the second shot?

13. PERSONNEL Job Foreman – His First Time in this Position Radiographer LA Radiographer Card Hired Fall of 2014 Radiographer’s Assistant A LA Trainee Card Hired as Area Monitor Radiographer’s Assistants B & C Long Time Employees Qualified Radiographer’s Assistants

14. INC IR-100 Certified Type B Package Automatic Positive Locking Safety Latch Plate Last Leak Tested 2/16/2015 Last DU Check 2/3/2015

15. SURVEY METER NDS ND-2000 Cal 1/19/2015 by NDS Products

16. SURVEY METER Intermittent Electrical Short Weak Batteries

17. ALARMING RATEMETERS Radiographer – Yes Radiographer’s Assistant A - ? Radiographer’s Assistant B – Dead Batteries Radiographer’s Assistant C - No

18. RADIOGRAPHER

19. RADIOGRAPHER’S ASSISTANT A

20. RADIOGRAPHER’S ASSISTANT B

21. RADIOGRAPHER’S ASSISTANT C

22. AGENCY’S DOSE ESTIMATES Assumptions Worst-Case Scenario No Shielding Time Out of Shield – 18 Minutes Distances Approximated

23. AGENCY’S DOSE ESTIMATES Initial Estimates Radiographer30 Rem Radiographer’s Assistant A11 Rem Radiographer’s Assistant B13 Rem Radiographer’s Assistant C483 Rem (Rt. Hip)

24. REACTIVE INSPECTION Conducted on March 31, 2015 Reviewed paperwork in regards to the incident Reviewed Training Records Identified 7 Apparent Violations

25. NOTICE OF VIOLATION Issued April 13, 2015 7 Apparent Violations Consideration of Civil Penalty Enforcement Conference

26. APPARENT VIOLATIONS Overexposure of Radiographic Personnel Inadequate Personnel Dosimetry Program Failure to Use an Operable Survey Meter Failure to Maintain Supervision of Radiographer’s Assistants Failure to Secure Sealed Source in Shielded Position Failure to Provide Refresher Training Failure to Conduct Practical Exam

27. FAILURE TO MAINTAIN SUPERVISION OF RADIOGRAPHER’S ASSISTANT 3 Radiographic Exposure Devices 3 Radiography Crews 2 Qualified Radiographers

28. REAC/TS RESULTS Received April 14, 2015 Results – All were less than 20RADs

29. ENFORCEMENT CONFERENCE May 1, 2015 Licensee’s Response to the Notice of Violation Corrective Measures Commitment to Field Audits Review of Dose Estimates Agency Actions Civil Penalty Consideration Coordination of Field Audits Information Notice to Licensees

30. CIVIL PENALTY ORDER Base Civil Penalty $10,000 per Violations (Severity II and Severity III) Factors Severity Levels Compliance History Small Entity status Order – $469.90

31. LICENSEE’S ACTIONS Hired a Safety Consultant 40 Hour Radiation Safety Training Field Audits Reviewed Dose Estimates

32. AGENCY’S ACTIONS Observed the Licensee’s Training Field Audits Information Notices Reviewed Dose Estimates

33. LICENSEE’S FINAL DOSE ESTIMATES Radiographer11.43 Rem Radiographer’s Assistant A9.06 Rem Radiographer’s Assistant B4.49 Rem Radiographer’s Assistant C0 Rem

34. AGENCY’S FOLLOW-UP DOSE ESTIMATES ASSUMPTIONS Source within the exposure device Not in the fully shielded position Approximately 3 to 5 inches from fully shielded position

35. AGENCY’S FINAL DOSE ESTIMATES Radiographer11.232 Rem Radiographer’s Assistant A3.33 Rem Radiographer’s Assistant B5 Rem Radiographer’s Assistant C17.09 Rem

36. FINAL CONCLUSION Is that how it really happened? Final Dose Estimates Assigned Radiographer – 11.232 Rem (from Badge Report) Radiographer’s Asst. A – 5 Rem Radiographer’s Asst. B – 5 Rem Radiographer’s Asst. C – 20 Rem

37. WHY DID IT HAPPEN? Time Constraints Equipment Malfunction Human Error Staff Turnover Poor Management Oversight

38. LESSONS LEARNED Time constraints will always be an issue The customer is not always right An operable survey meter is always your best line of defense A malfunctioning alarming ratemeter gives the same indication as a safe reading Changes in personnel can greatly affect a program Short term memory loss is a common trait after an incident Field audits are necessary

39. THANK YOU! For more information contact: David Turberville, Assistant Director Alabama Office of Radiation Control david.turberville@adph.state.al.us Myron Riley, Director Radioactive Materials Compliance Branch myron.riley@adph.state.al.us (334) 206-5391