[ RadSafe ] 1. official Belgian report on theSterigenicsradiationaccident

Sat Apr 15 09:33:26 CDT 2006

Dear John,

Thank you for your message.
Besides on what you wrote "particularly
industry", I would like to emphasize also medical practices. There are many
non compliance
events registered in medical practices, mismanagement,  misadministration
and lack
of  adequate program of quality control in radiography.
USA has an important and correct tradition to inform quickly the events in
open
sit the public, about any occurrence as you have mentioned, however this is
not common
attitudes in many RA.
Only when the level of the event has high significative consequences  the
public is informed,
however many of such information only after the press publication.
Considering practices in industry and medicine, The IAEA,  to help toward
training and information of events,
has published  (1996/2000)  3 Safety Series, 7, 13 and 17, and one Tech.
Report.
Safety Series 13 Radiation Protection and Safety in Industrial Radiography
Safety Series 7 Lessons Learned From Accidents in Industrial Radiography
Safety Series 17  Lessons Learned From Accidental Exposures in Radiotherapy
T. R - Lessons Learned from Accidents in Industrial Irradiation Facilities

The texts are basic for discussion in training courses considering Safety
Performance, Safety Problems and Safety Culture.

There are two available to download, to those interested look at the IAEA
sites to download
Safety Series 13
http://www-pub.iaea.org/MTCD/publications/PDF/P066_scr.pdf
Safety Series 7    (sorry not available)
Safety Series 17
http://www-pub.iaea.org/MTCD/publications/PDF/Pub1084_web.pdf
Lessons Learned from Accidents in Industrial Irradiation Facilities  (sorry
not available)

Jose
Jose Julio Rozental
joseroze at netvision.net.il
Israel

----- Original Message -----
From: "John Jacobus" <crispy_bird at yahoo.com>
To: "radsafe" <radsafe at radlab.nl>
Sent: Friday, April 14, 2006 7:05 PM
Subject: Fwd: Re: [ RadSafe ] 1. official Belgian report on
theSterigenicsradiationaccident

> Dr. Rozental,
> Thank you for posting these comments which I
> circulated at my place of work.
>
> The issue of why workers, particularly in industry, do
> not follow the regulations and training they learned
> in not a new one, and is a constant problem.  Our
> Nuclear Regulatory Commission publishes a newsletter
> that reports on regulatory actions, rules, inspection
> finding, enforcement actions and "significant events."
>  I find them very entertaining.
>
> For example, in the latest issue,
>
http://www.nrc.gov/reading-rm/doc-collections/nuregs/brochures/br0117/06-01.
pdf
>
>
> Event #1: Potential radiographer overexposure at
> a temporary job site
>
> Date and Place: November 18, 2005,
> Sand Springs, Oklahoma
>
> Nature and Probable Causes: The licensee, located
> in Tulsa, Oklahoma, reported a potential overexposure
> to a radiographer at a temporary job site. The
> crew was using a SPEC exposure device (Model
> 150) with a 2.44 terabecquerel (66 curie) Iridium-
> 192 source. The radiographer went to change the
> radiographic film, thinking that the assistant had
> fully retracted the source. While en route to change
> the film, the radiographer set down his radiation
> detection instrument to answer his cell phone. At the
> same time, the assistant was sending a text message
> on his cell phone. The radiographer was in front of
> the exposure device for approximately 3 minutes
> and his alarming rate meter was turned off. The
> calculated dose the radiographer received was 23
> centisieverts (rem). The radiographers were taken
> to the hospital for blood tests as a precautionary
> measure and their dosimeters were sent for analyses.
> The Oklahoma Department of Environmental
> Quality investigated the event on November 21,
> 2005, and determined that the radiographer's
> thermoluminescent dosimeter (TLD) result was 4.4
> centisieverts (rem), and the radiographer's total
> year-to-date whole-body exposure was 6.9
> centisieverts (rem). The assistant radiographer's
> TLD result was 1.21 millisieverts (121 millirem).
> Both radiographers were suspended pending further
> investigation.
>
> Update: The licensee contracted with the National
> Radiological Protection Board, in England, to
> perform cytogenetic testing on the radiographer.
> On December 20, 2005, the results of the test were
> received. The National Radiological Protection
> Board reported the whole-body exposure to be 4
> centisieverts (rem). This result is in agreement with
> the results of the TLD.
>
>
> > From: Jose Julio Rozental
> > <joseroze at netvision.net.il>
> > Subject: Re: [ RadSafe ] 1. official Belgian report
> > on the
> > Sterigenicsradiationaccident
> > To: "NIXON, Grant" <Grant.NIXON at mdsinc.com>,
> > radsafe at radlab.nl
> > CC:
> >
> >
> >
> > Your question: "Why would the operator, a veteran of
> > some 24 years, enter the room to initiate the
> > startup procedure without a survey meter in hand?
> > Our employees do not enter irradiation chambers
> > without a direct reading/alarming dosimeter in
> > addition to their survey meters, the latter are
> > checked for audible signal and needle deflection
> > prior to entry (with a check source stationed near
> > the entrance)."
> >
> > COMMENT:
> > . . .
>
> +++++++++++++++++++
> "A scientist's aim in a discussion with his colleagues is not to persuade,
but to clarify."
> Leo Szilard
> -- John
> John Jacobus, MS
> Certified Health Physicist
> e-mail:  crispy_bird at yahoo.com
>
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