[ RadSafe ] 1. official Belgian report on theSterigenicsradiationaccident

Sat Apr 15 19:46:35 CDT 2006

In any enterprise that involves humans actions, such
as radiography and medicine, it should be expected
that humans will make mistakes. 

It is interesting to consider that there are
relatively few accidents in a heavily
engineered.industry like nuclear power. 

--- Jose Julio Rozental <joseroze at netvision.net.il>
wrote:

> 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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> 
=== message truncated ===

+++++++++++++++++++
"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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