[ RadSafe ] Lost sources at Illinois Hospital

Doug Aitken jdaitken at sugar-land.oilfield.slb.com
Mon Jul 26 14:23:33 CDT 2010

It seems to me that the responsibility for source security is not with the
regulators but with the license holder.....
And obviously there was a lack of management control in this instance (and
most other cases of lost sources). And the fact that these were in a fixed
installation should have made it easier. 

Obviously, regulatory oversight and inspection is a valuable (essential)
element to ensure that license-holders are following the regulations, but it
is sad that license-holders management (knowing the importance of control)
can allow situations like this to arise.

It seems that this is not the case, as many of the worst instances (e.g.
Goyana, the recent one in India and the one in discussion here)  have been
in situations of medical sources falling "out of sight, out of mind".....

And the fact that the RSO may have been new in the job is no excuse:
management control was evidently lacking. And therefore the shortage of
oversight from regulators is indeed a problem, but a secondary one.

In the business of well logging (totally separate from NDT inspection!), a
number of international (and national) companies have a very large number of
sources (in a very large number of countries around the world!) constantly
moving between storage facilities and well sites, where they are lowered
into the well bore along with measurement instruments to determine the
geological and petrophysical conditions.

In such a dynamic situation, nothing can afford to be " out of sight, out of
mind". I am not saying that oilfied sources are never lost, but the level of
control the companies in this business are required to maintain makes the
loss of a source a rare event, generally occurring in the transport of
sources (this is apart from when the equipment and sources are lost in the
well-bore itself - where if not recovered, they can safely be isolated by

Doug Aitken
QHSE Advisor
D&M Operations Support
jdaitken at sugar-land.oilfield.slb.com
(alternate: doug.aitken at slb.com)
Phone (cell): 713-562-8585
Mail: c/o Therese Wigzell,
Drilling & Measurements HQ,
300 Schlumberger Drive, MD15,
Sugar Land, Texas 77478

-----Original Message-----
From: radsafe-bounces at health.phys.iit.edu
[mailto:radsafe-bounces at health.phys.iit.edu] On Behalf Of Clayton J Bradt
Sent: Monday, July 26, 2010 1:06 PM
To: blreider at aol.com; franz.schoenhofer at chello.at;
radsafe at health.phys.iit.edu
Subject: [ RadSafe ] Lost sources at Illinois Hospital

I posted a response to Barb's and Franz's  posts on Sunday morning but it
seems to be still floating out there somewhere. Let me try again:

I think Dan McCarn explained quite well what I was getting at with my
original comments.  I was not suggesting that ignoring regulations or losing
control of sources is acceptable. Nevertheless, these types of incidents
occur with regularity, and from my experience as a regulator the scenario
described in the report is typical.  I am convinced that without regular and
fairly frequent physical inspections by regulators, the control of
radioactive sources is jeopardized.  (Even with frequent inspections,
security is not guaranteed.)  This being the case, the intense pressure on
states to cut payrolls could very likely result in the reduction of the
frequency of inspections and thus increase the likelihood of more sources
being lost track of in the future. 

As to Barb's question about a mechanism for NRC to take back an agreement: 
Such a mechanism is written into Section 274 of the Atomic Energy Act. It
allows for a state to voluntarily discontinue its regulation of most
radioactive materials and for the NRC to assume control. It also allows for
the NRC to unilaterally terminate an agreement and assert regulatory
authority in cases where the public health and safety require it.  I am
aware of only one instance where an agreement was returned to the NRC. 
About 30 years ago (someone else may have a better recollection) the
governor of Idaho was persuaded to ask the commission to resume its
regulatory authority in that state. This came about only after a decade or
so of the state having no personnel assigned to its radiation control
program.  Presumably in the future the Commission will act with more

However, the existence of a mechanism doesn't mean that NRC has the capacity
to absorb the radiation control programs of every state that is facing
budgetary retrenchment.  The states regulate 80% of the materials licenses
in the US.  NRC would have difficulty absorbing even a fraction of this. 

Let me also reiterate here what Barb has said about Illinois having had
historically a very strong radiation control program. It has and I assume
still does, and there is nothing in this event to suggest otherwise. 

Clayton J. Bradt
Principal Radiophysicist
NYS Dept. of Health
Biggs Laboratory, Room D486A
Empire State Plaza
Albany, NY 12201-0509



Dear Clayton, 

After having read for years complaints about the "all to strict" US
regulations (spare me a comment), I am rather surprised to find here a
pledge for ignoring regulations!!! 

"Jaw dropping" has even a corresponding meaning in German and means more or
less the reaction to an opinion, which is first of all absolutely absurd and
unbelievable and secondarily totally unacceptable. 

Do you really recommend to forget radioactive sources somewhere, because
they are not needed any more? Do you recommend that they should be
forgotten, because a new RSO was appointed? 

And "retirement" is another excuse?

No, come one, you cannot be serious about your message!!!! Do other
RADSAFErs support these opinion? Hopefully not!

Clayton & RadSafers,

I believe Illinois used to have quite a robust agreement state oversight
program, perhaps they do not inspect known stored souces with the same
frequently as sources in use.  I find it surprising that the program would
not be required to have good records especially as concerns therapy sources,
and that the safety department would not be in the loop on where 
rad safety involvement is needed.   More information is needed before 
determining the root and contributing causes of the incident. 

The great beekeeper (D.S.) of INPO taught me that the root cause is almost
always management failure.  I do know of a (very) few cases where it was
not, for example I don't think managment should be held responsible for a
rogue bee flying into a car and stinging the driver. 

Is there a process that allows agreement states to revert to non-agreement
status if they cannot fulfill the tasks of maintaining proper oversight? I
have never seen the NRC revoke agreement state status.  I don't mean to
imply that this one incident reflects on  Illinois' program, I am just
asking in general since Clayton brought up the issue of the potential demise
of good agreement programs due to the economy.

Barbara Reider, CHP
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