[ RadSafe ] Lost sources at Illinois Hospital

Tue Jul 27 09:53:47 CDT 2010

Clayton:

I don’t think Franz (and myself!) missed the point. Regulatory oversight is
obviously a way to ensure that regulations are being followed and that a
robust system is in place. And by no means am I trying to minimize the
importance of regulatory oversight, without which things can certainly go
wrong.

But the loss of a source is a failure whose root cause needs to be
identified. And the fact that the hospital was not visited with sufficient
frequency by inspectors is not a root cause. It is that management did not
do their job. 

Perhaps there was not an effective handover of responsibility to the new RSO

Perhaps the system for tracking the sources was not being followed (a system
must have been in place for the hospital to be licensed)

All these speculations can be affirmed by the investigation..

Anyone know what sources were lost? 

Regards

Doug

___________________________________

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,
Schlumberger,
Drilling & Measurements HQ,
300 Schlumberger Drive, MD15,
Sugar Land, Texas 77478

From: Clayton J Bradt [mailto:CJB01 at health.state.ny.us] 
Sent: Tuesday, July 27, 2010 8:47 AM
To: Franz Schönhofer
Cc: blreider at aol.com; 'Clayton J Bradt'; 'Doug Aitken';
radsafe at health.phys.iit.edu
Subject: Re: AW: [ RadSafe ] Lost sources at Illinois Hospital

You're missing the point, Franz. No one was making excuses for the incident.
Of course the licensee is to be held accountable. The point is that there
are reasons for things like this happening, and a common one is the gap in
licensee oversight that can occur when the RSO changes. It is not supposed
to happen, but it does. The point of regulation is not to punish mistakes
after they happen - though this is a necessary component of the process -
rather it is to try to prevent these kinds of mistakes in the first place.
You can write all the rules you want, and make them ever more prescriptive
(and onerous), but no systems of regulations will police themselves. In my
experience, the best way to improve compliance by licensees is frequent
contact with regulators - boots on the ground, if you will. There is no
substitute for knowledgeable and experienced inspectors with sufficient time
and resources to do their jobs. 

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

518-474-1993

Franz Schönhofer <franz.schoenhofer at chello.at> wrote on 07/26/2010 06:42:47
PM:

> Franz Schönhofer <franz.schoenhofer at chello.at> 
> 07/26/2010 06:43 PM
> 
> To
> 
> "'Doug Aitken'" <jdaitken at sugar-land.oilfield.slb.com>, "'Clayton J 
> Bradt'" <CJB01 at health.state.ny.us>, <blreider at aol.com>, 
> <radsafe at health.phys.iit.edu>
> 
> cc
> 
> Subject
> 
> AW: [ RadSafe ] Lost sources at Illinois Hospital
> 
> Dough,
> 
> Gratulations! This is the only reasonable comment on the topic I read
until
> now. You really got to the point!!! It is not the fault of the licensing
> authority if licensees do not follow the licensing conditions!!!
> 
> Is it the fault of traffic autorities, if car drivers exceed the maximum
> allowed speed???
> 
> This discussion is rather annoying - violators should be punished and not
be
> allowed to make excuses, like "change of RSO", "not in use any more" etc.
> Not even in Austria, which is known for such "excuses" these would be
> honoured. 
> 
> Best regards.
> 
> Franz
> 
> Franz Schoenhofer, PhD
> MinRat i.R.
> Habicherg. 31/7
> A-1160 Wien/Vienna
> AUSTRIA
> 
> 
> -----Ursprüngliche Nachricht-----
> Von: Doug Aitken [mailto:jdaitken at sugar-land.oilfield.slb.com] 
> Gesendet: Montag, 26. Juli 2010 21:24
> An: 'Clayton J Bradt'; blreider at aol.com; franz.schoenhofer at chello.at;
> radsafe at health.phys.iit.edu
> Betreff: RE: [ RadSafe ] Lost sources at Illinois Hospital
> 
> 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
> cement). 
> 
> Regards
> Doug
> ___________________________________
> 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,
> Schlumberger,
> 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
> alacrity. 
> 
> 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
> 
> 518-474-1993
> 
> *****************************************
> 
> 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!
> 
> Franz
> ******************************************
> 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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