[ RadSafe ] lessons learned (was: Radiography Incident)

[Ahmad Al-Ani]

The lessons learned were not wrong Clayton, perhaps the root cause analysis were. The facilities were understaffed, and safety procedures were simplistic. When the NRC allowed the HDR procedures again, all the points you mentioned were enacted upon, and the pre and post treatment QA procedure was quite rigorous and redundant.

I however still do not understand why the design then did not include a radiation detector to confirm complete returning of the source to the safe. I read somewhere that the laser welding method estimated that even if you keep the wire running in and out for the three months, it would still be a small fractions of the cycles necessary to break the source off.

This is still the case with the industrial radiography devices.

Ahmad

>________________________________
> From: Clayton J Bradt <CJB01 at health.state.ny.us>
>To: radsafe at health.phys.iit.edu 
>Cc: doctorbill34 at gmail.com; ahmadalanimail at yahoo.com 
>Sent: Wednesday, April 4, 2012 9:06 PM
>Subject: lessons learned (was: Radiography Incident)
> 
>
>
>
>Bill & Ahmad:
>
>The lessons learned from this incident were all the wrong ones. NRC claimed that the root cause of this patient's death was a design flaw in the in the way the source/wire combination were stored within a teflon coated container. The radiolysis of the teflon generated corrosive chemicals that attacked and weakened the wire.  NRC criticized the State of Louisiana's radiation program for missing this design flaw when it conducted its Sealed Source and Device review for the source. 
>
>Of course the real cause of the patient's death was malfeasance by the licensee's personnel, the RSO and the NRC. 
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>1)The NRC had authorized the licensee to operate ten facilities with only one RSO. [This should never have been accepted by the NRC license reviewers. The RSO should either be on site or  available to respond immediately whenever treatments are being performed. This is impossible with ten facilities geographically scattered around the state.  The RSO is also responsible for ensuring licensee personnel are trained in and understand radiation safety procedures, but upon interviewing the employees at the Indiana, Pennsylvania facility (the site of the incident) it was learned that they didn't even know who the RSO was.] 
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>2)  The area radiation monitor, which did indicate that the source was still outside of its shield after treatment was finished, had a history of problems and instead of being repaired immediately it was simply assumed to be malfunctioning and ignored. [Area monitors should be operationally checked at the beginning of each day that treatment is to be performed.  If not operational it should be fixed before treatment can be performed.]
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>3) No survey of the patient with a hand held instrument was performed to verify removal of the source from the patient. [This is to be a double check of the area monitor and the source position indicator on the HDR.]
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>In the face of these glaring procedural failures, NRC chose to lay the blame at the feet of Louisiana's SS&D review!  Mechanical devices fail. Sources become disconnected. These are events that can be readily anticipated and procedures are supposed to be in place so that employees can detect and mitigate their effects. 
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>
>Clayton J. Bradt
>Principal Radiophysicist
>NYS Dept. of Health
>Biggs Laboratory, Room D486A
>Empire State Plaza
>Albany, NY 12201-0509
>
>518-474-1993
>
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