[ RadSafe ] radiography incident

[Chris Alston]

Folks

I especially hope that it was *not* a radiography "trainer" but a
trainee, who made this costly mistake.  Sixty-five (65) curies of
iridium is not a trivial quantity, unshielded, and without the
benefits of appropriate distancing.  Medical HDR sources are less than
20% of that activity.

Cheers
cja


---------- Forwarded message ----------
From: William Lipton <doctorbill34 at gmail.com>
Date: Thu, Mar 29, 2012 at 4:28 PM
Subject: [ RadSafe ] radiography incident
To: radsafe <radsafe at health.phys.iit.edu>


Note the carelessness and the high doses (*>* 56 rem whole body and 100 rem
extremity) in this incident. as reported to the NRC:

*AGREEMENT STATE REPORT - OVEREXPOSURE TO RADIOGRAPHER WHEN CAMERA SOURCE
BECAME DISCONNECTED

The following information was received by facsimile: * *

"On March 24, 2012, the licensee notified the Agency that it one of its
radiography teams had experienced a disconnect of a 65 curie iridium-192 on
a QSA Delta 880 radiography camera at a temporary work site in Pasadena,
Texas. The crank out drive cable had broken and the source had completely
disconnected. After an authorized individual performed the source
retrieval, the licensee's RSO learned that the radiographer trainer
disconnected the source tube from the camera and had carried the source
tube around his neck while he climbed down the ladder of the
scaffold[emphasis mine]. The source was in the tube at this time, but
it is
uncertain at this time the source's location within the tube. When the
radiographer trainer reached the platform he removed the source tube from
his neck. The licensee's initial dose estimates for the radiographer
trainer are a whole body dose of at least 56 rem and an extremity limit
that may exceed 100 rem. The radiographer's film badge is being sent for
immediate reading. The licensee is conducting an investigation. * *

"NOTE: During the licensee's initial phone call to the Agency, the Agency
understood the whole body dose estimate to be 6 rem and considered the
event to be a 24-hour report (the Agency did report to the NRC HOO within
24 hours). However, when the Agency received the written initial report
this morning, March 26, 2012, it was discovered that the estimate is 56
rem, which requires immediate notification. This report is being submitted
to update and upgrade the event. More information will be provided as it is
obtained. * *

The State also corrected the source strength to 65 curie Ir-192 source.
REAC/TS was notified on 03/26/12 and the licensee has made contact with
them. *

It seems that the radiographer had neither the training nor the alarming
dosimeter that are required by regulations.

I'll ask the same question that I've been asking for years:  When is the
NRC going to get serious about the hazards of radiography?

Bill Lipton
It's not about dose, it's about trust.
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