[ RadSafe ] radiography incident

Ted de Castro tdc at xrayted.com
Thu Mar 29 18:16:56 CDT 2012

This accident is SO typical of the industry.  Considering how many 
procedures are done - its obviously infrequent - however - when there IS 
an incident you can almost xerox the last one to report the next  one.  
So many things can be done and have been done to stop this very 
preventable accident.  Since the industry seems reluctant to use the 
administrative means prescribed to prevent these occurrences - it seems 
time to implement hardware safety provisions despite whatever minor 
operational inconveniences it may cause.  I mean detecting an exposed 65 
Curie source is just not that difficult.

Training, procedures and rules obviously just aren't working!  Its time 
for integrated, interlocked failsafed detectors and alarming area 
monitors.  It CAN be done.

On 3/29/2012 2:28 PM, William Lipton wrote:
> Note the carelessness and the high doses (*>* 56 rem whole body and 100 rem
> extremity) in this incident. as reported to the NRC:
> 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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