[ RadSafe ] radiography incident -Unpardonable carelessness

[parthasarathy k s]

Dear Dr Castro.

I brought this incident to the notice of officers in the Atomic Energy Regulatory Board, India. QSA Delta 880 radiography camera is very popular in India; about 600 of these are in use.

The incident occurred because of carelessness. The trainee did not use a radiation survey meter during the procedure. In our experience in India, such incident occurred because the trainee  did not follow safe procedures. He has no business to be in the area without having an operating radiation monitoring instrument.

I feel that besides training, a certain amount of indoctrination of workers is needed. In an international forum I argued that the educational material for trainees must contain really unpleasant pictures of radiation burns! It was not appreciated. The worker in the present case is lucky escaping without radiation burns.(We do not know about it yet!) Since the team apparently used no survey meter, the unshielded source would have exposed many unsuspecting individuals


regards
Parthasarathy




________________________________
 From: Ted de Castro <tdc at xrayted.com>
To: The International Radiation Protection (Health Physics) Mailing List <radsafe at health.phys.iit.edu> 
Sent: Thursday, 29 March 2012, 19:16
Subject: Re: [ RadSafe ] radiography incident
 
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:
>
> *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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