[ RadSafe ] radiography incident

Fri Mar 30 08:05:43 CDT 2012

As a former radiography inspector in an Agreement State (CO), I am
convinced that this is an industry problem more than a regulatory
problem.  The radiography regulations are pretty robust - it is the
institutionalized lack of respect for the regulations and downplaying of
the hazards (machismo?) that leads to bad behavior.  Inspections can be
increased, but what Agency still has enough trained staff to do
increased inspections?  State programs are being hammered by the
recession, inspectors are not plentiful (and while we are at it - they
need to be paid more to keep them.)

Clearly, this radiogrpaher or his assistant  did not have his alarming
ratemeter on his person.  In addition to the alarming ratemeter, each
person is also required to have a pocket dosimeter (0-200 mrem), and
they are required to measure the guide tube and camera with a hand held
instrument after each shot when coming back to the camera after a shot
is completed.

The Delta 880 is a fairly new design and has locking mechanisms.  It is
unusual for a complete disconnect, it will be interesting to see what
the investigation turns up.
Something doesn't make sense in this report.  Persons who are authorized
in source retrieval do not just walk around with the source when it  is
retrieved - they put it into a pig of some sort, and they are trained to
use tongs and lead shot, etc. to maximize distance and shield the source
until it can be put into a pig.  If the source was still in the guide
tube, I am not sure it was properly "retrieved." Since a ladder was
involved, there may be some circumstance that made proper retrieval
difficult.

These radiography crews are often paid "by the shot," so the more they
do on a shift, the more they will get paid; working safely by the book
can slow things down.  They are often not supervised, working in the
field and working odd hours.  Trainees, being on the bottom rung of the
ladder often eat the most dose.  Because of the 5 rem a year limit,
workers will often not wear their dosimeters so as not to be pulled from
the field by the RSO if their dose is approaching the annual limit.  I
also note that radiography is done every day around the world, with a 2
rem/y limit.  It can be done.

One good thing to consider is that digital industrial radiography is
now in use, and it uses much smaller sources.  They can use a 3 curie
source instead of a 100 curie source (Ir-192).
The equipment is very expensive and not all that rugged in the field,
but it is in use.  I have inspected crews using digital industrial
radiography.  It also eliminates the need for all the chemicals used to
develop film.  They are hazardous and who knows how safely they handle
that stuff...

Maybe they need to put pictures of radiographers with radiation burns in
every truck to remind the workers of the hazards, similar to what is
proposed for cigarette packs.

Philip Egidi
Environmental Scientist
U.S. Environmental Protection Agency
Office of Radiation and Indoor Air
Radiation Protection Division
Center for Waste Management and Regulations
Washington, DC

phone: 202-343-9186
email: egidi.philip at epa.gov
cell: 970-209-2885

From:	William Lipton <doctorbill34 at gmail.com>
To:	radsafe <radsafe at health.phys.iit.edu>
Date:	03/29/2012 05:29 PM
Subject:	[ RadSafe ] radiography incident
Sent by:	radsafe-bounces 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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