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RE: radiography - deja vu all over again

At 01:54 PM 5/20/03 -0400, Hart, Tim P GS (RASO) wrote:
Mr. Lipton,

The real question is when will people stop ignoring the rules?  Alarming
rate meters were added as a regulation because radiographers wouldn't carry
an instrument.  After that the NRC adopted a rule that each radiographer
must be tested and carry a certificate that could be yanked if they did
anything wrong.  Radiographers continue to screw-up, Doctors continue to run
neck-in-neck with radiographers in screw-ups when using isotopes with far
broader effects and at a much higher frequency.  When will the NRC do
something about them? 

This incident didn't happen in NRC jurisdiction, but in Texas, one of the
toughest and best regulated radiography agreement state programs.  What more
do you want the NRC to do?  Hold the hand of every radiographer during every
shot across the nation!  While they are at it they should be double checking
every doctor and hospital any time they use any isotope for treatment or
testing.

No more rules, lets just enforce the ones we have.  If the radiographer
loses his job, then the next guy might think before acting.



This is my opinion and only mine, not the U.S. Navy's.

Tim Hart
Radiation Protection Manager
NAVSEADET RASO
NWS P.O. Drawer 260
Yorktown, VA 23691-0260

Commercial: (757) 887-4692
DSN:  953-4692
Fax:  (757) 887-3235

"The true measure of a man is how he treats someone who can do him
absolutely no good." - Samuel Johnson




-----Original Message-----
From: William V Lipton [mailto:liptonw@DTEENERGY.COM]
Sent: Tuesday, May 20, 2003 11:48 AM
To: radsafe@list.vanderbilt.edu
Subject: radiography - deja vu all over again


Please see the attached item from the March 20, 2003, NRC Daily Event
Report.  Here's another preventable radiography incident.

my usual question:  When is the NRC going to start taking radiography
seriously?

Also, some key information seems to be missing from the report.  The
sequence of events seems to be:  (1) source exposed for shot, (2)
radiographer leaves work area prior to cranking back source, (3)
radiographer returns, changes film,and moves guide tube with source
still exposed.  The report then states, "At this point, he realized that
his survey meter had pegged high, and remembered that he had not cranked
the source back in prior to moving it..."

Assuming that TX regulations are similar to NRC regulations, consider 10
CFR 34.47(a):  "The licensee may not permit any individual to act as a
radiographer or a radiographer's assistant unless, at all times during
radiographic operations, each individual wears, on the trunk of the
body, ... an operating alarm ratemeter..."

I think it's just this scenario that the regulators had in mind when
they required an alarm ratemeter.  Where was it?

BTW, they were very lucky that the source had decayed down to 26 Ci.  If
I remember correctly, a fresh source is 80 - 100 Ci, which probably
would have caused an overexposure.

The opinions expressed are strictly mine.
It's not about dose, it's about trust.
Curies forever.

Bill Lipton
liptonw@dteenergy.com




AGREEMENT STATE
REPORT                                                       |
|
|
| The licensee reported a potential overexposure to a radiographer who
was     |
| x-raying some pipes at a worksite.  After completing a section of
piping,    |
| the radiographer should have cranked his source back in, but was
interrupted |
| by another technician and left his work area.  When he returned,
the         |
| radiographer changed out his film, and moved the guide tube to
another       |
| section of piping to begin more x-rays.  At this point, he realized
that his |
| survey meter had pegged high, and remembered that he had not cranked
the     |
| source back in prior to moving it.  He proceeded to immediately crank
the    |
| source back to its fully shielded position.  The exact time and
distance     |
| from the source for the radiographer's exposure is unknown, and the
licensee |
| is attempting to re-create the
scenario.                                     |
|
|
| The source was 26 Curies of Iridium 192, model number INC-32.  The
serial    |
| number is unknown at this time.  A preliminary investigation by the
licensee |
| estimates the radiographer's exposure to 800-900 millirem whole body.
There |
| is currently no exposure estimate for his
hands/extremities.                 |
|
|
| The radiographer's badge was sent off for processing.  Results will
be       |
| reported on 5/16/03 to the NRC.  The Texas Department of Health is
sending   |
| an additional inspector to the site to
investigate.                          |
|
|
|
|
| * * * UPDATE ON 5/16/03  @ 1120 BY  WATKINS TO GOULD * *
*                   |
|
|
| Blazer Industrial Radiography brought in a consultant to perform
preliminary |
| dose calculations for the whole body and the right hand of the
radiographer. |
| The results were 1.3R for the whole body and 37.1R for the right
hand,       |
| neither of which exceeds the annual regulatory
limit.                        |
+---------------------------------------------------------------------------
---+





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Dear Tim:

Let's be careful about the cracks concerning physicians.  Fifteen MILLION nuclear medicine procedures are performed each year.  Of the extremely small number of significant misadministrations and significant incidents that are reported, almost all are in practices where the authorized user physician is not board certified in nuclear medicine.  It is not the fault of nuclear medicine physicians that NRC will sell licenses to physicians with poor qualifications in the field---it is NRC's fault.  It needs the money desperately, and doesn't really care about medical quality.  In many of these non-nuclear medicine physician practices, techs run the program because the physician really does not know what to do.  No tech is qualified to practice any kind of medicine, including nuclear medicine.  If you're irate about medical problems, put the blame where it belongs. 

On February 6, 1990, at the request of Commissioner Curtiss, I was given all of NRC's reports from 1985-1988 and the first 3 quarters of 1999 and asked to analyze them.  My report showed that there were hardly any events of any significance, and almost all occurred in practices in which the physicians were not board certified in nuclear medicine.  Over the ensuing years, almost all the events are similarly insignificant, and almost all the physicians involved were not board certified nukes.  Most of the problems are among diagnostic radiologists doing therapy.  If NRC wanted to fix these problems, it would raise the training and experience for AU's to that of nuclear medicine physicians.  NRC's "Quality Management" Rule failed utterly because NRC refused to address the real problem, poorly qualified physicians.  The ACMUI told this to NRC, but NRC ignored it.  I was on the ACMUI at that time.

Ciao, Carol

Carol S. Marcus, Ph.D., M.D.
<csmarcus@ucla.edu>