Re: radiographer "overexposure"

[William V Lipton <liptonw@DTEENERGY.COM>]

According to the event report, the processor was questioned about the reading

and reaffirmed the 1,423,000 mrem reading.  It's thus a little more serious than

a typo.



The opinions expressed are strictly mine.

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

Curies forever.



Bill Lipton

liptonw@dteenergy.com



George Cicotte wrote:



> Does anyone recall the 513 REM extremity dose incident at San Onofre in the

> late 1980s?

>

> (Anyone at SONGS please correct me - going on recollection rather than

> review)

>

> To refresh everyone's  memory, the processor sent an email report to SONGS

> that said the dose was something like 13.333 REM.  The REM column had only

> two places.  The "flag" portion of the reporting program took its' input

> from the inserted (hundreds column truncated) entry, rather than from the

> absolute value that was the input to that entry, so the reported value

> didn't calculate out to over 75% of the extremity dose, and the report

> didn't highlight it as intended.  SONGS, not being aware of the program

> fault, didn't even ask for a reevaluation until later.

>

> The later, written report had the third digit, showing 513.333 (or whatever

> the mrem remainder was).  Eventually, the investigation cast doubt on

> whether the 513 was a good figure, but that's beside the point of whether

> the information was relayed in a manner that correctly alerted the user.

>

> Supposition:

>

> If the 1,423,000 mrem reported may be the result of a simple reporting

> problem, rather than a processing problem, the QA program for the dose could

> be just fine.  Perhaps the film badge was read as 1423 mrem, but the

> printout shows a multiplier, or the program for some reason screwed up place

> value.

>

> I have no personal knowledge of this incident, but I do have quite a bit of

> experience in how computers can make our lives and careers incredibly

> easier, until we let the computer do our thinking.

>

> I would also caution, from personal painful experience, against assuming we

> actually know enough about this to speak intelligently, or to criticize the

> regulators, who may have looked at the incident and may contemplate

> enforcement action or other followup, but with the processor rather than the

> licensee, who is allowed to rely on the processor in most instances

> (assuming they're NVLAP).

>

> Respectfully,

>

> George R. Cicotte

>

> DISCLAIMER:  I haven't asked my employer what he thinks about this, and it

> is, after all, opinion rather than learned study.

>





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