RE: radiographer "overexposure"

["George Cicotte" <cicottegr@HOTMAIL.COM>]

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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