ir accident case histories

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Module 7 Module 7 Protection Against Occupational Protection Against Occupational Exposure Exposure Industrial Radiography Industrial Radiography Accidents : lessons learned Accidents : lessons learned IAEA Post Graduate Educational Course in Radiation Protection and safety of Radiation Sources

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Page 1: IR Accident Case Histories

Module 7Module 7

Protection Against Occupational Protection Against Occupational ExposureExposure

Industrial RadiographyIndustrial Radiography

Accidents : lessons learnedAccidents : lessons learned

IAEA Post Graduate Educational Course in Radiation Protection and safety of Radiation Sources

Page 2: IR Accident Case Histories

Module 7 : Industrial Radiography 2

Aims and ObjectivesAims and Objectives

Be familiar with typical industrial Be familiar with typical industrial radiography accidentsradiography accidents

Understand specific contributing factorsUnderstand specific contributing factors Be aware of lessons learned from past Be aware of lessons learned from past

accidentsaccidents

Page 3: IR Accident Case Histories

Module 7 : Industrial Radiography 3

ContentsContents

Case histories describedCase histories described Consequence of each accident Consequence of each accident Lessons learnedLessons learned

Page 4: IR Accident Case Histories

Module 7 : Industrial Radiography 4

Gamma Site Radiography Lost SourceGamma Site Radiography Lost Source

550 GBq iridium-192550 GBq iridium-192 source became detached, fell from source became detached, fell from

guide tubeguide tube 5 days before loss was realised5 days before loss was realised 78 persons irradiated78 persons irradiated doses ranged from 11 mSv to 150 mSvdoses ranged from 11 mSv to 150 mSv

Page 5: IR Accident Case Histories

Module 7 : Industrial Radiography 5

Gamma Site Radiography Lost SourceGamma Site Radiography Lost Source

•Incorrect use of monitor

•inadequate monitoring

Page 6: IR Accident Case Histories

Module 7 : Industrial Radiography 6

Gamma Site Radiography Defective Gamma Site Radiography Defective EquipmentEquipment

3.2 TBq iridium-1923.2 TBq iridium-192 source jammed in exposed positionsource jammed in exposed position no emergency equipmentno emergency equipment no local rules or exposure warningsno local rules or exposure warnings IAEA assistance in source recoveryIAEA assistance in source recovery 7 persons involved in recovery, all doses 7 persons involved in recovery, all doses

< 1.0 mSv< 1.0 mSv

Page 7: IR Accident Case Histories

Module 7 : Industrial Radiography 7

Gamma Site Radiography Defective Gamma Site Radiography Defective EquipmentEquipment

lead container

guide tube

Page 8: IR Accident Case Histories

Module 7 : Industrial Radiography 8

Gamma Site Radiography Defective Gamma Site Radiography Defective EquipmentEquipment

source activity should be optimized- > 1.8 TBq for source activity should be optimized- > 1.8 TBq for site work should be justifiedsite work should be justified

reasonably foreseeable accidents should be reasonably foreseeable accidents should be highlighted in prior safety assessmentshighlighted in prior safety assessments

adequate maintenance of ancillary equipment is adequate maintenance of ancillary equipment is essentialessential

site radiography requiressite radiography requires

appropriate emergency & ancillary appropriate emergency & ancillary equipmentequipment

trained personneltrained personnel adequate supervisionadequate supervision

Page 9: IR Accident Case Histories

Module 7 : Industrial Radiography 9

X-Ray Site Radiography Localised X-Ray Site Radiography Localised ExposureExposure

X-Ray Site Radiography Localised X-Ray Site Radiography Localised

Exposure160 kV x-raysExposure160 kV x-rays No exposure warningsNo exposure warnings Fingers exposed to primary beam for ~ 10 Fingers exposed to primary beam for ~ 10

secondsseconds Localised dose of ~ 60 SvLocalised dose of ~ 60 Sv

Page 10: IR Accident Case Histories

Module 7 : Industrial Radiography 10

X-Ray Site Radiography Localised X-Ray Site Radiography Localised ExposureExposure

periodic checks on safety systems are periodic checks on safety systems are essentialessential

radiation monitoring is essentialradiation monitoring is essential local rules must be observedlocal rules must be observed personal alarm monitors can lessen the personal alarm monitors can lessen the

consequences of an accidentconsequences of an accident

Page 11: IR Accident Case Histories

Module 7 : Industrial Radiography 11

Gamma Site Radiography Gamma Site Radiography Disconnected SourceDisconnected Source

1100 GBq iridium-1921100 GBq iridium-192 source became disconnected from the source became disconnected from the

drive cabledrive cable source picked up by a member of the source picked up by a member of the

public and taken homepublic and taken home source “lost” from March to Junesource “lost” from March to June 8 persons died as direct result from 8 persons died as direct result from

exposure to radiationexposure to radiation

Page 12: IR Accident Case Histories

Module 7 : Industrial Radiography 12

Lessons learned : SummaryLessons learned : Summary

Adherence to established safety procedures Adherence to established safety procedures would have prevented most accidentswould have prevented most accidents

Safety may be compromised if regulatory Safety may be compromised if regulatory controls are not in placecontrols are not in place

Systematic audits by management help to ensure Systematic audits by management help to ensure that level of knowledge and performance of that level of knowledge and performance of radiographers is maintainedradiographers is maintained

A poor safety culture can result in degradation of A poor safety culture can result in degradation of safety systems and proceduressafety systems and procedures

Deficient training is contributory in the majority Deficient training is contributory in the majority of accidentsof accidents

Page 13: IR Accident Case Histories

Module 7 : Industrial Radiography 13

Lessons learned : SummaryLessons learned : Summary

Adherence to established safety procedures Adherence to established safety procedures would have prevented most accidentswould have prevented most accidents

Safety may be compromised if regulatory Safety may be compromised if regulatory controls are not in placecontrols are not in place

Systematic audits by management help to ensure Systematic audits by management help to ensure that level of knowledge and performance of that level of knowledge and performance of radiographers is maintainedradiographers is maintained

A poor safety culture can result in degradation of A poor safety culture can result in degradation of safety systems and proceduressafety systems and procedures

Deficient training is contributory in the majority Deficient training is contributory in the majority of accidentsof accidents

Page 14: IR Accident Case Histories

Module 7 : Industrial Radiography 14

Where to Get More InformationWhere to Get More Information

Course notesCourse notes IAEA publicationsIAEA publications

Page 15: IR Accident Case Histories

Module 7 : Industrial Radiography 15