Location

.Hydroelectric Construction Site in Yanango

Distance
from Lima: 300km (East)
District: San
.Romn, Department of Junn

What Happened
A nonlock to free
authorised person unscrewed the screws of the security
.the radioactive source of a Gammagraph
No key is
screwdriver

needed to remove the source, it can be done with an

Type: SPEC T-2

Radionucleid: Ir192
Activity Max: 3.7 TBq

Welder
pm: A worker (welder) finds the source of gammagraphy (192 4:00
Ir) abandoned in a water pipe. He puts it in the back pocket of his
.trousers
He works for six hours with the source in his pocket and his
assistant nearby

pm: He leaves work, takes a bus and travels home (he felt 10:00
little pain in his right leg). During his return, he travelled for 30
.minutes with 15 people
.He thinks that the red skin is due to an insect sting

His wife sat on the trousers for 10 minutes to feed their baby. Two
.kids slept nearby
.pm: The welder, takes the trousers off the room 11:00

Operator
pm: The operator makes a gammagraphy. The radiation 10:30
detector doesnt detect any readings. He assumes the equipment is
.not working well and stop to have dinner
am: He enters the water pipe, checks the gammagraphy 00:00
equipment and finds the no screws nor radioactive source. They
.start looking for the source

am: They find the welder in his house (February 21st). He 1:00
gets out with the source in his hands. The operator hits the welders
.hand, throws the source to the street and puts a stone to cover it
The source is recovered and secured in a container with iron walls 2 thick

?What was done

.Initially, the welder was hospitalised in the Cancer Centre of Lima
He was then sent to the Military Hospital Precy de Claart Grave Burns
.Treatment Centre in France

?What was done

.Initially, the welder was hospitalised in the Cancer Centre of Lima
He was then sent to the Military Hospital Precy de Claart Grave Burns
.Treatment Centre in France

Leg infection after 10 days

Leg Amputation after 4 months
(10/18/99)
Passed away with sever infection after one year

Lesson learned

Persons not directly working with radiation sources, but working nearby,
should be given appropriate information and may require training

ion and may require training. Co-operation between licensees/employers

and exchange of information can help to ensure that all relevant persons
are aware of the hazards and understand the protection and
safetymeasures to be taken

Radiography cameras need to be designed and constructed in a way that

prevents unauthorized access to the radioactive source. As mentioned
above, ISO 3999 [19] specifies the international standards for apparatus
.used for gamma radiography

having policies and procedures in place is not sufficient in itself to ensure

the required level of radiation safety using radiation detection alarm in
.place