192

13/02/2013 Ir Radioactive source stuck outside industrial radiography container

On 13 February 2013, an 192Ir radioactive source failed to return to the industrial radiography
container (Exertus DUAL 60) during activities inside the bunker of AVI in Wijnegem. The source
could be retracted to the safe position by an operator of the AVI response team (received dose
:672 Gy) with the help of a technician from OSERIX (received dose: 968 Sv). The container
was immediately removed from service until further notice. The industrial radiography container
in question was returned to the manufacturer OSERIX for investigation.
In response to these incidents, activities involving Exertus DUAL 60 have been suspended in all
three Belgian companies that use this kind of containers. OSERIX is now carrying out tests to
find the exact cause of the problem and to propose modifications for approval by the recognized
inspection organisations of the companies involved.

INES Rating: 1
192
06/02/2013 Ir Radioactive source stuck outside industrial radiography container

On 6 February 2013, an 192Ir radioactive source failed to return to the industrial radiography
container (Exertus DUAL 60) during activities inside the bunker of AVI in Houdeng. A member of
the response team managed to retract the source to the safe position after using another
remote control (both remote controls of the same type: BEST generation II). After a few tests, it
was decided to continue working with this configuration.
Activities continued on 7 February 2013 using the same combination of industrial radiography
container and remote control. Again, after a few tests, the source got stuck outside the
container and the same procedure had to be applied to return the source to the safe position.
However this operation was harder than the previous day.

INES Rating: 1

15/01/2013 Overexposure to Radiographers Assistant USA

A radiographer assistant exceeded the 50 mSv (5 rem) exposure limit for 2012. This individual
consistently had higher exposures than other employees and had failed to turn in his badge at
the end of April 2012, instead continuing to wear it through May. At the end of October, the
assistant again failed to turn in his badge and wore it through November. After his badge worn
during October and November 2012 was finally turned in and processed, it was identified that
his total dose for the year 2012 was 59 mSv (5.9 rem). After further investigation, the State
concluded that on two or three occasions, the radiographer had encountered a 500 mR/hr
radiation field while retracting the source, but did not report these incidents to the radiation
safety officer. The radiographer stated that in all cases, he had checked his and his assistants
direct-reading dosimeters and found they indicated a dose of 0.01 mSv (10 mrem) or less.
Therefore, he decided not to report them. He also stated that the need to keep up with the
work load played a role in his decision not to report these incidents. The State asked the
radiation safety officer to perform another
investigation into this incident, specifically focusing on whether this was an isolated incident or if
this was representative of the overall culture at the facility. The State informed the radiation
safety officer that enforcement action would be deferred pending the results of his investigation.

INES Rating: 2 - incident (Provisional) as per 29 January 2013

Impact on people and the environment
Release beyond authorized limits? No
Overexposure of a member of the public? No
Overexposure of a worker? Yes

Impact on the radiological barriers and controls at facilities

Contamination spread within the facility? No
Damage to radiological barriers (incl. fuel damage) within the facility? No

Degradation of Defence In-Depth : No

Person injured physically or casualty? No

Is there a continuing problem? No

18/10/2012 Overexposure of Workers Pakistan

On October 18, 2012, three workers were overexposed during industrial radiography at Phool
Nagar near Lahore. The event took place due to detachment of Ir-192 source (67 Ci) which
remained stuck in the Guide Tube. The workers could not notice this and loaded the Gamma
Projector and Guide Tube in the vehicle and traveled for almost 30 minutes from work site to
office while placing the Guide Tube very close to the leg of one worker (worker A sitting on
rear seat of the vehicle). After reaching the office, worker A unloaded the Gamma Projector to
place it in storage pit. Worker B performed radiation survey and found that the source was still
in the Guide Tube. Worker B and worker C (worker C was not a designated radiation worker)
conducted the recovery operation and brought the source to shielded position. Worker A
reported headache and vomiting within 24 hours and severe burns appeared on his left leg in
about 15 days which later developed into open wounds. Worker A is currently under medical
treatment. The event came into the knowledge of Pakistan Nuclear Regulatory Authority (PNRA)
by the end of November 2012. The matter was investigated and investigations found certain
violations of regulatory requirements and certain steps of safety procedures. PNRA has served
work stoppage notice to the company and further actions are under way. Calculations were
made to assess the dose received by the workers. The whole body dose to the worker A sitting
near to the source in the vehicle is estimated to be 2.02 Sv and for the other two workers sitting
at front seats of the vehicle is 0.81 Sv each.

INES Rating: 3 - Serious incident (Provisional) as per 10 January 2013

Impact on people and the environment

Release beyond authorized limits? No
Overexposure of a member of the public? Yes
Overexposure of a worker? Yes

Impact on the radiological barriers and controls at facilities

Contamination spread within the facility? No
Damage to radiological barriers (incl. fuel damage) within the facility? No

Degradation of Defence In-Depth : No

Person injured physically or casualty? Yes
Is there a continuing problem? No

05/10/2012 Belgium
On 5 October 2012, an operator of the IRM Group SA company, that manufactures X-ray
measuring instruments, suffered overexposure to radiation. The operator entered the protection
perimeter around a device under test in order to make adjustments on the X-ray tube. After the
intervention, he realized that the X-ray device was still running (settings: 65 kV 1.8 mA) and
informed his hierarchy. The FANC was informed of this incident on 8 October 2012 and
immediately started to investigate the circumstances of the event. The first results of this
investigation, based on reconstruction of the intervention and measurement of the dose in the
x-ray beam, reveal that the dose involved would range up to 5 to 10 Gy for both hands. Such
dose could cause X-ray-induced skin injuries. In this case, the medical staff found that there
were no such burn-injuries. However, the operator will receive medical follow-up until further
notice. Testing X-ray devices within the company has been suspended until it is decided to carry
out appropriate measures to avoid reoccurrence of such overexposure.

INES Rating: 2

19/09/2012 Belgium
On 19 September 2012, a radiologist working for the construction company Stork Technical
Services in Antwerp, that has its own industrial gamma radiography unit, got accidentally
exposed to ionising radiation emitted by an X-ray apparatus (settings: 225 kV - 4mA). The
incident occurred during activities performed with an X-ray device in a shielded bunker. The
FANC was informed on 2 October 2012 and immediately started an investigation.
Actually, the radiologist assumed that the exposure was over and he entered the bunker. When
he left, he realized that the X-ray device was still running and that his electronic dosimeter
alarm was triggered.
His electronic active dosimeter recorded a dose of 948 mSv. The radiologist underwent medical
examination. On the other hand, his passive dosimeter indicated a dose of 1,4 mSv. The
radiologist underwent medical examination that revealed no burn-injuries or direct effects. As a
precaution he will get further medical follow-up.
The X-ray device is currently out of service.

INES Rating: 2

24/03/2012 Overexposure to Radiographer USA

During work activities, a licensees radiographer [Radiographer A] appears to have been
overexposed while carrying a guide tube that contained a 2.405 TBq (65 curies) Ir-192 source.
Radiographer A was conducting work activities on a platform. When he had completed the
series of shots, he signaled to Radiographer B, on the deck below, to crank in the source.
Radiographer A surveyed the camera and then disconnected the source guide tube and laid it on
the scaffold while he lowered the camera. He then picked up the source guide tube, placed it
around his neck, and climbed down the ladder to the deck below. Radiographer A laid down the
source guide tube and noticed that Radiographer B was having trouble disconnecting the crank-
out device from the camera. Radiographer A observed that the camera was still unlocked. He
surveyed the camera and then the source guide tube. Radiographer A reported that it was then
that their survey meter indicated the source was in the source guide tube and both of their
personal dose rate alarms sounded. Radiographer A picked-up the guide tube using long tongs
and the source fell out of the guide tube onto the deck. Preliminary estimates are that the guide
tube containing the source was around the radiographers neck for approximately 15 seconds
and his hands were on the guide tube for approximately 30 seconds. However, the exact source
location inside the guide tube is presently unknown. The licensee estimated that the
radiographer received a 0.56 Sv (56 rem) dose to the whole body and possibly more than 1 Sv
(100 rem) dose to the extremities. The licensees consultant conducted the source retrieval.
Ongoing actions involve an investigation, reconstruction of the event to refine the dose
estimate, expedited processing of the licensees dosimetry, and contact with the U.S. Radiation
Emergency Assistance Center/Training Site (REAC/TS) to assist with the exposure evaluation.

INES Rating: 3 - Serious incident (Provisional) as per 27 March 2012

Impact on people and the environment

Release beyond authorized limits? No
Overexposure of a member of the public? No
Overexposure of a worker? Yes

Impact on the radiological barriers and controls at facilities

Contamination spread within the facility? No
Damage to radiological barriers (incl. fuel damage) within the facility? No

Degradation of Defence In-Depth : No

Person injured physically or casualty? No

Is there a continuing problem? No
12/01/2012 - Over Exposure to Radiographers Peru
A radiographer was taking several radiographic films to a pipes by the night. In order to be sure
that the guide tube was correctly the radiographer went to the tube guide an collimator to fix
them. This operation was made by 40 times. Eventually the radiographer touched with his left
hand, at least 10 times, the tube guide where the source was unnoticed. Also, two auxiliar staff
went to the radiographer position carrying the films to be checked at least by 40 and 20 times.
The radioactive source was 3199,5 GBq Ir-192. The event was detected at the end of job. The
radiographer adviced to radioprotection officer who jointly to other operator rescued the
radiactive source in safely manner. Operator showed mild symptoms as nausea and womiting
and other just nausea, but after all this symptoms are finished. The finger of operator showed a
blistering at the fifth day. Based in first calculations, symptoms and dosimeter reading the
operator could have received 6 - 7 Gy to whole body and > 50 Gy to finger. The other personnel
could have received doses from 1 to 3 Gy. Currently the personnel is being admitted to the
hospital and citogenetic dosimetry will be performed to adjust the doses.

INES Rating: 3 - Serious incident (Provisional) as per 17 January 2012

Impact on people and the environment

Release beyond authorized limits? No
Overexposure of a member of the public? No
Overexposure of a worker? Yes

Impact on the radiological barriers and controls at facilities

Contamination spread within the facility? No
Damage to radiological barriers (incl. fuel damage) within the facility? No

Degradation of Defence In-Depth : No

Person injured physically or casualty? No

Is there a continuing problem? No

28/10/2011 - Over Exposure to Radiographer USA

The licensee radiography crew believed they had retracted the source back into the body of the
radiography camera. They then approached the pipe. One radiographer noticed that an indicator
on the camera suggested the source was actually not fully retracted into the body of the
camera. The radiographers survey meters registered a zero reading; however, one
radiographers digital rate meter was alarming. One of the radiographers turned one crank on
the camera, and that is when the source became fully retracted. After observing their pocket
self-reading dosimeters, they realized the meters were off-scale. The licensee sent their
dosimetry badges for emergency processing. One of the badges recorded a whole body dose of
51 mSv (5.1 rem), which exceeds the statutory limit of 20 mSv (in Europe).

INES Rating: 2 - Incident (Final) as per 02 November 2011

Impact on people and the environment

Release beyond authorized limits? No
Overexposure of a member of the public? No
Overexposure of a worker? Yes
Impact on the radiological barriers and controls at facilities
Contamination spread within the facility? No
Damage to radiological barriers (incl. fuel damage) within the facility? No

Degradation of Defence In-Depth : No

Person injured physically or casualty? No

Is there a continuing problem? No

2011-10-12 - Overexposure to Radiographer USA

The licensee-radiographer, climbed a ladder to remove the guide tube from an SA Model 880
radiography camera, which contained a 1.8 TBq (49.3 curie) Ir-192 source. The radiography
camera was suspended by a rope. As he did this, another employee walked by and noticed that
the survey meter, which was on the ground, had pegged off scale. He communicated this to the
radiographer on the ladder who then realized the source was not retracted into the camera, but
was still in the guide tube. He then climbed down the ladder and retracted the source. The
licensee immediately sent his badge for processing. The result was a whole-body dose of 42
mSv (4.2 rem), which brought his total for the year to 52 mSv (5.2 rem). Furthermore, as a
result of the licensees investigation, it was determined that the radiographer also received an
estimated dose 580 mSv (58 rem) to his left hand, which had been on the guide tube. This was
consistent with the estimated extremity dose calculation performed by the State of Texas, who
is the regulatory authority.

INES Rating: 2 - Incident (Provisional) as per 28 October 2011

Impact on people and the environment

Release beyond authorized limits? No
Overexposure of a member of the public? No
Overexposure of a worker? Yes

Impact on the radiological barriers and controls at facilities

Contamination spread within the facility? No
Damage to radiological barriers (incl. fuel damage) within the facility? No

Degradation of Defence In-Depth : No

Person injured physically or casualty? No

Is there a continuing problem? No

22/09/2011 Radiography Overexposure - France

On 22 September 2011, an incident involving the use of a gamma-radiograph occurred in
Rambervillers (France).
A metal part fell on the guide tube causing it to deform, which prevented the return of the
radioactive source (source of Iridium 192 of 500 GBq) to its safe position inside the apparatus.
The analysis of the incident showed that the staff of the NDT company attempted to unblock the
source with a manual intervention on the guide on either side
of the presumed position of the source. Even though the intervention was of a very short
duration, this manual handling in the immediate proximity of a high activity sealed source does
not comply with the rules of radiation protection. Dosimetric evaluations are
ongoing in order to identify the doses received by the operators. This event did not lead to any
exposure of the public. Installing lead covers around the source enabled the danger zone to be
reduced, which was then limited to a portion of the building concerned. The French Nuclear
Safety Authority (ASN) asked the NDT company to ensure that the zone is monitored and to
define, in consultation with specialised companies, the measures necessary for recovery of the
source. The ASN classified the event at level 2 on the INES scale.

2011-09-13 - Overexposure to a Radiographer Trainee's Extremities

Preliminary information indicates that a radiographer trainee received an extremity exposure to
the fingers, as result of removing a radiography camera guide tube with the source still in it and
touching the source. The trainees fingers indicate observable deterministic effects, which
include blistering of the thumb, index and middle fingers. These types of effects correspond to
an exposure range of 20 to 30 Sv (2000 to 3000 rem) to the extremities. The trainee is receiving
medical care at an area hospital. The trainees whole body dosimeter was processed
immediately and the dose result indicates 14 mSv (1.4 rem). The State of Texas has initiated an
investigation to gather additional details of the event and to determine the estimated dose to
the extremities. These are all the known details at this time.

INES Rating: 3 - Serious incident (Provisional) as per 23 September 2011

Impact on people and the environment

Release beyond authorized limits? No
Overexposure of a member of the public? No
Overexposure of a worker? Yes

Impact on the radiological barriers and controls at facilities

Contamination spread within the facility? No
Damage to radiological barriers (incl. fuel damage) within the facility? No

Degradation of Defence In-Depth : No

Person injured physically or casualty? Yes

Is there a continuing problem? No

2010-09-16 - Radiography overexposure, Finland

On September 16, 2010 the radiation safety officer of a licensed industrial radiography company
notified the Regulatory Authority of an overexposure of a gammaradiography worker. The
worker was exposed by a 0.4 TBq cobalt-60 source, with the dose exceeding the annual dose
limit 50 mSv for radiation workers. The incident occurred when the radiographer entered the
bunker without retracting radiation source to its shielded position. The worker spent about 4
minutes in the bunker while replacing the radiography film. Inadvertent work was started
regardless relying on the alarming personal dose rate meter carried by the radiographer. Also
the personal dose rate meter was rendered inoperable by battery failure before the incident, but
the radiographer had carried on with the work regardless. These lapses in safety are in direct
conflict with regulatory requirements for gammaradiography in Finland.
The exposure would have been avoided had the individual been following written procedures
and had properly maintained radiation dose rate meter and a personal radiation alarm.

2010-05-28 - Contamination of 6 workers during the recovery of a gammagraphy

Co-60 source, France
Six workers participating in the task of unblocking a high activity radioactive source of cobalt-60
(1.25 TBq) were contaminated in Feursmetal premises (Feurs, Loire). The Co-60 source was
blocked since May 7 in the guide tube of a gammagraphy device which was located in a hot cell
of the Feursmetal company.
A first recovery operation was carried out unsuccessfully, on 10 May, under the responsibility of
Feursmetal and with the assistance of technical teams of the device inspection on 12 May to
verify the adequate implementation of provisions for radiation protection.
On 26 May, a second operation was carried out by Feursmetal and Cegelec with the support of
the French Institute for Radiation Protection and Nuclear Safety (IRSN) which provided specific
robots to retrieve and secure the radioactive source. The guide tube section in which the source
was blocked had been cut on both sides by the robot but, during this operation, the source was
damaged and its content spread. This damage was detected when the robot came out of the
hot cell for and triggered the contamination survey. The 6 workers (2 IRSN, 2 CEGELEC and 2
FEURSMETAL) in charge of the recovery operation were contaminated.
The workers were treated by the specialized medical unit of the EDF St. Albans NPP for
proximity reasons and this unit confirmed their internal contamination (anthropogammametry
result: contamination between 50 and 100 kBq). The level of contamination will be specified by
the ongoing radiotoxicological analysis, after doses reconstructions. Two inspectors from ASN
are on site since May 26 evening. ASN has provisionally classified this incident at level 2 on the
INES scale.

2009-11-12 - Worker overexposure, USA

During industrial radiography operations, a radiographer approached the camera, believing the
source to be in the shielded position. The radiographer did not have his survey meter, but was
wearing an alarming ratemeter and a pocket dosimeter. The radiographer was attempting to put
the safety plug on the end of the camera when he realized the source was not in the shielded
position. The radiographer did not contact the Radiation Safety Officer or secure the area, as
procedure required, but instead, with the assistance of another radiographer, he put the source
back into the shielded position. Both radiographers personal monitors were sent for emergency
processing. One received a whole body dose of 55.7 mSv for November, which made his exceed
the dose limit. The dose limit is 50 mSv.
Update: this rating is being updated to reflect the fact that the over exposures to the
radiographers have been confirmed. There are no other adjustments to this event.

2009-10-27 - Unnoticed public exposure, Peru

In the date Octobre 27th, while a radiography operation was being carried out a member of the
public entered the controlled area and stayed at 3 meters of the radiation source for 3 minutes
and then left the place, as he was warned by another worker. The radioactive source was Ir-192
having 171 GBq and the dose recieved by the member of public was 0,12 mSv. The oepration
was stoped and a report was sent to the Technical Office for National Authority (Regulatory
Body). Currently an investigation is being followed by regulatory body. The event has been
preliminary rated Level 0.
2009-09-29 - Unintended exposure of a worker during a welding test using gamma
radiography, France
The French Nuclear Safety Authority (ASN) has rated at level 2 on INES the accidental exposure
on the 29 September 2009 of a radiographer of the ABC Company y (HORUS holding) during a
welding test using gamma radiography at the Flamanville NPP operated by EDF. Through
violation of the working procedures, the worker entered the controlled area and remained in
during several seconds while the high activity source was not yet in its safe store position.
ASN was first quickly informed by EDF. Later on, ABC declared the event as significant incident
according to French technical guidelines. The worker received a dose of 5 mSv due to this
incident. The medical officer in charge of monitoring the worker was informed. He did not
consider it necessary to conduct a medical examination after the incident.
This accidental exposure has been caused by the non-compliance with basic radiation protection
procedures. Based on a misinterpretation of the actions performed by the radiographer
operating the radioactive source, the exposed worker, who was observing from the distance,
believed the exposure was completed. He then entered the controlled area while the radiation
source was still exposed without waiting for the formal confirmation of the end of operations
and without any survey meter to check the end of the exposure. A joint inspection by ASN and
the Labour Inspectorate was carried out on 29 October 2009.
Deviations from radiation protection approved standards were confirmed. The corrective actions
implemented by ABC and Horus were considered as satisfactory. ASN will ensure the follow-up
of the implementation of these actions. ASN has rated this incident at level 2 on INES (October
2008 version) due to the non respect of the
comprehensive set of safety rules to access the controlled area which has led to a significant
unintended exposure of a worker.
The device used is a gamma radiographer containing a high activity radioactive source of Ir 192
(1,73 TBq)

2009-07-27 - Overexposure in the field radiography, Poland

The incident happened during radiography work with Gammamat model TSI-3, containing Ir-
192 source with activity at the time 2.6 TBq (70.2 Ci). The technician operating remote crank
mechanism was not able to crank in the source to the shielded position. He asked for help
companys radiation protection inspector (RPI). The RPI with the second worker came in the
hurry, forgetting to take their individual dosemeters. The RPI had taken his own decision to
return the source to the shielded position by manually grapping the guide tube and force the
source to move to the shielded container. The source was returned back to the safe position.
The incident was on July 27th, but information about it was released by the company on 28
September, when the radiation burns of RPI became advanced. The National Atomic Energy
Agency (NAEA) Regulatory Inspectors investigated the incident in October and finished it in
December. There were no doses obtained by the public. The doses of the workers were
assessed on the basis of blood test (biodosimetry) and reconstruction of the event was
based on the statements of involved workers. The doses of RPI were approximated as: whole
body dose 365 mSv and externity effective dose about 5 Sv. The doses of second worker were
assessed by biodosimetry examination as whole body dose
182 mSv and externity dose about 2,3 Sv. The blood tests were performed by Central
Laboratory for Radiological Protection in Warsaw from blood samples taken at the beginning of
October and repeated at the beginning of November.
2009-05-26 - Overexposure of radiographer, Pakistan
On May 26, 2009 after performing RT with Ir-192 source of 60 Ci radiographer noted that all
used films were highly exposed. The unused films were also found exposed. The source guide
tube was inspected during which the source assembly fell on the ground. The radiographer
picked up the source assembly by hand and put it back into the projector. Erythema appeared
on his both hands in three days after the event. In two weeks, blistering appeared on hands
which developed into open wounds.
The incident was reported to Pakistan Nuclear Regulatory Authority (PNRA) on July 12, 2009.
Inspectors from PNRA visited the radiographer on July 14, 2009 and found healing wounds and
black spots on his palm and finger tips. The victim has been sent for further medical
investigation and treatment. The dose to the hands (extremities) was estimated to be between
25 to 30 Sv.
Investigations revealed that the worker violated the procedures under work pressure and safety
tools were not properly used. In addition, the radiographer also did not use personal dosimeter
and radiation monitor during the activity. Further the incident occurred due to faulty gamma
projector and drive cable which caused the source to disconnect and stuck in the guide tube.
Weaknesses were observed in management oversight, work supervision and safety culture of
the organization.
Work stoppage notice was served immediately to the company. Further enforcement actions are
being taken against the company involved in the incident. Due to overexposure of the worker
resulting in acute health effects, the incident is rated at level 3.

2009-03-03 - Overexposure of field radiography workers, Republic of Korea

A field of radiography worker took overexposure incidentally with radiography equipment
containing 2.1TBq (55.8Ci) Ir-192 source at the pipe welding workshop located in Jinju southern
part of Korean Peninsula, on March 3, 2009. The incident caused from the wrong direction of
crank handle by radiographers confusion. The investigation unfolded that any survey meter was
not deployed to working place and the worker did not wear a personal dosimeter as well as an
alarm meter. The absence of any detector made cognitive failure of worker that the pig-tail of
Ir-192 source was still being outside. The radiography worker burned severely on his fingers and
the extremity dose and whole body dose were estimated as being about 50 Gy and 200 mSv,
respectively. This event was rated as level 3 on the INES scale.

2008-11-04 - Overexposure of field radiography workers, Republic of Korea

On November 4, 2008, two field radiography workers took overexposure incidentally with
radiography equipment containing 1.8Tbq (47.7Ci) Ir-192 sources at pipe welding workshop
located in Yeosu province southern part of Korean Peninsula.
The incident caused from returning the disconnected pig-tail source to the source container by
those of two workers without any preventive or protective measures. The investigation unfolded
that any survey meter was not deployed to working place and an alarm meter worn by one of
worker was not properly working. They could not realize dislocated pig-tail source till loading the
source container on the vehicle due to the absence of any detector.
The received doses of the two workers were estimated as approximately 51 mSv and 62 mSv,
respectively and this event was rated as level 2 on the INES scale.