Lessons learned from

nuclear gauge accidents

Roel A. Loteriña
raloterina@pnri.dost.gov.ph
 Objectives
Lesson Learned From Incidents and Accidents
(Accidents that occurred in practices; sharing of operational experiences)

§ To incorporate lessons learned from actual

accidents involving radioactive materials to
develop safer practices.

§ To review and discuss available incident reports.

 Accidents involving gauges
Reports Country of origin

1 Contamination of persons and equipment by damaged level gauge source in food France
factory
2 Deterministic effects to worker’s hand during unauthorized density gauge disassembly France

3 Inadvertent disposal of textile gauge United Kingdom

4 Road density gauge crushed by road roller United Kingdom

5 Quarry level gauge fell out United Kingdom

6 Faulty shutter on a scanning beta thickness gauge United Kingdom

7 Contractor exposed during level gauge refurb, gauge poor labelling United Kingdom

8 Electrical fitter exposed during maintenance of cigarette manufacturing machines United Kingdom

9 Engineer exposed after removing beta gauge in paper manufacturing mill United Kingdom

10 Inadvertent disposal of redundant krypton-85 thickness gauge source United Kingdom

11 Thickness gauge purchased from another country with the shutter still open United Kingdom

12 Loss of a source that became detached from a coal ash analyzer gauge at a coal mine United Kingdom

13 Incident in a brewery due to the installation of a new x-ray tube in a fill-level gauging Slovenia
 Road density gauge
crushed by road roller
 Road density gauge crushed by road roller

• Description of the incident

− A portable density gauge belonging to a road
construction company, was badly damaged when it was
crushed by a road roller. This type of gauge, which
incorporates a 370 MBq caesium-137 source and a 1.85
GBq americium/beryllium source is commonly used in
road construction
− The gauge was left in the road whilst the operator
discussed his work with a supervisor on the nearby
footpath. The driver of the road roller did not see the
gauge as he traversed the site He was alerted to the
situation by the gauge operator, but was unable to stop
the roller in time. The operator cordoned off an area up
to five meters around the damaged gauge and called for
assistance.
 Road density gauge crushed by road roller

• Description of the incident

− The emergency services were alerted, and this led to a team of
physicists from a local hospital being called to the scene. In the
meantime, Fire and rescue personnel placed the damaged gauge in
a skip which they then filled with sand.
− The physicist surveyed the scene of the accident but found no
residual contamination and concluded that the sources in the
damaged gauge were intact. The gauge, still in the skip, was then
transported back to the company’s premises. The next day the
Radiation Protection Adviser visited the company’s premises and
the scene of the accident. He carried out a thorough inspection at
both locations and found no residual contamination. The gauge was
removed for subsequent disposal`
− The company involved in this incident was prosecuted by the
national regulator and was ordered to pay approximately €15,000 in
fines and costs.
Road density gauge crushed by road roller

• Nuclear density
gauge in use

• All users on site

must be aware of
the risks
Road density gauge crushed by road roller

• Damaged gauge
after being run over
by road roller

• However, the source

capsules were not
damaged during the
incident
 Road density gauge crushed by road roller

• Radiological consequences
− Despite the severe damage to these gauges, the
source capsules remained intact, and there was
no radioactive contamination.
− None of the persons involved in the recovery of
the gauges received a significant external
radiation (gamma and neutron) dose.
 Road density gauge crushed by road roller

• Lessons to be learned
− Operators of nuclear density gauges must be
aware of their supervisory duties and not leave a
gauge unattended unless it is securely stored in a
building or vehicle. This is particularly important
when large vehicles are in the vicinity.
− Consideration should be given to temporarily
demarcating an area around the gauge (e.g. with
suitable labelled traffic cones or flashing beacon),
where the supervision of the operator is not
considered sufficient to prevent incidents such as
those above.
 Road density gauge crushed by road roller

• Lessons to be learned
− Other persons working on site, e.g. drivers of large
vehicles, should be made aware of the safe
working procedures for working near to the gauge.
− Damage to a gauge by a vehicle on a road
construction site is a reasonably foreseeable
occurrence and the employer’s contingency plans
should have considered this. Operators must have
received training in implementation of the
contingency plans and also in the other safety
requirements for the work (e.g. source security).
 Road density gauge crushed by road roller

• Lessons to be learned
− If a nuclear density gauge, the integrity of both the
shielding and the source capsules should be
checked before the gauge is moved. The latter will
require leakage tests (for radioactive
contamination), which gauge operators are
unlikely to be able to do themselves. Thus,
employers should consider, an advance, how
these arrangements will be put in place.
 Road density gauge crushed by road roller

• Lessons to be learned
− If a nuclear density gauge is badly damaged, it
should not be immersed in material such sand or
stones since this obstructs a proper assessment
of the damage. It may in fact make the situation
worse if a radioactive source is ruptured, i.e.
because any material placed in contact with the
gauge could become contaminated. Instead, the
area around the gauge (2 meters is normally
sufficient) should be demarcated and the gauge
should not be touched until it has been examined
and checked for leakage or radioactive material
Faulty shutter on a scanning
beta thickness gauge
 Faulty shutter on a
scanning beta thickness gauge
 Faulty shutter on a
scanning beta thickness gauge

• A typical beta
thickness gauge
installation
 Faulty shutter on a
scanning beta thickness gauge

• Radiological consequences
− Nine members of staff had close access to the
gauge in the days leading up to the discovery of
the faulty shutter. They had performed tasks
such as re-threading the line and cleaning and
tidying the production area. However, there had
been no tasks such as foil changes carried out,
which require prolonged close access to the
source.
 Faulty shutter on a
scanning beta thickness gauge

• Radiological consequences
− These employees were interviewed to establish as
accurately as possible the length of time and their
proximity to the gauging system so that the
potential doses could be estimated. Personal
dosemeters were also returned to the dosimetry
laboratory for urgent assessment.
− The maximum beta radiation dose to the skin was
estimated to be 0.14 mSv. Any whole body doses
due to bremsstrahlung radiation would have been
negligible.
 Faulty shutter on a
scanning beta thickness gauge

• Lessons learned
− Equipment should be maintained in good
condition to reduce the risk of failure of
safety critical components
− All employees required to work in the
vicinity of a radioactive source must
receive appropriate information and
training, so that they are aware of the
potential risks and the necessary
precautions to take.
 Faulty shutter on a
scanning beta thickness gauge

• Lessons learned
− Radiation monitors must be used to verify the
correct closure of the shutter before working
close to sources of radiation, particularly where
significant radiation exposures may occur.
Records must be kept to demonstrate that this
requirement is complied with.
− Contingency plans must cover all reasonably
foreseeable incidents and they must be
implemented promptly on discovery of a problem.
 Contamination of brewery
premises during source removal
Contamination of brewery premises
during source removal
Contamination of brewery premises
during source removal

• A typical liquid level

gauge gauge in use

• The gauge heads

were dismantled in the
back of a small van in
the brewery car park
(note: not the actual vehicle shown above).
 Contamination of brewery premises
during source removal

• Radiological consequences
− The doses involved were primarily from intakes
of americium-241 and the committed effective
dose equivalents were estimated to be 20 mSv
and 2 mSv for two employees of the disposal
contractor and less than 1 mSv for the wife of the
highest exposed contractor.
 Contamination of brewery premises
during source removal
• Lessons learned
− Equipment holding radioactive sources
should, wherever possible, be transported
with the source undisturbed to suitable
facilities before dismantling takes place.
− Where removal of sources on site is
unavoidable, close liaison between the
companies (and their respective RPAs)
should take place with a view to ensuring
that adequate facilities are available for the
work to proceed safely.
 Contamination of brewery premises
during source removal

• Lessons learned
−Local rules should clearly and
unambiguously state what should be done
(or not done) if conditions change during
the work.
− Contingency plans should be incorporated
into local rules, made known to relevant
employees, and practiced.
 Contamination of brewery premises
during source removal

• Lessons learned
− After source manipulations appropriate monitoring
should be undertaken. In situations such as this,
contamination should always be considered
possible – not just from the manipulation
procedure, but also due to degradation of the
source integrity because of the environment in
which it has been used.
− Means should be provided for the checking of
radiation monitoring instruments on site before
each use. Spare batteries should be carried with
equipment.
Source fell out of shielding container
– level gauge in a quarry
Source fell out of shielding container – level
gauge in a quarry
Source fell out of shielding container – level
gauge in a quarry

• Radiological consequences
− The activity of the source was 1.85 GBq. Dose
estimations were made by the adviser using
measurements taken from the unshielded source.

Hand Whole body

Plant Operator 300 mSv 3 mSv
Supervisor 50 µSv 4.4 µSv
Adviser during recovery <10µSv <µSv
Source fell out of shielding container – level
gauge in a quarry
• Lessons learned
− The suppliers of the gauge should have ensured it was fit for
purpose and designed in such a way as to prevent the bolts
working loose.
− The site should have ensured that source location checks
included a check of the condition of the gauge. Remedial work
should have been carried out before the gauge became loose
and the source was able to fall out.
− All staff working in the vicinity of equipment containing a source
of radiation should receive awareness training concerning the
potential risks. They should also have been asked to read the
local rules In particular, they should be made aware of the
contingency plans and the importance them being properly
implemented should any defect or other incident arise.
Exposure of electrical fitter during
maintenance of cigarette
manufacturing machines
Exposure of electrical fitter during mintenance
of cigarette manufacturing machines
Exposure of electrical fitter during mintenance
of cigarette manufacturing machines
Exposure of electrical fitter during maintenance
of cigarette manufacturing machines

• Radiological consequences
The fitter's extremity dosemeter, worn on the
finger, recorded a dose of 60 mSv. The
body dosemeter recorded 0.0mSv (whole
body and skin doses). Fortunately the
sources were not damaged and hence there
was no contamination.
Exposure of electrical fitter during maintenance
of cigarette manufacturing machines
• Lessons learned
Engineer Exposed After Removing
Beta Thickness Gauge in Paper
Manufacturing Mill
 Engineer exposed after removing beta
thickness gauge in paper manufacturing mill
 Engineer exposed after removing beta
thickness gauge in paper manufacturing mill

• Radiological consequences
 Engineer exposed after removing beta
thickness gauge in paper manufacturing mill
• Lessons learned
Contractor exposed to radiation
during level gauge refurbishment
Contractor exposed to radiation during
level gauge refurbishment
Contractor exposed to radiation during
level gauge refurbishment
 Contractor exposed to radiation during
level gauge refurbishment

• Radiological consequences
 Contractor exposed to radiation during
level gauge refurbishment

• Lessons learned
 Deterministic effects to worker's
hand during unauthorized density
gauge disassembly
Deterministic effects to worker's hand during
unauthorized density gauge disassembly
Deterministic effects to worker's hand during
unauthorized density gauge disassembly
Deterministic effects to worker's hand during
unauthorized density gauge disassembly

• Radiological consequences
Deterministic effects to worker's hand during
unauthorized density gauge disassembly

• Lessons learned
 Loss of a source that became
detached from a coal ash analyser
gauge
Loss of a source that became detached
from a coal ash analyser gauge
Loss of a source that became detached
from a coal ash analyser gauge
Loss of a source that became detached
from a coal ash analyser gauge
 Loss of a source that became detached
from a coal ash analyser gauge

• Radiological consequences
 Loss of a source that became detached
from a coal ash analyser gauge

• Lessons learned
Inadvertent disposal of redundant
Kr-85 thickness gauge source
Inadvertent disposal of redundant Kr-85
thickness gauge source
Inadvertent disposal of redundant Kr-85
thickness gauge source
 Inadvertent disposal of redundant Kr-85
thickness gauge source

• Radiological consequences
 Inadvertent disposal of redundant Kr-85
thickness gauge source

• Lessons learned
Thickness gauge purchased from
another country with the shutter
still open
Thickness gauge purchased from another
country with the shutter still open
 Thickness gauge purchased from another
country with the shutter still open

• Radiological consequences
 Thickness gauge purchased from another
country with the shutter still open

• Lessons learned
 References:
http://www.othea.net/index.php/en/reports/i
ndustrial/gauges/139-jauge-de-densite-
ecrasee-par-un-rouleau-compresseur.html