ML19308A369
| ML19308A369 | |
| Person / Time | |
|---|---|
| Site: | 05000000 |
| Issue date: | 08/16/1979 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| To: | |
| References | |
| REF-SSINS-6830 IEC-79-16, NUDOCS 7908020542 | |
| Download: ML19308A369 (3) | |
Text
~70 0 $6 2 0 S Y N Accessions No.
7908020542 SSINS:6830
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UNITED STATES NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT WASHINGTON, D.C.
20555 August 16, 1979 IE Circular No. 79-16 EXCESSIVE RADIATION EXPOSURES TO MEMBERS OF THE GENERAL PUBLIC AN RADIOGRAPHER Description of Circumstances:
During radiographic operations using 40 curies of iridium-192, the source became disconnected unbeknownst to the radiographer--he did not use his After the radiographer left the facility, an employee survey instrument.
of the customer for which radiography was performed, saw the source and,He not knowing what it was, picked it up and placed it in his hip pocket.
carried it about for approximately two hours, later giving it to his super-While making a determination that it was something which visor to examine.
belonged to the radiographer, and while waiting for the radiographer to pick up the source, nine employees of the radiographer's customer The radiographer returned, examined and took the source assurring the customer's employees that there was no problem, stating that the source was a " detector".
On the evening of the event, the employee who had put the source in his At th.'t time pocket became nauseous and went to a hospital for treatment.The initial diagnosis and a blister was found on his buttock.
Thirty one days after this initial treatment toe indi-for an insect bite.
%t that vidual was hospitalized for treatment of the injury to his buttock.
time the individual asked the physicians if there could be any connectn,n of the injury to the radiography that had been perfonned at his place of work An investigation followed which disclosed the above one month previously.
information.
The individual who had carried the source in his pocket remains under medical The attending physician does not consider the care following surgery.
Neither does amputation appear necessary.
exposure to be life threatening.
The localized dose is estimated to be 1.5 million rem at skin surface, Estimated whole body 60,000 rem at 1 cm depth and 7,000 rem at 3 cm depth. Hand doses ranged to doses to other individuals ranged from 1 to 60 rem.
The radiographer received estimated doses of 14 rem to the whole 5,000 rem.
body and 50 rem to the hands.
However, another impartant aspect These are serious radiation overexposures.
of the case, second only to the physiological effects of the exposures, is the radiographer's apparent disregard for the health and safety of the exposed The radiographer's failure to individuals and for his own personal safety.
inform the involved individuals and to report the event to responsible management within his own and the customer's company is a serious disregard for safety and denied the exposed individuals early medical attention.
IE Circular No. 79-16 August 16, 1979 Page 2 of 3 The primary cause of this incident was the failure to perform a radiation survey, a comon underlying cause in radiation overexposures in the radiography industry. The number of radiation overexposures experienced in the radiography industry over the past several years has been higher than for any other single To inform radiography licensees of NRC's concern for group of NRC licensees.
these recurring overexposure incidents, NRC staff representatives met with licensees in a series of five regional meetings during the period December 1977 throught March 1978. The main purposes of the meetings were to express NRC's concern for the high incidence of overexposures, and to open a line of comunication between the NRC and radiography licensees in an effort to achieve the comon goal of improved radiation safety. A written sumary of those meetings was published by the NRC in NUREG-0495, "Public Meeting on Radiation Safety for Industrial Radiographers". A copy of that document was mailed to each NRC radiography licensee and to other companies which sent representatives to the meetings.
The remarks presented by the staff and subjects discussed at those meetings included, anong others, ways and means of incorporating safety into radiography operations, and case histories of overexposure incidents, with highlights of the causes and possible preventions.
In a discussion of the causes of over-exposures, a presentation of statistics at the meetings showed that the failure of the radiographers to perform a radiation survey after each radiographic While these surveys are required exposure was by far the most prevalent cause.
by regulation in 10 CFR 34.43(b), they are also the most basic, fundamental and comon-sense thing to do when dealing with radiation levels inherent in a typical Faiidre to perform the surveys indicates a lack of train-radiography operation.
ing intensive enough to permanently instill in radiographers the extreme importance l
Some of the case of surveys for protection of both themselves and other people.
histories discussed in NUREG-0495 resulted in painful radiation injury to hands and fingers, with eventual loss of one or more fingers in some cases.
Notice to Radiography Licensees:
NRC licensees authorized to use byproduct material under 10 CFR Part 34 are requested to take the following actions:
Review the event described in this Circular (and the other case histories 1.
in NUREG-0495) with all of your radiographic personnel at an early date; discuss and emphasi7e:
the extreme importance of radiction surveys in assuring protection a.
of themselves and of other people, and the importance o' reporting promptly any unusual events or circumstances b.
to responsible management.
Review your training to assure that appropriate emphasis is placed 2.
on the subjects in item 1 in both initial and refresher training courses.
I 3
August 16, 1979 IE Circular No. 79-16 Page 3 of 3 Review your internal audit program to assure that appropriate emphasis 3.
is placed on these same subjects, particularly the requirement for auditors to observe radiographic operations to assure the proper conduct of radiation surveys.
No written response to this Circular is required.
If you need additional information regarding this subject, please contact the Director of the appropriate NRC Regional Office.
}
IE Circular No. 79-16 Enclosure August 16, 1979 Page 1 of 2 LISTING 0F IE CIRCULARS ISSUED IN LAST SIX MONTHS Circular Subject Date of Issued to No.
Issue 79-03 Inadequate Guard Training-2/23/79 All Holders of Qualification and Falsified and applicants Training Records for Special Nuclear Material Licenses in Safeguards Group I 79-04 Loose Locking Nut On 3/16/79 All Holders of Limitorque Valve Reactor OLs or cps Operators 79-05 Moisture Leakage In 3/20/79 All Holders of Stranded Wire Conductors Reactor OLs or cps 79-06 Failure to Use Syringe 4/19/79 All Holders of and Battle Shields in Medical Licensees Nuclear Medicine except teletherapy licensees 79-07 Unexpected Speed Increase 5/2/79 All Holders of of Reactor Recirculation BWROL'sorCf's MG Set Resulted in Reactor Power Increase 79-08 Attempted Extortion - Low 5/18/79 All Fuel Facilities Enriched Uranium Licensed by NRC 79-09 Occurrences of Split or 6/22/79 All Materials Punctured Regulator Diaphragms Priority I, Fuel In Certain Self Contained Cycle and Operating-Breathing Apparatus Reactor Licensees 79-10 Pipefittings Manufactured 6/26/79
'All Power Reactor from Unacceptable Material Licensees with a CP and/or OL 79-11 Design / Construction 6/Z'//79 All Applicants Interface Problem for, and Holders of Power Reactor l
IE Circular No. 79-16 Enclosure August 16, 1979 Page 2 of 2 LISTING OF IE CIRCULARS ISSUED IN LAST SIX MONTHS Circular Subject Date of Issued to No.
Issued 79-12 Potential Disel Generator 6/28/79-All Power Reactors Turbocharger Problem Operating Facilities and all Utilities having a CP i
79-13 Replacement of Diesel 7/10/79 All Power Reactor Fire Pump Starting Operating Facilities Contactors and all Utilities having a CP i
79-14 Unauthorized Procurement and 7/13/79 All Medical Licensees Distribution of XE-133 except Teletheraphy Medical I.icensees and to all Raaiopharmaceu-l tical Suppliet s 79-15 Bursting of High Pressure Hose 8/8/79 All Materials Priority I, and Malfunction of Relief Fuel. Cycle and Operating Valve "0" Ring in Certain Self-Power Reactor Licensees Contained Breathing Apparatus i
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IE Circular No. 79-16 August 3, 1979 EXCESSIVE RADIATION EXPOSURES TO MEMBERS OF THE GENERAL PUBLIC AND A R Distribution:
Herbert Fontecilla, Technical Assistant, OCM (Hendrie)
H-ll49 George Eysymontt, Technical Assistant, OCM (Gilinsky)
H-ll49 H-ll49 John C. Guibert, Technical Assistant, OCM (Kennedy) ) H-ll49 Hugh L. Thompson, Technical Assistant, OCM (Bradford George D. Sauter, Technical Assistant, OCM (Ahearne)
H-ll49 H-ll49 SECY H-il59 C. Kammerer, Director, OCA.
H-1007 A. P. Kenneke, Acting Director, PE H-1047 L. Bickwit, General Counsel H-1016 R. F. Fraley, ACRS MNBB-6209 L. V. Gossick, ED0 MNBB-8103 J. R. Shea, Dir., 01P MNBB-3709 J. J. Fouchard, Director, PA MNBB-12105 N. M. Haller, Director, MPA MNBB-7210A G. Wayne Kerr, Asst. Dir., SA:SP MNBB-9604 J. Lieberman, ELD NL-5650 R. B. Minogue, Dir., SD NL-5650 G. A. Arlotto, Dir, DES:SD SS-958 W. J. Dircks, Dir., NMSS SS-ll30 S. Levine, Dir., RES Phil-428 H. R. Denton, Dir., NRR Phil-268 D. Vassalo, Acting Dir., DPM;NRR Phil-278 D. F. Ross, Deputy Director, DPM:NRR P-357 P. F. Collins, Chief, OLB:DPM:NRR Phil-216 J. R. Miller, DOR:NRR D. G. Eisenhut, Acting Dir., DOR:NRR Phil-266 P-514 R. H. Vollmer, Asst. Dir., SP: DOR:NRR Phil-416 G. C. Lainas, Chief, PSB:D0R:NRR Phil-370 B. K. Grimes, Asst. Dir., E/P: DOR:NRR Phil-202 R. J. Mattson, Dir., DSS:NRR Phil-722 R. M. Satterfield, Chief, ICSB: DSS:NRR P-320 W. P. Haass, Chief, QAB:0AO:NRR V. Stello, Director, IE D. Thompson, X005:IE R. C. Paulus, X00S:IE L. N. Underwood, X005:IE (Originsi)
H. D. Thornburg, RCI:IE G. W. Reinmuth, RCI:IE N. C. Moseley, ROI:IE E. L. Jordan, ROI:IE S. E. Bryan, ROI:IE J. H. Sniezek, FFMSI:IE R. Meyer, ROI:IE L. B. Higginbotham, FFMSI:IE E. M. Howard, SI:IE L. I. Cobb, X0MA:IE IE Files Phil-016 NRC Central Files IE Reading Files Phil-050 Mike Atsalinos, DSB:TIDC:ADM