RADIOGRAPHYRADIOGRAPHY

ACTIONS ACTIONS

PRECUATIONSPRECUATIONS

REQUIREMENTSREQUIREMENTS

PROTECTIVE EQUIPMENT,FILM PROTECTIVE EQUIPMENT,FILM BADGE AND DOSEMETER MUST BADGE AND DOSEMETER MUST ALWAYS BE WORNALWAYS BE WORN

SOURCES MUST NOT BE SOURCES MUST NOT BE HANDLED WITH BARE HANDLED WITH BARE HAND.HANDLING TOOLS HAND.HANDLING TOOLS CLAMPS OR REMOTE CONTROL CLAMPS OR REMOTE CONTROL DEVICES MUST BE USED.DEVICES MUST BE USED.

THE AREA OF RADIOGRAPHY MUST BE THE AREA OF RADIOGRAPHY MUST BE ISOLATED AND WARNING SIGNS, BLACK ISOLATED AND WARNING SIGNS, BLACK AND YELLOW WARNING TAPES, YELLOW AND YELLOW WARNING TAPES, YELLOW FLAGS, RED/ AMBER BLINKING LIGHTS FLAGS, RED/ AMBER BLINKING LIGHTS AND WARNING BOARD STATING AND WARNING BOARD STATING ”RADIOGRAPHY IN PROGRESS DONOT ”RADIOGRAPHY IN PROGRESS DONOT ENTER” SHALL BE USED FOR ENTER” SHALL BE USED FOR BARRICADING THE AREA. BARRICADING THE AREA.

ONLY CLASSIFIED WORKERS ONLY CLASSIFIED WORKERS PERMITTED TO ENTER IN THESE PERMITTED TO ENTER IN THESE RESTRICTED AREAS.RESTRICTED AREAS.

SOURCES NOT IS USE MUST BE SECURILY SOURCES NOT IS USE MUST BE SECURILY STOREDSTORED

Wrong practice

SOURCES MUST BE WITHDRAWN FROM SOURCES MUST BE WITHDRAWN FROM STORE ONLY FOR THE MINIMUM TIME STORE ONLY FOR THE MINIMUM TIME NECESSARY AND ONLY BY OR UNDER NECESSARY AND ONLY BY OR UNDER THE SUPERVISION OF AN AUTHORISED THE SUPERVISION OF AN AUTHORISED PERSON.PERSON.

IT MUST ALWAYS BE TRANSPORTED IN IT MUST ALWAYS BE TRANSPORTED IN THEIR PROTECTIVE CONTAINERS.THEIR PROTECTIVE CONTAINERS.

THE VEHICLE CARRYING THE SOURCE THE VEHICLE CARRYING THE SOURCE SHOULD HAVE WARNING BOARDS FIXED.SHOULD HAVE WARNING BOARDS FIXED.

THEY SHOULD NOT DRIVE THE VEHICLE THEY SHOULD NOT DRIVE THE VEHICLE MORE THAN 90 kmph MORE THAN 90 kmph

THIS VEHICLE SHOULD NOT BE PARKED THIS VEHICLE SHOULD NOT BE PARKED IN CONGUSTED AREASIN CONGUSTED AREAS. .

THE VEHICLE SHOUD NOT GET STUCK IN THE VEHICLE SHOUD NOT GET STUCK IN TRAFFIC JAM.TRAFFIC JAM.

THE AMOUNT OF RADIATION TO WORK THE AMOUNT OF RADIATION TO WORK POSITIONS MUST NOT EXCEED POSITIONS MUST NOT EXCEED PERMISSIBLE LEVELS.PERMISSIBLE LEVELS.

ANY BEAM MUST BE DIRECTED AWAY ANY BEAM MUST BE DIRECTED AWAY FROM ADJACENT OCUPIED AREAS.FROM ADJACENT OCUPIED AREAS.

ANY USEFUL BEAM MUST BE LIMITED TO ANY USEFUL BEAM MUST BE LIMITED TO THE MINIMUM NECESSARY FOR THE THE MINIMUM NECESSARY FOR THE WORKWORK..

REPORT IMMEDIATELY ANY BREAKAGE OF REPORT IMMEDIATELY ANY BREAKAGE OF OR SUSPECTED LEAKAGE FROM A OR SUSPECTED LEAKAGE FROM A SEALED SOURCE.SEALED SOURCE.

IF YOU THINK A SOURCE HAS BEEN LOST IF YOU THINK A SOURCE HAS BEEN LOST OR MIS-LAID, REPORT THE MATTER OR MIS-LAID, REPORT THE MATTER IMMEDIATELY.IMMEDIATELY.

DO NOT TRY TO SOME ALTERATIONS OR DO NOT TRY TO SOME ALTERATIONS OR REPAIRS IN THE EQUIPMENT IF YOU ARE REPAIRS IN THE EQUIPMENT IF YOU ARE NOT AUTHORISED.NOT AUTHORISED.

February 20th, 1999

Radiological Incident

Incident Synthesis

Location

Hydroelectric Construction Site in Yanango.

Distance from Lima: 300km (East)

District: San Román, Department of Junín.

What Happened

A non-authorised person unscrewed the screws of the security lock to free the radioactive source of a Gammagraph.

No key is needed to remove the source, it can be done with an screwdriver.

Equipment’s Characteristics

Security Lock

Type: SPEC T-2

Radionucleid: Ir192

Activity Max: 3.7 TBq

Equipment’s Characteristics

With a screwdriver, the safety lock can be removed and so the

source is accessible

Welder

- 4:00 pm: A worker (welder) finds the source of gammagraphy (192 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

- 10:00 pm: He leaves work, takes a bus and travels home (he felt 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.

- 11:00 pm: The welder, takes the trousers off the room.

Chronology

Operator

- 10:30 pm: The operator makes a gammagraphy. The radiation detector doesn’t detect any readings. He assumes the equipment is not working well and stop to have dinner.

- 00:00 am: He enters the water pipe, checks the gammagraphy equipment and finds the no screws nor radioactive source. They start looking for the source.

- 1:00 am: They find the welder in his house (February 21st). He 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.

Chronology

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.

Chronology

Consequences

Overradiation: 1 Person Exposed: 18 People

Effects on Leg(13:00pm 2/21/99)

16 Days After the incident

3/8/99

Effects on Leg(70 days after the incident 5/3/99)

Consequences

Leg Amputation(10/18/99)

Severe Infection12/14/99

What Went Wrong?

Organisation

- Procedures were not implemented.

- Absence of Safety Culture in the Company’s Management.

- Source inspection and measures were inadequate.

- Lack of training and qualification of the operators.

NATIONAL AUTHORITIES ESTABLISH:

The evaluation of the authorisations and inspections should be developed by an experienced and trained team.