CR79016 August 3, 1979 MEMORANDUM FOR: B. H. Grier, Director, Region I J. P. O'Reilly, Director, Region II J. G. Keppler, Director, Region III K. V. Seyfrit, Director, Region IV R. H. Engelken, Director, Region V FROM: L. B. Higginbotham, Assistant Director, Division of Fuel Facility and Materials Safety Inspection, Office of Inspection and Enforcement SUBJECT: IE CIRCULAR NO. 79-16, EXCESSIVE RADIATION EXPOSURES TO MEMBERS OF THE GENERAL PUBLIC AND A RADIOGRAPHER The enclosed IE Circular is transmitted for issuance on August 16, 1979. The Circular should be sent to all Radiography Licensees. Also enclosed is a draft copy of the transmittal letter and mailing labels for the radiography licensees in your region. L. B. Higginbotham, Assistant Director Division of Fuel Facility and Materials Safety Inspection Office of Inspection and Enforcement Enclosures: 1. Draft transmittal letter 2. IE Circular No. 79-16 3. Mailing labels CONTACT: R. Meyer 49-28188 . (Transmittal letter for Circular No. 79-16 to each Radiography Licensee) IE Circular No. 79-16 Addressee: The enclosed Circular No. 79-16 is forwarded to you for information. If there are any questions related to your understanding of the suggested action, please contact this office. Signature (Regional Director) Enclosures: 1. IE Circular No. 79-16 2. Listing of IE Circulars Issued in Last Six Months . Accessions No. 7908020542 SSINS:6830 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 AND A 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 survey instrument. After the radiographer left the facility, an employee of the customer for which radiography was performed, saw the source and, not knowing what it was, picked it up and placed it in his hip pocket. He carried it about for approximately two hours, later giving it to his supervisor to examine. While making a determination that it was something which belonged to the radiographer, and while waiting for the radiographer to pick up the source, nine employees of the radiographer's customer were exposed. The source was also left with a secretary who was instructed to contact the radiographer. The radiographer returned, examined and took the source assuring 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 pocket became nauseous and went to a hospital for treatment. At that time a blister was found on his buttock. The initial diagnosis and treatment was for an insect bite. Thirty one days after this initial treatment the individual was hospitalized for treatment of the injury to his buttock. At that time the individual asked the physicians if there could be any connection of the injury to the radiography that had been performed at his place of work one month previously. An investigation followed which disclosed the above information. The individual who had carried the source in his pocket remains under medical care following surgery. The attending physician does not consider the exposure to be life threatening. Neither does amputation appear necessary. The localized dose is estimated to be 1.5 million rem at skin surface, 60,000 rem at 1 cm depth and 7,000 rem at 3 cm depth. Estimated whole body doses to other individuals ranged from 1 to 60 rem. Hand doses ranged to 5,000 rem. The radiographer received estimated doses of 14 rem to the whole body and 50 rem to the hands. These are serious radiation overexposures. However, another important aspect 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 individuals and for his own personal safety. The radiographer's failure to 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 common 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 group of NRC licensees. To inform radiography licensees of NRC's concern for these recurring overexposure incidents, NRC staff representatives met with licensees in a series of five regional meetings during the period December 1977 through 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 communication between the NRC and radiography licensees in an effort to achieve the common goal of improved radiation safety. A written summary 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, among 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 overexposures, a presentation of statistics at the meetings showed that the failure of the radiographers to perform a radiation survey after each radiographic exposure was by far the most prevalent cause. While these surveys are required by regulation in 10 CFR 34.43(b), they are also the most basic, fundamental and common-sense thing to do when dealing with radiation levels inherent in a typical radiography operation. Failure to perform the surveys indicates a lack of training intensive enough to permanently instill in radiographers the extreme importance of surveys for protection of both themselves and other people. Some of the case 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: 1. Review the event described in this Circular (and the other case histories in NUREG-0495) with all of your radiographic personnel at an early date; discuss and emphasize: a. the extreme importance of radiation surveys in assuring protection of themselves and of other people, and b. the importance of reporting promptly any unusual events or circumstances to responsible management. 2. Review your training to assure that appropriate emphasis is placed on the subjects in item 1 in both initial and refresher training courses. . IE Circular No. 79-16 August 16, 1979 Page 3 of 3 3. Review your internal audit program to assure that appropriate emphasis 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.
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