IE Circular No. 79-16, Excessive Radiation Exposures to Members of the General Public and a Radiographer
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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