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


                              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 


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 

1.   Draft transmittal letter
2.   IE Circular No. 79-16
3.   Mailing labels

CONTACT:  R. Meyer 

(Transmittal letter for Circular No. 79-16 to each Radiography Licensee) 

                                                      IE Circular No. 79-16 


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. 

                                        (Regional Director) 

1.   IE Circular No. 79-16 
2.   Listing of IE Circulars 
       Issued in Last Six 

                                                           Accessions No. 

                              UNITED STATES 
                          WASHINGTON, D.C. 20555 
                              August 16, 1979 

                                                      IE Circular No. 79-16 


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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