08 Lessons Learned (Industry)

Radiation Safety Refresher Course
April 2016
NTC, PNRI
Edgar G. Racho
Nuclear Regulatory Division
Aims and Objectives
Introduction
Case Histories Described
Consequence of each accident
Primary Causes of Accidents
Prevention and Remedial Actions
Lessons Learned
Summary
References

Be familiar with typical industrial radiography and
industrial devices accidents
Understand specific contributing factors
Be aware of lessons learned from past accidents and
how accidents can be prevented

Throughout the history of industrial radiography and
industrial devices, accidents with some sources have
occurred that have resulted in fatalities and injury.
The practice of industrial gamma radiography in the
country has the most number of reported radiological
incidents
Knowledge gained and the lessons learned from these
accidents will ser ve as basis for implementing
necessary changes in the regulatory, licensing and
inspection procedures.

Any incident whether minor or major has to be
reported and investigated to determine its causes
which will become the basis for making the corrective
actions to prevent or minimize the occurrence /
recurrence of the incidents and to minimize the hazard.
It could also be a basis for re-evaluating and improving
safety program of the regulatory company involved.

Atomic Energy Facilities and Materials
Republic Act 2067 known as the Science Act of
1958
Republic Act 5207 of 1968 also known as An
Act Providing for the Licensing and Regulation
Laws of Atomic Energy Facilities and Materials
Executive Order 128 of 1987
Code of PAEC/PNRI Regulations
Standards, Rules and (promulgated by PAEC/PNRI Director)
Regulations, Admin. Orders Consists of Parts 0-27
Covers radiation protection, transport,
security and fees and practice specific
administrative and safety requirements
Guides, Regulatory Bulletins, Information
Notice Based on IAEA and USNRC CFR &
Guides

CPR Part2, “Licensing of Radioactive Materials”, Official Gazette,
1990
CPR Part 3, "Standards for Protection Against Radiation", Official
Gazette, 2004
CPR Part 4, "Safe Transport of Radioactive Materials in the
Philippines", Official Gazette, 2004
CPR Part 11, “Licenses for Industrial Radiography and Radiation
Safety Requirements for Radiographic Operations, Official
Gazette 2010
CPR Part 16, "Licenses for the Use of Radioactive Sources in
Industrial Devices”, Official Gazette, 2011

CPR Part 22, “Fees and Charges for Licensing
Radioactive Materials and Other Related Regulatory
Activities”, Official Gazette, 2003
CPR Part 25, ”Licenses for Commercial Providers of
Nuclear Technical Services”, Official Gazette, 2012
CPR Part 26, “Security of Radioactive Sources”, Official
Gazette, 2014
CPR Part 27, “Security in the Transport of Radioactive
Sources”, Official Gazette, 2014

Nuclear Accident
Device with a controlled chain reaction
e.g. Nuclear Power Plant, Research Reactor,
Nuclear-powered submarine
Radiological Accident
Other source of radiation with health threat
e.g. Medical therapy source, transport involving
radioactive material, irradiation facility, use of
radioactive sources in research, medicine and
industry (lost, found, unshielded or damaged),
satellite re-entry, plutonium dispersion

The International Atomic Energy Agency
(IAEA) has developed a categorization of
radioactive sources in terms of their
potential to cause immediate harmful
health effects if the source becomes
vulnerable or orphaned.
Category 1 – Extremely Dangerous
Category 2 – Very Dangerous
Industrial Radiography Sealed Sources
Category 3 – Dangerous
Category 4 & 5 –Very Low Danger
Industrial Gauges Sealed Sources

CPR Parts - Each licensee shall provide an immediate
report within twenty-four (24) hours followed by a
detailed written report within thirty (30) days to the
PNRI of the occurrence of any accident.
Information Bulletin 01-02 Notification and Reporting
of Incidents
Information Bulletin 04-03 Incident Reporting
Requirements for Radiography Licensees

Case No. 1 Site Radiography Lost Source
Description of Accident:
A 550 GBq Ir-192 source used to examine weld on
steel vessel. On completion of the work the winding
mechanism was used to return source to its container.
The monitor located at winding position recorded drop
in dose rate and the radiographers assumed the source
was back in the container.
The equipment was used 5 days later and the
resulting radiographs were blank, revealing the source
was missing from the container.

After a search the source was found near the
location it was last used.
The investigation found that the source had
become detached and fallen from guide tube during
dismantling. The noted drop in dose rate occurred
when the source became detached from drive cable
close to source container which shielded the dose rate
monitor from the source.
The source was recovered by the RSO.

Consequences:
78 persons irradiated
2 persons received a dose of 100-150 mSv
63 persons received a dose of < 11 mSv

Lessons Learned:
1. Dose rate monitor not used correctly. The container
should have been monitored
2. Monitoring should also have been carried out when
the container was returned to storage location. The
missing source would have been noted a lot sooner!

Case No. 2 Site Radiography Defective Equipment
Site Radiographers using a 3.2 TBq (86.4 Ci) Ir-192
source had no emergency equipment, no pre-
exposure or exposure warning signals, no local rules
or emergency plans. They have a dose rate monitor.
Source jammed in exposed position.
The radiographers secured the area and threw lead
sheets over the equipment until dose rate was below
10 Sv/h. (1 mR/hr)

The company undertaking the radiography, contacted
the equipment suppliers to assist. The fee quoted by
the suppliers was considered unacceptable so the
operator contacted the IAEA for assistance.
Recovery was difficult: the source could not be
returned to the container. Instead drive the source out
along the guide tube. The dose rate at 1m from
unshielded source was calculated to be 6 mSv/min. It
was decided to cut through the drive cable (long
handled cutters) and then use long handled tongs to
put detached source into spare lead container.

Consequences:
A temporary concrete
wall (50 cm ) was
built to shield the
recovery team. After
careful planning and
rehearsals the
source was
recovered.
Doses :
7 persons involved.
Recorded doses
were below 1 mSv.

Lessons Learned :
1. source activity should be optimized- > 1.8 TBq (48
Ci) for site work should be justified

2. reasonably foreseeable accidents should be
highlighted in prior safety assessments

3. adequate maintenance of ancillary equipment is
essential
4. site radiography requires
appropriate emergency & ancillary equipment

trained personnel
adequate supervision

Case No. 3 Site Radiography Source Disconnect
In 1984, 1100 GBq (29.7 Ci) Ir-192 source became
disconnected from drive cable and was not returned to
container. Guide tube was disconnected from exposure
device and source dropped to the ground.
A passer-by picked it up (tiny metal cylinder marked
only with the trefoil symbol) and took it home. The
source was lost from March to June.

Fig. 1 Radiographic
Exposure Device
Fig. 2 Radiographic Operation Set-up

Consequences:
8 members of the public died of over exposure
The passer-by and 7 relatives died and initially their
deaths were assumed to be due to poisoning.
Lessons Learned:
No radiation monitor used to ensure that the source
has fully returned to shielded container. The accident
would have been prevented the container had been
monitored.

The passer-by did not recognise the health hazard
associated with the source. The source should have
better markings to provide a warning.

Case No. 4 Retrieval of a Fire Damaged Gauge
Containing Radioactive Source
On the 16th January 2006 the Radiological Protection Institute
of Ireland (RPII) (the Regulatory Authority) learned from
media reports that a fire had destroyed part of a factory
situated in the midlands of Ireland. It was reported to have
started on the 15th January and firemen fought throughout
the night and into the next morning to contain the fire. As
the company who owned the factory held a license from
the RPII for the custody and use of a gauge containing a
radioactive source, plans were initiated to visit the scene.

The gauge formed part of a Heuft fill-height detection
system (Model – Basic 4) and it contained a 1.67 GBq
Americium-241 (Am-241) source. The system was used
on a production line as part of a quality control process
to determine the volume of contents in metal cans. The
Am-241 source and the associated radiation detector
are contained within a ‘bridge unit’.

Consequences:
The metal source block and the metal bridge unit
used by Heuft in this model of fill-height gauge are
very robust as they survived a significant fire
(estimated to be greater than 1000 0C for several
hours), and prevented any leakage or contamination
of the source.
The mounting plate which holds the Am-241 source
block inside the bridge unit is made of aluminum,
and during this fire the mounting plate melted which
resulted in the source block detaching from the
bridge unit and falling out onto the floor.
Figure 3. Front view of the
recovered component which
included the source block
containing the Am-241 source
Figure 1. Heuft fill- Figure 2. Damaged

height detection bridge unit being
system (Model Basic 4) surveyed outside the
on the production line building
of the plant (pre-fire)

Lessons Learned:
This incident highlights the importance of involving
the manufacturers of measurement systems
containing radioactive sources at an early stage. In
this case the information provided by Heuft UK was
instrumental in recovering the source.
The manufacturer, the RPII and other licensees with
a similar fill-height detection system have consulted
on the findings of this incident and the aluminum
mounting plate in all units has been replaced by one
made of stainless steel.

Case No. 5 Accident Involving Gauging System
The incident occurred in the UK, and involved a level
gauge system containing a 1 GBq Cesium-137 source.
The source assembly fell out of the shielded housing
onto the ground below. An employee subsequently
picked it up and took it to a control room where it
remained for almost 2 days. The presence of an
unshielded source was eventually recognized by a
supervisor, who was investigating the non-operation
of the gauge.
He immediately threw the source assembly out of
the window, after which he buried it in a soft mud
bank around which he set up an appropriate
exclusion zone. The source was subsequently
recovered (by NRPB) and placed in a shielded
container.
Workers did not wear personal dosimeters.
Consequently, a reconstruction of the incident, and
dose rate measurements were used to estimate the
doses received by the employee and the supervisor.

Consequences:
Person Estimated whole body (effective dose)
Employee 2 – 3 mSv ; Supervisor 0.05 mSv
Estimated (equivalent) dose to fingers
Employee 300 mSv max; Supervisor 0.04 mSv max
Lessons Learned:
Gauging systems are a very common application, and it is
extremely rare for the source to fall out under normal operating
conditions. In this case, the source housing was subject to
constant vibration, and this certainly was a major factor in a
securing bolt becoming loose.

Operators should be aware of this and put procedures
in place to immediately check the location of the
source in the event of such a failure.
Providing employees with suitable information,
instruction and training is important - even for those
who do not directly work with radiation sources. In this
case, simple radiation awareness training (location of
the sources on site, what they look like inside and
outside their containers, basic precautions, who to
contact, etc) could have helped avoid any radiation
exposures.

Case No. 6 Lost Radiography Sources During Transport
The incident happened on April 1, 1991 when the
taxi sped off with the source/camera (2.4 Ci Ir-192)
while the workers were unloading the other gadgets.
The radioactive material/equipment involved was
borrowed from other licensed radiography company
without the authorization from the Institute. The
source/camera was returned to PNRI after a high
media campaign.

Consequences:
No exposed personnel (no investigation)
Lessons Learned:
Use of company owned vehicle
No authorization from PNRI
Violation of operating procedures, particularly the
transport procedure
Unauthorized lease of source

(1) Inadequate Regulatory Control
Improper disposal methods result in public exposure
Untrained individual suffers acute radiation
syndrome
Source damage caused by improper recovery
Unqualified personnel perform source retrieval
Unlicensed and untrained workers perform
radiography/operates the device

(2) Failure to Follow Operational Procedures
Failure to connect a safety system
Inadequate radiation monitoring
Defeat of safety alarms
Failure to respond to radiation alarms
Failure to use a survey meter and personal
dosimeters

Failure to follow regulatory requirements
Continued operations with an inoperable survey
meter
Improper response to malfunctioning equipment
Death caused by the alleged mishandling of
radiographic/industrial device sources
Lack of radiation surveys results in excessive
exposure
Deaths from radiation overexposure

(3) Inadequate Training
Chest injury resulting from lack of training
Overexposure resulting from the disregard of an
alarm
Overexposure resulting from inadequate training
Radiation burn resulting from inappropriate
retrieval

(4) Inadequate Maintenance
Failure of a device lock after improper maintenance
Inadequate maintenance causes overexposure
(5) Human Error
Inappropriate response caused by panic
Exposure device lost during transport
Equipment damaged because of production pressure
Accidental exposure of two radiographers/operators

(6) Equipment Malfunction or Defect
Crank-out equipment failure
Defective locking mechanism/shutter
Disconnect caused by a defective connector
Source leaks that contaminated equipment and
personnel
(7) Design Flaws
Separation of a depleted uranium shield in an
exposure device
Source lost from a pneumatically operated container
Source disconnect

(8) Wilful Violation
Overexposure during a source capsule assembly
change
Theft resulting in public exposure
Untrained individuals who performed radiography or
operates the device without supervision
Theft of a radioactive source

Regulatory Authority
Radiographer
Operating Organization
Designers and Manufacturers
Site Operator (Client)
1. The importance of a well established regulatory
authority cannot be overwhelmed. Provisions should
be made not only for its creation but also for its
continuous development and improvement.
2. To ensure that the appropriate legislation is in place to
control the radiation safety of individual radiographic
equipment; this legislation needs to be adequate in
order to cover the operating organization, supplier and
manufacturer;
3. To ensure that the conditions of the regulatory
authorization are maintained, including:
(a) A requirement that a radiation safety officer be
a p p o i nte d b y t h e o p e rat i n g o rga n i zat i o n ,
particularly for training personnel and for advising
on radiation protection issues;
(b) A requirement that periodic safety audits be
performed;
(c) A requirement that a reporting system be set up
through which timely reports of abnormal events
and the experience gained therefrom would be
obtained.

4. To take prompt, vigorous and consistent enforcement
action when violations of requirements occur or
where unsafe conditions are found;
5. To recognize its limitations and to ask for external
assistance, e.g. from the IAEA or experts in the field,
as necessary;
6. To review their rules, codes of practice and guides
periodically and to update them to meet current
standards;
7. To ensure that adequate resources or arrangements are
made for the safe disposal and decommissioning of
facilities, as applicable;

8. To ensure that safety inspections, audits and
assessments are carried out, including
unannounced field site inspections;
9. To develop an effective communications network
such that all the relevant parties are notified
promptly of matters pertinent to the safe conduct
of radiography.

The primary responsibility for personal safety lies
with the radiographer. In addition, vigilance is
essential if the safety of other workers and the
general public is to be ensured.
RSO/Radiographer
1. To have an understanding of the effects and hazards
associated with radiography/use of nuclear devices;
2. To have the necessary training and qualifications to
perform the tasks required;
3. To ensure that the appropriate knowledge of the
devices being used;
4. To have a comprehensive knowledge of the devices
being used;
5. To have a comprehensive knowledge of the safety
equipment and systems necessary to perform the
tasks required;
6. To wear his/her personal dosimeters at all times when
handling or using radiographic/industrial equipment;
7. To ensure that sufficient resources are readily
accessible to cover emergencies;

8. To ensure that all the equipment used is maintained
to the prescribed standards, as defined by the
regulatory authority and in conjunction with the
manufacturer’s recommendations;
9. To have adequate emergency response training;
10. To take on the responsibility for reporting unsafe
conditions or practices to the radiation protection
officer and/or to the regulatory authority;
11. To refuse to perform procedures that are beyond
his/her knowledge, or are beyond the capability of
the equipment

Responsible for the possession and use of the industrial
radiographic sources and devices. This includes their
operation in accordance with regulatory authority
regulations, permits or authorization, or appropriate
international safety standards such as the Safety Report
on Radiation Safety in Industrial Radiography and
Industrial Devices.
Bears the prime responsibility for the safety of
industrial radiography. Management should exercise
leadership in developing and maintaining a safety
culture throughout the entire organization.

To notify the local regulatory authority as soon as
possible of the intent to purchase and use
radiographic / industrial devices, and to submit other
notifications as required by the regulatory authority;
To appoint an experienced Radiation Safety Officer who
is competent to develop and implement a radiation
safety programme;
To ensure that the resources necessary for maintaining a
radiation safety programme and compliance with the
requirements of the regulatory authority are
committed;

To seek, if appropriate, the advice of the manufacturer
on equipment malfunctions, source retrievals and
equipment service;
To develop and implement a training program that at
least covers:
(a) The basic radiation safety principles and safety
procedures;
(b) The requirements of the regulatory authority;
Specific device related training and supervised hands-
on experience to include radiographic / industrial
equipment, survey meters, remote handling tools and
personnel dosimetry;
To prepare, document, implement and audit a preventive
m a i n t e n a n c e p ro g ra m m e a s d e f i n e d b y t h e
regulatory authority, or as recommended by the IAEA
or the manufacturers;
To ensure that all operational, maintenance and safety
related instructions are available in the local
language(s);

To prepare, document, implement and audit emergency
procedures, including training as approved by the
regulatory authority, or as recommended by the
IAEA, in the absence of a local infrastructure;
To notify the regulatory authority of any intended device
modification that may affect safety prior to its
implementation (and in the absence of a local
infrastructure, to seek the advice of the
manufacturer);
To conduct a safety review that includes procedures,
training and audits of work and equipment at least
annually, and to document the result; records should
be available to the regulatory authority for review (if a
communication concerning the safe conduct of
radiography/nuclear gauging is received from a
manufacturer, supplier or regulatory authority, a review
of its applicability should be held as soon as possible);

To implement procedures as recommended by the
manufacturers or suppliers to maintain the integrity
of the equipment and to ensure that the equipment
complies with the latest regulatory requirements, or
IAEA recommendations.

Bear the responsibility for carrying out research, testing
and examination to ensure the safe design of shielded
enclosures, equipment and systems. These
organizations need to provide sufficient detailed
information to assist users in the development of
operating, maintenance and emergency procedures.
To assist the IAEA and its Members States in facilitating
the training and the regular retraining of radiography
personnel; this should include the training of regulatory
authority personnel in understanding the equipment

To maintain communication with the regulatory
authorities and to advise them on suggested
modifications to existing equipment, as well as on
operational experience;
To advise the IAEA if there is any difficulty in
establishing contact with the regulatory authorities, so
that points of contact can be established and
communications improved;
To ensure that source, radiographic and ancillary
equipment designs comply with the prevailing relevant
design standards, and that appropriate authorizations
are obtained
To keep users up to date with operational experience,
information and findings related to safety. Equipment
improvements and safety related modifications to the
equipment;
To provide comprehensive operating manuals for the
equipment, and to assist in any necessary training;
To respond promptly to user problems, and to
implement appropriate actions to address these
problems.

controls the site, co-ordinates the activities of all the
service companies employed there and may exercise
considerable commercial pressure on each service
company, including the one selected to perform the
radiography.
To ensure that the operating organization is given
sufficient lead time prior to the work in order to enable
any required advance notifications to be given to the
regulatory authority.

To ensure that the operating organization employed
has the necessary expertise and appropriate ancillary
equipment, e.g. monitoring instruments, barriers and
emergency equipment, to work competently and safely,
as evidenced by the appropriate regulatory
authorization; the judgement of the operating
organization needs to be respected and its advice relied
upon to ensure safe working practices.

To ensure that, if possible, the necessary space is
provided for the operating organization to safely and
securely store radioactive materials. Control of the
radiographic work area needs to be given to the
radiographers. Where necessary, supporting security
staff may be needed to prevent access to a controlled
area.

To make certain that contractual conditions do not
impose burdens on the selected operating
organizations; for example, the need to set up barriers
and to satisfy other conditions for safe working may
limit the number of radiographs that can be reasonably
practicable to produce within the time available;
regulatory and safety requirements should take
precedence.

To make certain that radiography is co-ordinated with
other work on the site; for example, to ensure that the
radiographic warning signals to be used do not have
different established meanings on the site (which could
confuse personnel), and that radiography is scheduled
to be done so that the necessary area can be evacuated
and made secure. A ‘permit to work’ method is a
control that can be used, and all sections and levels of
the workforce need to be informed about the safety
issues that concern radiography, and when it is to take
place.

provide manufacturer’s training program on the
technical and safe operation of the industrial device
that includes appropriate references to any instructions
given by the outside service agencies.
The name, training and experience of each person who
will provide substantial input for the instruction,
examination or qualification of operators should be
given in sufficient detail to establish his qualifications
to perform these services.
Appendix H shows the criteria for a training program

(1) Adherence to established safety procedures would
have prevented most of the accidents. Failure to
follow established safety procedures frequently
occurs because of commercial pressures and
production requirements, e.g.:
(a) In most of the overexposures, the individual
concerned failed to follow the appropriate
procedures, specifically the failure to perform an
adequate survey;
(b) In several of the overexposures, safety interlocks
or other safety systems had been deliberately
defeated, contrary to established procedures;

(c) In several of the overexposures, unqualified
personnel were inadequately supervised by a
radiographer / operator.
(2) Safety may be compromised if the regulatory
controls that encompass licensing, inspection and
enforcement are not in place. These controls include
consideration of device and source design, radiation
safety procedures and training. Where these were not
adequately considered, unsafe conditions resulted,
including radiation exposure to several members of the
public, e.g.:

(a) The failure to review device design has resulted in
source disconnect and exposure to members of
the public
(b) In regions outside the jurisdiction or in remote
outposts of a regulatory authority, procedures
have fallen short of the acceptable standards.
(3) Management can quickly lose control of the level of
knowledge and performance of radiographers unless
audits are conducted, adequacy of training is assessed
and employees are retrained, e.g.:

(a) In several cases, the radiography / operating
personnel involved in accidents were allowed to
use radiographic/industrial and safety equipment
without the necessary training;
(b) Radiography/operating personnel involved in
accidents frequently failed to use a radiation
survey meter, or did not use it correctly;
(c) Radiography/operating personnel involved in
accidents often failed to wear the required
personal dosimeters.

(4) In many cases, a poor safety culture resulted in the
degradation of safety systems and operating
procedures. It appears that workload and production
costs take precedence over safety, e.g.:
(a) During some source retrievals,
radiography/operating personnel deliberately
removed dosimeters before the recovery actions in
order to avoid an increase in the dose registered;
(b) Some accidents occurred owing to lack of care in
the maintenance of safety systems and equipment;

(c) Evidence was found of a high level of complacency
in personal safety and in the care of others;
(d) Frequently, an inadequate number of qualified
radiography/operating personnel is available to
cope with the prevailing conditions
(5) Training was found to be deficient in the majority
of accidents. This deficiency covers initial safety
training as well as training in proper emergency
procedures, e.g.;
(a) Source retrievals were attempted without the
p ro p e r e q u i p m e nt o r p l a n n i n g , a n d u n d e r
unfavorable environmental conditions;

(b) Radiography personnel involved in accidents
sometimes lacked a basic understanding of the
fundamental operating principles of the devices
with which they were working;
(c) In general, there appears to be lack of knowledge
of the basic principles of radiation safety;
(d) Radiography personnel failed to implement basic
operational and safety principles under stress, i.e.
their knowledge is not ingrained.

Adherence to established safety procedures would
have prevented most accidents
Safety may be compromised if regulatory controls are
not in place
Systematic audits by management help to ensure that
level of knowledge and performance of radiographers
is maintained
A poor safety culture can result in degradation of
safety systems and procedures
Deficient training is contributory in the majority of
accidents
CPR Part 11, “Licenses for Industrial Radiography and
Radiation Safety Requirements for Radiographic
Operations”, Official Gazette 2010
CPR Part 16, "Licenses for the Use of Radioactive Sources in
Industrial Devices”, Official Gazette, 2011
European ALARA Network, http://www.eu-
alara.net/index.php/incidents-lessons-learned-mainmenu-
45.html 3-25-15
A. M. Borras, SrSRS, NRD, PNRI, Radiological Incidents in
Industrial Gamma Radiography in the Philippines, 1979-
1993, PNRI Library
www.pnri.dost.gov.ph; [email protected]

Good Day Everyone!!!

08 Lessons Learned (Industry)

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Radiation Safety Refresher Course

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Ci) for site work should be justified

highlighted in prior safety assessments

appropriate emergency & ancillary equipment

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Figure 1. Heuft fill- Figure 2. Damaged

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