Safety Reports Series No. 7
Lessons Learned from Accidents in
Industrial Radiography
Practical Radiation Safety Manual
Manual on Gamma Radiography
Eric Reber, NSRW, IAEA
IAEA
International Atomic Energy Agency
HIERARCHY OF IAEA SAFETY STANDARDS
Fundamentals
Underlying principles
(aimed at politicians and
regulatory bodies)
Specific obligations and
responsibilities (“shall”)
Requirements
Guides
IAEA
Safety Reports &
TECDOCS provide
supplementary information
Recommendations
to help implement
requirements
(“should”)
• Objective: To draw lessons from the
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initiating events of accidents, the
contributing factors and the
consequences.
43 accidents are presented to illustrate the
primary causes of accidents
Measures to prevent the occurrence of
such accidents or to mitigate the
consequences of those accidents
Published in 1998
Out of print and not available on IAEA web
site
IAEA
43 Examples of Accidents Given
According to Primary Causes
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Inadequate regulatory control
Failure to follow operational procedures
Inadequate training
Inadequate maintenance
Human error
Equipment malfunction or defect
Design flaws
Wilful violation
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Lessons Learned – Failure to Follow Procedures
• Adherence to safety procedures would have prevented
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most accidents
Commercial pressures are a factor
Failure to perform an adequate survey was often a
cause of accidents.
Personnel allowed to use radiographic and safety
equipment without appropriate training
Several overexposures occurred because of a
deliberate attempt to defeat a safety interlock or other
safety system
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Lessons Learned – Inadequate Regulatory
Control
• Safety may be compromised if regulatory controls such as
licensing, inspection and enforcement are not in place.
• Failure to review device design has resulted in source
disconnect leading to exposure of members of the public
• Outside of regulatory jurisdiction, safety procedures have
fallen short of the acceptable standards.
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Lessons Learned – Poor Safety Culture
• Workload considerations and productions costs
have taken precedence over safety concerns
• During source retrievals, personnel deliberately
removed dosimeters
• Some accidents occurred owing to a lack of care in
the maintenance of safety systems and equipment
• High level of complacency
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Lessons Learned – Training deficiencies
• Radiography personnel sometimes lacked a basic
understanding of their equipment
• Lack of knowledge of the basic principles of radiation safety
• Radiography personnel failed to implement basic
operational and safety principles under stress, i.e., their
knowledge was not ingrained.
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Prevention and Remedial Actions –
Regulatory Authority
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Practice-specific regulations
Inspection
Enforcement
International assistance
Communications among stakeholders
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Prevention and Remedial Actions –
Operating Organization
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Management should develop and maintain safety culture
Radiation Protection Officer
Necessary resources for safety
Training programme
Seek advice from manufacturers on equipment issues
Preventive maintenance programme
Emergency procedures
Audit programme
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Prevention and Remedial Actions –
Designers and Manufacturers
• Maintain communication with regulatory authorities
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and users and to advise them on equipment
modifications and operational experience
Ensure that equipment meets design standards
Provide comprehensive manuals to users
Assist users in training
Respond to user problems and to implement
solutions
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Annex I – Radiographer Training
• Practical Training
• Hands on training
• Classroom Training
• Basic radiation safety training
• Detection and measurement of radiation
• ALARA
• Regulatory requirements
• Certification
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• Audience is the users of radioactive
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sources.
Provides step by step instructions with
many illustrations
One of a series of documents produced
in the 1990’s
Published in 1996
Out of print and not available on the web
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Concluding thoughts
• SRS No. 7 and Manual on Gamma Rad.
provide valuable information, but they were
published 16 and 18 years ago, respectively.
• Should these documents be revised?
• Should other documents be developed?
• Minimally, they should be available on the
IAEA’s website.
IAEA
Eric Reber, NSRW e.reber@iaea.org
Documents available temporarily at:
http://gnssn.iaea.org/CSN/TM%2048337%20Industrial%20Radiography/Forms/
AllItems.aspx
IAEA