CHOUCHANE C, HAMMOU A
1
INTRODUCTION
 Ionizing radiation (IR) are largely used in industry in
Tunisia
 The non destructive testing (NDT) are the most common
using Iridium sources
 Cases of accidental overexposure of workers was observed
and reported in many countries in this field of practices
 The causes of accident are often due to human fault or
lack of equipment manipulation or maintenance or lack
of respect of the radiation safety rules or the combination
of these factors as it is the case we are reporting
2
Objectives
 Report a typical deterministic effects of
ionizing radiation eg radiation burns
 Disseminate the lessons learned
 Recommendations to prevent such
accidents in industrial gammagraphy
3
Report of the event
 Workers in industrial radiography were victims of an accident that
caused a radiation skin burns in a worker observed in Tunisia in n 2008
and the follow up until today .
 Our study consists of two parts:
 Analytical study and etiological an observation burning suite has a
radiological accident in a patient occupationally exposed to IR.
 Post study: based on:
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

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The description of the workstation
The simulation of the accident which has allowed us to calculate:
Physical doses received by the victim in collaboration with an expert from the IAEA
(International Atomic Energy Agency);
Biological doses paramagnetic resonance in collaboration with an expert IRSN
(Institute for Radiological Protection and Nuclear Safety in France ).
4
22/03/2016
Hammou Chouchane Chadha
5
Report of the event
 23 March 2008 Three workers from a radiography
company located in Tunis, Tunisia were working at a
construction site in Rades, Tunisia,their assignment
was to conduct non-destructive testing of welds in a
spherical steel tank under construction, for the storage
of butane gas The accident occurred Sunday at 22h at
the top of the tank, and at the height of a scaffold 18 m.
 The gamma radiography source was an 80.1 Ci (2.96
TBq) Ir-192 sealed; the source activity when delivered to
the company was 118.8 Ci (4.396 TBq) on 10 February
2008.
6
 Worker A (assistant) Recently recruited, without prior
training on technical radiography and radiation protection
rules, he was helping set up the radiographic exposures on
the outside of the sphere. He had not received formal
training on radiography techniques nor radiation
protection, provided some on-the-job training, he was very
unfamiliar with the operation of the gamma radiography
system (camera) and understood little about the safety
procedures and the radiation hazards.
 Worker B (another assistant) was responsible for placing
the radiographic film in the proper location inside the
sphere. After setting the film in place, he would exit the
sphere and return to the trailer until the exposure was
completed.
7
 Worker C (supervisor) is the qualified Operator and was the leader of
the three-person team. He was the only person qualified to operate
the gamma radiographic device. After setting up for a 12 minute
exposure, the supervisor (C) left the construction site to retrieve some
unexposed film from the company office a few kilometres away. He
did not send of the assistants to get the film, because neither of them
had a drivers license. Before leaving, worker C instructed worker A to
terminate the exposure after 12 minutes. He was instructed to turn
the crank on the remote control to pull the source back into the
camera (shielded housing) and then set up the equipment for the next
exposure.
 Blocking the source in the duct ejection occurred Worker A handled without
success: Failing to position the source to the proper position he
disconnected the guide tube from the exit port. The source was still
attached to the drive cable and was hanging outside the exit port, so
he disconnected the source with this right hand, transferred it his left
hand, and then placed it in his left front pocket.
8
 He banged on the sphere to inform the other assistant (B) that they
needed to go to the trailer. Worker A walked down the steps to the
bottom of the sphere where he met worker B, and they proceeded to
walk to a construction trailer about 50 meters away.
 In the trailer, they sat on opposite sides of a small desk for about five
minutes and discussed what happened on the top of the sphere. It was
reported that worker A did not know that he had the source in his
hands. He thought it was just a part of the radiography device that had
broken off. He handed the source to worker B who held it for
approximately 10 seconds; he (B) saw the “Black Skull” danger symbol
and the word “radiation” on the source. At that point, worker B gave the
source back to worker A and told him that he thought this was the
source and it was very dangerous. Worker A placed the source on the
desk and they decided to call their supervisor (C) to inform him of the
incident, it took about two additional minutes for worker A to find his
phone and turn it on. Then, worker A left the trailer to call worker C;
leaving worker B in the trailer alone for an additional minute.
9
 The supervisor (C) returned to the construction site to verify if it was truly the
source that worker A removed from the device. Worker A entered the trailer first
and was there for approximately 30 seconds before worker C joined him. They
were in the trailer for approximately 30 more seconds and worker C verified that it
was the source and they both exited the trailer to a safe distance.
 After moving to the main gate of the constructions site about 100 meters away,
worker C called worker D (Company Technical Manager) to inform him of the
incident. Worker D picked up a 2-meter long remote handling tool from the
office and drove to the site. He instructed worker C to go up to the top of the
sphere to get the camera and leave it near the trailer. To recover the source,
worker C put the camera inside the trailer near the entrance. Worker D entered
the trailer and used the remote manipulator to pick up the source and put it into
the camera. Worker C stood 2 meters outside the trailer to verbally guide worker
D in placing the source in the camera. When the source was placed in the camera
the shutter was closed and the device was locked.
 To determine if that was actually the source, the guide tube and remote control
mechanism were attached and an unused film was exposed for three seconds.
Workers C and D reported that the device functioned correctly.
10
 24 March 2008 Worker D did not report the
incident to the appropriate regulatory agencies,
but did arrange for blood test to be conducted on
the four workers involved. They visited a general
practitioner (GP) that day to discuss the incident
and do determine if there were any medical
concerns. Worker D reported that the doctor told
him the blood counts were normal and they were
perfectly healthy
11
 Immediately after accident worker A reported itching of
the hands without other abnormalities.
 He received a blood laboratory tests and was sent to a
GP clinical examination unremarkable and prescribed
nan anti topic cream
 2nd week: redness, increased warmth of the hands and the
appearance of a brown spot at the left hand.
 Day14: consultation with an internal medicine specialist who
finds free circulation of lesions suggestive of recent burns,
without known cause, with both hands, more pronounced in
the left hand. Worker A was given antibiotics and antiseptics
for infection control.
 Day15: Worker A had a 2nd consultation and report exposure
to RI
12
 Day 25 Specialist of internal medecine
contacted Pr. A; Hammou (CNRP) to
inquire about the hazards from seeing a
patient exposed to a radiation source. He
explained the medical condition and
history of Worker A. Pr A. Hammou
requested that the Dr contact Worker A
and bring him to the CNRP immediately
for an interview and evaluation.
 CNRP DIRECTOR Pr A. Hammou
discovered the accident.
 The examination showed the presence
of blisters at the palmer and dorsal five
fingers right, plus a left palmer side
involvement.
 There is also a cupboard erythematous
localized at the upper part of the left
thigh with a localized depilation
14
 CNRP sent Worker A to the
specialized Burns center for
evaluation and possible care.
 The specialist concluded to
burns 2nd degree
intermediate and deep and
performed excision of the
blisters and prescribed a
symptomatic an antalgic
drogue
15
Specialized therapeutic care to Worker A
 Pr .A. Hammou immediately reported to the IAEA and the IRSN
accident as well as the Minister of health in order to obtain support
to send the victim to a specialized center abroad to evaluate the
radiation exposure of the other workers and to take measures against
the Gammaradiography society .
 IRSN recommended the transfer of the patient to the hospital of the
Armey instruction in Percy in Clamart, Paris a highly specialized
center for the treatment of severe radiation burns
 J36: Hospitalization and support involving transplants thin skin on
the fingers of both hands and adjuvant injection of autologous
mesenchymal stem cells.
 The immediate postoperative course was favorable and the healing
was complete. Worker also received pressotherapy by compression
gloves
16
 Follow up
 Painful extremities and
insomnia with subungual
secondary aseptic osteolysis
of the phalanges , requiring
the repetition of cell
therapy in Percy Hospital
with amputation of the pad
of the distal phalanx of the
left index
17
After 2-year follow up
 Painful inguinal necrosis in the
right middle finger leading to
distal phalanx osteolysis
 Local treatment and systemic
antibiotics.
 Evolution: spontaneous expulsion
of distal phalanx
18
After 3 years
 Severe dermatitis necrosis
previously healthy appearance
part: right atrial and left index

Local treatment, and
request for an opinion with the
doctor at the hospital Percy for a
possible re-hospitalization
19
The NDT place and the machine
20
The workplace
 NDT (nondestructive testing) work
was conducted in in a construction
site of a spherical steel tank for the
storage of liquid butane gas.
 Worker A assistant was assigned to
operate the “gammagraphe” to
perform the NDT tests at the outer
surface of the sphere.
 Worker B places the radiological
film in the inner side at the
internal surface of the sphere
21
The Equipment used:
 "GammaMat" TSI5 / 1 serial
number 428, equipped with a
sealed source of iridium (192Ir)
a 80.1 Ci (2.96 TBq) Ir-192
sealed; the source activity when
delivered to the company was
118.8 Ci (4.396 TBq) on 10
February 2008.
 The dose rate at one meter on
23/03/2008 was 385.19 mSv / h.
22
 The source was recovered by company employees
on 23 March 2008 and placed back into the gamma
radiography camera. An exposure was made to
determine that it was actually the source and that
the camera was functioning properly. A qualified
technician evaluated the camera on 29 April 2008
and reported that the system operated properly.
23
Simulation of the accident by CNRP/IAEA/ IRSN
 CNRP team conducted simulation of the accident which
led to the estimation of the whole body dose : 1.09Gy to
worker A
 Estimation and dose calculation is compleated by IAEA
and IRSN
 For Dose estimation : Times and distance measurements
are based on interviews and measurements during
accident reconstitution
 Worker A : TOTAL DOSE 1.09E+03 mSv
 Worker B : TOTAL DOSE 5.28E+01 mSv
 Worker C : TOTAL DOSE 1.69E+00 mSv
 Worker D : TOTAL DOSE 1.02E+00 mSv
24
 The dosiymetric reconstruction which was completed by
the IRSN
Dose à l’emplacement
de la biopsie osseuse
en Gy
Dose à la peau en Gy
Dose absorbée dans le
Avec 3mm
Avec 5mm
tissu osseux (Gy)
de tissu
de tissu
B1
41.1+/-1.8
42.6+-1.9
43.7+/-1.9
B2
39.0+/-1.6
40.4+/-1.7
41.4+/-1.7
biopsie
25
Comments
 The Non-Destructive Testing (C.N.D.) is a set of methods
to check the status of integrity of structures or materials,
without degrading during the roduction, use or under
maintenance.
 It uses SEALED SOURCES
 Risks of industrial radiography:
The "radiologists' operators are among the most exposed to
RI in normal working conditions as well as in accident
conditions
 Radiological burns or dermatitis: main result characterizing
the acute radiation syndrome localized to the skin showing
the effects of deterministic IR effects

26
Radiodermatitis
 It is a burn without a contact with a heat source or caustic
products gradual onset and insidious
 severity depends on the type of radiation, dose and dose
rate, duration of exposure and the anatomic site of the
lesion.
 3 Phases are described
 The initial phase is characterized by an increase in local heat
and erythema
 Phase of clinical latency may take several weeks , no physical
signs
 The Active phase whose manifestations are directly related
to the intensity dose,
27
The dermatitis (continued) Active Phase
 Erythematous dermatitis, is a pink erythema,
homogeneous, sometimes accompanied by swelling.
 Dry dermatitis: 10 or 15 days after the onset of erythema
which gives way to a dry desquamation, then a temporary
or permanent pigmentation. Transient hair removal can
also occur.
 Exudative dermatitis: erythema is complicated by
blisters and stinging and itching whose failure leaves
exposed dermis vesicles, the patient has a burning
sensation
 Radionecrosis: Upon reaching the basal layer is added
that the endothelial cells of the subcutaneous tissue with
ischemia and necrosis
28
 The dermatitis: clinical evolution: intense
pain, is an excellent functional premonitory
sign predictive of unfavorable recurrence of
the radiodermatitis
 Evolution is unpredictable
 The most complication is the appearance of a
basal cell carcinoma and squamous cell
carcinoma occurs less frequently on the bed of
a radiodystrophy
29
 Radiodermatitis: Treatment
 Treatment is directly related to the depth of the
burn, it is dominated by skin grafting, radiation
burn does not offer the same healing conditions
than thermal burns and therefore often there has
been a failed grafts.
 Cell therapy seems to emerge as an adjuvant
treatment, complementary and inseparable from
modern surgery in the management of acute
localized irradiation, allowing for conservative
treatment of very serious injuries
30
Radiological accidents in industrial radiography :
Predisposing factors
 The equipment malfunctions
 The regulatory offenses
 The loss or theft of a source.
 The absence or lack of regulatory control
 Non-compliance with work procedures
 Lack of operator training
 Defects in maintenance
 Human errors : lack of vigilance
 Combined factors
31
Radiation protection organization
 Radiation protection is based on three fundamental
principles:
 Justification of practices.
 Optimization: based on the ALARA principle
 Exposure dose limitation
 The protection means
 the distance from the source
 screens personal and collective protective devices use
 The minimisation of time of exposure
 Dose limitation: as recommended by the ICRP :
 The annual effective dose limit is set at 20 mSv for exposed
workers and 1 mSv for unexposed workers
32
National
Regulatory
framework
In Tunisia a legal framework and institutional framework has been put in

place since the early 80s.
 The legal system includes:






Law No. 81-51 of 18 June 1981 relating to the protection against the dangers of
ionizing radiation sources.
Law No. 96-41 of 10 June 1996 on waste and control of their management and
their disposal including radioactive waste.
Act No. 97-37 of 2 June 1997 on the transport by road of which materials and
radioactive sources hazardous materials.
Decree No. 82-1389 of 27 October 1982 on the organization and powers of
the National Centre for Radiation Protection.
Decree No. 86-433 of 26 March 1986 on the protection against ionizing
radiation.
89-1895 Decree of 85 December 1989 on the publication of the Vienna
Convention on Assistance in the Case of a Nuclear Accident or Radiological
Emergency
33
Institutional framework : CNRP is placed
under the tutele of Ministry of health :
 It promotes at national level Radiation
protection measures ,
 Training users of sources in Radiation protection
 Emergency preparedness and response
 CNRP delivers authorization of activities
and sources
 Enforces regulations and participate to
regulations elaboration.
 CNRP is in charge of Technical support
laboratories
of
dosimetry,
spectrometry
calibration and environmental monitoring
Réglementation
34
PREVENTION OF ACCIDENT
 Technical prevention is the individual and collective:
Collective prevention is based on the design premises, the delimitation and marking work
zones
 Individual prevention is based on the principal means of radiation protection (distance,
time display).

 medical prevention



Role of the occupational physician
Monitoring the health of workers is the responsibility of the employer;
Visit hiring
 Medical monitoring: radiography exposure are external exams are geared
toward any haematological, eye (cataracts) and skin.
 The occupational physician maintains a medical record that includes the dates
and results of dosimetric monitoring and additional medical examinations and
double the exposure record
 The classification of workers and their training and the study of post
 Investigation in case of an accident or incident, monitoring and rehabilitation
of the worker and the dissemination return of experience
35
 Acute and chronic radiation dermatitis are considered
professional in accordance with Table No. 76 of the
Tunisian list of tables for Occupational Diseases
diseases.
22/03/2016
Hammou Chouchane Chadha
36
recommandations
 Although rare workplace accidents are serious Industrial Radiography
 For prevention we offer the following recommendations:
 Unconditional compliance with permit conditions and use of sources
 The qualification and training of users, technical radiography, the
health effects of ionizing radiation and radiation protection principles
 control characteristics of the sources with the making available to all
workers in a diagram of the apparatus and an image of the source
 Maintenance program of the radiography device
 the availability of means of radiological protection of individual and
collective means of detection, marking, individual and operational
dosimetric monitoring.
37
 Recordkeeping written on procedures
 Compliance with safety and radiological safety of
sources in use, transport, storage and finally the
management of waste sources by returning to the
original supplier
 The development, approval and updating
emergency procedures
 This is the ROLE AND RESPONSIBILITY OF ALL:
Authorities, Regulatory, Employer, Worker and
Occupational Physician
38
ROOT CAUSE ANALYSIS
 deficiencies in the safety culture of the company : The
accident could have been prevented had some basic
safety practices such as adequate training, supervision,
and equipment were provided
Radiation Effects Awareness of
Medical Community
 deficiencies in the medical community to identify
radiation injuries
 The burn specialist did not recognize the radiation
burns and treated the burns as if they were thermal
burns.
 The internist who treated Worker A did not recognize
the radiation burns and only contacted the CNRP after
finding out that the worker was exposed to a radiation
source.
Lessons learned
 Medical awareness
 training medical personnel in the identification and
treatment of radiation injuries, as well as in the overall
medical response to radiation emergencies.
 IAEA training material and documents :poster ...
General recommendations
 Improve the awareness of radioactive material users and
licensees in regards to emergencies, procedures, and reporting.
 Require all workers to be fully qualified before being allowed to
use dangerous sources. Licensees should ensure that training,
dosimetery and safety equipment are provided.
 Expand the inspection and audit program for authorized users of
radioactive material to include more comprehensive inspections
prior to issuing a new authorization, and increasing the
inspection and audit frequency for existing users.
 Authorize CNRP to immediately stop work or suspend
radioactive material authorizations when unsafe practices or
working conditions are identified, which involve radioactive
materials.
 Upon receiving notification of an accident or incident
involving radioactive materials or radiation producing
devices, all operations associated with the material or
device should be immediately suspended pending an
investigation.

 During an investigation of a radiation accident or incident,
a complete review of the authorized user’s radiation
records should be immediately conducted. This should
include training, dosimetry, source maintenance and
calibration, radiation detection instrument maintenance
and calibration, source usage records.