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RADIOGRAPHY ACTIONS PRECUATIONS RADIOGRAPHY ACTIONS PRECUATIONS

REQUIREMENTS § PROTECTIVE EQUIPMENT, FILM BADGE AND DOSEMETER MUST ALWAYS BE WORN § SOURCES REQUIREMENTS § PROTECTIVE EQUIPMENT, FILM BADGE AND DOSEMETER MUST ALWAYS BE WORN § SOURCES MUST NOT BE HANDLED WITH BARE HANDLING TOOLS CLAMPS OR REMOTE CONTROL DEVICES MUST BE USED.

§ THE AREA OF RADIOGRAPHY MUST BE ISOLATED AND WARNING SIGNS, BLACK AND YELLOW § THE AREA OF RADIOGRAPHY MUST BE ISOLATED AND WARNING SIGNS, BLACK AND YELLOW WARNING TAPES, YELLOW FLAGS, RED/ AMBER BLINKING LIGHTS AND WARNING BOARD STATING ”RADIOGRAPHY IN PROGRESS DONOT ENTER” SHALL BE USED FOR BARRICADING THE AREA. § ONLY CLASSIFIED WORKERS PERMITTED TO ENTER IN THESE RESTRICTED AREAS.

§ SOURCES NOT IS USE MUST BE SECURILY STORED Wrong practice § SOURCES NOT IS USE MUST BE SECURILY STORED Wrong practice

§ SOURCES MUST BE WITHDRAWN FROM STORE ONLY FOR THE MINIMUM TIME NECESSARY AND § SOURCES MUST BE WITHDRAWN FROM STORE ONLY FOR THE MINIMUM TIME NECESSARY AND ONLY BY OR UNDER THE SUPERVISION OF AN AUTHORISED PERSON. § IT MUST ALWAYS BE TRANSPORTED IN THEIR PROTECTIVE CONTAINERS. § THE VEHICLE CARRYING THE SOURCE SHOULD HAVE WARNING BOARDS FIXED. § THEY SHOULD NOT DRIVE THE VEHICLE MORE THAN 90 kmph § THIS VEHICLE SHOULD NOT BE PARKED IN CONGUSTED AREAS.

§ THE VEHICLE SHOUD NOT GET STUCK IN TRAFFIC JAM. § THE AMOUNT OF § THE VEHICLE SHOUD NOT GET STUCK IN TRAFFIC JAM. § THE AMOUNT OF RADIATION TO WORK POSITIONS MUST NOT EXCEED PERMISSIBLE LEVELS. § ANY BEAM MUST BE DIRECTED AWAY FROM ADJACENT OCUPIED AREAS. § ANY USEFUL BEAM MUST BE LIMITED TO THE MINIMUM NECESSARY FOR THE WORK.

§ REPORT IMMEDIATELY ANY BREAKAGE OF OR SUSPECTED LEAKAGE FROM A SEALED SOURCE. § § REPORT IMMEDIATELY ANY BREAKAGE OF OR SUSPECTED LEAKAGE FROM A SEALED SOURCE. § IF YOU THINK A SOURCE HAS BEEN LOST OR MIS-LAID, REPORT THE MATTER IMMEDIATELY. § DO NOT TRY TO SOME ALTERATIONS OR REPAIRS IN THE EQUIPMENT IF YOU ARE NOT AUTHORISED.

Radiological Incident February 20 th, 1999 Radiological Incident February 20 th, 1999

Incident Synthesis Location Hydroelectric Construction Site in Yanango. Distance from Lima: 300 km (East) Incident Synthesis Location Hydroelectric Construction Site in Yanango. Distance from Lima: 300 km (East) District: San Román, Department of Junín. What Happened A non-authorised person unscrewed the screws of the security lock to free the radioactive source of a Gammagraph. No key is needed to remove the source, it can be done with an screwdriver.

Equipment’s Characteristics Security Lock Type: SPEC T-2 Radionucleid: Ir 192 Activity Max: 3. 7 Equipment’s Characteristics Security Lock Type: SPEC T-2 Radionucleid: Ir 192 Activity Max: 3. 7 TBq

Equipment’s Characteristics With a screwdriver, the safety lock can be removed and so the Equipment’s Characteristics With a screwdriver, the safety lock can be removed and so the source is accessible

Chronology Welder - 4: 00 pm: A worker (welder) finds the source of gammagraphy Chronology Welder - 4: 00 pm: A worker (welder) finds the source of gammagraphy (192 Ir) abandoned in a water pipe. He puts it in the back pocket of his trousers. - He works for six hours with the source in his pocket and his assistant nearby - 10: 00 pm: He leaves work, takes a bus and travels home (he felt little pain in his right leg). During his return, he travelled for 30 minutes with 15 people. - He thinks that the red skin is due to an insect sting. - His wife sat on the trousers for 10 minutes to feed their baby. Two kids slept nearby. - 11: 00 pm: The welder, takes the trousers off the room.

Chronology Operator - 10: 30 pm: The operator makes a gammagraphy. The radiation detector Chronology Operator - 10: 30 pm: The operator makes a gammagraphy. The radiation detector doesn’t detect any readings. He assumes the equipment is not working well and stop to have dinner. - 00: 00 am: He enters the water pipe, checks the gammagraphy equipment and finds the no screws nor radioactive source. They start looking for the source. - 1: 00 am: They find the welder in his house (February 21 st). He gets out with the source in his hands. The operator hits the welders hand, throws the source to the street and puts a stone to cover it. - The source is recovered and secured in a container with iron walls 2” thick.

Chronology What was done? Initially, the welder was hospitalised in the Cancer Centre of Chronology What was done? Initially, the welder was hospitalised in the Cancer Centre of Lima. He was then sent to the Military Hospital “Precy de Claart” Grave Burns Treatment Centre in France.

Consequences Overradiation: 1 Person 16 Days After the incident Effects on Leg (13: 00 Consequences Overradiation: 1 Person 16 Days After the incident Effects on Leg (13: 00 pm 2/21/99) 3/8/99 Exposed: 18 People Effects on Leg (70 days after the incident 5/3/99)

Consequences Leg Amputation (10/18/99) Severe Infection 12/14/99 Consequences Leg Amputation (10/18/99) Severe Infection 12/14/99

What Went Wrong? Organisation - Procedures were not implemented. - Absence of Safety Culture What Went Wrong? Organisation - Procedures were not implemented. - Absence of Safety Culture in the Company’s Management. - Source inspection and measures were inadequate. - Lack of training and qualification of the operators. NATIONAL AUTHORITIES ESTABLISH: The evaluation of the authorisations and inspections should be developed by an experienced and trained team.