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INES 2: Incident

Impact on People and Environment:
  • Exposure of a member of the public in excess of 10 mSv.
  • Exposure of a worker in excess of the statutory annual limits.
Impact on Radiological Barriers and Control:
  • Radiation levels in an operating area of more than 50 mSv/h.
  • Significant contamination within the facility into an area not expected by design.
Impact on Defence-in-Depth:
  • Significant failures in safety ­provisions but with no actual ­consequences.
  • Found highly radioactive sealed orphan source, device or transport package with safety provisions intact.
  • Inadequate packaging of a highly radioactive sealed source.
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INES-event
INES 2

Overexposure to Nuclear Medicine Technologist

In February 2015, it was determined that a nuclear medicine technologist received a cumulative annual whole body dose of 110 mSv (11 rem) for the time period of September 01, 2014 to January 07, 2015, which exceeds the annual statutory dose limit of 50 mSv (5 rem). The State completed their investigation and confirmed the validity of the whole body dose on July 13, 2015. The staff member received 100 mSv (10 rem) for 2014 and 10.1 mSv (1.01 rem) for 2015. NRC EN50877.

Category: Other United States of America »

INES-event
INES 2

Overexposure to Nuclear Medicine Technologist

In February 2015, it was determined that a nuclear medicine technologist received a cumulative annual whole body dose of 110 mSv (11 rem) for the time period of September 01, 2014 to January 07, 2015, which exceeds the annual statutory dose limit of 50 mSv (5 rem). The State completed their investigation and confirmed the validity of the whole body dose on July 13, 2015. The staff member received 100 mSv (10 rem) for 2014 and 10.1 mSv (1.01 rem) for 2015. NRC EN50877.

Category: Other United States of America »

INES-event
INES 2

Transport incident of a gamma ray projector

On 16th March 2015, ASN was informed by the ECW company (Courcelles-les-Lens) that one of their gamma ray projects had been carried on the public highway on 2nd March 2015 in conditions failing to comply with a number of requirements stipulated by the transport approval issued by ASN. Indeed, the device was not in the closed and locked position and was equipped with its site accessories, which prevented it from being fully inserted into its transport casing.

Category: Transportation France »

INES-event
INES 2

Overexposure to Radiographer

The Lead Radiographer and three assistant radiographers were completing two exposures lasting 35 seconds each. The set-up time for the exposures was approximately 15 to 18 minutes. After completing two exposures, one individual noticed that his pocket dosimeter read off scale, a second individual read their dosimetry at 0.5 mSv (50 mrem), the third individual read their pocket dosimeter as off scale, and the fourth individual was not wearing a dosimeter. Two individuals were wearing functioning rate meters and two were not.

Category: Radiation Source United States of America »

INES-event
INES 2

Uncontrolled release of radioactive effluents into the public sewerage system

On 2nd August 2013, ASN was informed by the Haut-Lévêque hospital in Pessac that an abnormal level of radioactivity had been discovered in a wastewater drain pipe. Investigations showed that radioactive effluents from the vectorised internal radiotherapy rooms were being discharged directly into the public sewerage network instead of being routed to the radioactive decay tanks, between August 2012 and 27th July 2013, owing to a piping connection error. The connection had been defective since works were carried out in August 2012.

Category: Other France »

INES-event
INES 2

A practitioner’s regulatory annual exposure dose limit was exceeded

On 14th October 2014, ASN was informed by Bordeaux CHU that the regulatory annual whole-body dose limit of 20 mSv was exceeded by an orthopaedic surgeon while using an interventional radiology device (image intensifier) in the operating theatre.

The event came to light when the practitioner’s passive dose monitoring results were received and showed that the dose received between June 2013 and June 2014 was 25 mSv.

Category: Other France »

INES-event
INES 2

Overexposure of a worker

On the 28th of January 2015, during an inspection of nuclear materials, a radiation worker accompanying the inspectors entered a hot cell containing a source of radiation. Worker remained inside the cell for about 1 minute. Worker’s personal dosimeter recorded an effective dose of 31 mSv which exceeds the annual statutory dose limit for radiation workers (20mSv). Doses received by the 3 inspectors present at the scene probably did not exceed 1 mSv (dose 0.7 mSv measured with personal electronic dosimeter, personal thermoluminescent dosimeters to be read).

Category: Radioisotope Processing/Handling Facility Poland »

INES-event
INES 2

Overexposure to Radiographer

While on location at a temporary jobsite, the licensee radiographer attempted to disconnect the guide tube from the radiography camera, without ensuring the source was in the shielded position. The licensee has confirmed a whole body dose of 64 mSv (6.4 rem) which exceeds the statutory dose limit of 50 mSv (5 rem). The licensee also confirmed a hand dose of 2,060 mSv (206 rem) which exceeds the statutory limit of 500 mSv (50 rem) for extremities. NRC EN50745.

Category: Radiation Source United States of America »

INES-event
INES 2

Interventional Radiology: exposure of a health professional in excess of the annual dose limit

On 18th August 2014, ASN was informed by the Val de Saône Polyclinic in Mâcon (Saône-et-Loire department) that a private-sector surgeon working in the operating block had exceeded the regulatory annual whole body dose limit of 20 mSv.

Category: Other France »

INES-event
INES 2

Realizing of maintenance activities without respecting the procedures

During maintenance activities that were conducted on some systems of one of the two irradiators present in the Sterigenic's installations, it was found that some safety-related equipment was unavailable. However, the availability of this equipment is requested as described in the procedure currently in application.

As this equipment was unavailable, Sterigenic's operators carried out those maintenance operations with only one safety device ensuring protection from a potential irradiation by the 60-Co sources that are used in the installations.

Category: Irradiation/Accelerators Facility Belgium »