1. IAEA International Atomic Energy Agency Safety Reports Series No. 7 Lessons Learned from Accidents in Industrial Radiography Practical Radiation Safety Manual Manual on Gamma Radiography Eric Reber, NSRW, IAEA

2. IAEA HIERARCHY OF IAEA SAFETY STANDARDS Fundamentals Underlying principles (aimed at politicians and regulatory bodies) Requirements Specific obligations and responsibilities (“shall”) Guides Recommendations to help implement requirements (“should”) Safety Reports & TECDOCS provide supplementary information

3. IAEA Objective: To draw lessons from the 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

4. IAEA 43 Examples of Accidents Given According to Primary Causes Inadequate regulatory control Failure to follow operational procedures Inadequate training Inadequate maintenance Human error Equipment malfunction or defect Design flaws Wilful violation

5. IAEA Lessons Learned – Failure to Follow Procedures Adherence to safety procedures would have prevented 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

6. IAEA 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.

7. IAEA 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

8. IAEA 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.

9. IAEA Prevention and Remedial Actions – Regulatory Authority Practice-specific regulations Inspection Enforcement International assistance Communications among stakeholders

10. IAEA Prevention and Remedial Actions – Operating Organization 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

11. IAEA Prevention and Remedial Actions – Designers and Manufacturers Maintain communication with regulatory authorities 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

12. IAEA Annex I – Radiographer Training Practical Training Hands on training Classroom Training Basic radiation safety training Detection and measurement of radiation ALARA Regulatory requirements Certification

13. IAEA Audience is the users of radioactive 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

14. IAEA

18. 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.

19. IAEA Eric Reber, NSRW e.reber@iaea.org Documents available temporarily at: http://gnssn.iaea.org/CSN/TM%2048337%20Industrial%20Radiography/Forms/ AllItems.aspx