Overexposure to a Radiographer Trainee's Extremities


Print View Posted on: 25 September 2015

Event Date: 12 September 2011 Event Type: Radiation Source
Event Location: United States of America, Lavaca, Texas INES Rating: 3 (Final)

UPDATE 9/25/2015: Preliminary information had indicated that a radiographer trainee received an extremity exposure to the fingers, as result of removing a radiography camera guide tube with the source still in it and touching the source. The trainee’s fingers indicated observable deterministic effects, which included blistering of the thumb, index, and middle fingers. These types of effects correspond to an exposure range of 20 to 30 Sv (2000 to 3000 rem) to the extremities. The trainee received medical care at an area hospital. The trainee’s whole body dosimeter was processed immediately and the dose result indicated 14 mSv (1.4 rem). On September 22, 2011, Texas performed an onsite investigation. Interviews with the radiographer trainer and trainee revealed conflicting information. The trainer stated that the trainee never removed the guide tube from the exposure device and that the trainee never had access to the device until the source was fully shielded and in the locked position. The trainer also stated that the trainee could not have been injured on September 12, 2011. The licensee conferred with the Radiation Emergency Assistance Center/Training Site (REAC/TS). Texas concluded that that the trainee had received the radiation overexposure. The trainer’s training status was revoked in the State of Texas and other radiographers received additional training. On January 2, 2013, the exposed trainee contacted Texas again and stated that radiation symptoms to this individual’s right hand were getting worse. The trainee was told to contact a physician at REAC/TS. The individual also contacted a physician in the Houston, Texas area and received additional care. On May 23, 2013, the radiography trainee's right index finger was amputated. The trainee also stated that he was experiencing trouble with his thumb and middle finger. NRC EN47283

****************************************************************************

UPDATE 6/1/2012: The State of Texas attempted to question the individuals and obtain their testimony to better understand the circumstances of the event, but was unable to do so. The final dose assigned to the radiographer trainee by the licensee was 27 Sv (2703 rem) to the extremities for the year 2011.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

ORIGINAL 9/23/2011: Preliminary information indicates that a radiographer trainee received an extremity exposure to the fingers, as result of removing a radiography camera guide tube with the source still in it and touching the source. The trainee’s fingers indicate observable deterministic effects, which include blistering of the thumb, index and middle fingers. These types of effects correspond to an exposure range of 20 to 30 Sv (2000 to 3000 rem) to the extremities. The trainee is receiving medical care at an area hospital. The trainee’s whole body dosimeter was processed immediately and the dose result indicates 14 mSv (1.4 rem). The State of Texas has initiated an investigation to gather additional details of the event and to determine the estimated dose to the extremities. These are all the known details at this time.

INES Rating: 3 - Serious incident (Final) as per 26 August 2015
Release beyond authorized limits? No
Overexposure of a member of the public? No
Overexposure of a worker? Yes

Contamination spread within the facility? No
Damage to radiological barriers (incl. fuel damage) within the facility? No

Degradation of Defence In-Depth No

Person injured physically or casualty? Yes
Is there a continuing problem? No

Patricia Milligan
Nuclear Regulatory Commission (NRC)

Patricia.Milligan@nrc.gov
http://www.nrc.gov
Site Sponsors
Site Sponsors: IAEA, NEA and WANO
This site is hosted by the International Atomic Energy Agency (IAEA) and co-sponsored by the Nuclear Energy Agency of the Organization of Economic Cooperation Development (OECD/NEA) and World Association of Nuclear Operators (WANO).
Disclaimer
This site is hosted by the IAEA, however, event reports are filed and updated by authorities in participating countries, which remain responsible for all related content. Read more >