Overexposure of a service technician repairing a biplane X-ray system

Print View Posted on: 29 July 2014

Event Date: 15 July 2014 Event Type: Irradiation/Accelerator Facility
Event Location: Switzerland, Hospital INES Rating: 3 (Provisional)

While repairing a biplane cardiovascular X-ray system in a hospital, a service technician accidentally activated the system’s floor pedal. Moving a mobile lead shield, he did not realize that the shield was jamming the pedal. He continued his work under unnoticed exposure for about 5 minutes until the system alarm was automatically activated. Most of the time, the upper part of his body was very close to the lateral x-ray tube. He wore a lead apron during the exposure but he forgot to wear his dosimeter that day.
About two hours after the exposure, the technician developed an erythema on the parts of his body that were not protected by the apron, mainly his face and neck. The next day, he reported his accident to the competent authorities and was immediately hospitalized in a unit specialized in treating heavily irradiated patients. After three days, he could leave the hospital and is now treated on outpatient basis. Considering the erythematous reaction and first information available, the local skin dose was roughly estimated to be around 5 Gray. The investigation of this accident is still ongoing.

INES Rating: 3 - Serious incident (Provisional) as per 29 July 2014
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

Raphael Elmiger
Federal Office of Public Health - FOPH

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