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Event Report Forms (ERFs) are filed to the IAEA. Sometimes there are multiple event reports, updating the rating, the event description. Here you only see the latest event report

ERF send date: Mon, 23-07-2012
ERF description: A radiographer was taking several radiographic films to pipes by the night. In order to be sure that the guide tube was correctly aligned the radiographer approached to the guide tube and collimator to fix them over the pipe. This operation was repeated by 40 times. Eventually the radiographer touched the tip of guide tube with his left hand where the source was unnoticed disengaged, at least 10 times. Also, as radiographer performed this operation two auxiliary staff approached to him carrying the films to be placed for the radiography, at least by 20 to 40 times. The radioactive source was 3199,5 GBq of 192Ir. The event was detected at the end of the job and the radiographer advised to the safety officer who jointly with other licensed operator recovered the radioactive source in a safely manner. Operator showed mild symptoms as nausea and vomiting at the end of job. The other auxiliary people showed just nausea symptoms. The symptoms finished after some hours. The finger of the operator showed blistering at the fifth day. Based in biological dosimetry the radiographer received a whole body doses of 1,86 Gy. The dose to his left hand was 35 Gy as average but the dose to the distal falange (finger) was 70 Gy, both based on electron paramagnetic resonance (EPR). The doses to assistants were 0,45 Gy and 0,75 Gy to whole body, based on biological dosimetry. The personnel were promptly admitted to the hospital for clinical analysis and medical examination. The operator was after derived to France (Percy Militar Hospital) for treatment but part of his finger was amputated. Currently he has returned to Peru and, according the medical evaluation, his health is good stable and going to recovery, but psychological treatment has been advised. The assistants are just under out-patient medical follow up.
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A radiographer was taking several radiographic films to a pipes by the night. In order to be sure that the guide tube was correctly the radiographer went to the tube guide an collimator to fix them. This operation was made by 40 times. Eventually the radiographer touched with his left hand, at least 10 times, the tube guide where the source was unnoticed. Also, two auxiliar staff went to the radiographer position carrying the films to be checked at least by 40 and 20 times. The radioactive source was 3199,5 GBq Ir-192. The event was detected at the end of job. The radiographer adviced to radioprotection officer who jointly to other operator rescued the radiactive source in safely manner. Operator showed mild symptoms as nausea and womiting and other just nausea, but after all this symptoms are finished. The finger of operator showed a blistering at the fifth day. Based in first calculations, symptoms and dosimeter reading the operator could have received 6 - 7 Gy to whole body and > 50 Gy to finger. The other personnel could have received doses from 1 to 3 Gy. Currently the personnel is being admitted to the hospital and citogenetic dosimetry will be performed to adjust the doses.
ERF rating date: 17-01-2012
ERF contact person: Renan Ramirez
ERF address: Reported by Instituto Peruano de Energia Nuclear of Peru on 23 Jul 2012. Last update on 23 Jul 2012
ERF affiliation: Instituto Peruano de Energia Nuclear

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