Ionising radiation incident database

OC 560/35

To

All HSE Inspectors (Bands 0-4),
EMAS Professional Staff (Bands unallocated)

This OC, prepared by HD, informs staff about the establishment of the Ionising Radiation Incident Database (IRID) by HSE, National Radiological Protection Board (NRPB) and Environment Agency (EA). It gives details of how HSE investigation reports on radiation incidents and occurrences should be used to provide input into IRID and it explains what information will be available to inspectors.

Introduction

1 In 1990, NRPB and HSE carried out a feasibility study to look at ways of improving feedback from investigations of radiation incidents. The study found that there were adequate systems for feeding back information to employers in the nuclear and transport sectors, but there were no equivalent arrangements for the non-nuclear sectors including industry, research, teaching and health care. It concluded that there would be significant benefits in establishing a national database to cover these sectors.

2 In 1993 NRPB and HSE agreed to form a partnership to develop a national incident database. The Environment Agency (then HMIP) joined the partnership in 1995. NRPB is responsible for the management of the database.

Objectives

3 The objectives of the Ionising Radiation Incident Database (IRID) are to:

Scope and purpose

4 IRID stores radiological data on accidents and incidents which either caused actual occupational and public exposure to ionising radiations or which had the potential for such exposure (so called 'near misses'). It also includes unintentional or unauthorised discharges of radioactive materials to the environment. Other incidents recorded on IRID are those which may not have led to an abnormal exposure but may be indicative of poor management systems, eg dosemeters exposed to ionising radiation when not being worn.

5 Some types of incident are excluded from IRID since they are already covered by existing arrangements, eg incidents involving nuclear safety or criticality; transport incidents (NRPB/HSE/DoT have a separate database for such incidents); and medical exposures of patients and research subjects.

Format of IRID data

6 Each IRID entry contains coded information (to help in searches and analysis) and a text summary outlining the cause of the incident or occurrence and the 'lessons learnt' (see Appendix 1 for an example of a text entry).

Providing HSE incident reports

Action by inspectors

7 HSE will normally provide between 10 and 20 reports to IRID each year.Radiation specialist inspectors in the relevant field consultant group (FCG) are responsible for completing IRID reports for non-licensed sites based on existing HSE investigation reports. Health physicists in NSD 2C are responsibe for licensed sites and HM principal inspector of engineering in mines is responsible for completing IRID reports for those investigations conducted at mines. The tick box proforma in Appendix 2 has been prepared for this purpose. It includes guidance on how to complete each section. The report should conclude with a short (approximately 200-300 word) summary of the incident and the general lessons learnt. The information required includes the type of action taken by the employer after the incident to prevent similar occurrences in future (see Appendix 2, section 18). The reports will help inspectors make sure that the lessons learnt from an incident are made widely available to those with responsibilities for radiation protection (see paras 13-15).

8 Inspectors should alert radiation specialist inspectors in the relevant FCG; the appropriate health physicist in NSD 2C for nuclear licensed sites; and HMPI of engineering in Mines to reported radiation incidents or occurrences at an early stage (see OC 560/37) so that, among other things, the information necessary for a proper IRID entry can be specified.

9 Normally, reports should be sent to IRID within 3 months of the investigation, except where enforcement action is likely or underway. Only one report should be sent, updates are not expected.

Dst management responsibilities for IRID

10 Directorate of Science and Technology, DST E4, Bootle, now have management responsibility for the IRID project within HSE. Responsibilities of this role include:

11 Checks to identify duplicate reports from 2 or more organisations reporting the same incident will be made by NRPB. If duplication is suspected, the contributors will be contacted and the NRPB database co-ordinator will produce a single incident report with their agreement.

Confidentiality and quality assurance

12 The information provided for IRID by the contributors will not contain any names or addresses of organisations or individuals. Only the originator of the incident entry will know the names and all data presented to NRPB will be in a 'sanitised' form. NRPB has undertaken not to divulge any privileged information to a third party. HSE and EA have given assurances that they will not seek to obtain further information from the other partners (or the contributing organisation if different) about any incident recorded on the database which was not reported to that regulator, even if it appears that the incident is one that should have been reported. This would not, however, prevent HSE or EA from following up incidents which they are informed about by other means, for example as a result of a complaint.

Feedback

13 The value of IRID will be judged on the quality and accessibility of feedback to employers, their advisers and regulators. Initially, the primary feedback route will be through publications:

HSE will also have access to regular updates of IRID data, ie new incident reports.

14 The first report was published in July 1996 (file 560). The report describes the operation of IRID and includes examples of incidents with schematic illustrations. Annual reports are planned to present examples of the incident data on IRID and, increasingly, analysis of typical causes of such incidents.

Use of IRID information

15 HSE inspectors will be able to use information from IRID - especially the lessons learnt, when speaking to employers and employees and when giving presentations.

Expansion of IRID

16 The present partners will be working to encourage other organisations to join or contribute to IRID over the next year so that IRID can become a more representative incident database for the UK. Professional bodies in the further education and medical sectors and corporate RPAs will be approached as well as other organisations which are likely to have been involved in the investigation of radiation incidents; some individual RPAs may also be interested in contributing incident reports to IRID.

18 March 1997

(220/FOD/196/1996)

Disc No: J:\Editors\CA1\ocfiles\560_35.sam

ASI headings

Database: Environmental Agency : ionising radiation(s): Ionising Radiation Incident Database: Ionising Radiations Regulations Regulations 1985: National Radiological Protection Board: radiation(s).

APPENDIX 1: Example of text entry for incidents reported to NRPB/HSE/EA database

(para 6)

Text

1 An assistant radiographer received a whole-body dose of about 30 mSv while setting up an exposure of pipework. His supervisor had left the site to make a phone call and neither had realised that the 18 Ci Iridium-192 source had become disconnected from the windout mechanism of the radiography equipment about 10 cms along the source tube after the last exposure: no radiation dose rate monitor was used to check that the source had fully retracted. Later examination of the equipment revealed serious wear of the windout mechanism that would have been picked up if the equipment had been subject to routine visual examination.

Lessons learnt

2 Radiography equipment should be subject to routine inspection as part of preventative maintenance.

3 Employers should provide sufficient dose rate monitoring instruments for those carrying out site radiography and instruct radiographers to use them to check after each exposure to make sure that the source has fully withdrawn (or X-ray equipment has stopped emitting radiation). This should be reinforced in the written local rules.

APPENDIX 2 Proforma for the provision of radiation incident data for the NRPB/HSE non-nuclear

(para 7)

1 Reports should relate to a defined set of circumstances (which are time and place limited). In some cases the 'event' may be discovered by an HSE inspector at a routine visit rather than reported by the employer. Normally, investigations of reported doses above relevant dose limits would be included; in cases of doubt reported exposures which approach deterministic levels should always be included. Completeseparatereports for incidents where a source is lost at one site and turns up elsewhere, eg at a scrap yard.

2 Do report'near miss' incidents (see para 4) where there was potential for persons to be significantly exposed (even if no one received an exposure), and 'incidents' where an individual's dosemeter was exposed when not being worn, eg it was left in a radiography enclosure and a significant dose was reported for that person as a consequence, in error.

3 Do not reporttransport incidents or incidents which only affected patients. Also, do not complete a form where there has been no accident, incident or occurrence. Examples of sustained bad practice resulting in higher than normalroutineexposures would not normally be reportable.

1 HSE incident reference number, eg FOCUS record

2 HSE Region/Division State HSE region where incident occurred. If not known, ie for peripatetic workers, state HSE region containing the local office or depot of the company for whom the affected employee worked.

3 Date of incident, eg 19/03/94 - please be as specific as possible. If the date is uncertain say between which dates the incident probably occurred.

4 Category of incident (tick one box only)

• person(s) not exposed, eg dosemeter not on person
• failure of interlocks, warning lights, components, safety procedures, but diversity/backup systems prevented abnormal exposure
• near miss but potential for significant exposure
• person(s) significantly exposed
• ot known

5 Exposure level (tick one box only)

• exposure insufficient to cause investigation level for occupational exposure tobe exceeded (15 msv whole body)
• exposure sufficient to cause investigation level for occupational exposure to be exceeded
• exposure 0.25 sv to the whole body, blood forming organs or other critical organs; and/or 6 sv to the skin locally; and/or 0.75 sv to other tissues or organs from external/internal sources
• not known

6 Onsite/offsite consequences (tickeachrelevant box)

• onsite consequences
• localised offsite consequences
• widespread offsite consequences
• not known

7 Nature of incident (tick each relevant box)

• lost source o external whole body exposure
• damaged or defective shielding
• localised exposure to external radiation/controls/source containment
• leaking source
• unauthorised discharges
• contaminated facilities
• contamination of person(s)
• dropped /mislaid dosemeter etc.
• unknown
• other (describe briefly)

8 Number exposed or potentially exposed (tick one box under each heading)

Only record the number of persons who were actually exposed or could have been exposed toionising radiations - events such as mislaid dosemeters exposed off the person and 'near misses' would normally be recorded as 'none'.

Workers public

• none
• one
• 2 to 5
• 6 to 10
• 10
• not known

9 estimate of doses received by those exposed

State any known doses in millisieverts for each exposed person indicating whether that assessed or estimated dose is whole body/extremity/organ and whether from internal or external radiation, eg 10 mSv gamma whole-body; 50 mSv beta/gamma hand.

Record the best estimate of dose (not a range) following the investigation, ie the recorded dose for a mislaid dosemeter would not normally be given except in the text description. It is recognised that there may be a mismatch between the dose recorded in this section and the 'legal dose' because the Ionising Radiations Special Entry Committee (IRSEC) might not recommend a special entry or the employer may not apply for one.

10 Occupation of worker(s) - (tick the most appropriate box). If more than one person involved can use 2 or more boxes if different categories. Select only one category for each individual; where persons carry out 2 functions such as permanent and site radiography the most appropriate category should be chosen (usually site radiography). If 2 or more persons are involved more than one category can be used.

Sector - Dental, medical and veterinary

• dental work
• veterinary work
• doctors - Medical applications not research
• nurses
• radiographers - Medical
• physicists and physics technicians (medical applications onlynotresearch)
• other medical applications

Sector- Mining/drilling/quarrying

• offshore work activities
• onshore drilling
• coal mining - Underground workers
• coal mining - Surface workers
• mining other minerals - Underground workers
• mining other minerals - Surface workers
• quarrying

Sector - Industrial

• industrial radiography using a permanent installation
• industrial radiography on site or works of engineering construction
• application and servicing of machines producing ionising radiation (unless covered elsewhere)
• application and manipulation of radioactive substances (unless covered elsewhere)
• recycling of materials
• other industrial applications (describe)

Sector - Research and teaching

• academic research and teaching
• industrial research

Sector - Other

• radioactive waste treatment/disposal
• radiation protection
• transport work, eg driver drops sources moving them to vehicle
• defence-related activities not covered above
• nuclear-related activities not covered above
• other occupations not mentioned above (describe)
• not known

Guidance on occupational categories

Medical/dental and veterinary

1 These categories should be used for those directly involved or supporting medical exposures of patients and intentional exposures of animals for the purpose of diagnosis or therapy. Doctors who undertake medical research in research laboratories should be assigned to one of the research categories.

Mining/drilling/quarrying

2 Those engaged in well logging or the use of gauges and those exposed to radon decay products in these industries will fall into this category. Contractors engaged in other types of generic work, eg site radiography should be placed in a more specific category.

Industrial radiography

3 The division between 'permanent' industrial radiography and 'site' radiography will depend on whether the majority of the work is carried out in purpose made shielded enclosures (either on the employer's premises or the client's premises) or under 'site radiography conditions'. Since the latter is far more likely to result in significant exposure, individuals who spend a significant proportion (>10%) of their time carrying out 'site radiography' should be assigned to that category.

4 Work with nuclear density moisture gauges, column scanning equipment and other work which does not result in the production of an image is not regarded as 'industrial radiography' and should be assigned to other categories in this sector.

Industrial applications

5 'Application and servicing of machines' is intended to cover both radiation generators and machines which incorporate radioactive sources, eg thickness, density and moisture gauges. It would also include work associated with sterilisation plants, eg gamma irradiators. LINACs, electron microscopes, and other high voltage equipment for industrial purposes. It also covers those who manufacture or service equipment, including medical X-ray equipment, and calibration (except where category 8 would be more appropriate).

6 It does not cover those who strip down articles containing radioactive substances, eg smoke detectors, for re-use or disposal of the source - use 'application and manipulation of radioactive substances' (which includes production of radiopharmaceuticals).

11 Type of Equipment involved (tick the most relevant box -oneonly)

• diagnostic x-rays o level gauges
• veterinary x-rays o density/moisture gauges
• teletherapy o analytical equipment
• brachytherapy o x-ray optics
• nuclear medicine (therapy and diagnostic) o electron beam equipment
• baggage inspection/security o unsealed radioactive materials
• gamma site radiography o smoke detectors
• gamma radiography - Permanent facility o x-ray site radiography o consumer productso static eliminators
• x-ray radiography - Permanent facility o irradiation facilities (x-ray, gamma, electron)
• laboratory/calibration sealed source o thickness gauges o yield monitors (agricultural) o radwaste treatment plant
• environmental tracer work o process ores/scrap
• other (describe)

Make an entry either in section 12 or section 13 - not both . If x-ray equipment and sealed sources could have been involved, choose most likely one here and explain in text description at end.

12 Radioactive material involved (state most significant isotope and activity, eg Cobalt-60, 1MBq).

13 Radiation generator (state Kilovoltage of any generator, eg 100kv medical x-ray set).

14 Cause of incident (tickup to 4 boxes)

• engineering failure - Design/installation inadequate o error by worker
• engineering failure - Inadequate maintenance o malicious act
• engineering failure - Shielding/containment o lost/stolen source
• engineering failure - Other o external factor
• inadequate supervisiono inadequate ppe
• inadequate personal training
• not known
• failure in the use of monitoring instruments, eg o other (describe)

Battery or component failure, wrong instrument, failure to use .

15 Contingency plans (tick most appropriate box -one only)

• not available
• available but not used
• available and used but not adequate
• available adequate and used
• not relevant, ie no incident occurred
• not known

16 RPA involvement (tick most appropriate box -one only)

• none appointed
• appointed and involved in investigation orpa is nrpb
• appointed but not involved in investigationorpa is not nrpb
• not known

17 RPS involvement (tick most appropriate box -one only)

• none appointed
• appointed, suitable and involved in investigation
• appointed, not suitable but involved in investigation
• appointed, not suitable and not involved in investigation
• not known

18 Follow up action by employer (tickone or more boxes)

• additional/revised operating procedures/local rules
• new/revised contingency plans
• engineering modifications including additional safety systems
• additional/revised training
• additional ppe
• revised maintenance procedures
• disciplinary action against individuals
• equipment taken out of use
• not known

19 Text description of the incident

Brief description of what happened including the cause of the accident or incident. Please includeseparate summaryof 'lessons to be learnt'; the aim here is toprovide general lessons, not specific lessons for the particular employer involved in the incident.

The total should normally be about 250 words but longer summaries are welcome for unusual or particularly important incidents. The text should give any reported or estimated doses and repeat details of the source.

The description is intended for general use outside HSE and should be anonymous, ie no names of companies or individuals or specific products such as 'Siemans' X-ray set model XYZ. It should not refer to enforcement action or to other HSE action, eg reference to IRSEC.

The purpose of the description is to give those outside HSE a clear idea of the main facts and the key lessons to be learnt from the incident so others can avoid making similar errors in future. Please aim to communicate the essential points to interested employers/RPAs - assume no special knowledge on the part of the reader. Headings might include: General description, doses, actual or potential consequences, lessons. For very serious incidents, medical management/consequences might be included.

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General description

Lessons learnt