On October 23 SGS TECNOS, S.A reported to the Spanish Regulatory Authority (CSN) an event resulting in the overexposure of one radiographer. The event occurred in an enclosure industrial radiography installation during the preparation of the radiography exposures. The event involved a gammagraphy device with a 2 TBq (55 Ci) Co-60 source. The interlock access control system to the room was broken so there were two fixed radiological survey instruments with visual alarm inside the room to check the radiation levels during operation. The worker carried a thermoluminescent personal dosimeter as well as a direct reading dosimeter with an acoustic alarm and a radiometer, but these monitoring systems had been failing occasionally. The operator did not realise the visual warning signals from the fixed instruments and remained inside the room for 10 -15 minutes while the source was exposed. The dose recorded by the thermoluminescent personal dosimeter was 718 mSv.
On October 29 the worker was submitted to a medical review following the national standard guidance for accidentally exposed individuals as well as dosimetry by chromosome aberration analysis.
An on site-inspection has been carried out to evaluate the safety systems, working procedures and event circumstances.
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