On September 25 th the CSN was informed through the Radiopathology National Hospital that an industrial radiography operator suffered from radiological skin injuries, on the fingertips of three fingers on his right hand. The operator complained of tightness in his fingers 24 hours and developed a blister and erythema 48 hours later of an incident involving an event with an remote portable industrial gammagraphy device with 0,8 TBq (21,4 Ci ) of Iridium-192 .
The event took place on August 1st and reported to the CSN on the 4th. On that day the operator was performing radiographic examinations of a pipe in the enclosure industrial radiography. The enclosure did not have the appropriate safety measures (safety interlocks or warning alarms) to perform that type of work. After entering the room, the operator unlatched the source guide tube of the device to set up the next exam, and then realized the source was out the safety containment. He had not noticed it before because he did not hear the acoustic alarm of his direct reading dosimeter as he was wearing acoustic protection to avoid the noise outside the enclosure.
Based on the recorded dose of both, the personal and the direct reading dosimeters (1,7 mSv), the event was initially considered of low safety significance. The CSN was not informed of the actual impact on the worker until the report from the hospital was received.
The effective dose as recorded by the personal dosimeter was below the dose limits and the event resulted in a local exposure of the right hand. The skin injuries on the fingertips have developed well; currently there is no sign of local effect. However the worker will remain under medical surveillance.
The CSN is carrying out an investigation of all the aspects involving the event in order to take the adequate actions. According to a previous CSN regulatory instruction the specific device involved in this event could only be used under the fulfilment of special precautions, including enclosure industrial facilities equipped with appropriate safety provisions.
Until the new INES Manual is not officially published, Spain is not using INES to communicate to the public the safety significance of radiological events occurred outside nuclear facilities.
Event date: Fri, 01-08-2008