Radiation accidents...Why report?
Radiation accident reporting in NSW serves the purpose of:
- encouraging situational awareness and fostering a radiation protection culture
- tracking overall accident trends to improve regulatory responses; and
- sharing the lessons learned with others to help prevent future accidents
Under the Protection from Harmful Radiation Act 1990 and the Protection from Harmful Radiation Regulation 2013 employers are required to investigate and report radiation accidents.
Employers must:
- report and investigate apparent radiation accidents within the specified time frames
- maintain a record of radiation accidents
- rectify faults or defects in radiation apparatus and inform anyone who may have been exposed to radiation as a result of these faults.
The EPA has prepared an online Radiation Accident Notification form that employers can use to report radiation accidents.
Definition of a 'radiation accident'
Duty to report and investigate apparent radiation accidents
Accident investigation details
Clarification of reportable extravasation incidents
Definition of a 'radiation accident'
A radiation accident is to be treated as having occurred if there is an occurrence that involves:
(a) The unplanned or unexpected emission of radiation where it is likely that:
- one or more persons have, or could have received an effective dose of radiation of at least:
- 5 millisieverts for an occupationally exposed person, or
- 1 millisievert for any other person, or
- the premises or environment may have become contaminated by radioactivity (see Section 21 of the Act, Decontamination and acquisition of premises). Examples of this type of radiation accident are emissions due to spillage or leakage of a radioactive substance, or damage to a radiation apparatus.
(b) The misuse of radiation apparatus or maladministration of radioactive substances used for medical purposes, including:
- administration of a radioactive substance for diagnostic purposes in a quantity of more than 50% greater than prescribed
- administration of a radioactive substance for therapeutic purposes at an activity differing by more than 15% from that prescribed
- administration of a therapeutic dose of radiation from radiation apparatus or a sealed radioactive source which differs by more than 10% from the total prescribed treatment dose
- the administration of a dose of radiation for diagnostic and interventional purposes from a radiation apparatus that results in one or more persons receiving an effective dose of radiation equal to or in excess of 1 millisievert
- unintended administration of radiation as the result of a malfunction of radiation apparatus
- the administration of a radiation dose to the wrong patient or to the wrong part of a patient’s body
- administration of a radiopharmaceutical other than as prescribed.
Duty to report and investigate apparent radiation accidents
As soon as it becomes apparent that a radiation accident has occurred, the person responsible for the regulated material must give written notice of the accident to the Chair of the EPA. The notice must be provided within the specified time frame and must include the following particulars:
within 48 hours of becoming aware of an apparent radiation accident (or immediately if it is likely that the premises or the environment may have become contaminated within the meaning of section 21 of the Act). Particulars of the accident must include, indicating as far as possible:
- the place where it occurred
- the period during which the emission of radiation was uncontrolled
- the area over which any radioactive substances may have been dispersed
- any steps taken to rectify the accident
- any personal injury or exposure that may have resulted.
within 10 days of becoming aware of an apparent radiation accident, particulars of the accident must include:
- assessment of the radiation dose that any person may have received as a result of the accident.
The person responsible for reporting accidents must ensure that reports do not contain the personal identification of the patients or individuals involved. Whenever there is doubt as to whether an incident is a radiation accident, the best course of action is to report the incident to the EPA.
Reports should be provided through the online Radiation Accident Notification form.
Accident investigation details
Situational awareness
Through the investigation of an apparent radiation accident, licence holders are prompted to consider the following questions (based on the Australian Transport Safety Bureau investigation analysis model 2017):
- what happened? What are the details of the accident?
- how did an individual’s actions contribute to the accident?
- why did the accident happen? Consider the context of the accident including:
a. local conditions (environmental e.g. distractions, shielding; and human factors (e.g. experience, shielding, fatigue)
b. the risk controls (e.g. training, normal procedures, supervision)
c. organisation factors (e.g. hazard identification, auditing, culture)
These questions ultimately aim to help licensees better identify and improve the preventative controls and the local conditions to better support individual actions and ultimately reduce the risk of the accident reoccurring.
Accident data collection
All accident reports in NSW are reviewed by the EPA with the help of the Radiation Advisory Council. These are then submitted to the Australian Radiation Incident Register (ARIR), who collate and review radiation accidents across all states and territories.
The data collection is analysed and used to identify the causes as well as patterns and incidence trends. Lessons learned and emerging issues are shared with all stakeholders through annual summary reports and safety alerts.
Register of accidents
A person responsible for regulated material must maintain a record of all radiation accidents and provide these records to the EPA if requested. Details recorded for each accident must include:
- the place where the accident occurred
- the period during which emission of radiation was uncontrolled
- the name of any occupationally exposed person or other person present during the emission of radiation
- an estimate of the radiation dose which any person may have received
- details and results of any medical examinations undertaken as a result of the accident
- particulars of the area over which any radioactive substances may have been dispersed
- particulars of any steps taken to rectify the accident
- the time at which the accident was reported to the employer
- the probable cause of the accident
- particulars of any investigations into the accident, including results of the investigations
- details of any steps taken to reduce the risk of a similar accident in the future.
Faults or defects
On becoming aware that a fault may exist in any radiation apparatus or sealed source device, the person responsible for regulated material must:
- immediately investigate the apparent fault
- if necessary, remove, replace or repair the apparatus or sealed source device
- within seven days inform all persons who may have been exposed to radiation in excess of what they would have normally received from the faultless operating apparatus or sealed source device.
EPA assessment and action
The EPA may seek expert advice on any accident reported to it under these requirements and may request additional information about the incident that may be necessary to form an opinion.
The EPA also has powers to take action or make directions to take action (orally or in writing), as it considers necessary to deal with:
- dangerous or potentially dangerous situations, or
- decontamination or acquisition of contaminated premises.
For further information contact the EPA Regulatory and Compliance Support Unit on (02) 9995 5959 or email hazardous.materials@epa.nsw.gov.au or contact EPA Environment Line 131 555.
Clarification of reportable extravasation incidents
Under the legislation, any unplanned exposure to radiation resulting from an extravasation incident is considered a reportable radiation accident. This includes repeat contrast/CT scans arising from an extravasation.