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2nd Prosecution of the Royal Free Hampstead NHS Trust

In September 2007 the HSE received a notification from the Royal Free Hampstead NHS Trust concerning a suspected overexposure to a Nuclear Medicine Consultant working at the Royal Free Hospital.

An extensive investigation into this suspected overexposure was carried out by Specialist Inspectors from the HSE’s Radiation Team. During the course of this investigation evidence of non-compliance with some of the requirements of The Ionising Radiations Regulations 1999 (IRR99) were identified and statements were taken from a number of employees.

The total whole body dose recorded was 18.6mSv in eight months and only failed to exceed the dose limit (20mSv) during the calendar year because the Trust carried out a review and took action following the notification.  If the Trust had acted upon the non return & late return of dosemeters then it could have carried out an investigation and acted to restrict doses much earlier. Classification of the worker should have been considered when it became apparent that he was likely to exceed three tenths of the relevant dose limit.  The investigation showed poor management of radiation protection and, in particular, poor management and control of personal dosemeters and dosimetry in general. There was also some evidence that personnel were failing to take good care of dosemeters issued to them which could have led to action being taken against the individuals concerned under Section 7 of the Health and Safety at Work etc. Act 1974.

In August 2009 the HSE prosecuted the Royal Free Hampstead NHS Trust at the City of London Magistrates Court. The Trust pleaded guilty to offences under Reg 8(1) and Reg 20(1) of the IRR99 and were fined £4000. Costs of £9000 were awarded to the HSE

This case highlights the need for close management control of radiological protection and the need for clear instructions about the use and care of personal dosemeters. Furthermore it is important that Trusts realise the importance of the supervision of all staff who wear personal dosemeters to ensure that they are following instructions about the wearing and return of personal dosemeters.

Whilst not directly related to this case HSE’s Radiation Team would like to remind Trusts that under Regulation 21 of the IRR99 a Trust has a duty to ensure appropriate personal dosimetry is provided and staff trained in its use. Staff also have a duty under Section 7 of the Health and Safety at Work etc Act 1974 to take good care of their personal dosemeter(s) and return it on time. In order to achieve proper management of exposures a Trust could remind staff of their duties and inform them that enforcement action could be taken against them personally should they fail to take good care of their dosemeter and return it on time.

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Compliance with IRR99: Action with professional organisations for dental practices and chiropractors

HSE’s Radiation Team (HSE RT) is concerned about the poor standards of compliance with the IRR99 they have found during inspections at Dental Practices and Chiropractors. Many fail to properly comply with the IRR99 and some have not even paid scant attention to its most basic requirements. As a result they have put themselves, their staff and members of the public to unnecessary risk and HSE RT has issued a number of enforcement notices.

HSE RT is puzzled about the low standards of compliance which occur, despite the wealth of guidance produced for these professions. They have, therefore, sought to liaise with the various professional bodies in order to improve standards of radiological protection and have met recently with the British Dental Association, the General Chiropractic Council and the British Chiropractic Association. These professional organisations will be reminding their members, or have already done so, of the need to properly comply with the IRR99. Common themes are:

HSE RT is anxious to continue to work closely with the professional organisations and stakeholders but inspectors will not hesitate to take enforcement action against those that fail to take action to comply with the IRR99 and other relevant statutory provisions.

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Health and safety guidance now free online

Authoritative guidance about how to protect employees from workplace dangers is now given away free by the Health and Safety Executive (HSE).

Since September 2009 around 250 priced publications ('HSG' and 'L' Series publications) that contain health and safety advice and guidance have been freely available from HSE’s website in PDF format to view and print.

The publications cover the full range of HSE’s guidance as well as approved codes of practice (ACOPs) and guidance on regulations.

HSE said it was making the information available to help employers better understand their legal duties and what health and safety precautions they need to take, and to help safety representatives in maintaining and improving health and safety in the workplace.

Those that wish to will still have the option to buy professionally produced printed versions from HSE Books.

Although the publications will be made freely available online, Crown copyright will still apply and organisations wishing to reproduce the information will still need an appropriate licence from the Office of Public Sector Information (OPSI).

This of course includes L121 - Work with Ionising Radiation.

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Report on incident involving 'premature lock out' on Techops 660 Gamma Radiography Source Projector

This RP News item has been supplied by High Technology Sources Limited (HSTL), the UK distributor of Techops/Sentinel products.
Following a recent incident involving a Techops 660 Gamma radiography projector, HSTL liaised with the user to investigate the problem.  The following is an edited extract from the final report.

"Following a gamma radiography exposure, the winding mechanism counter showed the source had not fully retracted by approximately 2 inches. After several attempts, it was apparent that the source could not be fully retracted.

The radiation meter showed a dose rate of 40 to 50 mSv/hr at the rear mechanism end and sides of the source container and it was noticed that the locking bar was in the locked/safe position, showing the Green Flag although the source was still not fully home.

An attempt was made to pull the drive cable back, to fully retract the source but it would not move backwards because the Pozilock sliding mechanism was in the safe position as confirmed by the coloured identification Flag (Green). It was decided to secure the container and report the situation."

At this point having established that the source was only 2 inches from the fully shielded position and within the DU shield, the best option would have been to reconnect the controls, push the lock slide to the expose position and wind the source back into the stored position from 25ft away.
HTSL were, however, called and  immediately mobilized a service engineer who attended the site and carried out a full inspection of the device and controls. All the equipment was found to be functioning correctly and within all the gauged tolerances.

After several attempts, it was possible to recreate the situation using a dummy source, however it was not easy. The conclusion of the visit was that the incident was caused by operator error, as the pozilock slide had not been pushed fully home.

It should be noted that all operators of these devices MUST read the appropriate manual for the device and understand the contents.
The 660 manual clearly indicates to push the lock slide till you hear a click and then test that the lock slide is fully seated in the open position by attempting to push the slide back to the lock position. (MAN 006, page 2.9 steps 3 and 4)

The later version of the source container, the "880"  has a modified slide lock slide assembly to prevent the possibility of premature lock out; this has been achieved by redesigning the lock slide and central sleeve to incorporate a chamfered location in the lock slide and a corresponding machining on the central sleeve so that the pozilock will only lock in the correct position. (Please note, these parts are not interchangeable with the 660.)

Techops 660 Gamma Radiography Source Projector

The lock slide and central sleeve showing the chamfered edges of the corresponding components to ensure positive location.

Techops 660 Gamma Radiography Source Projector

In this position, you can see how the lock slide slides across the front face of the central collar

Techops 660 Gamma Radiography Source Projector

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Inspections of nuclear density gauge users

During the last few months HSE’s Radiation Team (HSE RT) have carried out a number of inspections of users of nuclear density gauges (NDG). Rather disappointingly, the inspections revealed that the level of compliance with IRR99 was, in many cases, not good and as a consequence a number of Improvement Notices were served.

The main areas of concern identified during the visits are listed below:

  1. Prior risk assessment - many of the risk assessments seen were not suitable and sufficient in that they did not address all the relevant points given in paragraphs 44 and 45 of the ACOP to IRR99.
  2. It was noted that gauges are often used on other employer’s sites with a single operator.  In many cases no arrangements have been made with the site operators to ensure that the gauge could be made safe following the gauge operator becoming ill or being involved in an accident on the site.
  3. Contingency plans - many of the contingency plans in the local rules did not cover all reasonably foreseeable radiation accidents.  In addition many of the plans could not have been put into operation as the gauge users did not have all the equipment identified in the contingency plan.  It is important, therefore, to carry out rehearsals of contingency plans to ensure that those who have a role in the plan are aware of their responsibilities and to ensure that the plan is practical to implement and that all the relevant personnel can be contacted.  Many of the contingency plans rely on the RPA attending site and implementing recovery of a damaged gauge - if your plan is written in such a way you should ensure that your RPA is aware of these arrangements and that they would be available to attend site at short notice.
  4. Use of radiation monitors - NDGs should be accompanied by a suitable radiation monitor to ensure the correct designation of controlled areas, for use in any contingency plan and very importantly to ensure that the NDG shutter has closed properly prior to loading into its transport container.
  5. Local rules - these documents are supposed to be key working instructions; too many times they contain too much information, much of which should reside in the company’s radiation safety policy document.
  6. Source accountancy records - on several inspections it was found that the source accountancy records giving the location of each gauge was not up to date meaning that any losses of NDGs may not have been identified quickly.  This is very important as the loss of a NDG may well turn in to a major incident with its associated bad publicity for the company involved.

HSE have previously published an Ionising Radiation Protection Series Information Sheet "No 3: Portable nuclear moisture/density gauges in the construction industry".

Be assured that further inspections will be carried out in the near future.

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RPA certification for work in Ireland

Category II Approval Scheme - Industrial and Educational applications

The Radiological Protection Institute of Ireland (RPII) has recently instigated a procedure for the approval of all persons who wish to act as RPA to undertakings involved in the use of ionising radiation for non-medical applications [Category II RPA certification], i.e. industrial and educational applications and work activities.  This follows on from the existing approval scheme for Category I RPAs in medical and dental applications.

The scheme is based on a formal approval of "core competence" by the RPII. RPAs advising Category II employers in Ireland must therefore provide evidence from prior education, training and experience within a portfolio of evidence to the Assessment Committee. The application fee is currently €550.

The "core competence" is based on the topics contained in the "Basic Syllabus for the Qualified Expert in Radiation Protection" and the "Additional Topics Recommended for Specific Areas" as set out in the Official Journal of the European Communities C133;30.04.98. It is therefore very similar to the UK scheme in assessing the depth of knowledge or level of understanding of each topic and RPA 2000 certification provides substantial support to any application. However, additional Basic Understanding (BU) topic areas of General Industry and Research & Training together with a Detailed Understanding (DU) of Irish National Legislation and Regulations are also required.

An approval scheme for Category II corporate RPA bodies also exists that is similar to that operated by the HSE in the UK.

An Application Form, Guidance notes for applicants and Guidance notes for creating a portfolio of evidence for those seeking RPA approval for industrial and educational practices and work activities in Ireland are available from the RPII Regulatory Services Division. Contact Mr Jarlath Duffy or Dr Jack Madden for further information. Phone 00353 1 2697766.

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Security Screening for Appointed Doctors and Radiation Protection Advisers

In response to recent enquiries to HSE, employers are reminded that the competence recognition schemes operated by, or on behalf of, HSE for Appointed Doctors, Radiation Protection Advisers and RPA Bodies do not include aspects of Security Vetting or Screening. It is the responsibility of the employer to ensure that their employees have the required levels of security clearance.

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And finally…could this happen here ?

Updated 2015-07-06