Work Instruction 7.0-WI-26-OID/CNDT&PSU Issue Date: January 25, 2011 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE Table of Contents = 1 Purpose 2 Scope. 3 References... 4° Definitions... 5 Cautions/Danger. 6 7 8 9 Incident Classification Personnel Training Emergency DillS nnn 40 _ Incident Response Retrieval - General 11 Notification and Reporting 42. Post incident Actions 43 Incident Root Cause Analysis 14 Identify Preventative Measures. 15° Injuries. saa 46 Incidents invaiving Fire 47 Incidents Involving Contamination EMERGENCY CONTACT INFORMATION...... Attachments — Incident Type Response 1 Incident Type Assessment... 2 2 Retrieval Preparation - Plan 14 3 Excessive Radiation Dose. 18 4 Source Hang-Up (Stuck) reucannars 20 5 Source Disconnect 23 & Encapsulation Damage .. 26 7 Damaged Guide Tube amiss 2B 8 — Jammed Controls 33 9_Lostor Stolen Projector 36 40 Vehicle Accident sunais ST Prepared By :T.E. Scales Signature : FTedg— Date: 1/25/2011 Reviewed By : A. K. ALHamad f Soi ale a Date : es (2 Approved By :A.M.AkKhunaini Signature: Aeaehee—mo—— pate: //23/2el/ Previous Issue: New Issue Next Planned Update: January, 2016 Page 1 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE. 4. PURPOSE The purpose of this work instruction is to provide guidelines and instructions when issues related Radiation Safety and Industrial Radiography contribute to or result in an emergency. As a guideline, many provision in this Work Instruction are recommendations and not necessarily mandatory. For mandatory requirements, refer to the Radiation Safety procedures SAEP-1141 and Gl 150.003. 2. SCOPE This Work Instruction deals primarily with incidents involved in the use of radioactive material due to the hazardous nature regardless if in use, transport, or storage. X-ray tubes (electrically generated radiation source) is also addressed, but considered inherently safer due to the fact that when disconnected from a source of power, pose no hazard. This procedure is not intended for open distribution, but focused on those individuals authorized to manage and coordinate retrieval efforts. By default, individuals having a minimum of 10 years experience related to industrial radiography and attained supervisor role such as Group Leader, Area Coordinator, Field Supervisor, KAST Licensed RSO/RPO, etc. are considered authorized 3. REFERENCES GI 150.003 Ionizing Radiation Protection SAEP-1141 Industrial Radiation Safety King Abdulaziz City for Science and Technology (KACST) 2007 National Regulations 4. DEFINITIONS Incident: For the purposes of clarification and in reference to Radiation Safety an ‘Incident’ (or “Radiation Safety Incident’) is an issue or set of circumstances where there is an unintentional radiation exposure due to malfunction, operational error, or accident that could lead to or result in an over exposure to radiation to the technicians or public. A ‘source’ is a radioactive material or radiation generating equipment that emits ionizing electromagnetic radiation. For clarification, as used in this Work Instruction, a source refers to radioactive material such as Iridium-192 (Ir-192) and Cobalt-60 (Co-60). X-ray tube referred to in this Work Instruction refers a machine comprised of an x-ray tube and control/power unit capable of generating X-ray ionizing radiation. Projector: A “Projector” is a radiographic exposure device used for the shielded storage, transport, and controlled exposure of radioactive material for the purposes of Industrial Radiography. Associated equipment (equipment attachable to the projector) are items such as the guide tube, extension tubes, and wind-out (control) that contain and/or manipulate the position of the source. Page 2of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMER¢ (CY RESPONSE 5. CAUTIONS/IDANGER Radiation exposure at excessive levels is a very significant issue that when high enough could result in prolonged illness, serious life altering physical injury, or at substantially higher levels fatality preceded by severe illness. No approach to a radiation affected area is to be attempted individuals not having substantial experience and training or under the explicit guidance of such individuals. Resolution of Incidents can be accomplished safely without undue radiation exposure, but ‘only when a carefully crafted retrieval plan specific to the incident is established and carried out by knowledgeable, experience individuals, 6. INCIDENT CLASSIFICATION (KACST) 6.1. First Level Accidents An incident that is contained within a designated exposure facility. Applicable incidents include source disconnect, source stuck, or damaged or malfunctioning equipment. 62. Second Level Accidents A field related incident that occurs within a facility, concessionary area, easement, or right-of-way. Applicable incidents include source disconnect, source stuck, or damaged or maffunctioning equipment 6.3, Third Level Accidents ‘An incident that occurs outside of Company property. Typically, the only incidents related to industrial radiography that would occur outside the Company's property is ‘the loss or theft of a source or vehicular accident on public roads. 64, Fourth Level Accidents An incident that ocours and the effects thereof could extend beyond the Country's boundaries. Given the nature of industrial radiography, such incidents are not likely and therefore are not covered by this procedure. 7. PERSONNEL This Work Instruction covers non-contaminant radiation incidents. For radiation incidents whereby it is suspected that contamination may be involved (see Contamination attachment in this Work Instruction) the Environmental Protection Department, Radiation Protection Unit shall take the lead role for all mitigating activities. 7.4. Incident Recovery Team 7.1.1, Based on the initial notification and information received, the RSO or designated representative shall form a recovery team. Members of the team must be classified as Radiation Workers and have the dosimetry required by G1-150.003 and SAEP-1141 7.1.2. The number of individuals required for retrieval shall be determined by the RSO or designated representative upon determining the circumstances of the incident. Typically, in addition to the radiographic crew, two individual inclusive of the RSO or designated representative. However, the complexity Page 3 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE 72, 73, of the retrieval will determine the actual number of individuals to assure no one individual receives and unacceptable dose as a result of the retrieval. Unless absolutely necessary, Radiographic Technicians should not be used as direct recovery team members, but may be used in support roles. The Team Leader (typically the RSO or Designated Representative) is responsible for all communications among respondents (team members and other organizations) and coordination during the course of the incident and retrieval and shall have the final authority for actions to be taken. The Team leader should take advantage of available technology (e.g. cell phone, land line, radios, etc) and when environmental restrictions are imposed such as inside sensitive operating plants, utilize one individual as a relay for communications. The Team Leader must be open to suggestions from others on the team, collect relevant information from individuals involved in the incident and to assure thet all team members are informed of final decisions and methodology to be applied for the retrieval. Radiation Measurement & Monitoring 724 The Team Leader (RSO or designated representative) will 7.2.1.1. Assure all members of the team have a minimum of Radiation Survey Meter, Alarming Dosimeter, and TLD as required by SAEP-1141. Depending on the actual circumstances of the radiation incident, additional dosimeters (electronic andlor fiber quartz), and area Survey Meters with Dose and Dose Rate measurement capability may be provided 7.2.1.2. Define a scheme of measuring, monitoring, and recording dose levels of the team members appropriate to the actual incident circumstances. Whatever method of monitoring and recording determined by the team leader, it must, as a minimum, monitor initial dosimeter levels, intermediate levels at the completion of significant tasks, and upon completion of the incident retrieval for each member of the team. 7.2.1.3. The RSO or Team Leader shall be responsible for all communications during the course of the incident. Reporting is the responsibility of the User Organization ‘Additional Emergency Response Personnel In the event additional personnel are required for emergency issues related to the incident such as injury, fire, etc. refer to “Emergency Contacts” page 11 of this procedure. Page 4 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE 8. TRAINING 8.1. 82. Personnel involved in the retrieval of radiation sources should have prior Radiation Safety training to be acutely familiar with the hazards involved. The team leader or advisory RSO should have training associated with incident retrieval or have extensive experience. It must be recognized that industrial radiography and the associated equipment is mechanical in application and the typical incidents require a strong mechanical experiential background. The principal goal of any source retrieval is the resolution of obstacles in the ‘approach, access, and handling of the source to maintain the lowest dose possible through control of time, distance and shielding. Experience in industrial radiography is a key factor in readiness to respond to emergencies 8. Emergency Drills 9.1, 92 9.3. 94. The RSO or designated representative shall organize periodic drills choosing an incident scenario as an exercise Drills may be an administrative exercise such as response to a “Dropped TLD’ or complex involving a dummy or actual source in a “stuck source” exercise. Frequency of drills is at the discretion of the RSO, but at a minimum at least one ‘annual drill should be conducted. It should be recognized that the most effective drill is one involving an actual source (minimal activity) in order enforce competency of all factors including monitoring and controlling dose. Records of completed Emergency Drills may include trail reports and other information describing the drill conducted, personnel involved, and lessons learned, if any. Such documents should be retained for a minimum of 5 years. 10. Incident Response Retrieval- General 10.4 10.2, 10.3, 10.4 10.5, Secure the area of all non-essential personnel and personnel not classified as “Radiation Workers’ Survey the perimeter and assure that the dose level at the Restricted Area Barrier does not exceed 0.75 mRem/hr. Extend barrier signs and ropes/barrier tape as required. Notify site personnel in the area that an emergency situation exists and assure that they do not enter the Restricted Area. In complex area where observation of the Restricted and Controlled area is not possible, the Technician is to seek assistance from others such as Industrial Security, Loss Prevention, Plant Inspection, etc. to maintain control. Such personnel are not to enter the Restricted Area for any reason. Determine if there are any injured individuals involved and provide immediate first aid and notify Medical Emergency response personnel Page 5 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE 106. 10.7, Determine if there is a potential of fire associated with the incident. Mitigate any risk of fire before engaging in retrieval activities unless it is absolutely certain that mitigating activities will not contribute to the fire potential or be a risk to personnel Refer to the section on “Fire” in the Work Instruction. When dealing with the technicians, give special attention not to accuse the technicians of wrong doing as it is typical that the level of cooperation drops proportionately with the mode established by the RSO or designated representative. The policy "No Technicians is in Trouble" assures that greater cooperation is established for this incident as well as future issues. It is not intended that a “Blind Eye” approach be taken for violations contributing to the incident, but the reaction is different form typical violations encountered. 14. Notification and Reporting 4 11.2. 13, 11.5. Once the area is secured, one of the two technicians is to call the Area Radiation Safety Representative providing details of the incident. The Area Radiation Safety Representative should: 11.2.1. Determine from the call from the technicians 11.2.1.1. A description of the problem; 11.2.1.2. Confirm the exposure area has been restricted; 14.2.1.3, If the technician(s) received or believe they have received an excessive dos 14.2.1.4, Is there an physical injury involved; 14.2.1.5. Details of the area; and 11.2.1.6. If additional personnel are needed to go to the site and provide assistance in controlling access the Restricted Area and stand-by to assist in the recovery 11.2.2. Notify the Radiation Safety Officer (RSO) of the incident providing all available details of the location, personnel involved, circumstances as reported, and measures taken, Based on the information received, the RSO or designated representative may provide specific instructions intended to minimize the radiation affected area. Under no circumstances should actions be taken to recover the source without approval by the RSO or designated representative. ‘The User Organization with the assistance of the RSO or designated representative will provide notification in accordance with the requirements of SAEP-1141 Following the completion of incident recovery activities, the User Organization with the assistance of the RSO or designated representative will prepare a full report of all relevant details in accordance with the requirements of SAEP-1141 Page 6 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE 12, Post Incident Actions 13. 124 12.2. 123, 124, 125, 126. 127. 128. 12.9, 12.10. 12.14 13.4 13.2. Assure that all data collected from the incident is complete and accurate Interview each individual member of the crew taking notes to reconfirm the extent of their involvement and scope of activity Compile dose data of all individual involved. Secure the equipment for transport back to the nearest storage center and make arrangements to forward to Dhahran All equipment involved in the incident is to be quarantined and not used for any reason without release from the RSO or designated representative. In accordance with Inspection and Maintenance procedure all equipment associated with the incident is subject to “Full Service" Collect TLD badges from all employees involved in the incident and submit to EPDIRPU for immediate processing. Contract the respective RSO for contract technicians to have TLD collected and processed, Any individual where there is a high dose determined or suspected, must submit to CBC Blood test within 24 hours of the incident occurrence. The resulting information to be retained for incident evaluation, reporting, and preventative measure determination. It may be necessary to reconstruct the incident in a time motion study to further evaluate radiation dose. Incident recreation is at the sole discretion of the RSO or representative and is not within the scope of this Work Instruction. Such recreation, if deemed necessary, must be conducted within the safety provisions of SAEP-1141 and GI-150.003 If injury occurred, but immediate attention was not deemed necessary, affected individuals should go or be taken for medical attention, Refer to SAEP-1141 regarding reporting requirements, . Incident Root Cause Analysis It is the responsibility of the RSO or designated representative to identify root cause. ‘The methods used for this identification is at the sole discretion of the RSO and may include additional interview of all persons involved, recreation of the incident, dose evaluation of individuals, etc. All incidents have a root cause and must be identified. The User organization is responsible for all reports associated with Root Cause and/or Lessons Leamed, Root Cause analysis begins at the initial incident assessment. Accordingly, attention to recording/logging interview information, sequence of events, and retrieval and/or Page 7 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDE 'T EMERGENCY RESPONSE 13.3, 13.4, corrective action is essential. The format of such notes is at the sole discretion of the RSO or designated representative Caution must be exercised not to focus solely on the technicians and their actions, Most often there are contributive causes that are related to the implementation of Management Controls. Include Incident Root Cause as well as any identified secondary causes in the report. 14, Identify Preventative Measures. As improvements to equipment, procedures, and training continue, the occurrence of incidents has significantly reduced which gives clear evidence that Incidents are preventable. It is essential, when incidents do occur, lessons are leaned and measure taken to assure an incident is not repeated. Communication of the events is essential to prevention. The details of an incident should be included in technician safety meetings, training, etc. and other means of conveying the information, 415. Injuries Given the nature of the radiation sources used in Industrial radiography, incidents associated with Industrial Radiography do not typically involve injuries unless there is a direct contact with the source or, for extraordinary reasons, there is a prolonged exposure in close proximity. Industrial accidents such as falls, trips, or hazardous interaction with other equipment may contribute to a radiation incident. Though potential radiation levels could be high (in relative terms), typical dose levels associated with sources normally used in Industrial Radiography (e.g. Ir-192 and Co-60), can easily be controlled with minimal distances and maintaining as short of time as possible in the immediate area. 15.4 15.2. 15.3. ‘Advise the RSO of the situation and circumstances of the incident to determine, if possible, that the source can be moved. However, such action must not impede Tendering aid to the injured personnel, further complicate the retrieval process, or give cause to excessive radiation dose to the respondent or injured. Do not allow fear of a radiation dose to impede giving vital “First Aid” to injured Persons. Attempt to move the person from the immediate area, but not before rendering life sustaining “First Aid’ (e.g. control of bleeding, CPR, breathing, etc.) where required. 15.2.1. Stabilize individual and assure individual is capable of movement form the affected area 15.2.2. Give special caution to possible back and neck injuries as movement of the victim without proper training and equipment could lead to substantially greater life altering injuries, If it is determined that the injured person cannot be safely moved from the radiation area, review the surrounding area to locate material, equipment, etc. that can be Page 8 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE moved between the victim and the source of radiation to serve as shielding. Under the explicit n of the RSO, cover the source, if the location is know, to reduce radiation levels. \cidents Involving Fire For incidents involving fire, call the emergency number 110 or 998. The design of radiographic exposure devices and type “B(U)" transport containers used for shielding and transporting industrial radiographic address extreme conditions including exposure to fire though there are design limits. Though unlikely, contamination could occur associated with fire emergencies, 16.1. Do not attempt to enter and area where there is either an ongoing or immediate danger of fire. Get out, keep away, and call for help. It is better to keep away and be available to assist properly equipped and trained emergency responders than it is to be a potential victim 16.2. Make sure the proper authorities such as Security, the Police, and firefighters are Notified of the addition risk posed by the existence of a radiation source. 16.3. Provide details regarding the conditions of the source, location, exposed or shielded, ete. 16.4. Contact the RSO in order that he can respond and assist in recovery efforts and to initiate @ retrieval of the source in associate with the firefighters. 17. Incidents Involving Contamination The scope of radiation sources used for Industrial Radiography is limited. The most common use is encapsulated sealed radioactive material such as Iridium-192 and Cobalt- 60. To a lesser extent, electrically generated sources (e.g. x-ray tube and linear or betatron accelerators) are used. Electrically generated radiation sources used for Industrial Radiography pose no contamination hazard. It is extremely unlikely that issues of contamination are involved with the sealed radioactive material used for Industrial Radiography. In addition to the provisions of this Work Instruction and instructions associated with the Incident Type (other than contamination), the RSO must take into consideration additional requirements of the National Regulations related to contamination where such conditions are suspected. RSO (RPO) personnel typically involved in Industrial radiography are not trained in dealing with issues of Contamination. If the potential of contamination is identified, the RSO must immediately contact the Environmental Protection Department, Radiation Protection Unit for guidance. Should a condition of contamination be suspected, the RSO or designated should take the following actions (under the direction for EPD/RPU) prior to retrieval efforts. 17.1. Define the Exclusion Area (area of potential or actual contamination) 17.2. Control of access Page 9of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE, 17.3, 174, 17.2.1. Establishment of barriers 17.2.2, Secure the assistance of other personnel such as Security, Police, and Firefighters Establish preventative measures to protect personnel in the Exclusion Zone (Contamination) 17.3.1. If contamination is suspected, do not enter or allow others to enter the affected area and/or facility without additional PPE (e.g. protective clothing, respirators, etc.) as directed by EPD/RPU for personnel in the Exclusion area. The relevant Company and/or Regulatory authority must be involved to determine required PPE in the event of contamination. 17.3.2. Contamination Control (in general) 17.3.2.1. Fire fighting to avoid use of water 17.3.2.2. Control of entry/exit of personnel for possible decontamination 17.3.2.3. Control of vehicles and/or equipment 17.3.2.4, Prohibit foods and drinks in the restricted area or potentially contaminated 173.25. For structures, buildings, rooms, etc. affected by potential contamination, assure that all personnel are evacuated and there wherever possible, seal off the room until an effective decontamination plan is established. 17.3.2.6. Attention must be given to wind direction and speed when Particulate contamination is suspected. Approach to the affected area, when necessary, must be “cross-wind” to the wind direction to minimize personnel contamination 17.3.2.7. Persons involved in the incident or those responding, may be contaminated. Decontamination under the direction of a Health Physics professional is required. Refer to EPD for assistance. The process may include, among others: 1.1.1.1. Removal of contaminated clothing at the site ‘* Remove of contamination to skin ‘+ Address internal contamination of individuals to take necessary medical actions ‘Contamination control and remediation under the direction of EPD/RPU, the National Regulatory Authority, or the assigned personnel having training and experience in Health Physics, particulate contamination, and methods of personnel protection for contamination issues will assist in directing efforts for the retrieval of the radiation source. Page 10 of 38Document Responsibility: Inspection Dept. RSO Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 Inspection Department RSO** 7.0-WI-26-OID/CNTD&PSU RADIATION SAFETY INCIDENT EMERGENCY RESPONSE EMERGENCY CONTACT Northern Area Radiation Safety Representative Altemate Southern Area Radiation Safety Representative Alternate Central Region Area Radiation Safety Representative Alternate Western Region Area Radiation Safety Representative ** Note: Contact number sted directs to both Office and Cell Phone RELATED EMERGENCY CONTACT Ambulance Fire Security By Cell Phone: 110 or 997 110 or 998 110 or 998 Central Area Southem Area: Northern Area : Central Region’ Western Region’ (03) 872-0415 / (03) 872-0233 (03) 673-7818 / 055-588-6833 (03) 673-7462 / 050-481-8515 (03) 572-2483 / 050-585-0285 (03) 572-2363 / 050-592-6242 (01) 285-1510 / 053-190-1991 (01) 285-1516 / 056-752-8503 (02) 427-3864 / 050-482-3427 03-872-0110 03-572-0110 03-673-0110 01-285-0110 02-427-0110 Page I1 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE. Attachment 1 INCIDENT TYPE ASSESSMENT 1. Initial Assessment 14 12 13, 14, 15, 16 17. ‘The RSO or designated representative shall conduct an assessment of the incident type. Initial assessment begins with the notification received in order to determine Potential equipment required to address the incident. Confirm the location of the source and if a retrieval is required. With the safety improvements to equipment and procedures, not all incidents involve source retrieval. The most common incident is where the technicians encounter an issue and initial actions retumed the source to its shielded container. Once on site, technicians should be interviewed separate, if possible, keeping notes of the information received, Survey and observe the physical conditions of the site and circumstances to verify the information received from the interview. Clarify any obvious differences. ‘Secure, but an Incident has occurred 1.5.1. Confirm that the source is secure in the Radiographic Projector and that all radiation levels are within permissible limits. Maximum T-Index for radiographic projectors is 10 with a maximum surface radiation level not to exceed 2 mSvihr (200 mRem/nr), 1.5.2, Inspect the physical condition of the projector to assure that it is safe to transport 1.5.3, Refer to Dosimetry Data Collection is not Secure, 2 continuous radiation exposure exists, 1.6.1. Steps determined necessary in the retrieval process must take into consideration control and minimizing radiation dose to the team members. Careful attention to balance dose among members will assure that no one individual reaches a high dose level. While the regulator limits of individual ‘occupation radiation dose is 20mSv/year, much lower dose levels are easily achievable through careful planning. A target maximum for the typical industrial radiography related incident should not exceed 2mSv (200 mRem) 1.6.2. Every step of the retrieval process must take into consider successive steps to assure that any step taken does not inhibit the next step. More than often failure to fully consider the consequence of particular step in the retrieval process could lead to further complications and the risk potential During the initial assessment, identify all equipment (e.g. guide tubes, controls, etc) and that instructions are given to quarantine the equipment for further inspection and investigation. 2. Radiation Dose Data Page 12 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT IERGENCY RESPONSE Along with the initial assessment, the RSO or designated representative must collect dose data from technicians involved as well as responding personnel. It is the RSO or designated representative's sole discretion as to the method and format of data collection to be used. Every incident has its unique circumstances. The format of data collection must take into consideration the complexity of the incident encountered. Data may be collected and recorded in a simple log listing personnel, their identification, initial dose, and for those involved in retrieval, completion dose. For complex retrievals, tables similar to or the same as the attached example may be used. The principal goal of Dose Data Collection is to assure control over actions taken and anticipation and minimization of collective dose. 3. Incident Type Assessment - Classification Operational incidents typical to Industrial Radiography typically fall into two major categories; Excess Radiation Dose andior loss of immediate control of the source, 3.1. Qperational_Incidents typical to Industrial Radiography fall into two major ‘categories; Excess Radiation Dose and/or loss of immediate control of the source. Provided the technicians have maintained proper use of the Radiation Survey Meter, it is not uncommon that an incident has occurred where there is a look of immediate control of the source and there is no excess radiation dose involved. ‘© Excessive Radiation Dose Failure to use the Survey Meter Operational Error ‘+ Loss of immediate control of the Source Source Hang-Up Short radius bend(s) in the Guide Tube Premature trip of positive locking device Source/Control Cable Misalignment Source Disconnect Source disconnect between the source assembly and control cable ‘Source encapsulation damage Equipment Malfunction/Damage Damaged guide tube Jammed controls 3.2. Associated Cause Incidents are those related to the radiography task, but not part of the operational sequence. These include: ‘* Lost or Stolen Projector (Radiographic Exposure Device) * Transportation related accident © Fire in the area where radiography is being performed Page 13 of 38Document Responsibility: Inspection Dept. RSO 7.0-W1-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE Attachment 2 INCIDENT TYPE REMEDIATION Retrieval Preparation - Plan Preparation for retrieval is mandatory for a safe and successful resolution of an incident. Planning is the most essential component. The overall retrieval process can take many hours with planning and preparation requiring the greatest time. The actual recovery of the source can be as brief as a few minutes to even seconds for a properly planned retrieval. ‘The number of members of the retrieval team is in direct proportion to the complexity of the incident. The more steps involve and hence close proximity to the source, the greater the number of participants, the less radiation dose to each is encountered. Retrieval can be accomplished safety and with minimal dose well within both safe and administrative low levels. Remedial actions defined in the Work Instruction attachments are RECOMMENDATIONS. The RSO or designated representative has the authority to modify any step deemed necessary as mandated by the actual circumstances encountered. It is essential that authority not be divided to avoid conflict and confusion. The responsible RSO or designated responsibility maintains the final authority for the retrieval 1. Plan 1.1. Review the parameters of the incident and identity the type. 1.2. Review the instructions associated with the incident type and identify the steps necessary with the specific circumstance of the incident involved. 1.3. Methods of addressing and resolving an Incident must take into consideration efforts to: 1.3.1. minimize radiation exposure to participating personnel, 1.3.2. avoid collective dose 1.3.3. 8 preventative measure, employ basic radiation protection concepts of: © Control of Time * Maximize Distance * Take advantage of existing shielding and, where possible, additional shielding. 1.4. Determine the level of radiation by calculation based on the reported activity of the source and confirmation by used of the survey meter. Remember that surrounding ‘obstacles may be shielding the source and movement of the equipment during the retrieval process may result in higher levels than confirmed with the survey meter. 1.5. _ Estimate the time required for each step and the distance from the source. Page 14 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNID&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERG! NCY RESPONSE 2 16. 17. 18. 19, With the radiation level and distances required known, prepare a table to define the maximum stay time for anticipated dose levels. A chart with standard distances may be used. These distances should included: + 3'— shortest distance one should ever be in proximity of an unshielded source. * 6'— typical distance from the projector to the source stop taking into consideration positioning bends of the guide tube + 12'-reasonable distance to handle the weight of a projector and/or channel shielding block with ropes. Observe and review obstacles such as structures, equipment, ete. in the area of the incident and assure that the plan for safe approach and handling takes into consider possible hazards. If the equipment/source is at an elevated location, the retrieval plan should take into consideration relocation to ground level if at all possible. Source retrieval at ground level is much easier to control and overall radiation levels are lower for associated retrieval steps. Review the steps with retrieval team members. Practice is necessary for complex steps to assure proficiency and expedient completion, Assign the different steps to the team members with the estimated step completion time and maximum stay time noted. Assure a balance of dose in the assignment of steps to be completed by each member. Given that the team members are likely of both National and International origin review and agree upon units of measure to be used. Assure that all members are comfortable with the units and that radiation survey and monitoring equipment in the required unit is used. Plan Execution 24 22. 23. 24, Log dose levels for each member before and after each step the individual is involved in. Monitor the dose levels and the plan to assure that expected levels are not exceeded. If this occurs, step back, reconsider the plan and reevaluate the expected dose levels. It is not unusual that rebalancing of the dose among the members is necessary during the retrieval process. The goal is that all individuals involved complete the retrieval with as low a dose as reasonably achievable. Be prepared to adjust the plan for the unexpected. While all incidents follow relatively the same pattern for the incident type, each has their own unique circumstances. Document obstacles encountered and their impact on the plan. Page 15 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE 3. Source Location Techniques (The following are examples of deterring the loc n of the source. Regardless if one the following is used or the team members introduce a different ‘method, itis essential to a safe retrieval that the exact location of the source is known.) Do not attempt to recover the source without locating the precise position of the isotope. There are two basic techniques though the RSO may utilize other means. 34 32. 33. 34, Control Count ~ If the control is operable, use the number of rotations to determine the position of the isotope. One rotation of the control crank is equal to approximately 10" of isotope movement. High Energy Probe - Use a high-energy survey meter with the detector mounted on ‘an extended boom. This boom should be approximately three (3) meters or longer. Shielding — Using a lead sheet or block attached to ropes, drag the shield across the guide tube monitoring the radiation levels. A sudden drop in radiation levels indicates the location of the source. Note that this technique requires two people and that each end of the rope must be at least 3 meters long to minimize the dose. Positioning the source ~ If possible, push the isotope to the end of the guide tube so that it is positioned within the collimator. This will significantly reduce the radiation levels and provide a secure location of the source for the recovery. 4. EQUIPMENT 44 42. 43. Equipment requirement vary depending on the actual circumstances of the Incident. It is the responsibility of the RSO or designated representative to determine actual ‘equipment requirements, Caution must be given to the unexpected and not to allow pressure from others to ‘expedite retrieval without the equipment, tools, and materials necessary for a safe retrieval. Should unexpected complications occur requiring adcitional materials not readily available, suspend retrieval activities, minimize as much as possible the area affected by radiation, and secure whatever additional materials are required for a safe retrieval. Basic equipment/materials for incident response include: 43.1, Standard Personal Protective Equipment (PPE) such as hard hat, safety glasses, safety shoes and where retrieval is to be conducted as heights, safety harness. 4.3.2. Standard Dosimetry as required by SAEP-1141 including Radiation Survey Meter, Electronic Pocket Dosimeter, and TLD. 4.3.3, Remote handling tool(s) e.g. 3-meter CV Tongs 43.4. Additional Survey Meter with Dose monitoring capability Page 16 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE 435, 436. 437. 438. 43.9. Portable lighting either provided at the site or taken with the retrieval team. Small focus, high intensity flash light (torch) to aid in locating small ‘components, and pointer at night for discussion among the retrieval team. Binoculars, scope, or other devise to aid in close observation of incident circumstances, A mirror is often convenient for study of incident circumstances while positioned behind shielding It is realized that use of cameras in Saudi Aramco facilities is very tightly controlled. Attempt to gain permission for use of a camera. A camera will enable a quick pass of the affected area with minimal dose and subsequent close study of incident circumstances. Photographs taken will also aid in preparation of reports. 4.3.10. Refer to Incident Scenarios for recommended additional equipment. Page 17 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE. Attachment 3 INCIDENT TYPE REMEDIATION EXCESSIVE RADIATION DOSE SORCE RETURNED TO SHIELDED CONTAINER (PROJECTOR) The most common cause of excessive radiation dose is failure on the part of the technician to actively use the Radiation Survey Meter. This type of Incident offen does not require source retrieval as control of the source is maintained, yet due to not giving attention to radiation monitoring, the technician enters an area of High Radiation. Operational error(s) may contribute to an unexpected high radiation area, but having the Survey Meter in use at all time, easily avoids the potential of excess radiation dose 4. Incident Indicators 1.1. Technicians report that the incident occurred and that the source has been returned to the radiographic projector, or 1.2. Review of the technician's dosimetry has revealed a high radiation dose has occurred, or 1.3. _ Indirect report of an incident has been received. All rumors must be investigated. 2, Recommended Additional Equipment 2.1. No special equipment beyond the standard equipment defined in this Work Instruction is typically required except when the RSO or designated representative has identified recreation of the incident is required as part of the investigation. In such cases, the RSO or designated representative will identify any particular equipment up to and including the actual radiographic equipment involved 3. Typical Cause (Typical causes are provided as guidance in identifying actual cause, remedial action, and safely precautions. It is the responsibilty of the incident responders to give close attention to the actual details of the incident to accurately identify preventative measures.) 3.1. Failure to confirm full retraction of the source following a radiographic exposure 3.2. Sequential error whereby the technician(s) enter the exposure area without first retracting the source 3.3. Momentary source hang-up such as source/control cable misalignment whereby the source is temporality stuck at the entry of the projector. Note: this is an extremely rare event readily resolved by winding out the source to the guide tube source stop then retracting the source again. The potential of radiation dose occurs when the technicians attempt to resolve the incident himself without specific instructions from or involvement by the RSO or designated representative Page 18 of 38Document Responsibility: Inspection Dept. RSO 7.0-W1-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Updat Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE 34. Failure to adequately post waming signs and cordon off the Controlled Area and/or maintain constant observation of the Controlled Area and others enter the area without notice. 4, Remedial Action 44 42 43 44. 45. Collect Radiographer Permits from the technicians involved. Follow the instruction of this Work Instruction including such actions as interview of ‘the technicians involved, site visit, determination of the incident parameters, and Post Incident actions. Evaluate the potential of associated safety violations contributing to the incident. Refer to SAEP-1141 for actions associated with safety violations. ‘Take special precautions in dealing with the technicians. For reported incidents, every effort possible is to be taken to restore the individual to active work but only as permitted by the circumstances of the incident such as radiation dose. Should violations be involved, additional training and/or counseling may be sufficient as corrective action, but under no circumstance should be done as a disciplinary action. The technician will be the messenger to others and it is essential that incident reporting be supported and the technicians readily cooperative. Page 19 of 38Document Responsibility: Inspection Dept. RSO. 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE Attachment 4 INCIDENT TYPE REMEDIATION Loss of Immediate Control of the Source Source Hang-Up SORCE EXPOSED OUTSIDE THE SHIELDED CONTAINER (PROJECTOR) There are a variety of causes for a source hang-up in the guide tube. The most common is related to the position of the guide tube. Secondary and less common is a condition known as premature trip of the positive locking device. Recent changes in projector design have virtually eliminated this secondary cause. 4. Incident Indicators 1.1. The technician attempts to retract the source to the projector, but is not successful Radiation levels remain high in the immediate area 1.2. The number of rotations of the control is directly proportional to the distance of source movement in the guide tube. The source travels approximately 10° for each rotation. For a 7 foot guide tube, the number of rotations is approximately 8-1/2. The technician cannot complete the number or expected rotations. 1.3. The technician observes the position of the guide tube (from a distance) and notices a sharp radius bend. This may be from a loose fixture where the guide tube has fallen from it position during the radiograph. 2, Recommended Additional Equipment Typically, this type of incident is corrected by repositioning of the guide tube. For this in addition to the standard equipment defined in this work instruction, the RSO or Designated representative should have the following equipment 2.1. Source location devices including lead sheets, or extended probe source location survey meter. 2.2. Additional CV Tongs (3 meter) 2.3. Rope in the event it is necessary to reposition the projector. 2.4. In the event extraordinary measures are necessary, a channel shielding block, or lead shot bags, or lead sheets (less effective) should be taken to the site. 3. Typical Cause (Typical causes are provided as guidance in identifying actual cause, remedial action, and safety precautions. Iti the responsibilly of the incident responders to give close attention to the actual details of the incident to accurately identify preventative measures.) 34 ‘The technician positions the guide tube to excessive short radius bent. While it is not unusual that 2 source can pass through a short radius bend while exposing the source, retraction becomes difficut and either the cable or source can hang-up in the bend. Page 20 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE 3.2. 33, 34, 35. ‘Something during the course of the exposure has fallen causing a short radius bend the guide tube. The source stop was not adequately secured and during the course of the radiograph and came loose causing the guide to drop and form a short radius bend, ‘A rare combination of the rotational orientation of the connector between the source and control cable and sharp bend of the guide tube adjacent to the projector has caused a momentary misalignment of the connection between the source and control cable. The positive lock leaver was not fully engaged to release the source for a radiographic projector. This potential increases with poor maintenance of the projector, but with recent safety improvements to the equipment design, is very rare. As the source is exposed, vibration from the cable movement causes the incompletely engaged positive locking lever to slide partially or completely to the "Secured" (green) position Remedial Action 44 42 43 44 45, 46 Attempt to expose the source and then retract. Multiple movement of the source cable in the guide tube may be sufficient to straighten a bend enough for the source assembly to pass and retracted back to the projector. If unsuccessful, attempt to push the source to the collimator where the overall radiation levels will be reduced Using the source location method, confirm the location of the source. If itis determined by observation that the obstruction to movement is caused by the position of the guide tube, reposition the guide tube using 3-meter CV Tongs to loosen any bends. If the guide tube appears to be relatively straight except adjacent to the projector, then using CV-Tongs to position both the projector and the guide tube may be sufficient to correct orientation of the source connection in the guide tube. While dealing with the projector, it is a good idea to pass a rope through the handle to enable further repositioning and if necessary relocation of the equipment without the necessity of an unnecessary close approach to the projector. The preceding steps are effective in resolving a source hang-up where there is no damage to the guide tube. More extraordinary measures may be necessary that requires positioning of channel shielding block over the guide tube. This will provide an opportunity for more substantial shielding of the source within the guide tube. ‘Once the block is in place, there are two options to position the source within the shield 46.1. With rope attached to the channel shielding block, pull the block along the guide tube length until the radiation levels reduce significantly; or 4.6.2. If movement of the block is obstructed, use the rope passed through the handle of the projector to pull the projector and hence the guide tube under the channel shielding block to shield the source. Page 21 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE 46.3. 46.4, 465. It may be necessary to relocate the projector/control/guide tube assembly using the rope passed through the handle of the projector. Care must be given not to damage the control or control cable housing thus further complicating the retrieval ‘Once the source has been shielded and radiation levels at the projector confirmed to be within stay-time limits, further examination of the guide tube is possible that may reveal damage. If damage is identified, refer to the retrieval instructions for "DAMAGED GUIDE TUBE” After the source is secured in the projector, proceed to Post Retrieval actions. Page 22 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Update: Jan, 2016 RADIATION SAI 'Y INCIDENT EMERGENCY RESPONSE Attachment 5 INCIDENT TYPE REMEDIATION Loss of Immediate Control of the Source Source Disconnect SORCE EXPOSED OUTSIDE THE SHIELDED CONTAINER (PROJECTOR) Once a fairly common incident, safety improvements to the source to control cable connection land selector hub tolerance changes to the Projector have virtually eliminated this type of incident. Nevertheless, no matter how unlikely this incident type will occur, the potential remains as long as the technique of radiography involves the movement of the source from the projector into a guide tube, 1. Incident Indicators 14 12, The technician attempts to retract the source to the projector, but there is no change in the radiation level or as the source disconnected from the control cable moves by gravity from the collimator there is an increase, but no subsequent decrease as the number of rotation of the control is complete. The controls move easily and when the number of rotations required to retract the source is complete the positive lock indicator remains in the "Unlocked" position. 2. Recommended Additional Equipment In addition to the standard equipment defined in this work instruction, the RSO or Designated representative should have the following equipment: 24 22 23. 24. 25, Source location devices including lead sheets, or extended probe source location survey meter. Additional CV Tongs (3 meter) Rope in the event itis necessary to reposition the projector Emergency shielded container for temporary placement of the source: 2.4.1, Spare projector with black bayonet plug for the projector exit port or; 2.4.2. Source Changer or; 2.4.3. A designed for purpose retrieval shielded container Note: It may be necessary depending on the condition of the incident projector to use the temporary shielded container for transport of the source. If this becomes necessary, the selected container must be a certified Type B(U) device for transport on public roads. ‘Small sheet of plywood, heavy canvas or other material that can be used to place on the ground in the event the “Drop and Recover’ technique described below is used. Page 23 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE 3. Typical Cause (Typical causes are provided as guidance in identifying actual cause, remedial action, and safety precautions. It is the responsibilty of the incident responders to give close attention to the actual details ofthe incident to accurately identify preventative measures.) 3.1. The source connector assembly is damaged either physically distorted or by the presence of dust or debris preventing the inner locking sleeve to engage and secure the connection to the control cable. 3.2. Upon making the connection, the technician did not perform and “shake” test to assure the connection is secure. 4. Remedial Action 4.1. Using the source location method, confirm the location of the source. 4.2, Chase Cable Technique 424 4.2.2. 4.23. 4.24. 4.25. 426. 4.27. 4.28. Carefully retract the control cable monitoring the radiation levels at all time, Any indication of increase of radiation is an indication that the cable may be Partially or completely connected and that the type of incident has been miss- classified. If there is an increase in radiation, slowly push the control in the exposition to return the source under the shielding. Retract again and if there is, again, an increase in radiation, reclassify the incident. With the source shielded, disconnect the front-end tube from the projector. Move into place a second exposure device to be used as a recovery projector ‘and install the front-end tube. Using a U-tool, rotate the operator ring to “Operate” without controls attached ‘and engage the positive lock. Insert the chase cable until it stops at the source connector and attempt a connection While monitoring the radiation levels, slowly pull on the chase cable to Getermine if the isotope has connected. If there is an increase, the source is connected. Move away from the recovery projector holding the end of the chase cable ‘and pull carefully to bring the isotope into the recovery projector without forcing a disconnect. If the isotope becomes disconnected, it will be necessary to re-shield and try again. Do not attempt to use the chase cable to push the isotope. It may be more effective to revert to the “Drop and Recover" technique. 4.3. Drop and Recover 434 43.2 Carefully retract the control cable monitoring the radiation levels at all time. ‘Any indication of increase of radiation is an indication that the cable may be partially or completely connected and that the type of incident has been miss- classified If there is an increase in radiation, slowly push the control in the exposition to retum the source under the shielding. Retract again and if there is, again, an increase in radiation, reclassify the incident. Page 24 of 38Document Responsibility: Inspection Dept. RSO 7.0-W1-26-OID/CNTD&PSU Issue Date: January 25, 2011 Next Planned Update: Jan, 2016 RADIATION SA‘ 'Y INCIDENT EMERGENCY RESPONSE 4.3.3. With the source shielded, disconnect the front-end tube from the projector. 4.3.4. Onoe the front-end tube is disconnected, use a pair of CV Tongs — minimum 2m, pull the guide tube from under the shielding and shake the source onto the ground. Monitor close dose during this operation. 4.3.5. If there is sufficient stay-time left, grab the isotope connector with the CV Tongs and insert into either a recovery pot, front end of a spare exposure device (isotope end first) or transport pot. Before doing this, securely attach a funnel (either a plastic formed funnel or one made of rolled card weight paper) to the opening port of the recover pot to aid in inserting the source. 4.3.6. Before proceeding, inspect the connector and spring clip to assure that it is undamaged and not the case of the incident. 4.3.7. With another exposure device with controls attached, connect to the source and install in the usual manner. 4.3.8. After the source is secured in the projector, proceed to Post Retrieval actions Page 25 of 38Document Responsibility: Inspection Dept. RSO 7.0-WI-26-OID/CNTD&PSU Issue Date: January 25, 2011 ‘Next Planned Update: Jan, 2016 RADIATION SAFETY INCIDENT EMERGENCY RESPONSE Attachment 6 INCIDENT TYPE REMEDIATION Loss of Immediate Control of the Source Source Disconnect - Encapsulation Damage SORCE EXPOSED OUTSIDE THE SHIELDED CONTAINER (PROJECTOR) This type of incident has occurred only once in the history of radiograph on Saudi Aramco property. It substantiates the necessity for the RSO or designated representative and the retrieval team to be aware of the impact the unexpected can have. Once a fairly common incident, safety improvements to the source to control cable connection and selector hub tolerance changes to the Projector have virtually eliminated this type of incident. Nevertheless, no matter how unlikely this incident type will ocour, the potential remains as long as the technique of radiography involves the movement of the source from the projector into @ guide tube 4. Incident Indicators 1.1, The technician attempts to retract the source to the projector, but there is no change in the radiation level or as the source disconnected from the control cable moves by gravity from the collimator there is an increase, but no subsequent decrease as the ‘number of rotation of the control is complete. 1.2. The controls move easily and when the number of rotations required to retract the source is complete the positive lock indicator snaps and indicated that the source is secured in the projector. The component that initiates this indication is a “stop ball’ at the connector end of the source assembly. Even though the source is loose in the guide tube, the projector will function normally because the source assembly cable is still attached to the control cable. 2. Recommended Additional Equipment In addition to the standard equipment defined in this work instruction, the RSO or Designated representative should have the following equipment. 241, Source location devices including lead sheets, or extended probe source location survey meter. 2.2, Additional CV Tongs (3 meter) 2.3, Rope in the event it is necessary to reposition the projector. 2.4, Emergency shielded container for temporary placement of the source. For this type of retrieval, do not use a spare projector as it will not be possible to force 2 loose source capsule in the optimum shielded position of the projectors “S" tube. 2.4.1. Source Changer or, 2.4.2. A designed for purpose retrieval shielded container Page 26 of 38