Reported radiation incidents

Since 2004, ARPANSA has been compiling statistics of reported incidents through the annual summary reports. ARPANSA analyses all incidents reported to the ARIR to understand why and how they occurred. Information from this analysis is published below to raise awareness about radiation safety in Australia.

Common radiation incidents in Australia

Good radiation protection practices are generally observed in Australia and consequently incidents are rare. The majority of incidents reported to the ARIR are low dose incidents which are unlikely to cause observable effects. Learn about the most commonly reported incidents to the database, and their primary and contributory causes.

Lessons learned from reported radiation incidents

From data submitted to the ARIR, ARPANSA has identified the following common themes and contributing causes of radiation incidents.

1. Lack of commitment to holistic safety

Many incidents resulted from organisations or businesses not adopting a holistic or systemic view of safety. For example, incidents have occurred even when the organisation has focused on procedures, interlocks and barriers. While these are important areas to consider in the management of safety, it is equally important to consider human and organisational factors. For example, many of the incidents may not have occurred had the organisation provided training to staff on how the interlocks worked and provided safer systems of work (e.g. using checkboxes, easier systems or protocols than handwritten notes). The lesson to be learned from these incidents is that, in addition to addressing technological issues, safety management needs to consider human and organisational factors and develop a safety culture in the organisation. Learn more about Holistic Safety.

Key Action:

What systems (organisational systems or technological systems) can be changed or modified to minimise the likelihood of error occurring?

2. Outdated inventory of plant and equipment

Many reported incidents have occurred because radiation sources were not identified or recognised as radiation sources or forgotten about (also known as orphan sources). Almost all lost, stolen or found sources were the result of the organisation not maintaining an adequate inventory. This resulted in the sources being inadvertently discarded, abandoned or not being protected by adequate security measures. The lesson to be learned from these incidents is to maintain an up-to-date inventory of all radiation sources and to label the sources appropriately.

Key Action:

Have you placed all radiation sources on your hazard or source inventory? Is the inventory up-to-date?

3. Inadequate communication, training and awareness of workers

Many reported incidents have occurred because staff training on how to use the source safely was inadequate. Other incidents occurred because of communication issues: workers were not informed of the presence or location of the radiation source, or were unaware that the source was being maintained. For example, a small Portable Density and Moisture Gauge was run over by a vehicle because staff were unaware that the apparatus was on the construction site. Subsequently, staff were exposed to radioactivity because they did not know that the apparatus they had come into contact with was radioactive. The lesson to be learned from these incidents is to ensure adequate staff training and efficient communication at all levels of safety management, particularly on the locations of radiation sources and risks associated with their use and contact. This is especially important for contractors who are unfamiliar with the site.

Key Action:

Have you trained and explained to staff and contractors the radiation hazards present in your facility or premises? Are they confident enough to advise others?

4. Inadequate maintenance of plant equipment

Reported incidents highlighted the importance of maintenance of the equipment. Shutters, shields, cables that held or enclosed the radiation source, and the ancillary equipment (such as computers) that operated the apparatus have malfunctioned, resulting in an inappropriate or unnecessary radiation dose to workers or patients. While some of these are spurious and unavoidable, in most cases, a more systematic approach to maintenance, conducted on a regular basis would have limited the number of these incidents. The lesson to be learned is to have in place an inspection and maintenance program and that it be followed for all radiation sources.

Key Action:

Do you have a scheduled maintenance program for all your sources? Is it being followed and undertaken?

5. Inadequate oversight, monitoring and review of activities

Reported incidents highlighted the importance of monitoring and oversight. Many reported incidents where workers did not follow procedures. In some cases, this may be due to complacency setting in with time; for example, because checks and balances built into procedures seem unnecessary. In other cases, it may be due to workers finding what are perceived to be better, more efficient ways of working without properly assessing or understanding the safety consequences of the change. In any such case, work methods tend to drift to less safe practices. This occurs across a range of industry sectors: medical incidents (e.g. not following the 'Five Rights' principle: right patient, drug, dose, route, time) and industrial radiography incidents (e.g. incorrect use of a survey meter when testing that the source has retracted properly into its housing). More frequent oversight and monitoring of how work is actually performed can reduce the number of incidents by ensuring that safety controls remain in place. The lesson to be learned is to make sure there is frequent oversight and monitoring of processes, operations and activities to maintain best practice.

Key Action:

When was the last time you oversaw or monitored the practices undertaken by your staff?