Radiation incidents

Radiation incidents... why report?

Radiation incident reporting in NSW serves the purpose of:

• encouraging situational awareness and fostering a radiation protection culture
• tracking overall incident trends to improve regulatory responses; and
• sharing the lessons learned with others to help prevent future incidents.

Under the Protection from Harmful Radiation Act 1990 and the Protection from Harmful Radiation Regulation 2025 employers are required to investigate and report radiation incidents.

Employers must:

1. report and investigate apparent radiation incidents
2. maintain a record of radiation incidents
3. 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 Incident Notification form that employers can use to report radiation incidents.

Definition of a 'radiation incident'

Duty to report and investigate apparent radiation incidents

Incident investigation details

Incident data collection

Register of incidents

Dose calculation

Faults or defects

EPA assessment and action

Clarification of reportable extravasation incidents

Definition of a 'radiation incident'

(1) A radiation incident is taken to have occurred if:

1. There is an unplanned or unexpected emission of, or exposure to a person of, radiation, including as a result of:
   • the spillage or leakage of a radioactive substance, or
   • damage to, or the malfunctioning of, an ionising radiation apparatus or sealed source device, and;
2. 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 incident are emissions due to spillage or leakage of a radioactive substance, or damage to a radiation apparatus.

(2) A radiation incident is also taken to have occurred if the use of the radiative substance, ionising radiation apparatus or sealed source device used for medical purposes results in one or more of the following:

• the administration of a radioactive substance for diagnostic purposes at an activity that exceeds the activity prescribed by  50% or more
• the administration of a radioactive substance for therapeutic purposes at an activity differing by 15% or more from the activity prescribed
• the administration of radiation from an ionising radiation apparatus or a sealed source device for therapeutic purposes which differs from the total prescribed treatment dose by more than 10%
• the administration of radiation from an ionising radiation apparatus for diagnostic purposes, other than in the course of delivering radiation therapy, in a quantity of 50% or more of the initial intended dose and results in a person receiving an effective dose of radiation of at least 1 millisievert
• the administration of radiation to the wrong person or to the wrong part of a person’s body and results in a person receiving an effective dose of radiation of at least 1 millisievert
• the administration of a radiopharmaceutical other than as prescribed that results in a person receiving an effective dose of radiation of at least 1 millisievert
• the administration of radiation for diagnostic or interventional purposes resulting in an unanticipated or unexpected observable acute radiation effect
• the unplanned exposure of an embryo or foetus to radiation that results in the embryo or foetus receiving an absorbed dose of radiation of at least 1 milligray.
   

Duty to report and investigate apparent radiation incidents

The person responsible for the regulated material must give written notice of the incident to the EPA. 

Particulars of the incident must include, indicating as far as possible:

• the place where it occurred
• the period during which the emission of radiation was uncontrolled (as far as it is possible to be determined)
• the area over which any radioactive substances may have been dispersed
• any steps taken to rectify the incident
• any personal injury or exposure that may have resulted
• assessment of the radiation dose that any person may have received as a result of the incident (note: dose calculation for certain incidents must be made by a medical physicist - see below)
• any steps taken to reduce the risk of a similar incident occurring in the future.

The person responsible for reporting incidents 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 incident, the best course of action is to report the incident to the EPA.

Reports should be provided through the online Radiation Incident Notification form.

Incident investigation details

Situational awareness

Through the investigation of an apparent radiation incident, licence holders are prompted to consider the following questions (based on the Australian Transport Safety Bureau investigation analysis model 2017):

1. what happened? What are the details of the incident?
2. how did an individual’s actions contribute to the incident?
3. why did the incident happen? Consider the context of the incident 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 incident reoccurring. 
 

Incident data collection

All incident 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 incidents 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 incidents

A person responsible for regulated material must maintain a record of all radiation incidents and provide these records to the EPA if requested. Details recorded for each incident must include:

• the place where the incident occurred
• the period during which emission of radiation was uncontrolled (as far as it is possible to be determined)
• 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 (note: dose calculation for certain incidents must be made by a medical physicist - see below)
• details and results of any medical examinations undertaken as a result of the incident
• particulars of the area over which any radioactive substances may have been dispersed
• particulars of any steps taken to rectify the incident
• the time at which the incident was reported to the employer
• the probable cause of the incident
• particulars of any investigations into the incident, including results of the investigations
• details of any steps taken to reduce the risk of a similar incident in the future.

Dose calculation by a medical physicist for certain radiation incidents

For the following types of radiation incidents, the dose estimate must be calculated by a medical physicist:

• the administration of a radioactive substance for therapeutic purposes at an activity differing by 15% or more from the activity prescribed
• the administration of radiation from an ionising radiation apparatus or a sealed source device for therapeutic purposes which differs from the total prescribed treatment dose by more than 10%
• the administration of radiation for interventional purposes resulting in an unanticipated or unexpected observable acute radiation effect
• the unplanned exposure of an embryo or foetus to radiation that results in the embryo or foetus receiving an absorbed dose of radiation of at least 1 milligray.

Note: a medical physicist has the same meaning as in the Code for Radiation Protection in Medical Exposure.

Faults or defects

On becoming aware that a fault may exist in any ionising radiation apparatus or sealed source device, the person responsible for regulated material must:

• immediately investigate the actual or possible apparent fault or defect
• if necessary, remove, replace or repair the apparatus or sealed source device
• as soon as practicable after, but within 7 days of, becoming aware of the actual or possible fault or defect, 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 incident 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 [email protected] or contact EPA Environment Line 131 555.

Extravasation incidents

An unplanned exposure to radiation resulting from an extravasation incident is considered a reportable radiation incident. This includes repeat contrast/CT scans arising from an extravasation.