Senator LUDLAM-Thanks very much for coming in. I have a couple of questions regarding health and safety standards at ANSTO and in particular at ANSTO Radiopharmaceuticals and Industrials, ARI. First, could you briefly explain for us to the relationship between ANSTO and ARI?
Mr Adrian Paterson-ARI is one of our business units which is fully embedded in ANSTO, so it is directly under the control of the executive management structures of ANSTO.
Senator LUDLAM-I understand that an audit arising from an investigation of an event that took place in August 2008 found that there were deficiencies and opportunities for improvement in the safety management systems at ARI. Can you confirm that for us?
Dr Adrian Paterson-An audit was undertaken and there was a finding that we could improve the reporting of incident management.
Senator LUDLAM-We will go to that in a moment. I just want to have you talk through the details of the incident in question. My understanding is that it involved a vial of molybdenum-99 being dislodged from manipulator grips, presumably in one of the hot cells in the plant, which was then left where it had dropped and remained unreported for several hours exposing workers to radiation. Is that a correct characterisation of the incident?
Dr Adrian Paterson-I think that the wording that you have used is similar to wording that I have seen in the reports that I have reviewed but not identical.
Senator LUDLAM-I am not after the wording-is that an approximate description of the incident?
Dr Adrian Paterson-I think ‘several hours' would be something that I would have to go back and take on notice. There was a period of time where that vial was dropped and it was not timeously reported.
Senator LUDLAM-My understanding is that it was roughly three hours. But if your understanding is different, then if you could take that on notice for us, I would appreciate that. The audit found that proper processes were not followed: evacuation of the area did not occur, timely communication and event reporting, thorough investigation and follow-up did not occur. Is that your understanding also?
Dr Adrian Paterson-I think that that is a fair summary.
Senator LUDLAM-Is it the case that one of the staff present during that incident handling radioactive substances had not completed occupational health and safety induction training or the one-day radiation safety course, nor the ANSTO or ARI induction check lists?
Dr Adrian Paterson-I will take that on notice.
Senator LUDLAM-Is that because you are not aware of whether that is the case?
Dr Adrian Paterson-In the reports that I have seen, that has not been part of those reports.
Senator LUDLAM-So would it be surprising to you if there was somebody working in that environment who had not completed all those safety checks?
Dr Adrian Paterson-Yes.
Senator LUDLAM-What is ANSTO or ARI's policy about staff working in those environments?
Dr Adrian Paterson-The policy construct is very clear: all radiation workers have to be trained to the level of understanding the radiological situation in which they operate, the attendant risks, the mitigation of those risks, and the safe working procedures that are attendant to the normal operation of the plant.
Senator LUDLAM-Okay, that sounds sensible. How long has that plant been in operation for?
Dr Adrian Paterson-It has been operating of the order of 30 years.
Senator LUDLAM-So it would be very surprising, I suppose to both of us, if there still were not procedures in place that prevented people who had not had adequate radiation safety training from entering those areas of sources?
Dr Cameron-If I could just explain: the system we use at ANSTO is that each area is assessed for potential exposure and is therefore classified according to that. So a blue area or a white area, et cetera, indicates its potential for exposure. Therefore for each of those areas, given its classification, measures will be put in place to detect and monitor those areas for radiation. In addition, workers who go into those areas will be trained for working in those areas, and in addition they themselves will have personal monitors so that their radiation exposure is monitored and checked each month.
Senator LUDLAM-We will come to that in a moment. So the area that I am describing where this incident occurred, what is the classification of that as far as the different degrees that you are talking about?
Dr Cameron-It would be a blue area.
Senator LUDLAM-Blue is-
Dr Cameron-A white area is essentially an uncontrolled area and the blue area is our next level of control.
Senator LUDLAM-What is the highest level?
Dr Cameron-The highest level would be a red area, but red areas would be where people would not be allowed to go in.
Senator LUDLAM-Where human beings may not go. So blue is a hazardous workplace. How does somebody who has not completed that degree of radiation safety training find their way into an area like that?
Dr Cameron-There could be a number of ways. Generally what would happen is that in the course of their training they would be supervised by somebody else when they go into an area to be instructed in how it works. So people who are not fully qualified or certified for the areas would be escorted or supervised while they are there. They also would have personal monitors.
Senator LUDLAM-Dr Paterson has asked to take that question about that person's presence in that area on notice. Is that something that you are aware of though? Were you aware that in that incident there was somebody in that area who had not had the training?
Dr Cameron-I am not aware that that was the case but, as we said, we are happy to investigate further.
Senator LUDLAM-Thank you. Is it correct that the EPDs, the dosimeters that your staff use when they are in those areas, are not located on a part of the body that could have been affected by this incident? My understanding is the source was actually placed at quite a low level meaning at least one worker received a dose that was not actually received because the badge is placed higher on his body. Where do workers wear those dosimeters?
Dr Cameron-There are two types of dosimeters. There is the TLD, which is like the old film badge, which they wear continuously. And then many of them will also carry an electronic personal dosimeter, an EPD, which gives instant readout of what is going on. Generally they will wear those either on the chest level or around about their waist level. If we do suspect that there has been an exposure from another level, then we are able to calculate from the angle and the dose received what the exposure should be. So we can revert to theoretical methods of calculating if the dose happened to come from a different part.
Senator LUDLAM-Because the radiation is not behaving like a gas or a vapour, is it, it is a beam; it is quite directional.
Dr Cameron-It can be a beam or but it diffuses quite quickly.
Senator LUDLAM-I understand that one of the recommendations that arose from this incident is that ANSTO investigate the design of equipment so that the vials cannot be dropped into inaccessible locations. Can you describe for us what has happened to the equipment that the operators in that part of the facility are using, whether there has been any redesign or whether the plant was shut down and the equipment was modified or replaced?
Dr Adrian Paterson-There have been a number of improvement activities. The specific incident was investigated, and mitigation actions have been put in place to reduce the likelihood of it happening again. In the reports that I have seen, the likelihood is now much lower but not completely excluded. We have a continuous improvement program which resulted in part as a result of this particular incident, and I meet weekly with that group of people. We are looking at all of the significant and important risks on a weekly basis. We are taking action on the highest priority ones and working down through that list.
Secondly, the incident reporting format has been changed. All radiological incidents that are dose related, with doses that are above normal daily levels, when these are identified as occurring they are reported to me on the same day that they occur. They are also reported to the general manager in charge of the facility. The incident reporting is now driven from a management perspective in a completely different way. In addition, we have changed the reporting mechanism to ensure that the radiation physics people, who do the calculations that Dr Cameron was talking about, are fully involved on the day of the incident and are able to fully assess all of the impacts.
In the case of this particular incident, the thesis that the dosimeters were not correctly placed to assess the dose properly and accurately has been found to be a faulty thesis. We do believe we know what the dose levels were and we do believe that the dosimeters were effective. This will be checked in the further review of the incident report by ARPANSA who have complementary knowledge which shall be able to validate this. So we had a similar concern that it may not have been able to take a full reading but we do not believe that that is the case any more.
Senator LUDLAM-Because it is not about incorrect placing, is it, that is where they are supposed to wear it. But if you are taking a dose that is below the belt then you will need tocalculate indirectly what the dose was.
Dr. Adrian Paterson-Yes. In this particular case the dosimeter readings were evaluated and the calculations were made, and the dose levels were not at a level that would have created significant concern.
Senator LUDLAM-I will just quote one of the recommendations back to you:
Levels of radiation and contamination and the associated reporting and investigation should be developed. For example, internal contamination and external contamination on the skin should always result in an event report being raised. Level of contamination on PPE and reporting levels for example 50 cps. This needs to be determined in conjunction with RPA.
Can you confirm for us that levels of radiation and contamination are not yet determined in that incident or do you have a fairly good idea of what actually occurred?
Dr Adrian Paterson-I think there is a pretty good idea of what happened in this incident. I can also say there have been a number of other incidents which are now reported, as I indicated, on the day that they happen. The process of evaluation has been considerably strengthened and is done in a much more timely fashion. It is absolutely essential that the radiological risks in that production facility are known in detail and timeously so we can mitigate any risks.
Senator LUDLAM-What I found the most difficult to understand was how, if this plant has been operating for 30 years, these procedures are only just being put in place in the last 12 months as a result of these sorts of exposures of staff?
Dr Adrian Paterson-The procedures have always been in place. I think the procedures have operated in a satisfactory manner and the long-range tracking of dose accumulation in workers has been very satisfactory. Over the last 10 years the dose levels to workers in that facility have come down continuously every year, and that trend is likely to continue. Therefore we do believe there has been an improvement in radiological performance. We are investigating the root causes of these recent incidents to understand whether it is to do with the training and supervision of staff or whether it is to do with defects in the facility. There are a number of theses that are being investigated. When that full assessment is complete I will be happy to report as to what we believe the root causes were and what actions need to be taken to mitigate future risk.
Senator LUDLAM-We might come back to you on that at the next estimates session. Can you confirm that a worker was taken out of the lab for 12 months due to a high-level dose incident occurring in April 2007 and can you describe for us the nature of that incident?
Dr Cameron-Yes, senator, that is the case. There are from time to time examples of where, when we read a badge, we find there is a reading that is more than what we would expect for that worker. In that case, our normal procedure is to do a full investigation and, in doing that full investigation, the worker is removed from the area while that goes on. In most cases we are able to show that it was not a real exposure to the worker. What we find sometimes is that a worker will leave a badge near a source and the badge will get exposed, and we are able to show that was not a real exposure to the worker. But in this particular case we were not able to be sure in a 100 per cent way that it could not have been an exposure to the worker. So as a precautionary thing we took the worker out of the area for the period of time. The reason that is done is that essentially the dose constraint we set is an annual one. We do not like people to exceed a dose constraint on an annual basis so to make sure that he did not he has to be out of the area for a 12-month period before he can come back in again.
Senator LUDLAM-I understand that. I am wondering if you can describe the nature of the incident for us though.
Dr Cameron-The incident was the determination of a high level on a badge. An investigation was done. The investigation indicated that it was most likely to have been due to placement of a badge next to a source and not an exposure to a worker, but we could not definitely rule out that was the case. The interesting thing was there was an inconsistency between the badge which showed a high reading and his EPD which did not. That would indicate that he probably did not receive that exposure but, as a precautionary action, we took him out of the area for 12 months.
CHAIR-Thank you, Senator Ludlam. I am sorry, we are out of time, Senator Barnett.