IAEA培训材料_近年放射性事故分析 .pptxVIP

Module 2.10: Accident update – some newer events (UK, USA, France);Questions;Overview;Overview;1st example: Incorrect manual parameter transfer (UK);Background;Background;Background;Background;Background;What happened?;What happened?;What happened?;What happened?;What happened?;“Planner X” calculated another plan of the same kind and made the same mistake This time, the error was discovered by a senior checker (1st of Feb ‘’06) The same day, the error in calculations for Lisa Norris was also identified;The total dose to Lisa Norris from the Right and Left Lateral head fields was 55.5 Gy (19 x 2.92 Gy) She died nine months after the accident;;References;2nd example: Reversal of images (USA);What happened?;What happened?;;References;3rd example: Inappropriate measuring device (France);Background;Background;What happened?;What happened?;BrainLAB discovered that the measurement files did not match up with those at other comparable centres, during a worldwide intercomparison study It should be noted that the company does not validate or hold responsibility for local measurements or implementation;Impact of accident;;References;4th example: Erroneous calculation for soft wedges (France);Background;Background;Background;What happened?;What happened?;What happened?;What happened?;What happened?;Details not clear, BUT: it might have been when MU check software was replaced and updated to be able to handle independent checking of dynamic wedges.;Impact of accident;Information following accident;Information following accident;;References;Postscript to accident in Epinal;5th example: Incorrect IMRT planning (USA);Background;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;What happened?;Discovery of accident;;[Treatment Facility] Incident Evaluation Summary, CP-2005-049 VMS. 1-12 (2005