Défauts de gestion des moyens de surveillance dosimétriques

Secteur industriel – Contrôles non destructifs
Défauts( organisationnels( et( techniques( de( gestion( des( moyens( de( surveillance(
dosimétriques(dans(un(environnement(de(travail(défavorable(
(
!"#$%&"''(%&)*(+&"+#")%+,&-./+0/"'
(
Circonstances(
&
1+&./)"2324(%&"+)(',."%3&%,&(+&/")%5./)"2324(%&"+,%.6"%++%+,&)/+'&(+%&%+,.%7."'%&72(.&
%8/9"+%.& )%'& 7":#%'& %+& /3(9"+"(9& )%& ;<& 99& )*=7/"''%(.& >("& +%& +=#%''",%+,& 7/'& )%&
./?2+'&@&)%&-2.,%&=+%.4"%A&B%'&7/./9:,.%'&(,"3"'='&'2+,&3%'&'("6/+,'&C&DE&FGH&;E&9IH&JE&'K&
3%'& ,".'& '2+,& $2."L2+,/(8& )(& -/",& )%& 3/& +/,(.%& )%'& 7":#%'& M,N3%'& 73/,%'OH& 3%& -/"'#%/(& )(&
./?2++%9%+,&%',&P&%+6".2+&;HQE&9&)(&'23A&
&
R2(.&(+%&$/(,%&,%+'"2+&)%&DE&FGH&2+&2S,"%+,&)%'&./?2+'&@&)T%+6".2+&QE&F%G&MDE&8&UVJOA&
&
I7.:'& "+',/33/,"2+& MS/3"'/4%H& 72'","2++%9%+,& )(& ,(S%& %,& )(& 7(7",.%H& .=43/4%'AAAO& 3%'& ,".'&
#299%+#%+,K&3%&./)"2324(%&%,&'2+&/")%&72.,%+,&3%(.'&)2'"9:,.%'&M27=./,"2++%3&%,&7/''"-O&
P&3/&72",."+%A&
&
W+&73('&)%&3/&3(9":.%&)%&'"4+/3"'/,"2+&"+,."+':>(%&/(&7(7",.%H&(+%&3/97%&-3/'$&>("&'%.,&)%&
,=92"+&72(.&3*=9"''"2+&)%'&./?2+'&@&%',&#2++%#,=%&/(&7(7",.%&%,&72'","2++=%&P&7.28"9",=&
)%&#%3("5#"H&#%7%+)/+,&3T"+,%.6%+,"2+&'%&)=.2(3%&%+&%8,=."%(.&%,&3T"+,%+'",=&3(9"+%('%&)(%&
/(&'23%"3&.%+)&)"--"#"3%9%+,&7%.#%7,"S3%&3/&3/97%&%,&3/&3(9":.%&)%&'"4+/3"'/,"2+A&X%&73('H&#%&
Y2(.53PH& )%'& ,./6/(8& S.(?/+,'& M9"'%& %+& 73/#%& )T(+& S/.)/4%& 9=,/33">(%O& '2+,& .=/3"'='& P&
7.28"9",=&P&3T/")%&)T(+%&)"'>(%('%&%,&.%+)%+,&"+/()"S3%'&3%'&'"4+/(8&'2+2.%'&=9"'&)%7("'&
3%&7(7",.%&%+&)=S(,&%,&-"+&)T=9"''"2+&)%'&./?2+'&@A&
&
B%'& )%(8& "+,%.6%+/+,'& '2+,& ,2('& 3%'& )%(8& /(& 7(7",.%& 7%+)/+,& 3T=9"''"2+& )%'& ./?2+'& @&
M-"4A&;OA& Z3& %',& P& +2,%.& >(%& 3%& 7(7",.%& %',& =>("7=& )*(+%& 9"+(,%."%& >("& #2(7%&
/(,29/,">(%9%+,&3%'&@&/7.:'&3%&,%97'&7.24./99=&%,&>("&/(./",&)2+#&)(&[,.%&#2+,.N3=%&
7/.&3%&./)"2324(%&/6/+,&)%&'%&)=73/#%.A&&
&
I6/+,& 3/& -"+& )%& 3*=9"''"2+H& 3*/")%5./)"2324(%& '%& )=#/3%& 6%.'& 3/& ).2",%& M-"4A& UO& %,& 3%&
./)"2324(%&"+,%.7.=,/+,&#%&92(6%9%+,&#299%&=,/+,&3/&-"+&)%&3*=9"''"2+&&)%'&./?2+'&@&'%&
)"."4%&6%.'&3%&,(S%&/-"+&)%&.=#(7=.%.&3%&-"39&M-"4A&JOK&3*/")%5./)"2324(%&3%&'(",H&./)"/9:,.%&
%+&72#$%&M-"4A&QOA&&
&
B%&./)"2324(%&-/",&3%&,2(.&)%&3/&7":#%&P&./)"24./7$"%.&/-"+&)TN,%.&3%&-"39H&/32.'&>(%&3*/")%5
./)"2324(%& '%& )"."4%& 6%.'& 3T/..":.%& )(& ,(S%& 72(.& 92)"-"%.& 3T%973/#%9%+,& )%& #%3("5#"&
M-"4A&<OA&
&

Secteur industriel – Contrôles non destructifs
&
&
I32.'& >(%& 3%& ./)"2324(%& '%& ,.2(6%& )%..":.%& 3/& 7":#%H& )/+'& 3%& -/"'#%/(H& 3%& )2'"9:,.%&
27=./,"2++%3& )%& 3*/")%5./)"2324(%& '%& 9%,& %+& /3/.9%& C& "3& /6%.,",& 3%& ./)"2324(%& %,& "3'&
'T=32"4+%+,&,2('&3%'&)%(8&./7")%9%+,&K&3%&)2'"9:,.%&)(&./)"2324(%&+%&'*%',&7/'&)=#3%+#$=A&
Z3'& .%,2(.+%+,& )2+#& /(& 7(7",.%H& )2+,& 3/& 9"+(,%."%& /& %+,.%& ,%97'& #2(7=& 3%'& ./?2+'& @& %,&
-2+,&3%&72"+,&C&"3'&+*2S'%.6%+,&7/'&)%&)2'%&'(.&3%(.'&)2'"9:,.%'&27=./,"2++%3'&.%'7%#,"-'H&
%,&3%&./)"/9:,.%&)%& 3*/")%&./)"2324(%&%',&/..[,=& M(+&/..[,&/(,29/,">(%&)%&3*/77/.%"3&%',&
7.=6(& /7.:'& (+& ,%97'& )*(,"3"'/,"2+& )2++=H& 7/./9=,.=& 7/.& )=-/(,& %+& ('"+%& '(.& JE&
9"+(,%'OA&
&
R%+'/+,&P&(+&)=-/(,&)%&-2+#,"2++%9%+,&)(&./)"/9:,.%H&"3'&,%.9"+%+,&3%(.&"+,%.6%+,"2+&%,&
+%&Y(4%+,&7/'&+=#%''/".%&)%&7.=6%+".&3/&R\]&/(&6(&)%&3T/S'%+#%&)%&)2'%&27=./,"2++%33%A&
&
Conséquences(radiologiques(
(
B%'&.='(3,/,'&)%&3/&)2'"9=,."%&7/''"6%&M)2'"9=,."%&72",."+%O&)(&./)"2324(%&72(.&3%&92"'&
#2+#%.+=& -2+,& /77/./^,.%& (+%& )2'%& 7.2-2+)%(.& _7M;EO& )%& EH`& 9a6& %,& (+%& )2'%& 7%/(&
_7MEHEbO& )%& ;`& 9a6A& \%'& .='(3,/,'H& S"%+& >(%& ,.:'& 3/.4%9%+,& "+-=."%(.'& /(8& 3"9",%'&
.=43%9%+,/".%'&)%&3/&#/,=42."%&I&M.%'7%#,"6%9%+,&UE&9a6&%,&<EE&9a6O&/77/./"''%+,&%+&
.2(4%& 4./'& )/+'& 3%& ./772.,& )(& 3/S2./,2".%& '2",& 7/.#%& >(*"3'& '2+,& Y(4='& /+2.9/3%9%+,&
=3%6='&2(&%+&./"'2+&)%&3/&)"--=.%+#%&"+%873">(=%&%+,.%&3%'&)%(8&6/3%(.'A&_/S",(%33%9%+,H&
32.'& )%& #%& ,?7%& )*"+,%.6%+,"2+H& 3/& )2'"9=,."%& )(& ./)"2324(%& %',& )%& ;& ca6& 9/8"9(9& 7/.&
27=./,"2+&M<$&%+&92?%++%O&%,&'/&)2'%&9%+'(%33%&92?%++%&%',&#297."'%&%+,.%&EHU&%,&EHU<&
9a6A& B/& )2'%& .%0(%& 3%& 92"'& )%& 3*"+#")%+,& %',& )2+#& +%,,%9%+,& '(7=."%(.%& /(8& )2'%'&
R A
fig. 1
R A
fig. 2
R A
fig. 3
R
A
fig. 4
R
A
fig. 5
légende
R
A
pièce alu
dir. faisceau
tube géné X
pupitre
lampe flash
radiologue
aide-radiologue
protection

Secteur industriel – Contrôles non destructifs
9%+'(%33%'&.%0(%'&$/S",(%33%9%+,A&
W+&%--%,H&3/&+/,(.%&)%'&./?2++%9%+,'&(,"3"'=%&Md&)%&3TZ.;`U&%,&./?2+'&@&e&(,"3"'='&"#"O&+%&
)2++%& +2.9/3%9%+,& 7/'& 3"%(& P& (+%& ,%33%& )"--=.%+#%A& B%& .='(3,/,& )%& 3/& )2'"9=,."%&
27=./,"2++%33%H& "''(& )(& #/.+%,& )%& '("6"& )2'"9=,.">(%& )(& ./)"2324(%H& %',& )%& EHE`& 9a6H&
6/3%(.&;E&-2"'&"+-=."%(.%&P&#%33%&)(&)2'"9:,.%&7/''"-A&&
X2'"9=,."%&27=./,"2++%33%&
X2'"9=,."%&7/''"6%&
_7M;EO&
_7M;EO&
_7MEHEbO&
EHE`&9a6&
EH`&9'6&
;`&9a6&
&
I7.:'& #2+,/#,& /6%#& 3%& 3/S2./,2".%& )*2f& 7.26"%++%+,& 3%'& )2'"9:,.%'H& "3& 'T/6:.%& >(%& 3%&
)2'"9:,.%&7/''"-&/&=,=&%872'=&P&)%'&./?2++%9%+,'&@&)%&-/"S3%&=+%.4"%H&)%&3T2.).%&)%&QE&
F%G& K& 3%'& ./?2++%9%+,'& )%& #%,,%& =+%.4"%& '2+,& 3/.4%9%+,& /,,=+(='& 7/.& 3/& 7%/(& %,&
+T%872'%+,&3%'&,"''('&7.2-2+)'&>(%&7/.,"%33%9%+,H&)*2f&3/&)"--=.%+#%&%+,.%&3/&6/3%(.&7%/(&
%,&7.2-2+)%(.A&
B%&)2'"9:,.%&27=./,"2++%3&>(%&3%&./)"2324(%&72.,/",&)=,%#,%&3%'&./?2++%9%+,'&'"&#%(85#"&
2+,&(+%&=+%.4"%&'(7=."%(.%&P&UE&F%GA&g(/+,&/(&./)"/9:,.%&"3&)=,%#,%&3%'&7$2,2+'&P&7/.,".&
)%&JJ&F%GA&
&
B%& +2+& )=#3%+#$%9%+,& )%& 3T/3/.9%& )=S",& )%& )2'%& )(& )2'"9:,.%& 27=./,"2++%3& )(&
./)"2324(%& +T/& 7/'& =,=& %873">(=H& #%3("5#"& =,/+,& ,%#$+">(%9%+,H& '(.& 3%& 7/7"%.H& /7,%& P&
)=,%#,%.&)%'&@&)%&QE&F%GA&B%&-/S."#/+,&+T/&7/'&7(&/772.,%.&)%&.=72+'%&7.=#"'%&'(.&#%&-/",A&
I7.:'&6=."-"#/,"2+&)(&)2'"9:,.%&)(&./)"2324(%H&)/+'&3%'&9[9%'&#".#2+',/+#%'&>(%&#%33%'&
)%& 3T%872'","2+& MDE& FG& %,& ;E& 9IOH& "3& 'T/6:.%& >(%& #%3("5#"& -2+#,"2++%& #2..%#,%9%+,& %,& '%&
)=#3%+#$%&%+&/3/.9%&'(.&)=S",&)%&)2'%&/6/+,&)%&'%&,.2(6%.&)/+'&3%&-/"'#%/(A&
B/& -"#$%& )%& 6=."-"#/,"2+& )%& 3*%+,.%7."'%& )%& 9/"+,%+/+#%& )(& )2'"9:,.%H& 6/3")%& 3%& S2+&
-2+#,"2++%9%+,& )%& 3/& #%33(3%& _7MEHEbO& K& #%,,%& 6/3")/,"2+& %',& %--%#,(=%& 6"'5P56"'& )T(+%&
.=72+'%&)%&3/&#%33(3%&/(&)=S",&)%&)2'%&)T(+%&'2(.#%&#2++(%&P&(+%&)"',/+#%&#2++(%&9/"'&
+T%',&7/'&(+%&6=."-"#/,"2+&)%&3/&.=72+'%&%+&=+%.4"%A&
&
Arbre(des(causes(
(

Secteur industriel – Contrôles non destructifs
(
&
Leçons(à(tirer(
&
;A G=."-"%.& 3/& -"+& )%& 3*=9"''"2+& )%& 3/& '2(.#%& /6/+,& )%& >(",,%.& 3%& 72',%& )%& #2+,.N3%& %,&
.%,".%.&3/&#3%-&)%&'=#(.",=&72(.&4/./+,".&3/&-"+&)%&3*=9"''"2+&)%'&./?2+'&@A&
UA a(.& 3%& #$/+,"%.H& 'T/''(.%.& >(%& #%3("& >("& 'T/77.2#$%& %+& 7.%9"%.& )%& 3T/77/.%"3&
M4=+=./,%(.&@&2(&4/99/O&'2",&S"%+&#%3("&>("&%',&%+&72''%''"2+&)(&./)"/9:,.%H&&
JA \2+,/#,%.&3%&-/S."#/+,&)(&./)"/9:,.%&/-"+&)%&7/./9=,.%.&%+&('"+%&3T/..[,&/(,29/,">(%&
)%'&./)"/9:,.%'&'(.&(+%&)(.=%&)%&h&$%(.%'&/7.:'&)=9/../4%A&&
QA B/& S2++%& .=)/#,"2+& )(& 73/+& )%& 7.=6%+,"2+& %,& '2+& /773"#/,"2+& '(.& 3%& ,%../"+&
)%9%(.%+,&/(''"&3/&4/./+,"%&)T(+&#$/+,"%.&'=#(."'=A&&
<A B*/..[,=&L2+/4%&7.=62",&P&7.28"9",=&)%&3/&'2(.#%&(+&)"'72'","-&3(9"+%(8&%,V2(&'2+2.%&
M7/.& %8%973%& 3/97%& -3/'$O& %+& 73('& )%'& 62?/+,'& ,(S%'& %,& 7(7",.%& >("& )2",& .=/4".& P&
3*=9"''"2+&)%'&./?2++%9%+,'A&
DA B%&)2'"9:,.%&27=./,"2++%3&+*=,/+,&7/'&(+&./)"/9:,.%&%+&,/+,&>(%&,%3H&2+&+%&)2",&7/'&
3("&/##2.)%.&(+%&#2+-"/+#%&/6%(43%A&X/+'&#%.,/"+'&#/'&"3&+%&'%9S3%&7/'&/7,%&P&)=,%#,%.&
,2(,%'& 3%'& '",(/,"2+'& P& ."'>(%'& M./?2++%9%+,'& )%& -/"S3%& =+%.4"%H& i-/"S3%i& )=S",& )%&
)2'%OA& B/& ./)"24./7$"%& "+)(',."%33%H& >(T%33%& '2",& .=/3"'=%& '(.& #$/+,"%.& %8,=."%(.H& %+&
S32#F$/('H&%+& @&2(& %+&4/99/H& %',&(+%& ,%#$+">(%& >("&)%9/+)%& (+%&#$/.4%& 9%+,/3%&
"972.,/+,%&/(&6(&)%&3/&9(3,",()%&)%'&,j#$%'&P&.=/3"'%.&%,&)%&3/&.=7=,","6",=&)%&#%33%'5
#"A&W33%&"973">(%&)2+#&(+%&6"4"3/+#%&)%&#$/>(%&"+',/+,H&(+%&#299(+"#/,"2+&/(&'%"+&)%&
3T=>("7%& et( l'utilisation( impérative( du( radiamètre( /-"+&)%& 6/3")%.& 3%'& /#,"2+'H&
9[9%&'"&3/&'",(/,"2+&'%9S3%&'k.%A&&
bA B/& R\]& )2",& '=3%#,"2++%.& (+& )2'"9:,.%& %,& (+& ./)"/9:,.%& /)/7,=& P& 3*=+%.4"%& )%'&
./?2++%9%+,'& =9"'A& B%& ./)"2324(%& )2",& 6=."-"%.& >(%& 3%& ./)"/9:,.%& %',& /)/7,=& P&
3*=+%.4"%&)%'&./?2++%9%+,'A&
hA B/&R\]&)2",&)=-"+".&3%'&'%("3'&)*/3/.9%&%+&)2'%&%,&)=S",&)%&)2'%&%+&-2+#,"2+&)(&72',%&
pièce&de&grosse&
dimension
faisceau&X&
horizontal
A&se&décale&du&
pupitre
R&pense&que&le&
temps&de&pose&est&
terminé
R&veut&oter&le&film&
radiographié
R&se&dirige&vers&la&
pièce&à&contrôler
R&pénètre&dans&le&
faisceau&X&résiduel
dose&peau&
19,13&mSv&
dose&profondeur&
0,87&mSv
arrêt&automatique&
du&radiamètre&
1/2&h&après&
démarrage
radiamètre&arrêté
radiamètre&en&
possession&de&A&ne&
déclenche&pas&en&
alarme&ded
pièce&à&
radiographier&en&
alu,&tension&de&
60&kV
énergie&des&X&
(40&keV)&trop&faible&
pour&être&
détectée&?
dosimètre&
opérationnel&de&R&
ne&déclenche&pas&
en&alarme&débit&de&
dose
R&et&A&ne&sont&pas&
avertis&du&danger
ouvriers&utilisent&
une&disqueuse
R&et&A&ne&peuvent&
entendre&le&bip&
sonore&de&fin&
d'émission&des&X
lampe&flash&placée&
au&pupitre
lampe&flash&peu&
visible
intervention&en&
extérieur&au&soleil

Secteur industriel – Contrôles non destructifs
)%&,./6/"3A&