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 Society for Radiological Protection Journal of Radiological Protection

J. Radiol. Prot. 37 (2017) 68–83 doi:10.1088/1361-6498/37/1/68

Assessment of radiological protection

systems among diagnostic radiology
facilities in North East India
Thokchom Dewan Singh1,2, T Jayaraman2 and
B Arunkumar Sharma3
1
  Atomic Energy Regulatory Board, Mumbai 400094, India
2
  School of Habitat Studies, Tata Institute of Social Sciences, Mumbai 400088, India
3
  Department of Radiotherapy, Regional Institute of Medical Sciences, Imphal
795001, India

E-mail: [email protected]

Received 25 May 2016, revised 1 September 2016

Accepted for publication 21 September 2016
Published 13 December 2016

Abstract
This study aims to assess the adequacy level of radiological protection systems
available in the diagnostic radiology facilities located in three capital cities
of North East (NE) India. It further attempts to understand, using a multi-
disciplinary approach, how the safety codes/standards in diagnostic radiology
framed by the Atomic Energy Regulatory Board (AERB) and the International
Atomic Energy Agency (IAEA) to achieve adequate radiological protection in
facilities, have been perceived, conceptualized, and applied accordingly in
these facilities.
About 30 diagnostic radiology facilities were randomly selected from three
capitals of states in NE India; namely Imphal (Manipur), Shillong (Meghalaya)
and Guwahati (Assam). A semi-structured questionnaire developed based on a
multi-disciplinary approach was used for this study.
It was observed that radiological practices undertaken in these facilities
were not exactly in line with safety codes/standards in diagnostic radiology
of the AERB and the IAEA. About 50% of the facilities had registered/
licensed x-ray equipment with the AERB. More than 80% of the workers did
not use radiation protective devices, although these devices were available in
the facilities. About 85% of facilities had no institutional risk management
system. About 70% of the facilities did not carry out periodic quality
assurance testing of their x-ray equipment or surveys of radiation leakage
around the x-ray room, and did not display radiation safety indicators in the
x-ray rooms. Workers in these facilities exhibited low risk perception about
the risks associated with these practices.

1361-6498/17/010068+16$33.00  © 2016 IOP Publishing Ltd  Printed in the UK 68

J. Radiol. Prot. 37 (2017) 68 T D Singh et al

The majority of diagnostic radiology facilities in NE India did not comply

with the radiological safety codes/standards framed by the AERB and IAEA.
The study found inadequate levels of radiological protection systems in the
majority of facilities. This study suggests a need to establish firm measures
that comply with the radiological safety codes/standards of the AERB and
IAEA to protect patients, workers and the public of this region.

Keywords: radiology, ionising radiation, risk perception, worker

(Some figures may appear in colour only in the online journal)

1. Introduction

The use of ionising radiation in the diagnostic radiology facilities in India is on the rise, and it
has been reported that hundreds of pieces of x-ray equipment were added to facilities annually
(AERB 2005–2015). There is a mandate for these facilities to function as per the applicable
provisions of the Atomic Energy Act, 1962 (AEA 1962), and the Atomic Energy (Radiation
Protection) Rules, 2004 (RPR 2004) promulgated under the said act. The Chairman of the
Atomic Energy Regulatory Board (AERB), constituted in the year 1983 under section 27 of
the AEA 1962, is the competent authority for enforcing the act in the facilities. To protect
workers, patients and the public in the facilities, the AERB published a safety code for x-ray
equipment in the year 1986, and the same one was revised in 2001 and 2015. The AERB,
being a member organisation of the International Atomic Energy Agency (IAEA), reflects the
concepts of the safety standard series of the IAEA in its codes (RPR 2004, AERB 2016, IAEA
2006). Some of the parameters mentioned in the codes/standards for achieving radiological
protection in the facilities are the availability of qualified workers, protective devices, personal
monitoring devices (PMDs), radiation warning systems, quality assurance (QA), servicing
and maintenance of x-ray equipment, etc.
In India, there are many academic institutions offering various degree courses; these are
regulated by statutory bodies of the state or central government for radiologists, radiogra-
phers and medical practitioners, etc. There is at least one such academic institution in Imphal,
Shillong and Guwahati. Although the syllabus of these courses is not framed by the AERB,
such courses also have content on radiological physics, radiobiology, radiological protec-
tion and safety, etc. Furthermore, the Bhabha Atomic Research Centre, Mumbai conducts the
training with certification of the Radiological Safety Officer (RSO) in various radiation prac-
tices (Bhatia 2003) and final approval to act as RSO in the facility is accorded by AERB. The
regulatory requirements for the establishment of the facilities are also included in this training.
The AERB stipulates the dose limits for these workers, in line with ICRP 103 recommenda-
tions, except that it has 30 mSv as an effective dose for workers in any single year in India,
which is more stringent than ICRP 103 (table 1). In India, the preservation of the dose records
of workers in the facility until the workers reach the age of 75 years is mandatory as per RPR
2004. If the workers exceed 10mSv in a monitoring period, the AERB initiates an excessive
exposure investigation for taking remedial action accordingly.
In India, it is mandatory for the installation of fixed x-ray equipment in rooms to be approved
by the AERB, as per AERB code (RPR 2004,AERB 2016). The door and window glass in
the control console of such rooms should have a minimum lead equivalence of 1.7 mm and
1.5 mm, respectively. In certain radiological procedures that involve operation of mobile x-ray,
portable x-ray and interventional radiology, etc, the room structural shielding alone is insuf-
ficient to protect workers and patients. In such cases, the use of protective devices such as lead
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J. Radiol. Prot. 37 (2017) 68 T D Singh et al

Table 1.  Radiation dose limits for occupational workers and the public (ICRP 2007,
AERB 2011).
Occupational workers Public
Equivalent dose Equivalent
limits in any single dose yr−1
year (mSv) (mSv)
Effective dose Effective dose Lens Hands Effective
limits yr−1 over in any single of and dose limits Lens
Organisation 5 years (mSv) year (mSv) eye Skin feet yr−1 (mSv) of eye Skin
ICRP 103 20 50 150a 500 500 1 15 50
AERB 20 30 150a 500 500 1 15 50
a
 The AERB is now under review to reduce the equivalent dose limit to 20 mSv yr−1 in line with new ICRP 2013
recommendation.

protective aprons, gloves, thyroid shields, eye shields and gonad shields protects the worker
from the scattered radiation (IAEA 2006, Miller et al 2010, Khong et al 2013, Dance 2014).
The wearing of an apron reduces the radiation dose by up to 90% (Franken 2002). However,
in certain radiological procedures, such as fluoroscopic and image-guided interventional pro-
cedures, aprons are unable to protect the radiosensitive organs in the extremities of the body
such as the thyroid and hands from the scattered radiation. It has been reported that dose rate
at the position of workers during such procedures range from 0.5 to 10 mSv h−1 (Miller et al
2010). If appropriate protective devices are not used, their annual dose can exceed regulatory
dose limits (table 1). For gonads, although they are already protected by wearing a lead protec-
tive apron, the use of a gonad shield with 0.25 mm lead equivalent is required whenever the
gonads fall in the direction of the primary x-ray beam (IAEA 2006, AERB 2016).
The use of protective devices such as eye shields and gonad shields are also required for
patients undergoing brain and pelvic imaging (Wainwright 2000, RPR 2004, AERB 2016).
Another aspect of enhancing image quality and radiological protection systems in the facili-
ties are through periodic QA, performance testing, servicing and maintenance of x-ray equip-
ment (IAEA 2006, AERB 2016).
In India, there are provisions in AEA 1962 and RPR 2004 to impose penalty actions, such
as suspension or withdrawal of licence, fine or imprisonment, or both, against the contravener
of the said act, rule and safety code (RPR 2004, AERB 2016). In addition AERB has a sys-
tem of regulatory inspection of the facilities to find out the compliance status of the regula-
tory requirements. This inspection is based on the AERB safety manual, SM G-3, whose
conceptual framework reflects the IAEA inspection model (IAEA 2007, AERB 2014). The
AERB adopts a graded approach to enforcement actions that are commensurate with the pos-
sible effects of regulatory non-compliance found in the facilities during the inspection. Such
actions include a written directive or warning, shut down of the facilities, modification, sus-
pension or withdrawal of licence, and imposing penalty actions.
In the last decade, the AERB has increased the number of inspections of facilities; about 600
facilities were inspected between April 2014–March 2015 against 80 in the year 2006 (AERB
2005–2015). The AERB has taken appropriate enforcement action, including shutting down
facilities depending on the severity of non-compliance found in them (AERB 2015a, 2015b).
Although the AERB has taken many steps to regulate radiological practice, criticisms of
the failure of regulatory compliances, observed in most facilities throughout the country, were
even highlighted in the parliamentary session of the Government of India (Lok Sabha 2013,
2014, 2015a, 2015b). In a radiological safety survey carried out in 45 facilities, it was reported

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J. Radiol. Prot. 37 (2017) 68 T D Singh et al

that 29% did not have a warning light outside the x-ray room, 14% used mobile protective
barriers without lead glass viewing systems, and there was lack of radiological safety aware-
ness among the workers (Sonawane et al 2010). Similar types of findings, such as instances of
procedural deficiencies, non-compliance with regulatory requirements and workers exceeding
regulatory dose limits have been reported elsewhere (AERB 2005–2015).
In India, there are limited studies on the assessment of radiological protection systems
available in the facilities. Also, these studies did not reveal in detail the deviation of their radi-
ological protection systems from the national regulatory requirements and safety standards
of the IAEA. In addition these studies did not cover how the risk perceptions of workers and
policymakers of the institutions influence the system of radiological protection established in
the facilities. Studies carried out in other countries found that the actual risk, as defined by
natural sciences, underwent changes such as amplification and reduction of risk in resonance
with the risk perceptions of the various actors and groups (Slovic et al 1982, Covello et al
1986, Kasperson et  al 1988). Among scientists of the same discipline and institutions, the
same risk associated with radiation was perceived in different ways according to demographic
differences (Barke et al 1997, Slovic et al 1997). This present study attempts to integrate risk
assessment based on a technical approach with the risk perception approach. The components
of safety systems, whose failure may reduce the adequacy level of radiological protection in
facilities, were studied using a technical approach. The risk perception approach attempted to
find the reasons for the failure to deploy these safety components.
In the present study, the facility shall mean the diagnostic radiology facility. It may be a
part of an institution with multiple facilities other than a diagnostic radiology facility or an
institution with only x-ray equipment. X-ray equipment shall mean the radiation-generating
equipment used in the facilities. PMD shall mean a thermoluminescence dosimeter (TLD).
The workers shall mean radiologists and radiographers working in the facility. The manager
shall mean the person in charge of the facility that has responsibility for managing the routine
activities in the facility. Policymakers of the institution shall mean the members of the insti-
tution making the guidelines/procedures and implementing regulatory rules/requirements in
the institutional risk management system. Policymakers of radiology facility shall mean the
workers of the facility making guidelines/procedures specific to radiology safety for use in
the facility.

2.  Materials and method

2.1.  Study sites

This study was carried out in 30 facilities located in Imphal, Shillong and Guwahati of NE
India. About 70% of the facilities in Manipur were concentrated in Imphal. The combined
number of facilities in Imphal and Shillong was less than that of Guwahati. The approximate
distance between these facilities was between 120 km and 500 km. These study sites were
about 2600–3000 km from the headquarters of the AERB, Mumbai.

2.2. Method

The conceptual framework of this study, as shown in figure 1, was developed on the basis of
a multi-disciplinary approach (Van Der Plight et al 1986, Slovic 1987, Kasperson et al 1988,
Sjoberg 2001, IAEA 2007, AERB 2014). It comprised of prescriptive and risk perception
approaches. The components considered in the prescription approach and working behaviour
are shown in the figure 2 and table 2, respectively. The x-ray equipment considered in this
71
J. Radiol. Prot. 37 (2017) 68 T D Singh et al

Frame work for assessment of radiological protection in diagnostic radiology facilities

Prescriptive Approach Risk Perception

Approach

Assessment of protective Knowledge

devices

Assessment of Monitoring Experience

equipment, QA kits

Assessment of radiation Trust

warning signs and
labelling

Assessment of Institutional Working behaviour

risk management system

Figure 1. Framework for the assessment of radiological protection in diagnostic

radiology facilities located in NE India.

framework was computed tomography (CT), interventional radiology, fluoroscopy, C-arm,

fixed radiography, mobile radiography (MR), portable radiography (PR) and mammography
units. Using a behavioural checklist (table 2), the operations of the above listed equipment
in the 30 facilities were observed closely while concealing the identity of the researchers.
These facilities were randomly selected from a list of existing facilities in Imphal, Shillong
and Guwahati. A semi-structured questionnaire (appendix A) was then distributed among 80
workers across the 30 facilities, on the grounds that collected data would be used for academic
purposes only. About 60 respondents, consisting of 10% radiologist turned policy makers, 40%
radiologists and 50% radiographers, filled out the questionnaire. The researchers physically
verified the availability of the safety systems in the facilities as mentioned by respondents.
The respondent’s name and identity were coded on ethical grounds. An in-depth interview
was also conducted at the facilities using the questions provided in appendix B. The respond-
ents were interviewed regarding the regulatory requirements of the AERB, knowledge about
radiological protection, QA, attitude, working experience, etc.

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J. Radiol. Prot. 37 (2017) 68 T D Singh et al

Prescriptive Approach

Assessmet of Protective Assessment of Assessment of Assessment of

Devices/Systems Monitoring equipment Radiation Warning Institutional Risk
& Quality Signs and Management System
• Lead protective aprons assurance(QA) kits Labelling
• Lead protective gloves • Internal audit of work
• Thyroid shield for • Ageing of X-ray • Radiation warning procedures
workers equipment signs • Display of safety work
• Gonad shield for • Personal monitoring • Notices procedure
workers devices(PMD) • Illuminated Radiation • Periodic conduct of
• Eye shield for patients • Survey Meter ON/OFF indicator QA
• Gonad shield for • QA kits • Performance testing of
patients X-ray equipment at the
• Mobile protective lead time of installation
barrier • Periodic servicing and
• Room lay out approved maintenance of X-ray
by AERB equipment
• Lead lined • Maintenance of records
door(Patient entrance such as QA, PMD,
door) radiation survey
• Lead glass window report
(Control console) • Exchange of PMD at
the prescribed period
• Proper storage of PMD

Figure 2.  Parameters used in the prescriptive approach.

Table 2.  Checklist of working behaviours of workers in the facilities.

Behaviour observed
Applicable Not applicable Use of system No use of the
for using the for using the in the applicable system in the
Checklist system system cases applicable cases
1. Use of a PMD during
work procedure
2. Use of lead protective
aprons
3. Closing door while
radiation is ON
4. Operating x-ray
equipment in the presence
of non-patients
5. Checking collimator
light before radiation is
ON
6. Keeping lead aprons in
hanging position
7. Standing behind the
mobile protective barrier
8. Use of protective
devices for patients

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J. Radiol. Prot. 37 (2017) 68 T D Singh et al

Table 3. Assessment of the availability of radiological protection systems (number

of facilities  =  30; yes  =  availability of the system in the applicable cases; NA  =  not
applicable for the availability of the system, X  =  NA is nil).
% of facilities
Assessment in respects of availability of: Yes NA
Protective devices/ Lead protective aprons 93 X
systems Lead protective gloves 10 90
Thyroid shield for workers 7 93
Gonad shield for workers 7 93
Eye shield for patients 3 50
Gonad shield for patients 3 50
Mobile protective lead barrier 90 10
Room layout approved by AERB 20 20
Lead lined door (patient entrance door) 60 20
Lead glass window (control console) 60 20
Monitoring equipment Personal monitoring devices (PMDs) 40 X
and QA kits Survey meter 13 X
QA kits 13 X
Radiation warning Radiation warning signs 33 20
signs and labelling Notices 30 20
Illuminated radiation ON/OFF indicator 30 20
Institutional risk Internal audit of work procedures 3 X
management system Display of safety work procedure 3 X
Periodic conduct of QA 20 X
Performance testing of x-ray equipment 100 X
at the time of installation
Periodic servicing and maintenance of 20 X
x-ray equipment
Maintenance of records such as QA, 30 X
PMDs, radiation survey report
Exchange of PMDs after the prescribed 30 X
period
Proper storage of PMDs 7 X

2.3. Results

The safety assessments of facilities located in Imphal, Shillong and Guwahati are given in
tables 3 and 4. About 50% of the facilities registered/licensed for x-ray equipment, mostly
MR and PR, with the AERB after operation of the x-ray equipment for more than three years.
About 40% of the facilities had x-ray equipment less than 10 years old. This study found that,
apart from the availability of protective devices such as aprons and mobile protective lead
barriers, in the majority of facilities the protective devices were not properly utilised, wher-
ever required, such as in the operation of MR, PR, and fluoroscopy. The common perception
amongst these workers was that they did not experience radiation illness while performing
radiological procedures in the absence of these devices. A worker who did not use an apron
during the operation of PR said:
I have worked at this facility for over 30 years, even without lead protective aprons, a
gonad shield and a PMD. Up to now, I have not experienced any symptoms related to
radiation illness. I have not found any symptoms in my colleagues working in this facility.

74
J. Radiol. Prot. 37 (2017) 68 T D Singh et al

Table 4. Assessment of working behaviour of radiation workers (N  =  60, X  =  not

applicable is nil).
Behaviour observed
% of used Not applicable
systems in the for using the
Checklist applicable cases system
1. Use of PMD during work procedures 20 X
2. Use of lead protective aprons 15 33
3. Closing door while radiation is ON 50 10
4. Operating x-ray equipment in the presence of non-patients 42 X
5. Checking collimator light before radiation ON 67 20
6. Keeping lead aprons in hanging position 33 33
7. Standing behind the mobile protective barrier 25 33
8. Use of protective devices for patients 5 67

There was a little concern over the use of protective devices for patients who underwent
brain and pelvic imaging in the facilities. This finding supports the result of Rehani et  al
(2011) that patient safety in radiological procedures was of little concern. It was perceived
that protective devices were not required, as it was one-time imaging and the radiation dose
delivered could not cause significant effects of ionising radiation.
In the majority of the facilities, there was a lack of availability, usage, periodic exchange
and storage of PMDs, and the records of PMD used by the workers were not preserved. Among
the facilities that do not have PMDs, it was found that about 5% of the workers out of the 60
interviewed did not hear words such as PMD, survey meter, QA, etc. These groups of work-
ers exhibited a fatalistic character, which is one of the cultural prototypes found in Douglas’s
grid-group model (Douglas and Wildavsky 1982). These workers had no basic training in
radiology practices and no knowledge of radiological protection. They failed to recognise
the possible danger of exposure to radiation. However, they had no desire to know about the
nature of the risks likely to be encountered in radiological practice. They used a certain heu-
ristic approach for judging the radiological risk and underestimated the risk associated with
radiological practice. The demerit of using such an approach for risk judgement is explained
elsewhere (Tversky 1974). There were, however, workers who understood the importance of
wearing PMDs during radiological procedures but could not wear them due to their unavail-
ability, and even if they were available, the PMDs were expired. A worker in a facility who
wore the same PMD for more than five years without monitoring or exchanging it for a new
PMD, expressed the risk encountered in the facility as:
Our top managers do not consider this practice as a risky one compared with other
practices in the hospital. Their judgments are based on cases of non-occurring injuries/
fatalities among workers and patients. Though our hospital had been warned by AERB
for non-compliance of safety codes, the top management still do not consider implement-
ing the recommendations. As the institution is not clearing the bills for PMDs of the PMD
service provider, the PMDs are not exchanged on time. Hence, we are using PMDs that
expired five years ago. When we pointed out the non-implementation of safety procedures
to top managers, they cite so many other radiology facilities not having protective equip-
ment and safety features.
Although performance testing of x-ray equipment was carried out in all the facilities, at the
time of installation there was little effort applied in areas such as the installation of fixed x-ray

75
J. Radiol. Prot. 37 (2017) 68 T D Singh et al

equipment in the rooms approved by AERB, periodic QA, radiation leakage surveillance, ser-
vicing and maintenance of x-ray equipment, and display of radiation warning indicators in the
rooms with fixed x-ray equipment. Among the rooms not approved by the AERB, it was found
that one facility installed x-ray equipment in rooms with a concrete wall that has a thickness of
more than 30 cm, whereas the minimum requirement to achieve the desired level of radiologi-
cal protection is about 15 cm (AERB web, RPR 2004). In some facilities, x-ray equipment was
installed in a room with walls made of plywood.
The crowding of patients in and around the rooms with x-ray equipment was observed in
the facilities that did not have radiation warning systems. The interaction of patients in that
particular facility revealed that such crowding was due to a lack of awareness of the harmful
effects of ionising radiation. However, a worker explained such a working scenario as:
Communication with patients and their attendants poses the greatest threat to our lives.
You may be aware of the beating of staff by attendants of patients from our local news-
paper. Under such condition, it is not so easy to control crowds of patients and their
attendants. Sometimes we have to operate machines in their presence.
A common striking feature found in the majority of the facilities was the lack of an insti-
tutional risk management system, in spite of the availability of safety systems and trained
workers. This constitutes, among other factors, a source of failure of the implementation of the
regulatory requirements to achieve radiological protection systems in the facility. A worker
expressed the non-compliance of regulatory requirement in the facility as:
During my training course I came to know about the hazardous potential of radiation
and had a fear factor for working in radiology facilities. However, such fear eroded
slowly after working in the real field. According to me, risk doesn’t mean the effects
of hazardous potential of radiation. In the last twenty years of my service, I have not
experienced any radiation injuries or fatalities or cases of cancer to me or my fam-
ily, co-workers and patients. This is due to the use of advanced x-ray machines in our
facility. Risk, as we encounter frequently, is the communication with patients and their
attendants, work coordination among co-workers and establishing trust with our man-
agement. I feel personally that regulatory requirements are too stringent in certain cases
where it is not required at all.

2.4. Discussion

The use of x-ray equipment without any standard working procedures and radiation safety
norms in the early years of the introduction of this equipment in the medical field was consid-
ered to be due to the unavailability of safety standards, basic knowledge of the harmful effects
of radiation and radiation protective devices. The continuous technological evolution, har-
monisation, and standardisation in this radiological practice have been providing a means to
solve such challenges encountered. In India, the AERB has taken up many measures, includ-
ing the immediate shutdown and suitable penalties under AEA 1962 to the facilities operat-
ing x-ray equipment without an AERB registration/licence (AERB 2015a, 2015b), to achieve
radiological protection systems in the facilities.
Interestingly, this study found that violation of regulatory requirement remains a com-
mon striking feature among the facilities, including registered/licensed ones, and there was
little effort to achieve an adequate level of radiological protection. Many workers, including
policymakers, exhibited low-risk perception in radiological practice, and felt that many of
the safety requirements stipulated by the AERB were too stringent. Their low-risk percep-
tion was derived from not experiencing radiation injuries/fatalities among themselves, their

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J. Radiol. Prot. 37 (2017) 68 T D Singh et al

co-workers, patients and the public during their radiological practice in the facilities for more
than 20 years. They believed that modern x-ray equipment, having inherent safety features,
could reduce the risk drastically, and the risk generated in radiology facilities was sometimes
less than the risk associated with natural background radiation. These types of workers, pay-
ing little concern to wearing PMDs and appropriate protective devices, were found to be
working in CT units, fixed radiography and portable x-ray units. The workload of patients in
these units was less than 30 patients per week, and portable x-rays were used to radiograph
about 10–15 patients per month. The previous doses records of these workers revealed that
none of them exceeded 10 mSv per annum. As these workers were continuing in the same
working environ­ment, they were unlikely to exceed the AERB dose limits. It has also been
reported elsewhere that the dose in a properly designed control console was almost insignifi-
cant (UNSCEAR 2008). However, not wearing PMDs based on such estimations introduces a
gap in the preservation of the worker’s dose record as per RPR 2004. It makes it impractical to
determine the true occupational risk (NCRP 2008). Such perceptions induced unwillingness
to practice radiology as per the safety standards/codes of AERB and IAEA.
Although there were workers who preferred to carry out the procedures in line with
national/international safety codes and standards, they were bound to follow the existing work
procedures due to the hierarchy effect. The majority of policymakers in the facilities also had
a lack of institutional risk management system. This can be explained by using the The Social
Amplification of Risk Framework (SARF) (Kasperson et al 1988). They believed that many
other similar facilities also did not comply with all regulatory requirements, and complying
with all the safety requirements would increase the financial burden on them. They preferred
to continue their traditional practices. They attempted to support their low risk perception
in radiology practice by comparing it with the risk involved in other medical practices like
radiotherapy facilities, where very high hazard potential radiation sources such as medical
linear accelerators and telecobalt machines, etc were used. Such perceptions introduced seri-
ous errors and uncertainties into their risk management system. They are in contradiction to
the philosophy of the implementation of safety standards in the facilities to achieve adequacy
of radiological protection. They also reduced the adequacy of radiological protection in the
facilities, as policy makers had the final authority for making decisions about establishing the
safety standards in the facilities (Glasgow et al 1990, Krause 1997).
The AERB, also, may find it challenging to have routine connections with the facilities,
whose numbers attained 40 000 in the year 2005, and increasing rapidly (AERB 2005–2015,
Lok Sabha 2015a, 2015b). At present, the policy of the AERB for inspection of the facilities is
on a sample basis. It does not have a plan for the frequency of inspection in line with the IAEA
model for inspection of facilities. It indirectly assesses the facilities through safety reports
submitted by the facilities. The AERB needs to establish a practicable approach to verify their
trust in such assessment methods.

3. Conclusion

The reasons why facilities tended to deviate from the national and international safety require-
ments are cumbersome, complex, and are intertwined in the various actors involved in the
facility. The study found that factors such as low-risk perception among workers, exercising
a certain heuristic approach to taking decisions, a desire to continue their previous risky work
practices, lack of institutional risk management system, hierarchy effect, and lack of trust in
regulator system, etc, contribute to such deviations. A lack of technical skill in performing
QA and knowledge about radiation safety was also found among some workers. The facili-
ties need to adopt certain programmes such as continuous education programmes, radiation
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J. Radiol. Prot. 37 (2017) 68 T D Singh et al

safety meetings, correcting working behaviours, training of management and other relevant
programmes (workshops, conferences, sensitization, etc) to rectify the above factors.
Another aspect of improving the adequacy level of radiological protection in the facili-
ties is enhancing communication systems among various actors involved such as workers,
patients, policymakers, suppliers of equipment, and the regulator (AERB). The AERB needs
to explore various communication approaches that are commensurate with the possible conse-
quences likely to arise due to lack of direct monitoring of the facilities. The AERB also needs
to take stern steps in the registration/licensing of all facilities.

Acknowledgment

Thokchom Dewan Singh would like to thank Dr A U Sonawane, Head, RSD, AERB Mumbai
for his encouragement and support in the PhD Work. The authors would like to express sincere
gratitude to Dr Balamurugan Guru, Dr M Parivelan, Dr Nirmalya Choudhury and Shri Rakesh
Khwairakpam of Tata Institute of Social Sciences, Mumbai, Professor Paul Slovic, Decision
Research Eugene, USA, Shri R K Singh of Atomic Energy Regulatory Board, Government of
India and Dr T Priya Devi for their valuable comments and suggestions. Any opinions and find-
ings in this piece of research work are the views of the authors, and are not necessarily related
to/reflected by any individual/institutions including the Atomic Energy Regulatory Board, Gov-
ernment of India.

Appendix A.  Questionnaire

Q1. How long you have been working in a diagnostic radiology facility?
Q2. How often do you visit the Atomic Energy Regulatory Board (AERB) web site, www:aerb.
gov.in?
Less than once a year    Once a year    Not at all.
Q3. Are you familiar with the following organisations related to radiation?

Name of organisation Yes No

International Atomic Energy Agency (IAEA)
International Commission on Radiological Protection
(ICRP)
United Nations Scientific Committee on Effects of
Atomic Radiation (UNSCEAR)
National Council on Radiation Protection and
Measurement (NCRP)
Committee on Biological Effects of Ionising Radiation
(BEIR)

Q4. Assessment of availability of safety systems

A. i. Types of x-ray equipment available: .................................
  ii. Types of radiological procedures: .................................
B. Types of personal monitoring devices (PMDs) available such as thermoluminescence
dosimeters (TLDs) and pocket dosimeters:
C. Worker to patient ratio: .................................
D. Ageing of x-ray equipment: .................................
i. Equipment aged below ten years: .................................
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J. Radiol. Prot. 37 (2017) 68 T D Singh et al

E. Frequency of servicing and maintenance of equipment: .................................

F. Type of servicing; periodic/breakdown type: .................................
G. Types of protective devices/systems available (please tick all that apply:
i. Lead protective apron
ii. Lead protective globe
iii. Thyroid shield for workers
iv. Eye shield for workers
v. Gonad shield for workers
vi. Eye shield for patients
vii. Gonad shield for patients
H. Availability of records:
- incidence/accident in the facility (radiation injuries/fatalities/radiation related illness such
as cancer)
- internal audit of work procedures
- periodic conduct of quality assurance (QA), PMDs, radiation survey reports
I. For each of the following (1–27), please write: (i) ‘Yes’ for the system available (ii) ‘ No’
for the system not available (iii) ‘NA’ for the system not applicable.

1. Is the room layout of your facility approved by the Regulator Body?

2. Is the x-ray equipment registered/licensed with the Regulatory Body?
3. Do you have a radiological safety officer (RSO)?
4. Are the doors of the rooms having x-ray equipment lead lined?
5. Do the windows have lead glass?
6. Are radiation ON/OFF indicator lights connected to the radiation sources available at the
entry doors of radiation rooms?
7. Are radiation warning symbols available at the entry doors of rooms having x-ray equip-
ment?
8. Are Emergency Procedures displayed in the control console rooms having x-ray equip-
ment?
9. Do you display emergency contact numbers of various actors responsible for the mitiga-
tion of radiation?
10. Do service providers carry out performance testing of x-ray equipment at the time of
installation?
11. Is your x-ray equipment subjected to routine servicing and maintenance by authorized
service agents?
12. Do you have quality assurance (QA) tools and other appropriate instruments to carry out
QA of x-ray equipment?
13. Do you conduct QA of x-ray equipment at least once a year?
14. If ‘ No’ in the above question 13, is it conducted by authorized service agents, and what
is the frequency of conducting QA?
15. Do you have an appropriate radiation survey meter?
16. Do you carry out a radiation survey of radiation rooms at least once a year?
17. Do you use personnel monitoring devices (PMDs) such as thermoluminescence dosim-
eters (TLDs)? Do your co-workers also wear PMDs while working in radiation practice?
18. If ‘ Yes’ in the above question 17, do you get PMDs and their results on time without
interruption of service?
19. If ‘ No’ in the above question17, how long you have been working without PMDs?

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J. Radiol. Prot. 37 (2017) 68 T D Singh et al

20. Do you have proper storage of PMDs (TLDs)?

21. Is it crowded in and around the rooms having x-ray equipment?
22. Do you have written working procedures for your current radiological practice?
23. Does your institution conduct self-assessment programme for internal audit of work
procedures, radiation safety features of x-ray equipment?
24. Does your institution monitor the working conditions of radiation workers?
25. Does your institution monitor the working behaviour of radiation workers?
26. Does your institution conduct regular radiation safety meetings?
27. Do you submit a safety status report of your practice to the Regulatory Body at least once
a year?
Q5. What do you feel if you answered ‘No’ to any of the above questions 4I?
Q6. What do your co-workers do/feel if ‘No’ in the above questions 4I?
Q7. Do you/your co-workers protest against the facility/institution if ‘No’ in the above
questions 4I?
Q8. If ‘ No’ in the above questions Q7, why? (Please tick all that apply or express your own
experience).
- Non-availability of such features since for a long time there has been no adverse effect on
health
- Employer may take action such as delay in promotion/transfer of job/suspension of job
- Employer would never respond at all.
- The inherent safety features of x-ray equipment controls the risk at the source itself.
- Specify if any other: ...........................................................................
Q9. Why does your employer not implement radiation safety features? (Please tick all that
apply or express your own experience).
- Non-availability of such features since for a long time there has been no adverse effect on
health
- Implementation of such systems will cause financial burden to the institution
- Other institutions having similar radiation facilities also do not implement them
- Non-availability of service provider/supplier to implement such safety features
- The inherent safety features of x-ray equipment controls the risk at the source itself
- Taking decisions at the administrative and various layers of policy makers/authorities is time
consuming
- Lack of trained workers
- Acts, rules, codes, etc are too stringent.
- Specify if any other: ............................................................................

Appendix B.  In-depth interview questions

(Please express your own perceptions, conceptions and experiences, if any, in the
following questions)
Q1. Do you agree: ‘Our regulator (AERB) can be trusted with its codes/standards/guides,
and the Atomic Energy Act 1962 and Atomic Energy (Radiation Protection) Rule 2004 to
achieve radiological protection in the diagnostic radiology facility’? Do you think that your
co-workers, facility also agree with this?
Q2. Do you think that working in a diagnostic radiology facility may cause radiation related
diseases to you, your family members and future generations?

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J. Radiol. Prot. 37 (2017) 68 T D Singh et al

Q3. Do you think that natural background radiation is not dangerous for our life, since it is
found everywhere, including our body?
Q4. If the collimator light of diagnostic x-ray equipment (applicable if any) is not working,
how likely is it that the radiation dose given to the patient will cause skin erythema?
Q5. If appropriate radiation protective devices are not used for the patients during radiological
procedures, wherever required, how likely is that radiation the dose given to patient will cause
radiation related illness?
Q6. How would the majority of your co-workers behave if a radiation accident took place in
another facility/institution?
Q7. Do you agree that if a radiation accident takes place in another facility/institution, your
employer/policy maker would try to implement the lessons learnt from that accident to prevent
similar types of accidents in your facility?
Q8. Do you agree that the employer/policy makers of your facility would hide from the work-
ers any radiological risk that may be present in your current job, due to x-ray equipment not
meeting international standards?
Q9. How do your co-workers behave if any procedural error is committed? Will they tell the
employer?
Q10. How do your employer/policy makers react if any lapses in radiological protection sys-
tem are detected? Do they inform the regulatory body?
Q11. Do you agree that our future generation will get more benefit than harm as a result of
further advancements in radiation practices?
Q12. Do you agree: ‘If no health problems were detected in the last 25 years while working in
radiation practice without wearing a TLD and appropriate radiation protective equipment, we
need not use them further’? Do you observe that some of your co-workers/employer/policy
makers also agree and act accordingly?
Q13. Do you agree: ‘We no need to worry about the implementation of radiation safety norms
in radiation practice unless and until there is intervention by the Regulatory Body’. Do you
observe that some of your co-workers/employer/policy makers also agree and act accordingly?
Q14. Do you agree: ‘We do not need to worry about radiation symbols and warnings displayed at
the entry door of the diagnostic x-ray room as no fatalities have occured in such practice’? Do you
observe that some of your co workers/employer/policy makers also agree and act accordingly?
Q15. Do you agree: ‘ We do not need to worry about radiological protection systems in the
facility as we can’t do anything about achieving such protection’? Do you observe that some
of your co workers/employer/policy makers also agree and act accordingly?
Q16. Do you agree that in case of any difference of opinion about risk arising among the work-
ers, managers, policymakers and employer in your current radiation practice, your institution
would try to resolve the issue based on scientific data and analysis only?
Q17. Do you think your organisation would follow a risk management policy for the protec-
tion of workers and the public from the radiation activities going on in your facility? How do
they manage radiological protection systems?
Q18. What are the challenges encountered in achieving radiological protection in your facility?

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