IPEN : Ciencia y tecnología para la competitividad INSTITUTO PERUANO DE ENERGÍA NUCLEAR - IPEN FINDINGS AND PRELIMINARY RESULTS ON THE VENTANILLA ACCIDENT

IPEN : Ciencia y tecnología para la competitividad

INSTITUTO PERUANO DE ENERGÍA NUCLEAR - IPEN

FINDINGS AND PRELIMINARY RESULTS ON THE VENTANILLA ACCIDENT

MSc. Susana Gonzales

Occupational Radiation Protection Area - IPEN


GENERAL INFORMATION

IPEN is designated as the National Authority to control and enforce the law and apply its Regulations. It also apply sanctions when the regulations are not fulfilled.

Peru has the Law 28028 and its Regulation was issued in 2008.

What is it established in the Peruvian Regulation about Industrial Radiography?IR.001.12 Norm: Requirements of Radiological Security in Industrial Radiography SF.001.2012 Norm: Security Requirements for radioactive sources

• The Industrial Radiography activity is classified as category A (high risk)• This activity requires an operation license and also individual license for the radiographers and radioprotection officer• The Norm includes specific requirements for operation, training and Emergency Plan• The Minimum staff to perform a practice is one operator and one radioprotection officer• It is mandatory to carry an emergency equipment and to keep the records updated in each practice.

There are 40 Industrial Radiography companies.

136 Radiography equipment machines are movable and one is fixed

300 operators have individual licenses

64 radioprotection officers have licenses


Ventanilla Accident

Information of the accident

•Date: February 14th, 2014,

early morning (at 2: 30 a.m.)

•Place: Ventanilla, Callao

•Authorized activity:

Industrial Radiography

•Radioactive source: 192Ir

•Activity: 1221GBq (33 Ci) at that

time


BACKGROUND INFORMATION ON THE CIRCUMSTANCES OF THE ACCIDENT

The Industrial Radiography Company was subcontracted by an Enterprise which provided services to another company. Three workers carried out the work.

Work to be done: 15 inspections of welder joints

Equipment: SENTINEL - DELTA 880 model and series number D5188, which contained an

192-Ir source of 1221 GBq (33 Ci)

Operators Tasks Operator 1: He had license of Radioprotection officer. He delimited the work areas, placed the films in the

joints and moved the source from one place to another.

Operator 2 : He moved the equipment from one place to another and he made the shots, he controlled the exposure time, and he retrieved the source after the fixed time finished.

Operator 3 : He placed safety signs, identified the films, monitored the areas and moved the toolbox.

In this job, nobody did the work of radioprotection officer.


Joint 22 Joint 20

Joint 24

Joint 39

•The work was done 12 meters above from the floor. (height)•Operator 1 placed the films and the collimator in the joints.•He made 3 exposures per joint then he disconnected the guide tube by putting it around his body like a purse and placing the collimator inside his left vest pocket.•Operators believe that the source was unhooked in joint 22 because of what was shown when films 22 and 24 were veiled.•In the path of the joint 24 to the joint 39 (about 50 m. of distance), he heard the audible alarm.•It is believed that operator 1 was exposed to the radiation for 30 minutes.



BACKGROUND INFORMATION ON THE CIRCUMSTANCES OF THE ACCIDENTBACKGROUND INFORMATION ON THE CIRCUMSTANCES OF THE ACCIDENT

Operator 1 left the equipment and guide tube on the floor, proceeding to perform the rescue of the radioactive source, using a portable shield of an emergency kit.

Operators declared that in the area where they performed the work, there was a lot of noise (engines and other machineries). They did not use the radiation monitor.

The accident was reported to the Company’s manager. The operator 1 was taken to the Hospital and he is still under medical treatment.

The accident was reported to IPEN on February 14th in the morning.


Findings and Actions - 1

About the Company:

• The company had an operating license. The operators had valid individual licenses and the Operator 1 had a license as radioprotection officer.

• The Company was notified for causing severe damage to a worker, not complying with the requirements of safety and the requirements for the control of occupational exposure.

• It was verified that the radiation monitor was not used .

• It was verified that they did not keep any record of the practice on February 14th.

• Despite the accident, the company continued the operations on Saturday February 15th , with other staff.

• The Regulatory Body stopped the operations on February 17th .

• The reconstruction of the event was done on February 21st which allowed to calculate the dose to operator 1

• The OSL dosimeters readings were the following: Operator 1: 62,65 mSv, Operator 2: 15,85 mSv, Operator 3: 17,75 mSv

• Local dose in left hip was between 12 and 24 Gy aprox, maybe it is higher, more than 100 Gy. Nowadays, the operator 1 lesion is getting worse.

• It was confirmed the dosimeters readings of the operators 2 and 3.

• An average dose of a whole body is 0. 72 Gy , this data was reported by the biological dosimetry laboratory from the Argentina Regulatory Body.

• IPEN reported the accident to the Unified System for Information Exchange in Incidents and Emergencies (USIE) due to this, a medical team came to assist us in Peru. On June 9th Peru applied for assistance to the International Emergency Center.


Findings and Actions – 2

Root Causes

•The operators did not comply their duties.

•Nobody did the job of radiological protection officer

•There were no records.

•Lack of safety culture by the companies (contractor companies and industrial radiography companies).

•Companies seek guilty workers. Because of that, there is fear to report incidents.

•Overconfidence was shown by the workers.

Corrective Actions

•To improve Radioprotection courses that need to include training about emergencies.

•To promote a report culture.

•A safety culture needs to be fostered and maintained by management.

•To improve the knowledge of the radiological risks.

• To increase the inspections, especially those unplanned.

Lessons to be learned•Lack of culture and commitment of safety: Attitudes, Motivations, Values, Behaviors, Leadership

February 17 ( 03 days after exposure)February 17 ( 03 days after exposure)February 17 ( 03 days after exposure)February 17 ( 03 days after exposure)


April 11

(56 Days after the exposure)

April 11

(56 Days after the exposure)


SAFETY CULTURE

CONCLUSION

IS IT IMPORTANT SAFETY CULTURE?: YES

DO WE KNOW HOW TO DO IT?: NOT YET

DID WE LEARN? YES


Thank youGraciaswww.ipen.gob.pe [email protected]

Instituto Peruano de Energía Nuclear

Junio 2014

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IPEN : Ciencia y tecnología para la competitividad INSTITUTO PERUANO DE ENERGÍA NUCLEAR - IPEN FINDINGS AND PRELIMINARY RESULTS ON THE VENTANILLA ACCIDENT