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International Nuclear and Radiological - Latest Events


Recently posted reports on News.iaea.org
Recently posted reports on News.iaea.org

November 8th, 2024 08:55:53 EST -0500 Worker Overexposure
From September through December of 2022, a radioisotope processing facility had an equipment malfunction that caused syringes filled with Fluorine-18 to miss a shielding container and fall to the floor during production. During this time, workers retrieved the syringes by hand and manually loaded them into the shielded container. This change was not investigated by the radiation safety officer until after the occupational exposures were reviewed. One employee received an annual whole-body effective dose of 0.08 Sv (8.024 rem) which exceeded the U.S. regulatory limit for the annual whole-body effective dose of 0.05 Sv (5 rem). Extremity doses for the employee were below the U.S. regulatory limits. NMED Record 230077.
October 18th, 2024 03:16:07 EDT -0400 Unavailability of Reactor protection system of unit 3
Dukovany NPP is equipped by a digital Control and Protection system of Reactor. On January 11, 2024 Unit 3 of Dukovany NPP was a few days before refuelling outage, on stable operation on Power and Temperature effect with actual power 97 % Nnom, operation was in accordance with manuals. Routine testing of PPR Tester was planned. At 08:35 after connecting of the PPR Tester into division 3 of the reactor protection system a faulty connection was signalled and the test did not start. The personnel reconnected the PPR Tester and after that Error A1 was signalled. At the same time, the data in the safety network SN 3 become invalid. Subsequently all process units connected to this network (= whole division 3 of reactor protection system, including information subsystem) became invalid and stopped work. Investigation of event revealed, due to human errors and inner fault of the PPR tester a test data was transmitted into division 3 of the Reactor protection system. Due to architecture of the Reactor protection system, into Safety networks of division 1 and 2 of the Protection system also testing data was transmitted. It caused Divisions 1 and 2 also were blocked. The Tester was disconnected and testing was cancelled. The MCR stuff did not knew how complex problem was, they assumed safety functions were not affected. Investigation of event revealed, internal error of PPR Tester occurred 3 days before during maintenance of the PPR tester. 08:38 the MCR stuff started shut down of Unit 3 fluently according to General rules of OLC. 09:41 2 divisions of Reactor Protection system were restored, so Unit 3 entered into state defined in OLC and Unit 3 was stabilised on 81 % Nnom. 10:02 all 3 divisions of Reactor protection system were Restored, OLC were fully fulfilled. During the event manual control of reactor including manual trip, Post accident monitoring system and directly displayed data were available.
September 23rd, 2024 12:24:33 EDT -0400 Theft of a nuclear gauge
On September 20, at approximately 16:51 (UTC-22.51), the theft of a CPN nuclear densimeter, model MC-1, serial number MD10700322, was reported to the CNSNS office, which contains the following radioactive sources: 1- Am-241/Be (with an activity today of 1.75 GBq) 2- Cs–137 (with an activity today of 170 MBq). The theft occurred when the equipment was extracted from a vehicle owned by the company LAMSYCO LABORATORIOS, S.A. de C.V., at Boulevard 2000 in the Colonia Altiplano Tijuana, Baja California, México at approximately 15:00 (UTC-21:00) on September 20, 2024.
September 23rd, 2024 01:01:12 EDT -0400 Theft of a nuclear gauge
On September 20, at approximately 16:51 (UTC-22.51), the theft of a CPN nuclear densimeter, model MC-1, serial number MD10700322, was reported to the CNSNS office, which contains the following radioactive sources: 1- Am-241/Be (with an activity today of 1.75 GBq) 2- Cs–137 (with an activity today of 170 MBq). The theft occurred when the equipment was extracted from a vehicle owned by the company LAMSYCO LABORATORIOS, S.A. de C.V., at Boulevard 2000 in the Colonia Altiplano Tijuana, Baja California, México at approximately 15:00 (UTC-21:00) on September 20, 2024.
August 21st, 2024 09:35:22 EDT -0400 Worker Exceeded Annual Dose Limit
On December 11, 2023, a pharmaceutical technician noted a pressure issue with a synthesis cell, which contained 11.29 GBq (305 mCi) of Fluorine-18. The pharmaceutical technician opened the synthesis cell and Fluorine-18 splashed onto their upper chest, neck, and underarm. The pharmaceutical technician could feel wetness after the incident, and decontamination efforts were initiated within 3 to 5 minutes. The skin exposure calculations, based on radiological survey results, indicated that the pharmaceutical technician received an estimated shallow dose equivalent of 0.902 Sv (90.2 rem). The dose to the employee exceeded the U.S. regulatory limit for the annual dose to the skin of the extremities of 0.5 Sv (50 rem). NRC Event Number (EN) 56923
August 15th, 2024 07:24:15 EDT -0400 Worker Exceeded Statuary Annual Whole Body Dose Limits
On 09.03.2023, an employee of a company carried out a weld inspection using an X-ray device. To align a workpiece to be tested, the worker left his workstation disregarding the radiation protection warning measures, which consist of a barrier rope, a flashing warning light and the warning signal of a radiation protection dosimeter which measured the local dose rate. The workers head came into the beam of the X-ray device in operation for a duration of about 2 minutes. An effective whole body dose, an equivalent dose for the lens, and an equivalent dose for the skin were estimated based on a reconstruction of the likely scenario. The effective whole body dose was set to 230 mSv and the equivalent dose for the lens of the eye was set to 546 mSv by the authority. An expert inspection of the X-ray device determined that the equipment was technically in order. The cause of the incident was determined to be human error.
May 27th, 2024 21:37:22 EDT -0400 Missing dangerous source during transport had been found
On 11 January 2024 around 18.00 hours local time, BAPETEN received notification of missing dangerous source during transportation of a gamma camera containing of Ir-192 (the activity of the source when the incident occurred was 1917,8 GBq/51,8 Ci) in Sub District Jambangan, Surabaya, East Java. This equipment belongs to a company in Makassar, South Sulawesi and its type/serial number is LIR-05/008/AG624-8347G. The national protocol immediately activated and a search operation immediately carried out by the CBRNE Detachment at East Java Province Police. On 13 January 2024 around 07.00 hours local time, the gamma camera had been found and recovered by the CBRNE Detachment at East Java Province Police in the Sub District Pakal, Surabaya, East Java. The equipment remains intact and there was no measurable increase of radiation detected around the equipment surrounding. The incident involving criminal activities. Upon criminal investigation, the equipment had been submitted to the owner company in Makassar
April 29th, 2024 06:23:57 EDT -0400 Partial loss of post-trip cooling
The planned reactor trip triggered switching of the reactor’s eight Gas Circulators' (GC) power supply from “nominal - 11kV” to “variable speed – 3.3kV”. The 3.3kV power supply is provided by four Variable Frequency Convertors (VFC) and four Variable Speed Drives (VSD). In this case two VFC failed to start, and one VFC and one VSD tripped shortly after starting. Reactor cool down was safely provided by the remaining four GCs for 6 hours when the two failed VFCs were brought into service, which improved cooling margins.
April 17th, 2024 13:25:10 EDT -0400 Worker Exceeded Annual Extremity Dose Limit
An employee received a dose of 0.95 Sv (95 rem) to the extremities (hands) due to improper handling and response to an incident involving a damaged 85.1 MBq (2.3 mCi) Co-60 source. This dose was estimated by the Illinois Emergency Management Agency and confirmed by the licensee. The source was initially damaged when molten steel flowed over the source housing, severing the source into at least two pieces. The smaller portion, estimated to contain approximately 2.0 MBq (53 uCi), was inadvertently withdrawn from its shielded housing, fused with solidified steel and later partially recovered by the employee. The remainder of the Co-60 source was found to have been covered in solidified steel that prevented its return to the shield. The employee used a 4-inch angle grinder in an effort to remove the solidified steel so it would fit back into the shield. Inspection findings indicate the employee used gloved hands to effect recovery and handle both source fragments. Inspection findings also identified routine handling of intact sources during installation/removal. The combined activities, duration of the movements and frequency of handling were used to estimate the above extremity dose. During the grinding operation, the internal Co-60 wire was impacted and gave rise to site contamination. An examination of the source and estimates from the manufacturer indicate the amount of activity involved in the grinding operation (much less the portion available for respiration amongst sparks/abrasive material) was insufficient to result in an inhalation dose in excess of regulatory limits. The causes of the incident were inadequate training and failure to follow operating procedures. In addition, the improper handling of sources was due, in part, to an unauthorized modification of the sealed source, dated shielding assemblies and repeated physical damage and fouling of the threads atop the sealed source. The employee has ceased work with radioactive materials for the year. Corrective actions taken by the licensee in response to this event include writing a new procedure, making an engineering change to the system, and implementing improved procedures. The dose to the employee exceeded the U.S. regulatory limit for the annual dose to the skin of the extremities of 0.5 Sv (50 rem). EN57016
February 7th, 2024 09:25:39 EST -0500 Internal contamination of a worker in a fuel pellets fabrication workshop
The event occurred in the pelleting workshop, where mixtures of plutonium and uranium oxide powders are compacted into cylindrical pellets. These operations are carried out in glove boxes. While cleaning a glove box containing a compacting press, one of the gloves was punctured, causing atmospheric contamination of the working area. This contamination was detected by the room’s radiation monitors and the area was evacuated in accordance with the procedures in force. One of the three people present in this room was contaminated. The CEA Marcoule medical service then took charge of this person. Orano Cycle informed ASN of this event on 12 February, indicating that radio-toxicological analyses had been run to estimate the committed dose for this person. These analyses, which lasted several months, show that the committed dose could exceed the annual dose limit set at 20 mSv. Therefore, on 24 June 2020, Orano Cycle reported this event as a “significant event” in accordance with ASN’s requirements. The CEA Marcoule medical service and Orano Cycle are continuing their investigations in order to determine the committed dose value, since the estimated committed dose for this event is far higher than expected on the basis of the atmospheric contamination level measured by the workplace monitors when the event occurred. This event had no consequences on either the installations or the environment. Orano Cycle cleaned the room and assessed the equipment used. The licensee started to work on improving the mechanical strength of the gloves and the configuration of the workstations. ASN will also assess the results of investigations concerning the relationship between the level of contamination measured by the monitors and the estimated committed dose.
February 7th, 2024 09:24:24 EST -0500 Internal contamination of a worker in a fuel pellets fabrication workshop
The event occurred in the pelleting workshop, where mixtures of plutonium and uranium oxide powders are compacted into cylindrical pellets. These operations are carried out in glove boxes. While cleaning a glove box containing a compacting press, one of the gloves was punctured, causing atmospheric contamination of the working area. This contamination was detected by the room’s radiation monitors and the area was evacuated in accordance with the procedures in force. One of the three people present in this room was contaminated. The CEA Marcoule medical service then took charge of this person. Orano Cycle informed ASN of this event on 12 February, indicating that radio-toxicological analyses had been run to estimate the committed dose for this person. These analyses, which lasted several months, show that the committed dose could exceed the annual dose limit set at 20 mSv. Therefore, on 24 June 2020, Orano Cycle reported this event as a “significant event” in accordance with ASN’s requirements. The CEA Marcoule medical service and Orano Cycle are continuing their investigations in order to determine the committed dose value, since the estimated committed dose for this event is far higher than expected on the basis of the atmospheric contamination level measured by the workplace monitors when the event occurred. This event had no consequences on either the installations or the environment. Orano Cycle cleaned the room and assessed the equipment used. The licensee started to work on improving the mechanical strength of the gloves and the configuration of the workstations. ASN will also assess the results of investigations concerning the relationship between the level of contamination measured by the monitors and the estimated committed dose.
February 1st, 2024 19:18:44 EST -0500 Worker exposure to X-ray generator
On May 29, 2021, two workers were inspecting and calibrating the fluorescent X-ray adhesion meter (output 50kV x 40mA) at the Nippon Steel Setouchi Works in Himeji City, Hyogo Prefecture. There are three main operations for irradiating X-rays with this device. ・ Power supply to this device ・ Increase the voltage and current of the X-ray tube ・ Open the shutter of the irradiation window. These operations are usually performed on the control panel outside the irradiation room where the device is installed. Initially, the two workers were working on the control panel outside the irradiation room, but when the calibration sample showed abnormal measures, they entered in the irradiation room with the device on power. There is no legal requirement for this facility to have interlocks, which cut off the power supply when the irradiation room door opens. As the two workers in the irradiation room confirmed some deposits on the X-ray irradiation window of the device, one of the workers removed them with a hand tool, and the other assisted. The two workers believed that they had closed the shutter of the irradiation window when entering the irradiation room, but it was revealed that the shutter had not been closed and that the workers were exposed to the X-rays emitted from the device during the operation. On May 30, 2021, two workers were hospitalized and treated following physical complaints and erythema on their arms and faces, which are non-fatal symptoms. The two workers left the hospital by the end of December 2021. Base on the results of the biological dosimetry (measurement of the frequency of chromosomal abnormality) conducted by November 2023, the experts evaluated the exposure to 400-500 mGy for one worker and less than 100 mGy for the other worker.
January 26th, 2024 08:34:23 EST -0500 Radon Exposure at Boarding School
The incident occurred at a private boarding school where pupils, employees and their children had been exposed to high levels of radon gas in the atmosphere. The two employees and their two children were exposed to the high radon gas levels as a result of working and living at the school. The five overexposed pupils studied and lived at the school during this time. An investigation by the regulator (Health and Safety Executive) found that the school knew they had a radon problem as far back as 2007 when they carried out monitoring and installed some remediation to reduce radon levels. However, from 2010 to 2018 the school carried out no subsequent radon monitoring and had no systems in place to ensure radon control measures were adequate. Only following an intervention by the regulator in 2018 did the school find out about their previous radon problem when further radon monitoring and remediation was subsequently carried out to reduce radon levels. Dose estimations were made based on expected occupancy times for the individuals for that year, these were as follows: Employee 1 : 15mSv Employee 2 : 15mSv Employees child 1 (member of the public): 14mSv Employees child 2 (member of the public): 14mSv Pupil 1: (member of the public): 8mSv Pupil 2: (member of the public): 8mSv Pupil 3: (member of the public): 8mSv Pupil 4: (member of the public): 8mSv Pupil 5: (member of the public): 8mSv The annual effective dose limit in the UK for employees is 20mSv and for members of the public is 1mSv.
January 12th, 2024 17:41:33 EST -0500 Declaration of Unusual Event (NUP-4.1)
On January 4, 2024, the Unit 1 was operating at 100% power. At 09:00 (local time) the steam tunnel cooling unit “1-RRA-FC-009A” was started due to equipment rotation resulting in the loss of energy in the Motor Control Center (MCC) “1-R31-MCC-1BA-AA” with the failure of the electrical protection of the cubicle 5D of the MCC “1-R31-MCC-1BA-A”. At 09:05, the Auxiliary Reactor Operator reported the presence of smoke in the MCC “1-R31-MCC-1BA-A” preventing the manual opening of the cubicle 5D. At 09:10, the Auxiliary Turbine Operator reported that the switch 7A that energize the MCC “1-R31-MCC-1BA-A” could not be manually open. At 09:17, the Auxiliary Reactor Operator reported the presence of fire in the MCC “1-R31-MCC-1BA-A” located in the elevation 18.70 of the Reactor Building. The bus 14BA was de-energized by manually opening the switches 14BAM and 14BA resulting in entry to the procedure 1-OA-0556 "Loss of 4160/480VAC non-critical". The fire brigade was activated according to the procedure PAS-32 "Fire Protection Program". At 09:32, an Unusual Event was declared due to fire in the protected area not extinguished in 15 minutes (NUP-4.1). At 09:45, the Chief of the fire brigade reported that the event had been controlled and that maneuvers to recover the area would begin. At 13:30, the Unusual Event was declared finalized.
December 7th, 2023 08:35:30 EST -0500 Worker Exceeded Annual Whole Body Dose Limit
A radiography trainee received a dose of 0.075 Sv (7.50 rem) to the whole body and 0.258 Sv (25.8 rem) to the extremities due to a disconnected 2.33 TBq (63 Ci) Ir-192 source. This dose was determined through reconstruction of the event and dose calculations. The trainee did not wear his dosimetry badge and he did not turn on his alarming rate meter. He connected the source without supervision and began to take radiography shots of a pipe. After the third shot, he cranked the drive cable without the source back in the camera. He did not perform a survey to make sure the source was back in the camera. He walked up to the pipe and exchanged the film. He moved the end of the guide tube inside the pipe placing his hand approximately four inches from where the source was located. He walked back and cranked the drive cable back to the end of the guide tube and backed away from the cranks during the shot time. He repeated this three more times, and while he was disconnecting the guide tube from the camera to switch to a guide tube with a collimator, he noticed that the indicator on the camera showed that the source was not back in the camera. He checked his personal dosimeter and found it off scale. He reported this to his trainer. The radiation safety officer and an assistant arrived to perform the source retrieval. They inspected the source assembly connector and the drive cable connection, and connected them. They cranked the source back into the camera. The trainee did not have any symptoms of radiation exposure, which was supported by daily pictures of his hands and weekly bloodwork collected for a month. The cause of the incident was failure to properly connect the source assembly to the drive cable followed by a failure to use a survey meter. Another cause was that the trainer did not supervise the trainee. The licensee reported that they have conducted retraining with all radiographers and have suspended the two radiographers in this incident. The licensee has reported that they will increase the frequency of their audits. The dose to the trainee exceeded the U.S. regulatory limit for the annual whole body dose of 0.05 Sv (5 rem). EN56761.