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International Nuclear and Radiological - Latest Events


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

December 26th, 2024 05:58:24 EST -0500 Accidential Exposure of Industrial Radiography Worker
On September 12, 2023, during industrial radiography, the control cable of the equipment ruptured, causing the radiation source(Ir-192, 1.75 TBq) to detach inside the guide tube. The worker was unable to notice the detachment of the radiation source in time due to the lack of proper radiation safety equipment and continued working. After completing the work, it was confirmed that all the taken film were overexposed, leading to the realization that the radiation source had detached. Although no clinically significant effects, such as blood abnormalities or skin tissue reactions, were observed, the radiation dose assessment indicated an effective dose of 116 mSv and a hand (skin) equivalent dose of 1967 mSv.
December 26th, 2024 05:57:53 EST -0500 Exposure of Workers at a Facility using a Radiation Generating Device
In July 2017, at a semiconductor manufacturing company, seven workers were exposed to radiation due to the abnormal use of an X-ray generator(100 kVp, 0.1 mA) for product defect inspection. The X-ray generator was a cabinet-type device with a shielding door interlock, but the workers manually disabled the interlock, allowing the shielding door to be opened while the X-rays continued to emit. While the X-rays were being emitted, the workers inserted their hands and upper bodies into the device to perform the work. Among the seven exposed workers, two workers developed radiation effects on their hands, including erythema, pain, and blisters. Radiation dose assessments conducted that while the effective dose for the seven workers did not exceed the annual dose limit, the skin equivalent dose exceeded the annual dose limit for all of them.
December 26th, 2024 05:57:27 EST -0500 Accidential Exposure of Industrial Radiography Worker
On August 24, 2018, during industrial radiography using a sealed radiation source (Ir-192, 1.22 TBq), the radiation source became stuck inside the guide tube, making it impossible to retrieve. During the initial response, the remote control cable was incorrectly assembled in the opposite direction, but the worker did not notice this mistake. The worker believed that the source had been safely retrieved into a shielding container, but instead, the source was pushed outside the container and remained inside the guide tube. When the worker attempted to detach the guide tube from the shielding container, the source became exposed. The worker then physically handled the source capsule with bare hands, resulting in radiation exposure. At the time, the worker did not have a radiation detector, so the exact position of the source was unknown. The source was later safely retrieved by another worker. The worker’s hand equivalent dose was assessed as 960 mSv, which exceeds the dose limit.
December 26th, 2024 05:55:58 EST -0500 Exposure from a Medical Treatment Source
On July 21, 2017, at a hospital in Seoul, an incident occurred when the assigned staff member failed to follow the patient verification procedure in the I-131 therapy room. As a result, a dose of I-131 (5,550 MBq), intended for a thyroid desease patient, was mistakenly administered to another patient. The misadministrated patient had been hospitalized since July 19 for MIBG therapy and had already received a dose of I-131 (7,400 MBq). Due to the misadministration, the additional thyroid absorbed dose was estimated to be between 15.6 and 24.4 Gy.
December 26th, 2024 05:55:30 EST -0500 Workers Exceeded Annual Whole Body Dose Limits
In December 2016, it was reported to the regulatory authority that an industrial radiography worker's personal dosimeter reading had exceeded the annual dose limit. An investigation revealed that the worker had been exposed to high levels of radiation on a night-field radiography work during November and December 2016. As a result, the worker developed a deterministic effect(pancytopenia). Additionally, three other workers at the same company were found to have exceeded the dose limit. Among the four workers, the highest effective dose was evaluated at a maximum of 1.19 Sv.
December 26th, 2024 05:54:59 EST -0500 Accidential Exposure of Industrial Radiography Worker
On December 3, 2015, an industrial radiography worker repeatedly conducted NDT without realizing that a sealed radioactive source(Ir-192, 1.1 TBq) had not been properly retracted and remained at the end of the guide tube. On December 8, the worker began feeling symptoms such as pain, redness, and blisters on both hands. Although the worker received treatment at a common hospital, no further actions were taken at that time. On January 27, 2016, the incident was reported to the regulatory authority, and the worker received treatment at a specialized hospital on radiation hazard. The equivalent dose to the worker's hands was estimated to be approximately 30 Sv.
December 26th, 2024 05:53:22 EST -0500 Accidential Exposure of Industrial Radiography Worker
On April 20, 2015, two workers were conducting a industrial radiography for Non-Destructive Test on the welds of a large steel product. During the process, the guide tube of the irradiator was not properly connected, causing the radiation source (Co-60, 1.85 TBq) to be withdrawn but not retrieved. One of the workers entered the radiographic testing room to retrieve the radiation source but accidentally stepped on the source without realizing its location, resulting in radiation exposure. On May 6, 2015, erythema was observed on the sole of his right foot, leading to the recognition of excessive radiation exposure. The doses were assessed as an effective dose of 0.9 mSv and a foot equivalent dose of 2.5 Sv.
December 26th, 2024 05:52:41 EST -0500 Accidential Exposure of Industrial Radiography Worker
On June 26, 2014, during the setup and operation of testing equipment for industrial radiography, a radiation exposure incident occurred. The support structure of the equipment fell onto the guide tube, causing it to deform and disabling the retrieval of the radiation source(Co-60, 2.1 TBq). While attempting to repair the damaged portion of the guide tube by hand, the worker was exposed to radiation. The personal dosimeter reading indicated an effective dose of 117.1 mSv. Radiation burns were observed on the worker's hand, and the hand equivalent dose was estimated to be between 10 and 25.8 Sv.
December 18th, 2024 06:04:37 EST -0500 Package containing four radioactive sources lost.
On Thursday 12th December 2024, LOMA SYSTEMS S.R.O. sent from the Czech Republic a B(U) package, model NE4C, with 4 encapsulated radioactive sources of Se-75 (3.4 TBq each one), used for industrial radiography, to a radioactive facility located in Madrid. These sources are classified as category 2 according to IAEA RS-G-1.9. The package was sent from Prague airport, with ticket number AWB 797-1000 2016 of the airline TRAVEL SERVICE, A.S., on flight QS1056, which arrived at 13:05 at Madrid - Barajas Airport. On Friday 13th, staff of the consignee went to the cargo handling facility to pick up the package and transport it by road to the radioactive facility. Once there, they were unable to pick up the package as the handling agent indicated that they had no notification of receipt of the package at their facilities and therefore did not know its location. Throughout Friday, the consignee searched for information at the cargo at origin (Prague) and destination (Madrid) with the customs broker, freight forwarders, consignor and airline, but the result was unsuccessful. Investigations continued on Monday 16th, December to determine the location of the package. The final conclusions of all the investigation revealed that: - The sender stated that the flight left Prague Airport (PRG), and did not return, so the package must have been unloaded in Madrid. - According to the Travel Service airline, the camera system at Prague airport showed Skyport PRG airport handling staff placing the package on a trolley to the aircraft. They also had a statement from a ramp worker confirming that he loaded the package into the plane. - Skyport PRG searched its warehouse, but did not find the package. - The carrier (Hazmatcargo) requested a search of the station (MAD), where the aircraft later flew, but the results were negative, and the package was not located. On Monday 16th at 11:30 am, the consignee informed the CSN Emergency Room (SALEM) of the occurrence of the event according to IS-18 (instruction of the CSN concerning the radioactive facilities). Subsequently, the CSN Transport Department (ATMR) took charge of the event, once it was established that it was a transport event. Therefore the event should have been reported under IS-42, (Instruction of the CSN concerning event notifications at transport of radioactive material), by the transport enterprise. Once the notification was received, the CSN took the following actions on Monday 16th: - At 13:38 pm, the consignee was contacted by telephone to confirm the data received and to update the status of the event, and to request additional information. - At 14:28 pm,the handling agent was contacted to confirm the shipment data and it indicated that they never received the package at the freight/cargo terminal. - At approximately 17:00 pm, the CSN decided to compose a team of inspectors to visit the handling agent’s facilities at the airport, notifying them of the visit. - At the same time, in the interval until the CSN team arrived at the airport at 19:00 pm, communications with consignee and handling agent were repeated to gather additional information, but new data was not obtained. In the offices of the handling agent at the airport, the CSN team, accompanied by the personnel from the airport's Judicial Police, collected more detailed information from the managers of the handling agent, who contacted with the ground handling agent (the company in charge of ground activities at the airport). The Guardia Civil (Spain’s national law enforcement agency in charge of the customs control and airport security) joined the search for the missing package, checking the security cameras to determine whether the package had been unloaded from the aircraft. During the course of this check, the handling agent’s personnel, after a closer examination of their terminal goods receipt register, identified the entry corresponding to the missing package. Finally, as result of the investigations carried out by the Guardia Civil, the package was located in another terminal of the airport, hidden below a cone. Once the appropriate radiological controls were carried out by the CSN team, and the package was checked to be in perfect conditions, it was transferred to the in-transit radioactive materials storage facility of the handling agent, where it was verified that it was properly stored in compliance with the security measures. Preliminary analysis indicates that there are various regulatory non-compliances in the chain of events leading to the loss of the package. Therefore, an in depth assessment of those non compliances will be made in the short term as part of an inspection of the handling agent by the CSN.
December 18th, 2024 05:15:13 EST -0500 Package containing four radioactive sources lost.
On Thursday 12th December 2024, LOMA SYSTEMS S.R.O. sent from the Czech Republic a B(U) package, model NE4C, with 4 encapsulated radioactive sources of Se-75 (used for industrial radiography) to a radioactive facility located in Madrid. The package was sent from Prague airport, with ticket number AWB 797-1000 2016 of the airline TRAVEL SERVICE, A.S., on flight QS1056, which arrived at 13:05 at Madrid - Barajas Airport. On Friday 13th, staff of the consignee went to the cargo handling facility to pick up the package and transport it by road to the radioactive facility. Once there, they were unable to pick up the package as the handling agent indicated that they had no notification of receipt of the package at their facilities and therefore did not know its location. Throughout Friday, the consignee searched for information at the cargo at origin (Prague) and destination (Madrid) with the customs broker, freight forwarders, consignor and airline, but the result was unsuccessful. Investigations continued on Monday 16th, December to determine the location of the package. The final conclusions of all the investigation revealed that: - The sender stated that the flight left Prague Airport (PRG), and did not return, so the package must have been unloaded in Madrid. - According to the Travel Service airline, the camera system at Prague airport showed Skyport PRG airport handling staff placing the package on a trolley to the aircraft. They also had a statement from a ramp worker confirming that he loaded the package into the plane. - Skyport PRG searched its warehouse, but did not find the package. - The carrier (Hazmatcargo) requested a search of the station (MAD), where the aircraft later flew, but the results were negative, and the package was not located. On Monday 16th at 11:30 am, the consignee informed the CSN Emergency Room (SALEM) of the occurrence of the event according to IS-18 (instruction of the CSN concerning the radioactive facilities). Subsequently, the CSN Transport Department (ATMR) took charge of the event, once it was established that it was a transport event. Therefore the event should have been reported under IS-42, (Instruction of the CSN concerning event notifications at transport of radioactive material), by the transport enterprise. Once the notification was received, the CSN took the following actions on Monday 16th: - At 13:38 pm, the consignee was contacted by telephone to confirm the data received and to update the status of the event, and to request additional information. - At 14:28 pm,the handling agent was contacted to confirm the shipment data and it indicated that they never received the package at the freight/cargo terminal. - At approximately 17:00 pm, the CSN decided to compose a team of inspectors to visit the handling agent’s facilities at the airport, notifying them of the visit. - At the same time, in the interval until the CSN team arrived at the airport at 19:00 pm, communications with consignee and handling agent were repeated to gather additional information, but new data was not obtained. In the offices of the handling agent at the airport, the CSN team, accompanied by the personnel from the airport's Judicial Police, collected more detailed information from the managers of the handling agent, who contacted with the ground handling agent (the company in charge of ground activities at the airport). The Guardia Civil (Spain’s national law enforcement agency in charge of the customs control and airport security) joined the search for the missing package, checking the security cameras to determine whether the package had been unloaded from the aircraft. During the course of this check, the handling agent’s personnel, after a closer examination of their terminal goods receipt register, identified the entry corresponding to the missing package. Finally, as result of the investigations carried out by the Guardia Civil, the package was located in another terminal of the airport, hidden below a cone. Once the appropriate radiological controls were carried out by the CSN team, and the package was checked to be in perfect conditions, it was transferred to the in-transit radioactive materials storage facility of the handling agent, where it was verified that it was properly stored in compliance with the security measures. Preliminary analysis indicates that there are various regulatory non-compliances in the chain of events leading to the loss of the package. Therefore, an in depth assessment of those non compliances will be made in the short term as part of an inspection of the handling agent by the CSN.
December 17th, 2024 05:45:32 EST -0500 Triggering of the fire sprinkler system in a fuel production facility at a research center
During an exercise, the fire sprinkler system in a laboratory building was activated. Approximately 2000 liters of water affected 9 rooms in the facility. The water was gathered and collected in storage tanks. No radioactive contamination was detected in the water nor in the equipment used in the cleanup. On the day of the event a live action exercise was being conducted. The fire sprinkler system had been turned off so that smoke machines would not trigger them. When the fire sprinkler system was re-activated, a pre-warning was triggered at the fire station and the sprinklers were accidentally activated. 10 sprinklers were active for approximately 15 minutes, resulting in 2000 liters of water pooling on the floors of 9 rooms in the facility. There has been no contamination detected in the resulting water. Tools used to swab the water, and the floors themselves, were also tested for contaminants after the water was cleaned up. Background levels in the facility are normal.
December 10th, 2024 16:25:52 EST -0500 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. On December 6th, 2024 at 19:36 (UTC-6), the radiological officer of the affected company received an anonymous call telling that the equipment was located on the "Playas de Tijuana" highway. Finally, the device was secured and recovered at around 20:20 (UTC-6).
November 22nd, 2024 23:34:35 EST -0500 Fuel misplaced
On November 20, 2024, at around 15:00 hours, during the inspection carried out by IAEA safeguards personnel to perform the Criticality test of the MXA-TRIGA Mark III Reactor and verify its reactor configuration, it was detected that in position B-1 of ring B, which should be empty according to the configuration, there is nuclear fuel from position C-1. As corrective actions, the fuel in position B-1 will be returned to its correct position, after the inspection work on the aluminum coating of the reactor pool is completed and the water level is returned to its normal condition, since it is currently 4.40 m below its normal level. Finally, this regulatory body was notified on November 21, 2024.
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.