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FINDINGS AND PRELIMINARY RESULTS ON THE VENTANILLA ACCIDENT

FINDINGS AND PRELIMINARY RESULTS ON THE VENTANILLA ACCIDENT. MSc . Susana Gonzales Occupational Radiation Protection Area - IPEN.

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FINDINGS AND PRELIMINARY RESULTS ON THE VENTANILLA ACCIDENT

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  1. FINDINGS AND PRELIMINARY RESULTS ON THE VENTANILLA ACCIDENT MSc. Susana Gonzales OccupationalRadiation Protection Area - IPEN

  2. 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 Radiographycompanies. 136 Radiography equipment machines are movable and one is fixed 300 operatorshave individual licenses 64 radioprotectionofficershavelicenses GENERAL INFORMATION

  3. Ventanilla Accident Information of theaccident Date: February 14th, 2014, earlymorning (at 2: 30 a.m.) Place: Ventanilla, Callao Authorizedactivity: Industrial Radiography Radioactivesource: 192Ir Activity: 1221GBq (33 Ci) at that time

  4. 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.

  5. Joint 20 Joint 22 • 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. Joint 24 Joint 39

  6. BACKGROUND 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.

  7. Findingsand 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.

  8. Findings and Actions – 2 RootCauses The operators did not comply their duties. Nobody did the job of radiological protection officer Therewere 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. CorrectiveActions 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

  9. February 17 ( 03 daysafterexposure)

  10. April 11 (56 Daysaftertheexposure)

  11. SAFETY CULTURE CONCLUSION IS IT IMPORTANT SAFETY CULTURE?: YES DO WE KNOW HOW TO DO IT?: NOT YET DID WE LEARN? YES

  12. Instituto Peruano de Energía Nuclear Thank you Gracias www.ipen.gob.pe sgonzales@ipen.gob.pe Junio 2014

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