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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 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.
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.