1. 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

2. IPEN : Ciencia y tecnología para la competitividad 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

3. IPEN : Ciencia y tecnología para la competitividad 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: 192 Ir Activity: 1221GBq (33 Ci) at that time

4. IPEN : Ciencia y tecnología para la competitividad 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. IPEN : Ciencia y tecnología para la competitividad 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.

6. IPEN : Ciencia y tecnología para la competitividad

7. 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 14 th in the morning.

8. IPEN : Ciencia y tecnología para la competitividad 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 14 th. Despite the accident, the company continued the operations on Saturday February 15 th, with other staff. The Regulatory Body stopped the operations on February 17 th. The reconstruction of the event was done on February 21 st 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 9 th Peru applied for assistance to the International Emergency Center.

9. IPEN : Ciencia y tecnología para la competitividad 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

10. February 17 ( 03 days after exposure)

11. IPEN : Ciencia y tecnología para la competitividad April 11 (56 Days after the exposure)

12. IPEN : Ciencia y tecnología para la competitividad SAFETY CULTURE CONCLUSION IS IT IMPORTANT SAFETY CULTURE?: YES DO WE KNOW HOW TO DO IT?: NOT YET DID WE LEARN? YES

13. IPEN : Ciencia y tecnología para la competitividad Thank you Gracias www.ipen.gob.pe sgonzales@ipen.gob.pe Instituto Peruano de Energía Nuclear Junio 2014