1. Investigation of Accelerator Incidents – Regulatory Perspective Abdul Alwani Canadian Nuclear Safety Commission

2. Outline Regulation of Accelerators in Canada Why Incident Investigation How Incident Investigation Regulatory Practice Conclusion

3. Canadian Nuclear Safety Commission (CNSC) mission is to regulate the use of nuclear energy and materials to protect health, safety, security and the environment and to respect Canada's international commitments on the peaceful use of nuclear energy.

4. CNSC Independent federal government agency Licence required Licensee responsible for safety CNSC monitors compliance

5. Particle Accelerator Licensees in Canada Major Accelerators (Class I)2 –TRIUMF –CLSI PET Cyclotron Facilities 7 Industrial or Research Accelerators7 Medical Linac Facilities44

6. Operating Experience Why OPEX? –To learn from incidents –To provide performance assurances wrt compliance wrt model

7. System for Investigating Incidents Formal, systematic, structured, objective and comprehensive Approach Process and Methods

8. Failure Types Two types of failure Active Failure: one which has an immediate adverse effect Latent Failure: either decision or action, with damaging consequences which may lie dormant in the system for long time

9. Root Cause A Fundamental cause which, if corrected, will prevent recurrence of an event or condition

10. Analysis Techniques Many methods, common goal Tap Root @ HPES

11. Event and Causal Factors Charting A graphically displayed flow chart of the entire significant event, where the sequence of events is plotted on a time line. As the flow of events is established additional information relating to the secondary conditions or events, changes and barriers is added.

12. Effective Investigations Independent Prompt Expertise Corrective Actions Management Role Graded Approach

13. Reporting Requirements (a)failure of equipment or procedures which led to or which, in the absence of safety systems provided, could have led to any release of radioactive material from the facility; (b)failure of a safety or safety-related system which did prevent or could have prevented the system from performing its intended safety function as described in the [licensing] documents… or meeting the conditions for safe operation defined in the [licensing] documents…; (c)inaccuracy or incompleteness in the [licensing] documents …that could affect the results of the safety assessment in these documents; (d)hazard different in nature or greater in probability or magnitude than that described in the [licensing] documents …; and (e)event that constitutes or reveals a violation of any conditions of this licence, the Nuclear Safety and Control Act or its Regulations.

14. CNSC Follow Up Emergency Response Consequences Safety Case Corrective Action Plan

15. Example Electrical burn to a student’s finger while working on HV circuit –Investigation –Corrective Actions

16. Conclusion The CNSC considers that a systematic way of investigating incidents arising from the operation of accelerators and learning from them to improve safety is an essential capability and activity for the accelerator licensees. The CNSC promotes operating experience programs at the licensed accelerator facilities where undesirable events or near misses are turned into lesson opportunities.