Yanangio Nuclear power station accident, Perú - 1999

El 20 de Febrero de 1999, un soldador, trabajando con un tecnólogo radiólogo en una planta hidroeléctrica, tomó una fuente radiactiva industrial de iridio-192, accidentalmente perdida. El soldador puso en su bolsillo durante varias horas el material radiactivo. Después de seis horas, el trabajador comenzó a experimentar dolor en la parte posterior del muslo derecho. Se fue a su casa con la fuente, provocando exposiciones menores entre los miembros de su familia. El tecnólogo radiólogo, tras percatarse cerca de la medianoche de que la fuente radiactiva había desaparecido , llegó a la casa del soldador a la 1:00 am del 21 de febrero y ayudó a descubrir la fuente. El soldador recibió una dosis radiactiva en todo el cuerpo estimada en 150 rem, aunque las dosis localizada eran mucho más altas - hasta de 10,000 rad en una nalga - el tratamiento requirió la amputación de una pierna.

IAEA description: Incident with radiography source resulting in severe radiation burns.  level: 3

 www.google.com/fusiontables/DataSource?dsrcid=576709

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DESPUES DE LA LECTURA DE ESTE INFORME

A MUY POCAS PERSONAS LES QUEDARÁ DUDAS SOBRE LA CADENA DE NEGLIGENCIAS NUCLEARES QUE SE EVIDENCIARON EN 1999 EN LA HIDROELECTRICA DE YANANGIO ... LA EMERGENCIA NUCLEAR DE YANANGIO ESTA CONSIDERADA UNA DE LAS 30 MÁS GRAVES DEL MUNDO EN LOS ÚLTIMOS 50 AÑOS ... OTRA VEZ EL PERÚ FIGURA ENTRE LOS PRIMEROS ...

¿ESTA PERÚ PREPARADO PARA CENTRALES NUCLEARES? ... UN TÉCNICO OLVIDA EL MATERIAL RADIACTIVO EN UNA TUBERÍA POR AHÍ ... OTRO TÉCNICO "SE LO ENCUENTRA" Y SIN DECIR NADA SE LO EMBOLSICA ....

.www.asiainspectioncommunity.com/yanango-radio...

.www.asiainspectioncommunity.com/yanango-radio...

Chronology of the incident in brief

Welder

4:00 pm: A worker (welder) finds the source of gammagraphy (192 Ir) abandoned in a water pipe. He puts it in the back pocket of his trousers. He works for six hours with the source in his pocket and his assistant nearby

10:00 pm: He leaves work, takes a bus and travels home (he felt little pain in his right leg). During his return, he travelled for 30 minutes with 15 people. He thinks that the red skin is due to an insect sting. His wife sat on the trousers for 10 minutes to feed their baby. Two kids slept nearby.

11:00 pm: The welder, takes the trousers off the room.

Operator

10:30 pm: The operator makes a gammagraphy. The radiation detector doesn’t detect any readings. He assumes the equipment is not working well and stop to have dinner.

00:00 am: He enters the water pipe, checks the gammagraphy equipment and finds the no screws nor radioactive source. They start looking for the source.

1:00 am: They find the welder in his house (February 21st). He gets out with the source in his hands. The operator hits the welders hand, throws the source to the street and puts a stone to cover it. The source is recovered and secured in a container with iron walls 2” thick.

www.asiainspectioncommunity.com/yanango-radio...

www.asiainspectioncommunity.com/yanango-radio...

What Went Wrong? - Lesson Learnt

Organisation

- Procedures were not implemented.

- Absence of Safety Culture in the Company’s Management.

- Source inspection and measures were inadequate.

- Lack of training and qualification of the operators.

National Authorities

The evaluation of the authorisations and inspections should be developed by an experienced and trained team.

Equipment Manufacturers/Suppliers

Radiography cameras need to be designed and constructed in a way that prevents unauthorized access to the radioactive source.

Medical Community

Amputated tissue from highly exposed persons can provide an additional source of dose information that could help in the subsequent treatment of the patient. Care needs to be taken to ensure that such samples are kept until it is certain that they are no longer required.

References:

• IAEA, August 2000, The Radiological Accident in Yanago, IAEA (Vienna, Austria), on line at IAEA [http://www-pub.iaea.org/MTCD/publications/PDF/Pub1101_web.pdf].

• UNSCEAR, 2000, "Annex E: Occupational radiation exposures," in Sources and Effects of Ionizing Radiation: United Nations Scientific Committee on the Effects of Atomic Radiation UNSCEAR 2000 Report to the General Assembly, with Scientific Annexes, Volume I: Sources, UNSCEAR, on line at UNSCEAR [http://www.unscear.org/docs/reports/annexe.pdf].

www.asiainspectioncommunity.com/yanango-radio...

¿Qué salió mal en Yanangio? - Lecciones aprendidas

Organización

- Los procedimientos de trabajo con Fuentes Radiactivas no se implementaron.

- Ausencia de cultura de la seguridad en la gestión de Fuentes Radiactivas de la Compañía.

- Inspección de Fuentes Radiactivas y medidas de manipulación de Fuentes Radiactivas inadecuadas.

- Falta de formación, entrenamiento y calificación de los operadores de Fuentes Radiactivas.

Autoridades Nacionales

La evaluación de las autorizaciones y las inspecciones deben ser desarrolladas por un equipo experimentado y capacitado en Fuentes Radiactivas.

Fabricantes de Equipos / Proveedores

Las cámaras de radiografía deben ser diseñadas y construidas de manera que impidan el acceso no autorizado a la fuente radiactiva.

Médico de la Comunidad

El tejido amputado de las personas altamente expuestas a radioactividad puede proporcionar una fuente adicional de información sobre la dosis de exposición, que podrían ayudar en el tratamiento posterior de los pacientes. Se necesita tomar medidas de conservación de tales muestras, que aseguren tenerlas a mano, mientras sean necesarias.

www.asiainspectioncommunity.com/yanango-radio...

www.asiainspectioncommunity.com/yanango-radio...

www.asiainspectioncommunity.com/yanango-radio...

www.asiainspectioncommunity.com/yanango-radio...

 www.asiainspectioncommunity.com/yanango-radio...

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Riesgo Nuclear  en Perú: Yanangio 1999

Riesgo Nuclear  en Perú:

Yanangio 1999 -  the hydroelectric plant at Yanango.San Román, Department of Junín.

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Yanango orphaned source, 1999

compiled by Wm. Robert Johnston

last modified 11 June 2006 

Date: 20 February 1999

Location: Yanango, Peru

Type of event: lost source

Description:

A welder working with a radiographer at a hydroelectric plant picked up a lost iridium-192 industrial radiography source on 20 Feburary 1999 and put it in his pocket for several hours. After about six hours the worker began experiencing pain in the back of the right thigh. He went home with the source, causing minor exposures to family members. The radiographer, having discovered the source was missing about midnight, came to the welder's home at 1:00 AM on 21 February and helped discover the source. The welder received an estimated whole body dose of 150 rem, although localized doses were much higher--up to 10,000 rad to one buttock--requiring amputation of one leg.

Consequences: 1 injury.

References:

IAEA, August 2000, The Radiological Accident in Yanago, IAEA (Vienna, Austria), on line at IAEA [http://www-pub.iaea.org/MTCD/publications/PDF/Pub1101_web.pdf].

UNSCEAR, 2000, "Annex E: Occupational radiation exposures," in Sources and Effects of Ionizing Radiation: United Nations Scientific Committee on the Effects of Atomic Radiation UNSCEAR 2000 Report to the General Assembly, with Scientific Annexes, Volume I: Sources, UNSCEAR, on line at UNSCEAR [http://www.unscear.org/docs/reports/annexe.pdf].

 http://www.johnstonsarchive.net/nuclear/radevents/1999PER1.html

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Incident

INES level

Country

Location

IAEA description

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2011

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5

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2011

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2006

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2006

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2006

Erwin

US

36.145, -82.410833

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2005

Sellafield

3

UK

54.4205, -3.4975

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2005

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2

Argentina

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2005

Braidwood

US

41.243611, -88.229167

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2003

Paks

3

Hungary

46.5725, 18.854167

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1999

Tokaimura

4

Japan

36.4667, 140.5667

Fatal overexposures of workers following a criticality event at a nuclear facility

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1999

Yanangio

3

Peru

Latitude -11.2156 Longitude -75.4853

Incident with radiography source resulting in severe radiation burns

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1999

Ikitelli

3

Turkey

41.0792, 28.7825

Loss of a highly radioactive Co-60 source

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1999

Ishikawa

2

Japan

37.061111, 136.726389

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1993

Tomsk

4

Russia

56.5, 84.966667

Pressure buildup led to an explosive mechanical failure

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1993

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2

France

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1989

Vandellos

3

Spain

40.951389, 0.866667

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1989

Greifswald

Germany

54.140586, 13.664422

Excessive heating which damaged ten fuel rods

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1987

Goilnia

5

Brazil

-16.6746, -49.2641

Four people died and six received doses of a few Gy from an abandoned and ruptured highly radioactive Cs-137 source

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1986

Chernobyl

7

Russia

51.389553, 30.099147

Widespread health and environmental effects. External release of a significant fraction of reactor core inventory

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1986

Hamm-Uentrop

Germany

51.679167, 7.971667

Spherical fuel pebble became lodged in the pipe used to deliver fuel elements to the reactor

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1981

Tsuraga

2

Japan

35.672778, 136.0775

More than 100 workers were exposed to doses of up to 155 millirem per day radiation

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1980

Saint Laurent des Eaux

4

France

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Melting of one channel of fuel in the reactor with no release outside the site

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1979

Three Mile Island

5

US

40.153889, -76.724722

Severe damage to the reactor core

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1977

Jaslovsk Bohunice

4

Czechoslovakia

48.476111, 17.65

Damaged fuel integrity, extensive corrosion damage of fuel cladding and release of radioactivity

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1967

Chapelcross

UK

55.01566, -3.22605

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1966

Monroe

US

41.889167, -83.345556

Sodium cooling system malfunction

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1964

Charlestown

US

�Lat: 41.44N, Lon: 71.69W

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1959

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US

Santa Susana Field Laboratory, California

Partial core meltdown

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1958

Chalk River

Canada

Chalk River Nuclear Labs Chalk River, Ontario Canada K0J 1J0

Due to inadequate cooling a damaged uranium fuel rod caught fire and was torn in two

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1958

Vinca

Yugoslavia

Vin_a belgrade serbia

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1957

Kyshtym

6

Russia

Mayak, Russia

Significant release of radioactive material to the environment from explosion of a high activity waste tank.

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1957

Windscale Pile

5

UK

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1952

Chalk River

5

Canada

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A reactor shutoff rod failure, combined with several operator errors, led to a major power excursion of more than double the reactor's rated output at AECL's NRX reactor

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Hidroeléctrica Yanango (también conocida internacionalmente como Yanangio) lugar de la tragedia por exposición a radioactividad en 1999.