ML20236A177
| ML20236A177 | |
| Person / Time | |
|---|---|
| Issue date: | 03/02/1989 |
| From: | Chaney D, Lubenau J, Wilde R NRC OFFICE OF GOVERNMENTAL & PUBLIC AFFAIRS (GPA), NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| To: | |
| References | |
| PNO-GPA-89-001, PNO-GPA-89-1, NUDOCS 8903160439 | |
| Download: ML20236A177 (2) | |
Text
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' March'2,'1989 l
PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-GPA-89-01 j
This preliminary notification constitutes' EARLY notice of. events of POSSIBLE. safety or public interest significance. The information is as. initially received without verifi-cation or eval ~ation, and is basically all that is known by the Office of Governmental and Public Affairs staff on this date.
FACILITY: Delmed Licensee Emergency Classification:
San Salvador Notification of. Unusual Event El Salvador Alert Site Area Emergency General Emergency X Not Applicable
SUBJECT:
RADIATION OVEREXPOSURE AT P0OL IRRADIATOR GPA, NMSS, and Region I have collected the following information from the Department of
. State, the IAEA, and Nordion International, Inc. about a radiation incident in El Salvador.
On February 5, three employees of the Delmed company in San Salvador which operates an irradiator for medical sterilization were exposed to some dislodged source pencils from a'17 kilocurie cobalt-60 source supplied by AECL of Canada. The fact that.they were exposed was not discovered until well after the incident. The 3 workers known to have been exposed (more may be found later) received estimated doses of at least 400-600 rads. One individual is suffering severely from acute radiation sickness; the other two have moderate symptoms.
The Ministry of Social Security in El Salvador has requested urgent assistance from the IAEA, which has informally contacted the Oak Ridge Associated Universities (0RAU) for help. The IAEA plans to make a formal request for U.S. assistance. An ORAU REACTS team is awaiting further information and visas from the IAEA and will be dispatched as soon as possible.
i From what is now known, it appears there was no release of radioactivity to the environment.
Nordion International, Inc. is the successor to AECL's Radiochemical Company Division, which supplied the source.
The irradiator was installed at Delmed in 1974.
In June 1975, it had 108 kilocuries of Co-60. As a result of decay, its current loading is 17 kilocuries.
Prior to this incident, AECL-Nordion had not visited the company since December 1975, when some of the sources had come out of the source rack and fallen to the bottom of the pool. AECL was called upon to fix this, but neither it nor Nordion had visited again until February 1989.
The exact circumstances surrounding discovery of the problem are still uncertain. The following was reported. Nordion received a telephone call from the Delmed General Manager (GM) February 10. According to the GM, an operator had entered the room with the source rack down. Although he noticed that there were sources out of the rack, after leaving the room he brought the sources up anyway to perform the medical sterilizations. When the rack was lowered at the conclusion of the procedure, there was still radiation in the room.
-[i 8903160439 890302 PDR I&E Op' PNO-GPA-89-OO1 PDC
L There was a monitor in the maze, but it was inoperable and had been bypassed.
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Nordion agreed to send a team, which arrived in San Salvador on February 12 and was at the plant on February 13. They found the irradiator in a state of disrepair. The sole survey instrument in use was a Digi-Alert (which only alarms). As no test source was available, it was impossible to verify the instrument's operability.
l Using television cameras on the product conveyors, the Nordion team was able to locate the fallen source. They also measured a dose rate of 640 rad / hour at one meter.
On February 14-15, the Nordion team drilled a 4" hole through the concrete.
Sighting with the tv cameras, they were able to pick us the source with a lasso and lower it into the pool. They lef t the irradiator disa)1ed under water.
l February 16-17, they informed' Delmed that the irradiator could not be restarted until Delmed had made specifically identified repairs and modifications. The team then returned to Canada.
February 28, Nordion called Delmed to determine the status of the pool and to schedule a return visit.
In the course of this conversation, the Delmed GM asked Nordion whether the sources coming out of the rack could be the result of deliberate tampering.
Delmed had found a pole in the pool. The GM expressed the fear that the irradiator explosions nearby when they.were at the plant.) (The Nordion team had actually heard might become the target of guerrilla activity.
The GM also advised Nordion for the first time that 3 Delmed employees had been hospitalized with radiation sickness and that the El Salvador Ministry of Health had been notified.
j During a telephone call to NRC, Nordion advised that Becton-Dickinson in New Canaan, Connecticut had experienced what could be a " precursor-type" accident in 1981, when a product carrier had knocked some sources loose. AECL had issued a warning then, recommending that at the next source replenishment (typically about every 5 years) a shroud be placed around the sources which would cover and protect the source rack during irradiation activities. Nordion is almost positive that all U.S. irradiators have been so modified. No modifications had been made in El Salvador.
Nordion intends to write a report on this incident and will make it available to NRC.
They may also send an investigative team back to San Salvador. When the report is written depends upon their decision on sending the team. They did not know when this decision would be made.
This information is current as of 1:00 p.m. (EST) on March 2,1989.
(GPA/IP) - 492-0644; J. Lubenau (GPA/SLITP) - 492-0819; l
D.Chaney(NMSS/INMS)-
CONTACTS:
R. Wilde 492-3423 DISTRIBUTION:
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