Lessons learned from the radiological accident in Mayapuri ...Mayapuri is a locality in West Delhi....
Transcript of Lessons learned from the radiological accident in Mayapuri ...Mayapuri is a locality in West Delhi....
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Rajoo Kumar
Atomic Energy Regulatory Board
Government of India
Mumbai, India
www.aerb.gov.in
Lessons learned from the radiological
accident in Mayapuri, New Delhi, India
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Contents
About Mayapuri, New Delhi
About Gamma Cell
Various phases of accident handling
International Nuclear and Radiation Event Scale (INES)
Investigation on origin of sources
Accountability of sources
Medical Management of radiation victims
Conclusion and lessons learned
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Mayapuri Industrial Area, New Delhi
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Map of Mayapuri Scrap area, New Delhi
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About Mayapuri, New Delhi
Mayapuri is a locality in West Delhi. It used to be a major
hub of small scale industries, but following recent
government sanctions, most of the heavy metal industries
moved out. The place is now a combination of residential
flats, metal scrap market, metal factories and automobile
service stations.
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About Gamma Cell
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According to the design of the facility and, particularly, the
accessibility and shielding of the radioactive source)
there are four categories of Gamma Irradiators are:
Category I: An irradiator in which the sealed source is
completely enclosed in a dry container constructed of
solid materials and is shielded at all times, and where
human access to the sealed source and the volume
undergoing irradiation is not physically possible in the
designed configuration.
Ref: IAEA Safety Series No. 107 [5],
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Schematic diagram of Category-I Self
contained dry source storage irradiator
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Category –I Gamma Irradiator of
Model Gamma Cell 220
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Description of Gamma Cell involved in
the accident
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Gamma Cell ( Model- GC 220)
Manufactured by M/s Atomic Energy Canada Ltd. (AECL))
The GC purchased by one of the Departments of a University from M/s AECL in 1969.
The equipment has a cylindrical cage placed in with 16 pencils (which has a capacity to hold a maximum of 48 numbers of pencils), shielded by approximately three tonnes of lead.
Each pencil had 7 number of Co-60 slugs and 2 number of dummy spacers. Total activity content of the cell having 112 slugs (16 x 7) was 147.186 TBq (3978 Ci) as of Aug-Sep 1969.
Activity content in the pencils ranged between 6.15 – 10.21 GBq (166 – 276 Ci) and activity content in the slugs ranged between 740 – 3219 GBq (20 – 87 Ci).
In April 2010, total activity content estimated as 688.2 GBq (18.6 Ci). Activity content in the pencils is between 29.6 – 48.1 GBq (0.8 – 1.3 Ci) and activity content in the slugs ranged between 3.39 – 20.20 GBq (0.09 – 0.75 Ci).
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Photographs of actual source cage and
pencil recovered
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Accident Handling –Three Phases
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Sr.
No.
Phase of emergency Action
1 Initial phase Emergency first response
2 Accident control phase Radiation protection
3 Post-emergency phase Clean-up
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April 7, 2010 (Afternoon)- Message received by the AERB, from a reputed hospital located in New Delhi, stating that one person, aged 32 years, owner of a metal scrap shop in Mayapuri Industrial Area, New Delhi had been admitted on April 4, 2010. The message also stated that the patient had symptoms indicative of suspected exposure of radiation and requested advice on further course of action.
Advised on proper medical management of the radiation victims based on the symptoms, bio-dosimetry and follow-up.
Officers from AERB visited the place immediately with radiation detection equipment and monitored the radiation levels at various locations (scrap shops)
Initial Phase 1/2
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Radiation Level observed 2/2
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Location Radiation level
(mSv/h)
On the entrance of identified scrap shop 10 - 15
Inside a shop adjacent to identified scrap
shop
0.25 - 0.45
Inside a shop located rear side of identified
shop
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Inside of another scrap shop located about
300 m from identified shop
15-45
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Accident Control Phase 1/3
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April 8, 2010 –
On site planning for Emergency handling as various agencies involved Suitable radiation monitoring instruments ( Teletector,
radiation survey monitors, Isotope identifier, etc.) Personnel dosimeters Personnel Protective Equipments, Decontamination kits,
First Aid Box, etc. Source handling equipments, Source container (shielded
flask), etc. Identification of area Identification of source location (close proximity) Cordoning off area Verification of radioisotope identified (Co-60)
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Accident Control Phase - I 2/3
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Source recovery Operation (Phase –I, April 8-9, 2010)
Radioactive sources recovered
4 pencils sources,
3 gunny bags and
one drum containing radioactive scrap
This operation started at night of April 8, 2010 and continued till
the afternoon of April 9, 2010
All these recovered radioactive material was transported to the
nearest authorised waste disposal agency for safe storage and
further investigation.
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Accident Control Phase -II 3/3
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Source recovery Operation (Phase –II, April 13-14, 2010)
Radioactive sources recovered
One pencil source,
one cylindrical source cage of dia. ~25 cm with a source pencil
still in intact condition in one of the slots one drum containing
radioactive scrap
This operation started at night of April 13, 2010 and continued
till early morning of April 14, 2010
All these recovered radioactive material was transported to the
nearest authorised waste disposal agency for safe storage and
further investigation.
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Accident Control Phase -III 3/3
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Source recovery Operation (Phase –III, April 16-17, 2010)
Radioactive source recovered
One Co-60 slug from a wallet,
This source was transferred into shielded flask using remote
handling tong safe and transported to the nearest authorised
waste disposal agency for safe storage and further investigation.
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Location of source identified
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SOURCE SEARCH OPERATION
0:30 hrs, April 9,2010
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SOURCE SEARCH OPERATION
4:30 hrs, April 9,2010
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Preparation for source recovery
5:10 Hrs, April 9, 2010
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Shielded flask being brought closer to source
using crane for safe transfer, 5:40, April 9, 2010
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Scrap with source transferred in
shielded flask, 6:15, April 9, 2010
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Another source in the form of pencil
recovered, 8:30 April 9, 2010
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Another source found in a vessel, 9:00
Hrs, April 9, 2010
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Source received from the vessel, 9:15
Hrs, April 9, 2010
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Finally the truck is ready to depart for authorised waste
disposal facility for further investigation and safe
disposal, 12:15 hrs, April 9, 2010
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Co-60 pencil identified, 02:00 hrs, April 14,
2010
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Source cage identified, 03:00 hrs April 14,
2010
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Wallet containing Co-60 slug, 02:00 hrs
April 17, 2010
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Slug ( Co-60, 0.75 Ci) which was inside the
purse , April 17, 2010
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Post Emergency Phase – Decontamination
Operation
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Because of cutting exercise of Co-60 slugs, there was a spread
of radioactive contamination around the identified shop
Operation carried out in three phases:
Phase I May 15-16, 2010
Phase II May 22-24, 2010 and
Phase III June 14-18, 2010
In this entire operation more than 400 kg of contaminated soil
and 100 kg of scrap were recovered and safely disposed off at
nearest authorised disposal site
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Contaminated soil being collected, May 15,
2010, Overnight operation
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Scrap being checked for contamination,
May 16, 2010
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After excavation contaminated soil collected
in drum, May 16, 2010
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Concretized 3” thick inside the affected
shop, May 16, 2010
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Scrap being scanned, May 22-24, 2010
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Contaminated scrap detected, May 22-24,
2010
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Team involved in operation, May 22-24,
2010
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Affected road concretized after
decontamination, June 14-18, 2010
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Radiation level observed in
decontamination operation
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Before decontamination – spots (10-50Sq cm.)
– 41 spots (100-500 µSv/hr on contact) – on road
_ 5 spots ( 1000-2000 µSv/hr on contact) – inside the shop
After decontamination and concretization – Background level
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Notification to IAEA (INES)
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On April 22, 2010, a notification of the event was
communicated to IAEA and a provisional rating of Level
-3 (incident) on International Nuclear and Radiation
Event Scale (INES) was assigned.
On July 17, 2010, another notification of the event was
sent to IAEA and a final rating of Level -4 (accident) on
the INES was re-assigned.
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Investigation on origin of source 1/2
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Till April 16-17, 2010, the exact application of the source as
well as its origin was not known.
A visual inspection in a hot cell and inspection by
autoradiography technique of the sources indicated that the
source must have originated from a Gamma Chamber.
It also revealed that the source cage has 48 slots and the
dimensions of the source pencils are entirely different from
the indigenous pencils.
The visual inspection also revealed that there were cut marks
on the recovered slugs.
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Investigation on origin of source 2/2
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After a long interaction with the victims of radiation
exposure and showing photographs of GCs, one of the
victims recognized the Gamma Cell and informed that such
object was cut by one of the scrap dealer in Mayapuri.
The scrap dealer was identified and on subsequent
interrogation it was revealed that this GC was procured by
the scrap dealer through an auction from one of the
Universities.
Officer from AERB immediately visited this University and
confirmed the statement given by scrap dealer.
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Accountability of source and its activity
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It was confirmed by matching the records/data of
obtained from:
University
Supplier of Source
AERB records
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Accountability of radiation sources, May 3-4,
2010
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Accountability of radiation source, May 3-4,
2010
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Medical management of radiation victims
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S.No
.
Name Estimated dose due to
single exposure (Gy)
Dose assuming
protracted exposure
of 1-2 days (Gy)
1 Person A 3.7 6.8
2 Person B 0.6 0.9
3 Person C 0.4 0.6
4 Person D 1.6 2.8
5 Person E 1.8 3.1a
6 Person F 1.2 3.0
7 Person G 1.3 2.3
a Person died due to radiation sickness
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Conclusion and Lessons learned
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Negligence of the management of the licencee
Non-compliance with the National Regulations
Unauthorized disposal of radiation source violating
statute for safe disposal of radiation sources by the
University
An eye opener for users of radiation sources in the country
and particularly the academic institutions, the regulatory
body, other concerned agencies and the general public
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Follow-up Actions
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Verification and updating inventory of radiation sources being
used in the country
Spread of awareness on regulatory requirements by way of
issuing notices through print media
Training programmes on safe use and secure management of
radiation sources were conducted at various educational and
research institutes
Regulatory inspections of radiation facilities have been
significantly enhanced
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Follow-up Actions condt….
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eLORA (e-Licensing of Radiation Applications) system is
being implemented by AERB for automation of regulatory
processes associated with the use of ionizing radiation in
India.
The objective of this project:
Bring better transparency
Enhance efficiency
Electronic document management
Workflow Automation
Management Information
Decision Support
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(e-Licensing of Radiation Applications)
E-Licensing of Radiation Applications 52
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Thank You
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