SPECIAL ARTICLE
Safety First? Kaiga and Other Nuclear Stories
M V Ramana, Ashwin Kumar
The November 2009 exposure of employees at the Kaiga
nuclear power plant to tritiated water is not the first
instance of high radiation exposures to workers. Over
the years, many nuclear reactors and other facilities
associated with the nuclear fuel cycle operated by the
Department of Atomic Energy have had accidents of
varying severity. Many of these are a result of repeated
inattention to good safety practices, often due to lapses
by management. Therefore, the fact that catastrophic
radioactive releases have not occurred is not by itself a
source of comfort. To understand whether the DAE’S
facilities are safe, it is therefore necessary to take a closer
look at their operations. The description and discussion
in this paper of some accidents and organisational
practices offer a glimpse of the lack of priority given to
nuclear safety by the DAE. The evidence presented here
suggests that the organisation does not yet have the
capacity to safely manage India’s nuclear facilities.
M V Ramana (mvramana@gmail.com) is at the Program on Science and
Global Security, Woodrow Wilson School of Public and International
A ffairs, Princeton University, Princeton, USA. Ashwin Kumar (ashwink@
cmu.edu) is at the Department of Engineering and Public Policy,
Carnegie Mellon University, Pittsburgh, USA.
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1 Introduction
O
n 29 November 2009 the Atomic Energy Regulatory
Board (AERB) put out a press release, which is available
on its web site even as of January 2010. According to it,
An incident of tritium uptake of some workers at the Kaiga
G enerating Station (KGS) occurred on 24 November 2009. This was
noticed during the routine urine sample analysis of workers that is
carried out regularly at all nuclear power plants that use heavy
water… All persons working in the plant were checked and personnel found to have received any tritium uptake were referred to the
hospital… With this, now only two persons are having tritium in
their body that can cause their extrapolated annual radiation
e xposure to marginally exceed the AERB specified limit of 30 millisievert (mSv).
Little or no official news has come out about that event since
then. The nuclear establishment has tried to downplay the
import of this event. As might be expected of a regulator that is
not independent, the AERB ended the press release by stating
that it “would like to assure everyone that the incident is well
under control and there is no cause whatsoever for any
radiation safety concern”. The chairman and managing director of the Nuclear Power Corporation of India Ltd (NPCIL),
S K Jain, offered the assurance that “NPCIL has very high level
of safety compliance and the limits of regulatory authorities are
strictly complied with”. Even Prime Minister Manmohan Singh
has tried to mollify public apprehensions by describing it as a
“small matter of contamination” and claiming that there was
“nothing to worry”.
But the history of poor operations, many involving lapses of
safety at the many facilities run by the Department of Atomic
Energy (DAE) and its sister organisations, indicates that the safety
of the country’s nuclear facilities is indeed a matter of concern.
Many nuclear reactors and other facilities associated with the nuclear fuel cycle operated by the DAE have had accidents of varying severity.1 That none of these led to catastrophic radioactive
release to the environment is not by itself a source of comfort.
Safety theorists have argued cogently that this absence of evidence of “accidents should never be taken as evidence of the absence of risk”…and “… just because an operation has not failed
catastrophically in the past does not mean it is immune to such
failure in the future” (Wolf 2001).2
To understand whether the DAE’s facilities are safe, it is, therefore, necessary to take a closer look at their operations. The
description of some accidents below offers a glimpse of the lack
of priority given to nuclear safety by the DAE.3 Moreover, the
evidence that we present here suggests that the organisation has
not developed the capability to reliably manage hazardous
technologies (Kumar and Ramana in preparation).
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2 Tritiated Heavy Water
Kaiga and most of the other atomic power stations in India have
what are called pressurised heavy water reactors. As the name
suggests, they require heavy water – water with the hydrogen replaced by deuterium, a heavier isotope of hydrogen. The heavy
water is used both as moderator (to slow down neutrons emitted during fission so that they have a higher chance of being
captured by other fissile nuclei) and as coolant (to carry away
the heat produced).
Over a period of time, the heavy water loaded in a reactor becomes radioactive because some of the deuterium nuclei absorb a
neutron to become tritium (an even heavier isotope of hydrogen
with two neutrons). It is then called tritiated water. The radioactivity level of the tritiated water depends on the origin of the
heavy water (i e, from the coolant or the moderator) and the
length of the time it has been in the reactor. Typical values for
coolant heavy water are in the range of 0.5-2 curies/kg. Heavy
water from the moderator would have about 20-30 times more
radioactivity.
Tritiated water is easily absorbed by the body as it is chemically identical to water. In the reactor environment, there could
be a number of pathways for tritiated water to enter the body. It
could be drunk, absorbed through the skin, or tritiated water
vapour could be breathed in. In all these cases, the absorbed
tritiated water is rapidly distributed throughout the body via
the blood. This, in turn, mixes with extracellular fluid in about
12 minutes after ingestion. A special concern with tritiated water is that when ingested by pregnant women, it can pass through
the placenta, and affect the foetus. During this stage, the developing organism (the embryo and fetus) is highly radiosensitive
(ICRP 2003). In addition to forming tritiated water, tritium can
also displace hydrogen in other types of chemicals, especially
organic compounds where it gets bound to carbon. Such organically bound tritium (OBT) remains in the body for long periods
of time and therefore contributes to a much greater radiation
dose per unit of tritium absorbed (Harrison, Khursheed and
Lambert 2002).4
Because of these biochemical properties of tritiated heavy water,
the process of cleaning up the spills and recovering the heavy
water or flushing it into the environment almost invariably leads
to radiation doses to workers and, potentially, the general public.
3 A Partial History of Exposure
The Kaiga episode of this year is not the first time that workers at
nuclear power plants have had high radiation doses due to exposure to tritiated water. There have been past cases of such exposures to tritiated water as well as other radionuclides, which demonstrate poor safety practice as well as organisational neglect of
worker safety. What are described below are just a few of the many
publicly known cases.5 In addition, there could have been many
more instances that have not been divulged to the public.
3.1 Kalpakkam 1999
In March 1999, some personnel at the second unit of the Madras
Atomic Power Station (MAPS) were testing a device called BARCCIS
(Bhabha Atomic Research Center Channel Inspection System)
48
that was designed to inspect the reactor’s coolant tubes, which
had been routinely plagued by cracks and vibration problems
(Rethinaraj 1999). Suddenly a plug that sealed one of the coolant
channels, through which heavy water was to flow and remove
the heat produced during reactor operations, slipped away and a
large quantity of radioactive heavy water leaked out. Reportedly,
42 workers were involved in mopping up the leak and recovering
the heavy water (Subramanian 1999). A previous leak of a much
smaller quantity of heavy water at MAPS occurred on 5 March
1991, which took four days to clean up (BARC 1992).
For the leak in 1999, it can be shown using standard methods
of dose calculation that the radioactive dose to individual workers was on average about 6-8 mSv for each hour of work (Ramana
1999). Even at the lower level, an employee working for over five
hours would have received a dose in excess of the annual limit of
30 mSv.
Some weeks after the event, workers union representatives
revealed to the press that seven of the workers who helped
clean up were placed in the “removal category” and would not
be allowed to work in any radioactive areas in the future
(Radha krishnan 1999). This suggests that they did indeed have
radiation doses in excess of their annual quotas. Most of the remaining workers were placed in the “caution category”, meaning
that they could continue working but they were not allowed their
usual radiation dose.
This was not the only such event. On 20 November 2001, there
was a smaller leak involving 1.4 tonnes of heavy water at the
Narora I reactor; one person involved in the mopping up operations received a radiation dose of around 18 mSv, as reported by
the AERB (AERB 2002: 18). There have been numerous heavy water leaks in the DAE’s reactors (Ghosh 1996; IAEA 1998: 301-20;
AERB 2001: 13; 2004).
3.2 Kalpakkam 2003
On 21 January 2003, some employees at the Kalpakkam Atomic
Reprocessing Plant (KARP) were tasked with collecting a sample
of low-level waste from a part of the facility called the Waste
Tank Farm (WTF). Unknown to them, a valve had failed, resulting
in the release of high-level waste, with much higher levels of
radioactivity, into the part of the WTF where they were working.
Although the plant was five years old, no radiation monitors or
mechanisms to detect valve failure had been installed in that
area. The accident was recognised only after a sample was processed. In the meantime, six workers had been exposed to high
doses of radiation (Anand 2003).
Apart from the lack of monitoring mechanisms, the greatest
cause for concern was the response of management, in this case
BARC. Despite a safety committee’s recommendation that the
plant be shut down, BARC’s management decided to continue
operating the plant. The BARC Facilities Employees Association
(BFEA) wrote to the director setting forth 10 safety-related
demands, including the appointment of a full-time safety officer.
The letter also recounted two previous incidents where workers
were exposed to high levels of radiation in the past two years,
and how officials had always cited the existence of an “emergency
situation” as a reason for the health physics department’s failure
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to follow safety procedures. Once again there was no response
from management. In desperation, some months later the union
resorted to a strike. The management’s response was to transfer
some of the key workers involved in the agitation and threaten
others with similar consequences; two days later, all striking
workers returned to work. The BARC director’s public interpretation was that if the place had not been safe, the workers would
not have returned. Finally, the union leaked information about
the radiation exposure to the press.
Once the news became public, management grudgingly admitted that this was the “worst accident in radiation exposure in the
history of nuclear India” (Anand 2003). But it claimed the “incident” resulted from “over enthusiasm and error of judgment” on
the part of the workers (Venkatesh 2003). Management also tried
to blame the workers for not wearing their thermoluminescent
dosimeter badges, but this has nothing to do with the accident;
badges would not have warned the workers about radiation levels until well after they were exposed.6
For its part, the BFEA claimed the accident was only to be expected, and that because of the unrelenting pace of work at KARP
and “unsafe practices being forced on the workers”, accidents
have become regular (Anonymous 2003). Thus, there was no
consensus among management and workers on how to run the
Kalpakkam plant safely.
This pattern of discontent on the part of workers seems to be
commonplace. There is a history of poor relations between management and workers, from MAPS, KARP, and IGCAR. A longstanding problem seems to be one of control over safety at the
workplace and outside. For example, in 1997, MAPS workers went
on strike for 25 days after the management “suspended five radiation workers who refused to work in (areas with a) high radiation
level” (HT 1997). In 2005, IGCAR employees had threatened to go
on strike on account of a number of unmet demands. Among
them was that the road from the plant to the housing area be
broadened so that the workers would not get stuck in a traffic jam
in the event of an emergency (Anonymous 2003). Organisation
theorists who have examined high performing nuclear power
plants around the world via in-depth field studies have found
that they all share an atmosphere of openness and responsibility in which all employees feel free to point out their observations without fear. Unfortunately, DAE’s facilities do not seem to
share this feature.
3.3 Temporary Workers
The workers discussed above at least had recourse through their
union to resort to strikes. The lot of the many temporary workers
is worse. The employment of such workers, especially for cleaning
tasks in a number of nuclear facilities, has been reported by
many others. For example, in connection with the patterns of illhealth observed among villagers living near the Rawatbhata
reactor (Gadekar and Gadekar 1996), former AERB chairman,
A Gopalakrishnan pointed out that this may be because
many villagers in the late 1970s and the late 1980s were used as temporary workers within the power station to clean up radioactive material. There is no database with RAPS about how many people entered
the radioactive area or for how long each was exposed to it. As the
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chairman of the Atomic Energy Regulatory Board, I asked for such
information. I never received any” (DTE 1999).
The DAE claims that temporary workers have an even lower
dose limit (Mishra 2004), but such claims appear to be contradicted by many grass roots and independent accounts of poor
working conditions at nuclear facilities.
For example, here is a newspaper report on what happened
after a major radioactive leak “from ill-mantained pipelines in
the vicinity of the CIRUS and Dhruva” reactors at the Bhabha
Atomic Research Centre in 1991 (Chinai 1992). The management,
reportedly,
set six contract labourers on the task of digging a pit, to reach the burst
pipeline, eight feet below the surface. These workers wore no protective gear or radiation monitoring badges… The contract labourers
who had worked for almost eight hours inside the pit on 13 and 14 December 1991, were thereafter hastily pulled out, given a bath, new sets
of clothing and packed off home. There is no evidence of the labourers
having been subject to radiation monitoring tests (Chinai 1992).
Another example comes from the RAPS.
On 27th of July (1991), there were barrels of heavy water which
needed upgrading, standing in a corner of the upgrading plant
building. The building was to be whitewashed and a contractor had
been assigned the job. One of his labourers, Shri Madholal, who was
to do the whitewashing found that there was no water in the taps.
He made the wash in the barrel of heavy water and then proceeded
to put a coat of whitewash on the walls of the room. After finishing
his work, Shri Madholal washed his brush and then washed his
hands and face with the same heavy water… As soon as information
regarding this event reached the authorities, there was consternation and panic amongst them. The new coat of whitewash was
scraped off the walls and sent to the laboratory for tritium analysis.
Shri Madholal immediately disappeared from the scene and his
whereabouts were unknown (RP 1991).
High radiation doses to temporary workers seem to have
been especially common at the Tarapur reactors, which was
reported in the late 1970s to have areas “so radioactive that it is
impossible for maintenance jobs to be performed without the
maintenance personnel exceeding the fortnightly dose…in a
matter of minutes” (Bidwai 1978: 29). Because of the numerous
high radiation areas which had to be serviced, TAPS personnel
were “not capable of handling the larger-than-anticipated
volume of maintenance jobs, especially in areas with a large
number of hot spots” and so “outsiders…have to brought in so
as not to overexpose the already highly exposed TAPS
personnel to radiation” (ibid). Many of these “workers do not
have adequate knowledge or understanding of radiation
hazards” nor are they “entirely familiar either with the layout
of TAPS or the precise nature of the job they are ordered to
perform” (ibid).7
There is plentiful anecdotal evidence along these lines of poor
safety practices that frequently cause ill-health to workers. The
reason why these are mostly anecdotal is that outsiders do not
have access to the health records of DAE workers.
Two lessons can be drawn from this brief and partial history of
radiation doses to workers. One is that worker health has been
compromised repeatedly. The second is that there has been a
mple discord between management and workers at various
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facilities. Thus, it would seem that workers at DAE facilities do
have reasons to be disaffected, and this should be borne in mind
when thinking about the recent water cooler episode at Kaiga.
4 Poor Safety Management
One essential feature of safely run nuclear power plants around
the world is reliable backups in technical operations and in management of personnel, which prevents failures from escalating.
At the same time, there is always a belief that present levels of
safety are not enough, so that the guard is never let down. This
means that such organisations are always exploring what could
go wrong, and learning not only from their mistakes but also
from others’. In this section, we offer evidence of repeated failures
at DAE facilities, which have sometimes led to accidents.
4.1 Kaiga 1994
Danger to the workers at Kaiga began even before the reactor
was completed. On 13 May 1994, the inner containment dome –
the structure that is supposed to prevent the escape of radioactivity into the environment should an accident occur – of one of the
units of the Kaiga nuclear power plant collapsed during reactor
construction. The dome itself had been completed but cabling
and other tasks were being carried out (Havanur 1994). The official term for what occurred is delamination, but that does little
justice to the approximately 130 tonnes of concrete that fell from
the top of the containment (Subbarao 1998). The event happened
during the day with workers on site but miraculously only 14
workers were said to have been hurt, that too with minor injuries.
50
Analysts have offered several reasons that shed doubt on this
claim that only 14 of the hundreds of workers employed at the site
were hurt (Havanur 1994).
At least two underlying factors have been identified for the collapse. The first is faulty design (Pannerselvan 1999). Another is
lack of adequate quality control: according to DAE officials, “while
inputs such as cement and steel had been tested for quality, that
was not the case with the concrete blocks as a whole” (Mohan
1994). This goes against a basic requirement of nuclear safety:
“facilities (have to be) constructed to the highest standards” (NEA
1993: 51). Faulty work practices may also have played a role. Such
practices led some years later to a fire involving many cans of
paint on the same dome (ToI 1999). In addition, one local woman
activist, Kusuma Soraba, met with some of the construction
workers who accused the contractors of various malpractices in
construction (Havanur 1994).
The former head of the AERB has stated:
The delamination of the containment dome at Kaiga was an avoidable
incident. Senior NPC civil engineers and the private firms which provide civil engineering designs and construction drawings to the DAE
have had a close relationship. In this atmosphere of comradeship, the
NPC engineers did not carry out the necessary quality checks on the
designs they received before passing them on to the Kaiga project
team. The AERB also did not check this, because it had almost no civil
engineering staff with it. Serious design errors went undetected and
these eventually led to the failure of the dome. It was negligence by
the NPC civil engineering team that caused this. A distorted NPC report, which tried to cover up this reason, was rejected outright by the
non-DAE members of the AEC, while the AERB report that spelt out in
detail the actual reasons was approved (Gopalakrishnan 1999).
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The Kaiga dome collapse is unprecedented in the annals of nuclear energy history. It also points to one of the dangers with relying on redundancy as a safety mechanism. The reason for constructing a containment dome is that even if all safety mechanisms within the reactor fail and a severe accident occurs, the
strong containment building will be capable of withstanding the
high pressures that would accompany the accident and hold
(“contain”) all radioactive substances released from the reactor
core during the accident. So at face value this makes for greater
safety. But as Subbarao argues,
if such a collapse had taken place during operation of the nuclear
plant, about 130 tonnes of concrete falling from a height of nearly 30
meters would have damaged the automatic control rod drives that lie
below the crown of the dome, disabling them and making the safe
shutdown of the reactor difficult. The massive weight of concrete
might have led to damage to the nuclear coolant pumps and pipes, resulting in severe loss of coolant. This could have led to nuclear core
meltdown and the escape of large amounts of radioactive substances
to the environment (Subbarao 1998).
Fortunately, at the time of the accident, the reactor had not
been fully constructed and the core had not been loaded.
4.2 Narora 1993
The most serious accident at an Indian nuclear reactor occurred
on 31 March 1993. Early that morning, two blades of the turbine
at the first unit of the Narora power station (two 220 MW PHWRs)
broke off due to fatigue. These sliced through other blades, destabilising the turbine and making it vibrate excessively. The vibrations caused pipes carrying hydrogen gas that cooled the turbine
to break, releasing the hydrogen which soon caught fire. Around
the same time, lubricant oil had also leaked. The fire spread to
the oil and through the entire turbine building. Among the systems affected by the fire were four sets of cables that carried electricity, which led to a general blackout in the plant. One set supplied power to the secondary cooling systems, which were consequently rendered inoperable. In addition, the control room became filled with smoke and the staff was forced to leave it about
10 minutes after the blade failure.
The operators responded by manually actuating the primary
shutdown system of the reactor 39 seconds into the accident
(Koley et al 2006). Although the reactor was shutdown, some
operators, concerned about re-criticality, climbed onto the top of
the building and, under battery-operated portable lighting, manually opened valves to release liquid boron into the core to slowdown the reaction. It was necessary to do so because even though
the reactor was shutdown, it continued to generate heat; the fuel
rods in a reactor accumulate fission products – the elements created when a uranium atom splits – and these continue to undergo
radioactive decay and produce heat. While this so-called decay
heat is produced at a much smaller rate than when the reactor is
operating, it persists even with the reactor shutdown. If not removed promptly, decay heat can cause the fuel to reheat and meltdown. Thus, the reactor must continue to be cooled even after
shutdown. To accomplish this task, operators had to start up diesel
fire pumps to circulate water meant for fire control (NEI 1993).
It took 17 hours from the time the fire started for power to be
restored to the reactor and its safety systems. Operators who
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were forced to leave the control room because of smoke could not
re-enter for close to 13 hours. An attempt was made to take control of the plant from the emergency control room; but, since
there was no power available, the Unit 1 control panel of the
emergency control room was unusable. Thus, Narora was almost
unique in that the operators had no indication of the condition of
the reactor and were, in effect, “flying blind” (Nowlen, Kazarians
and Wyant 2001).
The Narora accident has been the DAE’s closest approach to a
catastrophic accident. More worrisome is the evidence that the
accident could have been foreseen and prevented.
First, the failure of the turbine blades was avoidable. In 1989,
General Electric communicated information to the turbine
manufacturer, Bharat Heavy Electricals Limited (BHEL), about a
design flaw which led to cracks in similar turbines around the
world. They recommended design modifications, and the manufacturer responded by preparing detailed drawings for NPC,
which operated the Narora reactor. In addition to General Electric, the manufacturer of the turbine, BHEL, also recommended
that NPC replace the blade design before an accident occurred.
However, NPC did not take any action until months after the accident (Gopalakrishnan 1999).
Second, even if the turbine blade failed despite modification,
the accident might have been averted if the safety systems had
been operating, which they presumably would have if only their
power supply had been encased in separate and fire resistant
ducts. By the time the Narora reactor was commissioned, this
was established wisdom in the nuclear design community and
had been ever since the fire at Browns Ferry in the US in 1975.
That accident resulted in a mandate to make significant changes
at all US nuclear plants (Ramsey and Modarres 1998: 106). The
physical and electrical systems were altered, with built-in
redundancies, to prevent fires. Other countries adopted similar
measures. All of this took place well before the Narora plant
attained criticality in 1989. Nevertheless, the plant was constructed with the four backup power supply systems laid in the
same duct, with no fire-resistant material enclosing or separating the cable systems.
Third, the DAE had not taken any serious steps towards fire
mitigation despite earlier fire accidents at its own reactors. In
1985, an overheated cable joint at RAPS II caused a fire that spread
through the cable trays and disabled four pumps (IAEA 1986: 244;
Gopalakrishnan 1999). A few years later, in 1991, there were fires
in the boiler room of the same unit and the turbo generator oil
system of RAPS I (IAEA 1992: 394-96).
The factors that contributed to the Narora accident were repeatedly present prior to the accident. Excessive vibrations in the
turbine bearings were common in Indian reactors. In 1981,
RAPS II was shut down twice because oil leakage in the turbine
building led to high levels of sparking in the generator exciter
(IAEA 1982: 235). After it was restarted, it had to be shutdown yet
again when it was found that large amounts of oil had leaked
from the turbine governing system. Only when the reactor was
restarted a third time, in early 1982, were the high vibrations of
the turbine bearings noticed and the failure of turbine blades discovered (IAEA 1983: 250). This led to a prolonged shutdown of
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more than five months; even after this problem had apparently
been fixed the reactor had to be shut down once again because of
high turbine bearing temperatures (IAEA 1983: 230). Again in
1983, high vibrations were noticed in turbine generator bearings
and it was revealed that two blades in the second stage of the
high pressure rotor had sheared off at the root (IAEA 1984: 292).
In 1985, the first unit of the Madras Atomic Power Station
(MAPS I) was shutdown repeatedly because of high bearing
vibrations in the turbine generator (IAEA 1986: 240). RAPS I had
to be shutdown due to high bearing vibrations in 1985, 1989, and
1990 (IAEA 1986: 242; 1990: 302; 1991: 298).
Oil leaks have also been common in Indian reactors. In 1988,
MAPS II was shutdown due to an oil leak from the generator transformer (IAEA 1990: 288). In 1989, a large spark was observed
from slip rings on the exciter end of the turbine in MAPS I; there
were also two other fires in the same reactor near the primary
heat transport system (IAEA 1990: 298). Oil leaked from a turbine
bearing in MAPS II in 1989 (IAEA 1990: 300). In 1992, there was an
oil leak in the turbine stop valve in MAPS II (IAEA 1993: 288). In
addition in 1992, there were two separate oil leak incidents in the
Narora I turbine generator system (IAEA 1993: 289). There was at
least one hydrogen gas leak prior to the Narora accident: this
happened in 1991 in the generator stator water system of MAPS II
(IAEA 1992: 390).
The DAE did not learn from these experiences, and this disregard was in part responsible for the Narora accident. When asked
by an interviewer about the recurrence of turbine blade failures
at nuclear reactors, AEC Chairman Chidambaram side stepped
the issue by suggesting “this kind of failure at Narora has happened for the first time…two blades failing” and then offering
the non sequitur, “You must remember that as far as nuclear reactor is concerned, there was no problem at Narora. The reactor
worked perfectly according to design” (Chidambaram 1993). By
ignoring these early warnings, the DAE set the stage for the
Narora failure that led to “widespread damage to the (turbine
generator) set, condenser and caused [a] fire which engulfed the
cables, the turbine building and control equipment room” (Ghosh
1996: 30).
4.3 Recurring Patterns
Another indicator of poor safety practices is repeated occurrences
of similar accidents. An important example is the set of failures
that led to the Narora accident, which have persisted in
many reactors.
In late 1993, high vibrations and temperature in both Narora-II
and RAPS-1 turbine generator buildings led to their being shutdown (IAEA 1994: 333-36). The problems in these reactors persisted into 1994, with Narora-II being shutdown due to high bearing temperatures and RAPS-1 due to turbine bearing vibrations
(IAEA 1995: 313-16). In 1995, even after repeated shutdowns supposedly meant to mitigate turbine problems, blades failed in the
turbine of Narora-II (IAEA 1996: 314).
Even after being restarted following the accident in 1993,
Narora-1 was shutdown repeatedly in 1995 because of high vibrations of the turbine generator bearing (IAEA 1996: 312). In 1997,
RAPS-1 had to be repeatedly shutdown due to high turbine bearing
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vibrations (IAEA 1998: 314). In 2000, Kaiga-II suffered from repeated turbine vibration problems (IAEA 2001: 294).
Fires have also occurred repeatedly. In Narora-II in 1996, there
was heavy oil smoke from the turbine building (IAEA 1997: 314).
That same year, there was an oil fire in the turbine building of
Kalpakkam-Ii (IAEA 1997: 310). The following year smoke was observed in Kalpakkam-Ii, there was a fire in the turbine generator
of Kakrapar-I, and smoke was observed from the insulation of the
main steam line of the turbine generator in Kakrapar-II (IAEA
1998: 302-08). There was a fire due to an oil leak in Kalpakkam-I
in 2000 (IAEA 2001: 300). There have also been numerous oil and
hydrogen leaks.8
Other examples are regular leaks and heavy water spills. While
these leaks are not themselves serious safety hazards, they could
be the precursors to more serious accidents, for example involving coolant failure. As mentioned earlier, the tritium in the water
also poses a health risk to workers.
Such leaks started with RAPS, the first heavy water reactor
constructed in India (Ghosh 1996). Despite much effort – understandable because heavy water is expensive and hard to produce
– the DAE has not managed to contain the leaks. In 1997 alone,
such leaks occurred at the Kakrapar I, MAPS II and Narora II reactors (IAEA 1998: 301-20). The leaks could involve significant
amounts of water. For example, on 15 April 2000, there was a
leak of seven tonnes of heavy water at the Narora II reactor (AERB
2001: 13). Three years later, on 25 April 2003, there was a six
tonne leak at the same reactor (AERB 2004).
The 2003 leak occurred while a device called BARCCIS which is
used to inspect coolant tubes in reactors, was in operation. After
a similar leak in March 1999 at MAPS, the AERB reviewed the
BARCCIS system and suggested design changes, operating procedures and training (AERB 2004: 18). But as mentioned earlier,
there was a similar leak at the Narora I reactor in 2001 despite
these changes. This indicates that there were weaknesses in the
implementation of the AERB’s suggestions, fundamental flaws in
the technical system, or continued operator errors.
4.4 Inoperative Safety Systems
A second notable and disturbing trend is the frequent failure of
safety devices. These are the mechanisms by which control of the
reactor ought to be maintained under unanticipated circumstances. If they do not work as expected, it is more likely that a
small event could cascade into a major accident. A related problem is of safety devices left in an inoperative state or neglect of
periodic maintenance.
An example of how minor failures contributed to escalating an
accident was during the 1993 Narora accident discussed earlier.
The accident may have been prevented had the smoke sensors in
the power control room at Narora detected the fire immediately.
Since that did not happen, the fire was detected only when the
flames were noticed by plant personnel (Srinivas 1993). A different complication arose three hours and fifty minutes into the
accident when the two operating diesel-driven fire water pumps
shutdown inexplicably (Nowlen, Kazarians and Wyant 2001). As
yet, the cause for this failure has not been identified. A third
pump was out of service for maintenance.
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Many of these problems are recurring. In 2005, for example,
the AERB found instances of failure in fire detectors at Kakrapar
and in the power supply for emergency cooling at the MAPS
(PTI 2005). Heat transport pumps are also frequently unavailable
for many reasons, most commonly because of frequency fluctuations in the electricity grid. In 2004, MAPS-II was shutdown for
eight days because the two main primary coolant pumps were
unavailable. After it was restarted, the reactor had to be shutdown again because the motor bearings of one of the pumps had
to be replaced.
5 Weakness of Safety Regulation
A separate reason to be concerned about the safety of the DAE’s
facilities is the regulatory structure that is involved in overseeing
safety. The DAE established the AERB to oversee and enforce
safety in all nuclear operations in 1983. This was modified in
2000 to exclude facilities involved, even peripherally, in the
nuclear weapons programme. The AERB reports to the Atomic
Energy Commission (AEC), whose chairman is always the head of
the DAE. The chairman of NPC is also a member of the AEC. Thus,
both the DAE and NPC exercise administrative powers over the
AERB. The AERB is financed by the DAE. There are, therefore,
institutional limits on the AERB’s effectiveness.
This administrative control is compounded by the AERB’s lack
of technical staff and testing facilities. As A Gopalakrishnan, the
former chairman of the AERB, has observed,
95% of the members of the AERB’s evaluation committees are scientists and engineers on the payrolls of the DAE. This dependency is deliberately exploited by the DAE management to influence, directly and
indirectly, the AERB’s safety evaluations and decisions. The interference has manifested itself in the AERB toning down the seriousness of
safety concerns, agreeing to the postponement of essential repairs to
suit the DAE’s time schedules, and allowing continued operation of installations when public safety considerations would warrant their
immediate shutdown and repair (Gopalakrishnan 1999).
Elsewhere, Gopalakrishnan has pointed to an example of
direct interference from the AEC, in the context of the collapse of
the containment dome in 1994 of one of the reactors under construction at Kaiga, Karnataka. “When, as chairman, I appointed
an independent expert committee to investigate the containment
collapse at Kaiga, the AEC chairman wanted its withdrawal and
matters left to the committee formed by the NPC (managing
director). DAE also complained to (the prime minister) who tried
to force me to back off” (Pannerselvan 1999).
Finally, the AERB’s recommendations are often ignored. For
example, according to Gopalakrishnan:
[The] AERB had directed the DAE to carry out an integrated Emergency
Core Cooling System (ECCS) testing in Kaiga I and II as well as RAPS III
and IV before start up. It also wanted proof and leakage tests conducted on the reactor containment. And finally, a full-scope simulator was
Notes
1
2
We use DAE as an umbrella term for referring
to both the DAE as well as its many allied
organisations, including the Nuclear Power
Corporation.
Or as James Reason argues, “even the most vulnerable systems can evade disaster, at least for a
time. Chance does not take sides. It afflicts the
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3
to be installed for operator training. None of these directives have
been complied with so far (Pannerselvan 1999).
Conclusions
The AERb is fond of claiming that it has lived up to Homi
Bhabha’s injunction in February 1960, “Radioactive materials
and sources of radiation should be handled in the Atomic Energy
Establishment [the former name of the Bhabha Atomic Research
Centre] in a manner which not only ensures that no harm (our
emphasis) can come to workers in the Establishment or anyone
else, but also in an exemplary manner, so as to set a standard
which other organisations in the country may be asked to
emulate’’ (Mishra 2004: 98). Since Bhabha’s time, it has been
established that all radiation brings with an increased risk of
cancer and other health damage. This risk is directly proportional to the radiation dose to the body and there is no threshold
below which the increased probability of cancer from radiation
exposure is zero. Regulatory limits are typically set at some
level of cancer risk to workers that is considered acceptable,
often by convention.
The largest study of nuclear workers, carried out by a large
team of researchers and headed by a team from the International
Agency for Research on Cancer (IARC), retrospectively examined
the health records of over 4,00,000 workers in 15 different countries and demonstrated that a small excess risk of cancer exists,
even at doses lower than typically mandated by radiation standards (Cardis et al 2005). At the typically mandated radiation
standards, workers could receive up to 100 mSv over five years.
This would, according to the IARC study, lead to a 9.7% increased
mortality from all cancers excluding leukaemia and a 19%
increased mortality from leukaemia (excluding chronic lymphocytic leukaemia). Radiation doses that exceed the annual
regulatory limits lead to a correspondingly higher risk of cancer.
Thus, numerous workers are likely to have been exposed to harm
by the nuclear establishment.
At a more general level, while the DAE, like other organisations
involved in nuclear activities, often verbalises safety goals, its
performance and decision-making often depart from public pronouncements.9 In its submission to the IAEA as part of its responsibilities under the 1994 Convention on Nuclear Safety, the DAE
stated that:
Safety is accorded overriding priority in all activities. All nuclear
facilities are sited, designed, constructed, commissioned and operated
in accordance with strict quality and safety standards… As a result,
India’s safety record has been excellent in over 260 reactor years of
operation of power reactors and various other applications (GoI 2007).
Alas, the DAE’s historical record is not even acceptable, let
alone excellent, a fact that should be borne in mind when drawing lessons to be learned from what happened last year at Kaiga.
deserving and preserves the unworthy” (Reason
2000).
To the extent possible, we derive these descriptions
from documents put out by the DAE and its sister
organisations. If these are not available, or as a supplement, we use news and media reports. We assume that these are being accurate unless there is
some strong reason to not believe the fact. We try
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5
6
not to place too much stock on any one report.
Organically bound tritium also delivers energy
more effectively than HTO and therefore imparts
a higher radiation dose (Chen 2006).
Not included in these, for example, are uranium
miners and millers who are exposed to both radon
gas and relatively high levels of dust.
These badges measure cumulative exposure over
53
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7
8
9
a period of time, and are meant to be submitted to
the health physics department for assessment.
Herein lies one problem with the notion of risk
as is commonly used – that the hazard possibility that underlies the risk calculation is not precisely determined, the way the association of
probability figures would suggest. Rather, the
risk involved in an activity depends on the control exercised by the worker in the workplace.
British radiation safety professional Dave
Rosenfeld offers this example: “ask a worker at
the Windscale nuclear fuel reprocessing plant to
repair pipework in a high-radiation area unfamiliar to him. Even if there are only a couple of
lethal “hotspots” where doses are high, the
whole area appears hazardous. To him (women
are not employed in high-radiation zones) a
walk in a straight line is like crossing the road
blindfold. As the management gives him a chart
of hotspots and a pocket alarm meter, he feels
sure to avoid deadly spots, confidently and consistently – as long as experience tells him that
the management or union safety committee
have assured the chart and meter are reliable”
(Rosenfeld 1984: 43).
Listed below are just those from the period
between 1995 and 2000. Operating records reveal
repeated oil leaks occurred in Kakrapar-II in 1995
(IAEA 1996: 306). In 1997, there were oil leaks in
Kalpakkam-II and a hydrogen leak in Kakrapar-II
(IAEA 1998: 304-08). In 1999, there was another
hydrogen leak in Kakrapar-II, as well as one in
Narora-II (IAEA 2000: 288-96). In 2000, there
were hydrogen leaks in Narora-I, Narora-II and
RAPS-III, and oil leaks in RAPS-III and Kaiga-II
(IAEA 2001: 294-312).
The confidence that permeates within the nuclear
establishment is also not conducive to safety. One of
the many paradoxes about safety is that “if an organisation is convinced that it has achieved a safe
culture, it almost certainly has not” (Reason 2000).
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