Nuclear crisis result of communication breakdown, report says

Globe and Mail: GLORIA GALLOWAY - July 28, 2008

OTTAWA A much-anticipated report into last fall's shutdown of the Chalk River, Ont., nuclear reactor says the unit's managers did not understand they were required to make mandated safety upgrades, a communications failure that ultimately spawned an international medical crisis.

The independent report by energy consultant Talisman International also says junior staff at the Canadian Nuclear Safety Commission knew the upgrades had not been completed. But they did not believe the situation was so dire that it needed to be challenged or even raised with their superiors.

The commission had ordered seven upgrades in December of 2005.

The Talisman study, completed in June and made public Monday by Atomic Energy of Canada Ltd., says the licences that permitted the National Research Universal reactor to operate were granted with the condition that all seven NRU upgrades are fully operational by Dec. 31, 2005.

But the licences were not clear and did not specify in any detail exactly which NRU safety upgrades were to be installed, according to the report.

As a result, the report says, the reactor's management did not believe there was a licensing requirement to install emergency power supplies to two of the main heavy-water pumps. As well, the safety benefit of connecting the power supplies to the pumps was not agreed upon or well understood by NRU site management.

Low-level CNSC staff who knew that mandated safety upgrades had not been completed did not feel the need to alert their senior management.

Consequently, the status of the [emergency power supply] connections was not effectively communicated within organizations and between organizations, the report said.

A separate report released Monday by a group of medical professionals says the resulting crisis left Canada's nuclear medical capability teetering on the brink of disaster.

When CNSC managers finally learned that the upgrades had not been done, they refused to allow the reactor to be restarted after a routine maintenance shutdown last November.

Between Nov. 27 and Nov. 30, nuclear-medicine specialists began to receive notices about a problem with the supply of isotopes, says the medical experts' report, which federal Health Minister Tony Clement commissioned.

By early December, it was becoming clear that the problem was not temporary. Many nuclear-medicine facilities across Canada and the United States were running out of the material that is used to diagnose and treat cancer, heart disease and other ailments.

On Dec. 5, the medical experts' report says, an emergency teleconference was organized by the Canadian Society of Nuclear Medicine, but there were no lines of communication with the government, the CNSC or AECL, so there was no means by which the medical community could raise the alarm.

The government, about the same time, learned of the situation, and on Dec. 12, ordered that the reactor be restarted.

For patients with serious and often life-threatening conditions, the lack of certainty was chilling, says the report by the medical experts.

People scheduled for diagnostic tests received little or no information about how long they would have to wait or whether they would have the prescribed test at all. In some circumstances, patients and their health-care providers had to decide whether they would resort to procedures known to have risks or to be less accurate.

The Talisman consulting report, which was accepted by both the AECL and the CNSC, makes its own wide-ranging recommendations.

It points out that the CNSC managers concluded, after realizing the upgrades had not been made, that a licensing amendment would be required for the reactor to be restarted. But they did not believe they had the power to make that amendment without the approval of the appointed CNSC commissioners.

CNSC president Linda Keen was fired in January for refusing to bend the rules to allow the restarting of the reactor.

In a telephone interview Monday, Mr. Clement said of the report: All it does is reinforce my conviction that we did the right thing in putting this before Parliament to get the reactor restarted ASAP.

If we had left it in the halls of bureaucracy, we would still be waiting.

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