Page 35 - Emergency Response Book

Causes 34

• Component failure

The company did not implement measures detailed in notices

from supplier designed to upgrade the safety of the facility

The installed safety systems had degenerated or been bypassed

over the years

• Operator error

Operators trained by the supplier of the irradiators had left at an

early stage and subsequent training was only oral and informal

• Violation of procedures

There was no regulatory control of radiological protection

matters nor any readily available expertise in El Salvador

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