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Case Study: The Chernobyl Disaster

Angie Daniela Tinjacá Vargas

ID: 781891
Jessica Alejandra Rosales Caicedo
ID: 768270

Minuto de Dios University Corporation

Management in Occupational Safety and Health
NRC 8457: Investigation of work events
José Mauricio Espinosa Flechas
November 06, 2022
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Case study: The Chernobyl disaster

Work Accident Investigation Report

Angie Daniela Tinjacá Vargas

ID: 781891
Jessica Alejandra Rosales Caicedo
ID: 768270

Minuto de Dios University Corporation

Administration in Occupational Health and Safety
NRC 8457: Investigation of workplace events
José Mauricio Espinosa Flechas
November 06, 2022
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Table of contents

Introduction.................................................................5

1. Definitions related to the case..............................................................7

2. Procedure of research................................................................................10

3. Analysis deep of the case........................................................................................11

4. References bibliographical references.........................................................................................16

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Table of figures

Figure 1. Flowchart.................................................................................................10
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Introduction

This work was done to describe and analyze the causes and

consequences of the Chernobyl disaster, a nuclear accident that occurred near the

Chernobyl city in the early morning of April 26 at the Vladimir Ilich Lenin power plant

in the north of Ukraine. This event was caused by mechanical and human failures that

ended up claiming the lives of more than 60,000 billion people where for a

explosion of reactor 4 of the plant when it was undergoing a cut test

electric, which invested heavily in nuclear energy after the Second World War.

The accident was kept a secret, it was a decisive moment for both

the Cold War as for the history of nuclear energy. More than 30 years later, the

scientists estimate that the area surrounding the old plant will not be habitable until

in 20,000 years.

This disaster is considered one of the worst nuclear accidents and

great environmental disasters in the world. The tragedy affected a large number

of people starting with the plant workers and nearby towns that

had to be completely evacuated, but the high levels of radiation already

they had been affected for some time now by the population in general. Also among them

Soldiers and scientists who took the courage to take control were affected.

in order to try to mitigate the situation.

Due to this entire emergency, many people died from the explosion.

caused by high concentrations of radioactivity or were left in a serious condition

for health reasons.

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In 1977, Soviet scientists began installing four reactors

RBMK nuclear reactors at the power plant, which is located just south of the

current border between Ukraine and Belarus.

With this research report, we want to highlight the consequences and

implications that had at the time of the occurrence of this disaster. It can also be

highlight the different conclusions that this event left throughout history in

moment of the event. Among them were:

Fatal losses.

Malformations.

Serious illnesses.

Serious environmental damage.

These consequences are evident in the place today, in such a way that

it continues to affect human beings.

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1. Definitions related to the case

Chernobyl Accident: It was a nuclear accident that occurred on April 26th.

1986 at the Vladimir Ilich Lenin nuclear power plant, caused by the explosion of

reactor 4 during a power cut test.

Work accident: Any sudden event that occurs due to or in

work occasion, and that produces a serious injury in the worker, a

disability, a chronic illness or even the death of a worker.

Nuclear reactor: It is a facility capable of starting, maintaining, and controlling the

chain fission reactions occurring in the reactor core,

composed of the fuel, the coolant, the control elements, the

structural materials and the moderator in the case of nuclear reactors

thermal.

Radioactivity: It is the process by which an unstable atomic nucleus loses

energy through the emission of radiation, such as an alpha particle, beta particle

with a neutrino or just a neutrino in the case of electron capture, or a ray

gamma or electron in the case of internal conversion.

Confined spaces: It refers to a space that due to its design has a

limited number of entry and exit openings, has ventilation

natural unfavorable that could contain or generate dangerous pollutants

of the air, and it is not meant for a continuous presence of employees.

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Accident or incident investigation: It is a systematic process that

determine the causes, facts or situations that generated the occurrence of the

accident or incident.

Basic causes: Real causes that manifest behind the symptoms;

reasons why unsafe acts and conditions occur; factors that

Once the identifiers allow for significant administrative control. The

Basic causes help to explain why unsafe acts are committed and why

these conditions exist.

Immediate causes: These are the circumstances that occur just at the moment.

before contact; they are generally observable or felt. They

they classify as unsafe acts.

Security protocol: It is a document where strategies are recorded with

the steps to be taken to implement protective measures and actions

safe within an area, city, etc.

Explosion: An explosion is understood as the violent and rapid expansion of a

a certain energy system, which can originate from different forms

of transformation (physical or chemical), accompanied by a change in its energy

potential and generally followed by a shock wave that acts in a way

destructive to the container or structure that holds it.

There are therefore two types of explosions:

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Physics: They are motivated by abrupt changes in pressure conditions and/or

temperature, which generates a overpressure capable of breaking the walls of the

container that holds it.

Chemicals: They are driven by violent chemical reactions, by deflagration or

detonation of gases, vapors or dusts or by decomposition of substances

explosive.

Disaster: It is a natural event or one caused by humans that affects

negatively on life, on livelihood or on industry and often leads to

in permanent changes in human societies and the animals that

they inhabit that place; in ecosystems and in the environment.

Consequence: It is that which results from a circumstance, an act or

a previous fact.

Precautions: These are the minimum prevention and control measures that

should be applied during healthcare to prevent the spread of

pathogenic microorganisms that are transmitted through blood, fluids

organic and/or through other known or unknown sources.

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2. Research procedure

Figure 1.

Flowchart
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Source. Flowchart of information about the Chernobyl disaster - Preparation

own (2022)

3. In-depth analysis of the case

The Chernobyl disaster occurred on April 26, 1986, at the nuclear power plant, it was

caused by a failure in the test of reactor 4 without power, which caused a

explosion in it. At that moment, no type of alert was generated to the

community nor the authorities as the magnitude of the accident was not understood.

Chernobyl was a type of low-power unstable reactor, a regime in which the

the reaction tends to escalate if not handled carefully. The operations of

off and on were extremely delicate.

At the bottom of the crater that remained in the reactor, the radioactive materials

continued burning at very high temperatures which generated clouds of dust and

radioactive smoke that eventually spread and affected several cities and countries.

The accident, which occurred in reactor 4 of the plant in the early morning of the 26th

April 1986, occurred when operators took actions in violation of the

plant procedures. The operators managed the plant at a very

down, without the appropriate safety precautions and without coordinating or communicating

appropriately the procedure with the security personnel. But we understand that

it was not just a matter of inappropriate procedures, which may have

became circumstantially relevant.

Other factors may need to be taken into account:

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The four reactors at the Chernobyl power plant operated with pressurized water.

They were designs developed using a combination of graphite as a moderator and

they used cooling water. These were highly unstable reactors operating at

low power, primarily due to the design of the control system and its

vulnerabilities in case of losing cooling water.

In this case, the energy overload caused a sudden increase in heat and

pressure, which broke the tubes containing the fuel. The hot fuel

reacted with water and generated steam, which in turn caused a first explosion, which

raised the reactor cover causing a rupture. The pressure in the tubes caused

a second explosion, exposing the reactor core to the environment.

Sequence of the events of April 25th:

01:07 a.m.: The gradual and scheduled reduction of power level began.

of the reactor.

03:47 a.m.: The power reduction stopped at 1600 MW thermal.

02:00 p.m.: The emergency cooling system of the core has been isolated.

to avoid the interruption of the test later. This fact did not contribute to the

accident, but if it had been available it would have reduced

minimally its severity. The power, however, should have been reduced.

even more. However, the Kiev electricity network regulator asked the operator

keep the minimum electricity production from the reactor for

properly meet the demand. Consequently, the power level of

the reactor remained at 1600 MW and the experiment was delayed.

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11:10 p.m.: Power reduction restarted.

Sequence of events on April 26:

12:00 a.m.: Staff shift change. The workers more

the experienced ones withdrew, being replaced by the young ones of the shift

Nocturne. If it hadn't been delayed, the test would have been carried out by

experienced engineers, and these latter would only have had to monitor

the residual heat in the reactor.

12:05 a.m.: The power level decreased to 720 MW and continued to decrease.

despite being prohibited.

12:38 a.m.: With the power level above 500 MW, the operator transferred the

control of the manual system to the automatic regulation system. The signal failed or

the regulatory system did not respond to her, which caused a fall

unexpected power of 30 MW.

12:43:27 a.m.: The firing signal of the turbogenerator was blocked according to

the procedures of the test, it is possible that it only delayed the start of the

accident about 39 seconds.

01:00 a.m.: The reactor's power stabilized at 200 MW. Despite the fact that the

the operators of the plant may be unaware of it, the required margin was violated

operational reactivity of 30 minimum bars. The decision was made to carry out

the summary tests of the turbogenerator with a power close to 200

MW.
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01:01 a.m.: A backup circulation pump was changed to the left of the

cooling circuit, in order to increase the water flow to the core.

01:07 a.m.: An additional cooling pump was replaced on the right.

cooling circuit as part of the testing procedure. The

operation of the additional cooling pumps removes heat

from the core more quickly, which leads to the decrease of the

reactivity makes it even more necessary to eliminate the absorption rods

to avoid a drop in power. The pumps extracted too much heat

to the point of exceeding the permitted limits.

01:19 a.m.: The battery vapor level approached the emergency level. A

the operator increased the flow of water, which in turn raised the level of

vapor and decreased the reactivity of the system. The control rods were raised.

to compensate for it, but it was necessary to raise more control bars to maintain the

reactivity balance. The pressure of the system began to drop, and for

It was necessary to close the bypass valve of the steam turbine to stabilize it.

01:22:30 a.m.: Subsequent calculations after the accident found that the ORM in

this point was equivalent to 8 control bars, when the regulations of

operation required a minimum of 30 bars at all times.

01:23:04 a.m.: The power supply to the turbines was cut off to allow for

they operated by inertia, during the 30 seconds after this moment not

no intervention was required from the staff.

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01:23:40 a.m.: The emergency button AZ-5 was pressed by an operator.

The control rods began to penetrate the reactor core, but the

Graphite tips increased reactivity at the bottom.

01:23:43 a.m.: The emergency power climbing protection system

It was activated. The power exceeded 530 MW.

01:23:46 a.m.: Disconnection of the first pair of main circulation pumps

(BCP) that are out of stock, followed by the second pair.

Strong decrease in the flow of the BCP that do not participate in

the unreliable testing and readings in the BCPs that do. Important

aumento en la presión de las baterías de separación de vapor. Fuerte aumento

at the water level of the vapor separation batteries.

01:23:48 a.m.: Restoration of the flow of the BCPs that did not participate in the

test up to the almost initial state.

01:23:49 a.m.: Increase in pressure in the reactor space, without voltage - 48V

and failure of the actuators of the automatic power controllers no.

1 and 2.

01:24 a.m.: Strong blows; the RPC bars stopped moving before reaching

at the lower limit; the power switch of the clutch mechanisms

it is off.

The control of the fire in the reactor claimed hundreds of lives of those who contributed.

your support, effort, and work being a consequence of exposure to the

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radioactivity, among them were soldiers, firefighters, miners, and the same

community that was near the nuclear plant.

4. Selection and explanation of themethodologyof applied research to

case

The ISHIKAWA diagram method, also known as the fishbone diagram

fishbone, it is a causal analysis method that can be used in accidents

serious or high-potential incidents to determine the potential causes or

reality of operational problems, such as what happened at the nuclear power plant

from Chernobyl. It is a of the better options because provides a

deep analysis of what happened at the nuclear plant and divide the investigation

in four areas: Method: the method can be defined as the way in which a

a person is used to performing a task. That is to say, it may be about the order of

actions that a person takes to prepare in the morning and be ready

for to leave the work for example, the tests of the

reactor started with blocked protection elements. People: they are the ones of

human origin that can contribute to or cause an accident, due to lack of

knowledge and incompetence etc. like what happened in the accident of

Chernobyl, the operators they were not adequately trained and

they did not understand the danger of the accident in which they were acting. Materials:

They are the personal protective equipment used by workers in case of

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emergency, hazardous products and substances that can cause problems of

health in work teams. Machine/Equipment: Any element of a

machine, plant or equipment that causes an accident during a process, such as a

structural defect.

[Link] of the accident

Work accidents can occur due to human or mechanical causes, which is why

It is necessary to analyze the working conditions that surrounded the accident and the

recent events that triggered it. The causes of the accident are divided into causes

immediate and basic causes, the former are the ones that materialize the event and are

related to the material and environmental conditions of the workplace. For

the ultimate root causes correspond to personal factors and work factors.

The Chernobyl disaster occurred due to two types of causes which were: design error.

and human errors.

The RBMK high power condenser number four of the nuclear plant

Chernobyl, in Pripyat (Ukraine) exploded. The officials at the plant did not follow the

security measures of the plant and the uranium fuel of the reactor overheated.

Those plants did not include what is known as structure of

containment, a concrete dome designed to keep radiation inside the

plant in case of such an accident, which would cause the explosion to end up provoking the

dispersion of radioactive elements, plutonium, iodine, strontium, and cesium.

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Graph on Chernobyl case statistics: number of people who died, number of

heridos, sobrevivientes, numero de contaminados %.

6. Filling out the research format up to the point "Summary of

causes

FORMAT FOR INVESTIGATION OF WORK INCIDENTS AND ACCIDENTS

FOR COMPANIES AFFILIATED WITH ARL-SURA RESOLUTION 1401 OF 2007

Version 2 - 12/20/2013

ACCIDENT SERIOUS ACCIDENT _______ FATAL ACCIDENT __x ACCIDENTE LEVE ________ INCIDENTE _____
DATE ON WHICH THE INVESTIGATION IS SENT TO THE ARL: DATE ON WHICH RECOMMENDATION IS SENT TO THE COMPANY:

04 / 26 / 1986MM/DD/AA MM/DD/YY

DELEGATED COORDINATOR: CARGO:

EPSALAQUEISAFFILIATED FAMISANAR CODE EP S ARL ALAAQUE IS AFFILIATED ARL CODE

SURAH
AFPALAQUE ISAFFILIATED TOCOMEFROM AFP CODE OR SOCIAL SECURITY
SOCIAL SECURITY YES NO WHICH

[Link],CONTRACTOR,ORCOOPERATIVE
TYPE OF EMPLOYMENT LINK: EMPLOYER (2) CONTRATANTE COOPERATIVE WORK ASSOCIATION

HEAD OFFICE
NAME OF THE ECONOMIC ACTIVITY CODE
NAMEORCOMPANYNAME CHERNOBYLNUCLEARPOWERPLANT TIP OR DEIDENTIFICATION NUMBER

NI CC CE N.U PA
ADDRESS NORTHOFUKRAINE PHONE FAX

EMAIL DEPARTMENT M U N I C I PA L I T Y ZONE

U R

WORK CENTER WHERE THE WORKER WORKS CODE

ONLY IN NEGATIVE CASE TO FILL OUT THE FOLLOWING BOXES ABOUT
ARETHEDATAFROMTHEWORKCENTERTHESAMEASTHOSEOFTHEMAINHEADQUARTERS? YES NO
WORKCENTER:
NAMEOFTHEECONOMICACTIVITY CODE OF ECONOMIC ACTIVITY
FROMTHEWORKCENTER FROMTHEWORKCENTER
ADDRESS PHONE FAX

DEPARTMENT M U N I C I PA L I T Y ZONE
U R

II. INFORMACIÓN DE LA PERSONA QUE SE ACCIDENTÓ

TYPEOFLINKAGE: PLANT MISSION COOPERATIVE STUDENT OR APPRENTICE INDEPENDENT CODE (5)

FIRST LAST NAME SECOND LAST NAME FIRST NAME SECOND NAME

GAURANICH GLED
TIP OF DEIDENTIFICATION NUMBER DATE OF BIRTH SEX

CC CE N.U TI PA 06 1 1 1940 M F
ADDRESS PHONE FAX
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INDICATE WHERE IT OCCURRED TIPODELESIÓN(MARQUECONUNAXCUÁLOCUÁLES)

WAREHOUSES OR DEPOSITS FRACTURE (70)POISONINGOR
(2)AREASOFPRODUCTION Luxation ACUTEINTOXICATIONORALLERGY

(3)RECREATIONALORPRODUCTIVEAREAS EFFECTOFTIME,OFTHECLIMATE
["TWISTING","SPRAIN","MUSCLETEAR","HERNIA"]
ANOTHERRELATEDTOIT
(4)CORRIDORS OR HALLWAYS Thelacerationofmuscleortendoninjury
ENVIRONMENT
STAIRS (30)INTERNALSHOCKORTRAUMA Asphyxia
PARKINGAREASORVEHICULARCIRCULATIONAREAS AMPUTATIONORENUCLEATION(Exclusionorlossoftheeye) EFFECTOFELECTRICITY
OFFICES WOUND HarmfulEffectofRadiation
OTHERCOMMONAREAS (50)SUPERFICIALTRAUMA(Includesscratch,punctureorprickand (90)MULTIPLEINJURIES
OTHER.(Pleasespecify) child injury to the eye due to a foreign body OTHER.(Pleasespecify)
BLOW,CONTUSIONORCRUSHING
BURN

PART
OFTHE
BODY
APPARENTLY
AFFECTED: AGENT OF THE ACCIDENT: (WITH WHAT DID HE GET INJURED) MECA NIS M O O FORM A D EL A C CIDEN TE
HEAD TRA
D
B
A
JOR FALL OF PERSONS
(1.12) OJ O FALLINGOBJECTS
NECK MACHINES AND/OR EQUIPMENT STEPS, COLLISIONS OR HITS

TRUNK(Includesback,spine,spinalcord) TRANSPORTATIONMEANS TRAPENVIRONMENTS

itisapine,pelvis (3)APARATOS OVEREXERTION, EXCESSIVE EFFORT O
THORAX (3.36)TOOLS,IMPLEMENTSANDUTENSILS FALSE MOVEMENT

ABDOMEN (4)MATERIALSORSUBSTANCES EXPOSITION OR CONTACT WITH TEMPERATURE

(4)SENIORMEMBERS (4.4) RADIATIONS EXTREME

HANDS (5)WORKENVIRONMENT(Includestransitand (7) EXPOSURE OR CONTACT WITH ELECTRICITY

LOWERMEMBERS work, furniture, roofs, in the exterior, interior or underground
(8) EXPOSITION O CONTACT WITH SUBSTANCES
PIES OTHERUNCLASSIFIEDAGENTS HARMFUL, RADIATIONS OR SPLASHES

MULTIPLE LOCATIONS ANIMALS (Live or animal products) OTHER.(Pleasespecify)

GENERALINJURIES OR OTHERS (7)UNCLASSIFIEDAGENTSDUETOLACKOFDATA

IV. DESCRIPTION OF THE ACCIDENT PEOPLE WHO WITNESSED THE ACCIDENT

EN CASE AFFIRMATIVE,
DESCRIBA DETALLADAMENTE ELACCIDENTE. QUÉLOORIGINO O CAUSÓ (Responda alas
questionswhathappened,when,where,howandwhy
WAS THERE ANYONE WHO WITNESSED THE ACCIDENT? YES NO to process it NEXT
INFORMATION:

On April 26, 1986, engineer GLEB GARANICH heard LASTNAMESANDFULLNAMES IDENTITY DOCUMENT

very loud noises and an explosion occurred in the reactor CC CE N.U TI PA

number 4 in the nuclear plant which spread a cloud CARGO No:
radioactive causing a large magnitude fire the flames
they caught up with the engineer causing his immediate death DECLARATION

at 1:45pm.

COMPANY:
LASTNAMESANDFULLNAMES IDENTITY DOCUMENT

CC CE N.U IT PA
CARGO No.

STATEMENT

SIGNATURE:

PERSON IN CHARGE OF THE REPORT (Representative or Delegate)

FullLastNamesandFirstNames IDENTITY DOCUMENT

ROSALES CAICEDO JESSICA ALEJANDRA CC CE N.U TI PA

CARGO
No. 1076670418
ADMINISTRATOR IN SECURITY AND HEALTH AT WORK
FIRM DATEOFCOMPLETIONOFTHE
INFORME DEL ACCIDENTE
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7. Bibliographic references

Arl Sura. (2007, May 24). Resolution No. 1401 of 2007. Arl Sura.

[Link]

option=com_content&view=article&id=854:resolution-no-1401#:~:text=

- Investigation of the

risks that caused it

Chacaliaza Ramos, G. (2014, marzo, 03).El desastre de Chernó[Link].

[Link]
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Nuclear Forum. Questions and answers. Do you know what a nuclear reactor is? Forum of the

Spanish nuclear industry. [Link]

nuclear/questions-and-answers/about-nuclear-energy/do-you-know-what-a-reactor-is

nuclear

Sánchez, C. (2007). The Chernobyl Disaster.

[Link]

Significados. (2013).Significado de Consecuencia. Qué es Consecuencia.

Meanings.

Spiral, M. (2020, marzo, 31).Protocolo de seguridad: las particularidades de este plan

of [Link] QHSE. [Link]

security-the-particularities-of-this-prevention-plan

Tomás, S. (2017, octubre, 21).Precauciones estándar: ¿qué son? ¿qué sabemos?

Survey... Regarding standard precautions to prevent infections.

FidiSp. [Link]

the measurements, other known or unknown sources

Wikipedia. (1986, abril, 26).Accidente de Chernó[Link].

[Link]

[Link]
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