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WANO REPORT
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APPLICABILITY
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Confidentiality notice
Copyright 2014 by the World Association of Nuclear Operators (WANO). All rights reserved. Not for sale or commercial use. This document is protected as an
unpublished work under the copyright laws of all countries which are signatories to the Berne Convention and the Universal Copyright Convention. Unauthorised
reproduction is a violation of applicable law. Translations are permitted. This document and its contents are confidential and shall be treated in strictest confidence. In
particular, except with the prior written consent of the WANO CEO, this document shall not be transferred or delivered to any third party and its contents shall not be
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CONTENTS
Analysis of Fire-related events 2
Purpose 2
Analysis Methodology 2
Summary 2
Lessons Learned 2
Main Trends 4
Analysis of Causes and Contributors for Fire-Related Events reported to WANO in the period from June
2012 to July 2014 8
Summary of Peer Review AFIs 11
Corrective Actions Identified by Stations: 11
Overview of the six Fire-related Events Classified as Significant 14
Attachment: List of Fire-Related Events 17
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Purpose
This report presents the analysis of 58 fire-related events that were reported to WANO from June 2012 to
July 2014. This review of fire-related events was initiated to communicate the trends, causes,
consequences and lessons learned by the member stations.
• How many fire-related events were classified as Significant and Noteworthy using the Operating
Experience (OE) reference manual?
• What were the major consequences of fire-related events and what were the main impacts to
operational safety and availability?
Analysis Methodology
Fire-related event reports were extracted from the WANO OE database using the keyword “fire”. Over a
24-month period (June 2012 to July 2014), 58 fire-related events were reported in the WANO OE database.
Some generated flames and/or caused explosions, some only produced substantial smoke (smoulder). The
events were analysed from different perspectives. Individual events were reviewed to identify important
lessons learned.
Summary
Fire hazards are a well-known issue in nuclear plants. Design features are in place to detect and mitigate
fires. However, several of the fires resulted in plant transients with the potential to challenge to personnel
and plant safety. Considering the 58 events reported to WANO over the last two years, there is not a
declining trend. Nine (15.5%) of the 58 events were classified as Significant or Noteworthy due to
substantial consequences. In some cases, the costs for restoration and generation losses were very high. It
is important member station personnel review and implement applicable lessons learned from the previous
fire-related events.
Lessons Learned
Seven of the nine events classified as Significant or Noteworthy are related to the large power
transformer and emergency diesel generators. Recommendations in SOER 2011-1 Rev 1, Large
Power Transformer Reliability, and SOER 2002-2, Emergency Power Reliability, are developed to
improve the reliability and operability of those critical components. Review and implementation of
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SOER recommendations, as well as use of lessons learned from previous events, can reduce the
potential of and minimise equipment damage from fires.
Some fires were initiated by faults in non-nuclear safety related (mainly) electrical sub components.
Preventive and predictive maintenance programmes for sub components on critical systems can
prevent these fires from happening. This can also include applying more strict quality acceptance
criteria when purchasing spare parts.
• Minimize fire hazards from leaks and combustible material storage and control.
Administrative controls to minimise fire hazards must be established and/or reinforced. Oil leak
controls, use of combustible material and storage of flammable and chemical substance must be
procedurally required and robustly implemented. Hot works should be under specific permission
and supervision. Weaknesses identified during WANO peer reviews in this area show that
enhancement and more management involvement are needed.
Reinforce a low tolerance for leaks of flammable fluids. Timely identification, monitoring and
repairs minimise the potential for fires. Find the causes and implement solutions to chronic and
repetitive leaks for long-term resolution.
Establish ownership and metrics with target goals to monitor leaks by age, significance and type.
Reinforce the need for leak identification during plant walkdowns by engineering, operations and
maintenance personnel.
• Maintain or upgrade the fire detection capability and check protection equipment status.
Appropriate capability of fire detection and firefighting system must be assessed and upgraded
based on risk analysis. Areas for improvement (AFIs) from WANO peer reviews and contributors to
some consequential fires show that fire detection shortfalls still exist at some stations.
Industry events have shown that fires can initiate significant transients during power operation or
jeopardise safety margins during unit shutdown. Designated plant personnel and firefighting
equipment should be maintained at a high state of readiness and prepared to respond to fire
events. Some stations use case studies, drills and simulation scenarios to improve firefighting
capabilities.
Most fires related to human factors were initiated by maintenance error during repair or
installation of electrical components, pipe laggings and oil pipes. Those were mainly related to
weaknesses in workers knowledge, skills, risk awareness, ownership and maintenance procedures.
For example, an emergency diesel fire resulted from a gasket oil leak due to loose bolting and
inadequate torque (WER ATL 12-0351).
Some fires resulted from inadequate lubrication of turbine systems, diesel engines, pumps and
fans. Programmes of monitoring lube oil system parameters for important systems and lubrication
routines should be reviewed and enhanced.
See the Corrective Actions section for specific examples of lessons learned.
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Main Trends
Analysis of fire-related events reported to WANO in the period from June 2012 to July 2014 identified the
following:
∗ Over the past two years, there has been no decreasing trend in fire-related events with substantial
consequences.
∗ Fire-related events occurred in all plant states: normal operations, outages, start-up and
construction.
∗ Fire-related events with major consequences are most of the time reported to WANO. However,
fire-related events with minor consequences are not often reported to WANO.
∗ Fire-related events adversely impacted station operation leading to reactor scrams, forced
shutdowns, extended outages and power reductions. In the worst cases, the fire-related events
caused long outages of up to several months.
∗ Electrical components were the main source for initiating fires. Mechanical components and
turbine and auxiliary components were the second biggest contributor.
∗ Fire-related events on turbine and auxiliary components were the second contributor to the more
consequential fire-related events.
Figure 1 shows the number of fire-related events reported to WANO and the number of the more
consequential fire-related events in the period from June 2012 to July 2014.
20
20
16
15 13
All Events
10 9
Events Classified as Significant
and Noteworthy
5 3 3
2
1
0
Jun. -Dec. Jan. - Jun. Jul. - Dec. Jan. - Jul.
2012 2013 2013 2014 *
∗ Additional fire-related events are expected to be reported for this period due to the lag time in
reporting events to WANO.
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Figure 2 illustrates the initial reactor status at the time the event occurred, for the fire-related events
reported to WANO between June 2012 and July 2014.
Figure 3 shows the classification status of fire-related events reported to WANO between June 2012 and
July 2014. Generally, fire-related events are classified as Significant or Noteworthy if there is substantial
loss of production or catastrophic damage to main components, as well as impairment to nuclear safety
functions. Fire-related events with less consequential economical loss or impairment on safety related
components are classified as Trending. Events classified as Other are those with minor or no consequence.
Trending, 32,
55%
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Figure 4 shows the consequences of the fire-related events reported to WANO between June 2012 and July
2014. Nearly 50% of events resulted in consequences. This ratio is higher than for other types of events.
Four people injured in two fires, one person received first and second degree burns while working with a
flammable gas cylinder in a confined space; three people injured while fighting a fire during an outage.
Figure 4:
Consequence of Fires
35
30
30
25
20
15
10
10 8 7 7
5 2
0
Minor Automatic Manual Scram Loss of Major Personal Injury
Consequence Scram Generation Due Equipment
to Downpower Damage
or Extended
Outage
Figure 5 shows the equipment initiating fire-related events reported to WANO between June 2012 and July
2014. Electrical components and pumps/fans contributed the largest hazard.
Figure 5:
Components Involved
30
27
25
20
15 13
10 8
6
5 4
0
Transformer Pumps and Fans Turbine and Others Emergency
and Other Auxiliary Diesels
Electrical Components Generators
Components
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Figure 6 shows the components involved or damaged in the more consequential fire-related events
reported to WANO in the period of June 2012 to July 2014. In five events, large power transformers were
damaged or involved. Two events were related to turbine and generator, and one caused emergency diesel
generator (EDG) damage.
Figure 6:
Components Involved in the More Consequential
Fire-Related Events
EDG, 1
Power
Cable, 1
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Analysis of Causes and Contributors for Fire-Related Events reported to WANO in the period of June 2012
to July 2014
Figures 7 and 8 show the cause analysis of all fire-related events reported to WANO in the period of June
2012 to July 2014. Of these events, 43% were due to equipment-related issues while 27% were human
performance related. Of nine more consequential fire-related events, six were due to equipment failure
and two due to human error. One is not determined. One example of a human-related fire involves a main
coolant pump fire being initiated by an oil leak caused by an incorrectly installed nozzle (WER PAR 14-
0070). Another example of equipment-related fire was a fire on the turbine lubricating oil purification
system skid, and the direct cause was a faulty contactor that allowed a heating element to continue to
operate after the system was shut down (WER ATL 13-0078).
Figure 7:
Cause analysis of All Fire-related Events
Other, 5,
9%
Not
Equipment
Identified,
Related, 25,
12, 21%
43%
Figure 8:
Cause Analysis of the More Consequential Fires
7
6
6
3
2
2
1
1
0
Equipment Related Human Related Not Identified
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Figure 9 shows the direct causes as identified by the stations. Electrical deficiency was the cause of 26 fire-
related events. Nine events were attributed to oil leaks, five occurred due to overheating caused by
mechanical issue, and four occurred due to overheating caused by inadequate configuration control. Five
fires happened because of inadequate management of combustible material, chemical products, solvents
and paints. In five fire-related event reports, a direct cause was not included.
20
15
10 9
5 5 5
5 4
0
Electrical Fault Fuel Oil and Overheating Due Combustible Unidentified Overheating Due
Lube Oil Leak to Mechanical Material Storage to Inadequate
Issues Configuration
Control
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Figure 10 shows the root causes as identified by the stations. Regarding equipment performance related
fires, ageing and component degradation is the biggest contributor. There were ten fires with incorrectly
performed maintenance as the root cause. Six events occurred due to housekeeping issues, such as
improper storage of combustible chemicals. Four event reports mentioned that the preventive
maintenance was not sufficient. In 13 event reports, root cause analysis was not included. The typical
causes of electrical faults are electrical short and arcing, ground fault, overload and loose connection.
20
20
15
13
10
10
7
6
5 4
0
Degraded Sub- Unidentified Maintenance Ageing of Housekeeping Preventive
component Performed Components Maintenance
Incorrectly Inadequate
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In 2012 and 2013, 48 AFIs were identified using the WANO fire protection performance objectives during
93 WANO peer reviews. Figure 11 shows that over 50% of these AFIs were related to shortfalls in work
practices, behaviours and conditions against fire safety (FP.4 in WANO PO&C 2005), which mainly include
uncontrolled fire load, oil leakages, inadequate hot work control and practices of maintaining firefighting
equipment. Twelve AFIs were related to fire protection facilities and equipment with inappropriate
capability and capacity (FP.6 in WANO PO&C 2005). The remaining fire protection AFIs were related to
weaknesses in knowledge, training and firefighting exercise, testing and preventive maintenance on fire
protection equipment (FP.5, FP.2 and FP.3 in WANO PO&C 2005).
1. Fires attributed to large power transformer: stations are reviewing implementation of SOER 2011-1
Rev 1, Large Power Transformer, recommendations.
For example, after a fire on the main transformer, one of the station corrective actions was to replace
the transformer with a new transformer provided with online condition monitoring equipment. (WER
TYO 13-0139)
2. Fires attributed to oil leaks include inadvertent ignitions of flammable oil and oil soaked material:
the leak management programme was reviewed and enhanced to reinforce standards and clarify
criteria.
For example, after a turbine and generator fire resulted from an oil leak, one of the station corrective
actions was to update the process to include a full assessment of where the leak could have originated
and the fire risk in the area. (WER PAR 14-0325)
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3. Fires attributed to electrical components failure: stations have strengthened quality requirements on
critical electrical parts to reduce manufacturing errors.
For example, after a battery fire, one of the station corrective actions was to revise the management
procedure on lithium battery quality acceptance requirements and after-use inspection. (WER PAR 13-
0128)
For example, after a transformer fire, one of the station corrective actions was to evaluate preventive
maintenance and testing activities for emergency oil pumps (such as turbine bearing oil, main
generator seal oil, and feedwater pump turbine oil pumps) and all supporting equipment (e.g.
batteries and breakers) to ensure the pumps would be able to perform their design functions. (WER
ATL 13-0006)
5. Fires attributed to component ageing: life cycle management on critical components and supporting
systems has been enhanced.
For example, after a transformer fire, one of the station corrective actions was to establish a life cycle
management replacement preventive maintenance of critical dry type transformers. (WER ATL 14-
0029)
For example, after an emergency diesel generator fire, one of the station corrective actions was to
include in the post-maintenance and post-modification test matrix the vendor recommendation for
not exceeding the time the EDG can operate unloaded. (WER ATL 12-0720)
For example, after a fire on a draught fan, one of the station corrective actions was to amend
maintenance work instructions to include a check that the motor cooling fan is required. (WER PAR 13-
0237)
8. Fire attributed to design or design margin inadequacy: modifications were implemented to correct
design flaws and improve fire protection status.
For example, after a fire on cable insulation, plant modifications were implemented to address the
latent flaws. (WER ATL 13-0474)
9. Fire damage and risk not being detected: fire detection systems were upgraded.
For example, after a battery fire, one of the station corrective actions was to replace the fire detection
system and upgrade fire detection system. (WER PAR 13-0372)
10. Fires particularly related to overheating due to inadequate lubrication: equipment operation status
monitoring was enhanced.
For example, after a fire on a reactor sea water pump, one of the station corrective actions was to
amend the existing lubrication routines and initiate six weekly ultrasound routine measurements.
(WER PAR 13-0353)
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11. Fires related to housekeeping: permit for hot work or combustible or chemicals storage were revised
to include proper risk assessment.
For example, after a fire resulted from inadequate storage of solvent, one of the station corrective
actions was to revise company rules stipulating containers for storing solvents. (WER TYO 12-0193)
12. Fires causing safety related equipment damage: the station created a scenario for simulation trainings
as a mean of mitigation in case that similar event occurred.
For example, after an electrical power supply bus fire, one of the station corrective actions was to use
the event for creation of a scenario for the simulator. (WER MOW 12-0090)
13. Training, oversight and reinforcing expectations related to fire protections were common method
embedded into corrective actions after fire-related events.
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During normal operation, an electrical fault in the auxiliary transformer caused a fire and explosion,
resulting in an automatic reactor scram and loss of offsite power. External support for fire suppression was
required. This event indicated a weakness in implementation of SOER 2011-1 Revision 1, Large Power
Transformer Reliability. (WER ATL 13-0800)
During power operation, a hydrogen and oil mixture leak from a bearing near the end of turbine shaft
resulted in a fire. Subsequently, the reactor was manually scrammed and the turbine generator taken out
of service. The fire also damaged equipment in the vicinity of the bearing, resulting in an outage of
approximately 27 days for repairs. (WER TYO 13-0034)
During power operation, the generator transformer Y-phase bushing insulation breakdown inside the
transformer resulted in arcing, bushing failure, an oil fire and a manual scram. The event resulted in
damage to major equipment and a five-month outage. It also indicated a deficiency in implementing SOER
2011-1, Large Power Transformer Reliability. (WER TYO 13-0139)
Photo of damaged high voltage bushing Photo of damaged lightening arrester and bushing
While performing a surveillance test on an EDG, alarms were received in the control room indicating
problems in the EDG. Control room operators generated an emergency trip signal but the generator failed
to stop. An auxiliary operator then cut the fuel supply by closing the fuel supply valves and causing the EDG
to trip. White smoke was also present in the diesel generator room; therefore, the fire brigade was
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activated. A subsequent investigation revealed extensive damage to the EDG. The most probable cause was
failure of the piston bearing coating material, leaving the material without proper lubrication. (WER ATL 12-
0720)
While the unit was in an outage, a fire occurred around the turbine lubricating oil purification system skid.
The sprinkler system activated and the internal fire brigade responded and extinguished the fire. The
turbine lubricating oil purification system skid and adjacent cablings were significantly damaged. The direct
and indirect impact of the fire on plant equipment resulted in a 45-day outage extension for repairs and
testing. The direct cause of the fire was a faulty contactor that allowed a heating element to continue to
operate after the turbine lubricating oil purification system skid and heater were shutdown. (WER ATL 13-
0078)
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Photograph of the Damaged Lube Oil Purifier Skid Photograph of the Damaged Cable Tray
With the unit in steady power operation, an unusual event was declared due to a main transformer fire.
The reactor automatically scrammed. The unit was cooled down on natural circulation due to the loss of
power to the reactor coolant pumps. Turbine bearing was damaged due to loss of power supply to lube oil
supply system. This event resulted in over three-month plant offline. (WER ATL 13-0006).
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Significant WER ATL 13-0006 Main Transformer Fire Results in Automatic Reactor Scram and Emergency
Preparedness Plan Activation
Significant WER TYO 13-0034 Manual Turbine Generator (TG) and Reactor Trip Due to Fire at TG Bearing-5
Area in NAPS-1
Significant WER ATL 13-0078 Turbine Lube Oil Purification System Fire
Significant WER ATL 12-0720 Failure of Emergency Diesel Generator Division III
Noteworthy WER ATL 12-0768 Main Transformer Failure Resulting in a Fire and Emergency Plan Activation
Noteworthy WER ATL 14-0029 #PRELIMINARY# Fire in 480 VAC Bus Results in Manual Reactor Scram and
Emergency Declaration
Noteworthy WER ATL 14-0222 Manual Reactor Scram and Alert Declaration Because of Fire in the Turbine
Building
Trending WER PAR 13-0376 Minor Fire in Turbine Hall – Site Incident
Trending WER ATL 13-0752 Unit 1 Turbine Manually Tripped Due to the Shaft Driven Turbine Lubricating
Oil Pump Motor Failure
Trending WER ATL 13-0717 #PRELIMINARY# Explosion and Fire in Turbine Building Resulting in a Manual
Scram and Emergency Declaration
Trending WER PAR 13-0353 2BY Reactor Sea Water (RSW) Motor In-Service Failure
Trending WER PAR 13-0461 Unexpected Chemical Reaction During Injection of Epoxy Resin in the Region
Between Fundamental Plate and Support Plate of the Main Generator Seal
Oil Supply Unit
Trending WER PAR 14-0275 Ignition of Hydrogen at the Top of Circulating Water Storage Tank by Cutting
and Grinding Work
Trending WER PAR 13-0372 Failure of Flammable Highlite 12FLB350 Lead Gel Battery Resulted in
Evolution of Smoke and Fume
Trending WER ATL 14-0069 #PRELIMINARY# Emergency Declaration Caused by Toxic Smoke
Trending WER PAR 13-0237 Fire on Aux Boiler 1 Forced Draught (FD) Fan
Trending WER MOW 14- #PRELIMINARY# Unit 2 Scrammed due to Reactor Protection Actuation
0037
Trending WER ATL 13-0474 Automatic Reactor Scram and Notification of Unusual Event Because of a
Fire in the Turbine Building
Trending WER ATL 12-0701 Unplanned Plant Downpower Due to Transmission Line Emergent Work
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Trending WER ATL 13-0528 Unit Auxiliary Transformer Fire Causes Loss of Backfeed and 13.8 kV
Electrical Bus
Trending WER ATL 13-0190 Notification of Unusual Event Based on a Fire in the Protected Area Lasting
Greater Than 15 Minutes
Trending WER ATL 14-0028 #PRELIMINARY# Plant Computer Room Fire Results in Emergency
Declaration
Trending WER MOW 14- #PRELIMINARY# A Short Circuit on the Non-Vital Bus of Metal Clad
0032 Switchgear 0.4 kV
Trending WER MOW 14- #PRELIMINARY# Two Safety System Simultaneous Inoperability During the
0060 Outage of Unit 1
Trending WER TYO 13-0123 Fire in Rear Compartment of Primary Feed Pump Circuit Breaker in TAPS-2
Trending WER ATL 13-0514 #PRELIMINARY# Alert Declared Because of Switchgear Explosion Affecting
Safe-Shutdown Equipment
Trending WER ATL 14-0155 Alert Declared Because of Fire in Emergency Diesel Generator Turbocharger
Lagging
Trending WER ATL 13-0722 Notification of Unusual Event Declared Due to Fire in the Turbine Building
Southeast Stairwell and on the Auxiliary Boiler Room Roof
Trending WER PAR 13-0197 R2 Shut Down Due to Small Fire on Turbine Pipework
Trending WER MOW 13- Simultaneous Unavailability of Two Emergency Power Supply Systems
0075
Trending WER ATL 13-0378 Employee Injured Due To Fire In Confined Space
Trending WER ATL 12-0531 Technical Specification Required Shutdown Based On Both Emergency
Diesels Being Declared Inoperable
Trending WER ATL 13-0571 Notification of Unusual Event Based on a Fire in the Turbine Building
Trending WER PAR 13-0187 #PRELIMINARY# Automatic Reactor Shutdown following loss of the auxiliary
transformer initiated by a fire outbreak.
Trending WER PAR 14-0325 Minor Fire in Turbine Hall – Site Incident
Other WER PAR 14-0131 Fire In Suction Pipe Insulation Of Boiler Feedwater Pump 4323 P102 C
Other WER PAR 14-0110 Failure of Plankton Sampling Unit Resulting in Fire Damage
Other WER TYO 12-0193 Fire (Small Fire) in Auxiliary Reactor Building
Other WER PAR 14-0040 Minor Fire in Unit 1 Main Cooling Water Inlet Culvert
Other WER PAR 14-0248 Turbine Building L2APP120VL Maintenance work set Shed on Fire
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Other WER PAR 13-0173 Fire on Stress Relief Panel T/A21/2 Located in Turbine Generator 21
Basement
Other WER TYO 12-0111 Occurrence of Burning of a Lighting Cable in the Miscellaneous Solid Melting
Treatment Building
Other WER PAR 13-0128 Spontaneous Combustion of Waste Lithium Battery in a Container at Ling’ao
Unit 1 Outage Site
Other WER ATL 14-0044 Fire in Substation Auto Transfer Switch #2. Fire was manually extinguished,
with CO2, in 3 minutes
Other WER ATL 14-0207 Fire on Turbine Driven Reactor Feed Pump Turbine B Insulation
Other WER TYO 14-0022 Fire Alarm Sounding at Auxiliary Public Facilities
Other WER ATL 13-0236 Exhaust Fan Bearing Fire due to Insufficient Lubrication
Other WER ATL 13-0196 Fire at the Stores Warehouse of the Becancour Gas Turbine Power Station
Other WER PAR 13-0235 Smoke from Coupling Buffer Block during Operation of NI Vent and Drain
System Pump
Other WER PAR 12-0133 Small Fire at High Pressure Cylinder Steam Pipework Lagging
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