lec 6 3 hps rad accidents[1]

8/2/2019 Lec 6 3 HPS Rad Accidents[1]

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Radiation Accidents

Presented by:

John Pickering

San Jose State University


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Types of Accidents

Reactor or Criticality

Windscale, England (1957)

Three Mile Island, USA (1979)

Chernobyl, Ukraine (1986)

Tokai-Mura, Japan (1999)

Mishandled/Lost/Stolen Sources

Mis-administration of MedicalRadiation


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Criteria for Classification

as an Accident= One of:

Whole Body Dose

>250 mSv (25 rem)

Skin or Extremity Dose >6,000 mSv (600 rem)

Other Tissue or Organ Dose(External) >750 mSv (75 rem)


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History of Accidents

1944 - 2000US non-US

#Reported Accidents 245 169

#People involved 1,351 132,391*

#Significant dose 792 2,206

#Fatalities 30 97*Mostly Chernobyl


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Fatal Criticality AccidentsWeapons Program

Los Alamos: 1945 (1), 1946 (1), 1958 (1)

Reactors

Idaho Falls: 1961 (3 - non-radiation)

Chernobyl: 1986 (28 + 3 explosion)

Fuel Handling

Rhode Island: 1964 (1)

Tokai-Mura, Japan:1999 (2)


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Fatal Source Accidents1981: Oklahoma (1 fatality)

1984: Morocco (16.3 Ci 192Ir; 8

fatalities)

1987: Goiania, Brazil (1375 Ci 137Cs; 4fatalities)

1993: Tallinn, Estonia (137Cs; 1 fatality)

2000: Bangkok, Thailand (750 Ci 60Co;3 fatalities)


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Fatal Medical Accidents1968: Wisconsin (1 fatality)

1975: Ohio (10 fatalities)

1980: Texas (7 fatalities)

1986: Texas (2 fatalities)

1990: Spain (10 fatalities)1992: Indiana, PA (1 fatality)

1996: Costa Rica (3-7 fatalities)


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Four Example AccidentsBangkok, Thailand: Lost(stolen)

Source

Tokai-Mura, Japan: Criticality

Tammiku, Estonia: Stolen Source

Indiana, PA: Medical


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Bangkok, Thailand

February 15, 2000Four Co-60 radiation therapy sources

left in parking lot

750 Ci; up to 10 Sv/hr (1000 rem/hr) atsurface

Person A sold source to scrapyardClaimed to have purchased it from others

Three others also accused of stealing

Person B purchased source

Persons B and C disassembled source


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Bangkok, Thailand

(Continued)Others who received a radiation dose

Person D: scrapyard owner

Person E: husband of owner

Persons F & G: workers

Person H: brother of person A

Source integrity apparently notbreached


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Bangkok, Thailand

Medical ConsequencesThree fatalitiesPerson C: March 9 (marrow erosion)

Person B: March 18 (marrow erosion)Persons E: march 25 (organ failure)

Two with burns

Person A: hands; gangrene to handsPerson H: hands


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Bangkok, Thailand

Medical ConsequencesThree with low blood counts

Person D

Person F

Person G

About 40 others had some low blood

counts &/or local tissue injury


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Tokai-Mura, Japan

September 30, 1999Criticality accident

Person A holding the funnel

Person B was pouring nitratesolution into vessel to dissolveuranium oxide (19% enriched)

Person C was in office, 5 m away


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Tokai-Mura, Japan

Accident EventsSolution went prompt critical

No explosion, but some fission

products released; criticality reactioncontinued for 17 hours

All three evacuated to hospital


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Tokai-Mura, Japan

DosesDifferent measurements gave

different doses

Radioactive sodium produced in blood

Blood cell changes

Person A: 10-20 Sv (1000 - 2000 rem)

Person B: 6 - 10 Sv (600 - 1000 rem)

Person C: 1- 3 Sv (100 - 300 rem)


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Tokai-Mura: Medical

Consequences: Person AImmediate loss of consciousness

Severe vomiting, diarrhea within 1 hr

Kidney failure in week 3

Severe skin damage over more than50% of body

Death on day 82 from massive organfailure


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Tokai-Mura: Medical

Consequences: Person BNausea and vomiting within 1 hr

Early decrease of lymphocyte counts

Skin reddening, blisters after 3weeks

Pneumonia, kidney failure

Death on day 210 from multipleorgan failure


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Tokai-Mura: Medical

Consequences: Person CSlight nausea at 4 hours

Lung problems (also a 2 pack/day

smoker)

Full recovery after 1 month


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Tammiku, Estonia

October 21, 1994Persons A, B, and C broke into

radioactive waste facility at night

Stole large Cs-137 sourceSource placed in coat pocket, taken

home, and hung on wall in entrance

hall and then in kitchenDose rates 0.14 Gy/hr (14 rem/hr) at 1

meter


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Tammiku, Estonia

Others ExposedPerson D: Persons A stepson

Person E: Person Ds mother

Person F: Person Ds great-grandmother

Dog (slept in kitchen)


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Tammiku, Estonia

Dose ReconstructionPerson A: 1830 Gy (183,000 rem) to thigh;

4 Gy (400 rem) whole body

Person B: 12 - 20 Gy (1200-2000 rem) tohands

Person C: < 1 Gy (


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Tammiku, Estonia

Medical ConsequencesPerson AHospitalized with severe injury to leg

Claimed injury while working in forestTreated for crush injury

Death on day 12Renal failure, hemorrhaging

Person BUlcerative lesion on thumb


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Tammiku, Estonia

Medical ConsequencesPerson CMild radiation syndrome; recovery

Person DBone marrow affected

Tissue death of fingers on left handAmputated


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Tammiku, Estonia

Medical ConsequencesPerson FModerate radiation syndrome

DogDeath


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Indiana, Pennsylvania

November 16, 1992Elderly patient being treated for anal

carcinoma

Treatment: brachytherapyFive catheters used

Ir-192 gamma source used


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Treatment ProblemsInsertion of source in first four

catheters successful

Fifth unsuccessful

Treatment terminated


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Safety ViolationsArea radiation monitor alarmed after

supposed retraction from fifth

catheterControl console indicated

successful retractionSource actually left in patient

Nobody used radiation meter tocheck the patient


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Source MovementsPatient transported to nursing home

Day 4: Catheter with source fell out

Personnel put it in biohazard bag

Stayed in storage room for 5 days

Day 9: Biohazards picked up

Driver had survey meter, but did not use it

Source put in trailer


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Source MovementsDay 11: Trailer driven to Warren, Ohio,

to disposal site

Radiation monitor soundedTraced source to hospital

Source sent back to hospital


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Radiation DosesPatient

16,000 Sv (1,600,000 rem) at 1 cm from

source (160 Sv (16,000 rem) at 10 cm)so internal organs received very largedose

Patient died: Acute Radiation Exposure

and Consequences thereof


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Radiation DosesOthers exposed

Hospital personnel, ambulance driver,

nursing home personnel, visitors, otherresidents, waste driver

Maximum dose

Estimated 0.7 - 1.6 Sv (70 - 160 rem) tohands of one nursing assistant


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Radiation DosesWhole body doses

# people dose range (mSv(rem))

1 150 - 200 (15 - 20)7 100 - 150 (10 - 15)

13 50 - 100 (5 - 10)

20 10 - 50 (1 - 5)

11 5 - 10 (0.5 - 1)

42 0 - 5 (0 - 0.5)


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CreditsThis presentation was developed by the HPS Science

Teachers Workshop Committee, 2000-2002

Members:

Lisa Bosworth (chair), John Doroski,

David Fogle, Ian Hamilton, Anne Harri,

Karen Langley, John Leighliter,

John Luetzelschwab, Margaret Marks, ,

Bill Somers, Carl Tarantino, C.M. Wood

Special Thanks to Richard Toohey for supplying much of theinformation

lec 6 3 hps rad accidents[1]

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