On 26 October 1991 at an industrial sterilisation facility in Nesvizh, Belarus, an operator entered the irradiation chamber and was exposed to a lethal dose of radiation. This publication, the third to be issued by IAEA on irradiator accidents, describes the events leading up to the accident, the dose received by the operator, the subsequent medical management and the lessons learned.
This was the fifth fatal irradiator accident in 20 years and, as with those previously reported by IAEA, a primary contributory factor to the accident was poorly designed and maintained safety and warning systems that were relatively easily overridden. The publication describes the safety systems of the facility in some detail, the main access safety feature being a moveable floor section at the maze entrance that was automatically retracted prior to source exposure to reveal a deep pit. A secondary safety feature was a large, pressure-sensitive plate covering the full width of the maze entrance. At the time of the accident the operator was alerted to a jam in the product transport mechanism by a warning on the control panel. He retracted the source to the safe position and went into the chamber to release the jam. However, he did not remove the primary control key from the panel, and hence did not deactivate the access safety systems. The IAEA team concluded that the operator must have climbed over the open pit by stepping on the floor drive motor conveniently placed in the centre of the pit, although he never admitted this fact. The method by which the operator got past the pressure-sensitive plate remains a mystery - it would not have been possible to jump over it and subsequent tests revealed it to be working correctly. The investigators were also unable to determine how the source subsequently became exposed while the worker was trying to release the jammed product carriers. Various hypotheses are put forward, including accidental depression of the exposure button (by a second person) or temporary failure of a component in the control circuit. What is clear, however, is that while the operator was working in the chamber the source became exposed and he received an estimated whole body dose of 11 Gy, with localised doses of up to 20 Gy. Despite intensive medical treatment he died 113 days later.
A significant feature of this accident is the knowledge gained from the medical management of the patient, and almost one-third of this publication is devoted to a detailed description of the clinical course of the injuries and the post-mortem findings. Much of this description is written for the medical specialist and hence is technical in content, but the conclusions arising from this medical work are of general interest.
The publication has been written to provide information to those with responsibility for the safety of irradiation facilities and to medical authorities that might be involved in the management of a radiation incident. It also provides a graphic account of the serious consequences of failures in both safety syst...