Radiation Incident in New Mexico (USA)

[Stanley Fitch <stanley_fitch@nmenv.state.nm.us>]

On Tuesday January 5, a radiation incident was reported to the New
Mexico Environment Department.  The incident occurred in December 1999
at a corporation in Albuquerque which develops experimental radiation
generating devices.  A worker responsible for testing the device
received an estimated 3,000+ rads to his fingertips, with 1000+ rads to
the remainder of his hands.  These early theoretical estimates
determined by radiation effects experts at the University of New
Mexico.  Both experts are renown, one a BEIR committee member and the
other a published medical physicist.  The worker received extensive
tissue damage and is experiencing severe pain even under narcotics.

An 800 kVp electron beam device was under development for sterilization
of small medical items.  The device had an open receiver to place the
medical items.  The device possessed no direct ability to decapacitate
charge, therefore the electron beam would remain active for
approximately one minute after termination.  To account for this,
company protocols called for a waiting period of one minute before items
were exchanged by the worker.  From early accounts, several factors
occurred leading to the incident.  Most notable are:
1) The geometry of the open receiver was enlarged making it possible for
the entire hand to be inserted.
2) Protocols and procedures were not modified to account for changes to
the device.
3) Adequate review and monitoring by the RSO was not conducted.
4) Research for the sterilization capabilities of the device was behind
schedule.  The worker was instructed to increase the number of
sterilization samples for proof of design and concept before the end of
the year.  The worker potentially took numerous shortcuts, most probably
not waiting for the device to fully deenergize before changing samples.
5) Tongs were required for changing samples.  At this point is unclear
whether the tongs were adequate, or even in use at the time of the
incident.

What type of legal action to be taken by the New Mexico Environment
Department is yet to be determined.

Stanley Fitch
stanley_fitch@nmenv.state.nm.us

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