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Re: Criticality accident



 
----- Original Message -----
Sent: Saturday, March 16, 2002 11:08 PM
Subject: Criticality accident

I heard an after-dinner talk Friday the subject of which I thougt might be of itnrest to RADSAFERs.  The talk was by Tom Laughlin (sp?), who has published (with others) a LANL report on criticality accidents.  He talked only about process accidents -- accidents that occur during chemical processing of fissile material.  Some interesting points:

There have been 22 such accidents since 1943, 21 of them in solution (liquid) media.

There have been 9 fatalities altogether (I think I remember this number correctly).

The accidents appear to be the result usually of
* not following specified procedures (taking short cuts)
* not being given proper procedures
*not understanding what the consequences of an accident would be.
 
  you can find such type of conclusions (and others related or not with human errors, e.g mechanical failure, lack  of internal audit) reading the investigations report of the recent and past cases of radiological accidents;
Generally, these are part of the weaknesses on safety culture:  the direct cases (why did it happen?) and the root cases (why were they not prevented?)  -  And lessons that should be learned to avoid recurrence: lack to implement corrective actions
These accidents pose occupational hazards.  There have been no health effects to anyone but workers, and no environmental effects.
 
 

This could be happen for these particular cases of accident, (or incident) probably no population were exposed, however in cases where population is involved no doubt that psychological also can be of major consequences.

Most interesting of all: in several accidents he discussed, workers stopping the criticality would get tens of rad or more in a very short time, with no apparent ill effect.  At Tokaimura, the two heavily exposed persons died (one after 4 months and one after 6 months), but the third person, who received several HUNDRED rad, is apparently not only alive but in good health and leading a normal life. 
 

In Goiania two patients who received high doses (7.0 and 5.5 Gy) and exhibited bone marrow depression recovered and survived

Jose Julio Rozental
Israel