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----- 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
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