Last decade accidents

["J. J. Rozental" <josrozen@netmedia.net.il>]

To Lopez <JLOPEZ@MEDNET.SWMED.EDU>

Jose Lopez, Ph.D., P.E.
Radiation Safety Officer
Univ. of Texas Southwestern Medical Center at Dallas
(214) 648-3952

To Franz   e-mail: schoenho@via.at
Franz Schoenhofer

To all
=================================
The following table  picture,  in terms of fatalities,  the accidents
occurred in the last  decade as a result of  failing of good procedures,
insufficient  control and  inadequate handling or uses of  sealed
sources.(no fuel cycle)

          
         -- RADIOLOGICAL ACCIDENTS IN TERMS OF FATALITIES 1981/1992

    YEAR	      LOCATION	      APPLICATION	       FATALITIES
WORKERS     PUBLIC
    1981	Okahoma, USA	Industrial Radiography	        1 
    1982	Kjeller, Norway	Irradiation Facility	        1
    1984	Marroco	Lost of source	                               8
1987	Goiania, Brazil	Teletherapy Device	               4            1989
El Salvador, Irradiation Facility	        1
    1990 	Israel	Irradiation Facility                    1               
    1990	Zaragoza, Spain	Linear Accelerator              3
    1991	Nesvizh,  Belarus Irradiation Facility	        1
    1992	Xinzhou, China	Lost of Co-60 source                    3

 (only in terms of fatality, not included accident without fatality , like
Juarez, Mexico, even with large number of over-exposure)

	 IAEA's documents mentions the occurrence of more than 100 registered
accidents  with sealed radiation sources involving about 700 persons
over-exposed to whole body dose larger than 0.25 Sv or to a local skin dose
above 6 Sv. In addition there have been accidents with sealed or unsealed
sources that were not reported, in number probably equally large.
	
	The main reason for the  accidents mentioned in the above Table  and
probably the great majority of accidents, as mentioned in several
references, were frequent workers' errors, some of them  incoherent, and the
lessons learned derived these incidents and accidents, many of them similar,
proves a serious lack of Safety Culture and Human Behavior and Dissemination
between  personal and organization and an  unequivocal and urgent necessity
of implementing a comprehensive understanding about the philosophy of Safety
Culture, especially to those countries, without any or little infrastructure.

	Considering the above statement, there is no doubt to conclude that the
reasons for so high number of incident and accidents and over-exposure,  are:
       
       * Lack of an appropriate legal  and  regulatory  framework;
       * Lack of an effective radiation  protection structure:
 			Notification,
			Registration, 
			Licensing,  
			Compliance monitoring,
			Enforcement;
       *  Insufficient training  
       * Lack of Safety Culture discerning 

With regard Franz Statement, I would like to draw his attention to the next
information:


"It seems to be more important to the
mass media to discuss potential risks involving a large number of
persons than actual accidents involving only one or a few persons who
died." 

I fully disagree of your point of view. Media is wonder for any potential
risk involving nuclear energy, in this include, even a single source of
radioactive material. I managed , in Goiania, Brazil, as general
coordinator, the Radiological Accident in Goiania,  the most serious
radiological accident to have occurred to date. It resulted in the injure by
radiation of many people, four of them fatally. In your concept, a small
number, however, even with such small number, I inform you that after almost
10  years, the lessons from the Radiological Accident in Goiania, have yet
to be fully learned, in this including:

1) Implausible Accident can happen suddenly, even when least expected;

2) Accident caught countries by surprise !!!!!

3) E.P.P. is still in many country in insipient stage;

======================================

"In fact  that accidents are uncommon should not, however, give grounds for
complacency. No radiological accident is acceptable, and    one that
threatens widespread contamination is bound to alarm a public  that has not
yet come to terms 
with radioactivity - Dr Hans Blik, IAEA , Director General"


===============================
again with regard Franz  information:
"If I remember correctly the IAEA has only recently published a book on
accidents in irradiation facilities and the lessons learned."

You are right the document: 

Radiological accidents in industrial facilities: main causes, lessons
learned and recomendations, 1996 IAEA TEC-DOC, still in final draft form.


J.J.Rozental <josrozen@netmedia.net.il>
Consultant, Radiantion Safety&Regulation
For Developing Countries
Israel