Date: 26 October 1991

Location: Nesvizh, Belarus

Type of event: accident at industrial irradiator

Description:

An accident occurred during repairs at an irradiation facility that used a 30 PBq cobalt-60 source for sterilization of medical equipment. Although the specific actions are not fully known, an operator (34-year old male) failed to follow operating procedures and circumvented safety features in entering the irradiation room to deal with a jam of the product transport system. The source was exposed at the time, and the operator walked to within 0.5 m of the source before realizing his error and exiting, spending between 1 and 2 minutes in the irradiation room. He received a whole body dose of 1,250 rem and localized doses of up to 1,800 rem. Within 3 minutes of exiting he experienced nausea and diarrhea after an additional 13 minutes. The operator received extensive medical treatment but died 113 days later.

Consequences: 1 fatality (1,250 rem).

References:

• Baranov, Alexandr E., Giorgi D. Selidovkin, Anna Butturini, and Robert Peter Gale, 1994, "Hematopoietic recovery after 10-Gy acute total body radiation," Blood, 83:596-599.
• IAEA, June 1996, The Radiological Accident at the Irradiation Facility in Nesvizh, IAEA (Vienna, Austria), on line at IAEA [http://www-pub.iaea.org/MTCD/publications/PDF/Pub1010_web.pdf].
• Ortiz, P., M. Oresegun, and J. Wheatley, 2000, "Lessons from major radiation accidents," on line, Internationl Radiation Protection Association [http://www.irpa.net/irpa10/cdrom/00140.pdf].
• Turai, Istvan, and Katalin Veress, 2001, "Radiation accidents: Occurrence, types, consequences, medical management, and the lessons to be learned," Central European Journal of Occupational and Environmental Medicine, 7:3-14, on line at CEJOEM [http://www.fjokk.hu/cejoem/files/Volume7/Vol7No1/CE01_1-01.html].
• UNSCEAR, 2000, "Annex E: Occupational radiation exposures," in Sources and Effects of Ionizing Radiation: United Nations Scientific Committee on the Effects of Atomic Radiation UNSCEAR 2000 Report to the General Assembly, with Scientific Annexes, Volume I: Sources, UNSCEAR, on line at UNSCEAR [http://www.unscear.org/docs/reports/annexe.pdf].

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Last modified 26 October 2008.
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