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English STI/PUB/1010 | 92-0-101396-5
76 pages | 37 figures | € 20.50 | Date published: 1996On 26 October 1991, a fatal radiological accident occurred at an industrial sterilization facility in Nesvizh, Belarus. Following a jam in the internal product transport system, the operator entered the irradiation chamber to clear the fault. In doing so, he bypassed a number of safety features, leaving the controls in a position such that exposure was imminent. It was estimated that he received a whole body dose of 11 Gy, with localized areas of up to 20 Gy. Despite intensive medical treatment, he died 113 days later. The significant feature of this case was related to the medical management. In its post-accident review, the IAEA also brought to light other circumstances of the accident. The present report documents the causes and consequences of the accident and defines the lessons learned with a view to assisting those people with responsibility for the safety of such facilities and those medical authorities who might be involved in the management of a radiation event.
Contents: 1. Introduction; 2. Irradiaton facility; 3. Radiation accident; 4. Dose estimation; 5. Lessons learned; 6. Medical management; Annex I: Estimation of whole body dose from blood cell counts; Annex II: Results of cytogenetic analyses; Annex III: List of drugs, doses and administration dates.
French, Russian and Spanish editions in preparation.
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