The Goiânia Accident (1987)

If you're not auditing your rare-action groups adherence to standards via indepdent, out-of-chain assessment, assume they're hopelessly broken.

December 2, 2001 – Lia radiological accident: In the village of Lia, Georgia three lumberjacks discovered two 90Sr cores from Soviet radioisotope thermoelectric generators. These were of the Beta-M type, built in the 80s, with an activity of 1295 TBq each. The lumberjacks were scavenging the forest for firewood, when they came across two metal cylinders melting snow within a one meter radius laying in the road. They picked up these objects to use as personal heaters, sleeping with their backs to them. All lumberjacks sought medical attention individually, and were treated for radiation injuries. One patient, DN-1, was seriously injured and required multiple skin grafts. After 893 days in the hospital, he was declared dead after sepsis caused by complications and infections of a radiation ulcer on the subject's back. [48] The disposal team consisted of 24 men who were restricted to a maximum of 40 seconds worth of exposure (max. 20mSv) each while transferring the canisters to lead-lined drums.

October 21, 1994 – a large caesium-137 source was stolen by scrap metal scavengers in Tammiku, Männiku, Saku Parish, Estonia. The man who carried the source home received a 4,000 rad whole-body dose and died 12 days after first taking it. In addition, the man's stepson sustained radiation burn injuries to his hands after he found and touched the source after the man had placed it inside a kitchen drawer

and the following stories are new to me and very disturbing. radiation is a long lasting invisible fire. not too scary except that we can't see it without tools.

January 23, 2008 – A licensed radiology technologist, Raven Knickerbocker, at Mad River Community Hospital in Arcata, California performed 151 CT scan slices on a single 3 mm level on the head of a 23-month-old child over a 65-minute period. The child suffered radiation burns (skin erythema) to a small strip of his face and head. In one report, an independent investigation of the child's blood was said to have found "substantial chromosomal damage"[65] but subsequent reports reported no lasting harm.[66] The technologist was fired, and her license was permanently revoked on March 16, 2011 by the state of California, citing "gross negligence".[65] The hospital's radiology manager, Bruce Fleck, testified that Knickerbocker's conduct was "a rogue act of insanity".

October 2011 – At a hospital in Rio de Janeiro, a 7-year-old girl was treated for acute lymphoblastic leukemia with whole brain radiation. The prescriptions were done manually in a form with no formal peer review process. Because of an error in the registration of the number of sessions, she received the full dose in each session of radiotherapy. Even with early toxicity, the doctor refused to assess the patient, because some of the complaints were usual. The full treatment was finished in about 8 sessions and the girl was admitted with radiation burns. She developed frontal lobe necrosis and died in June 2012. After an investigation, the physicist, technician, and physician were charged with manslaughter.[79]

EDIT - All good points below.

The only thing that seems clear-ish is that IGR considered that the device belonged to them according to their actions as described. If so it is very reasonable that they be held to account.

This does not mean that there aren't other responsibilities or that officials/the government tried to cover their asses later on. The Wikipedia article does mention, though that the National Nuclear Energy Commission ended up being ordered to pay compensation to the victims, which at face value sounds like an acknowledgement that they also bore some responsibility.

It also says that the thieves were not involved in the civil suit without mention of anything else. This may be an important point because the goal of a civil suit is to get money so there may be little point in suing poor people... They are obviously guilty of theft (criminal), and damage to property (criminal and civil), beyond that it's quite unclear and they did pay a heavy price.

This is the key line for me. Why did Saura Taniguti summon police force to prevent the removal of such a hazardous object?

The link above is helpful but you have to dig through a very long Portuguese website to find this key nugget (via Google translate):

> However, at the end of 1985, this institute stopped working in these facilities and moved to other new facilities. Meanwhile, the property of the clinic's services was disputed in court, and the cobalt 60 teletherapy unit was transferred to the new facilities and the teletherapy unit in Cesio 137 was abandoned in its original place because it was embargoed.

> Most part of the clinic was demolished as well as adjacent properties. The treatment rooms in the fueron were demolished but were in a ruined state, abandoned. The date has not been notified to the licensing authority - Comisión Nacional de Energía Nuclear: CNEN.

https://scienceinfo.net/nuclear-disaster-from-a-stolen-medic... adds that:

> According to [Saura Taniguti], because there was a dispute between IGR and Saint Vincent de Paul Association - which owned the real estate block - where the IGR Hospital was located, and the court had a sealed order and cut it [sic]. security guards should all equipment in the hospital must remain the status quo.

My guess is the events were probably something a bit like the following:

1. IGR decides to relocate.

2. The technicians in IGR seemed very aware of how dangerous the Cesium source was. It was likely installed in a large machine, that would be inaccessible until most of the other items in the facility had been relocated.

3. Furthermore, to move such a source, they would not just pick it up and carry it in their pocket - you'd book perhaps an armored/lead-lined car, carry Gieger counters, dose badges, and wear contamination suits in case of an incident. Speculation: IGR thought it would be prudent to have most of the facility moved by untrained movers, but leave the nuclear source in place to reduce risk of an incident. Once the facility was emptied, they could bring in the the hazmat suits and move the source more safely.

4. All articles agree that the landlord, SVPA, is unhappy. Speculation: IGR had to terminate its lease early, or SVPA couldn't find a new tenant to cover their losses on the space.

5. After the initial move of the "easy" items, SVPA learns some "important equipment" is still on premises. They move to seal the building, to gain leverage in court negotiations.

6. The court negotiations go on for two years. Meanwhile, the developer moves to demolish the property so that it may be redeveloped so they can monetize the land. Speculation: offers were made to move the radiation source, but this would only be allowed if IGR would, for example, agree to pay for the cost of the broken lease and lost rent. (This is almost the exact situation of the SFO Safer, the oil storage unit off the coast of Yemen; people want to make it safe, and have been try to for years; but the group controlling access to the vessel is unwilling to grant free access to it, because the vessel in its current state is too valuable for negotiations).

7. The IGR was prevented "by police" from moving the source on May 4 1987. While the source could have been carried out by one person, nobody who knew how dangerous it was would just casually carry it out. Speculation IGR made a last-ditch to recover the source, and a task force arrived with e.g. Geiger counters, hazmat suits and a containment vessel. This did not go unnoticed -- authorities were notified; police came to enforce the embargo, because once the radiation source was removed, SVPA would lose a key negotiating chip.

That would be my "read between the lines" of how the situation might have played out. Once the leak happened, of course, the finger pointing would begin and presumably someone with sufficient connections to prevent the radiation source from being removed would also have sufficient connections to pin the blame on someone else for having it not removed.

The incident reminds me a bit of the port explosion in Beirut -- authorities were made aware of the danger, but the right thing simply couldn't happen in time, and the entropy of the universe eventually won out.

edit: formatting and correction of acronym

> It depicts, on a red background, a black trefoil with waves of radiation streaming from it, along with a black skull and crossbones, and a running figure with an arrow pointing away from the scene. The radiating trefoil suggests the presence of radiation, while the red background and the skull and crossbones warn of danger. The figure running away from the scene is meant to suggest taking action to avoid the labeled material. The new symbol is not intended to be generally visible, but rather to appear on internal components of devices that house radiation sources so that if anybody attempts to disassemble such devices they will see an explicit warning not to proceed any further.

Probably there should be some sort of liability for people putting hazard labels on things that aren't hazardous. Ever looked at an MSDS for sodium chloride?

> Because the true nature of the radium had been kept from them, the Radium Girls painted their nails, teeth, and faces for fun with the deadly paint produced at the factory.

Holy shit! I've seen some bad employers while working in occupational medicine but this is on a whole new level.

Having new conversations about old topics is a normal part of communication between humans. Search shows this article is posted on average once per year which is hardly beating a dead horse on old exhausted discussions. I'm sensing there are reasons beneath the surface of why this is affecting you so deeply.