"Meanwhile, the ownership of the clinic's assets was being discussed in court, and the cobalt 60 teletherapy unit was moved to the new facilities and the cesium 137 teletherapy unit was abandoned in its original place due to being seized."
Sounds like the root cause was stupid bureaucrats, but that must of course not be admitted in public.
EDIT - All good points below.
And the "handover" to the new owners was very acrimonious, with the new and old owners fighting in court. What seems clear is that IGR lost access to the location and filed several complaints about the machine being left there.
If IGR was securing the machine and trying to get it moved before they were thrown out of the location and prevented from visiting it as they claim, I don't think they're to blame at all. Of course details are fuzzy on that.
---
EDIT: According to this court sentence [1], IGR never notified CNEM:
> Then, under pressure to leave the site, the IGR transferred its headquarters to another address, and ended up abandoning the obsolete Cesium-137 pump in the old building, without even notifying the CNEN or the State Health Secretariat of the fact.
> On 05/04/87, the demolition of the building began, by order of the former partner of IGR, AMAURILLO MONTEIRO DE OLIVEIRA, culminating with the almost total destruction of the original building, which left it without a roof, doors or windows, despite the existence of the aforementioned Cesium-137 pump on the site, without any warnings or notices.
---
EDIT2: According again to the court sentence, the demolition was ordered by former partner of IGR, who had to pay 100k for the whole ordeal.
> On 05/04/87, the demolition of the building began, by order of the former partner of IGR, AMAURILLO MONTEIRO DE OLIVEIRA, culminating with the almost total destruction of the original building, which left it without a roof, doors or windows, despite the existence of the aforementioned Cesium-137 bomb on the site, without any warnings or notices.
---
[1] https://jus.com.br/jurisprudencia/16292/sentenca-na-acao-civ...
But more importantly, "to seize" means to "take possession", doesn't it? And you need a license to possess a teletherapy machine, for the very good reason that the damn thing is dangerous. IGR had a license. The bureaucrats didn't. Neither did the new site owner, landlord, whatever you want to call them. They still took possession, by force.
Property rights are a set of rules. Nuclear safety regulations are a set of rules. These are not the same kind of rules, though. Not understanding the difference kills people. The court didn't understand the difference.
Courts are normally given all but total immunity in all jurisdictions. I'd argue that the court and SVdP were criminally negligent here.
(I'm just reading these details now through the Wikipedia article. I'm interested in a more complete report, because quite clearly things were fouled up quite badly.)
It belonged to them so it was first and foremost their responsibility to take care of it and not to leave it behind.
The Wikipedia page is too succinct to know what were the reasons for the courts to prevent removal later on but it does say that it was the court that took the decision to finally post a guard on site (albeit obviously a poor one), not the owners.
> The fate of the abandoned site was disputed in court between IGR and the Society of Saint Vincent de Paul, then owner of the premises
My understanding is that this is how the court got involved, not because of any radioactive materials; IGR owner tried to make the court aware & let him retrieve the radioactive materials but had no luck.
It is admittedly unclear if the guard was posted to protect the radioactive materials or just the building in general. However, do note that guard is also not one of the named defendants (if it was his responsibility specifically to protect the capsule, I argue that he failed big time and should've been prosecuted for it; if he was just told "guard the building", it's a different issue in my mind).
--
[edit] Also it seems that IGR were _forced_ to leave the caesium behind, in the first place: https://news.ycombinator.com/item?id=29148480
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.
It sounds pretty cut-and-dry. They were physically prevented from removing the equipment and they alerted the authorities to let then know how dangerous it was.
Again, it's hard to second guess based on a few lines on Wikipedia because there is no details but the main point remains that it does not sound strange at all that those who claim to be the owners be held to account (among others).
IGN and a lawyer expert in the matter claimed that the authorisation for moving the machine could only come from CNEN.
If anything, that's gross negligence from CNEN. IGR seemed very exasperated during the whole process, if they were really fighting court orders that prevented them from having access to the place (and the machine).
--
EDIT: However, according to this court sentence [2], it seems that IGR never told anything to CNEM:
> Then, under pressure to leave the site, the IGR transferred its headquarters to another address, and ended up abandoning the obsolete Cesium-137 bomb in the old building, without even notifying the CNEN or the State Health Secretariat of the fact.
> On 05/04/87, the demolition of the building began, by order of the former partner of IGR, AMAURILLO MONTEIRO DE OLIVEIRA, culminating with the almost total destruction of the original building, which left it without a roof, doors or windows, despite the existence of the aforementioned Cesium-137 bomb on the site, without any warnings or notices.
--
[1] https://web.archive.org/web/20040309113338/http://www.jornal...
[2] https://jus.com.br/jurisprudencia/16292/sentenca-na-acao-civ...
But sending a letter, even letters, to the CNEN does not absolve the owner's responsibility. It just shows that several organisations seem not to have done what they should have.
If this was indeed true and they acted on it, then it would absolve them. However a judge disagreed, so they also had to pay 100k.
---
EDIT: On the second page of the document above, the judge mentions that owners of IGR were free from paying. Only the nuclear physicist (Flamarion) and a former partner who ordered the demolition (Amaurillo) had to pony up the 100k.
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
According to court documents from 2000, the order to demolish the property came from one of the IGR [former] partners, Amaurillo Monteiro de Oliveira.
However this part of the court sentence doesn't make a lot of sense to me. If this were true then they wouldn't get away with only paying 100k... I'm trying to find other court documents, or maybe an appeal.
> On 05/04/87, the demolition of the building began, by order of the former partner of IGR, AMAURILLO MONTEIRO DE OLIVEIRA, culminating with the almost total destruction of the original building, which left it without a roof, doors or windows, despite the existence of the aforementioned Cesium-137 bomb on the site, without any warnings or notices.
[1] https://jus.com.br/jurisprudencia/16292/sentenca-na-acao-civ...
---
EDIT: On the second page, it is mentioned that only two of the former IGR partners had to pay up: Amaurillo, probably for the reason above, and the nuclear physicist Flamarion Barbosa Goulart.
EDIT 2: Ok, so it looks like he was indeed a former partner in IGR. Why he ended up ordering the demolishment, is beyond me. It seems the other IGR partners didn't have to pay anything.
> B) I exclude the FEDERAL UNION, CARLOS DE FIGUEIREDO BEZERRIL and CRISEIDE CASTRO DOURADO, ORLANDO ALVES TEIXEIRA from the procedural relationship due to passive illegitimacy (art. 3º, c/c art. 267, VI, of the CPC);
However it seems it's not clear if it was a clerical error or something more complex than that.
[1] https://jus.com.br/jurisprudencia/16292/sentenca-na-acao-civ...