# Presentation: 079410

## Fool Irradiation: A Potential Unwanted Byproduct of Food Irradiation?

- January 27, 1999 Health Physics Society
- Albuquerque, New Mexico

- Daniel J. Strom and Charles R. Watson
- Pacific Northwest National Laboratory
- Richland, Washington
- Work supported by the U.S. Department of Energy under
- Contract No. DE-AC06-76RLO 1830
**http://QECC.pnl.gov**

## Overview

- fool ~ a person lacking in judgment or prudence
- some are fools, most are innocent victims
- history of irradiator accidents
- Quantitative Evaluation of Contamination Consequences (QECC) database
- http://qecc.pnl.gov/
- qualitative and quantitative lessons from irradiator accidents

## Italy 1975

- ...an untrained worker was able to bypass all the safety and procedural controls by entering the irradiation cell through an opening that was not foreseen...
- died 13 days later

## Norway 1982

- flawed design
- one switch failure caused false reading
- 2 procedures violated
- didn’t note fixed radiation monitor
- didn’t use portable instruments
- died 13 days later

## El Salvador 1989

- operators had only received informal on-the-job training
- facility poorly maintained
- safety systems failed and were not replaced
- irregular maintenance
- operator manipulated ‘source down’ microswitch to induce a green light
- manipulated the control panel to simulate monitor detection of a safe radiation level
- 1 worker died, 1 with multiple amputations

## Israel 1990

- operating procedures not in local language
- didn’t follow procedures
- malfunctioning “source down” indicator
- disconnected radiation alarm
- used ‘established trick’ to simulate radiation monitor test
- did not check portable radiation monitor (inoperative)
- died 36 days later

## Belarus 1991

- details not known
- operating procedures not followed
- safety features circumvented
- died 113 days later

## Illinois 1965

- crawled under door, bypassing interlocks
- 10 MeV electron accelerator
- 0.002 to 2400 Gy
- amputation of arm and leg

## Maryland 1991

- no personnel dosimeters or survey meters
- flashing warning signals ignored
- padlock missing from gate
- 2 of 3 photocells inoperative (1 switched off)
- pressure mat removed
- deliberately passed beneath only working photocell
- safety procedures & interlocks routinely bypassed
- fingers of both hands amputated

## Viet Nam 1992

- complete lack of safety systems and procedures
- exposed physicist was officer responsible for radiological protection
- hand, fingers of other hand amputated

## Quantitative Lessons from Accidents

- QECC database produces “outcome measures”
- time-and-proximity factor (unshielded) (hr/m2, i.e., “hours at a meter”)

## QECC Data on Sealed Source Accidents

## Acceptance of Food Irradiation

- acute radiation deaths or injuries of food irradiation workers must not be substituted for the rare consumer death attributable to E coli
- irradiator accidents
- ghastly: horrible burns, amputation, sterility, death
- high “signal potential” to public
- failure to prevent such accidents is very bad press
- third world is a particular problem

## Sources of Information

- NRC NUREG-1345, 1989: *Review of Events at Large Pool-Type Irradiators*
- IAEA 1996: *Lessons Learned from Accidents in Industrial Irradiation Facilities*
- ICRP Pub. 76, 1997: *Protection from Potential Exposures: Application to Selected Radiation Sources*
- IAEA SRS No. 7, 1998:* Lessons Learned from Accidents in Industrial Radiography*

## Conclusions

- radiation accidents have occurred too frequently
- >300 resulting in injury
- 55 in QECC
- design, maintenance, training, inspection, and safety culture needed for safe use
- fool irradiation can be a threat to food irradiation
- please share your data to help us learn *quantitative* lessons
- daniel.j.strom@pnl.gov