SOURCES AND EFFECTS OFIONIZING RADIATION
United Nations Scientific Committee on the
Effects of Atomic Radiation
UNSCEAR 2008
Report to the General Assemblywith Scientific Annexes

VOLUME II
Scientific Annexes C, D and E

UNITED NATIONSNew York, 2011

NOTE
The report of the Committee without its annexes appears as Official Records of the General
Assembly, Sixty-third Session, Supplement No. 46.
The designations employed and the presentation of material in this publication do not imply
the expression of any opinion whatsoever on the part of the Secretariat of the United Nations­
concerning the legal status of any country, territory, city or area, or of its authorities, or ­concerning
the delimitation of its frontiers or boundaries.
The country names used in this document are, in most cases, those that were in use at the time thedata were collected or the text prepared. In other cases, however, the names have been updated,
where this was possible and appropriate, to reflect political changes.

UNITED NATIONS PUBLICATION
Sales No. E.11.IX.3
ISBN-13: 978-92-1-142280-1
e-ISBN-13: 978-92-1-054482-5© United Nations, April 2011. All rights reserved.
Publishing production: English, Publishing and Library Section, United Nations Officeat Vienna.

Corrigendum to Sales No. E.11.IX.3

18 May 2016

Sources and Effects of Ionizing Radiation: United Nations
Scientific Committee on the Effects of Atomic Radiation
2008 Report
Volume II
Annex C (Radiation exposures in accidents)
Corrigendum
1.

Page 24, table 3, section headed “Sealed radioactive sources”, column
headed “Industrial source/installation”, first row

For 137Co source read 60Co source

V.16-02681 (E)*1602681*

CONTENTS
Page

VOLUME I: SOURCES
Report of the United Nations Scientific Committee on the Effects of Atomic Radiation
to the General Assembly
Scientific Annexes
Annex A. Medical radiation exposures
Annex B. Exposures of the public and workers from various sources of radiation
VOLUME II: EFFECTS
Annex C. Radiation exposures in accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1Annex D. Health effects due to radiation from the Chernobyl accident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Annex E. Effects of ionizing radiation on non-human biota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

iii

ANNEX C
RADIATION exposures IN ACCIDENTS
Contents
Page

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1

I. ACCIDENTS AT NUCLEAR FACILITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
		 A. Accidents related to nuclear weapons programmes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
			 1. Criticality accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
			 2. Other accidents with only on-site consequences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
			 3. Accidents with releases to the environment and potentially significant population exposures. . . . . . .
		 B. Accidents not related to nuclear weapons programmes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
			 1. Criticality accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
			 2. Other accidents with only on-site consequences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
			 3. Accidents with releases to the environment and potentially significant population exposures. . . . . . .
		 C. Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2
2
2
5
5
5
5
6
6
7

II.
		
		
		

ACCIDENTS AT INDUSTRIAL FACILITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A. Sealed radioactive sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. Accelerators and X-ray devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7
7
9
9

III. ACCIDENTS INVOLVING ORPHAN SOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
		 A. Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9
13

IV.
		
		
		

ACCIDENTS AT ACADEMIC AND RESEARCH FACILITIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A. Sealed radioactive sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. Accelerators and X-ray devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13
13
13
14

V.
		
		
		
		

ACCIDENTS ASSOCIATED WITH THE MEDICAL USE OF RADIATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A. Nuclear medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. Sealed radioactive sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. Accelerators and X-ray devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14
14
14
15
16

VI. OTHER ACCIDENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
		 A. Transport accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
		 B. Suspected malicious act. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16
16
16

VII. SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

ACKNOWLEDGEMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

TABLES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39v

introduction
workers or members of the public in a fashion that results inacute (i.e. deterministic) health effects.” Selected accidents
of significant public interest and/or involving environmental contamination were also to be considered. Thus, forthe purpose of this annex, radiation accidents are definedas unintended events in which at least one person experienced early acute health effects that required some degreeof medical intervention, and unintended events that caused
significant population exposures due to environmental
contamination.

1. In the course of the research and development for andthe application of atomic energy and nuclear ­t echnologies,
a number of radiation accidents have occurred. Some ofthese accidents have resulted in significant health effectsand ­o ccasionally in fatal outcomes. The application of­t echnologies that make use of radiation is increasingly­w idespread around the world. Millions of people have­o ccupations related to the use of radiation, and hundredsof millions of individuals benefit from these uses. Facilities using intense radiation sources for energy production and for purposes such as radiotherapy, sterilizationof products, preservation of foodstuffs and gamma radiography require special care in the design and operationof equipment to avoid radiation injury to workers or to
the public. Experience has shown that such technology
is generally used safely, but on occasion controls havebeen circumvented and serious radiation accidents haveensued.

6. It should be noted that the Committee has not considered
accidents that may have been significant from a technicalpoint of view (e.g. failures in safety systems at nuclear power
plants) but that did not lead to radiation exposures. ­Moreover,
it is not the purpose of this annex, and indeed it is outside
the remit of the Committee, to investigate the root causesof the accidents, analyse accident ­progressions, conduct­probabilistic risk assessments and forecast trends. Never­theless, in order to provide a better qualitative ­appreciationof the range of characteristics and common features of theaccidents that have occurred, the Committee has provided
brief summaries of selected accidents, their circumstances
and their health consequences, and has described overall
trends when possible.

2. Reviews of radiation exposures from accidents havebeen presented in previous UNSCEAR reports. The lastreport containing an exclusive chapter on exposures from
accidents was the UNSCEAR 1993 Report [U6].
3. This annex is aimed at providing a sound basis for­conclusions regarding the number of significant radiation
accidents that have occurred, the corresponding levels ofradiation exposures and numbers of deaths and injuries,
and the general trends for various practices. Its conclusions are to be seen in the context of the Committee’s
overall evaluations of the levels and effects of exposure toionizing radiation.

7. Accidents were selected for inclusion in the text and/or tables if information about the accident was available
in published literature in medicine, radiation protection or
dosimetry, or other relevant scientific or government literature, or in publications of the International Atomic Energy
Agency (IAEA) or the World Health Organization (WHO).
Malicious acts (intentional as opposed to accidental), with
one exception of topical interest (see paragraph 124), are notincluded in this compilation, nor are accidents that occurred
during nuclear weapons testing. During the fifty-fifth session of the Scientific Committee, it was agreed that nodescriptions of accidents occurring after July 2007 would be
included in this annex.

4. The Committee’s evaluations of public, occupationaland medical diagnostic exposures are mostly concernedwith chronic exposures of various population groups at levels that are well below the thresholds for early acute (deterministic) health effects. In contrast, accidents can involve
relatively high exposures, above such thresholds, and it isnecessary to consider separately the early acute healtheffects, which essentially occur only in accidents and which
are clearly attributable to radiation exposure. In addition, a
few accidents have led to elevated exposures among larger
populations, usually by releasing radioactive material into
the environment; the Committee has attempted to assess thecontribution such accidents have made to overall population
radiation exposures.

8. The IAEA and WHO publish important documents
related to accidents for which they have provided assistance in response; these documents contain extensive
descriptions of the event, dose assessments, health consequences and medical treatment. Accident catalogues
are maintained by the Institute of Biophysics, Moscow,
Russian Federation; by SEARCH in Ulm, Germany; by
the Curie Institute, Paris, France; and by REAC/TS in
Oak Ridge, Tennessee, United States of America. Table 1

5. The scope of this annex was to include “a survey ofaccidents whereby exposure to radioactive material affected1

2

UNSCEAR 2008 REPORT: VOLUME IIprovides a summary of accidents recorded for the territoryof the former Soviet Union, some of which are described inthis report [M4].

11.

- Section I covers criticalities and other operational
accidents occurring at nuclear facilities, including
accidents resulting in releases to the environment.
- Section II describes accidents involving sources, accelerators and X-ray devices used in industrial facilities.

9. The Committee considers it likely that most of theserious accidents at nuclear facilities have been reported.
In contrast, it considers it probable that many smallerindustrial accidents, accidents with “orphan” sources,
accidents in academic or research work and very many
accidents in the medical uses of radiation have not beenreported. There may be various reasons for this, including cultural and professional attitudes, fear of prosecution and ineffective regulatory regimes. In any case, it isclear that this review of accidents cannot be considered
comprehensive.

- Section III provides examples of accidents associated with orphan sources and devices.
- Section IV describes accidents involving sources
and radiation-generating devices used in academic
and research environments.
- Section V provides examples of medical accidents
involving sources, radiation-generating devices andnuclear medicine.

10. Nevertheless the Committee considers that its assessment does provide a depiction of the number of significant
radiation accidents that have occurred, the corresponding
levels of radiation ­exposures and numbers of deaths andinjuries, and the general trends for various practices, as abasis for evaluating the ­contribution made by accidents tooverall radiation ­exposures and effects.

I.

The review of selected radiation accidents has six sections:- Section VI addresses other accidents, principallythose connected with the transport and movementof radioactive and nuclear materials in land, air,sea, undersea and space vehicles.
- Section VII summarizes information about accidents in various practices.

ACCIDENTS AT NUCLEAR FACILITIES- Accidents with releases to the environment andpotentially significant population exposures.
Tables 2a and 2b summarize key information onseven accidents (including one criticality accident)
at nuclear facilities that resulted in significant­exposures of the general public.

12. Accidents at nuclear facilities are considered in two
categories: those related to nuclear weapons programmes
and those not related to nuclear weapons programmes. Eachcategory is considered in three subsections:- Criticality accidents. These are generally considered significant owing to the potential loss of
special nuclear material, serious contamination of
the workplace, the possibility of off-site contamination and, in some cases, serious medical consequences. A large number of such accidents haveoccurred, although most of them took place in theearly research and development of nuclear ­weapons
technologies. This annex summarizes only thosecriticality accidents that led to serious medical
consequences, and tables 2a and 2b summarize
information on the 23 criticality accidents that havebeen reported.
- Other accidents with only on-site consequences.
These have occurred during operations at nuclear
facilities, and affected principally on-site workers.
Some also involved the release of radioactive material to the outside environment and possible exposureof off-site populations. Tables 2a and 2b summarize
key information on eight such accidents (other thancriticality accidents) that led to early health effects
among operators, plant staff or emergency response
personnel, but had no significant off-site exposuresof the general population or environment.

A.

Accidents related to nuclear weapons programmes
1. Criticality accidents

13. Of the 23 criticality accidents in total that have beenreported, 17 occurred at facilities related to nuclear weapons programmes, which are listed in table 2a and briefly
described below.
14. United States, Los Alamos National Laboratory, 1945.
Three serious accidents have occurred at Los ­Alamos National
Laboratory in Los Alamos, New Mexico. The first occurredin August 1945 when a critical assembly was being createdby stacking tungsten carbide bricks around a ­plutonium core.
The experimenter was moving the final block into place when
he noted the neutron count ­indicating that the addition of thelast brick would make the ­assembly supercritical. As he withdrew his hand, the final brick slipped and fell into the ­centre,
creating the criticality. His dose1 was ­estimated at 5.1 Gy from1

Dose, unless otherwise specified, refers to whole-body dose.

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

a yield of 1016 fissions. He died 28 days after the exposure. An
army guard assigned to the ­building but not directly involved
with the experiment received a dose ­estimated at 0.5 Gy [L1].
15. United States, Los Alamos National Laboratory, 1946.
In May 1946, the plutonium core described above was being
used in a demonstration of the techniques for creating a
metal critical assembly using beryllium as a reflector. The
individual conducting the demonstration was holding the top
cell with his left thumb and inadvertently allowed one edgeof the upper hemisphere to come into contact with the lower
hemisphere. He attempted to place a screwdriver under partof the upper hemisphere not in contact with the lower hemisphere. The screwdriver slipped, resulting in a criticality
excursion with an estimated yield of 3 × 1015 fissions. The
individual conducting the experiment died nine days after
the exposure, following a dose estimated at 21 Gy. Seven
other individuals in the room received doses ranging from
0.37 to 3.6 Gy [L1].
16. United States, Argonne National Laboratory, 1952.
In June 1952, an accident occurred at Argonne National
Labora­tory in Argonne, Illinois, in a light water moderated
core in which 6.8 kg of 235U oxide was embedded in strips ofpolystyrene plastic. The system became critical following anattempt to replace the control rod when the normal amountof water was in the core. Four individuals received radiation
doses of 1.36, 1.27, 0.6 and 0.09 Gy [L1].
17. Former Soviet Union, Mayak Complex, 1953. In March
1953, a criticality excursion occurred at the Mayak Complex
in Chelyabinsk involving seven 40 L tanks of unfavourable
geometry used for the mixing, dilution, sample storage andtransfer of plutonium nitrate derived from irradiated reactor fuel. No radiation monitoring equipment was available
to workers; therefore the seriousness of the event was notrecognized. The estimated yield was 2.5 × 1017 fissions. An
operator received about 10 Gy whole-body dose, but thiswas very non-uniform (more than 30 Gy to the legs). He
survived a moderate degree of acute radiation syndrome(ARS) but amputation of both legs was necessary. The doseto a second operator was about 1.5–2.0 Gy and she survived
a mild degree of ARS [G5, L1, V1].
18. Former Soviet Union, Mayak Complex, 1957. In April
1957, a second event occurred involving a tank used foroxalate purification and filtration of highly enriched uranium solutions. An unsafe geometry resulted in a criticality
with a fission yield estimated at 2 × 1017. The operator, who
remained in the area for approximately ten minutes, died
12 days later, having received a whole-body dose estimatedat about 10 Gy (based on an analysis of the 24Na levels in
his blood). Five other workers experienced ARS of different severities depending on the doses received, which ranged
from 2.0 to 6.0 Gy [G5, L1, V1].
19. Former Soviet Union, Mayak Complex, 1958. In ­January
1958, a third event occurred that was related to the use of atest tank built for determining critical parameters for solutions

3of uranium. After a test, a team of four persons decided to
speed the draining of a solution. The ­combination of the solution geometry in the tank and neutron reflection by the workers’ bodies resulted in a criticality involving approximately
2.3 × 1017 fissions. Three of the four persons died within
one week, with doses estimated to have been in the range
40–50 Gy. The fourth person, who had been 3 m away fromthe tank, received a dose estimated at 6 Gy and ­presented
symptoms of ARS and of visual impairment. She survived,
although ­long-term health problems related to organs on theleft side of her body were observed, including skin fibrosis,
kidney sclerosis and cataracts [B11, G5, K2, L1, V1].
20. United States, Y-12 plant, 1958. In June 1958, a­criticality ­accident occurred at the Y‑12 plant in Oak Ridge,­Tennessee, during recovery of enriched uranium from various solid wastes. Prior to the accident and unbeknown to anyone, uranyl nitrate had been collecting in a vessel because ofa leaking valve. When an operator opened the vessel to drainwater into a 55 gallon (208 L) drum, the water was precededby the enriched uranium solution. The unsafe geometry inthe drum resulted in a criticality excursion with an estimatedyield of 6 × 1016 fissions. A second excursion occurred 15
seconds later. Eight male workers (aged 25 to 56 years) were
exposed, with five of the men receiving whole-body dosesof between 2.36 and 3.65 Gy. Three others received dosesof below 0.7 Gy. Long-term follow-ups with annual medical
evaluations were conducted [A1].
21. United States, Los Alamos National Laboratory, 1958.
In December 1958, a third accident at Los Alamos National
Laboratory occurred during an annual physical inventory
when process streams were interrupted in a unit used topurify and concentrate plutonium from slag, crucible andother lean residues from recovery processes. Dilute aqueousand organic solutions from two vessels were washed into asingle large vessel. The addition of a nitric acid wash to thetank is believed to have separated the liquid phases, resulting
in an excursion when a stirrer was activated. The excursion
had a yield of 1.5 × 1017 fissions. The accident resulted in thedeath of the operator 36 hours after exposure, with a doseto the upper torso estimated at approximately 120 Gy. Twoother individuals suffered no ill effects after doses ­estimatedat 1.34 and 0.53 Gy [L1].
22. United States, National Reactor Testing Station, 1961.
In ­January 1961, a serious event occurred at the National
Reactor Testing Station in Idaho Falls, Idaho, involving a
direct-cycle boiling water reactor of 3 MW gross thermal
power. The reactor used enriched uranium fuel plates cladin aluminium, and was water moderated and cooled. Aftera routine shutdown for maintenance, a three-man crew was
assigned the task of reassembling the control rod drives andpreparing the reactor for start-up the following day. The
best available evidence suggests that the central control rod
was manually pulled out too fast, causing the power to rise.
A subsequent steam explosion destroyed the reactor andinstantly killed two men; the third man died two hours after
the accident as a result of a head injury [L1].

4

UNSCEAR 2008 REPORT: VOLUME II

23. Former Soviet Union, Siberian Chemical Complex,
1961. In August 1961, an accident occurred at the ­Siberian
Chemical Complex in Seversk at an experimental facility
used for purifying enriched (22.6%) uranium ­hexafluoride.
The main cylinder lacked sufficient cooling, and another­vessel was bypassed. The criticality alarm system was­activated, and personnel evacuated the facility. ­Radiation
surveys in the area using portable gamma monitoring­instruments did not indicate abnormal radiation levels, andwork resumed, resulting in a second criticality. The yieldof each pulse was estimated to be 1016 fissions. The process
operator received a dose estimated at 2 Gy and experienced
mild symptoms related to ARS [L1, V1].
24. United States, Hanford Facility, 1962. In April 1962,
an accident at a Recuplex System Process Plant in Richland,
Washington, occurred as a result of the following set of
conditions: cleaning the floor of a solvent extraction hood;a product receiver tank that could overflow into the hood;a temporary line running from the hood floor to a transfertank; and the apparent improper operation of valves. A criticality excursion occurred followed by supercriticality for37.5 hours as the power steadily decreased. The total excursion yield was 8 × 1017 fissions. Of the 22 individuals in thebuilding, only three received significant doses of radiation
ranging from 0.10 to 1.1 Gy [L1].
25. Former Soviet Union, Arzamas-16 Nuclear Centre,
1963. In March 1963, a criticality excursion occurred at theArzamas-16 Nuclear Centre in Sarov in a system using plutonium with a deuteride reflector. The accident was due tothe inadvertent closure of the assembly by the operator. Two
individuals received doses estimated at 3.7 and 5.5 Gy. Bothexperienced a mild form of ARS and survived more than 25
years after the exposure. Four other persons received dosesthat were medically insignificant [L1].
26. United States, Wood River Junction Chemical Process
Plant, 1964. In July 1964, an accident occurred at the Wood
River Junction Chemical Process Plant in Rhode Island. The
facility’s function was to recover highly enriched ­uranium
from scrap metal left over from the production of fuel­elements. A variety of chemical procedures were involved in
the overall process. On the day prior to the accident, a plantevaporator failed to operate properly, making it ­necessary todisassemble it for cleaning. During the cleaning process, aplug of uranium nitrate crystals was discovered in the connecting line. The crystals were dissolved with steam anddrained into polyethylene bottles that were identical to thosethat normally held a very low concentration of fissile material. The bottles were labelled as high-concentration solutions. On the day of the accident the operator mistakenly
poured the contents of a high-concentration bottle into the
make-up vessel, which already contained 41 L of sodium
carbonate solution that was being agitated by a stirrer. A
critical state was reached when nearly all the uranium had
been transferred. The excursion of 1.0 × 1017 to 1.1 × 1017
fissions created a flash of light and the loss of approximately
20% of the solution on to the ceiling, walls and operator.

The radiation dose to the operator was estimated to beapproximately 100 Gy. He died 49 hours after the exposure.
Two workers who entered the room received doses of 1 and
0.6 Gy [K1, L1].
27. Former Soviet Union, Russian Federal Nuclear ­Centre,
1968. In April 1968, two technicians failed to ­reposition thelower reflector of an assembly prior to ­initiating a new testat the Russian Federal Nuclear Centre in Chelyabinsk. There
was no criticality alarm system installed at the time, andhealth physics support was not present. The two ­techniciansreceived estimated neutron/gamma doses of 5–10 and
20–40 Gy. The technician who received the higher dose diedthree days later, and the other technician died after 54 days
[L1].
28. Former Soviet Union, Mayak Complex, 1968. In
December 1968, a fourth event occurred at the Mayak­plutonium extraction facility during a test of a new ­extraction
process when an unusually high plutonium concentrationand the presence of organic material were detected in thesolution. When the solution was poured into a vessel of
unsafe geometry, the operator saw a flash, the criticality
alarm was activated and all personnel evacuated the facility.
The shift supervisor later returned and attempted to poursome liquid into a drain, resulting in a second criticality. The
first excursion yielded 1016 fissions and the second 1015 fissions. The shift supervisor died on day 34 of very severe
ARS. The operator survived ARS of moderate severity, but
subsequently both legs and one arm were amputated [V1,V4].
29. Former Soviet Union, Siberian Chemical Complex,
1978. In December 1978, another event at the complex
occurred in a section of a glovebox line where plutonium
metal ingots were being packed into storage boxes. The box
design was deficient and it was possible to load more than
one ingot into a box. A criticality excursion occurred whenfour ingots were loaded into a single box. The yield was
3 × 1015 fissions. One ingot was physically ejected and theoperator removed the other ingots manually. The operator
received a dose estimated at 2.5 Gy to the whole body andabout 70 Gy to the hands; he experienced ARS of ­moderate
severity, but amputation to above the elbows was ­necessary.
Eyesight impairment occurred some time later. Seven otherworkers received doses estimated at between 0.05 and
0.6 Gy [B11, L1, V1].
30. Russian Federation, Arzamas-16 Nuclear Centre,
1997. In June 1997, a second criticality accident occurredat Arzamas-16 during experimental manipulation of a critical assembly. A technician was working alone in the assembly area when a component from the upper reflector slippedfrom his hand and fell on to the lower assembly containing the enriched uranium core. There was a flash of light,
and the technician realized that a criticality had occurred.
He left the experiment hall and reported the accident to his
supervisors and colleagues. Initial estimates suggested awhole-body dose of 45 Gy from neutrons and 3.5 Gy from

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

gamma rays. The technician was promptly hospitalized.
He died 66.5 hours after the exposure, despite prompt andintensive medical care [I5, L1].
2.

Other accidents with only on-site consequences

31. Of the eight accidents (other than criticality ­accidents)
in total that occurred during the operation of nuclear ­facilities
and that led to early health effects among ­operators, plantstaff or emergency response personnel, but had no ­off-site
consequences for health or the environment, five occurred at
facilities associated with nuclear weapons ­programmes andare listed in table 2a. A brief description of one of these isprovided here to illustrate the nature of such events.
32. United States, Hanford Facility, 1976. In August 1976,
a 64-year-old chemical operator was injured by a chemical
explosion of an ion exchange column used for recovery of241
Am at the Hanford Facility in Richland, Washington. The
operator sustained chemical burns of the face, eyes, neck andright shoulder, as well as lacerations and embedded foreign
bodies in these areas. He was heavily contaminated externally with 241Am and inhaled an estimated 40.7 MBq of theradionuclide. Aggressive medical therapy began immediately, including on-site decontamination and administrationof calcium- and zinc-DTPA. Chelation therapy continued formany months and was responsible for a significant reductionin the 241Am body burden. The estimated cumulative doses
three years after the accident to bone, lung and liver were
8.6, 2 and 1.6 Gy, respectively [H2].
3. Accidents with releases to the environment
and potentially significant population exposures
33. Of the seven accidents at nuclear facilities that resulted
in potentially significant exposures of the general public orthe environment, four were associated with nuclear weapons
programmes and are listed in table 2a. Three of these aredescribed briefly below.
34. Former Soviet Union, Mayak Complex, 1957. In
1957, at the Mayak Complex, overheating of a storagetank ­containing radioactive nitrate–acetate salts led toan ­explosion and the release of some 740 PBq of radio­
active products off-site to an area of some 20,000 km2 ofthe ­Chelyabinsk and ­Sverdlovsk regions. The contaminated zone had a population of 272,000. There were 1,154­individuals inhabiting areas with a 90Sr deposition density ofgreater than 40 MBq/m2 [U6].
35. United Kingdom, Windscale, 1957. In 1957, a fire in
the Windscale graphite reactor burned for three days, resulting in major releases of radioiodine and other nuclides into
the environment in and around Cumbria. The release of131
I was estimated at some 740 TBq. It was accompanied
by 22 TBq of 137Cs, 3 TBq of 106Ru, 16 PBq of 133Xe and
8.8 TBq of 210Po. The maximum doses to local individuals

5

were ­estimated to be 0.01 Gy to the thyroids of adults and
0.1 Gy to the ­thyroids of children. Measurements in Leeds
and London indicated thyroid doses of 0.001 and 0.0004 Gy[C2, G4, U6, U9].
36. Russian Federation, Siberian Chemical ­Enterprises,
1993. In April 1993, a serious accident occurred at the­Siberian Chemical Enterprises facility at Tomsk-7. The­accident caused damage to both the reprocessing line
and the building, resulting in the release of about 30 TBq
of beta- and gamma-emitting radionuclides and about
6 GBq of 239Pu. Radiological monitoring of plant ­personnel­demonstrated that only six individuals received doses ofabove the 0.2 mGy detection thresholds of the dosimetersused. Dosimetry on 14 of the 20 firefighters indicated­individual doses of 1–7 mGy [I19].

B.

Accidents not related to nuclear weapons programmes
1. Criticality accidents

37. Of the 23 criticality accidents in total that have beenreported, 6 occurred at facilities not related to nuclear­weapons programmes; they are listed in table 2b andbriefly described below. One of these, the 1999 accident
at ­Tokai-mura, is also listed under accidents with releases
to the environment and potentially significant population
exposures.
38. Former Yugoslavia, Boris Kidrich Institute, 1958.
In October 1958, a criticality accident occurred ­during
an ­experiment at a zero power reactor facility at the Boris­K idrich Institute in Vinca. The accident exposed six­individuals to relatively uniform doses of 4.36, 4.26, 4.19,
4.14, 3.23 and 2.07 Gy. One individual died as a result of theaccident [L1, M4].
39. Belgium, Venus Assembly, 1965. In December 1965,
an accident occurred at the Venus Assembly in Mol,
­involving a tank type water moderated (70% H 2O and
30% D2O) critical assembly operating with 7% enriched
UO2 rods. Although there was a written rule in the reactor
safety report that no ­manipulation of a manual rod shouldbe performed without first ­emptying the vessel, a written
order was given to a ­technician ­prescribing the loading ofa manual control rod followed by the unloading of anotherone. The ­technician inadvertently extracted the manual
rod instead of first ­inserting the other rod, and a criticality
resulted. The ­technician received approximately 3–4 Gy
to the head and approximately 3–10 Gy to the trunk. The
dose to his feet was estimated to be 40 Gy. Medical treatment was successful, but amputation of his left foot wasnecessary [J3, L1, P2].
40. Former Soviet Union, Kurchatov Institute, 1971. In
February 1971, an accident occurred at Kurchatov ­Institute in
Moscow during a series of experiments designed to evaluate

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UNSCEAR 2008 REPORT: VOLUME II

the relative effectiveness of iron and metallic beryllium as areflector on a power reactor core. The supervisor determinedthat the substitution of iron for beryllium would not result inany considerable increase in reactivity. He supervised the
addition of water prior to the arrival of the console operator and supervising physicist. The control rods had not been
actuated, and a criticality occurred, evidenced by a flash ofblue light. The supervisor and two visiting scientists were
exposed; each received a whole-body dose of about 3 Gy;
the supervisor and one of the visitors received doses to thelegs of between 15 and 20 Gy [L1, V4].
41. Former Soviet Union, Kurchatov Institute, 1971.
In May 1971, a second accident occurred at Kurchatov­Institute ­during an experimental programme to measure
critical masses formed by a certain type of highly enriched(about 90%) 235U fuel rod. Following the insertion of control
rods and removal of the neutron source from the core, the­supervisor ordered the water to be removed through a fast
dump valve. Because the gap size was smaller than the sizeof the fast dump outlet, an internal plate sagged and fuel rods
fell out of the lattice into an unsafe geometry, resulting in a
criticality excursion. The yield was estimated to be 5 × 1018
fissions. Four individuals were in the facility at the time of
the criticality. A technician received about 60 Gy and died
five days after the accident. The supervisor received about
20 Gy and died after 15 days. The other two individuals
survived doses estimated at 7–8 Gy, but suffered long-term
health effects [L1, S2].
42. Argentina, Constituyentes Atomic Centre, 1983. In
September 1983, at the Constituyentes Atomic Centre,a prompt criticality accident occurred at the RA-2 zero
power critical facility light water cooled test and training
reactor near Buenos Aires. RA-2 utilized 90% enricheduranium MTR-type fuel. Facility procedures requiredthat fuel and control rod alterations be performed without the moderator present. The operator attempted tomake changes to the core configuration without draining the moderator water. The core went prompt critical,
resulting in the moderator expanding rapidly and shutting down the reactor. It is estimated that the operator
received an initial average whole-body dose of 17 Gy due
to fast neutrons and about 20 Gy due to gamma photons.
He experienced symptoms of ARS, including neurological disorders, and died two days after the accident [B15,G6, L1, N1, P3, W4, W5].
43. Japan, Tokai-mura fuel conversion plant, 1999. In
September 1999, a criticality accident occurred in a fuel­conversion plant in Tokai-mura during the ­processing ofhighly enriched fuel for an experimental fast ­reactor. Using
unauthorized procedures, the workers poured 16.6 kg of
18.8% enriched uranium into a precipitation tank, ­resulting
in a criticality excursion. Two individuals ­working near
the precipitation tank received whole-body doses of
10–20 Gy Eq (individual A) and 6–10 Gy Eq (individual B)
from gamma rays and neutrons, using a value for the ­relative
biological effectiveness (RBE) of 1.7. A third individual,

several metres distant from the precipitation tank, received adose estimated to be 1.2–5.5 Gy Eq. Early administration of
granulocyte colony-stimulating factor (G-CSF) was used in
the medical management of these individuals. Individual A
died 83 days after exposure and individual B 211 days after
exposure. In the course of treatment, individual A received
peripheral blood stem cell transplantation from his HLAidentical sister, and individual B received a transplant ofumbilical cord blood.
44. The accident resulted in off-site doses from direct­neutron and gamma irradiation to nearby populations,although no significant long-term effects are expected.
Approximately 200 residents living within a 350 m radius
were evacuated. Ninety per cent of them received doses ofless than 5 mSv. Ten per cent received doses of between
5 mSv and 25 mSv. While there were measurable levelsof airborne fission products on local plant life, maximum­readings were less than 0.01 mGy/h, and the activity was
short-lived [A2, I6].

2.

Other accidents with only on-site consequences

45. Of the eight accidents (other than criticality ­accidents)
in total that occurred during the operation of nuclear ­facilities
and that led to early health effects among ­operators, plantstaff or emergency response personnel, but had no off-site
consequences for public health or the environment, threeoccurred at facilities not associated with nuclear weapons
programmes and are listed in table 2b.

3. Accidents with releases to the environment
and potentially significant population exposures
46. Of the seven accidents at nuclear facilities that
resulted in significant exposures of the general public or the environment, three were not associated with
nuclear ­weapons programmes; they are listed in table 2b.
Two of these are described briefly below. One other, the1999 ­accident at Tokai-mura, has been listed also under“­criticality accidents” and has been described briefly insubsection 1 above.
47. United States, Three Mile Island, 1979. In March
1979, an ­accident occurred at the Three Mile Island nuclear
power plant near Harrisburg, Pennsylvania. The sequenceof events leading to the accident began with the closureof a valve that fed water to the boiler. A series of events
thereafter led to core melt and the release of fission products through a relief valve in the primary water make-up
system. Most fission products were retained in the water,
but about 370 PBq of noble gases, mainly 133Xe, and some
550 GBq of 131I were released into the atmosphere. While
the accident released large amounts of activity from thefailed reactor core, the resulting exposures of the public
were negligible [U6, U9].

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

48. Former Soviet Union, Chernobyl nuclear power plant,
1986. The 1986 accident at the Chernobyl nuclear power
plant was the most severe accident ever to have occurredin the civilian nuclear power industry. Two workers died in
the immediate aftermath, and high doses of radiation to 134
plant staff and a number of emergency ­personnel resultedin ARS, which proved fatal for 28 of them. The accident
caused the largest uncontrolled radioactive release intothe ­environment ever recorded for any ­civilian ­operation,­including 1,760 PBq 131I and 86 PBq 137Cs. It depositedradioactive material over large areas of the former Soviet
Union and some other ­countries in Europe, ­contaminating
land, water and biota, and causing serious social and­economic disruption for large populations in Belarus,
the Russian ­Federation and Ukraine. The ­consumption of
fresh milk contaminated with 131I in the first weeks after
the accident led to thyroid doses that have been estimatedto range between 0.05 and 5 Gy to ­populations of ­Belarus,
the Russian Federation and Ukraine. More details are­provided in annex D, “Health effects due to radiation fromthe ­Chernobyl accident”.

II.

C. Summary
49. Tables 2a and 2b list 35 reported accidents at nuclear
facilities that resulted in acute health effects or caused­significant population exposures, of which 24 were at­facilities associated with nuclear weapons programmes.
In general, criticality accidents have occurred during­experiments or operations in research reactors, or ­during
work with fissile material in solution or slurries. One ­accident
occurred in the processing of metal ingots. Only one criticality resulted in the release of radioactive ­material off-site,
albeit a very small quantity. Of the 23 criticality accidents,
17 were at facilities associated with nuclear ­weapons programmes. Of the ­accidents at nuclear power plants, the 1986
Chernobyl accident was by far the most serious. Causes
identified in these accidents were: inadequate facility design,­process equipment that resulted in poor geometry, personnel
errors and violation of operational procedures. Because ofthe ­regulatory regimes in place, the Committee considers
it likely that most of the fatal radiation accidents at nuclear
facilities have been reported.

ACCIDENTS AT INDUSTRIAL FACILITIES

50. Table 3 summarizes information on 80 accidents thathave been reported at industrial facilities. Of these, 17 aredescribed briefly below to illustrate the characteristics ofthese events. Section A presents accidents with sealed radioactive sources and section B accidents involving machinegenerated radiation (i.e. from accelerators or X-ray devices).
A.

7

Sealed radioactive sources

51. Table 3 summarizes information on 59 accidents thathave been reported involving sealed radioactive sources
at industrial facilities; 13 of these accidents are describedbriefly here.
52. USSR, 1973. Disregarding rules, an operator entered
the main room of an industrial gamma–facility in the ­Moscow
area, where the 4.2 PBq 60Co source was unshielded. The
operator walked around the source and as soon as he sawthat it was in the “on” mode he immediately left the room.
The estimated distance from the source to the victim ranged
from 0.75 to 1 m. The whole-body dose appeared to be about
4 Gy and he survived a moderate ARS [B11].
53. United States, 1974. In June 1974, at a medical ­productsterilization facility in New Jersey, a 61-year-old man was
exposed for 5–10 seconds to gamma radiation from a 4.4 PBq
60
Co industrial source. The individual had failed to use asurvey meter upon entering the facility and received a non-­uniform exposure owing to partial shielding from Teflon-filled
fibre drums. Nausea and vomiting were evident one hour after

exposure, and the haematological nadir was reached about one
month after exposure. The estimated dose, using cytogenetic
dosimetry, was 4.1 Gy, and the patient was treated with standard antibiotic therapy and platelet/leucocyte trans­fusions. The
individual returned to work in October 1974 [B2].
54. United States, 1977. In September 1977. at a facility
in New ­Jersey, a 32-year-old man was exposed for about ten­seconds to gamma radiation from an 18.5 PBq 60Co source
used to sterilize medical and chemical products. The ­accident
was caused by construction work that had led to ­alterationsin the hot cell entry area, failure to see the interlock ­warningand interlock failure. The individual ­experienced nausea andvomiting two hours after ­exposure. The estimated dose, using
cytogenetic dosimetry, was 2.0 Gy. The patient reached thehaematological nadir about 30 days after exposure and wastreated with standard anti­biotic therapy. Peripheral bloodcounts returned to normal in August 1978 [B2].
55. United States, 1978. In June 1978, an industrial radio­
grapher working on a barge off the coast of Louisiana in
the Gulf of Mexico sustained a radiation injury to the handfrom a 3.7 TBq 192Ir source. A dosimeter malfunction was
thought to be the cause of the accident. About three weeks
after the ­suspected date of exposure, the individual experienced a burning sensation, swelling, erythema and drynessof the thumb, index finger and middle finger of the left hand.
The formation of bullae occurred one week later, and healing
was apparent within 5–8 weeks, although the palmar surfaces
demonstrated thin epithelium. Amputation of the digital two
thirds of the index finger was performed at six months [S1].

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UNSCEAR 2008 REPORT: VOLUME II

56. USSR, 1980. An accident occurred in a gamma­irradiation facility in Leningrad with a 22.2 PBq 60Co
source. The operator entered the irradiation room thinking
the source was “down”. Within less than a minute and assoon as he realized he was wrong, he left the room. However
the whole-body dose appeared to be more than 12 Gy, andhe died on day 10 [S2].
57. China, 1980. In 1980, a 25-year-old man was­accidentally exposed to a 60Co source in Shanghai. The­estimated source activity was 1.96 PBq, and the exposure
time was about 40 seconds. The individual experienced early
profuse vomiting and a rapid fall in lymphocytes and otherhaematological parameters. The estimated dose based on thesurvival of haemopoietic stem cells was 5.22 Gy. ­Following
treatment, the patient was discharged from the hospital fivemonths after exposure. Radiation-induced ­cataracts wereobserved three years after exposure [U3, Y1].
58. Norway, 1982. In 1982, an accident occurred ina gamma irradiation plant at the Institute of Energy­Technology at ­Kjeller near Oslo. The plant was used forsterilization of ­medical equipment. A 2.43 PBq 60Co source
could be raised to various positions above the shielded
position on the ­concrete floor. Owing to technical failure and human error, the operator entered the irradiation
room although the source was not in the shielded position.
He stayed in the ­irradiation room for several minutes andshortly afterwards was found sitting outside the plant andobviously ill. Shortly after the event he was admitted to a
local hospital ­suffering from nausea, vomiting and facial
erythema. ­During the next four days he had ­persistent nausea and increasing ­mucositis in the mouth. After a week
his haematological values were markedly reduced. On thebasis of dose ­reconstruction using electron spin ­resonance(ESR) spectroscopy of nitro­glycerine tablets in his pocket,
the mean whole-body dose was considered to have beenslightly above 20 Gy. The patient died 13 days after­exposure [R1, S3].

61. El Salvador, 1989. An accident occurred in February
1989 at an industrial irradiation facility near San ­Salvador.
The facility had 0.66 PBq of 60Co in a movable source
rack, badly degraded safety systems and poor maintenanceat the time of the accident. After the unshielded source
rack became stuck, three individuals entered the radiation
room and received non-uniform doses to the whole body.
­Subsequently they all developed ARS. Cytogenetic studies
indicated doses of 8 Gy to patient A, 3.6 Gy to patient B
and 3 Gy to patient C. Two of these individuals experienced
serious radiation-induced injuries of the lower extremities,
with doses estimated at 100 Gy. They were transferred toa specialized hospital in Mexico City. The leg of the most­seriously irradiated individual was amputated approximately
four months after exposure. Following transfer back to El
Salvador, this patient died as a result of a surgical procedureand complications due to radiation-induced lung damage.
Another individual required amputation of both legs. A third
individual experienced minor injuries to one foot. Before theaccident was fully understood, a fourth individual, a maintenance manager, entered the facility and received a wholebody dose that was medically insignificant [I1].
62. Israel, 1990. In June 1990, at a commercial ­irradiation
facility in Soreq, an operator bypassed safety systems toenter the irradiation room in order to free cartons stuck on
the conveyor system. He was not aware that the movable60
Co source rack was obstructed in the irradiation position.
At the time of the accident the total activity was 12.6 PBq.
He promptly developed symptoms and left the area. It wasdetermined that his whole-body dose was between 10 and
20 Gy. He was hospitalized with severe haematopoietic
and gastrointestinal syndromes, and skin injury was soon
­evident. Despite aggressive medical efforts, including useof haematopoietic growth factors and a bone marrow transplant, he died 36 days after exposure [I2].

59. China, 1986. In May 1986, in Kaifun, Honan ­Province,a young man and a young woman were accidentally exposed
to a 255 TBq 60Co source for about 1.5–2 minutes at a
local irradiation facility. The man received a whole-bodydose estimated at 3.5 Gy and the woman a dose estimatedat 2.6 Gy. Both individuals experienced radiation-induced
vomiting and haematological depression [W2, Y1].

63. China, 1990. In June 1990, seven workers were
exposed to radiation from a 60Co source at an industrial
facility in Shanghai. The accident was caused by improper­maintenance of safety features. None of the workers was
wearing a ­personal dosimeter at the time of the accident. One
individual, with a dose estimated at 12 Gy, died 25 days after
exposure. A second individual, whose dose was ­estimatedat 11 Gy, died 90 days after exposure. The other five workers received doses estimated to range from 2 to 5.2 Gy andrecovered after medical treatment [L2, P1].

60. China, 1987. In March 1987, in Zhengzhou, Honan
Province, a young man was exposed for 10–15 seconds tophotons from a 60Co source of 3.29 PBq. The ­estimated­exposure was 1.35–1.45 Gy. He experienced lassitude,
thirst and dryness of the eyes immediately after ­exposure.
Four hours later he experienced nausea and anorexia
but no ­vomiting. The nadir values of leucocytes and­platelets occurred on the 35th and 31st days, respectively.
­Restoration of his leucocyte count was rather slow, andthe count remained subnormal until the 120th day after­exposure [Y1].

64. Belarus, 1991. In October 1991, an accident occurred
at a 60Co irradiation facility used to sterilize agriculturaland medical products in the town of Nesvizh. The source
activity was 28.1 PBq at the time of the accident. Owing toa malfunction of the product transport system and humanerror, the operator entered the irradiation area and remained
inside for 1–2 minutes with the source array in the full “out”
position. He received prompt medical attention in Belarus
and then in Moscow. He experienced ARS and skin injuries
resulting from an estimated whole-body dose of 11–18 Gy.
His intensive medical treatment included administration of

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

granulocyte–macrophage colony-stimulating factor (GMCSF). He died 113 days after exposure of pulmonary andmultiorgan failure [I3].

9The amputation sites manifested lack of healing, and further necrosis led to 11 additional operative procedures overa 22 month period. The patient was eventually fitted withprostheses on all extremities. He required psychologicalsupport for many years [G2, G3].

B. Accelerators and X-ray devices
65. Table 3 summarizes 21 accidents involving machinegenerated radiation (i.e. from accelerators or X-ray devices),four of which are described briefly here.
66. United States, 1960. In March 1960 nine civilian­employees at a military installation in Lockport, New York,
were exposed to X-radiation from an unshielded klystrontube. Two of the individuals were seriously injured, fiveother ­individuals demonstrated less severe injuries and two­individuals remained asymptomatic. The highest dose received
was ­estimated to be 12–15 Gy (non-uniform). Seven exposed
individuals demonstrated varying degrees of nausea, ­vomiting,headache, erythema, fatigue, epilation and ­conjunctival­reddening. The individual with the highest ­estimated dosedemonstrated signs and symptoms of ARS [H5].
67. United States, 1967. In October 1967 three technicians in Pittsburgh, Pennsylvania, simultaneously incurred
accidental non-uniform whole-body exposures to radiationfrom a water-cooled Van de Graaff linear accelerator. The
water cooling system had failed, and the technicians wereattempting to repair the system. They followed all safety
procedures and entered the accelerator area unaware thatthe safety interlock system had failed. The workers experienced early signs and symptoms of radiation injury, anddosimetric tests indicated whole-body exposures of 1, 3 and6 Gy. The most seriously irradiated worker also had localized doses of 59 Gy to the hands and 27 Gy to the feet. He
had a more complicated clinical course, and demonstrated
pancytopenia and complete bone marrow depletion. His situation was unique because he had an identical twin brotherwho donated bone marrow for transplant on the eighth day
after exposure. The patient developed extensive local skin
injury to the hands and feet, and four months after exposure,amputation of portions of the hands and feet was performed.

III.

68. France, 1991. In July and August 1991, three ­individuals
working at an accelerator facility in Forbach received highdoses of radiation from a Van de Graaff device. The ­accident
was reportedly due to negligence and non-compliancewith regulatory requirements. The ­workers’ exposure was­associated with “dark current” after the ­accelerator had been
turned off, although the voltage was maintained to save time.
The residual dose rate was a few grays per second. The most
severely exposed individual suffered skin lesions ­following
a dose estimated at 40 Gy, while the other two were less­seriously affected [C1, U3, Z3].
69. United States, 1991. In 1991, an accelerator operator ata ­facility near Baltimore, Maryland, was exposed to electron
dark current during routine maintenance. The filament voltage was off, but the high voltage was on, resulting in dose
rates of 0.4–13 Gy/s. The operator placed his hands, head
and feet in the beam. Three months later, most of the digits
on both of the operator’s hands had to be amputated. Using
electron paramagnetic resonance (EPR) on bone samples
from the fingers, the dose was estimated to be 55 Gy [D3].
C. Summary
70. Table 3 lists 80 accidents at industrial facilities. Nine
deaths were reported in these accidents. They all occurred
at industrial irradiation facilities using high-activity sealed
sources, primarily because of improper entry into the hot
cell, and a lack or failure of safety mechanisms. At least 84
other people were excessively overexposed in these ­facilities.
In other industries, 36 workers were injured during the useof radiography sources, X-ray devices and ­accelerators, andduring manufacturing procedures. The Committee ­considers
it probable that some accidents at industrial ­facilities­involving deaths and injuries have not been reported.

Accidents involving orphan sources

71. Orphan sources are radioactive sources that were neverunder regulatory control or were under regulatory control
but then abandoned, lost, misplaced, stolen or otherwisetransferred without authorization [G1]. Orphan sources
have been the cause of serious accidents involving membersof the general public, who were entirely unaware that they
were being exposed to radiation. Table 4 summarizes key
information about 34 accidents involving orphan sources(sometimes multiple sources). Of these, 20 are describedbriefly below to illustrate some of the characteristics ofthese events.

72. Mexico, 1962. Between March and September 1962,an engineer left a 200 GBq 60Co source unprotected in theyard of a house in Mexico City. The source was found by a
10-year-old boy and subsequently taken to his home, where
it remained for approximately four months. The boy and his
sister died following estimated protracted whole-body dosesof 47 and 28.7 Gy, respectively. The children’s mother andgrandmother also died following doses estimated at 35 and30 Gy, respectively. The children’s father survived, although
he became permanently sterile, following an estimated­protracted dose of 120 Gy [M6].

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73. China, 1963. In 1963, a 60Co source with an ­estimatedactivity of 0.43 TBq was found in a lead cask by a farmer
fishing near the Anhui Agricultural Institute, locatedin Hefei City in Anhui Province. He took the source andreturned to his home. Nine days later, authorities located thesource. The six individuals living in the home were sent to a
hospital for medical assistance. Two individuals in the homereceived estimated whole-body doses of 80 Gy and 40 Gy,
and died within the following two weeks. The other fourindividuals received doses estimated at 8, 6, 4 and 2 Gy, andsurvived after medical treatment. No significant long-term
effects were noted 17 years after exposure [P1].
74. Mexico, 1973. On 24 May 1973, during the ­constructionof the refinery at Tula, in Hidalgo state, a truck was trans­
porting a container holding a 137Cs source. The container had
a “plug” made of a piece of wood. Owing to the motion of
the truck, the plug failed and allowed the source to emerge
from the container. The box that held the container had acrack, and the source fell out on to the road. A 38-year-old
bricklayer found it and took it home, carrying the source in
his trouser pocket for several hours. The dose to the thigh
was reported to be 1,386 Gy. He subsequently suffered radio­
dermatitis of the left thigh median third and the buttock. Hisleft leg was amputated from the hip down; the middle fingerof the right hand was also amputated. His family, who were
exposed to the source over three days, showed no symptomsof radiation injury [N5].
75. Algeria, 1978. In May 1978, a 925 GBq 192Ir source
used for industrial radiography fell from a truck travellingon the road from Algiers to Setif. Two young boys found thesource a few days later. Both boys handled the source, andit was eventually placed in their home. It remained there for
5–6 weeks, exposing the family to radiation under ­various
conditions depending on their location and time spent in
the kitchen. The two boys developed serious skin lesions;
their 47-year-old grandmother and four females aged 14,
17, 19 and 20 years, who spent most of their time in thehouse, were exposed to varying doses. The actual doses tothese five females were difficult to resolve, owing to many
­uncertainties, including those in the total time of exposure
per day, geometry, shielding and distance from the source
over a period of 38 days. Thus their treatment was based­primarily on haematological presentations. The ­grandmotherdied in late June 1978. The foetus of the ­pregnant 20-yearold woman also died during the haematological recovery
period of the mother, and both boys required ­surgery for
their skin injuries [J2].
76. United States, 1979. In June 1979 a worker at an industrial site in Los Angeles (Riverside), California, found alost 192Ir radio­graphy source with an estimated activity of
1.04–1.22 TBq. The worker placed the source in his right
hip pocket and left it there for approximately 45 minutes. He
subsequently developed a severe ulcerated radiation burn.
The estimated skin surface dose was 800–4,000 Gy, and the
1 cm tissue depth dose was 520 Gy to an area measuring
11 × 9 × 2 cm. At 36 days after exposure a full-thickness

myocutaneous flap, with vascular pedicle intact, was mobilized from the right thigh and sutured to the bed of theexcised ulcer. Additional surgeries were required since thelesion did not completely heal. Five other workers ­handled
the source before it was returned to the radiographer.
Four of these workers developed moderate injuries to the­fingertips. An additional five workers did not have medicallysignificant exposures [H8, R2].
77. Mexico, 1983. In early December 1983, a 60Co therapy
machine was dismantled and loaded into a pick-up truck. The
machine had been acquired in November 1977 by the Centro
Medico Hospital in Ciudad Juarez and had been in storage
since its acquisition. The source activity was about 16.6 TBq
contained in some 6,000 small pellets, each with an average
activity of 2.77 GBq. During the dismantling, the source container was punctured and a number of ­pellets (800–1,000), withan estimated activity of 1.85 TBq, were spilled into the truck’s
cargo area. The truck was later parked on a city street and was
not discovered for about seven weeks. The machine was soldat a local scrapyard and then to ­foundries in ­Chihuahua andDurango, Mexico, with subsequent ­contamination of metal.
During movement of the machine, some cobalt pellets werelost on the streets of Ciudad Juarez, in the scrapyard, along
highways and in the foundries.
78. The accident was not discovered until January 1984
when a truck loaded with contaminated rebar stopped at an
entrance to the Los Alamos National Laboratory in New
Mexico, United States, and tripped radiation alarms. An
investigation led to the discovery of the pick-up truck. No
acute effects were noted in the general population; doses
were protracted over a period of about 60 days. ­Cytogenetic
dosimetry was performed on two scrapyard employees
and eight individuals living near where the truck had beenparked. Owing to uncertainties regarding exposures of the­individuals, two mathematical models were used to ­estimate
doses. The mathematical model used to extrapolate dose
assuming acute exposure at a high dose rate resulted in­estimates of 0.09–1.91 Gy. The estimate assuming chronic
exposure at a low dose rate ranged from 0.13 to 15.16 Gy.
There were no fatalities reported following the accident [B3].
79. Morocco, 1984. In March 1984, a worker at a facility
in Casablanca took home an industrial radiography source(603 GBq of 192Ir) and placed it on a shelf near his bed. The
worker died 44 days after exposure. Over the next several
weeks, the worker’s pregnant wife and their four children also
died as a result of their exposures. After the father’s death,a cousin and his mother stayed in the house, using the room
where the source was located. These two individuals also diedas a result of their exposures. Three other persons living in
the house experienced bone marrow suppression but survived
their overexposures. Authorities recovered the source 80 days
after it was removed from the facility [M2, M5].
80. China, 1985. In April 1985, an accident occurred in
Mudanjiang when a lost source (370 GBq of 137Cs) was
brought into a dwelling where a 21-year-old man and his

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

p­ arents (the mother was 68 years old and the father 66 years
old) were exposed over a period of 150 days with ­estimated­cumulative whole-body doses of 8–10 Gy to each individual.
The father also experienced a radiation-induced burn on his
right thigh. The clinical findings upon ­hospital ­admission were­general malaise, bleeding and ­pancytopenia. The ­therapeutic­measures were bed rest, adequate ­nutrition and strict control
of infection. The father died from ­myelodysplastic syndrome
complicated by pulmonary ­fungal infection 22 months after
exposure. The other two individuals remained apparently well[Y1].
81. Brazil, 1987. In 1987, an abandoned 50.9 TBq 137Cs­teletherapy device located in Goiânia was stolen and­dismantled, and the source capsule ruptured. Over the next
two weeks, 137Cs chloride powder was spread throughout a scrapyard, surrounding homes and the vicinity. The­problem of radiation exposure was noted after numerous
individuals developed illness and skin lesions. Subsequentlya ­monitoring station was set up at a soccer stadium and
110,000 persons were monitored for contamination withradioactive material. Of these individuals, 249 were found tohave 137Cs deposits on their skin or clothing, and 129 of these
persons were found to be internally contaminated with 137Cs.
Outpatient care was provided to 79 ­individuals, while 50
required close medical surveillance. Of these ­latter patients,
14 required intensive medical care for ARS, ­internal contamination and local lesions. Four persons died, including
one child. There are 150 persons currently in a follow-up
cohort. A group of 755 professionals participated in extensive environmental decontamination. Eighty-five ­residences
required decontamination, and seven residences had to be
demolished. The total volume of waste generated for temporary storage amounted to 3,134.5 m3 and since 1987 has been
disposed in a repository [I11, I12, N8].
82. USSR, Ukraine, 1988–1991. This accident occurred
when a family consisting of a man, a woman and two­children moved to an apartment in a new complex built
200 km south-east of Kiev. After several months theolder son became ill and was found to have bone ­marrow­depression. The cause was not identified, and the boy­recovered and returned home. Over the next year the same
scenario was repeated several times, and the boy developed
osteosarcoma of the foot and died of metastatic disease. His
younger brother was then allowed to move into his bedroom,
and within several months developed severe bone marrowdepression. The younger boy also developed a necrotic lesion
on his foot. Thinking the problem was associated with theChernobyl accident, the boys’ mother requested ­authorities
to ­survey the apartment for radiation. Finally a 2.6 TBq137
Cs ­industrial source was found embedded in the wall of
the boys’ bedroom, located near the foot of the bed. How
the source came to be there was never clear. Several months
later the younger boy ­developed additional haematologicalproblems and ­subsequently died [M2, S2].
83. China, 1992. In November 1992, in Xinzhou, Shanxi
Province, a farmer was demolishing a closed irradiation

11

facility when he found a 100 GBq 60Co source contained ina ­cylindrical steel bar. The individual placed the bar in his
jacket. Later that afternoon he was sent to a local ­hospital
after ­complaining of nausea followed by vomiting. The
jacket containing the source remained with the individual
during his hospitalization. He died in early December. His
father and elder brother, who had taken care of him at the­hospital, died from exposure the following week. The­farmer’s wife also assisted in his care, and in mid-December
she requested ­medical assistance. The doctors suspected thatshe, too, was suffering from radiation exposure. Through dose­reconstruction, the farmer, his father and his brother were
estimated to have received doses of greater than 8 Gy, and thedose to his wife was estimated to be about 2.3 Gy [P1].
84. Turkey, 1993–1998. Unauthorized long-term storage(1993–1998) and subsequent transport and transfer to a newowner resulted in a loss of control over two 60Co therapy
sources in Istanbul. The packages containing the sourceswere sold as scrap. Later the shielding of one container was
opened at the scrapyard. In December 1998 ten persons fell
ill, and six experienced nausea and vomiting. The cause of
their illness was not diagnosed until four weeks later. Oncethe cause had been diagnosed, media reports caused alarm,and 404 persons applied for medical examinations. ­Eighteen
persons (including seven children) were admitted to ­hospital.
Ten of the hospitalized adults exhibited signs and symptomsof ARS. Five of these persons were hospitalized for 45 days.
One person had local injury to a finger [I7].
85. Estonia, 1994. In October 1994 in Tammiku, threebrothers entered a waste repository without authorization
and removed a metal container holding a 1.6 TBq 137Cs
source. During removal the source was dislodged and fell to
the ground. One of the men picked it up and placed it in his
pocket. Before leaving the repository, he began to feel ill. A
few hours later he began to vomit. He took the source to hishome in the nearby village of Kiisa. Subsequently he wasadmitted to a hospital with severe injuries to his leg and hip,and he died on 2 November 1994.
86. The injury and subsequent death were not initiallyattributed to radiation exposure, and the source remained in
the man’s house with his wife, his stepson and the boy’s greatgrandmother. The boy was hospitalized on 17 ­November
with severe burns on his hands, and a ­doctor ­identified theburns as being induced by radiation. The authorities werealerted, and the Estonia Rescue Board recovered the sourcefrom the house. The occupants of the house and one of
the man’s two brothers were hospitalized and diagnosedas ­suffering from radiation-induced injuries of varying­severity. All were subsequently released from the hospitaland continued to receive outpatient treatment for at least four
years. Studies conducted on other people living in the area
where the source was discovered revealed no ­symptoms ofradiation sickness [I13].
87. Russian Federation, 1995. In 1995, a 48 GBq 137Cs
source was discovered in the cabin door pocket on the

12

UNSCEAR 2008 REPORT: VOLUME IIdriver’s side of a truck near Moscow. The driver of the truck
was apparently overexposed over a period of about fivemonths. The dose rate at the left side of the driver’s seat wasestimated to be about 50 mGy/h. An estimate of the average whole-body dose of 7.9 ± 1.3 Gy was made on the basisof cytogenetic studies of chromosomal aberrations in thedriver’s blood lymphocytes. The driver was hospitalized in
Moscow in July 1995 with complaints of fatigue and shortness of breath. Epilation was evident on the lateral surfacesof the left thigh and buttock. Pancytopenia, myelodysplasia
and anaemia progressed over the next several months, eventually leading to myelomonocytic leukaemia. The individual
died 22 months after the source was discovered [B7, S7].
88. Islamic Republic of Iran, 1996. In July 1996, ­industrial
radiography was under way at the Gilan ­combined cycle­fossil fuel power plant located 600 km north of Tehran.
After making a series of radiographs, the radiography
team failed to notice that the 185 GBq 192Ir source was­m issing from the container. A 33-year-old plant employee
found the source, handled it and then placed it in his shirt
pocket, where it remained for about 90 minutes. Over the
next few weeks the irradiated individual demonstrated­haematological ­depression and was treated with anti­biotics,
platelet trans­fusions, and the haematological growth ­factor
granulocyte-colony-stimulating factor (G-CSF). He also
developed lesions to the right thorax, right elbow, rightthigh and left palmar surface. He was treated in Tehranand ­subsequently transferred to Paris for treatment of hisskin lesions. His chest and thigh lesions were successfully treated with a free graft from the undamaged thigh.
About 16 months after ­exposure, the skin lesions healed,
although there was ­thickening of the skin on the hand, slight­retraction on the right side due to the fibrotic chest graft andcontracture of the right elbow. The estimated whole-bodydose was 2–4 Gy, while the ­maximum skin doses did notexceed about 40 Gy [I21].
89. Georgia, 1996–1997. Numerous sources were­abandoned when Soviet troops turned over the Lilo ­Training
Centre to the Georgian army in 1992. From April to August
1997, several Georgian soldiers sought medical care becauseof skin lesions. After radiation injury was diagnosed,
high-activity sources were found 30 cm below the surface
of a ­soccer field, 10 cm below ground in an area used for­smoking, stored in lead containers and in the pocket of asoldier’s ­winter jacket. In addition, 200 discarded sighting
devices containing 226Ra and a 60Co source were found. In
total, 12 137Cs sources were located. Eleven persons ­sufferedlocal and systemic effects as a result of their ­exposures. The
estimated doses for protracted exposures ranged from 4.2
to 0.6 Gy. Seven patients remained under treatment in 1999
[I20].
90. Peru, 1999. In February 1999, an 192Ir industrial radio­
graphy source with an estimated activity of 1.37 TBq was lostat the Yanango hydroelectric power plant in the San Ramon
district 300 km east of Lima. A few hours later a welder
found the source and placed it in the right back pocket of

his trousers. Over the next several hours the welder worked
in a pipe and then took a minibus home. He changed clothing, placing his trousers (with the source still in the pocket)
on the floor, and sought local medical assistance becauseof pain in his right thigh. He was diagnosed with an insect
bite. Meanwhile his wife sat on the trousers while breastfeeding her 18-month-old child. Authorities recovered thesource at 1 a.m. the following morning, and the welder wastransferred to Lima for medical care. The estimated 1 cm
depth dose to his thigh was 9,966 Gy, and over the next threemonths he developed an extensive severe lesion on the rightthigh. He was then transferred to Paris for skin grafts using
porcine xenografts. The grafts failed, and the right leg was
disarticulated at the hip. Additional surgeries were required
after the welder’s return to Peru. His wife developed moist
desquamation and ulcerative and fibrotic lesions of her lower
back [I8].
91. Thailand, 2000. In 1999, unauthorized teletherapy
sources were relocated to an unsecured site in Samut Prakarn.
In January 2000, four scrap collectors gained access to thefacility, partially disassembled a teletherapy head and took
the device home for further disassembly. On 1 ­February
two of the individuals sold the components to a junk dealer.
­During further disassembly of the device at the junkyard,
the source fell out of its housing but was not noticed. By
mid-February several individuals had sought medical­attention, and suspicion of radiation injury was reported tothe authorities. The 15.7 TBq 60Co source was recovered on
20 February. Ten people were hospitalized. Three junkyard
employees died of ARS-associated ­infections in March.
Four other individuals suffered local injuries; one required
hand amputation. G‑CSF and GM‑CSF were used in the
medical management of these patients [I9].
92. Egypt, 2000. In May 2000, a farmer from Meet Halfa
village found a 1.17 TBq 192Ir industrial gamma radio­graphysource that had been lost by a worker testing pipe welds.
The farmer took the source to his home, where he lived withhis wife, a sister and four children. In the ­following weeks
the source was handled by family ­members and moved
to ­various locations within the ­family home. The 9-yearold son died in June, and death was reported to be due tobone marrow ­failure and inflammation caused by a viral or­bacterial infection. Other family members were also foundto be sick with skin lesions, bone marrow ­failure and gastro­
intestinal symptoms, but the diagnosis again was ­incorrect.
On 16 June the farmer died. On 25 June, a ­fact-finding­mission detected high radiation levels at the family home,
and the source was recovered. Family ­members were
­hospitalized with skin lesions and bone marrow depression.
G-CSF was used in their treatment. Dose estimates were:father, 7.5–8 Gy; 9-year-old son, 5–6 Gy; five other family
members, 3.5–4 Gy. Between 200 and 300 neighbours andrelatives were monitored, and the affected family received
continuing treatment and surveillance [E1, I10].
93. Georgia, 2001. In December 2001, three ­woodsmen
found two heat-emanating ceramic objects near theirANNEX C: RADIATION EXPOSURES IN ACCIDENTS

campsite in the remote Inguri River Valley of Georgia. Twoof the woodsmen carried the containers on their backs, andexperienced nausea, vomiting and dizziness within hours of
exposure. The third carried the source attached to a wire.
At a hospital in Tbilisi, the woodsmen were ­diagnosed
with radiation sickness and severe radiation burns, and at
least two of the three men were in serious condition. A
Georgian team recovered the sources in early 2002 withthe ­assistance of the International Atomic Energy Agency(IAEA). They were unshielded ceramic sources from two
Soviet-era radioisotope thermoelectric generators (RTGs),
each containing about 30,000 Ci (1 PBq) of 90Sr. Two of thepatients were treated in hospitals in Paris and Moscow forIV.

many months before recovering from their severe radiation
burns [I23].
A. Summary
94. Table 4 presents information on 34 accidents involving orphan sources. These accidents resulted in 42 early
deaths and in disfiguring injuries to both children andadults. Significant environmental contamination and theinternal contamination of 129 persons occurred in one ofthese accidents. The Committee considers it probable thatsome radiation accidents involving orphan sources and that
resulted in deaths or injuries have not been reported.

ACCIDENTS AT ACADEMIC AND RESEARCH FACILITIES

95. Table 5 summarizes information about 22 radiation accidents at academic and research facilities, seven­involving sealed radioactive sources and 15 involving
machine-­generated radiation (i.e. from accelerators and
X-ray devices). Some examples of these accidents aredescribed briefly below to illustrate the nature of these
events.
A.

13

Sealed radioactive sources

96. USSR, 1962. A 60Co source of about 1.9 PBq was used at
a research institute in Moscow for irradiating metal ­samples.
A researcher opened the locked door and entered the irradiation room, believing the time to change the ­sample would
be so short as to be not dangerous. However, she received
a whole-body dose (non-uniform) of about 2.5–3.0 Gy, and
12 Gy to her right hand. She survived a moderate ARS withmild local skin injury [G5].
97. United States, 1971. In February 1971, a 32-year-oldt­ echnician was performing seed irradiation ­experiments atthe ­Variable Dose Rate Irradiation Facility at the ­Universityof ­Tennessee Comparative Animal Research Facility in
Oak Ridge. Because of an interlock failure, the ­technician
was able to enter the facility with a 285 TBq 60Co source
unshielded. He was within 50 cm in front of an unshielded
source for about 40 seconds. When the ­technician left
the facility, the operator noticed that the source wasunshielded and ­notified the authorities. The technician was­hospitalized within two hours, and experienced episodesof nausea and vomiting starting 2.25 hours after exposureand lasting for about 24 hours. Maximum haematologicaldepression lasted from day 24 to day 34 after exposure.
The estimated whole-body and bone marrow doses were1.27 Gy and 1.18 Gy. The patient was treated with ­standard
antibiotic and haematological ­support, and returned towork 11 weeks after exposure [V2].

B.

Accelerators and X-ray devices

98. USSR, 1977. In March 1977, a 40 MeV proton­accelerator in the Institute of Nuclear Physics, Kiev, wasactivated for the first time. A physicist—who had fosteredits construction—decided to demonstrate the presence ofthe beam. He inserted a luminescent lamp by hand “into thebeam”, and it illuminated. However the physicist received anabsorbed dose within the hands’ tissues ranging from 12 Gyon the surface to more than 30 Gy at the depth of 0.5 cm
at some points. This led to a complicated clinical course of
local radiation injury to both hands, and several surgicalinterventions were performed in order to save some of thehands’ functionalities [A5, B12].
99. United States, 1977. In April 1977, a graduate student
at the ­Donner Laboratory of Lawrence Berkeley Laboratory, ­University of California at Berkeley, was conducting a
research experiment involving the effects of X-rays (about
30 kVp) on yeast cultures. On the day of the accident the­student was to expose 60 Petri dishes of yeast cultures. Aninterlock failure resulted in the student’s hands ­receiving
about 70 Gy. There was noticeable erythema within 12hours, followed by blistering and desquamation over a
period of several months. Two fingers on the left hand and
one finger on the right hand were amputated [T2, U3].
100. USSR, 1978. A powerful 70 GeV proton accelerator
was used at the Institute of High Energy Physics, ­Protvino,
for a broad spectrum of scientific experiments. In June
1978, after a long chain of procedure violations and errors,a researcher was accidentally exposed to a needle-thin beamof protons, which pierced his head from left occipital lobeof the brain to the left nostril. His middle ear was destroyed,
and facial nerve injured. He survived, and the function of
the facial nerve was restored. However, deafness in his left
ear and a scar on the left nostril remained; and brain damage
caused mild epilepsy six years later [B13].

14

UNSCEAR 2008 REPORT: VOLUME II

101. USSR, 1978. An accident occurred in an electron­linear accelerator in Leningrad, involving a 12.7 MeV ­electron
beam. A worker entered the experimental room after irradiation was complete and a timer had cut the ­voltage to the controlling electrode. She stood with her back to the exit window
and then turned 180°. It appeared that she was exposed twice
owing to so-called “dark current”, because the high voltage
to the accelerating tube was still on. The ­localized doses toher back and chest were ­estimated as more than 20 Gy and8 Gy respectively. Skin ­reactions ­corresponded to these doses;
however, signs of severe ­radiation damage to the spinal cord
appeared six months later [A5].
102. Vietnam, 1992. In November 1992, an accident­involving a research X-ray accelerator occurred at the Hanoi
Institute of Health Physics. One individual entered the irradiation room without supervision and subsequently exposed
his hands to the X-ray beam. The dose to the individual’sleft hand was estimated to be 10–25 Gy, and the whole-bodydose was estimated to be 1–2 Gy. The individual’s hands
were seriously injured, and one hand had to be amputated[I4].
103. United States, 1994. In June 1994 two ­graduate students at the University of California at Davis were ­analysing­samples using a water-cooled Enraf-Nonius X-ray ­diffraction

unit operating at 45 kVp, 25 mA, with the timer mode set
in the “continuous” position. On previous ­occasions, the­students and a faculty member had dismantled the unit toclean ­corrosion that had built up between the X-ray tube
column and the primary shutter. Procedures called forthe unit’s electrical power to be in the “off” position. The­students had, however, adopted the practice of expediting
sample changing by bypassing the cabinet door safety interlock rather than turning the power to the “off” position. This
led to significant exposure to areas of both hands of one of
the students. The skin entrance dose rate was 960 Gy/min.
The clinical course over one year after exposure included­tightness and paraesthesiae in the student’s fingers, swelling,erythema, bullae, hyperkeratosis and significant pain [B4].
C. Summary
104. Table 5 lists accidents in academic and research facilities. Twenty-two accidents have been reported in the use ofaccelerators, research reactors, radiochemistry laboratories,
small irradiation facilities, and with the use of X-ray diffraction, spectroscopy, crystallography and fluorescence units.
The hands were commonly the area injured. The ­Committee
considers it probable that some radiation accidents in­academic and research work have not been reported.

V. ACCIDENTS ASSOCIATED WITH THE MEDICAL USE OF RADIATION
105. A summary of nearly 100 radiotherapy accidents has
been presented by the IAEA [I25], and a similar number
have been reported by the International Commission on
Radiological Protection (ICRP) [I24]. Table 6 summarizes
information on 32 serious radiation accidents associatedwith the medical use of radiation. Some examples of accidents associated with the diagnostic and therapeutic usesof radioactive materials and machine-generated ionizing
radiation are described briefly below. More discussion on
accidents in radiotherapy is provided in annex A, “Medical
radiation exposures”.
A.

Nuclear medicine

106. United States, 1968. In August 1968 a 73-year-old
woman was scheduled for a diagnostic nuclear medicine
liver/spleen scan at a hospital in Wisconsin. The radio­
pharmaceutical being used was colloidal 198Au, administered intravenously. The intended activity was 7.4 MBq, but
because of an error, the patient received 1,000 times moreof the radionuclide, or 7.4 GBq. The estimated bone marrowdose was 4–5 Gy, and the dose to the liver was 70–90 Gy.
The patient died 69 days after exposure [M3].

B.

Sealed radioactive sources

107. United States, 1974–1976. This accident involved
426 patients being treated with a 60Co teletherapy unit overa 16-month period (1974–1976) at the Riverside Hospital in­Columbus, Ohio. Dose rates had been underestimated by
10–45% owing to an error in calculating the source decay
and to a lack of routine periodic calibration. Of the 183 who­survived beyond one year, 34% had severe complications,some of which led to death. Fifteen years after the accident, 18 ­individuals remained alive, with 50% experiencing
severe complications [M1].
108. France, 1981. During the initial loading of a radiation therapy device in a new radiotherapy department inSaintes, the 137 TBq 60Co source had become jammed in
the loading channel instead of being in its retracted, shielded
position. Unaware of this, an assistant operator placed hishands in contact with the device in an area where the source
was jammed. On removal of the source transport apparatus that contained a dummy source, both the dummy source
and the 60Co source fell on to the floor. Despite 25 years ofexperience, the main operator picked up the source with hisbare hands and put it in a safe position. Doses to the hands

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

of both the operator and his assistant exceeded 25 Gy at thewrists. The amputations of both hands of both victims wereunavoidable. A third operator received an unexplained highlevel exposure of one hand, leading to amputation of a large
portion of the hand [N7].
109. United States, 1992. An accident occurred in­November 1992 in Indiana, Pennsylvania, involving a female
patient scheduled for a high-dose-rate brachytherapy procedure using a 159 GBq 192Ir source. The treatment was to begiven in three fractions of 6 Gy each. During the first procedure the source broke off the guide wire and remained inside
one of the catheters surgically implanted into the patient’s
tumour. A radiological survey of the patient was not performed, and she was returned to a local nursing home. The
source became dislodged from the catheter on day 4 and was
discarded in the biohazard waste. It was discovered somedays later when a waste truck passed through a radiation
detector installed at an incinerator facility.
110. The estimated dose at 1 cm in tissue was 16,000 Gy.
Death occurred four days after the procedure, but wasthought to be associated with the patient’s disease and age.
The patient’s remains were later exhumed and an autopsy
was performed, resulting in the death certificate beingchanged to reflect death from ARS. Ninety-four additional
individuals, including staff, visitors, family members andother nursing home residents, were exposed, although thedoses were not medically significant [N4].
111. Costa Rica, 1996. In August 1996, a 60Co radio­
therapy source was replaced at a hospital in San José.
­Following the replacement, a calibration error was made.
Over the next 37 days, radiation doses 50–60% greater thanthose prescribed were delivered to 115 patients under treatment for neoplasms. These overexposures were confirmedby recalibration of the source and review of ­individual
patient charts. In July 1997, an IAEA investigation teamevaluated 70 of the 73 patients who were still living. The
team concluded that 20 patients were suffering from major
adverse effects due to their overexposures, with 26 other
patients experiencing less severe effects. Twenty-two had
no discernible effects, because of incomplete therapy. Twopatients were underexposed and three were not examined.
Seventeen deaths associated with the radiation exposures
were reported [I14, I24].
112. Panama, 2000. At the Instituto Oncológico Nacional
in Panama, a computerized treatment planning system wasused to calculate the dose distribution and determine treatment times. In August 2000, medical physicists changed themethod for entering data on shielding blocks in the computer
program in order to overcome limitations for treatments that
required more than four blocks. Soon thereafter, the radiation oncologists started to observe prolonged diarrhoea insome patients. In March 2001, physicists identified a problem
with the calculation of exposure times, and the treatment of

15

patients with abnormal symptoms was suspended. Further
studies revealed that 28 patients had received a proportionately higher dose than prescribed. Further investigations
were undertaken, although eight patients had already died.
At least five of these deaths were probably radiation related.
The 20 surviving patients were examined, and a number
were found to be suffering from bloody diarrhoea, necrosis,
ulceration and anaemia [B10, I15].

C.

Accelerators and X-ray devices

113. United States and Canada, 1985–1987. In 1985,
1986 and 1987, several serious overexposures occurred
when patients were being treated for carcinoma using a
Therac-25 ­electron linear accelerator. The device was firstmanufactured in 1982, and 12 units were in use within the
United States and ­Canada. Accidents occurred in UnitedStates hospitals located in Marietta, Georgia; Tyler,
Texas; and Yakima, Washington; as well as at a hospitalin ­Hamilton, Ontario, Canada. Control of the device wasachieved using a small digital computer. Unfortunately,
the computer had a software problem such that when thetechnician made an error in the treatment procedure, thecomputer screen displayed a “malfunction 54”, which was
the code for “dose input error”. This resulted in the patient
receiving a direct electron beam at 25 MeV.
114. Six patients were irradiated during machine malfunction and received severe burns. Two of the patients diedas a result of their injuries following therapy in Texas. In
March 1986, a 33-year-old man with a liposarcoma on his
left upper back was treated; owing to the machine malfunction, the patient experienced severe damage to the cervicalcord, resulting in death five months after exposure. In April
1986, a 66-year-old man with a multifocal skin cancer on theleft side of the face was treated during machine malfunction.
He died three weeks later from damage to the right temporal
lobe of the brain and the brain stem [N2].
115. Spain, 1990. In Zaragoza, 27 patients received higher
radiotherapy doses than those prescribed, because of a malfunction in a linear accelerator. During a repair procedure,
the electron energy of the accelerator was ­modified, and thischange was not noted by the therapists, who thought thatthe meter on the control panel was faulty. The increased
energy resulted in greater penetration of energy and effects
on deeper tissues. In addition, the electrons were focused ina smaller cross-section of the beam. This resulted in doses
three to seven times higher than intended. Patients ­developed
injuries in the lungs, pharynx and spinal cord, complicatedby vascular and skin injuries. As the victims of this malfunction were suffering severe tumours for which they werebeing treated with radiation, it is difficult to ­accurately assess
the contribution of the accident to the number of deceased.
It was estimated that 15 patients died with radiation as theprimary or major cause of death, while others had severe
disabilities [I24, S5].

16

UNSCEAR 2008 REPORT: VOLUME II

116. Poland, 2001. In February 2001, at the Bialystok
Oncology Centre, a serious accidental overexposure injured
five female patients undergoing post-operative radio­therapy
for breast cancer. The accident involved a NEPTUN 10P linear accelerator. A transitory electrical power loss occurred,and following restart of the device, the patients received
considerably higher doses than planned. Prescribed doses
were 2–2.5 Gy per fraction from an 8 MeV electron beam.
EPR assessment of rib samples resulted in dose estimates of
60–80 Gy. Medical examination revealed local injuries in
the five patients, which worsened over time. Surgical intervention was necessary in all cases. The condition of four
patients improved with the use of hyperbaric oxygen therapy[I22].
117. United Kingdom, 2006. In January 2006, a 15-yearold female patient was receiving radiotherapy for a brain
tumour at an oncology centre in Glasgow. Twenty planned
fractions of 1.75 Gy (35 Gy total) were to be delivered using
a linac system, but owing to a dose planning error undiscovered until the 19th fraction, the estimated delivered dose was55.5 Gy [J5].

VI.
A.

D.

Summary

118. Those at risk in the medical use of radiation include
patients, physicians and staff, as well as those involved inchanging sources, repairing devices, and so on. Humanerror has been a common cause of these accidents in the
medical field. Examples of errors include delivering theradiation dose to the wrong patient or to the wrong location, giving the wrong dose because of errors in treatment
planning and failure to use survey equipment/monitors as
intended. The IAEA [I25] and ICRP [I24] have catalogued
over 100 radiotherapy accidents, and table 6 lists 32 examples of serious radiation accidents in the medical field.
It is noteworthy that such accidents were sometimes notrecognized, because injuries were not always evident until
some time after a procedure, or symptoms were masked by
the severity of the underlying disease process. Both under­
exposure and overexposure to radiation have had serious
consequences. Only overexposures have been included inthis annex. The Committee considers it likely that somedeaths and many injuries in the medical use of radiation
have not been reported.

OTHER ACCIDENTS

Transport accidents

119. Millions of packages of radioactive material aresafely transported throughout the world each year. Most ofthese materials are for medical or general industrial use.
Many packages are manually handled and are transported
by road, or sometimes by air, sea or rail. Some packages
require remote handling because of their weight. Road andrail traffic is often through urban areas, and members of
the public may be in close proximity to the packages. In theevent of an accident, there could be a local release with some
atmospheric or aquatic dispersion [H1, I16].
120. Accidents do occur during transport, although any
consequences are normally limited by built-in safety ­featuresof the packages/containers and by adherence to ­regulatory
controls, including emergency response ­procedures. (See­reference [I17] for detailed information regarding ­accident
frequency, types and consequences.) A recent United­K ingdom study of accidents and incidents over the period
1958–2004 concluded that the most serious radiological consequences occurred as a result of transporting ­improperly
packaged industrial radiography sources [H10].
121. Less commonly, accidents have occurred during­military and civilian movement of radiological or nuclear
materials by aircraft, ship, submarine or spacecraft (seetable 7). These accidents have involved small nuclear­reactors, RTGs, nuclear weapons, nuclear waste and otherradioactive shipments [B1, I16, I18, T1]. A number of these

accidents have resulted in loss of life due to causes otherthan radiation. Again, consequences have been limitedby the substantial built-in safety features, by adherence tothe controls required for transport, and by the emergency
response and recovery procedures utilized.
122. Table 7 summarizes 24 accidents involving sea, air andspace vehicles. With the exception of the submarine ­accidents
in the former Soviet Union (see table 1), these ­accidents did
not lead to early acute effects of radiation exposure. Some ofthem, however, did lead to widespread dispersion of radioactive material in the environment. Military activities have
involved at least two documented serious transport accidents
that led to environmental contamination: the accidents at
Palomares, Spain, and Thule, Greenland. These accidents
were described in the UNSCEAR 1993 Report [U6]. Moredetailed information on accidents and losses in the marine
environment can be found in reference [I18].
B.

Suspected malicious act

123. While malicious acts are clearly not accidental, they
are in principle of interest for the Committee’s assessments ifthey lead to early acute health effects of radiation or to widespread significant population exposures. The ­Committee has
not reviewed such events comprehensively in the context of
this report. Nevertheless, it considered it appropriate to notea recent suspected malicious act that received much media
attention.

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

124. On or about 1 November 2006, a Russian living in the
United Kingdom was allegedly poisoned with 210Po [H9]. He
died on 23 November 2006 [H6]. The death caused widespread
public interest. An extensive public monitoring ­programme
revealed no public health consequences for open public spaces.

17

More than 700 persons in the United ­Kingdom were tested forPo ­contamination. Of these, more than 100 showed 210Po concentrations in urine indicating some contamination from theincident, but fewer than 20 had results ­indicating committed
effective doses of greater than 6 mSv [H7, U17].
210

VII. Summary
125. Early acute (deterministic) health effects of ­radiation
exposure have occurred as a result of accidents or ­malicious
acts. Some serious accidents have additionally led to­significant population exposures (at levels below that for
deterministic effects) owing to widespread dispersion ofradioactive material in the environment.
126. This annex categorizes and summarizes radiation
accidents that have resulted in early acute health effects,
deaths and/or major environmental contamination ­during
the past 60 years (tables 2–6). Selected examples of eachaccident type have been briefly described in the text to­provide insight into the nature of the reported accidents,
their medical consequences and the associated radiation
doses that resulted in injuries and deaths.
127. Table 8 presents an overall summary of the numberof accidents reported in each category over time. Table 9
presents published estimates of the collective doses for aspectrum of accidents that have led to significant population
exposures owing to environmental contamination. Table 10
presents a summary of the numbers of deaths and early
health effects that have been reported owing to radiation­accidents over the last 60 years. These summaries cannot
be deemed complete. For example, it was not possible to use
fully the summary information in table 1.
128. In more than 60 years (1945–2007) of work at nuclear
facilities there have been 35 serious radiation ­accidents
reported. Seven of these caused off-site releases of radioactive ­materials, with potential for significant ­population
exposures. Of the 35 reported accidents, 24 were in­facilities related to nuclear weapons research, ­developmentand ­production, and to the reprocessing of nuclear fuel for­weapons ­programmes. Other accidents occurred in powerreactor research, ­development and operation, and in the­reprocessing of nuclear fuel. Excluding the 1986 accident
at Chernobyl, 32 deaths are known to have occurred as aresult of radiation exposure in accidents at nuclear facilities,
and 61 workers suffered radiation injuries ­requiring medicalcare. The ­incidence of accidents in these facilities has fallen;
most of the deaths and injuries occurred in the early years of
research and development in the ­context of nuclear weapons
programmes. Only one criticality ­accident, with the death of
two workers, has occurred in the past 20 years.
129. Eighty accidents were reported at other industrial
facilities utilizing radiation sources, accelerators and X-ray

devices. Nine deaths were reported in these accidents, and120 workers were injured, with the hands being a commonsite of injury. Serious injuries frequently led to amputations.
Acute radiation syndrome developed in some injured workers, and multiple amputations were necessary in some cases.
130. Thirty-four accidents have been attributed to lost,
stolen or abandoned sources (orphan sources) since 1960.
These accidents are known to have resulted in the deathsof 42 members of the public, including children. In addition, ARS, serious local injuries, internal contamination or
psychological problems necessitated medical care for hundreds of persons. The number of reported accidents involving orphan sources has increased in the past 20 years (seetable 8). It is noteworthy that six accidents were associatedwith abandoned medical therapy units.
131. Reports of accidents in academic and researchfacilities have been rare, with 22 accidents since 1960 andonly four within the past 20 years. Most of these accidents
resulted in injuries to the hands.
132. The Committee considers that accidents associatedwith the medical use of radiation in diagnosis and treatment
may have been under-reported. There have been relatively
few reports of serious accidents, considering the extremely
large number of procedures performed annually throughout
the world (annex A). Since 1967, 32 accidents with 46 deaths
have been considered here. However, there have been a large
number (623) of persons who developed early acute (deterministic) health effects as a result of these accidents. Delays
in recognizing errors led to greater numbers of persons
being injured. The 32 accidents considered here involved
serious overexposures to radiation, but underexposures canalso have serious consequences for patients.
133. The extensive worldwide civilian transport of radio­
active materials has not resulted in any human injuries related
to radiation exposure. Accidents have occurred during military transport of radioactive materials. Some resulted in, or
had the potential for causing, environmental contamination,and some have resulted in the loss of lives (although not­necessarily because of the radioactivity). A limited numberof spacecraft carrying radioactive material have burned up
on re-entry into the earth’s atmosphere or have crashed,resulting in significant releases of radioactive material to theenvironment. However, there is no documented evidence ofanyone sustaining injury from these events.

18

UNSCEAR 2008 REPORT: VOLUME II

134. This annex does not explicitly address observable
late effects due to ionizing radiation exposure. However, for­comparative purposes, table 9 presents estimates for ­collective
doses sustained by local and regional ­populations from a­spectrum of accidents that led to dispersion of radioactive
material in the environment. One accident dominates the collective dose, namely the 1986 Chernobyl accident, on which
the Committee has prepared a dedicated annex, annex D,“Health effects due to radiation from the ­Chernobyl accident”.

remains unreported in the literature. Human error, carelessness, failure to follow procedures and safety guidelines, defective equipment or defective repair, inadequate­training, loss of control and source abandonment, and other­conditions have led to accidents in the past 60 years, and willprobably lead to accidents in the future.

135. Serious radiation accidents have been rare occurrences. Much information has been published about these
accidents, but information about some less serious accidents

136. The Committee wishes to express its gratitude for the
support provided by M.-E. Berger and E. Rochedo to thelead author, R. Ricks.

Acknowledgements

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

19

Table 1. Major types of radiation accident on the territory of the former USSR and the nature of their early effects
As recorded up to 30 June 2003 [I27]TypeRadioisotope units and their sources(total)Number of people with significant clinical symptoms
ARS severity gradeb

Number of radiation
accidents

Total(ARS + LRI)a

I

II

III

IV

Died

92

170

49

27

11

6

16

Co

17

28

15

9

6

3

3

137

Cs

19

59

13

7

1

—

9

192

Ir

60

37

54

10

3

—

—

1

Other gamma emitters

8

10

2

1

—

—

—

beta/gamma emitters

2

2

—

—

—

—

—

beta emitters

9

17

9

7

4

3

3

X-ray units and accelerators (total)

39

43

—

—

—

—

—

27

30

—

—

—

—

—

Electron accelerators

9

10

—

—

—

—

—

Proton accelerators

3

3

—

—

—

—

—

33

82

73

39

25

13

13

X-ray units

Reactors and critical fissile materials(total excluding Chernobyl accident)
Criticality

16

42

42

30

20

10

10

Reactors (other than criticality)

17

40

31

9

5

3

3

Mayak Production Association(1949–1956) with LRI

168 c

168

—

—

—

—

—

Nuclear submarine

4

133

85

29

19

12

12

Others

12

17

7

3

2

2

2

Total excluding Chernobyl accident

348 c

613

214

98

57

33

43

1

134

134

93

43

21

28

349 c

747

348

191

100

54

71

Chernobyl accident
Total

a Acute radiation syndrome (ARS) and local radiation injuries (LRI).
b ARS severity grades: I – mild, II – moderate, III – severe, IV – extremely severe.
c Each LRI case at Mayak Production Association (1949–1956) is considered as a separate accident.

Year

Accidents at nuclear facilities: Related to nuclear weapons programmes
Location

Operation/
installation

20

Table 2A.

Early

Main cause of accident
DeathsNature of exposure/health consequences

Ref.

Effects

Criticality accidents
United States:
Los Alamos, New
MexicoNuclear researchfacility

Unsafe procedure; during a critical assembly
experiment, a scientist’s hand slipped, allowing atungsten carbide brick to fall into the assembly11Experimenter received 5.1 Gy whole-body dose and died 28 days after
exposure; a guard received 0.5 Gy

[L1]

1946

United States:
Los Alamos, New
MexicoNuclear researchfacility

Unsafe procedure; a critical assembly reflected byberyllium was being demonstrated; the reflector
slipped, allowing a criticality excursion

1

6

Man performing demonstration died nine days after exposure of 21 Gy;seven others had doses of between 0.37 and 3.6 Gy

[L1]

1952

United States:
Argonne,Illinois

Nuclear researchfacility

Failure to follow operating procedure during
replacement of control rod

3

Radiation doses to four workers were 1.36, 1.27, 0.6 and 0.09 Gy

[L1]

1953

USSR:
Chelyabinsk

Nuclear research andreprocessing facility

Poor design; unfavourable geometry used for
mixing, dilution, storage, etc. of plutonium nitrate
products

2

Chief operator received 10 Gy non-uniform whole-body exposure withmaximum dose of 30 Gy to legs; survived moderate ARS, and both legs
were amputated; another worker survived moderate ARS (1.5–2.0 Gy)[G5, L1, V1]

1957

USSR:
Chelyabinsk a

Nuclear research andreprocessing facility

Poor design; accumulation of uranyl oxalate inunsafe geometry

1

5

Operator exposed for approximately 10 minutes, dose estimate was morethan 10 Gy, died 12 days after exposure; five others had ARS (2.0–6.0 Gy)
but recovered[G5, L1, V1]

1958

USSR:
Chelyabinsk

Nuclear research andreprocessing facility

Unsafe geometry during draining of uranium solution; neutron reflector contributed to criticality

3

1

Three workers died in 5–6 days; doses estimated at 40–50 Gy; a fourth
person was approximately 3 m away and survived, with continuing healthproblems and loss of eyesight[B11, G5,
K2, L1, V1]

1958

United States:
Oak Ridge,
Tennessee

Nuclear processing
facility

Valve leakage led to an unplanned transfer ofenriched uranium solution to a 55-gallon (208 L)
drum. Unsafe geometry resulted in a criticality

8

Doses of the eight injured ranged from 0.7 to 3.65 Gy; all survived

[A1]

1958

United States:
Los Alamos, New
MexicoNuclear researchfacility

Unsafe geometry occurred when plutonium solids
were washed from two vessels into one

1

Operator died 36 hours after the accident; dose to upper torso wasestimated to be 120 Gy; two others had whole-body doses of 1.34 and0.53 Gy but no ill effects

[L1]

1961

United States:
Idaho Falls, Idaho

Reactor researchfacility

Evidence suggests control rod was manually pulled
out too fast, causing power rise3
(trauma)

Two men were killed instantly from a steam explosion; a third man died
two hours later as a result of head injury

[L1]

1961

USSR:
Seversk, Siberia

Chemical processing
facility

Criticality controls were not in place during condensing and evaporation of uranium hexafluoride

1

Process operator received a dose of about 2 Gy, with mild radiation­sickness symptoms[L1, V1]

1962

United States:
Hanford,
Washington

Processing facility

Improper control of solutions led to unfavourable
geometry1

One person received 1.1 Gy

[L1]

1963

USSR:
Arzamas,
Sarov

Nuclear weapons
research facility

Violation of operating procedures

2

Two operators received doses of 3.7 and 5.5 Gy; both developed radiation
sickness but survived; four others working in adjacent areas received low
doses (0.07–0.0002 Gy)[L1]UNSCEAR 2008 REPORT: VOLUME II

1945

Year

Location

Operation/
installation

Main cause of accident

Early

Nature of exposure/health consequences

Deaths

Effects2

United States:
Wood River Junction, Rhode Island

Chemical processing
facility

Human factors; labelled bottle indicated highc­ oncentration of U; contents were transferred tovessel and unsafe geometry resulted

1

1968

USSR:
Chelyabinsk-70

Reactor

Violation of procedures; failure to reposition areflector

2

1968

USSR:
Chelyabinsk-40

Plutonium extraction
facility

Inadequate design leading to unfavourable­geometry of plutonium solution

1

1978

USSR:
Siberia

Plutonium processing
facility

Unfavourable geometry of plutonium ingots during
packaging; deficient box design

1997

RussianFederation:
Sarov

Nuclear weapons
research facility

Criticality; experimenter violated safety
requirements

Radiation dose to the operator was estimated to be 100 Gy; he died 49
hours after the accident; two individuals who entered the room received
doses of 1 and 0.6 Gy[K1, L1]

One technician received 20–40 Gy from gamma and neutron exposuresand died three days later; a second technician received 5–10 Gy and died
54 days after the excursion

[L1]

1

Shift supervisor died on day 34 after receiving whole-body dose of morethan 7 Gy and 50 Gy to the legs; the operator survived moderate ARS andsubsequently had both legs and one arm amputated[V1, V4]

1

Operator received approximately 2.5 Gy whole-body dose and 70 Gy
to the hands, he survived moderate ARS, but with amputation of both
hands; seven others received doses of between 0.05 and 0.6 Gy[B11, L1,V1]

45 Gy neutrons and 3.5 Gy gamma whole-body dose; death in 66.5 hours[I5, L1]

External gamma and beta exposure causing local and/or ARS injury

[S2]
[S2]

1

Other accidents with only on-site consequences
1951

USSR:
Chelyabinsk-40

Nuclear research andreprocessing facility

Unknown

1

1952

USSR:
Chelyabinsk-40

Nuclear research andreprocessing facility

Unknown

2

Internal contamination with tritiated water

1954

USSR:
Arzamas, Sarov

Nuclear weapons
facility

Unknown

1

210

1976

United States:
Hanford,
Washington

Research processing
facility

Chemical explosion in glovebox

1986

United States:
Gore, Oklahoma b

Uranium processing
facility

Accidental rupture of a 14 ton (1 270 kg) cylinderof UF6

1(trauma)4

Po internal exposure; ARS

[S2]

1

Worker injured by glass, nitric acid and intake of 241Am; 8.6 Gy dose tobone marrow; death 11 years later of cardiovascular disease

[H2]

7

Internal contamination of workers as well as low-level internal contamination of seven members of the public[N3]

Accidents with releases to the environment and potential public health consequences
Year

Location

Operation/
installation

Main cause and nature of accident

Ref.

1957

USSR: Mayak Complex, Kyshtym aRadiochemical plant

Overheating and resulting explosion of a storage tank led to release of 740 PBq of radioactive products

1957

United Kingdom: Windscale,
Cumbria

Graphite reactor

Overheating and fire resulted in release of 740 TBq

1986

United States: Gore, Oklahoma b

Uranium processing facility

Accidental rupture of a 14-ton (1 270 kg) UF 6 cylinder resulting in a trauma death as well as low-level contamination of sevenmembers of the public and of the environment

[N3]

1993

Russian Federation: Tomsk, Siberia

Reprocessing facility

Largest occupational group exposed were 1 920 persons involved in clean-up; build-up of gases in vessel followed by explosive
rupture and explosion of flammable cloud[I19]

I; other radionuclides also released

131

[U6]
[C2, G4,
U6, U9]21

a This accident is listed twice in this table under two categories: Criticality accidents and Accidents with releases to the environment and potentially significant population exposures.
b This accident is listed twice in this table under two categories: Other accidents with only on-site consequences, and Accidents with releases to the environment and potentially significant population exposures.

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

1964

Ref.

Year

Accidents at nuclear facilities: Not related to nuclear weapons programmes
Location

Operation/
installation

22

Table 2B.

Early

Main cause of accident
DeathsNature of exposure/health consequences

Ref.

Effects

Criticality accidents
Yugoslavia:
Vinca

Zero power reactor

Equipment failure (controls) caused nuclear
excursion

1965

Belgium:
Mol

Experimental reactor

1971

USSR:
Moscow1971

1

5

Five individuals recovered from severe cases of radiation sickness;radiation doses ranged from 2.07 to 4.36 Gy[L1, M4]

Failure to follow safety procedures, resulting in
criticality excursion

1

Technician received non-uniform exposure of 3–40 Gy, with highest
exposure to left foot; medical therapy was successful but left footrequired amputation[J3, L1, P2]

Power reactor researchfacility

Violation of operating procedures; control rods not
actuated when water was added to tank containing
fuel rods3

Three persons received whole-body doses of about 3 Gy; two of themalso received doses of about 20 Gy to the legs

[L1, V4]

USSR:
Moscow

Power reactor researchfacility

Faulty construction of the fuel assembly in the reactor; fuel rods fell into highly supercritical geometry2

2Technician received approximately 60 Gy and died in five days;s­ upervisor received 20 Gy and died within 15 days; two others received
7–8 Gy and survived with long-term health effects[L1, S2]

1983

Argentina:
Buenos Aires

Critical facility

Failure to follow procedures in removing water fromtank containing fissile material

1

Acute whole-body dose (17 Gy neutron and 20 Gy gamma); death twodays after the accident from ARS (neurological) with radiopneumonitis
in right lung

[L1, N1]

1999

Japan:
Tokai-mura a

Fuel conversion plant

Workers unknowingly added higher enriched uranium into a tank bypassing criticality controls2

Two fatalities (uneven exposures of 10–20 Gy Eq and 6–10 Gy Eq) and
one person with whole-body dose of 1.2 to 5.5 Gy Eq[A2, I6]

1

Other accidents with only on-site consequences
1977

Argentina:
Atucha1985

Czechoslovakia:
Petrvald

1989

Hungary:
Paks

Nuclear power plant

Nuclear power plant

Worker not wearing lead gloves

1

Wound contaminated with 3 800 Bq; mean beta dose of 364 Gy inperiod 1977–1985 and annual gamma dose of 0.04 Gy in 1 cm 3 of soft
tissue[U3]

Carelessness and inadequate equipment for workwith transuranics

1

Intake through wound of 600 Bq of 241Am; surgical excision of wound
and administration of DTPA

[U3]

Careless handling of detectors from reactor vessel

1

Whole-body dose of 29 mGy; 1 Gy to fingers of left hand; slight increasein chromosomal aberrations[U3]

Accidents with releases to the environment and potentially significant population exposures
Year

1979

Location

United States:
Three Mile Island,
Pennsylvania

Operation/
installation
Nuclear power plant

Early
DeathsMain cause and nature of accident

Ref.

Effects
Low water levels in reactor led to severe damage to fuel elements; 550 GBq 131I released to the atmosphere.
Limited evacuation of local population[U6, U9]UNSCEAR 2008 REPORT: VOLUME II

1958

Year

Location

Operation/
installation

Early

Main cause of accident
DeathsNature of exposure/health consequences

Ref.

Effects

1986

USSR: Chernobyl

Nuclear power plant

28 radiationinduced,
2 trauma106

Breach of operating rules and violation of safety procedures, combined with a flawed design resulted in a steame­ xplosion, fire and destruction of the reactor. Whole-body doses of 1–16 Gy and localized doses to skin among
plant staff and emergency personnel; 30 deaths; 106 others with ARS; medical treatment, including bone marrowtransplants (101 others initially examined for ARS). Significant release of radionuclides into the environment (including
1 760 PBq of 131I and 86 PBq of 137Cs). Major evacuation and relocation of populations in the area. See annex D, “Healtheffects due to radiation from the Chernobyl accident” for more details

[U7]

1999

Japan:
Tokai-mura a

Fuel conversion plant2

1

Overfilling of tank led to criticality, neutron and gamma irradiation of people in the vicinity of the facility, and a verysmall release of fission products into the air. Limited evacuation of local population[A2, I6]

a This accident is listed twice in this table under two categories: Criticality accidents and Accidents with releases to the environment and potentially significant population exposures.

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS
23

Accidents at industrial facilities

Year

Location

24

Table 3.

Industrial source/
installation

Early

Main cause of accident
DeathsNature of exposure/health consequences

Ref.

Effects

Sealed radioactive sources
Worker carried a 0.5 TBq source in pocket for 18
hours

1

Whole-body dose of 0.5 Gy; maximum dose to thigh of 17 000 Gy;
both legs amputated[B6, B16]

192

Ir source

Worker picked up a source that had fallen off acamera and kept it in his pocket for two hours

1

Skin dose of 130 Gy; ulcer took one year to heal

[A3]

Germany192

Ir source

Worker carried source in jacket pocket

1

Whole-body dose of 1 Gy; maximum dose to pelvis and thigh of
40–60 Gy

[S4]

1969

United Kingdom:
Scotland192

Ir sourceRadiographer travelled with unshielded source

1

Whole-body dose of 0.6 Gy; dose to chest of 20–200 Gy; skin graft
to chest required

[H4]

1972

China:
Sichuan60

Co irradiation facility

Accidental entry into the irradiation room

Unknown

0.5–1.47 Gy whole-body exposure to workers

[P1]

1973

USSR, Moscow
area

4.2 PBq 60Co industrial
sourceOperator entered room while source was in“on” mode1

Operator survived whole-body dose of about 4 Gy

[B11]

1974

United States:
New Jersey

4.4 PBq 60Co industrial
sourceFailure to use survey meter prior to entering­irradiation room1

Non-uniform exposure estimated to be 4.1 Gy

[B2]

1975

Italy:
Brescia60
Co industrial irradiation facility

Lack of safety systems on conveyer entry point

Non-uniform exposure with mean whole-body dose of 12 Gy;­haematopoietic syndrome; death 12 days after exposure[J3, U3]

1975

USSR: Kazan

60

1975

Iraq

1976

Argentina

60

1968

India

1968

1

Co irradiation facility

Deterioration of safety system and improper actions
to regain control

2Whole-body doses of 3 and 5 Gy; dose to hands of 30 Gy and morethan 50 Gy[N10, U3]

192

Ir radiography source

Unknown

1

Whole-body dose of 0.3 Gy plus localized exposure of hand

[U3]

United States:
Pittsburgh,
Pennsylvania

192

Ir radiography source

Unknown

1

Dose of 10 Gy to hand

[U3]

1976

USSR: Moscow
region60

Co irradiation facility

Technical failure of the equipment and improper
entry

1

Whole-body dose of 4 Gy; moderate ARS

[U3]

1977

Czechoslovakia:
Pardubice192

Ir industrial irradiation
sourceTechnical failure of the equipment and improper
actions to bring source back under control

1

Whole-body dose of about 5 mGy; data insufficient for estimating
local doses; bullous dermatitis of the thumb of the right hand; plastic
surgery two years later

[U3]

1977

United States:
Rockaway, New
Jersey60
Co industrial irradiation source of 18.5 PBq

Construction in the facility, lack of safety precautions
and interlock failure

1

Whole-body dose of 2 Gy

[B2]UNSCEAR 2008 REPORT: VOLUME II

Co source

1968

Year

Location

Early

Industrial source/
installation

Main cause of accident

Ir radiography source

Operator working in a confined area held source for
90 seconds while conducting radiography on a weld

1

Equivalent whole-body dose of <0.1 Gy estimated on the basis of
cytogenetic dosimetry; radiation burns on three fingers[U3]

DeathsNature of exposure/health consequences

Ref.

Effects

192

1977

Hungary:Györ

Industrial defectoscope

Failure of equipment to withdraw source into its
container

1

Whole-body dose of 1.2 Gy; slight nausea, changes in blood andincreased frequency of chromosomal aberrations

[U3]

1977

United Kingdom

Filling gaseous tritium
light source

Broken inlet manifold led to the release and escapeof 11–15 TBq of tritium

2

Whole-body doses of 0.62 and 0.64 Gy

[U3]

1977

South Africa:
Sasolburg,
Transvaal

192

Ir source

Faulty operation of pneumatically operated container
and monitor; carelessness of operator

1

Whole-body dose of 1.16 Gy; amputation of two fingers, rib removal
and skin grafts

[U3]

1977

Peru:
Ona del Oleoducto

192

Ir source

Untrained personnel and lack of supervision;­equipment neither registered nor authorized3

Maximum doses of 164 Gy to hands; 0.9 Gy to lens of the eye; 2 Gy to
the whole body; amputation of fingers of two people and effects on
the left hand of another person

[U3]

1978

Argentina:
Buenos Aires

192

Ir industrial source

Manual handling of source

1

Dose of 12–16 Gy, causing radiation burns on two fingers of left hand

[U3]

1978

United States:
Monroe, Louisiana

192

Ir radiography source

Radiography of pipe welds on barge (off-shore
drilling)

1

Localized exposure of hand; amputation of finger

[S1]

1979

Czechoslovakia:
Sokolov

192

Technical failure of the equipment and inadequate
monitoring during and after work

1

Whole-body dose of about 5 mGy; data insufficient for estimating
local doses; bullous dermatitis of the third finger of the left hand andadjacent areas; plastic surgery two years later

[U3]

1979

France:Montpelier

192

Ir radiography source

Unknown

1

Whole-body and localized exposure; amputation of left arm

[U3]

1980

USSR:
Leningrad60

Co irradiation facility

Failure of safety device and improper entry

Whole-body dose of more than 12 Gy

[S2]

1980

China:
Shanghai60

Co irradiation facility

Entry into the irradiation chamber during power
failure and with defective interlocks

1

Whole-body dose of 5.22 Gy and localized exposure[U3, Y1]

1980

USSR

60

Co irradiation facility

Unknown

1

Dose of 50 Gy to lens of eye

[U3]

1981

Argentina:
Buenos Aires

192

Ir industrial source

Source became detached and lodged in the delivery
tube

2

Doses were not specified; radiation burns on fingertips

[U3]

1982

Norway:Kjeller60

Co irradiation facility

Failure of safety device and failure to follow
procedures

Mean whole-body dose estimated to be slightly higher than 20 Gy;
death 13 days after exposure[R1, S3]

1983

United Kingdom

Gamma radiographysourceInadvertent exposure to radiographer

1

Whole-body dose of 0.56 Gy

[U3]

1983

German Democratic Republic:
Schwarze Pumpe

192

Technical defect and inappropriate handling

1

Dose to the right hand of about 5 Gy; acute and chronic radio­
dermatitis (1st degree)[U3]

Ir industrial
radiography

Ir industrial source

1

1

25

United Kingdom

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

1977

Location

Industrial source/
installation

Early

Main cause of accident
DeathsNature of exposure/health consequences

Ref.

Effects

India:
Muland, Bombay

192

Ir radiography
projector

Operation by untrained personnel

1

Dose to the skin of 20 Gy and whole-body dose of 0.6 Gy; severed­ amage to fingers; four were amputated

[U3]

1984

Hungary:
Tiszafured

192

Ir industrial
defectoscope

Failure of equipment and careless handling of source

1

Whole-body dose of 46 mGy; 20–30 Gy estimated to fingers of left
hand; irreversible necrosis at tip of one finger, surgically removed;slight increase in chromosomal aberrations

[U3]

1984

Argentina:
Mendoza

192

Operator pushed source into camera using a finger

1

Dose of 18 Gy to finger (radiation burn on finger) and whole-body doseof 0.11 Gy

[U3]

1985

India:Yamunanager

192

Ir radiography
projector

Violation of safe working practices associated withpower failure in the workplace

2

Doses of 8–20 Gy to hands of both operators; damage to fingers; twofingers amputated from each individual

[U3]

1985

India:
Visakhapatnam

60
Co radiography
projector

Violation of safe working practices and lack ofmaintenance2

Skin dose of 10–20 Gy to operator and 0.18 Gy to an assistant;d­ amage to fingers; one finger amputated

[U3]

1986

China:
Harran60

Co irradiation facility

Power loss occurred and source was ­manuallyraised; workers entered room with source
unshielded2

Doses to workers of 3.5 and 2.6 Gy

[U3]

1986

China:
Beijing60

Co irradiation facility

Workers entered irradiation room when source wasunshielded; failed drive system; door open2

Doses to workers of 0.7 and 0.8 Gy

[U3]

1986

China:
Kaifun City

60

Co source

Accidental exposure for about 1.5–2 minutes

2

Whole-body doses of 2.6–3.5 Gy; haemopoietic type of ARS[W2, Y1]

1987

China:
Zhengzhou City

60

Co irradiation facility

Accidental entry into irradiation room, 10–15
seconds

1

Estimated whole-body dose of 1.35–1.45 Gy; anorexia and nausea
four hours later; severe damage to haemopoietic system with­relatively slow restoration of white blood cells

[Y1]

1988

China:
Liaoning

Radiography source

Workers handled source with hands

6

Local exposure of 0.1–12.6 Gy

[Z2]

1988

Czechoslovakia:
PragueManufacturing of foils
containing 241Am for use
in fire alarms

New rolling methods untested; poor radiation
protection practice1

Inhalation of 50 kBq of dispersed 241Am; hospitalization and administration of DTPA; no clinical manifestations

[U3]

1988

China:
Zhao Xian60

Co irradiation facility

Accidental entry into irradiation room, about 40
seconds

1

Estimated whole-body dose of 5.2 Gy; ARS (bone marrow syndrome);
after three years of follow-up, condition good

[U3]

1989

India:
Hazira Gujarat

192

Ir radiography
projector

Failure of safety management and improper
maintenance1

Dose of 10 Gy to fingers and whole-body dose of 0.65 Gy; radiation
burns on fingers of both hands; fingers amputated

[U3]

1989

South Africa:
Witbank,
Transvaal

192

Ir industrial radiography source

Detached source; negligence of radiographer (source
improperly attached) and failure of portable monitor
to register detached source

3

Whole-body doses to three workers were 0.78, 0.1 and 0.09 Gy;computed effective dose to the most exposed worker was 2.25 Gy;
this worker had amputation of right leg at the hip six months after
exposure and amputation of three fingers one year after exposure

[U3]

1989

China

192

Ir radiography source

Unknown1

Localized dose of 18.37 Gy

[U3]

1989

Bangladesh192

Ir source

Unknown

1

Whole-body dose of 2.3 Gy[U3]UNSCEAR 2008 REPORT: VOLUME II

1983

Ir radiography source

26

Year

Year

Location

Industrial source/
installation

Early

Main cause of accident
DeathsChina:
Beijing60

Co source

Accidental exposure to source for about four minutes

1989

El Salvador:
San Salvador

60

Co irradiation facility

Deterioration of safety system and lack of understanding of radiation hazards

1990

South Africa:
Sasolburg,
Transvaal

60
Co industrial radiography source

Source left behind after radiography work; loss
undetected because of inadequate monitoring;source handled by six people

1990

Israel:Soreq

60

Co irradiation facility

Improper entry and maintenance

1

1990

China:
Shanghai60

Co irradiation facility

Entry into the irradiation chamber during power
failure and with defective interlocks

2

1991

Belarus:Nesvizh60

Co irradiation facility

Improper entry with source exposed

1

1991

United Kingdom

Industrial radiography

Chronic incidents over 14 years

1

1992

China

Irradiation facility

1992

Switzerland

192

1993

United Kingdom

1998

Ref.

2

Whole-body doses of 0.87 and 0.61 Gy; two workers suffered mild
haemopoietic radiation sickness; recovered

[U3]

2

Three workers developed ARS after whole-body doses of 3–8 Gy;
all three had local radiation injuries; one patient had both legs
­amputated; the most seriously irradiated patient had one leg­amputated and died 197 days after exposure

[I1]

6

One individual had right hand amputated above the wrist; three others
had local radiation injuries; whole-body doses were less than 0.55 Gy[U3]

10–20 Gy whole-body dose; death 36 days after exposure; bone­marrow transplant and growth factors administered[I2]

Workers received doses of 2–12 Gy; the two who received 11 and12 Gy died

[L2, P1]

11–18 Gy whole-body dose; death in 113 days; haematopoietic growth
factor administered

[I3]

1

30 Gy to fingers, parts of two fingers amputated; estimated wholebody dose (chronic) of <10 Gy; death from acute myeloid leukaemia[U3]Power loss and safety interlocks out of order4

One worker with ARS[P1]Jammed 700 GBq source; released by hand

1

Erythema of fingers: 3.5–10 Gy[U3]Gamma radiography unit

Improper procedures

1

Overexposure caused erythema and subsequent necrotic ulceration;
hand dose of 30 Gy[U3]China:
HarbinUnknown

Safety equipment failure1

One worker with ARS

[P1]

2000

Brazil:Rio de Janeiro

60
Co industrial gamma
radiography

Exposure during a routine service

1

Serious injuries to left hand

[D1]

2006

Belgium:
Fleurus60

Malfunction of a command/control hydraulic systemand failure of safety system

1

Worker entered an irradiation area and stayed approximately 20
seconds; he developed nausea and vomiting but did not seek medical
attention until he developed massive hair loss; estimated whole-bodydose of 4.4–4.8 Gy

Ir radiography source

Co irradiation facility

1

5

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

1989

Nature of exposure/health consequences
Effects[S9]

Accelerators and X-ray devices
United States:
Lockport, NewYork

Klystron tube
X-irradiation

Shielding not in place during maintenance/repair

7

Non-uniform exposures; two individuals seriously injured, five otherswith less severe injuries

[H5]

1965

United States:
Rockford, Illinois

Accelerator (10 MeV
electrons)

Unknown1

Man received 290 Gy to right ankle, 420 Gy to right hand and 0.05 Gy
whole-body dose; amputations necessary[G2, L3]

1967

United States:
Pittsburgh,
Pennsylvania

Linear accelerator

Failure of safety interlock system

3

One individual with severe radiation syndrome and multiple­amputations; two other individuals had exposures of 3 and 1 Gy

[G2, G3]
27

1960

Location

Industrial source/
installation

Early

Main cause of accident
DeathsNature of exposure/health consequences

Ref.

28

Year

Effects

Germany

X-ray fluorescence unit

Carelessness and technical faults during repair

1

Estimated dose of 30 Gy to the fingers; reddening of two fingers tendays after exposure

[U3]

1975

Germany

X-ray equipment

Carelessness and technical defects

1

Welding seam test; estimated dose of 2 Gy to the stomach region

[U3]

1976

Germany

X-ray equipment

Inexpert handling of equipment

1

Estimated whole-body dose of 1 Gy; reddening of skin after 24 hours
and radiation after-effects

[U3]

1977

Argentina:
La Plata

X-ray crystallography

Shutter removed from crystallography set

3

Dose of 10 Gy to hands of one operator (radiation burns); doses to two
workers not specified

[U3]

1978

France:Nancy

X-ray equipment

Unknown1

Localized exposure of hand; amputation of finger

[U3]

1979

German Democratic Republic:
Freiberg

X-ray fluorescence unit

Violation of safe working practice1

Dose of 10–30 Gy to right hand and whole-body dose of 0.2–0.5 Gy;acute and chronic radiodermatitis (2nd and 3rd degree)

[U3]

1980

German Democratic Republic:
BohlenAnalytical X-ray unit

Violation of safe working practice1

Dose of 15–30 Gy to left hand; acute and chronic radiodermatitis(2nd and 3rd degree)

[U3]

1980

Germany

Radiography

Defective equipment

2

Estimated dose of 23 Gy to the hand and an effective dose of 0.2 Gy

[U3]

1981

Germany

X-ray fluorescencedeviceViolation of safe working practice1

Partial-body exposure with 20–30 Gy dose to the right thumb;­extensive tissue damage developing over several months

[U3]

1983

Germany

X-ray equipment

Defective equipment

1

Partial-body exposure of approximately 6–12 Gy to regions of thebody; localized physical changes

[U3]

1985

China:
ShanghaiAccelerator

Entry into irradiation area while main motor was
running

1

Worker incurred local radiation injury with dose of 25–210 Gy

[Z1]

1991

France:ForbachIrradiation accelerator

Exposure to dark current

3

Severe skin lesions to one worker; less serious injury to two others[C1, U3, Z3]

1991

United States:
Baltimore,
MarylandAccelerator

Exposure to dark current during maintenance1

55 Gy to fingers; most required amputation

[D3]

1992

Italy

X-ray spectrometer

Improper procedure during maintenance1

Acute radiodermatitis of fingers of both hands

[S6]

1993

United Kingdom~160 kV radiography
unit

Improper procedures

1

Erythema of hands leading to necrotic ulceration

[I26]

1994

Mexico:Lazarus Cardenas

X-ray spectrometer

Failure to de-energize device prior to repair

1

Amputation of portion of finger necessitated

[B8]

1995

Brazil

X-ray diffraction unit

Poor maintenance of device allowing open backwindow

3

Acute radiodermatitis of hands caused by low-energy X‑rays

[V3]

1999

United States

Electron beam device

Residual beam exposed operator’s hand during
manufacture testing

1

Skin dose to hand estimated to be 50 Gy[M1]

UNSCEAR 2008 REPORT: VOLUME II

1975

Table 4.

Accidents involving orphan sources

Year

Location

Operation/
installation

1960

USSR: Moscow

137

1962

Mexico:Mexico City

1963

Cs source

Early

Main cause of accident
Deaths1

60

Co source(0.2 TBq)

Unsecured source removed from site

4

China:
Hefei City, Sanli’an

60
Co source(0.43 TBq)

Abandoned source taken to farmer’s home

2

1971

Japan:
Chiba

192

Ir source

1973

Mexico:Tula, Hidalgo

137

Cs source

1975

USSR:
Sverdlovsk

60
Co medical source(17 TBq)

1977

South Africa

192

Ir source

1978

China:
Herran137

1978

Algeria

1979

Ref.

Effects[D2]

1

Family died as a result of exposure. The 10-year-old boy had a protracted(four months) exposure of 47 Gy; the 3-year-old child received a dose of
28.7 Gy, the 27-year-old pregnant mother 35 Gy and the 57-year-old grandmother 30 Gy; the father’s exposure over approximately seven months was
120 Gy and he survived

[M6]

4

Farmer’s dose was 80 Gy; source was in his pocket for approximately 52
hours; his 7-year-old brother had the source in his pocket for 18 hours,
receiving a dose of 40 Gy; both failed to respond to medical treatment; theother four people exposed had doses of 8, 6, 4 and 2 Gy and survived[P1, W2]

Lost source picked up by worker

6

Three patients had minimal blood changes and were hospitalized for twomonths; three others had ARS and local radiation injuries[H3]

Source fell out of its container in truck and was
picked up and put in pocket

1

One person suffered injury to hand, thigh and buttock, leading to amputation of left leg and one finger; estimated local dose to thigh of 1 386 Gy

[N5]

2

Driver died from very severe ARS (7 Gy) on day 33; two others (about 3 Gy)
survived moderate ARS[B11, S2]

Source picked up from factory floor and taken home

1

Burns of hands and chest; skin graft on chest required; whole-body dose of
1.1 Gy; maximum skin dose of 50–100 Gy; three individuals with low-level
symptoms[L5]

Cs source

Unused source was taken to worker’s home29

Doses of 0.01–0.53 Gy to bone marrow of individuals

[U3]

192

Ir radiographysourceSource fell out of truck and was picked up

6

One fatality (member of public); source found by boys aged 3 and 7 years;
one foetus also aborted[J2]

United States:
Los Angeles,
California

Lost 192Ir radiography source

Failure of radiographer to check source storage

5

Individual who carried source in hip pocket developed severe lesion to theright buttock from a dose at the skin surface of 800–4 000 Gy; whole-bodydose was 0.75–1 Gy; four individuals had minor skin injuries; 11 persons
were involved

[R2]

1980

USSR:
Yuzhno-Sakhalinsk

192

Ir radiographysourceTaken from improper storage by 2 children for play;
one put it in jacket pocket

1

1First boy received more than 15 Gy to the hands, and two spots on abdomen received more than 20 Gy; he died after 3 months from poor liverfunction; second boy received 8 Gy to the hand, and developed not severe
local radiation injury

[N11]

1982

China:
Hanzhong

60

Co source

Source was stolen

Not specified

Doses ranged from 0.42 to 3 Gy

[W1]

Source fell unnoticed during transport for burial

1

1

29

Whole-body dose of 14.8 Gy; maximum dose to several points of skin of
1 650 Gy; death on day 18

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

Person deliberately placed source in belt of trousers
and around body for suicide

Nature of exposure/health consequencesLocation

Operation/
installation

Main cause of accident

Cs military source

Two abandoned sources circulated among soldiers

Co medical source

Abandoned device containing the source wasdismantled by hospital patients; a man found thesource and took it home; on the next day, 11 otherpeople touched it

Early

Nature of exposure/health consequences

Ref.

Deaths

Effects

5

17

Five of the most exposed had very severe radiation injury to one or boththighs and lower abdomen (doses from 500 to 900 Gy); one died on day 26,
three others in spite of treatment within 3-4 months; the fifth died after ayear. Seventeen people developed local radiation injuries

[N11]

13

A patient who dismantled the device and the man discovering the source
received whole-body doses of 2 Gy and 6 Gy, and doses to the hands of
30 Gy and 700 Gy respectively. Both hands of the latter person were amputated. Eleven other people developed local radiation injuries to the hands

[N11]

2

ARS and local injuries

[S2]

10

Source contained 60Co in tiny pellets of 2.77 GBq each; total activity was
16.6 TBq[B3]

USSR: Azerbaijan

137

1982

USSR:
Turkmenistan

60

1982

USSR: Ukraine

137

1983

Mexico:Ciudad Juarez

60
Co teletherapy
sourceDevice disassembled and sold to a scrapyard; lackof control

1984

Morocco192

Ir radiographysource (603 GBq)

Source was taken home, kept in family bedroom
and discovered after 80 days

8

3

Protracted exposures resulted in deaths of four adults and four children(ages 4, 5, 7 and 8)[M2, M5]

1985

China:
Mudanjiang

137

Cs source

370 GBq source was found and taken home12

Accumulated local doses were 8–10 Gy; one person died after 22 months

[Y1]

1987

Brazil:Goiânia137

Cs radiotherapy
deviceAbandoned device containing caesium source,disassembled

4129

21 persons had doses in excess of 1.0 Gy (up to 7 Gy); 50 persons wereadmitted to hospital or primary care units; 79 persons received dispensarycare. ARS, skin injuries and internal contamination were problems. Local
environmental contamination occurred[I11, I12]

1988–
1991

USSR:
Ukraine137

Cs source(2.6 TBq)

Source found embedded in bedroom wall

2

1

Chronic exposure. Young boy had radiation injury of foot skin witht­ ransformation into sarcoma, and died; his 9-year-old brother had radiation
injury of the foot and bone marrow depression with transformation into
leukaemia, and died; a third person incurred mild chronic skin radiation
injury and survived[M2, S2]

1992

China:
Xinzhou

Former 60Co irradiation facility

Farmer working on the site demolishing the facility
picked up source; it went with him to the hospital3

11

14 persons were exposed to doses of >0.25 Gy; three received doses of>8 Gy and died

[P1]

1993–
1998

Turkey:Istanbul

Two 60Co medical
therapy sources

Poor source security

18

Five persons with ARS (up to 3 Gy), one with lesions on one hand

[I7]

1994

Estonia:
Tammiku

1.6 TBq 137Cs sourcefrom part of an
irradiator

Theft of source and poor source security

1

5

Whole-body exposure of up to 4 Gy, variety of localized exposures of up to
1 800 Gy

[I13]

1995

RussianFederation

137

Cs source(48 GBq)

Unshielded source in truck for approximately fivemonths1

Source located in door pocket of truck; protracted dose of 7.9 Gy(­whole-body); local dose of approximately 65 Gy; death at 22 months
after discovery[B7, S7]

1995

France192

Ir gamma radiography source

Direct handling of 1 TBq source

Erythema of hands; estimated local dose of >30 Gy[U3]

Cs source

2

1

UNSCEAR 2008 REPORT: VOLUME II

1982

30

Year

Year

Location

Operation/
installation

Early

Main cause of accident
DeathsNature of exposure/health consequences

Ref.

Effects

France137

Cs density gaugesourceUnknown1

Erythema of hands

[U3]

1996

Islamic Republicof Iran: Gilan

192

Ir radiographysourcePoor procedures; failure of lock on radiography
container

1

Labourer found source and put it in breast pocket; 2–4 Gy whole-body dose,
40 Gy to chest

[I21]

1996–
1997

Georgia:
Lilo137

Cs training
sources, 60Co
source and sighting
devices

Abandoned sources at a military training centre

11

12 sources (137Cs) were found; later 200 discarded sighting devices (226Ra)
were found; local injuries and some individuals with systemic effects

[I20]

1999

China:
Henan60

Co “ex-service”
therapy source

Source found in residence of farmer

7

Seven persons received high doses (1.0–6.0 Gy)

[X1]

1999

Peru:
Yanango1.37 TBq 192Ir source

Welder found industrial radiation source2

Source found and placed in trouser pocket; severe exposure to right thigh,perineum and hip led to amputation, colostomy; welder’s wife received
local injury while sitting on trousers containing source

[I8]

2000

Thailand:Samut Prakarn

60
Co radiotherapy
sources

Poor source security leading to three old therapy
units ending up in scrapyard

3

7

Ten persons were hospitalized; three died

[I9]

2000

Egypt:
Meet Halfa

192

Ir radiographysourceSource lost by worker testing pipe welds was foundby farmer

2

5

Abandoned source was taken home by farmer; he died 40 days later; hisson died after 30 days of exposure. Dose estimates were: father 7.5–8 Gy;
son 5–6 Gy; and five others 3.5–4 Gy[E1, I10]

2000

RussianFederation:
Samara Oblast

192

Ir radiographysourceInsufficient safety training of radiographers

3

Three radiographers received whole-body doses of 1–3 Gy; one of them had
hand burns due to localized doses of 30–70 Gy

[S8]

2001

Georgia:
Lia

90
Sr radioisotope
thermoelectric
generator

Two abandoned sources3

Woodsmen found thermally hot objects and used them as heaters. They
suffered systemic effects; two developed severe local injuries[I23, J1]

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

1995

31

Year

Accidents at academic and research facilities
Location

Operation/
installation

32

Table 5.

Early

Main cause of accident
DeathsNature of exposure/health consequences

Ref.

Effects

Sealed radioactive sources
Co source

1

Graduate student exposed to 7 TBq 60Co whole-body dose of 2.5–3 Gy;
maximum skin dose of 30 Gy[R3]Violation of safe working practices, improper entry
to irradiation room

1

Whole-body dose of 2.5-3.0 Gy and 12 Gy to the hand[G5]

Co irradiation

Equipment malfunction and operational error

1Technician was in front of unshielded source for approximately 40 seconds;
whole-body dose of <2 Gy, dose to hand of 12 Gy[V2]Sweden:Nykoping

Research reactor

Instructions for work not followed

1

Dose of 30 Gy to skin of hand; radiation burn to skin

[U3]

1979

Germany:
Rossendorf

Research reactor

Neutron activation of a sample grossly
underestimated1

Dose of 20–30 Gy to right hand; acute and chronic radiodermatitis(2nd and 3rd degree) and oedema

[U3]

1980

Germany:
Rossendorf

Radiochemicallaboratory

Defect in protective glove led to contamination with
32
P

1

Dose of 100 Gy to skin of left hand; no clinical symptoms

[U3]

1983

GermanDemocratic
Republic:
Leipzig

Radiochemicallaboratory

Explosion of vial containing 241Am solution

1

Committed effective dose of 0.076 Gy[U3]

United States

60

1962

USSR:
Moscow

60
Co source(1.9 PBq)

1971

United States:
Tennessee

60

1978

Accelerators and X-ray devices
1972

UnitedKingdom

X-ray crystallography

Shutter was removed prior to and during servicing

1

Dose to two fingers of 15–20 Gy, resulting in burns

[L4]

1974

United States:
Davis,
California

X-ray diffraction unit

Safety interlock bypassed; failure to note warning
light

2

Localized exposure of hands; one person had serious injuries

[B4]

1975

Germany

X-ray fluorescence unit

Violation of safe working practice1

Dose of 1.2–2 Gy to finger; acute radiodermatitis

[U3]

1977

USSR: Kiev

Proton accelerator(40 MeV)

Violation in beam testing examinations

1

Localized doses to hands of 12–30 Gy[A5, B12]1977

United States:
Berkeley,
California

X-ray

Safety interlock failure1

Loss of two fingers on one hand and one finger on the other hand

[T2, U3]

1978

USSR:
Protvino

Proton accelerator(70 GeV)

Improper entry to adjust sample in beam

1

Beam pierced man’s head; middle ear destroyed, facial nerve injured,­abortive epilepsy developed

[B13]

1978

United States

Accelerator

Unknown1

Localized exposure to abdomen, hands, thighs[U3]

UNSCEAR 2008 REPORT: VOLUME II

Source detached during irradiation of samples

1960

Year

Location

Operation/
installation

Early

Main cause of accident
DeathsNature of exposure/health consequences

Ref.

Effects

USSR:
LeningradElectron accelerator(12.7 MeV)

Improper entry

1

Localized doses to back and chest of more than 20 Gy and 8 Gy
­respectively. Local radiation injury of skin and spinal cord

[A5]

1981

Germany:
BerlinAnalytical X-ray unit

Violation of safe working practice1

Dose of 5 Gy to the left hand; acute radiodermatitis (1st degree)

[U3]

1982

Germany:
BerlinAnalytical X-ray unit

Violation of safe working practice1

Dose of 6–18 Gy to the right forefinger; acute radiodermatitis (2nd degree)

[U3]

1984

Peru:
Lima

X-ray diffraction
equipment

Fault of supervision, deliberate exposure from lackof knowledge of risk; equipment not registered withauthorities

6

Localized doses of 5–40 Gy to fingers; skin burns and blistering leaving
residual scar tissue

[U3]

1988

GermanDemocratic
Republic:
Trustetal

Analytical X-ray unit

Technical defect2

Maximum dose of 4 Gy to the hand of one person; acute radiodermatitis(1st degree) in one person

[U3]

1988

GermanDemocratic
Republic:
Jena

Analytical X-ray unit

Violation of safe working practice1

Dose of 3 Gy to left hand; acute radiodermatitis (1st degree)

[U3]

1992

Vietnam:
Hanoi

Research accelerator

Improper entry to adjust sample in beam

1

Individual unknowingly exposed hands; dose to left hand of 10–25 Gy, toright hand 20–50 Gy; fingers and one hand amputated; whole-body dose
estimated to be 1–2 Gy

[I4]

1994

United States:
Davis,
California

X-ray diffraction
equipment

Bypass of safety interlock to effect repair

1

Exposure of both hands with formation of bullae[B4]

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

1978

33

Accidents associated with the medical use of radiation

Year

Location

Operation/
installation

34

Table 6.

Early

Main cause of accident
DeathsUSSR: Kaluga

X-ray equipment (50 kV)

Poor maintenance

1967

India

60

Co teletherapy

Source gain during transfer

1968

United States:
Wisconsin

Nuclear medicine,1972

China:
Wukan

60

Co radiotherapy

Source fell from holder and was unnoticed
for 16 days; design of device did not meetinternational standards

United States:
Riverside, Ohio60

Co teletherapy

1975

Germany

1975

Argentina:
Tucumán

60

1977

Germany

192

1977

United Kingdom

1979

Ref.

Localized dose to face and head of more than 20 Gy.
Local radiation injury developed into atrophy and scars of face, loss ofleft eye; bone necrosis; death in year 7 of late radiation encephalitis[B14, G5]Skin dose to hand of 80 Gy[B5]Acute whole-body radiation exposure from internal source; patientdied 69 days after the misadministration[B9, M3]28

20 patients and eight workers received doses in the range
0.5–2.45 Gy[W1]

Use of incorrect decay curve, lack of periodic
calibration of output

426

Overexposure of 426 patients; dose rates had been underestimatedby 10–45%[M1]

X-ray equipment

Probable violation of safe working practice inmaintenance1

Dose in excess of 1 Gy to head and upper torso[U3]

Co teletherapy

Failure of source mechanical mechanism

2

Technician and physician both received high doses to fingers; radiation
burns on fingers[U3]

Ir radiography

Defective equipment

1

Estimated dose to hand of about 5 Gy and effective dose of 0.01 mGy;
temporary reddening of fingers[U3]

Laboratory

Accidental contamination of laboratory
workers2

Thyroid dose of 1.7 Gy to one person from a 125I intake of about 1 MBq;a low dose to another person[U3]

Argentina:
Paraná

Diagnostic radiology

Faulty wiring led to emission of X-rays when
the top of the fluoroscope was open

1

Nurse received a whole-body dose of 0.94 Gy; slight bone marrowdepression

[U3]

1981

France:Saintes60
Co radiotherapy
sourceDirect hand contact with 137 TBq 60Co source
during source loading3

Two victims had both hands amputated owing to severe injury causedby exposures estimated at >25 Gy; a third victim had a large portionof his right hand amputated

[N7]

1982

Argentina:
La Plata

X-ray therapy facility

Operator looked through window while changing tubes without recognizing system wasenergized

1

Whole-body dose of 0.12 Gy and dose of 5.8 Gy to lens of eye;c­ ataracts in both eyes

[N2]

1985

United States:
Marietta, Georgia

Therac-25 accelerator

Problem of integration of hardware andsoftware of system

1

Loss of function of one arm and shoulder

[N2]

1985

Canada:Hamilton, Ontario

Therac-25 accelerator

Problem of integration of hardware andsoftware of system

1

Severe burn on hip; patient died of cancer four months after theaccident

[N2]

1985

United Kingdom

Laboratory

Technician cut finger; poor technique

1

Technician cut his finger while wearing a glove contaminated with 125I;
sucked cut finger, which resulted in an intake of about 740 MBq and athyroid dose of 400 Gy[U3]

1974–1976

198

Au

Higher than prescribed dose administered

1

1
1

UNSCEAR 2008 REPORT: VOLUME II

1966

Nature of exposure/health consequences
Effects

Year

Location

Operation/
installation

Main cause of accident

Early
DeathsUnited Kingdom

60

Co radiotherapy

Exposure during source changing

1986

United States:
Tyler, Texas

Therac-25 accelerator

Problem of integration of hardware andsoftware of system

1986

United States:
Tyler, Texas

Therac-25 accelerator

Problem of integration of hardware andsoftware of system

1987

United States:
Yakima, Washington

Therac-25 accelerator

Problem of integration of hardware andsoftware of system; operator error

1987–1988

United States:
Maryland60

Co therapy

1988

Netherlands:
Rotterdam

1990

Ref.

[U3]

1

Loss of function of arm and both lower extremities; skin injuries;p­ eriodic nausea and vomiting; radiation-induced myelitis at C5, C6level of cervical cord; death five months after the accident

[N2]

1

Victim died three weeks after the accident; acute high dose radiation
injury to the right temporal lobe of the brain and brain stem

[N2]

1

90–100 Gy accidentally delivered to chest of patient; the patient
subsequently died of oesophageal carcinoma[N2]

Treatment planning; computer file was not
updated after source change

33

33 patients received whole-brain doses 75% greater than prescribed;
20 patients died either during or after completion of therapy[I24]

Sagittaire accelerator

Leakage of radiation during therapy

1

Severe skin reactions of thorax, head and upper arm; dose estimatedat 10–20 Gy[W3]Spain:
Zaragoza

Linear accelerator

Assumption that meter on control panel wasstuck, although electron energy had been
modified by technician

15

12

27 patients received doses 3–7 times higher than intended; 15
died with radiation exposure as primary cause; others had majordisabilities[I24, S5]

1992

United States:
Indiana, Pennsylvania

Brachytherapy source

Source dislodged; failure to check for source’s
return to shielded holder

1

Source remained in patient for four days; 94 other individuals were
exposed at the clinic, nursing home and other areas[I24, N4]

1994

United States

High-dose-ratebrachytherapy

Treatment planning errors

1

Patient was given a dose of 12 Gy to the vaginal area instead of theprescribed dose

[N6]

1996

Costa Rica:
San José

60

Co teletherapy

Error in calculating dose rate

46

Exposures were significantly higher (50–60%) than prescribed[I14, I24]

1996

Russian Federation,
Moscow

Accelerator accident

Accidental dose rate increase1

Localized dose of more than 100 Gy. Acute, high dose radiation injury
to left part of chest[B11]

Panama:Panama City

60

Co teletherapy

Misuse of treatment planning system

23

Patient doses were doubled; five died of radiation injuries; two deaths
were questionable; nine of 16 survivors had marked or catastrophic
complications[B10, I15]

2001

Russian Federation:
Nizhny Novgorod

X-ray cosmetic therapy

Systematic errors in dose rate calculations

9

Local radiation injuries to facial skin – dry and moist desquamation

[B11]

2001

Poland:Bialystok

Linear accelerator

Power failure causing equipment damage

5

Local radiation injuries were present in five patients; severely injured
patients required surgery and skin grafts

[I22]

2004

France:ÉpinalHospital/therapy

Errors in treatment planning; operator’s
instructions not in language understood

19

23 patients received overdoses (20% more than intended); onepatient died of radiation exposure; three died of severe radiationinduced complications

[A4]

2006

United Kingdom:
Glasgow, Scotland

Linear accelerator

Inexperienced treatment planner

1

Critical error made in data used during treatment delivery; 15-year-old
female was given 58% higher dose than planned

[J5]

2007

United States:
Detroit, Michigan

Gamma knife
radiotherapy

Image reversal on MRI led to wrong side ofbrain being treated1

Small area of normal brain tissue and 7% of lesion treated with 18 Gy
exposure, rather than whole lesion volume being treated

[N9]

17

5

4

35

Dose of 15 Gy to hand; erythema, blistering at two weeks

2000–2001

1

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

1986

Nature of exposure/health consequences
Effects

Summaries of sea, air and space vehicle accidents

Year

Country

Vehicle type36

Table 7.

Accident location

Identifying nameCause and result

Reference

Sea
USSR

Nuclear submarine

North-west Atlantic

K-19

Leakage in heat transfer circuit with fuel overheating; submarine towed to base[B1, I18]

1963

United States

Nuclear submarine

Atlantic (unspecified)ThresherUnknown cause; lost at sea with entire crew

[I18]

1968

USSR

Diesel submarine

Pacific near Hawaii

K-129

Submarine sank carrying two nuclear warheads that were subsequently
recovered[B1, I18]

1968

United States

Nuclear submarine

Atlantic (unspecified)

Scorpion

Unknown cause; lost at sea with entire crew

[I18]

1970

USSR

Nuclear submarine

Bicay Bay

K-8

Fire; rubber seals in hull failed and seawater entered; sank north-west of Spain[B1, I18]

1978

Unspecified

Surface vessel

South-east Barents Sea

Nikel

Lighter carrying encapsulated waste was lost at sea during storm

[I18]

1984

FranceSurface vessel

North Sea

Mont Louis

Collision of vessel and ferry; ship carrying 30 containers of <1% enriched UF 6
sank off Zeebrugge; all containers recovered

[I18]

1985

USSR

Nuclear submarine

Chazma Bay

K-431

Explosive criticality occurred during refuelling; environmental contamination in
Russia resulted[B1, I18]

1986

USSR

Nuclear submarine

North-east Atlantic

K-219

Fire and explosion damaged hull; towed to 6 000 m depth and sunk (Bermuda)[B1, I18]

1989

USSR

Nuclear submarine

Norwegian Sea

K-278

Fire in the stern compartment while submerged; submarine sank

[B1, I18]

1989

USSR

Nuclear submarine

Ara Bay

Unknown member ofNorth Fleet

Unknown problem; largest reported release of radioactive material

[I18]

1997

PanamaSurface vessel

Atlantic, Azores

MSC Carla

Three Type B packages containing 137Cs involved

[I18]

2000

Russian Federation

Nuclear submarine

Barents Sea

Kursk

Cause unknown; two seismic events occurred on the day of the accident; thesubmarine sank with 118 crew members on-board; subsequently, the reactors
on-board were found to be intact

[I18]

Air
1965

United States

AircraftNear Okinawa, Japan

Skyhawk jet

Jet carrying nuclear weapon rolled off aircraft carrier

[I18]

1966

United States

Aircraft

Palomares, Spain

Bomber (B-52)

Aircraft collision during refuelling; four nuclear weapons involved; two recovered
intact, two destroyed on impact with land; significant ongoing plutonium­contamination of the environment resulted

[I18]

1968

United States

AircraftThule, Greenland

Bomber (B-92)

Aircraft crashed; four nuclear weapons destroyed, spreading plutoniumc­ ontamination over large area of marine environment

[I18]

1987

USSR

Aircraft

Sea of Okhotsk

Helicopter emergency resulted in drop of RTG equipped with 90Sr source (12.95–
25.3 PBq) at sea in 30 m of water; attempts to locate it have been unsuccessful

[I18]

1997

Russian Federation

Aircraft

Sea of Okhotsk

Helicopter emergency resulted in disposal of RTG containing 1.3 PBq 90Sr

[I18]

UNSCEAR 2008 REPORT: VOLUME II

1961

Year

Country

Vehicle type

Accident location

Identifying nameCause and result

Reference

Space vehicle
United States

SpacecraftWest Indies Ocean

SNAP-9A Transit-5BN3

Satellite containing 630 TBq of 238Pu failed to achieve orbit and vaporized during
re-entry in the Southern Hemisphere

[I18]

1968

United States

Spacecraft

Santa Barbara, California

Nimbus BI

Spacecraft failed to achieve orbit; two RTGs recovered intact

[I18]

1970

United States

Spacecraft

South Pacific

Apollo 13

Malfunction in oxygen supply led to emergency return to Earth in the lunar­landing module; an RTG on-board re-entered intact and is at a depth of not lessthan 6 000 m in the Tonga Trench

[I18]

1978

USSR

Spacecraft

Northern Canada

Cosmos 954

Research satellite carrying small nuclear reactor re-entered atmosphere andspread radioactive fragments over wide area

[I18]

1983

USSR

Spacecraft

South Atlantic

Cosmos 1402

Satellite failed to boost nuclear reactor into higher orbit after completion of mission; reactor core and fission products re-entered atmosphere east of Brazil

[I18]

1996

United States

Spacecraft

Pacific Ocean

Mars 96

Unsuccessful burn of booster resulted in re-entry into Earth’s atmosphere westof Chile; 18 RTGs onboard with total 238Pu activity of 174 TBq[I18]

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

1964

37

38

UNSCEAR 2008 REPORT: VOLUME IITable 8. Number of accidents resulting in early acute health effects or significant population exposures
Based on published information; excludes malicious acts and nuclear testingType of accident

1945–1965

1966–1986

1987–2007

Accidents at nuclear facilities

19

12

4

Industrial accidents

2

50

28

Orphan source accidents

3

15

16

Accidents in academic/research work

2

16

4

Unknown

18

14

Accidents in medical use aa The IAEA [I25] and ICRP [I24] have reported more than 100 accidents in radiotherapy. This table considers only serious radiation accidents in medicine.

Table 9. Estimated collective doses for a spectrum of accidents increasing population exposure
Not comprehensive, an illustrative selection; excludes malicious acts and nuclear testingYear

Accident

Local and regional collective effective dose (man Sv)
320 000 a

1986

USSR: Chernobyl (see annex D)

1964

SNAP-9A [U6]1957

United Kingdom: Windscale, Cumbria [U6]

2 000

1957

USSR: Mayak Complex, Kyshtym [U6]

1 200

1983

Mexico: Ciudad Juarez [U6]

150

1987

Brazil: Goiânia [U6]

60

1979

United States: Three Mile Island, Pennsylvania [U6]

40

1966

Spain: Palomares [U6]

3

1999

Japan: Tokai-mura<0.6 c1993

Russian Federation: Tomsk, Siberia [I19]0.02 b

a Sum of collective dose estimates for 1986–2005 for evacuees and inhabitants of Belarus, the Russian Federation and Ukraine, and of the rest of Europe (annex D) multipliedby 1.25 to take account of dose yet to be delivered. The 61 000 man Sv received by the recovery workers is not included here.
b Estimated collective dose to the recovery workers was 13.3 man Sv [I19].
c Based on reference [M7].

Table 10.

Numbers of deaths and early acute health effects due to radiation accidents

Based on published information; excludes malicious acts and nuclear testingType of accident
Accidents at nuclear
facilities

1945–1965

1966–1986

42 early effects
13 deaths

Industrial accidents

8 early effects

Orphan source accidents

61 early effects

5 early effects

Accidents in medical use

205 early effects

22 early effects

308 early effects
42 deaths

5 early effects
0 deaths

470 early effects
4 deaths

119 early effects
9 deaths

16 deaths

0 deaths
Unknown

Unknown

51 early effects

98 early effects

2 early effects
0 deaths

167 early effects
50 deaths

6 deaths

19 deaths

Total

2 early effects
3 deaths

3 deaths

7 deaths
Accidents in academic/
research work

123 early effects
34 deaths

0 deaths

1987–200729 early effects
0 deaths

153 early effects
42 deaths

623 early effects
46 deaths

ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

39

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ANNEX C: RADIATION EXPOSURES IN ACCIDENTS

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