The radiological accident at the irradiation facility in Nesvizh

More than 40 years of experience in radiation processing has shown that such technology is generally used safely, and steady improvement in the design of facilities and careful selection and training of operators have contributed to this good safety record. However, some cases of circumvention of safety systems have been registered and it is documented that the consequences of radiological accidents at industrial radiation facilities can be extremely serious. The causes of accidents may have some points in common, but at the same time may be highly specific. A detailed study of these common and specific features seems to be of great importance for further improvements in safety systems. One such event occurred on 26 October 1991 at an industrial sterilization facility in Nesvizh, Belarus, when the operator entered the irradiation chamber and was severely exposed to a lethal dose of radiation. The significant feature of this case was related to the medical management. It should be underlined that some circumstances of the accident only came to light during the post-accident review made by the IAEA. To document the causes and consequences of the accident and to define the lessons learned are of help to those people with responsibility for the safety of such facilities and to those medical authorities who might be involved in the management of a radiation event. 16 refs, figs, tabs, photographs