The Radiological Accident in Goiânia, Brazil. Annex I. Case study that considers the guidance and recommendations provided in this Safety Guide

In 1985 a radiotherapy institute, the Instituto Goiano de Radioterapia in Goiânia, Brazil, moved to new premises. During this process a ¹³⁷Cs teletherapy unit was left in place. The licensing authority, the Brazilian National Nuclear Energy Commission (CNEN), was not notified, even though such a notification was required under the terms of the institute's licence. The former premises of the institute were subsequently partly demolished. As a result, the radioactive source remained in an insecure condition, which subsequently led to the radiological accident (elaborated in detail in INTERNATIONAL ATOMIC ENERGY AGENCY, The Radiological Accident in Goiânia, IAEA, Vienna (1988))