The Radiological Accident in Nueva Aldea - Publications

101 Pages·2009·3.17 MB·English

The Radiological Accident
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This report describes the radiological accident that occurred n
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in Nueva Aldea, Chile, in December 2005, and the response N
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to it by the IAEA under the Convention on Assistance in the ev
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Case of a Nuclear Accident or Radiological Emergency. The ld
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subsequent medical treatment of the workers who were injured
is described in detail. The report will be of interest to, among
others, emergency response planners, medical specialists,
physicists and persons responsible for radiation protection.
INTERNATIONAL ATOMIC ENERGY AGENCY
VIENNA
ISBN 978–92–0–103009–2
P1389_covI-IV.indd 1 2009-09-01 09:29:45
THE RADIOLOGICAL ACCIDENT
IN NUEVA ALDEA
The following States are Members of the International Atomic Energy Agency:
AFGHANISTAN GHANA NIGERIA
ALBANIA GREECE NORWAY
ALGERIA GUATEMALA OMAN
ANGOLA HAITI PAKISTAN
ARGENTINA HOLY SEE PALAU
ARMENIA HONDURAS PANAMA
AUSTRALIA HUNGARY PARAGUAY
AUSTRIA ICELAND PERU
AZERBAIJAN INDIA PHILIPPINES
BAHRAIN INDONESIA POLAND
BANGLADESH IRAN, ISLAMIC REPUBLIC OF PORTUGAL
BELARUS IRAQ QATAR
BELGIUM IRELAND REPUBLIC OF MOLDOVA
BELIZE ISRAEL ROMANIA
BENIN ITALY RUSSIAN FEDERATION
BOLIVIA JAMAICA SAUDI ARABIA
BOSNIA AND HERZEGOVINA JAPAN SENEGAL
BOTSWANA JORDAN SERBIA
BRAZIL KAZAKHSTAN SEYCHELLES
BULGARIA KENYA SIERRA LEONE
BURKINA FASO KOREA, REPUBLIC OF SINGAPORE
BURUNDI KUWAIT SLOVAKIA
CAMEROON KYRGYZSTAN SLOVENIA
CANADA LATVIA SOUTH AFRICA
CENTRAL AFRICAN  LEBANON SPAIN
REPUBLIC LESOTHO SRI LANKA
CHAD LIBERIA SUDAN
CHILE LIBYAN ARAB JAMAHIRIYA SWEDEN
CHINA LIECHTENSTEIN SWITZERLAND
COLOMBIA LITHUANIA SYRIAN ARAB REPUBLIC
CONGO LUXEMBOURG TAJIKISTAN
COSTA RICA MADAGASCAR THAILAND
CÔTE D’IVOIRE MALAWI THE FORMER YUGOSLAV 
CROATIA MALAYSIA REPUBLIC OF MACEDONIA
CUBA MALI TUNISIA
CYPRUS MALTA TURKEY
CZECH REPUBLIC MARSHALL ISLANDS UGANDA
DEMOCRATIC REPUBLIC  MAURITANIA UKRAINE
OF THE CONGO MAURITIUS UNITED ARAB EMIRATES
DENMARK MEXICO UNITED KINGDOM OF 
DOMINICAN REPUBLIC MONACO GREAT BRITAIN AND 
ECUADOR MONGOLIA NORTHERN IRELAND
EGYPT MONTENEGRO UNITED REPUBLIC 
EL SALVADOR MOROCCO OF TANZANIA
ERITREA MOZAMBIQUE UNITED STATES OF AMERICA
ESTONIA MYANMAR URUGUAY
ETHIOPIA NAMIBIA UZBEKISTAN
FINLAND NEPAL VENEZUELA
FRANCE NETHERLANDS VIETNAM
GABON NEW ZEALAND YEMEN
GEORGIA NICARAGUA ZAMBIA
GERMANY NIGER ZIMBABWE
The Agency’s Statute was approved on 23 October 1956 by the Conference on the Statute of
the IAEA held at United Nations Headquarters, New York; it entered into force on 29 July 1957.
The Headquarters of the Agency are situated in Vienna. Its principal objective is “to accelerate and
enlarge the contribution of atomic energy to peace, health and prosperity throughout the world’’.
THE RADIOLOGICAL ACCIDENT
IN NUEVA ALDEA
INTERNATIONAL ATOMIC ENERGY AGENCY
VIENNA, 2009
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© IAEA, 2009
Printed by the IAEA in Austria
September 2009
STI/PUB/1389
IAEA Library Cataloguing in Publication Data
The radiological accident in Nueva Aldea. — Vienna : International
Atomic Energy Agency, 2009.
p. ; 24 cm.
STI/PUB/1389
ISBN 978–92–0–103009–2
Includes bibliographical references.
1. Radiography, Industrial — Accidents — Chile — Concepcion.
2. Radiation — Physiological effect — Chile — Concepcion.
3. Radiation injuries — Case studies. I. International Atomic Energy
Agency.
IAEAL 09–00586
FOREWORD
The use of radioactive material offers a wide range of benefits to
medicine, research and industry throughout the world. Precautions are,
however, necessary to limit the exposure of people to the radiation that is
emitted. Where the amount of radioactive material is substantial, as in the case
of radiotherapy or industrial radiography sources, great care is necessary to
prevent accidents, which could have severe consequences. Nevertheless, in
spite of the precautions taken, serious accidents with involvement of radiation
sources continue to occur, although infrequently. As part of its programme on
emergency preparedness and response, the IAEA conducts follow-up reviews
of such serious accidents, to give an account of their circumstances and
consequences, from which organizations with responsibilities for radiation
protection, safety of sources and emergency preparedness and response may
learn.
A serious radiological accident occurred in Chile, on 14 December 2005,
when at a cellulose plant under construction a radioactive source containing
192Ir fell out of gamma radiography equipment unnoticed, and was later found
and handled by three scaffolding workers. Under the Convention on
Assistance in the Case of a Nuclear Accident or Radiological Emergency, the
Chilean authorities requested assistance from the IAEA in terms of advice on
the dose assessment and medical management of those involved in the
accident.
The IAEA wishes to thank the experts from Argentina, Brazil and France
who went to Santiago as members of the IAEA Assistance Mission and, in
particular, France and its Institut de radioprotection et de sûreté nucléaire and
the Burn Treatment Centre of the Hôpital d’instruction des armées Percy, in
Paris, for treatment of the most exposed victim.
The IAEA is grateful to the Government of Chile for the opportunity to
report on this accident in order to disseminate the valuable lessons learned. In
particular, the IAEA wishes to express its gratitude to the Chilean Nuclear
Energy Commission and Mutual de Seguridad de la Cámara Chilena de la
Construcción (C.Ch.C.) for their assistance in the preparation of this report.
The IAEA officers responsible for the preparation of this publication
were E. Buglova and R. Martinčič of the IAEA’s Incident and Emergency
Centre.
EDITORIAL NOTE
This report is based on information made available to the IAEA by or through the
authorities of Chile. Neither the IAEA nor its Member States assume any responsibility
for consequences, which may arise from its use.
The report does not address questions of responsibility, legal or otherwise, for acts
or omissions on the part of any person.
The use of particular designations of countries or territories does not imply any
judgement by the publisher, the IAEA, as to the legal status of such countries or territories,
of their authorities and institutions or of the delimitation of their boundaries.
The mention of names of specific companies or products (whether or not indicated
as registered) does not imply any intention to infringe proprietary rights, nor should it be
construed as an endorsement or recommendation on the part of the IAEA.
CONTENTS
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2. Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.3. Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.4. Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. BACKGROUND INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.1. Regulatory infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.2. The device and source involved in the accident . . . . . . . . . . . . . 7
3. THE ACCIDENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3.1. Description of the accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3.2. Recovery of the source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
4. THE RESPONSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4.1. Response at the national level . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4.2. Involvement of the IAEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
5. RADIOLOGICAL CONSIDERATIONS . . . . . . . . . . . . . . . . . . . . . 23
5.1. Initial dose assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
5.1.1. The results of the Chilean experts . . . . . . . . . . . . . . . . . . 26
5.1.2. The results of the international experts . . . . . . . . . . . . . 30
5.1.2.1. The results for worker A . . . . . . . . . . . . . . . . . 30
5.1.2.2. The results for workers B and C . . . . . . . . . . . 31
5.1.2.3. The results for radiography workers D, E, F,
H and manager I . . . . . . . . . . . . . . . . . . . . . . . . 32
5.1.2.4. The results for other possibly exposed
persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5.2. Biodosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
5.2.1. Workers A, B and C and radiography workers . . . . . . . 34
5.2.1.1. Initial dose evaluation . . . . . . . . . . . . . . . . . . . 34
5.2.1.2. Final dose evaluation . . . . . . . . . . . . . . . . . . . . 36
5.2.1.3. Biodosimetry performed in France . . . . . . . . . 37
5.2.2. Other individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
5.2.3. Dose comparisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
6. RADIOPATHOLOGICAL CONSIDERATIONS . . . . . . . . . . . . . . 43
6.1. Clinical signs of exposure and treatment . . . . . . . . . . . . . . . . . . 43
6.1.1. Worker B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
6.1.2. Worker C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
6.1.3. Radiography assistant E . . . . . . . . . . . . . . . . . . . . . . . . . . 49
7. INITIAL MEDICAL MANAGEMENT OF WORKER A 
IN CHILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
8. MEDICAL MANAGEMENT OF WORKER A IN FRANCE
(DECEMBER 2005–MAY 2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
8.1. Medical management of the buttock lesion . . . . . . . . . . . . . . . . 56
8.1.1. Dose estimation (calculations using a voxel
anthropomorphic phantom) . . . . . . . . . . . . . . . . . . . . . . 56
8.1.2. Innovative therapeutic strategy . . . . . . . . . . . . . . . . . . . . 56
8.1.3. Autologous MSC production . . . . . . . . . . . . . . . . . . . . . . 58
8.1.4. Dosimetry guided surgery . . . . . . . . . . . . . . . . . . . . . . . . 60
8.1.5. Histology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
8.1.6. Autologous MSC injection . . . . . . . . . . . . . . . . . . . . . . . . 62
8.1.7. Clinical evolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
8.1.8. Medical management of the left hand lesions . . . . . . . . 64
8.2. Medical management of the oral mucositis . . . . . . . . . . . . . . . . 64
8.2.1. Dose estimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
8.2.2. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
9. FOLLOW-UP OF WORKER A IN CHILE 
(MAY 2006–OCTOBER 2007) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
10. MEDICAL MANAGEMENT OF WORKER A IN FRANCE
(OCTOBER 2007–JANUARY 2008) . . . . . . . . . . . . . . . . . . . . . . . . . . 69
11. FOLLOW-UP OF WORKER A IN CHILE
FROM FEBRUARY 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
12. FINDINGS AND CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 70
13. LESSONS TO BE LEARNED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
13.1. Operating organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
13.2. National authorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
13.3. International cooperation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
13.4. Medical community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
APPENDIX: CHILEAN REGULATIONS, AND SAFETY AND
RADIOLOGICAL NORMS . . . . . . . . . . . . . . . . . . . . . . . . . 79
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
CONTRIBUTORS TO DRAFTING AND REVIEW. . . . . . . . . . . . . . . . 87