Irradiation Radiation

The consequences of improper training can many times lead to serious injuries and death. This was the case on February 5, 1989. Three employees were exposed to radiation at a cobalt-60 irradiation facility in San Salvador, El Salvador. All three employees received no formal training in radiation safety, and in result, led to one fatality and radiation poisoning and serious burns on the other two employees. The accident was reported four days later, due to the employees being diagnosed with food poisoning rather than radiation poisoning.

DelMed Company owned the facility, where they used cobalt-60 to sterilize medical supplies such as intravenous solutions and blood dispersion sets. The factory was built in 1974 and commissioned in 1975. Inside the irradiation chamber the packages are sterilized by a Model JS6300 Gamma Sterilizer, which was manufactured and installed by Atomic Energy of Canada, Ltd. The packages to be sterilized are loaded into large product boxes and moved by pistons around a centrally located, vertical rectangular source rack. The source rack contains cobalt-60 in the form of rods. The source is shielded when not in use by lowering the source into a pool of water. Cobalt-60 is a powerful, synthetic radioactive isotope used in gamma radiation. It has a half-life of 5.4 years, which means it takes almost five and a half years for it to decay to half of its original strength. One gram of cobalt-60 is equal to about 1,100 curies, or 15,950 R/hr. Cobalt-60 is well known for its penetrating gamma rays.

The incident occurred when a worker responded to a malfunction inside the irradiation chamber. The source was automatically lowered to the shielded position due to problems caused by power failures and piston malfunction...

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...o send anyone to the facility because the corruption of the country could jeopardize the personal safety of employee. Furthermore, the facility received instructions pertaining to upgraded safety, however, were not implemented by the facility.

At the time of the incident, there was no agency or regulations governing the use of gamma radiation. The lack of regulatory control and the loss of contact with experts in radiation matters led to a decline in standards of radiation safety. The removal of the fixed radiation safety alarm several years prior to the incident contributed to the incident, as well. Had they been replaced, along with the expertise of a well trained operator, the incident could have been avoided. In fact, the facility had experienced a similar situation in 1975. It was dealt with in a proper manner by operators that had been trained by the supplier.