Today, we’re going to take a little excursion away from the realm of coffee and cold beer. I’m going to share one of the accidents I’ll be discussing with my students tonight. This is partially a matter of my marshaling my thoughts together for them. Ignoring Chernoybl & Fukushima, this remains the worst accident with radioactive materials in history.

NB: Yes, I am well aware that we killed plenty of people with Fat Man & Little Boy and that we have contaminated vast tracts of land with nuclear weapons testing. But one must remember, those were done intentionally. To a first approximation, we knew what we were doing and had taken appropriate precautions. Or, as one notable former Nevada Test Site employee said, “We never made the same mistake twice. Can’t think of many other institutions that can claim that.”

This story all began when a private cancer clinic with a nuclear medicine center shut down in Goiania, Brazil.  By 1987, much of the clinic was demolished but as derelict buildings in increasingly bad parts of town tend to go, it got a bad case of squatters.  Squatters are poor folk looking for any way to scrape by; one of those more popular ways is scavenging.  And what do most people scavenge: Metal.  Just ask your local homeless person with bags full of cans if you doubt me.  Why everything wasn’t gone when they shut down is a good question, but easy to answer: it wasn’t worth the effort.  What could easily be removed and/or be sold had been, what couldn’t they left, like the radiotherapy unit. Add in a side order of legal dispute about who was responsible for the unit and minimal regulatory oversight authority, and there you go.

Two hearty scavenging lads found this thing with lots of steel and aluminum in the clinic and thought they’d hit the jackpot.  The thought was doubly confirmed as they started tearing it apart and found this heavy metal bar with a goldish black window.  It felt much heavier that steel, and judging by the window, wow, that must mean gold.  So, they broke the window.  Within was a bluish glowing powder.  It wasn’t gold but they figured they could still get a couple bucks at the junkyard and that they did.

The owner of the junkyard thought it was beautiful and strange.  He thought it would make a great ring for his wife, Maria, so he set his workmen to task cracking the bar open and getting the pretty blue stuff out.  It was no easy task.  The found that inside the steel sheath was lead shielding containing an ampule filled with this metallic powder.

One yard worker died, the other lost an arm.  Despite taking what would otherwise be considered a very lethal dose, the owner lived.

After the workers got it free, they brought it back to their boss who then took it home.  His six year old daughter thought it was pretty and asked to play with it.  Being a doting father, how could he deny her?

Of all the people exposed in this incident, the daughter took the highest dose as she tended to eat her sandwiches on the same floor where she’d been playing with the source.  When she finally died a month later, she had to be buried in a lead lined concrete coffin.

Being social people, friends and family came over for a good extended family dinner.  The owner showed the blue powder to his brother who thought it was a miracle.  He asked for some, which his brother gave to him.  The brother went home and painted himself with the powder in the shape of cross, much like at Carnival, and then went out to work with the animals.

Everyone at the dinner party trailed contamination home with them and then to their families.  This is how the count of exposed people needing treatment rose to the hundreds.  Needless to say, the brother lost his arm…and all the contaminated livestock were slaughtered.  Luckily, none had gone to market before discovery of the incident.

When people started getting sick all at the same time, at first Maria started to think that she’d served some bad meat or juice.  She asked a local doctor if that made sense.  He said maybe.  Then she realized people who hadn’t been at the party were getting sick.  It occurred to her that it might be the blue stuff.  After the doctor sent her back home, she got progressively sicker.  Her mother moved in to care for her.

Both Maria and her mother died.

By the time Maria had brought the remains of the radiotherapy source to doctor, contaminating the bus she rode on in the process, 90% of the powdered metal had already been lost, spreading contamination through out the community.  According to Brookhaven National Laboratory, who originally made the Cs-137 cesium chloride source in 1971, it had an activity of approximately 1400 curies. Just for reference, the americium-241 source in your smoke detector contains less than 1 microcurie.  This radiotherapy source was, professionally speaking, motherfucking screaming hot.

This is not to say that comparing Cs-137 to Am-241 is apples to apples when discussing activity. At that point it becomes a matter of chemical characteristics and biological/environmental fate to determine exactly how dangerous a given isotope is for a given activity. However, I’ll have you know that this is a brown trousers time so hard your pants shoot across the room quantity of activity of Cs-137 from the safety point of view when there’s a loss of control. From a medical point of view, it was weak enough they probably couldn’t sell it off as a proper radiotherapy source anymore so they abandoned it.

Authorities learned of the loose source about a month after the scavengers first bust it open.  It took several more days for them to follow the trail back to community in Goiania and start getting people medical treatment; a couple more weeks to discover the full horrible extent of the contamination.  Only four people died, 54 people had exposures serious enough to merit hospitalization out of the 249 people found to be contaminated. This is of the 112,000 people that mobbed the public health officials & hospitals fearing they were going to have a horrible Hiroshima worthy death. It was wisely decided to move triage evaluation to the Olympic Stadium so that they could accommodate everyone, but it was still a nightmare processing everyone that was afraid. Several buildings were demolished and the top several feet of soil were removed as a part of the clean up, with an estimated 3500cu.yd. of contaminated material getting buried in a hole somewhere in Brazil.

As yet another a deeply tarnished silver lining, a lot of good health physics lessons were learned at Chernobyl (once international aid was invited to help with containment and cleanup) which, depending on your point of view, were fortunately/unfortunately put to excellent use at here.

I took a different lesson home when I first learned about this accident in detail several years ago: You Cannot Take ANY Knowledge For Granted. The radioactive source from the radiotherapy machine was prominently marked with the radiation trefoil but in this instance (and many, many others) it didn’t register with the victims in question that this denoted a hazard. This caused the IAEA to create a new ionizing radiation hazard symbol, a mishmash of somewhat familiar international symbols in hopes of scaring people off (skull & crossbones for “poison” and running guy with an arrow for “leave”) that has been called cluttered and confusing. My willfully obtuse reading of the new symbol to my old department chair was “Propeller wind causes pirates, go starboard”.

I think the root cause can be laid at a general lack of awareness/education about ionizing radiation. In First World countries, education has been lax though awareness is quite high, not necessarily in a good way as it is rather paranoid and poorly informed. Hell, I have a hard time getting nuclear engineering students to handle their rather benign sealed check sources. When items made in the First World end up lost downstream in the Third, a heavy price gets paid by the most vulnerable and least knowledgeable when control is weak or non-existent. There are dozens of reports of lost radiography sources at mines in the hinterlands all over the world being picked up because they were shiny and looked like silver (and thus valuable), taken home, and injuring the discoverer and/or their families. There are also far too many incidents of scrap yards like this one in Goiania receiving radioactive materials as metal salvage, reselling them and then tossing them into a smelter for recycling.

If I have any good news to share, it’s that the rate of incidents like this has decreased dramatically despite the increased use of materials worldwide. We’re getting better at playing with this particularly special kind of fire.