A Brief History of: The Soreq Radiation Accident 1990 (Documentary) 

Would you consider a vocal appearance on my show?

How about the Carrington event? It's probably not what you meant, but I think you could make an interesting video of it

Nope. There are things that you might take chances with and things that you definitely shouldn't - radiation is one thing that you shouldn't.

Nope. Just nope.

Castle Bravo and the unexpected amount of fallout?

Yeah, for some reason people always assume that the most dangerous warning is the false one. Aircraft have crashed because the pilots ignored the ground-proximity alarm just because it conflicted with their *faulty* altimeter.

Eh, I'd say more the moral of the story is better training. High radiation alarm was the first warning. Not seeing the tell-tale Cherenkov radiation was another. Watching this entire thing all I could wonder was "why" every damned time something was ignored. Someone didn't properly drill home that a screw-up with this equipment causes death, not just a boo-boo you can brush under the rug. Of course, most of PD's videos involving radiation accidents/incidents leave me asking "how the eff did no one get through the technician's skulls that they will die if something goes awry and over-abundance of caution is a must-have in these situations".

Follow the loaded gun rule: If something tells the gun is loaded, assume it is loaded even if all other evidence points to the contrary

Exactly, when dealing with conflicting warnings always trust the one that says you will die if you don't listen to it.

You know what's weird about this situation? In this context, if you see shiny blue air it means the source is properly stowed and the room is *safe* ... it's if you do *not* see shiny blue air that the room is deadly.

That's a rather snobbish way of looking at situations. There are many reasons why one might not follow regulations that are more applicable than one's stupidity. And, you'll get a lot further in increasing safety and usability by teaching and educating than by looking down on them. It's perfectly okay to make mistakes. There are a lot of things that we need to account for and most of them may not necessarily even be known. But, use it as a learning opportunity and design something better instead of implying that your design was perfectly made to be "idiot proof" and blame it on "people getting stupider".

A saying in socialism: Capitalism Kills

@@petrapedia there's 100+ million people from the last century who have either been starved to death or killed in socialist regimes who would beg to differ.

@@ShroudedWolf51 thankyou Karen.

@@timhinchcliffe5372 communism*. but OK, boomer

I thought it too. If the place was being operated with safety as a priority, there's no way anyone would have known that door trick.

I'm reminded of videos and coaching sessions with bikers... The videos because there's several comments regarding "Gear" or rather a lack thereof... and then you get the "obvious noobs" who have to point out that it's on a helmet cam' and you can't see the biker not wearing gear... BUT you have a good view of bare arms and hands... 999 times out of 1000, if that much is bare, there's no boots or pants or armor other than the helmet (to screw a camera to his head)... AND along with that, at least in the videos, you can bet money he or she is riding at least double the posted limit... Coaching sessions for all the arguments about (more or less) "Would you rather sweat a little or bleed a LOT?" because that's really what they all come down to... after the excuses start... Some people ONLY grasp the true point and purposes of "Safety" from learning those lessons "the HARD way"... Most of us fall to experience on some points and details of the matter, but there will always be a few you just can't reach without a hefty dose of pain and/or darwinism outright. ...AND if it ain't got metal and FULL GRAIN leather, it's not "real armor" in my opinion... Synthetic gear can last up to 4 seconds worth of asphalt skid... Leather can last 8 to 12 at highway speeds. {just for those who want/need to know} ;o)

@@nemo-x I suspect the operators did not fully understand what it was they were working with in totality and therefore did not realize the life threatening danger they would be put in if something went wrong.

I'd say that he died because he walked into an irradiated room. Equally dumb. Obviously he didn't want to die horribly, but it seems like it would at least make sense to bring a properly calibrated meter into the room.

And probably pressure from management. Being cautious costs money. Get the job done, no matter what.

I agree there with you. How people can bypass safety systems is scary!

This also sounds like a case of poor training also. Like, people should be WELL aware that an "oopsie" means death, and should know exactly how their life safety equipment works. If one has to fool the interlock into opening, they should be ESPECIALLY WEARY before entering. The fact that the poor guy just walked in and didn't even try to verify radiation readings with a 2nd meter, or another worker just shows how ill trained these folks were with the totality of the process. It's like telling someone 500 times not to get inside an industrial oven and they all say "yeah i get it, it could turn on and bake me" but never telling them other facts, like the door is also impossible to open from the inside, and is capable of auto closing and needs a blocking pin installed... They don't have all the information and therefore assume it's "silly" safety stuff.

The fact that they didn't have a calibrated field meter to take readings on entering the maze tells me a lot about how little training they had, honestly I'm amazed it was only the one death

I can totally imagine people disconnecting an audible alarm because there literally is no point in listening to it going off for an hour waiting for the tech to arrive, but the console should at least have something resembling a christmastree full of big red lights that are impossible to turn off when there is an alarm. What I wonder is how it's even possible for the radiation source to get stuck by broken product. Such an important and extremely deadly object should not be blockable by anything short of sabotage. I'f expect there to be a failsafe on the outside where one coould just pull a lever and mechanically drop the sourceback into the water. But hey, I'm just a guy with common sense who has watched a few too many episodes of Plainly Difficult. :)

@@vinny142 if its a radiation alarm, god no, you put up with it. And there should indeed be a visual warning in addition to the audible alarm, it's entirely possible for someone hard of hearing to work in the industry, and accessible design is important. We have an audible and visual alert that we're about to beam on and whilst the beam is on. Occasionally an alarm may jam on, and that usually requires going into the bunker to reset the interlock circuitry. Someone is in the control room, and the tech grabs a dose alarm *and* a field meter and talks about the radiation levels as they carefully move down the maze. We know the linac is off but the radiation alarm is on, so we believe the alarm until proven otherwise. We don't break the interlock system, disable the alarm sounder, and just saunter into the bunker. If an alarm sounder is disconnected you make *damn sure* that all operators know what has happened why you did it and hand over the known status of the kit that is tripping an alarm

I think you should make it more simpler like Alarm go beep beep when no no air is near them

Ah yes, the floor here is made of floor...

I'm just a programmer and don't work with radiation, but I understand what it's like to have stupid alarms go off when there is no issue - the more it cries wolf, the more you ignore it. Granted, this is a life and death situation, however, I understand the indifference that grows. For me, the biggest issue is that people who are not programmers set up alarms that they do not have to listen to cry wolf constantly. I tell them that this is bad and will cause people to ignore the alarms, which it of course does and they of course don't fix.

Incomplete! Pro-tip #2: RADIATION can kill you. Pro-tip #3: Getting killed is bad for you. Best not to cut any corners!

@@dmhendricks EE here, i deal with automation a lot, alarms are made to be super sensitive, a cut wire or some corosion, a loose conection, a bent cable, may all result in false alarms. 9/10 it will be false. 10/10 times you will think it is false, it is correct.

Sounds legit.

Sounds legit, just those fuel gauge gluers wont remove themselves from gene pool.

Not if you think it's faulty

Presumably no one here has unplugged a smoke detector that goes off for no reason

@@no_peace damn you're really just refusing to believe that the worker mainly at fault instead of the company for once and making it everyone else's problem huh? I mean even in the scenario you made with the smoke detector, it would and should be my fault for turning it off.

Every person is the center of their own universe, and for each person, the fatality rate is 0%, until it is 100%.

On a long enough timeline, the survivability rate for anyone drops to 0.

but everyone ia ignoring one thing: how did they know exactly what to do to get the lock open? it probably happened before!

@@sayori3939 Oh no, they mention it...they got used to using the interlock-disable and shutting down the radiation alarm. The only way they could open the damaged and ill-fitting door was often by using the alarm-disable 'turn it on and off a lot' thing. The facility was wretchedly-maintained, and documented mostly in English, which was not a native...nor even commonly-understood...language since this was in Israel, I think? These almost-untrained workers had little idea of how much danger they might be faced with, or else they would have been much more careful. It may have been 'like magic, so who cares? Boxes go in, boxes come out, and I get paid to keep them moving'. Complacency, from management and then also (though more innocently) among the workers. The workers could only know better if they could find out what they needed to know. Management should have told them, but apparently it wasn't cost-effective for the managers to be bothered. :-\ Management is all too often the source, by proxy if not directly, of far too many incidents and tragedies. This worker just enhanced things by rushing and being far too used to cheating the computer. It was midnight; he was likely tired and just wanted to go back home again quickly.

@@profdc9501 Oh that’s really well put.

He said it before and it's sadly true.

It is actually very old and is stated several different ways, but remains true.

blood and money is more accurate.

I've run across that phrase on aircraft accident investigation sites/TV channels.

The "safety rules are written in blood" variation is often heard by engineers in construction or operators of heavy machinery.

That's terrifying

Indeed. The known issue with the switch and the fact that he just casually popped the door open and walked in there suggests very strongly that this is far from the first time they've defeated the security to clear a jam. Definitely the last time though. Nothing ever gets fixed until someone dies.

Yeah, that's what I'm suspecting. You don't willy-nilly start swapping key switches around and flicking the system on/off.

Great observation!!!☢☣🙏

@@hotlavatube Yeah, made me wonder how they even got to the right sequence of actions to trick the machine, like, who thinks to "play around" with a console that controls something radioactive? Guess they've learned now. I hope.

Meat production is awful for this.

exactly. imagine that happening in your health care..cuz it does

Exactly. It always comes back to “but we told them during training…” and never admitting to overwhelming their employees to the point of breaking rules meant to keep us safe. Sad ):

And sometimes it is just that the employees are lazy and don’t want to do the job correctly. Liberals have brainwashed people to hate big companies and rich people.

@@TheHikeChoseMe I have worked in the medical profession for over 30 years, working at some of the largest hospitals in the nation down to small rural ones. I have never seen anyone cut corners when it came to the safety of the patient.

progressive calibration failures, and/or signal interference would be my guess. EDIT, from page 14 of the IAEA report (1993): Over time the Geiger-Muller tubes degrade owing to radiation damage, causing a loss of sensitivity. The supplier took account of this by providing for compensatory sensitivity adjustment in the monitor circuits. Eventually further adjustment was no longer possible, whereupon the tubes should have been replaced. ...PAGE 25: The efficiency of Geiger-Muller tubes decreases with time. This means that after a time the number of pulses generated by background radiation in the test procedure could fall below the minimum number that the circuitry recognizes as an acceptable detection rate. This was the reason why the operators found the test procedure to be 'obstinate' and used unauthorized means to speed things up. The sensitivity of the system can be adjusted to overcome this problem ...PG 15: It was subsequently found that at the time of the accident the [portable] meter was not responding to radiation on the more sensitive low dose rate range owing to a broken internal electrical connection. ...PG19: One of these was a senior staff member who on his way out switched off the power to the unit to silence the alarm. He was not familiar with the equipment and left it to the qualified operator to deal with.

@@LynxSnowCat wow cool, thanks for looking into the report. Basically what I was afraid of: the safety procedures had been sloppy for a while and the staff didn't trust critical equipment. This accident had been a long time coming it seems.

I want to fix the machine -> the machine is telling me not to fix it -> I cannot fix the machine -> I make the machine be quiet -> all good, right?

Everything is "harmless" to the folks that don't have to use them. 1, 1, 1 trichlor is as "harmless" as any other liver-eating solvent. Glad you got free.

@@pfadiva booze?

Management does not lie, they just have different definitions of safe and harmless

@AV Systems In the Air Force, we used Trichlorothane for cleaning and preping repairs. We used it quite alot, along with White Spirit, as they were the best cleaners.

@@pfadiva Reading the studies and SDS and such, it seems barely more harmful than rubbing alcohol. At least in terms of toxicity.

This might sound exceedingly edgy but at this point any other method of self termination might be preferable, dying to ARS might just be the absolute worst way to go

Or at the very least have have triple doses of Morphine available.

if you get a really high dose of radiation it doesn't kill you right away. the highest dose of radiation ever recorded was someone in japan named hisashi ouchi, i believe it was 3 times the lethal dose. he initially showed very few signs of being ill, the doctors were surprised at how good he looked. he lived for 83 days after (granted, the doctors probably should have let him die much sooner, but kept resuscitating him at the request of his family)

@@tedros6917 As I understand it the medical community kind of used him as a lab rat also. 🐀. Nobody had ever been where he was medically before and he was studied extensively and quite a bit of knowledge was gleaned from his tragedy .

@@roguedalek900 It's been well documented that it was Ouchi's family, not his doctors, who insisted on keeping him alive, in the misguided hope that he might survive. They couldn't bring themselves to let him go, refusing to either leave the hospital, or sign a DNR order for him, but eventually his medical staff were able to convince them that he would never recover, and they agreed to it. The least to be said is that the poor man had been comatose for weeks at this point.

I understand the need to get the operator’s attention but a loud alarm can prevent you from thinking clearly or communicating with another operator.

@@carlam6669 And that's what they should have done, get far away from the alarm, go to that 24h nuclear facility where they actually know how to do stuff and tell them the machine is stuck and the alarm went off. Let them deal with it, because they have the proper equipment and tests.

It happens often enough that there's a name for it. Fool irradiation. Wordplay on "Food irradiation" as plenty of food irradiation operators have done the exact same thing, bypassed interlocks and got radiationed to death.

I know right? I’ve watched docs about plane crashes with similar circumstances

"Wow, i'll turn of this annoying alarm" *Then enters the irradiated room* Shocked Pikachu face with eyes burning.png

It scary to think how much accidents there has been with nuclear radiation of all discriptions.

Quite honestly.. the accidents with nuclear matter is relatively low.. cars crash every day. Boats sink, planes crash, toxic waste gets spilled.. nuclear is probably the lowest of any industry.

@@Astinsan Yep, overall very safe. It's just that any/every incident is given way more attention than in other industries. There's no Manifestly Onerous channel showing videos of someone who died doing stupid crap on a forklift in a warehouse.

@@pullt I used to manage a night freight crew.. those machines were so heavy that it was only a matter of time before I had to document a serious injury (quiver).. had to put on the concerned optimism face… 🤠… “so what happened here?”

@@pullt Now I'm inspired. Manifestly Onerous Documentaries. We cover forklift accidents. The really gruesome ones that end up in safety videos.

Because you only survive the instances of it being safe.

Because people don't understand radiation in general.

Yeah -- "Okay, I've got a 50-50 chance of dying; sounds good to me!" 🙄

Probably evidence that it had happened before and been a false alarm. Just like how the guy knew how to defeat the safety interlock - they'd probably done it many times and had it been fine.

Darwinism.

I agree in general but if that had happened 3x before and all 3 times it had been a false alarm... I'm not saying that happened, I'm saying that's often why things like this happen, because it was fine every other time (whether your boss told you the alarm is faulty, or your coworker told you they always go in and fix it, etc.)

I work with steam locomotives and that follows what I was taught there; of the two boiler water level readings you always go with the lowest.

That is why average people should just stay or be kept far far away. I would have never noticed any warning to begin with, let alone wonder if this particular warning is trustworthy or not.

Narcissism. It may be that the operators considered themselves clever by bypassing the safeties. Classic Dunning Kruger.

@@princeofcupspoc9073 let's not assume things about a man that died here. He was a worker that did not know better and often people choose to believe what feels likely to them. He made a mistake but calling him out on his mistake is damn easy sitting here and watching a literal breakdown on how a man killed himself. So don't come here with "Narcissism" about a man we only know so little about.

If you don't have 3 of them by the time you leave...

Yeah, as I mentioned above, most of PD's radiation accident/incident videos seem to be cause by an under-abundance of caution and leave me asking "why". I can only assume people, in general, are either not bright or have not had "death will occur" drilled far enough into their heads.

@@AC-cg4be or their equipment sucks and they think their families will starve if they lose the job

@@AC-cg4be a lot of these stories are due to some form of malfunction or faulty equipment that is (often) known about by the manufacturer or company, but the malfunctioning machinery or safety locks are not replaced due to inconvenience for the companies and to cut corners to maximize profit over worker safety. For instance, the shroud that was recommended for this equipment that would prevent items from jamming the source in a dangerous position and prevent it from being able to be lowered, this company decided it was a level of safety not necessary. That and some of these people in these horrific accidents aren't aware of the flawed equip or fully trained in radioactive materials and safety measures, on top of being pressured by management to ignore the safety protocols.

@@notshardain AND we still have people wondering why nuclear facilities run by industrialist corporates owned through the stock market keep hitting political walls with "NIMBY" arguments... right? ;o)

You would get fired for that and replaced with someone dumb enough to ignore the warnings if the place operated how this one did.

when you work with a system for a long time, you learn its idiosyncracies. I've found workarounds for things to systems at work, though obviously nothing as serious as this

It was probably something like this: "Oh my gosh, the production stopped and I need to get inside to fix it so I can finally go home.. let me just try put in a different key a few times and press this button."

Someone in the facility taught people how to do the bypass, according to articles I've found he received 3 months of community service following the incident.

I hope you've viewed videos about the demon core and the SL-1 incident by now!

He suffered 36 days needlessly. Doctors barbaric to rack up medical bills, they knew he had no chance. Put him down.

@@justtime6736 That's the thing though, people *have* gotten better from very lethal exposures. Only a very very few people though. :/

@@justtime6736 Thats not how doctors work, part of their job is to limit suffering. Not everyone is a greedy asshat. The possibility of recovering is there, and if no request to kill the victim is given by the family, or often the contrary, that have no legal ability to do so.

That's the problem with radiation. If someone receives such a lethal dose to the point that it kills 90% of those afflicted, they may still survive and live on. It would be remiss of the Doctors to give that person no chance to live. For instance at the Chernobyl disaster, Yuvchenko was the man who held the reactor door open so the exposed reactor could be inspected, he received a dose of radiation lethal to most people who receive it, but he survived and lived for another 20 years.

Unfortunately I think most people are hard wired to hope against hope even up the the end that just possibly they will make it. Usually by the time it’s obvious that you’re NOT going to make it, you’re probably past the point of being able to make the end quick and painless. Bad way to go, I’d say.

He did so 4 years ago, it's titled "Brief History of: The Kyshtym Disaster"

@Márton Sonkoly there have been numerous accidents and excursions at the Mayak facility. The one Arkadia Moon is referring to was a criticality accident caused by stupidity with some ignorance mixed in. For once, the surrounding country side was not exposed to radiation.

@@pfadiva Well then I await that video too. The other one overshadowed this event it seems, but as you decribe it, it seems they tried their best again...

@LynxSnowCat cited the report which said the portable meter was broken

People break safety rules all the time because their bosses coerce them. I don't know how hard it was to get a job in that area at that time but people do things for a reason. Very likely he had done the same thing before but it was fine. I doubt he's the one who discovered how to defeat the safety protections

I hadn't heard all the things the company had done wrong yet... It's definitely their fault

The fact that power cycling the control unit was a known “trick” to bypass the safety interlock suggests that unsafe procedures were the norm at this facility.

The amounts of safety violations I've found at my jobs (none of which dealt with radioactive materials) that have passed in the 95+% of testing I am not surprised in the least by such dangerous things unfortunately. At one job management wanted some pork sausage rolls on a roller grill that didn't heat the food to a high enough temperature. I voiced my refusal to serve dangerously undercooked food to management and the other employees. When the health inspector came by for the scheduled inspection some nitwit had put those sausage rolls on the grill resulting in too low temperature readings and the store got demerits. One thing that disgusted me was the unhygenic things I pointed out to the inspector was completely ignored and not tested or inspected.

Pilot error. Recommendation 1) Install a camera system (X 2 for redundancy) for visual confirmation of safed radiation source. The sheer number of intentional safety bypasses and ignored procedures is staggering (pun intended!) What actions other than running did this guy take that wouldn't have killed him? A bone marrow transplant was not an optimal choice. High doses of opiates was. The Canadian company had acted in good faith with the jam prevention fix not implemented.

Well how else are you gonna get out the manufacured radiators out. That's what irradiators do, right? They make radiators to heat water. I'm joking btw.

Seems legit

To GaIn SuPeR pOwErS

Your name is Homer Simpson.

To clear a blockage?

The shroud was designed to prevent that issue... but they didn't install it 🤦‍♂️

@@revenevan11 The shroud didn't prevent conveyor jams- it prevented jams from stopping the core dropping to safe. The better solution would have been designing the conveyor to not jam, thus eliminating the whole problem. There should also have been a visual means to ensure the core was safe as well as redundancy if the micro-switch which should have been designed better too. The problem with automation and engineering in general is the designers thinking that they're smart in trying to make something that can work instead of trying to make something which cannot fail. How you look at things changes what you see, and what you see determines what you'll do. Always prepare for idiots because the world is chock-full of them.

Yeah my first instinct was "uh don't put your life at risk so your boss will make money" but then i started to think "well, they're medical products, maybe that's why they're so invested"... Then i started to think that a lot of these accidents happen in countries without support systems or certain labor protections (not necessarily Israel) and losing a job there could mean your family being homeless and going hungry, or maybe even jail I'm not saying the US is great btw, we don't have real support systems either, just enough for me to say "I'm not dying so you can increase revenue 0.005%"

Sounds reasonable

Every freaking time!

This is when the operator should override orders from superiors, simply say, I wont do it because of the alarm, I know its unsafe. Losing a job is better than losing your life.

@@monad_tcp sadly, that level of awareness and moral courage is often hard to find. Working in ignorance makes it even harder to do, as the worker may not even know what is hazardous.

@@lairdcummings9092 Your last sentence is spot on. If the company ignored the need for the shroud to prevent blockages that prevent the source from lowering, it's equally likely that they didn't properly train their workers in regards to PROPER safety procedures. The company already skipped multiple pieces of safe operating procedures for years, so I doubt the workers were fully aware.

It's pretty safe to say that it applies to any job or pursuit with an element of physical danger.

I'm sure those last days felt like years, just waiting for the pain to stop. Horrible

Interact with community posts

Great username

It must have been horrific.

@@shannon9993 I....I don't have the capacity to contemplate that

yeah, me neither. None of these cases.

Especially day 37

@@BrianClem I'm thinking like day 15...Day 37 is a gift at that point

Welcome to IT Turning it off and on again like black magic will suddenly have it work I'm not even joking I've disassembled so many computers to check what's wrong, checked the drives Just turning it off and on had it working perfectly all of the sudden

Thanks 🔥

Probably. However, in this case the source had already become blocked and prevented from dropping - rendering another source drop interlock useless. I’m guessing this operator would have defeated the gate too, but who knows.

Much more simpler rule applies for hydraulic press- do not put your fingers where you wouldn't put your willie. This rule is universal, dont mess with safety interlocks, especially when there is invisible danger related to it.

machine needs a better design

Boxes shouldn't be able to get in the way of the rack dropping

@@no_peace Actually, the company knew for 20 years that the installation of a shroud would prevent the source rack from being interfered with, but they ignored the notification from AEC and didn't install the shroud. They must have figured it would be cheaper to just go in and clear the jam. They were wrong.

Multiple punctuation marks at the end of sentence shouldn't happen in English? Shirley you can't be serious?!

At least it is written right to left lol

Why wait when you can cause a 10/10 catastrophe yourself? Go get 'em!

🇵🇸