Radiotherapy accident in Zaragoza
Encyclopedia
The radioactive accident at the Clinic of Zaragoza was a radiological accident that occurred from December 10-20, 1990, at the Clinic of Zaragoza
, in Spain
.
In the accident, at least 27 patients were injured, and 11 of them died, according to International Atomic Energy Agency
(IAEA). All of the injured were cancer
patients receiving radiotherapy.
On December 7, 1990, a technician performed maintenance on an electron accelerator at the Clinic of Zaragoza. On December 10, it returned to service after the repairs. On December 19, the Spanish Nuclear Safety Board was scheduled to make its annual review to the device, but due to bureaucratic reasons this review was delayed. The Spanish Nuclear Safety Board found the electron accelerator power was too high. On December 20, 1990, the unit was stopped, and was restarted on March 8, 1991.
of the internal organs and bone marrow
. The first patient died on February 16, 1991, two months after irradiation. Fatalities increased until, on December 25, 1991, the last of a total of 25 patients died. However, the IAEA established that eleven of the deaths were due to the faulty maintenance.
The number affected might have been higher, because 31 other cancer patients were receiving treatment with the accelerator, but the other unit at the clinic was in perfect working condition.
were instead treated at 40 MeV.
blamed General Electric
(GE), the makers of the radiological unit, who had contracted out the maintenance.
Finally, on April 6, 1993, the hospital, its staff, and the National Institute of Health were acquitted. The court
found the technician who performed the repair guilty, and secondarily, found General Electric guilty. GE had to compensate the affected families with 400 million pesetas (around 2.4 million euros).
Zaragoza
Zaragoza , also called Saragossa in English, is the capital city of the Zaragoza Province and of the autonomous community of Aragon, Spain...
, in Spain
Spain
Spain , officially the Kingdom of Spain languages]] under the European Charter for Regional or Minority Languages. In each of these, Spain's official name is as follows:;;;;;;), is a country and member state of the European Union located in southwestern Europe on the Iberian Peninsula...
.
In the accident, at least 27 patients were injured, and 11 of them died, according to International Atomic Energy Agency
International Atomic Energy Agency
The International Atomic Energy Agency is an international organization that seeks to promote the peaceful use of nuclear energy, and to inhibit its use for any military purpose, including nuclear weapons. The IAEA was established as an autonomous organization on 29 July 1957...
(IAEA). All of the injured were cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
patients receiving radiotherapy.
On December 7, 1990, a technician performed maintenance on an electron accelerator at the Clinic of Zaragoza. On December 10, it returned to service after the repairs. On December 19, the Spanish Nuclear Safety Board was scheduled to make its annual review to the device, but due to bureaucratic reasons this review was delayed. The Spanish Nuclear Safety Board found the electron accelerator power was too high. On December 20, 1990, the unit was stopped, and was restarted on March 8, 1991.
Chronology
Affected patients immediately suffered burns on the skin of the irradiated area, as well as inflammationInflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
of the internal organs and bone marrow
Bone marrow
Bone marrow is the flexible tissue found in the interior of bones. In humans, bone marrow in large bones produces new blood cells. On average, bone marrow constitutes 4% of the total body mass of humans; in adults weighing 65 kg , bone marrow accounts for approximately 2.6 kg...
. The first patient died on February 16, 1991, two months after irradiation. Fatalities increased until, on December 25, 1991, the last of a total of 25 patients died. However, the IAEA established that eleven of the deaths were due to the faulty maintenance.
The number affected might have been higher, because 31 other cancer patients were receiving treatment with the accelerator, but the other unit at the clinic was in perfect working condition.
The accident
The radiotherapy unit was repaired without following the correct instructions. The unit, in service 14 years at the time of the failure, had a breakdown in the electron beam accelerator control system ('deviator'). Repairs incorrectly increased output power, so patients that should have received therapy at 7 MeVElectronvolt
In physics, the electron volt is a unit of energy equal to approximately joule . By definition, it is equal to the amount of kinetic energy gained by a single unbound electron when it accelerates through an electric potential difference of one volt...
were instead treated at 40 MeV.
Responsibilities
Initially, the hospital was thought responsible for the accident, and specifically, the management of the radiological unit. The manager of the hospital said that the maintenance technician was responsible, and the Health MinisterHealth minister
A health minister is the member of a country's government typically responsible for protecting and promoting public health and providing welfare and other social security services....
blamed General Electric
General Electric
General Electric Company , or GE, is an American multinational conglomerate corporation incorporated in Schenectady, New York and headquartered in Fairfield, Connecticut, United States...
(GE), the makers of the radiological unit, who had contracted out the maintenance.
Finally, on April 6, 1993, the hospital, its staff, and the National Institute of Health were acquitted. The court
Court
A court is a form of tribunal, often a governmental institution, with the authority to adjudicate legal disputes between parties and carry out the administration of justice in civil, criminal, and administrative matters in accordance with the rule of law...
found the technician who performed the repair guilty, and secondarily, found General Electric guilty. GE had to compensate the affected families with 400 million pesetas (around 2.4 million euros).
Out of service
The device continued working until December 1996, when it was switched off and scrapped. This was done discreetly to avoid publicity.See also
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- Radiotherapy accident in Costa RicaRadiotherapy accident in Costa RicaThe radiotherapy accident in Costa Rica occurred with the Alcyon II radiotherapy unit at San Juan de Dios Hospital in San José, Costa Rica. It was related to a Cobalt-60 source that was being used for radiotherapy in 1996...
- List of civilian radiation accidents
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