1990 Clinic of Zaragoza radiotherapy accident

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The 1990 Clinic of Zaragoza radiotherapy accident was a radiological accident that occurred from December 10–20, 1990, at the Clinic of Zaragoza, in Spain.

Zaragoza Place in Aragon, Spain

Zaragoza is the capital city of the Zaragoza province and of the autonomous community of Aragon, Spain. It lies by the Ebro river and its tributaries, the Huerva and the Gállego, roughly in the center of both Aragon and the Ebro basin.

Spain Kingdom in Southwest Europe

Spain, officially the Kingdom of Spain, is a country mostly located on the Iberian Peninsula in Europe. Its territory also includes two archipelagoes: the Canary Islands off the coast of Africa, and the Balearic Islands in the Mediterranean Sea. The African enclaves of Ceuta and Melilla make Spain the only European country to have a physical border with an African country (Morocco). Several small islands in the Alboran Sea are also part of Spanish territory. The country's mainland is bordered to the south and east by the Mediterranean Sea except for a small land boundary with Gibraltar; to the north and northeast by France, Andorra, and the Bay of Biscay; and to the west and northwest by Portugal and the Atlantic Ocean.

Contents

In the accident, at least 27 patients were injured, and 11 of them died, according to International Atomic Energy Agency (IAEA). [1] All of the injured were cancer patients receiving radiotherapy. [2]

International Atomic Energy Agency 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 International Atomic Energy Agency (IAEA) 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 organisation on 29 July 1957. Though established independently of the United Nations through its own international treaty, the IAEA Statute, the IAEA reports to both the United Nations General Assembly and Security Council.

Cancer disease of uncontrolled, unregulated and abnormal cell growth

Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal bleeding, prolonged cough, unexplained weight loss and a change in bowel movements. While these symptoms may indicate cancer, they may have other causes. Over 100 types of cancers affect humans.

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, [3] 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 inflammation 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.

Inflammation signs of activation of the immune system

Inflammation is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molecular mediators. The function of inflammation is to eliminate the initial cause of cell injury, clear out necrotic cells and tissues damaged from the original insult and the inflammatory process, and initiate tissue repair.

Bone marrow is a semi-solid tissue which may be found within the spongy or cancellous portions of bones. In birds and mammals, bone marrow is the primary site of new blood cell production or hematopoiesis. It is composed of hematopoietic cells, marrow adipose tissue, and supportive stromal cells. In adult humans, bone marrow is primarily located in the ribs, vertebrae, sternum, and bones of the pelvis. On average, bone marrow constitutes 4% of the total body mass of humans; in an adult having 65 kilograms of mass, bone marrow typically accounts for approximately 2.6 kilograms (5.7 lb).

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 MeV were instead treated at 40 MeV. [4]

In physics, the electronvolt is a unit of energy equal to approximately 1.6×10−19 joules in SI units.

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 Minister blamed General Electric (GE), the makers of the radiological unit, who had contracted out the maintenance.

General Electric American multinational conglomerate corporation

General Electric Company (GE) is an American multinational conglomerate incorporated in New York and headquartered in Boston. As of 2018, the company operates through the following segments: aviation, healthcare, power, renewable energy, digital industry, additive manufacturing, venture capital and finance, lighting, transportation, and oil and gas.

Finally, on April 6, 1993, the hospital, its staff, and the Spanish 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).

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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References

  1. "IAEA Bulletin 413" (PDF). Archived from the original (PDF) on June 8, 2009.
  2. "El accidente del Clínico de Zaragoza, una cadena de fallos humanos única en el mundo, según los expertos". El País (in Spanish). October 12, 1991. Archived from the original on October 10, 2012.
  3. Garriga, Josep; Ortega, Javier (February 23, 1991). "El CSN no controló el aparato radiactivo del Clínico de Zaragoza en un año y medio". El País (in Spanish). Archived from the original on October 10, 2012.
  4. Serrano, Sebastian (February 26, 1991). "Un técnico revisó el acelerador del Clínico de Zaragoza tres días antes del accidente". El País (in Spanish). Archived from the original on October 10, 2012.

Coordinates: 41°38′N0°54′W / 41.63°N 0.9°W / 41.63; -0.9