
An ‘extraordinarily severe’ emergency: the radioactive leak at Harborview - curtis
http://www.capitolhillseattle.com/2019/06/an-extraordinarily-severe-emergency-the-radioactive-leak-at-harborview/
======
YeGoblynQueenne
The International Atomic Energey Committee who is tasked with investigating
this kind of accident has many reports on accidents including irradiators. It
seems that these are not uncommon (as radiation accidents go), probably
because the radioactive sources in irradiators are made to be moved about and
occasionally transported, much more so than, e.g. the radioactive fuel in
reactors, or even weapons.

Lax standards or just changing circumstances such as an owner moving or going
out of business (or collapsing entirely, like in the case of the USSR) has
caused accidents, in the past.

A famous example is the accident in Goiânia, in Brazil, in 1985. In short, a
private radiotherapy institute moved house leaving behind a working caesium
137 teletherapy unit with the source still in it. Two people took parts of the
unit, broke them apart and sold them to a scrap yard. The owner noticed the
blue glow of the strange salt-like substance in the unit and took it home and
showed it to his friends and family. People became fascinated with the sight
and took fragments of it to their homes where their kids and family played
with it. Eventually, someone connected the fact that people were getting sick
with the strange glowing stuff and took a sample to the public health
department. This led to the accident being discovered.

Some 250 people were contaminated and four died while others suffered
radiation sickness, but fortunately recovered. Lest this be taken as evidence
of the low risk from such accidents let it just be said: you don't want your
kids playing with sparkly blue radioactive stardust.

IAEA accident report here:

[https://www.iaea.org/publications/3684/the-radiological-
acci...](https://www.iaea.org/publications/3684/the-radiological-accident-in-
goiania)

~~~
thatfunkymunki
This is interestingly similar to the Star Trek episode "Thine Own Self" where
there is a village similarly interested in radioactive material.

~~~
mixmastamyk
TNG, with an amnesiac Data and a blonde girl. The town people are not very
advanced and turn against him.

------
aabajian
I'm a radiology resident at UW and we haven't really heard much about this
event. Harborview is a phenomenal hospital, and (in my opinion) the best one
in the UW system. The University has a pretty good track record of admitting
fault, even when it costs the system millions. See:
[https://www.seattletimes.com/seattle-news/health/uw-
medicine...](https://www.seattletimes.com/seattle-news/health/uw-medicine-
mistakenly-exposed-information-on-nearly-1-million-patients/)

UW Medicine itself is not doing well financially (they lost $75 million last
year):
[https://www.washington.edu/regents/files/2018/01/2018-02-B-2...](https://www.washington.edu/regents/files/2018/01/2018-02-B-2.pdf)

Harborview was the only profitable hospital in the system. Seattle is the
second-largest tech city in the nation and housing prices have grown
astronomically, just like in SF. The difference between UW and, say, Stanford
or UCSF, is that UW's patient population comes from the WWAMI states. They
don't typically treat the young tech works, although I have had a couple older
Boeing/Microsoft patients. UW/Harborview patients continue to be mostly low-
income Seattlites and tertiary care/trauma patients from the WWAMI states. The
UW takes care of poor/rural patients while existing in a wealthy city. It's a
unique place to work.

EDIT: I asked my fellow radiology residents about this event

"We had a nuc med lecture on the event! It's super interesting how they
managed it."

"We had a separate nuclear medicine lecture on a Tuesday by the woman who
helped managed the incident and is responsible for nuclear accidents."

"Was on HMC call that night. Physics lecture on that was useful. Radiation -->
reflex call radiologist is a real thing."

"Cool. Honestly they should just reflex call them. I just paged them anyway."

“3.6 roentgens per hour. Not great, not terrible.”

~~~
pbourke
>“3.6 roentgens per hour. Not great, not terrible.”

Is that a “Chernobyl” (HBO miniseries) reference? (Protip: watch it)

~~~
glitchcrab
It definitely was.

------
ISL
Thank you, Capitol Hill Seattle (and Margo Vansynghel in particular!), for
real investigative journalism that the major Seattle papers and news outlets
haven't done on this story.

I have minor quibbles on the facts, and with some of the tone of the story,
but I'm glad to see that a journalist was able to put in the time to research
and write a long-form story about which the Seattle community will care.

For the commenters lining up to throw stones -- we all find in time that our
own homes are made, at least in part, of glass. It is intrinsic to any
accident that at least one mistake was made, but discerning how and why the
mistake came to pass almost always takes longer than anyone would like.
Throwing stones too early often means that they will miss their mark, becoming
mistakes of their own.

 _Edit: crediting Margo Vansynghel, the article 's author_

~~~
mannykannot
Criticizing people with the use of hindsight is one thing, but if "this is
unacceptably risky" would have been the right response to the planned
procedure beforehand, then it is still valid afterwards.

------
mirimir
For context:
[https://en.wikipedia.org/wiki/Goi%C3%A2nia_accident](https://en.wikipedia.org/wiki/Goi%C3%A2nia_accident)

> The Goiânia accident [ɡojˈjɐniɐ] was a radioactive contamination accident
> that occurred on September 13, 1987, in Goiânia, in the Brazilian state of
> Goiás, after a forgotten radiotherapy source was taken from an abandoned
> hospital site in the city. It was subsequently handled by many people,
> resulting in four deaths. About 112,000 people were examined for radioactive
> contamination and 249 were found to have significant levels of radioactive
> material in or on their bodies.

> In the cleanup operation, topsoil had to be removed from several sites, and
> several hundred houses were demolished. All the objects from within those
> houses, including personal possessions, were seized and incinerated. Time
> magazine has identified the accident as one of the world's "worst nuclear
> disasters" and the International Atomic Energy Agency called it "one of the
> world's worst radiological incidents".

~~~
LeifCarrotson
How does incinerating a contaminated radioactive object help clean up the
accident?

That sounds like a "Dilute the pollution by pouring it into the ocean"
solution. Isn't burial the better option?

~~~
i_am_proteus
Dilution is the solution to pollution.

For radioactive isotopes with moderate half lives (that are not produced
industrially in serious abundance), this actually works.

~~~
mirimir
With dilution, for ~rapidly decaying isotopes, nobody arguably gets more than
a _de minimis_ dose. Comparable to a chest X-ray, transcontinental flight,
etc.

But that doesn't work for isotopes that bioaccumulate, and get concentrated up
the food chain. Especially if that happens faster than radioactive decay.

A good example is plutonium production. Back in the 40s-60s, they'd dissolve
irradiated uranium in nitric acid. With remote manipulators, behind massive
steel/lead/concrete shielding. But two of the major fission fragments are
gases at processing temperatures: Xe-131 and I-131. So they just blew that up
the stacks.

Xe-131 stable, but inert, so dilution is arguably OK. Although the I-131 half-
life is only ~8 days, animals bioaccumulate it _very_ effectively. Also, it's
concentrated in milk.

In designing Hanford, scientists did a risk assessment for I-131 releases.
They got that releasing I-131 was risky when the wind was blowing westward,
toward coastal cities. But when the wind was blowing eastward, no problem.
Especially because, for commercial milk production, delay from deposition on
fodder to milk sales is (as I recall) on the order of weeks.

However, they didn't consider subsistence farmers living around Hanford,
raising cattle and goats for milk. For them, delay from deposition on fodder
to milk consumption is on the order of days. Oops. So a bunch of people
(mainly children) developed thyroid disorders and cancer.

I could tell a similar story about radioisotope releases from above-ground
testing. Which increased incidence of thyroid disorders and cancer throughout
the US. But I'll just share the false assumption.

Nuclear explosions inject crap into the lower stratosphere. Where it floats,
just above the stratopause, driven by the jet stream. So there's not much
dilution, just movement. And then, somewhere, there's an intense thunderstorm,
which punches convection into the lower stratosphere. If that happens to
intersect a mass of radioactive crap, it comes down right there. Almost as if
the explosion had occurred right overhead.

Who would have thought? If you're interested, you can find maps online that
show deposition patterns for all of the above-ground test series.

------
Mbaqanga
It sounds like the removal of the vial was done on-site for somewhat
reasonable reasons, but in the future they ought to have a temporary structure
erected during removal so that if something happens, the dust doesn't get
blown and tracked everywhere. Doing this in a shipping container would have
avoided all of these problems and most of the exposure to people as well.

~~~
simonh
From the article:

"International Isotopes contractors had set up a secure steel “chamber”
wherein they would perform a crucial, most perilous part of the operation:
removing the capsule with cesium-137 from the irradiator."

The problem is they didn't realise it had happened straight away. They only
discovered the leak later, when performing a routine wipe-down check of the
area. There are still details missing though, like how come they didn't
perform the wipe-down check before opening the chamber? Or did they? As the
article says, it's not clear exactly what happened.

~~~
jcims
I’m curious how you don’t know that you cut into the capsule. It’s supposedly
a white powder, wouldn’t it make a cloud?

Also if this is possible wouldn’t you put sone contingencies in place, like
mount the grinder on limited travel arm or something? Sound’s like they just
went at it with a $30 DeWalt.

The whole thing seems kind of ridiculous.

~~~
kevan
When you're grinding there's significant metal and abrasive dust thrown into
the air. Given the airflow they generate and how fine the radioactive powder
is even a small nick in the capsule could end up with a lot of material in the
air without you noticing it.

A jig to limit grinder motion sounds like really cheap insurance to prevent
this failure mode.

~~~
ethbro
I'm curious if the capsules like this are standardized or one-off. The
description of the tungsten plug makes it sound like the latter.

In which case a more sane procedure would probably mandate some examination of
the capsule, formulation of a plan off-site, then implementation of said plan.

------
bluescrn
A decommissioning process that involves bringing cutting tools very near to
the capsule of very dangerous stuff sounds like a bit of a design flaw?

~~~
a3n
Maybe they never considered decommissioning in the design. Which itself would
be a pretty severe flaw.

~~~
rootusrootus
Perhaps the main focus is making it extremely difficult to access the
radioactive material. So, no locks or anything that easy, you weld the thing
shut. Makes it harder to decommission, but also makes it harder to steal.

------
dustfinger
>This could destroy the careers of people who have been working their entire
lives on research meant to save lives and improve public health and hospital
outcomes

That is devastating for the researchers.

~~~
closeparen
Happened on my campus. Freezers even had temperature alarms monitored by the
university police, but no one reacted to the alerts. Among other things, an 80
year longitudinal study was lost.

------
jcims
In looking for the construction of the capsule I found this article about a
similar contamination issue with Cesium. Reading through the Events section
that discovers theft and attempts at recovering the Cesium because of its blue
glow are mind blowing.

[https://en.wikipedia.org/wiki/Goi%C3%A2nia_accident#Events](https://en.wikipedia.org/wiki/Goi%C3%A2nia_accident#Events)

~~~
andbberger
Thanks for sharing. Makes one think about all those efforts to come up with a
way to make nuclear waste sites look scary for millenia. Of course, you could
just bury it somewhere and not leave a mark, but that's no fun.

------
dustfinger
Why is the cleanup crew not wearing safety gear? Given how easily the cesium
powder disperses in the air, at the very least, I would want a mask to prevent
the cesium from entering my lungs.

~~~
hanniabu
Costs over safety. If a regulation isn't enforced, it will likely be forgone.

------
sunebeck
I wonder why they named the picture 'Tsjernobyl-1.jpg'.

[https://i2.wp.com/www.capitolhillseattle.com/wp-
content/uplo...](https://i2.wp.com/www.capitolhillseattle.com/wp-
content/uploads/2019/06/Tsjernobyl-1.jpg?fit=1700%2C832)

~~~
cesarb
Even more bizarre, the gallery page for that picture has a slug of "on-the-
list-before-stonewall-film-ginsberg-poetry-festival-at-volunteer-park-seattle-
poetry-slam": [http://www.capitolhillseattle.com/2019/06/on-the-list-
before...](http://www.capitolhillseattle.com/2019/06/on-the-list-before-
stonewall-film-ginsberg-poetry-festival-at-volunteer-park-seattle-poetry-
slam/tsjernobyl-1/) (and the image is titled "Leak 2"). There are other
interesting images in that gallery that aren't on the article (or perhaps are
visible only if you have javascript enabled).

~~~
boogiewoogie
SEO is my first inclination

------
jpindar
According to the NRC notice, it's a JL Shepard Mark 168A

[https://www.nrc.gov/reading-rm/doc-collections/event-
status/...](https://www.nrc.gov/reading-rm/doc-collections/event-
status/event/2019/20190510en.html)

There's some pictures of a similar device here:

[https://www.bnl.gov/nsrl/grsf/](https://www.bnl.gov/nsrl/grsf/)

It doesn't show why you'd need a grinder to take it apart, though.

------
Stay_frostJebel
About half of this machine's radioactive material leaked into the immediate
vicinity after the radioactive source was removed from a larger machine as
part of routine decommissioning.

~~~
heisenbit
Basically equivalent to a dirty nuclear bomb going off with an under-powered
dispersing mechanism. That building is not easy to clean up if at that is at
all possible.

~~~
jsjohnst
Cesium-137 cleanup isn’t especially difficult compared to some other
radioactive agents. A rather painful vigorous scrubbing (speaking from
experience) is effective for external exposure and Prussian Blue is a
moderately effective antidote for internal exposure that will likely prevent
loss of life. No radiation contamination is “safe” and Cesium-137 is
particularly nasty, but cleanup is definitely possible without long term
effects (like at the Chernobyl site) generally.

------
lifeisstillgood
Reading this I realise that the idea of "Health and Safety" is a good one.
Make a plan for the bad things that could happen and you just follow the plan
- "Action On" it is called in the mklitary I believe

The bit where someone asks "did you turn off the HVAC in the building once the
radioactive particles went airborne?" is a classic example.

------
devit
It doesn't seem ideal to require cutting to remove a radioactive capsule. If
done for security, a lock seems better.

------
bahmboo
This is a well researched article. Although mistakes can be made it's a bit
puzzling that there was so much miscommunication. Maybe too many orgs
involved. That Seattle fire department wasn't even informed beforehand seems
clumsy.

~~~
lostlogin
It seems like the miscommunication was intentional, but that’s just my
interpretation.

------
dmix
> Things were far from being back to normal, however. That the HVAC system was
> shut off to prohibit the cesium from spreading through the building was a
> good thing. But as it stayed off, in the days after the leak, the building
> started to heat up. Which meant the freezers in the building, which keep
> research specimen at -80°C, had to work harder to stay cool. Some were
> failing. Important research samples were in danger.

> “Hundreds of thousands of dollars worth of equipment, labor, and samples are
> being lost on a daily basis. This could destroy the careers of people who
> have been working their entire lives on research meant to save lives and
> improve public health and hospital outcomes,” an anonymous source told KIRO.

> UW/Harborview personnel moved the contents of some units to other freezers
> nearby about a week after the spill, said Susan Gregg of the UW Medicine.

> “If they were showing signs of failure, the materials were moved to other
> freezers,” Gregg said. “We were very diligent that none of those research
> specimens were damaged.” No specimens were found to have any contamination,
> she added. The animals, mostly rodents, held in the building’s vivarium,
> have all been moved to another location as well. It took about two weeks for
> the HVAC system to be turned back on.

I love how they use a FUD quote from an "anonymous" source while following it
up with an actual source which claims the complete opposite...

People love to be dramatic.

Also an interesting fact from Wikipedia:

>> Accidental ingestion of caesium-137 can be treated with Prussian blue,
which binds to it chemically and reduces the biological half-life to 30 days.

[https://www.wikiwand.com/en/Caesium-137#/Health_risk_of_radi...](https://www.wikiwand.com/en/Caesium-137#/Health_risk_of_radioactive_caesium)

~~~
YeGoblynQueenne
Regarding the accidental ingestion of Cs-137. The radioactive source in this
case, according to the article, was in the form of talkum powder. The danger
with this kind of material is not that it will be accidentally ingested, but
that it will find its way into the respiratory system, where it can't be
easily bound by Prussian blue.

Accidents with irradiation sources of Caesium 137 have previously happened.
See my other comment in this thread on the radiological accident in Goiania,
Brazil, in the 1980's, where the source of the radiation was a radiotherapy
unit with a Cs-137 source, that was sold for scrap and taken to peoples' homes
for the strange blue glow it emited.

With radiation risks, the idea is to find a balance: don't go mad with fear,
but don't treat it like it's trivial, either. I mean, it's not like because
you can neutralise Cs-137 with Prussian blue, you can go ahead and solve some
in your afternoon tea and imbibe it, and no worries.

~~~
dmix
That's interesting but I wasn't making any sort of statement that Prussian
Blue is some sort of solution to these problems. I just found it to be an
interesting fact.

~~~
YeGoblynQueenne
Yes, your comment makes this clear. My bad then. Apologies for the
misunderstanding.

------
arzel
Great article, surprised this is the first time I’m hearing about this.

------
stefan_
If this is how involved _removing_ the thing is, how exactly was it built? And
if you can't transport it inside the irradiator, how did the irradiator get
there?

~~~
droithomme
> how did the irradiator get there

On a flatbed or inside a semi, down the freeway, then installed with a
combination of cranes and forklifts.

The irradiator goes out on the truck, but in modern times they don't want the
cesium in it because of less perceived risk of truck accidents and terrorist
hijackings. The small radioactive capsule can be sent more discretely via a
smaller vehicle, and a security escort.

------
goldenkey
What surprises me the most is that they did the cutting in an open room (door
open) without taping over the HVAC vents. They literally could have made a
makeshift tent out of plastic tarps to do the cutting inside. Such bad safety
precautions...

~~~
ricardobeat
The article says they put up a steel chamber for that purpose, but it’s
totally unclear what exactly happened.

------
jswizzy
As a former Rad worker who has even cleaned up a radioactive spill I'm just
shacking my head at the all the "experts" in the comments.

~~~
lasdfas
It took me a while to realize this. It wasn't until there was a post about
something I was an expert on. I finally realized people respond here often
with little knowledge or even no knowledge at all. It made me question
everything I read before on this site.

~~~
edoceo
It's not just commenters on this site; planet wide problem.

~~~
krapp
This site (or at least the community around it) does claim a degree of
highbrow intellectual merit and deep technical expertise that places it in a
self-determined echelon above the rest of the web, which one can readily see
in the disdain that commenters here have for Reddit, other social media sites,
most non-technical fields and people in general.

So it is ironic and kind of funny when you realize that, apart from a few
outliers, Hacker News is just as infested with trolls, fools, posers and
Dunning-Krueger as the rest of the web.

It is just a more polite /g/ without the pictures and memes. That's not an
insult, just an observation of how deeply the sets of users here, there, on
Reddit and elsewhere overlap.

~~~
LMYahooTFY
This seems demonstrably false.

If only, at the least, because the guidelines for HN discourage pointless and
inane commentary. Reddit is very likely 95% funny one liners on the most
active threads.

There are observably obvious differences, even if you don't agree with any
inferences made from them.

~~~
krapp
I suspect you're confusing the quality of commentary with the quality of a
commenter's expertise. Someone's comment can read as if they know what they're
talking about, being well written and civil, without that commenter actually
knowing what they're talking about.

Also, Reddit is not 95% funny one liners in technical or programming forums,
and the guidelines for those often also discourage pointless and inane
commentary. Go look at /r/askhistorians for one example. Reddit does have a
higher tolerance for humor and memes than HN, but humorlessness is not
necessarily an indicator of quality.

~~~
LMYahooTFY
To your second point, I agree, but I was comparing specifically the common top
posts ("front page") to one another. HN is obviously more niche, but the ways
in which its niche is defined are what I contend do, in fact, result in a
better quality of discussion.

To your first point, I also concede that this phenomenon certainly does
happen, but would counter with the notion that this probably happens with
every conversation ever, with it perhaps tapering off in materials science
discussions amongst experts.

I'd assert that it's happening right now, given that neither of us are likely
informed enough to empirically support our assertions here. We're merely
sharing our rather vague impressions.

~~~
krapp
>I'd assert that it's happening right now, given that neither of us are likely
informed enough to empirically support our assertions here. We're merely
sharing our rather vague impressions.

That's fair. A lot of what happens here can probably be described as anecdotes
sparring with other anecdotes.

------
Katzenjammer
Jesus that read like a big ol fuck up. The lack of preparation for a spill,
despite having all these people on site, is the most glaring issue. SFD didn’t
even get a heads up.

