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Anatoli Bugorski stuck his head inside a particle accelerator (2020) (amusingplanet.com)
127 points by spekcular 4 days ago | hide | past | favorite | 79 comments

> Unknown to Bugorski, the accelerator was still running, and the warning lights that would have alerted Bugorski of the hazard had been switched off during a previous experiment, and had not been turned back on.

I'd love to know why a safety mechanism like this had an off switch, and under what circumstances that off switch is to be used. I feel like safety mechanisms should be always on, since they exist to prevent us from making mistakes when we forget things?

This is a hobby interest of mine but switching alarm systems off to do a quick bit of work has caused at least three radiological accidents in irradiation facilities in Nesvizh, Belarus, in Soreq, Israel and in San Salvador, El Salvador. You can find the details in IAEA reports:

The one in Nesvizh:


The one in San Salvador:


The one in Soreq:


In each case the facility operator entered the irradiation chamber after switching off safety mechanisms (such as alarms or mechanisms placing the radiation source in a safe position, inside a pit) in order to unblock the conveyor system from packages that had become lodged in the mechanism. These facilities usually have a conveyor system that takes packages of products like food or medicine around a radiocative source to be sterilised. The packages seem to have a tendency to get stuck in the conveyor mechanism's parts often at which point proper procedure is to power everything down before someone can enter the facility to service the mechanism. Obviously that causes severe delays to production and obviously people simply override this procedure, that is in place to protect them. They go into the facility, they find the source in an active position and become irradiated.

My favourite of the bunch above is the one in Nesvizh, where the irradiation facility was built like a miniature maze from D&D, lacking only the guardian minotaurs with double axes (or Ogres, I guess). The radiation chamber was an actual maze, like a square spiral of concrete. The way to the source at the center of the maze was littered with pressure sensors that triggered alarms and there was even a moving hatch at the entrance that exposed a pit too deep and long to jump over. IAEA's investigation never found out how the operator managed to cross the pit, navigate the maze and get to the center of the chamber without triggering any alarms that would have normally stored the source to its safe position inside a dry pit, but he sure did it, then realised suddendly that the source was in the active position and ran back out. He died later of radiation poisoning before having the chance to tell anyone how he managed the feat.

Are lockout/tagout controls not used in these systems? Industry has (mostly) solved this problem long ago.

There was a key in the radiation chamber's control panel that turned the power to the chamber on and off. This key had to first be turned to the "off" position, then carried to the entrance of the maze to activate the panel that slid the section of floor over the pit towards the entrance, thus allowing er entrance.

It seems this procedure took too long so the operator only turned the key to "off" in the main control panel, then crossed the pit at the maze entrance on his own.

In my comment above I say they don't know exactly how he crossed this pit with the mechanical hatch, but I seem to have misremembered. The motor that moved the hatch was inside the pit and he could have stepped on it and jumped over to the far side. What the IAEA doesn't know is how he managed to cross a pressure plate after the pit that would have normally stored the source to its safe position.

I just read through the report and you haven’t exaggerated a bit. Somehow, an otherwise intelligent and well-educated engineer decided to go full mission impossible just to kill himself in the most miserable way possible.

What a crazy story, thanks for sharing it and the sources!

Build an idiot-proof system and the universe will build a better idiot I guess :(

Yep, it was through incidents like these that we developed Lockout Tagout:


You cannot "switch off" a cobalt 60

This is a great resource, and makes for great reading after finishing the NTSB reports. My personal take on the Nesvizh incident was that it was made to be 'too inconvenient' to remove the key from the panel and the operator became complacent; simply hopping over the man trap via the motor housing was easier than the correct procedure. I'm not sure how the pressure plate was defeated, but what was the logic for a plate tripping while the key was in 'run'? I think in modern design a safety relay would have been tripped, and be unable to be reset until the source had returned home and the lid was locked.

Edit: to expand on the pressure plate, maybe the logical fault was assuming the plate couldn't be accessed without the mantrap covered, requiring the key removed from panel.

I too wonder about the pressure plate and the IAEA report is uncertain of what exactly happened. The IAEA assumes he could not have circumvented the pressure plate and for my part I don't see why he would try to, at that point. From the report I didn't get an impression that stepping on the plate would have caused further delay, e.g. I didn't understand that there would be a new alarm etc. Rather it seems the only possible effect would be to lower the source if it was still in the "on" position, and I don't understand why he would have decided to override that particular safety feature. Clearly he had lots of experience sneaking in the maze past the safety systems so he must have known what he was doing and I don't see someone like that acting so foolishly for no good reason. The IAEA hypothesises some mechanical or electrical fault, or that the wrong buttons were pressed etc, but I guess we'll just never know. Perhaps even this guy who knew the facility like the back of his hand didn't know everything about it, after all.

Thanks for the pointer to the NTSB reports. I didn't realise they're all there!

Did you read the NTSB report on El Faro?

thank you

Actually the light bulb that was supposed to be on to signal that the beam was on had burned out that very day.

Talk about failing unsafe

“Fail-safe systems fail by failing to fail safely.”

>I'd love to know why a safety mechanism like this had an off switch, and under what circumstances that off switch is to be used.

then you are in for a treat - just read how Chernobyl happened.

It didn't have an off switch, it burned out moments before the man went in, literally so many unlucky events had to happen to have this event occur.

This approach to safety devices or safeguards is painfully typical in Russian culture. I live in Moscow, and about a half of taxi drivers don't buckle up their safety belts.

Don't you know you go faster if you don't wear your safety belt?

Especially when you hit something. Much, much faster.

I disagree. You go the same speed, just further away.

Just for giggles: anesthesia & icu alarms have off switches too. For cases where, for example the surgeon complains that he can't concentrate because of the noise. Additional fun fact: you've got an off switch but it's actually forbidden to use it ;-)

what do you mean you've got an off switch?

You can completely silence all alarms on anesthesia and icu monitors, even though it's forbidden to do so. Or do you mean for the surgeon? Well, unfortunately not all surgeons come with an off switch.

Because light bulbs were expensive and in deficit and people were cheap and plenty in USSR.

In 1978 two light bulbs wired in parallel could not be a lunch bill even in Russia.

You don't understand, how planned economy works, do you?

If you were given N lightbulbs at the beginning of the year and all of them went "pop" or were "taken home", you won't have more until next year, no matter what. And by "you" here I mean support person, responsible for putting spare lightbulbs into sockets.

The scientist's performance assessment on the other hand is not tied to support supply chain troubles. He must continue with experiments and must use "hidden reserves" (disable safety system) if necessary.

Yeah, nuclear scientists grew on trees in the USSR. Love how authoritative americans are with their stereotypes.

Unless you are taking these words absolutely literally, the OP is right. Economizing + achieving the marks set by CPSU at all cost was prioritized over everything, including safety even in armed forces. Source: born, and raised there.

I'm not an American. I was born in USSR and lived there until its long awaited collapse.

is there a name for the phenomenon of assuming someone on the internet is an American whenever they express a negative sentiment about anything?

There should be.

It’s called projection

"He struggles to pay for his epilepsy medication, since the city cut budget to the institute and his former workplace. In 1996, he applied for disabled status but his application was rejected."

Site... amusingplanet.com

someone should get in touch with him. I would send some cash his way.

I would to do same just for the sheer fact he’s a legend. He should create a gofundme page.

Talking with a friend about this. Anyone here thats has a good idea to how we can track this guy down and create a donation page for him?

There has been several articles about this man recently. I come away from them wanting to help him financially. I feel if you're going to publish an article about him, and make money from adverts on your website, you have a responsibility to try and help this man. If not it's just exploitation.

Same feeling. Does he speak English? Maybe we could create a go fund me.

A biology professor I knew long ago had done a summer internship at a physics lab on Long Island. She said that some of the physicists would align the particle beam from a cyclotron by placing an eye behind the target and waiting for the retina to fluoresce. She later heard that some of them developed cataracts earlier than one usually does.

That sounds like the joke in the laser lab I did my PhD in: some alignments you can only do twice.

>gastrointestinal track

I've seen 'tract' and 'track' confused so often that I wonder if the latter is taking over as standard use, and me shaking my gnarled fist at the skies. cf. "Phenomena" instead of "phenomenon", "bias" instead of "biased", etc etc

err... is "phenomena" not the plural of phenomenon? and isn't "biased" the past tense (or adjective) form of bias?

totally agree with gastrointestinal track being wrong though, that's a definite error!

EDIT: I searched google and the first result for phenomena was (under "People Also Ask") "What is an example of a phenomena" which is probably the kind of nonsense you are referring to..

> isn't "biased" the past tense (or adjective) form of bias?

This form is called "participle" if you are curious:


Twice this week I’ve seen someone mention how they were going to “sus out” $thing and I can’t help but feel like Among Us has forever changed the spelling of “suss” and conflated “suss” with “suspicious”.

“suss” is also derived from the word “suspect”/“suspicious”. Suspicere means “to mistrust”.

https://youtu.be/JTslqcXsFd4 covers a bunch of these (no homophones though since it seems to be about speaking rather than writing).

Shaking your fist? Literally? Or literally?

There's a video about his case: https://www.youtube.com/watch?v=mD4J5VUwiAs

called "What happens if you put your head in a particle accelerator?"

As one would imagine, interlocks on modern accelerators are much better. Things like room radiation monitors combined with switches on motorized doors only closable from outside help alot. This way exposure is only possible if someone else accidentally closes you in, and there are very loud klaxons that warn you when beam coming through is imminent. Getting into a target or radiation area when the accelerator is powered on requires taking a key from the console which blocks the beam at an early stage before it is accelerated.

I’d expect the inside to be a vacuum. Isn’t the air causing trouble or energy loss for the beam?

I'm guessing he was working on an experiment where the proton beam exits the vacuum chamber and interacts with a sample and some detectors outside of a vacuum. https://www.isis.stfc.ac.uk/Pages/Chipir-technical-informati... shows an example where a neutron beam exits into a shielded block house where experiments can take place. In this modern particle accelerator access to the block house is controlled by digital and mechanical interlocks to prevent such an accident occurring.

As described in Kyle Hill's video about the incident, the proton beam crosses through air in a room to reach various instruments and that's where it was accessible to a curious head poking in.

This is a rehash of the referenced wired article, which itself is much older (1997).

Hopefully he managed to get social welfare payments since then.

This story was also getting pumped up on my Youtube page a couple of days ago.

A funny coincidence?

This is the sort of thing that LOTO locks a are used to prevent from happening.

Everyone whispers "Dr. Manhattan"

(2020) mods.

not great, not terrible

To add context for readers spatially or temporaly (too young) outside of USSR: there was a frequently used saying "We do not have irreplaceable people". Death of a person had neutral to positive effect in Soviet state value system. The smarter the person is the more positive the effect.

Allegedly, similar logic was applied to development of weapons- the designed lifetime of some was deliberately capped at a few hundred rounds because "soldiers won't last longer".

It wasn't that "soldiers won't last longer" - it was that the division wouldn't last longer.

Soviet doctrine solved the problem of maintaining fast advance with fragile men and equipment by subjecting individual units to intense, but very short, engagements. Specifically, a field army would have "echelons", where divisions of the first echelon would fight an extremely intense battle to achieve a breakthrough. Once that breakthrough was achieved (or failed), entire divisions would be rotated out, allowing fresh second-echelon divisions to take up the battle.

This meant that if your tank could only do a combat-week's worth of driving before needing to go back to a depot for refit, that was fine; your armored division would send its tanks to the maintenance depot all at once while the troops were recovering from their week in hell.

For more on how this would work in practice, see this NATO write-up of Soviet doctrine (specifically starting at around page 2-5 in their weird page-numbering scheme): https://fas.org/irp/doddir/army/fm100-2-1.pdf

Just an FYI 2-5 denotes the chapter (or section) and page. This is super common in technical manuals where sections are grouped based on content, then the page refers to the page number in that particular section.

That's a brilliant insight. I have also seen it in the attitude of some CEOs of USSR vintage w.r.t to company culture.

i.e. crunch time, followed by actual R&R/downtime?

That would be logical for USSR culture, but it's completely at odds with AK family reputation — these rifles are said to be one very durable with minimum maintenance.

Now during Ukraine-Russia war after storages of Soviet weapon were opened in Ukraine, some series/years of AK assault rifles were dismissed outright as unusable.

Quality and reliability weren't controlled for in USSR. Only sheer numbers.

> Quality and reliability weren't controlled for in USSR.

That's a very strong statement. Could you elaborate on that a bit more please?

There were no penalties in USSR for doing half-assed job (unless someone died because of it, and even then not always). Everyone had a right to work. Even if you're fired (which almost didn't happen), you'll have another shitty job with the same shitty pay in no time.

No incentives for quality.

> No incentives for quality.

Is that so? https://en.wikipedia.org/wiki/State_quality_mark_of_the_USSR: "Obtaining the sign allowed the enterprises to increase the state controlled price for the goods by ten percent." Arguably this was abused, as explained later, but the original statement that quality control was absent in USSR is not entirely correct. There were penalties for "doing things deliberately wrong" and quite severe from what I recall. Then again I might have warped perception as I grew up in a city with several "black box factories".

Edit: typo

There is a difference between actual quality of mass produced items and "obtaining the sign". Either decision was made behind closed doors according to Party interests or limited series (tens of units if not less) were manufactured to get positive assessment.

Everything made in USSR was shit, unless manufactured on recently imported equipment.

Yes, but when the soldier dies and drops his weapon, the soldier just behind him, who was sent to the front without a weapon, needs to be able to pick up the dropped weapon and continue shooting. That's how it was during the Great Patriotic War. Or so I've heard. Cue men's choir singing Polyushko-polye ...

Such episodes weren't unheard of, but they were rare, and occured during forst months of war, because armories close to front lines were bombed or captured, and military factories were in the process of being relocated farther into the country


Please don't take HN threads into ideological or nationalistic flamewar, or whatever kind of flamewar this is. It leads to hellish discussions, the kind we don't want here.



Please don't perpetuate flamewars on HN, and please don't post unsubstantive comments.


My apologies


Two minutes for paratroopers and fifteen minutes for tanks.

I'm having trouble parsing this. I find confusing as it is thoroughly interesting. Is it the outcome of Soviet culture pre-communist rule or a result of the communist ideology?

Say you had 4 decade veterans/experts in a particular field, a couple die from cholera or TB or something. How is that doctrine a net positive for the state?

Because state goal is not the advancement of the particular field(s). State goal is to maintain (build) communism within particular county (USSR) and Warsaw Pact block.

Smart people opposed (unrealistic) party goals. so their death was net positive for Communist state.

For details see multiple waves of intelligentsia cleansing during 1920-40.

It would only have been a net positive in terms of relative support for the political apparatus, and even then only in the short term. Retaining political control would still ultimately rely on infrastructure and military force driven by technical support & advancement. Then again it may very well have been such short term thinking that contributed to the ultimate collapse of Soviet Russia.

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