Did you do a vid on Alexander Litvinenko? The dose of radiation he received was comparable to this one, although obviously receiving it internally would be that much more devastating. The fact that either victim didn't die within days is a testament to the toughness of the human body...
Medical linear accelerator incidents would be interesting topics... Therac 25, the Neptun linac overdoses in Poland, etc. I'm a medical physicist, if you do videos on any of these I'd be happy to field any questions you'd have about them.
Man, this is kind of a weird one where *nothing* really broke down, the safety was reasonable and strong, the system was well-designed, the operator was trained... Cripes, just guess it goes to show that familiarity with a system breeds a lot of contempt for the risks. At least the only guy that got hurt was the one that did the stupid himself, and he didn't take anyone else with him.
The radioactive emitter was not stowed, despite the worker pressing the button that stows it. I'd call that "something major breaking down." This is why you engineer redundancy into safety-critical situations, and hopefully hire people with the wisdom not to subvert the redundant systems, on the logic of, "well, the first step should be enough, right?
It’s true. There was a guy near me that ran potato harvesters for years with no issues. They’ve got cleaning rollers that bounce the dirt off the spuds and pull out stones and roots. One day something got jammed on the rollers so he poked it down with his boot. The rollers grabbed him and ripped the meat off his leg and mangled his D and Bs. Just one dumb moment will put you in a bag.
The safety was stupid as hell, are you nuts? It is a very good example of the illusion of failsafe. This sort of this is the most dangerous because it looks smart but its terrible.
I find such accidents terrifying. That operator made a fatal mistake, and probably knew, within days, that he would die. He had three months, suffering horribly, knowing that his mistake will cost him his life. That's what I find so frightening with radiation accidents... the knowledge that you're going to die in weeks.
chronic illness is also crazy like that, you don’t recover from that foreboding feeling you get when you realize how fragile you are. i tell that to ppl who have very ill loved ones
I know right? I'm just stunned that someone would take shortcuts with such a scary piece of equipment. I can't imagine what went through his head as he realised he was exposed after having circumvented some safety systems.
ya that's the creepy part, these guys know they're going to die and have a matter of hours before their bodies start reacting to the trauma so they can walk out of these facilities 'fine' and give interviews before dying to radiation poisoning
I worked in a mine and steel factory Q&A lab, we had plenty of dangerous stuff and an equal number of procedures about how to deal with unforeseen situations regarding those risk factors (heat, pneumatic stuff, radiation, aspestos, etc). I always respected veteran operators, but if they tend to do one thing, is discard those exact procedures in favor of not interrupting productivity etc. This works fine as long nothing happens, and maybe you get away with it for decades, until you don't. It's really difficult to deal with these colleagues with more experience and authority, but also have grown insensitive to the actual dangers. More often than not, the culture in management is to blame.
In my experience the culture in management is to implement more rules, instead of disciplining the offenders who failed to follow the rules already in place. Especially if the industry you work in makes it difficult to fire worthless people due to fear of being sued.
This. In highly dangerous scenarios where neglecting maintenance can lead to high casualties, machines SHOULD be stopped for maintenance. Unfortunately, the higher-ups in those companies/labs are more interested in capital than the safety of their employees.
Doing it dangerously incorrectly for 20 years is NOT "experience"... It does NOT provide any form of useful practice. Just because you "get away with it" doesn't make it alright for another 20 years. That's what too many of these so-called "veterans of the industry" can't seem to get through their heads. I might ride a motorcycle for the next 20 years without a stitch of gear or helmet... and be fine. That does NOT make it right when something goes sideways and I'm caught completely unprepared for it. ;o)
@@gnarthdarkanen7464 You're perfectly right, but sometimes when you work in a complex system those veterans have a way bigger picture of the process than you do due to their experience. But that same awareness can then bite them in the ass when they try to "play" said system and processes though, because their priority is to resume productivity ASAP, not safety, and in my experience the older the operator, not even quality anymore. This gets encouraged by managers that favor workers that bring no problems to them, over workers that bring them up.
Wodka makes things straight forward ... 😅 The guy said he was "tired and can"t remember ....." I live in Poland, and this means over here DRUNK as a SKUNK ...
@@HenriFaust Proper use of a meter is meter out front eyes on the needle and you start with the lowest scale. At 1,200 Rad an hour disorientation can certainly happen but I bet he did not check the meter or lied about taking it with him. If he was worried about time he would not go back for it. Also, he was deceptive about how he got across the plate. There is always the possibility he used the meter properly and was able to get in since the source was properly shielded then it was raised while he was inside. Could have been someone at the control panel since he left the key in. Need to get a dose map of the interior and see if the dose he got matched up with the area he was for the time he was in the room.
One small point: isotope irradiators that use highly gamma-energetic rods that need to be stored underwater are becoming more and more uncommon. Aside from the obvious issues with keeping a caged tiger that's angry 24/7, they found that a lot of them leak radiation into the water and then subsequently contaminate the entire building via evaporation. They are being replaced with electron beam irradiators that are vastly safer and easier to work with, although much more expensive. It's nice to be able to actually turn the death beam off when you're not using it.
Although there are some subtleties in the "beam off" condition. When the electron source is turned off, but the accelerating field is still present, stray electrons entering the field continue forming a beam. This "dark current" beam is very weak compared to the normal beam, but can still cause serious injuries. This problem is serious in potential-drop accelerators, where the accelerating field decays gradually after the machine is switched off. This requires a substantial waiting time until the field reaches negligible levels, making it safe to enter the beam area. Incidents have occurred where premature entry led to serious radiation injury. (RF accelerators have essentially instantaneous decay of the accelerating field, so they're safe immediately after switching off, but they have even higher costs since they use more electricity for the same beam power).
@@CoastalSphinxYup. With a photon detector you could observe the same effect in most CRTs. The anode remains charged, and thus provides accelerating field, for a very long time. There are electrons accelerated into the middle of the screen even with cathode stone cold. Just not enough to see with any illumination, and sometimes too few to see with a naked eye in darkness as the phosphor becomes inefficient when the electron energy is too low. Large color TVs from 70s and 80s had a central CRT glow barely visible in total darkness for hours after the TV was turned off. I was fascinated with it when I was a wee lad. It was too dim to see by adults past their 30s, but certainly very obvious to me and my young siblings. Kids with normal vision have excellent retinal sensitivity, it goes downhill once you turn 25 or so.
@@absurdengineeringwhen we look back and remember our parents saying DONT STAND SO CLOSE TO THE TV.... looking back... man those things were fkin weird machines. having a thing glowing for hours even when off next to your kids heads mustve been very uncomfourtable when TVs came out not safe like those ciggies we use to smoke when pregnant tho
For the Soviet built the safety systems were actually pretty impressive - huge pit, pressure plate - it's like from Indiana Jones movie, and yet it's so simple solution it makes you wonder why wasn't it implement in every facility in the world.
@@mikeydk Maybe that is what they need, tranquilizer darts or knock out gas so you physically cannot proceed any further. Because obviously if your continuing on common sense and more warnings are not going to stop you.
He "Prince of Persia'd" his way to his own horrible demise. People always think they know best. As a person, I can attest to this. I have gotten lost, electrically shocked, wet, sad and more, as a result. Thankfully still alive. Keep me out of the dangerous trades...
Nicely explained 👍 I worked in oil fields for 7 years as a crude oil hauler. Whenever some incident would happen, the driver involved would inevitably lie about how the incident happened to try and save his job or bonus. Once he was cleared to continue working, or even if he wasn't, he was always forthcoming to the other drivers as to what _actually_ happened. The other drivers wouldn't tell the supervisors and the incident was considered closed. Only if the driver ended up fired would they usually get the whole truth of what happened. Chalk that up to human nature. If you're more motivated to avoid the consequences of your actions, expect the person in question to lie. Bottom line: talk to the other employees until you get the truth. Someone else knows what really happened.
"Balls" "Yes balls" I absolutely love that you always inject some humor into these. I'm currently binging your entire channel while I work. Thanks for keeping me company!
I catch myself wondering "what kind of idiot would bypass established safety procedures" but then I personally have experience with people doing the same things! Like, in a confined space with an air quality monitor. Using isopropyl alcohol to wipe down the inside of a tank, even with massive ventilation, eventually the fumes build up to the point it is hard to breathe and unsafe. I was inside one time and we'd gone out several times to let the air clear a bit after the monitor alarmed. The final time, we were really trying to finish, it got to the point I thought "holy shit my eyes are on FIRE!" I walked up the ladder and the custodian said the monitor was about to alarm, so everyone come on out. Everyone got out and went down the lifts fine. TURNS OUT the monitors start from 0, and ramp up over time. If you just keep turning the monitor off before it alarms, it never alarms! Thanks, confined space custodian!
It's a "the rules don't apply to me, only to idiots" deal really. People break safety regulations all the time. For example, speeding in their car. They are so good at driving that they are ENTITLED to speed. The speed limits are too low, the speed limit only applies to grandmothers and other bad drivers. The speed limits are only there to punish people going over them with fines, it's a racket... There's all kinds of explanations really, but at the end of the day. The speed limit isn't there because you can't go over it without crashing. It's there because in the one out of a thousand events, the lower speed will save lives. And i am not talking about when crashes happen either. I am actually talking about when something unexpected happens that COULD lead to a crash. Going 80 mph on a 65 mph road means what could have been not a crash is now most definitely a crash, with potential death to follow for the driver or other victims on the road. So yeah, it happens all the time. And people die a lot more than they otherwise would.
My headcanon is that the engineer planned for the pit to be filled with snakes but that was dropped because appropriately venomous snakes could not be sourced. The swinging guillotine blades triggered by the pressure switch were cut for budgetary reasons.
I think he concocted the story about leaping over the pit and the pressure plate as a way of protecting his assistant from criminal charges. There was no reason for him to avoid the pressure plate. I think he followed the rules for entry. Used his key, walked into the exposure room and was working on the track with the source down. At some point he asked his assistant to take the key and jog the track from the control room while the operator observed the track. The assistant misunderstood what the operator wanted (or he was still unfamiliar with the control panel ) and instead of turning the track on and off , he raised the source. When the operator noticed the counterweights moving he ran out of there as fast as he could , but still received a lethal dose. The operator was a dead man and he knew it, he also knew that it was mostly his own fault to begin with ,so he made up a story that put all of the blame on himself.
There was a reason for him to avoid the pressure plate. If the pressure plate is activated, the Co-60 source is dropped into the storage pit, meaning a loss of time (and production, which never went well for you in the Soviet Union). See the video at about 4:34. Apparently he wanted to NOT trigger the shutdown, which is strange because pressing the panel shutdown button also moved the Co-60 source to the storage pit--which the Senior Operator did, temporarily ending production. In a hurry he leaves the safety key in the control panel, leaving the "safety pit" floor open, so he can't enter the irradiation chamber, which he wants to enter to find the jammed rack or tray. This is why the Senior Operator's story is suspect; it doesn't make sense. All the Senior had to do was go back, remove his key, the safety pit floor would extend, he could enter the chamber with the rad source safely stowed (supposedly, assuming the door interlock and entire system worked right; he needed the safety key to unlock the maze room door. But now he's playing MacGyver trying to bypass a safety system when he doesn't have to. So now we look at the Asst. Operator. IF the source was in the storage pit, there would be only a minimal radiator hazard (if any) to the Senior Operator. So if the Asst. Operator made a mistake, there would be no safety override to keep the source shielded, since the pressure plate would not trip the shutdown, and the push-button shutdown on the panel would be overriden with the safety key still in the panel. Did the Senior tell him "Dimitry, move the rack please", and the Asst. Operator moved the source rack instead by mistake? Or did the source rack get stuck on the way down, and the panel did not have sufficient indicators of the rack's exposure? But that conflicts with the Senior Operator's story of the radiation detector not showing a reading matching an "exposed rack" when he used the detector (the readings would be much higher than if the source rack was in the enclosure). Yet the source rack was exposed per the victim's statements. His dose was consistent with the source rack being exposed. It is very possible that whatever actually happened (the Report notes there are inconsistencies in the stories told, results of equipment inspection and testing, etc.) the story the Senior told was to take the blame for the Asst. Operator making a terrible fatal mistake or more.
Bingo!!!! I see situations like this daily in our warehouse yet only 1 in the past 5yrs I've been there has been fatally injured (not to say that there won't be a handful more before retirement) but complacency breeds and fuels dangerous, yet avoidable, situations.... Especially when it comes to production lines and corporate only caring about THEIR bottom line and not OURS- the worker aka the life(s) on the line!!! Complete shitshow on a daily basis for top pay seems like a risk many will take (not me- I got kids to raise) and am a stickler for doing things the "right" way the first time, screw the higher ups that don't know f@$k all about day to day operations...not worth it!
This was my thought also. The assistant would likely have been in line for some draconian Soviet-style punishment. The operator saw no reason for _two_ people to have their life destroyed over a misunderstanding.
Interesting theory, but if he had ran as soon as the source rack went up, he would have received a much lower dose. He has to have had spent some time in there with it.
@@markh.6687 We'll never find out what actually happened but you've sold me. It's not like the Belarusian authorities valued honesty, that seems mostly likely what happened. He kept the key in to fix it fast and the assistant hit the wrong button, overriding security because of the key. Big shame because apparently there was a lot of redundant security on this thing for once, they just overruled it.
There's an old engineering saying: "I can fix stupid, I can't fix BLOODY stupid". The safety systems were amazingly thorough, and yet the accident still happened. This is what is known as an "ID10T" error. In any system, the human factor is the most dangerous. Pressures of production and a "I know how this works" attitude are not a good combination. There is also an element of "familiarity breeds contempt" here. The experienced operator (also an engineer) not only knew how the system worked but ALSO how to bypass the safety protocols. There is a factor regarding the difference between using a dry pit and a pool to contain the source rack when in the lowered position. If the lowered rack is in a pool of water, there is an (unofficial) indicator-Cherenkov Radiation from the interaction of the radioactive source with the water in the pool. The lack of a blue glow coming from the pool is an indicator that the rack has not been properly lowered. It's not foolproof (you'll still get the glow if the rack is only partially submerged, but it is an extra thing to check. Perhaps all facilities like this need to have the kind of checklist protocols that airline pilots use. Two people, each checking to make sure that everything on the list has been done.
There are no shortcuts when it comes to radioactive materials, it's either do it right or die a rather unpleasant death, or at the very least, survive with fewer body parts and high chances of other complications causing an unpleasant death... :\
I have to wonder: Did climbing across the pit, and doing whatever he did to defeat the pressure plate really save time over doing it the right way: Pulling the key and using it to close the pit? Or was there some malfunction in the pit closing mechanism that led the worker to improvise a workaround?
As someone who works in a post soviet country I can tell you a lot of sad and dumb stories of people bypassing safety equipment in CNC machines. Ive seen so many unscrewed interlocks by simple workers because "manually adjusting a machine is faster this way and you don't have to stop the production too many times wich might get you into trouble". Most of the time they get a verbal warning thats all. Yet still we got so many stabbed hands and cut off fingers that the higher ups of my workplace decided "damn it lets weld the interlocks shut and drill the hexagon screws". For safety. Sometimes you just cant stop stupidity without welding stuff closed. Source. I was a CNC operator and now an electrician in the same company. Sorry for my bad English.
Probably removing the key would trigger a bunch of time limited locks in the restart process, and those could be saved. Also it would allow the second guy to start the restart when the first one emptied the main room but not yet left the entire maze. As usual, no amount of safety can prevent deliberate idiots to avoid it.
The operator was performing a live action Indiana Jones and the temple of doom reenactment with all those safety bypasses but forgot that you can't outrun radiation like you can an enormous rolling rock.
There is sort of brutal irony in creating an obvious safety hazard in an attempt to prevent access to a less obvious but much more dangerous safety hazard. It has some logic behind it though. Fall into that pit, and maybe you break a leg. Broken legs are no fun, but they do eventually heal. Acute radiation poisoning is a very nasty way to die. It would never fly in the US, as OSHA would require a guard rail to be installed around the pit. It would never fly in the US. OSHA would require that a guard rail be installed around the pit.
@@russlehman2070 I could just imagine what OSHA would say when that came up on the blueprints. Your not wrong about it being a deterrent but it clearly wasn't enough. Like Siller Barly49 said, they should have put spikes at the bottom.
it takes a special kind of stupidity for a "highly trained" person to actively disable/bypass safety systems to allow them to enter a room with deadly levels of gamma radiation that they KNOW IS THERE.
@@krashd he didn't know, because they had disabled the safety systems. disabling the safety systems was the act of suicide. it was merely a matter of time before the final act occurred.
Every time an operator bypasses safety to go into a room with a source I just think of the Spongbob meme "How many times do we have to teach you this lesson, old man?"
@@DavidCowie2022 and then they actually have to follow the procedure they have just read! I have long since lost count of the production incidents I have investigated where an operator or technician had signed off to say they had read a procedural change then gone straight on to try and do things the old way and expensively crash the process machinery.
@Cen Blackwell The airline industry being a very good case in point. Those thousands of deaths means flying is safer than ever. Though there's still the odd case of the most experienced pilot proving his arrogance all the way into the side of a mountain as the first officer is saying "Sir, Sir, Sir" and the alarm voice is imploring, "Terrain, terrain" "Pull up. Pull up"
@@annakeye Yep, I think aviation is a really good example. In fact, probably mass transit in general - plenty of regulation in the rail industry came from various disasters.
You know you have a competent employee when he knows all the systems of his workplace to the point of managing in bypassing all the safety features of the plant he's meant to supervise... Too bad he died, he would have made a very good security inspector if he survived. "Look, this pit is unsafe, it can be defeated by using a whip to suspend yourself and jump above it. We should add snakes, and maybe a tribe of cannibals too".
Another excellent video John. Doesn't matter how many times one reads about exposure episodes, criticality in a U bend, or an excursion event - I'm a sucker for your diagrams and narration. And the little thingy in the corner before an advert makes me feel all nostalgic!
Excellent episode! I do love a good radiological disaster, even if it does not include a blue flash! From the photos the facility looked either poorly built or poorly maintained, perhaps both. This could help explain the mystery of the raising of the source… or it was an operator issue.
Thanks for the great video. I find these radiological accident videos you do really interesting and your about the only channel that covers this topic.
Pretty interesting case here. Usually with these situations, the safety procedures are non existent or a total joke but it looks here that they were pretty hardcore about it, it’s just someone decided to break the rules
They had excellent procedures on paper, and excellent safeguards in materials, but they couldn't supervise their people properly or teach them the procedures in 1991 Belarus and thus they formed their own ersatz procedures which were insane and dangerous.
Never bypass a safety mechanism. No, there isn't a good reason. No, the ride on mower's engine doesn't need to keep running when you get off. Just start it again. It starts easily once it's warm. No, you don't need to run the grinder without a shield. Just walk around the other side and come at it from a second angle you lazy sod. No, you don't need to save 4 minutes. Just read your newspaper a bit longer and take the key out.
It's a really interesting balance, between "technically safe" and "what people will accept." You end up with a situation with kind of a sliding scale between safety and usability, and tied to that scale is a percentage of people that will alter the setup to make it more usable regardless of safety. So it seems that the really golden mean is making a safety system that is unobtrusive to the operator, and figuring out where this is more by working with actual people than by lawyers. A lot of power and lawn equipment are superb examples, where they have so many safety switches and lockouts that if you're, say, left handed or trying to use the tool in any condition *except* standing with both feet planted on the ground and both hands free, it is virtually impossible to operate. That will absolutely inevitably result in people disabling your safety designs so they can use the tool. Good example of ways around that? Make the mower shut down *the blades* when you get off instead of killing the engine, and reset the startup where all you have to do is slap the deck switch when you get back on to re-start them. For the grinder, do what DeWalt is doing, and make the guard pivot freely around the central axis with a tool-free lever, so you can just spin it easily out of the way without removing it entirely. Things like that, where you make it simple enough that the operator doesn't go "oh great, more lawyer s^^t" and simply zip-tie down the safety bar, remove the switch block with a pair of snips, etc.
No, you don't need to take your safety glasses off to see what you're doing. Clean your fucking glasses like you're supposed to and you'll always be able to see what you're doing.
The easy solution here would honestly be to make the counterweight also function as a gate. As long as the irradiator is up, the gate is down, and you cannot enter. Though, that said, i have no clue how much the irradiator weighs.
What Marc-André said. I was about to comment similar, why not have a door that only works with the on/off key, but yeah, the products also need to get in.
@@marc-andreservant201 How so? The gate closes as long as the irradiator is in the irradiating position, which is the position you don't want it to be in when a person enters. Person goes in, places material inside, leaves, and then the irradiator is lifted out of the hole it is in, thus also closing the gate.
@@Jourei_ So? You put the irradiator in the down position, which opens the gate. Then you put the product in, leave, and put the irradiator back up, which shuts the gate. Unless i completely misunderstood how this device works, i don't see the issue. Also, the reason i'm thinking this is a good solution is that you'd have to have quite a spectacular series of events unfold for this failsafe to not work.
It's absurd that the operator forgot his key in the console. I mean, that's his main responsibility to allow no one else access. I don't they were honest. Furthermore, I think it's more likely that they did a couple of modifications to the safety system to allow quicker entry, and it's required that the key stayed in position to quickly start again. They probably reversed that before anyone could check for this in fear of punishment. The operator has had to pay the price for that - while probably not responsible.
The old saying that "familiarity breeds contempt" is absolutely true when people work daily in dangerous situations. You may logically still know that something is very dangerous, but as you get used to it your brain stops seeing it as a threat. Someone new to a danger will treat it very warily, someone very familiar with it can become over confident and careless. I'm not surprised at all that the victim here was someone who had worked there for a long time.
Plainly ( John ) ,as usual a fantastic explanation of a completely preventable disaster. This guy definitely felt under pressure to get things moving as fast as possible. I feel he did grab the transport rails and simply hand grabbed his way over the pit. His stupid refusal to simply admit anything shows his method. Strange as it sounds,there is a phenomemonon with electric motion systems that I call bounceback. If a switch fails to set itself properly,the object in motion will reach the end of it's travel and it will then start back in the other direction of it's travel. Not a big deal in a electric window of a car but a horrible thing in this case. Did bounceback happen here? Who knows. But this man would still be alive if he simply followed all the rules. I cannot think of a more horribly slow way to kill yourself. May he rest in peace.
I’m surprised so far in my country we haven’t had an issue like that, or any other nuclear accident. And we build our own nuclear reactors for energy, build reactors for other countries and both medical and research reactors.
Man I always wondered if I'm the weirdest nerd cuz I've been reading those IAEA reports over and over. They're just so fascinating and incredibly well-documented! So cool to see you making them into videos, I really enjoyed it. At least, it seems, there's two of us!
This is very good reasearch and reporting. I am sure most of us would never know about these events, but they are important for reducing risks in the future. Also, your animation dialog is entertaining, to say the least! Wonderful work. All good wishes.
Unfortunately, the longer you work in a dangerous work environment the less you think about, just how bad of a situation you are in…. I worked at a steel mill, in the continuous caster unit. Was around liquid steel day in and day out. It’s amazing what you can “get used” to……
30 petabequerels is pretty close to one megacurie. That is a LOT of radioactivity, especially seeing as 60Co is a pretty "hard" gamma emitter (two principal peaks at 1.2MeV and 1.33MeV). You really don't want to be anywhere that much activity. For this source intensity, you're still receiving a dose rate of 100microCi almost two kilometres away!
A little story from a warehouse somewhere: A newly built part of my workplace opened a few months ago. In this department there is a long roller conveyor from which operators take items off as they work. The conveyor is about at chest level and it is about 20m long with workstations on the side. This conveyor has an emergency stop button at about every 5 meters. I approached a manager and asked why this conveyor does not have a pull cord along it? The buttons are out of reach for most of the operators and there is a real danger getting stuck. The answer: Yeah, but if you keep all the rules and pay attention all the time, you are not going to get stuck. What if you trip in something? What if there is something slippery on the floor? What if...? As long as we have these detached from reality corpo-rat wiesels everywhere who keep the OSHA lexicon on they night stand as a bible and unwilling to use common sense and make changes were necesary, minimum wage employee blood stays the prefered ink for safety rules. EDIT: I no longer work there. Followup on the story: I approached multiple managers and filed two written complaints about the matter and according to my source who works there, there are still not enouh safety buttons. Also the main drive belt of this roller conveyor (a 5cm wide wowen belt driven by five 2kW motors) is exposed underneeth wuthout any protection. Good job corporate!
Too much time pressure, routine, sometimes incompetence and sheer sloppiness are the main reasons for such things in my experience. Have been working in industrial production for 4 years. Worked at a small chemical plant producing colours for one year - in that time I walked out of the facility in a hurry twice after warning my superiors of an explosion hazard and being ignored. My direct superior was clueless and the fire prevention "expert" was a heavy-drinking alcoholic. Top staff. ^^
@@PlainlyDifficult Uh, the man himself, what an honour! ^^ Yeah, it was a great relief to finally leave the place. I also encouraged people I liked to get another job, too.
I'm a veterinary nurse and use many single use items that are sterilized with radiation. I never really put thought into the people who work the dangerous job of actually doing the sterilizing.
Probably be a lot safer if the product were raised up into the radiation chamber or room.. that way if there was a jam, they know without a doubt- go into that chamber and your're going to die. They would know that the product must come out some other way, no matter what. Sad situation. I love the narration- it's the most pleasant I've ever heard! Thank you :)
My first degree was in chemistry and my university had a thorium room. Wow, the safety around this room was like nothing on earth. Everybody knew that entering would mean death so we knew not to enter. I wonder what was going on in this man’s mind as he must have known too. He paid the ultimate price…
Sounds like jams were routine and the operator bypassing the safety systems in order to quickly clear the jam was routine. What was different this time is that the emitter was in the up position. I have had enough conversations with trade guys that complain about all those OH&S mandated guards getting in the way of their work to get an inkling of what happened here.
I love that you have pictures for this one, had a hard time visualizing the San Salvador one, that is a very corroded facility, they were in dire need of a anti-oxidant paint day.
IIRC one of the Murphy's Laws states that it's absolutely impossible to make any piece of equipment foolproof. People find it challenging to solve problems along the path to their untimely demise...
I'm recent subscriber, really enjoy your format and you have subjects I've not heard of before too. I actually worked at Flixborough docks for a couple of shifts 10 or so years ago, so that one was especially interesting to me! Thanks for your work 🤓!
Do you have any plans to cover the recent exposure of Russian troops digging, manning and living in trenches in and around Chernobyl and the red forest?
I reckon he would have to uncover documented evidence that it actually happened and isn’t just wartime propaganda. Considering the plethora of fake stories coming out of Ukraine that have later been admitted to as being made up to boost morale and garner support, I’m leaning towards no on this one.
@@TheSaltyExplorer like the evidence gained from the radiation sensors all around Chernobyl that are internationally monitored and their increase, some even going off-line, during the Russian invasion in the region?
@@TheSaltyExplorer I wouldn't think trench-based stuff particularly likely, but the tracked and wheeled transport vehicles would and did stir up a lot of radioactive material. The length of exposure, type of exposure and the isotopes around would be very difficult to ascertain. I took your comment to mean you did not believe that there had been any increase in radioactive activity rather than the nature of the troop activity.
When dealing with an invisible danger...such as intelligence....or radiation.....one must think their actions through thoroughly before acting.......not after.
I have designed and programmed industrial safety interlock systems (category 2,3,4); not for nuclear facilities but printing mills and filling systems. On one job site less than 4 months after completing an upgrade to the safety interlocks of an offset printing line an operator who had run the machines for 20 years was killed. He had deliberately by-passed the safety systems to observe what he thought was a mechanical fault. He closed a service access gate behind himself while in the path of the machine and then instructed the junior operator to start it. He was crushed when it started. Accidents, machine failures, absent mindedness may be guarded against but deliberate and planned suborning of safety protocols and systems is impossible to prevent.
A very good episode and adequately thorough. Most of these accidents appear to be in parts of the world where circumventing the rules is part of the culture. You should do an episode about the recent Chernobyl incident where Russian soldiers made sand bags with soil taken from the red forest. (Now called the yellow forest)
You know, it makes me think these sort of devices should have a sort of dead-man's switch like they have in subway trains. Example: While irradiating, the user must hold down a button to keep the source in the active position. The moment pressure on the deadman's switch is released, the source automatically drops down into the safe position and the system has to be restarted manually.
Dead-mans switches are routinely bypassed. Just put something heavy down on the switch/lever/pedal/etc and you've gotten rid of the safety mechanism entirely. So you have to design around that as well. The more obnoxious the system feels to the operator, the more incentive to defeat it.
@@henke37 I think you're mistaken. The one I visited runs 24/7 when it is busy enough to justify it. It has a large conveyor system where dozens of boxes of materials (fruit, bandages, etc) sit on conveyors with the exposed element for several days, ~100 hours if memory serves. The conveyors loop around the central core in such a way that all sides of the boxes are exposed at one point or another, and every hour or so the computer moves the conveyor 3 feet or something. After ~100 hours or whatever a given box emerges on the other side, as sterile as the Moon and smelling faintly of ozone and other gaseous free radicals released by the gamma bath.
I really love your videos. Simply... fantastic work, educating and entertaining at the same time with really nice presentation. Thank you for all your work!
As a retired major-crimes investigator, my suspicion lies with the assistant, who could easily have gone to the control room when the victim entered the chamber and raised the rack. I wonder what their relationship was. Also what the professional climate was like at the establishment and whether the assistant would benefit from the removal of the victim from the workforce.
Always, always, ALWAYS know and *respect* your equipment. I work with stone heavy grinding wheels and sharpen steel for work on a daily basis. Those wheels spin about 3600 rpm and they're about 8 inches in diameter and a half inch thick. Catch that thing in the wrong spot and you're either getting partially degloved (the nasty kind, don't Google it) or losing a few fingers. Has yet to hurt me in 15 years because I'm always on alert when my equipment is in use. Contempt breeds disaster in a busy and dangerous work environment.
No matter how much you idiot-proof things, there will always be at least one idiot who is just smart enough to get around your safeguards and hurt himself.
What gets me the most about this one is that the operator had to have done something intentionally out of line to end up in such a way and even after knowing he's going to die is so stubborn about it refuses to disclose exactly what he did. Like, my guy, you're not going to get in much more trouble than being dead.
I think... If I had to design a system to do similar exposure, I'd add a physical lock on a door that uses the same key as what is used to arm and disarm the rack. Sure you might be able to work around that by picking the lock, but it's probably easier to just go grab the key by that point.
After watching all these radioactive and industrial disasters (and wondering how many happened/happen without anyone figuring out), I'm not surprised that there are so many cancer cases around the World anymore...
It's so sad to see these incidents at both style plants, when the ultimate engineering solution is so damned simple I'm shocked neither company figured it out. Put the counterweights in the way of the maze path! Turn them into a door, literally... and of course have some pins on the mechanism so it can be disconnected, dropping the weight AND the source immediately if it starts to rise while occupied. If you want to go double extra, have a little pushrod that moves when the source is exposed and physically blocks another door closed. Don't concern yourself with pits and pressure plates, make it so you physically cannot enter the space without the source being in it's storage position. If it breaks with the source up, that's why god invented bolt-on hatches, with LOTS of big bolts so whoever's going in has plenty of time to think about it. Maybe even tack weld a nut or two on where it's easy to grind.
Not glorifying radiation disaster...but it's very fascinating..impressive that this element makes...a technology that could revolutionize a lot but we just don't know how to deal with it..! See Joema's disaster!
As an engineer I can tell you with 100% certainty the designer was an Indiana Jones fan, AND he sucks at his job. The rack should always fall into the isolation pit when unpowered.
People get complacent at work and begin to take shortcuts, no matter how qualified. My Dad is a dentist and was trained on how to you use a strong halogen lamp to harden synthetic materials used to reconstruct damaged teeth. Somewhere along the way he decided that putting on the protection goggles was too annoying and that blinking and squeezing his eyes shut was good enough. Now he can only work with extremely strong glasses because he ruined his eyes.
I hope you enjoyed the video, do you have any suggestions for future videos? Let me know below 👇
Where did this fall on the patented scale?
hey mate, you fix that bit about the Armenian Deportations yet?
You could also do a video on why the Armenians were not "deported" and instead were the victims of "genocide"
Did you do a vid on Alexander Litvinenko?
The dose of radiation he received was comparable to this one, although obviously receiving it internally would be that much more devastating. The fact that either victim didn't die within days is a testament to the toughness of the human body...
Medical linear accelerator incidents would be interesting topics... Therac 25, the Neptun linac overdoses in Poland, etc. I'm a medical physicist, if you do videos on any of these I'd be happy to field any questions you'd have about them.
Designers: We literally took the floor away to prevent you from harming yourself.
Operator: ¯\_(ツ)_/¯
Universe- "Built a better idiot!"
If it was modern day I'm sure he would have shouted "Parkour!"
Operator: hold my beer... lol
"I've seen this one on Funniest Home Videos."
The floor is not dying of radiation poisoning
Man, this is kind of a weird one where *nothing* really broke down, the safety was reasonable and strong, the system was well-designed, the operator was trained... Cripes, just guess it goes to show that familiarity with a system breeds a lot of contempt for the risks. At least the only guy that got hurt was the one that did the stupid himself, and he didn't take anyone else with him.
The radioactive emitter was not stowed, despite the worker pressing the button that stows it. I'd call that "something major breaking down."
This is why you engineer redundancy into safety-critical situations, and hopefully hire people with the wisdom not to subvert the redundant systems, on the logic of, "well, the first step should be enough, right?
that just shows that no matter what you do the world will always find a better idiot to get around your safety systems
It’s true. There was a guy near me that ran potato harvesters for years with no issues. They’ve got cleaning rollers that bounce the dirt off the spuds and pull out stones and roots. One day something got jammed on the rollers so he poked it down with his boot. The rollers grabbed him and ripped the meat off his leg and mangled his D and Bs. Just one dumb moment will put you in a bag.
@@NinoJoel This case shows there is no hurdle slav will jump over to get in harms way. Source: russian dash cams, also am slav.
The safety was stupid as hell, are you nuts? It is a very good example of the illusion of failsafe. This sort of this is the most dangerous because it looks smart but its terrible.
I find such accidents terrifying. That operator made a fatal mistake, and probably knew, within days, that he would die. He had three months, suffering horribly, knowing that his mistake will cost him his life. That's what I find so frightening with radiation accidents... the knowledge that you're going to die in weeks.
Just give me a cocktail of drugs and let me slip into the next life at that point.
chronic illness is also crazy like that, you don’t recover from that foreboding feeling you get when you realize how fragile you are. i tell that to ppl who have very ill loved ones
I know right? I'm just stunned that someone would take shortcuts with such a scary piece of equipment. I can't imagine what went through his head as he realised he was exposed after having circumvented some safety systems.
I reckon he knew as soon as he made eye contact with the source rack. That’s a hell of a dose.
ya that's the creepy part, these guys know they're going to die and have a matter of hours before their bodies start reacting to the trauma so they can walk out of these facilities 'fine' and give interviews before dying to radiation poisoning
I worked in a mine and steel factory Q&A lab, we had plenty of dangerous stuff and an equal number of procedures about how to deal with unforeseen situations regarding those risk factors (heat, pneumatic stuff, radiation, aspestos, etc). I always respected veteran operators, but if they tend to do one thing, is discard those exact procedures in favor of not interrupting productivity etc. This works fine as long nothing happens, and maybe you get away with it for decades, until you don't. It's really difficult to deal with these colleagues with more experience and authority, but also have grown insensitive to the actual dangers. More often than not, the culture in management is to blame.
In my experience the culture in management is to implement more rules, instead of disciplining the offenders who failed to follow the rules already in place. Especially if the industry you work in makes it difficult to fire worthless people due to fear of being sued.
This. In highly dangerous scenarios where neglecting maintenance can lead to high casualties, machines SHOULD be stopped for maintenance. Unfortunately, the higher-ups in those companies/labs are more interested in capital than the safety of their employees.
Doing it dangerously incorrectly for 20 years is NOT "experience"... It does NOT provide any form of useful practice. Just because you "get away with it" doesn't make it alright for another 20 years. That's what too many of these so-called "veterans of the industry" can't seem to get through their heads.
I might ride a motorcycle for the next 20 years without a stitch of gear or helmet... and be fine. That does NOT make it right when something goes sideways and I'm caught completely unprepared for it. ;o)
@N Fels Sounds like you are my type of manager. Never give up on the good fight.
@@gnarthdarkanen7464 You're perfectly right, but sometimes when you work in a complex system those veterans have a way bigger picture of the process than you do due to their experience. But that same awareness can then bite them in the ass when they try to "play" said system and processes though, because their priority is to resume productivity ASAP, not safety, and in my experience the older the operator, not even quality anymore. This gets encouraged by managers that favor workers that bring no problems to them, over workers that bring them up.
I guess he did't bother checking his Scintillation counter when he was actually near the check source for some bizarre reason.
Wodka makes things straight forward ... 😅
The guy said he was "tired and can"t remember ....."
I live in Poland, and this means over here DRUNK as a SKUNK ...
@@TomKappeln With a dose of 12 Gray in just a few minutes, it's also possible that his memory was affected.
@@HenriFaust His brain was Gamma Ray blasted I'll bet.
Welp nice to see you here
@@HenriFaust Proper use of a meter is meter out front eyes on the needle and you start with the lowest scale. At 1,200 Rad an hour disorientation can certainly happen but I bet he did not check the meter or lied about taking it with him. If he was worried about time he would not go back for it. Also, he was deceptive about how he got across the plate. There is always the possibility he used the meter properly and was able to get in since the source was properly shielded then it was raised while he was inside. Could have been someone at the control panel since he left the key in. Need to get a dose map of the interior and see if the dose he got matched up with the area he was for the time he was in the room.
One small point: isotope irradiators that use highly gamma-energetic rods that need to be stored underwater are becoming more and more uncommon. Aside from the obvious issues with keeping a caged tiger that's angry 24/7, they found that a lot of them leak radiation into the water and then subsequently contaminate the entire building via evaporation. They are being replaced with electron beam irradiators that are vastly safer and easier to work with, although much more expensive. It's nice to be able to actually turn the death beam off when you're not using it.
Although there are some subtleties in the "beam off" condition. When the electron source is turned off, but the accelerating field is still present, stray electrons entering the field continue forming a beam. This "dark current" beam is very weak compared to the normal beam, but can still cause serious injuries.
This problem is serious in potential-drop accelerators, where the accelerating field decays gradually after the machine is switched off. This requires a substantial waiting time until the field reaches negligible levels, making it safe to enter the beam area. Incidents have occurred where premature entry led to serious radiation injury.
(RF accelerators have essentially instantaneous decay of the accelerating field, so they're safe immediately after switching off, but they have even higher costs since they use more electricity for the same beam power).
@@CoastalSphinxYup. With a photon detector you could observe the same effect in most CRTs. The anode remains charged, and thus provides accelerating field, for a very long time. There are electrons accelerated into the middle of the screen even with cathode stone cold. Just not enough to see with any illumination, and sometimes too few to see with a naked eye in darkness as the phosphor becomes inefficient when the electron energy is too low. Large color TVs from 70s and 80s had a central CRT glow barely visible in total darkness for hours after the TV was turned off. I was fascinated with it when I was a wee lad. It was too dim to see by adults past their 30s, but certainly very obvious to me and my young siblings. Kids with normal vision have excellent retinal sensitivity, it goes downhill once you turn 25 or so.
@@absurdengineeringI remember wondering why the screen flowed for so long after the tv was turned off, thank you for the explanation!
@@absurdengineeringwhen we look back and remember our parents saying DONT STAND SO CLOSE TO THE TV.... looking back... man those things were fkin weird machines. having a thing glowing for hours even when off next to your kids heads mustve been very uncomfourtable when TVs came out
not safe like those ciggies we use to smoke when pregnant tho
For the Soviet built the safety systems were actually pretty impressive - huge pit, pressure plate - it's like from Indiana Jones movie, and yet it's so simple solution it makes you wonder why wasn't it implement in every facility in the world.
But no poison arrows getting fired at you :(
@@mikeydk Maybe that is what they need, tranquilizer darts or knock out gas so you physically cannot proceed any further. Because obviously if your continuing on common sense and more warnings are not going to stop you.
@@mikeydk Invisible poisonous "darts" at the end, though.
Maybe because the Soviets also implemented communism, where a shoe factory manager can be promoted to be a reactor operator and “whoops…” meltdown.
@@D3M3NT3Dstrang3r Ah, aggressive safety system. I love the idea!
He "Prince of Persia'd" his way to his own horrible demise.
People always think they know best. As a person, I can attest to this. I have gotten lost, electrically shocked, wet, sad and more, as a result. Thankfully still alive. Keep me out of the dangerous trades...
Very good way to describe it!
Seems like what an alien would say...
@@amberblyledge7859 Hello fellow human how is your being? ;)
Nicely explained 👍
I worked in oil fields for 7 years as a crude oil hauler. Whenever some incident would happen, the driver involved would inevitably lie about how the incident happened to try and save his job or bonus. Once he was cleared to continue working, or even if he wasn't, he was always forthcoming to the other drivers as to what _actually_ happened.
The other drivers wouldn't tell the supervisors and the incident was considered closed.
Only if the driver ended up fired would they usually get the whole truth of what happened.
Chalk that up to human nature. If you're more motivated to avoid the consequences of your actions, expect the person in question to lie.
Bottom line: talk to the other employees until you get the truth. Someone else knows what really happened.
People cover everything up.
They usually don't find out till spring time anyway.
"Balls"
"Yes balls"
I absolutely love that you always inject some humor into these.
I'm currently binging your entire channel while I work. Thanks for keeping me company!
Balls
Balls
@@dpadjoystick Yes balls
Is balls some British slang or what? I always laugh at it but it makes me wonder
I catch myself wondering "what kind of idiot would bypass established safety procedures" but then I personally have experience with people doing the same things! Like, in a confined space with an air quality monitor. Using isopropyl alcohol to wipe down the inside of a tank, even with massive ventilation, eventually the fumes build up to the point it is hard to breathe and unsafe. I was inside one time and we'd gone out several times to let the air clear a bit after the monitor alarmed. The final time, we were really trying to finish, it got to the point I thought "holy shit my eyes are on FIRE!" I walked up the ladder and the custodian said the monitor was about to alarm, so everyone come on out. Everyone got out and went down the lifts fine. TURNS OUT the monitors start from 0, and ramp up over time. If you just keep turning the monitor off before it alarms, it never alarms! Thanks, confined space custodian!
Just goes to show that, no matter how hard you try to make something idiot proof, some clever idiot will find a way around it.
It's a "the rules don't apply to me, only to idiots" deal really.
People break safety regulations all the time. For example, speeding in their car.
They are so good at driving that they are ENTITLED to speed. The speed limits are too low, the speed limit only applies to grandmothers and other bad drivers. The speed limits are only there to punish people going over them with fines, it's a racket...
There's all kinds of explanations really, but at the end of the day. The speed limit isn't there because you can't go over it without crashing. It's there because in the one out of a thousand events, the lower speed will save lives. And i am not talking about when crashes happen either. I am actually talking about when something unexpected happens that COULD lead to a crash.
Going 80 mph on a 65 mph road means what could have been not a crash is now most definitely a crash, with potential death to follow for the driver or other victims on the road.
So yeah, it happens all the time. And people die a lot more than they otherwise would.
That custodian would have been tasting knuckles if they'd pulled that trick on me!
@@RealCadde Humility is a shocking rarity.
Bored workers trying to save time and effort will put the Mission Impossible guys to shame every time. Sadly it always catches up to them though. 😕
My headcanon is that the engineer planned for the pit to be filled with snakes but that was dropped because appropriately venomous snakes could not be sourced. The swinging guillotine blades triggered by the pressure switch were cut for budgetary reasons.
No, asps and serpents require upkeep - Feeding, cleaning. Far too expensive. The blades themselves are of course an OHS violation.
Please don't use that word outside of your parents basement thank you.
*Indiana Jones theme gets louder*
@@dalegribble1945???
I think he concocted the story about leaping over the pit and the pressure plate as a way of protecting his assistant from criminal charges.
There was no reason for him to avoid the pressure plate.
I think he followed the rules for entry.
Used his key, walked into the exposure room and was working on the track with the source down.
At some point he asked his assistant to take the key and jog the track from the control room while the operator observed the track.
The assistant misunderstood what the operator wanted (or he was still unfamiliar with the control panel ) and instead of turning the track on and off , he raised the source.
When the operator noticed the counterweights moving he ran out of there as fast as he could , but still received a lethal dose.
The operator was a dead man and he knew it, he also knew that it was mostly his own fault to begin with ,so he made up a story that put all of the blame on himself.
There was a reason for him to avoid the pressure plate. If the pressure plate is activated, the Co-60 source is dropped into the storage pit, meaning a loss of time (and production, which never went well for you in the Soviet Union). See the video at about 4:34. Apparently he wanted to NOT trigger the shutdown, which is strange because pressing the panel shutdown button also moved the Co-60 source to the storage pit--which the Senior Operator did, temporarily ending production.
In a hurry he leaves the safety key in the control panel, leaving the "safety pit" floor open, so he can't enter the irradiation chamber, which he wants to enter to find the jammed rack or tray. This is why the Senior Operator's story is suspect; it doesn't make sense. All the Senior had to do was go back, remove his key, the safety pit floor would extend, he could enter the chamber with the rad source safely stowed (supposedly, assuming the door interlock and entire system worked right; he needed the safety key to unlock the maze room door. But now he's playing MacGyver trying to bypass a safety system when he doesn't have to.
So now we look at the Asst. Operator. IF the source was in the storage pit, there would be only a minimal radiator hazard (if any) to the Senior Operator. So if the Asst. Operator made a mistake, there would be no safety override to keep the source shielded, since the pressure plate would not trip the shutdown, and the push-button shutdown on the panel would be overriden with the safety key still in the panel. Did the Senior tell him "Dimitry, move the rack please", and the Asst. Operator moved the source rack instead by mistake? Or did the source rack get stuck on the way down, and the panel did not have sufficient indicators of the rack's exposure? But that conflicts with the Senior Operator's story of the radiation detector not showing a reading matching an "exposed rack" when he used the detector (the readings would be much higher than if the source rack was in the enclosure). Yet the source rack was exposed per the victim's statements. His dose was consistent with the source rack being exposed.
It is very possible that whatever actually happened (the Report notes there are inconsistencies in the stories told, results of equipment inspection and testing, etc.) the story the Senior told was to take the blame for the Asst. Operator making a terrible fatal mistake or more.
Bingo!!!! I see situations like this daily in our warehouse yet only 1 in the past 5yrs I've been there has been fatally injured (not to say that there won't be a handful more before retirement) but complacency breeds and fuels dangerous, yet avoidable, situations.... Especially when it comes to production lines and corporate only caring about THEIR bottom line and not OURS- the worker aka the life(s) on the line!!! Complete shitshow on a daily basis for top pay seems like a risk many will take (not me- I got kids to raise) and am a stickler for doing things the "right" way the first time, screw the higher ups that don't know f@$k all about day to day operations...not worth it!
This was my thought also. The assistant would likely have been in line for some draconian Soviet-style punishment. The operator saw no reason for _two_ people to have their life destroyed over a misunderstanding.
Interesting theory, but if he had ran as soon as the source rack went up, he would have received a much lower dose. He has to have had spent some time in there with it.
@@markh.6687 We'll never find out what actually happened but you've sold me. It's not like the Belarusian authorities valued honesty, that seems mostly likely what happened. He kept the key in to fix it fast and the assistant hit the wrong button, overriding security because of the key. Big shame because apparently there was a lot of redundant security on this thing for once, they just overruled it.
There's an old engineering saying: "I can fix stupid, I can't fix BLOODY stupid". The safety systems were amazingly thorough, and yet the accident still happened.
This is what is known as an "ID10T" error. In any system, the human factor is the most dangerous. Pressures of production and a "I know how this works" attitude are not a good combination.
There is also an element of "familiarity breeds contempt" here. The experienced operator (also an engineer) not only knew how the system worked but ALSO how to bypass the safety protocols.
There is a factor regarding the difference between using a dry pit and a pool to contain the source rack when in the lowered position.
If the lowered rack is in a pool of water, there is an (unofficial) indicator-Cherenkov Radiation from the interaction of the radioactive source with the water in the pool.
The lack of a blue glow coming from the pool is an indicator that the rack has not been properly lowered.
It's not foolproof (you'll still get the glow if the rack is only partially submerged, but it is an extra thing to check.
Perhaps all facilities like this need to have the kind of checklist protocols that airline pilots use. Two people, each checking to make sure that everything on the list has been done.
Definitely is needed
?
This guy had worked there since it opened so he may not listen if the other person said hey you can't do that.
Incorrect: the safest way to enter a radiation room is not to enter a radiation room
This is simultaneously the wisest and dumbest sentence I've read today.
There are no shortcuts when it comes to radioactive materials, it's either do it right or die a rather unpleasant death, or at the very least, survive with fewer body parts and high chances of other complications causing an unpleasant death... :\
I have to wonder: Did climbing across the pit, and doing whatever he did to defeat the pressure plate really save time over doing it the right way: Pulling the key and using it to close the pit? Or was there some malfunction in the pit closing mechanism that led the worker to improvise a workaround?
As someone who works in a post soviet country I can tell you a lot of sad and dumb stories of people bypassing safety equipment in CNC machines.
Ive seen so many unscrewed interlocks by simple workers because "manually adjusting a machine is faster this way and you don't have to stop the production too many times wich might get you into trouble".
Most of the time they get a verbal warning thats all.
Yet still we got so many stabbed hands and cut off fingers that the higher ups of my workplace decided "damn it lets weld the interlocks shut and drill the hexagon screws". For safety.
Sometimes you just cant stop stupidity without welding stuff closed.
Source. I was a CNC operator and now an electrician in the same company.
Sorry for my bad English.
Being it was Russia it didnt work correctly
@@poiiop2626 english is perfect mate
Probably removing the key would trigger a bunch of time limited locks in the restart process, and those could be saved. Also it would allow the second guy to start the restart when the first one emptied the main room but not yet left the entire maze. As usual, no amount of safety can prevent deliberate idiots to avoid it.
@@poiiop2626 Your English is far better than that of many Americans I've encountered!
Hello from Canada. :)
The operator was performing a live action Indiana Jones and the temple of doom reenactment with all those safety bypasses but forgot that you can't outrun radiation like you can an enormous rolling rock.
😂😂
And he didn't have a lead-lined fridge to hand either.
The rolling rock scene is from raiders of the lost ark, not temple of doom.
OK I love the death pit security system. I get the feeling the architect was a big Indiana Jones fan.
There is sort of brutal irony in creating an obvious safety hazard in an attempt to prevent access to a less obvious but much more dangerous safety hazard. It has some logic behind it though. Fall into that pit, and maybe you break a leg. Broken legs are no fun, but they do eventually heal. Acute radiation poisoning is a very nasty way to die.
It would never fly in the US, as OSHA would require a guard rail to be installed around the pit. It would never fly in the US. OSHA would require that a guard rail be installed around the pit.
All that was missing was spikes at the bottom of the pit, and a pressure plate that shoots poison darts out of the wall
@@russlehman2070 I could just imagine what OSHA would say when that came up on the blueprints.
Your not wrong about it being a deterrent but it clearly wasn't enough. Like Siller Barly49 said, they should have put spikes at the bottom.
@@sillerbarly4927 and a knight with a cup.
Or a giant bolder that falls from the ceiling and rolls down the maze
it takes a special kind of stupidity for a "highly trained" person to actively disable/bypass safety systems to allow them to enter a room with deadly levels of gamma radiation that they KNOW IS THERE.
Deserves a mention in the History of Stupidity.
It's horrible, but there were so many things in place to keep this guy from doing what he did.
Except he didn't know it was there, if he had known the source was there then this would clearly be a suicide.
@@krashd he didn't know, because they had disabled the safety systems. disabling the safety systems was the act of suicide. it was merely a matter of time before the final act occurred.
the absolute joy i get when i see you’ve uploaded a new radiation incident is absurd 🤣❤️
Thank you
i will get into a radiation incident to get featured on this channel because its my favorite channel
@Sam A. Murphy Does it make you feel...radiant?
Every time an operator bypasses safety to go into a room with a source I just think of the Spongbob meme "How many times do we have to teach you this lesson, old man?"
As usual, regulations and safety procedures tend to be written in blood. Excellent video as usual!
Yes they do indeed. 🤔
Write your regulations however you like, you still have to make people read them.
@@DavidCowie2022 and then they actually have to follow the procedure they have just read!
I have long since lost count of the production incidents I have investigated where an operator or technician had signed off to say they had read a procedural change then gone straight on to try and do things the old way and expensively crash the process machinery.
@Cen Blackwell
The airline industry being a very good case in point. Those thousands of deaths means flying is safer than ever. Though there's still the odd case of the most experienced pilot proving his arrogance all the way into the side of a mountain as the first officer is saying "Sir, Sir, Sir" and the alarm voice is imploring, "Terrain, terrain" "Pull up. Pull up"
@@annakeye Yep, I think aviation is a really good example. In fact, probably mass transit in general - plenty of regulation in the rail industry came from various disasters.
You know you have a competent employee when he knows all the systems of his workplace to the point of managing in bypassing all the safety features of the plant he's meant to supervise...
Too bad he died, he would have made a very good security inspector if he survived. "Look, this pit is unsafe, it can be defeated by using a whip to suspend yourself and jump above it. We should add snakes, and maybe a tribe of cannibals too".
Another excellent video John. Doesn't matter how many times one reads about exposure episodes, criticality in a U bend, or an excursion event - I'm a sucker for your diagrams and narration. And the little thingy in the corner before an advert makes me feel all nostalgic!
Excellent episode! I do love a good radiological disaster, even if it does not include a blue flash!
From the photos the facility looked either poorly built or poorly maintained, perhaps both. This could help explain the mystery of the raising of the source… or it was an operator issue.
Man, I'm from Belarus and my university roommate was from Nesvizh. Never knew about this accident. Thanks for the video!
This guy was so hell bend on getting radiation poisoning he defeated a bunch of dnd dungeon traps.
I'm watching this half asleep using a projector, the shadow of that guy at 0:50 nearly gave me a heart attack!
Lmao
Just want to say I really appreciate the upgrade in your subtitles recently!
Thank you
I am flabbergasted at the number of these radiological incidents that you have brought to my attention John.
Well done as always !!!
Thanks for the great video.
I find these radiological accident videos you do really interesting and your about the only channel that covers this topic.
"Balls"
"Yes, balls"
Accurate summary of the situation. Lol
Thank you
Pretty interesting case here. Usually with these situations, the safety procedures are non existent or a total joke but it looks here that they were pretty hardcore about it, it’s just someone decided to break the rules
They had excellent procedures on paper, and excellent safeguards in materials, but they couldn't supervise their people properly or teach them the procedures in 1991 Belarus and thus they formed their own ersatz procedures which were insane and dangerous.
Never bypass a safety mechanism. No, there isn't a good reason.
No, the ride on mower's engine doesn't need to keep running when you get off. Just start it again. It starts easily once it's warm.
No, you don't need to run the grinder without a shield. Just walk around the other side and come at it from a second angle you lazy sod.
No, you don't need to save 4 minutes. Just read your newspaper a bit longer and take the key out.
And protect the lungs! A good VOC respirator can protect your lungs perfectly.
It's a really interesting balance, between "technically safe" and "what people will accept." You end up with a situation with kind of a sliding scale between safety and usability, and tied to that scale is a percentage of people that will alter the setup to make it more usable regardless of safety. So it seems that the really golden mean is making a safety system that is unobtrusive to the operator, and figuring out where this is more by working with actual people than by lawyers. A lot of power and lawn equipment are superb examples, where they have so many safety switches and lockouts that if you're, say, left handed or trying to use the tool in any condition *except* standing with both feet planted on the ground and both hands free, it is virtually impossible to operate. That will absolutely inevitably result in people disabling your safety designs so they can use the tool.
Good example of ways around that? Make the mower shut down *the blades* when you get off instead of killing the engine, and reset the startup where all you have to do is slap the deck switch when you get back on to re-start them. For the grinder, do what DeWalt is doing, and make the guard pivot freely around the central axis with a tool-free lever, so you can just spin it easily out of the way without removing it entirely. Things like that, where you make it simple enough that the operator doesn't go "oh great, more lawyer s^^t" and simply zip-tie down the safety bar, remove the switch block with a pair of snips, etc.
No, you don't need to take your safety glasses off to see what you're doing. Clean your fucking glasses like you're supposed to and you'll always be able to see what you're doing.
Me, who actually _likes_ doing projects:
'wait .. you WANT chemically nerveshot hands at only 40 years old? 40 is waay too young for me!'
@@komitadjie Yes, make safety intuitive. Ideally, make it more useful than not having it.
Dying of radiation poisoning is my worst nightmare. It's always a slow very painful death..
Very illustrative. Designing security systems to avoid these incidents seems like a very interesting job.
The easy solution here would honestly be to make the counterweight also function as a gate. As long as the irradiator is up, the gate is down, and you cannot enter. Though, that said, i have no clue how much the irradiator weighs.
This would prevent the entry of products in the irradiation room, defeating the purpose. You only want to prevent humans from entering.
What Marc-André said.
I was about to comment similar, why not have a door that only works with the on/off key, but yeah, the products also need to get in.
@@marc-andreservant201 How so? The gate closes as long as the irradiator is in the irradiating position, which is the position you don't want it to be in when a person enters. Person goes in, places material inside, leaves, and then the irradiator is lifted out of the hole it is in, thus also closing the gate.
@@Jourei_ So? You put the irradiator in the down position, which opens the gate. Then you put the product in, leave, and put the irradiator back up, which shuts the gate. Unless i completely misunderstood how this device works, i don't see the issue. Also, the reason i'm thinking this is a good solution is that you'd have to have quite a spectacular series of events unfold for this failsafe to not work.
If the irrigator jambs in the up position, it would be impossible to fix it.
It's absurd that the operator forgot his key in the console. I mean, that's his main responsibility to allow no one else access. I don't they were honest. Furthermore, I think it's more likely that they did a couple of modifications to the safety system to allow quicker entry, and it's required that the key stayed in position to quickly start again.
They probably reversed that before anyone could check for this in fear of punishment. The operator has had to pay the price for that - while probably not responsible.
Everyone is responsible for their own safety.
The old saying that "familiarity breeds contempt" is absolutely true when people work daily in dangerous situations. You may logically still know that something is very dangerous, but as you get used to it your brain stops seeing it as a threat. Someone new to a danger will treat it very warily, someone very familiar with it can become over confident and careless.
I'm not surprised at all that the victim here was someone who had worked there for a long time.
You always deliver, thanks again !
Thank you
I love how technical you get it's very refreshing
Thank you for your work and time on this video.
Love the longer format videos. Thank you man.
Plainly ( John ) ,as usual a fantastic explanation of a completely preventable disaster.
This guy definitely felt under pressure to get things moving as fast as possible.
I feel he did grab the transport rails and simply hand grabbed his way over the pit.
His stupid refusal to simply admit anything shows his method.
Strange as it sounds,there is a phenomemonon with electric motion systems that I call bounceback.
If a switch fails to set itself properly,the object in motion will reach the end of it's travel and it will then start back in the other direction of it's travel.
Not a big deal in a electric window of a car but a horrible thing in this case.
Did bounceback happen here?
Who knows.
But this man would still be alive if he simply followed all the rules.
I cannot think of a more horribly slow way to kill yourself.
May he rest in peace.
Great video as always. I love that you add the links to the reports. Thanks
I’m surprised so far in my country we haven’t had an issue like that, or any other nuclear accident. And we build our own nuclear reactors for energy, build reactors for other countries and both medical and research reactors.
Perhaps they learn the mistakes of events like this one
Man I always wondered if I'm the weirdest nerd cuz I've been reading those IAEA reports over and over. They're just so fascinating and incredibly well-documented! So cool to see you making them into videos, I really enjoyed it. At least, it seems, there's two of us!
Proof that if you engineer a more idiot proof system, the universe will balance this out by making greater idiots.
This is very good reasearch and reporting. I am sure most of us would never know about these events, but they are important for reducing risks in the future. Also, your animation dialog is entertaining, to say the least! Wonderful work. All good wishes.
What these videos show is that there is no job so dangerous or intimidating that someone won't eventually get complacent and mess up.
Unfortunately, the longer you work in a dangerous work environment the less you think about, just how bad of a situation you are in…. I worked at a steel mill, in the continuous caster unit. Was around liquid steel day in and day out. It’s amazing what you can “get used” to……
30 petabequerels is pretty close to one megacurie. That is a LOT of radioactivity, especially seeing as 60Co is a pretty "hard" gamma emitter (two principal peaks at 1.2MeV and 1.33MeV). You really don't want to be anywhere that much activity. For this source intensity, you're still receiving a dose rate of 100microCi almost two kilometres away!
I'm fascinated by radiation disasters like these. Thanks, it was a good video.
Radiation devices are safe as long humans are not involved...
The Dead Hand would like a word.
glad i woke up to a new plainly difficult upload in my notifications thanks
May I suggest the 1977 and 1990 orphan source incidents in Sasolburg, South Africa as topics for a future video?
The detail you have on this process is crazy thorough
A little story from a warehouse somewhere:
A newly built part of my workplace opened a few months ago.
In this department there is a long roller conveyor from which operators take items off as they work. The conveyor is about at chest level and it is about 20m long with workstations on the side.
This conveyor has an emergency stop button at about every 5 meters.
I approached a manager and asked why this conveyor does not have a pull cord along it? The buttons are out of reach for most of the operators and there is a real danger getting stuck.
The answer: Yeah, but if you keep all the rules and pay attention all the time, you are not going to get stuck.
What if you trip in something?
What if there is something slippery on the floor?
What if...?
As long as we have these detached from reality corpo-rat wiesels everywhere who keep the OSHA lexicon on they night stand as a bible and unwilling to use common sense and make changes were necesary, minimum wage employee blood stays the prefered ink for safety rules.
EDIT:
I no longer work there.
Followup on the story: I approached multiple managers and filed two written complaints about the matter and according to my source who works there, there are still not enouh safety buttons. Also the main drive belt of this roller conveyor (a 5cm wide wowen belt driven by five 2kW motors) is exposed underneeth wuthout any protection.
Good job corporate!
its amazon huh?
@@smartmonkey777 It is not amazon, but it is owned by it 😉
You akways post when im opening on Saturdays thank you for that
Too much time pressure, routine, sometimes incompetence and sheer sloppiness are the main reasons for such things in my experience.
Have been working in industrial production for 4 years.
Worked at a small chemical plant producing colours for one year - in that time I walked out of the facility in a hurry twice after warning my superiors of an explosion hazard and being ignored. My direct superior was clueless and the fire prevention "expert" was a heavy-drinking alcoholic. Top staff. ^^
That sounds like a lovely place to work!
@@PlainlyDifficult Uh, the man himself, what an honour! ^^
Yeah, it was a great relief to finally leave the place. I also encouraged people I liked to get another job, too.
I'm a veterinary nurse and use many single use items that are sterilized with radiation. I never really put thought into the people who work the dangerous job of actually doing the sterilizing.
Balls!
Yes, balls!
Probably be a lot safer if the product were raised up into the radiation chamber or room.. that way if there was a jam, they know without a doubt- go into that chamber and your're going to die. They would know that the product must come out some other way, no matter what. Sad situation. I love the narration- it's the most pleasant I've ever heard! Thank you :)
Why does this place look like a horror game location
My first degree was in chemistry and my university had a thorium room. Wow, the safety around this room was like nothing on earth. Everybody knew that entering would mean death so we knew not to enter. I wonder what was going on in this man’s mind as he must have known too. He paid the ultimate price…
Sounds like jams were routine and the operator bypassing the safety systems in order to quickly clear the jam was routine. What was different this time is that the emitter was in the up position. I have had enough conversations with trade guys that complain about all those OH&S mandated guards getting in the way of their work to get an inkling of what happened here.
I love that you have pictures for this one, had a hard time visualizing the San Salvador one, that is a very corroded facility, they were in dire need of a anti-oxidant paint day.
IIRC one of the Murphy's Laws states that it's absolutely impossible to make any piece of equipment foolproof. People find it challenging to solve problems along the path to their untimely demise...
That's an application of Murphy's Law. Not "one of them."
I'm recent subscriber, really enjoy your format and you have subjects I've not heard of before too.
I actually worked at Flixborough docks for a couple of shifts 10 or so years ago, so that one was especially interesting to me!
Thanks for your work 🤓!
Do you have any plans to cover the recent exposure of Russian troops digging, manning and living in trenches in and around Chernobyl and the red forest?
Oh, that would be really interesting
I reckon he would have to uncover documented evidence that it actually happened and isn’t just wartime propaganda. Considering the plethora of fake stories coming out of Ukraine that have later been admitted to as being made up to boost morale and garner support, I’m leaning towards no on this one.
@@TheSaltyExplorer like the evidence gained from the radiation sensors all around Chernobyl that are internationally monitored and their increase, some even going off-line, during the Russian invasion in the region?
@@saxon215 does that mean they were for sure living in radioactive trenches? Look, I’m not saying it didn’t happen, but come on.
@@TheSaltyExplorer I wouldn't think trench-based stuff particularly likely, but the tracked and wheeled transport vehicles would and did stir up a lot of radioactive material. The length of exposure, type of exposure and the isotopes around would be very difficult to ascertain. I took your comment to mean you did not believe that there had been any increase in radioactive activity rather than the nature of the troop activity.
I spent a few months erroneously unsubscribed to this channel by RUclips. I did not enjoy myself during that period of time. It's good to be back!
Maybe the guy was afraid of getting into trouble but I think he knew he was doomed and was covering for someone else.
Another good one John, cheers
Thank you! Cheers!
When dealing with an invisible danger...such as intelligence....or radiation.....one must think their actions through thoroughly before acting.......not after.
@Miss Understanding True. I'm glad you reminded us. 👍
I have designed and programmed industrial safety interlock systems (category 2,3,4); not for nuclear facilities but printing mills and filling systems. On one job site less than 4 months after completing an upgrade to the safety interlocks of an offset printing line an operator who had run the machines for 20 years was killed. He had deliberately by-passed the safety systems to observe what he thought was a mechanical fault. He closed a service access gate behind himself while in the path of the machine and then instructed the junior operator to start it. He was crushed when it started. Accidents, machine failures, absent mindedness may be guarded against but deliberate and planned suborning of safety protocols and systems is impossible to prevent.
A very good episode and adequately thorough. Most of these accidents appear to be in parts of the world where circumventing the rules is part of the culture. You should do an episode about the recent Chernobyl incident where Russian soldiers made sand bags with soil taken from the red forest. (Now called the yellow forest)
Thank you I recently did a video on that!
@@PlainlyDifficult link?
@@markrice41 ruclips.net/video/I78MShTR_rA/видео.html at time stamp 26:14
Really well done. Informative and engaging. Great work.
You know, it makes me think these sort of devices should have a sort of dead-man's switch like they have in subway trains. Example: While irradiating, the user must hold down a button to keep the source in the active position. The moment pressure on the deadman's switch is released, the source automatically drops down into the safe position and the system has to be restarted manually.
Perhaps if it was less than a minute. These radiation devices run for a good hour, minimum. Maybe even half a day.
Dead-mans switches are routinely bypassed. Just put something heavy down on the switch/lever/pedal/etc and you've gotten rid of the safety mechanism entirely. So you have to design around that as well. The more obnoxious the system feels to the operator, the more incentive to defeat it.
@@toisitrappings6483 You could get away with a heart rate monitor, so a human must be present
@@henke37 I think you're mistaken. The one I visited runs 24/7 when it is busy enough to justify it. It has a large conveyor system where dozens of boxes of materials (fruit, bandages, etc) sit on conveyors with the exposed element for several days, ~100 hours if memory serves. The conveyors loop around the central core in such a way that all sides of the boxes are exposed at one point or another, and every hour or so the computer moves the conveyor 3 feet or something. After ~100 hours or whatever a given box emerges on the other side, as sterile as the Moon and smelling faintly of ozone and other gaseous free radicals released by the gamma bath.
I really love your videos. Simply... fantastic work, educating and entertaining at the same time with really nice presentation. Thank you for all your work!
As a retired major-crimes investigator, my suspicion lies with the assistant, who could easily have gone to the control room when the victim entered the chamber and raised the rack.
I wonder what their relationship was. Also what the professional climate was like at the establishment and whether the assistant would benefit from the removal of the victim from the workforce.
I now picture everyone calmly standing around after the incident just sipping tea and quietly exclaiming "balls" "yes, balls"
Sad. I don't understand why anyone would do this. He'd have saved only a few minutes at best while taking all this risk.
He was probably being hounded by his boss who was hounded by his boss who was hounded by his boss to keep up production or “else”.
Always, always, ALWAYS know and *respect* your equipment. I work with stone heavy grinding wheels and sharpen steel for work on a daily basis. Those wheels spin about 3600 rpm and they're about 8 inches in diameter and a half inch thick. Catch that thing in the wrong spot and you're either getting partially degloved (the nasty kind, don't Google it) or losing a few fingers.
Has yet to hurt me in 15 years because I'm always on alert when my equipment is in use. Contempt breeds disaster in a busy and dangerous work environment.
Not radiation relate, but...the US CSB has a video on their channel about one that blew up. No radiation, just a lot of stupidityradition
The CSB has a lot of videos about "someone cut corners/didn't follow rules and ☠️"
I nominate all of them for the Plainly Simple treatment.
Yes I've watched ALL if them. They are so good but would be even better with John's voice and style. I second that nomination
The Canadian Worksafe videos are better.
Great video John
Thank you
No matter how much you idiot-proof things, there will always be at least one idiot who is just smart enough to get around your safeguards and hurt himself.
Sadly true
What gets me the most about this one is that the operator had to have done something intentionally out of line to end up in such a way and even after knowing he's going to die is so stubborn about it refuses to disclose exactly what he did. Like, my guy, you're not going to get in much more trouble than being dead.
I think... If I had to design a system to do similar exposure, I'd add a physical lock on a door that uses the same key as what is used to arm and disarm the rack.
Sure you might be able to work around that by picking the lock, but it's probably easier to just go grab the key by that point.
Some other systems have that but operators have still managed to bypass it
"This is the lock picking lawyer and what we have for you today is a..."
"This is the lock picking lawyer and what we have for you today is a..."
Another solid video mate. Cheers.
After watching all these radioactive and industrial disasters (and wondering how many happened/happen without anyone figuring out), I'm not surprised that there are so many cancer cases around the World anymore...
Evolution requires pain.
@@justtime6736 oh yeah, not screams evolution like DNA corrupted by radiation!
no matter how perfect is the system is, human error always there become big factor for disaster anytime.
It's so sad to see these incidents at both style plants, when the ultimate engineering solution is so damned simple I'm shocked neither company figured it out. Put the counterweights in the way of the maze path! Turn them into a door, literally... and of course have some pins on the mechanism so it can be disconnected, dropping the weight AND the source immediately if it starts to rise while occupied.
If you want to go double extra, have a little pushrod that moves when the source is exposed and physically blocks another door closed. Don't concern yourself with pits and pressure plates, make it so you physically cannot enter the space without the source being in it's storage position. If it breaks with the source up, that's why god invented bolt-on hatches, with LOTS of big bolts so whoever's going in has plenty of time to think about it. Maybe even tack weld a nut or two on where it's easy to grind.
Can't add a door as the product needs to get through.
So he was dead - but survived - for 3 months. A literal walking dead. Must be horrifying coming to terms that you will die soon and horribly.
Not glorifying radiation disaster...but it's very fascinating..impressive that this element makes...a technology that could revolutionize a lot but we just don't know how to deal with it..! See Joema's disaster!
I love to learn about radiation/nuclear disasters… always interesting
Learning about radiation accidents is the cleanest, best pleasure
As an engineer I can tell you with 100% certainty the designer was an Indiana Jones fan, AND he sucks at his job. The rack should always fall into the isolation pit when unpowered.
You are not engineer. Guess why i know it.
@@commieprop Because the rack *was* powered.
People get complacent at work and begin to take shortcuts, no matter how qualified. My Dad is a dentist and was trained on how to you use a strong halogen lamp to harden synthetic materials used to reconstruct damaged teeth. Somewhere along the way he decided that putting on the protection goggles was too annoying and that blinking and squeezing his eyes shut was good enough. Now he can only work with extremely strong glasses because he ruined his eyes.
The Soviets had some of the weirdest radiation accidents of all time.
Very true
Very true
A big reason for that is we never hear about the accidents in these. They are concealed.
I like how whenever something bad happens, they say "Balls" and then someone replies, "Yes balls". Such a simple yet expressive response.