The 1990 Clinic of Zaragoza radiotherapy accident was a

radiological In physics, radiation is the emission or transmission of energy in the form of waves or particles through space or through a material medium. This includes: * ''electromagnetic radiation'', such as radio waves, microwaves, infrared, visib ...

accident that occurred from 10 to 20 December 1990, at the Clinic of

Zaragoza Zaragoza, also known in English as Saragossa,''Encyclopædia Britannica'"Zaragoza (conventional Saragossa)" is the capital city of the Zaragoza Province and of the autonomous community of Aragon, Spain. It lies by the Ebro river and its tributari ...

, in

Aragon Aragon ( , ; Spanish and an, Aragón ; ca, Aragó ) is an autonomous community in Spain, coextensive with the medieval Kingdom of Aragon. In northeastern Spain, the Aragonese autonomous community comprises three provinces (from north to sou ...

Spain , image_flag = Bandera de España.svg , image_coat = Escudo de España (mazonado).svg , national_motto = ''Plus ultra'' (Latin)(English: "Further Beyond") , national_anthem = (English: "Royal March") , i ...

. In the accident, at least 27 patients were

injured Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Depending ...

, and 11 of them died due to the overexposure, according to

International Atomic Energy Agency The International Atomic Energy Agency (IAEA) is an intergovernmental organization that seeks to promote the peaceful use of nuclear energy and to inhibit its use for any military purpose, including nuclear weapons. It was established in 1957 ...

(IAEA). All of the injured were

cancer Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...

patients receiving

external beam radiotherapy External beam radiotherapy (EBRT) is the most common form of radiotherapy (radiation therapy). The patient sits or lies on a couch and an external source of ionizing radiation is pointed at a particular part of the body. In contrast to brachyt ...

Chronology

On 7 December 1990, a technician performed maintenance on an

electron accelerator A particle accelerator is a machine that uses electromagnetic fields to propel charged particles to very high speeds and energies, and to contain them in well-defined beams. Large accelerators are used for fundamental research in particle ...

at the Clinic of Zaragoza. On 10 December, it returned to service after the repairs. Affected patients immediately suffered

burns Burns may refer to: * Burn, an injury (plural) People: * Burns (surname), includes list of people and characters Business: * Burns London, a British guitar maker Places: ;In the United States * Burns, Colorado, unincorporated community in Eagle ...

on the skin of the irradiated area, as well as

inflammation Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...

of the

internal organ In biology, an organ is a collection of tissues joined in a structural unit to serve a common function. In the hierarchy of life, an organ lies between tissue and an organ system. Tissues are formed from same type cells to act together in a f ...

s and

bone marrow Bone marrow is a semi-solid tissue found within the spongy (also known as cancellous) portions of bones. In birds and mammals, bone marrow is the primary site of new blood cell production (or haematopoiesis). It is composed of hematopoietic ce ...

. The first overexposed patient died on 16 February 1991, two months after irradiation. Fatalities increased until, on 25 December 1991, the last of a total of 25 patients died. The IAEA established that 11 of the deaths were due to the faulty maintenance. On 19 December, the Nuclear Safety Council (CSN) was scheduled to make its annual review of the device but, due to bureaucratic reasons, this review was delayed. The CSN found the electron accelerator power was too high. The unit was deactivated on 20 December 1990 and restarted on 8 March 1991.

The accident

The radiotherapy unit was repaired without following the correct instructions. The unit, in service 14 years at the time of the failure, had a breakdown in the electron beam accelerator control system (" deviator"). Repairs incorrectly increased output power, so patients that should have received therapy at 7

MeV In physics, an electronvolt (symbol eV, also written electron-volt and electron volt) is the measure of an amount of kinetic energy gained by a single electron accelerating from rest through an Voltage, electric potential difference of one volt i ...

were instead treated at 40 MeV.

References

Clinic radiotherapy accident Man-made disasters in Spain Medical error Radiation accidents and incidents 1990 in Spain 1990 industrial disasters 1990s in Aragon December 1990 events in Europe 1990 disasters in Spain {{Disaster-stub

Chronology

The accident

See also

References