The Goiânia accident was a radioactive contamination event in 1987 in Brazil caused when an unsecured radiotherapy source was stolen from an abandoned hospital. It was mishandled by several people, resulting in 4 deaths. Over 100,000 people were examined and 249 were found to be contaminated. Responses included medical treatment, decontamination of areas and vehicles, waste disposal, and long-term environmental monitoring and health screening. It demonstrated the need for strict regulation and security of radioactive materials.

1. The Radiological accident
in Goiânia
Presented by_
Champak Mudoi
Taushiful Hoque
M.Sc. Radiological Physics , 4th Semester
Gauhati University – Dr. B. Barooah Cancer Institute

2. Contents
 Introduction
 Description of the Source
 Chronology of the accident
 Discovery of the accident
 Initial action after the discovery
 Medical Responses
 Dosimetry Used
 Environmental Contamination
 Radiation Surveys
 Decontamination
 Disposal of the waste
 International Co-operation
 Lesson learned

3.  The Goiânia accident was a radioactive
contamination accident that occurred on
September 13, 1987, in Goiânia, in the state
of Goiás ,Brazil ,after an
unsecured radiotherapy source was stolen
from an abandoned hospital site in the city.
 It was subsequently handled by many people,
resulting in 4 deaths. About 112,000 people
were examined for radioactive contamination
and 249 of them were found to have been
contaminated.
Introduction

4. Level of the Accident
A nuclear and radiation accident is defined by
the International Atomic Energy Agency (IAEA) as
"an event that has led to significant consequences to
people, the environment or the facility. Examples
include lethal effects to individuals
INES : in order to enable prompt communication
of safety significant information in case of nuclear
accidents by IAEA in 1990
Goiania Radiation accident is the 5 INES Level of
Radiation accident with wider consequences

5. Competent Authority for Nuclear Energy in Brazil
The competent national authority for nuclear energy in
Brazil is the National Nuclear Energy Commission (CNEN),
whose President reports directly to the President of the
Republic.
CNEN is the regulatory authority for licensing the
purchase and transport of radioactive sources
It also has the responsibility and power to regulate the
production, use, security and disposal of radioactive
materials in their various areas of use.
In the area of medical uses, both CNEN & Federal and
State Health Secretaries have regulatory responsibilities.

6. Description of the Source
Basic data on caesium-137
• Source : CsCl - Caesium chloride
• Radioactivity (1971): 71 TBq (1919 Ci)
• Radioactivity (Sept, 1987): 50.9 TBq (1375 Ci)
• CsCl Mass : 93 g
• Cs-137 Mass : 19.3 g
• Gamma emissions : 0.66 MeV (84%)
• Beta emissions : Maximum energies : i) 0.51 MeV (95%)
ii)1.17 MeV (5%)
• Half-life : 30 years

7. Machine Specification
The teletherapy unit
Make : Barazetti - Generay SpA , Italy.
Model : Cesapan F-3000 , 1951
Manufactured : 1970
A wheel type radiotherapy device which has
a long collimator to focus the radiation into a
narrow beam. The caesium chloride radioactive
source is the blue rectangle, and gamma rays
are represented by the beam emerging from the
aperture.

8. Chronology of the accident
(1) the demolished clinic of the IGR;
(2) removal of the rotating source assembly from an
abandoned teletherapy machine by R.A. and W.P.
(3) source assembly placed in R.A. 's yard near houses
rented out by R.A. 's mother
(4) R.A. and W.P. break up source wheel and puncture
source capsule
(5) R.A. sells pieces of the source assembly to Junkyard I
(6) Junkyard I. the caesium chloride is fragmented and
dispersed by I. S. and A.S. via public places
(7) D.F. 's house: contamination is further dispersed
(8) visitors and neighbours , e.g. O.F. I , are contaminated

9. Chronology of the accident
(9) E.F.I and E.F 2 contaminated;
(10) IF. 's house; other arrows indicate dispersion via
visitors and contaminated scrap paper sent to other
towns;
(11) contamination is spread to Junkyard II;
(12) contamination is spread to Junkyard III,
(13) K. S returns to the IGR clinic to remove the rest
of the teletherapy machine to Junkyard II;
(14) M.F.I and G.S. take the source remnants by city
bus to the Vigilancia Sanitaria;
(15) contamination transferred to other towns by
M.A.I. (By courtesy of CNEN, Brazil.)

10. Discovery of the accident
 On September 28, one of the persons irradiated, named Maria Ferreira, connected the illnesses
with the source capsule and took the remnants to the public health department in the city with
the help of her husband’s employee by bus.
 Both were admitted in the hospital and later sent to a tropical hospital because their symptoms
were confused with tropical disease.
 A doctor suspects that the skin lesions had been caused by radiation damage and after consulting
with his colleagues, decided to call in a medical physicist to look at the suspicious package.
 In the morning of September 29, a visiting medical physicist used a scintillation counter to
confirm the presence of radioactivity and persuaded the authorities to take immediate action.
The city, state, and national governments were all aware of the incident by the end of the day.

11. Initial action after the discovery
 Medical triage
 Monitoring of the people and survey the environment
 Medical treatment of the irradiated/contaminated persons
 Actions to bring sources of exposure under control
 Decontamination of the main sites of contamination (houses, public places, vehicles, etc.)
 Demolition and removal of houses
 Removal of contaminated soil
 Clear information to the public

12. Medical Triage
Population Triage Period:
September 30 - December 21, 1987
Number of persons 112,800
Internal/external contamination 129
Contamination of clothes and shoes 120
Persons hospitalized 20
Local radiation injuries 28
Bone marrow depression 14
Acute radiation syndrome 8
Deaths 4
Basic facts about triage performed
Olympic Stadium (112,800 persons monitored)

13. Medical Responses
The therapeutic procedures followed during the critical phase of
the emergency response included —
 managing the critical period of the acute radiation syndrome
 manifested by bone marrow depression
 treating local radiation injury
 decorporation of caesium-137 from the body
 general support and psychotherapy.

14. Decorporation of Cs-137 with Prussian Blue
One notable feature of the accident in Goiania was the severe
external and internal contamination with caesium-137 that
complicated patient care and prompted the extensive use of
hexacyanoferrate, [Fe(CN)6]4 (as Prussian Blue, or Radiogardase ) for
the first time in the history of radiological accident
 In the Goiania accident, Prussian Blue (Radiogardase ) was
administered to 46 persons.
 The doses of Prussian Blue varied from 1 g/day to 10 g/day
 The initial dose for adults was 3 g/day in three equal doses
 Patients who intakes more than five times the annual limit of Cs-
137 intake, doses varied from 4 g/day to 6 g/day
 The dose administered to 13 children was initially 1.0-1.5 g/day

15. Fatalities
Ages in years are given, with dosages listed in grays (Gy) :
 Leide das Neves Ferreira, aged 6 (6.0 Gy), was the daughter of Ivo Ferreira. She gradually
experienced swelling in the upper body, hair loss, kidney and lung damage, and internal
bleeding. She died on October 23, 1987, of "septicemia and generalized infection" at the
Marcilio Dias Navy Hospital, in Rio de Janeiro.
 Maria Gabriela Ferreira, aged 37 (5.7 Gy), wife of scrapyard owner Devair Ferreira, she
developed hair loss and internal bleeding, especially of the limbs, eyes, and digestive tract.
She suffered mental confusion, diarrhea, and acute renal insufficiency and died on October
23, 1987.

16. Fatalities
 Admilson Alves de Souza, aged 18 (5.3 Gy), was an employee of Devair Ferreira who
worked on the radioactive source. He developed lung damage, internal bleeding, and heart
damage, and died on October 28, 1987.
 Israel Batista dos Santos, aged 22 (4.5 Gy), was also an employee of Devair Ferreira who
worked on the radioactive source primarily to extract the lead. He developed serious
respiratory and lymphatic complications, died on October 27, 1987.
Devair Ferreira himself survived despite receiving 7 Gy of radiation. He died in 1994
of cirrhosis aggravated by depression and binge drinking. Ivo Ferreira died
of emphysema in 2003.

17. Highly contaminated Individuals
 8 ARS patients with estimated doses
 1  2-4 Gy
 5  4-6 Gy
 2  >6 Gy
 Two patients who received high doses
(7.0 and 5.5 Gy) and exhibited bone
marrow depression but recovered and
survived

18. Dosimetry Used
From the initial discovery of the accident in Goiania it was evident that many individuals had
been irradiated.
Various dosimetry techniques were used to provide inputs to the initial screening of potentially
exposed persons, the subsequent medical management of patients, and a general scientific
assessment of the accident.
The principal techniques used were as follows :
Internal dosimetry: bioassay and whole body monitoring
Cytogenetics: estimation of doses by chromosomal aberration analysis
External dosimetry: dose estimates from reconstructions and on the basis of radiation effects

19. Internal Dosimetry
A bioassay is a method of determining the amount of
radioactive material in your body.
It is used to determine (calculate) the dose from this
radioactive material. There are two techniques for
bioassays:
(1) Measure the amount of radioactivity directly - this is
called an in vivo (in life), a “whole body count” (WBC).
(2) Measure the amount of radioactivity excreted from
your body - this is called an in vitro (in glass) bioassay. The
concentration of radioactivity in urine or faecal
samples can be used to determine the amount of activity in
your body.

20. Cytogenetic Analysis
 The process of analyzing cells in a sample of tissue, blood,
bone marrow to look for changes in chromosomes,
including broken, missing, rearranged etc.
 Cytogenetic dosimetry is an extremely useful technique for
estimating the external whole body radiation dose and the
inhomogeneity of dose of the irradiated person.
 It is helpful in providing useful information to the physician
responsible for diagnosis and prognosis

21. Medical Follow-up of the victims
 Status of skin injuries after initial healing
• 8 patients required surgery in 1989
• 6 patients required surgery in 1990
• 1 patients required surgery in 1991
 1 cancer death (1993), 1 suicide (1992)
 5 year follow-up of children
• no significant findings (occasional eosinophilia, chronic anaemia)
• 7 exposed in-utero have no abnormalities
• 10 conceived post-accident born with no abnormalities

22. Environmental Contamination
The environment was severely contaminated
in the accident.
 Initial surveys conducted in suspect homes and
work areas
 67 km2 urban area of Goiania city monitored
using helicopter to identify all hotspots (few
mGy/hr to >2 Gy/hr)
 2000 m2 contaminated
 Several household pets (cats and dogs) and
some livestock (pigs) slaughtered

23. Environmental contamination
The actions taken to clean up the contamination can be divided into two phases
• The first phase : actions needed to bring all potential sources of
contamination under control, completed by 3 October,
• The second phase : action needed to restore normal living conditions,
lasted until March 1988

24. Radiation Surveys
For Radiation Surveys
 55 dose rate meters,
 23 contamination monitors and
 450 QFEs (quartz fibre electrometers — dosimetric pens) were used
 Aerial survey with helicopter equipped with radiation detector (67
km2 monitored)
 Terrestrial survey with a car equipped with NaI(Tl) and GM detector

25. Radiation Surveys
 Aerial survey
• To do this, an aerial survey of Goiania was carried out by
helicopter on 7 and 8 October.
• A portable battery powered gamma spectrometer having
Nal(Tl) detectors with a total volume of 840 cm3 was used.
• Maximum dose rate it recorded was 21 mSv/h at 1 m

26. Radiation Surveys
 Survey by car :
• mounting the detectors used in the helicopter in a car and
surveying the areas adjacent to the main foci of contamination
• Both 100 mm x 100 mm Nal(Tl) detectors and Geiger-Muller (GM)
type detectors were used
• One problem encountered was that the electronics were sensitive
to temperature variations
 Use of hand held monitors
• More broad dose rates and contamination bands around the several
principal foci showed by this precise dose rate measurements

27. Environmental Monitoring
To quantify the environmental dispersion of caesium, more
than 1300 measurements were made of radioactivity due to
caesium-137 in soil, vegetation, water and air.
 In soil measurements ,the levels ranged from 102 to 105 Bq/kg
and decreased with distance from the main foci.
 At the same locations as for soil, 263 samples of vegetation
were collected and analyzed, including leaves, branches and
fruit.
 The radiation level is below the minimum detectable (1 Bq/L)
when measured in pubic water supply.

28. Environmental Monitoring
 In Ground water measurements, only wells near the main foci
had levels of radioactivity above the detection limit (1.5 Bq/L).
The highest level of radioactivity detected,30 Bq/L, was in the
disused well of a residence.
 No caesium-137 was detected above the level of the limit of
detection (150 Bq/L ), during rainwater measurements.
 In the Capim Puba creek , Jao Dam , a tributary of the Meia
Ponte river that receives flood control water and sewage ,a
survey was conducted on the sewerage system of the district.
Monitoring showed no significant radioactivity

29. Decontamination was undoubtedly the most
resource intensive element of the response to the
accident
with some 550 workers participating m Goiania
This section presents the salient features of this
work.
• 7 main contaminated places
• 42 additional contaminated places
• 85 contaminated houses; 7 demolished
• 50 vehicles decontaminated
Decontamination

30. DECONTAMINATION
PROCESSES
a) the gamma dose rate was measured.
b) Daily dose limit for workers set as 1.5mSv
c) the area in which the highest dose rate was found was profiled.
d) the soil layer indicated by the profile was removed, and then an
additional layer was removed.
e) the gamma dose rate and the soil's average specific radioactivity
were measured.
f) if these measurements were close to derived limits, the area
was covered with 30 mm of new soil.

31. Disposal of the waste
 Waste storage site:
 20 km away from the city
 Designed to accommodate 4-5 km3 of waste
 Classification and Control system :
1) Non-radioactive: radioactivity <74 kBq/h
2) Low level waste: dose rate < 2 mSv/h close to the surface of the
package
3) Intermediate level waste: dose rate > 2 mSv/h
but < 20 mSv/h Liquid waste was solidified in cement and
classified in the same way.

32. Disposal of waste
 Types of waste packaging used:
 4,500 metal drums (200L)
 1,400 metal boxes (5 tones)
 10 shipping containers (32m3)
 6 sets of concrete packaging
 Volume of waste stored: 3,500 m3,
or more than 275 construction lorry loads

33. Disposal of the waste
 Transport of the waste to the storage site
transported in such a way as to meet
Brazilian legal requirements and IAEA's Regulations
for the Safe Transport of Radioactive Material
Between 25 October and 19 December, 275
lorry loads of waste were transported to the
temporary storage site
 Inventory
Data on the external dose rates for packages,
recorded on the inventory cards, were used later to
estimate the radioactivity of each drum
About 44 TBq (1200 Ci) of radioactive waste
recovered.

34. GUIDELINES FOLLOWED FOR THE
DISCHARGE OF PATIENTS
 It is recommended that monitoring in whole
body counters and 24 hour urine collection be
carried out for internal contamination.
 It is further recommended that only those
persons whose levels of in-body radioactivity
are lower than the applicable values given in
Table, and the mean radioactivity of whose
urine is less than 15 kBq/L (0.4 µCi/L ),
should be discharged from hospital to rejoin
the community.

35. Radiological Protection
 Routine contamination measurements were made to define the need of decontamination
 Air monitoring was undertaken ,Water and solid effluents were also monitored
 Plastic sheeting was put on floors and walls to facilitate decontamination.
 Numerous spots where dose rate exceeded 1.0 Sv/h . decontamination had to be planned.
 Film badge and QFE pens were used to monitor the radiation level in workers
 To help in this planning and in the general control of doses, authorized dose limits for
workers were set for various time periods, namely: • 1.5 mSv per day
• 5.0 mSv per week
• 15.0 mSv per month
• 30.0 mSv per quarter

36. Psychological Follow-up of the victims
 Psychological alterations
• Continuation of some early problems
• Discrimination from the other people
• Establishment of illness behavior
• Concern about the consequences of the exposure
 Stigmatization
• Victims blamed for accident by many citizens

37. International Co-operation
 An IAEA-Brazil co-operation programme on emergency preparedness had
made a significant contribution to their preparedness well before the
accident in Goiania
 The Brazilian authorities informed the IAEA of the accident soon after its
discovery ,requested assistance under the terms of the international
Convention on Assistance in case of a radiological emergency
 Since the accident, numerous collaborative activities have been
undertaken by Brazilian and other experts to evaluate the experiences
and to learn lessons from it

38. LESSON LEARNED
The following lessons were drawn by CNEN from the accident in Goiania:
 A radiological accident like Goiania incident can be very much fatal if much time
elapses before the discovery of the accident.
 The physical and chemical properties of a radioactive source are important factors in
an accident. The records of sealed sources should contain that information.
 An adequate system of information is essential to avert panic on the part of the public.
 An adequate system of social and psychological support should be provided following a
radiological accident causing serious contamination.

39. LESSON LEARNED
 Instrumentation should be capable of being adjusted to withstand field conditions, so
that it can be used in high humidities, high temperatures and unstable environmental
conditions.
 Experts in each area of action should be available to be contacted in the event of an
emergency to give support to the local radiological protection teams.
 The provision of a temporary waste storage site near the area affected by a
radiological accident is mandatory.
 Training programme should be arranged to train the radiation worker for radiation
emergency situation

40. Bibliography
 Report “THE RADIOLOGICAL ACCIDENT IN GOIANIA , INTERNATIONAL ATOMIC ENERGY AGENCY
VIENNA, 1988”
 Wikipedia.org/wiki/Goiânia_accident
 Dosimetric and medical aspects of the radiological accident in Goiânia in 1987, IAEA ,1998
 Radiation sources: Lessons from Goiânia report By IAEA
 Wikipedia.org/wiki/International_Nuclear_Event_Scale

41. THANK YOU