A Brief History of: The Soreq Radiation Accident 1990 (Documentary)

[@PlainlyDifficult]

Would have you walked into the irradiator room? and do you have any nuclear suggestions let me know? 👇

[@CaucAsianSasquatch]

Would you consider a vocal appearance on my show?

[@bobby_greene]

How about the Carrington event? It's probably not what you meant, but I think you could make an interesting video of it

[@ianmacfarlane1241]

Nope. There are things that you might take chances with and things that you definitely shouldn't - radiation is one thing that you shouldn't.

[@MomMom4Cubs]

Nope. Just nope.

[@oTownruler]

Castle Bravo and the unexpected amount of fallout?

[@F_I_J_I_W_A_T_E_R]

The moral of the story: If there are conflicting messages that say "high radiation" and "no radiation", trust the first one.

[@vinny142]

Yeah, for some reason people always assume that the most dangerous warning is the false one. Aircraft have crashed because the pilots ignored the ground-proximity alarm just because it conflicted with their *faulty* altimeter.

[@AC-cg4be]

Eh, I'd say more the moral of the story is better training. High radiation alarm was the first warning. Not seeing the tell-tale Cherenkov radiation was another. Watching this entire thing all I could wonder was "why" every damned time something was ignored. Someone didn't properly drill home that a screw-up with this equipment causes death, not just a boo-boo you can brush under the rug. Of course, most of PD's videos involving radiation accidents/incidents leave me asking "how the eff did no one get through the technician's skulls that they will die if something goes awry and over-abundance of caution is a must-have in these situations".

[@kurumachikuroe442]

Follow the loaded gun rule: If something tells the gun is loaded, assume it is loaded even if all other evidence points to the contrary

[@KopitioBozynski]

Exactly, when dealing with conflicting warnings always trust the one that says you will die if you don't listen to it.

[@Tindometari]

You know what's weird about this situation? In this context, if you see shiny blue air it means the source is properly stowed and the room is *safe* ... it's if you do *not* see shiny blue air that the room is deadly.

[@mrkeogh]

Pro-tip: radiation alarms are set off by RADIATION.

[@goodboi6030]

I think you should make it more simpler like Alarm go beep beep when no no air is near them

[@TheConjurersTower]

Ah yes, the floor here is made of floor...

[@dmhendricks]

I'm just a programmer and don't work with radiation, but I understand what it's like to have stupid alarms go off when there is no issue - the more it cries wolf, the more you ignore it. Granted, this is a life and death situation, however, I understand the indifference that grows. For me, the biggest issue is that people who are not programmers set up alarms that they do not have to listen to cry wolf constantly. I tell them that this is bad and will cause people to ignore the alarms, which it of course does and they of course don't fix.

[@FlyingSavannahs]

Incomplete! Pro-tip #2: RADIATION can kill you. Pro-tip #3: Getting killed is bad for you. Best not to cut any corners!

[@kapioskapiopoylos7338]

@@dmhendricks EE here, i deal with automation a lot, alarms are made to be super sensitive, a cut wire or some corosion, a loose conection, a bent cable, may all result in false alarms. 9/10 it will be false. 10/10 times you will think it is false, it is correct.

[@keleighshepherd345]

Medical linac engineer here, the thought of being able to exploit an interlock failure mode is terrifying. I work primarily with external beam radiotherapy machines, but I have basic safety crosstraining with a high dose rate source machine for brachytherapy. I remind myself any time I walk into a bunker that the machine wants to kill me. One can easily get inured to the threats posed, not just from the ionising radiation, but the machinery itself, a gantry of several tonnes will win most arguments with squishy meat sacks, and the high voltage circuitry in the stand can - and will - murder you to death. Interlocks are the operator's friend. Do not think they're mollycoddling "health and safety gone masaaaaaaaaaaaaaad". If you do not have a dose alarm you do not know straight away that you have been irradiated. Alarms should never be disconnected, and always *ALWAYS* respected.

[@ametrinemoon]

I agree there with you. How people can bypass safety systems is scary!

[@volvo09]

This also sounds like a case of poor training also. Like, people should be WELL aware that an "oopsie" means death, and should know exactly how their life safety equipment works. If one has to fool the interlock into opening, they should be ESPECIALLY WEARY before entering. The fact that the poor guy just walked in and didn't even try to verify radiation readings with a 2nd meter, or another worker just shows how ill trained these folks were with the totality of the process. It's like telling someone 500 times not to get inside an industrial oven and they all say "yeah i get it, it could turn on and bake me" but never telling them other facts, like the door is also impossible to open from the inside, and is capable of auto closing and needs a blocking pin installed... They don't have all the information and therefore assume it's "silly" safety stuff.

[@keleighshepherd345]

The fact that they didn't have a calibrated field meter to take readings on entering the maze tells me a lot about how little training they had, honestly I'm amazed it was only the one death

[@vinny142]

I can totally imagine people disconnecting an audible alarm because there literally is no point in listening to it going off for an hour waiting for the tech to arrive, but the console should at least have something resembling a christmastree full of big red lights that are impossible to turn off when there is an alarm. What I wonder is how it's even possible for the radiation source to get stuck by broken product. Such an important and extremely deadly object should not be blockable by anything short of sabotage. I'f expect there to be a failsafe on the outside where one coould just pull a lever and mechanically drop the sourceback into the water. But hey, I'm just a guy with common sense who has watched a few too many episodes of Plainly Difficult. :)

[@keleighshepherd345]

@@vinny142 if its a radiation alarm, god no, you put up with it. And there should indeed be a visual warning in addition to the audible alarm, it's entirely possible for someone hard of hearing to work in the industry, and accessible design is important. We have an audible and visual alert that we're about to beam on and whilst the beam is on. Occasionally an alarm may jam on, and that usually requires going into the bunker to reset the interlock circuitry. Someone is in the control room, and the tech grabs a dose alarm *and* a field meter and talks about the radiation levels as they carefully move down the maze. We know the linac is off but the radiation alarm is on, so we believe the alarm until proven otherwise. We don't break the interlock system, disable the alarm sounder, and just saunter into the bunker. If an alarm sounder is disconnected you make *damn sure* that all operators know what has happened why you did it and hand over the known status of the kit that is tripping an alarm

[@nomad3239]

Disconnecting the radiation alarm because you don't like what it is saying is like gluing the fuel gauge on your dashboard to the "full" position so do don't have to buy more gas.

[@AC-cg4be]

Sounds legit.

[@JanicekTrnecka]

Sounds legit, just those fuel gauge gluers wont remove themselves from gene pool.

[@no_peace]

Not if you think it's faulty

[@no_peace]

Presumably no one here has unplugged a smoke detector that goes off for no reason

[@ocationalyfunny1927]

@@no_peace damn you're really just refusing to believe that the worker mainly at fault instead of the company for once and making it everyone else's problem huh? I mean even in the scenario you made with the smoke detector, it would and should be my fault for turning it off.

[@ianmacfarlane1241]

A tragic incident, but the fact that the operator knew how to bypass/trick the door would suggest that there was a lax attitude towards operator safety in general. Dying because of a stuck cardboard box...

[@wellie_]

I thought it too. If the place was being operated with safety as a priority, there's no way anyone would have known that door trick.

[@gnarthdarkanen7464]

I'm reminded of videos and coaching sessions with bikers... The videos because there's several comments regarding "Gear" or rather a lack thereof... and then you get the "obvious noobs" who have to point out that it's on a helmet cam' and you can't see the biker not wearing gear... BUT you have a good view of bare arms and hands... 999 times out of 1000, if that much is bare, there's no boots or pants or armor other than the helmet (to screw a camera to his head)... AND along with that, at least in the videos, you can bet money he or she is riding at least double the posted limit... Coaching sessions for all the arguments about (more or less) "Would you rather sweat a little or bleed a LOT?" because that's really what they all come down to... after the excuses start... Some people ONLY grasp the true point and purposes of "Safety" from learning those lessons "the HARD way"... Most of us fall to experience on some points and details of the matter, but there will always be a few you just can't reach without a hefty dose of pain and/or darwinism outright. ...AND if it ain't got metal and FULL GRAIN leather, it's not "real armor" in my opinion... Synthetic gear can last up to 4 seconds worth of asphalt skid... Leather can last 8 to 12 at highway speeds. {just for those who want/need to know} ;o)

[@clueless_cutie]

@@nemo-x I suspect the operators did not fully understand what it was they were working with in totality and therefore did not realize the life threatening danger they would be put in if something went wrong.

[@dmhendricks]

I'd say that he died because he walked into an irradiated room. Equally dumb. Obviously he didn't want to die horribly, but it seems like it would at least make sense to bring a properly calibrated meter into the room.

[@princeofcupspoc9073]

And probably pressure from management. Being cautious costs money. Get the job done, no matter what.

[@jacobellinger8027]

the bypass trick could only have been known if the issue with the faulty system was so common that someone found a workaround.

[@justtime6736]

That's terrifying

[@arandomperson8336]

Indeed. The known issue with the switch and the fact that he just casually popped the door open and walked in there suggests very strongly that this is far from the first time they've defeated the security to clear a jam. Definitely the last time though. Nothing ever gets fixed until someone dies.

[@hotlavatube]

Yeah, that's what I'm suspecting. You don't willy-nilly start swapping key switches around and flicking the system on/off.

[@mauricedavis8261]

Great observation!!!☢☣🙏

[@kentario1610]

@@hotlavatube Yeah, made me wonder how they even got to the right sequence of actions to trick the machine, like, who thinks to "play around" with a console that controls something radioactive? Guess they've learned now. I hope.

[@melodyszadkowski5256]

Throughout my naval career, I can remember only two occasions when someone was boneheaded enough to deliberately defeat an interlock. One resulted in an amputated arm and the other in the fatal electrocution of the bonehead's shipmate. "It can't happen to me" is behind every incident.

[@profdc9501]

Every person is the center of their own universe, and for each person, the fatality rate is 0%, until it is 100%.

[@jdmbeats]

On a long enough timeline, the survivability rate for anyone drops to 0.

[@sayori3939]

but everyone ia ignoring one thing: how did they know exactly what to do to get the lock open? it probably happened before!

[@EShirako]

@@sayori3939 Oh no, they mention it...they got used to using the interlock-disable and shutting down the radiation alarm. The only way they could open the damaged and ill-fitting door was often by using the alarm-disable 'turn it on and off a lot' thing. The facility was wretchedly-maintained, and documented mostly in English, which was not a native...nor even commonly-understood...language since this was in Israel, I think? These almost-untrained workers had little idea of how much danger they might be faced with, or else they would have been much more careful. It may have been 'like magic, so who cares? Boxes go in, boxes come out, and I get paid to keep them moving'. Complacency, from management and then also (though more innocently) among the workers. The workers could only know better if they could find out what they needed to know. Management should have told them, but apparently it wasn't cost-effective for the managers to be bothered. :-\ Management is all too often the source, by proxy if not directly, of far too many incidents and tragedies. This worker just enhanced things by rushing and being far too used to cheating the computer. It was midnight; he was likely tired and just wanted to go back home again quickly.

[@Jessesgirl2013]

@@profdc9501 Oh that’s really well put.

[@timhinchcliffe5372]

A saying in engineering; _When you design something to be idiot proof, they'll design a better idiot._

[@ShroudedWolf51]

That's a rather snobbish way of looking at situations. There are many reasons why one might not follow regulations that are more applicable than one's stupidity. And, you'll get a lot further in increasing safety and usability by teaching and educating than by looking down on them. It's perfectly okay to make mistakes. There are a lot of things that we need to account for and most of them may not necessarily even be known. But, use it as a learning opportunity and design something better instead of implying that your design was perfectly made to be "idiot proof" and blame it on "people getting stupider".

[@petrapedia]

A saying in socialism: Capitalism Kills

[@timhinchcliffe5372]

@@petrapedia there's 100+ million people from the last century who have either been starved to death or killed in socialist regimes who would beg to differ.

[@timhinchcliffe5372]

@@ShroudedWolf51 thankyou Karen.

[@petrapedia]

@@timhinchcliffe5372 communism*. but OK, boomer

[@NicholasKratzer]

"Rulebooks are written in blood." That's the first I've heard that one, but damn if it isn't tragically true.

[@hanfred]

He said it before and it's sadly true.

[@MrSunrise-]

It is actually very old and is stated several different ways, but remains true.

[@scout360pyroz]

blood and money is more accurate.

[@Otokichi786]

I've run across that phrase on aircraft accident investigation sites/TV channels.

[@foxman105]

The "safety rules are written in blood" variation is often heard by engineers in construction or operators of heavy machinery.

[@ShionWinkler]

Sad part is this is normal for most professions. The demand to be faster makes workers cut corners, then when they get hurt, their employers go "we never told them to do that!". Rinse and repeat.

[@clueless_cutie]

Meat production is awful for this.

[@TheHikeChoseMe]

exactly. imagine that happening in your health care..cuz it does

[@sed6657]

Exactly. It always comes back to “but we told them during training…” and never admitting to overwhelming their employees to the point of breaking rules meant to keep us safe. Sad ):

[@mopar_dude9227]

And sometimes it is just that the employees are lazy and don’t want to do the job correctly. Liberals have brainwashed people to hate big companies and rich people.

[@mopar_dude9227]

@@TheHikeChoseMe I have worked in the medical profession for over 30 years, working at some of the largest hospitals in the nation down to small rural ones. I have never seen anyone cut corners when it came to the safety of the patient.

[@unvergebeneid]

I wonder how the operators even _knew_ that you could bypass the radiation alarm by power cycling the system. Like... what had happened at that facility before for that to be common knowledge?

[@LynxSnowCat]

progressive calibration failures, and/or signal interference would be my guess. EDIT, from page 14 of the IAEA report (1993): Over time the Geiger-Muller tubes degrade owing to radiation damage, causing a loss of sensitivity. The supplier took account of this by providing for compensatory sensitivity adjustment in the monitor circuits. Eventually further adjustment was no longer possible, whereupon the tubes should have been replaced. ...PAGE 25: The efficiency of Geiger-Muller tubes decreases with time. This means that after a time the number of pulses generated by background radiation in the test procedure could fall below the minimum number that the circuitry recognizes as an acceptable detection rate. This was the reason why the operators found the test procedure to be 'obstinate' and used unauthorized means to speed things up. The sensitivity of the system can be adjusted to overcome this problem ...PG 15: It was subsequently found that at the time of the accident the [portable] meter was not responding to radiation on the more sensitive low dose rate range owing to a broken internal electrical connection. ...PG19: One of these was a senior staff member who on his way out switched off the power to the unit to silence the alarm. He was not familiar with the equipment and left it to the qualified operator to deal with.

[@unvergebeneid]

@@LynxSnowCat wow cool, thanks for looking into the report. Basically what I was afraid of: the safety procedures had been sloppy for a while and the staff didn't trust critical equipment. This accident had been a long time coming it seems.

[@Tindometari]

If what you are proposing to do involves defeating a safety interlock ... stop what you're doing *RIGHT NOW* and reconsider.

[@RyanTosh]

I want to fix the machine -> the machine is telling me not to fix it -> I cannot fix the machine -> I make the machine be quiet -> all good, right?

[@avsystem3142]

Many years ago I worked as an R&D technician for Raychem Corporation. Their primary business was the production of plastic shape memory products (think shrink tubing). There are a number of ways to crosslink the polyolefin plastics so they would have to ability to assume the desired properties. One of the methods that was used was to employ an electron beam to irradiate the material. The electron beam equipment was massive, occupying a large two-story concrete walled chamber. Although entirely safe once the beam was turned off I do remember the sharp smell of ozone when I went into the chamber to retrieve a sample after it had been irradiated. One of the reasons I left to seek other employment was the frequent exposure to potentially toxic chemicals. In particular, I was frequently exposed to 1,1,1 trichloroethane, which was used as a cleaning solvent. At the time I was assured by management that it was harmless.

[@pfadiva]

Everything is "harmless" to the folks that don't have to use them. 1, 1, 1 trichlor is as "harmless" as any other liver-eating solvent. Glad you got free.

[@capnskiddies]

@@pfadiva booze?

[@rezhaadriantanuharja3389]

Management does not lie, they just have different definitions of safe and harmless

[@trespire]

@AV Systems In the Air Force, we used Trichlorothane for cleaning and preping repairs. We used it quite alot, along with White Spirit, as they were the best cleaners.

[@lobsterbark]

@@pfadiva Reading the studies and SDS and such, it seems barely more harmful than rubbing alcohol. At least in terms of toxicity.

[@BrorAppelsin]

If I've learned something from these radiation accident videos... it's that if I ever knowingly get near exposed source, I will stick around for the radiation to kill me as fast as possible. Chances of successful recovery seem to be pretty slim.

[@chikirin9349]

This might sound exceedingly edgy but at this point any other method of self termination might be preferable, dying to ARS might just be the absolute worst way to go

[@jeffreyskoritowski4114]

Or at the very least have have triple doses of Morphine available.

[@tedros6917]

if you get a really high dose of radiation it doesn't kill you right away. the highest dose of radiation ever recorded was someone in japan named hisashi ouchi, i believe it was 3 times the lethal dose. he initially showed very few signs of being ill, the doctors were surprised at how good he looked. he lived for 83 days after (granted, the doctors probably should have let him die much sooner, but kept resuscitating him at the request of his family)

[@roguedalek900]

@@tedros6917 As I understand it the medical community kind of used him as a lab rat also. 🐀. Nobody had ever been where he was medically before and he was studied extensively and quite a bit of knowledge was gleaned from his tragedy .

[@neuralmute]

@@roguedalek900 It's been well documented that it was Ouchi's family, not his doctors, who insisted on keeping him alive, in the misguided hope that he might survive. They couldn't bring themselves to let him go, refusing to either leave the hospital, or sign a DNR order for him, but eventually his medical staff were able to convince them that he would never recover, and they agreed to it. The least to be said is that the poor man had been comatose for weeks at this point.

[@mattblom3990]

I love all the videos, but it's always nice to go back to classic Plainly Difficult with a nuclear incident :))

[@ametrinemoon]

It scary to think how much accidents there has been with nuclear radiation of all discriptions.

[@Astinsan]

Quite honestly.. the accidents with nuclear matter is relatively low.. cars crash every day. Boats sink, planes crash, toxic waste gets spilled.. nuclear is probably the lowest of any industry.

[@pullt]

@@Astinsan Yep, overall very safe. It's just that any/every incident is given way more attention than in other industries. There's no Manifestly Onerous channel showing videos of someone who died doing stupid crap on a forklift in a warehouse.

[@Astinsan]

@@pullt I used to manage a night freight crew.. those machines were so heavy that it was only a matter of time before I had to document a serious injury (quiver).. had to put on the concerned optimism face… 🤠… “so what happened here?”

[@darwinprime]

@@pullt Now I'm inspired. Manifestly Onerous Documentaries. We cover forklift accidents. The really gruesome ones that end up in safety videos.

[@neetard7360]

>eyes burning Ooooh, shit, I've heard all sorts of accounts of short term radiation poisoning, never have I heard *that* being noted from a full body exposure incident

[@masterpassword2]

It amazes me why this guy chose to trust the "everything is okay" signal and disregard the "if you go in, you die" signal instead.

[@turrboenvy4612]

When faced with conflicting data on radiation why would anyone ever assume it must be safe?

[@Argosh]

Because you only survive the instances of it being safe.

[@AC-cg4be]

Because people don't understand radiation in general.

[@KarlBunker]

Yeah -- "Okay, I've got a 50-50 chance of dying; sounds good to me!" 🙄

[@24HoLTeam93]

Probably evidence that it had happened before and been a false alarm. Just like how the guy knew how to defeat the safety interlock - they'd probably done it many times and had it been fine.

[@CantHandleThisCanYa]

Darwinism.

[@RCAvhstape]

"Wow, that radiation alarm is annoying. Let me unplug it so I don't have to listen to it as I step into an area containing a radiation source." The company had a lot to answer for, as usual, but in this case it just seems like it mainly comes down to really poor judgement on the victim's part.

[@carlam6669]

I understand the need to get the operator’s attention but a loud alarm can prevent you from thinking clearly or communicating with another operator.

[@monad_tcp]

@@carlam6669 And that's what they should have done, get far away from the alarm, go to that 24h nuclear facility where they actually know how to do stuff and tell them the machine is stuck and the alarm went off. Let them deal with it, because they have the proper equipment and tests.

[@daviddavidson2357]

It happens often enough that there's a name for it. Fool irradiation. Wordplay on "Food irradiation" as plenty of food irradiation operators have done the exact same thing, bypassed interlocks and got radiationed to death.

[@paul6925]

I know right? I’ve watched docs about plane crashes with similar circumstances

[@calibula95]

"Wow, i'll turn of this annoying alarm" *Then enters the irradiated room* Shocked Pikachu face with eyes burning.png

[@bskull3232]

The man: trained professional intentionally using radiation to kill all living matters. Also the same man: let me poke myself into this actively radiating machine.

[@JIMJAMSC]

I ran a flight based operation and we had a major fuel spill when a truck's auto full mech didn't work overfilling over 500 gallons on the ground. A "dead man's" large lever was installed forcing the linemen to hold it open as it was spring loaded. Well quickly they began tying a rope from it to a pipe so they didn't have to hold it. Eventually, we made it mandatory they had to get on the truck, open the hatch and visually watch the level while holding the rope. Then the midnight guy alone was topping a truck off with JET A fuel, and took a nap on top while it filled. The auto fill AGAIN failed, fuel started gushing out.. He wakes up, high from the fumes he then proceeds to fall off the truck approx 8 feet breaking his leg. All said and done over 2000 gallons of kerosene was lost. The fines were well over $20000, DHEC required 2x yearly checks of the water table and the area saturated had to be dug up, burned and replaced. If there is a will, there is a way and no matter how well designed a safety mechanism is, a employee given enough time can figure out HOW to bypass it.

[@flightmedic7634]

Before I started watching this channel I thought the only real radiation incidents were Chernobyl, 3 Mile Island and Fukushima. Your content is absolutely outstanding. Thanks for all the work that you put into making such amazing content!

[@brucelytle1144]

I hope you've viewed videos about the demon core and the SL-1 incident by now!

[@hotlavatube]

I wonder how the worker learned how to bypass the door interlock. Was this a matter of him being too smart for his own good and tracing the circuit diagram/wires, or was that knowledge passed down from someone else who knew how to bypass it. The procedure doesn't sound like something the operator would have stumbled upon by accident. It sounds like multiple operators were well versed in subverting the safety systems.

[@kahlzun]

when you work with a system for a long time, you learn its idiosyncracies. I've found workarounds for things to systems at work, though obviously nothing as serious as this

[@DarkPrinceNeo]

It was probably something like this: "Oh my gosh, the production stopped and I need to get inside to fix it so I can finally go home.. let me just try put in a different key a few times and press this button."

[@Blue..]

Someone in the facility taught people how to do the bypass, according to articles I've found he received 3 months of community service following the incident.

[@boozydaboozer]

If there are conflicting indicators I'd choose to beleive the one that says 'danger radiation'.

[@no_peace]

I agree in general but if that had happened 3x before and all 3 times it had been a false alarm... I'm not saying that happened, I'm saying that's often why things like this happen, because it was fine every other time (whether your boss told you the alarm is faulty, or your coworker told you they always go in and fix it, etc.)

[@Anbregour]

I work with steam locomotives and that follows what I was taught there; of the two boiler water level readings you always go with the lowest.

[@bubba99009]

Man I don't know why you'd trust a mechanical limit switch over a radiation monitor. The mechanical switch is a much more likely source of failure and if you aren't sure which is wrong better safe than irradiated.

[@Arwcwb]

That is why average people should just stay or be kept far far away. I would have never noticed any warning to begin with, let alone wonder if this particular warning is trustworthy or not.

[@princeofcupspoc9073]

Narcissism. It may be that the operators considered themselves clever by bypassing the safeties. Classic Dunning Kruger.

[@Zenheizer]

@@princeofcupspoc9073 let's not assume things about a man that died here. He was a worker that did not know better and often people choose to believe what feels likely to them. He made a mistake but calling him out on his mistake is damn easy sitting here and watching a literal breakdown on how a man killed himself. So don't come here with "Narcissism" about a man we only know so little about.

[@Sylaise]

Maybe it's just me but if I worked in a place where radiation poisoning was a possibility and warning signs started going off, I would treat it like the real deal every time. Supervisors would absolutely hate me, calling it in every 5 secs but... oh well!

[@AC-cg4be]

Yeah, as I mentioned above, most of PD's radiation accident/incident videos seem to be cause by an under-abundance of caution and leave me asking "why". I can only assume people, in general, are either not bright or have not had "death will occur" drilled far enough into their heads.

[@no_peace]

@@AC-cg4be or their equipment sucks and they think their families will starve if they lose the job

[@notshardain]

@@AC-cg4be a lot of these stories are due to some form of malfunction or faulty equipment that is (often) known about by the manufacturer or company, but the malfunctioning machinery or safety locks are not replaced due to inconvenience for the companies and to cut corners to maximize profit over worker safety. For instance, the shroud that was recommended for this equipment that would prevent items from jamming the source in a dangerous position and prevent it from being able to be lowered, this company decided it was a level of safety not necessary. That and some of these people in these horrific accidents aren't aware of the flawed equip or fully trained in radioactive materials and safety measures, on top of being pressured by management to ignore the safety protocols.

[@gnarthdarkanen7464]

@@notshardain AND we still have people wondering why nuclear facilities run by industrialist corporates owned through the stock market keep hitting political walls with "NIMBY" arguments... right? ;o)

[@lobsterbark]

You would get fired for that and replaced with someone dumb enough to ignore the warnings if the place operated how this one did.

[@SRFriso94]

I think that if you're in a room full of cobalt-60, you've earned the right to use something a bit stronger than 'balls'.

[@dsnodgrass4843]

If you don't have 3 of them by the time you leave...

[@TheCzomolungm]

I really appreciate that in recent videos you started talking a bit slower and focused on pronunciation a bit more. It really helps me as a non-native English speaker. Not that I wasn't able to understand - now it's just much easier, so I don't have to think about it as much when watching. Great video as always!

[@LeCharles07]

If I had had enough exposure to feel the radiation, I'd probably think about making the end quick and painless. ARS is a brutal way to die.

[@justtime6736]

He suffered 36 days needlessly. Doctors barbaric to rack up medical bills, they knew he had no chance. Put him down.

[@LeCharles07]

@@justtime6736 That's the thing though, people *have* gotten better from very lethal exposures. Only a very very few people though. :/

[@basil9973]

@@justtime6736 Thats not how doctors work, part of their job is to limit suffering. Not everyone is a greedy asshat. The possibility of recovering is there, and if no request to kill the victim is given by the family, or often the contrary, that have no legal ability to do so.

[@Edax_Royeaux]

That's the problem with radiation. If someone receives such a lethal dose to the point that it kills 90% of those afflicted, they may still survive and live on. It would be remiss of the Doctors to give that person no chance to live. For instance at the Chernobyl disaster, Yuvchenko was the man who held the reactor door open so the exposed reactor could be inspected, he received a dose of radiation lethal to most people who receive it, but he survived and lived for another 20 years.

[@MrRugercat45]

Unfortunately I think most people are hard wired to hope against hope even up the the end that just possibly they will make it. Usually by the time it’s obvious that you’re NOT going to make it, you’re probably past the point of being able to make the end quick and painless. Bad way to go, I’d say.

[@Panda-cute]

I love how this video made me feel intense dread within 30 seconds of starting. Great work! It’s always a good day when Plainly Difficult uploads :)

[@ZGryphon]

What strikes me most about this accident is that the failure wasn't even strictly one of radiological safety. In _any_ industry, screwing around with malfunctioning machinery without following a rigorous lockout/tagout procedure is a huge no.

[@justanotheryoutubechannel]

This is shocking, it’s so similar to the incident that happened in San Salvador, I can’t believe this was allowed to happen twice.

[@stanislavkostarnov2157]

this guy basically broke most safety rules there were... whatever the other reasons, I believe it was largely his own actions that caused a normalish event to turn into a major incident.... whilst the lack of information for the operator, and the general potential for the conveyor to block the scram like mechanism as a design issue are very concerning, the radiation alarm had worked, and a lot of effort was needed to bypass the safeties and get into the room. I think the blame only in a small part lies with the design or company, since the normal adherence to what was designed for safety could and should have prevented this accident.

[@no_peace]

People break safety rules all the time because their bosses coerce them. I don't know how hard it was to get a job in that area at that time but people do things for a reason. Very likely he had done the same thing before but it was fine. I doubt he's the one who discovered how to defeat the safety protections

[@no_peace]

I hadn't heard all the things the company had done wrong yet... It's definitely their fault

[@NoahSpurrier]

The fact that power cycling the control unit was a known “trick” to bypass the safety interlock suggests that unsafe procedures were the norm at this facility.

[@Nomed38]

The amounts of safety violations I've found at my jobs (none of which dealt with radioactive materials) that have passed in the 95+% of testing I am not surprised in the least by such dangerous things unfortunately. At one job management wanted some pork sausage rolls on a roller grill that didn't heat the food to a high enough temperature. I voiced my refusal to serve dangerously undercooked food to management and the other employees. When the health inspector came by for the scheduled inspection some nitwit had put those sausage rolls on the grill resulting in too low temperature readings and the store got demerits. One thing that disgusted me was the unhygenic things I pointed out to the inspector was completely ignored and not tested or inspected.

[@FlyingSavannahs]

Pilot error. Recommendation 1) Install a camera system (X 2 for redundancy) for visual confirmation of safed radiation source. The sheer number of intentional safety bypasses and ignored procedures is staggering (pun intended!) What actions other than running did this guy take that wouldn't have killed him? A bone marrow transplant was not an optimal choice. High doses of opiates was. The Canadian company had acted in good faith with the jam prevention fix not implemented.

[@BB-gr9hq]

I enjoy your videos. I retired from a facility that used a 9MeV accelerator to radiograph nuclear weapon sub-assemblies. We also used several 2 MeV acelerators to radiograph "piece parts". The accounts of the safety interlocks and the reasons people come up with for bypassing them are amusing. I also find it interesting that operators from all cultures have the same impulse to regard an "off scale" survey instrument as giving a false reading. "It must be broken" if it's alarming or off scale.

[@CarlDidur]

Every freaking time!

[@spiwolf6998]

"The radiation alarm keeps going off!" "Have you tried unplugging it?" "Hang on...Okay everything appears normal now. It must be safe to go in."

[@Tindometari]

I'd love to see you look at the -Tomsk- Mayak (mea culpa) criticality accident of 10 Dec 1968 that involved some gloriously silly Russian nuclear cowboy action in the basement. I mean, imagine David Hahn left unsupervised in a nuclear fuel processing facility. That's pretty much the level. There's not much humour in a criticality accident, but I confess that when I read the story in LANL's "A Review Of Criticality Accidents" (highly recommended read, by the way) -- I couldn't help laughing repeatedly and asking out loud, "They did *WHAT*?! He did *WHAT*?! Damn, Soviet nuke techs were crazy!"

[@Sonkalino]

He did so 4 years ago, it's titled "Brief History of: The Kyshtym Disaster"

[@pfadiva]

@Márton Sonkoly there have been numerous accidents and excursions at the Mayak facility. The one Arkadia Moon is referring to was a criticality accident caused by stupidity with some ignorance mixed in. For once, the surrounding country side was not exposed to radiation.

[@Sonkalino]

@@pfadiva Well then I await that video too. The other one overshadowed this event it seems, but as you decribe it, it seems they tried their best again...

[@empireoflizards]

When choosing between a system alarm and a limit switch, I'll go with the alarm. When doing industrial machine repair, limit/micro switches can jam up randomly. Something like this needed better equipment, such as switches/sensors that don't need constant maintenance or jam up randomly.

[@davelowets]

I have a hard time believing that an "uncalibrated" Geiger counter, ionization chamber, or any other type of radiation detector would NOT have given a screaming indication in the room with THAT large of an amount of Gamma rays present. I have a feeling that it was a LIE that the man had brought a detector with him at all. If the staff was well versed in constantly tricking the system to gain access to the radiation room, I highly doubt that any of them took the time to follow any other safety procedures, such as bringing a radiation detector with them, when accessing the room. Stupid is, as stupid does... One should NEVER fuck about when it comes to rad safety, or ANY safety, for that matter.

[@pilotcritic]

@LynxSnowCat cited the report which said the portable meter was broken

[@AsbestosMuffins]

called it! also WHY WOULD YOU EVER STEP INTO SOMETHING CALLED AN IRRADIATOR

[@foxman105]

Well how else are you gonna get out the manufacured radiators out. That's what irradiators do, right? They make radiators to heat water. I'm joking btw.

[@PlainlyDifficult]

Seems legit

[@snowfish7294]

To GaIn SuPeR pOwErS

[@Thirdbase9]

Your name is Homer Simpson.

[@TripleAlfafa]

To clear a blockage?

[@AsbestosMuffins]

man I've worked with enough finicky automated conveyors to know the pain these guys faced with shitty equipment. They should have built containers that couldn't burst in the machinery

[@revenevan11]

The shroud was designed to prevent that issue... but they didn't install it 🤦‍♂️

[@P_RO_]

@@revenevan11 The shroud didn't prevent conveyor jams- it prevented jams from stopping the core dropping to safe. The better solution would have been designing the conveyor to not jam, thus eliminating the whole problem. There should also have been a visual means to ensure the core was safe as well as redundancy if the micro-switch which should have been designed better too. The problem with automation and engineering in general is the designers thinking that they're smart in trying to make something that can work instead of trying to make something which cannot fail. How you look at things changes what you see, and what you see determines what you'll do. Always prepare for idiots because the world is chock-full of them.

[@danielslubski1028]

As israelis we have our good and bad traits,one of them is called,in slang,being a "big head",solving problems by yourself,not disturbing your superiors if not needed,if you can solve it yourself by taking an initiative,sometimes it's good,in this case... Bad.i live 15 minutes from soreq and didn't know about that,great video.

[@mirnacudiczgela1963]

Yes, unfortunately, he paid with his life for his "big head". 😢

[@Loki_K]

Every safety mechanism and government regulation is written in the blood of those who came before. I have regularly worked with high-voltage machinery (neurochemist focused in proteomics, working/adjusting LC-MS, MALDI-TOF, etc.). The first thing my advisor taught me - and I do mean very first, before she even taught me the software - was "stick your left hand in your pocket, and grab the fabric, so you never, ever use that hand." Why? Because if there is EVER a short, the current would streak through my right arm, cross my abdomen, down my leg(s), and would discharge while I'm thrown backwards. Shortest path. Using my left arm means that same path, mirrored, crosses my heart, stopping it. And using both hands turns ME into the shortest path, so it never throws me free - and that's game over. Respect. Science. We are infants poking things into sockets and recording the data. Our knowledge is exponentially greater than 2 generations prior - and also pathetic compared to what our great-grandchildren will casually learn in middle school. Value those who came before, who caused the regulations that keep you safe, so that the forks we stick in sockets are now rubber-coated.

[@threestackable3655]

With every video of yours I watch, I'm reminded of how absolutely fucking terrifying radiation can be

[@lim-dulspaladin50]

I wish there was a way to feed the algorithm that credited the channel more so then the individual videos. Love the content of Plainly Difficult excellent work every time!

[@petrapedia]

Interact with community posts

[@justtime6736]

Great username

[@lairdcummings9092]

When you said "By the Power of Gravity," I heard that in He Man's voice... "By the Power of Greyskull!" Edit: Rules are written in blood - except that good rules *were* in place. This man died of greed - the unwillingness of the owner/management to pay for a full translation, pay for installing the shroud, and unwillingness to pay to properly train the operator.

[@monad_tcp]

This is when the operator should override orders from superiors, simply say, I wont do it because of the alarm, I know its unsafe. Losing a job is better than losing your life.

[@lairdcummings9092]

@@monad_tcp sadly, that level of awareness and moral courage is often hard to find. Working in ignorance makes it even harder to do, as the worker may not even know what is hazardous.

[@notshardain]

@@lairdcummings9092 Your last sentence is spot on. If the company ignored the need for the shroud to prevent blockages that prevent the source from lowering, it's equally likely that they didn't properly train their workers in regards to PROPER safety procedures. The company already skipped multiple pieces of safe operating procedures for years, so I doubt the workers were fully aware.

[@andredeketeleastutecomplex]

Human: it's safe to go through the door. Radiation: am I a joke to you?

[@512TheWolf512]

i have no idea, i would rather get fired from my job than die of radiation sickness

[@no_peace]

Yeah my first instinct was "uh don't put your life at risk so your boss will make money" but then i started to think "well, they're medical products, maybe that's why they're so invested"... Then i started to think that a lot of these accidents happen in countries without support systems or certain labor protections (not necessarily Israel) and losing a job there could mean your family being homeless and going hungry, or maybe even jail I'm not saying the US is great btw, we don't have real support systems either, just enough for me to say "I'm not dying so you can increase revenue 0.005%"

[@LuizDahoraavida]

Sounds reasonable

[@iitzfizz]

Holy shit, death 36 days after irradiation. It's like so long a time to suffer but also not long for the rest of your life

[@jdmbeats]

I'm sure those last days felt like years, just waiting for the pain to stop. Horrible

[@natasha8007]

I first thought I read that wrong. So glad you’re covering this, we used to tell this story as a ghost story as kids.

[@Lythiaren]

The more Plainly Difficult I watch, the more I support strict regulations. Most of the incidents on this channel were the direct result of somebody disregarding safety rules and/or vital maintenance due to inexperience, time pressure, or simply not caring.

[@cholebhature1957]

great work bro

[@PlainlyDifficult]

Thanks 🔥

[@colemarie9262]

"Decided to try and clear the jam himself" are like final last words in every working trade there is plus a bunch of recreational activities... That phrase seems like you're losing an hand at best, exploding at worst in basically any scenario involving mechanics of *any damn kind* Probably just......don't? Just don't do that.

[@828enigma6]

Hard to make things foolproof, as fools are so ingenious. Condolences to the family.

[@nathanarievlis3985]

Your work is appreciated . Not only for the entertainment value , but for the lesson that complacency kills. Some of us are working dangerous jobs and every now again we need the reminder to take a beat and REALLY assess a situation before jumping in. Thx again and stay safe guys.

[@nonmihiseddeo4181]

"The rule books are plainly written in blood" definitely applies to aviation, also.

[@familyman3573]

It's pretty safe to say that it applies to any job or pursuit with an element of physical danger.

[@Rotem_S]

This is one of those channels where you really don't want to see your country referenced huh? Also, two really small corrections about the Hebrew: 7:07 Like English, Hebrew has either a question mark or a period at the end of a sentence and not both (this may not be a language mistake actually) 11:33 The hospital is named "Ichilov" with the "ch" doing a voiceless uvular fricative /χ/ sound, like the "ch" in the German name "Bach" Obviously these are really minor, overall nice video!

[@SlavicCelery]

Multiple punctuation marks at the end of sentence shouldn't happen in English? Shirley you can't be serious?!

[@red__guy]

At least it is written right to left lol

[@AsbestosMuffins]

Almost seems like there should have been a mechanical interlock to drop the source if the door was opened while the pneumatic cylinder is retracted or some kind of gate by the end of the maze to trip the mechanical failsafe if the source was still out of the pool

[@a1nelson]

Probably. However, in this case the source had already become blocked and prevented from dropping - rendering another source drop interlock useless. I’m guessing this operator would have defeated the gate too, but who knows.

[@JanicekTrnecka]

Much more simpler rule applies for hydraulic press- do not put your fingers where you wouldn't put your willie. This rule is universal, dont mess with safety interlocks, especially when there is invisible danger related to it.

[@monad_tcp]

machine needs a better design

[@no_peace]

Boxes shouldn't be able to get in the way of the rack dropping

[@michaelcherry8952]

@@no_peace Actually, the company knew for 20 years that the installation of a shroud would prevent the source rack from being interfered with, but they ignored the notification from AEC and didn't install the shroud. They must have figured it would be cheaper to just go in and clear the jam. They were wrong.

[@KimdraStBiryukova]

Ah, back to the good ol' Plainly Irradiated videos.

[@astronomydemon6312]

Ah, a plainly difficult video when I needed it most

[@_motho_]

The worst part about radiation is if you can actually tell you’re being irradiated because you feel a physical sensation, you are WAAAY beyond fucked.

[@Astinsan]

How is it an accident when you bypass every safety system?

[@lazarusrat6159]

It's amazing what people will do to bypass safety measures.

[@chesspiece81]

Did he really use The IT Crowd method of trouble shooting by trying to turn it off and on again?

[@commisaryarreck3974]

Welcome to IT Turning it off and on again like black magic will suddenly have it work I'm not even joking I've disassembled so many computers to check what's wrong, checked the drives Just turning it off and on had it working perfectly all of the sudden

[@KD2HJP]

confronted with a whole load of Co-60 would ruin that person's next ~36 days

[@shannon9993]

It must have been horrific.

[@KD2HJP]

@@shannon9993 I....I don't have the capacity to contemplate that

[@shannon9993]

yeah, me neither. None of these cases.

[@BrianClem]

Especially day 37

[@KD2HJP]

@@BrianClem I'm thinking like day 15...Day 37 is a gift at that point

[@paul6925]

I would never have known how many radiation incidents there have been if it weren’t for your channel! It’s a little disturbing how careless some of them are.

[@rapomnam]

I used to work with a fellow that worked for AECL many years ago. The incident at Soreq was one of his investigations, and one of the main reasons he hated going to on site investigations.

[@kapioskapiopoylos7338]

all safety "fail-safes" will fail if the operator tries hard enough, disconecting the alarm conectors shows a clear disrespect for safety. also the fast power-cycling to bypass the safety systems didn't help i guess, just shows how little safety was concening them. on conflicting messages, always, every single time asume the worse (if you think that you can be too safe, rest in natural selection, sadly sometimes you may take more souls with you).

[@q3st1on19]

Ayyyy more plainlyd, also obligatory first

[@JamesFromTexas]

Time stamps show you missed first by two.

[@q3st1on19]

@@JamesFromTexas yeah, but they didn't put the obligatory first. Sidenote 1: it's to close to call who was truly first to the video as I typed out a different comment and then deleted it and wrote out that one. Sidenote 2: I expected this channel is now big enough that there are multiple people online the moment a video goes live. Sidenote 3: I know when I loaded to the video page it said something like 11 seconds ago so there was a gap someone else could have viewed it before. The view counter said 0 views but view counts aren't real time.

[@PlzReturnYourShoppingCart]

I'm so happy this channel exists. My love watching the videos this guy makes!

[@jgellert]

The best system debuggers are the operators ,they will find every bug efficiently ,also they know how to use the universal programming buttons,the restart/reset and turn off buttons.

[@IacobucciB]

Just a recommendation for a future video - Deepwater Horizon. It seems lots of media surrounding the disaster is very sensationalized, and I feel your approach would do the disaster lots of justice. Great video as always.

[@marc-andreservant201]

Source position sensor: Everything safe. Radiation alarm: BEEP BEEP BEEP! Operator: Yeah, I'll pick the one that says it's safe, I like that one better.

[@shgstewart4674]

This is also a really good example of why good documentation is needed. Hire a technical writer - the life you save could be your own!

[@williamdemeritt8886]

"He ignored the radiation alarm" about sums it up

[@cricketthebeardie325]

I live in Israel and I've never heard of this incident. Thanks for the great vid!

[@thecatdragon589]

🇵🇸

[@beyondfubar]

Being more fearful of management than the risks directly contributed to this.

[@sashkad9246]

as with any complex system, the buggiest part is the human...

[@BrianKelsay]

I assume the shroud could be as simple as a piece of plexiglass that keeps boxes from jamming the cobalt source. Having worked around conveyors, rollers and cardboard boxes, I see how this could happen. The more danger that the safeties protect you from, the more important it is to adhere to them.

[@claudioavia]

Very nice video and it shows how well done was your research. 👏🏼

[@R.O.T.C._SEEM]

During hearing all the safety features of the plant I'm like, this is high IQ thinking, surely no one can screw this up but surely someone finds a way to screw it up

[@ThisFinalHandle]

I'm all for safety procedures as long as they don't kill this channel.

[@0xEmmy]

Here's my question: why wasn't the indicator designed better? e.x. attach a cable or chain to the top and bottom of the cage, forming a loop. Put the loop through a mechanical tension sensor (e.x. make it suspend a weight, and sound an alarm if the weight rises or falls beyond set limits). Attach markers to the cable, to indicate the cage position. These markers can easily be connected to sensors or interlocks, and the marker's position can be locked mechanically to lock the cradle in place. As an added bit of safety, maybe make the point where the cradle top connects to the cable slightly flimsy, so that the cradle's own weight will break it, rather than the cable keeping it from lowering. Perhaps double or triple up the system, so that one cable breaking leaves some indication. This way, any error that could cause an incorrect reading will also trip the tension sensor. A jam anywhere will cause too much tension, while a snap without a jam will cause too little. As an added bonus, add a thick glass window into the cradle chamber for camera insertion. Or add a periscope to the 'maze'. Or a set of independently operating cameras. Something to provide vision into the chamber (to troubleshoot weirder errors) without opening it. Long story short, the fact that the only outside-visible safety indicator could fail so easily, AND into a state indistinguishable from valid operation, is inexcusable. Oh, and if you've got two different readings of danger, trust whichever won't get you killed if it's wrong. I'd hope that much is obvious.

[@colbypupgaming1962]

This was an AECL product, they don't exactly have a stellar record for making fail-safe products.

[@michaelcherry8952]

@@colbypupgaming1962 I'm sorry, but I don't agree. There were multiple safety systems in place that were bypassed and/or ignored. There were clear maintenance procedures regarding the rack indicator microswitch that were not carried out by the company that was using the equipment. There was also a notification from AEC that a conveyor jam-up could interfere with the lowering of the Cobalt-60 source into the water pool AND a directive to install a shroud to prevent the problem from happening. That notification was ignored by the company for 20 YEARS. There's an old Engineering saying: "I can fix stupid, I can't fix BLOODY stupid!" Do you think the technician found out how to bypass the radiation monitor interlock by accident? Obviously people were messing around with the equipment to get around the safety measures, probably because doing it the right way would take too long and get management on the warpath. As usual, safety took a back seat to getting the product out the door.

[@drdrew3]

A 24 hour facility needs 24 hours of consistent safety rules. Having different protocols for day versus night shifts is a recipe for disaster. Hopefully they recognized and fixed this procedural error but that was never mentioned in the video. When working with hazardous materials proper staffing and training is expensive but the lack of it is deadly.

[@Phoenix-ej2sh]

I watch all your videos to the end, just to get a weather report on your corner of London.

[@davejones9469]

My cousin is a physicist at a university, and he says their radiation room has armed guards...and we're in Canada!

[@thejudgmentalcat]

"Rule books are written in blood" I'd never thought of it that way

[@galashery7264]

I used to live about 15 minutes away from Soreq Research Plant and I passed by it a million times and I never knew that someone died there until now. Thanks PD Edit: obviously no one passes by the real thing it’s a bit secluded. There’s a sign on the motorway nearby

[@twocvbloke]

A sad instance of the all too familiar employer pressuring employee to get stuff done, despite the risks of death involved, when it comes to radiation, assume dangerous until someone with the right kit proves otherwise, given machinery can and has failed to do so, such as in this example... :\

[@nicklacerte7134]

You literally open this video with my birth date. Thanks man! I had to stop and rewind after only 5 seconds to make sure. 6.21.90. Now i know this happened on the day I was born. Learn something new everyday

[@airgunzel4430]

Could you have a look at the Baneberry Test December 18, 1970 - Nevada Test Site - Accidental venting of a nuclear explosion. A plume of hot gases and radioactive dust was released raining fallout; The three diverging jet stream layers conducted radionuclides across the US to Canada, the Gulf of Mexico and the Atlantic Ocean.

[@ldti]

A radiation incident at a facility that's a 15 minutes drive from my house. Lovely. Just lovely.

[@TheSarcasticEngineer]

Seriously, if you have conflicting info that says "radiation" and "safe", you couldn't pay me to go in there without it being triple checked. Production be damned. There's no bravery medals from work, you won't get a raise for putting yourself in the firing line.

[@AntCooke]

This was a really interesting one. Feel sorry for the poor chap.

[@buffclary]

Blaring radiation alarm, noisy enough that ppl keep disconnecting it, and he decides to go in there? Ok dude, bye-bye!!

[@abbiekennedy2861]

Great video as always!

[@ritecomment2098]

dual channel, better designed and fail safe switches that do not rely on adjustment, or even a video camera would have solved this.

[@dmhendricks]

A video camera would have prevented him from going into the room?

[@ritecomment2098]

@@dmhendricks "oh look I dont see the source in the pool", I better not go in there" or "oh I see the source is still raised, I better not go in there" video cameras can record visual imagery to be displayed on a visual display terminal in another room(s)

[@ritecomment2098]

dual channel limit switches, made by different manufacturers, with plausibility checks for advance/return, feeding into a safety PLC with enforced time limits on switch checks, with interlocked gate switches with removable captive keys. all in a days work for STEPS/EDDI messaging!

[@fuzzymath6240]

This is the BEST issue yet!! Brilliant mate!!

[@happninmojo]

Amazing. Think of the sheer gall (and chutzpah if you like) that was needed to manually disconnect a blaring alarm at a nuclear facility. I get antsy disconnecting a smoke detector ...

[@vancemacy1850]

Hope you find more criticality stories. They are the most interesting ones on your channel. Good work. I like your presentation style !