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A Review of Criticality Accidents A Review of Criticality Accidents

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On 11 March 1963, the facility chief and the<br />

operations engineer proceeded with pre-experiment<br />

operations with the assembly pieces still in place. The<br />

experimentalists attempted to make adjustments to the<br />

machinery <strong>of</strong> MSKS using unauthorized attachments<br />

in violation <strong>of</strong> the operating procedures. As they<br />

worked on MSKS adjusting the electromechanical lift<br />

mechanism, an excursion occurred. Seeing a flash <strong>of</strong><br />

light, the experimentalists immediately exited and went<br />

to the control room, where the facility chief pushed the<br />

control button lowering the table. The automatic scram<br />

system did not activate because the detectors to which<br />

it was tied were not operating.<br />

The accident was the result <strong>of</strong> gross violations <strong>of</strong><br />

the MSKS operating procedures by the facility chief<br />

and operations engineer. The excursion was due to the<br />

inadvertent closure <strong>of</strong> the assembly by the experimentalists.<br />

As a result <strong>of</strong> the accident investigation and<br />

analysis, it was judged that the assembly had approached<br />

or possibly even exceeded the prompt critical<br />

Neutron Detectors<br />

FKBN<br />

MSKS<br />

Neutron Detectors<br />

FKBN<br />

Control Room<br />

Figure 52. Building B floor plan.<br />

state. The number <strong>of</strong> fissions was estimated to be<br />

~5 × 10 15 fissions. The nickel clad <strong>of</strong> the plutonium<br />

was not breached and therefore no contamination<br />

resulted. MSKS itself was undamaged and remained in<br />

long-term service. 54<br />

Since the assembly parts were not damaged, they<br />

were used in a special set <strong>of</strong> experiments to more<br />

accurately estimate the exposure to personnel. The<br />

facility chief’s dose was ~370 rem, and the operations<br />

engineer received ~550 rem. Both experienced<br />

radiation sickness. The facility chief survived for<br />

26 years, and the operations engineer was still alive<br />

36 years after the accident. Both were immediately<br />

taken to a hospital for treatment. Eventually they<br />

returned to work at the VNIIEF Physics Division. Four<br />

other people working in adjacent area also received<br />

doses, although much lower (~7, ~1, ~1, and<br />

~0.02 rem).<br />

MSKS<br />

Control Room<br />

FKBN<br />

Control<br />

Panel MSKS<br />

Control<br />

Panel<br />

Corridor<br />

Rail Track<br />

Neutron Source<br />

Entrance<br />

85

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