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A Case Study on an Incident


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Title: A Case Study on an Incident

A Case Study on an Incident
  • NIST Boulder Plutonium Spill June 9, 2008

Presented by Timothy Mengers, CHP, PE NIST RSO
Definition of the incident June 9, 2008
  • On Monday, June 9, 2008 between 1445 and 1515
    a glass vial containing 0.25 grams of a mixed
    Plutonium isotopic standard Certified Reference
    Material of PuSO4 was broken spilling a
    substantial fraction of its powdered contents on
    the bench top and floor.
  • The incident occurred in a general purpose multi
    use unsecured laboratory at NISTs Boulder
    facility with no contamination controls.
  • The experimenter had no radiation safety
  • The experimenter washed his hands in the sink,
    left the lab.
  • The experimenter failed to report the problem for
    approximately one hour during which several
    others had entered, worked in , and left the lab.

What was the experiment all about? Micro
calorimetric based spectroscopy - High
resolution some possible Non-proliferation
The Quantum Sensors A pixilated array of micro-
The Cryostat
The Electronics

The program started with little sources
But it grew very quickly CRM - 138 Plutonium
Isotopic Standard for radio chemistry PuSO4
Source Term Its just a ¼ gram ( its an
encapsulated source ….)
Time line The First day
  • 245 PM Experiment setup vial probably broken
    during set up
  • 308 PM Researcher left lab and went to his
  • 338 PM - Researcher returned to the lab
    discovered the broken vial, contained it in a
    scotch taped can. Put another source on detector
  • 354 PM - Researcher washed hands in sink
    unmonitored release - left lab with
    contaminated note book
  • 357 PM researcher told Principal Investigator
    there might be a crack in the vial then went
    to 3rd floor office of associate.
  • 410 PM The PI called researcher for help , bare
    hands - opened taped can and saw vial was broken,
    ordered evacuation of room. Researcher and PI

Time line The First day
  • 441 PM - PI and researcher surveyed sensor table
    with a gm meter - found high dose rate.
  • 443 PM - PI notified supervisor, the RSO
    Safety Office by phone.
  • 500 PM - PI shut off room FCUs. equipment fans
    and unfiltered hood remained on.
  • 410 - 600 PM - Several individuals including
    some who had been in the lab moved around the
    wing to various labs, offices, restrooms.
    Several people used corridor leaving work.

Triage - the First Night
  • 500 PM - RSO called in route from annual leave
    recommended gathering everyone in corridor - and
    closing corridor to traffic. but Corridor is
    not secured.
  • 600 PM - The RSO arrived, isolated corridor,
    set up step off vestibule, initiated personnel
    decon and clearance.
  • 730 PM - Decontamination and clearance completed
    for 17 individuals. All foot contamination
    1000 CPM
  • Researcher and PI hands and pockets contaminated
    (3000 CPM). None on face - Decon takes all

Triage - the First Night
  • 730 PM - RSO inserts air sampler High MDA High
  • 900 PM - Lab is isolated.
  • 900 PM 700 AM - RSO and volunteers survey
    and decon hallway and office floors. Foot step
    patterns lt 3000 CPM (4 nCi) - inhalation ALI 6
    nCi ingestion ALI 800 nCi
  • Material spots clean easily with water and mild
  • In the morning notification to NRC and
    Gaithersburg management begins.

The end of the 1st night.
We werent ready Catching up! Tuesday through
  • Source Term Analysis incomplete information
    separation daughter in-growth calculated
    from1988 later found to be 1966?
  • Bioassays - Contacted PNL for advice Missed
    nasal smears. Contracted GEL labs for Bioassay
    analysis. Without protocol tried small sample
    similar to H-3 too small to be useful.
  • Equipment Acquisition - only 2 hand held alpha
    probes still working and an uncharacterized
    single LSC and low volume air pumps.
  • Written Testimonies - Began interviews
  • HP Support RSO from Gaithersburg arrived on
    Thursday night.

A crowded multi use lab
Entries and Discoveries
Foot Step Patterns 1000 to 6000 CPM (minimal
indication of general distribution on elevated
200,000 CPM alpha Some response (mR/hr range) on
Ion Chamber
An Alpha emitter ??? ! Off scale at
500,000 CPM 8 mR/hr with sealed ion chamber at 1
No Eating, Drinking, Smoking Allowed but they
are Sealed Sources and … we have to get our data!
May Be Broken Bottle

Yep Its broken (32 mr/hr with ion chamber at
near contact)
Discoveries and Assessments
  • We had something more than alpha emitters
  • We had an unauthorized sewer release
  • Some key individuals testimony was not
    consistent with evidence
  • No indication of airborne distribution… So Far
  • Dry smears did not effectively remove the
  • The material caked on the glass similar to the
    powder in a light bulb.
  • We needed a better measurement of retained

Calling for Back-up
  • We did not have adequate smear counting
  • We did not have adequate spectroscopy capability
  • We did not have adequate air sampling capability
  • We did not have adequate respiratory protection
  • We did not have adequate HVAC filtration and
    effluent control.

DOE Radiological Assistance Program (The
Cavalry comes over the hill)
  • RAP 6 and RAP 7 responded with equipment and
    personnel. sterling cooled gamma spec, alpha
    CAM, i-solo smear counters,
  • RAP 6 made gamma spec measurements on vials, and
    maslin large area wipes of spill area
  • High airborne reading 37.5 DAC forced termination
    of entries.
  • Radon was a serious confounder forcing decay
    before analysis.

Characterization The Sterling Standard
Pegged in the spill zone
Bioassays taken and retaken
  • Monitored up to 35 individuals (17 had actual
    potential for an uptake.) Initial small samples
  • 24 hour urines for all, fecals for major
  • Standard alpha counting performed by GEL labs
  • Thermal Ionization Mass Spectroscopy (TIMS)
    performed by LANL. (10 times more sensitive)
  • Whole body gamma spec performed by Colorado
    Department of Public Health and Environment for
    primary participants
  • Medical advice provided by REACTS Chelating
    provided early on for one individual
  • ORAU/REACTS provided internal dosimetry

NRC Confirmatory Action Letter Dont just do
Something!…. Stand there!
  • Stop Work Order for use of sources
  • Dose Assessment
  • Training of Users
  • Assess and Report Effluent to NRC and Boulder
  • Root Cause Analysis
  • No Entry without NRC approved work plan
  • Contract for DD
  • http//boulder-incident.nist.gov/plutonium/NRC_con

Stabilization concerns source distribution
  • Still had computer and instrument fans on
  • Still had soldering irons on
  • Still had hood on maintaining weak negative
  • Chemical change to oxide?.... Alpha creep?
  • Other potential vectors for distribution ???

Contracted Stabilization and DD
  • A competitive bid was won by ESI they have been
  • DD efforts began in August
  • Most recovered material was transferred to LANL
  • Low DCRFs and ALIs were a challenge.
  • Am-241 in-growth became key measureable marker
  • Radon and NORM is a major confounding factor
    all positive air samples and smears needed multi
    hour gamma specs.
  • Final status surveys completed in April
  • NRC confirmatory surveys and samples collected
    we are awaiting final reports but currently looks

Public Responses
  • Stake holders Affected lab users, NIST
    Employees, NIST Child Care Center, the
    surrounding neighborhoods, local waste water
    treatment facility, local city council, Colorado
    Politicians, DOC leadership, U.S. Congress
  • Distribution more people had been in corridor
    and left before surveys….Some items removed from
    lab before alarm… Demand Bioassays for all…
    Demand surveys everywhere.
  • How did untrained unsupervised workers get this
  • Why didnt any one know The Most Dangerous
    Material Known To Man was on site?
  • What other hazards havent you told us about?

Public and Business Affairs ( The news cycle ---
you have to be up front)
  • Need to get the information out you cant leave
    a vacuum to be filled with speculation and rumor
  • Problem You often have incomplete information
  • Challenge Sometimes what you reported on
    incomplete information needs to be corrected
    makes it really tough to keep credibility
  • Balance When do you go to press on each new

The Investigations Begin
  • NIST Safety Office time lines and status
  • NIST Ionizing Radiation Safety Committee
  • NIST contracted Panel of Experts
  • Congressional Hearings
  • Root Cause Review - Contracted Booze Allen
  • DOC Blue Ribbon Commission
  • DOC Office of the Inspector General
  • NRC

Panel of Experts Investigation
  • Paul S. Hoover Senior Advisor,
  • Radiation Protection Division, Los Alamos
    National Laboratory
  • Lester A. Slaback, Jr.
  • Former Supervisory Health Physicist, NIST
    (retired in 2001)
  • Kenneth C. Rogers
  • Former Commissioner, Nuclear Regulatory
    Commission (1987-1997)
  • J. Michael Rowe
  • Consultant - Former Director, NIST Center for
    Neutron Research (retired 2004)
  • Richard E. Toohey
  • Director, Dose Reconstruction Programs, Oak
    Ridge Associated Universities

Time line The Precursors (We all get Pre -
  • 2003 Boulder campus shared by NTIS, NOAA, and
    NIST Safety Admin. run by MASC - returned to NIST
    includes NRC license.
  • 2004 NRC license due for renewal. IRSC audit
    finds inadequate hand off of records - Recommends
    Boulder safety chief be trained and recover
    records from MASC/NOAA.
  • 2004 - Rad-worker training for Sensors staff
    emphasizes source security and handling controls.
    - typically check sources, Fe-55.
  • 2004 - Sensors program indicates growth IRSC
    discusses license models (Broad Scope or
    Specific) and Recommends NIST Boulder hire HP.

Precursors -
  • 2004 Gaithersburg RSO assists Boulder writing
    Specific License Renewal Application Sensors
    program requests additional isotopes Boulder
    commits to NUREG 1556 vol 7 requirements for
    procedures but not implemented…
  • 2006 - Gaithersburg RSO audit - continued records
    and procedure problems - Interviews for New RSO
    in Boulder to fix problems
  • 2006 - Gaithersburg HP trains sensors program
    staff including hazards assessment of licensed
    sources, security training rules.
  • 2006 - Boulder RSO / LSO hired, (2 1/2 years
    after need identified) but not funded…. Used
    labor lapse from environmental vacancy.

Precursors -
  • 2006 - New Boulder RSO studies NIST Gaithersburg
    procedures…. to be modified for specific license
    per NUREG 1556 v7.
  • 2006 - Boulder RSO submits License amendment -
    resembles broad scope C - Encapsulated
    sources - IRSC reviews after submittal and
    recommends caution, but trusts RSO control.
  • 2006 - Sensors program collaboration with LANL.
    IRSC recommends SNM work only at DOE labs.
    Trials conducted.
  • 2007 - Sensors program requests SNM check
    sources - Boulder RSO discusses NMMSS RIS,
    SNM exempt quantities with G-burg RSO and NRC
    region 4. Submits amendment (6th in 4 years)
    - approved by NRC Inadequate (NO) IRSC review.

License Limits Amendment 29
  • 2008 - Reorganization - Boulder Safety under
    Gaithersburg Safety, but no funding, no line
    authority Gaithersburg HP over Boulder HP.
  • 2008 - per collaborator recommendations ordered
    Pu CRM isotopic standards for radiochemistry…
    NBL sent instruction not to remove from
    containers except in a glove box only PI (and
    RSO?) see this notice.
  • 2008 - NIST 364 form proposal to acquire a
    radiation source was filled out the day of
    receipt without approval signatures or protocol
  • 2008 - Associate researcher assigned to project
    in April PI gives access to sources
    NoTraining Not expected to receive more than
    100 millirem per year violates NIST policy -
    All rad users must be trained.

Lacked license and procedural review and
  • Previous work was all with lower activity
    encapsulated sources
  • Minimal detection equipment funding problems.
  • No contamination controls normally used
    encapsulated sources
  • The RSO hired to improve and support program
  • Tough balance - Rad support or Rad Cop?
  • The RSO enabled license amendments to support the
    programs desires… Specific license resembles a
    broad scope type C
  • RSOs failed as gate keepers - Inadequate review
    or coordination with IRSC in Gaithersburg.
  • Acquisition violated NIST procedures
    transferred procedure not properly implemented in

IRSC Investigation (root cause lite) Reviewed and
confirmed by Booze Allen Hamilton study
  • The Root cause of the plutonium spill and
    resulting contamination was a lack of management
    accountability and commitment at the highest
    levels at NIST to an effective operational safety
    culture at the Boulder NIST facility
  • http//www.nist.gov/public_affairs/releases/root_c

Contributing Causes (management and culture)
  • Inadequate management oversight or supported
    all division level program management in
    Gaithersburg Boulder lab director had no real
    line authority Boulder Safety office had no
    real authority or resources
  • Inadequate operational safety management system
    Roles Responsibilities, Authorities and
    Accountabilities existed on paper but not known,
    implemented, or followed bench supervision
    claimed to be unaware of hazards and
    requirements to assure training and oversight
  • Poor organizational safety culture Science
    research productivity first safety stifles the
    scientists creativity overhead functions divert
    resources from the real work were the experts
    we know what were doing - research program grew
    too quickly with lagging safety support or

Contributing causes (operational)
  • Inadequate hazard analysis Hazard never
    recognized or analyzed - Assumed to be a sealed
    check source never considered leakage or
    rupture written procedures for hazard
    assessment process not properly implemented no
    clear disclosure of intended use or materials
    review circumvented .. no written protocol
  • Poor safety training Previous training and
    instruction provided to PI and group leader were
    ignored or forgotten, None was taken by associate
    researchers handling source despite
    recommendations from co-workers
  • Inadequate Emergency Response no emergency
    response planning or training, inadequate
    equipment researchers lacking training did
    almost everything wrong…. Commissioner Rogers
    noted serious lack of common sense

NRC Investigation
  • Final reports not yet issued awaiting final
    status of DD, Effluent, and Dose assessments.

Final Dose and Effluent Results (Dodging the
Bullet - and other Real Miracles)
  • No One Exceeded Occupational Dose Limits
    ! Probably due to chemical composition Did not
  • Most were non-detects.
  • At least 84 of the material recovered or
    retained as waste.
  • Sewer release approximately 71 of 30 day
    average release concentration limit.

  • Serious loss of reputation and public trust.
  • Operations halted probable license termination
  • Very long hours for staff 2900 hour OT
  • 70,000/week - DD contractor staff deployed.
  • Accountability Roles, Responsibilities,
    Authorities, and Accountabilities have been
    reviewed. Several positions have changed.

And a Path forward??????
  • Facility Radiation Specific
  • Decommission Boulder Radiation Facility
  • Transfer work to another facility…. Or terminate?
  • Terminate Boulder License impacts other

NIST Safety Culture a Path Forward
  • Hazard Assessment, Mitigation and Emergency
    Response Planning
  • Train Supervisors and Management on Safety Roles,
    Responsibility, Authority, and Accountability
  • Increase Safety Infrastructure Staff and
  • Require job specific safety training for all NIST
    staff before work begins

The lessons will be learned! Or else well be in
this condition again… Or worse!

  • PNL Bioassay Advise and GEL Labs contacts -
    Dan Strom, Gene Carbaugh, Stan Morton, Valerie
  • RAP 6 and 7 measurements equipment Kevin
    Hungate, Doug Walker, Dave Everett
  • DOE Headquarters Debbie Wilbur, Steve
    Marielli, Alan Remick, Antonio Arogon
  • LANL Dosimetry Group Performing TIMS Dr.
    Leslie Hoover
  • ORAU/REACTS medical management, consultation,
    Dose assessments, - Dr Christenson, Dr Toohey ,
    Dr. Theodore Cetaruk
  • Colorado Dept. of the Environment Whole body
    scans - Tony Harrison
  • Panel of Experts - J Michael Rowe, Paul Hoover,
    Lester Slaback, Kenneth Rogers, Richard Toohey
  • NRC Region IV HQ Arthur Howell, Vivian
    Campbell, Richard Leonardi , Sami Sherbini
  • Gaithersburg HP staff James Clark, James Tracy,
    Keith Consani, Tom Grove others
  • Safety Office Rosamond Rutledge Burns, Sonja
    Ringen, Dave Garrity others
  • NIST Directors Office Rich Kayser, Pat
    Gallagher and the IRSC
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