A Case Study on an Incident

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A Case Study on an Incident

• NIST Boulder Plutonium Spill June 9, 2008

Presented by Timothy Mengers, CHP, PENIST RSO
Gaithersburg
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Definition of the incidentJune 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
  training.
• 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.
  

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

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The program started with little sources
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But it grew very quicklyCRM - 138 Plutonium
Isotopic Standard for radio chemistry PuSO4
5H2O
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Source Term Its just a ¼ gram( its an
encapsulated source .)
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Time lineThe First day

• 245 PM Experiment setup vial probably broken
  during set up
• 308 PM Researcher left lab and went to his
  office
• 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
  stayed.

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Time lineThe 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.

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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
  night.

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Triage - the First Night

• 730 PM - RSO inserts air sampler High MDA High
  Radon
• 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
  soap.
• In the morning notification to NRC and
  Gaithersburg management begins.

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The end of the 1st night.
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We werent readyCatching up!Tuesday through
Friday

• 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.

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A crowded multi use lab
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Entries and Discoveries
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Foot Step Patterns1000 to 6000 CPM(minimal
indication of general distribution on elevated
surfaces)
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200,000 CPM alpha Some response (mR/hr range) on
Ion Chamber
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An Alpha emitter ??? ! Off scale at
500,000 CPM8 mR/hr with sealed ion chamber at 1
inch
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No Eating, Drinking, Smoking Allowed but they
are Sealed Sources and we have to get our data!
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May Be Broken Bottle

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Yep Its broken(32 mr/hr with ion chamber at
near contact)
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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
  material
• The material caked on the glass similar to the
  powder in a light bulb.
• We needed a better measurement of retained
  material.

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Calling for Back-up

• We did not have adequate smear counting
  capability
• 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.
• IT WAS TIME TO CALL RAP

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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.

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CharacterizationThe Sterling Standard
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Pegged in the spill zone
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Bioassays taken and retaken

• Monitored up to 35 individuals (17 had actual
  potential for an uptake.) Initial small samples
  inadequate.
• 24 hour urines for all, fecals for major
  participants
• 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
  precautionary
• ORAU/REACTS provided internal dosimetry
  calculations

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NRC Confirmatory Action LetterDont 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
  City
• Root Cause Analysis
• No Entry without NRC approved work plan
• Contract for DD
• http//boulder-incident.nist.gov/plutonium/NRC_con
  firmatoryLetter.pdf

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Stabilization concernssource distribution

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

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Contracted Stabilization and DD

• A competitive bid was won by ESI they have been
  excellent
• 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
  good

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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
  stuff?
• Why didnt any one know The Most Dangerous
  Material Known To Man was on site?
• What other hazards havent you told us about?

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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
  development????

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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

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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

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Time line The Precursors(We all get Pre -
cursed)

• 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.

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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.

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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.

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License Limits Amendment 29
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Precursors

• 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
  review.
• 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.

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Lacked license and procedural review and
constraints

• 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
  Boulder.

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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
  ause_plutonium_010709.pdf

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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
  oversight

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Contributing causes(operational)

• Inadequate hazard analysisHazard 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 trainingPrevious 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 Responseno emergency
  response planning or training, inadequate
  equipment researchers lacking training did
  almost everything wrong. Commissioner Rogers
  noted serious lack of common sense

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NRC Investigation

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

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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
  distribute.
• 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.

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Costs

• 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.

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And a Path forward??????

• Facility Radiation Specific
• Decommission Boulder Radiation Facility
• Transfer work to another facility. Or terminate?
• Terminate Boulder License impacts other
  research

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NIST Safety Culture a Path Forward

• Hazard Assessment, Mitigation and Emergency
  Response Planning
• Train Supervisors and Management on Safety Roles,
  Responsibility, Authority, and Accountability
  (R2A2)
• Increase Safety Infrastructure Staff and
  Resources
• Require job specific safety training for all NIST
  staff before work begins

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

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Acknowledgements

• PNL Bioassay Advise and GEL Labs contacts -
  Dan Strom, Gene Carbaugh, Stan Morton, Valerie
  Davis
• 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