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NIST-BOULDER_PLUTONIUM_CONTAMINATION_EVENT

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									NIST-BOULDER PLUTONIUM CONTAMINATION EVENT
           NRC SPECIAL INSPECTION
Events Leading Up to the
Plutonium Spill
 Untrained researchers use the plutonium,
  unsupervised
 Researcher ruptures the plutonium source
  during an experiment on June 9, 2008
 Researcher washes hands in sink
 Researcher unknowingly tracks the loose
  plutonium powder throughout the building
 Untrained workers attempt to
  decontaminate the building
Initial Event Response
 NIST personnel attempt to decontaminate
  the building themselves
 NIST contacts the NRC to report the event
  the day after it occurred
 NRC dispatches a Health Physicist to NIST
  the following day
 NRC identifies multiple deficiencies in the
  NIST initial response
Continued Event Response
 On June 19, a second Health Physics
  inspector was dispatched by NRC
 DOE’s Radiological Assistance Program
  (RAP) Team was also there during this time
  to characterize the extent of contamination
 Due to the results of the DOE
  characterization, a NRC Special Inspection
  Team was dispatched on June 30, 2008
EPA Involvement in the NIST
Event

   The City of Boulder, in coordination with the
    US EPA, Region VIII, initiated a biosolids
    monitoring program to analyze the extent of
    plutonium contamination, if any, in the
    Boulder Waste Water Treatment Facility

   None of the samples revealed the presence
    of plutonium above background levels
Plutonium Sources and Containers
WING 1 BUILDING 1
LABORATORY 2120/2124 DIAGRAM
MULTI-USE LABORATORY
DETECTOR RESEARCH PROJECT
DETECTOR CRYOSTAT/LEAD BRICKS/MARBLE TABLE
NO EATING OR DRINKING ALLOWED!
LABORATORY 2124
TIME TO CALL IN DOE’s RAP TEAM
INSTRUMENT PEGGED
SOURCE STORAGE CABINET
STORAGE OF PLUTONIUM
Two Centimeters Wide By Four Centimeters High
MAY BE BROKEN?????
YEP, IT’S BROKEN!
LABORATORY 2124
HEPA-FILTRATION SYSTEM and CAM
HAGEN CONTAINERS
SOURCE RECOVERY DRY-RUN
326 MILLICURIES OF RECOVERED PLUTONIUM
TIME TO CLEAN (DECONTAMINATE)
48,000 POUNDS OF WASTE
312 DAYS FOR CLEAN-UP
CREEP, CREEP, CREEP
EXCAVATION OF OUTDOOR DRAINLINE
SOIL SAMPLES FROM OUTSIDE TRENCH
REMOVAL OF CONCRETE FLOOR
EXCAVATION OF INDOOR DRAINLINE
ENERGYSOLUTIONS MOBILE LABORATORY
SHIPMENT OF LLW
SOIL SAMPLES FROM INSIDE TRENCH
ORISE CONFIRMATORY SURVEYS
     RADIOLOGICAL CONSEQUENCES

Radiological consequences were potentially
very significant, but actual safety
consequences were minimal
· No dose limits were exceeded
· Material potentially discharged to sewer
   did not exceed regulatory limits
· Contaminated areas of the NIST facility
   were cleaned
              DIRECT CAUSE

Breakage of glass bottle containing
plutonium on a hard surface led directly to
the incident
· Marble top laboratory table
· Lead bricks
· Detector cryostat
           CONTRIBUTING CAUSES

· Personnel were inexperienced and not
  properly trained
· An adequate hazard analysis was not
  performed
· Written operating procedures were not
  developed
            CONTRIBUTING CAUSES

· Plutonium sources were used and stored in
  a mixed –use laboratory
· The setup of the experiment was
  insufficient
· Direct oversight of work involving plutonium
  was inadequate
· The immediate emergency response to the
  event was inadequate
              ROOT CAUSE




Inadequate management oversight and
accountability to ensure that the Radiation
Safety Program was sufficient to handle
plutonium safely
                 NEXT STEPS



· 10 apparent violations identified
· Inspection report issued
· Enforcement pending
Read The NIST Report Yourself
   Go to www.nrc.gov/reading-rm/adams.html

   Pull up ADAMS ML 093080053

								
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