NIST-BOULDER PLUTONIUM CONTAMINATION EVENTNRC 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