NIST-BOULDER PLUTONIUM CONTAMINATION EVENT NRC SPECIAL INSPECTION

1. NIST-BOULDER PLUTONIUM CONTAMINATION EVENTNRC SPECIAL INSPECTION

2. 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

3. 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

4. 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

5. 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

6. Plutonium Sources and Containers

7. WING 1 BUILDING 1

8. LABORATORY 2120/2124 DIAGRAM

9. MULTI-USE LABORATORY

10. DETECTOR RESEARCH PROJECT

11. DETECTOR CRYOSTAT/LEAD BRICKS/MARBLE TABLE

12. NO EATING OR DRINKING ALLOWED!

13. LABORATORY 2124

14. TIME TO CALL IN DOE’s RAP TEAM

15. INSTRUMENT PEGGED

16. SOURCE STORAGE CABINET

17. STORAGE OF PLUTONIUM

18. Two Centimeters Wide By Four Centimeters High

19. MAY BE BROKEN?????

20. YEP, IT’S BROKEN!

21. LABORATORY 2124

22. HEPA-FILTRATION SYSTEM and CAM

23. HAGEN CONTAINERS

24. SOURCE RECOVERY DRY-RUN

25. 326 MILLICURIES OF RECOVERED PLUTONIUM

26. TIME TO CLEAN (DECONTAMINATE)

27. 48,000 POUNDS OF WASTE

28. 312 DAYS FOR CLEAN-UP

29. CREEP, CREEP, CREEP

30. EXCAVATION OF OUTDOOR DRAINLINE

31. SOIL SAMPLES FROM OUTSIDE TRENCH

32. REMOVAL OF CONCRETE FLOOR

33. EXCAVATION OF INDOOR DRAINLINE

34. ENERGYSOLUTIONS MOBILE LABORATORY

35. SHIPMENT OF LLW

36. SOIL SAMPLES FROM INSIDE TRENCH

37. ORISE CONFIRMATORY SURVEYS

38. 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

39. 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

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

41. 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

42. ROOT CAUSE Inadequate management oversight and accountability to ensure that the Radiation Safety Program was sufficient to handle plutonium safely

43. NEXT STEPS · 10 apparent violations identified · Inspection report issued · Enforcement pending

44. Read The NIST Report Yourself • Go to www.nrc.gov/reading-rm/adams.html • Pull up ADAMS ML 093080053