DOE skewers INL management over radiation accident
SVEN BERG
sberg@postregister.com
A report released Wednesday places the blame for the radiation exposure of 16 Idaho National Laboratory employees squarely on the shoulders of laboratory management.
Missed opportunities, inadequate safety assessments and ineffective training were among INL's failures that contributed to the exposure, according to a 123-page report by the U.S. Department of Energy, which oversees the lab.
It all added up to a failure to understand the severity of potential consequences from handling nuclear fuel plates, as a group of workers did the morning of Nov. 8 at INL's Materials and Fuels Complex. That failure led to concerns about systemic weaknesses in the complex's safety policies.
The Nov. 8 accident occurred when a worker inside the building that once housed the Zero Power Physics Reactor exposed a nuclear fuel plate containing plutonium-239. At least one worker inhaled a radioactive substance, lab officials said two days after the accident.
In the wake of the accident, the DOE dispatched a group of investigators from its headquarters in Washington, D.C., to find out what happened. Their report concluded that the seeds of the accident were planted years before it actually occurred.
Perhaps the most glaring safety oversight occurred more than four months before the accident. On June 23, an unnamed safety official at the complex presented Phil Breidenbach, who had recently taken over as director of nuclear operations at the complex, with a document that contained recommendations for safe handling of fuel plates stored at the reactor building.
It was the second time since January 2009 that the document and its recommendations were presented to members of the complex's management team. But both times the document's "significance was not recognized and no action was taken," according to the DOE report.
Deputy laboratory director Riley Chase said the lab is "looking into" Breidenbach's failure to take the document's recommendations into account. Breidenbach, who reports directly to Chase, was part of a high-level management change at the complex in May of last year. The complex's history of unplanned radiation exposures and other safety events were a factor in the decision to change its management team, Chase said in December.
Another contributing factor mentioned was the loss of information about the condition of fuel plates, some of which were stored for 30 years in the reactor building. According to the DOE report, this occurred between 2004 and 2005 -- about the time the agency awarded Battelle Energy Alliance a 10-year contract to manage INL.
Chronology of the incident
At 10:39 a.m. on the day of the accident, according to the report, workers removed four small boxes containing plutonium fuel plates from a vault at the reactor building. Two of the boxes, called clamshells, were labeled with warnings about radioactive contents and abnormalities in the fuel plates' conditions.
According to the report, a shift supervisor called the complex's nuclear facility manager 10 minutes later to discuss the labels. During the course of that phone conversation, Chase said, the facility manager and the shift supervisor worked out a plan for how to proceed with opening the clamshells and handling the fuel plates.
Other than gloves that a few were wearing, the workers were dressed in standard work clothing without protective features.
Just after 11 a.m., the workers placed the clamshells on a confinement hood -- a device designed for use "when hazards are acceptably low, as indicated by the quantity of the material involved, the specific operation to be performed, and the hazardous nature and chemical form of material involved," according to a DOE handbook published in 1999.
An operator opened one of the clamshells at 11:01, according to the report. One operator told DOE investigators that he or she asked what the workers should do in the event of a fire or finding a powder. The operator said the shift supervisor responded that it was "not a valid question."
Two minutes later, after the first operator cut through a plastic wrap that covered the fuel plate, a black powder spilled out of the wrapping.
According to the report, the shift supervisor did not recall a conversation about the potential for encountering a powder.
In the minutes that followed the powder's discovery, the workers conducted a series of tests to determine what they had found. At 11:07, an air monitor detected plutonium in the room. An alarm sounded, and workers began evacuating the room.
Contributing factors
The release of plutonium is believed to have stemmed from corrosion of the fuel plate's cladding -- a stainless steel layer that encased the plutonium -- that occurred during decades of exposure to air and moisture. The interaction of air with the plutonium would have gradually produced a substance like the powder that fell out of the plastic wrapping, INL and DOE officials believe.
Brian Edgerton, who spent some 30 years working at various facilities on the DOE site west of Idaho Falls, said in a telephone conversation Wednesday that the decision to open the clamshell and cut through the plastic wrapping after only a brief conversation with the facility manager raises questions about attention to safety protocols at the complex. If the shift supervisor truly did brush off an operator's question about finding a powder, he said, it is further evidence of a deep and systemic problem.
If such a problem does exist, he said, the responsibility for it lies with the lab's managers and not individual workers.
"In my experience, when you come across something different, you don't just gloss over it and say it's OK to proceed," Edgerton said. "That may imply that there's an underlying safety culture weakness with the line management out there."
The DOE's report also criticized training of workers in the field of plutonium awareness.
"This lack of awareness contributed to the workers delaying their evacuation for nearly four minutes until they heard the radiation alarm," the report states.
Included in the report are 18 recommendations from the DOE for how to avoid similar mishaps. One of them suggests Battelle officials seek approval from the DOE when handling plutonium fuel outside of a glove box, which is a much more robust containment device than a confinement hood.
Underestimated hazards
Chase said the central failure by lab management was underestimating the hazard posed by handling decades-old plutonium fuel plates without proper protective equipment. Had they predicted the hazard, he said, they would have handled the fuel plates in a glove box.
Other recommendations state that Battelle should reinforce proper work procedures and improve the quality and depth of self-assessments at the complex.
The DOE's Idaho offices did not entirely escape criticism, either. Even though the agency's investigative team concluded that DOE-Idaho's oversight of MFC has been "appropriately balanced and effective," its report stated that local officials "accepted the risk of known safety ... deficiencies and allowed continued operation of the (reactor) facility ... without putting effective interim controls in place."
Chase said Battelle will develop a set of corrective actions designed to help the lab avoid further accidents of this kind. The contractor will deliver those proposals to the DOE in early March, he said.
According to a DOE-Idaho statement, the department's local office "agrees with the findings of the investigation team and will be working with (Battelle) to identify and implement the appropriate corrective actions."
"DOE is considering fee reduction and enforcement options, but has not made any determination at this point," according to the statement.
Meanwhile, monitoring of the exposed workers continues. Sharon Dossett, the lab's director of environment, safety and health, said a precise measurement of the radiation doses each worker received won't be known for a number of months.
At least one of the workers is believed to have inhaled plutonium contamination.
"Internal exposure to plutonium is an extremely serious health hazard," according to the U.S. Environmental Protection Agency website. "It generally stays in the body for decades, exposing organs and tissues to radiation, and increasing the risk of cancer. Plutonium is also a toxic metal and may cause damage to the kidneys."
Dossett said she expects to discover the workers' doses were low enough that they will cause no short- or long-term health effects.
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