' 1 * *

Pacific Northwest Laboratories

To RA Wal ters A

Project Number 331Drum. InV

Internal Distribution

WJ Apley WJ Bjorklund LE Braby KC Brog TD Chikal la

* MF Gillis DP Higby GR Hoenes BW K i l l a n d

LV Kimmel RR King WJ Madia HT Ti 1 den JE Trevino . MA Wi 11 iams Operations Mgrs Res Fac Mgrs Fi 1 e/LB

331 Bui 1 d i nq Drum Pressuri r a t i on Incident .Investiqation Report

Subject

Per your January 12, 1995 memo, "Investigation of 331 Barrel Incident i n Room 175" (Exhibit A) , the Investigation Board has completed i t s investigation of the incident and i s submi t t i .ng the attached report. The Investigation Board recommends t h a t

0 the Laboratory provide guidance for appropriate management and disposit ion of "legacy" materials. The guidance should, a t a minimum, instruct staff that whenever unknown 1 egacy materi a1 s are encountered, Laboratory Safety and Radio1 ogi cal Control s ta f f should be contacted for a coordinated deci si on on proper hand1 i ng and d i sposi t i on of the material.

0 * the Laboratory's Operations Improvement Team include i n i t s development o f improvement ini t ia t ives the following as examples of inadequate l ine management imp1 ementation of PNL pol i cy/procedure.

- Noncompliance w i t h PNL-MA-8, Subsection 8.4.1, "When a project ends or an employee terminates, ensure that no waste remains unaccounted or u n i denti f i ed. I'

- Noncompl i ance w i t h PNL-MA-6 , Arti cl e 351 and PNL-MA-7 , Appendix J . Arti cl e 351' establ i shes t h e requi rement for conducting critiques of radi ol ogi cal events; Appendix J suppl i es the procedure.

- Noncompliance w i t h PNL-MA-50, Section 4.3, "Conduct o f Operations Assessment Checklist.!' This section s ta tes that "The assessment checklist i s a record document that must be completed prior t o .

ini t ia t ion of work act ivi t ies and (must be) appropriately maintained by the activity manager."

e the appropriate training classes be updated to include the message: " i f a container i s sealed and i,ts contents are unknown or questionable - do not open.

Staff need to be instructed on how to identify hazards. In addition t o the training, s taff should be provided w i t h frequent and imaginative. examples o f risks from the manager's assessment o f operations, as well

Contact Laboratory Safety for help." .

as examples from the PNL Lessons Learned Program.

DSTRIBUTION OF THIS DOCUMENT IS UNLIMITED €54-1900.001 I101891

$5

RA Wal te rs February 9, 1995 Page 2

Lessons Learned a r t i cl es be prepared for Laboratory-wi de d i s t r i b u t i on and for d i s t r i b u t i o n t o the Hanford Lessons Learned Coordinator for Site-wide dissemination. A t a minimum, the a r t ic le needs t o address Lessons Learned from 1) handling a sealed drum containing unknown contents , 2) sel ecti ng an inappropriate Radi ol ogi cal Work Permit (RWP) , and 3) the potential for exposure t o unknown chemicals d u r i n g an evacuation.

The Lessons Learned ar t ic le could be used t o encourage staff t o maintain a questioning att i tude, and could also be used t o inspire management t o employ administrative aids (e.g. , termination checklists) t o guard against legacies l e f t behind by retiring, transferring, o r terminating s t a f f . .. . .

the Laboratory devel op gui del4 nes and an appropri ate trai n i ng program on "materi a1 spi 11 response" requirements for a1 1 appropriate management and s ta f f .

Whi 1 e the Investigation Board acknowledges. that such g u i dance i s under . development and will be incorporated into the building emergency

procedures , i t i s recommended that thi s guidance resolve the fol 1 owi ng concerns :

- How and when .is a determination made by the field (e.g., Building Emergency Director, Lab Monitor, ES&H Offi cer, 1 i ne management) t h a t a spil l i s hazardous versus nonhazardous, t ak ing into consideration the t y p and quantity of materi a1 ?

- If the field defers the above decision t o Laboratory Safety, what interim actions should the field take until Laboratory Safety arrives?

- How w i 11 PNL "ensure.. . s taff . . .understand their acti ons and responsi b i 1 i ti es" before a spi 11 occurs? -

- Is the guidance practical and the training effective?

If you have any questions, please contact me a t 376-4188.

RAP:ms

Attachment

For Internal Use Only

INVESTIGATION OF DRUM PRESSURIZATION INCIDENT IN THE 33.1 BUILDING, ROOM 175

ON JANUARY 10, 1995

FEBRUARY 1995

DISCLAIMER

This report was prepared as an account of work sponsored by an agency of the United States Government. Neither the United States Government nor any agency thereof, nor any of their employees. makes any warranty, express or implied, or assumes any legal liability or responsi- bility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe privately owned rights. Refer- ence herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not necessarily constitute or imply its endorsement, ream- mendation, or favoring by the United States Government or any agency thereof. The views and opinions of authors expressed herein do not necessarily state or reflect those of the United States Government or any agency thereof.

*

. -

PACIFIC NORTHWEST LABORATORY ' RICHLAND, WASHINGTON

DISCLAIMER

Portions of this document may be illegible in electronic image products. Images are produced from the best available original document.

. .

CONTENTS

SCOPE . . 1

SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

FACTS SECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 T H E E V E N T . . . . . . . . . . . . . . . . . . . . . . . . . . 4 RESPONSE TO THE EVENT . . . . . . . . . . . . . . . . . . . . . . 5

ANALYSIS SECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

THE EVENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 POSSIBLE SCENARIOS . . . . . . . . . . . . . . . . . . . . . . . 9 ROOT CAUSE METHODOLOGY . . . . . . . . . . . . . . . . . . . . 11

CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

GOOD PRACTICES . . . . . . . . . . . . . . . . . . . . . . . . 11 FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 CAUSAL FACTORS . . . . . . . . . . . . . . . . . . . . . . . . . 13

D i r e c t C a u s e . . . . . . . . . . . . . . . . . . . . . . . . 13 C o n t r i b u t i n g Causes . . . . . . . . . : . . . . . . . . . . . 14 R o o t C a u s e . . . . . . . . . . . . . . . . . . . . . . . . . 14

JUDGEMENT OF NEEDS . . . . . . . . . . . . . . . . . . . . . . 15

S I GNATURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ii

XT... .. T.. ... .I._. . I -.*,.-r.T--.--- . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... .I.'>.. . . . . . ,.,e,. ... A. .... . .

A. B. C. D. E. F. G. H.

EXHIBITS

APPOINTMENT LETTER ROOM DIAGRAM PHOTOGRAPHS NDA REPORT RADIO LOG I CAL SURVEY REPORT PNL 2400 REPORT RWPs REFERENCES

Ind i v idua l s I n t e r v i ewed Documents Reviewed

iii

SCOPE

On January 10, 1995, a t approximately 0830 hours, a pressurized drum incident occurred a t the 331 B u i l d i n g , Room 175. On January 12, 1995, the Manager of the Life Sciences Center appointed members t o an Investigation Board to investigate the incident (see Exhib i t A ) .

This incident was in i t i a l ly categorized as an Off-Normal Occurrence, b u t was la te r elevated t o an Unusual Occurrence by the Occurrence Classifier. The scope of this investigation was to

employ a formal method of root cause analysis, identify the methodology, and report the results of the analysis, ful ly explaining the technical elements of the causal sequence along w i t h a description of the barriers t h a t should have or coul'd have prevented the occurrence.

During the course of the investigation, the scene of the event was not accessible. Therefore, the investigation re1 ied primarily on testimony from staff members.directly involved and their management. outside professionals were also consulted (see E x h i b i t H).. . The Investigation Board visited the previous location of the drum, 331A Building, Room 9; Room 173, which fronts room 175, was also visited. The Investigation Board revi ewed sel ected documents, whi ch are a1 so 1 i sted i n Exhi b i t H .

In addition, other

SUMMARY

The 331 Building, also known as Life Science Laboratory 1, is a U.S. Department of Energy Faci 1 i t y operated by Battell e Memori a1 Insti tute. The 331 Building is the largest of ten buildings which comprise the 331 Facility.

On December 30', 1994, a 55-gallon black steel drum located i n the 331A Building,. Room 9, was discovered to have rust on i t s base rim.

On January 5, 1995, the drum was brought into the 331 B u i l d i n g , Room 175, to be opened so t h a t the contents could-be inventoried and repackaged i n a new drum.

On January 10, 1995, the Hazardous Materials Coordinator (HMC) and a volunteer (a senior research scient is t from t h e . b u i l d i n g ) gathered to s t a r t the inventorying and repackaging task. Very shortly thereafter, the researcher, HMC, and the attending Radiological Control Technologist (RCT) were involved in a potentially dangerous situation when the l i d blew off the pressurized drum. The l i d presumably.struck an overhead l ight , breaking its cover and . bulb, and landed approximately eight feet away. ejected from the drum; two of the bottles were empty and two contained l i q u i d , some of which spilled o u t on to the floor. The floor of the room was found to be contaminated, as were the personal shoes of the HMC and researcher. No one

Four 120-1111 bottles were

1

was injured and there was no spread of contamination outside the room. Later in the morning, the RCT reentered Room 175, stabilized the sp.illed liquid, upgraded the post ing for the room, and locked the door. During this reentry, the RCT was outfitted w i t h the Personnel Protective Equipment (PPE) speci f i ed by Radiological Work Permit (RWP) #PNL-6 (Exhibit. G) and as supplemented by the Manager of Radiological Control Operations. The Manager of the Life Sciences Center then appointed an Investigation Board t o investigate the incident.

Given that the drum was already pressurized and that the (controllable) incident was actually the inadvertent release of that pressure, the Investigation Board concl uded that the direct cause of the incident was inadequate content in training; i .e. , those involved proceeded w i t h opening a sealed container .without knowledge of the contents because their training did not identify the specific risk (potential pressurization without obvious physical indicators , caused by unknown contents).

A significant contributing cause was "inadequate procedure. (RWP f331-32, Rev.16) was originally written for the routine "shipping, receiving, and unpacking of radioactive shipments." While i t i s clearly understood t h a t RWPs are not procedures, the selection of this RWP effectually circumvented the conduct of operations assessment check1 i st. uniqueness of the work activity been recognized, the appropriate work controls may have been establ i shed. They .are 1 isted on page 15.)

The selected RWP

Had the

(Other c o n t r i b u t i n g causes were a1 so i denti f i ed.

The root cause for this incident i s a t t r ibu ted t o "management problem - policy not adequately defined, disseminated, enforced." A policy on how the Laboratory should manage 1 egacy and/or unknown materi a1 s i s not clearly defined nor i s guidance provided t o the field. With the appropriate policy, . guidance, and corresponding t r a i n i n g , the Laboratory should be ab1 e t o manage i t s legacy issues and avoid a recurrence o f this type o f incident.

FACTS SECTION

This section contains a description of background information on 331 Building operations that led t o the drum. pressurization, the incident, and the response t o the incident.

BACKGROUND

Approximately three years ago, the Biology and Chemistry Department appointed one of i t s staff members as the Department's HMC. Department has demonstrated aggressiveness in i t s pursuit t o el imi nate unneeded materi a1 s 1 ocated within .the 331 Faci 1 i t y compl ex. highlights of this campaign include the disposal of 40 used High Efficient Particulate Air (HEPA) f i l t e r s from the second floor mechanical room, five drums of unknown liquids t h a t had been located on.the 331 dock, and five or

Since that time, the

Notabl e .

six 4 x 4 x 8 f t plywood boxes of unneeded research materials that had, been stored a t 331C, the 331 Facility Warehouse.

In June 1992, during th i s cleanout program, the RCT discovered a black, 17H, 55-gallon steel drum in Building 331A, Room 9. Taped t o the top of the drum l id was a Nondestructive Assay (NDA) report (Exhibit D) dated October 17, 1989. The report d i d not include an identificati'on tracking number. The drum. was the. type used for disposal of "dry" low-level radioactive material and i s thought t o have originated in the 1980s. The exact contents of the drum were unknown. . .

When the drum Mas discovered, management recognized tha t i t would have t o be opened so the contents could be inventoried and evaluated for subsequent retention or disposal. Management gave this task a lower priority, however, a f te r 1) considering the drum's probable contents (1 ow-1 eve1 radioactive material ; an assumption based on knowledge of past operations, which was supported by i t s low weight and the absence of l'sloshing"), and 2) recognizing more pressing regulatory waste disposal issues. Another factor contributing t o this decision was t h a t the drum was being stored inside Room 9, rather than on a dock where i t would be exposed t o the' elements.

.

On December 30, 1994, two-and-one-half years after management's decision, the RCT assigned t o the 331 Facility was conducting a routine radiological survey of the Building 331A, Room 9. This survey would also serve as a re-posting survey t o change the room's designation t o a Radiological Control Area only. Because the room i s so small (-5 x 8 f t ) , the RCT had t o move the drum ou t of the way in order t o survey the face of the hood. A t th i s time, the RCT noticed a rust r i n g had formed on the floor below the drum. As the drum was moved, a s l ight rocking'motion was noticed. The RCT promptly reported the situation t o the HMC, who decided tha t the drum would have t o be emptied and the contents inventoried and repackaged. The decision was made t o move the drum into Room 175, where this work could b e performed under control?ed conditions. On January 5, 1995, three working days af ter discovery of the drum, a serviceman moved the drum into the doorway of.Room 175 and the HMC positioned the drum in front of the fume hood nearest the door. hours, the temperature was -9" C and the humidity was 90 percent. temperature for that day was -1" C w i t h 48 percent humidity.)

(At 0400 . . The high

.Room 175 was chosen as a location for this work because i t 1) i s a Radiation Area/Radioactive Material Area, 2) has no floor drains, 3) i s equipped with two fume hoods with double.HEPA f i l t ra t ion , 4) i s maintained w i t h a negative a i r pressure relative t o the hallway, 5) i s typically used. for the receiving and unpacking of radioactive shipments, and 6) has been used for other drum repackaging act ivi t ies . (P-32) , which had been held in storage for up t o a year t o allow natural decay, were brought t o Room 175 for repackaging for the purpose.of waste minimization. In addition, drums of low-level waste o f known contents were also repackaged in the room due t o changes in waste acceptance c r i te r ia .

For example, drums of waste containing Phosphorus-32

3

The RWP that governs these activ.ities i s RWP #331-32, Rev.16 (see Exhibit G ) . The scope'of th i s RWP includes 1) entry for observat.ion, 2) transferring materials and containers between Rooms 175A and 175, 3) shipping and receiving radioactive shipments, and 4) unpacking radioactive shipments.

In preparing for the work, an empty 55-gallon blue drum was positioned i n front of the second fume hood, up against the back wall, t o receive the materials that would be removed from the black drum.

Based on past practices.and the expectation that the drum contained dry materials, the HMC and RCT decided t h a t R\JP #331-32 would be the applicable permit for the intended opening, inventorying, and repackaging of the drum.

On the morning of the event (-0815 hours on January 10, 1995), the RCT collected a routine a i r sample from the room and took a dose reading a t the drum: . the ra te was < 0.5 mrem/hr: A direct reading from 'the drum surface read 10,000 disintegration per minute (dpm).

During the course of the staff interviews, various statements were made t h a t suggested the drum may have been deformed.

.

.

.

The RCT noted tha t while moving the drum around in Room 9 . (December 30), i.t wobbled l ike i t had an uneven bottom or was on an uneven surface.

The HMC stated that the drum l id appeared t o be slightly bulged on the morning of January 10. During a subsequent v i s i t t o the 331A Building, the HMC pointed o u t a similarly bulged l i d on a drum s i t t ing on the dock. be bulged. '

The l id on this drum did not appear t o the Investigation Board t o

During the researcher's interview, ttie drum was .described as s i t t ing "uneven.

THE EVENT

Shortly af ter the RCT collected the air sample, the HMC, RCT, and a resident senior research scientist - (who volunteered t o assist the HMC) gathered for the repackaging task.

A t the time o f the incident'(-0830 hours), the HMC was positioned i n front o t and facing the work bench. opposite side between the black drum and the new' blue drum. the doorway between Rooms 175. and 173, receiving a lab coat from another researcher who was i n Room 173. The researcher i n Room 173 was waiting t o neutralize samples in one of the hoods i n Room 175. This researcher had just returned - t o Room 173 af ter retrieving more Tab coats, as there were only two lab coats i n Room 175.

The researcher, who opened the drum, was on the The RCT was a t

4

Both.the HMC and assisting researcher, who were i n Room 175, were wearing the PPE specified in RWP #331-32: lab coat, gloves, and 'safety glasses. Exhibit B for position of s taff . )

(See

In preparation t o remove the l id , the researcher unscrewed the bolt from the ring holding the 1 id (there was no locking n u t on the bo1 t) . When the ring could not be removed by hand, the researcher used a hammer t o tap the .ring .and break i t loose from the rim. I t was a t this time tha t pressure w i t h i n the drum was released; the l id and ring were blown off and four 120-1111 bottles from within the drum were cast ou t ' on to the floor. broken.

None of the bottles were - .

The l id landed on the floor about eight feet from the drum. The r i n g settled on the floor near the base of the drum. The four bottles landed on the floor a t various locations within four feet of the drum. Two of the bottles leaked .a total of 20 t o 30 m l of liquid, which i s believ.ed t o be two normal n i t r ic acid (2N HNO,) , an assumption based on knowledge of past operations. The other two bottles were empty. (See Exhibit C for photographf 'of the scene of the event and Exhibit E for radiological survey results.)

During this event, the drum l id presumably struck the overhead l ight fixture (the ceiling i s about eight feet high). The floor was sho-wered w i t h broken pieces from the light cover and bulb (see E x h i b i t C) . A cloud of particulate was also immediately visible. I t i s believed the cloud was composed of. d u s t from the l ight cover and the powdery substance from inside the fluorescent bulb. . . RESPONSE TO EVENT

A verbal exchange confirmed t h a t no one was injured.

The HMC and the researcher proceeded t o the exit. The HMC l e f t the room t o self survey f i r s t , while the researcher remained in Room 175, near the entrance. To get t o this position; the researcher had t o pass by the drum, which the researcher did by purposefully t a k i n g the p a t h opposite the airstream from the open drum t o the fume hood.

-

While s t i l l in Room 175, the HMC removed PPE, which was bagged and placed on the floor inside the door of Room 175. The HMC then exited to Room 173 and stepped onto the hand and foot counter. The counter alarmed for the r i g h t shoe.

During this time, t h e researcher who had been waiting t o use'one of the hoods l e f t the area t o report the incident t o the Manager o f Biology and Chemistry (the responsible 1 ine manager); the Manager in turn contacted the Occurrence Classifier and the Single Point Contact. That call was received a t 0834 hours, according- t o the 2400 Report (see Exhibit F) .

5

Using a portable instrument, the RCT performed a whole body f r isk of the HMC and discovered an alpha contamination reading of 2,000'dpm on the bot tom of one shoe. After removing both shoes, the HMC performed another hand and foo t counter survey, this time w i t h negative results.. The contaminated shoe and the clean shoe were bagged and placed inside the door of Room 175.

While the HMC was being surveyed, the researcher used a phone i n Room 175 t o ' call and.request that the RCT's supervisor come t o the scene o f the event.

Next, while s t i l l a t the door, the researcher removed al l PPE and a whole body frisk was performed by.the RCT using the portable instrument. This survey found alpha contamination on the soles of b o t h shoes: These shoes were also bagged and placed inside the door of Room 175. assisting researcher then performed a se1.f survey on the hand and foot counter w i t h negative results.

10,000 and 5,000 dpm. The

A t about this time, the RCT's supervisor and the Alternate Building Emergency Director (BED) arrived a t the scene. The Alternate BED i s also the l ine manager responsible for operations i n Room 175.

After the personnel surveys were completed, the RCT took nasal smears from bo th the HMC and the researcher. There were no readings above action levels.

The next'action taken was t o close and lock the door t o Room 175. maintained on negative air pressure and i s equipped w i t h double HEPA f i l t e r exhaust. ai r pressure was s t i 11 being mai ntai ned. )

The room i s

(When checked by Air Balance staff on January 19, 1995, the negative

A t -0944 hours, the RCT set up t o collect an a i r sample from within Room 173, near the entrance t o Room 175. The sample was timed o u t a t 1040 hours.

I t was around this time that both the Manager of Radiological Control Operations and the primary BED arrived a t the scene of the.event.

An informal plan was conceived for reentering Room 175 i n order t o stabil ize the spilled liquid and coJlect an air sample. govern the reentry. The stipulated PPE included head cover with air-purifying respirator (equipped with HEPA and acid/gas f i l ter ing cartridges), two sets of surgeons gloves plus acid resistant gloves, two sets of coveralls, and. shoe covers. Control Operations; who has RCI?A/CERCLA experience, including 40-hour HAZWOPER t r a i n i n g . was based on knowledge of past operations, indicating .that the l i q u i d was . bel i eved t o be 2N HNO,.

RWP #PNL-6 was selected t o

The adequacy of the PPE was .confirmed by the Manager of Radiological

The choice of the acid/gas f i l ter ing cartridges for the respirator

Incidental t o this event was that a t about 0815 hours o n the morning of the event, the RCT collected an a i r sample from Room 175 as part of the morning routine. and restoration act ivi t ies which are under development.

That a i r sample should serve as a timely benchmark for the recovery

6

A t approximately 1050 hours, the RCT reentered Room 175.

The RCT's f i r s t task was t o remove the air sample (that had been started a t 0815 hours). whi 1 e the gloves were s t i 11 cl eaduncontami nated. was sent t o the Counting Lab a t the 3745 Building.

The a i r sampl e

After removing the sample, the RCT picked up the bagged PPE and shoes and discarded them i n a waste drum located in the room. . The lab coats were not sent t o Laundry since the incident involved alpha contamination and PPE contaminated w i t h alpha i s not accepted a t the Laundry.

The RCT then 1) picked up the four 120-ml bottles and returned t h e m t o the cardboard container inside the drum, 2) p u t the drum r ing i n a plastic bag and s e t ' i t on the floor between the drum and the hood, 3) wiped up the spilled liquid from the floor (using three set of three Terri Towels, one swipe apiece) and placed the towels in the drum, 4) picked up the largest pieces of broken l ight cover and bulb, placing them in the new drum, 5) used a masslinn mop head t o sweep up remaining broken pieces of 1 ight cover/bul b and placed the pieces in a new drum, and 6) handed the masslinn mop through the door t o a second RCT in Room.173, who surveyed i t (see Exhibit E, th is was smear M2). The RCT in Room 175 then checked the floor once again, going over the areas with a clean Terri Towel (which was also placed i n the subject drum). For the final task, the RCT took tech smears 1 through 5 (see Exhib i t E) and handed them t o the second RCT for survey.

To exit Room 175, the RCT placed two sheets of plastic on the floor near the door (inside Room 175) t o stand on while removing al l PPE. The-RCT stepped o u t of the room t o self survey w i t h portable instruments and the hand and foot counter. No contamination was detected.

While the RCT was working in Room 175, the second RCT in Room 173 took a masslinn smear M1 from the floor o f Room 175 (see E x h i b i t E) by reaching across the threshold of the door. The survey of this smear detected alpha contamination of 750 dpm. The other masslinn smear sample recorded alpha contamination of 25,000 dpm and beta-gamma of 5,000 dpm.

Of the five tech smears, two were collected from the bench t o p , one from the . ledge of the nearest hood, and two from the floor near the drum. Only the

tech smears taken from the floor produced any. detectable levels of contamination. of 150,000 dpm and beta-gamma of 5,000 dpm.

The most contaminated of the two detected a1 pha 'contamination

All smear samples, masslinn mops, and tech smears were double-bagged and placed on the floor inside Room 175.

The door t o Room 175 was closed and locked and the room was posted as an Ai rborne Radi oacti vi t y Area and High Contami nati on Area.

The RCT finished the Radiological Survey Report a t 1145 hours.

7

Due t o equipment problems, the a i r sample that was sent t o the Counting Lab was forwarded t o the 329 Building for analysis. Since the 329 Building equipment i s set up t o provide readings of environmental concern, the results indicated only t h a t there was a sl ight peak in activity. This information was subsequently used for the decision t o send the HMC, researcher, and the RCT for a Whole Body C o u n t (WBC). reported a t t h a t time; counting data was n o t available for the a i r sample t h a t had been started a t 0815 hours and pulled when the RCT reentered the room a t 1050 hours.

On January 10, a l l of the available information was gathered and a "fact sheet" was published.

Not al l a i r samples had been analyzed and

On January 11, the Manager of Biology and Chemistry issued a "required readi ngl' message t o a1 1 331 Bui 1 ding occupants t o communicate immediate Lessons Learned. On January 13, the Director of Facilities and Operations called for the release of a formal "Heads Up" detailing the immediate Lessons Learned t o a l l Level 1 organizations. I t was transmitted'on January 17.

On' January 13, 1995, three days af ter the incident, the HMC; researcher, and RCT were sent t o the WBC for complete surveys.

On Saturday, January 14, a technician from PNL Dose Assessment delivered fecal sample packages to the RCT and the researcher a t their homes. A fecal sample kit was delivered t o the HMC's home on Monday, January 16, since the HMC's home could not be located d u r i n g the weekend.

Management also conducted a search for other sealed containers w i t h unknown contents.

The Investigation Board has not looked into the results of the air sample, the WBC, o r the fecal samples.

To date, the room has not been reentered' for recovery operations and the Investigation Board has not physically inspected the room and the evidence contained i n the room.

ANALYSIS SECTION

THE EVENT

The sudden depressurization of the drum corresponded t o the exact moment the researcher tapped the retaining r i n g w i t h the hammer. The fact that something, presumably the drum l id , was launched i n t o the overhead l i g h t fixture and t h a t the l id landed eight feet away suggests that the pressurization was substantial. been inspected (e.g., possible drum deformities) and the cause of the pressurization has not yet been determined. However, potential contributing

The physical evidence a t the scene has n o t

. 8

factors i ncl ude temperature change (outside t o inside temperature change of almost 25"C), radiolysis, possi-ble organic decomposition and chemical reaction, or a combination of these' factors-.

The damage caused by the incident amounted t o a broken l i g h t cover and fluorescent bulb. The extent of the damage appears relatively minor.

While no physical harm resulted from this incident, some potential .for injury existed .from the release of energy and/or illness from exposure t o the chemical s . A1 though know1 edge of past operations 1 ed -to a reasonable assumpti,on regarding the drums contents ( tha t they were dry materials), the absence of an actual inventory sheet should have established the contents as unknown. ' As an unknown, i t should have been treated as a unique work activity rather than as routine.

The NDA Report'identified isotopes of Pu present i n the drum, there i s some concern that the quantities could be regarded as transuranic (TRU) . However, there is insufficient data available t o make t h a t determination or even t o .

. verify t h a t this NDA report belonged t o this drum ('i .e., there was no identification tracking number t o connect the NDA results w i t h th is specific drum). constitute material bal ance area quanti t i e s of nuclear materi a1 . I t is also impossible a t this time t o determine if the contents

Furthermore, there i s insufficient data available t o determine the classification for this waste. l iquid(s), including radiolytic and chemical analysis.

Determination will rely on analysis of the .

POSSIBLE SCENARIOS

Given the current information, some possible scenarios exist that may account for the pressurization o f this drum.

One scenario i s radiolytic decomposition of plastic l iner (see E x h i b i t C - plastic l iner shows signs of deterioration). T h i s concern i s i l lustrated by the following, which was extracted from a 1993 Defense Program (DP) Safety Action Letter (SAL) :

"DP faci 1 i t y management and personnel (were a1 erted to) . potenti a1 safety concerns associated w i t h the potential pressurization of stored waste drums containing transuranic (TRU) waste i n contact w i t h hydrogenous materi a1 s. I'

radiolytic degradation.) (That i s , materi a1 s capabl e of generating hydrogen through

The SAL presented two concerns: drums w i t h nonvented 1 ids which contain TRU and. organic materi a1 s" and

"...radiolytic pressurization of waste

9 . _

"waste drums having vent f i l t e r s may be susceptible t o pressurization i f significant corrosion o f the vent f i l t e r s has occurred." - The SAL also says, "Many organic materials can decompose when exposed t o radiation. can cause si g n i f i cant gas. generati on and possi bl e drum pressuri zati on. Another safety concern i s the potential generation of flammable o r explosive mixtures of gases in waste drums containing TRUs and organic materials. For example, the radiolytic decomposition of plastic waste packages found i n many D P waste storage drums can produce hydrogen hazards t o workers and the environment. a1 1 evi a te these potenti a1 hazards. 'I

In particular, alpha radiolysis of org.anics i n TRU wastes .

Venting of waste drums may

Although the materials present in the drum in Room 175 are most likely not TRU, the probable decomposition i n that drum, coupled w i t h the change i n atmospheric pressure (outside t o inside temperature change of almost 25°C) , may have been sufficient t o cause the 331 Building drum pressurization incident.

Also possible in this scenario i s that the.drum contained low-level -radioactive material and was air-tight may have been enough. Although the details are l i t t l e sketchy, the following example i l lustrates th i s p o i n t (reference: Westi nghouse Hanford Occurreiice Report RL--WHC-WHCZOOEM-l992-

. 0051):

On August 28, 1992, PEDF .personnel noted that one of their 55-gal lon drums of waste was bulging. "The team tr ied t o d r i l l through the drum ... w i t h no success. was moved i n t o the facility^(2724-W) and opened." mention how drum was opened.) the drum l id upward discharging sand and .other drum contents. HAZMAT Team personnel performed a sniffing operation with negative results. 'I

"When the l id was off the inside contents (were surveyed and produced a reading of) 20,000 dpm." The emitter was not specified i n the report.

The emergency response team was summoned. The drum

(the report does not The drum "displayed some force propelling

.

. "The method of packaging' of (1 ow-1 eve1 radioactive waste) drums caused the metal drums t o be air-t ight along w i t h a chemical o r heat reaction of drum contents.. .could have caused an internal gas buildup w i t h i n the drums. With thi s combination , an internal reaction caused an outward d i s t o r t i o n (bulging) o f the drums l id ."

Another conceivable scenario i s t h a t the drum contains 'some unexpected and i ncompati bl e chemical s. This will be detemi ned af ter recovery and restoration act ivi t ies begin and the contents of the drum are analyzed.

10

' I

St i l l another poss ib i l i ty , organic decomposition, can be drawn from the fol 1 owing . event that happen a t Oak Ridge National Laboratory 1 as t year (reference Martin Mari e t t a Occurrence Report ORO--MMES-Y 12WASTE-1994-.0001) :

"On Apri 1 5, 1994, . . . a metal .1 i d on a sealed 55-gal lon drum containing soiled gloves, rags, and f i l t e r s was blown off under pressure which had b u i l t up inside the container over an extended period of time. This incident occurred as the 'drum ring' ... was being adjusted by two. . .employees. . . . The .metal 1 i d was blown approximately 14 feet i n t o the air, landing eight feet.from the drum. The decaying process of the organic material (sludge) which 'covered the contents of the container created a methane gas, causing the drum t o become pressurized." ..

ROOT CAUSE METHODOLOGY

Causal factors charting was the primary analysis tool used. Causal Analysis. Worksheet (from PNL-MA-41, PNL ES&H Management Sel f-Assessment Program) was used t o augment the causal factors analysis.

In addition, a

CONCLUSIONS

GOOD PRACTIC~S

The Investigation' Board acknowledges the significant and careful work that the . HMC has accomplished over the past few .years. The record would appear t o .

support a significant contribution t o the Department and Laboratory w i t h no prior i nci dents and shoul d not go unrecognized..

In addition, the RCT's good survey routine is credited w i t h the in i t ia l discovery of the drum i n June 1992, which was brought t o the attention of Management who acknowledged the iieed t o inventory and repackage the contents.

Many of the immediate actions taken a t the scene of the incident were commendable: ou t of an airstream between open drum and fume hood while exiting the room, 3) orderly and thorough personnel radiation surveys, i ncl udi ng use of makeshift step-off pads, 4) timely notification - t o management, including BED,' and the RCT supervisor and manager, 5) the call t o Single Poin t Contact, 6) efforts t o control the spi l l ( t o wipe i t up before i t dried i n order t o avoid dispersal of alpha contamination); and 7) securing and pos t ing Room 175.

1) concern expressed for personal safety, 2) foresight t o stay

Timely, p r u d e n t , and appropriate actions were also demonstrated by management ' s decision t o prepare and disseminate both 'a "required reading" message t o b u i l d i n g occupants and a Lessons Learned "Heads Up" across the Laboratory and t o conduct a h u n t for other sealed containers w i t h unknown contents.

11

FIND I NGS

a Sufficient information' was not available on the contents o f the drum t o support a decision on how t o proceed with repackaging.

Ownership of the drum was unknown, the date the drum was originally packaged and sealed was unknown, the specific inventory was unknown, and the drum's NDA report d i d not link i t s results w i t h th is specific drum by an identification number.

Management has not been i n compliance w i t h PN'L-MA-8, Waste Management & Environmental Compl.iance, Subsection 8.4.1.

Thi s Subsection 1 i sts the responsi bi 1 i t i e s of Line ManagerslProject Managers with regards t o Hazardous Waste. ends o r an employee terminates, ensure that no waste remains unaccounted or unidentified."

I t states, "When a project

0 No conduct of operations assessment checkl i s t was completed and documented for this work activity. need for a t least a Job Hazard Breakdown (JHB) could have been recognized and the risk assessed.

If a checklist had been u,sed, the

As a result , the wrong RWP (RWP #331-32, Rev.16) was selected.

RWP #331-32, Rev.16, was written for shipping, receiving, and unpacking radioactive shipments (i.e., known commodities) and had been used in the past t o permit repackaging waste from drums w i t h known contents (e.g., drums of waste containing P-32).

However, regardless- of past practices, relying on the existing RWP was inappropriate for an unknown commodity. A special RWP and work document (e.g., a Safe Operating Procedure o r JHB) were needed for thi.s unique task. operations assessment checkl i s t .

T h a t need could have been identi.fied through a conduct of

a The immediate actions taken were deficient. The researcher d i d not exit Room 175 immediately following the incident.

All workers should have evacuated Room 175. The researcher should have a t least stepped. into Room 173 t o reduce potential radiological and chemi cal exposure.

Although, i t was probably good judgement t o theorize that the spilled liquids were 2N HNO, (since staff present were familiar w i t h the type of bottl es i nvol ved) , there were s t i 11 uncertainties regarding the remainder of the drum's contents (contents t h a t were not known o r i.n view). To e r r on the side for worker's safety would have been a preferabl e AURA approach.

12

8 Communication between' the event scene and the Single Point Contact was less than adequate.

The incident was in i t ia l ly thought t o be a radiological event. As a result , when the Laboratory Safety contact was made no indication was given that would a le r t the Laboratory Safety contact that an Indu.stria1 Hygi eni s t , Waste Management, o r Envi ronmental Compl iance professional was needed a t the scene.

a Ini t ia l reentry planning was less than adequate. .

Since the Laboratory Safety professionals were not included i n the event response (see previous f ind ing ) , the reentry decision 1 acked i n p u t and approval for hazardous chemi cal concerns.

This oversight, however, could have been remedied if the B u i l d i n g Emergency Plan (BEP) detailed i ts requirement t o "take steps t o contain (the sp i l l ) i f possible." Specifically, the BEP needs t o direct 0ccupant.s t o contact Laboratory Safety when the spilled l i q u i d i s unknown. I t would also be.helpfu1 i f the BEP addressed -- i n what situations are s taff t o take steps? In what situations. should they n o t take steps? And what would prompt them. t o contact others (e.g., PNL Waste Management, Hanford Fire Department HAZMAT response) for? assistance?

0 Event critique was less than adequate. -

Although information was informally gathered and a "fact sheet" was distributed (and the manager who would have been responsible for leading the cri t ique was involved), a formal critique was no t conducted, as required by PNL-MA-6, and the information gathering process d i d n o t benefit from the i nvol vement of other disci pl i nes and procedural gui del i nes , w h i ch are speci f i ed i n PNL-MA-7, Appendix J .

CAUSAL FACTORS

Direct Cause

I Training Deficiency - Inadequate Content (5000.3~ Cause Code 5c)

Although i t is probable that the pressurization of the drum was caused by a combination of atmospheric changes and organic decomposition (as evidenced by the' condition of the plastic 1 iner) , the incident occurred because no one was ab1 e t o recognize . and anticipate the hazard. The drum l i d was opened because no one had instructed the workers about what t o do when one encounters a seal ed xontai ner w i t h unknown, or even questionable, contents. Therefore, training related t o hazards awareness i s found t o be less than adequate.

13

Contr i b u t i n q Cause(s1

Personnel Problem - Inattention t o Detail (5000.3~ Cause Code 36)

When the drum was packaged, inattention to detail on the part of the original packer resulted i n the lack of sufficient labeling.

No recommendati odcorrecti ve action is needed for t h i s i denti f i ed cause since current procedures present adequate requi rements to protect against the generati oil of new 1 egaci es . Note: l e f t over from past projects/operations that are not identified or no longer have funding t o support continued use or disposal.

Legacy materials are defined as those materials that were

- Inadequate Admi.ni strati ve Control (5000.38 Cause Code 6 ~ ) . .

Past practices a1 1 owed generation of 1 egacy materi a1 s w i t h o u t proper packagi ng and/or i nvenloryi ng . In this specific case, management's fai 1 ure to comply w i t h PNL-MA- 8, Subsection 8.4.1, resulted i n the drum not being disposed of or properly 1 abel ed before accountabi 1 i t y was los t through s taff termination.

Hark Organization/PlanRing Deficiency (5000.36 Cause Code 68)

This work activity d i d not receive the level o f planning needed fo r a drum containing unknown contents. Management needs to have i n place a mechanism/understanding w i t h s taff to ensure that unique, first-time tasks are identified as such, and management i s gi,ven the opportunity to help s taff plan the work to avoid potenti a1 ri sks. T h i s mechani sm/understanding must a1 so provide some assurance to management that work act ivi t ies are being performed under the appropriate procedures. use of the conduct of operations assessment checkli,st would have been benef i ci a1 .

Fami 1 i ar i t y w i t h and

Root Cause

Policy Not Adequately Defined & Disseminated ( 5 0 ~ 1 0 . 3 ~ Cause Code 6 ~ )

The Laboratory lacks a policy regarding the handling o f sealed containers w i t h unknown or questionable contents.

Legacy issues are certainly not an uncommon phenomenon throughout industry. In FY 1994, several thousand dollars were set asi,de to fund a program aimed a t reducing the Laboratory's holdings of "1 egacy waste. It

14

Since legacy issues have been and s t i l l are a management concern, the Laboratory'is deficient i n no t having developed a plan for' deal i n g w i t h seal ed containers and their potenti a1 hazards. If such guidance had been published and the t r a i n i n g related t o hazardous materi a1 s issues upgraded, the HMC and assisting researcher woul d have possessed the information needed to ' avoi d th is incident and potential exposure t o unknown chemicals that may be i n the drum.

JUDGEMENT OF NEEDS

The goal o f this Investigation Board is t o provide the Laboratory w i t h information t h a t can help management.and staff avoid a recurrence of this o r a similar incident. Toward tha t end, the Investigation Board issues the following judgement o f needs:

The Laboratory (not exclusively the Life Sciences Center) needs t o establish a policy and provide guidance on how i t .will manage and dispose of b o t h known . and unknown 1 egacy materi a1 s. Without such guidance, the Laboratory i s unable . t o consistently and effectively deal w i t h and minimize risks t o staff, the f ac i l i t i e s , and the environment. The result is t h a t conduct of operations assessments are not triggered , appropri ate procedures and t r a i n i n g are not provided , and event response actions (e.g . , spi 11 response and amel i o ra t i on) may be i nappropri a te or i ncompl ete.

15

SIGNATURES

BOARD MEMBERS :

EX OFFICIO:

..-

Roger' A. /pol 1 bri , Chai man . Date Performance Assurance DOE Cert i f i ed Acci dent Invest i gat or

Performance Assurance

m - * r Rene L. Jo s Mixed Waste Engineer Waste ManaMent Section Laboratory Safety Department

Life Sciences Center

J o b E. Trevino, Date Facility Representative Laboratory Management D i v i si on R i chl and Operations Office

. 16

INVESTIGATION BOARD APPOINTMENT LETTER

EXHIBIT A 0

Pacific Northwest Laboratories

Date January 12, '1995

To RA. Pol 1 a r i

From RA Waltersh

Subject Investigation o f 331 Bui ld ing Barrel Incident i n Room 175

Project Number

Internal Distribution

LA Braby KC Brog TO Chikalla T Hikido GR Hoenes RL Jones WJ Madia JD. Saffer JE Trevino JY Young Fi 1 e/LB

You are hereby appointed as chair o f a board t o investigate the incident that occurred January 10, 1995 a t the 331 building. appointed as members o f the board:

The following personnel are

T H i kido, Performance Assurance Department RL Jones, Waste Management Section JY Young, Toxicology Department .

The RL S i t e Representative, JE Trevino, has been 'informed o f the investigation and is a l so t o be included on a17 board ac t iv i t ies as an observer. provide Mr. Trevino a schedule o f a l l board ac t iv i t ies and a copy of your report.

Please

The investigation is t o employ a formal method o f r o o t cause analysis lead by Roger Pollari , a cer t i f ied accident investigator. the methodology used and the results o f the analysis, ful ly explaining the

,technical elements 'of the causal sequence along w i t h a description o f the barriers tha t s h o u l d have or could. have prevented the occurrence. recommendations for correction actions will be required. preliminary report by January 27.

I f you have any questions or concerns, please call me on 375-4532.

That report should identify

Appropri ate I would appreciate a

I-

R A W : t az

. E54-leooQol (lolaq .

7

EXHIBIT B-

ROOM DIAGRAM

L b-8 ,- e.-

€ 0 0 LI

E .

Z ' -

.v) C

8

x CrJ 3 - - 4

m II

Y u 8 5 m

It I t . I I It

J

EXHIBIT C

PHOTOGRAPHS

.. . . . I-.

NON-DESTRUCTIVE ASSAY (NDA) REPORT

E X H I B I T D

_ _ ~

Pacific Northwest laboratories

Date October 17, 1989

To Jerry Powers

From Ron Brodzinski

Subject Barrel Assay

Project Number

Internal Distribution

F i 1 e/LB

The data sheets from oup assay of your drum are enclosed for your f i l es . following isotopes were quantitatively determined.

- 237Np = 213 p g ='Pu = 142 mg

244Cm . . 9 1.35 mg

- i .. *. *. 241pu. = 521 p g .: . . .,

- . . . .

The

In addition, the 240pil can be estimated based on the 2jgPu/241Pu r a t io . This. presumes t h a t no 24iPu hasedecayed. Hence for old material, the 24gPu is

0. '. ' essentially a lower limit;

R1B:ldb

Encl osures -

-.. \. -' . .. . f.? % ,: -*.-, %-: .-. ; . .

.-

. .

I

0

EXHIBIT E

RADIOLOGICAL SURVEY REPORT

I .* .

-. ..

-7

,p: , , I II\ 1 -

.Gi75@ (

Ill\ I I -. I '

2 0 . 1 . 02361 9861 's ''2 U O Y d

n

L

N " . n "

0

n m

n

n

c 0 Y L.

. ' . I

I I ' I I I 1

,

@ Baltelle PWIlo Nonhmrl Lab#rlocmr

. 7 -.. -1

RAOlATtON PROTECTION COUNYNO LABORATORY RECORD NASAL SMEAR REPORT FORM .

;.:.> ". .. -.-d

-

Counter LorAlan (Rtdg) 3746

I

I . . L

Countcd BY F.' Gonzalez

Oackgmund Count (10 rnin.): a= 5 8 1 1772

Oetedion Levela a= 6.76 P" 66.1728

1035 Time I QQb Timu .

CaLCULATiONAL FORMULAS

Detection LImit - 2.41 + 4.65,/- Smear Activity - (a cb) E '(1U) ((1 O W N

Where: Cb 0 10 min. Background wunt Action Lcvels: Cs = 10 min. Smear Count E = Counter EffiClenq (mtrnts pet disfntigratlon)

AlDna = 25 dpm above detodion levcl Beta = 100 Jprn above aeteaion level.

' d ZZ!Cl 9OCt'S 'S .

Radidogical Control Record Q~ame .p.arre-- RADIOLOGICAL SURVEY REPORT

En, e - '1

*--

* I -.---

Ddr

$ma .

T l m PUP= of 3 0 ~ Monthly /XJ Rautirn [ I Demand

L 0.5

?Oom(r) A9

...- . I

Eoikhg A m RWP Numkr 33 1 300

4 o . c

- .

UOYd

E X H I B I T F

PNL 2400 REPORT

7

OFFICIAL USE ONLY

PNL 2400 REPORT

REPORT %: 95-003

DATE OF INCIDENT: JANWRY 10. 1995 TIHE OF CALL: 0834:32

CRC OH O m : B WIUIPHSON / KE KOGLIN -

INCIDENT: CONTNlIhWT SPIU 331 8UIUIING.

NOTIFIED BY: LA BRABY CALLERS LOCATION: 331 BLCG CALLERS PHONE k 376-5685

CAUS PLACED BY CRC TIME OF CALL ( X I IF CONTACT . CAUS PLACED 8Y CRC TIME OF CALL JX, IF CONTACT

RHABRAHAM (EM)

T HIKIW (OC) T HIKIW (OCI IA BRABY (MI 'FJ W E (RPT)

oaa : 37 0839:06 . 0839:22

0843:19

0834:22 . 0843:OS .

No

x CELLULAR

No-MESSAGE

X

J JACOBSON (RPTI

L NELSON (RPT)

L NELSON (RPT) RH EUua (SAFE)

OE43:49

0844: 16

0845::9

0846:28

X - NOTIFIED US AG MINISTER (SAFE) 0847:OO

No U HARVEY (PR) 0842:U

U CWZVEY (PR) 0850: 51

X

No - PAGED X

NO

X

NO

NO - ?AGED

ON JANUARY 10. 1995 AT 0834:32 HOURS. IA BRABY CAUED,THE CONTXOL ROOH AND ADVISED THAT A LOW LEVEL WASTE CONTAINER .HA0 BEDS GROUBfl INTO THE 331 BUIUIING. R0oi.I 175. THIS WAS TO CHECK THE PACKAGING. DUE TO THE TEMPERNURE'CHANGE THE LID POPPED Off THE CONTAINER ALLOWING A SHAU M U N T OF MERICIUM AND PLUTONIUM TU ESCAPE. THERE WAS A RPT

PRESENT. T HIKIW (OCI CLASSIFIED THIS AS A Off N O W OCCURRENCE. THE ABOVE STAFF WERE NOTIFIED.

OFFICIAL USE ONLY

.. -

EXHIBIT G

. RADIOLOGICAL WORK PERMITS

.7 .. _ . . . _c

CONTRACTOR: Battelle Pacific Northwest Laboratorles HANFORD RADIOLOGlCAL WORK PERMIT

Jobspecific 0 NIA 1 NIA NIA . 53 1-52 Rev. 16 General pi Tech. Oocument No. location Code W N RWP Number

start Date End Oate Termination Oate Oy:

Biology and Chemistry, Cdlular and Mammalian Biology, D7A25

Room 175 and 175A; 33 1 Building; 200 Area

Storage of Radionuclides in rooms 175 and 17% Receiving and unpacking of radioactive shipments in 175. .

1/28/94 1/28/95 ExtendedTo: NIA NIA Responsible Organization

Job Location

Job Description and Type of Area: Radiation Arra. Radioactive Mamid:

PrimaryIsotope(s): PI-MFP PI-MAP 0-Cs 0-3r 0-11-3 0-U 0-Pu O-Other: ladlation Emitted Estimated Dose Rates Estimated Contamination Levels Radiological Worker Training Req

.............. ........ . PI Beta General Area: 10 mremlh Beta-gamma: ,000 dpmll00 an2 I ........ n M Alpha

PI Photons Maximum Contact 25 mnmlh Alpha: e20 dpmllOO an2 .............. . ............. II [XI 0 Neutrons ...... Internal Dosimetry Requirements (for routine worlc under this RWP. except those entering for observation only)

Annual Whole Body Count 0- Lung Count [I-UnflalysiS Isotopes to Test for CI any):

MINIMUM RADIOLOGICAL PROTECTI~NREQUIREMENTS

D

D

Entry for observation:

Transfer of between rooms 175 and 17W Intermittent RPT coverage I Basic TLD I Lab coat.

Intermittent RPT coverage / Multipurpose TLD / Lab coat I Surgeon's gloves

Continuous RPI coverage / Multipurpose TLD I Lab coat

Continuous RPT coverage / MulGpurpose TLD /Lab coat / Surgeon's gloves

Shipping and Recdving radioacthe shipments:

Unpacking radioactive shipmentsf . .

I

SPECIAL INSTRUCTIONS (SI)

1.

2

3.

4. 5. 6.

7.

For off shfl RPT coverage contact the RP Duty Supenisor at 376- 2244, or page 546-6298. Emergencies contad Battelle Emercjency at375-2400. . This R W is limited to conditions where general area dose rates are c 50 r n m h andlor contamination levels c 1,000 dpmllOO an2 betaqamma or 20 dpmll00 cm2 alpha Airborne radioactivity revels are limited to 10% DAC. If any of these leveb are exceeded, a new or revised RWP is required. Receptade containing radionuclides shall not be opened in Room 1754. Sealed Radionuclide containers shall be moved to Room 175 prior to removal of any material in any container. Cabinets containing radionuclides shall be appropriately posted. 175 and 17% shall be locked when the room is not occupied. Mateiiak for storage shall be triple packaged. ihe outer container shall be metal, free of removable contamination and l$eled as to dose rate, contamination, radioisotope, date, and RPT initials.

. .

Perform a hand and foot survey for alpha and betagamma contamination prior toeaving Room 175.

4URA Review: Not Required IWP Prepared By: CL Maples . Phone: 376-5470 I RPT Phone: 376-1615

I Prq'ob Briefing: YES 0 NO [XI 1 Post Job ALARA Review Required YES [1 NO M I

Oate Phone

Phone Date

Phone Date ;3/9/9/J

3 m ~ a 7 a / m y 376-3 1 55 zj,{ I 2 +

LM ABRAHAM 376-70 1 2 CknowledgedBy: // Date:

1 I Date: "1 RWP Change Approvals: HSRCM-RWP (1193

Page 1 of 2

HANFORD RADlOLOGICAL WORK PERMIT Radiological Work Permit $33 1-32 Rev. 1 :

Paae 2 of: "

ACKNOWLEDGMENTIREVIEW Staff Member Signature .

--

Payroll Number

3 f Y u 7 3 K 7 4 3 A7.52

Date

DO NOT remove or dispose of this page, it MUST be posted with the RWP it pertains to. Return this form to Radiological Control, 'MSIN P7-78, when this RWP expires, is voided, or is replaced with a new revision.

- CONTRACTOR $v&

Tsb Banefie P a a l i c N o n ~ s L s ~ i o n

HAN.FORD RADIOLOGICAL WORK PERMIT

JobSpecific l?(] PNL-MA-507 NIA XIA PNL-6 Rev.2 * Gzneral 0 Tecn. Document No. Location Cade €AN RWP Number

MINIMUM RADIOLOGICAL PROTECTION REOUIREMENTS Radiation Area entry:

!adlation Emitted [XI Alpha VI Beta

Photons IXJ Neutrons

Multipurpose TLD / See SI $ 3

Contamination Area entry : Multipurpose TLD I 1 Full Set of PCs

High Contamination Area entry: Multipurpose TLD 12 Full Sets of PCs I Full face respirttor

Estimated Dose Rates Estimated Contamination Levels Radiological Worker Training Rec , General Area: ... See SI $ 4 mremlh Betagamma:; ... See SI $ 4 dpmllOO an2 I ....... c]

II ...... [XJ Extremity: ... See SI 8 4 mrem/h Alph =....See SI $ 4 dpmll00 an2

High Radiation Area entry: Multipurpose TLD I G m m a pencil I See SI $ 3

I I RWP Change Approvals:

Respond to CAM alarms: Multipurpose TLD I 1 Full set of PCs I Full face respirator

I Date:

Respond to ARM alarms: Multipurpose TLD / Gamma pencil / See SI $ 3

Decontamination of Personnel: Multipurpose TLD I See St $ 6

1.

2

3.

1. 3. I.

SPECIAL INSTRUCTIONS (SI) For off shfi RPT coverage conBct the RP Duty Supervisor at 376-2244, or page 546-6298. Emergenaes contact Battelle Emergency at 375-2400. Limiting Conditions that void this RWP: 0 General Area Dose.Rates: 2 1,000 mre& 0 Airborne Radioactivity wlo respirator: 1 10% of my DAC.

Airborne Radioactivity with a respirator: 1 5 DAC If these limits are exceeded, a new or revised RWP is required. Additional Protective dothing may be required for area of entry. Comply with area entry postings. Perform required personal surveys prior to exit Review the current survey map for the area This RWP shall not be used to provide job coverage. Lab coat and Surgeon's gloves are the minimum protective dothing required for decontaminating personnel. Addiional protective dothing may be required based on the extent of antamination levels and the potential fw contamination spread.

.

ALARA Review Not Required RWP Prepared By: CL M a p l e s Phone: 376-5470 I tine Management DP HIGBY

. I Pre-job Briefing: YES 0 NO [XI I Post Job ALARA Review Required YES fl NO M

Phone 376-3057

ygy //-,&-e7 SR BlVlNS

. I Date:

Page 1 of 2

E X H I B I T H

REFERENCES

INDIVIDUALS INTERVIEWED:

Kathy Lauhal a, Hazardous Material Coordinator Jim Morris, Assisting Researcher June Robinson, RCT Dennis Mahlum, Researcher Waiting i n Room 173 Les Braby, B i ol ogy and Chemistry Department Manager Jon Hudspeth, RCT's Supervisor Joe Jacobsen, Radiological Control Section Manager Ray Abraham, 331 Building Manager

.

OTHER INDIVIDUALS CONTACTED:

Ron Brodzinski , Nondestructive Assay Andrea Taylor, Laboratory Safety Trainer (RAD worker training) Ray Kofoed, Single Point Contact (SPC) Consultant Andy Minister, Laboratory Safety Representative contacted by SPC Teresa Zinn , Executive Assistant, Life Sciences Center .. .. . Laboratory Training Coordination (for training records)

DOCUMENTS REVIEWED:

RADIOLOGICAL GlORK PERMITS:

RWP #331-32, Rev.16 RWP IPNL-6

ASSESSMENTS/SURVEILLANCES

PNL response to the Dames and Moore report, PACIFIC NORTHWEST LABORATORY (PNL) BUILDING 331 RESOURCE CONSERVATION AND RECOVERY ACT (RCRA) ASSESSMENT, PNL-CC95-0030. October 31, 1994.

Response dated

PNL report, CONDUCT OF OPERATIONS 'ASSESSMENT-331 FACILITY, dated September 1994

TRAINING RECORDS

Kathy Lauhala, Hazardous Material Coordinator (HMC) Jim Morris, Assisting Researcher

PNL MANUALS

PNL-MA-5 , Nuclear Materi a1 Control and Accountabi 1 i t y PNL-MA-6, PNL Radiological Control Manual PNL-MA-7, Off-Normal Event Reporting System PNL-MA-8, Waste Management and Environmental Compl iance PNL-MA-11, Emergency Preparedness . PNL-MA-41, PNL ES&H Management Sel f-Assessment Program PNL-MA-43, Industrial Hygiene, Occupational Safety, and

PNL-MA-50, PNL Operations Manual Fire Protection Programs