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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
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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
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