Wednesday, July 27, 2005

Americium241 Contamination Closes Sigma Complex until at Least Thursday

From Anonymous:

Please post this anonymously....

Yes, kiddies. It seems that NMT11 believes that it can send Americium241 contaminated viles to anyone in the Lab, and CYA it with a simple "Radioactive Material Inside" sticker.

Here's the real story: MST6 was expecting Uranium only--with no hitchhikers, and ten days ago an individual got contaminated while handling what he thought were Uranium-only filled viles. Unfortunately, he didn't find out until yesterday those viles were laced with Americium241 and he was contaminated. By pure luck the RCT had a Alpa monitor and picked up something "abnormal". See this is a Uranium facility and not equipped to handle let alone monitor Alpha or Gamma radiation when it inadvertently gets shipped there. Who knows who else NMT11 contaminates with this stuff in its shipments to unsuspecting facilities!

The poor unfortunate researcher and technician, not only got exposed, but took it home with them, and over the last ten days to who knows where else in the community at large. Teams are out now trying to decontaminate at least one persons home.

To their credit, MST6 Group Management and MST OPS made everyone who resides in the building get a full body scan, and had them evacuate the building until the RCTs could investigate and decontaminate areas that turned up hot--like the stair rails, door knobs, PC equipment, chairs and who knows what else (ventilation system?). No one can return to this facility until at least Thursday.

This situation makes you hope that the Anti-nuclear bidders win! Whoever takes over LANL had better realize just what a mess it will be inheriting.

The event happened 10 days ago, with members of the Los Alamos community potentially having been exposed to contamination in the intervening period. The contamination was supposedly discovered yesterday, and yet there has been no official word from LANL. Why is that?
Does the term "cowboys and buttheads" ring a bell. Maybe Pete was right.
Incredible, but status quo for LANL management. We wouldn't want word of this to get out, would we?
Should NMT 11 not be shut down??? How something of this incredibly stupid magnitude could happen is beyond comprehension!!
do us all a favor 'kiddies' and wait for the whole story to might be surprised to hear the ending to this one...
Before everyone flips their lid, why don't we wait until LANL issues a formal statement so we can know the full details? All this speculation on what may have happened (and why) only damages the Laboratory even more. These incidents take time to investigate and report, be patient. LANL HAS TO make sure they have the facts straight before releasing any details to the press. Why anyone would post this comment before a formal statement has been issued is beyond me. If you don't love and want to protect this institution, why are you here? I hope for the sake of the nation that the original poster does not have a clearance. I'd hate to see what other information they would leak.
11:17:31 AM:

How long do you suggest we wait for LANL PA to fill us in on what really happened? Should we be concerned that they might try to put a "Happy Face" on it?
To 11:21:09 AM:

"Why anyone would post this comment before a formal statement has been issued is beyond me."

I believe the answer to your dilemma is that most of us have developed a strong disregard for "Baghdad Bob" Jim Fallin, and his lying ways. You can believe what comes out of LANL PA if you so choose, but I, myself, will remain sceptical of any "official" story versions which come out of that office.
Reminds me of Chernobyl when the Soviet government waited for several days until making an official announcement about the reactor explosion and only then started to evacuate the contaminated area.
To 12:03:42 PM

Oh, give me a break. That is a ludicrous statement.
The 11:21 poster has an interesting position. We should wait for the official version from the Lab spokesman. The same spokesmen who has been observed spinning all previous Lab screw ups. And the suggestion that this could involve a security infraction, thus we should not encourage the enemies of the Lab. There seems nothing to support that view; it seems like a materials handling screw up. Am I missing something?
Lastly, isn't this on the Occurrence Reporting system? Seems like it would be.
We will wait until the Kremlin aka PA first acknowledges this. Then the Lab will backpeddle like GW Bush - Rove - CIA agent. Then we will take credit for producing 27 feet project management mumbo jumbo to clean up.

Too bad the fire didn't destroy everything.
While the investigation may take some time, it's worth asking in the mean time why this could happen when we have heaping mountains of safety paper in place to protect everyone from everything.

I submit that the mountains of paper do not make anyone safe. It is a placebo for real safety, real management, and real results. We are forced to take this medicine, and everyone is made to believe it is the best way to be safe, but actually it's worse than nothing, because it breeds a false sense of security.

In the mean time, I've seen education, real hands-on practical training, apprenticeship, proficiency, knowledge, understanding and job discipline along with real risk-management get tossed to the side and put down as "expert-based safety."

Somehow, "paper-based safety" which we now rely on, draws no where near the skepticism it should, even while serious incidents continue to occur.

We do not, and can not, do risk-free work at LANL, any more than anyone can be alive without taking risks.

This does not mean doing nothing--it means managing the probability and the consequences of something going wrong with an activity.

Writing tomes of mindless check-lists that have an impied assertion that all contingencies are covered is ludicrous, yet that's what the IWD's etc. seem to try to do.

This is not MANAGING risk. This is writing about risk, and substituting real mitigation with administrative controls that can never be complete, and can never prevent anything in the physical world.

I've seen time and again at the Laboratory management turn first to administrative controls, rather than last. These are the weakest controls possible, and yet the strongest safety controls--engineered controls--are routinely dismissed by management as too expensive, too difficult to implement, too slow to implement, too anything except effective.

For 09:44:07am to cast aspersions on the staff as being cowboy's again completely ignores what ensures the safety of workers--a work environment designed and engineered to ensure safety is automatically applied to the work.

This is the age-old fallacy of blaming workers for their injuries. Would 9:44:07am blame a factory worker for getting caught in unguarded machinery because there was a paper procedure that said not to get caught in unguarded machinery? Would 9:44:07am blame the Columbia shuttle crew for their ship burning up and killing all of them.

'Yes' is what it sounds like.

What we appear to have is a long running, systemic management failure at LANL to properly implement a work environment that is engineered to be safe, instead turning to paper controls and blaming workers as being cowboys because it's quick, convenient and looks good to the clueless onlookers and regulators.
I think we should change the lettering at Diamond and State Road 4:
LANL run by NO ONE for DOE

Science has left the building.
Safety has left the building.
Security has left the building.
Soon UC will have left the building.
The outside world is coming to learn that the LANL PA offices has put a policy of lies and spin in place. The mantra heard throughout the halls of PA: "Let no bad news escape."

I suppose the good news is that if BB Fallin does try to "put a Happy Face" on this, and the incident turns out to not deserve one, then that should be the last hurrah for BB at LANL.
Years ago DOE mandated that SOPs be replaced by HCPs because SOPs did not document the safety analysis used to generate the SOP. Many of us argued that we could simply add the safety analysis to the SOP as an appendix.

I don't know where the format of the HCP came from, but it ruined the simplicity of the SOP documentation we had used for years and evolved into the mess IWDs (or whatever you call them now) the Lab has today.

The Lab wide shutdown to improve safety and security which lasted nearly a year resulted in new procedures that did not prevent a person from getting hurt using a power tool; people getting hurt when a beaker exploded; and now possibly widespread radioactive contamination. Did I miss anything? I'm an outsider now.

I'm sure this incident will result in a new series of corrective action plans that will do nothing more than further complicate your ability to do work safely.

Larry Creamer, Retired
The Detonator Group
1944 - 2004
According to the post, ten days ago, an MST-6 person received some vile vials containing Americium 241 that were not properly labeled. Over the past ten days the contamination was spread over a wide area in and outside the Lab because it took that much time for an RCT to be in the area to accidentally detect the abnormal radiation.

If NMT-11 had an IWD for shipping radioactive material it was inadequate or not followed. If MST-6 had an IWD for receiving radioactive material it was inadequate or not followed. No matter what mistake led to the exposure, a number of people have a increased risk of organ cancer.
1:40 is absolutely correct in every respect. 4:55 is also right about one thing; ultimately, people will die from such accidents. When you pretend to improve safety by replacing genuine expertise with computer generated paperwork, ultimately morons will run the show. When morons run a show as potentially dangerous and complex as a National Laboratory, people and productivity will both suffer.
REALITY CHECK: Priority one: teams should be sent out to discover the extent of the contamination, render assistance to persons affected, and remediate the sites while another team discovers the proximate root cause of the incident. IF there has been a coverup going on, the lawyers are lined up for the kill on this one.
If MST6 is a Uranium facility, why can they not detect alpha contamination? Even natural U emits alpha.
Larry Creamer is absolutely right. SOP's were straight-forward, useable documents. The derivatives that attempt to correct their deficiencies fall far short, and make the whole process confusing to the young, inexperienced personnel who are rapidly replacing the experts with little or no mentoring being done before the experts run out the door.

Before you continue to destroy NMT-11 as the culprit in this fiasco, let the real story come out. It's not unheard of to pick up low levels of contamination from glove-boxes on the plastic bags that contain samples. If NMT-11 was following all of their procedures, and MST-6 was not, then perhaps we know why this happened. I agree with the last poster, uranium and americium both emit alpha activity that is detectable, and should have been picked up by the Sigma detection system. The real question is, why didn't it?
Creamer is not quite correct. There was freedom for workers to tailor-make an HCP in a format that made it useful for aiding safe performance of work. And in my group's experience, you could improve an existing HCP if you converted. But it is certainly true that it is not possible to create an IWD that is as useful as an HCP (or SOP). Of course, none of these documents are perfect, nor can any be. Persons performing other than paperwork will always have opportunities to be injured.

If what's being discussed is vials with less emmision than a household smoke detector, there are other things more important, aren't there?
My, my, what would the Admiral do in response to this??? Another standdown??
The admiral would permanently shut us down.
Actually, he first carefully explain that if he didn't shut us down, then DOE would. Then he's go call his buddy Linton and say, "Linton, back me up on this one, ok?"

And then he'd shut us down.
Then he'd fire people and destroy careers and lives to cover his tracks.
So why do we have (IMP300 compliant) IWDs, PLUS HCPs (to track training) and SOPs (which actually state what we do)???
Isn't MST-6 the group that brought in such shining stars as Rich Mah and Rich Castro? Who is running the group now? Is s/he another Rich?
Someone's in an awful big hurry to paint MST-6 as the victim in this incident. A uranium facility like Sigma should be equipped with radiation montioring systems, and personnel who are experts in using them. Uranium isotopes are actually easier to detect using beta/gamma monitors (rather than alpha monitors), but the kicker is that Americium 241 also has a very clear gamma signal. You absolutely don't need an alpha monitor to detect americium contamination. Although you wouldn't be able to distinguish uranium from americium using a simple hand-held beta/gamma detector, you'd sure as heck know that a radioactive material had slipped the boundaries of the glovebox. Any health physics staffer worth their salt would then follow up by taking direct and/or "swipe" measurements on the contaminants.

In my experience, it's also SOP to have health physics support present when opening a radioactive material shipment. At the risk of monday-morning-quarterbacking: If I knew the shipment was coming from a glovebox in a plutonium facility, I'd be doubly cautious.

Also, it's irresponsible to compare the amount of americium contamination in this incident to the amount in a smoke detector. The difference is that the smoke detector is designed to keep the americium safely encapsulated to prevent its spread throughout your house. If we were talking about a comparable amount of plutonium instead of americium, this blog would be on fire.
For a group of people who screamed at being burned by a rush to public judgment with the missing CREM and the misplaced hard drives, you sure have a lot to say before the facts are all in.

One of the problems with the current DOE-mandated reporting timeline of reportable events is that the reports are required long before a definitive assessment can be made (like whether the issue is real? how much harm has been done, etc. ). This report goes up a chain that appears to include enemies of LANL, because confidential information is immediately passed to anti-LANL NGOs who pass it to the media with great fanfare. You may remember that I mentioned this to AMB Brooks in an all hands meeting. He is put in a situation of having to respond to a negative media fire storm without data.

Now, why was there not an avalanche of condemnation on the duffus who made a premature public report in the blog? Obviously an investigation and a remediation effort were already underway. Instead there is free-flying condemnation of organizations without data to back it up. Seems like a double standard of accountability for laying blame. Only harm can result from premature media attention.
The "Doofus" did us all a favor by reporting that a contamination event had occured.

Gary apparently wishes that news of the contamination had been kept secret by LANL for even longer than it was.

I, for one, am grateful to the "Doofus" for letting us know that the contamination occured. Had he not done so, how long do you think we would have waited before LANL chose to pass that information on?
I agree completely with 8:06 a.m. Any shipment coming out of the TA-55 facility shoud be treated as potentially contaminated. For the MST-6 person to assume the internal packing was clean, not wear gloves, or ask for RCT assistance while opening, was NOT following good practice when handling rad material.
and to the 4:55 poster. MST-6 did not receive unlabelled vials of Am-241. They were encapsulated uranium nitride pellets, whose container was externally contaminated with Am-241. Not surprising since it came from a glove box at 55.
Should this contamination have been discovered while still at TA-55??????

WE once worked together, at a time when you didn't have your head quite so far up your a**. The DOE reporting chain requirements have little if anything (from a regulatory/legal basis) to do with if, when, and how LANL decides to make a public release about what's going on. The fact that the first, and at the time ONLY information available to the public, many hours after LANL management knew they had a problem (maybe days), was the post on this blog site, was a result of LANL management choice, not a requirement from NNSA, DOE, NRC, or anyone else. LANL management chose not to say anything before they were more or less compelled to by someone flagging the occurrence in this forum.

The original post was indeed flawed. However, that's the kind of thing that happens when managers CHOOSE to withhold information, and the only "facts" are whatever people weave together from the rumor and hearsay available to them.
For those of us who live in White Rock, I would like to know when LANL employees are potentially contaminating my community (stores, restaurants, etc.) as soon as possible, not after a complete investigation has been done! If it is serious enough to de-contminate his house, car, etc. what about other places that could ut the public at risk. I have no patience for those IDIOTS who are more concerned about "how it will make the Lab look" than about the public's safety. So thanks to the poster and I pray that "Gary" and the other people who care more about image and less about people never reach positions where they get to make important decisions!
The items were probably triply contained for shipping. Items were bagged out from the glove box, then placed into either a clean bag or clean slip-top container, then into another shipping-type container. The primary internal bag and item should always be considered contaminated. The RCT will swipe/monitor the second container prior to placing in the outer and final container. Of course, the outer container is checked for contamination prior to shipping. Again, the receiver used poor protocol when handling but the Type A invesitgation will ultimately find out what happened.
03:27- I hope that the responsible LANL officials continue to respond appropriately to the level of the risk. I remember a few years back, when there was the potential of White Rock being contaminated by chemical and radioactive toxins during the Cerro Grande fire, that the community was evacuated. The risk was real, though not sure. A judgment was made, without reference to public opinion. People were enormously inconvenienced for a risk that did not materialize. That was a responsible judgment.

I am confidant that there are similar guidelines for proportionate levels of response to risk today and that those guidelines were closely followed. I do not have personal knowledge of this and am willing to listen to someone who does have current and relevant knowledge, including knowledge to the contrary. It will be interesting to eventually hear the level of risk imposed on the community by this serious mistake. I suspect that this risk is small.

I for one do not want the community evacuated, or seriously alarmed, when the risk is very small. Do you really want it differently? In fact, do you want the alarm to go out on all of the health risks that arise in the community; e.g. lab-generated traffic, over-eating (like the “test-site tumor” that was so common from the generous portions and low-cost at the NTS cafeterias), smoking, high-altitude cosmic-ray background, arsenic in the soil, radon in your basement, carcinogens in your fuels and clothes, etc? The sirens would be going off constantly. How do you differentiate low-level risks you want to generate a special alert? Is radiation special? Or does it have to be linked to LANL?

If the trace amounts of errant radioactive material can be detected, they will be cleaned away, by policy. That does not mean that there was a likely risk to you. However, if there were a real risk, I am confident that the appropriate level of alarm would be sounded and remediation would be done.

I'm in awe. In adition to your prowess in the field of management consultation you seem to know far more than the rest of us (who actually work with transuranics) on the subject of how much material is required to pose a risk. One of us is misinformed.

My poor understanding, after 20+ years of working with material in gloveboxes, and collaborating with experts in the field of radiation health effects (OK Terry, so maybe they weren't from UC or UNM, but they nevertheless seemed to have a rudimentary grasp of the subject), is that in the case of materials such as plutonium and americium all it may take in ideal circumstances to get a detectable uptake is a single particle of an appropriate size and composition. This isn't to say that a detectable uptake always equals a specific health effect. However, probabilities are just that, and no one would argue that a person is better off with, than without, an uptake of a material such as americium.

All of that aside, I must say that I am equally awed by your stated trust in the powers that be in, and saintly powers of, LANL/UC management. Apparently you truly believe that everything they do and say (or don't) is for our own good, and that they always know best even when they can't tell us what's going on because we might get confused. You just don't find that kind of trust anymore, with possible exception of the guys who believe the story about the 72 virgins waiting for them in the afterlife.

If I thought it would make any difference, I'd also point out that all of the examples of risk behavior that you tried to compare to the risk associated with "trace" (or low level, depending on LANL's most current press release) americium contamination potentially being spread around town (and apparently a few other states!!!) result from INDIVIDUAL CHOICE! and not risks thrust upon people by an all-knowing and all-seeing third party. But why go into that, it would only confuse you and raise doubts in the minds of the other inmates.

signed "shocked and awed"
I would like to point out the above post as a case of a thoughtful response. Insulting, yes; sarcastic, yes; condescending, yes; but it crosses my threshold for “thoughtful”.

To the author of 08:52- Thanks for the comment “in the case of materials such as plutonium and americium all it may take in ideal circumstances to get a detectable uptake is a single particle of an appropriate size and composition” and your implied caveat that the probabilities are of such “ideal” uptake are negligible. The risks I cited are not all voluntary or understood. And there are many more involuntary risks imposed by others than my short list indicates. A few minutes of thought will yield a respectable list.

If you are so distrustful of “the powers that be in, and saintly powers of, LANL/UC management” you should run, not walk, from the community, because of the potential for deadly mischief by management if they are as incompetent as you and your anonymous colleagues state; what with nuclear-weapons grade materials, high-explosives, cranes, Humvees, automatic weapons, etc. I do not believe that management here is always aligned with your desires, but I know that there are substantial performance requirements, and that these issues are taken seriously. You and I both know that not everyone vested with responsibility has the capability to execute it, but this is not grounds for a blanket indictment of all LANL management.
The point you missed, is that there are levels of risk and the person I was responding to seemed to desire a crisis level of response for a very small risk. This is irrational, but seems to be well accepted here.

Go I did. I'm gone. From LANL and from Los Alamos. Life has never been better.

And don't misconstrue my reasons for leaving. My lack of confidence in a large fraction of LANL, UC, and NNSA management has nothing at all to do with the hazards present "on the hill" (radioactive materials, toxic chemicals, cranes, explosives, etc.)or the finite probability that on any given day there may be an incident associated with these items. Sh** happens, and only a fool believes that it won't or can't. Further, I believe that the importance of the work done at LANL more than balances the potential downside of these events.

No, my lack of confidence and my decision to leave was based on a single precept I believe central to good management, responsible stewardship of this Nation's nuclear weapons, and health of the "crown jewel" that truly is the LANL staff. That precept is the ability to admit you made a mistake. Making mistakes is how individuals and organizations grow and improve. If you never admit to a mistake, and instead expend effort in spin and rationalization, it is impossile to learn; you are doomed to obsolescence or extinction. Can you spell NIF?

At 50, having had over 20 years with LANL, most of them great, I realized that my time could be better spent in an organization capable of understanding that if you want your head to stop hurting, you should cease telling everyone that with additional funding you can construct a real-time 3-D model of neurological response on the cranium surface that may eliminate all headaches forever, and instead just stop banging your head against the wall.
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