Probe points to lax practices

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Contamination: Accident board finds more than two dozen in direct contact

By John Severance

First in a series

A recently released 116-page federal report said the accident involving Technetium-99 at the Los Alamos National Laboratory’s Neutron Center was “entirely preventable.”

The federal report detailed how on Aug. 20, a LANL worker at the Neutron Science Center unknowingly opened a canister, which contained an uncontrolled radioactive substance.

It was quickly determined that the contamination had spread offsite and response teams were immediately brought in. 

“The Operating Contractor restricted access to the affected facilities, recalled personnel who may have been contaminated and requested that they bring potentially affected clothing and vehicles so they could be surveyed,” the report stated. “These responses, along with actions of the offsite response teams, stopped the spread of contamination offsite, retrieved contaminated items that could not be cleared for release and decontaminated items where needed. The Operating Contractor preserved the onsite accident scene and initiated an internal investigation.

“The contamination found offsite was above DOE’s release criteria in some instances, however it was at levels far below those expected to have a discernible health effect and the safety of the workers, public, and the environment was not affected by the event.”

A statement from the lab released last week said, “We accept the NNSA’s report and thank the investigation team. In addition to internal follow-up already under way, the lab will now develop a corrective action plan to address the judgments of need and other issues outlined in the report.

“Although the contamination never posed a public health hazard, the deficiencies that led to the accident are not acceptable. Safety of our workers and the public is our highest priority. We can and must do better.  We will take the actions necessary to correct the deficiencies and prevent a recurrence. 

“We apologize to our scientific colleagues from outside institutions who were not able to conduct experiments at the Luján Center.  We are working to reopen the facility as soon as possible and accommodate our affected users.”

On Aug. 29, NNSA administrator Tom D’Agostino appointed a Federal Accident Investigation Board to determine how the accident occurred and look at ways to prevent recurrence. 

From Sept. 4-18, the AIB interviewed 270 individuals and visited more than two dozen homes.

The accident investigation report said that five people were found with skin contamination and 25 people had clothing or personal items with contamination from the incident.

The investigation board said lax management processes and careless disregard for safety requirements at the Neutron Center were the causes of the accident.

 “An accident of this type was inevitable and not attributable to the actions of any single individual,” the report said. “Rather, the accident was the result of management conditions and routine practices developed over years that were incompatible with a non-routine hazard.”