D National Nuclear Security Administration Federal Accident Investigation Accident Investigation into Contamination at the Los Alamos Neutron Science Center on or about August 21, 2012 September 2012 This page was intentionally left blank. RELEASE AUTHORIZATION On August 29, 2012, I appointed a Federal Accident Investigation Board (AIB) to investigate the accident which occurred at the Los Alamos Neutron Science Center (LANSCE), Los Alamos, New Mexico on or about August 21, 2012. The AIB’s responsibilities have been completed with respect to this investigation. The analyses and the identification of the contributing causes, the root causes and the Judgments of Need resulting from this investigation were performed in accordance with DOE Order 225.1B, Accident Investigations. I accept the report of the AIB and authorize the release of this report for general distribution. Thomas P. D’Agostino Date Administrator National Nuclear Security Administration This report is an independent product of the Federal Accident Investigation Board (AIB) appointed by Thomas P. D’Agostino, Administrator, National Nuclear Security Administration (NNSA). The AIB was appointed to perform a Federal Investigation of the accident and prepare an investigation report in accordance with DOE O 225.12B, Accident Investigations. The discussion of the facts, as determined by the AIB, and the views expressed in this report do not assume and are not intended to establish the existence of any duty at law on the part of the U.S. Government, its employees or agents, contractors, their employees or agents or subcontractors at any tier, or any other party. This report neither determines nor implies liability. This page was intentionally left blank. TABLE OF CONTENTS Page APPENDICES ....................................................................................................... ii  TABLES ................................................................................................................ ii  FIGURES .............................................................................................................. ii  ACRONYMS ........................................................................................................ iii  EXECUTIVE SUMMARY ......................................................................................1  1.0  BACKGROUND ....................................................................................1-1  1.1  Los Alamos Site Office..........................................................................1-1  1.2  Los Alamos Neutron Science Center ....................................................1-1  1.3  Manuel Lujan Jr. Neutron Scattering Center .........................................1-1  1.4  Scope and Methodology .......................................................................1-2  2.0  ACCIDENT DESCRIPTION AND ANALYSIS OF EVENTS .................2-1  2.1  Accident Narrative ................................................................................2-1  2.1.1  Loss of Control ...............................................................................2-1  2.1.2  Loss of Containment ....................................................................2-10   2.2  Emergency Response.........................................................................2-26   2.3  Description of Extent of Contamination ...............................................2-28   3.0  MANAGEMENT SYSTEMS EVALUATION ..........................................3-1  3.1  DOE Oversight ......................................................................................3-1  3.1.1  Core Function 1, Define the Scope of Work ...................................3-2  3.1.2  Core Function 2, Analyze the Hazards ...........................................3-3  3.1.3  Core Function 3, Develop/Implement Controls ...............................3-3  3.1.4  Core Function 4, Perform Work Safely ...........................................3-5  3.1.5  Core Function 5, Feedback and Improvement ...............................3-6  3.2  Implementation of LANL Radiation Protection Program .......................3-7  3.2.1  Control of Radioactive Samples .....................................................3-7  3.2.2  Control of Radioactive Contamination ..........................................3-11   3.3  LANL Implementation of Integrated Safety Management ...................3-12   3.3.1  Core Function 1, Define the Scope of Work .................................3-15   3.3.2  Core Function 2, Analyze the Hazards .........................................3-16   3.3.3  Core Function 3, Develop/Implement Controls .............................3-17   3.3.4  Core Function 4, Perform Work Safely .........................................3-18   3.3.5  Core Function 5, Feedback and Improvement .............................3-19   4.0  Human Performance Improvement Analysis ........................................4-1  4.1  Error Prone Conditions .........................................................................4-1  5.0  CAUSAL FACTORS .............................................................................5-1  5.1  Direct Cause .........................................................................................5-1  5.2  Root Cause ...........................................................................................5-1  5.3  Contributing Causes .............................................................................5-1  6.0  CONCLUSIONS AND JUDGMENTS OF NEED ...................................6-1  7.0  LIST OF AIB MEMBERS, ADVISORS AND STAFF .............................7-1  8.0  SIGNATURES ......................................................................................8-1  i APPENDICES APPENDIX A - APPOINTMENT OF FEDERAL ACCIDENT INVESIGATION BOARD..................................................................................... A-1  APPENDIX B - BARRIER ANALYSIS ............................................................... B-1  APPENDIX C - CHANGE ANALYSIS ............................................................... C-1  APPENDIX D - ACCIDENT INVESTIGATION TERMINOLOGY ....................... D-1  TABLES Table 5-1. Conclusions and Judgments of Need ..............................................6-2  Table B-1. Barrier Analysis .............................................................................. B-3  Table C-1. Change Analysis ............................................................................ C-3  FIGURES Figure 2.1.1. Typical Assembled Vanadium Sample Canister shown with Praseodymium and Neodymium Technetate Sample Canisters . 2-2  Figure 2.1.3. FP-04 Radioactive Material Storage Cabinet ...............................2-4  Figure 2.1.4. Inside of FP-04 Radioactive Materials Cabinet ............................2-5  Figure 2.1.5. Pr and Nd Technetate Sample Canisters.....................................2-6  Figure 2.1.6. Contents of the Pr and Nd Technetate Containers ......................2-7  Figure 2.1.7. Displex Cold Finger and Close Up of Tungsten Sample ............2-11   Figure 2.1.8. Supply Cabinet on FP-04 Sample Desk .....................................2-12   Figure 2.1.9. Drawers from Sample Desk Supply Cabinet ..............................2-13   Figure 2.1.10. Blow up of Drawer 60...............................................................2-14   Figure 2.1.11. Empty Vanadium Tube and Collar from Sample Desk with Zip- lock Bag and User Sample Staged for Processing ..................2-15   Figure 2.1.12. Top Drawer of FP-04 Tool Box ................................................2-16   Figure 2.1.13. Comparison of Pr, Nd, and Lu/W Sample Canisters ................2-17   Figure 2.1.14. Lutetium Technetate Canister Re-used for W (Tungsten) ........2-18   Figure 3.1. Packaging and Labeling used for Tc-99 Samples Shipped from UNLV .............................................................................................3-8  Figure 3.2. Sample to be Surveyed Label .........................................................3-9  ii ACRONYMS AIB Federal Accident Investigation Board ALARA As Low As Reasonably Achievable APIC Alternate Person in Charge CAS Contractor Assurance System CFR Code of Federal Regulation CoO Conduct of Operations COR Contracting Officer Representative DOE Department of Energy dpm Disintegrations Per Minute EE Effectiveness Evaluation ER-1 and ER-2 Experimental area rooms 1 and 2 in the Lujan Center EM Emergency Management EOC Emergency Operations Center FAMs Functional Area Managers FOD Facility Operations Director FP-04 Flight Path 4 FP-04 S FP-04 Scientist FR Facility Representative FRPR Facility Radiation Protection Requirements HA Hazard Analysis HIPPO High-Pressure Preferred Orientation Neutron Diffractometer HPI Human Performance Improvement HQ Headquarters IN Instrumentation Technician ISM Integrated Safety Management ISMS Integrated Safety Management System IS(PIC) The Instrument Scientist/Person-in-Charge, IWD Integrated Work Document IWM Integrated Work Management IPF Isotope Production Facility JON Judgments of Need K Kelvin KeV Kilo-electron volt KOP Knowledge of Process iii LANL Los Alamos National Laboratory LANS Los Alamos National Security LLC LANSCE Los Alamos Neutron Science Center LASO Los Alamos Site Office MeV Million-electron volt M&O Management and Operating mCi Millicurie mg Milligram MOV Management Observation Verification MP Management Procedure NDA No Detectable Activity NNSA National Nuclear Security Administration OE Operational Emergency OP Operating Procedure PEG Plutonium-239 Equivalent Grams PEP Project Execution Plan PHS Primary Hazard Screening PI-1 Principal Investigator PPE Personal Protective Equipment RAP Radiological Assistance Program RBO Risk-Based Oversight R&D Research and Development RCT Radiological Control Technicians RMI Radiation Monitoring Instruction RP Radiation Protection RP-1 Health Physics Operations Group RPO Radiation Protection Observation RPP Radiation Protection Program RWP Radiological Work Permits SD System Description SAD Safety Assessment Document SME Subject Matter Expert SMP Safety Management Program TA Technical Area Tc-99 Technetium-99 UNLV University of Nevada, Las Vegas iv EXECUTIVE SUMMARY On August 25, 2012, radioactive contamination was identified on Flight Path 04 of the Lujan Center, an experimental area that is part of the Los Alamos Neutron Science Center at the Los Alamos National Laboratory in New Mexico. Los Alamos National Laboratory is operated by Los Alamos National Security, LLC. The Operating Contractor 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. 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. Precise estimates of the extent of personnel contamination and maximum doses are outside the scope of this report. However, based on the amount of contamination, no dose is expected to exceed 1 millirem. Note that persons living in the United States typically receive between 300 and 600 millirem annually from routine, natural and manmade sources (such as cosmic radiation and medical procedures). On August 29, 2012, the Administrator of the National Nuclear Security Administration appointed a Federal Accident Investigation Board (AIB) to determine how the accident occurred and prevent recurrence. From September 4-18, 2012, the AIB interviewed witnesses and reviewed evidence. Because the area where the most significant events occurred was contaminated with radioactive material, the AIB relied heavily on the preliminary Contractor investigation (including voluminous photographic evidence), as well as information gathered in response to AIB requests. AIB members did not physically enter the rooms in the Lujan Center that were contaminated. Accident Description, Analysis and Conclusions The Lujan Center is a national facility for defense and civilian research in nuclear and condensed-matter sciences, hosting scientists from national laboratories, universities, industry, and international research facilities. One type of experiment conducted there is irradiation of sample materials in a neutron beam. Between 2010 and 2012, Lujan Center personnel worked with personnel from the University of Nevada, Las Vegas, to irradiate samples of powdered Praseodymium Technetate, Neodymium Technetate, and Lutetium Technetate. Each of the three samples contained Technetium-99 (Tc-99), an intrinsically radioactive isotope that emits low energy beta particles. The beta radiation from Tc-99 is of such a low energy that it will not penetrate the sample canister wall. ES-1 Thus, it is difficult to know that a sample canister contains Tc-99 if the canister is not clearly marked and/or labeled. The Lutetium Technetate sample was later determined to be the source of the contamination in the August 2012 event. The samples were prepared at the university in 2010, put into empty sample canisters (provided by Lujan Center personnel), sealed, and shipped to the Lujan Center. The shipping containers and packaging were clearly marked to indicate that they contained radioactive material. However, the canisters themselves were not marked to indicate they contained a hazardous or radioactive material, nor was there a process at the Lujan Center for doing so. They were only marked “Pr,” “Nd,” and “Lu,” respectively. Element symbols from the Periodic Table, such as the letters Lu or Nd, were typically used to denote the chemical contents of a sample canister. However, most sample canisters observed by the AIB had more complete markings on them to indicate their contents than these three. Because it was only marked “Lu,” someone looking at the third sample canister, separated from its paperwork, would probably have surmised that it contained Lutetium, which (if not activated) is a mostly nonradioactive element that may be harmful if inhaled but that otherwise has low toxicity. That person would have had no indication of the Technetate (i.e. radioactive) contents from the markings alone. Lujan Center safety personnel assumed that the canisters would not be opened, but would be returned to the university. Beyond this assumption, no additional controls were established to ensure that the sample canisters were not opened. Each of the sample canisters had a cap with six screw holes that could be used to connect the cap to the canister. Screws were only threaded into three of the six available holes to secure the caps. No engineering analysis was performed to verify that the use of three screws provided an adequate seal for the expected environments that the canisters would experience. Two of the samples were irradiated at the Lujan Center in late 2010 and returned to storage. The third, containing Lutetium Technetate, was irradiated in January 2012. Following irradiation, positive control of the third sample was lost. Internal management processes at the Lujan Center were not of sufficient rigor to ensure positive control and tracking of radiological or hazardous samples throughout their life cycle. Comprehensive chain of custody procedures had not been implemented, and the third canister cannot be accounted for between January and August 2012. On August 20, 2012, an instrument operator in the Lujan Center put Tungsten powder into a sample canister and sealed it with a cap and three screws. The canister was to be used in a procedure to align an experimental apparatus. It was later discovered that this sample canister was built using parts from the Lutetium Technetate sample canister. When retrieved during the investigation, the internal contents of the canister were found to be contaminated with Tc-99. ES-2