Jan 11, 2008

Nuclear weapons chief warns lab on safety

From Lab Notes Compiled by ROGER SNODGRASS, Monitor Editor

National Nuclear Security Administrator Thomas D’Agostino has formally admonished Los Alamos National Laboratory about its unsatisfactory nuclear safety performance.

In a letter dated Jan. 4, D’Agostino cited two separate contamination incidents early last year involving radiation exposures to workers conducting separate glovebox activities at the laboratory’s plutonium facility, Technical Area 55, and the Chemistry and Metallurgy Research facilities.

One of the workers, a pit machinist in TA-55, received an exposure greater than the annual regulatory exposure limit, D’Agostino wrote.

While core activities at the laboratory, including plutonium pit manufacturing at TA-55, were meeting targets, “support operations and safety programs are increasingly strained to meet commitments within budget,” reported the site representative of the Defense Nuclear Facility Safety Board at the time of the incident.

A subsequent memorandum reported that NNSA’s director for Nuclear and High Hazard Operations was leading an eight-person investigation team with participants from the four parent corporations of the laboratory manager, Los Alamos National Security, LLC.

A prepared statement by the laboratory acknowledged the two incidents and said that they led to a temporary pause of glove box operations involving plutonium where similar hazards existed.

“The laboratory director immediately began a process to minimize or eliminate the possibility of recurrence,” according to a statement from LANL spokesman Kevin Roark this morning. “At the conclusion of the investigation, the laboratory developed and implemented a corrective action plan. Safety of our employees is our primary concern, particularly those employees involved in potentially hazardous work,”

“Nuclear safety performance at LANL over the past several years has been inadequate,” D’Agostino wrote, adding that the changes in senior management, organizational structure and corrective safety programs in June 2006 “have not led to sustained performance improvement.”

D’Agostino’s letter stated that enforcement action would be deferred at this time, “in favor of enabling you to focus management attention on identifying the broad deficiencies which led to these events.”

Rather than imposing penalties at this time, the administrator said he was issuing the Special Report Order, giving the laboratory 90 days to examine the specific incidents and all glovebox activities and take appropriate corrective actions.

Under the terms of the special order, the response of Los Alamos National Security will be evaluated with the input of NNSA’s local staff of the Los Alamos Site Office. The progress accomplished will be weighed in the context of “recent nuclear safety performance.”

LANL was given 10 days to appeal the order.


Anonymous said...

I worked closely with the Pu machinist who got the high dose. He is well known as a "cowboy" to quote that jackass Nanos. I am sorry for his health issue associated with this accident, however, I cannot say loudly enough that he is simply an arrogant and ignorant worker who had no place working in a high-hazard facility. The admonishment by NNSA should be for LANS employing such an idiot.

Lets keep the focus on getting the skilled workers at LANL under the right degree of safety oversight.

Anonymous said...

Well, I don't personally know the machinist but I would have to agree that TA-55 employs less than stellar folks to work in PF-4. Most of the technicians are high school educated. There are some good staff but most are BS-level engineers or BS-level staff with irrelevant degrees like biology or environmental science. Unfortunately, its very difficult to recruit more qualified people to work in this type of environment. There is no incentive (except retention pay which has been frozen to new hires and done away with for staff), either through raises or salaries, to work with a lot of Pu, associated health risks (potential for uptakes), yearly doses, relentless training and of course, HRP requirements.

Anonymous said...

We've seen the messenger, D'Agostino, attacked in an earlier post. Now the worker is at fault. Next look for someone to point out that this happens at all the labs. And finally, someone will rave about the health benefits of plutonium inhalation. Did I miss any pages out of the LANL playbook?

By the way 5:41, if what you say about the machinist is true why didn't you speak up?

Anonymous said...

Got to keep up the appearance of running a tight ship ya know...Hurrumph!...

Anonymous said...

5:41 here

I was a manager at TA-55 but have since resigned that position due largely to the sheer complacency of my managers. When I would challenge their indifference to the poor environment we worked under , I was essentially ignored and best and often was left feeling like a nuisance. Much of the fault was ours (all of TA-55) as we were simply to stuck in "our way" to change. However, the lab, NNSA, and the public sure could make life hard by not being logical about safety thresholds.

Bottom line, I did speak up to my management, but way too afraid to speak out any higher up. Yes I am a chicken when it comes to losing my job!

Oh and I agree wholeheartedly with 6:59 about both the low education level and the tools that HR gives us to recruit and retain the "best and brightest" to work there. Many may find fault with this, but there is a lot of science and engineering to be done in the Pu business. I realize that LANS could and should pursue other areas of expertise, but the Pu business is very challenging and draws on many disciplines.

Anonymous said...

I also worked in that area, the level of saftey is questionable, some take it seriously and others don't. The level of education is a concern, but so is the "attitude", and thats the problem. Until that changes, we could expect to a shut down.

Anonymous said...

SO 5:41 PM, if what you say is true then why is the "cowboy" still working here. WHy didn't LANS get rid of him?

Anonymous said...


So hire better people? Hmm... a reoccurring theme. Hire better people, hire better people, hire better people ... never mind hire whoever.

In anycase you can blame any
incident on a cowboy, however someone had to hire him, so I blame the institution.

As for Nanos he ironicly is a classic "cowboy", an arrogant and
ignorant person who thought he was above rules and above the law.

Anonymous said...

6:59 pm: "Well, I don't personally know the machinist but I would have to agree that TA-55 employs less than stellar folks to work in PF-4."

Hear, hear! If NNSA want nuclear "grunt work" done at LANL it will get nuclear "grunt workers," not "stellar" employees. Why the surprise? Accidents are almost always the fault of the worker who cuts corners, doesn't feel concerned, or just plain thinks he knows better than those "safety jerks." It is true throughout US industry, not just at LANL or within DOE. Unions protect most such workers from the correct managemnt response, which is summary firing, but not at LANL. Somebody should have been letting this guy go a long time ago.

Anonymous said...

Just being slapped with wet noodle. Business as usual. Just posturing, and nothing more. Like two wimps at a fight - eact to scared to be the first one to hit.

Anonymous said...

5:41 here again

Low level (GL and below) management tried to let go of this guy. At least three problems scuttled with that proposal:
1) It looked punitive to HR to terminate a worker who suffered this "accident."
2) Lower management had sold upper management and HR on how skilled and rare these Pu machinists were and that we would disrupt the precious Pit Production mission if we lost any WR qualified machinists. Note by the way that the Pu machinists were part of the workforce that was not eligible for SSP.
3) The causal analysis performed and the corrective action took aim at the team leaders (now first line managers FLM). The "fix" would be to train (ha ha ha) the new FLMs and make them accountable for safety. BTW this is not looking to be silver bullet to these problems.

Anonymous said...

From AGS American Glovebox Society, Advancing the Science of Glovebox Technology Since 1986:

" Standards Committee

The Standards Development Committee (SDC) was formed at the Third Annual Conference of the American Glovebox Society in Denver, Colorado, in 1989.The original purpose of the SDC was the development of documents to guide designers, fabricators, and users in the proper and consistent design, fabrication, and operation of gloveboxes, while minimizing the cost involved.

The SDC has committee meetings on a regular basis, usually at the annual conference and at two other times between conferences.

The chairperson of the SDC is Dean Shipley of BWXT Y-12 LLC. BWXT operates the Y-12 Plant in Oak Ridge, Tennessee, for the Department of Energy (DOE). The SDC co-chairperson is Art Frigo of Argonne National Laboratory.

The SDC has written and is developing several more Standard-of-Practice (SOP) booklets related to glovebox technology. In 1998, two SOPs were published - the first for the design and fabrication of glovebags, and a second for the application of linings to gloveboxes. The efforts associated with these documents were led by Carl Fink of CTL Corp and Ted Hutton of Atofina, respectively.

In 2003, the SDC completed another SOP for the specification of gloves for gloveboxes. Other SOPs being developed, and for which technical expertise is always welcomed, include one for glovebox leak testing, another for glovebox fire protection, and a third for the design and fabrication of gloveboxes for the containment for materials that emit low-penetrating ionizing radiation. The first two of these new SOPs are in the early stage of development, whereas the third one is in final preparation and is expected to be published in late 2004.

To order AGS Guidelines or Standards of Practice, download the publication order form.

The American Glovebox Society welcomes anyone with an interest in gloveboxes to join its Standards Development Committee. Please contact the Society Office if you are interested in joining and would like to be added to the mailing list announcing upcoming meetings."


"Conferences - Expos - Events

AGS Annual Conference
July 14-16, 2008

Hilton Daytona Beach Oceanfront Resort
Daytona Beach, FL

Room Rate: $ 134
Reservations: (866) 536-8477
Cut-off Date: June 12, 2008
Group Code: AGS"


"Leadership, AGS Officers and Directors for 2005-2006


- President, Fidel Vigil, LANL
- President-Elect, Ken Rosenberg, Idaho National Laboratory
- Secretary, Keith Landy, Purified microEnvironments
- Treasurer, Jim Spolyar, Aseptic Barrier Systems LLC
- Immediate Past President, John Newman, IP Systems, Inc.

AGS Board of Directors (Listed Alphabetically)

- Mark Borland, INEL
- Steve Chunglo, laCalhene
- Paul Contreras, LANL
- Carl Fink, CTL Corp
- Lyle Freeman, Premier Technology
- Nate Levene, Merrick & Company
- Russ Krainak, Flanders Filters, Inc.
- Ron Smith, Consultant
- Patrick Westover, Savannah River National Laboratory
- Trish Wright, LANL"



Anonymous said...

1/11/08 11:17 PM

Keep the advertising out and stop wasting our time

Anonymous said...

Oh look, they offer education and training too!

Anonymous said...

"I also worked in that area, the level of saftey is questionable, some take it seriously and others don't. The level of education is a concern, but so is the "attitude", and thats the problem. Until that changes, we could expect to a shut down."

It aint "saftey" and it aint "thats". How did this get here??? Geeze!!!

Anonymous said...

5:41/10:50 PM - you nailed it on the head. Nobody gets rid of the problems at LANL and everyone who has "sufferred" an injury at LANL has been heralded as a "victim" of the supervisor. No line manager at LANL ever places blame on the worker who fucked-up and ignored the rules. We have seen this time and time again.

Anonymous said...

It ain't "aint" neither.

Anonymous said...


Original Publication OE96-10

On February 27, 1996, a worker at the Los Alamos Chemistry and Metallurgy Research facility left the site with alpha contamination on his personal clothing. Radiological control technicians (RCTs) detected two spots of alpha contamination measured 1,200 dpm on the heel of his personal shoe and 300 dpm on his right pants leg. The probable contaminants are isotopes of plutonium and uranium. This is significant because of the loss of control of radioactive material and its appearance where the general public could be affected. (ORPS Reports ALO-LA-LANL-CMR-1996-0006)

After one employee detected contamination on his hands while exiting a work area, RCTs investigated and found three other workers who were involved in the same work that day. One employee had already gone home, so the RCTs contacted him there. Following the discovery of the alpha contamination, the RCT and employee removed and properly packaged the contaminated clothing. He detected no other contamination on the employee. He also surveyed the employee's home, automobile, and areas where the employee had been since leaving work, including a barber shop. No other contamination was detected. All four employees submitted nasal smears, which tested negative.

Analysts performed an isotopic analysis of the contamination on the employee's shoe, identifying the contamination as plutonium-239. They later identified the contamination on the pants as uranium-235. Contamination in the room where the four had worked included alpha and beta emitting uranium isotopes. Their activities did not involve plutonium-239. Facility RCTs are still searching for the source of the plutonium-239 and the alpha-emitting contamination on the second worker's hands.

The Chemistry and Metallurgy Research facility manager, facility division director and group leaders met on February 29, and discussed corrective actions, including a standdown of programmatic activities. They determined that complacency to radiological hazards and failure to enforce radiological controls were contributing causes of recent incidents. Another contributing cause was determined to be the technique of portal frisking with anti-c's on, which shields the affects of alpha contamination on personal clothes under the protective clothing. During the standdown, the facility manager and group leaders told workers that all personnel will be held accountable for their actions.

OEAF engineers reviewed the facility's occurrence reports and noticed that, although the total number of reportable events appears to be decreasing, some of the decrease may be the result of a change in reporting requirements in 1994. More importantly, the fraction of events coded 01D, loss of control of radiological material / spread of contamination, has been increasing.

Reportable Events from ORPS Data

These events underscore the need for enforcing radiological controls at the worker level. Complacency to radiological contamination must be avoided through the development of effective controls. NRC Information Notice 94-16, Recent Incidents Resulting in Offsite Contamination, cites similar occurrences in the commercial nuclear industry. Weekly Summary 93-11 reported a similar off-site contamination event at Michigan State University Superconducting Cyclotron Laboratory, a nuclear research facility where a staff scientist left site with 300,000 dpm/100 cm2 carbon-14 from a leaking target and traveled 1000 miles home, leaving a trail of contamination.

DOE 5400.5, Radiation Protection of the Public and the Environment, and 10CFR835; Occupational Radiation Protection, Final Rule; provide limits for public and qualified worker exposure and contamination. DOE/EH-0256T, Radiological Control Manual, revision 1, identifies controls and techniques to preclude contamination. Chapter 1, "Excellence in Radiological Control" provides guidance in establishment and maintenance of control programs.

KEYWORDS: contamination control

FUNCTIONAL AREAS: operations, decontamination

Anonymous said...

Hopefully, the next presidential administration will evidence the ability to resolve problems without immediately resorting to confrontation. The temporary enjoyment of writing that snotty memo to Anastasio is not worth the distrust it will breed.

Anonymous said...

I agree about the historical and legacy attitudes but education and training are important. I've seen technicians who can't even do basic math required for MC&A transactions. So, how can the facility be safe in criticality space, when they don't understand the concepts behind fission OR can't do the basic math, i.e I have this much Pu currently in my GB, I need to bring in more, I have this much going out, how much can I actually bring in without causing a crit infraction. I'm not trying to point fingers because there are some good folks but in general, the grunts outweigh the good people. Its a pervasive problem and I'm not sure the current management can change it unless we wipe the slates clean and start all over. Again, how are we as an institution going to attract the best and the brightest to perform "grunt nuclear work." And I don't buy what Mike Mallory preached about "LANL has the highest paid workers in the nuclear production complex." So basically, you guys are already over-compensated so suck it up and deal with it.

Anonymous said...

"And I don't buy what Mike Mallory preached about "LANL has the highest paid workers in the nuclear production complex."

Those data are, of course, skewed by Mike Mallory's very high salary.

Anonymous said...

2:34 PM - yes, you brought up a good point. Mallory's salary is higher than Mikey's but he doesn't get all the same well-deserved bonuses that Mike gets.

Anonymous said...

Can someone explain how the molehills of

"... two spots of alpha contamination...."

can be grown into the mountain of

"..loss of control of radioactive material..." ?

just a bit of misrepresentation here?

Seems like its gonna take a long time for enough of these spots to get together to matter.

Maybe they'll hitchhike to Yucca Mountain and spring their entrapped Actinide-gangland buddies.

Watch out, Chicken littles, for the attack of the Hot Spot gang.

Anonymous said...

300,000 dpm/100 cm2 carbon-14 from a leaking target and traveled 1000 miles home, leaving a trail of contamination....

why didn't somebody think of this for the exits of Tora Bora?

Anonymous said...

Once again, the folks at LANL screw up and LLNL has to be part of the cure - yet another safety class. Though I do think this particular one should have been a requirement a long time ago.

HS0023 Safety Leadership Workshop is a one-day training requirement for all LLNL managers and supervisors (payroll and work). The goal is to help participants manage safety as an integral part of work at the Laboratory. This will be achieved through lecture, group exercises and discussion. Participants will evaluate their leadership skills, identify opportunities for improvement and commit to a personal action plan for safety.

Topics include:

Critical safety leadership behaviors
Zero accident tolerance philosophy
Cost of accidents
Accident/incident causation flow
Utilizing leading indicators
People/behavior-based safety management
Personal communications
Course registration begins Wednesday Jan. 16. All supervisors will receive e-mail notification with registration information. The course must be completed no later than Sept. 30.

Anonymous said...

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