Aug 28, 2009

TA-35

DNFSB reports are only one page per week and are delayed for weeks. A reader sent this one to me, which describes some of the events at TA-35 last month.
DEFENSE NUCLEAR FACILITIES SAFETY BOARD
July 24, 2009
MEMORANDUM FOR: T. J. Dwyer, Technical Director
FROM: B. Broderick and R.T. Davis
SUBJECT: Los Alamos Report for Week Ending July 24, 2009

Emergency Management: On Thursday, LANL conducted its annual full scale emergency exercise. The exercise simulated an explosion in the Beryllium Technology Facility foundry resulting in several worker casualties and a release of Beryllium from the facility. At one point, the exercise had to be paused for several hours when key participants including Los Alamos County Fire Department, LANL Emergency Response and LANL Emergency Management personnel were called away to deal with an actual hazardous material event, discussed below. Work has begun on an exercise after-action report that will analyze performance and identify opportunities for improvement.

Target Fabrication Facility: The event that led to the pause in the full scale exercise occurred at the Target Fabrication Facility, a radiological facility in Technical Area 35. A worker was transferring a nitric acid solution into a shipping container to prepare it for disposition when an unexpected chemical reaction occurred causing reddish fumes to begin evolving from the container. The worker became concerned that an exothermic reaction occurring inside the shipping container could cause it to fail, so he attempted to transfer the reacting solution into a more robust container. During this attempted transfer liquid began to bubble out of the container. At this point the worker left the room and prompted a facility evacuation. The facility evacuation was complicated by the evacuation alarm being out of service. Also, one individual had not been issued a facility emergency notification pager and remained unaware of the situation and inside the facility for a significant period of time.

Incident command decided to order adjacent facilities in TA-50 to shelter-in-place to protect personnel from exposure to any chemical vapors being exhausted from the Target Fabrication Facility through an unfiltered stack. Notification to shelter-in-place does not appear to have been effectively communicated to all impacted TA-50 facilities, including the WCRR repackaging facility.

Ultimately a hazardous materials team made entry into the facility and stabilized the scene. Fourteen workers, including the individual directly involved in the event were transported to Occupational Medicine where they were examined and released without restriction. The direct cause of the chemical reaction that initiated the event is still under investigation. In part due to similarities with the July 8th exothermic chemical reaction event at another TA-35 facility, the Material Science and Technology division has paused operations involving chemicals, pending reviews of work control documents and walkdowns of laboratory spaces where work with chemicals is performed (site rep weekly 7/10/09).
[...]

43 comments:

Anonymous said...

"The facility evacuation was complicated by the evacuation alarm being out of service."

Say, what? We have multi-million dollar alarm systems that are constantly being checked and repaired by the facilities people at LANL at great expense to the operating budget and when they are finally needed in an emergency.... they are Out of Service!!!

Anonymous said...

Is there a PBI for alarms?

MIKEY!

Anonymous said...

It should be emphasized that these Defense Nuclear Facility Safety Board (DNFSB) weekly reports are released about a month following the actual incident, hence an incident in late July released to the public in late August. This raises several issues. Why does the public and workers have to wait a month to hear of potentially dangerous releases to the public and workers from a Category 2 or 3 nuclear facility? It is appalling that the public and workers did not learn of this incident from LANS but from the DNFSB. It should also be noted that LANS would like to eliminate DNFSB oversight. If the DNFSB is eliminated then how will the public and workers be notified of these incidents, be it a month following the incident when we have be long exposed to the release. Fortunately, the release caused no public or worker fatalities, this time.

Anonymous said...

The events described in this report are NOT the way even Susan Seestrum has described them. LANS has lied to the DNFSB and are covering up the actual events.

Anonymous said...

4:30 pm: "LANS has lied to the DNFSB and are covering up the actual events."

The LANL-resident DNFSB folks don't get their info from LANS management - they are in the facilities daily. So if there is lying going on, it is at all levels of LANL workers and management, and the DNFSB folks are blind as well, which having worked with them, I don't believe. Go figure.

Anonymous said...

The staff in some nearby buildings were not warned to shelter in place, that's total bullshit. We saw the roadblock, but many thought it was an only an exercise. We found out hours later, and not from management, that it was indeed a serious accident. This is totally inexcusable as it followed closely behind the mishandled emergency notifications during the student acid screw-up in TA-35.

LANS should be fired. Period.

Anonymous said...

"Why does the public and workers have to wait a month to hear of potentially dangerous releases to the public and workers from a Category 2 or 3 nuclear facility?"

Um... what? Neither BTF nor Target Fab are nukes.

Anonymous said...

LANS should be fired. Period.

8/28/09 7:38 PM


No, no, no. NNSA is paying LANS a bundle to manage the lab and thinks they are doing a fine job. That's all that matters any more. Besides, Tom D'Agostino will be wanting to hire on as a high paid executive with Bechtel in the not too distant future. He can't afford to let them lose any of their current NNSA contracts.

Anonymous said...

It's all part ofthe plan.

Anonymous said...

ORNL is run by a non-profit for only $10 M per year, honors science, and is rapidly growing.

LANL is run by a for-profit construction company for $200 M per year, is killing off science, and is rapidly shrinking.

I see a pattern here.

Anonymous said...

I see a pattern here.

A bigger pattern is that ORNL is an Office of Science lab not shackled to a Manhattan Project legacy. That's someone else's problem over the ridge at Y12.

For decades the Manhattan Project afterglow was a great benefit to the now NNSA labs. Times change.

Anonymous said...

According to the report, "A worker was transferring a nitric acid solution...when an unexpected chemical reaction occurred causing reddish fumes to begin evolving from the container."

This reaction was NOT unexpected. Nitric acid almost always produces red fumes, exothermicity, and bubbles.

This is very similar to the famous "aqua regia" incident, as well as many other incidents in TA48 and probably in every chemistry lab in the world.

Yet, it is described as unexpected in every report ever written.

Frank Young said...

The report never mentions if the evacuation alarm was known to be out of service. If so, one has to wonder why operations in that building were not paused.

The report also implies there are not enough emergency responders to handle an exercise and a real emergency simultaneously. I wonder what would happen if there were two simultaneous real emergencies.

Anonymous said...

8/29/09 2:25 PM
This is very similar to the famous "aqua regia" incident, as well as many other incidents in TA48 and probably in every chemistry lab in the world.

No it is NOT! The 'aqua regia' incident happened because a malicious TSM - Kiplinger - forced her postdocs to do something dangerous and outside the boundaries of an approved IWD and almost killed her postdocs Tournear and Schelter.

Anonymous said...

"No it is NOT! The 'aqua regia' incident happened because a malicious TSM - Kiplinger - forced her postdocs to do something dangerous and outside the boundaries of an approved IWD and almost killed her postdocs Tournear and Schelter.

8/29/09 8:40 PM"

And how would you know???. Hmmm

Anonymous said...

8:40 PM - We all just wish she'd tried a bit harder.

Anonymous said...

Regardless of whether Tounear was ordered to not use a hood, regardless about whether Jackie did yada yada, etc.

Nitric acid still almost always gives off red-brown fumes and bubbles exothermically when it is used. Only a first time HNO3 user would be surprised by it. Only a CYA activity would claim it is unexpected.

Since there have been multiple problems with HNO3, and none of the corrective actions or lessons learned seem to make a difference, HNO3 use should be locked out from further use.

Anonymous said...

It has been awhile since Doc Aq and the aqua regia gang has surfaced on the blog. I was beginning to worry.

Back to the title topic ...

The important item that keeps getting covered up by LANS is the way that HazMatt fucked up this inicident and the acetone-into-the-HNO3 incident. Revealing the gross incompetence and errors by HazMatt will cost LANS dearly. This is where the Defense Nuclear Facility Safety Board (DNFSB) should look...

Anonymous said...

And ice is slippery, and electricity involves voltage and current, and using a computer requires sitting in one position for a while.

Ban 'em all.

Anonymous said...

9:36 and 9:51 AM, oh I agree! And while we are add it let's get rid of all those pesky FN's. You know, they "could" cause us embarassment with a security infraction even though all the big ones lately have been caused by Mary Neu and her husband Wolfgang Runde.

Anonymous said...

I "alignment" with 9:36 AM, I think we should also do the same with unlabeled vials of Cs and Rb.

Anonymous said...

This is 9:36.

I did NOT say that HNO3 should be banned because it is hazardous.

I said it should be banned because the exact same problem with HNO3 has come up every few months in the almost 20 years I have been here, and no one here is apparently willing to handle it properly.

Anonymous said...

Like these?

http://lanl-the-rest-of-the-story.blogspot.com/2008/07/last-chance-rubidium-and-cesium-vials.html

Anonymous said...

Johny was a chemist.
Johny is not more.
What he thought was H20 was H2S04.

____________________________

Not exactly HNO3, but close.
Go to http://www.dnfsb.gov/pub_docs/weekly_reports/lanl/wr_la.php to get the latest DNFSB scoop

Anonymous said...

DEFENSE NUCLEAR FACILITIES SAFETY BOARD
October 14, 2005
MEMORANDUM FOR: J. Kent Fortenberry, Technical Director
FROM: C. H. Keilers, Jr.
SUBJECT: Los Alamos Report for Week Ending October 14, 2005
Jordan was on site this week augmenting site rep coverage.
DOE Independent Oversight: The DOE Office of Independent Oversight and Performance
Assessment (DOE-OA) is here this week and next inspecting NNSA & LANL management programs
for environment, health, and safety; a major focus of their inspection is status of corrective actions
developed in response to last year’s resumption reviews. They return in mid-Nov to validate findings.
Waste Operations: Based on a LANL management self-assessment, NNSA has approved restart of
examining and repackaging of transuranic waste in the TA-50 WCRR Facility; this is an essential step
for LANL to move forward on the Quick-to-WIPP risk reductions (site rep weekly 9/16/05).
Plutonium-238 Operations: By Oct 31st, LANL expects to complete decontamination of the room
that was contaminated in August 2003. Currently, four cans in the room await packaging; the
remainder (~234) have been packaged for eventual shipment to WIPP via Area G or for eventual
stabilization (e.g., pyrolysis) and disposition (e.g., aqueous recovery) within TA-55.
DOE-NE (Nuclear Energy) and LANL currently expect LANL to resume bench-scale and start up fullscale
aqueous recovery operations in Nov 2005 and Feb 2006, respectively. NNSA is requiring that
“applicable” TA-55 interim TSRs first be implemented for both lines to address the building leak-path
issue; it appears appropriate for NNSA and LANL to formally agree on specifically which new TSR
controls must be implemented and verified as a pre-start for these operations. Some of the other steps
required to support full-scale startup are: (a) resolution of remaining questions on effectiveness of
safety basis controls (e.g., hydrogen generation); (b) closure of pre-start findings and definition of
path-forward for post-starts from the LANL June 2005 readiness assessment (RA); (c) final LANL &
NNSA RAs, covering also applicable interim TSRs; and (d) opening safe disposition pathways for
residues and waste, preferably including the pyrolysis pathway (site rep weeklies 9/16/05, 5/27/05).
NNSA Type B Accident Investigations: NNSA has completed its investigation into the TA-48 acid
inhalation injuries; the investigation into the Am-241 release continues (site rep weekly 8/12/05).
Among conclusions from the former are that the acid injuries resulted from mixing and using acids
outside a functional hood; those involved did not believe that a reportable accident had occurred;
management did not ensure that workers recognized the full extent of hazards or that the workers were
trained in the work control process or that the workers followed institutional practices; the workers’s
drive to accomplish research took priority over housekeeping, even though both had equivalent
hazards; by reducing oversight and field presence, the NNSA Site Office (LASO) lost an opportunity
to gauge the LANL integrated work management process; LASO followup on previous investigations
has not driven LANL to establish a robust line management assessment program; LASO followup has
also been slow, indicating weak NNSA commitment to using feedback to drive improvements.
Management: The LANL Institutional Assurance Board (IAB) and the Nuclear Safety Executive
Board (NSEB) have been increasingly effective; LASO participation with these boards has dropped,
which is unfortunate. The IAB does change control for the Operational Efficiency Project, while the
NSEB reviews closure of PAAA corrective actions. LANL staff presentations before the NSEB also
provide a uniquely useful and succinct analysis on the state and direction of LANL nuclear operations.

Anonymous said...

Does this work?

Johny wanted to be a chemist.
But it was not to be.
What he thought was H20 was HNO3.

(Or should it be Jamie?)

Anonymous said...

Almost, how about this version?

Eric Schelter and Jaime Tourner wanted to be big famous LANL chemists.
But it was not to be.
What their ladder-climbing boss Doc Aq said was H20, instead was HCl and HNO3.

Frank Young said...

There is already a post on Doc Aq. Maybe I should do one on the postdocs so this crap will be on topic somewhere.

Doug Roberts said...

Works for me, Frank. If they are that eager to air their dirty laundry, let's let them go for it.

Anonymous said...

This is 2:25. I apologize for mentioning Tournear and thereby setting off the crazies.

The critical point, I think, is that HNO3 always behaves like this, and reports always whitewash it by claiming no one could have predicted brown fumes and exothermicity.

Anonymous said...

11:20 am,

Are you sure that you work at LANL? It is extremely uncharacteristic for LANL anonymous posters to this blog to apologize for anything, as it is never their fault.

;-}

Anonymous said...

11:20 am, agreed. But this is clearly something the officials are not getting either. And what about the ADCLES who has a degree in chemistry? Why is she not piping up? Bonus at risk? Or is she just this fucking stupid?

Anonymous said...

12:00 PM - yes, she is fucking stupid and only got her current post by well ... shall we say, pleasing Mikey and Terry.

Frank Young said...

8/31/09 11:20 AM,
No worries. I appreciate your point and I'd like you to keep making it. Who is making all these mistakes; non-chemists, bad chemists, inexperienced chemists? Is there no experienced chemistry expert to oversee these types of operations?

And though I'm an EE I know you aren't serious about halting HNO3 use. That isn't an option. What is the path forward?

Anonymous said...

Sorry for the delay in responding.

I would say all chemists use HNO3 in this cavalier manner. Experienced, inexperienced, good, or bad. We all know that there is a puff of brown smoke.

It's only when there is an accident or when an outsider sees it that everyone starts pretending that it is a totally unique, unpredictable situation. Management goes along with that explanation, because it can be sorted out with a minor change to a safety plan.

Aqua regia, by the way, is pretty much the same as HNO3 for most all purposes, except for dissolving coinage metals. It is unclear why Jackie and Jamie were using it for what I believe was organometallic uranium residues. Probably out of thoughtless habit. However, the incident would have been the same with HNO3 or aqua regia (HNO3/HCl mixed), and the use of aqua regia did not exacerbate whatever happened as compared to HNO3.

I would not recommend getting rid of HNO3, which you correctly point out, is hard to replace. However, given the number of accidents and the number of times that it is unneccessary, I would lock it out of service except for situations with a proven necessity. There is no need for run of the mill carelessness to cause such a useful chemical to be banned, which is the risk I see from these accidents.

Anonymous said...

8:51, as an anlytical chemist, I have a healthy respect for nitric acid, but I don't fear it like you seem to think I should.

A fearful demeanor at the bench is just as inimical to safety as a cavalier one.

Anonymous said...

Incidentally - uranium residues can be unpredictable in their dissolution behavior. A mixture of nitric and hydrochloric acids is really not an unreasonable approach for cleaning glassware, if you don't have the luxury of simply throwing it away.

Anonymous said...

From 8/31/09 12:00 PM ...."
ADCLES who has a degree in chemistry? Why is she not piping up? Bonus at risk? Or is she just this fucking stupid?"

It is the bonus. This past week I had the misfortune to sit in on an ADEPS super-manager meeting in which people were lamenting the fact that ADEPS is losing good managers because of all the electrical paperwork, etc. that is being mandated for no reason other than paperwork makes you safer. Seestrom's response was "I don't care if people can't take the pressure, two high-profile electrical incidents happened in my directorate and my PBI's are at risk of not being met (and by default my $1.2M bonus)."

Yes folks, Seestrom is throwing people under the bus for her pocket book. It has nothing to so with caring about people or leadership, but cold hard cash.

By extension, I am sure Mary Neu feels the same way ... fuck the employees, what about my $1.2M bonus?

Anonymous said...

I'm not sure how you got the impression I feared HNO3, 9:21.

I said that the general half-assed approach that is currently taken risks a blanket ban which will affect people who actually need it.

I completely disagree with your comment that "A mixture of nitric and hydrochloric acids is really not an unreasonable approach for cleaning glassware..." I think it is unreasonable and thoughtless, since you don't need the chloride ligand to stabilize the higher oxidation states of uranium, in contrast to the way you need the chloride for dissolving metallic gold. It is certainly unreasonable to reach for aqua regia as a first resort.

I also disagree with your concept that "...you don't have the luxury of simply throwing [glassware] away." The cost of the relevant glassware was small compared to the cost of an accident. If the project cannot afford appropriate glassware, then it cannot afford to pay the risks of being performed at LANL.

Anonymous said...

It's a wonder LANL was ever able to build the first bomb. With today's rise-adverse tolerance, i.e. locking HNO3 out of service for those situations really requiring it, we should just shut down all the laboratories working with chemicals. We wouldn't want the potential for any accidents involving those nasty acids and bases. Ship the chemists back to universities or industry where they can perform their butt-head research activities with aqua regia and *shudder* nitric acid!

Anonymous said...

To: 9/5/09 8:51 PM and 9/6/09 11:18 AM

Not only do you have your facts wrong, but you too fucking stupid to even warrant the energy for a detailed, insightful response. Let me guess ... you work for a "support" organization at LANL, don't you?

Anonymous said...

LOL, 5:15. Either I was so drunk that I don't remember posting, or you've channeled my every thought. This discussion is truly too stupid to merit any further expenditure of my time or energy.

Anonymous said...

"my $1.2M bonus?"

Do they really get 1.2Mill a year?
That is too high te be safe. I undertand how a say 25% bonus is good but at 1.2million you are inviting pure corruption at that point. In other words when the money is that good, everything will be covered up, hell you just give out 100K to someone who had an incident and you would still get mill, for this amount of money you can just pay off people and still make a killing.