Protecting People and the EnvironmentUNITED STATES NUCLEAR REGULATORY COMMISSION
ACCESSION #: 9603050207
DEPARTMENT OF THE ARMY
UNITED STATES ARMY TANK - AUTOMOTIVE AND ARMAMENTS COMMAND
ARMAMENT AND CHEMICAL ACQUISITION AND LOGISTICS ACTIVITY
ROCK ISLAND, ILLINOIS 61299-7630
February 1, 1996
AMSTA-AC-SF
Nuclear Regulatory Commission
Region III
Division of Radiation Safety & Safeguards
801 Warrenville Road/Attn: Mr. Sam Mulay
Lisle, Illinois 60532-4351
Dear Sir:
On December 19, 1995, a shipment of radioactive material (a boxed,
damaged MI Al collimator) was received at the Marine Corps Logistics Base
(MCLB), Barstow CA. The box was delivered to the Defense Logistics
Agency (DLA) radioactive material receipt area ( Bldg 401) on December
19, 1995, but not officially received by DLA personnel until December 26,
1995. Upon official receipt, the box was wipe surveyed and found to
exceed the external contaminated limits of 49CFR 173.443. The box was
placed in a controlled radioactive material storage warehouse (Bldg 403),
isolated, and further surveyed.
ACALA Safety office received notification on January 3, 1996.
Investigation revealed that the collimator had been boxed and shipped by
Marine Corps Base, Hawaii (MCBH), Kaneohe, HI. Further investigation
revealed that MCBH Kaneohe, HI had not performed any contamination
surveys of the collimator prior to boxing, nor the box prior to shipment.
Conversation with MCBH, Kaneohe, HI revealed that no Radiation Protection
Program had been implemented on their facility.
An ACALA Safety Office representative visited MCBH, Kaneohe, In to
investigate the events leading to the shipping of the contaminated
collimator, and the status of their Radiation Protection Program.
Attached is information delineating the sequence of events at MCLB,
Barstow, CA (Encl 1), and MCBH, Kaneohe, HI (Encl 2).
-2-
This action has been coordinated with and approved by the
Headquarters, Army Materiel Command Safety Office.
The point of contact for this report is Timothy J. Mohs, AMSTA-AC-
SF, (309) 782-6228.
Sincerely,
John A. Mattila
Chief, Safety Office
Enclosure(s)
Copies Furnished:
Cdr, AMC, ATTN: John Manfre, Alexandria, VA 22333 -0001
SHIPMENT OF BROKEN COLLIMATOR FROM KANEOHE HI. TO BARSTOW CA
COLLIMATOR SHIPMENT
SEQUENCE OF EVENTS
On September 6, 1995, personnel of "C" Battery, 1st Battalion, 12th
Marines attempted to set up a collimator as part of an
inspection/instrument check. Due to faulty tripod legs, the collimator
fell over onto the source end.
When the troops righted the collimator it was noted that the lens
appeared cracked. The collimator was immediately taken to the 1 st
Battalion, 12th Marines Ordinance shop (located in the same building).
The Master Sergeant (MSGT) looked at the collimator and agreed that the
lens had been broken. The MSGT instructed the troops to double bag the
collimator and transport it to the Combat Service Support Group (CSSG-3)
optical maintenance shop. The collimator was delivered to the optical
shop at CSSG-3 on the same day as the incident (6 Sep 95).
The Staff Sergeant (SSGT) in charge of the optical shop received the
collimator, noted the broken condition, and placed the collimator on the
floor adjacent to his desk. A Request For Disposition (RFD) was written,
and sent off on 12 October 95, to Albany, GA. for disposition
instructions. The answer to the RFD was received by the optical shop on
30 Oct 95, instructing the optical shop to ship the collimator to Marine
Corps Logistics Base, (MCLB) Barstow, CA. After receiving the RFD answer
the collimator was transported (7 November 1995) to the
shipping/receiving office for packaging and shipment to MCLB, Barstow.
After receipt of the collimator at the shipping and receiving docks, the
collimator was boxed and delivered to the base post office for delivery
to Barstow CA.
PROBLEMS WITH THE PROCESS
Upon noting the broken lens on the collimator, no safety personnel were
informed. Even after taken to the MSGT at 1st Battalion, 12th Marines,
no safety personnel were made aware of the incident. No wipe surveys
were conducted of the area, and no evaluation of the potential for
internal exposure during the spill.
The optical shop was not is not set up to work radiological components.
No posting exists in the area, nor any of the required posted documents.
This was corrected during the visit. Upon questioning the optical shop
personnel, it was learned that no precautions were taken when working on
tritium containing components such as covering area with paper and
wearing gloves. This too has been corrected. It was also noted that
collimator purging is done inside that optical shop (an enclosed area).
Wipe surveys have been conducted in the optical shop. Wipe tests of the
optical and shipping area have been analyzed and found to be within
acceptable limits.
Encl 1/Page 1 of 2
The collimator sat in the optical shop, on the floor adjacent to the
SSGT's desk, without controls and without surveys for at least 9 weeks.
During that time the collimator would have been gassing-off through the
double plastic bags. By the time the collimator was transferred to the
shipping and receiving docks, the outside of the double bags may have
been contaminated to some unknown level. This possibility would have, at
the least, contributed to the eventual external contamination discovered
upon receipt at MCLB, Barstow, CA.
No contamination testing was performed prior to transferring the
collimator to the shipping docks or after it was received at the shipping
docks. Likewise, no contamination testing was performed after packaging
or prior to delivery to the Post office. The shipping area lacked any
posting and did not have any of the required documents posted in the
area.
KANEOHE SAFETY OFFICE CONDITIONS
Prior to this incident the safety office at Marine Corps Base Hawaii
(MCBH) was not set up to perform appropriate radiological oversight of
their radiological commodities. Efforts are being made to correct the
long standing situation. As a result of this incident and the attention
given to the situation by the ACALA Safety Office much is being
accomplished. Two safety office people have completed the 40 hour CECOM
Radiation Protection Training course. A Radiation Protection Officer
(RPO), and an Assistant RPO have been appointed and trained, and a
Standard Operating Procedure (SOP) is being written.
A meeting was held the afternoon of 17 Jan 95, the findings and their
implications were discussed, and a list of corrective actions were
established with mile-stones, responsible parties, and assigned
completion dates. These efforts are only a beginning, and much work
remains. A positive attitude exists within the safety office, with a
good group of people to work though all the details.
The RPO is in contact with the RPO for the Army, at Wheeler Army Air
Field. The Wheeler Army Air Field RPO has an exemplary Radiation
Protection Program and has agreed to assist the Kaneohe Marine Base RPO
in getting his program up and running.
CONCLUSIONS
Our office will be in frequent phone contact with the Kaneohe RPO. We
are setting up an audit/inspection team visit to the Kaneohe Marine Corps
Base for April of this year. Also a letter is being written to Marine
Corps Headquarters to apprise them of this situation. We are requesting
they report the status of Radiation Protection Programs Marine Corps wide
to the ACALA Safety Office. ACALA visits to selected Marine Corps Bases
will be scheduled as needed base on the results.
Encl /Page 2 of 2
KANEOHE/BARSTOW INCIDENT
Arrived at Barstow, MCLB about) 7:30, 10 JAN and proceeded to the MCLB
Safety Office. Met with Odis Gentry to discuss his involvement in the
DLA's situation. Mr Gentry took me out to the Yermo Annex to meet with
the DLA RPO and ARPO. Arrived at the storage facillity about 09:00 to
see the offending box/collimator. Dicussed the condition of the box and
the circumstances under which the box was received and subsequently
handled. Discussed possible actions to determine how the exerior of the
box could have become contaminated to the levels noted.
The box is in great condition, with no signs of having been mishandled in
shipment. Also noted that there were no markings on the box to indicate
it contained radioactive material. There was, however a "crayon" marking
on one side that indicated that it was part of a group of packages which
were sent to DRMO somewhere. A curious thing ... I'd like to here what
it is all about.
Looked at and discussed all the paper trails generated at Barstow since
arrival. Mr. Haeveth has kept a great record of what's been done since
DLA received the box. All of Mr. Harvaths action were and continue to
be in accord with regulations. The box is being kept in a controlled
area, and has been double bagged.
As a means to to test a theory, I suggested Mr. Harvath and Mr. Smith
remove the collimator and rebox it in a new box of the same dementions as
the original. They will use all the original packing, and establish, as
close as possiible, the condition of the double bags on the colimator,
and then place it on a shelf and wipe the external of the box
periodically to see if and to what extent the tritium migrates to the
outside of the box. The original box was in transient at least 5 weeks,
therefore this test will run for 5 weeks to see if contamination to the
same level can be generated by a leakinf 10 curie source.
REPORT FOR THE RECORD
TO: Sandy Steck
FROM: Dale Harvath
SUBJECT: Possible radiation contamination to personnel
DATE: 26 DEC 1995
REFERENCES:
1. Material movement sheet dated 19 Dec 1995.
(Attachment 1)
2. Copy of DD Form 1348-1.
(Attachment 2)
3. Copy of Tritium wipe test results.
(Attachment 3)
Upon returning to work 26 Dec 1995, I discovered a M1A1 Collimator, NSN
1240-00-332-1780, Document Number M133105284E720, qty 1 ea., in the
radioactive receiving area of Bldg. 401. See attachment 2. I asked
Chris Garcia when the item came in. He provided me with the material
movement sheet dated 19 Dec 1995. See attachment 1. Due to the
radioisotope, activity level, and the length of time that this item was
in the radioactive receiving area all being above the maximum allowable
limits, I transported this item to Bldg. 430, radioactive storage. I
then did an external and internal wipe test to check for contamination of
the carton and took them to Cal Lab. Cal Lab completed a Scintillation
test and Alex Guzza from Cal Lab notified me that this item was in excess
of the permissible maximum disintegrations per minute allowed for any
exterior surface. See attachment 3. He advised me to contact Base
Safety Office, Odis Gentry. Odis asked me to come by his office with all
pertinent documentation.
I also contacted my immediate supervisor, Sandy Steck. Sandy told me to
come to her office to try to get this problem straightened out with Ben
Fields, Warehouse 7 receiving supervisor; since it was his people who did
the initial receiving of this item. Mr. Fields stated that all
radioactive items were to sent to Bldg. 401, radioactive receiving area.
He claimed that he had never been told about the one half curie limit for
non-radioactive personnel to handle. He also claimed he was unaware that
any activity level equal to or greater than one half curie was not to be
worked or handled, but that the RPO office was to be immediately notified
instead. As a result of these claims we discussed that reinforced
training will be made available to all receiving personnel that could
possibly come in contact with radioactive items.
I discussed with Sandy Steck the possible contamination to Amalie
Johnson, of Bldg. 401, who received this item in Bldg. 401 from personnel
from Warehouse 7. See attachment 1. Sandy Steck deferred judgment to
the Base Safety Office, Odis Gentry, for guidance. Mr. Gentry's
decision was for Ms. Johnson to
complete a one time bio-assay when she returns from leave, She is
expected to return the 28 or 29 of Dec 1995 according to Chris Garcia,
Work Leader, Bldg. 401. Mr. Gentry will have the necessary forms for
Ms. Johnson to take to the Medical Clinic.
I will be in touch with Jim Reese, RSO Region, in the morning, 27 Dec
1995, for guidance. I will also contact Mr. Gentry to maintain
continuity between the Marine Corps and DLA. A complete report will
follow upon completion of investigation of this matter and will be
forwarded to Sandy Steck.
DALE HARVATH
Alt. Local Radiation Protection Officer
December 28, 1995
Received fax from Jim Reese dated 28 Dec. 1995, subject items to
consider during contamination investigation. Following days will cover
items contained in the fax.
Took nine wipe tests. See tab second wipe test delivered to Cal
lab. No one available to run scintillation tests. Some one will be in
tomorrow.
Reviewed radiation health manual, 49CFR and 10 CFR. Discussed with
Odis Gentry, BSO, for any SOPS covering this incident.
Received written statements from three employees: Terry White, Chris
Garcia, and Carl Dawson.
December 29, 1995
Received fax from Jim Reese, DDRW RSO, concerning information
regarding ACALA license. I reviewed fax.
Discussed with Odis Gentry, BSO, decontamination procedures, and
requested his presence, since he is the leading RSO on the base, to
confirm that I was doing it correctly.
First decontamination process of vehicle used to transport
contaminated item was completed by Odis Gentry and myself in
approximately two hours. I then took a wipe test. See tab decon swipe
test reference M13310-5284-E720 1st decon of #9. Even though the levels
were greatly reduced since non-radiation workers use this vehicle, it was
unacceptable.
Second decontamination process of vehicle used to transport
contaminated item was complete by myself in approximately another two
hours. I took a swipe test. See tab decon swipe test reference M13310-
5284-E720 2nd decon of #9. Levels were acceptable. ALARA has been
achieved.
Odis Gentry stopped by with swipe test results taken from the Post
Office where they showed him the box was thought to have been staged. He
had taken a single wipe test and it came back at below background levels.
I have no personal knowledge to the accuracy of this test.
January 2, 1996
Called Phil Smith at home and told him to stop by the office before
going to Sandy Steck's office because Phil was on leave the week prior.
When Phil came in I notified him of incident.
Went to see Mr. Conwell Tubbs, OPS Branch Chief, and notified him of
the incident because he was on leave the week prior.
Notified Robert Castillio, receiving supervisor Bldg. 401 of
incident, because he was on leave the week prior.
Reviewed with Phil all documents and discussed procedures used and
processes in place about the incident. Phil agrees, with one
recommendation, which is for photos to be taken.
Phil and I meet with Sandy Steck to review incident and how the
matter is being handled to date.
Since Odis Gentry from BSO left it up to me to decide who requires
bioassay and to cover all bases of personnel who came in contact, the
following people are scheduled for bio-assay: Dale Harvath, Amalie
Johnson, Steve Broughton, and Lamont Pease. Odis left blank UA sample
forms with his signature on them for me to use.
Had meeting Phil Smith, Conwell Tubbs, Ben Fields, and myself.
Discussed receiving procedures and (illegible) as follows:
1. At the time a receiving clerk discovers a radioactive item in a non-
multi pack, they are not to open it, but are to immediately call the RPO
office for pick up.
2. If a radioactive item is discovered in a multi pack they are to stop
and immediately call the RPO office for pick up.
3. If a radioactive item is discovered and it is above the .5 curie
level they are not to touch the container, but are to immediately call
the RPO office for wipe test and pick up.
4. If a radioactive item is discovered in a multi pack and is above the
.5 curie level they are to stop all work on the multi pack, to include
non-radioacitve items and immediately call the RPO office for wipe test
and pick up.
5. All suspected NSN's will be varified by the receiving clerk against
radioactive materials list provided by the RPO office.
Received written statement from employee Richard Ferrell.
January 3, 1996
Received phone call from Tim Mohs, the Army License Manager, in
response to my phone call to his office on 29 Dec, 1995, that I made at
the direction of Jim Reese, DDRW RSO Fax dated 28 Dec. 1995 to explain
the contamination incident.
Phoned photo lab to schedule pictures to be taken of contaminated
box for 4 Jan. 1996 at 8:00 a.m.
Prepared shipping papers and UA containers for bio-assays for the
following people: Dale Harvath, Amalie Johnson, Steve Broughton, and
Lamont Pease.
Amalie Johnson will not be in to work until after lunch, and Lamont
Pease will not be here tomorrow. Needs to be done today!
Steve Broughton comes to Bldg. 401. He is unwilling to cooperate
with UA testing. He claimed mistrust in results, and would prefer to use
his private physician in case there is any settlement money involved.
Phil and I explained to Steve that it not the Marine Corps who does the
test, but it is the Air Force. We explained the only reason we need the
LA sample is to confirm that there was no contamination to him, and that
we have no input to the report sent back. We also told him that he would
he would be provided a copy of the results, and that if he still declined
our request for the UA to please put it in writing with a signature and
date. He decided to consent to the UA, and provided us with a sample.
Steve also expressed health concerns from this possible over-exposure.
Phil discussed his health concerns until Steve seemed satisfied that
everything should be OK.
I went to Amalie Johnson to ask for a UA. She consented. I
notified her that if a catch basin was necessary, that she could go to
the med clinic and see Sam (industrial hygienist), who I made sure had
one available for her use necessary. Amalie declined the use of a catch
basin and provided a UA sample in Bldg. 401. She also expressed some
health concerns. I referred her to Phil Smith.
I, Dale Harvath, provided a UA sample for bio-assay.
I phoned warehouse 7 to see if Lamont Pease was available for UA.
Ben Fields, his supervisor, answered and stated he was out unloading a
truck. I discussed with Mr. Fields the possibility of coming over to get
a LA sample from Lamont. He stated, "Lots of Luck". I went in and
talked to Phil about the attitude and asked him to accompany me to
warehouse 7. We met with Lamont and he wanted his health concerns
addressed first. Phil and I responded to his questions. He provided the
UA sample.
January 4, 1996
Scheduled to meet Base Photographer at 8:00 a.m. Prepared placard
for pictures. Met with photographer and she took pictures of exterior of
the contaminated box. Removed collimator from box and took pictures of
the double bagging, the holes in the bags, and the yellow card attached
to the collimator. Removed packing peanuts from contaminated box for
placement in dry activated waste. Returned collimator to box and double
bagged box.
Received phone call from Rich Johnson from BSO (Odis Gentry's
supervisor). Since Odis was off on leave, Rich needed to be briefed on
the incident.
Received second phone call from Rich Johnson. He wanted to know if
Odis or I had contacted MCBH, Hawaii. I told him that I had not, and I
did not know if Odis had. Rich stated Tim Mohs was trying to contact
MCBH, Hawaii, and had contacted the NRC for clarification as to whether
or not it was a reportable incident.
Had a phone message to call Tim Mohs. I returned his call and got a
recording.
Received phone call from Tim Mohs. He stated that it did not meet
the requirements for NRC notification. He also asked for information
from the DD Form 1348-1. He also requested information concerning the
condition, the marking, and the labeling of the contaminated box, and how
it was shipped. He also wanted to know if the bio-assays had been taken.
I gave him the information from the 1348-1. 1 told him there was no
damage to the contaminated box, and there was no type of marking or
labeling on the exterior of the box that indicated that is was a
radioactive shipment. I also told him that the bio-assays were completed
on Jan. 3, 1996.
January 5, 1996
Today Phil Smith, RPO, and I, Dale Harvath, went to Bldg. 430 to do
a wipe test on the interior of the collimator. We opened the exterior
box and removed the collimator from the box. We removed double plastic
bag from the collimator and opened the view port adjacent to the ten
curie tritium source. We could see underneath the protective lens that
the interior lens was broken and in pieces. Phil did a wipe test of the
collimator on and around the lens and source retainer. I took the wipe
test to Cal lab while Phil stayed at Bldg. 430 to allow air to ventilate
the collimator. I came back from Cal lab a few minutes later because no
one in Cal lab was there to do the liquid Scintillation test. While I
was gone Phil had moved the collimator outside onto a piece of plastic to
air out. Since no one was at Cal lab, we decided to put the collimator
back in Bldg. 430 on a piece of plastic to allow it to air there until
the next day. I exited and locked the back door, Phil walked to the
front and locked it. By the time I had reached the front end of the
Bldg. the tritium air monitor alarm was sounding. Phil opened up the
front door, I opened up the back door. We backed away from the area to
let the Bldg. air out. We could see the air monitor was reading
approximately 7 micro curies per cubic meter. The normal rate for this
Bldg. is about 1.3 micro curies per cubic meter. The alarm tolerance is
set at 5 micro curies per cubic meter. When it reached the nominal range
we entered the Bldg., reset the alarm. We bagged the collimator, put it
back into the contaminated box, and double bagged the box. We then
closed Bldg. 430, waited for a few minutes to see it the alarm sounded
again, since it did not, we left that Bldg. for the day.
We received a phone call from LT. Moore from Hawaii. He stated
that it was the 1st Bn. 12th Marines who shipped the collimator to
Maintenance Co., CSSG three third FSSG MCBH, Hawaii. They could not
repair the collimator. They forwarded it to a civilian contractor who
handles shipments for them. The name of this company was PEMCO. Lt.
Moore asked our advice as to what to do, since he was not familiar with
the isotope tritium. We suggested he possibly contact the sub-base RSO
to help him with this. We advised he might also want to investigate all
possible areas that this collimator had been, and learn if any person had
come into direct contact with the collimator. If anyone had, they might
want to consider a bio-assay. Lt. Moore expressed concern for the
upcoming visit with Tim Mohs. He expressed appreciation for the
information and for our help, and stated he would keep in contact with
us.
A phone call from Tim Mohs indicated that he had further
investigated this incident, and it was necessary to report it to the NRC
I.A.W. 10 CFR 1906 (d)(1), and had already done so. He also notified us
that he was coming to MCLB, Barstow on his way to MCBH, Hawaii on the
10th and 11th of January, 1996.
January 27, 1995
Contacted Jim Reese, DDRW RSO, and notified him of incident. Gave
his requested information about the contaminated item. He asked me if
the base safety office had been contacted, which it had. He also asked
if Odis from the BSO or I had contacted the License Manager (Betty
Peterson) or Tim Mohs. I told him, "No, I had not," that Odis and I
agreed that only one voice would be needed so that we did not have
interpretation problems. Note: Hope they call back soon, Odis is going
on leave Friday.
Sandy Steck requests point paper prepared for Mr. Pinson. Have
meeting scheduled with him at 1:00.
Meet with Mr. Pinson (Deputy Director) and Sandy Steck in Mr.
Pinson's office. Notify Mr. Pinson of incident. He reviews point
paper, and asks about health ramifications. I inform him biological half
life is approximately 12.5 days. He likes content of point paper (but
sends it back for smoothing).
On our way back from warehouse 7 Phil and I stopped by Bldg. 402,
Packing and Preservation. George Palmer was unavailable to receive UA
samples. They were given to Joe Trad, supervisor of P and P branch, for
preparation for fed-ex shipment.
Received three employee statements: Amalie Johnson, Steve Broughton,
and Lamont Pease.
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