Lesson Learned Statement:Failure to implement radiological protection requirements and provide the quality controls necessary to protect workers involved in High Efficiency Particulate Air (HEPA) filter shredding operations or to take timely and appropriate corrective actions when deficiencies are noted, can result in a Price Anderson Amendments Act (PAAA) Preliminary Notice of Violation (PNOV).Discussion:On March 9, 1998, the DOE Office of Enforcement and Investigation issued a Preliminary Notice of Violation (PNOV) under the Price-Anderson Amendments Act (PAAA) to Lawrence Livermore National Laboratory (LLNL) for multiple failures to implement radiological protection requirements and provide the quality controls necessary to protect workers involved in High Efficiency Particulate Air (HEPA) filter shredding operations. On July 2, 1997, five workers received curium intakes and spread contamination in a laboratory room when they shredded a HEPA filter. The HEPA filter contained approximately 100 mCi of curium, which exceeded the operational safety procedure permissible radiological activity limit of 1 mCi per 7.5 cubic feet by more than 500 times. LLNL personnel estimated that one worker received a whole body dose of 15 to 30 rem committed effective dose equivalent and 250 to 500 rem committed dose equivalent to his bone surface. This was at least three times the 5-rem annual limit for the whole body and five times the 50-rem annual limit to the bone surface. The notice also addressed ineffective corrective actions in response to a November 1996 LLNL report that identified significant and potentially widespread problems with workers not following operational safety procedures. Investigators determined that multiple failures occurred in the use of equipment and tools for the shredding process and during work performance. They determined that waste characterization data was available for the shredded HEPA filter, but it was incorrectly identified on the HEPA-filter waste storage box label and on the radioactive waste disposal requisition form. They also determined that no one confirmed the label accuracy or performed radiological surveys or additional characterization of the HEPA filter before it was shredded. On the day of the event, operators opened the HEPA filter box, removed the protective plastic from the filter, roughed-up the filter edges using a hand-held electric reciprocating saw, and shredded the filter. Investigators determined that no one performed radiological surveys or swipes to assess filter contamination levels after removing the filter plastic. They also determined that someone had turned off the room's continuous air monitor alarm, and no warning was available when airborne contamination in the room reached high levels. In addition, investigators determined that facility personnel modified the shredder ventilation system without following the required review and approval process.Analysis:N/ARecommended Actions:In August 1997, DOE issued DOE/OAK-540, Rev. 0, "Type B Accident Investigation Board Report of the July 2, 1997 Curium Intake by Shredder Operator at Building 513 Lawrence Livermore National Laboratory, Livermore, California." This report concluded that (1) Hazardous Waste Management failed to properly analyze hazards for shredding waste and establish appropriate procedures or controls for defense in depth, (2) supervision and management failed to provide adequate oversight to ensure procedural compliance, (3) Hazardous Waste Management failed to accurately characterize waste, and (4) Lawrence Livermore management failed to adequately disseminate waste characterization and hazard knowledge between organizations. These conclusions led to the development of several judgments of need. Following are some of the judgments of need. (a) Hazardous Waste Management should establish procedures to ensure that appropriate analyses are performed and reviewed before beginning work and should ensure that operations are completely analyzed and controlled. (b) Hazardous Waste Management should improve compliance enforcement through existing procedures; increase management involvement in operations assessments; and ensure personnel are trained in procedures, safety equipment, and alarm usage. (c) LLNL management should evaluate waste characterization program effectiveness, identify errors, and determine corrective actions where appropriate. (d) LLNL management should develop and implement mechanisms to share waste characterization and hazard data.Originator:DOE Operating Experience Weekly Report 98-11Validator:N/AContact:N/AName Of Authorized Derivative Classifier:N/AName Of Reviewing Official:N/APriority Descriptor:Blue / InformationKeywords:RADIATION PROTECTION, ALARA, ENFORCEMENT, PRICE-ANDERSON ACTReferences:NTS Report NTS-SAN--LLNL-LLNL-1997-0001 ORPS Report SAN--LLNL-LLNL-1997-0038 DOE OE Weekly Summary 98-11 http://tis-hq.eh.doe.gov:80/web/oeaf/oe_weekly/oe_weekly_98/oe98-11.htmlInformation in this report is accurate to the best of our knowledge. As means of measuring the effectiveness of this report please use the "Comment" link at the bottom of this page to notify the Lessons Learned Web Site Administrator of any action taken as a result of this report or of any technical inaccuracies you find. Your feedback is important and appreciated. DOE Function / Work Categories:Radiation ProtectionISM Category:Hazard:Radiological Release
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