ABQjournal: DOE Slams Lab Report on 2001 Accident

Wednesday, March 26, 2003

DOE Slams Lab Report on 2001 Accident

By Adam Rankin
Journal Staff Writer
    A review by the Department of Energy Inspector General found that Los Alamos National Laboratory failed to accurately and fully report on a glove box accident at its nuclear materials facility in 2001 and did not report that two workers were contaminated as a result.
    The report, released on Tuesday, concluded the accident was partially the result of a failure to follow procedures for safely handling plutonium-238 and chastised LANL for not considering the violations in its own review of the accident.
    LANL spokesman Jim Danneskiold said the lab disagrees that its reporting system — called occurrence reports — failed to analyze the accident properly.
    "The analysis did not find significant procedural violations in this incident," he said.
    All the occurrence reports are done openly, with input solicited from everyone involved, and LANL's report on the accident, which is accessible online, includes the best available information on the root cause and lessons learned, Danneskiold said.
    He also said all LANL occurrence reports are approved by the DOE.
    The Department of Energy's Office of the Inspector General investigated the accident because an anonymous complaint following the accident alleged LANL nuclear materials managers were engaged in "factual distortion, spin doctoring and deliberate concealment of (Radiological Incident Report) events within the (Technical Area-55) facility."
    TA-55 is the LANL facility that handles plutonium research, which includes building plutonium triggers for nuclear weapons.
    The accident happened on Feb. 15, 2001. Plutonium-238, which gives off heat, was released into the air from a glove box when the hot nuclear material caused a crack in a technician's uninsulated glove, according to the IG report.
    When a monitoring device detected the leak, the lead technician attempted to reset the device with his contaminated hand, but could not reach the button. After picking up a notebook with the contaminated hand, the technician reset the monitoring device and passed the notebook to a team member, thereby contaminating him as well, according to the report.
    "(LANL's) occurrence report did not accurately or completely describe the cause of the airborne release," the IG's report states. "It did not mention the deviations from the (plutonium-238) handling procedures, the cause of the glove failure, or the subsequent spread of radioactive contamination by the lead technician."
    The IG discovered through interviews with LANL managers that the technicians should have been using tools to manipulate the plutonium because its high temperature degrades the gloves.
    LANL reported the cause was an "Equipment/Material Problem, Defective or Failed Part," without mentioning the failure to use tools, according to the IG report.
    The IG report also said the cause of the contamination spread — the lead technician removing his hands from the glove box — was also only learned through its interviews and was not mentioned in the lab's report.
    Bill Parras, a former occurrence report analyst at LANL, said he was shocked the DOE IG would investigate the issue, because he felt at times DOE was part of the problem by looking the other way when contamination incidents occurred.
    Parras, who is now court administrator for the First District Court in Santa Fe, said he was laid off in a reduction in force in 1995 because of his reluctance to change incident reports to downplay the seriousness of accidents.
    "I found management looking the other way a lot," he said. "There were a lot of glove box leak incidents and people who were not trained well to use a glove box."
    He said LANL managers would try to downplay or not even report when people were contaminated.
    "In my experience, from having worked in the middle of all that at TA-55, they hit the bullseye in terms of accuracy," he said about the IG report.
    Danneskiold said a lab review found the glove box incident was handled well by staff, who managed to evacuate everyone in the room at the time even before alarms sounded. He said all employees in the room at that time have undergone special bioassay follow-ups.