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|  Radiological Assessor Training
DOE-HDBK-1141-2001
Instructor's Guide
Show OT 16.6.
There was a portable fan temporarily positioned to
cool employees just north of the 5 West autoclave
control panel, inside the Contamination Zone. The
fan had only been in place a few weeks. It was
operating during the shift in question. Apparently no
one had questioned the use of this fan in the area
prior to the event. Circumstantial evidence places
one operator exiting from either the 4 West or 5
West autoclave in the path of this fan while trying to
remove a pigtail gasket. The area of highest surface
contamination was spread along a line from the fan
(located by 5 West autoclave), past the 4 West
autoclave to the 3 West autoclave control panel in
the direction that the fan blows.
Self-monitoring performed by the employees upon
exiting the Contamination Zone where the job was
performed was inadequate, in that the employees
did not recognize the contamination present on their
skin and/or clothing. The employees performed
their other duties during the remainder of the shift,
thereby spreading this contamination to both
radiological and nonradiological areas. This spread
of contamination to nonradiological areas through
failure to recognize personal contamination at exit
monitoring stations caused other personnel to
become contaminated when the shift change at
0700 on August 23, 1991, brought new personnel
into these areas.
Based on the interview with Employee No. 1, the
employee traveled to C-337 around 0400 for a
break. Upon exiting the vaporizer Contamination
Zone and going to the C-337-A Operation's
Monitoring Room, the Bicron frisker was indicating
high but not alarming due to high ambient
background radiation levels. The employee reset
the monitor and remonitored. The employee
indicated that the reading was elevated, but was not
alarmed this time. The employee stated this was
normal since the background in that area is often
high.
Module 16 7
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