Description of occurrence (edited from investigation report) cont'd

Radiological Assessor Training

DOE-HDBK-1141-2001

Student's Guide

two locks and lockers used by Employee No. 1 (who

performed the pigtail changes on the previous shift)

were contaminated. This employee returned to work

at 1830 on August 23, 1991. Surveys of the locker

contents indicated contamination on company-

issued clothing worn the previous shift. The

employee was also found to have skin

contamination of 6500 dpm/100 cm2 on the arm,

4500 dpm/100 cm2 on the knee, and 2750 dpm/100

cm2 on each ankle.

A survey of the employee's coworker's (Employee

No. 2) locker revealed contaminated items (both

company-issued and personal). Personal surveys

conducted when Employee No. 2 returned to work

showed the presence of skin contamination of 4500

dpm/100 cm2 on hair, 5000 dpm/100 cm2 on neck,

and 40,000 and 15,000 dpm/100 cm2 on wrists.

Later (2130 hours on August 23 for Employee No. 2,

and 1900 hours on August 24 for Employee No. 1)

surveys were conducted at the employees' homes.

Monitoring of one employee's home found one

T-shirt and one pillowcase slightly contaminated. A

pair of shoes at the other employee's home was

found slightly contaminated. This employee's (No.

2) coveralls had already been sent to the laundry,

since it was not recognized they were contaminated.

After laundering, significant contamination was still

present (up to levels of 250,000 dpm/100 cm2 at

ankles, and lower levels at other places). A survey

of the laundry equipment did not indicate any

contamination.

Based on statements from the involved employees,

they utilized the required personal protective

clothing and equipment for the job at the time. The

autoclave area is designated as a Contamination

Zone. Anti-contamination clothing designated for

cylinder changes at the time of the incident

consisted of company-issued coveralls (blues),

gloves, and shoe scuffs. Operational procedures

require the use of a respirator when disconnecting

pigtails. Surveys conducted as part of this

investigation did not show any contamination on the

Module 16 - 3