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| Radiological Safety Training for Plutonium Facilities
DOEHDBK11452001
Handouts
Lessons Learned 1
Internal Doses Exceeding Regulatory Limit
On March 16, 2000, an airborne release of plutonium-238 occurred near a glovebox in
the Plutonium Processing and Handling Facility (TA-55) of the Los Alamos National
Laboratory (ALA-LA-LANL-TA55-2000-0009). The first indication of a release was when
the hand monitor on the glovebox being examined by an electrical technician alarmed.
Then a second hand monitor on the associated dropbox alarmed. Radiological Control
Technicians believed the alarms to be spurious and tried to reset them. A third hand
monitor on a nearby glovebox alarmed and almost simultaneously a continuous air monitor
(CAM) in a corner of the room alarmed. In less than a minute all four CAMs in the room
had alarmed. In addition, CAMs in two adjacent rooms alarmed. All personnel in the room
evacuated to the hallway.
On scene surveys of the eight affected workers revealed contamination on anti-
contamination clothing up to 140,000 dpm and skin contamination up to 20,000 dpm.
Decontamination of the workers was completed within 30 minutes. Nasal smears were
taken before decontamination and sent to the Health Physics Analytical Laboratory. Five of
the workers had positive smears and management decided to send all of them for medical
follow-up. The four workers with the highest results were offered chelation therapy to
accelerate removal of plutonium from their bodies and all signed consent forms.
Intravenous administration of diethylenetriaminepentaacetic acid (DTPA) was then
completed for each. Preliminary estimates of the committed effective dose equivalent
(CEDE) for the four most highly exposed workers gave 300 rem to the most highly exposed
worker and >5 rem for the other three.
The accident occurred when an electrical/mechanical technician attempted to determine
why the argon flow bubbler to the glovebox was not working. While he was examining the
piping under the glovebox, the monitors alarmed. It was subsequently found that a Teflon
gasket in the airlock had failed due to radiation degradation and the piping had not been
adequately secured at one of the fittings.
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