# Presentation: 230209

## Lessons Learned 

*Z-Machine Beryllium Investigation*
*Veronica P. Martinez*
*Facility Representative, Sandia Site Office*
*2004*

## Slide 2

##     What is beryllium ?

-     What are the health affects of beryllium ?

-     How is beryllium used at Z-Machine?

-     What happened at Z-Machine ?

- Lessons Learned & ISM

**Notes:**
Before we start to discuss the Z-machine incident, it is important to get a general understanding of beryllium and the health affects of beryllium.

## What is beryllium ?

- What is beryllium ?
- Beryllium (Symbol Be, Atomic Number 4)
**	**

- A naturally occurring, silver-gray metal that has:
-  low density (only 1/3 as heavy as aluminum)
- 	high melting point (1285 C)
- 	good mechanical properties:
- 		high permeability to x-rays, corrosion resistance,       	hardness, strength, high electrical and thermal 	conductivity, and fatigue.

## The DOE Beryllium Rule (10 CFR 850) defines beryllium as:

- elemental beryllium and any insoluble beryllium compound or alloy containing 0.1 percent beryllium or greater _that may be released as an airborne particulate_.  (10CFR850.3)

## Beryllium-copper (BeCu) alloys - 

- Beryllium-copper (BeCu) alloys -
- usually contain about 2 percent beryllium, but vary greatly in composition to meet different industrial and consumer needs.  For example, BeCu springs “bounce back” to their original shape again and again.

## Beryllium-copper (BeCu) alloys are used for:

- Springs, switches, relays and connectors in automobiles, computers, radar and telecommunications equipment.
- High Strength nonsparking tools
- Molds or casts to make metal, glass and plastic items
- Sports equipment such as golf clubs and bicycle frames
- Dental bridges and related applications.

## What are the health affects of beryllium ?

- This illness is **chronic beryllium disease** or CBD, an incureable and sometimes fatal scarring of the lungs.

- What are the health affects of beryllium ?

## How Beryllium Enters Your Body – 

- Routes of Entry
**	****	**Breathing/inhalation
- 		Swallowing/ingestion
- 		Skin wounds
- 		Skin Contact

**disease**

**Notes:**
Sensitization means...
Doctors use the beryllium lymphocyte proliferation test (BeLPT) to diagnose beryllium sensitization in people with no symptoms of illness. 

## As Beryllium Enters Your Body – 

**Be**

- The T-Cell reacts !
- This type of cell can sense when harmful foreign substances have entered the body.

**Notes:**

The T- cell react to it– Tcells have thin cellular walls, little cytoplasm, large nucleus filled with software.
Instruct the autoimmune system to react.

## Be

**Be**

**Notes:**

Instruct the autoimmune system to react.
The Tcell wall sends a signal to the nucleus.  The T Cell sends out a signal to proliferate more T cells. A process associated with sensitization.  Another signal is sent out to generate another type of cell the Macrophage.

Nucleus recognizes Be as a harmful foreign substance.  

Macrophage.. Try to engulf foreign matter, encase it and then eject it of the body.
.  It is thought that cytoplasm within mycrophage cells  is damaging to lung tissue.

Lung tissue damage is CBD.

## What is Z-Machine?

- Z-Machine is a radially configured pulsed power accelerator consisting of 36 modules arranged radially around a central experiment vacuum chamber.
-   	located in a liquid filled tank that is 108 ft in   	diameter and 20 ft in height
-  	contains 540,000 gallons of transformer oil
-  	contains 600,000 gallons of deionized water
-   	vacuum chamber

## What is Z-Machine?

## How is beryllium used at Z-Machine ?

- Some targets have beryllium spokes (<50mg), in a wagon wheel configuration to aid in the transfer of power.  These targets are vaporized during a shot.

## What happened at Z-Machine ?

- A bridge crane, which had been released for reuse almost a year earlier, did not comply with all of the requirements of 10 CFR 850.

## Z-Machine Management had suspended all material leaving the facility until adequate controls were in place.  That next day, potentially beryllium contaminated laundry was picked up by a private laundry facility.

-  In January 2003, two vacuum pumps were removed from the facility and given to another organization.  In November 2003, the pumps were sent to a local vendor to be refurbished.  The pumps are potentially beryllium contaminated.

## In addition, SNL discovered beryllium contamination outside of the facilities designated operational areas.

- These events, all having potential beryllium contamination – prompted the Center 3100 Director to charter a Root Cause Analysis Team on January 8, 2004 to perform an investigation of the implementation of 10 CFR 850 to Type B rigor.

## Direct Cause

**Contamination controls, material release controls and personnel exposure controls were not identified in the facility for areas where workers are routinely in the presence of Beryllium as part of their work activity.**

- The Site-Specific Chronic Beryllium Disease Prevention Program Implementation Plan, the baseline survey and the site-specific training identified the operational areas.  However no controls were implemented inside or at the boundaries of operational areas to prevent the spread of contamination.

## Root Cause

- The Site-Specific Chronic Be Disease Prevention Program Implementation Plan was inadequate to meet the requirements of 10 CFR 850.
- 	Z-Machine management did not implement the 	requirements from 10 CFR 850 that were 	included in the site specific CBDPP.
- 	The SNL customer support team supporting Z-	Machine did not provide adequate guidance and 	support with regards to the implementation of 	the requirements of 10 CFR 850.

## Housekeeping (850.30) Housekeeping surveys were not performed quarterly as required by the first CBDPP Plan.

- Release Criteria.  The process for evaluating removable contamination levels on equipment from the restricted areas was stopped when an informal release process was established in CY2003.
- Waste Disposal.  There was no process in place for managing Be waste in accordance with 10 CFR 850.

## Lessons Learned & ISM

**Identify Hazards** –

- What hazards do you have in your facility?  Have you (as an FR) identified all of your hazards? Do you understand all of your hazards?
- Sometimes, you enter a workspace and quickly identify the big main hazards (electrical safety, high voltage capacitors, LOTO), hoisting & rigging (20 ton crane), lasers(class IV lasers)) and you forget to look at the smaller hazards.  The amount of beryllium that Z-Machine uses was fairly small.  (<50mg).

## Lessons Learned & ISM

**Identify Hazards** –

- Sometimes, as an FR you are more comfortable providing oversight to a select few areas such as radiation protection, chemicals and lasers.  Your oversight may focus on these areas.  However there may be other hazards/areas that you are not knowledgeable about (beryllium, explosives). The FRs should be given time to become trained and knowledable on these other areas to provide adequate oversight.  Seek assistance if necessary.

## Lessons Learned & ISM

**Control Hazards –**

- Does each hazard have their own controls?  What are the engineering and administrative controls?  What regulations (10 CFR 850) and procedures (site specific CBDPP) apply?  Is their any conflicting information found in the procedures and what is seen on the job site.
- Review the procedures and then walk down the procedures to see how the operation works.
- Communicate with the staff.

## Lessons Learned & ISM

**Feedback & Improvements –**

- Is their any conflicting information found in the procedures and what is seen on the job site.
- Review the procedures and then walk down the procedures to see how the operation works.
- Try to observe work in progress using the procedures.
- Communicate with the staff. And ask lots of questions.

**Notes:**
The Beryllium training contained information designating the Beryllium operational areas however, there never was any posting or controls of these areas.  

## References:

-         SNL/NM Investigation of 10CFR 850  	Implementation in Building 983.  March 2004
-        	Z-Machine Operations Website
-  	Z-Machine Beryllium Training
- http://environmentalchemistry.com/yogi/periodic/Be.html#Regulatory

## The End

**Any Questions/ Comments or Suggestions?**