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Executive Summary

EVALUATION: Office of Oversight

InvestigationóPhase II

SITE: Paducah Gaseous Diffusion

Plant

DATES: October-November 1999

Background/Scope

In August 1999, in response to environment,

safety, and health (ES&H) allegations and

subsequent worker and public concerns, the

Secretary of Energy initiated an independent

investigation at the Paducah Gaseous Diffusion

Plant (PGDP or Plant). These ES&H allegations

and concerns included inadequate controls for

workers exposed to uranium and transuranic

elements, ineffective communication of hazards

and radiation exposures to workers, and improper

release, dumping, or burial of radioactive and other

hazardous materials at unapproved onsite and

offsite locations. This investigation was divided

into two phases: first, to provide timely information

on the status of current operations, and second,

to perform a more lengthy investigation of

historical operations.

The first phase of the investigation

concentrated on the period 1990 to the present

and included the current facilities, areas,

operations, and activities that are the responsibility

of the Department of Energy (DOE) and its

current management and integrating contractor.

Operations controlled by the United States

Enrichment Corporation (USEC) were not

evaluated. A report was published in October

1999. Immediate actions were initiated to address

issues regarding inadequate posting (i.e.,

identification) of radiological hazards both on and

off DOE property. More detailed, comprehensive,

and long-term corrective action plans are currently

being developed to address the more complex

ES&H program weaknesses identified in the

Phase I investigation.

The second phase of this investigation

addressed historical conditions and activities from

startup of the Plant in 1952 until 1990. In his

testimony to Congress prior to the start of this

Phase II investigation, Dr. David Michaels,

Assistant Secretary for Environment, Safety and

Health, stated, ìWe need to determine how well

the workers knew of and understood the hazards

they were working with, and how well they were

protected from these hazards ñ even in very small

amounts. We will learn much more as our

investigation moves ahead and seeks to confirm ñ

in todayís regulatory environment ñ whether the

presence of these materials represented a potential

health risk at Paducah or any other DOE plant.î

The Phase II investigation focused on:

ï Identifying the concerns and questions of

current and former workers and their level of

understanding of site hazards and ES&H

practices

ï Understanding the operations, activities,

conditions, and hazards in the workplace

ï Identifying the management practices and

controls employed and the applicable

standards and regulations

ï Determining where management practices and

controls may not have been effective in

protecting workers, the public, or the

environment.

A vast amount of information was collected

and analyzed to accomplish these objectives. To

better understand the various site operations and

conditions, the investigation team interviewed

hundreds of current and former workers and

managers, reviewed thousands of historical records

and documents, toured workplaces, and performed

limited walk-over surveys of possible disposal

sites. The team examined dozens of events, about

40 separate major operations and activities, and

related ES&H practices.

The intent of this investigation was to identify

and address the overall ES&H concerns and

questions of current and former workers and the

public, not to determine the validity of specific
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allegations. Several ongoing or proposed initiatives of

the DOE Office of Environment, Safety and Health

should provide greater understanding of certain aspects

of these issues:

ï The mass balance project will recreate the historical

flow of recycled uranium and its contaminants

across the DOE complex.

ï The medical surveillance project will determine the

presence and prevalence of adverse worker health

effects from employment at gaseous diffusion plants.

ï The exposure assessment project will determine how

workers at the gaseous diffusion plants were exposed

to radiation, to how much, and from what source.

Determining any long-term effects on employee

health from working conditions and management

practices at the PGDP will require study that is beyond

the scope and resources of this investigation. Similarly,

detailed examination of any work that PGDP might

have performed for others in relation to weapons

systems as well as the effectiveness of any associated

ES&H practices was not part of the investigation.

Results

Certain external conditions and influences had a

significant effect on the ES&H-related behavior and

intentions of both management and workers at the

PGDP during the 1952-1990 period. When the PGDP

started operation, World War II had recently ended,

the country was involved in a major conflict in Korea,

and the Cold War was a reality. Many of the workers

were military veterans. The work being done was

classified, involved high technology, and was important

to the national defense. The ìneed to knowî was an

ingrained security policy that had a major effect on

attitudes toward sensitive operations and materials at

the PGDP. The Plant was the biggest employer in the

region, paying wages significantly higher than previously

available in this rural farming area; people in Paducah

and the surrounding area wanted these jobs.

Management and the Atomic Energy Commission (AEC)

were under pressure to maximize production. Workers

in this environment were not inclined to ask many

questions. While most of the hundreds of workers

interviewed by the team indicated, in response to specific

questioning, that they were unafraid to ask questions

about safety and they had no fear of reprisals, a few

interviewees did express concerns about both. Further,

industries in the 1950s, including AEC facilities, were

largely self-regulated, and guidance and regulatory

requirements were minimal and evolving. Significant

industrial and environmental legislation that would focus

attention and actions toward greater protection of

workers and the environment was not enacted until the

1970s.

During the period 1952 to the early 1980s, oversight

by the governing Federal agenciesóAEC, the Energy

Research and Development Administration (ERDA),

and DOEówas primarily directed at cost, schedule,

and production, not ES&H. A March 1960 letter

revealed that AEC and contractor management,

including the PGDP Health Physics and Hygiene

Department, were aware of the potential hazards

presented by transuranic elements contained in the feed

material the Plant received from Hanford reactor tails

and the workersí lack of compliance with respiratory

protection measures. The document stated that 300

persons at Paducah ìshould be checked out,î but that

management was hesitant to study the issue intensively

for fear that the labor union would demand hazard pay.

Health and safety programs were always in place

and functioning at PGDP, with a strong emphasis on

industrial safety. Policies, procedures, and training were

provided that addressed hazards in the workplace and

specified recommended personnel protection and

controls. Safety meetings were frequent, and job hazard

analyses that described hazards and controls were soon

developed for most work activities. The Health Physics

and Hygiene Department, although minimally staffed

for most of the 38 years covered in this investigation,

was active in studying hazards and health effects,

analyzing air monitoring results, surveying work areas,

and recommending engineering and administrative

controls for identified hazards. Fixed and portable

ventilation and vacuum systems were installed in some

areas to control workersí exposure to radiation and

chemicals as well as the spread of contamination. Safety

glasses, gloves, and hearing protection were made

available to workers, and for certain work activities,

the company supplied coveralls, shoes, caps,

undergarments, and respiratory protection equipment.

By 1960, all personnel exposures to radiation were

monitored using film badges and, for targeted

workgroups, bioassay techniques, including scheduled

and event-driven urinalysis and lung counting. Workers

showing high uranium excretion rates were removed from

high exposure work. Workers who were excreting uranium

over threshold limits were put on a recall urinalysis program

until their excretion rates fell to baseline levels, usually

within hours or days. Exposures to fluorides were also

monitored through the urinalysis program.
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Radiological and chemical hazards and exposure

risks to personnel were much higher in certain work

locations and activities at the Plant than in others.

Significant external and internal exposure to concentrated

transuranics was possible in handling feed production

ash and in uranium, neptunium, and technetium recovery

operations. Feed plant operations presented high

exposures to airborne UO3, UF4, and to HF. Exposure

to airborne UF4,magnesium powder, uranium oxides,

and HF was possible in the metals plant. Maintenance

and modification activities involved potential airborne

and point source exposures to UF6, HF, UO2F2,

transuranics, and uranium daughter products in many

locations; these activities included bag house filter

changeouts, converter modification work, and

compressor and seal disassembly repair and replacement.

Workers performing decontamination and cleaning

operations in Building C-400 had significant exposures

to trichloroethene (TCE) in addition to radioactivity.

Although the intent to protect workers from hazards

was apparent, the protection programs were not always

conservative or consistent. Air emissions, liquid

effluents, and solid waste disposal were consistent with

practices in general industry and the DOE complex at

the time (e.g., dilution, burial, and burning) but resulted

in significant adverse impacts on the environment. The

following sections summarize the conditions, practices,

and consequences in key ES&H areas.

Radiological Protection

The risks and hazards of exposure to uranium and

transuranics were neither fully understood nor

appreciated. PGDP considered that intakes of uranium

were from soluble compounds and would be quickly

excreted through the kidneys. This assumption may

not have been accurate for all uranium compounds at

the Plant, particularly aerosols generated in the feed

plant and during maintenance operations such as

grinding, buffing, or welding. The comfort level of

PGDP technical staff regarding exposure to uranium is

reflected in a research experiment, conducted in the

late 1950s, where Health Physics and Hygiene staff

members voluntarily inhaled and ingested known

quantities of uranium compounds to measure excretion

rates. In addition, in 1956, test subjects at the Plant,

wearing different types of respirators, were exposed to

several known concentrations of airborne uranium

compounds to determine subsequent excretion rates.

External exposures were monitored using film

badges. However, extremity dosimetry was not

employed, even though requirements dating from the

late 1950s mandated that such monitoring be conducted

when the potential exposure could exceed 10 percent of

the extremity limit. Over the 38 years of operations, only

two exposures over regulatory limits were documented.

However, due to high concentrations and variable dose

rates in certain areas of the Plant, workers in these areas

may have received significant unmonitored exposures to

hands and feet during some operations. The concept of

keeping exposures as low as reasonably achievable

(ALARA) was, in various forms, AEC/ERDA/DOE policy.

However, PGDP policies and practices focused on

preventing personnel exposures from exceeding Federal

Radiation Protection Guidelines, rather than keeping them

as low as reasonably achievable.

Contamination controls at Paducah were limited,

even into the early 1980s. Eating, drinking, and smoking

in contaminated work areas was common practice.

Although personnel wearing company clothing typically

showered before changing into their personal clothes

and leaving the site, the practice was not mandatory,

and workers were not required to wash their hands and

other exposed skin, or remove contaminated clothing,

before entering cafeterias, break areas, and even the

main site meeting area in the C-100 ìRoxie theatre.î

Friskers and whole body monitors were not employed

until the mid-1980s. As a result, Plant workers probably

took radioactive contamination outside site boundaries.

As early as 1957, the site became aware of the

presence of transuranic elements (those with atomic

numbers higher than uranium) and fission products in

feed materials processed from spent reactor fuel at the

Hanford and Savannah River Sites. Transuranics and

fission products have a much higher specific activity

than uranium and resulted in much higher dose to some

workers. These materials were a concern where they

were concentrated, such as in the ìheelsî remaining in

empty UF6

 cylinders and in the uranium, technetium,

and neptunium recovery processes, or where there was

airborne exposure such as reactor tails feed material

ash in the feed plant, metals production, and

maintenance/modification activities. However, the

presence of these materials, the increased risks involved,

and the rationale for additional controls were not shared

with workers. Workersí incomplete awareness of these

hazards contributed to and fostered inconsistent

compliance with recommended protective measures.

Initial comprehensive operations training programs,

which included radiation theory and control, quickly

declined in scope and frequency as resources and

attention focused on production. Information

concerning workplace radiation and chemical hazards

and protective measures was subsequently
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communicated primarily through informal on-the-job

training, passed from experienced workers to new ones.

Although exposure history information was collected

from monitoring film badges, bioassays, and lung counts,

it was not openly communicated, nor was its meaning

explained to workers unless requested.

The Health Physics and Hygiene Department

provided monitoring, investigation of elevated intakes

and air samples, and recommendations for radiological

controls. However, line management had ultimate

responsibility for implementing radiation protection

measures. In many cases, recommendations for

controls or improved protection were the result of high

exposures or sample readings, rather than conservative,

proactive planning. Workersí compliance with

recommended controls (engineering, procedural, and

personal protective equipment or PPE) and

managementís enforcement of compliance were

inconsistent. In many areas, individual workers or

supervisors decided whether recommended PPE would

be used, and early masks and respirators did not fit

well, hindering vision in work environments. The

inconsistent use of respirators was especially important

because they were heavily relied on to minimize

workersí inhalation of radioactive materials.

Chemical Hazard Exposure

Acute and chronic exposures to a number of

hazardous chemicals used at the Plant were frequent

occurrences, and the risks and long-term health effects

of such exposures were not fully recognized by the

Health Physics and Hygiene Department and

consequently, by the workers. Exposures to

polychlorinated biphenyls (PCBs), TCE, fungicides used

on the cooling towers, and asbestos did not result in

apparent, immediate health effects, nor was there

recognition of adverse long-term health effects. National

standards related to exposure to these materials did not

appear until the 1970s or 1980s. An asbestos screening

program for asbestos workers was initiated by the Oil,

Chemical & Atomic Workers International Union in the

mid-1980s. Exposures to caustic HF resulted in frequent

burns and respiratory injury. The effects of these

exposures were believed to be temporary only, when,

in fact, there may be long-term consequences.

Airborne Emissions

 Radioactive and fluorine emissions to the

atmosphere from stacks, diffuse and fugitive emissions,

accidents, and a small number of planned releases have

occurred since Plant startup in 1952. Stack emissions

were not monitored until the mid-1970s; process

knowledge was used to estimate potential releases before

then. Published reports estimated that approximately

60,000 kilograms of uranium were released to the

atmosphere from 1952 to 1990, 75 percent of it before

1965. There is evidence that past estimates did not

include all process gas releases, diffuse emissions,

accidental releases, and unauthorized process gas

venting. Consequently, the accuracy and conservatism

of past public dose estimates are questionable.

Liquid Effluents

Liquid effluents from past operations have had a

significant adverse impact on the environmental quality

of onsite ditches and streams and groundwater sources

in the vicinity of the site. Uranium, thorium, TCE, and

small quantities of transuranics and fission products have

been released to the environment, primarily from

cleaning and decontamination in Building C-400.

Significant amounts of chromates and fluorides were

released to the environment, as approximately 500,000

gallons of recirculating cooling tower blowdown water

were pumped into Little Bayou Creek every day. From

the beginning of Plant operations, liquid effluent control

was based on dilution, with the objective of ensuring

no unacceptable impact on the Ohio River; there was

much less concern about onsite and local waterways

and groundwater. As a result of increasing regulatory

requirements and an increased sensitivity to

environmental protection, significant efforts were

undertaken in the 1970s that improved the quality of

area surface waters.

Waste Disposal

Radioactive and chemically hazardous materials

were dumped and buried in numerous locations both

inside and outside the site fence. Hazardous and

radioactively contaminated materials were often mixed

with normal trash and waste materials, and waste

disposal was not well monitored, controlled, or

documented. Large quantities of radioactive materials,

including uranium metals and powders and

contaminated waste, were packed in metal barrels and

buried. Contaminated empty barrels remain piled in

ìDrum Mountain.î Contaminated concrete rubble and

roofing materials were disposed outside the Plant

boundaries, some in wildlife areas where public use
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and access were authorized and encouraged.

Contaminated sludge and floor sweepings were placed

in landfills, and the sludge was applied to Plant lawns

as fertilizer. Rainfall runoff and leaching have moved

contaminants from the disposal sites into the

surrounding environment. Federal environmental

regulations were enacted in the 1970s, and the Material

Terminal Management organization, established in the

early 1980s, implemented an integrated waste

management program that reduced the amount of

radioactive waste disposed of on site and achieved

greater control over waste segregation and disposal.

Summary

External conditions significantly affected the policies,

practices, and performance of PGDP management (both

the Federal owners and the contractors) and workers

during the first 38 years of Plant operation. To put

PGDP conditions and activities into perspective, it must

be considered that almost 50 years ago there was a

significantly smaller body of knowledge about radiation,

chemical, and other industrial hazards and their effects

on humans and the environment. While evidence

reviewed indicates that managers were concerned with

the safety and health of workers, management decisions

and practices were not always conservative.

Consequently, worker radiation exposures were higher

than necessary, and some workers may have been

exposed to hazards that were not adequately monitored

or understood. Communication of hazards, the rationale

for protective measures, and information about radiation

exposure were inadequate. Further, workers were

exposed to various chemical hazards for which adverse

health effects had not yet been identified. Environmental

practices prior to Federal and state legislation in the

1970s and 1980s resulted in many adverse impacts to

the environment, both on and off Federal property.