2P.3 RADIOLOGICAL PROTECTION PROCEDURES AND POSTING ”

,

PERFORMANCE OBJECTIVE: Radiation protection procedures for the control and
ase of radioactive materials and radiation generating devices should provide
for safe operations and for clearly identified areas of potential

consequences.

FINDINGS: LANL has a policy. on posting controlled and radiological
areas in administrative requirements {See LANL AR 3-7,
"Radiation Exposure Control,” dated January 11, 1991)
which parallel the requirements of DOE 5480.11.

This policy does not include the criteria for determining
how to establish a comprehensive posting and control
program in the workplace. Consequently, posting
rinarily reflects the practices established at each
iiding.

Posting is inconsistent throughout LANL; sometimes it is
inconsistent within a building, and sometimes it is also
inconsistent within buildings operated by the group.

LANL management failed to provide the necessary resources
to assure that the posting requirements were uniformly
implemented in the zoning and posting of each facility.

Some signs are prepared and posted by line management in
a facility without input. by the Health Pliysics Operations
Group and the Health Physics Policy and Programs Group.
These signs do not meet DOE 5480.11 requirements.

Posting intended for use within buildings, which is based
on DOE 5480.11, has been inappropriately used on fences
outside buildings.

Posting on the fence outside the Ion Beam Facility
Building was changed to "Controlied Area” during the
appraisal, However, no control over visitors or private
vehicles was instituted. Subsequently, the signs were
removed.

Management, radiation workers, and radiation protection
technicians are not trained in the new posting
requirements.

The LANL DOE 5480.11 Compliance Plan, Rev. 2, made the
following commitments:

- Alt work areas will be evaluated for sign
requirements (April 20, 1990). .

Signs and labels will be provided and installed
(July 31, 1990).

These commitments were not met.
4-379



\ | FINDINGS: ° The LANL ventilation system data base does not include
i ofl information related to whether ventilation systems are
rated for the use of flammables: :

Exhaust systems in LANL accelerator ‘facilities do not
have signs or labels indicating whether they are approved
for use with flammable liquids, vapors, and gases.

e A cleaning operation was observed in TA-53 Bldg. MPF-2
. wherein open trays of flammable Jiquids {acetone and
alcohol) were being used with an exhaust system that was
not electrically rated for flammable vapors.

The following concern was partially identified in the ;
LANL self-assessment.

. CONCERN: Flammable liquids at Los ‘Alamos National Laboratory are bein
EY) (TSA-3) used with ventilation systems that are not properly rated for
oreo (PP.6-3) flammable vapors as required by 29 CFR 1910.307.
ay ({H1/C1)
fi
TM . . FINDINGS: . Welding, cutting, and brazing were conducted in LANL
| accelerator facilities using exhaust systems that have
5 . not been quantitatively tested.
& ° A ventilation program has not been developed to require
‘ that ventilation systems for welding exhaust to have a
HI -] ’ mininum of 100 feet per minute of linear flow, as
if required by 29 CFR 1910.252, or that. welding be performec
‘ within that envelope.
{ ° The following concern was identified in the LANL self-
; assessment.
j CONCERN: Los Alamos National Laboratory does not have @ ventilation
(ee) program that implements the requirements of 29 CFR 1910.252
Se HI7¢1)
FINDINGS: ° LANL has not documented radio frequency emissions for tr
portable linear accelerator.
° LANL has not conducted radio frequency surveys of the
PHERMEX facility.
° LANL has not conducted radio frequency surveys of the
Rework Laboratory in TA-53 Bldg. MPF-19,
° LANL has not prepared an administrative requirement or
otherwise established a program to implement the

requirements of ANSI c95.1-1982.

. The following concern was partially identified in the
LANL self-assessment.

® 4-576



RP.12 RECORDS

PERFORMANCE OBJECTIVE: Records related to occupational radiation exposure
should be maintained in a manner that permits easy retrievability, allows

trend analysis, and aids in the protection of an individual and control of
radiation exposure,

FINDINGS: « ANST NI3.6 requires that all standard operating
procedures, radiation work permits, and special work
permits, involving the control of work with radiation or

radioactive material be included in an occupational
exposure record system.

:
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CONCERN: See Concérn TSA-1, RP.12-1. *

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4,5.4.13 Radiological io thS, €, at,
4.5.4.13.1 Overview $$, 43, 4$,S4}

Appraisal of the radiological protection programs and activities at

S&H Subteam 4 addressed all 12 performance objectives in the Radiological
Protection technical area; however, concerns were only identified under seven
performance objectives. The appraisal was conducted by interviewing
management and staff of the Health and Safety Division, interviewing other
division managers and personnel, and by reviewing documents relevant to
radiological protection activities at LANL. The appraisal also involved tours
and inspections of various technical areas, facilities, buildings, equipment,
and operations.

The primary technical areas and facilities visited by S&H Subteam 4 included
the TA-3 Sigma Complex, Bldgs. SM-130, 39, 102, and the Chemistry and
Metallurgical Research Building; the PHERMEX site in TA-15; the TA-21
laboratories and DP-West facilities; TA-35 Bldg. 2; the Health Research
Laboratory and In Vivo Counting Facility in TA-43; TA-48 Bldg. 1
Radiochemistry; the TA-54 areas G and L low-level waste management sites; and
the offsite laundry facility used by the Laboratory.

Laboratory operations, processes, Weapons research and development, and
associated experiments involve a wide variety of radiation sources and
radioactive materials. Radioactive materials include tritium, enriched and
depleted uranium, plutonium, americium, technetium, and a variety of other
natural and manmade radionuclides. Nuclear reactors at the site generate both
Fission and activation products. High-dose-rate cobalt and cesium sources and
linear accelerators are used in the study of radiation effects, while other
radiation-generating devices are used for and in a variety of experiments
{most of which were reviewed by S&H Subteams 1, 2, and 3).

The primary responsibility for radiological protection at LANL is assigned to
Tine managers, who develop individual radiation protection programs for their
- Own organization or facilities. Administrative requirements of ES&H Manual,

Section 3, describes the scope of the radiological protection program at LANL.

Technical suppert for the various LANL divisions for radiological protection
is provided by the Health and Safety Division, Technical groups in this
division having radiation protection responsibilities include the Health
Physics Operations Group, the Health Physics Measurements Group, the Nuclear
Criticality Safety Group, and the Health Physics Policy and Programs Group,
Field health physics activities such as radiation monitoring, surveying, and
contamination control are performed by radiation protection technicians under
the management of the Health Physics Operations Group. Radiological
laboratory measurements, calibrations, and in vivo counting are functions of
the Health Physics Measurements Group, and external and internal dose
assessment are performed in the Health Physics Policy and Programs Group.

Several characteristics of the radiological protection Program at LANL were
evident from the appraisal. Radiologica? protection programs vary
considerably from group-to-group and diviston-to-division within the
Laboratory, even thoygh the requirements and conditions are similar, There
are many reasons for these inconsistencies, including (1) lack of adequate

4-772



s

expianations for not returning the: instruments for
recalibration was the amount of time required.

The ‘number of tritium smears that are counted has
4ncreased by 75 percent over the past 3 years. It takes
from 2 40 5 weeks to get the smear processed. Currently,
there is a backlog of nearly 3000 samples even though at
Jeast one-half person year in overtime is being expended.

A counting room used in the smear- and air-sample ©
counting laboratory is Jocated in a hallway between two
rooms in which smearable contamination exceeds the limits
specified by. DOE 5480.11, Appendix 2. The presence of
alpha contamination in the counting room could bias”
results or could result in the room being shut down.
This is reportedly the only space available for this
valuable, important resource for the contamination
control program. In comparison, in the counting room at
TA-55 Bldg. PF-4, only clean protective clothing is
permitted and the area is not a contaminated area.

Approximately 12 temporary radiation protection
technicians are being used by LANL to supplement the
available staff of radiation protection technicians.
These temporary radiation protection technicians are
required to provide valuable health physics support with

only limited plant-specific training.

The calibration of high-level, portable, fixed radiation
{TA-2) and criticality (TA-55) detection instruments
cannot be properly performed because of the limited dose
rate available in the old LANL calibration facility.

The health physics groups have identified the shortfall
of people and facility resources through their
organization self-assessment. ,

Line management oversight of the LANL Radiation
Protection Program for radiation-producing devices does
not ensure that ali requirements of mandatory standards
in DOE 5480.11 are implemented, Responsibility is not
defined or assigned to ensure that the radiation safety
officer and qualified expert requirements associated with

accelerators and radiation-producing machines are .
implemented tn accordance with ANSI 43.1, ANSI 43.2, and

ANSI 43.5. (See Section 4.5.3.13.2, RP.1.)

The following concern was partially identified in the
LANL self-assessment.

Management at Los Alamos National Laboratory has not
‘implemented a high-quality radiation protection program as
required by SEN-6D-91 and DOE 5480.18. :



RP.5 EXTERNAL RADIATION DOSINETRY ow

PERFORMANCE OBJECTIVE: The routine and accident personne! radiation dosimetry
programs should ensure that personnel radiation exposures are accurately
getermined and recorded.

FINDINGS: .

CONCERN:

(H3/C2
FINDINGS: °

CONCERN:

(TSA-2)
RP.5-2)
H2/C2)

In many of the buildings where tritium operations are
conducted, there are no external radiation areas as
defined by DOE 5480.11. .Even so, personnel in the
tritium facilities are assigned external dosimeters which
are processed on a monthly basis.

Annual doses in most cases for these personnel are less
than 100 mrem.

Positive or negative errors can be introduced in the
annual dose records when the dosimeters are used for
_control of dose rather than measurement for compliance.

See Concern TSA-4, RP.5-X.

The following concern was not identified in the LANL
self-assessment. ‘

A documented basis has not been provided for choosing the
processing frequency of or need for external dosimetry for

personnel in the tritiun facilities at Les Alamos National
Laboratory. :

Personnel Nuclear Accident Dosimeters are assigned to
personnel entering TA-18 as required by DOE 5480.11.

The International Atomic Energy Agency Safety Series
Bulletin No. 152 suggests the need for developing a
quick-sort method to be applied in the event of a
criticality incident to quickly identify persons who are
exposed.

One quick-sort method involves the direct survey of
Personnel Nuclear Accident Dosimeters.

Radiation protection technicians have not been trained to
survey Personnel Nuclear Accident Dosimeters after a
suspected criticality incident to separate highly exposed
personnel. .

The following concern was not identified in the LANL
self-assessment. :

A method to use Personne? Nuclear Accident Dosimeters for
quickly identifying personnel who are exposed has not been
developed at the Los Alamos National Laboratory.



“1 Caweg

Table WS-3

Technical Area Inspections and Noncompliance Information

Ni
Other-Than- Imminent
kocation Serjous —Serious..  Wiliful = _Danger_ soe
TA-11 0 2 0 0
TA-15 11 3 0 0 “=
TA-16 5 0 Lt) G
TA-18 § 0 0 9
TA-3 a7 t 0 0
TA+35 3 9 v 0
TA-36 . 3 -0 0 tt]
TA-46 6 0 0 0
TA-53 83 7 0 Q *
TA-8 2 2 my —
TOTAL ‘ 135 B 0 0
Percentage 91.22 8.78 Q 9 —
Total Noncompliance 148

Compressed gas cylinder systems were found that have been locally constructed,
have not been identified or inspected, or are missing pressure relief devices.
There is no program in place to ensure that these systems, operating ina
research environment, conform to industry standards and are appropriately
certified. The confined space -entry program is inconsistent. ~ The ‘monttoring
program for entry does not contain enough checks to ensure that the spaces are
safe to enter: Oxygen monitors in place are not calibrated on a regular basis
or according to the manufacturer’s recommendations. Personnel protective
equipment is not readily available and is not always located in areas where
routinely required. The requirements for such equipment are not uniformly
defined or made mandatory in work areas where serious injuries could occur.

Training retated to safety and health issues in the workplace has not been
provided to all managers and personnel responsible for complying with these
mandated regulations. When training has been provided, it has not been of
sufficient depth or quality to ensure that QE objectives for workers safety
and health are achieved,

The LANL self-assessment found the Laboratory was not in compliance with eight
complete subparts and four mandated programs of the OSHA standards. The
fladings in the LANL self-assessment are written so broadly that it will be
very difficult to develop a plan of action to abate the deficiencies
identified throughout these areas. .

a5 Haare sa bath che 5 ud

4-573



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RP.7 INTERNAL RADIATION DOSIMETRY

PERFORMANCE OBJECTIVE: The internal radiation dosimetry program should ensure
that personnel radiation exposures are accurately determined and recorded.

FINDINGS: ° In TA-55, personnel are evaluated for inclusion in the

: bioassay program based on the expected type of work to be

performed.

° A conservative approach to bicassay in TA-50 is taken so
that all radiation workers participate in the program.

: At the firing sites, including TA-36 and TA-15, LANL
_ . personnel are not evalua’ ‘or inc Tus bioassay
s program.

° Health and Safety Procedure HSE-10-06-02 and LANL AR 3-7
requires that all personnel be evaluated for inclusion in
the bioassay program.

DOE 5480.11 requires bioassay for any worker with the
potential to receive 100 mrem annual effective dose
equivalent from internal exposures.

Not al] personnel at the plutonium and depleted uranium
facilities are evaluated for participation in the
bioassay program to comply with DOE 5480.11.

See Concern TSA-4, RP.7-1.



RP.10 RADIATION MONTTORING/CONTAMINATION CONTROL

PERFORMANCE OBJECTIVE: The radiation monitoring and contamination control
Program should ensure worker protection from radiation exposures, —~

FINDINGS: . No consistent radiation monitoring survey program that
includes an established frequency and location for
surveys is in evidence in the Health Physics Operations
Group.

trai ished to ensure that
routine dose rate and contamination surveys are conduc
n a Consistel er
erent Oe

° The Health Physics Measurements Group has not prepared a
field manual for use by radiation protection technicians
that explains proper use and interpretation of atl
radiation protection instruments. :

. Facility air monitor alarm points used in accordance with
the requirements of DOE 5480.11-to warn workers that
airborne radioactive material contamination levels have
exceeded an action level, are not always set at a uniform

Tevel. The setpoint may vary from monitor to monitor
- even in the same building. Te enereware teeta a attr
er nee nn
CONCERN: See Concern TSA-4, RP.10-1.

FINDINGS: . DOE 6430.1A, Section 1300-6.5.7, requires that, in
addition to local alarms, radiation monitoring systems
(criticality alarms and room and stack air monitors}
“shall have central (i.e., contre] room or radiation
monitoring office) readout and alarm panels that are
assessable after a design basis accident (DBA) to
evajuate. internal conditions." ~~ -

e LANL has developed a systematic control, alarm, and
monitoring (SCAM) system which meets the intent of DOE
6430.1A and is staffed 24 hours a day.

© The decision to place critical building alarms on the _
SCAM system is left to operating management rather than
being required. Radiation instrumentation alarms from
two buildings (TA-2 and TA-35 Bldg. 213) are involved in
the system.

. Most room, stack, and return gir monitors do not feed
into a central location that can be occupied during an
accident.

* See Concern TSA-2, AX.8-1.

w

4-394



See Concern TSA-4, RP.3-1,

At LANL yellow rope, tape, and Paint are used for many
purposes {a.g., to control entry and to seal packages).
It is not uniforaly used to identify a special radiation
area or condition,

Step-off pads are used at several locations where shoe
covers are required. Instructions are aot always
available on or near the pad.

In some locations, step-off pads are not used as required
by OOE 5480.11, even though shee covers are required.

Tools used in maintenance work involving radioactive

material contamination aré not uniquely identified to
prevent use in an uncontrolied area,

A yellow rope is used at TA-z Bldg. 1 (outside the
building) to prevent personnel from exiting a potentially
contaminated area and proceeding directly into an
uncontrolied area. Staff have reportedly removed this
temporary barrier several times. Thus, contamination
control requirements are violated. The two signs posted
at this location ("Control Area* and "Radiation Area")
are incompatible.

Personnel at TA-18 were working in a posted contamination
area wearing blue protective clothing in violation of
LANL policy.

In most tritium facilities at LANL, hoods and gloveboxes
are posted as contamination areas and the surrounding
areas are posted as controlled areas. In actual
practice, the space in front of these hoods is treated by
operations as a contamination area, Protective clothing
must be changed frequently (as often as every 15 minutes)
and the used clothing is to be placed in a receptacle
Tocated close to the hood and glovebox. This practice is
inconsistent with the existing posting.

At the Ton Beam Facility, the S&H Subteam 2 passed
through controlled and contamination areas without any
Clear demarkation. This included an unenclosed area jn
which smearable tritium contamination in excess of 10°
D/M/100 cm? is routinely found. No special posting or
other warning was available to Show the presence of high
levels of tritium contamination.

See Concerns TSA-2, MA.2-4, and TSA-2, WS.4-1,

The following concern was partially identified in the
LANL self-assessment.

“

4-380



CONCERN:
{TSA-2)
{RP.6-3)
(H1/C1)
CAT. If

At Los Alamos National Laboratory, the contamination control
program at the Ion Beam Facility does not provide necessary
protection for radiation workers against internal tritiua
exposure as required by DOE 5480.11.

4-386 -



RP.4 EXTERNAL RADIATION EXPOSURE CONTROL PROGRAM

PERFORMANCE OBJECTIVE: External radiation exposure controls should ninimize
personnel radiation exposure.

FINDINGS: . Records are not provided at some workplaces to
demonstrate that warning lights and interlocks are fail-
safe for radiation-generating machines {e.g., x-ray
radiography units).

° Radiation protection technicians assigned to buildings
where these units are housed are unaware of the results
of the annual leakage survey and interlock test.

. Posting at the machines was nonuniform and, in most
cases, did not identify the purpose or requirements of
the warning lights. This does not meet DOE 5480.11
requivenents for control of potentially high radiation
levels,

. Neither the Health Physics Policy and Programs Grou
radiation- producing device control office nor the health
Physics Operations Group is required to approve standard
operating procedures or the annual review and update of
such procedures.

° The interlocks on an x-ray radiography machine at the

~ Tritium Salt Facility could be bypassed and the machine
operated without proper shielding. Additional
administrative controls were in place to prevent
deliberate tampering. However, S&H Subteam.2 continues
to be concerned about the absence of a positive physical
control. The standard operating procedure for this
machine permits the operation of the unit even if it is
nalfunctioning without obtaiwing a°spectal work periiit
from the Health Physics Operations Group and without the
presence of a radiation protection technician, The
Health Physics Policy and Programs Group radiation-
producing device control office did not have a copy of

. the current standard operating procedure for that
installation because it was not on the distribution list
for the procedure.

° See Concern TSA-3, RP.4-4.

The following concern was not identified in the LANL
self-assessment. . “

CONCERN: The Los Alamos National Laboratory x-ray safety program does
{TSA-2) not provide the level of protection required by DOE 5480.11
ely for potentially high levels of radiation.

1,

4-382



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° The following concern was not identified iff the LANL
self-assessment.

CONCERN: Alarm signals from critical building radiation monitoring

{TSA-2} instrumentation at Los Alamos National Laboratory are not

(RP.10-1} routed te a continuously staffed central location as required
ci in DOE 6430. 1A.



wea

RP.3- RADIOLOGICAL PROTECTION PROCEDURES AND POSTING os

PERFORMANCE OBJECTIVE: Radiation protection procedures for the control and
use of radioactive materials and radiation generating devices should provide
for safe operations and for clearly identified areas of potential
consequences.

UY RANE ¢

FINDINGS: LANL has a policy on posting controlled and radiological
areas in administrative requirements (See LANL AR 3-7,
"Radiation Exposure Controi,” dated January 11, 1991)
which parallel the requirements of DOE 5480.11.

i This policy does not include the criteria for determining
| how te establish a comprehensive posting and contro]

Ff program in the workplace. Consequently, posting
prinarily reflects the practices established at each

ui lding.

Posting is inconsistent throughout LANL; sometimes it is
inconsistent within a building, and sometimes it is also
inconsistent within buildings operated by the group.

LANL management failed to provide the necessary resources
to assure that the posting requirements were uniformly
implemented in the zoning and posting of each facility.

Some signs are prepared and posted by line management in
a facility without input by the Health Physics Operations
Group and the Health Physics Policy and Programs Group.
These signs do not meet DOE 5480.11 requirements.

Posting intended for use within buildings, which is based
on DOE 5480.11, has been inappropriately used on fences
outside buildings.

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Posting on the fence outside the Ion Beam Facility
Building was changed to "Controlled Area” during the
appraisal. However, no contro] over visitors or private
vehicles was instituted. Subsequently, the signs were
removed,

Management, radiation workers, and radiation protection
technicians are not trained in the new posting
requirements.

The LANL DOE 5480.21 Compliance Plan, Rev. 2, made the
following commitments:

- Ait work areas wil] be evaluated for sign
requirements (April 20, 1990).

Signs and labels will be provided and installed
(July 31, 1990).

These commitmel ere not met.

4-379





Source checks of portable health physics instruments used
at accelerator facilities are nat performed in accordance

with the requirements of ANSI N323. (See Section
4,5.3.13.2, RP.8.)

The following concern was not identified in the LANL
self-assessment.

CONCERN: Calibration, maintenance, and periodic source checks of fixed
(TSA-2) and portable radiation protection instruments at Los Alamos
teed). National Laboratory do not meet ANSI N323 requirements,

{H2/C .

ow

4-392



7

RP.8 FIXED AND PORTABLE JNSTRUMENTATION st

PERFORMANCE OBJECTIVE: Personne} dosimetry and radiological protection
instrumentation used to obtain measurements of radioactivity’ should be
calibrated, used, and maintained so that results are accurately determined.

FINDINGS: . ANSI N323 requires the type, acceptance, and performance
testing of radiation protection jnstrumentation, Testing
of instruments at a factor of two to 10 times the top

range is required to determine whether the {nstrument
will saturate {paralyze} and, thus, not respond at all.

. ANSI N42, paragraphs 17a, b, and c, further defines
testing criteria and procedures in support of ANSI N323.

. The Health Physics Measurement Group has not established
a comprehensive performance and acceptance program. Many
of their instruments receive only limited testing of
performance capabilities.

° The Health Physics Measurement Group does not have the
capability to calibrate and test instruments used to
measure high dose equivalent rates (such as the Eberline
RMS-II) which are used to detect a criticality event.

. The-Eberl ine fUS-[1- which is used as a.criticalit
detector in some facilities \e-9- ~ iG. Pr-4) may
Saturate {paratyze ‘pos c) rate.
These instruments were not tested using gamma dose of a
sufficient level to determine whether equivalent rates
could occur. If it does, the instrument might paralyze
during a critical radiation event, even though the alarm
setpoint is at the Jow end of the range. :

e See Concern TSA-2, RP.8-5.

. The following concern was partially identified in the
LANL self-assessment.

CONCERN: gs Alamos Nationa Laboratory does not have the capability
(TSA-2) 0 Ca test the MERAS-1 CO aeaane
{RP.8-1) srwhéther. instrument performance meets requirements for a

(H1/C1) high-range instrument used for emergency ‘warning and
CAT. I evacuation by workers.

FINDINGS: . The Health Physics Measurement Group does not use
available resources to calibrate and test portable
instruments used to measure high dose. equivalent rates.

A tetetector similar to the one used at LANL has

.
exhibited problems with saturatiol aralyzing) which 1 can
result i Adi NG es

S|
Gverexpasure occurred in a y.S. nuctear facility as a
result of this problem.



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CONCERN:
(TSA-1)
{RP.8-1)
(H2/Ci)

FINDINGS:

CONCERN:
FINDINGS:

CONCERN:
(TSA-1)
(RP.8-2)
(#2/c1)

fi je Hea y’ nts Group precedures.
(See Section 4.5,2.13.2, RP.8.}

we
Radiation protection instruments are_nét bein returned
for_calibration and maintenance as required by ANST NOZ3
Sid the Health Phystes Heasorente:
There are no procedures to ensure that failed radiation
protection equipment at accelerators are promptly removed
from operation and evaluated to determine the impact of
the failure. (See Section 4.5.3.13.2, RP.8.) ‘

The following concern was partially identified in the
LANL self-assessment. ‘

Fixed and portable radiation survey instruments are not
Calibrated annually or source checked in compliance with Los
Alamos National Laboratory procedures and ANSI N323-1978, and
instruments past calibration are not removed from service in
compliance with Los Alamos, National Laboratory AR 3-2.

Tritium detectors in laboratories and on stack monitors
are not source checked.

Tritium process monitors that have an effluent control
function were found out of calibration but were not taken
out of service.

The tritium process monitors are the property of one of
the operating groups.

The Health and Safety Division has no control over the d
tritium process monitors.

See Concern TSA-2, RP.8-5.

The following concern was fully identified in the LANL
self-assessment. :

At the Los Alamos National Laboratory, process control
monitors, for which calibration is required by DOE 5700.6C,
are not under the oversight of Health and Safety Division
even though they have the potential to be effective health
and safety instruments.

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RP.8 FIXED AND PORTABLE INSTRUMENTATION

PERFORMANCE OBJECTIVE: Personnel dosimetry and radiological protection
instrumentation used to obtain measurements of radioactivity should be
calibrated, used, and maintained so that results are accurately determined.

FINDINGS: ° The detectors on the Ludlum 214 fixed instruments (hand
. and foot monitors) are interchanged wjthout recalibration
or response testing. o ae

° The detectors on the Ludlum 139 portable instruments are
interchanged and response tested at each scale, but full
==> calibrations are not performed,

. The check sources used to response check Fixed
instrumentation are disks of depteted uranium attached to

each detector. The sources have not been characterized,
are not documented, and-emit at an unmeasured rate.

° The backlog in calibrating Ludjum 214 hand and foot

monitors resulted ina ange number of instruments that
were gut-of-calibrd ron. _In order to relieve

0g, a technician Was trained and certified to
perform a calibration that did not include the
electronics check required by ANSI N323-1978, Following
the calibration procedure, a calibration sticker was

affixed to the instrument.

« Documented studies of the field minimum detectable
activity for fixed and survey instrumentation have not
been performed. .

. Several glovebox hand and foot monitors are out-of-
~ calibration (calibration date has passed). The, .
calibration cycle has recently been changed from 2 years
to 1 year. As a consequence the calibration facility is

unable to keep up with the inc! ero
“IMSTPUMEHS HAE Tepuire calibration.

Hand and foot monitors that are past the calibration date

are not placed out-of-service a required by -
“DeCaSe Sufficient numbers oF replacement instruments are

hot available.

* Annual calibration of instruments is required by ANSI
N323-1978.

° Printouts describing instruments that require calibration
Show calibration frequencies of both 12 and,24 months for
the same type of instrument {Ludlum 214 hand and foot
Monitors) .

° See Concern TSA-1, QV.4-1.

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RP.2 INTERNAL AUDITS AND INVESTIGATIONS

PERFORMANCE OBJECTIVE: The interna) audit program for both routine operations 4
and unusual radiological occurrences should provide adequate performance 4
assessments.

FINDINGS: = ¢ —_LANL has an internal audit program that meets the
criteria and requirements of DOE 5482.18.

. The Health and Safety Division performed audits in 1989
and 1990. A tracking system is in place which provides
the status of the findings from these audits.

. The audit and tracking system does not include review of
standard operating procedures for correctness, approval
by Health and Safety Division, or to determine whether
standard operating procedures are current. :

. A printout dated August 14, 1991, lists 52 action items
with their due dates and status. To date, 22 items have
been completed.

. The following concern was identified in the LANL self-

assessment.
CONCERN: The internal audit system at Los Alamos National Laboratory
(TSA-2) does not include all elements of the Radiation Protection
(RP.2-1) Program to ensure prompt action. =
(H3/C2)
a
#

4-378



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RP.10 RADIATION MONITORING/CONTAMIMATIGN CONTROL fd

PERFORMANCE OBJECTIVE: The radiation monitoring and contamination contro]
program should ensure worker protection from radiation exposures,

FINDINGS: =~ Hloor suryeys in TA-55 are performed with ‘go/no go-- .
: instruments . 2 minimum detectable activity of these
instruments is greater than the Te
. oor surveys are not performed in TA-50 as required by
procedures:

° Surface contamination in TA-55 is determined through
surveys of booties. Booty surveys are performed with
Portable instrumentation with a much RIGS hia

etectable activity than smear surveys can achieve,
ne

CONCERN: See Concern TSA-4, RP.10-1,

FINDINGS: . Smear surveys of objects carried into Bldg. PF-4 are
performed prior to their release. However, unless
specifically reminded by management, no ition is

consistent] egarding the release of these
‘Waterrats.

. The basement area of Bldg. PF-4 is used as a staging area
for radioactive waste, including equipment. Documented
smears are not performed on the high {greater than 50,000
counts per minute) count areas. Smears are performed .
when equipment is moved, but the results are not

documented.

. At TA-3 (Sigma Complex), procedures for removal of
protective clothing are not posted at step-off pads, and
surveying procedures are not being followed. The
operational group realizes that training is needed, but
they are delaying this training until sufficient numbers
of monitoring equipment are available.

H . At Bldg. PF-4, procedures for removal of protective
clothing are posted at exits from the controlled areas,
Radiation protection technicians are posted at these
areas to ensure that procedures are followed.

|

. In the TA-21 Chemistry Laboratory, an air filter had
fallen off the fixed vacuum head, no means is provided
for real-time checking of the airflow from the room into

the hoods, and noc! is provided at the hand
and foot monitor at the exit from

|

° See Concern TSA-1, QV.1-2.

CONCERN: See Concern TSA-4, RP.10-4.

4-187



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internal exposures
FINDINGS: °

42702)
FINDINGS: e

“i

. No aj i levels of
airborne tritium contamination in the workplace” he
WET Faerrity; 3 portable BUBB Ter “Saiipler ea

RP.G INTERNAL RADIATION EXPOSURE CONTROL PROGRAM
PERFORMANCE OBJECTIVE: Internal radiation exposure controls should minimize

The engineered controls for airborne tritium
contamination ranged from superior in a new facility
(e.g., the WET Facility) to marginal in some old
facilities.

Vacuum systems and pumps are not contained in enclosures
(@.g., hoods and gloveboxes); thus, personnel can come
into direct contact with tritium-contaminated oi7 and
airborne contamination.

Not all hoods or gloveboxes are posted correctly as te
airflow conditions and restrictions.

With the exception of the WET Facility, documented
Studies of airflow ip the workplace weré not available to
ify the airflow patterns and problem .

See Concern TSA-2, AX.5-2.

The following concern was not identified in the LANL
self-assessment,

- ~ CONCERN: Los Alamos National Laboratory cannot demonstrate that
(TSA-2) engineering controls in tritium facilities will winimize
eye} internal tritium exposure.

Airflow studies have not been performed and documented to
demonstrate proper location and number of air monitors..

for tritium as suggested by DOE 5480.11, except at the .

WET Facility. &”

Tritium air monitors do not have a uniform alarm,

Setpoint, an RQ written pati Tication Was avatlable for ,
e alarm setpoints th chosen: ;

5 ailable for
special work...

Tt takes from 2 to 5 weeks to obtain the results of
analyses of tritium smears rather than overnight. The
number of smears for tritium contamination has increased
by approximately 75 percent over the past 3 years. There
is a current backlog of approximately 3000 samples.

Routine tritium bioassay samples scheduled by the field
may‘ remain in the field for several weeks rather than
eing turned in immediately after they are provided.

4-384



”

° DOE 5480.12 and ANSI N2.1 require that a radiation symbol
with a yellow background be used to identify
contamination levels greater than 10 times the levels

+ listed in DOE 5480.11.

. LANL AR 3.7 requires posting at the levels in
DOE 5480.11.

See Concern TSA-4, RP.3-1.

FINDINGS: . Radiation sources in the Calibration Section of the
Nuclear Materials Measurements and Accountability Group

* and Health Physics Measurements Group are not being
i periodically leak tested and no schedule for leak testing
é exists.

. The following concern was identified in the LANL self-
assessment.

CONCERN: AV] groups are not implementing the radiation source leak

: {TSA-1} test program as required by Los Alamos National Laboratory AR
: {RP.3-3) 3-4.

(H2/C1)



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4.5.4.13.2 Findings and Concerns
RP.1 ORGANIZATION AND ADMINISTRATION

PERFORMANCE OBJECTIVE: Site/facility organization and administration should ‘ |
ensure effective implementation and control of radiological protection 3
activities, .
FINDINGS: . Health and safety audits are conducted by the Laboratory

Assessment Office. They are not Comprehensive throughout
the Laboratory and do not have oversight by or
participation from the Health and Safety Division.

Neither a formalized audit nor an inspection program is
conducted by Health and Safety Division specialists.

Oversight of radiological protection activities is
dependent on the elites of uw individual division or
group manager and consistency of oversight is not a
general Laboratory urement. ee

Many open items remain on auditable inspections and
reports performed by various organizations in the past,

Appraisals of accelerater facilities have not been |
conducted as required by DOE 5482.18 and DOE 5480.11.
(See Section 4.5.3,13.2, RP.2.)

See Concerns TSA-4, PP.1-3, and TSA-4, PP.3-1,

The following concern was identified in the LANL self-
assessment.

CONCERN: At the Los Alamos National Laboratory, scheduled inspections and
ATSA-4) audits. are not conducted: by health and safety specialists as TM
RP.1.1} required by DOE 5480.11 and DOE 5482.1B; the closure of open ites
H2/C4) from previous audits has not been compteted,

FINDINGS: e

There is a lack of review or approval by the Health and
Safety Division of. standard operating procedures,
radiation work permits, and division ES&H plans and
programs throughout the Laboratory.

The review by Health and Safety Division of ES&H standard
operating procedures, radiation work permits, and DOE
5480.11 implementation plans occurs only upon the request
of the originators of those- documents. There is no
assurance that the required reviews are accomp] ished.

See Concern TSA-4, OP.2-4,

CONCERN: See Concern TSA-1, RP.3-1.

a

ow

4-774



rd
st

jessons learned from a Class C incident that occurred in May 1990. Staff
continually tried to impress the S&H Subteam with the assurance that they are
the experts and that the risk from exposure to tritium gas is minimal.

Many of the concerns-identified-in-this S&H Subteam 2 report relate to an
inadequacy in allocation or reallocation of physical and human resources to
and within the Health and Safety Division. Operating organization management
and personnel continually complain that they cannot obtain timely support from
the Health and Safety Division. However, in only a few instances has
management provided direct funding to increase health and safety support.

Some of the same organizations have provided direct support for the senior
health and safety personnel that they are adding to their own groups under the
"safety and radiation protection officer” concept. This new effort has
further led to the nonuniformity of the radiation protection program at LANL
rather than improvement. For at least the past 4 years, the Health and Safety
Division has identified the need for a new centralized calibration facility to
meet the tough new requirements of DOE 5480.11, ANSI N323, and OOE 5480.15.
LANL may be the only major OOE site which does not have either a new
calibration facility or approval for constructing one.

The LANL self-assessment marginally: addressed the concerns identified by S&H
Subteam 2. The Health and Safety Division self-assessment dealt primarily
with management responsibilities of the division. They were not asked to
provide an independent assessment of the sitewide problems in the area of
radiation protection. Thus, the LANL self-assessment suffered because there
was inadequate input from the excellent staff of health physics professionals

available at LANL.

While there is some isolated improvement in radiation protection in the
facilities visited by S&H Subteam 2, the overall quality of the program is
lower than in the past. The increased emphasis on line management
responsibilities has added to the attitude of some managers that they do not
need direct support and approval from the safety professionals. The attitude
of "don’t call us, we'll call you" appears to be stronger than in the past.
If management does not want the review or approval of the Health and Safety
Division they simply do not request it. LANL management must make a
substantial commitment toward the upgrade of the radiation protection program
if the Laboratory is to be fully committed to the quality program currently
envisioned in the DOE Orders and by the Secretary of Energy.



3
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(4210 ml sin Re.

4.5.2.13.1 Overview

All 12 performance objectives in the Radiological Protection technical area
were addressed in this appraisal. However, findings and concerns in RP.4
External Radiation Exposure Contro? Program are included in other technical
areas. Data was gathered through site visits, interviews with operational
personnel, radiation protection technicians, Health and Safety Division
personnel, and health physicists and through review of LANL policies,
procedures, standard operating procedures, and internal correspondence
regarding conduct of radiation protection. Data also came from management’ s
description of responsibilities deriving from DOE 5480.11.

Tritium facilities include the following: TA-3 Bldg. 16 (Ion Beam Facility),
TA-16 Bldg. 205 (WET Facility), TA-21 Bidg. 155 (Tritium Systems Test
Assembly), TA-21 Bldg. 209 (Tritium Salt Facility), TA-33 Bldg. 86 (High
Pressure Tritium Laboratory), TA-35 Bldg. 34 (Beta Decay Experiment}, TA-35
Bldg. 213 (Target Fabrication Facility), and TA-41 Bldg. 4 (Ice House).
Additional facilities included in the appraisal were TA-2 Bldg. 1 (OWR}, TA-18
(Pajarito Site), and TA-3 Bldg. 40 (Radiological Calibrations Facility},

The radiation protection functions in the facilities visited by S&H Subteam 2
demonstrate the nonuniformity of the radiation protection program at LANL.
The reasons for this nonuniformity are apparently numerous; for example, until
recently the health physics operating groups were geographically controlled
and philosophically separate. Consequently, the programs were operated
differently. In several instances a vacuum appears to exist at LANL in the
implementation of the more conservative requirements of DOE 5480.11.
Management has unilaterally instituted Changes which are contrary to

DOE 5480.11 and/or LANL requirements, Management develops standard operating
procedures, radiation work permits, and special work permits without review or
approval of the Health and Safety Division.

Posting and contamination contre? in tritium facilities is nonuniform (even
when the facilities are in the same division). This nonconservative aspect of
the program coupled with the absence of timely tritium smear and bioassay
analyses makes the quality of radiation worker protection hard to quantify.

In addition, it will be difficult or impossible to demonstrate that exposures
are ALARA and that timely response will be taken in the event of an undetected
tritium release.

An occurrence identified by S&H Subteam 2 at the Ion Beam Facility, involving
naintenance of a highly contaminated building vacuum pump, demonstrated the
apparent absence of management concern for the conduct of a conservative
radiation protection program, This occurrence, coupled with the decision that
it was not reportable under DOE 5000.3A and LANL requirements, has led to a
strong concern on the part of the S&H Subteam as to whether continued safe
operation of the facility from a radiation protection point of view can be
assured. . .

Operations staff in some of the tritium facilities apparently believe they are
dealing only with tritium.gas, in which case, the risk to workers would be
extremely low because tritiated water or tritiated organics would not be
Present. At TA-41 Bldg. 4, management does not appear to have accepted the

4-372



CONCERN:

fs
WS.3-1)

(H1/€1)

» Excavation }

Y
Los Alamos National Laboratory, does net fully comply with
jaza

the requirements of 29 CFR 1910.1200, ‘ications
and 29 CFR 1910.1450, Occupational Exposure to Hazardous
Chemicals in Laboratories.

At the Los Alamos National Laboratory, emergency eyewash and
shower’ facilities are not always available or readily
accessible as specified in 29 CFR 1910, Subpart K, Medical
and First Aid,

At the Los Alamos National Laboratory, danger, warning, and
safety information Signs are not Consistently posted as
required by 29 CFR 1910, and 29 CFR 1926.

At the Los Alamos National Laboratory, machine guarding does
hot meet the requirements of 29 CFR 1910, Subpart 0,
Machinery and Machine Guarding,

See Concern TSA-4, FP.2-1, -
Los Alamos National Laboratories does not comply with 29 CFR

1910, Subpart s, Electrical, in that electrical hazards
Present shock or electrocution hazards,

at the ios A
conducted in accordance with 29 CFR 1926, Subpart P,
Pxcavations, and Subpart C, Genera} Safety and Health
rovisions.

Los Alamos National Laboratory has not developed,
implemented, and enforced a comprehensive Safety oversight
with al) applicable sections of 29 CFR 1926.

4.5.4.16 Fire Protection

The Los Alamos National Laboratory Fire Protection Program
and organization is not well defined and does hot achieve
compliance with DOE 5480.7.

The Albuquerque Field Office is not performing fire
protection appraisals of Los Alamos National Laboratory in a
manner which wil] assure Compliance with DOE 5480.7,

4-973

amos National Laboratory #s not

¥



”
. One tritium room air monitor was instalied without an air
sample pump.

e One new stack air monitor was equipped with a moisture
trap by operations without contacting the Health Physics
Neasurenent Group. This omission made the calibration
invalid. .

. The following concern was partially identified in the
LANL self-assessment.

ONCERN: Operations management purchases radiation protection
TSA-2} instruments without review, approval, testing, and
RP.8-4) calibration by the Health Physics Measurements Group as -
H2/C1) required by Los Alamos National Laboratory AR 3-1. :

INDINGS: . ANSI N323 requires the use of check sources that can be
referenced to the instrument calibration for periodic
checks, Some check sources cannot be referenced to the
calibration.

. Results of periodic (i.e., daily, weekly, etc.)
instrument checks are to be recorded to demonstrate
continued proper operation. Instrument response checks
are not performed uniformly at all buildings.

. Some check sources will drive an instrument off scale
when they should be checking the alarm setpoint on an
instrument used for qualification rather than
quantification.

high-range gamma detectors) are "calibrated" in the field
under Tess than ideal conditions. The "calibration" is
not always performed under fixed geometric conditions.
Not al} scales can be calibrated. A quality control
program has not been established to demonstrate the
continued quality of calibration under nonideal
conditions.

° Maintenance is performed in the field for some
instruments such as the Eberline RMS-I1 used for
criticality detection. The maintenance program is not

. Some instruments (e.g., tritium air monitors and

the same as the one conducted in the Health Physics r
Measurement Group. Records of ma tenance as required by 7
ANSI N323 are not generated and maintain fe “Heater

ies Measurement Group, Testing of electronic rise
“Tile; -a-requirement-oP ANSI 8.3, is not routinely
performed to ensure that electronic components have not
deteriorated. This same test was not performed on the
new Ebertine RMS-IIs when they were received, Ht

° Operational response checks of tritium monitors,
including stack monitors, are not routinely performed as
required by ANSI N323. (See Concern TSA-1, RP.8.)

4-391



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RP.2 INTERNAL AUDITS AND INVESTIGATIONS *

PERFORMANCE GBJECTIVE: The internal audit program for both routine operations

and unusual radiological occurrences should provide adequate performance
assessments. °

FIRDINGS: «There are no gocunented procedures or administrative

«LANL £S8H policies and procedures do not describe the
action to be taken by Health Physics Policy and Programs
Group in conjunction with the Occupational Medicine Group
following a major exposure to radiation. Policies and
procedures do not include methods for work restrictions,

decontamination, chelation therapy, and fotlowup dose
assessment.

The following concern was ident
assessment.

ified by the LANL self-

CONCERN: Los Alamos National Laboratory does not have documented procedures
eal for evaluating and managing worker exposures to radioactive
RP.2-1) materials, as required by DOE 5480.4 and National Council on
(H2/c2) Radiation Protection and Measurements Report Number 65.

FINDINGS: ° The Laboratory Assessment Office is responsible for
analysis and trending of occurrence reports. There are
ho procedures and methods for performing this function.

. AR 1-1, "Accident/Incident Reporting," Apri] 1988,
incorrectly describes the current organization for
occurrence reporting.

° AR 1-1 provides a description of events that require
reporting, but its criteria for reportable radiation

occurrences are not consistent with those required in DOE
5000.3A.

. Personnel have not been trained in use of the new
reporting system,

. The management system developed by LANL to meet the
reporting criteria in DOE 5000.3A does not lead to
Correct reporting decisions and followup actions. (See
Section 4.5.2.13.2, RP.1.)

. See Concerns TSA-4, £A.4-2, and TSA-4, OP.2-2.

s AR 1-1 requires that the Health Physics Operations Group
be notified of each radiation incident and that they
document these incidents in a Radiation Occurrence

Report. However, the Radiation Occurrence Report system
is not defined in a formal program. The system does not

4-775



. See the findings for Concern TSA-2, RP.8-1.

i . . The following concern was partially identified in the
LANL self-assessment.

CONCERN: Los Alamos Nationa) Laboratory does not use available

TSA-2) resources to calibrate and test portable high dose equivalent
RP.8-2) rate instruments to determine proper instrument performance
{H1/Ci) as required by ANSI N323. .

FINDINGS: . As @ result of findings from the TA-55 TSA in 1987, LANL
established an inventory system for use in identifying
and retrieving overdue instruments. The Health Physics
Measurement Group procedures require that radiation
protection instruments be returned at a set frequency for
maintenance and recalibration.

At one LANL facility, pinatel 100 radiation
Reasons for the delay included

detection in

S$ to make the exchange, (2) too
much time to get instruments recalibrated, and (3} a
preference for field calibration.

. The Following concern was partially identified in the
LANL self-assessment.

CONCERN: Radiation protection instruments at Los Alamos National

(TSA-2) Laboratory are not being returned for calibration and

(RP.8-3) maintenance as required by ANSI N323 and Health Physics

(H2/C1) Measurements Group procedures. .

» FINDINGS: . LANL AR 3-1, "Radiation Protection Program,“ dated. e .
face August 30, 1991, ‘requires the reView and approval of the

purchase of al] instruments used for radiation protection
purposes,

. Chirpers (electronic dosimeters) were purchased by
operations management at one site for use by visitors
entering the facility. These devices were not purchased
through, calibrated by, or tested at the calibration
facility.

~pribiun room air monitors were. purchased at.TA-41 Bldg. 4
y Operations personne! without support from calibrations.

staff or calibration and testing at the calibration

act yity.

. Against the advice of calibrations personnel, a portable
passive hand-held tritium survey instrument was purchased
by operations. It was not calibrated and tested by
calibrations personnel. Operations did not mark it "use
for test and evaluation purpose only."

4-390



RP.9 AIR MONITORING

PERFORMANCE OBJECTIVE: Air monitoring systems through selection, location,
Calibration, and maintenance should ensure reliable estimates of air activity
for radiological control purposes.

FINDINGS: « Air flow studies have been performed and updated at Bidg.
PF-4 to ensure that the positioning of the continuous air
monitors is adequate to monitor for airborne activity.
However, formally documented studies do not exist for the
depleted uranium facilities at TA-50 and TA-3 {Sigma
Complex).

. Particle size studies of airborne radioactive
contaminants at Bldg. PF-4 have commenced but are not
complete. Solubility studies have been completed and
“documented.

. The following concern was partially identified in the
LANL self-assessment. :

Bo. CONCERN: . At the Los Alamos National Laboratory, pirtlow.particle
(TSA-1)} size, and solubility Studies hays at been documented at al}
plutonium and depleted uranium facilities, su =50, TA-
3 (Sigma Complex), and the firing sites, to verify the proper
sitioning of the continuous air monitors for moniter ig
- iron BOUT TY en re cece

eerace erie ee”

ee +

FINDINGS: . The tritium stack monitors are not calibrated due to the
‘ large quantities of tritium released during calibration.
Electronic calibrations are performed at a specified
frequency. L
& “ ° The Kanne chamber used as a stack monitor can measure

. concentrations up to. 20 mCi/m’.

e Short-term releases in excess of 20 mCi/m® have occurred
at TA-55.

° See Concern TSA-1, QV.4-1.

. The following concern was partially identified in the
LANL self-assessment.

CONCERN: At the Los Atamos National Laboratory, the tritium stack
{TSA-1)} monitor at Building PF-4 are not calibrated as required by
(RP.9-2) ANSI N13.10-1974, and the range of response of the instrument
(H2/C1) does not ensure accurate deteraination of released quantities

of tritium during accident situations.

4-186

z
i.



CONCERN:

an]
RP.3-1)

(He/c1)

a

a af
The contamination contvol policy at Los Alamos National
Laboratory tritium facilities does not cover all required
elements, does not meet the requirements of DOE 5480.11 for
control, does not provide positive control of personnel in
contaminated areas, and is not rigorously enforced,



|
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PP.2 PROCEDURES AND DOCUMENTATION

PERFORMANCE OBJECTIVE: Procedures and documentation should provide
appropriate direction, ‘record generation, and support for the personnel
protection program.

FINDINGS: °

The Confined Space Entry Program at LANL does not
incorporate al] requirements of ANSI Z117.1-1989.
Omitted requirements include controls for physical or
mechanical hazards, use of double block and bleed, and
lockout/tagout requirements. ;

No chemical hygiene plan has been published or
implemented for LANL accelerator facilities as required
by 29 CFR 1910.1450.

Contrary to 29 CFR 1910, Subpart Z, LANL policy currently
does not address the application of cosmetics in
workplaces where materials are present.

Procedures applicable to LANL accelerator facilities have
not been developed to ensure proper response to low
oxygen level alarms.

No program or procedures appticable to LANL accelerator
facilities have been developed to ensure that flammabje
liquids, gases, and vapors wil} be used only in
Jaboratory hoods that meet the requirements of 29 CFR
1910.307. : .

A program has not been established to ensure that exhaust
hoods used for welding in LANL accelerator facilities
comply with 29 CFR 1910.252.

The LANL Laser Program and its standard operat ing
procedures applicable to accelerator facilities do not
address al} requirements of ANSI 2136.1-1986. For
example, standard operating procedures related to lasers
do not require approval by the Laser Safety Officer.

A nonionizing radiation program applicable to LANL
accelerator facilities is not in place to address the
requirenents of ANSI C95,1-1982 for radio frequency
hazards.

Although several sources of static magnetic fields were
identified in LANL accelerator facilities, a program has
not been established to implement the requirements of the
American Conference of Governmental Industrial Hygienists
as Set forth in, "Threshold Limit Values for Chemical
Substances and Physical Agents and Biological Exposure
Indices," dated ‘1990-1991, with respect to static
magnetic fields.



“1 Fawn

PP.5 PERSONNEL COMMUNICATION PROGRAM

PERFORMANCE OBJECTIVE: Site/facility personne) should be adequately informed
of chemical, physical, and biological stresses that tay be encountered in
their work environment. Written pri rams, of sufficient quality to comply
with all Department of Energy prescribed occupational safety and health
standards, should be available,

pererarvarenes

LANL does not have documents for a laboratory safety

program or 2 chemical hygiene plan as required by 29 CFR
10. ‘.

191.1450

Laboratories observed in accelerator facilities were
operating without laboratory-specific safe Operating
procedure as required by 29 CFR 1910.1450.

required that he periodically cut and weld stainless

* steel. This employee was unaware that the chromium and
nickel compounds emitted during welding were potentially
carcinogenic.

An interview was conducted with a LANL emptoyee whose job :

Unlabeled process piping was observed in several LANL
accelerator facilities. z~ =

Accelerator facility personnel were unable to ‘locate
material safety data sheets for selected chemicals found
in the workplace. .

LANL does not have a uniform policy regarding the
labeling of secondary containers, LANL policy currently —
permits the use of several labeling systems,

‘See Concern TSA-4, WS.3-1.

4-573



RP.7 INTERNAL RADIATION DOSIMETRY 3 4 | WM

PERFORMANCE OBJECTIVE: The internal radiation dosimetry program should ensure
that personnel radiation exposures are accurately determined and recorded,

FINDINGS: . DOE 5480.11 contains specific requirements for a bioassay
program for al] radiation workers who are likely to
receive 100 mrem annual effective dose equivalent as a
result of internal exposure:

. If proper decisions are to be made, applications of the
above requirements to work situations and potential
exposures requires the direct involvement of health
physics personnel whe are knowledgeable about internal
dose evaluation.

. Because of constraints on the internal dosimetrists time
and the large number of buildings where internal exposure
is possible, the In j
upgraded to

et the requirements at all facilities.

. Some line managers are determining who should be placed
on the bioassay program without direct input by the
Health Physics Operations Group and the Health Physics
Policy and Programs Group staff.

. Management at_TA-33 Bide. 86 decided that a spot tritium
bioassay sample was to be collected from each individual ;

who enters the building. Instructions were prepared by

line management without thé Knowledge or involvemen

TANL “internal dosimetrists.
we eet Conn ntenge :

. See Concern TSA-2, RP.6-2.

The following concern was identified by LANL in their
self-assessment.

CONCERN: DOE 5480.11 requirements for tritium internal dosimetry are
(TSA-2) not uniformly applied throughout al} buildings at Los Alamos
{RP-7-1) National Laboratory and are not defined by internal

{H2/C1) dosimetrists in all cases.

FINDINGS: . As a result of a Class C incident in at TA-41 Bldg. 4

(dated May 1990), one of the causes of the increased dose
was a delay in processing bioassay samples and,
therefore, a delay in treatment brought about by the
level of exposure.

° A chain-of-custody program for bioassay samples was
initiated as a result of the above incident. —

° Appendix G of LANL AR 3-6, “Personnel Radiation
Dosimetry," dated August 30, 1991, requires chain-of-
custody control of bioassay samples. This requirement
places the responsibility on operations management for

§-387

— ON fERNAL

E


RP.G INTERNAL RADIATION EXPOSURE CONTROL PROGRAM

PERFORMANCE OBJECTIVE: Internal radiation exposure controls should minimize
internal exposures.

FINDINGS: . Commingling areas are areas where personnel in protective
clothing (both Taboratory coats and coveralls) are
allowed to share the same facilities with personne)
wearing street clothing. Commingling areas exist in
Bldg. PF-4, including two break rooms (one smoking, one
nonsmoking).

* Eating, drinking, and using tobacco products are allowed
in the break areas.

« ~ The following concern was identified in the LANL self-

assessment.
CONCERN: At the Les Alamos National Laboratory, internal radiation
(TSA-1) exposure controls do not preclude eating, drinking, and using
(RP.6-1) tobacco products in commingling areas and do not minimize
(83/1) internal exposures as required to comply with DOE 5480.11.

FINDINGS: ° . The frequency of surveying mandated by procedures is not
conststently followed. In particular, floor surveys are
Performed as needed but LANL policy requires semi-annual
surveys,

. Documentation of floor surveys indicted that some
laboratory floors had not been Surveyed during 1991.

. The following concern was identified in the LANL self-

assessment.
CONCERN: At the Los Alamos National Laboratory, radiation surveys are
{TSA-1) not performed so as to comply with Health and Safety Division
{RP.6-2) procedures.

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m. review by Health and Safety Division professionals, (2) the lack of rigor and
m formality in the administrative requirements, (3) the reassignment of safety
personne! and technicians away from the Health and Safety Division into the

research and development divisions, and (4) the jack of oversight by
laboratory managers from al? divisions.

The quality of the radiation protection programs at LANL aiso varies. Many of
the elements of the good programs could easily be transferred to weaker
programs. Examples include training and retraining programs {especially for
radiological protection technicians), procedures, record keeping systems,
routine survey programs, and others. it is not a question of not wanting to
share information and ideas throughout the Laboratory, but rather, lack of
effective promotion of excellence in ES&H program elements by line management.

There is evidence of need for better management of personnel resources within
the Health and Safety Division. The distribution of work appears to be
skewed, with the Health Physics Operation Groups having the larger share,
particularly in day-to-day operations. The interactions required to maintain
an excellent program will increase as the Laboratory program mix changes from
a few large programs to many smaller research and development programs.

Line managers have not uniformly provided the information needed to determine
which personnel should be included in the various radiation protection
programs, including extremity dosimetry and radiobioassay. Many have not met
their responsibility for the timely collection and processing of radiation
dosimeters and bioassay samples.

The decommissioning and decontamination of aging plutonium and uranium
facilities will] require particular emphasis on quality radiation protection.
At the same time, efforts to minimize the generation of radioactive waste, as
required by DOE Orders, will necessitate a greater commitment from management
and staff. This current commitment is-not satisfactory, perhaps due to lack
of incentive. :

Comments were made to S&H Subteam members that responses to requests from
research and development divisions for various radiological protection
services have been less than satisfactory. Radiological protection services
will deteriorate in the future unless current structures, staffing levels,
authorities and responsibilities, and other priorities improve within the
Health and Safety Division. The Division is hindered in conducting its
programs and supplying technical support as a result of Tack of facilities,
equipment, and other resources. An example is the difficulty experienced by
the Health Physics Measurements Group in obtaining a germanium detector array
for lung measurements on personnel working with plutonium.

Most of the concerns were previously identified or were partially identified
in the LANL self-assessment. However, the root causes for these concerns are
not, in every case, similar. The S&H subteam identified several findings and
concerns having a common root cause associated with the lack of oversight by
Health and Safety Division line managers, review of standard operating
procedures and special work permits, and review of radiation protection plans
by Health and Safety Division personnel. Program deficiencies also resulted
from the lack of "striving for excellence“ in health and safety practices and
operations by LANL line managers and staff.

4-773





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FINDINGS

CONCERN:
(TSA-2)
{RP.1-3)
(H2/c2)

FINDINGS:

Safety and radiation protection officers are being
assigned to various levels in operating groups,
divisions, and directorates.

Many of the safety and radiation protection officers were
senior staff hired from the Health and Safety Division;

can and do institute changes in radiation protection
without the involvement of Health and Safety Division
personnel. .

A few safety and radiation protection officers reported
that they did n 9 seek approval from the Health
Safety Division for changes tn 3 ai ‘opel
procedures, etc.” In addition, ey
’ ndations from Health and Safety Division.

In the standard operating procedure for one radiation

generating machine, line management is ermitted to
authorize continue On Of a Une ng Unt
without obtaining approval from the ea ‘ani
Division or the presence of a radiation protection
technician.

The following concern was not identified in the LANL
self-assessment.

Los Alamos National Laboratory has not defined the
responsibilities and authorities of safety and radiation
protection officers and their relationship with the Health
and Safety Division.

DOE 5000.3A requires that occurrences and off-normal,

- vents. be-reported, even when the ‘avert “did Not result in
Personnel exposure and/or release of radioactive materia}
to the environment.

LANL developed DOE 5000.3A categorization criteria to be
used by facility management. in deciding whether an off-
normal event is reportable.

There is no oversight required by Health and Safety
Division staff or higher management when facility
management decides that the incident is not reportable,

S&H Subteam 2 discovered a building vacuum system in the
basement of the Ion Beam Facility that had been opened in
violation of the standard operating procedure and LANL
AR 1-3, "Standard Operating Procedures and-Special Work
Permits," dated October 31, 1987, Tritium contamination
in excess of the LANL smearable tritium contamination
Vimit of 10° 0/H/106 ea? (1000 disintegrations per minute
per; 100 square centimeters) was found on the outside of
~the vacuum pump and. piping. The level of contamination
was in excess of 10° D/H/100 cm’. Operations had no

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RP.2 INTERNAL AUDITS AND INVEST: TGATIONS

PERFORMANCE OBJECTIVE: The internal audit program for bo

and unusual radiological occurrences should
assessments, :

th routine operations
provide adequate performance

FINDINGS: ° LANE has an internal audit program that meets the
. criteria and requirements of DOE 5482.1B.

. The Health and Safety Division performed audits in 1989

and 1990. A tracking system is in place which provides
the status of the Findings from these audits,

* The audit and tracking system doe

hot ide review
standard oper: edures for correc: ESS, approva

ealth and Safety Diviston; or to determine whether
standard operating procedures are current,

° A printout dated August 14, 1991, lists $2 action items
with their due dates and status. To date, 22 items have
been completed.

. The following concern was identified in the LANL self-
assessment.

CONCERN: The internal audit system at Los Alamos National Laboratory
(TSA-2) does not include all elements of the Radiation Protection
{isyeay Program to ensure prompt action.
H3/C;



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P53. EXTERHAL RADIATION. DOSIMETRY =. gee ee

Be PERFORMANCE OBJECTIVE: The routine and accident personnel radiation dosimetry
E programs should ensure that personnel radiation exposures are accurately
determined and recorded. : :

FINDINGS: > Whole body dosimeters are issued to al] LANL personnel
who enter areas where they might be exposed to ionizing
radiation. DOE 5480.11 requires issuing of a dosimeter
to anyone with the potential to receive greater than 100
mrem annual effective dose to the whole body, five rem to
either the skin or any extremity, or 1.5 rem to the lens
of the eye.

Because the minimum detectable limit for the LANL whole-
body dosimeter is 10 vem, an-annual missed-dose_aslarge,
as 108 mrem is possible with monthly dosimeter exchanges.

Whole body dosimeters are worn either directly attached
to the outer clothing or on a necklace. When the
dosimeter is on a necklace, the actual position of the
dosimeter can be ¥ to 10 cm from the outer clothing. No
studies have been made to show that the dose measured at
the surface of the body is the same as the dose at a
distance of 10 cm.

See Concern TSA-4, RP.5-3.

The following concern was not identified in the LANL
self-assessment.

CONCERN: The issuance of dosimeters to al? Los Alamos Nationa}

{TSA-1) Laboratory personnel is not technically based on the
RP.5-1) radiation dose criteria specified in DOE 5480.11.
H2/C1)

FINDINGS: ° The most likely type of radiation dose to extremities in

nonaccident situations at TA-55 is from neutron and gamma
radiation. Extremity neutron.doses are determined from
ratios of gamma-to-neutron doses for whole body
dosimeters. This ratio includes shielding and albedo
effects that may not be applicable to extremities,
especially tron doses. :

renee .

ae :

° Extremity dosimetry is not worn when handling cast
depleted uranium, 9°

. Extremity doses from handling newly cast depleted uranium

and its oxide can be significant.
poesia nemneaany

° Extremity doses are not measured accurately as required
by DOE 5480.11.

. The following concern was partially identified in the
LANL self-assessment.

CONCERN: See Concern TSA-4, RP.5-5.

4-181



Faw’

4.5.3.14 Personne] Protection

4,5.3.14.1 Overview

This portion of the appraisal was performed using each of the six performance
objectives in the Personnel Protection technical area. Concerns related to
accelerator facilities at LANL were identified in each of the six performance
objectives. The appraisal was performed by means of (1) interviews with
professional health and safety staff, (2) interviews with facility supervisors
and managers, (3) reviews of program documentation, and (4) walkthroughs of
representative accelerator facilities. The performance of both LANL and DOE
was evaluated. Findings and concerns in the Worker Safety technical area were
also considered in preparing this portion of the report.

Performance in the area of personnel protection varies greatly at LANL, Ina
few cases, such as with hoisting and rigging activities within the Dynamics
Testing Division, no deficiencies were observed, Overall, however, programs
related to personnel protection are substantially deficient. Health and
safety leadership on the part of LANL managers and oversight from DOE have
been ineffective.

Health and safety issues at the Laboratory have traditionally been addressed
from the bottom of the organizational chart instead of from the top. Although
a highly qualified professional health and safety staff is in place, none of
these individuals have the authority to cause a change in the program.

ES&H programs related to personnel protection, as described in the LANL ES&H
Manual, frequently do not reflect the requirements of long-standing mandatory
DOE requirements. For example, the administrative requirement for eye
protection does not state that the use of safety eyewear with side protectors
is mandatory for shop operations such as grinding. Within this portion of the
appraisal, programmatic-related deficiencies were identified--including those
for confined spaces, safety eyewear, lasers, steady-state magnetic fields, and

_ venti lation--that, had not been established..to meet. mandatory requirements.

Historically, there has been no oversight to ensure that LANL activities
related to nonnuclear facilities are in compliance with either the existing
ES&H Manual or with mandatory DOE requirements, Each division, and in many
cases each group within a division, has been free to comply with these
requirements to whatever extent the organization deemed appropriate. A
techanism is not even in place to require that al] operations involving

hazardous materials or operations be reviewed and approved by cognizant health ,

and safety professionals.

Oversight of LANL activities by DOE has not been effective in ensuring that
SANL is in compliance with the requirements of applicable DOE Orders. The
system of appraisal management is cumbersome and insensitive to the need to
proceed in a timely manner, In some cases, hazards persist for months while
appraisal-related documentation is processed.

The LANL self-assessment reflects a lack of experience in managing health and
safety issues. The LANL self-assessment Fully documented only a fraction of
the deficiencies identified during the preparation of this portion of the
appraisal report, It was noted, however, that the professional health and
safety personnel were aware of virtually-all the deficiencies identified but,
in some cases, have been unable to convince Management that these issues
Should be addressed in the LANL self-assessment report.

4-565

rites Bid eva a eR Fe A



2 Even if the tritium bioassay samples’ are returned on
schedule, the resuits may be delayed for 2 to 5 weeks.

e , The need for additjona) resources (staff and equipment)
to cope with the backlog nas been identified by the
Health and Safety Division but has not received
management approval.

. See Concerns TSA-2, RP.7-1, and TSA-2, RP.7-2.

. The following concern was not identified in the LANL
self-assessment.

CONCERN: The internal contamination contro} program at Los Alamos

(TSA-2} National Laboratory relies primarily on administrative

(RP.6-2) controls to maintain tritium exposures as low as reasonably

{H2/C1) achievable instead of obtaining quantitative data from
airborne, surface, and bioassay samples results.

FINDINGS: . At the building housing the Ion Beam Facility, a vacuum
system was dismantled without the presence of a radiation -
protection technician or the issuance of a radiation work

permit.

. The vacuum system was left open to the air with only
aluminum foil covering the open pipes. The power to the
vacuum pump was not locked out to prevent inadvertent
activation.

. No_ special ai ntamination sampling was

erformed during the work. eres

earn ae

. Levels of surface contamination equal to greater than 10°
D/M/100 cm” were detected during a followup survey after

S&H Subteam 2 identified the problem.

. The area surrounding the vacuum pump was a controlled
area leaving no place to establish contro] to prevent the
spread of contamination.

° The area occupied by the vacuum pump was not properly
posted as a contamination area which contained high
levels of contamination. In addition, there were no
barricade, warning sign, or step-off pad to effect
control over the potential spread of contamination.

. ALANL employee was. potentially exposed to substantial
uantities of tritium contamination (1.8., oxtde-and ~~
Sraente Bound) at the fon Beam Facility. The facility

does not provide proper controls and protection or >
PECUITE ‘BiGaSsay-anatyses-for-potentiatty exposed —

personner:
en

. The following concern was not identified in the LANL
self-assessment.

4-385



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RP.4 EXTERNAL RADIATION EXPOSURE CONTROL PROGRAM

PERFORMANCE OBJECTIVE: External radiation exposure controls should minimize
personnel radiation exposure.

FINDINGS: . At the orientation briefing for TA-21, it was pointed out
by the TA-21 Manager that many of the personnel there are
students. When asked if any of the students were less
than 18 year of age, he responded that he did not know,
but some probably were.

. DOE 5480.11 limits exposure of individual under age 18-to
0.1 rem in a year.

. The following concern was not identified in the LANL
self-assessment.

CONCERN: At Los Alamos National Laboratory, positive control is not
(TSA-1) exercised by TA-21 line management as necessary to ensure

RP.4-1) compliance with radiation dose limitations of DOE 5480.11

H2/C1) concerning minors.

4-180



5 AIR MONITORING po

”
FORMANCE OBJECTIVE: Air monitoring systems through selection, Jocation
{pration, and maintenance should ensure yeliadle estimates of air activity

+ padiojogical contre} purposes.

at the WET Facility, i les are collected
itijumafacilities 09 ify levels of airborne
adioa e makerial. conte nation 18 ces even
jough the potentia) exists to p he
derived air concentration.

WINGS: . Except

. Except at the WET Facility, the location setected for air
monitors is not based on airflow studies.

<Not enough air monitors are available to cover ali of the
tritium areas. Some air monitors are not calibrated at
the calibration facility, and some are not calibrated at

all.

. LANL instrument response checks for room and stack air
monitors. do not provide a good indication of proper
operation and are not referenced to the calibration in

accordance with ANSI N323 requirements.

. The requirements for proper Jocation of air samples and
air monitors are described in ANST Ni3.2.

. Written bases have not been provided for establishing the
alarm setpoint, and setpoints vary from building to
building.

. See Concern TSA-2, AX.2-1.

. The following concern was not identified in the LANL
self-assessment.

CONCERN: - The Los Alamos National Laboratory air-sampling and
(TSA-2) monitoring program does not meet the requirements contained
{RP.9-1) Gn DOE 5480.11, ANSI Ni3.1, and ANSI N323.



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CONCERN:
(TSA-4)

(pp4 2)
HI/c1)

CONCERN;

CONCERN:
(TSA-4)
(PP.6-5)
(41/1)

CONCERN:

A program to perform health and safety surveillance,
oversight, and: appraisals has not been implemented at Los
Alanos National Laboratory as required by DOE 5480.10 and. DOE

At the Los Alamos National Laboratory, effective programs are
not in place to identify, evaluate, monitor, and control
credible chemical, physical, and safety hazards as required
by DOE 5480.10, DOE 5480.4 and Occupational Safety and Health
Administrations regulations.

See Concern TSA-4, WS.3-1.

* See Concern TSA-4, TC.1,1.

Los Alamos National Laboratory exercises little, if any,
management or technical oversight and contro} of asbestos
abatement activities, and abatement actions are not conducted
in compliance with 29 CFR 1926.58 and Environmental
Protection Agency "Guidance for Controlling Asbestos
Containing Materials in Buildings.”

Los Alamos National Laboratory has not developed and
implemented an effective carcinogen program as required by
DOE 5480.10 and 29 CFR 1910.1200 and does not consistently
enforce its own procedure.

Laser operations are not in compliance with Los Alamos
National Laboratory AR 5-2, ANSI Z136.1-1986, and DOE 5480.4.

Los Alamos National Laboratory confined space entry is not

controlled by a qualified person aid procédures donot’ ~~

conform to ANSI Z117.1-1989 which is mandated by DOE 5480.4
and Draft 29 CFR 1910.146.

At the Los Alamos National Laberatory, chemical handling and
storage does not comply with requirements of Occupational
Safety and Health Administration regulations mandated by
DOE 5480.4, such as 29 CFR 1910.1200 and 29 CFR 1910,
subpart i. .

4,5.4.15 Worker Safety and Health (OSHA) Compliance
See Concern TSA-4, PP.6-4.

4-972



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CONCERN:
FINDINGS:

CONCERN:

appointing a custedian and an alternate to conduct the
program.

° The chain-of-custody requirement for bioassay samples

involves staff signing for receipt of the sample
Container and the sample custodian signing when the
sample is returned.

° Line management at some facilities has not accepted

*

responsibility for conducting the -chatn-of scustody

program. Consequently, the responstbility was placed on

radiation protection technicians. In several instances,
adi ection te thy

Radiation protection technicians were trained in the new
chain-of- custody requirements; however, a few do not
properly conduct the proaran. AC TA-35 Bldg. 2, Several
‘overdue bioassay samples were found. Three of the
samples were dated July 1991 (almost 4 months before they
were found). Several others were dated September 16,
1991. Sample labels were not properly completed, and

some samples were not sealed, The chain-of-custody
F) net functioning properly.

At TA-18, several bioassay samples were left beyond the
I-week pickup requirement.

See Concern TSA-4, RP.7-2.

It is a common industry practice to pick up tritium
bioassay samples the same. day. they are submitted and
process them within 48 hours in order to conduct an
effective contamination control program.

At LANL, tritium bioassay samples are picked up from
field locations once a week (on Tuesdays). Normally
these samples are processed on the following Friday, and
the results are available the following week (1 to 2
weeks after the sample is submitted by the staff person).

Some studies indicate that varying amounts of tritium may
be held up in the polyethylene container when timely
(within a few hours} processing of samples does not
occur. This retention process can be reversed if an
extra step is introduced into the analytical procedure.

See Concern TSA-2, RP.6-2.

4-388



4.5.2.13.2 Findings and Concerns .
RP.1 ORGANIZATION AND ADMINISTRATION : : . -

PERFORMANCE OBJECTIVE:—Site/faciTity organization and adninistration should
ensure effective implementation and control of radiological protection

activities.

FINDINGS: Radiation protection technicians are jot _being provided a im
ap formal radiation protection technic tan training cone — :

Some radiation Sire rpoiniaat nt received no
job-specific trainin joining LANL.

Some radiation protection technicians do not demonstrate
=p proper knowledge of h use S

CONCERN:
(TSA-2}
(RP.1-1)
(H2/C1)

FINDINGS:

equired by AT’ 4]

Some radiation protection technicians do not understand
the requirements of DOE 5480.11 and have not received
special instruction on these requirements.

iggtrument speration. ely demonstrated knowledge o

the use and interpretation of resul ts from radiation

protection instrumentation is nonuniform, Misuse and
ue

wisinterpretation of instrument results coi nm some
TaStanees PESUTE TWAT BVEFERPOSURES mn

Management has not provided the resources for proper
training of radiation protection technicians.

Training of radiation protection technicians was
identified as one of the DOE 5480.1 implementation
problems.

The following concern was identified in the LANL self- 7 |
assessment. ]

Los Alamos National Laboratory radiation protection
technicians have not been trained to meet niniaun
requirements specified in DOE 5480.11.

At the Ion Beam Facility, where an incident occurred
during this appraisal, the responsibilities of the
radiation protection technician are divided among seven
buildings. Line Management has requested full-time
Support at this facility,

Management personnel at several Facilities complained
that they do not get radiation protection technicians
agsigned Go TheT FaCTTT UTES Trresponse Te
requests.

ore

‘Approximately 100 radiation protection instruments are
out of calibration-at “One building. “Une of the
Serena owners .

4-374



current measurement of 3 the contaminat ig Tevel in the
oil, and they have not established a limit above which
the oi] must be replaced.

The Health and Safety Division staff recommended that
this occurrence be reported since several of the LANL
Categorization Criteria (DOE 5000.3A reporting criteria)
were applicable.

ividual involved has ‘dicated no no contaninat fon" and
no detectable release has been measured.”

See Concern TSA-2, OA.5-1.
See Concern TSA-4, RP.2-Z.