OP.3 OPERATIONS PROCEDURES AND DOCUMENTATION

PERFORMANCE OBJECTIVE: Approved written procedures, procedure policies, and

data sheets should provide effective guidance for normal and abnormal
Operation of each facility on a site.

FINDINGS: ° Operating procedures for the secondary beamlines at LAMPE
are out-of-date,

. Engineering support procedures in use at accelerator
facilities are not contro] led documents. Procedures were
missing from manuals used by the support staff at LAMPF.

. Cave sweep procedures have not been established for IBF,
and operations personnel stated that alternate sweep

sequences were permissible at the discretion of the
staff,

° The Operations Group at the Betatron (TA-8 Bldg. WA-23)
has no procedure for testing the interlocks. When
debriefed, two qualified operators described different
methods for Conducting the same test

. No procedure has been developed for handling flaky or
degraded targets at IBML.

. Detailed procedures have not been developed for
conducting interlock tests on Safety systems for liquid
hydrogen targets used at accelerator facilities.

° Before issuance of the 199] LANL procedure on locks and
tags, the Operations Group had conducted a Tockout/tagout

once {over 15 years ago) at the Betatron facility in TA-8
Bldg. WA-23. : a “

CONCERN: See Concern TSA-1, OP.3-2,

FINDINGS: . Operators of the TA-8 linear accelerator log only those
machine operations that result in radiographic images.

° When used in portable field radiography, the logbook for
the TA-18 linear accelerator does not record the
Placement of the device or of Postings and barriers used
to limit access to the radiation area,

. All bypasses at LAMPF are removed at the end of an
operating period. The board where bypasses are kept has
hone remaining in use. Yet, the bypass installation and

removal logbook at LAMPE indicates that several bypasses
have not been removed,

. Some entries into the operations logbook at GTA are
recorded in pencil. ne
oof

4-464



. 0 KEE

Oak Ridge Medical anc
Associated Post Office Box 117 Health Scerces
Universities Oak Ridge, Tennessee 37831-0117

April 20, 1987 ¢

Mr, Milan Makale

Department of Zoology

University of Alberta

Edmonton, Canada T6G 2E9 :

Dear Dr. Milan:

I enjoyed reviewing with you the material on the Argentina II accident of
i 9/23/83 (Osvaldo Rogulich). We have been trying to obtain medical information
: on .the case because the published cause of death (radfation pneumonitis in 49
hours) does not-seem to be correct to me. Your information from Dan Bénizson
that suggests thet this diagnosis is based on histologic evidence obtained at
autopsy surprised me because our records indicate that no autopsy was done. I
hope we are wrong, Our records also do not contaia any medical data and are
i flawed by there being two, rather than Just one, dose estimates. As far as we
~ know a definitive report in the medical literature Was never made. I hope Mr.
Jorge Skvarca will tell us @i{fferently when you write to him. Please let me

know.

I've attached a copy of a November 1983 memo I wrote to the file about a
bone marrow rem dose estimate I made from the 1400 neutron rad/400 gamma rad
exposure (7) estimate. This estimate is meaningless because of ay arbitrary
choice of an RBE of 10 for the 25% of the neutrons that might have reached his : a
marrow. se .

The other dose (?) estimate in our records is ~2000 Fads gamma ‘and 1700

. vads neutrons. Using the questionable “gymnatistics" stated in this 1983 meno
‘(assuming these rad measurements are in kerma (“exposure rads"), I derive a
corrected dose estimate of 6379 rem for the tone marrow. As long as you don't
believe that the number has any certainty, a bone marrow dose that could be
assigned to this case for reference purposes might be 5350 ren + 1030 rem (the
average of the two extrapolations I made from the two respective fields~of-
exposure-dose estimates). So 1£ you like to “round off,” You could say that

“got 5000 + 1000 xem in comparison tow ~ “d086"Of500%ren -and
dose of 8000 rem: Subtracting the nonsense out of what I've just
said, you axe left with the conclusion that’ and ¢ are in

the same class of rad{ation accident victims and died from a common pathologic
modality which is basically vescular damage according to me. Loosely speaking,
severe vascular damage, chiefly of the lung, can be called pneumonitis and
this could produce a pre-(right sided) cardise vascular obstruction that would
terminate in a forward failure, hypotension, cerebral edema, and ischemia, I
can't image therefore why the Argentine investigators didn't classify this
death as CNS. (They would have been wrong if they had.) They were tempted to
call it G.I. syndrome but I inferred from what's Keported that they didn't
believe he survived long enough for the "G.I. syndrome” to he operative.



RP.20 RADIATION MONITORING/CONTAMINATION CONTROL’

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

FINDINGS: . Inappropriate contamination controls are implemented for
personnel exiting from a contaminated area in the TA-53
Isetepe Préduction Area.

. After exiting from contaminated areas at the Isotope
Production Facility and Area A-East in TA-53, personne]
perform contamination monitoring while wearing plastic

i booties and rubber gloves. final monitoring is not
j -_ performed after ‘protective cTothing 1s removed. ~~

° Work was performed on a potentially contaminated Piece of
" equipment in the Radioactive Storage Facility at TA-53
without using controls to minimize the spread of
contamination.

contaminated area at Area A-East and in a contaminated
material storage cage in LANSCE (TA-53 Bldg. MPF-30).
Posting and contro? of the LANSCE storage area were

|
| ; : . Loose debris and dirt were observed in one section of a
i .
i incorrect.

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

CONCERN: Personnel monitoring and contamination contrat at the Clinton
(TSA-3) P. Anderson Meson Physics Facility at the Los Alamos National
({RP.10-1) Laboratory are not always conducted in accordance with the
{H2/C1) requirements of DOE 5480.11.

FINDINGS: . LANL has not developed or implemented a program to
identify, control, and store potentially volume-
contaminated material before it is released for
unrestricted use.

. Significant amounts of material at LAMPF have been
exposed to protons and neutrons and are potentially
| volume contaminated. The IBML also generates potentially
volume-contaminated material.

° LANL does not have criteria or. survey techniques approved
by the office of the Assistant Secretary for Environment,
Safety and Health to release volume-contaminated
material.

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





ra

“
CONCERN: Surface contamination limits for tritium and pure gamma emitters in

{TSA-4) Los Alamos National Laboratory AR 3-7, Appendix C, do not comply
anata with the Namits specified in DOE 5480.11.
(H/C. .

FINDINGS: > Engineered ventilation controls to prevent the intake of
radioactive materials in some plutonium areas do not have
backup power inthe event of interruption of electrical
power. -

. Following the loss of and then restoration of electrical
power in TA-2] DP-West laboratories, pre-entry surveys
were not conducted by radiation protection technicians
prior to re-entry of evacuated personnel. TA-21 does not
have a re-entry plan. .

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

CONCERN: At the Los Alamos National Laboratory, engineered controls and
{TSA-4) radiological re-entry surveys are not performed following the Toss
{RP.10-3) of electrical powen as required by DOE 5480.11; therefore,

(H1/C1} contamination control cannot be assured.

Personnel in the TA-48 Bidg. RC-1 operates under their

FINDINGS:
Giation protection plan, date

. "Self-surveying” as observed throughout Laboratory
facilities is ineffective in assuring contamination
contro}.

. Anti-contamination protective clothing removal procedures
were not posted at al] controlled locations.

* The current use of "green tags” to identify surplus
materials is an ineffective means of certifying materials
and equipment for release or salvage.

° LANL does not have a procedure approved by the Office of
the Assistant Secretary for Environment, Safety and
Health for release of volume contaminated materials and
equipment to the public.

. Radiation monitoring and contamination control procedures
(and documentation) at the plutonium and depleted uranium
areas do not ensure control of the. spread of
contamination as required by DOE 5480.11. (See
Section 4.5,1.14,2, RP.10.)

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


4.5.3.13 iological t
4.5.3,13.1 Overview

Radiological protection practices conducted at accelerator facilities,
installations with x-ray generating devices and sealed gamma ray sources, and
‘incidental x-ray radiation-producing devices at LANL were evaluated against
all 12 performance objectives of the Radiological Protection technical area,
LANL operations were reviewed against the requirements of DOE Orders,
Prescribed DOE policies and ANSI standards, documented and accepted best

practices, and recommended standards.

The Radiological Protection appraisal for radiation-generating, devices at LANL
was conducted by a team of two health physicists. One health physicist
primarily evaluated X-ray producing devices and some sealed sources, The
other reviewed radiological protection programs for accelerators and
participated in the review of x-ray devices. The appraisal was conducted by
(1) interviewing LANL employees; (2) inspecting selected facilities; and (3)
reviewing documents, procedures, and records associated with radiological
Protection programs. During the appraisal, 12 of 21 accelerators, 30 of 265
x-ray installations, and 4 sealed-source installations were inspected. These
inspections represent a cross-section of the types of radiation-producing
devices being operated at LANL.

Based on the these observations, the Radiological Protection appraisal
concluded that LANL does not provide effective management oversight for
implementation of a safety program for designing, Operating, and surveying
radiation-producing installations. Consequently, these devices do not comply
with the requirements of regulatory standards.

All observed installations having radiation-producing devices (with the
exceptions of LAMPF, LANSCE, and the Weapons Neutron Research Facility) fail
to implement at least some of the requirements for interlocks, barriers,
warning devices,. interJock and. personnel safety ‘system testing, and postings.
Some facilities do not meet any of these requirements. This is a Category IT
concern because of the scope of the problem and because LANL has not
established any sitewide standards or mechanisms to facilitate compliance with
the requirements. LAMPF, LANSCE, and the Weapons Neutron Research Facility
have .a formal and well-developed program to meet these requirements, and
although it is not perfect, it meets the principal requirements of the
Standards.

LANL has not identified the need to develop a program to identify, control,
and release potentially volume-contaminated material in accordance with the
requirements of DOE 5400.5. Radiation protection technicians and radiation
workers are not appropriately trained. Deficiencies have also been identified
in the following areas: (1) procedures; (2) control of radiation exposure
from depleted uranium; (3) selection, installation, and source checks of
radiation instruments; (4) radiation monitoring and contamination control; and
(5) ALARA programs.

Radiation protection for accelerators, x-ray devices, and source. installations
at LANL is implemented at the group level, with no single organization
assigned the responsibility for sitewide standards and oversight. Radiation
protection is a line responsibility, and the Health and Safety Division serves

4-548



January 5.

RADIATION EXPGSURE REPORT



r RP.5 EXTERNAL RADIATION DOSIMETRY

PERFORMANCE OBJECTIVE: The routine and accident Personnel radiation dosimetry
Programs should ensure that personnel radiation exposures are accurately

determined and recorded.

FINDINGS: . External radiation personnel dosimeters are exchanged ©
monthly, sitewide, without regard to a worker’s potential
for exposure.

. . The LANL external radiation personnel dosimeter is

accredited by the Department of Energy Laboratory
Accreditation Program (DOELAP) and was recently re-
accredited; however, it was not accredited in all
13 categories.
a

. The existing LANL external dosimeter cannot be used for
determini = beta or positron doses, such as
from thal} ium-204.

. LANL has determined that medium-energy beta emitters are
infrequently handled at the Laboratory and has opted not
to test in the low-energy beta categories. The dosimeter

in use cannot meet the criteria for accreditation in
those categories.

LANL has an_assessment of their -
requir =: eta dosimetry, even though
ey currently process and handle radionuclide. faving

. low-energy beta radiations. These include bromine-77,
technetium-99, and uranium. DOE 5480.11 requires the
monitoring of al? workers where the potential for
exposure exceeds 100 millirem per year to the whole body
and 5 rem to the skin and extremities. .

° The following concern was identified in the LANL self-

assessment.
CONCERN: The Los Alamos National Laboratory personnel dosimeter can not
{TSA-4) accurately measure some radiations to which workers are exposed 33
{RP5-1) required by DOE 5480.11. ~
(H2/C1)
. There is one outstanding deficiency from the last
accreditation site review: approximately 200 to 500
personnel dosimeters out of a tota OG are not
e hed a ea x a e pe Og 0 process ng. A
effective means is not in place to reduce the number of
é personnel dosimeters that are not returned on time,

. The personnel dosimeter has a lower limit of detection of
10 mrem, resulting in doses of 9 mrem or less being
recorded as zero. This practice results in a potential
missed dose of up to 108 mrem per year.

4-780



RP.G INTERNAL RADIATION EXPOSURE CONTROL PROGRAM “

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

FINDINGS: . HEPA filters on yacuum cleaners and pumps used for
[or fated areas at the Proton Storage Ring and Area A~
East in-TA-53 are not efficiency tested or replaced on a
periodic bas¥3- aie

. HEPA filters for vacuum cleaners and pumps are not
checked by an approved DOE facility before being placed
into service.

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

CONCERN: The testing program for high-efficiency particulate air
{TSA-3) filters at the Los Alamos National Laboratory does not
(RP.6-2) incjude periodic testing and replacement of filters on
{H2/c2) contaminated vacuum cleaners and pumps used at accelerator

€

facilities, nor does it ensure that the filters are certified -

by an approved Department of Energy facility before
installation.

4-559

erwin ee

“aed. asia

“ibtiieanemssties

monet


“pulsed High Energy Rad ograpiric Haent= withing K-Rays -- -- ~
{PHERMEX) personnel have no knowledge of DOE records
i Logbooks from thé’ 1960s are kept

retention requirements.
in a desk and have never been microfitmed.

° After a high tritium alarm at IBF,
No formal notes were

was held in the control room.
taken. The information was not recorded in the Jogbeok.

ees

an informal debrief -

See Concern TSA-4, OP.4-1. -

CONCERN:

|
i
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i



ow
radiation protection technicians in the Tritium/Other
Sites Health Physics Section of the Health Physics
Operations Group.

° LANL does not require that radiation protection
technicians be trained before or during assignment to
their duties.‘

» LANL policy allows individuals to perform work before
they have received radiation worker or x-ray operator

training.
° The following concern was identified in the LANL self-
assessment.
CONCERN: Training of radiation protection technicians and radiation
(TSA-3) workers at facilities with radiation-producing devices does
(RP.1-1) not meet the requirements of DOE 5480.11 and Los Alamos '

{H2/01) National Laboratory AR 3-1. i

FINDINGS: . Shielding initially installed over. Line D at LAMPF was
not designed to provide radiation protection for a

maximum credible accident. {
. Shielding at the LANSCE Target 1 Service Area is not
designed to provide radiation protection for a maximum 5
credible accident. i
*- See Concern TSA-3, OP.2-1. j
. The following concern was partially identified in the 3
LANL self-assessment. i
CONCERN: Qualified expert reviews of accelerator and shielding design, | |
TSA-3) required by ANSI N43.1, did not correct shielding {!
RP.1-2) deficiencies in the design of some accelerator facilities at ‘

'HI/C1) the Los Alamos National Laboratory.



|
i

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i
]
i
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OP.5 OPERATION STATIONS AND EQUIPRENT

”
PERFORMANCE OBJECTIVE: Operation stations and facility equipment should
effectively support facility operation.

. Persopnel_ate LANPF were not trained to use the portable

FINDINGS:
Survey instruments provided as a convenience at exits.

No external dose survey meter is available at the
Betatron in TA-8. _

chamber survey instr

release limits, and personnel are no y
fhe use and proper” dacumentation of surveys.
rtabie linear accelerators are,

neither trained nor equipped to monitor for radiation.
Health Physics Operations Group personnel do perform
monitoring but are not required to be present during

operation.
See Concerns TSA-3, TC.4-1, and FSA-3, RP,1-2.

° Operations personnel at po

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



RP.8 FIXED AND PORTABLE INSTRUMENTATION

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

FINDINGS: +  Portable-health physics survey instruments used by Tine
Personnel in some accelerator organizations are not

always source-checked before and during routihe~ ~~
Operations TM~

. Reference readings are not obtained and récorded on each
instrument by exposing them to a check source in a
constant and reproducible manner at the time of, or

; promptly after, primary calibration.
Source checks ar erformed for each ins Je
or decade normally used. @ allowed instrument response

to a source check is greater than £20 percent of the
reference value.

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

FINDINGS: . Most line personnel at accelerator facilities are not
formally-trained in the use of portable health physics
survey instruments .

ocedures establishing requirements for the control
source check, use, and return of portable survey ,
instruments by Tine personnel are not in. Place at most

accelerator facilities.
° Untrained personnel are not restricted from using
portable health physics instruments to survey and release
- potentially contaminated material. oe

° The following concern was identified in the LANL self-

assessment,
CONCERN; Procedures and training to contro} the use of portable health
{TSA-3) physics survey instruments by line personnel are not in place
(RP.8-1) at some Los Alamos National Laboratory accelerator facilities
(H2/C1) to ensure that the monitoring requirements of DOE 5480.12 and

DOE 5400.5 are met.

4-560



OP.2 CONDUCT OF OPERATIONS

PERFORMANCE GBJECTIVE: Operational activities should be conducted in a manner “F4TM ¢:
that achieves safe and reliable operation. : F id

FINDINGS: . Passive shielding for Line LI of the LANSCE beam delivery
system is insufficient to protect against accidental. beam
loss. Accidental loss can result in more than 3000 rem
per hour fields, exceeding LAMPF policy.

. LAMPF has studied the issue of shielding in the past;
however, the methods used for design and review were
insufficient to discover all problem areas.

+ The GTA will require added shielding to prevent high
radiation lévels under failure conditions of active
safety systems. :

. The barrier fence for the beam stop at the ITS/DARHT
facility is not substantial and does not prevent access
to a very high radiation area.

. The beam stop for the Free Electron Laser Tocated at
Bldg, WA-161 is obtained by directing the electron beam
into the floor with a magnet. The magnet current is
interlocked with a current comparator circuit. No active —
external radiation monitors are available.

. LANL has not effectively implemented policies or
guidetines detailing the requirements for shielding and
barriers, .

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

CONCERN: Los Alamos National Laboratory has not implemented policies

(TSA-3) for the design, installation, testing, and operation of i
{OP.2-1} barriers; moreover, accelerator operations do not ensure that Hy
{HI/€1) the dose limits of DOE 5480.11 and ANSI N 43.1 are met,

FINDINGS: ° No accelerator at LANL has implemented DOE 5480.19.
. LANL did not establish a timely schedule for compliance.

° The following concern was identified in the LANL self-

assessment. : ,
CONCERN: Operations at accelerators at the Los Alamos National
(TSA-3) Laboratory are not conducted in accordance with the '
(OP.2-2) requirements of DOE 5480.19. i

(H2/C1)

FINDINGS: . Durjng a recently observed response to an alarm at the
IBF, the reconfiguration of the building air was delayed
“and no evacuation was ordered,

4-462

|
{



wee ee a re ee tay

° Not all workers at the plutonium and depleted uraniun
facilities are evaluated for participation in the
bioassay program as required by DOE 5480.11. (See
Section 4.5.1.14.2, RP.7.)

° The following concern was addressed in the LANL self-
assessment.

CONCERN: Los Alamos National Laboratory is not effectively identifying
(tsa. *) workers for whom bioassay is required under DOE 5480.11. .
(RP.7-

(#2/C1) .

FINDINGS: . The time taken to collect, process, and analyze some

bioassay samples is longer than appropriate for timely
evatuati Ssure the a rker
jose assessment.

_—————o

. There is a deficiency in the bioassay program for short-
term workers, visitors, and students that leads to the
failure to obtain. baseline and routine samples during and
after work with radioactive materials.

° Not all managers have exercised their responsibility to
conduct the chain-of-custody program for bioassay samples
as required in AR 3-6, Appendix G. (See .
Section 4.5.2.13.2, RP.7-2.)

. The following concern was identified in the LANL seTf-

assessment.
CONCERN: Procedures for collecting, processing, and analyzing some bioassay]
(TSA-4) samples do not ensure the accuracy, timeliness, and quality of 4
(RP.7-2) internal dose assessment as required by DOE 5480.12 and Los Alams'
(H2/C1) National Laboratory AR 3-6, Appendix G.

measurements on bioassay samples.

FINDINGS: Internal dosimetry program personnel do not conduct an
internal i ure quality radiochemistry

« . Nasal smears are counted for plutonium, uranium, and
other radionuclides in the TA-55 Health Physics Analysis
Laboratory Tiguid-scintillation counter system.
Secondary faba, counting. standards. are made at LANL. for
system caJibration and quality assurance/quatity control,

ut traceability of these standards to the National
Institute fandards and Technology 1s not establisned.

e _Chain-of-custody paperwork to track bioassay samples is

not always completed, making it difficult to track the
status of many samples_or to assure that ing with
the samples did not occur. Bioassay sample collection
kits are sometimes Teft mm rest rooms and not picked up

» for analysis in a timely manner.
A

4-784



CONCERN:
{TSA-3)
(RP.4-3)
(H2/c1)

FINDINGS:

Personnel assigned to x-ray installations are not
familiar with the ANSI standards that address the
requirements for the design and operation of these
installations.

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

Definitions for x-ray generating devices in Los Alamos
National Laboratory AR 3-3 do not conform with existing
standards, and many x-ray installations do not fully comply
with ANSI N543 and ANSI N43.2.

Some open-beam x-ray devices at LANL do not have. ports
equipped with beam shutter interlocks; some have shutters
at unused ports that are not physically secured; some do
not fave guards or interlocks; and some have system
barriers consisting of plexiglass shields that are not
interlocked or otherwise passively controlled,

Some enclosed beam SCINTAG access doors are not
interlocked with the x-ray tube high-voltage supply or
primary beam shutter. The shutters, which are not fail-
safe, fail in the open position.

Some x-ray generating devices do not have separate red
warning-Tights located near all energizing switches to
indicate "x ray on.”

Interlocks, indicator lights, and other safety functions
are not adequately tested to ensure that they are fail-
safe or that they perform their intended function. Nor
are detailed procedures provided to describe how such
tests are performed.

Some installations do not have any interlocks at al], and
others have only a single interlock. Some interlocks
appear to be relatively small and of light-weight
construction.

Some open x-ray installations do not have conspicuously
posted perimeters limiting the area in which exposure
could exceed 100 millirem per hour. These perimeters are
not posted with signs reading, "Danger High Radiation
rea,

Some open x-ray installations do not have conspicuously
posted perimeters limiting the area in which exposure
could exceed a 5 millirem per hour. These perimeters are
not posted with signs reading, "Caution Radiation Area."

Open x-ray installations do not have any positive means,
such as locked enclosures, for preventing access during
periods of unattended exposure. Use of these devices is

4-557


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{

CONCERN:
(TSA-3)
{RP,3-1)
~ (41/02)
car. HW

FINDINGS: °

CONCERN:
(TSA-3)
(RP.3-2)
(HI/cl)

: FINDINGS, .

ay

See Concern TSA-3, TS.3-1.

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

The design, installation, maintenance, and testing of
accelerator interlock and warning systems at the Los Alamos
National Laboratory do not meet the requirements of ANSI
N43.1.

“The accelerator and x-ray firing areas at TA-36 are not
surrounded by a barrier, and the fences surrounding
PHERNEX and ITS/DARHT do not provide reasonable access
restraint.

The key to the main door of the building housing
1TS/DARHT is tightly controlled, but the access doer in
the rear of the building may be opened with a key that is
commonly available to workers at the facility.

Access to the upper level of the BANSHEE accelerator is
~ blocked by a gate that does not provide reasonable access
restraint.

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

Contrary to the requirements of ANSI N43.1, not all
accelerator facilities at the Los Alamos National Laboratory

have been provided with barriers that restrain access to
areas where dose limits could be exceeded.

1 is of documentation that leads from.
the radiation protection standards set forth in the ES&H
Manual to line management implementation procedures.

The Health Physics Operations Group does not have a

standard set of operational health physics procedures. A
«different set of procedures is used a each of the two
ea sics Operations Gri sections havin
Saree or SoRSTBTTIEtes- aid the two sets are not
4 < earenerens

consistent.

Procedures are not issued and maintained under a
controlled copy system, and all procedures do not have
properly completed approval sheets.

+ Most accelerator line divisions do not have standard
operat in lures for all work Felated to FadTological

or safety systems.

a tae oe a

——
CONCERN: _ See Concern TSA-1, RP.3-2,

rs
“

4-554



dosimeter under-response are derived for high exposures,

2 but. routine data are not corrected,
j @ date, LANL has not reported extremity dosimetry
e Tesults to DOE as required by DOE 5484.1.

‘+ See Section 4.5.1.14.2, RP.5.

° The following concern was identified in the LANL sel f-

: assessment.
CONCERN: The Los Alamos National Laboratory extremity dosimetry system. ;
(TSA-4) cannot. meet the external radiation monitoring. and accuracy
beep. : requirements specified in DOE 5480.11.

H2/C1)

4-782



i
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H
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|

° See Section 4.5.1.14.2, RP.3. “

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

CONCERN : At the Los Alamos National Laboratory an effective personnel

(TSA-4) dosimeter exchange program is not in place, and this deficiency is
RP.5-2) an unresolved issue from a previous appraisal conducted under
'H2/C1) requirements of DOE 5480.15.

FINDINGS: . There is no program in place to assure that the personnel

dosimeter is worn correctly by LANL personnel.

. The improper use-of-chains-and neck}aces, and the
clipping of dosimeters to shirt collars may result in

erroneous albedo measurement of neutron doses.

See Section 4.5.1.14.2, RP.5.

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

CONCERN: At the Los Alamos National Laboratory, the correct use and wearing

TSA-4) of personnel dosimeters to assure the accuracy of the measurement
RP. 5-3) of worker dose as required by DOE 5480.11 and Los Alamos National
{W2/c1) Laboratory are not enforced.

FINDINGS: . Line managers _do not mak jate ch ina staff
member’s dosimetry requirements using the Employee Health
PhyStes-CHeckT Ist [ESHA Form 3-14), is required in the
event of intra-group trans i tent changes.

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

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

CONCERN: At the Los Alamos National Laboratery, there is no Health and

{TSA-4} Safety Division assurance that accurate monitoring of either

(RP.5-4)} external or internal exposures is accomplished using current

(H2/Ci) procedures. and policies or that DOE 5480.11 monitoring requirements
are satisfied,

FINDINGS: . The current LANL extremity dosimetry system uses thick Pd
chins sensitive only to Beaton and hehcenergy sta
particles. The system cannot meet all impending DOELAP
performance objectives. .

. Extremity exposures involving neutrons are corrected i
the field using assumed neutron-to-gamma ratios, put.

these corrections are not entered in the dosimetry
records for the individual,

. High extremity exposures involving beta radiation are
investigated. Retrospective correction factors for

4-781


ane 2 i GMoniion.aithe [BE was resp’
“by Operations staff without ES&H review or approval. The

OF  ehrcuvatton that was Shout TO TE-AgprerserRas writen
. on a desk pad. Personnel were unable to provide any

technical basis for the stack alarm or vault alarm
setpoints. .

° IBF personnel declined either to attempt to reset the
alarm or to purge the monitor, noting that the monitor
was ES&H equipment and that they lacked the proper
training. IBF personnel, however, had modified the alarm
setpoint.

. During the response te the tritium alarm, IBF personnel
declined to fix a jammed strip chart rec ‘or the
stack tritium i based on ining
and Tack of system ownership. Later, the ES&H
technicians who responded to a request for service for
the tritium alarm also declined to fix the jammed strip
chart recorder because of lack of ownership.

. See Concern TSA-3, AX.1-3.

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

CONCERN: At the Los Alamos National Laboratory, the response to off-
{T5A°3) normal conditions at the Ion Beam Facility is not conducted
thee ] in accordance with DOE 5480.19.



_ INTERN AL

RP.7 INTERNAL RADIATION DOSIMETRY ”

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

FINDINGS: “ . The LANL internal dosimetry program involves staff fron
three separate organizations. The program lacks clear
organization, defined responsibilities, and authorities.

° The information needed by internal dosimetry specialists
from thé Employee Health Physics Checklist (HS Form 3-1A)
is not being obtained by internal dosimetry specialists
for various reasons.‘ In many cases, the checklists are

ot filled out and returned to the Heal STE cy
and Programs Group; in other cases the of

submitted is incomplete, inconsistent wor’
assignments, or Tnaccurate. (See Concern TSA-4, RP,5-4,)
. Employee Health Physics Checklists are often not reviewed
and resubmitted by Tine management and reevaluated by the
Health Physics Policy and Programs Group when specific
work assignments change. Reminder letters to Tine
managers from the Health Physics Policy and Programs
Group for return of checklists in many cases received no

response. One example was observed where a response was
not received after eight reminder letters were sent.

. Personnel of the Isotope and Structural Chemistry Group,
@ Ceramic Science and Technology Group, and the

Materials Technology Metallurgy Group working with
thorium-232 and its decay products during chemistry
Operations at TA-21 and TA-3 Bldg. SM-66 are not enrolled
in the bioassay Program for assessment of potential
internal exposures. Line managers were not aware that .

- thorium and- its-decay products were internal radiological
hazards and that workers handling gran quantities of
dispersable thorium oxide powders and other thorium
Compounds should be identified by the checklist system
for participation in the bioassay program.

. There is no formalized authority to allow the Health and
Safety Division personnel to stop work for Noncomp] iance
with the bioassay program checklist system.

Fequirement,

. The appendices to AR 3-6, "Personnel Radiation
Dosimetry," August 30, 1991, provide criteria for worker

participation in the bioassay program. These appendices

are cumbersome, difficult to interpret, and difficult te
implement and enforce.
eee

; Radiation protection techni

§ : Qberations involving Tadjoactive materials to ensure that
4 ker's who should participate in the bioassay program do
4 @ r 4 So. Ww Is given to enforcement of the

4-783



~
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primarily in a support role. Consequently, radiation protection programs are
devetoped and implemented without uniformity between divisions or groups
within the same division. Commensurate with this role, the Health and Safety
Division does not’ haye the authority or responsibility to develop radiation
protection policies, establish standards, or provide oversight to assure that
line organizations conform with regulatory standards.

|

Radiation protection programs at accelerator facilities are primarily
implemented as cooperative efforts between the Health and Safety Division and
the line organizations. However, the relationship and interface between line
and Health and Safety Division groups and line radiation protection officers
is not well defined. These cooperative efforts work well at TA-53 because an
entire health physics section provides dedicated support to this area. This
practice does not work well at other accelerator facilities because, in most
cases, there is only a single radiation protection technician assigned to a
facility or because it is covered by a roving radiation protection technician.

Accelerators used to produce x-rays are considered “special case" accelerators
at LANL and are treated and controlled by the Health and Safety Division in
the same manner as simple x-ray machines. These accelerators require much
more complicated radiation protectign controls and surveys than do
conventional x-ray machines. A single individual is assigned responsibility
to survey and inspect x-ray accelerators, along with concurrent sitewide
responsibilities to control about 265 x-ray machines and 319 registered sealed
sources. Effective oversight and control--in addition to compliance with
regulatory requirements--is not achieved for these accelerators, x-ray
devices, and sealed sources.

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LANL has partially recognized these deficiencies and has initiated preliminary
steps toward correcting them. Operational health physics functions have been
assigned to a single group, and changes have been made in the ES&H Manual.
More importantly, the Director has issued a series of policies assigning
radiation protection responsibilities and clarifying the interrelationship
between the Health and Safety Division and the line organizations.

The development of uniform standards and programs is essential in order to
implement these new policies. The Health and Safety Division is developing
standards and sitewide programs, but its progress is hampered by limited
resources. Line organizations are having trouble implementing radiation
protection requirements because of the absence of definitive standards,
because they do not have the necessary expertise, and because the Health and
Safety Division cannot provide the necessary technical support.

The LANL self-assessment identifies the oversight concerns regarding
radiation-producing installations; however, it does not identify the more
detailed concerns associated with the safe operation and interlocks of
accelerators, x-ray and sealed source installations, and incidental x-ray
devices. Twenty concerns have been identified by the Radiological Protection
portion of this appraisal. Of these, approximately one-third have already
been identified in the LANL self-assessment, one-third have been partially
identified, and one-third have not been identified.

4-549



implement procedures for root Cause and causal factors
analyses and review of Prior reports to identify trends
and recurrent issues.

° At present, Personnel are not assigned to review and
closeout corrective actions associated with Radiation
Occurrence Reports.

The LANL Radiation Occurrence Report system is not
Compatible with the DOE 5000.3A system and does not
include DOE 5000.3A radiological occurrence criteria,

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

CONCERN: The Los Alamos National Laboratory Radiol ogical Occurrence :
(TSA-4) Reporting System is not defined or implemented with trend analysis
Ney and followup and is not consistent with DOE 5000.3A.

H2/c. ,

FINDINGS; e Director’s Policy (OP No. 107) requires that the Health
and Safety Division develop performance indicators for
the radiological -protection program, The Health and
Safety Division has not established a sitewide
radiological protection performance indicators program,

. AR 3-8, "ALARA Program," November 30, 1990, requires that
the Health and Safety As-Low-As-Reasonably Achievable
Coordinator perform sitewide trend analysis of
radiological parameters and distribute the results to
Management. This requirement has not been implemented.

. The following concern was identified in the LANL self-

assessment.
CONCERN: Los Alamos National Laboratory has not implemented a formal
fe) Sitewide radiological protection performance indicator program as
RP.2-3) required by DOE 5482.18 and SEN-29-91,

(H2/C1)

w

4-776



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State of Nete Mexica
House of Representatifes “~~
Santa HE

“st ROVE

SEC 5!

COMMITTEES:

INTERIM COMMITTEES-

June 23, 2006

SEC 00051

Office of Compensation Analysis & Support
NIOSH MS-C-47

4676 Columbia Parkway

Cincinnati, OH 45226

Larry J. Eltiott, MSPH, CH
Director; .

In response to your letter dated May 25, 2006, I have enclosed the following. Please feel free to
contact me at ($05) 771-3059 if you have any questions or need additional information. 1 look
forward to working with you and Laurie Ishal here in New Mexico in the near future.

REFERENCE:

£5: Exhibit A. Affidavit from
Exhibit B. Affidavit from
Exhibit E. Affidavit from
Exhibit F. Affidavit from
Exhibit G. Affidavit from
Exhibit H. Affidavit from
Exhibit 1. Affidavit from
Exhibit J. Affidavit from
Exhibit K. Affidavit fro

F 2: Exhibit C. Los Alamos National Laboratory EEOICPA Dosimetry Response RE:

Exhibit D. National Institute for Occupational Safety and Health (NIOSH) on
August 16,2006 Page 6, Highlighted areas

Respectfully,





wa

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

CONCERN: + The Los Alamos National Laboratory internal dosimetry program lacks

{TSA-4} the functional elements of an internal audit program to assure the
(RP.7-3) qual ity and accuracy of bioassay measurements required by
(H2/C1) DOE dd and DOE 5480.18.

FINDINGS: ge Studie

aracterize

Sitewide studies have not been performed at LANL to

determine aerosol particle-size ibutions in

Tocattons where processed uranium or plutontum may be
y workers. ;

——_——e

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

CONCERN: At the Los Alamos National Laboratory, characterization of airborne
(TSA-4) radioactive material is not performed to allow appropriate

tueyeay’ assessment of internal dose as suggested by DOE 5480.11.

H2/€2)

FINDINGS: ° Plutonium workers in some facilities (e.g., TA-3

Chemistry and Metallurgical Research Building) handle
mixtures of plutonium, americium, uranium, and fission
Products. About 1600 workers are counted each year in
the LANL In Vivo Measurements Laboratory for potential

intakes of radioactive materials. the-Laborat ory Uses
oswich detectors: for measuring plutonium and
; unin the Tungs. Howev

not state-of-the-art and cam

» The In Vivo Measurements Laboratory cannot meet the
requirements of draft standard ANSI N13.30.

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

CONCERN: At the Los Alamos National Laboratory, the In Vivo Measurements
{TSA-4) Laboratory cannot provide monitoring appropriate to the workplace
(RP.7-5) or adequate to demonstrate compliance with radiation protection

* (H2/eh Standards as currently required by DOE 5480.11.

4-785





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RP.4 EXTERNAL RADIATION EXPOSURE CONTROL PROGRAM

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

FINDINGS:

2 The need for requirements to control dose to the skin,
extremities, and lens of the eye during work performed
with depleted uranium components has not been evaluated
and documented.

Accelerator personne] who work with dep] i .
‘coaponents or wi ichiva jets in ave not
een evaluated to determine wi er they must wear

extremity dosimeters. re
Radeaiielh< OAL AL

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

Work at the Ion Beam Materials Laboratory and with depleted
uranium components at the Los Alamos Nationa? Laboratory has
not been evaluated to ensure compliance with the external
exposure control and dosimetry requirements of DOE 5480.11.

Tate 65 X-ray gene

FINDINGS: The staff of the. fety Division is too smal?
—> to Condi] par oi suriavs-and eae aE or
Soca

CONCERN:
(TSA-3)
{RP.4-2)
(H1/C1)

FINDINGS:

accelerators, and incidental x-ray generating
instal ations.

° Periodic inspections are not always conducted to check

interlocks and access controls.

The and Safety Division staff is too small to.
provide. overs ight. of rai ~Sikeuis

rs
r--~ including 319. negi stered-sealed-sources, arid’ to conduct
the radioactive source inventory program, including
registration and leak testing.

. The following concern was partially identified in the

LANL self-assessment.

The Health and Safety Division staff at the Los Alamos
National Laboratory is too small to provide sitewide
oversight and to conduct periodic surveys and inspections for
radiation-producing devices and sources as required by DOE
5480.4, ANSI N543, and ANSI N43.1.

X-ray installations as defined by LANL AR 3-3, "X-Ray
Generating Devices," dated July 19, 1991, do not conform
to existing ANSI standards.

LANL AR 3-3 does not include guidance and requirements to
assist in the design, modification, and operation of x-
ray installations. :

4-556



. | Speclal Exposure Cohort Petition U.S. Department of Health and Human Services
. under the Energy Employees Occupational Centers for Disease Contral and Prevention |
. Uiness Compensation Act National Institute for Occupational Safaty and Health

OMB Number: 0920-0639

ires: 05/31/2007
cael Petitioner 2 !

Use this Appendix for Petitioner 2. |

‘This appendix form is fo be used as needed. Petitioner 2, or his or her representative, should complete the
parts applicable to him orher. * |

Refer to the General Instructions on completing petitioner information for Parts A, B, or C. |

If you need more space to provide additional information, use the continuation page provided af the end of
the form and attach the completed continuation page(s) to Form B.

i
|
Except for signatures, please PRINT all information clearly and neatly on the form. |

Q An Energy Employee (current or former), Start at C
if you are: | A Survivor (of a former Energy Employee), Start at B

Start at A

A Representative information — Complete Section A if you are authorized by an Employee or
Survivor(s) to petition on behalf of a class.

& A Representative (of a current or former Energy Employee),

A.1 Are you a contact person for an organization? Q Yes (Go to A2)
A2 Organization Information:

& No (Go to A.3)

Name of Organization

Position of Contact Person
A.3 Name of Petition Representative:

Mr/MrsJMs. First Name Middle Initial ~~ Last Name

AA Address:
Street Apt# P.O. Box
City State Zip Code

A5 Telephone Number: .
AS — Email Address:

AY Q Check the box at left to indicate you have attached to the back of this form written authorization to

petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization
form for this purpose is pri

Name or Social Security Number of First Petitioner: _ :



FINDINGS: . Postings at access points and marked boutdaries of
accelerator facilities, except at TA-53, are incorrectly
based on the radiation field at the access point rather
than on the radiation field within the area. The fences
around the ITS/DARHT and PHERMEX outdoor exclusion zones
are not posted as radiation areas.

. The area outside the roliup doors at the Betatron in TA-8
js not posted as a radiation area, even though radiation
levels in excess of 5 millirem per hour have been
meastired under operating conditions.

° Posted barricades have not been erected around any of the
areas where accelerators or x-ray machines in TA-36 are
used to perform radiography of explosive events. Very
high radiation dose rates exist in these areas whenever
the machines are in operation.

CONCERN: See Concern TSA~4, RP.3-1.

4-855



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OP.4 FACILITY STATUS CONTROLS

PERFORMANCE OBJECTIVE: Operations personnel Should know the status of the
Systems and equipment under their contro? and should know the effect of non-
operational systems and equipment on continued operations.- They should ensure
that systems and equipment are controlled in a manner that supports safe and
reliable operation.

FINDINGS: . system i io ensure that the environmental
qualification of monitors at F has been established
: and that use of the radiation monitors is restricted to

conditions for which the devices are qualified.

. The interlock system for the portable linear accelerator
at TA-18 uses radiation monitors with Geiger-Muller
detectors that cannot monitor pulsed radiation from an
electron linear accelerator. These devices do not
perform their intended safety function.

° The. Betatron in TA-8 does not have any radiation area
monitors. WV

. Radiation detectors at the IBF have not been evaluated to
determine whether they must be part of the interlock
system.

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

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

CONCERN: At the Los Alamos National Laboratory, continuous radiation
(TSA-3) monitoring systems, for which appropriate monitoring

. (OP.4-1) equipment is readily available, are not designed or installed
(H1/C1) at accelerators in accordance with ANSE N43.4. . .

4-466



TC.9 RADIOLOGICAL PROTECTION PERSONNEL

PERFORMANCE OBJECTIVE: The radiological protection personnel training and
qualification program should develop and improve the knowledge and skills
necessary to perform assigned job functions.

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FINDINGS: ° Three operational ‘health physics groups with
responsibilities for radiation protection technicians
required to fulfil? DOE 5490.11 training were combined
into the Health Physics Operations Group in July 1991.
Each of the three groups have been developing and
conducting radiation protection training which was
partially coordinated across all] groups.

° Two of the three groups have not specified the
requirements that radiation protection technicians are
required to complete to become certified. The Health
Physics Operations Group has no approved training plan
for radiation protection training.

Staff_within the Health Physics Operations Group could

ne eG in, initial meetings with S&H Subteams 2 and 4

Qn ign protection technicians had fulfilled
yall of the required traiitny TUr°DUE Sago Tr In

mid-October 1991 they wrote the internal “procedure

establishing the training requirements that each

technician must complete.

e Not all site-specific procedures for operations performed
by radiation protection technicians have been written.
Therefore, site-specific on-the-job training using
procedures has not been completed. (See Concern TSA-1,

P.3-2.)

. Untrained radiation protection technicians, as defined in
DOE 5480.33, are technicians that are not certified to

} have been trained. LANL untrained technicians cannot be

i identified by sight. Some untrained radiation protection

! technicians are working alone but are encouraged to

telephone their supervisors if they have questions.

. No documentation was provided indicating that lead
technicians were informed of their supervisory
responsibilities or their personal liabilities for
Untrained technicians.

operated using four, three-person shifts of trained and
untrained health physics technicians who were responsible
for 267 buildings with a variety of radiation concerns,
making it essential that each crew include at least two
trained technicians.

| ° The Clinton P. Anderson Meson Physics Facility is
}
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° Reeertification of radiation protection technicians is in
“the planning stage for each former group, but lack of

4-674



v

documentation on when the original training was completed 3
has hindered the efforts to identify the required date
for recertification. : Pad

. The requirements for the Health Physics Operations &roup
Training Coordinator for radiation protection technicians
cannot be fulfilled as a half-time position.

. The radiation protection techician training program is
not audited periodically as required by ASME NQA-1-1989.
(See Section 4.5.2.5.2, 1.9.)

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

CONCERN ieee At the Los Alamos National Laboratory, radiation protection
(TSA-4, technician training does not meet the requirements of DOE
(10.9-1) 5480.11.

{H1/C1)

8-675



~ : RP.2 INTERNAL AUDITS AND INVESTIGATIONS

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

FINDINGS: . Internal appraisals of radiological protection have not
been performed for any accelerator facilities.

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

4-552 . j



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have required warning signs at the entrance to the
installation.

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

CONCERN: At the Los Alamos National Laboratory, the two gama irradiators in
(TSA-4} the TA-43 Health Research Laboratory do not have positive controls
(RP.3-3) for radiological protection as required by ANSI N543-1974,

cate it

CAT.

FINDINGS: Line managers "must ensure" compliance with the
requirements specified in AR 3-4 "Radioactive Source

Control," July 19, 1991, However, only 76 of 209 groups
at LANL have complied. .

ak testing of encapsulated radioactive Sources does not
meet the requirements of AR 3-4 and, in many cases, has

never been performed. Only one-third the required tests
have been completed.

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

CONCERN: There is no program at Los Alamos National Laboratory to identify
{TSA-4) deficiencies in radioactive source contro] and to assure the

{RP.3-4) integrity of encapsulated sources, as required by Las Alamis
(#i2/C1) National Laboratory AR 3-4.

FINDINGS: There is no audit program in place to identify
discrepancies in the radioactive source control program,

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

CONCERN: The source contro] and audit program (inventory, location, and

fess) Sustodian) does not comply with Los-Alamos National Laboratory AR
-3- 4,

(H2/C1)





ee



CONCERN:
(TSA-4)
(RP.20-5)
(#2/¢1)

CONCERN:

{1sA4)
RP.10-6)

(ti2/C1)

The Los Alamos National Laboratory radiation protection plans and @
procedures do not preclude the spread of radioactive contamination’
Doe epovers and the public as required by DOE 5480.11 and

Areas exist within certain firing test areas where a
radioactive uranium “hot spots" have not been identified.
TA-15 is one example where there are readily identifiable
pieces of depleted uranium on the ground.

The need for extensive radiation protection procedures
(respiratory protection, bioassay, etc.) was considered
by LANL to be unnecessary Following previous experience
- with health physics coverage of test-firing areas,
However, there is no documentation of those Findings.

Cleanup procedures following test Firings of depleted
uranium do not comply with DOE 5400.5 and DOE 5480.11 for
radiological controts.

The following concerns were not identified in the LANL
self-assessment.

At the Los Alamos National Laboratory, the partial cleanup of sited
following test-firing of depleted uranium does not prevent the
further release of uranium to the environment or the spread of
contamination by workers on the site; satisfactory cleanup ts
required by DOE 5400.5.

At the Los Alamos National Laboratory, there are deficiencies in
the procedures and documentation of health physics surveys,
bioassay results, and studies on the spread of contamination by
airborne transport or other means after test-firings using deple
uranium; these radiological protection procedures are ‘required to
document need, quality, and appropriateness as required by OE 43
$480.21.

4-788



—

LAMPE
(TASS) 7
a
other
— Accrenahels



CONCERN: At the Los Alamos National Laboratory, specification of .

(TSA-4) radiologically controlled areas and the posting of the radiological

(RP.3-1} conditions of hat-spots, access points, and perimeters are not

{H2/C1) consistently in compliance with the requirements of DOE 5480.11.
Contaminated items, such as wood Scraps, wire rope and

FINDINGS: .

hooks, tools, pumps, and other equipment were improperly
stared in the depieted uranium storage area of the TA-3
dg. 66.

Packaged radioactive waste was stored in mislabeled areas
within corridors of the Chemistry and Metallurgical
Research Building.

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

CONCERN: The practice of storing materials and radioactive wastes at Los
{TSA-4) Alamos National Laboratory does not comply with recommendations
(RP.3-2) given in DOE 4330.4A, Chapter 2.

(H2/C2) ’

FINDINGS: . Although line management is responsible for the approval

of standard operating procedures and special work permits
to identify potential hazards, Health and Safety Division
personne? are not required to be involved in either the
development process or the review process until the
procedure has been approved by line management.

There is no assurance that Health and Safety Division

recommendations are incorporated into standard operating
procedures and special work permits.

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

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

FINDINGS:

—>

o

‘The large cobalt-60 (2500 Ci) sealed-source irradiator in
the TA-43 Health Research Laboratory does not have )
audible or visual warning devices to alert personne
within the installation that the startup procedure is
being initiated; (2) a "crash" button within the
installation that can be used by personne] remaining in
the instatlation to interrupt the startup procedure or
the active beam; or (3) required warning signs at the
entrance to the installation. Operating personnel
maintain that the video camera within the installation is
sufficient for identifying personnel working in the
enclosure, However, a brick wall constructed around the
sealed source obstructs the view of the’ camera.

The large cesium-137 irradiator in the TA-43 Health

Research Laboratory has two sources {about 900 Ci, and 9
“Ci, respectively). This irradiator has neither the

required audible or visual warning devices, nor does it

4-778



CONCERN: Los Alamos National Laboratory does not have a program to

(TSA-3) ensure that the unrestricted release of potential?y volume-
(RP.10-2) contaminated material from acceleratar facilities is
(H2/C1) conducted in accordance with the requirements of DOE 5400.5.
FINDINGS: . Standards, procedures, or requirements are not in place

to perform prestartup surveys at accelerators that are
used as x-ray machines.

Surveys of the portable linear acceterator used at the

Betatron i = sider. fa worst-
Scenario involving scattered radiation. from the
adiographed. -

° Operating restrictions based on the results of surveys
are not established for all accejerators.

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

CONCERN: Prestartup and routine surveys at some Los Alamos National
{TSA-3) Laboratory accelerators are not performed in accordance with
(RP.10-3) the requirements of ANSI 43.1.
(H2/C1)

-

4-562



4.5.3.13.2 Findings and Concerns “
RP.1 ORGANIZATION AND ADMINISTRATION

PERFORMANCE OBJECTIVE:’ Site/facility organization and administration should
ensure effective implementation and control of radiological protection
activities.

. FINDINGS: . The Health and Safety Division has oversight.
responsibility for radiation protection at accelerator
facilities, but forma] mechanisms are not in place to
ensure that line management complies with radiological
protection requirements.

. LANL does not provide management oversight for
- implementation of a safety program for design and
operation of facilities with radiation-producing devices.

0: | acrelarators.do not have-2- desianated radiation,
tection officer as required by ANSI i.
fe Y ith a designated FadTation zx .

celerators Wi gi ‘adTacion protection
officer have not established position descriptions,
minimum qualifications, and procedures for implementing
the radiation protection officer responsibilities defined
in ANSI N43.1. .

. Qualified individuals are not assigned as radiation
protection officers for x-ray devices as required by ANSI
N43.2 and ANSI N543. The role of the x-ray safety
officer relative to the x-ray machine radiation
protection officer required by ANSI standards is not

lefined.

® The division of responsibilities and interaction between
radiation protection officers and the Health and Safety
Division are not defined.

CONCERN: See Concern TSA-2, RP.1-2.

FINDINGS: © . Sone Dynamic Tasting-Divison-pargonne? who work with
dep1ted ura or in the proximity of accelerators and
radiation-producing devices are not classified and
trained as radiation workers. A review of 1990 Dynamic

Testing Division dosimetry records indicates that some
7 : iat sore t

personnel received. more, thas.100 millirem dur’

—_ fre not classified as radiation workers. Se

ee aaroars
Individuals who operate radiation-producing devices or
who work with radioactive material are not always trained
as radiation workers, even though they are defined as
such by LANL AR 3-1, "Radiation Protection Program,”
dated August 30, 1991.

7
ve A formal training program for radiation protection
technicians at accelerator facilities is not in place for

4-550



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RP.3 RADIOLOGICAL PROTECTION PROCEDURES AND POSTING

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

consequences,
FINDINGS:

CONCERN:
FINDINGS:

Radiation protection procedures developed at the division
evel for various buildings and operations are

inconsistent throughout the Laboratory. Procedures used
by different groups within the Health and Safety Division

are also inconsistent.

The Health and Safety Division does not, in many cases,
participate in review of organization and site-specific
radiation protection programs.

Some LANL divisions are preparing separate DOE 5480.11
implementation plans that are inconsistent with the
sitewide implementation plan approved by DOE,

See Concern TSA-1, RP.3-2.

Criteria for defining, selecting, and identifying
radiologically controlled areas are not consistent
throughout the Laboratory.

The posting of controlled areas is not uniform or
consistent throughout the Laboratory and is not in
compliance with DOE 5480.11.

The technical bases for defining controlled areas is not
documented.

The posting policy is not uniform throughout LANL
technical areas and facilities.

Posted radiation survey information was found to be more
than 1 year out-of-date in several facilities.

Signs used to indicate controlled radialogical areas are
often not of acceptable quality or color and often do not
contain information on the current radiological status of
the area as required.

Radiological hot-~spots within controlled areas are not
consistently posted according to DOE 5480.11, ANSI N2.1,
and LANL AR 3-7, (See Section 4.5.1.14.2, RP,3.)

Radiological area posting at access points and perimeters
is not performed in accordance with the requirements of
DOE 5480.11. (See Section 4.5.2.13.2, RP.3,)

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

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ie ‘

unattended because operators are located in a bunker with
no visual access to the exposure area.

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

CONCERN: Not all x-ray installations at the Los Alamos National
(TSA-3) Laboratory include access control and warning devices
(RP.4-4) required by ANSI N43.2 and ANSI N543.
(H1/C1)

“

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+3 RADIOLOGICAL PROTECTION PROCEDURES AND POSTING. “*
PERFORMANCE OBJECTIVE: Radiation protection procedures for the contro] and

;
;

use of radioactive materials and radiation generating devices should provide
for safe operations and for clearly identified areas of potential

Interlock testing at TA-36 and TA-15 determines whether
the failure of an intertock will prevent the machine from
being operated. This type of test fails to evaluate
whether the interlock system will shut down the machine
during operation.

The interlock test procedures at ITS/DARHT, Beam
Accelerator for Novel Super High Energy Electrons
(BANSHEE), and GTA confirm that the controller receives a
scram signal but does not verify that the operation
interrupt performs as designed.

Many accelerator facilities do not perform and document
full interlock testing every 6 months, and some do not
perform any formal interlock checks at all.

Access points to outdoor exclusion areas at PHERMEX and
ITS/DARHT are not equipped with interlocks. Entry te
these exclusion areas is not passively controlled to
prevent activation of the accelerator while personnel are
in the exclusion zone.

Scram switches are not installed in al? exclusion areas
{indoor and outdoor) at accelerator facilities. Many
interlocks are designed so that a local reset, followed
by a reset at the console, is not required to resume
operations. Interlock hardware, solid-state relays,
programmable controllers, and associated wiring are not
hardened and tamperproof. Some facilities do not
maintain formal controlled copies of interlock
schematics.

Entrance points to all high radiation areas do not have
warning lights. In general, there is no consistency in
warning lights between different facilities, and an alarm
does not sound when a warning Tight malfunctions.

Software used to implement the interfock logic at IBF and
PIXY is not developed, tested, and maintained using
formal QA controls. Testing is not performed every time
the program is loaded, and the interlock logic
configuration at IBF is chosen from menu selections that
are not independently verified by another operator.

Evaluations have not been performed at all facilities
with radiation producing devices to determine when
duplicate or redundant interlocks must be installed as
recommended by ANSI N43.1 and NCRP 88.

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CAR

RP.10 RADIATION MONITORING/CONTAMINATION CONTROL

PERFORMANCE OBJECTIVE: The radiation monitoring and contamination contro}
Program ‘shoutd ensure worker protection from radiation exposures. -

os

The use of front hoods in the TA-3 Ch

Metallurgical Research Building leads to an increased
frequency oF Fadtoact ive material contamination

incidents,

AR 3-7, "Radiation Exposure Controt,” January U1, 1991,
refers to a workplace tonitoring program. Responsibitity
for a current plan rests with each line manager,
resulting in different radiation Survey programs and
program inconsistencies,

Cracked glovebox gloves Contaminated with Plutonium were
observed in TA-2) Bldg. 146.

The storage of new HEPA filters was found to have signs
th rodent infestation that could lead to rodent damage of
the filters,

TA-21 Bldg. 5, room 500A, has various vacuun systems and
pumps connected with tygon tubing. The tubing has
several low spots with most having 04) accumulations.

LANL does not have a formal program to ensure quality and
timely radiation Surveys as required by DOE 5480.11.
(See Section 4.5.2.13.2, RP.10.}

Floor surveys in TA-55 Bldg, PF-4 are not performed at a
Frequency or with the precision to ensure the . .. .

minimization -of the spread of contamination as required
by DOE 5480.11. (See Section 4.5.1.14.2, RP.10.)

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

CONCERN: ". At the Los Alamos National Laboratory, the lack of thorough
(TSA-4) radiation protection practices could result in loss of

{RP.10-1) contamination contro] required by DOE 5480.11 and the release of  ;
{HI/C1) radioactive materials in excess of limits specified ia DOE $400.5,

FINDINGS: e

The removable- and fixed-contamination limits for tritium
and pure gamma emitters are Specified in AR 3-7, Appendix
C, as 100,000 disintegrations per minute per 100
Centimeters square. This limit contradicts the surface

Contamination limit specified in OOE 5480.11, Attachment
2 4

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

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AX.5 VENTILATION SYSTENS

PERFORMANCE OBJECTIVE: Yentilation systems should reiiably direct al]
airborne effluents from contaminated zones or potentially contaminated zones
through cleanup systems to ensure that the effluent reaching the environment
is be oH the maximum permissible concentration and is as tow as reasonably
achievable. Pane

FINDINGS:

In TA-48 Bldg. 1, Radio Chemistry, magnehelic gages in
the exhaust system at the point of discharge are not
routinely calibrated. (See Concern TSA-4, QV.4-1.)

« - In TA-48 Bldg. 1, Radio Chemistry, the exhaust system
recently had to be shut down to replace the HEPA filters = -
when airflow became inadequate. ne .
q

° In TA-48 Bld istry, alpha hood ventilation
is being controlled in a reactive mode by changin
filters based on periodic airflow checks; the system has
no real time equipment, with alarms, to notify occupants
when ventilation is inadequate.
° LANL does not have a real time program for capturing
change in pressure data over time in order to predict the
appropriate time for filter changes.

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

ia
5 CONCERN: Los Alamos National Laboratory has not implemented a program
EB (TSA-4) for utilizing available data to alert when high-efficiency
‘AX.5-1) particulate air filters should be changed as required by DOE
: 2/1) 5480.19.

FINDINGS: ° TA-59 Bldg. 1, Occupational Health, is an aging facility
with air-balancing problems in the ventilation system,
which has had several modifications since the original ..

design.

. Current air-balancing problems with the ventilation
system surfaced about 2 years ago. i

. Flue gases from the two forced-draft gas-fired boilers
have back-flowed carbon monoxide into the basement of the
facility on several occasions.

. The exhaust from the forced-draft gas-fired boilers, the
ventilation exhaust, and the laboratory hoods discharge
into the same exhaust stack in close proximity to each ,
other.

oe In TA-59 Bldg. 1, Occupational Health, the facility
outside air dampers were held open by 2-inch by 4-inch
wooden props, indicating control problems with aging
equipment.

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