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T r i – V a l l e y C A R E s 

Communities Against a Radioactive Environment

 2582 Old First Street, Livermore, CA 94551 z (925) 443-7148 z www.trivalleycares.org

October 29, 2007 

Department of Health and Human Services 

National Institute for Occupational Safety and Health (NIOSH) 

Robert A. Taft Laboratories MS-C34 

4676 Columbia Parkway 

Cincinnati, OH 45226 

Transmitted Electronically to NIOCINDOCKET@cdc.gov 

RE: Initial Comments on Summary Site Profile for Sandia National Laboratories in Livermore, California 

Tri-Valley CAREs has been actively monitoring the Livermore and Sandia labs for over twenty-five years. During 

this time, Tri-Valley CAREs has been very careful to document the accidents and releases that have come to light 

and has worked closely with workers in those endeavors. We now hold support group meetings for sick workers, 

many of whom have or will apply for compensation under the Energy Employees Occupational Illness and 

Compensation Program Act (EEOICPA). 

The number of workers from Sandia / Livermore who have received compensation through the EEOICPA 

program is dismal. Out of 221 cases filed as of October 14, 2007, only 12 cases have been paid. That is 

approximately 5% of all of the claimants. While we witness the sickness and death that these workers suffer that is 

clearly due to their exposures, we are horrified as we see the former workers and their families suffer through this 

complicated and frustrating compensation process. In light of this, we are especially disappointed by the quality of 

this Site Profile summary document. 

In our review of the Sandia Site Profile, we have found numerous inaccuracies and shortfalls that significantly 

disadvantage the worker in the dose reconstruction process. Our evaluation of the Site Profile revealed major 

oversights and inconsistencies in the document that conflict with the documentation that we have gathered. 

Defective procedures, missing documents, absent references, and omitted incidents are its most significant flaws. 

We have recommendations to include additional sections and supplementary information to achieve a more 

accurate dose Site Profile that does not so negatively prejudice the sick workers’ claims. We urge you to revise the 

Site Profile to include our comments, recommendations and general concerns that we outline below. 

Problems with dose calculations:

NIOSH states: “As much as possible, the basis for dose to individuals should be the dosimetry records.” However, 

we have encountered many flaws with calculating dose in this manner. Lab workers were not properly instructed in 

the application of the dosimeter badges, including the fact that they should be worn on the chest outside of clothing 

in order to be function properly. Many factors prevented the badges from accurately recording radiation. Workers 

were instructed to wear their badges behind their plastic security badges, effectively shielding radiation from 

reaching the dosimeter! This is not mentioned in the Site Profile but clearly represents a major impediment to the 

radiation monitoring at the site. The accuracy of these records is at best questionable and therefore reliance upon 

these records should be qualified with a section disclosing the known problems with dosimeter monitoring through 

the years at Sandia, Livermore. 

Peace Justice Environment 

since 1983
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References:

The Site Profile list of references did not include a number of valuable reports that could significantly affect the 

dose reconstruction process. At times the Site Profile inadequately incorporated the information it did reference. 

We recommend the following documents be included / emphasized: 

The Tiger Team Report from 1990 was not given any consideration in the Site Profile. An empty notation on the 

list of references does not help workers. The report should be incorporated meaningfully into the Site Profile 

document. This report must be given paramount consequence and weight because it casts doubt on the 

Environment Safety and Health programs within the lab that existed prior to 1990. This report contradicts the Site 

Profile’s implicit assumption that rules and regulations on the books accurately reflected the actual practices at the 

site. 

This document contained the following observations about Sandia’s internal processes: 

- Widespread noncompliance exists relative to DOE Orders, Federal regulations, and SNL procedures. 

- The deficiencies identified during this assessment exist largely as a consequence of the lack of trainings, 

procedures, and an audit program. Some supervisors are not carrying out their responsibility in the areas of 

making data sheets available and accessible, labeling containers with a description of their content and 

hazard rating and consistently communicating safety information to working level employees. 

- Sandia management systems lack the control, discipline and formality necessary to consistently accomplish 

Environment Safety and Health objectives.

This shows that the practices at the Sandia, Livermore site cannot be correlated to the rules on the books. To 

assume that procedures and practices were followed does a disservice to the workers seeking compensation through 

the already frustrating EEOICPA process. 

The Occurrence Reporting System is absent from Sandia, Livermore Site Profile. This is a system of 

documenting most accidents at Sandia. It is a veritable goldmine of information about exposures to workers and the 

history of accidents. It does an injustice to the workers to fail to include and consider these documents. 

Incident Reports were also omitted from any mention in the Site Profile. They, too, contain information crucial to 

profiling the Sandia, Livermore Lab and understanding pathways to worker exposures.

The DOE publication Operating Experience Weekly Summaries were processed as external sources of lessons 

learned information. These relied upon daily operations reports, notification reports, and time permitting, 

conversations with DOE facility or field office staff. The Operating Experience Weekly describes accidents at 

Sandia Lab, which must be included. Some faults found in the reports include inadequate procedures, workers’ 

incomplete understanding of systems they operate, inadequate work planning, and changes in job design. 

Documentation about Decommissioning and Decontamination of buildings was omitted from the Site Profile. 

In addition to listing decommissioning dates when a building is put out of use, a separate section dedicated to 

Decommissioning and Decontamination should be included as well. Whenever buildings are demolished or 

decommissioned, a substantial amount of documentation is created that describes the actual, rather than the 

expected or recorded, contamination in a building. This information will substantiate workers’ claims that 

contamination exists when the other official records do not support it. It is the responsibility of NIOSH to include 

this information in the Site Profile process to shift some of the onus of documentation away from the workers. 

These sick workers who were told to not keep documentation of classified or “sensitive” activities are now asked 

for documents to substantiate their memories. This is unjust and can be alleviated by good faith efforts to 

incorporate this information and the associated data into the Site Profile process and into the dose reconstruction 

assumptions. 
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Pursuant to the National Environmental Policy Act and the California Environmental Quality Act

documents have been drafted that contain a lot of information from the last four decades about the types of 

materials in different areas of the laboratory, proposed projects, known contamination and projected releases based 

upon routine operations. These documents should be mined for information to include in the Site Profile and 

should be listed as references at the end of the Site Profile. To offer but one example, state regulators discovered 

that Sandia, Livermore was running a hazardous waste incinerator that did not have a permit. Moreover, the Sandia, 

Livermore permit application that regulators were in the process of evaluating did not disclose or mention the 

incinerator. Only after state regulators found it during an onsite inspection did Sandia, Livermore end the practice 

of burning hazardous wastes in it. 

Significant events/incidents not included in Site Profile:

We’ve spoken with a number of workers from Sandia, Livermore who were exposed to ionizing radiation and other 

toxic and hazardous materials while on the job. Here are a few accounts of accidents at Sandia as told by former 

workers. These accidents should be included in the Site Profile. 

1973 or 1974: PCB spill 

One worker drove a forklift of capacitators containing PCBs in 21⁄2 ft tall crates. The forklift hit a lip in the land, 

resulting in an oil spill on the ground and the worker was exposed to the contamination. 

(Interview with Retired Sandia Worker) 

Jan 14 or 16, 1975: Fuel Oil Tank Leak 

During construction, a contractor drove a grounding rod through the feed line connecting the fuel oil storage tank 

to the central boilers. On the 31st, a natural gas service to Sandia, Livermore was interrupted and oil was let into the 

line so that oil could be pumped from the fuel oil storage tank into the day tanks serving the central boilers. A gross 

leak resulted, which was discovered on Feb 11 after rain displaced oil to the surface. About one third of the fuel oil 

stored there had seeped into the ground. (Draft – environmental impact statement – Livermore Site, Sept 1978) 

1978 and 1979: 2 X-ray Diffractometer incidents 

There were two incidents involving a mechanical failure of a safety interlock and the bypassing of a shutter in an Xray Diffractometer. The 1979 incident was mentioned in the Site Profile, while the 1978 incident was not. In the 

1978 incident, the safety interlocks failed while calibrating a Diffractometer. As a result, the operator received an 

accidental elevated exposure of ionizing radiation. Unaware of the shutter failure the operator continued with the 

calibration exposing himself and those in the vicinity for a 20-30 minute period. Still unaware of the shutter failure 

the operator was further exposed when he placed a fluorescent screen in the direct beam to verify calibration. The 

operator received a direct beam exposure for another 2-3 minutes. The resultant exposures were to the operator’s 

fingers, hands and arms, and upper trunk of the body. At the time the dosimeter was not in view of the exposures 

and there were not any area monitors to record the radiation that was being emitted about the room. 

In the 1979 incident, the shutter was removed, which allowed a full intensity beam without any shielding or 

collimation to reach the operator. A reenactment of the 1979 incident showed that at the closest exposure point, the 

beam size was 13 centimeters in diameter and the exposure time ranged from 15 to 20 seconds. 

 (SEC Petition Evaluation Report: Sandia National Laboratories, Livermore 

http://www.cdc.gov/niosh/ocas/pdfs/sec/sandiaca/ersnl.pdf) 
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Circa 1991: Valve Crack - Tritium Release 

A tritium leak occurred at Sandia Livermore, when a Teflon seat in a pressure regulator valve on a 

deuterium/tritium bottle cracked after exposure to the 800-psi gas mixture. Operations personnel did not realize 

that the pressure regulator contained Teflon; therefore, they took no special precautions. 

(Operating Experience Summary http://hss.energy.gov/csa/analysis/oesummary/oesummary2006/2006-

14screen.pdf) 

1996: Tritium Accident 

Four workers involved with dismantling the Vacuum Effluent Recovery System (VERS) and Gas Purification 

System (GPS) were involved in an incident with tritium contaminated hardware. The VERS typically collects 

effluent from gloveboxes and the exhaust from vacuum pumps. The oil from the vacuum pumps normally 

condenses in its exhaust manifolds. In BUILDING 968 Room 115A, workers were cutting up contaminated copper 

and steel pipe with Jaws of Life units. They encountered an unknown oil pocket which spilled on one worker’s 

garment and shoes. Work was suspended, the oil spill was cleaned up and the room was evacuated. Bio-assay and 

perspiration swipes (sample) were immediately taken which showed elevated radioactive levels in the body. 

Inappropriate Procedures:

In addition to specific incidents that harmed lab employees, long-term practices that led to radioactive exposure 

should also be acknowledged in the Site Profile. These exposures are not listed because they were part of standard 

procedure and thus not classified as ‘incidents’ or ‘accidents’. There may be various areas and tasks within the 

Sandia, Livermore site of this nature that have been overlooked. These ongoing exposures should be documented 

because they may not be reflected in dosimeter readings. The following accounts illustrate a few examples: 

- Instrument repair: 

Contaminated electronic instrumentation and hardware used in explosions at tests sites are one example. 

From their mobile trailer unit the workers would normally power was them with water and a detergent in an 

open booth prior to working on them. The water bath was recirculated and used over and over again 

resulting in a contamination build up. The workers wore gloves, aprons, and safety goggles for protection. 

The booth was not monitored for contamination, radioactive or toxic, and dosimeters were shielded by the 

aprons. Workers may have been at risk of long-term exposure. 

-Tritium lab alarm response: 

Employees would be called to respond to alarms in the tritium laboratory. These alarms typically 

represented a malfunction, either an operational or hazardous situation. When a responder was called in to 

mitigate a situation, such as a tritium monitor alarm, the operator was often unaware which form of tritium 

was present as the tritium monitors did not distinguish between tritium gas and tritium oxide. In some 

circumstances the situation required additional personnel who were also potentially exposed. 

- Tritium monitor calibrations: 

Workers would use radioactive materials such as cesium-137and strontium-90, replicating (respectively) low 

level and high level exposures, to verify tritium monitor calibrations. Workers handled these radioactive 

sources with their bare hands or on the end of a long rod to reach the tritium monitor ionization chamber. 

This practice was a likely pathway of exposures’ that went unmonitored as personal external dosimetry 

badges were no longer utilized during this time period.