4.0 EXECUTIVE SUMMARY
Introduction

On October 16, 2000, a Department of Energy Rocky Flats Field Office (DOE-RFFO)
sepresentative performing a routine surveillance in Building 771 found that an air
sampier being used for monitoring airbome radioaciivity levels inside the containment
tent in Room 186 was past due for calibration. Upon further investigation, building
management determined that routine measurements from the air sarnpler were not
Properly documented from September 7 through October 17, 2000. Subsequent testing
on the air sampler demonstrated that it was within calibration tolerances and functioning
Properly.

Bioassay monitoring of individuals associated with D&D operations in the Room 486 tent
was initiated. A total of 11 workers who worked in the containment tent between
September 7 and October 17 submitted fecal samples for bioassay. All of the workers
had been wearing the required level of personal protective equipment while working in
the tent. This equipment included full-face powered air purifying respirators and anti-
contamination clothing. :

Preliminary bioassay results, issued in late November 2000, showed unexpected levels
of intemal exposure in 10 of the 14 workers. To further quantify the results, 3 workers
with the highest results were assayed using a tung counter. Results indicated exposures
of less than the minirnum sensitivity of the lung count analysis.

Rocky Flats site managers requested reanalysis of the initial bioassay samples, offered
the opportunity for volunteers to provide fecal samples, suspended work in Building 771,
and began a review to identify the source of the radioactivity that caused the positive
fecal results. The management review identified numerous contamination control
weaknesses for which compensatory measures were applied. However, a clear Source
for the internal depositions was not identified. As the investigation progressed,
additional waste workers and several individuals who provided voluntary fecal samples
also showed positive fecal bioassay results. As of the time of this report, some samples
continue to be analyzed. Results for nine of the original 11 workers.are in.the range of 6
millirem to-60 millirem, which Is a 50-year committed effective dose equivalent. This
equates to 0.12 to 1.2 millirem per year over a 50-year period. Results are pending on
two of the original 11 workers. One of these two is expected to also be in a similar
range. The fast worker's dose is expected to be somewhat higher than this range, and
the Site continues to review the possibility that this worker was involved in a separate
event. A discussion of these two workers is included as Appendix 2.

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An Investigation Team was chartered December 13, 2000, to investigate the source of
internal exposures involving personnel! in Building 771.

Investigation Methodology

The Investigation Team reviewed work histories of the personnel and reconstructed a
timeline of their activities. Records and documents pertinent to Building 771 radiological
safety, work controls and the site radiological safety program were reviewed. Personnel
pertinent to the incident, building managers, and other support personnel, were
interviewed.



°

7.0 RECOMMENDATIONS

Training Recommendations Include:

Develop a Toolbox briefing for Site RCTs conceming the proper method to detect
alpha contamination. This training shall include increased usage of large area wipes,
increased use of the SAC-4, and guidance on the handling of wet swipes and
surfaces.

Incorporate the lessons leamed from this investigation into the various modules of
RCT and RCTTS continuing training.

Develop a training package on improvements needed in radiologicaf records and
documentation and train RCTs and RCTTS in the modules of RCT Continuing
Training.

Develop an ALARA “Too! Box® briefing for D&D workers and First Line Supervisors
that is similar to the Leaming Objectives for the ALARA Training for Technical
Support Personnel and that stresses the lessons leamed from this investigation.
Provide examples of key conditions to include during interpretation of smoke-testing
data in Radiological Engineer Training. Develop and provide training.

Provide awareness training for Radiological Engineers, Planners, . Building
Management related to potential radiological hazards that need to be considered and
on engineering controls to mitigate the hazards.

Train Radiologicat Engineers, RCTs, and RCTTSs on proper performance of smoke-
testing.

Hold a toolbox on changing hazard recognition to inform workers and first-line
supervisors of the need to involve Radiological Engineering when radiological
conditions change and/or when existing controls are insufficient to control demolition
dusts. This training has been conducted and documented by the project.

- Procedure Recommendations Include:

Modify Site procedures to require independent Radiological Engineering review of

the use of point sources as an engineering control. :

Réquire mock-up, smoke and velocity testing of any new ventilation designs prior to

actual use,

Modify Site procedures to require the optimal design of focal ventilation controls.

Require mock-up and smoke and velocity testing of any new hood designs prior to

actual use.

Modify the RWPs to evaluate the need for respiratory protection when handling

Jaundty, low-level and transuranic wastes, when opening drums and TRUPACTs that

contains these items.

Modify RSPs

> to require formal quarterly “During Work ALARA Job Reviews” for work activities
covered by AJRs extending for more than 3 months.

> toaliow the RCTTS to determine release points on airflow pattem surveys with
concurrence from the Radiological Engineer :

> to inelude documentation of vertical references for smoke release on airflow
pattern surveys.

> to include examples of configuration changes that require AME placement
evaluation.



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without respiratory protection. Operations included the packaging of waste bags into the
appropriate waste containers pending final disposition.

Waste bags were usually surveyed with a Ludlum 12-1A prior to their transfer to Room
179. These susveys typically included a scan and large area wipe of the exterior surface
of the bag.. The large area wipe also was surveyed in the work location with the Ludium
12-14. Normally no swipes were taken and counted on a SAC-4 or equivalent.

improper Survey Techniques

The RCTs sometimes used the Ludium 12-1A-survey instrument to monitor wet surfaces
for radioactive contamination during the berm removal project(s). Using an alpha
detector on a wet surface will not accurately detect low levels of contamination.

The team was provided evidence that during the berm removal project(s), RCTs
performed alpha scan surveys of wet/moist concrete surfaces. Water mist was directly
applied to the concrete berms as a dust control method. It is assumed that the applied
water probably caused a significant attenuation of the potential alpha surface
contamination. The surveys typically consisted of a scan and several fixed points
relative to the exterior surfaces of the berm. No swipes were taken and counted on a.
SAC-~4. It is expected that the survey results probably underestimated the actual
contamination levels due to the wei/moist surfaces. These underestimated alpha
contamination Jevels were especially problematic since it was reported that some of the
concrete berm materials dried duting handling and transfer operations.

By using the less sensitive Ludlum 142-1A instrument, in addition to performing the alpha
surveys on wet/moist surfaces, it is conceivabie that a portion of the berm material,
designated as “clean,” could have actually possessed surface contamination levels
slightly less than 500 dpm/100 cm?. After the berm material dried, a portion of this
undetected surface contamination could have subsequently created a localized airhome
area and inadvertently be inhaled by co-located workers.

Housekeeping

During a tour of Building 771, it was noted that dusts and debris were collecting in the
rooms, hallways and air exhaust pre-filters of the facility, Resuspension of loyevels of
contaminated dusts may have contributed to the worker uptakes. Deconstruction dusts,
dirt, human hair, and other debris will collect in low airflow areas and can be re-
suspended by turbulent work activities, cart movements, etc. It is a nuclear industry
good work practice to periodically clean work areas and traffic pattems using “maslin
mops” to help minimize the dust build-up and problems associated with its re-
suspension. The mop surfaces are usually monitored for contamination collection
similar to a large area wipe.

2)


ACRONYMS

ALARA
ASR
AKI
APR
CAM
CCA
CEDE
DAC

DPM

RRPT
RSP
RSSM
RWP
SAAM
sco
SWB
TEDE

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8
=

As Low As Reasonably Achievable

ALARA Job Review

Annular Kinetic impactor

Air Puntiying Respirator

Continuous Air Monitor

Configuration Control

Committed Effective Dose Equivalent

Derived Air Concentration

Decontamination & Decommissioning
Disintegration Per Minute

Extraneous Condition Affecting Quality
Engineering, Environmental, Safety & Quality Programs
Environmental, Safety, Health & Quality
Facility Representative -

High Efficiency Particulate Air

Health fnvestigation System -

In Accordance With

integrated Work Control Program

Less Than Adequate

Minimum Detectable Activity

Oxford Alpha Spectroscopy Integrated System
Occurrence Reporting & Processing System
Price Anderson Amendments Act :
Powered Air Purifying Respirator

Personnel Contamination Monitor

Protection Factor

Plan of the Day

Radiological Control Technician

Radiological Controt Technician Technical Supervisor
Radiological Engineer

Rocky Flats-Environmental Technology Site
Rocky Flats Field Office

Radiological Improvement Report

Registered Radiation Protection Technologist
Radiological Safety Procedure

Radiological Safety Section Manager
Radiological Work Permit

Selective Alpha Air Monitor

Surface Contaminated Object
Standard Waste Box

- Total Effective Dose Equivalent

30



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"a

~

Recommendations (Preliminary) °

1. Establish a program to reevaluate a substantial number
of neutron films.

Investigate/fund development of an automated film
reader system,

Establish in-house program and/or offsite
contract.

2. Establish a program to reconstruct neutron doses for
persons not monitored in 1950's,

3. Review and reconstruct the lifetime dose status of

active workers who may have been exposed to neutrons
at Rocky Flats prior to 1967,

4, Reconstruct the lifetime dose status of former workers
who records Indicate were exposed to neutrons prior to
1967.

5, After identification of exposed individuals, notify each

One of dosimetry gaps in thelr record and offer to

include them in medical monitoring recall program for
former radiation workers. :

N, Gal ROCKY FLATS | J
_ May 18, 1994 CaN dae ;



da. Examine the details and status of the RCM Article 555
exception.

e. Review the progress of the RFP implementation of the SAAM
Improvements and the Capital Project Air Monitoring
Improvement Program.

£. Review the results of the Building 771 ra@iation survey
taken in the vicinity of the Ladies
Locker Room, Guard Post and TLD Storage Rack.
3 ATTACHMENT (1) ROCKY FLATS PLANT
KEY ISSUBS FOR RADIOLOGICAL CONTROL MANUAL IMPLANTATION

Key issues associated with the implementation of the are:

1. Integration of Radiation Worker and RPTs will require a
significant development effort, and student training times will
increase. For example, RPTs initial training will increase from
8 weeks to 26 weeks, and requalification will increase from 2
weeks to 12 weeks.

2. Physical Facility Modifications will be required because the
proximity of dress out and removal facilities to RCA entrance
does not exist in most facilities, and step-off-pad arrangements
are not readily supported with existing accommodations. In
addition, current laundry capacity may not be capable of
supporting layered clothing.

3. Capital Equipment funds are extremely limited, and
compliance with other requirements (RCRA) has higher priority
in allocation of available funds.

4. Conversion of historical exposure data to Committed

Bffective Dose Equivalent

(CEDE) requires a significant effort (10 person-years). The

conversion process will be complicated since depositions were

originally quantified in terms of
activity (% organ or % body
burdens), and by the fact that dose
information from other sites is not
in the system.

5. Change in the Radiological Operations culture will include:
1) conversion to "Safety" over “Production,” 2) individual
worker and line management acceptance of responsibility for
radiological control, 3) confusion and/or complacency in workers
because of vapid and extensive change in requirements, and 4)
development of credibility of Radiation Protection with external
groups and workers.

6. Schedule - Full compliance by 1996 is considered extremely
challenging. The down-sizing of the site as part of mission
change creates significant competition for resources.
Significant ad@itional upgrades are required. Training mst
incorporate requalification requirement.

3. staffing ~ Reduction in force requires maximized
utilization of displaced resources to fill staff openings.
Existing resources have a limit with respect to being matched

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8. Respiratory Protection

A briefing on the Respiratory Protection Program at the RFP was
given by the Respiratory Protection Program Administrator
(RPPA) -

Training was discussed, and it was noted by the RPPA that: 1)
training was in place for users of respiratory protection
devices, 2) training has been developed for issuers of
there is no training for some of the respiratory protection
decision makers (i.e., the Radiological Building Engineers or
Radiation Protection Technicians) .

Blthough the RFP has a documented Respiratory Protection Program
in place, it did not appear that the program was in complete
accord with the RCM Chapter 5, Part 3 Respiratory Protection
Program. The RFP RCM Implementation Plan identifies that the
program elements within the requirements are not fully
implemented, and schedules compliance with the RCM requirements
(Articles 531 through 535) in March 1994. This completion date
is not coordinated with specific corrective action plans.
Specifically, a new Respiratory Protection Program is identified
as a corrective action and is projected to take 720 days to
complete, and training requirements are projected to take 365
days.
Why so much time is required to achieve compliance is not
apparent.

¢- Radiation Protection Training and Qualification

The DNFSB staff reviewed the Radiological Training Program for
Radiation Workers, Radiological Protection Technicians and their
supervisors. The program was in the process of being revised
to meet the requirements of the RCM. It was noted that the
modified training would require additional manpower.

General Employee Radiological Training, (GERT), Radiation Worker

. raining (RWI) ahd Radiation Protection Technician (RPT)
Training was noted by EG&G personnel as in compliance with DOE
Order 5480.11. The Radiation Safety orientation module of the
initial General Employee Training (GET) includes the RCM GERT
material but tests are not tracked separately. GET Radiation
Safety Modules for subcontractors and requalification, and RWT
courses do not include the RCM core training materials. The RPT
requalification course is being taught by using the Core
modules. Radiation Protection Supervisors are required to
attend RPT training and the Supervisors Academy. However, they
are not required to receive additional technical training or
demonstrate knowledge above the RPT level.

DNFSB staff review of the RCM Implementation Plan revealed that
a majority of the RCM Chapter 6 training requirements will not
be completed until July to September 1995. The RFP plan to
accomplish RCM training is not consistent with the DOE's
Implementation Plan for DNFSB Recommendation 91-6, which
committed DOE to having General Employee Radiological Training,
Radiation Worker I and II Training, and Radiological Protection
Technician training for all affected workers using the
standardized core training material completed by December 1994.

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Attachment (5)

Buildings 707, 771, and 881 were toured by DNFSB staff with RFP
personel. EG&G line personnel conducted the tour, made
observations and compiled notes. Excerpts from the tours are
provided below:

Building 707

A large number of radiological deficiencies were identified
during the tour. This was especially surprising as BG&G
persomel had inspected the building in preparation for not only
this tour, but for a preceding tour by members of the DOE Office
of Nuclear Safety (ONS) Team.

Several of the deficiencies noted in the August 1993 tour were
observed again in September 1993 during a return visit by the
DNFSB OE.

Examples of deficiencies observed in August 1993 included:

1. Radiation areas were not shown on survey maps posted at
the entrance to modules within the building.

2. Contamination areas were not shown on survey maps posted
at the entrance to modules within the building.

3. Differences were noted between radiation levels recorded
on survey maps posted at the entrance to modules and those
posted on radiation area signs within the module.

4. Radiation survey data was not available for the area of a
glove port with the shield open.

5. be contamination containment wrapping on one large
contaminated item was not completely taped in place and
therefore was not sealed-

6. A Radiation Area sign in the J-Module referred to a
radiation area in the overhead. It could not be determined
from the sign where in the overhead the Radiation Area was.
Scaffolding in the area allowed access to the actual Radiation
Area without passing the sign, and effectively rendered the
Radiation Area un-posted.

7. Not all information required to be provided on a survey
map was filled in.

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Page 14 of 1S

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months. ‘These improvements were attributed to holding personnel
accountable, and to new procedures that have enforcement
measures -

Internal Dosimetry Program ~ The Internal Dosimetry Program was
discussed with the manager of the RFP Internal Dosimetry
Program. It was noted that there is a TBD for the Internal
Dosimetry Program, and that it is a controlled document.

The Internal Dosimetry Program is in transition from a program
xequiring each person on-site to participate in fecal sampling
te a program requiring periodic urine sampling and lung
counting, with a fecal sampling required when other conditions
indicate an uptake might have occurred. A new procedure is in
draft (revised HSP 18.20), and the program change needs FY94
funding. EG&G plans to have the new program in place by the end
of 1993. Currently only one lung counter is operational, with
a second lung counter to be in operation in the near future.
It was stated that the equipment is old, and that a capital
equipment project to replace it is funded. In addition two
identical wound counters are in use.

Management of the bioassay program did not appear to be fully
developed. RFP personnel noted during briefings that the
Radiation Work Permits (RWP) do not stipulate the requirements
for bioassay. Review by the DNFSB staff revealed that RWPs did
provide a checkpoint to identify if pre- or post- exposure
bioassay were required. The discussions did not make clear how
contractors are included in the bioassay program. For example,
when asked about other subcontractors, RFP personnel indicated
that contractors may come and go and not be bioassayed. A
deliberate delinquency tracking system does not exist, but
delinquencies are identified by other means. There are plans
to use a computer system to track and schedule bioassays.

Recurring operational problems with the on-site analytical lab
affecting the plant's bioassay program were noted by RFP
personnel. Problems include resource allocation and Resource

- Conservation Recovéry Act (RCRA) issues. RFP management is
currently establishing an off-site bioassay lab contingency,
and interfacing with on-site labs to resolve problems and
concerns.

6. Radiological Instrumentation and Equipment

Radioactive Source Accountability -~ DOE sites maintain radiation
sources for the calibration of instruments and equipment, and
to perform radiography. These sources frequently contain
significant amounts of radioactivity. EG&G stated that many of
these sources would have to be licensed under current NRC
regulation, if the NRC ha@ jurisdiction. RFP personnel reported
that three to seven registered sources, and one-hundred-thirty
accountable sources cannot be found at the plant. They plan to
inventory database records against file records, cross check
historical records against current records, archive all file
records for sources that have been disposed of and create a
mechanism to make contractors and subcontractors accountable for
their sources. A semi-annual inspection is in progress. DOE
Order 5000.3B, Occurrence Reporting and Processing of Operations
Information, gives the requirement to report an "Unusual

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incorporate the unexpected positive fecal results and additional information, and an
event investigation/root cause analysis was requested to identify the cauSe of the
exposures.

The Building 771 assessment negates the conclusion that the work done in the Room
186 tent would result in the intakes identified from the eleven workers. Work histories
and workplace indicators for the employees were then reviewed. One employee had
been involved in a positive CAM alarm on Oct 20, 2000, that was determined to
contribute to a positive bioassay. This alarm stemmed from a separate work activity and
was fot related to the tent work in Room 186. The other workers had nothing in their
work histories that would indicate an event that could have caused positive fecal results.

Facility Background

The Building 771/774 Complex was primarily used to recover plutonium, using numerous
hazardous chemicals in the recovery, separation, and purification processes. During its
operational lifetime, Building 771 has had several significant fires and releases ‘of
radiological contamination within the building, leaving a unique Challenge - to
Decontamination and Decommissioning (D&D) activities.

The D&D work is essentially the deconstruction of the facility. The building has miles of
contaminated pipes running throughout the building connecting tanks, glove boxes, and
plutonium process systems. Some of the pipes and tanks once contained hazardous
chemicals such as kathene, hydrochloric acid, or nitric acid. Some of the tanks that
once held plutonium solutions are large, weighing at least 1500 pounds empty.
Gloveboxes in which plutonium was once processed are highly contaminated. Every
tank that once contained gas, chemicals, or solutions must be emptied, the contents
safely disposed of, and sent out as waste. Every fiquid solution must be analyzed for
contamination and to verify its identity before it can be safely disposed of. The building
has been in place since 1953, and can contain hidden hazards. For instance, chemical
and contamination spills can feave a lasting effect when the flooring is removed or when
@ tank is moved revealing contamination.undemeath the-feet-of the’ tank? Work’ miuist
procéed cautiously, requiring planning, anticipation of possible hazards, and with proper
worker protection.

Compared to other Site plutonium buildings, Building 771 is currently involved in much
mote complex, intrusive D&D work creating a higher potential for resuspension of
contamination. This is evidenced by the number of positive, event-triggered bioassay
samples. Building 771 received the majority of Rocky Flats internal dose during 2000,
approximately 70% of alt the Site dose. Building 779 was in D&D activities in 1999.
During that year, the building workers received the majority of the Site’s intemal dose,
approximately 64%.



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to include acceptable differential pressure range for air movers. Include note not
to wet HEPA filters.
to require that samplers in airborne contamination areas have properly controlled
exhaust
to provide prescriptive guidance of survey map quality regarding current
configuration of room including equipment located within the room.
to clarify requirements for determination, documentation and periodic inspection
‘of face airflow velocity and air mover differential pressures
to require the selective use lapel air samplers to confirm the results of low-
volume job coverage air samplers
Modify Site procedures to require electrical engineer evaluation of the adequacy of
circuits used to support equipment used for radiological control.
Modify other applicable procedures to clarify responsibility for performance of the
Tent Inspection.
Revise OO-771-197 to clarify responsibility for performance of the Tent Inspection.
To evaluate the feasibility of modifying the actions for potential intakes :

Engineering Controls Recommendations Include:

Evaluate the use of “drop-down” or temporary ventilation exhaust points at or near to
the elevation of the pre-D&D airflow exhaust suction points to maintain the high-to-
tow ventilation airflow path.

Discontinue use of and disassemble the Room 186 Tent. Do not use the downdraft
table unti it has met the requirements in RSP-01.02.

KH Radiological Engineering independently reviews new construction of D&D tents
for design and ventilation considerations. :

Address the uncharacterized facility hazards through the use of improved survey
techniques; placing increased emphasis on engineered controls; and institute the
conservative use of Personal Protective Equipment (PPE) when conditions are
unknown.

Revise the Airborne Radioactivity Area posting fevel to 0.1 DAC.

Increase the total aitflow within the facility to the maximum practical. If unable to
increase airflow, increase intra-facility air filtration through the use of HEPA filter
equipped air-movers. . . . .

Programmatic/Administrative Recommendations:

Site Radiological Protection group to evaluate site-wide retum to posting/de-posting :

ARAs at 10% DAC and revise Technical Bases and procedures as appropriate.

D&D supervisors should check to ensure that work to be performed is within the work
scope of the AJR. .
Radiological Engineers should periodically tour the workplace and review work in
progress for adherence to approved AJR work scope and ALARA opportunities.
investigate airflow pattem surveys and re-perform as necessary to ensure building
ventilation and differential pressure is adequate for radiological controls (i.e., rooms
being negative to corridor; airflow between rooms documented; and airflow going
from RBA to CA}.

Evaluate requiring DAC hour tracking for all personnel weating respiratory protection
for radiological protection purposes.

26



74 : >)
Excerpt from: July Monthly Progress Report, Chemisiry
Lab. and Personnel Meters

August 4, 1958

from S, E. Hammond to C. W. Piltingsrud

Neutron film has been furnished 71-bidg., to start personnel
dosimetry there thls month. An estimated twenty persons will be
covered. Following extensive studies by Ray, Gronquist, and Owen
on heutron dosimetry at 71-bldg., we changed aur method of
Interpreting neutron film as reported by memo eartler this month. It
is interesting to note that if we had used this method during the
previous coverage at 71-bidg., fortnightly neutron doses as high as
4 rem would have been reported. “

2y8GsG ROCKY FLaTs —/

April 28, 1894



Lack of Adequate Containment/Surveys

During this period, there was a lack of adequate containment of items staged for size
reduction, that surveys of these items were not being conducted and documented, that
Surveys in overhead areas were not adequate, and that many job coverage. surveys
were not documented. Interviews revealed that some of these surveys had been
conducted but that the results had not been recorded properly.

{t was the usual practice to stage gloveboxes, tanks, etc. for size reduction without
taking special precautions to contain and/or prevent the spread of contamination while
the items were in the staged locations. In addition, these items were not included in
routine surveys to ensure that there were no releases of contamination in the area from
‘this equipment. .

Surveys of the overhead areas were conducted only when work was planned for a
particular area. There were no routine contamination surveys in these areas. When
conducting certain activities in the overhead spaces, the contamination situation in the
overheads (and the impact on co-located workers) was not completely understood.

Co-located Worker Effects

Planning for use of the hydraulically operated pipe crimper/cutter toot did not fully
consider the potential of this activity for spreading contamination. Considerable effort
was applied during D&D planning to develop the capability to crimp and cut piping of
various sizes using a hydraulically powered crimping/cutting tool. This cutting method
was relatively fast compared to the use of roller cutters or saws. However, this cutting
method caused considerable shock to piping runs and adjacent support structures that
could have extended to adjacent rooms and had the potential for dislodging
contamination. It was standard practice to require respiratory protection in rooms where
this tool was used to cut radioactive/contaminated piping. However, on some occasions,
Personnel in the vicinity of non-contaminated piping crimping/cutting were not required to
wear respirators. In these instances there was a potential for exposure to contamination
from the shock to adjacent piping.

Use of Low-Volume Samplers

Low-volume air samplers used without controlled exhaust (HEPA filtration) could
increase the risk to co-located workers. It was observed that a low-volume air sampler
was exhausting from the Room 186 tent directly into Room 186 proper. Examination of
the configuration revealed that the low-volume air sampler exhaust hose had been

disconnected inadvertently from the Room 186 tent. Under normal conditions, this hose
was attached and routed the exhaust from the low-volume air sampler back into the

Room 186 tent. In addition, this iow-volume air sampler was not equipped with a HEPA

filtered exhaust. Therefore, this uncontrolled exhaust from a CA/HCA could have

created a ‘localized airbome radioactivity area. This contamination could have been

inhaled inadvertently by waste management workers.



Results of Investigation

From the review of the timeline of possible inhalation events studied during the course of
this investigation, there Is no event in which all 11 workers were present and no series of
events in which various groups of the workers could have received a single, large intake.
An analysis was conducted of intemal dosimetry results for the past six years. These
results demonstrated that during airbome contamination incidents for which the workers
were not contaminated and not wearing respirators, the individuals did not receive an
intake resulting in a dose greater than a few millirem. Thus, it is extremely unlikely that
the positive fecal results under investigation were due to an acute inhalation because an
acute airbome contamination incident high enough to cause a detectable intake would
have resulted in a Continuous Air Monitor (CAM) alarm. With one exception, all of the
individuals stated that they were not in rooms in which a CAM alarmed when they were
not wearing respirators.

in addition, the Investigation Team conducted an analysis to determine the average,
steady-state level of airborne contamination throughout Building 771 from January 28,
2000 to January 19, 2001. Breathing the average air within Building 771 for 25 hours
per week would resutt in an annual intemal dose of 4 millirem. Since the dose range

- Identified was between 6 millirem and 60 millirem, it is therefore extremely unlikely that

intakes occurred due to slightly elevated, ambient airbome radioactivity in Building 771.

The Investigation Team reviewed studies from the Hanford and Savannah River sites

that revealed that internal plutonium exposures could be detected in scheduled fecal
examination in the absence of workplace indicators such as personnel contamination or
airbome radioactivity alarms. The rates of positive (above background) fecal results in

the two studies were comparable to the overall results seen in Building 771. Air samples
at Hanford were consistent with those at Rocky Flats. .

The Hanford study indicated that the fecal bioassay results changed with time depending
on the work being performed (e.g., maintenance and repair versus routine processing
operations), Since the weekly air sample results in Building 771 appear to fluctuate with
the number of radiological work hours fogged, it can be expecied that the Rocky Flats
intakes will follow a similar patter. Therefore, the fecal values seen at Building 771 are
most likely to be the result of a series of smaii, acute events and/or a series of small,
chronic exposure periods, interrupted by weekends, holidays, training, etc. These
intakes have been modeled as “effective” chronic intakes.

The fecal sampling in Building 771 revealed that. workers were incurring very low-level
intakes below the threshold of workplace monitoring systems.

Conclusion and Judgement of Need

Decontamination and decommissioning activities such as those currently under way at
Building 771 are vastly different from many other radiological activities normally
encountered in the DOE complex. The destructive nature of D&D activities can produce
localized contarnination and airbome radioactivity. When D&D activities take place in
facilities contaminated with plutonium, the challenges to a radiation safety program are
especially great. Workplace indicators are not capable of detecting low levels of
plutonium contamination in equipment and materials or as aitbome radioactivity.



over a short uninterrupted period of time such as one work week. The sampling should
be conducted before work with radioactive materials is allowed to continue. The internal
dose from any accumulated exposure, that was otherwise unevaluated, should be
assigned based on the DAC-hour tracking logs.

RFETS Bioassay Monitoring Program

Workers who are likely to receive 100 mrem in a year from all intemal exposures are
placed in a routine bioassay program. They are required to provide annual urine
samples and have periodic lung counts. In a plutonium facility, neither of these two
methods has the sensitivity to detect small intakes (less than 100 mrem). They do,
however, have the ability to detect intakes at less than the federal limit of 5 rem for
occupationally exposed workers. The inability of the routine bioassay program to detect
small intakes is termed the “technology shortfalf" for plutonium bioassay.

As described above, a system of workplace indicators, following DOE guidance, has
been implemented to provide early detection of personnel intakes and to trigger follow-
up or “special” bioassay monitoring. The workplace indicators include such things as
personnel contamination, airborne radioactivity, and CAM alarms. For each indicator, a
value is cafculated based on a workplace measurement, which indicates the fevel of
potential internal exposure. The building radiological safety organization or the
individual worker can request sampfing even if the workplace indicators are not
triggered.

Because of its sensitivity to small intakes, fecal bioassay sampling is included in the
special bioassay monitoring protocols. Fecal sampling is not included as a part of the
routine bioassay program because the analysis is complex for the bioassay laboratory, it
is harder to gain worker compliance, and the interpretation of the results is difficult. The
last point will be detailed below, during the discussion of the interpretation of bioassay
results from personnel in Building 771.

Accuracy of Bioassay Results

The intemal Dosimetry Program (DP) at RFETS is defined by a set of documents
designed to meet or exceed the requirements of 10 CFR 835 and 10 CFR 830.120.
These include the Internal Dosimetry Technical Basis Documentation, -procedures
manual, Quality Assurance Plan, and Bioassay Statement of Work (SOW). Since 1997
Rocky Flats has used contract laboratories exclusively for indirect bioassay analyses. An
independent consultant to the Investigation Team reviewed the bioassay quality
assurance protocols and found them to be adequate.

The Bioassay SOW contains detailed customer requirements and includes a general
analytical laboratory module and a specific module for bioassay analyses. These SOW
modules detail the requirements with which the laboratories must comply to be awarded
and maintain a contract for the analysis of RFETS bioassay samples, Analytical
Services Division provides an indirect bioassay subject matter expert (6.g., &
radiochemist) to guide development and maintenance of the SOW and evaluation of
Jaboratory performance. Each data package is reviewed independently before being
forwarded to Internal Dosimetry. A blind audit program is used to verify that the
analytical laboratory’s performance is in accordance with the Bioassay SOW. This

1


2.0 METHODOLOGY

The Phoenix methodology of incident investigation was followed for this investigation in
compliance with MAN-062-CAUSEANALYSIS, Revision 2, Cause Analysis
Requirements Manual. Records and documents pertinent to Building 771 Radiological
Safety, Building 771 work controls, and the Site Radiological Safety program were
reviewed. A complete listing of documents reviewed is included in the bibliography
following this report. Personnel pertinent to the incident, Building Managers and staff
support were interviewed and information was verified and corroborated to the extent
practicable. Analytical tools such as the Comparative Timeline were used to reconstruct
activities and events related to the personnel involved and are retained in the analysis
records. The analysis team meets the requirements specified in MAN-062-
CAUSEANALYSIS, Revision 2.

3.0 BACKGROUND

On October 16, 2000, a DOE-RFFO facility representative performing a routine
surveillance in Building 771 found that an air sampler being used for monitoring airborne
radioactivity levels inside the containment tent in Room 186 was past dué for calibration. .
Upon further investigation, building management determined that routine measurements
from the air sampler were not property documented from September 7 through October
16, 2000.

The air sampler was checked and was found to be within tolerances and did not require
seadjustment. This indicated that even though the calibration time period had expired,
the monitor had been working properly. The 11 workers determined to have worked in
the containment tent between September 7 and October 17 submiited fecal samples for
bioassay. This testing was precautionary since all of the workers working in the Room
186 tent had been wearing the required level of Personal Protective Equipment (full-face
powered air purifying respirators and anti-contamination clothing). The purpose of the
testing was to determine if there had been,any exposure incidents in the tent during the
time period in question. Eight of these workers were waste handlers, three were
Radiological Control Technician (RCTs).

it was anticipated that small non-event-related intakes could be occurring (possibly from
the tent or other activities performed) which would be detected by a fecal bioassay.
When workers’ samples showed radioactivity, additional fecal samples were requested
in an attempt to identify the source of the intakes. In addition, management made an
offer to the other workers in the building to perform fecal bioassay sampling. Workers:
accepting this offer were asked to submit three fecal bioassay samples in order to
establish the time dependence of the results. -

The preliminary bioassay results, issued in Jate November 2000, were unexpectedly
above the decision level. Three of the workers with the highest results were given lung
Counts that indicated the internal exposutes were less than the approximate minimum
sensitivity of the analysis.

Building 771 management assessed the adequacy of the facility's Radiological Safety
Program and found numerous weaknesses, which were reported under the Price-
Anderson Amendments Act (PAAA) on November 30, 2000 as NTS-RFO—KHLL-

T71OPS-2000-0003, 8771 Fradiological Safety Program. The report was amended to

7



Fixed Air Head Fitter Loading

The fitters In the Building 771 fixed air heads are removed weekly and analyzed for
alpha contamination. The amount of industrial grit deposited on the filter is unknown.
Dust or grit on the filter can mask the alpha radiation emanating from the filter: This
would cause-a fess accurate reading, and depending on the absorption factor used in
calculating the airborne radioactivity level, may cause an erroneously low reading.

Building Ventilation

Building ventilation (airflow) is maintained by 3 sets of main plenum supply and exhaust
fans. Each set of exhaust fans has 2 fans and 1 flow meter. During normal operation
any combination of fans can be used. The flow meters associated with each fan set
sense the airfiow and send a signal to a “totalizer.” The totalizer sums the signals from
the 3 fan sets and indicates the total amount of air being exhausted from the buil
During the year 2000, airflow in the facility was increased by increasing the speeds of
the supply and exhaust fans and accomplished in a manner to maintain the differential
Pressures within the building more or less constant. The objective of the building
exhaust ventilation is to maintain the rooms negative with respect to the hallways.

Nt was noted that, in Room 186,-the differential pressure occasionally would become
Positive with respect to that of the hallway, possibly due to door openings and closings.
This may be an artifact of the slow response of the exhaust ventilation fan-speed control
system. However, it also could be an indication that engineering controls in place are
not effective in maintaining the appropriate airflow in the building, thus increasing the
potential for intakes of radioactive material.

Following glove box removal, HEPA filters are sometimes installed at the new terminus
of the exhaust ducts. These HEPA filters are positioned high in the overhead. Although
‘the radiological source term has been removed from the locations where the glove
boxes have been dismantled and the differential pressure between the room and the
hallway has been maintained as before, the effect of placing the HEPA filters high in the
overhead degrades the high-to-ow ventilation airflow path. normally. maintained -in
nuclear. facilities to minimize the potential for worker exposure to airbome radioactive
material. :

Use of the Ludlum Model 12-1A Survey Instrument

The site-wide use of the Ludlum Model 12-1A survey instrument for general
contamination monitoring increases the potential for low-levels of undetected surface
contamination: When.used under optimum laboratory conditions, the sensitivity of the
instrument is approximately 500-dpm/100 om?. However, when used by RFETS RCTs
for field sutveys, the instrument may not be detecting contamination levels of fess than
1000 dpm/100 om?.

Most low-level waste was not bagged or wrapped prior to packaging into low-level waste
crates or drums. After a scan and large area wipe survey, most waste packages were
deemed free from contamination and subsequently handled by personnel in Room 179.
The affected waste management personnel routinely handied such waste packages

20



March 15, 2001

On December 13, 2000, ! established a team to Investigate the source of internal
radiological exposures involving personnel from Building 771. The purpose of this
investigation was to determine the cause or potential cause of the Building 771 worker
exposures and to make recommendations to mitigate recurrence in keeping withthe =
Site’s commitment to As Low As Reasonably Achievable, goals.

As of today, March 15, 2001, | accept the findings and recommendations of this team
and the team’s responsibilities are completed.

Kaiser-Hill takes any worker exposure very seriously and we remain fully committed to
the safe, accelerated closure of Rocky Flats.

AS Se

Ge Se

Kaiser-Hill Vice President :
Engineering, Environmental, Safety and Quality Programs

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Year 1961. Reevaluated Neutron Doses for Which
Initial Evaluation Was Zero, 2-week Period

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‘Number

Neutron Dose (mrem)

Notes:
1. Highest Neutron Dose = 1,085 mrem

2. 49% > 100 mrem
3, 12% > 200 mrem



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5.0 POTENTIAL CAUSES

Root Cause

The Investigation Team concluded that the most likely cause of the positive bioassay
Tesults was exposure to low levels of aitbome plutonium radioactivity from radiological
work operations exacerbated by D&D operations. These low levels of airborne
radioactivity are below the threshold of workplace indicators.

Vulnerabilities and Exacerbating Factors

Vulnerabilities are conditions that existed in the workplace that allowed the exposures to
happen. Exacetbating factors potentially contributed to the exposure issue — potentially
affecting the amount of intemal exposure received. Both are potential contributors and
are discussed in the same section for that reason,

Lack of Respiratory Protection When Handling/Packaging Waste

Waste crew members received, handled, packaged, and transported items throughout
the contamination area without respiratory protection. These items had been surveyed
by wiping and checking with a Lidium 12-1A, which had a minimum sensitivity of about
500 dpm/wipe. However, the possibility of the undetected lowtevel removable
contamination still existing on these items that could have contributed to potential
intakes was not considered_ .

Use of inadequate Local Ventilation

The investigation team identified several weaknesses associated with engineered
controls, particularly local ventilation. Local ventilation is a key engineered control used
during D&D activities when there is inadequate total containment that confines the
radioactive material. The. investigation Team identified several iicidences where there
was insufficient use of localized ventilation controls that could have resulted in spreading
removable contamination to the surrounding areas and could have resutted in elevated
airborne radioactivity.

Further details and additional examples of these weaknesses are addressed in NTS-
RFO—KHLL-77140PS-2000-003, Building 771 Radiological Safety Program Concems.

17



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Slightly Elevated Airborne Radioactivity in the Atmosphere in Building 771

An analysis of the fixed air head data in Building 771 indicates that workers breathing
the average air within the building would receive an internal dose of 4 mrem in one year.
Since the-11 workers received intakes greater than 4 mrem, itis considered unlikely that
their doses were due to slightly elevated airbome radioactivity in the building.

Hypothesis

One hypothesis for the source of the intakes to the eleven workers was that the Steady
State concentration of airborne radioactivity in Building 771 was causing the intakes. For
this hypothesis to be true, the radioactivity level, measured in units of Derived Air
Concentration (DAC), would have to be high enough to account for the intakes seen.
Also, all workers who spent the same amount of time in the Contaminated Area would
have the same intake.

Analysis of the Fixed Air Head Data for All of Building 77?

The fixed air head data for Building 771, from January 28, 2000 through January 19,
2001, was obtained and analyzed. A piot of all data, for each room as well as for the
building, was prepared (see Figuré 2). It was clear that several known airbome.
radioactivity releases were skewing the average airborne concentration erroneously
high. To attempt to see just the steady state average DAC value of the building, these
event-related periods of radioactivity were removed in several stages. This resulted in
semoving 1.7% of the data (64 data points were removed out of a data set of 3,735 data
points). See Figure 3 for a count of the data points in the data set.

An analysis of the fixed air head data in Building 771 demonstrates that when the event-
related periods of airborne contamination greater than 6% DAC are removed, the
average steady state level of airborne contamination throughout Building 771 from
September 1, 2000 to January 19, 2001, is essentially at the minimum detectable activity
(MDA) of 0.21% DAC. The calendar year 2000 average is about 0.3% DAG. See
Figure 4 for graphs depicting the average. DAC by room-and by week. ‘It is believed that
the data analysis approach is sound and the results are an accurate indication of the
steady state atmosphere within Building 771. Breathing the “average air” within Building
771 for 25 hours per week would result in an intake with an annual intemal! dose of about
4mrem. Itis thereforé unlikely that intakes occurred due to slightly elevated airbome
activity in the atmosphere of the building.

Evaluation of intakes of Workers in Building 771

intemal dosimetry data was grouped into three sets: the Waste Packaging Crew and the
RCTs, the D&D workers, and others in the building. The Waste Packaging Crew and the
RCTs have statistically significant higher intakes than the other populations. This further
supports the contention that the Intakes were not a result of a high steady state
radioactivity level in the building. .

4



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1959 88.3
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1964 95.6

1962 ° 54.4

— ey SG ROCKY FLATS

_ April 28, 1994



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TABLE OF CONTENTS

Section

Charter Letter

Table of Contents

1.0 Executive Summary ..

20 Methodology... —
3.0

4.0

5.0

6.0 Compensatory Measures
7.0 Recommendations ...
8.0

investigation Team Approvals

Investigation Team Members.

ACTONYIS -oosssssscsseseessrecsnsersone

Glossary of Temns........

BibMOgraphy..csecrncecee

Appendix 1
investigation Team Charter Memorandums

Appendix 2
Worker Analysis..sesesessees

Appendix 3
Exposure Model......2-+..

Appendix 4
Fecal Sampling Experiences at DOE Sites Compared to RFETS ........:e00

Figures.



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Workplace Monitoring and Controls

All Rocky Flats personnel who work in the contamination areas wear several items of
required protective clothing designed to protect the worker from skin contamination.
When working in airbome radioactivity areas, workers are required to wear respiratory
protection. During the time period in which the air sampler was past calibration in
Building 773 and airbome radioactivity measurements were not being documented,
workers in the Room 186 tent were weating PAPRs, which provide a protection factor of
1000 in airbome radioactivity areas.

A system of workplace indicators has been implemented at Rocky Flats to provide early
detection of intakes and to trigger special bioassay monitoring. These indicators are
summarized below, and the technical justification is documented in the Internal
Dosimetry Technical Basis Documentation. These workplace indicators are
implemented site-wide through procedure 3-PRO-210-RSP-14.01, Bioassay Monitoring,
Criteria and Actions for Potential Intakes. The workplace indicators are used to trigger
special bioassay sampling protocols using the guidance in the established Internal
Dosimetry procedures (RDI-5106, Response to Potential Intakes) and the Internal

The workplace indicators implemented by the Rocky Flats Site are equivalent to or
exceed the guidance contained in DOE-STD-1128-98. A surmmary of the workplace
indicators used to trigger Intemal Dosimetry evaiuation and their comparison to the
Jevels in DOE-STD-1128-98 are listed below.

Workplace Indicator RFETS Lower Limit DOE-STD-1128-98
1| Nasal/Mouth Swabs Detectable activity Detectable activity |
2} Facial Contamination 60 dpm 200 dpm
(area normally inside :
respirator seal) :
“| 3} Contamination inside - 60 dpm Detectable activity
respirator
4] Head/neck contamination 300 dpm’ 2000 dpm
| {area normally outside .
respirator seal)
5{ Alrbome contamination. 40 DAC-hours 40 DAC-hours
8} Verified CAW/SAAM 600 dpm on fitter (~40 40 DAC-hours
alarm DAC-hours)
7 | Handfiorearm/clothing 1600 dom 40,000 dpm
contamination,
8] Wounds Any wound occurring in a Any skin break while
CA, HCA, or ARA (follow- | handling material other
. up for wounds occurring in | than sealed sources.
an RBA is optional).

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Appropriate respiratory protection factors are applied to indicators 4 through 7. All
contamination levels are based on total alpha activity and not activity per unit area. The
minimum detectable activity for the most sensitive field survey instrumentation in use at
the Rocky Flats Site (NE Electra) for aipha contamination surveys is approximately 60

=


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Accuracy and completeness of historical neutron doses

affects:

e Legal Defensibility

Epidemiological and Health Effects Studies (CDH Cancer Incidence
Study, CEDR)

bd Radiation Protection based on lifetime doses/Radiation Record
Credibility

Py B23 ROCKY FLaTs —/

April 27, 1994



fage 201 19

noting that two TLDs that hung on the rack for six months
had received Approximate THe Stare
“@uéstioned whether any TURGAEOTSd Workers had spent a
significant amount of thé workday—iw tire ares>—Rrp—
personnel noted that a quard-sratio-was-atyacent to the
area, and that the guards were not required to wear
dosimeters on a routine basis. The radiation level in
the guard area was not known at the time of the review,
and was to be determined. If the radiation level in the
guard's post is similar to that at the TLD storage board,

exposure of guards to-ionizing radiation may exceed the

TOO mrem per imit those who are not monitored.

ec. Subcontractors working at the plant did not appear to be
totally integrated into some Radiation Protection
Programs. Currently, their contracts do not require
compliance with the RCM, but plans are to include this
xequirement at the next contract modification. The DNFSB
staff did not find that the subcontractors were included
in the plant's Radiation Protection As Low As Reasonably

Achievable (ALARA) Program, and it was not clear that
bioassays for subcontractors were thoroughly managed.

a. The plant's Radioactive Source Control Program has identified

a number of sources that can- not be accounted for. There
are 2,428 sources, and approximately
137 sources cannot be located. A
semi-annual inspection was in
progress at the time of the review.
EG&G stated that many of these
sources would have to be licensed
under current Nuclear Regulatory
Commission (NRC) regulation, if the
NRC had jurisdiction.

3. Background: Department of Energy (DOE) Order 5480.11,
Radiation Protection for Occupational Workers, DOE Notice
5480.6, Radiological Control,. and DOR Order 5400.5, “Radiation
Protection of the Public and the Environment establishes the
requirements for radiation protection for workers, the public
and the environment, and provided the basis for the radiation
protection review at the Rocky Flats Plant. These standards
were used in the assessment of the program, work practices,
training and knowledge level. Evaluation of the implementation
of the Radiation Protection Program at Rocky Flats was achieved
through review of the program at the Plant and Building levels,
observations of practices in the field, and interviews with
personnel. The following outlines the areas covered in the
review:

A. Radiation Protection Standards Implementation,
B. Radiological Health Operations,

Cc. Radiation Protection Training and Qualification,
D. Personnel Interviews, and

E. Building Yours.

The review was conducted by: Dan Burnfield, dim Troan, DNFSB
Staff members, and Ted Quale, Outside Expert.

<4. Discussion/Observations: Observations and discussions are

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hittp://www.dnfsb.gov/pub docs/rfets/sir 19930829 rf.txt 01/07/2005



4 >

Excerpt from: Status Report - Dosimetry - February
9

March 8, 1967

from John Mann to C, W. Piltingsrud

“ January neutron dosimetry film were evaluated using the new track
reading procedure. About half of the total film developed were read
out, thus allowing twice as much time for reading each film. The
average neutron dose assigned to those personnel that worked in
the highest neutron exposure areas In Bullding 71 increased by a
factor of 5 over the average for 1966, “

— April 28, 1994 ° Jy EGsa ROCKY FLATS /



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Page 15 of 15

Attachment (6)

Building 772

1. The Building ALARA Program does not include subcontractors
{i.e., J. A. Jones) -

2. Higher than usual radiation exposure was noted by RFP
personnel for people who store their TLDs at the TLD Board
near the Ladies Locker Room. Radiation levels were estimated
at approximately 300 milli-rem over a 6 month period. During
discussions it was noted that Wackenhut Security Guards in an
adjacent vestibule were not required to wear TLDs. EG&G
personnel stated that they plan to study radiation levels in
these areas.

3. A Radiation Protection Technician (RPT) was observed
working at an entrance to Airborne Radioactivity Area. Mo
step off pads were used at entry/exit point, as required by
RCM Art. 335.4.

4. Storage of chemicals appeared to be uncontrolled. The
following axe examples: H2S04 was stored apparently for use
for a system that was out-of-use, a container (drum) of paint
thinner appeared to be waste, and a Chemical Storage Cabinet
was in need of an inventory.

5. Vacuum cleaners that were located in the RCA were not
outfitted or marked in accordance with the RCM requirements
(art. 464).

6. Fire extinguisher throughout the building were overdue for
periodic inspections.

7. Amnouncements made on the building's Public Address System
were sometimes inaudible.

8. Prisking at: exit from the RCA was rapid (typically less
than 2 minutes), and did not conform to the requirements of
the RCM requirements (RCM, Appendix 3D).

9. Radiological control requirements varied within the RCA.
The tour group was required to wear protective gloves, while
personnel in a Control Room (without frisking equipment at the
entry/exit point) wore no protective gloves.

Building 881

2. The DNFSB staff had no comments.

Attachment (6)



3.0 ATTACHMENTS

INVESTIGATION TEAM SIGNATURES

Prepared By:

Prepared By:

“Prepared By:

Prepared By:

Prepared By:

Prepared By: k 3 {y‘loy
Kevin K. Kénzen, CHP, RRPT Date

— Ce
Prepared By: /C Uli
Date

Eugene W. Potter, CHP

Radiological Health
Prepared By: tA, FLSA
Norman R. Warling, RCT Date
Prepared By: GULL Sppditloy
Edward B! Wilkes, CHP, RHPT Date
Radiological Engineering

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that demonstrated the DAC value in Room 179 was reasonable, given the waste
packaging that occurred there (see Appendix 3 for the Exposure Model).

Modeling of Bioassay Results.

As stated in the previous section, the Investigation Team concluded that it was unlikely
that the exposures of the waste team members were due to a single, unknown acute
event in which all eleven workers were exposed. Internal Dosimetry used this
information to mode! the bioassay results and determine the intakes and doses.

Sufficient data did not exist to model the series of small acute exposures, which
represented the actual conditions in the building. In such cases, a chronic intake
tepresents a reasonable approximation or “effective” model for a seties of small acute
exposures. The chronic intake was assumed to begin on January 1, 2000 (or the first
RWP entry} and end on December 31, 2000 (or the last RWP entry). Generally, the
doses determined in this manner resulted in calculated total exposures of 40-20 DAC-
hours protracted over the entire year. This agrees with the above analysis since it is »
feasible that the workplace indicators would not have detected intakes at this level:

Doses for 9 of the 11 original workers ranged from 6 to 60 mrem. Results are pending
on two of the original 11 workers. One of those workers’ dose is expected to be similar
in range. The last worker's dose is expected to be less than 300 mrem, and the Site
continues to review the possibility that this individual was involved in a separate event.
See Appendix 2 for a discussion of these two workers. .

Doses for the nine that have been assigned were verified, and final reports were peer-
reviewed by a second Intema! Dosimetry health physicist. Intemal Dosimetry health
physicists briefed those workers on the results of their dose assessments.

Bioassay Results for Workers Submitting Personal Request Samples

Preliminary statistical tests performed on the data indicate that there is a difference in
the proportion of greater than decision level results between grotips. The proportions of
greater than decision level results are not statistically different for the RCTS and waste
crew and for the D&D workers and others (non"hands-on” workers). In addition, there is.
@ statistically significant difference in the magnitude of the results for the different
groups. These results are consistent with the observation that the waste crew as a
group spends the most time in the contamination area. This additional time provides the
opportunity for more exposure to ambient airbome radioactivity and additional
opportunities for exposure to small acute events. It is also consistent with the work
practices in place at the time. For example, D&D workers wearing respiratory protection
brought waste that had been surveyed, and the waste crew accepted it without wearing

respiratory,protection.



Page 4 of 1>

presented in the five categories relevant to the Radiation
Protection Program.

a- Radiation Protection Standards Implementation

The state of the implementation of Radiation Protection
Standards at the RFP varies among the buildings. Presently,
there is an effort at the RFP to upgrade to the DOE Order
$480.11 standard, in advance of the RCM implementation.

There is one Compliance Schedule Approval (CSA) for relevant DOE
Orders. Specifically, DOE Order 5480.11, Radiation Protection
for Occupational Workers has one CSA, because EG&G Rocky Flats
does not have a program for routine bioassay monitoring in
place.

In the case of DOE Order 5400.5, Radiation Protection of the
Public and the Environment, EG&G Rocky Flets personnel believe
that EG&G Rocky Flats Inc. is in compliance, and Environmental
Protection Agency (EPA) concurrence is expected for the
compliance assessments that were submitted in December 1992.

Implementation of the requirements of the DOE Radiological
Control Manual (DOE-RCM), that was promulgated by DOE Notice
5480.6, Radiological Control is in progress. The EG&G Project
Manager responsible for the Radiological Control Manual (RCM)
Implementation reported that the RFP was 43% administratively
compliant with the DOE RCM, and that EG&G was working towards
implementation. Compliance by subcontractors will be
contractually invoked with the next modification to their
contract.

DNFSB staff review of the RCM Implementation Plan revealed that
technical justification was not always given for compensatory
actions, or in the case of no compensatory actions when there
was a non-compliance. In some cases the Plan states: "No
additional compensatory actions beyond continued compliance with
DOE 5480.11 and 5400.5 and other appropriate Orders or
Directives are warranted.". Adequate basis for this argument has
not been stated, given that DOE Order 5480.11 has not been fully
implemented at the RFP. The Plan was fairly detailed at a
macroscopic or progranmatic level, but instances of incomplete
corrective action plans and schedule inconsistencies were noted.
The Plan's implementation schedule does not show full compliance
with the RCM until February 1998. However, EG&G personnel
indicated a commitment to achieve full compliance with the RCM
by 1996. Wot enough detail is provided to substantiate this
extended length of time to reach compliance. RFP personnel
explained that the RCM Implementation Phase(s) during 1994 would
result in the development of detailed plans to achieve full
compliance. Key issues identified by RFP personnel associated
with the RCM Implementation at the RFP are given in Attachment
(1). A separate DNPSB Outside Expert review of the RCM
Implementation plan identified that of all DOE sites, RFP had
the greatest number of Articles in a "not in full compliance”
status. Attachment (2) provides RCM Implementation Plan
highlights.

b. Radiological Health Operations

1. DOE

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Numerous Small inhalation Intakes

Numerous small releases of plutonium causing elevated airbome radioactivity below the
air monitoring equipment alarm capabilities was determined to be the most likely cause
of- the low-level uptakes. ‘From interviews, it was learned that the waste workers
considered the waste they were handling either “cold” {uncontaminated) or “hot”
(contaminated) [their words}. They typically handled waste and packed waste boxes and
drums without respiratory protection when they were told by the RCT that the waste was
“cold” The RCTs used a Ludium 12-1A portable instrument to perform the survey.

Due to the history of Building 771 there are small amounts of loose surface
Contamination on pipes, under pipe hangers, and at pipe joints, in addition to being in
cracks and crevices of other waste the workers handled. When this material was
disturbed in the D&D process (crimped, band-sawed, etc.}, and handled, the surface
Contamination that has been there under years of accumulated dust and grime may
become airbome. It follows then that as the waste workers packed the waste crates
small releases of contamination could result.

Room 179, the Location of Most of the Low Level Waste Packaging, has a Higher
Average DAC than Other Rooms

As shown in Figure 5, the average DAC value in Room 179 is one of the highest of any
room in Building 771. The waste crew spent significant time in this room.

The DAC Value from the Fixed Airhead in Room 179 Increased As More Waste Was
Packaged

Since virtually no D&D work was done in Room 179, the question becomes one of
exactly where did the higher level of airborne radioactivity come from? ‘If it Indeed were
the result of waste packaging, then as more waste was packaged, more radioactive
contamination would be released. As shown in Figure’6, the average DAC level in
Room 179 approximately follows the volume of low level waste packaged.

The More D&D Work Being Done in the Building, the Higher the Average DAC

Most of the work in Building 771 during this timeframe was facility D&D. The D&D work,
being intrusive, would raise the average DAC level in the building. As can be seen in
Figure 7, the average DAC value in the building approximately correlated to the hours
worked.

An Exposure Model of the Building 771, Room 179 Atmosphere During Low Level
Radioactive Waste Packaging

The average airborne contamination level in room 179 during the Year 2000 was

approximately 0.5% DAC, as determined from the fixed air head, when transients
caused by known releases were deleted from the data base. A model was developed

1s



Year 1959. Reevaluated Neutron Doses for Which
Initial Evaluation Was Zero, 2-week Period

Number

Neutron Dose (mrem)

Notes:
1. Highest Neutron Dose = 466 mrem

2. 81% > 100 mrem
3. 12% > 200 mrem



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In addition, urinalysis ahd lung counting do not have the sensitivity necessary to detect
intakes of plutonium at the DOE investigation level of 100 millirem. While the analysis of
fecal samples does offer the necessary sensitivity, fecal sampling is not used routinely at
Rocky Flats because compliance of the workforce is difficult to maintain and
interpretation of resutfs without a known intake event is very difficult. Fecal examination
is required when workplace indicators signal the possibility of intemal deposition of
radionuclides.

In summary, the investigation Team concluded that the most likely Cause of the positive
bioassay results was exposure to low levels of airbome plutonium radioactivity from
radiological work operations exacerbated by D&D operations. These tow levels of
airbome radioactivity are below the threshold of workplace indicators.

While the exposure to individuals from these intakes are well within regulatory limits, the
critical nature of the investigation into positive fecal results from workers from Building
771 identified several areas for improvement that could contribute to maintaining .
exposures to the Site’s As Low As Reasonably Achievable goals. These include i
requirements for respiratory protection in situations involving direct waste handling,
improved containment of items staged for size reduction, improved building ventilation,
and Improved engineered controls. Corrective actions are detailed in a corrective action
plan that will be submitted as a result of this report, and also as part of a March 14, 20017
Root Cause Analysis on Building 771 Radiological Safety Program Concems.

However, with the most robust controls for contamination in place and highest attainable
compliance with protective processes and procedures, some level of intemal exposure
to radionuclides will most likely occur in individuals who are directly involved in high-tisk
activities associated with the decontamination and decommissioning of Rocky Flats
former plutonium processing facilities.



Page 13 of 1S

previous year's external exposure total is simply factored down
by 10 &. Allowances are not made for changes in work load or
personnel staffing from year to year. Major changes in work
assignments can significantly affect a groups external radiation
exposure for a year. However, provisions apparently do not
exist to adjust a goal during the year to account for these
changes. These issues limit the usefulness of the goals as a
management tool-

The BG&G collective dose for 1st and 2nd quarter 1993 was equal
to 56 and 82 person-rem respectively, and exceeds the EG&G
cumulative dose goal of 100.

The EG&G collective dose 1992 total was 231 person-rem, and the
1992 goal was 157. BGG is working to determine the reasons for
the difference. During briefings, EG&G personnel gave four

reasons for last quarter CY 92 increase above goal. These were:

1) material moves in Bldg 991;

2) on-line work in Bldg 707;

3) dose reconstruction for 1992; and
4) data base programming problem.

Attachment (4)0 ATTACHMENT

1. Past practice was to shut down buildings without lay-up,
but currently a Transition Program has been implemented in
Building 865.

2. Implementation of engineering controls was described as
in infancy." Engineering controls, such as glovebags on
ventilation plenums, are being used in Building 707.

3. In the past there was a lack of timely closure of
Radiological Deficiency Reports (RDRs). Some RDRs have
_xemained opened for up to 2.5 years. Recéntly, the data entry
backlog has been eliminated, the number of outstanding RDRs
have been reduced by 10% over previous years, and further
improvements are planned.

4. Radiation Work Permit compliance lacks positive control
from non~Integrated Work Control Procedure, and lacks control
of external dose. RFP personnel plan to move the RWP Issue
Point to Radiological Control Area (RCA) step-off pads, revise
procedures to minimize redundancy, purchase computerized
access control programs (pending funding), and implement the
use of direct reading dosimeters.

5. Radiological Building Engineers were noted as needing
additional training in the conduct of ALARA Reviews, and
action plans have been developed to provide specific training
im ALARA Reviews.

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equipment, materials, etc., or as airbome radioactivity. For example, while acute
exposures at high DAC-hour levels should be detected readily, an exposure in the range
of 10 to 20 DAC-hours protracted over a working year would not be detected by work
place indicators. .

In addition, urinalysis and lung counting do not have the sensitivity necessary to detect
intakes of plutonium at the DOE investigation level of 100 mrem, while the analysis of
fecal samples does offer the necessary sensitivity. Despite the sensitivity offered by
fecal sampling, interpretation of the results, without a known intake event, is. very
difficult.

Although the exposures in question are low — ranging from 6 to 60 mrem, GEDE — the
site takes its As Low As Reasonably Achievable goal and responsibility very seriously
and will take corrective actions to reduce the chances of long-term low level exposures
in the work place. However, even if all corrective actions are 100 percent implemented,
it will not completely eliminate the low-level exposures received from performing work in
@ plutonium facility.

6.0 COMPENSATORY MEASURES

The following compensatory actions were initiated on November 29, 2000 after the
Building 771 management became aware of the positive bioassay results for ten of the
eleven individuals and suspended-work to assess the situation. These actions were
complete and/or ongoing when work was authorized to resume on December 712, 2000.
The investigation team examined these actions to confirm they were ongoing or
complete.

* All removed gioveboxes that have been staged for size reduction were contained in
plastic sheeting. Weekly surveys of stored/staged gloveboxes for contamination
were required.

¢ Fixed airhead results, CAM/SAAM alarm logs, air sampling trends, DAC-hour _
tracking, routine surveys, and key facility logs for the preceding thred months were
reviewed in an attempt to clearly identify the source of radioactivity in the fecal
samples.

* The containments on cut process fines (piping) were re-inspected for proper
containment and, if necessary, re-contained.

* Reemphasized the requirement to perform smoke-testing of airflow patterns after
room configuration changes.

* Performed continuous low-volume air sampling in each room during D&D work,
rather than just when respiratory protection was being wom. © :

* Radiological contamination surveys of the entire building floors and overhead areas
were petformed. These surveys identified several areas of contamination but they
were in areas generally not worked and were not thought to be not high enough to
have directly caused the intakes. A quarterly contamination survey of overhead



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areas was added to the list of required surveys. A requirement that respiratory
protection be wom for all intrusive work in overhead areas was implemented.

The number of survey points was increased on routine contamination surveys.
RCTs were briefed on the need to improve job coverage survey documentation.

Respiratory protection was required for all waste transportation and packaging
activities.

Lapel air samplers were required for all workers involved in the Room 186 tent.
Nasal and mouth smears were required for each worker exiting the Room 186 tent
after wearing respiratory protection.

Temporary lapel air samplers were required for one member of each work crew in
Building 771. .

Supervisors, including RCT supervisors, were required to maintain logs.

Toolbox training was provided to workers and RCTs on proper work practices for
containing waste, for having RCTs. present, and for wearing respiratary protection
when handling, transporting and/or processing waste.

Stop-work protocols and procedure hold-points were reemphasized to all personnel.

Personne! were required to monitor anti-contamination ‘clothing Prior to doffing to
address the possiblity that higher than expected residual contamination may be
present on the clothing. This requirement was discontinued on January 16, 2001
after results showed no increase in radioactivity levels.

CAMs were placed at each of the two step-olf pads. Building management
discontinued this practice on January 16, 2001 after Radi iological Engineering
analysis of the data.

An additional CAM was added in Room 186.

An assessment of respirator cleaning, testing, training, issuance, and use was
performed by the Site Industrial Hygiene organization. The results showed no
shortcomings that would explain the uptakes.

Each work crew was briefed on the integrated Work Control Program and procedure
compliance including Job Hazard Analyses, ALARA Job Reviews, and Radiation
Work Pemnits.

Since the investigation had not been successful in clearly identifying the source of
the uptakes, respiratory protection was required to be wom for all D&D work
activities until determined that it is no longer needed.



Lage yo io

@ the following highlights from discussion with EG&G and
obsexvations are provided:

Forty percent of the Radiological Operations Section
Managers and foremen (supervisors) have attended the
Supervisors Academy.

J EG&G is anticipatang that approximately 40% of RPTs will
fail the RCM Training. Curxently, the training work package
budget considers 40% remedial training.

3 Building Radiological Engineers do not have position
descriptions.

= The glovebox training course provided to RPTs has not been
reviewed or approved by radiological controls personnel. This
course was prepared and is presented by personnel from the Job
Specific Training Section of the Performance Based Training
Organization.

3 RPfs are encouraged to pursue registration by the National
Registry of Radiation Protection Technologist (NRRPT).

In light of the fact that RFP Radiological Protection Program
training is not meeting the DOE Implementation Plan for
Recommendation 91-6, the DNFSB staff
considers RPP Radiological Training
Program progress unacceptable.

dad. Personnel Interviews

Personnel interviews to discuss radiation protection were
conducted by DNFSB Staff. Employees interviewed were from the
following categories: 1) Radiation Workers, 2) Radiological
Control Technicians and 3) Radiological Controls Supervisor.

In general, employees were confident and knowledgeable about
radiation protection commensurate with their position. Response
to questions indicated that the radiation program discussed in
the briefings was in place, or was in the process of being
implemented.

e. Building Tours

Buildings 707, 771, and 881 were toured by DNFSB staff with REP

personnel. EG&G line personnel conducted the tour, made

Observations and compiled notes. Excerpts from the tours are

provided in Attachment (6).

5. DNFSB Staff Follow-up

a. Follow progress made towards achieving RCM compliance.

b. Follow implementation of the computerized tracking and
scheduling program for bioassay. Verify that it includes
subcontractors who work at the plant.

¢. Follow the progress made in resolving deficiencies associated
‘with radioactive source accountability-

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Program includes pre-award and annual performance verification samples as well as
shipping. In addition to testing by RFETS, the laboratory used during the Building 771
investigation has participated in a number of laboratory inter-comparison studies. In
every case, the laboratory exceeded the requirements.

During the investigation, some sample analyses failed the quality control requirements.
An investigation by Intemal Dosimetry and Analytical Services determined that these
problems were primarily due to shipping an extremely large number of samples
(equivalent to approximately 6 months’ workload) to the laboratory in the month of
December. The contract specifies tumaround times based on a given workload. . The
samples that were sent during the Building 771 event far exceeded that workload. There
is currently only one laboratory which has met the SOW requirements to process
bioassay samples. Analytical Services has been trying to qualify additional laboratories
for at least two years without success. .

The quality control program worked as designed because the laboratory self-identified
problems, operations were paused until corrective actions could be implemented, and
then resumed operations with minimal toss of data. Performance testing results have
consistently demonstrated the laboratory's ability to perform quality work. There is no
evidence that the results seen in the Building 771 bioassay samples should not be
accepted. These results are also consistent with the fecal sample results from plutonium

* facilities at Hanford and the Savannah River Site (see Appendix 4).

4.0 ANALYSIS
Intake Pathways

The possible intake routes for internal radiation exposure is ingestion, injection,
absorption through the skin, and inhalation. Each of these routes are evaluated below.
The investigative tearm ruled out ingestion by direct contact with the mouth, injection, and
absorption as pathways and focused on inhalation as the primary pathway for these
exposures.

@ Ingestion. This pathway includes two sources: (1) Inhalation of airborne particles
through the nose or mouth, trapped by the mucous membranes, and subsequently
swallowed. This pathway accounts for a large portion of the intake during inhalation.
(2) Ingestion by direct contact with the mouth. It is not likely that all 14 workers
ingested plutonium by contaminating their faces. There are data to show that none
of them received any skin contamination. These results were confirmed through
interviews.

b. Injection. There are no data to support injection, such as a puncture wound, as a
route of intake by any worker.

¢. Absorption. No skin contamination was reported by any of the eleven workers during
the time period in question.

d. Inhalation. There are three possible general scenarios for inhalation intakes: a single
large event, breathing a slightly elevated, airbome radioactivity level and numerous
‘smaif intakes by inhalation.

2


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Attachment (3)0

ALARA Program Performance Indicators were presented in the
following areas: 1) Personnel Cumulative Radiation Exposure, 2)
Confirmed Intakes greater than 100 mrem CEDE, 3) Skin/Clothing and
Area Contaminations and 4) Number. of Individuals Exceeding
Administrative Dose Guidelines (ADG). The following observations
were made during the review:

1. The Operations Management for one building was not able to
recall either the five catego: ¢ of ALARA goals or what the
specific goals were for their building for 1993.

2. Although the liquid waste treatment facility is operating
essentially at capacity, little if any successful effort has
been initiated to reduce the generation rate. This situation
is not being addressed as one of the ALARA program goals.

3. Despite the fact that subcontractors do a significant amount
of radiological work, they are not totally included in the
site's ALARA program.

4. During tours of various facilities it was noted that ALARA
information posted on bulletin boards was not current, and in
some cases, was incomplete.

5. The method used for development of ALARA external exposure
is without a strong foundation. Typically, the estimate of the

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Page 12 of 15

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DEFENSE NUCLEAR FACILITIES SAFETY BOARD

December 1, 1993

MEMORANDUM FOR: G. W. Cunningham,. Technical Director
COPIES: Board Members

FROM: ad. W. Troan

SUBJECT: Report on the Radiation Protection Review at

the Rocky Flats Plant

1. Purpose: This memorandum documents the Defense Nuclear
Facilities Safety Board (DNFSB) technical staff and outside
expert trip to the Rocky Flats Plant to review the Radiation
Protection Program. The review was based on a visit to Rocky
Flats on August 16-20, 1993.

2. Summary: The staff reviewed the Radiation Protection Program
for consistency with Department of Energy (DOB) Order 5480.11,
Radiation Protection for Occupational Workers, DOE Notice
5480.6, Radiological Control, and DOE Order 5400.5, Radiation
Protection of the Public and the Environment.

The Rocky Flats Plant Radiation Protection Program was
considered by the staff to be adequate. The following are the
significant staff observations:

a. The staff noted that the Managing and Operating (M&O)
contractor (EG&G, Rocky Flats Inc.) was working towards
implementing the DOE Radiological Protection requirements
of DOE Order 5480.11 and the DOE Notice 5480.6. Full
compliance with the Radiological Control Manual (RCM) was
originally planned to be achieved by October 1997.
However, EG&G personnel indicated a commitment to achieve
full..compliance with -the REM-by 1996. “Plans déveloped to
date do not give enough detail to justify the extended
length of time it takes to achieve compliance. In
particular, a majority of RCM Chapter 6 training
requirements will not be completed until the July to
September 1995 time frame. The Rocky Flats Plant (RFP)
plan to accomplish RCM training is not consistent with
the DOE's Implementation Plan for DNFSB Recommendation
91-6 , which committed to having General Employee
Radiological Training, Radiation Worker I and II, and
Radiological Control Technician training for all affected
workers using the standardized core training material
completed by December 1994.

b The staff noted that a potential existed for workers to
be exposed to radiation without being monitored ip
accordance with the Radiological Control Manual (ROM) and
DOE Order 5480.11. In discussions with Building 771
personnel, it was noted that the Thermoluminescent
Dosimeter (TLD) badge storage rack was being evaluated to
determine the amount of radiation the dosimeters were
exposed to while hanging on the rack. This evaluation
was being accomplished as a result of RFP personnel

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INVESTIGATION TEAM MEMBERS, ADVISORS, CONSULTANTS, STAFF, AND
OVERSIGHT

Investigation Team Members: .

Joseph W. Mahatfey (Team Lead), KH, Radiological Engineering Manager
Kenneth E. Harrawood, RRPT, KH, Deputy Manager ESH&aQ

Edward B. Wilkes, CHP, RRPT, KH, Site ALARA Program Manager
Eugene W. Potter, CHP, KH, Dosimetry Team Leader

Norman R. Warling, KH, Radiological Controls Technician

Karel D. Kelldorf, Esg., TENERA, Program Representative

Jeffrey P Ambrose, Bartlett, Principal Health Physicist

Kevin K. Konzen, CHP, RRPT, Bartlett, Principal Health Physicist

Richard G. Johnson, RAPT, RMAS, Principal Health Physicist

Advisors:

Michael J. Kriz, KH, 771 Closure Project ESH&Q Manager
Jeffrey B. Barroso, KH, Material Stewardship RSSM
Darren M. Boone, KH, 771 Closure Project RSSM

William J. Bair, RMRS, Principal Health Physicist

Consultants: .
John W. Poston, PhD, Texas A&M University, Professor of Nuclear Engineering

Staff:

Peggy J. Hamilton, KH, Principal Administrative Technician -
Lauri L. Mastriona, KH, Executive Secretary :

Beverly J. Smith, KH, Principal Administrative Technician

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to resource needs, and the schedule does not facilitate
retraining.

Attachment (1)0
ATTACHMENT (2) - RCM IMPLEMENTATION PLAN HIGHLIGHTS

The Rocky Flats Plant (RFP) Radiological Control Manual (RCM)
Implementation Plan
was reviewed and the following highlights are provided:

A. ROM Compliance Status:
In compliance with 45 items (22.4%).

Non-compliant with 156 items (77.6%).
No items were identified as Not-Applicable.

ood

Note: Items include Articles (with numbers), Text sections
which follow a chapter part but precede a numbered article
and Tables which contain requirement statements.
Requirement statements are specific and implied "shali” and
*should® statements.

B. Exceptions:

Article 521, Internal Dosimetry
Article 555, Aixborne Radioactivity Monitoring

C. Approval Status:

Implementation Plan noted by BG&G as approved by DOE with
comments.

D. Compliance Schedule:

Refer to the following page(s}. _

Attachment (2)2

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01/07/2005


investigation Team Report

Investigation of the source of potential internal radiological
exposures involving eleven personnel in Building 771

March 15, 2001

Reviewed for
Classification/UCNI

By: Karel Kelldorf / v/xu
HSS Beitdore fy

Date: March 15, 2001
March 15, 2001 _

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Room 186 Tent Design to Support Size Reduction Activities

The Room 186 tent design was appropriate for its initial use, the in-situ size-reduction of
the glove box #865. The design was not optimal for the size reduction and waste
packaging activities for which it was later used. The tent design lacked adequate
accommodations for incoming material staging.

The radiological engineer smoke tested the downdraft table but did not perform the
required ventilation flow rate check. Furthermore, the radiological engineer did not
smoke-test the downdraft table with the workers standing in their work locations or with
the band saw installed on the worktable. This could result in the reliance on a fess than
optimum control.

Other Vulnerabilities and Exacerbating Factors .

Other potential vulnerabiities and exacerbating factors included: .
© Compliance with ALARA Job Reviews, -
e Engineering controls during berm removal, ~

© Radiological Control Supervisor/Management expectations and Performance § issues,
* Field instrument performance checks, and

_® Deficiencies in radiological record-keeping.

A thorough discussion of these topics is included in the doctiment NTS-RFO—KHLL-
T7IOPS-2000-003, Building 77% Radiological Safety Program Concems.

Mitigating Factors

There are several factors that prevented the exposures from being worse. The
respiratory protection is very good and often protects workers against contamination
levels much higher than that which they are expected to encounter. The workplace
indicators such as the FAH monitoring, SAAM/CAM alarms, and personnel monitoring
can identify contamination releases independent of the Jow-volume air samplers. The
Building 771 employee concer resolution process and union safety concems programs
have. identified actual and/or potential Problems and have resolved them before
unwarranted risks were taken.

Conclusion

The positive bioassay results for the waste crew workers in Building 771 were most likely
the eos of econ of orale namaste Similar, but somewhat lower, results seen .
in the workers submitting personal request fecal samples are consistent with the
observation that the waste crew typically spent the most time in the contamination area.
Waste packaging activities were also likely contributors to the exposures.

Decontamination and decommissioning activities are significantly different from many
other radiological activities normally encountered in the complex. The destructive nature
of D&D activities may produce high levels of localized contamination and/or airbome
radioactivity. When the D&D activities take place in facilities contaminated with
plutonium, the challenges to a radiation safety program are especially great. Work place
indicators may not be capable of detecting tow levels of plutonium contamination on

22



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dpm. In addition, the building radiological safety organization or the individual worker
can request bioassay sampling even if the workplace indicator lower limits are not
exceeded.

The workplace indicators were designed to define potential intake events, which require
follow-up bioassay sampling and which may result in dose of 100’ mrem of more.- In
actual practice, the doses assigned are much lower than predicted by the workplace
indicators due to the conservative assumptions used in their development.

The workplace indicator program has three vulnerabilities. First, it relies on the proper
field measurements being taken in the proper way and at the proper time. For example,
the need to take nasalimouth swabs must be recognized, the swabs must be taken
prompily, and they must be prepared and sent to the laboratory. Second, the program
must rely on the professional judgement of the field radiation safety personnel to identify
additional intakes since not all situations can be anticipated. Third, the workplace
indicator program was not designed to detect lowtevel intakes protracted over long
periods of time, nor can it be reasonably redesigned to do so. a .
The follow-up sampling initiated following a potential acute inhalation incident typically
includes one or more fecal samples. The individual involved is required to refrain from
work with radiological materials until after all requested samples are collected. Fecal
sampling is a more sensitive method for detecting intakes; however, it is also highly
dependent on the time interval between the intake and the collection of the sample and
the particle size of the inhaled material. The minimum detectable dose for a single fecal
“sample can range from less than one mrem to more than 200 mrem CEDE, for samples
collected Jess than five days and more than 14 days after an acute inhalation.
Interpretation of fecal bioassay results can also be confounded by small ingestion
intakes. nos

The interpretation of fecal bioassay sample results is more complicated for the case of a
chronic intake scenario. To accurately determine the intake rate and corresponding
internal dose, it is necessary to know the relation between the start and end of the intake
as well as the sample collection date. Following the start of a chronic inhalation of
Intemational Commission on Radiological Protection (ICRP). Class-Y material with a
particle size. of 1 pm: Average Médiari Aerodynamic Diameter (AMAD), the fecal
excretion increases to an equilibrium state within approximately 10 days. When the
inhalation has ended, the fecal excretion decreases by approximately a factor of seven
within the first five days. If the chronic inhalation is interrupted by time off from work with
radioactive materials or by the use of protective equipment, then the fecal excretion will
decrease during the interruption and then increase when the intake resumes. Also,
interpretation of the fecal results is likely to be confounded by ingestion or small acute
inhalations near the end of the exposure period. Since these events are unlikely to be
identified by other workplace indicators, their resulting contribution to the fecal results
would be interpreted as being due to the chronic inhalation and therefore result in an
overestimate in the chronic intake rate.

Due to the event date-dependant nature of fecal samples, as well as confounding factors
of otherwise undetected small ingestion or acute inhalation events, it is not
tecommended that the accumulation of any set number of DAC-hours over an extended
period of time be used fo trigger follow-up bioassay sampling. it would be reasonable to
‘tigger bioassay sampling if the DAC-hour tracking indicates an unusual accumulation

10


eee ddd ddd ddd ddd ddd dd ddd dd dddedddded dds

ra

Approach:

Reevaluate neutron doses from old film, 1959 to 1966.

Retrieve film and worksheets from storage.

Read selected film microscopically.

Compare new evaluation with initial evaluation.

2. Review old records to reconstruct the

early history of neutron
dosimetry at Rocky Flats,

Team aaa 3 ~— dL eGsG ROCKY FLATS

>



The DOE Rocky Flats Office (DOE-RFO) Radiological Protection and
Health Physics Branch consists of a staff of five, with a
contractor support staff of seven.

2. Contractor

The Radiation Protection organization consists of approximately
500 personnel, of about 8000 personnel who work at the plant.

The RFP Radiation Protection Program implementation lacks
consistency across the Plant. The Deputy Plant Manager stated
that the Radiological Control Manual (RCM) implementation is the
first step towards Radiation Protection standardization at the
plant. However, the resource requirements that are currently
defined may be underestimated. The Radiation protection
Director stated that although the plant has had funding cuts,
none had been made in the area of Radiological Control
implementation. Later in the review, BG&G personnel identified
that the Radiation Assistance Program (RAP), a national DOR
program had been defunded.

3. Performance Indicators

The Radiological Performance Indicators (PIs) showed a continued
reduction in skin contaminations for 1991, 1992 and 1993.
Examples of other PIs are given in Attachment (3). The
performance indicators presented covered a majority of the
suggested Radiological Performance Indicators topics that are
identified by the RCM.

4. ALARA Implementation
{a) Plant Level

A program exists for maintaining radiation exposure As Low As
Reasonably Achievable (ALARA) at the RFP. An ALARA Oversight
Committee (AOC) has been established and advises the'General
Manager (GM) on the effectiveness of the ALARA effort and makes
recommendations to strengthen the program. During the briefings
by EG&G management, it was stated that the ALARA program had
several areas of weaknesses. These include inadequate field
implementation, inadequate training for management and
xadiological engineers and the failure to properly develop and
commmicate ALARA goals. Several observations made during the
review strongly support this characterization. Attachment (4)
provides observations concerning the ALARA Program.

A DNESB Staff review of the RFP ALARA program, performed from
March 29 to April 2, 1993, identified similar problems. The
review also noted that the DOE-RFO Radiation Protection and
Health Physics Branch was in the process of performing a
comprehensive review of the ALARA program. Although little
progress has been made toward correcting the deficiencies
identified in the earlier DNFSB stafi review, the DOB-RFO
surveillance was completed and identified several fundamental
problems with the ALARA program. EG&G is developing corrective
action plans to resolve the surveillance findings. These plans
have not been finalized and are not assessed here.

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Facility Airflow Pattern Surveys and Checks

The airflow pattern surveys were reviewed for adequacy to determine if air-monitoring
equipment is properly situated to detect an airbome release of radioactivity. The review
identified several weaknesses, which appear to be a combination of unclear procedural
guidance and insufficient rigor of compliance with existing requirements. For example:

1, Airflow pattem surveys were not routinely conducted following room configuration
changes, such as removal of gloveboxes, tanks, and wall penetrations.

2. There were several instances where Radiological Safety chose an insufficient
number of release points to evaluate the placement of air-monitoring equipment.

3. Anumber of airflow pattem surveys demonstrated problems with the placement of
the ait-monitoring equipment and building ventilation problems that were not
analyzed by Radiological Engineering to require further investigation of action.

4. There were several instances of poor survey documentation, such as: maps were not
representative of the areas being surveyed; the comments section was lacking in .
resolving questions regarding airflow pattems on the survey; and the vertical .
placement of the smoke device was not recorded. : >

Control and Reuse of Respiratory Protection Equipment Within Contamination Areas

Respiratory protective devices used by personnel in Building 773 were sometimes used
for multiple entries into Airborne Radioactivity Area {ARAs) within the contamination
areas, increasing the tisk of exposure from undetected contamination in the respiratory
protection equipment. Some workers have stored respirators in the Contaminated Area
(CA), which may increase the risk of intakes.

The practice of reusing respirators provides opportunities for individuals to have an
uptake of radioactive material. Normally respirators that are to be reused would be
surveyed for contamination upon doifing. Then the respirator would be placed in a bag
and sealed, ready for its next use. These respirators would not be surveyed again prior
to a second wearing. However, the respirator may have low levels of contamination
inside the mask due to the survey techniques used. _ if the respirator were. being stored
and/or. reused. within the: contamination’ aréa, the individuals would be handling the
respirator with gloves that were only frisked with either an Electra or Ludium-12-1A
survey instrument. The preferable method would be to swipe the interior of the
respirator and count ft on a SAC-4 system to verity the fevels of contamination below 20-
dpm/100 cm?,

However, it should be noted that there is no prescriptive guidance on surveying
fespirators for re-use. Even if procedures were developed to specify the approach to
surveying the respirator for reuse, opportunities of cross-contamination due to the
weating of contaminated gloves remain high. Therefore, the Practice of reusing
respirators’ provides vulnerabilities in the program in which individuals could receive
uptakes of radioactive material. -



SSCHOHHHOHHSHHHSHOHHSHOHHOOHHOHSHOHOHHOHHSOHSHOOEOOHOCESS

Evaluate the Site process for DAG hour wracking for purpose of improving
implementation and effectiveness and for providing supporting documentation for
use on the assignment of dose.

Enhance the DAG-hour tracking program to allow caiculation of doses due to low-
level protracted exposures.

The contract with the company providing the fixed air head data should be re~
evaluated to allow each building to receive the fixed air head data electronically, to
allow easier trending of DAC values near the MDA.

Implement requirements to contain staged glove boxes, survey of staged glove
boxes and equipment, and perform surveys in the overheard periodically,

Improve job coverage surveys and increase the nurnber of survey points on weekly
routine contamination surveys in the CA.

Develop and provide specific guidance on the re-use of respirators.

A scientific study using the current filters and as-built air flow rates should be
conducted to empirically determine a self-absorption correction factor that takes into
account filter loading from industrial grit associated with D&D activities.

Smplement the use of “Maslin Mops” (or equivalent) to maintain a cleaner work
environment minimize the build-up of dusts and debris, and detect low-level
contamination.

The central Radiological Engineering group should develop an evaluation process to
supplement the intemal audit program specified by 10 CFR 835.102.

Assess the current work activities and current building configuration in Building 771
to determine applicability to the Building 779 lessons leamed.

Perform particle size and solubility studies to allow for more accurate dose
assignments from DAC-hour tracking.

improve communications and coordination between operations and support
Personnel through adherence to ISM; defining roles and responsibilities; and
increasing Radiation Protection staffing/support.

Develop a Technical Basis addressing protracted low-level intakes.

27


SOHOHOHHHHSHHSHSHOHSHSHHHSHSSHSSSOHOHHHHOHHHOOHOHSCOOEOE

Because ingestion by direct oral contact, injection, and absorption are considered
extremely unlikely to be the cause of the intakes, the only possible route is inhalation.
The three inhalation scenarios of a single, large event, a slightly elevated steady state
airbome radioactivity level, and numerous small intakes, were analyzed using the
available data to determine the most likely cause of the internal doses. Each of these
scenarios is addressed below. A backup analysis was conducted to further confirm that
a single inhalation event did not cause the internal doses.

Single Large Inhalation Event

From review of the possible inhalation events timeline generated during the course of
this investigation, there is no event in which ail 11 workers were present and no series of
events in which various groups of the workers received a single, large intake.

Timeline Development

The Investigation Team evaluated over 200 events, culled from all available,
documentation, that could have reasonably caused a release of contamination. This data.
was put into a timeline format, and each incident was examined to determine if any of
the #1 workers were present, and whether the release could then have been the source ©
of the intakes of the 11 workers. Twenty of the most likely events to cause an intake
were then exhaustively stiidied. After many hundreds of hours of analysis, it was
determiried that there were no events where ail 11 workers were present, and no series
of events where various groups of the workers could have received a single, large

intake,

Internal Dosimetry Backup Analysis

To testthe hypothesis that a worker without a respirator would not receive an intake in a
room with a CAM alarm (assuming, of course, that the worker exits the area prompity),
the past six years of intemal dosimetry data was analyzed. All intakes that were due to
inhalation events were reviewed; a total of 156 cases that fit the hypothesis were
evaluated; these are fisted in the accompanying Figure 1 (aif figures are in the back of
this report). These results show that during airbome contamination incidents, with no
concurrent personnel contamination (where personnel are not in respiratory protection),
the individuals will not receive an intake resulting in a dose greater than a few millirem.
Thus, the Building 771 intake is extremely unlikely to have been due to an acute
inhalation, because an acute airbome contamination incident high enough to cause a
detectable intake would have resulted in a CAM alarm, assuming proper placement of
the CAM.



NEUTRON FILM PROCESSED BY YEAR

16,0004 : |

14,0004

12,0004

10,000-

8,0004

8,000

# Of Neutron Film Developed

4,000

2,000~

1963 1964 1965 1966 1967 1968 1969
Years

1958 1959 1960 1961 i962



POOH HHOHHHHSHHOHHOHOHOHOOHOOHHHOHSOHOSOOHOHOHSHHOHOOEO

(b) RPP Buildings

The DNFSB staff reviewed the ALARA Program at the building level
for several buildings through discussion with personnel and
observations. In general, the staff found that some building
ALARA programs were not effectively implemented. As expected,
the shortcomings observed mirrored those noted at the plant
level. One particular deficiency is that the ALARA program does
not totally integrate subcontractors. (See Attachment 4).

5. Dosimetry

External Dosimetry Program - RFP personnel noted that the Whole
Body Dosimeter Program passed the DOE Laboratory Accreditation
Program (DOELAP) in 1990, and that the accreditation certificate
was received in October 1991. RFP noted that the program's
algorithm has been changed since the last accreditation, and
that a wrong correction factor may have been applied in the case
of the K17 dosimeter chip. In accordance with the DOEBLAP
procedure, accreditation occurs every two years, and is expected
to be accomplished this fall.

RFP personnel recognized that DOELAP accreditation does uot test
the capability of the dosimeter to respond adequately to
plant's various neutron radiation fields. Because of neutron
felt Weasurement uncertainties, RFP plats a field
characterization study next year. However, RFP personnel feel
that the current system is adequate in the interim since it
tends to over-estimate the neutron dose.

A comprehensive Technical Basis Document (TBD) for the External
Dosimetry Program is currently being developed. The RFP has
received no guidance from DOEZ-HQ on how to. prepare that
document. RFP personnel stated that they viewed the purpose of
the TBD as a means to document the framework of the program, and
to state policy. * The TBD is expected to be final in January
1994.

Of thé 8000 personne? on site, approximately 5000 receive
dosimeters. The criteria for requiring dosimeters is defined
in Procedure HSP 18.07, with the Radiation Engineering Group
making the determination of whe to include.

RPP personnel stated that the Extremity (Wrist) Dosimetry
Program was designed to meet the Draft DOEZLAP Extremity
Dosimetry Program Standard. When asked who is required to wear
extremity dosimeters, RFP personne] stated that the Radiological
Building Engineer would be contacted and would make the
decision. RFP personnel stated that there were no specific
criteria, but that the question is asked during the Integrated
Work Control Package (IWCP) process.

The Extremity (Finger) Dosimetry Program is under development.
It is designed to meet the Draft Extremity Standard. Field
testing is currently underway, and expected to be complete in
mid FY 94.

The periodic turn-in of dosimeters for determining dose
(dosimetry exchange) was discussed. A graph of dosimeter
excharge versus date showed improvements over the last few

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Occurrence" in the event of loss of accountability of a
radioactive source which exceeds the lesser value of exempt
quantities as specified in DOE Notice N5400.9 (Sealed
Radioactive Source Accountability) or state
standards/regulations. The applicability of these reporting
requirements were not ascertained at the time of the review.

Instrumentation - The DNFSB staff observed that EG&G had
developed and documented a process for defining requirements and
acceptance criteria for instruments and using it to establish
the technical basis for selection of Health Physics
Instrumentation. This program appeared to be well constructed
and likely to result in properly defined equipment
specifications. This procedure was prepared for EG&G Corporate
Government Contracted and Operated Facilities, and its use may
extend beyond Rocky Flats (i.e., EG&G Mound, REECo Nevada
Operations, Idaho National Engineering Laboratory) -

Workplace Air Monitoring - RFP personnel described the Work
Place Air Monitoring Program at the RFP as an integrated program
consisting of seven elements ranging from Selected Alpha Air
Monitors (SAAM) to bioassay. Air monitoring in the workplace
at RFP is not in compliance with the requirements of the RCM.
Specifically, the RCM article 555, Airborne Radioactivity
Monitoring, paragraph 5 requires that Continuous Air Monitors
should be capable of measuring one (1) Derived Air Concentration
{DAC) when averaged over eight (8) hours (8 DAC-hours) under
laboratory conditions. SAAMs used at the RFP were stated by RFP
personnel to have a sensitivity of approximately 42 DAC-hours.
Improvements are planned and are expected to increase the SAAM
sensitivity to approximately 8.5 DAC-hours. In support of this
improvement effort, a pilot program has been completed in
Building 707 Module J and Building 371. Im addition to the
sensitivity problem, SAAMs are no longer in production and the
RFP relies on cannibalizing or replacing units from
approximately 150 spare units held at the Plant. A Capital
roject Air Monitoring Improvement Program is in place to
support the air monitoring requirements for the.future
Decontamination and Decommissioning (D&D) work at the RFP.

DNPSB staff review of the RFP RCM Implementation Plan identified
that EG&G has not included the upgrade to meet the requirement
in their Implementation Plan, but has taken an exception to RCM
Article 555.

7. Radiation Work Permits and Procedures

Work Control and Planning - As RFP described it, the RFP
radiological work control and planning process does not include
methods to prioritize their work. Currently, there is more work
than Radiological Operations can svpport. The workload is
handled by overtime requests in building work packages. A Plant
Priority System is scheduled for implementation in FY 94. This
problem is expected to be temporarily exacerbated by further
reduction in Radiation Protection Technicians (RPT)
availability, when increased training requirements reduce RPT
availability below 1993 levels.

Contamination Control -‘Radiological Operations personnel
discussed contamination control at the RFP, noting key issues,
and indicating improvement. - Attachment (5) provides highlights.

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ages urs

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COHOSHOH HOH OOOOOOOOOOOCOOCOOOOEOOOOHOOCOOCO

Special Exposure Cohort Petition, Form B OMB #0920-0639 Expires 05/31/07
Appendix - Continuation Page

F.4 Records and Information are Inadequate for Individual Dose:

Technical Reports from Government Entities or Journals

Attached is a copy of the March 15, 2001, Investigation Report for the Building 771 worker
exposures that shows that D&D activities have created unmonitored exposures over time that go
undetected by workplace indicators and have resulted in undetected worker exposures. Attached
are copies of technical reports from the Defense Nuclear Facilities Safety Board (DNFSB)
supporting our basis for petition that unmonitored exposures and deficiencies have created a
situation in which accurate dose reconstruction cannot be performed. Also attached are DNFSB
documents that support the contention that processes involving high fired oxides were conducted
as recently as the 1990s-2000s with oxide stabilization processes in both Building 707 and 371.
Also attached are Price Anderson Enforcement documents that provide evidence of issues
surrounding unmonitored exposures and chronic exposures over time that are not detected by
work place monitors. Other relevant supporting documentation is also attached. All of the
attached documents support our basis for petition.

The USWA, Local 8031 reserves the fight fo provide additional information beyond that which is included in this petition
and in support of cur ability to obtain Special Exposure Cohort designation for the Rocky Flats class of workers.
26