Eti-Ology Contaminated Wounds

d +.i i i WHC-SA-1484-FP I-

MAY 2 2 1992

Eti-ology Contaminated Wounds

Prepared for the US. Department of Energy Office of Environmental Restoration and Waste Management

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\ ' wHC-SA--14 84 DE92 0142116

Etiology of Contaminated Wounds R. H. Sudmann

Date Published March 1992

To Be Presented at 25 Mid Year Topical Meeting-Health Physics Society Dearborn, Michigan January 12-16,1992

Prepared for the US. Department of Energy Office of Environmental Restoration and Waste Management

westinghouse P.O. Box 1970 bnfOrd CmQIaIIy Richland, Washington 99352 Hanford Operations and Engineering Contractor for the U.S. Department of Energy under Contract DE-AC06-87RL10930

Copyright License By aeosptanca of this &de. the publisher and/or mcpmt a&mwb&w the U.S. Government's 6~hlto rehn a nonexdusnm. rcyaiiy-free liinse in and lo any ~~yflgMmvermg thls paper.

Approved for Public Release WHC-SA-1484-FP

ETIOLOGY OF CONTAMINATED WOUNDS

R. H. Sudmann

ABSTRACT

The U.S. Department of Energy reports of events that occurred in the

chemical processing 200 Areas of the Hanford Site during the period from 1972

through 1986 were reviewed to identify the causes of contaminated wounds.

Contaminated wounds were reported in 19 events involving 20 workers. The

causal agents (high risk operations) and the root causes were characterized, Emergency actions taken and their efficacy were noted.

The 19 wound events were compared with 17 events with the potential for-

inhalation. It was found that the wound events involve a single worker and

frequently result in an internal contamination and its resulting dose.

Inhalation events involve groups of workers and rarely resulted in detectable

internal contamination. The difference is attributed to anticipation of an

inhalation event and use of respiratory protection and continuous air monitors to mitigate its effects.

LESSON LEARNED: The majority of the wound events might have been prevented with basic industrial safety contro’ls. Radiation protection professionals should become more conscious of basic industria7 safety concepts

and their application.

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TABLE OF CONTENTS

INTRODUCTION ...... 1

EVENT DATA BASE ...... a . . 1 ACCIDENT OR ABNORMAL OPERATIONS ...... 2 WOUNDS VS INHALATION ...... 2 WORK ENVIRONMENT AND CAUSAL AGENTS ...... 9 HANDS-ON OPERATIONS ...... 11 CHEMICAL REACTIONS ...... 11 RADIOLYSIS ...... 14 DOSECONSEQUENCE ...... 14 EMERGENCY RESPONSE ...... 16 PREVENTION ...... 17 CONCLUSION ...... 17 REFERENCES ...... 18

iv ......

WHC-SA-1484-FP

LIST OF TABLES

1 Contaminated Wounds Reported in the Hanford Site 200 Areas 1972-1986 ...... 3 2 Events with Potential for Inhalation in Hanford 200 West Area 1972-1986 ...... 5 3 Events 1972-1986 ...... 7 4 Characteristics of Accidents and Abnormal Operations ...... 8 5 Wound and Inhalation Frequencies ...... 8 6 Agents Identified ...... 10 7 What Happened Where - Wounds ...... 12 8 What Happened Where - Inhalations ...... 13 9 Internal Dosimetry Estimates for Contaminated Wound Events ...... 15

V WHC-SA-1484-FP

LIST OF TERMS

ALARA as low as reasonably achievable CAM continuous air monitor CEDE committed effective dose equivalent D&D decontamination and decommissioning DOE U.S. Department of Energy DTPA diethyl enetetraamine pantaaceat ic acid EDF Emergency Decontamination Facility NRC U.S. Nuclear Regulatory Commission ON Off-Normal Report PFP Plutonium Finishing Plant PFP- FSAR Plutonium Finishing Plant Final Safety Analysis Report PUREX Plutonium/Uranium Extraction (Plant) RL U.S. Department of Energy, Richland Field Office UOR Unusual Occurrence Report WESF Waste Encapsul ation and Storage Faci 1 i ty

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INTRODUCTION

The Hanford Site is located in the arid area of southeastern Washington State. This site has been operated by the U.S. Department of Energy and its predecessors for almost 40 years for the production of plutonium and the management of associated wastes. The chemical separation of the plutonium was performed in the plants located within the 200 East and West areas. Once separated from the irradiated fuel, the plutonium solution was transferred to the Plutonium Finishing Plant (PFP) for conversion to metal. The PFP has been operating since 1950. Its current mission is the stabilization and storage of plutonium scrap. Many of the processes at PFP involve hands-on glovebox operations.

This study developed during the preparation of the Plutonium Finishing P1 ant Final Safety Analysis Report (PFP-FSAR) . The PFP-FSAR was prepared in accordance with the U.S. Nuclear Regulatory Commission (NRC) Regulatory Guide 3.39 Standard Format and Content of License Applications for Plutoniuav Processing and Fuel Fabrication Plants (Regulatory Guide 3.39) (NRC 1976). The Regulatory Guide 3.39 requires the analysis of not only the credible accidents but a1 so "abnormal operations. I' Abnormal operations were interpreted as lesser anticipated events involving contamination spreads and internal/external contamination of workers.

Rather than conjure up scenarios or depend on anecdotal material from "old timers," the study used a collection of real events already available to the public. These are unusual occurrence reports (UOR). An analysis of the events that occurred in the plant while it was operating (1972-86) provided the needed reality for accidents and abnormal operations covered in Chapter 9.0 of the PFP-FSAR. Scenarios resulting in internal contamination were included in this category of events. The events analyzed were real not "what if" situations; as such, they provided lessons learned that were incorporated throughout the FSAR.

EVENT DATA BASE

In 1972 the unusual occurrence reporting system was initiated by the U.S. Atomic Energy Commission, Richland Operations Office. Between 1972 and 1986, 1,742 UORs were issued for events that occurred in chemical processing facilities in the Hanford 200 Areas. In 1981 the U.S. Department of Energy (DOE), Richland Field Office (RL) directed that events of less consequence than an UOR also be documented. The Off Normal Report (ON) was initiated, and between 1981 and 1986 over 1,000 reports were issued. These reports and investigations are available to the public at the DOE Richland Operations Pub1 ic Reading Room in Richland, Washington.

This collection documenting over 2,700 events was reviewed to identify those reporting wounds or the potential for inhalations; 36 were found. Analysis of the causes and circumstances of potential or actual internal contaminations was conducted. Thirty-four events occurred at PFP between 19'72

1 WHC-SA-1484-FP

INTRODUCTION

The Hanford Site is located in the arid area of southeastern Washington State. This site has been operated by the U.S. Department of Energy and its predecessors for almost 40 years for the production of plutonium and the management of associated wastes. The chemical separation of the plutonium was performed in the plants located within the 200 East and West areas. Once separated from the irradiated fuel , the plutonium solution was transferred to the Plutonium Finishing Plant (PFP) for conversion to metal. The PFP has been operating since 1950. Its current mission is the stabilization and storage of plutonium scrap. Many of the processes at PFP involve hands-on glovebox operations.

This study developed during the preparation of the Plutonium Finishing Plant Final Safety Analysis Report (PFP-FSAR). The PFP-FSAR was prepared in1 accordance with the U.S. Nuclear Regulatory Commission (NRC) Regulatory Guide 3.39 Standard Format and Content of License Applications for Plutonium Processing and Fuel fabrication Plants (Regulatory Guide 3.39) (NRC 147~). The Regulatory Guide 3.39 requires the analysis of not only the credible accidents but a1 so "abnormal operations. I' Abnormal operations were interpreted as lesser anticipated events involving contamination spreads and internal/external contamination of workers.

Rather than conjure up scenarios or depend on anecdotal material from "old timers,'' the study used a collection of real events already available to the public. These are unusual occurrence reports (UOR). An analysis of the events that occurred in the plant while it was operating (1972-86) provided the needed reality for accidents and abnormal operations covered in Chapter 9.0 of the PFP-FSAR. Scenarios resulting in internal contamination were included in this category of events. The events analyzed were real not "what if" situations; as such, they provided lessons learned that were incorporated throughout the FSAR.

EVENT DATA BASE

1 WHC-SA-1484-FP and 1986 and one each occurred at the 222-S Laboratory and the Waste Encapsulation and Storage Facility (WESF). The pattern of events reflects differing types of operations in facilities and should not be interpreted to mean that there were periods of lapses in safety.

ACCIDENT OR ABNORMAL OPERATIONS

The 36 events were separated into two categories. Contaminated wounds are summarized in Table 1. Events with an inhalation potential are listed in Table 2. The event that occurred at 222-S Laboratory (RHO 1985c) was included in both tables. The events, which were categorized by the operation in progress when they occurred and the agent or failure that occurred, are presented in Table 3. From the review of the database a set of elements appeared that might be used to differentiate between or characterize "abnormal operations" and "accidents." The elements listed in Table 4 may be useful to analysts working on safety analysis report scenarios. Is there a clear separation between an accident and abnormal operations? The pattern suggests that; abnormal operations involve the failure of an engineered barrier and subsequent release of contamination. Inhalation events are classic candidates as abnormal operations because mu1 tiple barrier/safety systems are in place to prevent them. Accidents suggest an unknown or unrecognized agent that breaches the barrier. In most wound events an obscure or innocuous agent/sharp object breaches the barrier, then the skin, resulting in internal contamination. Wound occurrences may be postulated, but are not predictable.

WOUNDS VS INHALATION

Based on the differing characteristics of an event, the consequences are quite predictable. Concentrated contamination from a wound is introduced into the body close to the blood stream. The solubility of the contaminant is thle main limit to the potential for an internal contamination. Inhaled contaminants are dilute compared to those encountered in a wound, and must penetrate not only the personnel respiratory protection and the battery of detection devices, i.e., continuous air monitors (CAM), but the body's own respiratory system. In a facility such as PFP, the contaminated wound is the predominant cause of detectable internal contamination. From Hanford Site experience, wounds involve single workers whereas inhalations involve groups. These numbers are compared in Table 5. The majority (91%) of the events analyzed occurred at PFP and involved pl utoni urn-contami nated faci 1 it i es. The 19 wound events occurred over 15 years and were associated with the hands-on glovebox operations. In the glovebox environment, or when hand1 ing plutonium-contaminated materials, any scratch, prick, or wound has a high potential for internal contamination.

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Table 1. Contaminated Wounds ReDorted in the Hanford Site 200 Areas 1972-1986. (2 sheets) Ref. No. y;; Event summary ARH 1972a (6-9-72) Wound; An operator was cleaning the floor of the glovebox hood, the middle finger left hand was punctured by an unknown object. ~ ~ ~~ ~~ ~ 1 ARH 1972b A.3 (12-22-72) Wound; An operator was cleaning the floor of the glovebox hood, the right little finger was punctured by an unknown object. ARH 1973a A.2 (1-9-73) Wound; An operator's left index finger was punctured by a l-in. wire while sorting leachable scrap.

~ ~ ~~ ~~ ~ ~ ARH 1973b A.2 (1-6-73) Wound; An operator sorting leachable scrap punctured his left thumb on a 1/2-in. piece of wire concealed in a bag of waste. ARH 1973c A.2 (1-17-73) Wound; An operator punctured the 1 i ttle finger left hand with a piece of wire while removing material from leach pot. ARH 1973d A.2 (1-23-73) Wound; An operator jabbed his left thumb with a scissor while opening a bag to sort scrap. (3-29-73) Wound; Operator abraded knuckle of right hand ARH 1973e I A.5 while removing scrap from hood. (6-7-73) Wound; An operator preparing a drum of segregated waste cut the right thumb on a piece of stainless steel tubi ng. (6-27-73) Wound; An operator taking a sample in a glovebox, dropped the bottle. While reaching blindly for a sample bottle, he received a deep puncture wound in left palm from a screwdriver left in the glovebox. ARH 1976 (8-30-76) An operator received mu1 tipl e superf icia1 :-[ contaminated cuts and first- and second-degree burns 1 when a cation column in Americium recovery process exploded. ARH 1978c (8-15-78) Wound; Operator was using pry bar to remove failed canister vacuum filter. The glove was torn and left index knuckle lacerated when the bar slipped. ARH 1981c A.7 (10-2-81) Cut; An operator was removing a manipulator tape with pliers. His left index finger was cut when the pliers sl ipped and the tape rebounded.

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Table 1. Contaminated Wounds Reported in the Hanford Site 200 Areas 1972-1986. (2 sheets) Ref. No. Event summary

~~ ~~~~~~ ~ ARH 1983 A.3 (5-2-83) Wound/cut; A chemist was performing housekeeping operation in a glovebox. Cut right index finger while moving equipment around a plastic waste bag containing broken glass. The waste bag contained glass bottles that had been broken during waste volume reduct i on and was awai ti ng seal out. DOE 1985 A. 1 (1-29-85) Wound; An operator stabbed the base of his left thumb while scraping out a container with a 1 aboratory thermometer. - RHO 1985a A.4 (5-14-85) Wound; An operator inspecting a bag of waste., punctured his right thumb on an 8-in.-long corroded speedometer cable. The cable had been used to unplug small diameter tubing. RHO 1985b A.3 (5-22-85) Wound; An operator punctured middle finger right hand while cleaning the floor of a glovebox. The corroded handle of an adjustable wrench caused the wound. RHO 1985c A.8 (7-17-85) Radiolysis caused the pressurization of a U-233 standard, which exploded. Internal contamination was associated with the skin decontamination efforts. See also inhalation RHO 1986a A.3 (3-13-86) Wound; An operator bagging out waste from a glovebox, punctured the left ring finger on a corroded pair of groove-joint pliers on the floor of the gl ovebox. RHO 1986b A.7 (4-15-86) Millwright was removing a HEPA filter and associated fire screen from a glovebox. A 4-12 shift millwright punctured the left palm. The operation continued, and the 12-8 shift millwright punctured the left little finger. HEPA = high-eff iciency particul ate air (filter)

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Table 2. Events with Potential for Inhalation in Hanford 200 West Area 1972-1986. (2 sheets)

~~ Event summary ARH 1973h (6-26-73) A glovebox failed during the repair of a crucible cutter, 2 maintenance personnel involved. The failure was detected during post-job survey. RHO 1977 (7-28-77) An operator used a glove that was isolated with 1 13: a plastic bag, without surveying it first. The glove had fai 1 ed previously . Two operators were i nvol ved. RHO 1978a (3-23-78) Contamination spread from filter box on Z-9 Pad outside the plant. A pipefitter received skin contamination and was exposed to airborne contamination. RHO 1978b B.l (5-23-78) A chemical technologist was working in a glovebox. In a post-job survey, it was found that the glove had failed allowing a contamination spread.

~ (10-12-78) Canned Pu metal was placed in a open-faced hood before placement in a glovebox for repackaging. It was found that the can lid seal had failed. There was a 1 ocal contami nation spread; 5 workers were i nvol ved. CAMS a1 armed. RHO 1979a 6.2 (January 1979) Reports of a problem of numerous failures of sealout bags, related to sealer bar and sealing technique. RHO 1979b B.2 (4-17-79) Failure of seal around 15-in. bagout port. Local contamination spread and a CAM alarm sounded. RHO 1979c B.2 (4-17-79) A new 8-in. plastic bag was placed on a bag port. Source of local contamination was found to be a failed seam on the new bag. There was no CAM alarm. RHO 1979di (11-12-79) Five workers received external contamination 1:: when ,a bag failed during the seal-out process. The CAM a1 arm sounded. RHO 1979e (12-12-79) Glovebox glove failed while in use. Operator I s hand was contaminated and contamination was pumped out locally. The CAM alarm sounded. Three operators were involved. (4-23-80) During a seal -out operation , 1 ocal contamination occurred from a faulty bottom seal in an 8-in. PVC bag. A CAM alarm and respiratory protection -I-was in use.

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Table 2. Events with Potential for Inhalation in Hanford 200 West Area 1972-1986. (2 sheets) Ref. No. Type Event summary 1 RHO 1980b B.8 (10-9-80) Reactive scrap was being repackaged and bagged out of a glovebox. Once the package was out of the glovebox, the scrap sparked igniting the plastic packaging. The operator (without respiratory protection) put out the fire, inhaling Pu that was resuspended by the fire extingui sher. RHO 1981a 8.4 (3-10-81) Operators were changing glove port covers when a CAM alarmed. After a CAM alarm, the SWP clothing of 2 operators and the local area was found contaminated. RHO 1981b B.l (6-23-91) During a repackaging operation, a glovebox glove failed when cut on a sharp edge of an opened button can; three operators were involved.

~ ~~ (10-23-81) Operations personnel were packing PuBe sources for shipment. Fourteen workers were involved, one had a positive nasal smear, but none of the 5 CAMs alarmed. - (6-4-82) Cans of PuO were being labeled for shipment. When CAMs alarmed, 8 workers evacuated the facility. Source of contamination was a failed can-lid seal.

~~ I RHO 1984 I B.l (12-11-84) Pipefitter noticed the glove he was working in had ripped around its circumference. The CAMs alarmed and four involved personnel evacuated the area. (7-17-85) Radioloysis caused the pressurization of a U-233 solution, which exploded. Inhalation and internal deposition associated with the skin decontamination efforts. See also: contaminated wounds.

CAM = continuous air monitor PVC = polyvinyl chloride SWP = Special Work Permit (protective clothing).

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Table 3. Events 1972-1986. I No. of Events I A. Contaminated wounds from the following:

~ ~ ~ ~ ~~~ ~ ~~ ~ 1. GB Operations - Processing waste 2 2. GB Operations - Sorting Waste 4 3. GB Operations - Cleanup/out 5 4. GB Operations - waste bagout 1 5. Hood Operations - waste bagout 1 6. Filing Waste Drum 1 7. Maintenance 3 8. Pressurization*/explosion 2

~ ~ ~~ TOTAL 19 B. Inhalation potential associated with the following: 1. Failure of glovebox gloves 6 2. Failure of sealout bags 5 3. Failure of can seals 2 4. Failure of glove port cover 1 5. Leaking Source (PuBe) 1

~~ ~ 6. Pressurized container* 7. Outside operations - Z-9 pad 1 8. Fire 1 TOTAL 18 I Note: RHO 1985c was identified as both A-8 and B-6. GB = glovebox.

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. Accidents Abnormal Operations Unexpected Predictable and anticipated, therefore monitoring or some form of protection is in place

~~~~~~~~~~~~~~ ~ ~~ Acute/instantaneous/violent Event may be extended or chronic not 1 generally violent Individual workers, 1 oca1 i zed Groups of workers, area or environmental re1 ease Wounds Inhalations High concentrations and Low concentration and potential for individual contamination/dose lower individual/group dose ~~-~~ I Heroic acts 1 Control 1 ed response

Tab1 e 5. Wound and Inhal at i on Frequencies . I I Wound I Inhalation I ~ ~ ~ ~ ~ ~~ Events/Reports 19 17 No. of Workers involved 20 56+ Worker w/detectabl e 15 4 contamination Worker w/contamination >1% 3* 6* ~~~~ I ~ I ~ ~~ *The worker involved (RHO 1985c) is included in both categories since the mode of entry can not be identi f i ed speci f ical ly.

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The low incidence of internal contamination from inhalation was associated with the safety systems in place. Early warning is provided through the extensive use of CAMS. The CAM alarm level is set at the lowest level-possi ble without causing an undue number of fa1 se a1 arms registering the presence of radon. Respiratory protection is used extensively where the potential for airborne contamination is suspected. The presence of pluton um makes all of radiation safety more conservative.

A significant internal contamination deposition was received through inhalation in 1980 (RHO 1980b). The inhalation occurred when an oDerator removed a source from the gloiebox, then took off the respiratory protecti n (which was within procedure). The source, reactive scrap, ignited the plastic packaging releasing contamination. The operator put out the minor fire with an extinguisher rather than evacuating and while doing so received an internal ---&-.-2.--&2-.- 1- &I-:- ---- IIL 2-11 _..-.____---lC 4. TL- conLdrninaLion. in Lriis cidse, rieroic irisLincL uvercdrne sei r-triLeresL. trie event suggests that the instinct to fight back is difficult to suppress, even when the hazard is recognized.

It was found that the plutonium workers represent a major safety element. Plutonium workers are well trained, aware of the hazards they work with, and conservative in their work practices. They recognize the difficulties of working with the engineered barriers of a glovebox and are tolerant of them. These factors may be the reasons for the relatively low incidence of wounds compared to the number of needle stabs experienced in the nation's hospitals. The potential consequence of a contaminated wound at the Hanford Site is internal contamination, whereas in a hospital it could be contracting AIDS or hepatitis.

WORK ENVIRONMENT AND CAUSAL AGENTS

The work environment generally associated with the wounds reported are gloveboxes , hoods , or thei r associated areas. These work spaces invol ve engineered barriers that control and contain contamination, but are notoriously difficult to work in. The operations had been analyzed for radiological problems and found safe. The factors that appeared not to have been adequately evaluated are the common industrial safety concerns. A pin prick normally requires a BANDAID*, however in a plutonium-contaminated environment it is escalated to a cause celebre. It is apparent from Table 1 that the wound events involve an industrial safety event, a breach of containment with escalation related to plutonium contamination.

The glovebox is a controlled protective barrier with limited access to the work space. Inherent to a glovebox is limited work space and visibility. Working in glovebox gloves is awkward and, because of the low visibility, encourages an operator to grope blindly around the work environment to accomplish a task. Just beyond the operator's line of sight the potential for a "sharp" exists. The "sharp" is any item that could puncture the barrier provided by the glovebox gloves. Sharp agents that could cause a puncture

~ ~ ~~ ~~ *BANDAID is a registered trademark of the Johnson & Johnson Company.

9 WHC-SA-1484-FP wound or violate the glove must be eliminated from the work environment. While not deliberate, sharps do occur or are created in the glovebox environment. Many otherwise innocuous or commonplace iterns present an inherent potential danger that may not be recognized by the operator until it is too late. The commonplace items identified as sharps are listed in Table 6.

Table 6. Agents Identified. I Tools 171 Wire or tubing 5 I Unknown object on floor I 2" I I Glass I Equipment in tight quarters I 2 1 *Thought to have been corroded tool s or equipment .

Tools, including makeshift items, were the most frequently identified agents causing the wound (7 cases, 37%). In most cases, the tools had been introduced into the glovebox during a job, forgotten, and not removed. The hazard develops when the corrosive nitric acid environment of the glovebox attacks the benign wrench and dissolves the handle into a sharp instrument. Corroded tools that have been identified include an adjustable wrench, locking pliers, screwdrivers, and a speedometer cable used to unplug lines. These items remain on the glovebox floor or in the waste awaiting discovery by the victim while sorting the waste or cleaning up. It is suspected that the two cases in 1972 (ARH 1972a, ARH 1972b) may have been caused by corroded tools also, but they were not readily recognizable. I believe that the introduction of stainless steel tools has proven effective in reducing the incidence of wound events. The most effective action is strict configuration management of everything that is placed in a glovebox. Log-in and log-out may appear to take time, but it is a lot less than the shutdown that results after an accident.

In 1985 (DOE 1985), a laboratory-type dial thermometer was placed in a process glovebox to monitor the temperature of a dissolution vessel in response to an earlier incident. No one anticipated that the thermometer could become a problem. While not in use it was placed on the glovebox f1oo.r in reach of the work station. In this event, an operator was loading scrap from a plastic bottle into the dissolution vessel. Some residue stuck to the bottle and had to be scraped out. Looking for something to scrape out the container, he picked up the thermometer and subsequently pushed it through the bottle, the glovebox glove, and into his hand. In the austere environment 0.F a glovebox the potential exists for an operator to misuse any available item rather than "bag in" the appropriate tool.

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Wires were identified in five (26%) of the events. Cut off ends of wire, an inch long or shorter, thrown into the waste were frequently named as the cause. The problem associated with these wires is analogous to that of contaminated needles at a hospital. Measures similar to those taken by the U.S. Occupational Safety and Health Administration (OSHA) should be considered to control small wires in gloveboxes and dry contaminated waste.

HANDS-ON OPERATIONS

Fingers and hands are the most frequently injured portion of the human body (90%). There are two solutions: eliminate hands or eliminate all hands-on operations. Neither of these alternatives is practical. The glamourless operations like housekeeping, rarely receive the level of safety analysis or coverage as the production process does. Hands-on maintenance and cleanup of gloveboxes is still necessary and should be recognized as an accident waiting to happen. Of the 19 wound events, 12 (63%) resulted from hands-on cleanup or waste hand1 ing . The hands-on operations associated with the events of the 70s, shown in Table 7, have been terminated and the facilities retired awaiting decontamination and decommissioning (D&D). These events should not be repeated, yet they serve as examples of what can happen without joint health physics and industrial safety oversight. The previous emphasis on radiation safety, in many cases to the exclusion of industrial safety, no longer exists. The hazards associated with maintenance, clean-up, and D&D remain to be addressed by professionals in both fields. It will be important in the future as the weapons complex comes up for D&D. When comparing the events shown in Tables 7 and 8, a change in operations is clear. Wounds and inhalation incidents are separate in time. Wounds are associated with waste sorting and cleanup of gloveboxes, while inhalations are linked to barrier breaches during movement of sources.

CHEMICAL REACTIONS

The McClusky incident (ARH 1976) is well known because of its radiological consequences. The precursors and cause are less pub1 icized. The Americium Recovery Facility, 242-2, was shut down by a labor strike in June 1976. During the ensuing 5 months, an ion exchange column dried out and the its resin became nitrated. Once the strike was settled, the facility was restarted. The decision was made to not rinse the column before restart. The column was restarted in August 1976 by adding fresh nitric acid. Soon thereafter a violent reaction occurred, shattering the glovebox and pepperin13 McClusky with americium-contaminated glass shards and nitric acid. While most people talk about this as a "radiological" event, the life-threatening aspects were really related to shock and acid burns.

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Table 7. What Happened Where - Wounds. Table 3 Faci1 i ty’ Agent Body Burden‘ I Ref. I Category I 234-52 tl%MPBB (Pu) 242-Z4 2% MPBB (Pu) 232-2 Wire . 1 ARH 1973b 1 A.2 232-2 Wire I LTD I ARH 1973c 232-2 Wire ARH 19734 1 232-2 ARH 1973e 236-2

ARH 1973f A.6 236-2 SS lube I tl%MPBB (Pu) [II 242-Z4 Screwdriver No added intake ARH 1976 242-2 Chemical explosion 190% MPBB (Am)

RHO 1978 232-2 Equipment.. I RHO 1981 WESF Equipment I 90Sr and 137Cs lRH0 1983 I A.3 234-52 Glass shard tl%MPBB (Pu) DOE 1985 236-2, MT-5 236-2, MT-6 RHO 1985b 234-52 Corroded wrench lRH0 1985c 1 i:i 222-s RHO 1986a 234-51, RMC RHO 1986b 234-5, RMC Wire mesh on filter A. el% MPBB (Pu), IB. 6.1% MPBB (Pu) 1 I I NOTES * iFacilities: Plutonium Finishing Plant: 234-52, 242, 232, 236, 2736; Waste Encapsulation Storage Facil ity (WESF) ; and 222-S Laboratory. ‘Reporting terminology reflects that in use at the time of the event (ICRP-2). CEDE were calculated on post 1980 events by Pacific Northwest Laboratory. 3While the agent was unknown, it is thought to have been a corroded tool. 41nternal contamination from ARH 1972b masked any from ARH 19739. MPBB = maximum permissible body burden. LTD = less than detectable.

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Table 8. What Happened Where - Inhalations. Faci 1 ity/Comment' Burdens'

~ ~ ~~ ~~~~ ~~ - ARH 1973h B.l 234-52, Maintenance 2 detectable Am RHO 1977 B.l 234-52 2 0.07 nCi, LTD RHO 1978a 6.7 234-52, 2-9 Filter Pad 1 SC t LTD 1 6.1 0 RHO 1978b I I 234-52 ~ ~~~~ I1 ' - RHO 1978d B.3 234-52 5 LTD - RHO 1979a 6.2 236-2, Respiratory protection Multiple 0 used - RHO 1979b B.2 236-2, Respiratory protection ? 0 used RHO 1979c B.2 234-52, Respiratory protection ? 0 used RHO 19794 B.2 234-52, Respiratory protection 5 0 used RHO 1979e I B. 1 1234-52 I 3+ LTD - RHO 1980a 1 B.2 I EG?dZ, Respiratory protection l1 sc 8.8 234-52, Respiratory protection burden w/CGE lg80bI I removed - RHO 1981a 1 6.4 1 i:?dZ, Respiratory protection l2 0 RHO 0 1981b I B.l I 234-52 ~ ~~~ 15 RHO 1981d I B.5 1234-52, PuBe source failure -114 0 RHO 1982 B.4 2736-2 8 0 RHO 1984 B. 1 PUREX, N-Cel 1 4 0 - RHO 1985 B.6 222-S Laboratory, deposition 1 t3% 233u also attributed to decontamination

~ ~ ~ ~~ NOTES: 'Facilities: Plutonium Finishing Piant: 234-52, 242, 232, 236, 2?36; Waste Enc ipsulation Storage Facilit (UESF); and 222-S Laboratory. 'Reporting terminology reflects that in use at the time of the event (ICRP-2). :EDE were calculated on post 1980 events by Pacific Northwest Laboratory. PUREX = Plutoniun/Uraniun Extraction (Plant) CEDE = comnitted effective dose equivalent SC = skin contamination LTD = less than detectable.

13 . ~~.~ ~ ......

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The root cause was failure to appreciate the potential for a violent chemical reaction in a dried-out ion exchange column. This potential is recognized by chemical engineers, but was apparently over1 ooked because of our emphasis on radiological safety.

RADIOLYSIS

In 1986 a laboratory technician moved a vial containing a liquid 233U standard to remove another vial from a cabinet (RHO 1985~). Within minutes there was an small "explosion." The screw top was blown off a 50-ml vial containing the liquid standard of 233U, contaminating a worker and the 1 aboratory.

Subsequent investigation indicated that the cause was the buildup of radiolytic gases in the aqueous solution. Radiolysis is the disassociation of water into hydrogen and oxygen caused by radiation bombardment. It was initially reported by Mme Curie, who recognized it in 1911. Radiolysis occurs to some small extent in all aqueous radioactive solutions. Most of the times the gaseous products either recombine or are dissipated. However, in a sealed environment, pressure can only build up.

This 233U standard had been sitting undisturbed on a laboratory shelf for 2 years. The slight movement may have been enough to release some of the dissolved gas from solution, increasing the internal pressure. A corrodzed screw cap and an internal pressure calculated/estimated at over 50 lb/in (gauge) resulted in an explosion. Radiolysis associated with plutonium is recognized and source maintenance to re1ieve pressure is performed periodically. The small uranium samples were not considered a problem. The lesson learned: in time all unvented aqueous radioactive sources are potenti a1 problems.

DOSE CONSEQUENCE

The estimates of internal dose for the contaminated-wound events are given in Table 9. The radioisotopes of concern are plutonium and its daughters (i.e., americium). The chemical and physical form of the contaminant are a major factor in the dose consequence. In PFP, three general forms of contamination that could be associated with wound events are present: nitrate, oxide, and relatively insoluble organic complexes. When hand1 ing contaminated waste the potential for all three to be present is apparent. From the doses reported/calculated it appears that much of the material was in an insoluble form and probably site restricted. The rapid excision, within ii few hours of the contamination, and the prophylactic use of a salt of diethylenetetraamine pantaaceatic acid (DTPA) further 1imited the depositions, and therefore the dose. In most cases, this rapid response limited the magnitude of the internal contamination and dose.

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Table 9. Internal Dosimetry Estimates for Contaminated Wound Events. (2 sheets) -~ Ref. No. I Date Actions and Dose Estimate

~ ARH 1972a 6-9-72 DPTA, excision, tl%MPBB (Pu), no CEDE cal cul ated ARH 1972b 12-22-72 DTPA, excision, 2% MPBB (Pu), no CEDE calcul ated ARH 1973a 1-9-73 No DTPA or excision, no confirmation of intake, no CEDE calculated ARH 1973b 1-6-73 No DTPA or excision, no confirmed Pu deposition, no CEDE cal cul ated ARH 1973~ 1-17-73 No DTPA or excision, no confirmed Pu deposition , no CEDE cal cul ated DTPA, excision, tl%MPBB (Pu), no CEDE cal cul ated

DTPA, excision, tl%MPBB (Pu), no CEDE calcul ated ARH 1973f 1 6-7-73 DTPA, excision, tl%MPBB (Pu), no CEDE cal cul ated

~ ~~ ARH 19739 I 6-27-73 DTPA, excision, no added intake, see ARH 1972b ARH 1976 I 8-30-76 Extended DTPA Therapy, 190 MPBB Am, (USTR case 246), (McClusky, HP 1983) RHO 1978~ 8-15-78 No DTPA or excision, no confirmed -intake, no I CEDE RHO 1981~ 10-2-81 90Sr, 137Cs wound at 2258. No TRU involved, no deposition, no CEDE cal cul ated RHO 1983 5-2-83 DTPA, excision, 1% MPBB (PU), CEDE = 1.2 rem I RHO 1985a 5-14-85 DTPA, excision, 4%MPBB (Pu), no CEDE +-cal cul ated I RHO 1985bl 5-22-85

~~ DOE 1985 1-29-85 160% MPBB (PutAm), wound residual 130 nCi (PutAm), CEDE = 130 rem

RHO 1986a 3-13-86 DTPA, excision, tl%MPBB (Pu), no CEDE cal cul ated

RHO 1986b 4-16-86 First worker DTPA, excision, tl%MPBB (Pu), no CEDE calculated Second worker DTPA, exci sion , 6.1% MPBB (PutAm) , CEDE = 8 rem

15 -.. . . - ...... ~...... -

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Table 9. Internal Dosimetry Estimates for Contaminated Wound Events. (2 sheets) Ref. No. Date Actions and Dose Estimate I I I ~ ~~~~~~~~ I I Internal contamination From Wound and Inhal at i on --1 RHO 1985c 7-17-85 Inhalation and absorption through the skin, debraded bg decontamination efforts. Soluble form of 23 U, Maximum Lung dose = 3% of 15 rem/yr DOE-RPS (Q=lO) CEDE = 0.51 rem

I Internal contamination From Inhal at i on ~ 7 RHO 1980b 10-9-80 Worker A - DTPA, Lung burden, CEDE 2.6 rem I I I Worker B - DTPA, Lung burden, CEDE 48 rem I NOTE: Reporting terminology reflects that in use at the time of the event (ICRP-2). The CEDE were calculated on post-1980 events by Pacific Northwest Laboratory. DTPA = diethylenetetraamine pantaaceatic acid MPBB = Maximum Permissible Body Burden CEDE = Committed Effective Dose Equivalent USTR = United States Transuranic Registry HP = Health Physics TRU = transuranic (waste) DOE-RPS = U.S. Department of Energy-Radiation Protection Standard.

Worker internal dose assessment for radiological events at the Hanford Site is the responsibility of the Pacific Northwest Laboratory (PNL) in Richland, Washington. The committed effective dose equivalent (CEDE) has only been calculated for plutonium events after 1980.

EMERGENCY RESPONSE

The emergency response to a wound event is procedural ized and we1 1 documented at the Hanford Site. While the health physics technician initiates local decontamination a call is made for medical support. The situation is communicated to the doctor on call and a determination made on the use of a chelating agent (DTPA) is discussed with the PNL exposure evaluator before administration. When the nurse arrives, the orders, if any, for administering an initial prophylactic injection of DTPA are carried out. The patient is subsequently transported to the doctor's office or an Emergency Decontamination Facility (EDF) in Richland, Washington. A team composed of a surgeon, health physics personnel, and PNL internal dosimetry personnel await the patient's arrival. The contamination is excised with the dosimetry personnel using a wound counter to monitor the material

16 WHC-SA-1484-FP

removed and remaining. The emergency response associated with these events was effective in limiting the internal contaminations. The reports of the January 29, 1985 event (DOE 1985) and the McClusky event (ARH 1976, HP 19831, describe emergency response in detail. The efficacy of rapid intervention, use of DTPA, and surgical removal of the contamination has been documented.

It was noted that in one case (RHO 1985c) aggressive decontamination is thought to have be a contributing factor to the internal contamination. A lesson to be learned is that too much of a good thing can cause an internal contamination also. Unfortunately, we do not know how much is too much.

PREVENTION

The safety adage that "all accidents are preventable, but not all accidents can be prevented" is true. Much can and has been done to prevent the recurrence of events such as those reported. The primary action is the investigation and identification of the root cause or causal agent. Once the cause is identified, remove it and ensure that a safe configuration is maintained.

After tending to the victim, a thorough investigation is most important. The causal agent and root cause need to be identified. Strict control should be placed on the area or operation to prevent recurrence and a new victim (RHO 1986b).

Proven approaches to the prevention of wounds are the following:

Good housekeeping

Control of sharps

Enhanced industrial safety analysis of all operations performed in contaminated areas

A trained and aware work force As low as reasonably achievable (ALARA) program. . CONCLUSION

The operational health physicist is in reality a "safety engineer" practicing in a radioactively contaminated environment. With the majority 01' our time spent trying to prevent Contamination and resulting radiation doses,. we tend to forget about the measures that must be taken to prevent the basic accident. The time we invest in industrial safety will be repaid with greatly reduced radiological doses or internal contamination.

17 WHC-SA-1484-FP

REFERENCES

ARH, 1972a, "Contaminated Puncture Wound Requiring Excising, I' Unusual Occurrence Report 72-34, Atlantic Richfield Hanford Company, Richland, Washington.

ARH, 1972b, "Contaminated Puncture Wound Requiring Excising," Unusual Occurrence Report 72-78, At1 antic Richfield Hanford Company, Richl and, Washington.

ARH, 1973a, "Contaminated Puncture Wound Requiring Excising," Unusual Occurrence Report 73-02, Atlantic Richfield Hanford Company, Richland, Washington.

ARH, 1973b, "Contaminated Puncture Wound, I' Unusual Occurrence Report 73-05, At1antic Richf ield Hanford Company, Richland, Washington.

ARH, 1973c, "Contaminated Puncture Wound, I' Unusual Occurrence Report 73-10, At1antic Richfield Hanford Company, Richland, Washington. ARH, 1973d, "Contaminated Puncture Wound," Unusual Occurrence Report 73-12, At1 antic Richfield Hanford Company, Richland, Washington.

ARH, 1973e, "Finger Abrasion, I' Unusual Occurrence Report 73-24, At1 antic Richfield Hanford Company, Richland, Washington.

ARH, 1973f, "Contaminated Puncture Wound Requiring Excising," Unusual Occurrence Report 73-35, Atlantic Richfield Hanford Company, Richland, Washington.

ARH, 19739, "Contaminated Puncture Wound Requiring Excising, I' Unusual Occurrence Report 73-42, Atlantic Richfield Hanford Company, Richland, Washington.

ARH, 1973h, "Potential Lung Deposition,'' Unusual Occurrence Report 73-51 , Atlantic Richfield Hanford Company, Richland, Washington.

ARH, 1976, "Explosion of Cation Exchange Column in Americium Recovery Service, Hanford Plant August 30, 1976," Atlantic Richfield Hanford Company, Richl and, Washington.

Carbaugh, E. H., W. A. Decker, and M. J. Swint, 1989, Medical and Hea7th Physics Management of A Plutonium Wound, Radiation Protect ion Dosimetry, Vol. 26, No. 174, pp 345-349, Nuclear Technology Publishing. DOE, 1985, "Plutonium Contaminated Puncture Wound - January 29, 1985," U.S. Department of Energy, Richland Field Office, Richland, Washington. HP, 1976, Hanford Americium Exposure Incident, Health Physics 45(4) (1983) , (The entire volume is devoted to the event), Health Physics, Richland, Washington.

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NRC, 1976, Standard Format and Content of license App7ications for Plutonium Processing and Fuel Fabrication Plants, Regulatory Guide 3.39, U.S. Nuclear Regulatory Commission, Washington, D.C.

RHO, 1977, "Personnel Internal Contamination, I' Unusual Occurrence Report 77-128, Rockwell Hanford Operations, Richland, Washington.

RHO, 1978a, "Spread of Contamination on 2-9 Pad and Personnel Clothing," Unusual Occurrence Report 78-31 , Rockwell Hanford Operations, Richl and, Washington.

RHO, 1978b, "Employee Inhalation of Plutonium Oxide," Unusual Occurrence Report 78-52, Rockwell Hanford Operations, Richland, Washington.

RHO, 1978c, "Punctured Glovebox Hood Glove August 15, 1978," Unusual Occurrence Report 78-85, Rockwell Hanford Operations, Richl and, Washington.

RHO, 19784, "Contamination Spread and Plutonium Inhalation," Unusual Occurrence Report 78-110, Rockwell Hanford Operations, Richl and, Washington.

RHO, 1979a, "Failure of Plastic Bags Used to Seal Out Contaminated Item," Unusual Occurrence Report 79-19 (Series) , Rockwell Hanford Operations, Richland, Washington.

RHO, 1979b, "Contamination Spread - Room 42, 236-2, It Unusual Occurrence Report 79-46, Rockwell Hanford Operations, Richl and, Washington. RHO, 1979c, "8 Inch Plastic Bag with a Failed Seam - Room 228, HC-7C Hood," Unusual Occurrence Report 79-47, Rockwell Hanford Operations, Richl and, Washington. RHO, 1979d, "Ruptured Sealout Polyethylene Bag - Hood 9E, RMA Oxide Line," Unusual Occurrence Report 79-1 11, Rockwell Hanford Operations, Richl and !, Washington. RHO, 1979e, "Personnel Contamination Due to Ruptured Hood Glove, Room 232-A," Unusual Occurrence Report 79-122, Rockwell Hanford Operations, Richl and, Washington.

RHO, 1980a, "Contamination Spread Within 232-2 Building (Incinerator) ,I1 - Unusual Occurrence Report 80-43, Rockwell Hanford Operations, Richl and, Washington.

RHO, 1980b, "Repackaged Plutonium Scrap Contamination Incident, Room 230-Cy 234-5 Building," RHO-CD-1197, Rockwell Hanford Operations, Richland, Washington.

RHO, 1981a, "Contamination Spread in Room 230-C While Changing Port Covers," Unusual Occurrence Report 81-21, Rockwell Hanford Operations, Richl and, Washington.

19 WHC-SA-1484-FP

RHO, 1981b, "Contamination Spread Due to failed Hood Glove, Room 230A," Unusual Occurrence Report 81-42, Rockwell Hanford Operati ons, Ri chl and !, Washington.

RHO, 1981c, "Manipulator Tape Wound contamination, 'I Unusual Occurrence Report 81-65, Rockwell Hanford Operations, Richland, Washington. RHO, 1981d, "Failed Pu-Be Source Resulting in Contamination Spread, Room 236," Unusual Occurrence Report 81-71, Rockwell Hanford Operations, Richl and, Washington. RHO, 1982, "Skin Contamination Resulting From a Failed Can Seal," Unusual Occurrence Report 82-25, Rockwell Hanford Operations, Richland, Washington. RHO, 1983, "Plutonium Contaminated Cut On Right Index Finger," Unusual Occurrence Report 83-10, Rockwell Hanford Operations, Richl and, Washington. RHO, 1984, "Glovebox Glove Failure on PUREX N-Cell Glovebox, Subsequent Contamination Spread, Skin Contamination and Positive Nasal Smears," Unusual Occurrence Report 84-79, Rockwell Hanford Operations, Richland, Washington.

RHO, 1985a, "Contaminated Skin Puncture in Glove Box MT-6, 'I Unusual Occurrence Report 85-43, Rockwell Hanford Operations, Richland, Washington. RHO, 1985b, "Contaminated Puncture Wound Received While Cleaning in Glove Box 227-S," Unusual Occurrence Report 85-46, Rockwell Hanford Operations, Richland, Washington. RHO, 1985c, "Skin Contamination When Solution of Uranium 233 Sprayed on Employee," Unusual Occurrence Report 85-61, Rockwell Hanford Operations, Richl and, Washington. RHO, 1986a, "Puncture Wound, Glove Box MT-6, 236-2 Building March 13, 1986," Unusual Occurrence Report 86-01 1, Rockwell Hanford Operations, Ri chl and, Washington.

* RHO, 1986b, "Contaminated Puncture Wounds to Two Rockwell Craftsmen, It Unusual Occurrence Report 86-019, Rockwell Hanford Operations, Richl and, Washington.

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