On July 13, 1993, a technician working in room 3117 in the Chemistry and Metallurgy Research facility at Los Alamos National Laboratory became contaminated with plutonium-239 and then spread contamination onto various surfaces in the room. The Chemistry and Metallurgy Research facility processes and handles plutonium. Contamination occurred when, just prior to exiting the room and without protective gloves, the technician reached into an open-faced glovebox posted "Radioactive Materials" and as a radioactive materials and a radioactive materials management area (RMMA), removed a roll of masking tape to fix a note directed to another technician onto a room door, and returned the tape to the glovebox. Before exiting the room, also posted for radiological purposes, the technician performed hand and foot monitoring with an alpha monitor located at the room exit and discovered contamination on the fingers of the right hand. The technician walked a short distance to the monitor in the next room and performed hand monitoring, confirming the contamination.
A nearby radiological control technician (RCT) implemented a survey of the technician's hands and recorded a surface alpha activity of 40,000 dpm per 100 cm2 on the fingers of the right hand and approximately 2,000 dpm per 100 cm2 on the fingers of the left hand. The technician moved to a decontamination area and decontaminated to a no-detectable-activity level. Radiological control technicians obtained nose swipes and found no detectable activity.
Radiological control technicians surveyed areas contacted by the technician and located surface alpha activity levels of 1,000 dpm per 100 cm2 on a spot on the room door, 8,000 dpm per 100 cm2 on the room door handle, 400,000 dpm per 100 cm2 on the masking tape attached to the note, and 2,000,000 dpm per 100 cm2 on the tape in the glovebox. Technicians decontaminated the spot on the door and the door handle to a no-detectable-activity level and then bagged and discarded the tape, note, and decontamination materials in accordance with procedures. (ALO-LA-LANL-CMR-1993- 0016)
Facility management personnel reported that the glovebox was known to contain radioactive materials by personnel routinely working in the room and that tape was ordinarily kept inside the glovebox. They also reported that the technician was new to the area of the facility containing room 3117 and had not been pre-job briefed on the specific hazards in that room. However, the technician was familiar with similar work areas and postings in the building. Access to the glovebox by the technician was not needed to perform the assigned task of checking a computer located within a few feet of the glovebox. An approximate 4-by-5-inch yellow sticker was attached to the glovebox with the information: "Caution Radioactive Materials," then "RMMA," and "All wastes from this enclosure shall be treated as radioactive unless it is monitored or analyzed and found to be free from contamination." The room posting, located near the door, read: "Notice: Controlled Area - Access Controlled for Radiological Purposes. Contamination and radiation areas may exist within this area." The technician was current in bi-annual radiation worker training (last received during April 1992), which covered the meaning of the postings. The technician reported during the event critique that the postings were understood.
As part of the corrective actions, management personnel counseled the technician on the importance of adhering to radiation postings. In addition, the technician will be scheduled for enhanced radiation worker training. Another action possible is pre-job briefings on radiological hazards in areas for personnel new to those areas.
This event emphasizes the importance of adhering to instructions posted in radiologically controlled areas and of ensuring that personnel understand the radiological hazards in their work areas.