On August 23, 1994, a plutonium worker at the Los Alamos National Laboratory Chemistry and Metallurgy Research Facility accidentally injured herself while removing plutonium oxides from small samples of plutonium metal with a jeweler's file. She punctured the glove-box glove and the backside of her left thumb with the file. A radiological control technician performed several wholebody surveys of the worker with negative results and then escorted her to the occupational health medical facility for assessment and treatment of the puncture wound. The wound count indicated 8.58 nanocuries of plutonium-239 inside the wound. After non-intrusive decontamination methods were unsuccessful, a physician performed three excisions reducing the contamination to 0.46 nanocuries. There was no contamination to the worker's skin nor any spread of contamination outside the glove-box. (ORPS Report ALO-LA-LANL-CMR-1994-0022)
The plutonium worker was wearing a laboratory coat, booties, and a pair of surgical gloves as required for this operation. After puncturing the back of her thumb, she left the work area, monitored her hands and booties, found no detectable radioactivity, and reported the accident to her supervisor. The supervisor contacted a radiological control technician who performed two whole body surveys on the worker, surveyed the work area, and found no detectable radioactivity. The worker also submitted nose swipes which resulted in no detectable radioactivity. After surgical decontamination of the puncture wound, medical personnel sutured and bandaged the worker's thumb and dosimetry personnel issued a special bioassay kit to the worker.
Facility managers critiqued the event and determined that the current method of preparing small plutonium metal samples by removing the metal oxides with a small jeweler's file is too hazardous to be used for this application. Alternate methods, such as using sample holders or contained mechanical cleaning, are being considered.
Based on review of the ORPS data base, it appears that contaminated puncture wounds occur infrequently at DOE facilities. Following are two examples of similar occurrences.
On October 5, 1992, a nuclear chemist cleaning up contaminated glassware in a glove-box in the heavy element facility at Lawrence Livermore National Laboratory punctured his glove and thumb with a curium-244 contaminated pipette. Evaluation of the decontaminated wound indicated 0.3 nanocuries residual and 41 nanocuries in the excised tissue. (ORPS Report SAN--LLNL-LLNL-1992-0090)
On December 9,1993, a worker disassembling wooden boxes in a glove-box in Building 707 at Rocky Flats punctured his hand on the box nails. The wound was contaminated to a level of 21,000 disintegrations per minute. After surgical decontamination, the final wound count was 5,500 disintegrations per minute. (ORPS Report RFO--EGGR-PUFAB-1993-0194)
Although contaminated puncture wounds are not common at DOE facilities, such wounds can present a serious hazard to the people involved, requiring surgical excision, medical treatment, and monitoring. Most such accidents can be avoided through thorough job preplanning, including careful task analysis, provision of appropriate tooling and protective devices, awareness of the work environment, and attention to detail.
Chapter I of the guidelines in DOE 5480.19, Conduct of Operations Requirements for DOE Facilities, states the following. "Facility guidance should exist which describes safety preplanning requirements for all operational activities. The guidance should explain the role of safety analysis reviews, job safety analyses, and the handling of safety matters. All operations personnel should understand the safety planning requirements."