Final Report
An employee at Los Alamos National Laboratory found plutonium contamination on his right wrist during a radiological survey after moving a furnace contaminated with plutonium-239 from one glove box to another in Room 7125 of the Chemistry and Metallurgy Research Building. The survey indicated alpha contamination of 8,000 disintegrations per minute. The worker called a radiation protection technician for assistance, who verified the contamination and decontaminated the employee's skin with soap and water. The technician surveyed the laboratory floor, equipment and the employee's clothing and found all were free of contamination. He also took nasal swipes from the employee, which gave no indication of radiological uptake. (ORPS Report ALO-LA- LANL-CMR-1992-0018)
Investigators reported that the employee initially wore two pairs of gloves, but removed the outer rubber gloves prior to placing the furnace in the second glove box. He continued his task wearing only the inner cloth gloves. The investigators attributed the root cause of the incident to an inadequate procedure. Facility personnel revised the procedure to specify the presence of a radiation protection technician during all glove or waste bagouts in the Chemistry and Metallurgy Research Building to provide control of radioactive materials and oversight of personnel activities for the purpose of reducing the potential of contamination.
This event underscores the need for detailed procedures governing the handling and transfer of potentially contaminated materials. Such procedures should address the proper use of personnel protective clothing and requirements for monitoring and oversight by radiation protection or health physics personnel.