Compilation of responses: Training non-rad workers

["Michel, Rene" <rmichel@iastate.edu>]

Dear Radsafers,

Thanks to all Radsafe members that responded to my request regarding
"Experiences that justify training non-radiation workers".   I recommend
those involved in radiation safety training to review the following
compilation of the responses.

Thanks,

 -Rene

Rene Michel
Health Physicist
Iowa State University
Phone (515) 294-3314
FAX (515) 294-3199
rmichel@iastate.edu

________________________________________________________________________
______________________

Experience #1

One event I recall occurred at a VA facility.  It involved the loss of
power to a freezer in a research lab, which contained some radioactive
materials.  (The lab and the freezer were both posted with radioactive
materials signs.)  A housekeeping staff member found the spill and
mopped up the liquid on the floor.  They he/she proceeded to continue
mopping the rest of the floor (hallway, etc.) with the same mop/water.
Later in the day, personnel doing wipe tests found contamination in
laboratories where radioactive materials was not used.  That led to
expanding the entire floor where even more contamination was discovered.
Not knowing the extent or cause of the spill, the RSO had to shut down
the entire research building, check staff on the way out for
contamination, etc.  Once again, not knowing the amount of materials
involved at the time, they ended up calling the NRC thinking they had a
larger spill/release.

Eventually, the cause of the contamination was discovered and it was
determined that the amount of material involved was not as great as
originally anticipated.  However, it made for a rough few days of
performing unnecessary surveys, urine bioassays, dealing with the NRC
emergency response/investigation team, etc.

The lesson to be learned from this story is that spills in areas labeled
as Radioactive Materials areas need to be treated as radioactive until
qualified individuals determine that it is not.

Experience #2

Electricians repairing radiation monitors routinely replaced detectors
that contained Am-241 "Keep-Alive" sources.  They tossed the old
detectors in the "clean" trash, which was then removed by the custodial
staff. The eventual destination was the landfill. A lot of detectors
made it to the landfill before the radiation safety staff realized what
was happening.

Experience # 3

A shipping clerk decided that it was a nice day for a motorcycle ride,
grabbed a box of radiation instruments which contained radioactive check
sources and headed for the calibration facility in a nearby town.
The police stopped him at the entrance to a tunnel between the site and
the calibration facility. Fortunately for him, they just turned him
around. Hazardous materials were banned from the tunnel.
	
Experience # 4

I've seen quite a few cases where radioactive materials have been
ordered, purchased and delivered without anyone contacting the radiation
safety office. The requesting staff and the procurement office "didn't
know there was anything special that needed to be done. "The vendor"
figured a company as big as that had to have a radioactive materials
license."

Experience # 5

An untrained animal care person felt sorry for pigs that looked very
warm and hosed them down with city water to cool them off.  The force of
the water jarred 7 Ir-192 seed sources loose from their template on the
pigs. 6 went down the sanitary sewer and were never recovered, one seed
found in the pin under a mat.  Incident made the local news (paper &
TV). $1,250 civil payment imposed by the NRC.
Seeds were surgically implanted on the pigs as part of medical physics
experiment.

Experience # 6

A few years back I was the RSO for a University.  One of the first tasks
I undertook when I started there was a check of all the inventories to
ensure they were correct. The university had a Neutron Activation
Analysis facility. The target within the accelerator head assembly was a
disc of Titanium tritide (or similar - I can't recall exactly), which
contained about 10Ci of tritium (when new). The accelerator head had
been replaced a year or so prior to me arriving, and according to the
inventory, the old head should have still been stored in the facility.
Despite turning the place upside down, the old head could not be
located. Some investigation revealed the following:

The lab manager, responsible for the administration of all labs in the
School of Physics, had decided to do some Spring-cleaning. He came
across the accelerator head in storage, suitably labeled.

He noted that it contained a nominal activity of about 10Ci of tritium,
which he knew to be a large activity. He also noted that the accelerator
head was about 20 years old.

Concerned about the large activity, he did a quick survey with a
borrowed survey meter, and was surprised when he didn't see any
significant increase above background.

Perplexed, he did his homework and checked on the half-life of tritium.
Finding that it had a half-life of 12 years, and knowing that the source
was about 20 years old, he concluded that all of the tritium had decayed
away 8 years ago. That explained why the survey meter didn't see
anything!

Accordingly, the head was discarded with other general waste, and ended
up as land fill.

The regulators took a rather dim view of all of this. Luckily, the risk
associated with the accelerator head was very small (3Ci of H3, tightly
bound in a matrix with titanium, enclosed within multiple envelopes of
glass and steel, buried somewhere). Perhaps the moral to this story is
that a little bit of knowledge is dangerous.  If only he had made one
phone call.......


Experience # 7

A custodian went into an office to collect the regular trash.  The
connecting door to the research lab was open so he decided to dispose of
the waste in the trash can he saw from the doorway and mistakenly grab
what was in fact P-32 waste.  Poor labeling of the rad waste container
and unmonitored accessibility to a lab from an office were primarily to
blame for the incident.

Nevertheless, the custodian continued on his rounds that afternoon
disposing of trash from office spaces and relining the wastebaskets with
his supply of plastic bags.  Unfortunately, having contaminated his
gloves with the P-32 waste, every plastic bag he touched had been cross
contaminated.

Fortunately, someone in the lab notice shortly thereafter that the waste
container had a regular wastebasket plastic bag and alerted our office
of a potential problem.  By the time we found the custodian he had been
in and out of dozens of offices.

So we spent the rest of the afternoon surveying every wastebasket on the
next three floors.  Many of them were in fact, lightly contaminated with
P-32.  You and I would understand the extremely low levels we are
talking about (tens of microcuries total) but try telling that to the
secretary who hears a Geiger counter clicking away in here office and
then sees us remove some of the trash bags.

Experience # 8

Several years ago we had a dock worker who experienced a rather severe
C-14 skin contamination as a result of handling a leaking shipping box.
I like to remind them in my safety class that Radiation Safety exists to
answer questions and check out potential hazards, so they should never
try to guess if a stain on a box is a contamination.

Experience # 9

At my previous employer (a commercial environmental laboratory) where I
was RSO, we held a two-hour lab orientation tour for our custodial
personnel.  Part of this instruction was emergency response (whom to
call), identification of hazards (spills, leaks, etc), and radiation
protection signs, symbols and warnings.  This was particularly necessary
since our custodial contractor employed recent immigrants whose primary
language was not English.

Despite all of these training precautions we still had a lab employee
remove the yellow rad trash bag from a rad waste container and place it
next to the receptacle.  The custodial crew removed the bag and placed
it in the dumpster.  The dumpster was picked up by the disposal company
before the missing bag was discovered.  We were able to contact the
waste disposal company and pull the truck out of line waiting to dump
his load into a commercial  sanitary landfill.  The truck returned to
our site....we lined a loading dock ramp with visqueen (thick plastic)
and had the driver dump his load.  15 trained personnel had to dress out
in Level B to go through the load.  We were able to locate the missing
bag within an hour.  We then used front end loaders to reload the trash
into two 20 cu yd open top containers. Total cost of this
goof......about $10,000......We made mandatory reports and were
fortunate that we were not fined.

We recovered all of the cost from the custodial service's insurance/bond
company because of our training ("due diligence" was the operable
phrase).  The custodial training was also required by our licensing
agency.

Experience # 10

An incident I recall involved a "community" pickup truck (the keys were
always in the ignition) which had a package of labeled rad material in
it being driven into town for lunch by an admin type worker.

Experience # 11

Experienced a situation years ago that might fit into your study.  Some
rats had been injected with H-3 for a research experiment and were later
sacrificed.  The radioactive rat carcasses were bagged, labeled, and
frozen in the lab freezer, awaiting pickup for radioactive waste
disposal.  Non-radioactive animal experiments happened to be performed
in the same lab.  The radioactive carcasses were in the same freezer as
the non-radioactive ones.  The researcher (not trained in radioactive
work) performing the non-rad work thought he would be helpful by
disposing of all the rat carcasses (rad and non-rad) at the same time.
Problem was he treated them all as non-radioactive and the radioactive
ones were hence disposed of inappropriately.  State regulators had to be
notified of the loss of control of the H-3.  I forget the activity
involved.

Experience # 12

During an NRC inspection of a lab, a technician came into the lab to
check the fire extinguisher. He works for an outside contractor and had
not been trained in radiation safety. The inspector jumped on him and
apparently gave him a hard time. We were not aware of outside people
coming in and they were not aware of the training requirement. Anyway,
this resulted in an NOV for failure to train people with access to the
labs. Of course we provide them with training now!

Experience #13

The day after the inspectors left, we were called by the housekeeping
supervisor who said radioactive materials were in the hallway. It turned
out to be two plastic containers of P-32 waste. The night shift had
moved them into the hallway while they waxed the lab floor. They
shouldn't have done that of course, but the morning shift knew to
callus. We have since included an extra inservice for the night shift.

Experience #14

After about two hours of receiving 100 mCi of I-131, a hospital patient
vomited in a toilet located in the eight floor of the building.
Sometime later, a plumber in the fourth floor started working on a pipe
that was plugged.  Not realizing that the materials removed from the
pipe were contaminated with I-131, the worker contaminated him self, his
equipment and the area were he was working.

Experience #15

At a hospital, maintenance personnel removed hood filters used for I-131
procedures without consulting with the RSO.