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KCP PM 147 Contamination Time Line

Summary of Report of Investigation of Pm 147 Contamination, February 10, 1989, Kansas City Plant, Kansas City, MO, Published September 1989

Click here to see the complete Report of Investigation of Pm 147 Contamination, Feb 10, 1989

Background

The Kansas City Plant (KCP) requested (via a series of telephone calls only) Oak Ridge National Laboratory (ORNL) Isotope Products Division to provide the Pm 147 (Promethium) sources with 10-590 millicurie activities in 1974. No formal specifications were documented, but per the verbal agreement by both parties, ORNL provided experimental sources of Pm 147 to KCP.

The two people who made these verbal arrangements at KCP and ORNL retired in 1982 and 1984 respectively. The process of fabricating the source from 1980-1989 was nearly identical to the process prior to 1980, according to ORNL.

ORNL never intended these sources to meet the criteria of ‘sealed’ sources, however, KCP assumed that they were sealed. Neither facility ever conducted tests to validate if they were sealed or unsealed.

In September 1983, a Pm 147 source fell from a counter top to the floor in the ORNL facility. The glass shattered and spread throughout the area, requiring extensive decontamination cleanup of the radioactive materials.

Where was Pm 147 going to be used by KCP?

In beta backscatter units located in the following areas:

  • D456, FE-49  – Quality Engineering’s Non-Destructive Test Lab
  • D842, BW-31 – Electronic Engineering Laboratory
  • D423, BO-29 – Metrology Laboratory
  • D33, FU-33 – Precision Pattern Assembly Area
  • D436-97, FG-51 – Plating and Chemical Milling

 What is Pm 147?

Pm 147 is a donut shaped source (200 millicurie) that surrounds an aperture specially created for KCP because no known commercial sources existed over 50 millicurie. 

Fabricated by absorbing the radioactive material salt into a Vycor glass preforms through a series of soaking and heating processes (Vycor is a ‘thirsty glass’ that absorbs chemicals). The glass is then placed into a platinum source holder with adhesive and attached to an aperture with screws (all supplied by KCP) undergoing additional heating processes for the adhesive. After verifying that the radioactive transferable activity was less than 500 dpm (disintegrations per minute) with swipe testing, this entire unit was placed into a lead-lined jar and packaged for shipment with handling instructions for KCP.

The shipping document provided by ORNL:

“Warning: This shipment must not be opened until adequate health and safety measures are taken (such as placed in a hood, glove box, cell) so as to protect the handler from excessive exposure to the body as a result of radiation and/or contamination. KCP was inspected and all specialize safety measures (clothing, shielding, gloves, etc) were available for the employees who handled the Pm 174”.

  • Millicuri: a unit of radioactivity equal to one thousandth of a curie. It means that amount of radioactive material which disintegrates at the rate of 37 million atoms per second
  • Dpm (disintegrations per minute ) is the number of atoms that have decayed, not the number of atoms that have been measured as decayed. Dpm is commonly used as a measure of radioactive contamination.
  • 1 millicurie = 2,200,000,000 disintegrations per minute

What happened when the Pm 147 arrived at KCP?

Industrial Hygiene Department personnel unpackaged the sources and wiped them down with alcohol soaked cotton swabs to test for leaks. The transferable activity was measured and compared against the ANSI standard measurement only, disregarding the remainder of the code because the Pm 147 was considered experimental.

 (Code of Federal Regulations, Title 10 CFR (NRC) Subpart B, Radiation Safety Requirements, Paragraph 34.25, Leak Testing, Repair, Tagging, Opening, Modification and Replacement of Sealed Sources. Tests of sources which reveal 0.005 microcurie or more of removable radioactive material shall be considered to be leaking and removed from service to be repaired or disposed)

Every 6 months, the same test was to be performed by the hygienists. (See pages 49-50 for listing of all Pm 174 sources received by KCP)

Time Line of Events

Department 456

Available Testing Equipment: Radiological Monitoring Equipment: Victoreen Model 444

Year

Month/Day

Event

1983

December

Shipment of Pm 147 found to be contaminated

(during development of a probe for Mound)

1984

June

Probe filled with Pm 147 was “knocked over” causing a section of material to break loose, the clean up methods undocumented (Exhibit 2)

1984

July

Two Pm 147 sources were ‘chipped and falling apart’.  The material was chipped away from the platinum source holders and disposed of by Waste Management (D187) (Exhibit 3)

1984

July

A Pm 147 source was falling out of the platinum holder, so it was replaced

1988

April

Loose radioactive contamination discovered on apertures and on a tabletop

1988

June

Loose radioactive contamination discovered on apertures and on a tabletop (Exhibit 4)

1988

October 19

Pm 147 source created by ORNL registered over the desired 500 dpm. KCP instructed ORNL to ship as is

 

October

A 200 Millicurie source arrived, tested for leaks, and finding none, loaded into a probe and shipped to D33

1989

February 9

Confirmed radioactive contamination of the elastic bands of the KCP employee’s left and right ring dosimeters. Dosimeters confirmed readings of radiological exposure.  The low-level beta energy range of Pm 147 cannot be detected by the dosimeters worn by the employees. The radiological exposure read was the result of the amount of exposure time to the radioactive source

1989

Feb 10 (Friday)

Radiology readings were detected during a routine survey on an X-ray fluorescence machine cabinet by a Vicrorean Model 471 Meter

The same area was surveyed using the Eberline 530, contamination was found on the stool, tabletop and on the hand of the employee

Employee was informed to notify DOE-KCAO

Laboratory was put into restricted access

The shoes of all 11 employees were tested, 5 were positive for radioactive contamination

The shoes were wiped down with alcohol (swipes were later sent to the KCP Health Physicist consultant for determination of the radioactive material (read on the following Monday)

The area was determined to be uncontaminated at 11:40 am

All areas of the plant that used radioactive materials were isolated ed at 3:50 PM.

A suggestion was made that all employees were to wear respirators, associated dosimeters should be collected and air handlers were to be shut down.

At 5:15 pm, the area was sealed off for the weekend, keys were collected and signs posted, and the air handling equipment was turned off.

1989

Feb 13-17

Discovered that the air-handling unit had not been shut off, instead a baffle had been installed in the ductwork that supplied the NDT laboratory.

Airflow grills between D456 and D435 were monitored

Stairwell connecting D456 and D456 office area was monitored

Contamination discovered outside of D456

1989

Feb 14

The inside of a shoe worn by a janitor was confirmed to be contaminated               

                       

Metrology –

Available Testing Equipment: NONE

Year

Month/Day

Event

1988

April

Loose radioactive contamination discovered on apertures

Department 33

Radiological Monitoring Equipment: NONE

Year

Month/Day

Event

1978

April

Beta Backscatter Unit (GT1014) began operation

1985

February

Replaced the plastic apertures with metal apertures on the beta backscatter unit (last time changed)

1985 – 1986

 

Backscatter equipments sat unused, containing a full probe of Pm 147

1987

February

Probe loaded with Pm 147 crashed into the beta backscatter unit during calibration.

1988

October

Probe loaded with 200 Millicuries of Pm 147 received from D456

Operators noted the aperture/source holder was not seated properly –

Attempted to tighten screws

Removed the aperture from the probe assembly and replaced it

Probe was relocated into the beta backscatter fixture

Next day, opened the probe nose assembly and lost a screw that attached the apertures to the source holder assembly

1988

December

Probe crashed into the beta backscatter unit

1989

January 3-13

Probe crashed into the beta backscatter unit’s scale actuator, breaking the beryllium window

1989

January

Beta backscatter unit is repaired, replacing the corroded electrical connections and replacing a cooling fan. The integrity of the Pm 147 was questioned, but was told it had just been received. In reality, it had been received in Oct of 1988

1989

Feb 13

Loose radioactive contamination was discovered in the beta backscatter unit of room E with readings up to 15,000 cpm (where people were still working).

Floor and area adjacent to the Beta backscatter unit was found to be contaminated in excess of 2,500 cpm

Area was secured at 11:50 am

1989

Feb 14

Crews from Sandia (SNLA) and Los Alamos National Laboratories (LANL) arrived to bag and seal the source probe of Pm 174 (dressed in full gear with high efficiency respirators).

Inside of the probe transfer cap was swipe tested and found to be 230,000 cpm.

Cardboard box used to transfer the probe was swipe tested and found to be 70,000 cpm inside and 3000 cpm outside

All items were bagged, sealed and left in the area

D842 basement BQ-28        

Radiological Monitoring Equipment: NONE

Year

Month/Day

Event

1989

Week of Feb 13

No contamination was found (the area used a similar Beta backscatter unit but a Pm 147 probe had not been used since 1/16/88)

Testing Equipment (Purchase/Calibration) Time Line

Year

Month/Day

Event

Unknown

Unknown

Victoreen Models 440 and 471 – used to detect swipe tests for low-level beta sources, unfortunately, this equipment could not detect low-level beta sources.

1974

March

Purchased Eberline E530 meter

Prior to 1980

 

Purchased HP260 probe (Exact date unknown)

1987

1987

E530/HP260 were first calibrated for Pm 147

 

1988

June

Victoreen 471 was calibrated for the first time (still only able to detect 61% of the spectrum that the E530/HP260 can detect)

Testing Time Line

Prior to 1985 – the survey instruments at KCP were not adequate to test the sources for contamination

Date(s)

Event

Late 1985-Feb 1986

Eberline E530 meter/HP260 probe was first used to test leaking radioactive sources at KCP (Exact date unknown), but since the testing unit was not calibrated for Pm 147, nothing was found

March 1986- January1988

No leak tests conducted by the Industrial Hygiene Department on Pm 174 sources due to funding and manpower constraints

Feb 15, 1988

Rumors of leaking Pm 147 prompted health checks

April 1988

First time the E530/HP260 testing units were used for leak testing

January 1989

The swipe samples taken from the contaminated shoes of the employees of D456 taken to the Health Physicist consultant at KCP to determine the type of radioactive contamination.

 Contamination Notification Time Line by KCP

Date(s)

Event

Between 2/14 and 3/1

KCP employees were kept up to date of the clean up progress through in-plant publications and televised interviews

Feb 15, 1898

Contact was made to the following agencies of the Pm 147 incident:

EPA Region 7 Waste Management Division

MODNR Emergency Response Commission

MO Dept. of Health, Radiological Health Division

NRC, Chicago Office

KCP Medical Department

Feb 18, 1989

Contact was made to the following agencies of positive bio assays:

EPA Region 7 Waste Management Division

MO DNR

MO Dept. of Health, Radiological Health Division

Feb 20, 1989

Notification to KCMO Health Department of off-site contamination

Clean Up Time Line

Industrial Hygiene staff of KCP was not equipped or trained to clean up radioactive materials, so additional teams were formed

Date(s)

Event

Feb 14, 1989

Crews from Sandia (SNLA) and Los Alamos National Laboratories (LANL) arrived to bag and seal the source probe of Pm 174

Feb 14, 1989

Allied Signal team of health physicists (3 LANL, 2 SNLA and 1 DOE AL individual)

Intent: asses the spread of radioactive contamination, conduct minor decontamination activities and advise the KCP management team of situation recovery

Feb 15, 1989

Industrial Hygiene department requested 24-hour urine samples of the nine KCP employees who were involved with Pm 147 sources

Feb 16, 1989

Samples shipped to Eberline for analysis

Feb 16, 1989

Due to the widespread level of contamination, Rocketdyne Division of Rockwell International Corporation at Canoga Park CA was contracted to complete the decontamination actives.

Feb 18, 1989

Eberline confirms positive tests for radioactivity of 4 employees from the urine samples, varying from 13-66 picocuries on a count of 100

Feb 18, 1989

Positive contamination of 4 employees found and whose homes were to be surveyed by 3 teams. Specific areas of the homes were identified for the survey. A second survey was to be completed on each individual’s vehicle. 3 of the 4 employees had their homes surveyed starting at 7:40 pm.  A pair of slippers was tested at 500-600 cpm. They were bagged tested further testing. The 4th employee was provided a bioassay bottle for the following day.

Feb 19, 1989

The slippers were not found contaminated with Pm 174 from Feb 18, the readings now down to between 100-200 cpm, were attributed to radon.

Feb 19, 1989

The home of the 4th employee was surveyed. Loose radioactive contamination was found within the first hour

Feb 20, 1989

Eberline reports that the positive readings of the 4 employees were in error, further testing of the samples did not find any evidence of radioactive contamination

Feb 20 – March 9

Rocketdyne Team completes decontamination

Collected and analyzed swipe samples and air particles and found them to contain Pm 147 (Exhibit 5)

Feb 22, 1989

Decontamination of the 4th employee’s home was completed.

March 1, 1989

4 Pm 147 sources, two assembled beta backscatter probes with Pm 147, 1 Pm 147 source holder and aperture from D33 and D456 were sent to SNLA by Rocketdyne

March 3, 1989

The original urine samples of the 4 employees were divided and sent to the DOE, Idaho Operations Office, Radiological and Environmental Services Laboratory and to Eberline for result comparison.  Both found the samples to be within normal limits.

March 8, 1989

Rockwell International positively identified samples contaminated by Pm 147 from KCP

March 20, 1989

A total of 97 employees who were tested for Pm 147, no radioactive contamination found


Rocketdyne Contamination/Clean Up Report Summary

All seven sources had detectable and spreadable contamination, appearing to be losing Pm 147; the coatings were flaking off, the aperture on one source was tightened to the point of crushing the Pm 147 glass and causing fine, free dust particles, and one source was gouged, destroying the integrity of the coating.

The 1988 source (the one that was 200 millicurie that KCP said to ship ‘as is’) was highly contaminated and leaking, and a chip of the glass was missing.

Table 3. Samples and Swipe Data

Survey team identified the following areas as contaminated:

  • Department 456 Non-Destructive Laboratory
    • Entire area
  • Department 456 mezzanine offices (An open office area containing a manager’s office, secretarial area, bull-pen desk area for 9 workers)
  • Department 435 X-Ray
  • Department 33 Inspection
    • Backscatter device
    • Sub Floor Tiles
    • Filters from the air handling system
  • 1 Employee Apartment

A total of 283.36 cubic feet of contaminated materials, classified as radioactive waste, was removed

A water line riser was knocked off and flooded D33 during the decontamination process. The water was allowed to flow into the drain by Rocketdyne.

Contamination started in D456 and once airborne, the Pm 147 was deposited on hard surfaces and then spread as it deposited on the clothing, hands and shoes of the employees. The probe with the loose fitting that was transferred from D456 to D33 (October 1988) further spread the contamination. Once in D33, the crew released the contaminated materials during the installation process into the beta backscatter unit.

The procurement process was mishandled, inventories unregulated and un-monitored. Some of the sources we left uncapped in the storage cabinet contaminating other sources, the cabinet and the Strontium 90 and Thallium sources as well. Transportation between receipt and between the various offices was lax, often using cardboard boxes or plastic bags, and sometimes without any covering of any kind.

Workstations where the Pm 147 was handled did not have exhaust hoods or glove boxes. The facility was not a negative pressure facility. Janitorial containment checks were never conducted. No protective gear was worn. The storage facilities were inadequate. No special precautions were taken in regards to the integrity of the sources upon receipt.

The whole body badge worn by the employees was ineffective in detecting Pm 147 contamination based on the position in which they were located.

The ring dosimeters contained a TLD chip, making them insensitive to Pm 147, the only reason they contamination was found was due of the length of exposure time.  Eberline knew this information but he did not notify KCP of the findings immediately.

Industrial Hygiene staff was not equipped or trained to clean up radioactive materials, yet they assisted the staff of each area in decontamination when a spill occurred.

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