Gaithersburg, Md. – Responding to shortcomings highlighted by a June 9 spill of plutonium at its Boulder, Colo., laboratory, the National Institute of Standards and Technology (NIST) announced today that it will implement specific improvements to its safety programs called for in a new report by a NIST internal committee.
Consistent with recommendations published today* by NIST's Ionizing Radiation Safety Committee (IRSC), the agency said it will re-evaluate its organizational lines of responsibility and accountability for safety programs, seek independent assessments of its safety management, expand and strengthen its safety office, and develop a comprehensive plan for corrective action with dates for completing specific measures.
In addition, in a recent letter to the City of Boulder, NIST outlined plans to conduct an assessment and inspection of hazardous materials on the Boulder campus; to audit safety and training procedures for hazardous materials; and to benchmark with other federal agencies about their handling, treatment, and monitoring of hazardous waste materials and to implement any best practices not already being implemented on the NIST Boulder site.
The IRSC committee's report incorporates and expands upon previous reviews of the plutonium spill by five nationally known radiation health and safety experts, by NIST's own health and safety personnel, and by the NIST unit in which the spill occurred.
The committee found that a failure in the safety management system, exacerbated by a "casual and informal research environment that appears to have valued research results above safety considerations," is the most probable root cause of the incident.
The committee further recommends that NIST strengthen its "safety culture" by securing the commitment and active participation of senior NIST management and effectively integrating safety management practices into core NIST management functions.
"We are developing a comprehensive plan and putting in place actions that address the committee's recommendations," NIST Deputy Director James M. Turner said. In addition, NIST's parent agency, the Department of Commerce, is establishing a blue ribbon panel to examine safety matters at NIST.
The new report examines circumstances and actions leading up to and including the spill of powdered material from a vial containing about 1/4 gram (1/100th of an ounce) of plutonium. It identifies causes, immediate corrective actions, and underlying weaknesses in NIST's safety management. The report is the first phase of a comprehensive investigation.
The incident was reported to the NRC, which has been inspecting NIST's actions, including its response to the incident and its plans to decontaminate the lab. NIST has already stopped use of radioactive materials in research at its Boulder laboratories.
The IRSC report cited "widespread deficiencies noted in the sequence of events that can be traced directly to the roles and responsibilities that were neither clearly defined nor clearly understood by Boulder personnel and are at the heart of both the NIST Radiation Safety Program and the NIST SOS [Safety Operational System] ... ."
"The failure to properly recognize the significant hazards associated with a powdered plutonium source contained only by a glass bottle had devastating consequences for the subsequent events," the report states. The report cites a number of "missed opportunities" to intervene in the chain of events, such as the failure to conduct an appropriate hazard analysis at the time the plutonium sample was purchased.
According to the report, some personnel involved in the incident seemed unaware of required or appropriate procedures or controls. In other cases, they seemed to know them but failed to apply them correctly. Sometimes they recognized a requirement (e.g., for basic radiation safety training) but failed to take appropriate action. In addition, the committee found that managers for the affected unit did not exercise oversight until after the spill occurred.
Several weeks after the incident, to address this issue, NIST announced that its managers had been required to re-certify that all employees, guest researchers, and others working in its laboratories or offices have all training necessary to do their jobs safely.
The IRSC also found fault with itself for failing to ensure that the plutonium source would not exceed the capabilities of the NIST Boulder radiation protection program.
The IRSC further recommends conducting additional external reviews focusing on a formal root cause analysis; lessons learned about incident management and communication; and the health physics response, including dose assessment and decontamination. These reviews have been authorized, according to Turner.
*NIST Ionizing Radiation Safety Committee, Initial Report of Plutonium Contamination at NIST Boulder, July 30, 2008, 62 pgs (PDF).
Additional information on the NIST Boulder plutonium incident is available online.