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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=904">Awareness of Prior Facility Use is Vital to Assessing Potential Workplace Hazards, Fluor-B&W Portsmouth LLC</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>For a copy of the original report, see ¿Attachments¿ on Lessons Learned page.
A lab area had previously been used for radiological sampling and analysis but neither the Radiological Control Technicians (RCTs) performing routine annual surveys nor the lab worker were aware of the prior radiological operations. This resulted in radiologically contaminated rags being treated as sanitary trash for eventual transport offsite and disposal.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On April 9, 2015, a lab worker needed to prepare a reagent, but found the normal hood used for preparation was out of service. The lab worker used another hood (EF-153) even though it had not been used for many years. Before starting work the lab worker noticed that EF-153 was dirty and wiped down the floor with paper wipes. The wipes were then disposed of in the laboratory sanitary waste.
Four days later, on April 13, 2015, an RCT began routine surveys. Results indicate that no removable contamination was present.
A second set of survey points were then sampled and fixed contamination of 32,000 disintegrations per minute (dpm)/cm2 alpha and 13,000 dpm/cm2 beta was identified in EF-153. Due to the surveys being over 5000 dpm/cm2, additional surveys were performed. These indicated removable legacy contamination of approximately 4300 dpm/cm2 alpha and 3400 dpm/cm2 beta/gamma.
The RCT questioned the lab worker concerning the contamination findings in EF-153. The lab worker told the RTC about cleaning the hood and disposing of the wipes in the sanitary trash. The trash was then staged in a locked dumpster for later removal. The RCT discovered that the dumpster had been emptied earlier that day.
The truck was immediately returned to the site and maintained in a Controlled Area pending development and execution of a survey plan. Surveys on the trash found the contaminated. Contamination had not spread beyond the rags. Subsequent surveys discovered the highest readings measured being 21,100 dpm/100 cm2, total alpha and 5,180 dpm/100cm2 removable alpha as well as, 66,956 dpm/100cm2 total beta/gamma and 2,300 dpm/cm2 removable beta/gamma.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>The investigation revealed that prior to 1991 the lab had been used for radiological operations. In 1991 it had been downgraded by a site contractor. Neither the RCT nor the lab worker knew the lab¿s history. This fact coupled with the long term use of the room as a clean area led personnel to believe that there was no risk.
Previous annual surveys did not include survey points for the fume hoods. The procedure used lacked detail in addressing random sampling in laboratories that contain hoods.
Other contributing factors included sanitary trash surveying being conducted per Standing Order (SO) SO-13-RP-177, Sanitary Waste Surveys. The SO requires surveying of one bag per lot and visual inspection of the remainder.
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Below are the consequences of the above event. They are provided for information and discussion purposes only.
Annual surveys, conducted in areas that are considered clean, should not be completely random. Areas that have a higher probability of contamination (e.g., fume hoods, legacy equipment) should be regularly included in all surveys.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab has a robust Industrial Hygiene Program that provides detailed equipment surveying. The Radiation Control Department trains and authorizes individuals who are likely to be exposed to this type of hazard and encourages all employees to take General Employee Radiological Safety Training (GERT) to ensure hazard awareness. Facilities Management and Logistics maintains details of room use and hazard potentials. </pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">9/15/2015 4:38:08 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with
SAF901: SAFETY WARDEN TRAINING
SAF903: RESPONDING TO CHEMICAL SPILLS (HAZWOPER)
SAF830: RAM SHIPPING/RECEIVING</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">904</td>
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<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2015-JLAB-904</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
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<td class="label" nowrap>Safety Related:</td>
<td class="dataval">NO</td>
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<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Issued:</td>
<td class="dataval">9/15/2015 4:34:53 PM</td>
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<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">9/15/2015 4:38:08 PM</td>
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<td class="label">Source:</td>
<td class="dataval">
DOECRD
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<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">OTHER</td>
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<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
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<td class="label" nowrap>Contact:</td>
<td class="dataval">Mike Brabender, Manager Environmental Remediation / Sample and Data Management, 740/897-4708</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">1 times</td>
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<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=4022">DOE - Room Use.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Chemicals</li>
<li>Hazardous Material Transport - On or Off Site</li>
<li>Radiation - Ionizing</li>
</ul>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF901: SAFETY WARDEN TRAINING</li>
<li>SAF903: RESPONDING TO CHEMICAL SPILLS (HAZWOPER)</li>
<li>SAF830: RAM SHIPPING/RECEIVING</li>
</ul>
</fieldset>
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<legend>Distribution/Notification</legend>
<ul class="lesson_attribute_listing">
<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
</ul>
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Do you have a lesson learned you would like to contribute? Contact the <a href="mailto:mbailey@jlab.org,sjsmith@jlab.org,cjohnson@jlab.org">Lesson Learned Coordinator</a>.