Part 21 Report - 1996-250

ACCESSION #: 9603050207 DEPARTMENT OF THE ARMY UNITED STATES ARMY TANK - AUTOMOTIVE AND ARMAMENTS COMMAND ARMAMENT AND CHEMICAL ACQUISITION AND LOGISTICS ACTIVITY ROCK ISLAND, ILLINOIS 61299-7630 February 1, 1996 AMSTA-AC-SF Nuclear Regulatory Commission Region III Division of Radiation Safety & Safeguards 801 Warrenville Road/Attn: Mr. Sam Mulay Lisle, Illinois 60532-4351 Dear Sir: On December 19, 1995, a shipment of radioactive material (a boxed, damaged MI Al collimator) was received at the Marine Corps Logistics Base (MCLB), Barstow CA. The box was delivered to the Defense Logistics Agency (DLA) radioactive material receipt area ( Bldg 401) on December 19, 1995, but not officially received by DLA personnel until December 26, 1995. Upon official receipt, the box was wipe surveyed and found to exceed the external contaminated limits of 49CFR 173.443. The box was placed in a controlled radioactive material storage warehouse (Bldg 403), isolated, and further surveyed. ACALA Safety office received notification on January 3, 1996. Investigation revealed that the collimator had been boxed and shipped by Marine Corps Base, Hawaii (MCBH), Kaneohe, HI. Further investigation revealed that MCBH Kaneohe, HI had not performed any contamination surveys of the collimator prior to boxing, nor the box prior to shipment. Conversation with MCBH, Kaneohe, HI revealed that no Radiation Protection Program had been implemented on their facility. An ACALA Safety Office representative visited MCBH, Kaneohe, In to investigate the events leading to the shipping of the contaminated collimator, and the status of their Radiation Protection Program. Attached is information delineating the sequence of events at MCLB, Barstow, CA (Encl 1), and MCBH, Kaneohe, HI (Encl 2). -2- This action has been coordinated with and approved by the Headquarters, Army Materiel Command Safety Office. The point of contact for this report is Timothy J. Mohs, AMSTA-AC- SF, (309) 782-6228. Sincerely, John A. Mattila Chief, Safety Office Enclosure(s) Copies Furnished: Cdr, AMC, ATTN: John Manfre, Alexandria, VA 22333 -0001 SHIPMENT OF BROKEN COLLIMATOR FROM KANEOHE HI. TO BARSTOW CA COLLIMATOR SHIPMENT SEQUENCE OF EVENTS On September 6, 1995, personnel of "C" Battery, 1st Battalion, 12th Marines attempted to set up a collimator as part of an inspection/instrument check. Due to faulty tripod legs, the collimator fell over onto the source end. When the troops righted the collimator it was noted that the lens appeared cracked. The collimator was immediately taken to the 1 st Battalion, 12th Marines Ordinance shop (located in the same building). The Master Sergeant (MSGT) looked at the collimator and agreed that the lens had been broken. The MSGT instructed the troops to double bag the collimator and transport it to the Combat Service Support Group (CSSG-3) optical maintenance shop. The collimator was delivered to the optical shop at CSSG-3 on the same day as the incident (6 Sep 95). The Staff Sergeant (SSGT) in charge of the optical shop received the collimator, noted the broken condition, and placed the collimator on the floor adjacent to his desk. A Request For Disposition (RFD) was written, and sent off on 12 October 95, to Albany, GA. for disposition instructions. The answer to the RFD was received by the optical shop on 30 Oct 95, instructing the optical shop to ship the collimator to Marine Corps Logistics Base, (MCLB) Barstow, CA. After receiving the RFD answer the collimator was transported (7 November 1995) to the shipping/receiving office for packaging and shipment to MCLB, Barstow. After receipt of the collimator at the shipping and receiving docks, the collimator was boxed and delivered to the base post office for delivery to Barstow CA. PROBLEMS WITH THE PROCESS Upon noting the broken lens on the collimator, no safety personnel were informed. Even after taken to the MSGT at 1st Battalion, 12th Marines, no safety personnel were made aware of the incident. No wipe surveys were conducted of the area, and no evaluation of the potential for internal exposure during the spill. The optical shop was not is not set up to work radiological components. No posting exists in the area, nor any of the required posted documents. This was corrected during the visit. Upon questioning the optical shop personnel, it was learned that no precautions were taken when working on tritium containing components such as covering area with paper and wearing gloves. This too has been corrected. It was also noted that collimator purging is done inside that optical shop (an enclosed area). Wipe surveys have been conducted in the optical shop. Wipe tests of the optical and shipping area have been analyzed and found to be within acceptable limits. Encl 1/Page 1 of 2 The collimator sat in the optical shop, on the floor adjacent to the SSGT's desk, without controls and without surveys for at least 9 weeks. During that time the collimator would have been gassing-off through the double plastic bags. By the time the collimator was transferred to the shipping and receiving docks, the outside of the double bags may have been contaminated to some unknown level. This possibility would have, at the least, contributed to the eventual external contamination discovered upon receipt at MCLB, Barstow, CA. No contamination testing was performed prior to transferring the collimator to the shipping docks or after it was received at the shipping docks. Likewise, no contamination testing was performed after packaging or prior to delivery to the Post office. The shipping area lacked any posting and did not have any of the required documents posted in the area. KANEOHE SAFETY OFFICE CONDITIONS Prior to this incident the safety office at Marine Corps Base Hawaii (MCBH) was not set up to perform appropriate radiological oversight of their radiological commodities. Efforts are being made to correct the long standing situation. As a result of this incident and the attention given to the situation by the ACALA Safety Office much is being accomplished. Two safety office people have completed the 40 hour CECOM Radiation Protection Training course. A Radiation Protection Officer (RPO), and an Assistant RPO have been appointed and trained, and a Standard Operating Procedure (SOP) is being written. A meeting was held the afternoon of 17 Jan 95, the findings and their implications were discussed, and a list of corrective actions were established with mile-stones, responsible parties, and assigned completion dates. These efforts are only a beginning, and much work remains. A positive attitude exists within the safety office, with a good group of people to work though all the details. The RPO is in contact with the RPO for the Army, at Wheeler Army Air Field. The Wheeler Army Air Field RPO has an exemplary Radiation Protection Program and has agreed to assist the Kaneohe Marine Base RPO in getting his program up and running. CONCLUSIONS Our office will be in frequent phone contact with the Kaneohe RPO. We are setting up an audit/inspection team visit to the Kaneohe Marine Corps Base for April of this year. Also a letter is being written to Marine Corps Headquarters to apprise them of this situation. We are requesting they report the status of Radiation Protection Programs Marine Corps wide to the ACALA Safety Office. ACALA visits to selected Marine Corps Bases will be scheduled as needed base on the results. Encl /Page 2 of 2 KANEOHE/BARSTOW INCIDENT Arrived at Barstow, MCLB about) 7:30, 10 JAN and proceeded to the MCLB Safety Office. Met with Odis Gentry to discuss his involvement in the DLA's situation. Mr Gentry took me out to the Yermo Annex to meet with the DLA RPO and ARPO. Arrived at the storage facillity about 09:00 to see the offending box/collimator. Dicussed the condition of the box and the circumstances under which the box was received and subsequently handled. Discussed possible actions to determine how the exerior of the box could have become contaminated to the levels noted. The box is in great condition, with no signs of having been mishandled in shipment. Also noted that there were no markings on the box to indicate it contained radioactive material. There was, however a "crayon" marking on one side that indicated that it was part of a group of packages which were sent to DRMO somewhere. A curious thing ... I'd like to here what it is all about. Looked at and discussed all the paper trails generated at Barstow since arrival. Mr. Haeveth has kept a great record of what's been done since DLA received the box. All of Mr. Harvaths action were and continue to be in accord with regulations. The box is being kept in a controlled area, and has been double bagged. As a means to to test a theory, I suggested Mr. Harvath and Mr. Smith remove the collimator and rebox it in a new box of the same dementions as the original. They will use all the original packing, and establish, as close as possiible, the condition of the double bags on the colimator, and then place it on a shelf and wipe the external of the box periodically to see if and to what extent the tritium migrates to the outside of the box. The original box was in transient at least 5 weeks, therefore this test will run for 5 weeks to see if contamination to the same level can be generated by a leakinf 10 curie source. REPORT FOR THE RECORD TO: Sandy Steck FROM: Dale Harvath SUBJECT: Possible radiation contamination to personnel DATE: 26 DEC 1995 REFERENCES: 1. Material movement sheet dated 19 Dec 1995. (Attachment 1) 2. Copy of DD Form 1348-1. (Attachment 2) 3. Copy of Tritium wipe test results. (Attachment 3) Upon returning to work 26 Dec 1995, I discovered a M1A1 Collimator, NSN 1240-00-332-1780, Document Number M133105284E720, qty 1 ea., in the radioactive receiving area of Bldg. 401. See attachment 2. I asked Chris Garcia when the item came in. He provided me with the material movement sheet dated 19 Dec 1995. See attachment 1. Due to the radioisotope, activity level, and the length of time that this item was in the radioactive receiving area all being above the maximum allowable limits, I transported this item to Bldg. 430, radioactive storage. I then did an external and internal wipe test to check for contamination of the carton and took them to Cal Lab. Cal Lab completed a Scintillation test and Alex Guzza from Cal Lab notified me that this item was in excess of the permissible maximum disintegrations per minute allowed for any exterior surface. See attachment 3. He advised me to contact Base Safety Office, Odis Gentry. Odis asked me to come by his office with all pertinent documentation. I also contacted my immediate supervisor, Sandy Steck. Sandy told me to come to her office to try to get this problem straightened out with Ben Fields, Warehouse 7 receiving supervisor; since it was his people who did the initial receiving of this item. Mr. Fields stated that all radioactive items were to sent to Bldg. 401, radioactive receiving area. He claimed that he had never been told about the one half curie limit for non-radioactive personnel to handle. He also claimed he was unaware that any activity level equal to or greater than one half curie was not to be worked or handled, but that the RPO office was to be immediately notified instead. As a result of these claims we discussed that reinforced training will be made available to all receiving personnel that could possibly come in contact with radioactive items. I discussed with Sandy Steck the possible contamination to Amalie Johnson, of Bldg. 401, who received this item in Bldg. 401 from personnel from Warehouse 7. See attachment 1. Sandy Steck deferred judgment to the Base Safety Office, Odis Gentry, for guidance. Mr. Gentry's decision was for Ms. Johnson to complete a one time bio-assay when she returns from leave, She is expected to return the 28 or 29 of Dec 1995 according to Chris Garcia, Work Leader, Bldg. 401. Mr. Gentry will have the necessary forms for Ms. Johnson to take to the Medical Clinic. I will be in touch with Jim Reese, RSO Region, in the morning, 27 Dec 1995, for guidance. I will also contact Mr. Gentry to maintain continuity between the Marine Corps and DLA. A complete report will follow upon completion of investigation of this matter and will be forwarded to Sandy Steck. DALE HARVATH Alt. Local Radiation Protection Officer December 28, 1995 Received fax from Jim Reese dated 28 Dec. 1995, subject items to consider during contamination investigation. Following days will cover items contained in the fax. Took nine wipe tests. See tab second wipe test delivered to Cal lab. No one available to run scintillation tests. Some one will be in tomorrow. Reviewed radiation health manual, 49CFR and 10 CFR. Discussed with Odis Gentry, BSO, for any SOPS covering this incident. Received written statements from three employees: Terry White, Chris Garcia, and Carl Dawson. December 29, 1995 Received fax from Jim Reese, DDRW RSO, concerning information regarding ACALA license. I reviewed fax. Discussed with Odis Gentry, BSO, decontamination procedures, and requested his presence, since he is the leading RSO on the base, to confirm that I was doing it correctly. First decontamination process of vehicle used to transport contaminated item was completed by Odis Gentry and myself in approximately two hours. I then took a wipe test. See tab decon swipe test reference M13310-5284-E720 1st decon of #9. Even though the levels were greatly reduced since non-radiation workers use this vehicle, it was unacceptable. Second decontamination process of vehicle used to transport contaminated item was complete by myself in approximately another two hours. I took a swipe test. See tab decon swipe test reference M13310- 5284-E720 2nd decon of #9. Levels were acceptable. ALARA has been achieved. Odis Gentry stopped by with swipe test results taken from the Post Office where they showed him the box was thought to have been staged. He had taken a single wipe test and it came back at below background levels. I have no personal knowledge to the accuracy of this test. January 2, 1996 Called Phil Smith at home and told him to stop by the office before going to Sandy Steck's office because Phil was on leave the week prior. When Phil came in I notified him of incident. Went to see Mr. Conwell Tubbs, OPS Branch Chief, and notified him of the incident because he was on leave the week prior. Notified Robert Castillio, receiving supervisor Bldg. 401 of incident, because he was on leave the week prior. Reviewed with Phil all documents and discussed procedures used and processes in place about the incident. Phil agrees, with one recommendation, which is for photos to be taken. Phil and I meet with Sandy Steck to review incident and how the matter is being handled to date. Since Odis Gentry from BSO left it up to me to decide who requires bioassay and to cover all bases of personnel who came in contact, the following people are scheduled for bio-assay: Dale Harvath, Amalie Johnson, Steve Broughton, and Lamont Pease. Odis left blank UA sample forms with his signature on them for me to use. Had meeting Phil Smith, Conwell Tubbs, Ben Fields, and myself. Discussed receiving procedures and (illegible) as follows: 1. At the time a receiving clerk discovers a radioactive item in a non- multi pack, they are not to open it, but are to immediately call the RPO office for pick up. 2. If a radioactive item is discovered in a multi pack they are to stop and immediately call the RPO office for pick up. 3. If a radioactive item is discovered and it is above the .5 curie level they are not to touch the container, but are to immediately call the RPO office for wipe test and pick up. 4. If a radioactive item is discovered in a multi pack and is above the .5 curie level they are to stop all work on the multi pack, to include non-radioacitve items and immediately call the RPO office for wipe test and pick up. 5. All suspected NSN's will be varified by the receiving clerk against radioactive materials list provided by the RPO office. Received written statement from employee Richard Ferrell. January 3, 1996 Received phone call from Tim Mohs, the Army License Manager, in response to my phone call to his office on 29 Dec, 1995, that I made at the direction of Jim Reese, DDRW RSO Fax dated 28 Dec. 1995 to explain the contamination incident. Phoned photo lab to schedule pictures to be taken of contaminated box for 4 Jan. 1996 at 8:00 a.m. Prepared shipping papers and UA containers for bio-assays for the following people: Dale Harvath, Amalie Johnson, Steve Broughton, and Lamont Pease. Amalie Johnson will not be in to work until after lunch, and Lamont Pease will not be here tomorrow. Needs to be done today! Steve Broughton comes to Bldg. 401. He is unwilling to cooperate with UA testing. He claimed mistrust in results, and would prefer to use his private physician in case there is any settlement money involved. Phil and I explained to Steve that it not the Marine Corps who does the test, but it is the Air Force. We explained the only reason we need the LA sample is to confirm that there was no contamination to him, and that we have no input to the report sent back. We also told him that he would he would be provided a copy of the results, and that if he still declined our request for the UA to please put it in writing with a signature and date. He decided to consent to the UA, and provided us with a sample. Steve also expressed health concerns from this possible over-exposure. Phil discussed his health concerns until Steve seemed satisfied that everything should be OK. I went to Amalie Johnson to ask for a UA. She consented. I notified her that if a catch basin was necessary, that she could go to the med clinic and see Sam (industrial hygienist), who I made sure had one available for her use necessary. Amalie declined the use of a catch basin and provided a UA sample in Bldg. 401. She also expressed some health concerns. I referred her to Phil Smith. I, Dale Harvath, provided a UA sample for bio-assay. I phoned warehouse 7 to see if Lamont Pease was available for UA. Ben Fields, his supervisor, answered and stated he was out unloading a truck. I discussed with Mr. Fields the possibility of coming over to get a LA sample from Lamont. He stated, "Lots of Luck". I went in and talked to Phil about the attitude and asked him to accompany me to warehouse 7. We met with Lamont and he wanted his health concerns addressed first. Phil and I responded to his questions. He provided the UA sample. January 4, 1996 Scheduled to meet Base Photographer at 8:00 a.m. Prepared placard for pictures. Met with photographer and she took pictures of exterior of the contaminated box. Removed collimator from box and took pictures of the double bagging, the holes in the bags, and the yellow card attached to the collimator. Removed packing peanuts from contaminated box for placement in dry activated waste. Returned collimator to box and double bagged box. Received phone call from Rich Johnson from BSO (Odis Gentry's supervisor). Since Odis was off on leave, Rich needed to be briefed on the incident. Received second phone call from Rich Johnson. He wanted to know if Odis or I had contacted MCBH, Hawaii. I told him that I had not, and I did not know if Odis had. Rich stated Tim Mohs was trying to contact MCBH, Hawaii, and had contacted the NRC for clarification as to whether or not it was a reportable incident. Had a phone message to call Tim Mohs. I returned his call and got a recording. Received phone call from Tim Mohs. He stated that it did not meet the requirements for NRC notification. He also asked for information from the DD Form 1348-1. He also requested information concerning the condition, the marking, and the labeling of the contaminated box, and how it was shipped. He also wanted to know if the bio-assays had been taken. I gave him the information from the 1348-1. 1 told him there was no damage to the contaminated box, and there was no type of marking or labeling on the exterior of the box that indicated that is was a radioactive shipment. I also told him that the bio-assays were completed on Jan. 3, 1996. January 5, 1996 Today Phil Smith, RPO, and I, Dale Harvath, went to Bldg. 430 to do a wipe test on the interior of the collimator. We opened the exterior box and removed the collimator from the box. We removed double plastic bag from the collimator and opened the view port adjacent to the ten curie tritium source. We could see underneath the protective lens that the interior lens was broken and in pieces. Phil did a wipe test of the collimator on and around the lens and source retainer. I took the wipe test to Cal lab while Phil stayed at Bldg. 430 to allow air to ventilate the collimator. I came back from Cal lab a few minutes later because no one in Cal lab was there to do the liquid Scintillation test. While I was gone Phil had moved the collimator outside onto a piece of plastic to air out. Since no one was at Cal lab, we decided to put the collimator back in Bldg. 430 on a piece of plastic to allow it to air there until the next day. I exited and locked the back door, Phil walked to the front and locked it. By the time I had reached the front end of the Bldg. the tritium air monitor alarm was sounding. Phil opened up the front door, I opened up the back door. We backed away from the area to let the Bldg. air out. We could see the air monitor was reading approximately 7 micro curies per cubic meter. The normal rate for this Bldg. is about 1.3 micro curies per cubic meter. The alarm tolerance is set at 5 micro curies per cubic meter. When it reached the nominal range we entered the Bldg., reset the alarm. We bagged the collimator, put it back into the contaminated box, and double bagged the box. We then closed Bldg. 430, waited for a few minutes to see it the alarm sounded again, since it did not, we left that Bldg. for the day. We received a phone call from LT. Moore from Hawaii. He stated that it was the 1st Bn. 12th Marines who shipped the collimator to Maintenance Co., CSSG three third FSSG MCBH, Hawaii. They could not repair the collimator. They forwarded it to a civilian contractor who handles shipments for them. The name of this company was PEMCO. Lt. Moore asked our advice as to what to do, since he was not familiar with the isotope tritium. We suggested he possibly contact the sub-base RSO to help him with this. We advised he might also want to investigate all possible areas that this collimator had been, and learn if any person had come into direct contact with the collimator. If anyone had, they might want to consider a bio-assay. Lt. Moore expressed concern for the upcoming visit with Tim Mohs. He expressed appreciation for the information and for our help, and stated he would keep in contact with us. A phone call from Tim Mohs indicated that he had further investigated this incident, and it was necessary to report it to the NRC I.A.W. 10 CFR 1906 (d)(1), and had already done so. He also notified us that he was coming to MCLB, Barstow on his way to MCBH, Hawaii on the 10th and 11th of January, 1996. January 27, 1995 Contacted Jim Reese, DDRW RSO, and notified him of incident. Gave his requested information about the contaminated item. He asked me if the base safety office had been contacted, which it had. He also asked if Odis from the BSO or I had contacted the License Manager (Betty Peterson) or Tim Mohs. I told him, "No, I had not," that Odis and I agreed that only one voice would be needed so that we did not have interpretation problems. Note: Hope they call back soon, Odis is going on leave Friday. Sandy Steck requests point paper prepared for Mr. Pinson. Have meeting scheduled with him at 1:00. Meet with Mr. Pinson (Deputy Director) and Sandy Steck in Mr. Pinson's office. Notify Mr. Pinson of incident. He reviews point paper, and asks about health ramifications. I inform him biological half life is approximately 12.5 days. He likes content of point paper (but sends it back for smoothing). On our way back from warehouse 7 Phil and I stopped by Bldg. 402, Packing and Preservation. George Palmer was unavailable to receive UA samples. They were given to Joe Trad, supervisor of P and P branch, for preparation for fed-ex shipment. Received three employee statements: Amalie Johnson, Steve Broughton, and Lamont Pease. *** END OF DOCUMENT ***

Page Last Reviewed/Updated Friday, January 31, 2020