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For Immediate Release February 15, 1999
Media Contact: James R. Giusti   (803) 725-2889


DOE Releases Accident Investigation Report
On FB-Line Workers' Plutonium Intake

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Aiken, SC - The Department of Energy's Savannah River Operations Office (SR) today issued its Accident Investigation Board's findings on the cause of plutonium intakes by seven Savannah River Site (SRS) employees in the FB-Line facility.

On September 1, 1999, plutonium was released from a failed plutonium storage canister at the Site's FB-Line facility and resulted in plutonium intakes by seven workers. The Westinghouse Savannah River Company (WSRC) safety strategy for the FB-Line relied on canister integrity being maintained and the canister being free of defects; however, adequate quality assurance controls were not in place to ensure that a canister with a failed weld would not be stored in the FB-Line vault.

The Accident Investigation Board found two root causes for this accident:

  •   Quality assurance on the bagless transfer system canister was not adequate to identify the weld defect.

  •   Implementation of integrated safety management for plutonium vault operations was inadequate to provide worker protection during interim plutonium storage and handling.

Integrated safety management is systematically integrating safety into management and work practices at all levels so that missions are accomplished while protecting the public, the worker, and the environment.

According to the investigation report, once the plutonium storage canister failed, the physical environment of the storage vault and adjacent vestibule contributed to the accident. Insufficient ventilation did not allow for timely respones of the air monitor. Command and Control and communication among the workers during the accident were also not adequate, and contributed to confusion over material control and accountability requirements and delays in alarm response.

"This accident highlights the importance of ensuring an effective Integrated Safety Management System approach to operations," said Jeff Allison, the Investigation Board Chairman.

During the Department's accident investigation, other deficiencies were also identified in each of the five core functions of integrated safety management. The Accident Investigation Board concluded that there is a need for the WSRC, and DOE Savannah River Operations Office to analyze FB-Line operations and take appropriate corrective action to ensure feedback and improvement aspects of integrated safety management are effectively implemented. Wackenhut Services, Inc. (WSI) also needs to ensure security post orders contain response requirements for abnormal conditions.

Initial corrective actions are in place and are underway at SRS in response to the Accident Investigation's findings and recommendations, including upgrading the training program with an increase in the number of drills, senior management briefings to employees on following procedures and doing work safely, and a detailed contractor investigation into the quality assurance program with changes implemented. Formal correction action plans must be submitted to the DOE site manager by March 9, 2000.

Attached to this news release is the executive summary of the report. Copies of the Department's accident report can be obtain through the mail by calling (803) 725-2889.





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