[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
THE LOW-LEVEL PLUTONIUM SPILL
AT NIST-BOULDER: CONTAMINATION
OF LAB AND PERSONNEL
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON TECHNOLOGY AND INNOVATION
COMMITTEE ON SCIENCE AND TECHNOLOGY
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
JULY 15, 2008
__________
Serial No. 110-115
__________
Printed for the use of the Committee on Science and Technology
Available via the World Wide Web: http://www.science.house.gov
----------
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COMMITTEE ON SCIENCE AND TECHNOLOGY
HON. BART GORDON, Tennessee, Chairman
JERRY F. COSTELLO, Illinois RALPH M. HALL, Texas
EDDIE BERNICE JOHNSON, Texas F. JAMES SENSENBRENNER JR.,
LYNN C. WOOLSEY, California Wisconsin
MARK UDALL, Colorado LAMAR S. SMITH, Texas
DAVID WU, Oregon DANA ROHRABACHER, California
BRIAN BAIRD, Washington ROSCOE G. BARTLETT, Maryland
BRAD MILLER, North Carolina VERNON J. EHLERS, Michigan
DANIEL LIPINSKI, Illinois FRANK D. LUCAS, Oklahoma
NICK LAMPSON, Texas JUDY BIGGERT, Illinois
GABRIELLE GIFFORDS, Arizona W. TODD AKIN, Missouri
JERRY MCNERNEY, California JO BONNER, Alabama
LAURA RICHARDSON, California TOM FEENEY, Florida
PAUL KANJORSKI, Pennsylvania RANDY NEUGEBAUER, Texas
STEVEN R. ROTHMAN, New Jersey BOB INGLIS, South Carolina
JIM MATHESON, Utah DAVID G. REICHERT, Washington
MIKE ROSS, Arkansas MICHAEL T. MCCAUL, Texas
BEN CHANDLER, Kentucky MARIO DIAZ-BALART, Florida
RUSS CARNAHAN, Missouri PHIL GINGREY, Georgia
CHARLIE MELANCON, Louisiana BRIAN P. BILBRAY, California
BARON P. HILL, Indiana ADRIAN SMITH, Nebraska
HARRY E. MITCHELL, Arizona PAUL C. BROUN, Georgia
CHARLES A. WILSON, Ohio
ANDRE CARSON, Indiana
------
Subcommittee on Technology and Innovation
HON. DAVID WU, Oregon, Chairman
JIM MATHESON, Utah PHIL GINGREY, Georgia
HARRY E. MITCHELL, Arizona VERNON J. EHLERS, Michigan
CHARLIE A. WILSON, Ohio JUDY BIGGERT, Illinois
BEN CHANDLER, Kentucky ADRIAN SMITH, Nebraska
MIKE ROSS, Arizona PAUL C. BROUN, Georgia
LAURA RICHARDSON, California
BART GORDON, Tennessee RALPH M. HALL, Texas
MIKE QUEAR Subcommittee Staff Director
RACHEL JAGODA BRUNETTE Democratic Professional Staff Member
MEGHAN HOUSEWRIGHT Democratic Professional Staff Member
TIND SHEPPER RYEN Republican Professional Staff Member
PIPER LARGENT Republican Professional Staff Member
C O N T E N T S
July 15, 2008
Page
Witness List..................................................... 2
Hearing Charter.................................................. 3
Opening Statements
Statement by Representative David Wu, Chairman, Subcommittee on
Technology and Innovation, Committee on Science and Technology,
U.S. House of Representatives.................................. 8
Written Statement............................................ 8
Statement by Representative Phil Gingrey, Ranking Minority
Member, Subcommittee on Technology and Innovation, Committee on
Science and Technology, U.S. House of Representatives.......... 9
Written Statement............................................ 10
Prepared Statement by Representative Harry E. Mitchell, Member,
Subcommittee on Technology and Innovation, Committee on Science
and Technology, U.S. House of Representatives.................. 11
Prepared Statement by Representative Laura Richardson, Member,
Subcommittee on Technology and Innovation, Committee on Science
and Technology, U.S. House of Representatives.................. 11
Witnesses:
Dr. James M. Turner, Deputy Director, National Institute of
Standards and Technology, U.S. Department of Commerce
Oral Statement............................................... 12
Written Statement............................................ 14
Biography.................................................... 23
Dr. Charles L. Miller, Director, Office of Federal and State
Materials and Environmental Management Programs, U.S. Nuclear
Regulatory Commission; accompanied by Dr. Elmo E. Collins,
Regional Administrator, Region IV Office, U.S. Nuclear
Regulatory Commission
Oral Statement............................................... 23
Written Statement............................................ 25
Biography.................................................... 29
Biography for Elmo E. Collins................................ 30
Dr. Kenneth C. Rogers, Former Commissioner, U.S. Nuclear
Regulatory Commission
Oral Statement............................................... 30
Written Statement............................................ 32
Biography.................................................... 43
Discussion....................................................... 46
Appendix: Answers to Post-Hearing Questions
Dr. James M. Turner, Deputy Director, National Institute of
Standards and Technology, U.S. Department of Commerce.......... 70
Dr. Charles L. Miller, Director, Office of Federal and State
Materials and Environmental Management Programs, U.S. Nuclear
Regulatory Commission; accompanied by Dr. Elmo E. Collins,
Regional Administrator, Region IV Office, U.S. Nuclear
Regulatory Commission.......................................... 74
Dr. Kenneth C. Rogers, Former Commissioner, U.S. Nuclear
Regulatory Commission.......................................... 78
THE LOW-LEVEL PLUTONIUM SPILL AT NIST-BOULDER; CONTAMINATION OF LAB AND
PERSONNEL
----------
TUESDAY, JULY 15, 2008
House of Representatives,
Subcommittee on Technology and Innovation,
Committee on Science and Technology,
Washington, DC.
The Subcommittee met, pursuant to call, at 11:07 a.m., in
Room 2325 of the Rayburn House Office Building, Hon. David Wu
[Chairman of the Subcommittee] presiding.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
hearing charter
SUBCOMMITTEE ON TECHNOLOGY AND INNOVATION
COMMITTEE ON SCIENCE AND TECHNOLOGY
U.S. HOUSE OF REPRESENTATIVES
The Low-level Plutonium Spill
at NIST-Boulder: Contamination
of Lab and Personnel
tuesday, july 15, 2008
11:00 a.m.-1:00 p.m.
2325 rayburn house office building
I. Purpose
On June 9, 2008, researchers working at the National Institute of
Standards and Technology (NIST) facility in Boulder, Colorado were
working with a small sample of plutonium when some of the sample
spilled from its container and contaminated the lab and personnel.
Contamination spread to other areas of the building, and a small amount
of the material was washed away in the lab sink. The purpose of this
hearing is to examine the causes of the incident and the subsequent
response to the situation by NIST employees, and to discuss
improvements to environmental, health, and safety practices at NIST.
II. Witnesses
Dr. James Turner is the Acting Director of the National Institute of
Standards and Technology (NIST).
Dr. Charles Miller is the Director of the Office of Federal and State
Materials and Environmental Management Programs at the U.S. Nuclear
Regulatory Commission.
Dr. Kenneth Rogers is one of five independent investigators appointed
by NIST to review the June 9, 2008 plutonium spill and a former
Commissioner of the U.S. Nuclear Regulatory Commission.
Dr. Elmo Collins is the Regional Administrator of the Region IV Office,
U.S. Nuclear Regulatory Commission.
III. Brief Overview
On June 9, 2008, researchers working with a 0.25 gram
sample of plutonium noticed that the glass vial had cracked and
some of the powder had spilled. Radiological contamination was
found on the hands of two people, the shoes of 20 others, and
the hallway and office space near the lab. The individuals were
decontaminated and given medical tests to determine if any
plutonium had been ingested or inhaled. The major health risk
posed by the plutonium in this case is an increased long-term
cancer risk from internal exposure. The area around the lab was
cleaned and the lab itself sealed.
Nearly one week following the incident, contamination
was discovered in a laboratory sink, indicating that some
plutonium had been washed down the drain to the municipal sewer
system. Additionally, several new individuals were identified
as possibly having been exposed to the plutonium and traces of
contamination were discovered in other areas of the NIST
facility.
On June 27, NIST reported that sensitive medical
tests for multiple individuals had returned results positive
for internal exposure to plutonium. Under the advice of
radiation health physicians, one individual began prophylactic
treatment for exposure; the others are awaiting the results of
further tests to determine if treatment is necessary. In total,
29 people are receiving these medical tests. However, NIST
reports that initial test results show that individuals did not
receive medically significant levels of internal radiation
exposure.
The spill likely could have been prevented had proper
safety protocols and handling procedures been followed.
Documentation provided to the Committee indicates that two
individuals working with the plutonium sample--including one
directly involved with the accident--had not received the
required radiation safety training. Discussions with NIST
personnel also revealed that the plutonium was not sealed in
its original protective packaging, as it should have been. It
is evident from the growing scope of the incident and the
inadequate communication between NIST and State and local
officials, NIST employees, and others that NIST did not have a
comprehensive, practiced emergency response plan in place at
the time of the incident.
NIST relies on supervisors and lab directors to
provide safety training to the researchers in their lab and
ensure all work is undertaken safely. This system, clearly
failed in this case. The FY 2006 Visiting Committee on Advanced
Technology (VCAT) report noted a lax culture of environmental,
health, and safety (EH&S) at NIST and recommended that NIST
management devote more effort to engendering safety among the
NIST staff. The Committee has asked for extensive documentation
on EH&S practices at NIST and proof of current training for all
employees to assess whether this incident reveals a larger
problem at NIST.\1\ Thus far, NIST has not provided many of
these documents, raising the concern that the lapses in good
EH&S practice that contributed to this incident are not
isolated.
---------------------------------------------------------------------------
\1\ Letter sent June 19, 2008 requesting these documents is
attached.
IV. Issues and Concerns
While a final account of the incident is forthcoming, initial
reports that untrained personnel were working with radioactive material
are troubling. In February 2007, NIST-Boulder applied to the Nuclear
Regulatory Commission (NRC) to amend their materials license for
plutonium. As part of the agreement to amend their license, NIST stated
that personnel handling and working in the area with the nuclear
material would follow strict training procedures. NIST claims that most
of the individuals who required the two-hour training received it in
2007, but no documentation has been provided to show that the
authorized user on the NRC license received the full eight hours of
training required. Also, the NRC license lists two authorized users for
the plutonium, neither of whom were supervising the experiment at the
time of the incident.
On the NRC license amendment application, NIST references an
emergency response plan and a contamination minimization program. NIST
has not provided these documents to the Committee, but the handling of
this incident shows poor implementation of both of these aspects of
proper incident response. It is unclear from the training materials
provided to the Committee what specific instructions employees received
to minimize the extent of contamination and what specific steps they
were to take in an emergency. The fact that radioactive material was
discharged to the municipal sewer system--though the amount was later
determined to be insignificant--and was undiscovered until nearly a
week after the initial incident illustrates that personnel did not
appreciate the basics of contamination minimization. Similarly, it
appears that NIST-Boulder does not have a comprehensive, well practiced
emergency plan. Communication with State and local officials was lax,
and the lack of communication with employees working at an adjacent
National Oceanic and Atmospheric Administration (NOAA) facility created
unnecessary anxiety for those individuals.
The FY 2006 VCAT report stated:
NIST has made solid improvements over the years to improve its
laboratory safety. . . . However, there are still
inconsistencies in application of safety procedures across the
laboratories. Safety is a leadership activity that the senior
NIST leadership must be actively involved in.
Although not associated with high-energy radiation, the nuclear
material involved in this incident still poses a serious health risk,
as illustrated by the treatment measures currently being taken by at
least one individual involved. Given that NIST researchers also work
with material more hazardous than plutonium, health and safety
practices should not be taken for granted by NIST management. The
Safety Office at NIST has seen inadequate funding in recent years and
the safety officers have little authority to enforce safety procedures.
The lack of oversight of safety by NIST management contributed to this
incident, and while NIST has engaged outside experts to investigate the
incident, they must commission an external panel to evaluate EH&S
practices across all of the NIST laboratories and programs. This is a
necessary step to ensure safety for NIST employees and the surrounding
communities.
V. Background
The small plutonium sample was being used in a research project to
develop improved radiation detectors for use in applications such as
anti-nuclear proliferation enforcement, homeland security, and basic
research. The work was being done in collaboration with Los Alamos
National Laboratories.
The spilled plutonium weighed approximately 0.25g and was used as a
reference material of known radioactivity. The type of radiation
emitted by this sample is primarily alpha particles, which are easily
shielded but have significant risks from internal exposure.
Attachment
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Wu. I want to welcome everyone to this morning's
hearing. It is not unusual for the Subcommittee to hold
oversight hearings about NIST. However, events over the past
six months have revealed some serious flaws in the
environmental, health, and safety programs at NIST.
This subcommittee has been the strongest champion of NIST
in Congress, and its Members have spent a lot of time educating
our colleagues on the outstanding scientific and technical work
of NIST employees and the tremendous value of NIST's work. On a
bipartisan basis, this subcommittee has championed increased
funding for NIST's scientific and technical activities.
However, along with scientific and technical excellence,
NIST needs an equal dedication to safe laboratory and general
practices. This is especially true at the NIST labs where staff
routinely work with hazardous materials and high-powered
equipment such as radioactive material and lasers. In the past
six months NIST has had at least two significant accidents.
The first involved the use of laser in Gaithersburg,
Maryland, and the second was the accidental release of
plutonium in Boulder, Colorado. Initial investigations revealed
the same basic issue in both cases; a lack of training for the
researchers performing the experiments and inadequate
laboratory safety policies.
These might sound like minor incidents, but they have had
medical ramifications for NIST employees, including one person
who experienced eye damage from the laser and another who
underwent prophylactic treatment for radiation exposure.
I am concerned that the laser event did not trigger an
immediate review of all of NIST's safety training which might
have prevented the subsequent incident in June. I am also
concerned that NIST did not act on the Visiting Committee on
Advanced Technology's, or VCAT's, 2006 recommendation that
management needed to be more involved in and place more
emphasis on environmental, health, and safety issues.
I am also deeply concerned that there did not seem to be a
sensitivity and appropriate priority placed on communicating
with the surrounding communities to prevent the dissemination
of information which might be alarming and which may or may not
be accurate to the surrounding communities.
The purpose of today's hearing is not to place blame. It is
to understand how this situation developed, and what needs to
be done to instill a culture of safety in the NIST laboratories
while maintaining scientific excellence.
I want to thank our outside experts for assisting the
Subcommittee in its endeavors, and I now would like to
recognize my friend from Georgia, the Subcommittee's Ranking
Member, Dr. Gingrey, for his opening statement.
[The prepared statement of Chairman Wu follows:]
Prepared Statement of Chairman David Wu
I want to welcome everyone to this morning's hearing. It's not
unusual for the Subcommittee to hold oversight hearings of NIST.
However, events over the past six months have revealed serious flaws in
the environmental, health, and safety programs at NIST.
This subcommittee has been the strongest champion of NIST in
Congress, and its Members have spent a lot of time educating our
colleagues on the outstanding scientific and technical work of NIST
employees. On a bipartisan basis, this subcommittee has championed
increased funding for NIST's scientific and technical activities.
However, along with scientific and technical excellence, NIST needs
an equal dedication to safe laboratory practices.
This is especially true at the NIST labs where staff routinely work
with hazardous materials and high powered equipment, such as
radioactive material and lasers. In the past six months, NIST has had
two significant accidents.
The first involved the use of a laser in Gaithersburg, Maryland,
and the second was the accidental release of plutonium in Boulder,
Colorado. Initial investigations revealed the same basic issue in both
cases--a lack of training for the researchers performing the
experiments and inadequate laboratory safety policies.
These might sound like minor incidents, but they have had medical
ramifications for NIST employees, including one person who experienced
eye damage from the laser and another who underwent prophylactic
treatment for radiation exposure.
I am concerned that the laser event did not trigger an immediate
review of all of NIST's safety training which might have prevented the
accident in June.
I am also concerned that NIST did not act on the Visiting Committee
on Advanced Technology's 2006 recommendation that management needed to
be more involved in, and place more emphasis on, environmental, health,
and safety issues.
The purpose of today's hearing is not to place blame; it is to
understand how this situation developed and what needs to be done to
instill a culture of safety in the NIST labs, while maintaining
scientific excellence.
I especially want to thank our outside experts for assisting the
Subcommittee in its endeavors.
I now recognize my friend from Georgia, the Subcommittee Ranking
Member, Dr. Gingrey, for his opening statement.
Mr. Gingrey. Mr. Chairman, thank you for calling today's
hearing to review the details and the causes of the June 9
spill of plutonium that occurred at the NIST labs in Boulder,
and of course, you mentioned also the laser accident at
Gaithersburg.
First and foremost, I am very thankful that those in
proximity of the spill have thus far shown no adverse side
effects from their exposure to plutonium, and of course, as I
said, the other accident involving the laser. We--it will take
time. Only time will tell the adverse effects of those two
incidents.
That is not to say, however, that the sample containing 250
milligrams of various plutonium isotopes pose no health or
safety risks when it was mishandled. I am very disappointed
that the preliminary investigations of this incident to date
have revealed not just a stunning lack of preparation but also
a complete lack of understanding of the potential risks
involved in the use of encapsulated plutonium samples.
It appears as though researchers were unaware of the
potential risks and quickly went forward to obtain and use the
samples without appropriate precautions in place. Of even
greater concern, safety protocol was either not in place or not
properly followed, that would have flagged this acquisition
ahead of time or insured that proper training and equipment
were available.
Mr. Chairman, this incident is absolutely unacceptable. It
could have been avoided, and it should have been avoided. One
of the NIST independent reviewers, Dr. Lester Slaback, notes in
his report, the incident was the inevitable or at least highly
likely and foreseeable end result of numerous individual and
organizational failures.
I do applaud Dr. Turner for recognizing the gravity of the
problem at NIST, and I am cautiously optimistic that employees
throughout the agency will also heed this wake-up call.
However, this incident makes clear that simply having
safety policies on paper does not ensure that they will be
adequately executed. And I hope Dr. Turner recognizes, I am
sure he does, that a fix will not come through onerous safety
directions from top level officials. Rather, change must
involve every employee or visiting affiliate at NIST adhering
to documented safety procedures so that an incident like this
does not occur again.
I expect that during the question and answer portion of
today's hearing we will be able to discuss how NIST can ensure
that their safety programs, including radiological safety,
become examples of best practices instead of examples of
shortcomings and inadequate preparation. Indeed, you know, when
I think of NIST and what I have learned of NIST and visited at
Gaithersburg in the time that I have been a Member of this
committee, I have come to expect the very best of this age-old
organization that is practically called for in our United
States Constitution. I mean, it is hugely, hugely important,
and it is just shocking that this would have occurred.
The Nuclear Regulatory Commission's investigation of this
incident is, of course, still ongoing, so I am sensitive to the
need of the Commission to complete that work before discussing
their findings. I am thankful, though, that Dr. Miller and
Dr.--and Mr. Collins have made themselves available to explain
the NRC licensing requirements, safety guidelines, and process
for responding to this event. Their expertise and insight will
be extraordinarily useful to the Committee as we place this
incident in its proper context and seek ways to improve the
safety systems at NIST.
Mr. Chairman, NIST has a scientific legacy of achievement
for which we are rightfully proud. I think we all agree that
equal effort must go into safety considerations at NIST. We
cannot accept a cavalier attitude towards safety. We are not
using plutonium as if we are trying to send a DeLorean back in
time like in the film, Back to the Future. There are greater
safety concerns for which our researches at NIST should be
prepared, and moving forward this agency should be better
positioned to implement better training and safety protocols.
With that, Mr. Chairman, I yield back to you.
[The prepared statement of Mr. Gingrey follows:]
Prepared Statement of Representative Phil Gingrey
Mr. Chairman, thank you for calling today's hearing to review the
details and causes of the June 9th spill of plutonium at the NIST labs
in Boulder. First and foremost, I am very thankful that those in
proximity of the spill have thus far shown no adverse side effects from
their exposure to plutonium. That is not to say, however, that the
sample containing 250 milligrams of various plutonium isotopes posed no
health or safety risks when it was mishandled.
I am very disappointed that the preliminary investigations of this
incident to date have revealed not just a stunning lack of preparation,
but also a complete lack of understanding of the potential risks
involved in the use of encapsulated plutonium samples. It appears as
though researchers were unaware of the potential risks and quickly went
forward to obtain and use the samples without appropriate precautions
in place. Of even greater concern, safety protocol was either not in
place or not properly followed. That would have flagged this
acquisition ahead of time or ensured that proper training and equipment
were available.
Mr. Chairman, this incident is absolutely unacceptable. It could
have been avoided, and it should have been avoided.
One of the NIST independent reviewers, Dr. Lester Slaback, notes in
his report that, ``[the incident] was the inevitable (or at least
highly likely) and foreseeable end result'' of numerous individual and
organizational failures. I do applaud Dr. Turner for recognizing the
gravity of the problem at NIST, and I am cautiously optimistic that
employees throughout the agency will also heed this wake-up call.
However, this incident makes clear that simply having safety policies
on paper does not ensure that they will be adequately executed. I hope
Dr. Turner recognizes that a fix will not come through onerous safety
directives from top level officials. Rather, change must involve every
employee or visiting affiliate at NIST adhering to documented safety
procedures so that an incident like this does not occur again. I expect
that during the Question and Answer portion of today's hearing, we will
be able to discuss how NIST can ensure that their safety programs,
including radiological safety, become examples of best-practices
instead of examples of shortcomings and inadequate preparation.
The Nuclear Regulatory Commission's investigation of this incident
is still ongoing, so I am sensitive to the need for the Commission to
complete that work before discussing their findings. I am thankful,
though, that Dr. Miller and Dr. Collins have made themselves available
to explain the NRC's licensing requirements, safety guidelines, and
process for responding to this event. Their expertise and insight will
be extraordinarily useful to the Committee as we place this incident in
context and seek ways to improve the safety systems at NIST.
Mr. Chairman, NIST has a scientific legacy of achievement for which
we are rightfully proud. I think we all agree that equal effort must go
into safety considerations at NIST. We cannot accept a cavalier
attitude towards safety. We are not using plutonium as if we are trying
to send a DeLorean back in time, like in the film Back to the Future.
There are greater safety concerns for which our researchers at NIST
should be prepared, and moving forward, this agency should be better
positioned to implement better training and safety protocols.
With that, I yield back the balance of my time.
Chairman Wu. I thank the gentleman. If there are any other
Members who wish to submit additional opening statements, your
statements will be added to the record at this point.
[The prepared statement of Mr. Mitchell follows:]
Prepared Statement of Representative Harry E. Mitchell
Thank you, Mr. Chairman.
On June 9, 2008, there was an incident at the National Institute of
Standards and Technology (NIST) facility in Boulder, CO involving a
plutonium sample spill which contaminated the lab and personnel.
Today we will examine the causes of this incident and how the NIST
employees responded.
According to documentation provided for this committee, two NIST
employees working with this plutonium sample did not receive the
required radiation safety training, and this plutonium was not properly
stored. Furthermore, NIST did not have a comprehensive emergency
response plan in place at the time of the incident.
Even more troubling, even though the Committee has requested
extensive documentation on the environmental, health, and safety
practices at NIST, NIST has yet to provide many of these documents,
which raises the concern that lapses that caused the incident in
Boulder are not isolated.
I find this deeply concerning. Federal agencies like NIST have
safety regulations in place for a reason.
I look forward to hearing more from our witnesses on what we can do
to improve the environmental, health, and safety practices at NIST.
I yield back.
[The prepared statement of Ms. Richardson follows:]
Prepared Statement of Representative Laura Richardson
Thank you Chairman Wu for holding this very important hearing
today, and our witnesses for their appearance. The purpose of today's
hearing is to examine the causes of the plutonium spill at the NIST
laboratories in Boulder, Colorado; the response to this spill; and the
overall status of environmental, health, and safety practices
(``EH&S'') at NIST laboratories.
First and foremost let me begin by stating that I was concerned
when I gained knowledge of this incident. I understand that mistakes
happen, but what concerns me more than anything else was the subsequent
response or the lack of an adequate response to the situation. This
spill opened our eyes to a host of procedures that, had they been
followed, would have negated the necessity of this hearing. Nonetheless
here we are. Now let me state this, NIST is an excellent organization,
with a group of scientist that are the best in the world, so I am
shocked to discover that EH&S practices do not receive the attention
they deserve at NIST laboratories.
When an institution like NIST applies to the Nuclear Regulatory
Commission for a license to handle dangerous materials like plutonium,
they make assurances. One of these assurances is that every individual
who will work with the material, or come in close proximity to the
material, receives adequate safety training. Furthermore, when NIST
applied for the license to handle plutonium, the representation was
made that only two individuals would be allowed to handle the
plutonium. However, reports indicate that the visiting researcher who
spilled the plutonium was not one of the individuals designated on the
NIST application as a handler, he did not receive adequate training,
his supervisor may not have received adequate training, and the chief
scientist with the authorization to handle the plutonium was not in the
room supervising the visiting researcher. In light of these facts it is
obvious why we are here today.
Add to this the fact that the administrators at NIST failed to
inform the elected officials of Boulder, and the neighboring NOAA
facility (National Oceanic and Atmospheric Administration) of the spill
leads me to believe that someone might have deliberately attempted to
hide knowledge of the spill.
Likewise, the fact that the Visiting Committee on Advanced
Technology (VCAT) noted the lax culture of EH&S at NIST, and
recommended that NIST management address this matter, yet this incident
still occurs, demonstrates sub-standard behavior on the part of the
NIST administration.
I know that this hearing will produce results, and I expect the
administration of NIST to deliver those results. There is NO room for
compromise when it comes to public safety.
Mr. Chairman I yield back my time.
Chairman Wu. I would like to introduce our witnesses, and I
thank you all for appearing before the Subcommittee today. Dr.
James Turner, who is the Acting Director of NIST, Dr. Charles
Miller, who is the Director of the Office of Federal and State
Materials and Environmental Management Programs at the Nuclear
Regulatory Commission.
He is joined from the NRC by Mr. Elmo Collins, who is the
Regional Administrator of Region IV based in Arlington, Texas.
Mr. Collins is directly involved in investigating the June 9
incident at the Boulder Laboratories.
Lastly, Dr. Kenneth Rogers. Dr. Rogers was asked by NIST to
provide an independent review, one of several individuals asked
for independent reviews of the June 9 incident, and to offer
recommendations, and Dr. Rogers is also a former Commissioner
of the Nuclear Regulatory Commission.
As our witnesses know, spoken testimony is limited to five
minutes, after which the Members of the Committee will have
five minutes each to ask questions. Your written statements
will be fully taken into the record.
And with that, Dr. Turner, if you would, please commence.
STATEMENT OF DR. JAMES M. TURNER, DEPUTY DIRECTOR, NATIONAL
INSTITUTE OF STANDARDS AND TECHNOLOGY, U.S. DEPARTMENT OF
COMMERCE
Dr. Turner. Thank you very much, Mr. Chairman. Chairman Wu,
Ranking Member Gingrey, and Members of the Subcommittee, thank
you for the opportunity to appear before you today to discuss
the June 9, 2008, incident involving the release of plutonium
at the National Institute of Standards and Technology, NIST,
Boulder Laboratory, as well as NIST's environment, safety, and
health practices.
Mr. Chairman, I deeply regret the incident. My top priority
has been, and continues to be, the health and safety of our
staff involved in this incident. According to the latest
analysis of the medical testing of the personnel involved, the
physicians have relayed that the increased overall risk for
cancer based on dose estimates are so small they don't expect
there to be any clinically-significant impact on either the
short- or long-term health of anyone exposed. We will continue
to provide our personnel with access to top medical care as
well as we continue testing.
We have been able to ascertain through numerous interviews
and reports that the incident involved a guest researcher who
handled the radioactive source without appropriate training and
supervision. My written testimony provides further details
about the incident and the immediate response.
The researcher handling the source material at the time
most certainly should have been--should have had the required
training appropriate to the researcher's work and consistent
with the commitments made under the NRC license. Partially as a
result of a lack of this training, actions taken during the
incident and immediately afterward by the researcher
exacerbated the extent of the incident and complicated the
response.
The incident and the conditions that permitted this
incident to take place are unacceptable. I pledge to you and
this subcommittee my personal assurance that we will do what is
necessary to find the root cause or causes, take appropriate
actions, and ensure to the best of our abilities that such a
failure does not occur in the future.
The Department of Commerce is establishing a blue ribbon
panel to look broadly at safety and training issues at NIST.
Also, the Department's Office of Inspector General is
conducting a broad review of management, training, safety, and
response operations at all NIST facilities.
I have welcomed the involvement of external individuals and
organizations to provide advice, guidance, counsel--tough
counsel--as to what NIST could have done, can do in the short-
term, and must do longer-term to address shortcomings in our
safety, training, and emergency response preparedness.
As a direct result--as a direct follow-up to this incident,
NIST's senior management has taken a variety of actions
including requiring that each laboratory director and chief
officer certify that all staff, employees, and associate have
in place the required safety training prior to being allowed to
continue their work. Issuing safety stand-downs, creating new
lab teams to review hazards in the labs, initiating more
systematic approaches to eliminating, reducing, or controlling
the risks of different hazards, including emergency response
and recovery.
I have taken several immediate actions, and we are
conducting our own investigations. I have moved the Office of
the NIST Safety, Health, and Environment Division into the
Director's office so that it now reports to the NIST Deputy
Director, who is our chief safety officer. I have asked my
staff to revamp NIST's emergency communications procedures. I
have also designated NIST's Chief Scientist as the Incident
Response Director in order to provide stronger on-site support
in Boulder. He is currently on-site leading the effort and will
be there indefinitely.
I have traveled to Boulder and plan to return there after
this hearing. I am attempting to arrange meetings with State,
county, and local officials during this visit. I have ensured
that NIST-Boulder issue a stop work order for all radioactive
materials in use, and a preliminary decision has been made to
limit the use of radioactive materials in Boulder in the future
to sealed sources.
At my request five eminent experts in radiation health
safety conducted an assessment of the incident. An author of
one of those reports, Dr. Ken Rogers, is on the panel today,
and you will hear from him directly on his findings and
recommendations. Their reports are sobering in their assessment
of our challenges, and I take their words seriously. Their
views about our shortcomings confirm my belief of the need to
focus our efforts on NIST's entire environment, health, safety,
and emergency response protocols and safety culture to ensure
that we are measuring up to both the requirements and the
highest expectations for a world-class organization. I expect
that these experts will continue to provide insights to me and
others at NIST in the coming weeks.
The lack of training provided disturbs me greatly, Mr.
Chairman. I am committed to making the changes necessary to
reduce to the maximum extent possible the opportunity for such
a situation to occur in the future. This includes reevaluating
our training to make sure it is appropriate, establishing
testing mechanisms to ensure that training is mastered, and
creating controls to document training. Our ongoing assessment
will help us address critical areas for improvement.
Mr. Chairman, based on the information available at this
time, this incident was preventable. NIST's culture and
organizational structure contributed to an environment in which
line supervisors failed to take adequate responsibility for
safety issues, and safety personnel failed to assert a
sufficient level of authority to ensure compliance with
existing procedures and practices.
I, again, pledge to you my commitment to improve our safety
practices, engrain a sustainable safety culture, and thereby
ensuring the health and safety of our employees and local
communities. I will report to you regularly and will keep you
apprised of our findings and projects.
Thank you, Mr. Chairman. I will be pleased to answer any
questions you may have.
[The prepared statement of Dr. Turner follows:]
Prepared Statement of James M. Turner
Chairman Wu, Ranking Member Gingrey, and Members of the
Subcommittee, thank you for the opportunity to appear before you today
to discuss the June 9, 2008, incident involving the release of
plutonium at the National Institute of Standards and Technology's
(NIST) Boulder Laboratory--as well as NIST's environment, health, and
safety practices.
Introduction
Mr. Chairman, I deeply regret the incident that occurred at the
NIST-Boulder Laboratories on June 9, 2008. First, my top priority has
been and continues to be the health and safety of our staff involved in
this incident. I am pleased to report that, according to the latest
analysis of the medical testing on the personnel involved, the
physicians are relaying that no significant health risks are expected
based on the test results to date. I hope the affected individuals and
their families are encouraged by these test results. The physicians are
relaying that the estimated doses, and the increased overall risk for
cancer based on these estimates, are so small we don't expect there to
be any clinically significant impact on either the short- or long-term
health of anyone exposed. We will continue to provide our personnel
with access to top medical care as we continue testing.
However, the incident raises very serious and significant issues at
NIST with regard to safety, safety culture, training, and emergency
response policies, protocols, and NIST's implementation of and
adherence to them. The incident and the conditions that permitted this
incident to take place are unacceptable, Mr. Chairman, and I pledge to
you and this subcommittee my personal assurance that we will do what is
necessary to find the root cause or causes, take appropriate actions,
and ensure to the best of our abilities that such a failure does not
occur in the future.
The Department has taken a number of steps to ensure that
independent reviews of NIST training, safety, and response protocols
are conducted. Multiple investigations of the incident have been
completed, are underway, or are to be conducted at NIST. These
investigations include, but are not limited to: (1) the NIST Safety,
Health and Environment Division (SHED) investigation; (2) the NIST
Ionizing Radiation Safety Committee (IRSC) investigation; (3) the five
preliminary individual experts' investigations ordered by the NIST
Deputy Director; (4) the Department of Commerce (DOC) Inspector General
(IG) investigation; and (5) the Nuclear Regulatory Commission (NRC)
inspection. In addition, the need for a blue ribbon panel was
identified by the Department, at the direction of Deputy Secretary John
Sullivan, and work has already begun to establish such a panel. In
addition, on July 1, 2008, Deputy Secretary Sullivan requested that the
Department of Commerce's Inspector General conduct a broad review of
management, training, safety, and response operations at all NIST
facilities. We look forward to working with you as we institute these
important additional reviews of NIST's safety practices.
We must be able to assure not just the Subcommittee, but the entire
NIST family and the communities in which we live and work that NIST not
only does cutting-edge, world-class research, but that we do so in
accordance with the highest standards for safety, training, and
emergency response preparedness. NIST science is renowned for its
meticulous attention to detail; that same attitude must pervade our
safety culture.
I am testifying today on the current status of this incident. We
have made available information to this committee, our staff, the
media, the public, and the NRC. This includes our 30-day report to the
NRC and the reports to us by five individual experts we commissioned.
We still have much to do and I will continue to keep you apprised of
our progress as we gather more information.
Since the incident, NIST leadership in Gaithersburg and Boulder has
been working to ensure our employees' safety and answer three key
questions:
1) What happened on that day and how did NIST respond?
2) How could such an incident occur in the first place? and
3) What are we doing to ensure that we have the structure,
policies and procedures in place to prevent such an incident
from occurring in the future?
Although we do not have all of the answers to these questions yet--
and I assure you that we will continue to work to get those answers,
take appropriate actions, and keep you informed--we do know that this
specific incident was the result of both significant individual and
systemic failures.
An Overview of the Events on June 9th
Before I begin with an overview of the events on June 9, let me
state that the facts that I am about to relay represent NIST's best
understanding of the facts at this time, based on testimony of those
with first hand knowledge, and a review of all the evidence available
to us currently. NIST's and other investigations are on-going, however,
and we may learn more, or different, facts as we all continue to
clarify our understanding of what happened.
Through interviews we have been able to ascertain that the incident
involved a guest researcher who handled a radioactive source without
appropriate training and supervision. During the course of this
handling, the vial cracked and a portion of the approximately one-
fourth gram of plutonium contained in the vial spilled out.
The affected laboratory and an adjacent lab were sealed off and
personnel who were identified as working in or near the lab were asked
to remain in the area and any radioactive material on their clothing or
bodies was removed. The personnel were also subsequently given bioassay
tests to determine if any internal contamination occurred. (Since that
time, several additional personnel identified themselves as having
potential exposure and have had these tests conducted.)
External trace contamination was found on some employees, and in
most cases this contamination was easily removed using soapy water. The
personnel were sent home with the exception of two individuals who
evidenced very low levels of contamination on their hands. (These two
were provided with gloves to wear--to prevent the spread of the
material--until repeated hand washing eliminated the remaining
contamination.) NIST radiation safety personnel supervised the testing
of the adjacent areas leading to other parts of the building, a men's
restroom and doorways leading out of the building. Some areas of trace
contamination were discovered and these areas were cleaned and retested
to ensure they were contamination free. At that time, there was no
evidence that there had been any contamination aside from those areas.
The affected laboratory and the adjacent connecting laboratory
continue to remain sealed off for further testing and remain so pending
approval of the decontamination process by the NRC.
As our investigation continued, we conducted subsequent extended
interviews and discovered trace contamination in other areas. These
areas, too, were thoroughly cleaned and retested to ensure they were
free of contamination.
Failures Leading to the Incident
Mr. Chairman, NIST's safety culture is deficient. Later in this
testimony I will focus on our policy and system for safety and
training. Some things are clear:
1) The NRC regulates the use of radioactive materials at all NIST
laboratories and is investigating the plutonium spill at the Boulder
Laboratory and NIST's response. Specifically, the NRC is currently
conducting an inspection that will result in the definitive account of
the spill and its aftermath.
2) In January 2007, NIST filed an amended Application for Radioactive
Material, an Addendum to the NRC Form 313, for the purposes of using
encapsulated plutonium in research. In that amended license, NIST
committed to do certain things, particularly in the areas of training.
It appears that we did not meet those commitments. Such a failure is a
serious breach and must be dealt with accordingly. I must stress that
at this point our main focus is the health of those affected.
The researcher handling the source material at the time most
certainly should have had the required training appropriate to his work
and consistent with the commitments made under the NRC application.
Partially as a result of this lack of training, actions taken during
the incident and immediately afterward by the researcher appears to
have exacerbated the extent of the incident and complicated the
response.
While we cannot necessarily extrapolate from a single incident, I
am also looking at issues that this incident raises about cultural
barriers in our environment, health and safety policies and procedures,
including our training practices, system-wide.
Response Subsequent to the Incident
Mr. Chairman, I have already taken several immediate actions and we
are conducting our own investigations and assisting with external
assessments. I have welcomed the involvement of the NRC, the Department
of Commerce's Office of Inspector General, and individual radiation
safety experts to provide advice, guidance and counsel--tough counsel--
as to what NIST could have done, can do in the short-term, and must do
longer-term to address shortcomings in our safety, training and
emergency response preparedness. I am moving the NIST Safety, Health,
and Environment Division into the Director's office so that it now
reports to the NIST Deputy Director, who is the agency's Chief Safety
Officer. I have asked my staff to revamp NIST emergency communications
procedures and we are developing a plan for moving forward which will
include external input, participation and review.
In order to provide stronger on-site support to Boulder, I
designated the NIST Chief Scientist, Dr. Richard Kayser, as the
Incident Response Director, who took over for the NIST-Boulder
Laboratory's Director, Dr. Thomas O'Brian, who served as the Incident
Response Coordinator. I directed Dr. Kayser to be on site in Boulder
indefinitely leading this effort. His team is developing--and has
already been implementing portions of--an incident response plan which
includes continuing to reach out to employees who have any concerns
about their health, identifying any additional spaces that may need to
be surveyed, better coordination of outreach and response to the
Boulder community and other federal, State, and local agencies, and
Congress, and moving forward on the development of a decontamination
plan. That decontamination will take place once all the other bodies
conducting their assessment of the situation no longer need access to
the lab--and once our decontamination plan has been reviewed and
approved by the NRC.
I have traveled to Boulder and plan to return tomorrow. In
addition, the Chief of the NIST Safety, Health and Environment
Division, as well as the senior NIST health physicist from Gaithersburg
have been stationed in Boulder for the past several weeks. Other NIST-
Gaithersburg personnel have also been on-site in Boulder as needed and
additional personnel have been provided to Boulder by National Oceanic
and Atmospheric Administration (NOAA) and by the Department of
Commerce. We will continue to have appropriate resources on site until
this cleanup is completed.
Results of Internal Investigation
While we have investigations ongoing, they have at this point
revealed that the probable cause of the incident was handler error.
Source material was removed from its secondary containment, and its
vial broke after contact with a hard surface.
However, I want to make clear that overall organizational failures
contributed to this handler error. Specifically:
Procedures for acquiring source material were not
followed as line management was not always aware of source
material acquisition.
Individuals, both those handling source material and
those working in the vicinity, were not provided proper
training or the necessary information to allow them to evaluate
and understand the risks involved.
Available training was inadequate for the
circumstances.
Lack of an emergency response plan contributed to the
potential spread of contamination beyond the spill zone.
Employees were neither prepared nor equipped to respond to the
situation, and safety personnel were forced to respond as
events unfolded, rather than from established protocols.
NIST's organizational structure contributed to an environment in
which line supervisors failed to take adequate responsibility for
safety issues, and safety personnel failed to assert a sufficient level
of authority to ensure compliance with existing procedures and
policies. In sum, a culture has developed with respect to safety issues
that NIST understands must be addressed broadly, beyond this specific
event.
Preliminary analysis indicates that multiple organizational
failures contributed to the incident. Specifically, proper procedures
were not followed for acquiring a radiation source and line management
was not aware of the inappropriate handling of the source material. As
a result, a proper risk assessment was not conducted.
There were no procedures in place for source handling and
utilization nor was there an incident response plan or an audit program
for radiation safety at NIST-Boulder. Our investigation has revealed at
this point that the scope of the hazardous materials programs expanded
without reevaluation of the risks involved and without a commensurate
strengthening of the radiation safety program. As a result, there was
inadequate infrastructure to support the use of encapsulated sources.
This clearly shows that we do not have systems in place to adequately
identify and manage risks as they change. As we move forward and revise
our safety program, we must integrate risk management into it. We must
train our personnel so that when they are preparing to perform a task
or proposing a new process/procedure that they are trained and have the
resources to: 1. Identify the risks involved; 2. Identify the controls
necessary to reduce or eliminate those risks; 3. Implement those
controls; and 4. Monitor those controls to ensure the risks are in fact
reduced or eliminated. If the fourth step identifies weaknesses in the
controls or if the risk(s) have changed, our personnel will know they
must go back to the first step and begin this process again.
Available training was inadequate and insufficient with respect to
the number of individuals trained. Existing training requirements were
ignored by researchers and not identified by safety personnel.
Specifically, three individuals involved received inadequate or no
training. We recognize that insufficient/inadequate training or
training that was ignored, which are examples of management failures.
We will integrate relevant training, with appropriate measures to
document and evaluate the effectiveness of that training into our
revised safety program. We will also include mechanisms to hold
supervisors accountable for the training of their personnel.
Use of the posted radiation laboratory as a multi-use laboratory
accessed by untrained and uninformed individuals contributed to risk,
which was exacerbated by the lack of an accurate hazard posting on
laboratory door.
In general, there was weak engagement by line management in
overseeing personnel, programs, and safety-related activities.
Similarly, safety personnel failed to identify and/or address obvious
safety issues.
Timeline Since the Incident
Mr. Chairman, this section provides a summary of the communications
and actions taken since the incident occurred.
Dr. William Anderson, Director of the NIST Electronics and
Electrical Engineering Laboratory, sent an e-mail to the NIST Chief
Scientist, Dr. Richard Kayser, and me, at 9 p.m. on June 9th. I did not
see that e-mail until the following morning. Clearly, e-mail is not
sufficient in case of emergencies. I understand that on June 10th the
Director of the Boulder Labs called the City of Boulder to inform them
of the situation and offered to brief the City on the incident.
Managers at NOAA, housed in a physically separate building on the
campus, and the National Telecommunications and Information
Administration (NTIA), which has people in the same building as the
affected lab, were also apprised of the situation and offered a
briefing.
In this instance, some of the initial outreach was timely; in other
cases it was not. The lack of a clearly articulated plan with names and
contacts hampered the efforts by NIST-Boulder staff to inform those who
must know or needed to know the situation. This is why immediately
after the incident I directed the NIST Director of Emergency Services
to develop a notification checklist for Boulder similar to what is kept
in Gaithersburg. This can be used in an emergency to assure systematic
notification and not rely on someone remembering something during a
stressful situation. I will be happy to provide for the record more
specifics on our emergency notifications procedures.
The Boulder staff was advised via an e-mail and has continued to
receive updates as new information becomes available. In addition, on
June 10th, NIST Congressional and Legislative Affairs notified this
subcommittee and the staff of the local Colorado Representative and
Senators of the incident. We have and will continue to provide updates
as the assessment and investigation continues. In addition, a news
release was provided to the local news media and posted on the NIST
external Web site, and the NRC was advised about the incident, within
the required 24-hour period.
The NRC arrived at NIST-Boulder for an initial assessment on June
11th and I dispatched a health physicist from NIST-Gaithersburg to
assist the Radiation Safety Officer in Boulder.
As I mentioned earlier, the health physicists initiated the first
of a series of bioassay tests for personnel either known to have trace
external contamination or determined to be potentially contaminated, or
for personnel who self-identified themselves to us as having a possible
concern for their risk of exposure. Initial tests indicated no evidence
of significant internal contamination of individuals. More sensitive
follow-up tests as recommended by the Department of Energy (DOE)
physicians and radiation experts showed some internal contamination for
a small number of individuals. But as I mentioned, these results
support our current understanding that the exposure level is very low
and will accord no significant health risk to the personnel affected.
We await additional test results.
Even more sensitive testing, known as a ``TIMS'' (thermal
ionization mass spectrometry) test, has been initiated for all
individuals who potentially have been exposed or who have requested to
be tested. In addition, several other professionals who entered the lab
as part of the investigation have been provided tests--which is a
standard procedure for such radiation workers. These tests are complex
and require several weeks to receive results. We hope to receive final
results at the end of this month.
It is reported to me that on-going interviews on June 12th revealed
that the guest researcher who had handled the plutonium had walked to
other parts of the building before being decontaminated. Over the next
few hours, the potentially affected areas were then surveyed. The
resurvey showed trace amounts of contamination in one office on one
desk, a lab notebook on the desk, and the chair associated with that
desk, that had been used by the affected individual, as well as in a
stairway leading to the office. As a precaution, the room was sealed
until more thorough testing and evaluation could be completed. The
hallway and stairway outside the affected room was surveyed and it was
reported that no evidence of removable contamination beyond normal
background was detected.
NIST provided notice of the new findings to Congressional staff,
the City of Boulder, the media, the public, the NRC, and the Boulder
NOAA and NTIA site. We called in and began our first consultation with
the DOE National Nuclear Security Administration's (NNSA) Radiological
Assistance Program (RAP).
Over that weekend, NIST health physicists (part of our safety
operation) made the initial controlled entry into the sealed lab in
order to conduct a radiation survey as part of NIST's internal
investigation. Late Saturday, June 14th, the initial survey revealed
contamination in the lab sink. It was subsequently learned--through a
re-interview--that the researcher who worked most directly with the
plutonium sample washed his/her hands in that sink during the incident,
a critical fact that had not been initially reported.
I understand that a NIST-Boulder official contacted the City of
Boulder's waste water treatment plant manager early on Monday, June
16th, to alert the city that there was a possible discharge into the
city waste water system. NIST was not able to quantify the amount of
the possible discharge at that time.
As a result of the finding in the lab sink, public notice of the
discovery that some unknown amount of plutonium was discharged into the
city waste water system also was made to the DOC Boulder campus,
Congress, the media, the public and the City of Boulder City Manager.
The Boulder Director offered to brief the City management, NOAA, and
NTIA on the incident. All NIST-Boulder staff was invited to a briefing
on the incident. We also initiated communications with the Department
of Commerce OIG on the incident.
NIST worked to develop plans for the DOE RAP team to conduct a full
radiation survey of the affected lab, to assist NIST's internal
investigation, and to help determine the upper limit on the possible
discharge of plutonium through the lab sink into the municipal sewer
system. A briefing for NTIA staff also was scheduled.
Our latest information from the medical experts, based on the most
recent test results, is that personnel with internal plutonium exposure
are not expected to face significant health risks. As I mentioned, we
are waiting on the most sensitive test, the TIMS, to confirm these
findings. I am concerned for the health and safety of our personnel and
we are getting advice from the best medical experts in the country and
will do everything we can to ensure that the people affected get the
best possible medical treatment.
Preliminary Corrective Actions Taken
First Mr. Chairman, I have ensured that NIST-Boulder has issued a
stop work order for all radioactive materials in use, and a preliminary
decision has been made to limit the use of radioactive materials in
Boulder in the future to sealed sources.
At my request, five eminent experts in radiation health safety
conducted an assessment of the incident. They were asked to report
their initial findings individually directly to me. On July 9th, I
received the last of these reports. An author of one of those reports,
Dr. Ken Rogers, is on the panel today and you will hear from him
directly on his findings and recommendations. I recently received the
last of these reports and we transmitted them to this committee and
made them public.
Their reports are sobering in their assessment of our challenges,
and I take their words very seriously. Their views about our
shortcomings confirm my belief of the need to focus our efforts on
NIST's entire environment, health, safety, and emergency response
protocols and safety culture to ensure that we are measuring up to both
requirements and the highest expectations for a world-class
organization. I expect that these experts will continue to provide
insights to me and to others at NIST in the coming weeks.
Training Protocols for All NIST Employees
The lack of training provided disturbs me greatly, Mr. Chairman. I
am committed to making the changes necessary to reduce to the maximum
extent possible the opportunity for such a situation to occur in the
future. This includes re-evaluating our training to make certain it is
appropriate, establishing testing mechanisms to assure training was
mastered, and creating the controls to document training.
Mr. Chairman, let me initially say what our NIST policy is, and
what it is supposed to be. I will then discuss what we believe we know
at this time as to how NIST complied with or acts in accord with its
own policy in this matter.
It is NIST policy to establish, coordinate, and maintain a
comprehensive and effective NIST Safety Operational System (SOS)
consistent with the standards prescribed by Section 6 of the
Occupational Safety and Health Act of 1970, ANSI-Z10 Occupational
Health and Safety Management System (OHSMS), and other applicable
regulations.
Every manager, employee, and associate in the organization has the
responsibility for systematically identifying risks, hazards, or
potentially unsafe situations or practices and for taking steps to
ensure adequate safety. Emphasis is placed on identification of risks
and implementation of measures to control those risks. Implementation
of effective OHSMS programs relies on recognition and adoption of the
following principles by management, employees, and associates:
a. Incidents/Accidents can and should be prevented.
b. Line management is responsible for the safe conduct of
operations. Management systems can be designed to avoid unsafe
acts, unsafe conditions, and incidents/accidents. Individuals
are, however, responsible for their own safe behavior.
c. Management should establish challenging goals for safety,
and take the responsibility to plan and implement actions to
achieve the goals.
d. The keys to effective line safety performance are
management procedures that create a culture of safety, while
defining and expecting accountability for results and
minimizing hazards. Safe behavior and actions are expected and
should be recognized, while unsafe behavior is discouraged and
must be promptly corrected. There also must be effective safety
oversight to assure compliance.
e. One of the functions of the safety staff is to immediately
stop any work where safety is questionable. Safety staff should
be included in discussions of current and proposed operations
to assist with identifying safety deficiencies within those
operations and making recommendation to reduce the potential
for incidents/accidents. Safety staff should develop safety
programs that include documented training for line managers/
supervisor, employees, and associates.
However, Mr. Chairman, in reality, the culture that existed at
least in the laboratory involved in this incident was one in which
safety was not the highest priority and led to an untrained guest
researcher, improperly supervised, handling a dangerous radioactive
source.
It is NIST policy that upon entrance on duty, new employees must
attend a general safety orientation session presented by the NIST
Safety, Health and Environment Division. One of the gaps that we have
identified is that new associates (e.g., guest researchers from other
institutions) are not currently required to attend this orientation. It
is the responsibility of line supervisors to instruct all new or
transferred appointees (employees and associates) assigned to their
units, in the occupational safety, health and environmental
requirements applicable to the specific job, preferably on the first
day, but in any event during the first week of such assignment.
Appointees who will be working in a laboratory must be instructed in
NIST laboratory safety practices and be given a copy of the NIST
Laboratory Safety Manual by their supervisor.
New or transferred appointees (employees and associates) who will
be working in a laboratory or other hazardous environment, (e.g.,
mechanical shops), are to be provided adequate laboratory/shop-specific
on-the-job training within one month of their employment. We are
reviewing this requirement which currently would allow an individual to
work in a lab for 30 days without appropriate training. Since functions
differ among the laboratories/shops, each laboratory/shop is to develop
its laboratory/shop-specific safety-training checklist to ensure that
all safety areas are adequately covered. The laboratory/shop-specific
safety checklist may be used to document the first month of employment
safety training requirement. The safety checklist should identify the
total number of hours necessary to cover all safety areas.
Line supervisors must ensure that pertinent safety and health
instructions, relating to conditions and practices that may be
necessary to eliminate or control specific job hazards, are routinely
incorporated into regular operating procedures, shop orders, preventive
maintenance instructions, etc.
A minimum of four hours of relevant safety training must be
provided to all employees and associates on an annual basis. Not less
than quarterly in all non-administrative units (typically including
laboratory activities; warehousing; trades, craft, maintenance, labor,
protective, and transportation services; etc.) line supervisors are to
schedule and conduct a safety awareness meeting with all assigned unit
personnel, for the specific purpose of discussing safety issues
pertinent to the unit's operations. Brief written reports of such
meetings are to be forwarded through the applicable division or office
chief to the NIST Safety, Health and Environment Division. Where there
is need for specialized safety training beyond the capability or
resources of a unit, the scope and method of training is to be
determined through the coordinated efforts of the unit involved, the
training personnel, and the safety staff.
That is the policy. There must be effective controls to flag
deficiencies, mechanisms such as testing to gauge mastery of the
training material, and formal documentation of training. Our ongoing
assessment will help us address critical areas for improvement.
Conclusion
Mr. Chairman, based on the information available at this time, this
incident was preventable. Thankfully, the medical experts tell us that
as of this time there are expected to be no significant health effects
for the people involved. This incident is a sobering reminder of the
importance of establishing clear, comprehensive and appropriate safety
policies and rigorously adhering to safety protocols. As is abundantly
clear, when we do not approach these matters with the necessary rigor,
clarity and sense of purpose there can be serious consequences.
I again pledge to you my commitment to improving our environmental,
health and safety practices, ingraining a sustainable safety culture
and thereby ensuring the health and safety of our employees and local
communities. I will report to you regularly and will keep you apprised
of our findings and our progress. It is crucial to our ability to
achieve our mission and ensure our workforce that they have a safe
working environment.
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Biography for James M. Turner
Dr. James M. Turner is the Deputy Director of the U.S. Department
of Commerce's National Institute of Standards and Technology (NIST). He
is also carrying out the responsibilities of the Director. (The NIST
Director position is vacant.) Turner provides high-level oversight and
direction for NIST. The agency promotes U.S. innovation and industrial
competitiveness by advancing measurement science, standards, and
technology. NIST's FY 2008 resources total $931.5 million and the
agency employs about 2,800 scientists, engineers, technicians, support
staff and administrative personnel at two main locations in
Gaithersburg, MD and Boulder, CO. Along with the Department of Energy
Office of Science, and the National Science Foundation, NIST is slated
for substantial budget increases for its core research programs under
the President's American Competitiveness Initiative.
Prior to joining NIST on April 16, 2007, Turner served as the
Assistant Deputy Administrator for Nuclear Risk Reduction in the
Department of Energy's National Nuclear Security Administration. In
that position, he was responsible for major projects in Russia to
permanently shut down their last three weapons-grade plutonium-
production reactors. He also worked with foreign governments and
international agencies to reduce the consequences of nuclear accidents
by strengthening their capability to respond to nuclear emergencies.
Prior to that assignment, Turner held several senior management
posts at DOE concerned with laboratory oversight and with nuclear
safety and the safeguarding of nuclear weapons both here and abroad.
He holds degrees in Physics from the Massachusetts Institute of
Technology (Ph.D.) and Johns Hopkins University (B.A.), and taught for
five years as an Associate Professor of Physics and Engineering at
Morehouse College.
Among other honors, he has received the U.S. Government
Presidential Rank Award for Meritorious Service, three times received
the U.S. Department of Energy Exceptional Service Award, and earned the
Secretary of Energy Gold Award and the National Nuclear Security
Administration's Gold Medal. Dr. Turner is an active member of the
American Physical Society, the American Chemical Society, the American
Nuclear Society, the American Association for the Advancement of
Science, ASTM, the Council on Foreign Relations, IEEE, Phi Beta Kappa,
Sigma Xi, and the World Affairs Council.
Dr. Turner is a native of Washington, DC, is married, and has five
children and one grandchild. He enjoys doing yoga and Tai Chi. He and
his wife, Paulette, reside in Olney, Maryland.
Chairman Wu. Thank you very much, Dr. Turner.
Dr. Miller, please proceed.
STATEMENT OF DR. CHARLES L. MILLER, DIRECTOR, OFFICE OF FEDERAL
AND STATE MATERIALS AND ENVIRONMENTAL MANAGEMENT PROGRAMS, U.S.
NUCLEAR REGULATORY COMMISSION; ACCOMPANIED BY DR. ELMO E.
COLLINS, REGIONAL ADMINISTRATOR, REGION IV OFFICE, U.S. NUCLEAR
REGULATORY COMMISSION
Dr. Miller. Mr. Chairman and Members of the Committee, I am
honored to appear before you today to discuss the U.S. Nuclear
Regulatory Commission's role in regulating and inspecting
radioactive materials facilities. I hope that my testimony will
be helpful to you in understanding the regulatory framework and
the oversight of facilities such as NIST and how NRC responds
to events at these facilities. My written testimony has been
submitted for the record, and I will use my time this morning
to highlight some of the key points.
Following that during the question and answer period, Mr.
Collins and I would be happy to answer any questions with
regard to our activities, including the inspection.
Under the authorities and responsibilities granted by the
Atomic Energy Act of 1954, as amended, NRC issues licenses for
use of radioactive material to qualified applicants that meet
our regulatory requirements. Primary responsibility for safety
and security of the radioactive material lies with the
licensees who possess and use the material.
NRC inspects the users of radioactive material for
compliance with both safety of the regulations and any
additional conditions made during the licensing. Perspective
licensees wishing to possess and use radioactive material must
submit a license application to the NRC, showing how their
facility's personnel and program controls meet the regulations
and protect the workers, the public, and the environment, and
provide adequate security of the radioactive material.
Each application is reviewed by NRC technical staff. If the
regulatory requirements are met, NRC issues a license outlining
the conditions under which the radioactive material can be
used. Licensees must request and obtain from NRC a license
amendment to change its license or its condition. Because of
the potentially serious consequences that can result from the
failure to comply with NRC regulations, every licensee must
conduct its radiation safety program according to the
conditions of its NRC license, representations made in its
license application, and NRC regulations.
NIST is licensed to use solid encapsulated plutonium in
quantities less than critical mass. Use of the material must be
done in accordance with explicit procedures. NIST's NRC license
requires a Radiation Safety Officer, whose role is to ensure
license conditions are met and radiation safety practices are
followed. The NIST license also includes a commitment that all
individuals working with license sources or those who frequent
areas or license sources are present, shall receive annual
radiation safety training at a level appropriate for their
assigned duties.
It is the responsibility of the licensee's management and
the radiation safety officer to ensure individuals who access
these sources or facilities receive appropriate training. NRC
conducts periodic inspections of licensees to ensure compliance
with regulatory requirements and license conditions. The
licensing decision was to assign an inspection frequency at the
NIST-Boulder facility of every five years because of its
activities, which are relatively low risk given the small
amount of radioactive material that the lab is authorized to
possess and the approved uses of the material within the lab.
NRC may supplement the periodic inspections with reactive
inspections. A reactive inspection is a special inspection in
response to an incident, an allegation, or information obtained
by the NRC to focus on the sequences of events leading up to
the incident, the contributing root causes of the event,
corrective actions taken or proposed by the licensee, and a
discussion of the regulations applying to the incident, and
where they were not met. All NRC inspections are documented,
and the results are provided to the licensee. With the
exception of some security inspections, they are publicly
available also.
Failure to conduct operations in accordance with the
regulations and licensed conditions can result in enforcement
action against the licensee or even individuals. NRC's
enforcement program is built upon a potential or actual safety
significance and considers program factors such as repeat
violation, willfulness or disregard for the requirements.
The June--on June 10, NIST informed the NRC of the June 9
contamination event. Upon learning of the event, NRC dispatched
a health physics inspector to the site on June 12, and followed
that with a senior health physics inspector on the 19th. Upon
the consideration and the feedback from those inspectors, we
escalated our inspection activities to a special inspection
team, and that was dispatched to Boulder on June 30.
The team's detailed inspection is in progress. Results of
the special inspection and the team's work will be issued
within 45 days upon the conclusion of the inspection. On July
2, we issued a confirmatory action letter (CAL), confirming the
agreed-upon actions that NIST took and plans to take as a
result of the event and the order. Pursuant to the CAL, NIST
has agreed to take a number of actions. Those actions are
outlined in my detailed written testimony.
Although we have yet to identify any safety aspects of the
June 9, event with significant impacts on the worker or public
health safety, we are continuing our evaluation of the
circumstances of the event itself and how NIST's programs,
procedures, and policies contributed to the event. NRC's
efforts will ensure that if there were violations, NIST will
develop and implement effective and lasting corrective actions.
I hope my testimony provides you with an understanding of
our regulatory role at the NRC, how it fits NIST, and how the
NRC responds to events at these facilities and the seriousness
with which we take our duty to protect public health and safety
in the environment.
Dr. Collins and I will be pleased to respond to your
questions. Thank you, Mr. Chairman.
[The prepared statement of Dr. Miller follows:]
Prepared Statement of Charles L. Miller
INTRODUCTION
Mr. Chairman and Members of the Committee, I am honored to appear
before you today to discuss the U.S. Nuclear Regulatory Commission's
(NRC's) role in regulating and inspecting radioactive materials
facilities. I hope that my testimony will be helpful to you in
understanding the regulatory framework and oversight of facilities such
as the National Institute of Standards and Technology (NIST), and how
the NRC responds to events at these facilities. The NRC's work in
response to the June 9, 2008 event at NIST's Boulder facility is
ongoing. Mr. Elmo Collins, Regional Administrator for the NRC's Region
IV office, and the home base for the agency's special inspection team
for this event, is here with me today to answer any questions about our
inspection activities up to this point.
On June 10, 2008, the NRC received a report of a contamination
event at the NIST facility in Boulder, Colorado. The previous day, a
junior researcher had broken a glass vial containing one-fourth of a
gram of plutonium powder. The junior researcher and other individuals,
working both inside and outside the specific laboratory suite were
contaminated. The researcher apparently washed his hands to remove the
plutonium contamination, thus introducing a small amount of plutonium
into the sewer system. More importantly, analysis confirmed that the
junior researcher, as well as others, ingested or inhaled some of the
plutonium.
The NRC dispatched a health physics inspector to the site an June
12, who verified that the lab was acceptably isolated for the short-
term. A second health physics inspector was dispatched by NRC an June
19. NRC's initial assessment of the event and NIST's follow-up actions
indicated that there was no immediate threat to additional workers or
to public health and safety. However on the basis of the inspectors'
observations on-site, NRC management determined that an enhanced agency
response was needed to ensure that the licensee conducted licensed
activities safely in the short-term and that further inspection follow-
up was needed to more fully understand the circumstances, causes, and
licensee actions. Additionally, on June 27, the licensee reported that
the junior researcher received a potentially significant radiation
dose. On June 30, a five-member Special Inspection Team (SIT),
dispatched from NRC's Region IV Office in Arlington, Texas, began
conducting a more detailed review of the event. I will further explain
the SIT later in this testimony. The team's inspection is in progress.
As I will discuss further elsewhere in this testimony, NIST--in
consultation with NRC--has also agreed to suspend all use of plutonium
sources pending NRC approval of the resumption of such activities.
NRC REGULATORY FRAMEWORK TO ENSURE SAFE USE OF RADIOACTIVE MATERIAL
Before I address the specifics related to the NIST license and the
event, I would like to briefly describe NRC's structure and regulatory
approach to licensing, inspection, and enforcement. Through the
Agreement States Program, the NRC shares its regulatory authority to
license and oversee the use of certain types of radioactive material.
Although Colorado is one of the 35 Agreement States, NRC retains
regulatory jurisdiction for NIST-Boulder because it is a federal
facility. Therefore, this testimony will focus on NRC's program and not
on the role of Agreement States.
OVERALL FRAMEWORK AND MISSION
The mission of the NRC is to license and regulate the Nation's
civilian use of byproduct, source, and special nuclear material to
ensure adequate protection of public health and safety, promote the
common defense and security, and protect the environment. The Atomic
Energy Act of 1954, as amended, grants NRC the authorities and
responsibilities needed to accomplish this mission. NRC has issued
regulations that are designed to protect the public and occupational
workers from radiation hazards. NRC issues licenses for use of
radioactive material to qualified applicants who meet regulatory
requirements. The responsibility for safety and security of the
radioactive material lies with the licensees who possess and use the
material. NRC inspects the users of radioactive material to ensure
compliance with both NRC safety regulations and any additional
conditions imposed during the licensing. Enforcement against licensees
as well as individuals can be pursued by NRC for noncompliance with
these regulations and conditions.
Within NRC, the Office of Federal and State Materials and
Environmental Management Programs, of which I am the Director, is
responsible for the development, implementation, and oversight of the
regulatory framework for industrial, commercial and medical uses of
radioactive material, uranium recovery activities, and the
decommissioning of previously operating nuclear facilities and power
plants. NRC also has Regional Offices which conduct inspection,
enforcement, investigation, licensing, and emergency response programs
for radioactive material licensees. NRC currently has approximately
3,700 licensees for radioactive material, and conducts approximately
1,200 inspections annually.
LICENSING AND REGULATIONS
Prospective licensees wishing to possess and use radioactive
material such as those possessed and used by NIST must submit a license
application to the NRC showing how their planned facilities, personnel,
program controls, and equipment meet NRC regulations and protect the
workers, public, and environment, and provide adequate security of the
radioactive material. Each application is reviewed by NRC staff
according to established procedures and criteria, and if the regulatory
requirements are met, NRC issues a license outlining the conditions
under which the company or individual can possess the radioactive
material. In addition, licensees must request and obtain a license
amendment to alter a license or its conditions.
As mentioned above, the responsibility for safety and security of
the radioactive material lies with the licensee. Assignment of this
responsibility varies from licensee to licensee and facility to
facility, but is delineated in the license application and license
conditions. In general, each licensee's environmental health and safety
(EH&S) officials and management have the responsibility for
establishing the policies and procedures to ensure safe handling of
radioactive material and compliance with regulatory requirements; for
ensuring that those individuals using radioactive material have
adequate training; and for oversight of the program and users to ensure
adherence to established policies and procedures. Individuals using
radioactive material have the responsibility to adhere to established
policies and procedures, including reporting any deviations or issues
to Radiation Safety Officer (RSO) and/or management.
NRC expects licensees to conduct their programs with meticulous
attention to detail and a high standard of compliance and holds them
accountable for doing so through inspections and enforcement. Because
of the potentially serious consequences that can result from failure to
comply with NRC regulations, every licensee must conduct its radiation
safety program according to the conditions of its NRC license,
representations made in its license application, NRC regulations, and
NRC Orders. Specifically, licensees are subject to NRC regulations in
10 CFR Part 19, ``Notices, Instructions and Reports to Workers:
Inspection and Investigations,'' 10 CFR Part 20, ``Standards for
Protection Against Radiation,'' and other applicable regulations. The
regulations also specify reporting requirements to inform the NRC of
significant events, including loss of material, release of material to
the environment, radiation exposures to workers or the public that
exceed limits specified in the regulations, damaged sources or devices,
equipment that fails to function as designed, and leaking sources.
The following items are the key requirements in NRC regulations
that must be addressed by applicants before NRC issues a license
authorizing possession and use of radioactive material:
Applicants must be qualified by reason of training
and experience to use special nuclear material of the types and
quantities requested;
Applicants must have the facilities and equipment to
protect health and safety and minimize danger to life or
property;
Applicants must have the procedures to protect health
and to minimize danger to life or property.
NRC INSPECTION AND ENFORCEMENT PROGRAM
NRC conducts periodic inspections of licensees to ensure compliance
with regulatory requirements and license conditions. To enable NRC to
apply its resources most effectively to the highest risk activities, an
inspection priority code from 1 to 5 is assigned to each type of use
authorized by a license. The priority code equals the normal inspection
interval in years, with code 1 being the greatest potential risk to the
health and safety of workers, members of the public, and the
environment. In the licensing process, an inspection frequency of once
every five years was assigned to the NIST-Boulder facility because its
activities are relatively low-risk given the small amount of
radioactive material that the lab is authorized to possess and the
approved uses of this source within the lab.
If there are licensee performance issues, or events, NRC may
supplement the periodic inspections with ``reactive'' inspections. A
reactive inspection is a special inspection in response to an incident,
allegation, or information obtained by NRC (e.g., report of a medical
event or other federal agency interest). The scope of the reactive
inspections is normally to focus on the sequence of events leading up
to the incident, the contributing and root causes of the event,
corrective actions taken or proposed by the licensee, and a discussion
of the regulations applying to the incident and if and where they were
not met. Reactive inspections can focus in on one or several issues,
using more specialized technical or management expertise than a normal
inspection, and thus do not necessarily examine the totality of a
licensee's program.
All NRC inspections are documented and the results are provided to
the licensee; with the exception of some security inspections, these
documents are publicly available. If deficiencies are identified, the
inspector brings them to the attention of licensee management at the
exit meeting and also in the cover letter transmitting the inspection
report or Notice of Violation (NOV). An NOV is a formal notification to
the licensee that an apparent noncompliance with regulations or
conditions has been identified. The NOV requires a written response
including a description of the proposed corrective actions. It is the
first step in the NRC's enforcement process.
Failure to conduct operations according to regulations and license
conditions may result in enforcement action against the licensee as
well as individuals. This could include more frequent inspections;
issuance of a notice of violation; imposition of a civil penalty; and/
or an order suspending, modifying, or revoking the license. NRC's
enforcement program is built around potential or actual safety
significance, and considers performance factors such as repeat
violations, willfulness, or disregard for requirements.
Because of its relevance to today's hearing subject, I would like
to mention that one of several tools that NRC uses with its licensees
is a confirmatory action letter (CAL). A CAL documents agreed upon
actions that the licensee will take to address concerns with their
activities. These actions can either be permanent or can be on a
temporary basis to address concerns until a final assessment can be
made regarding the need for permanent changes. A CAL can also ensure a
clear understanding of and commitment to necessary actions to control
and assess an unexpected event. In cases where a CAL is neither
appropriate nor sufficient to ensure safety, the NRC may issue an Order
requiring mandatory licensee action.
NIST LICENSE
Let me now turn to the specifics of the NIST facility in Boulder
with respect to its license conditions and requirements, as well as the
event that occurred on June 9, 2008.
NRC initially issued a Byproduct Material License (No-05-03166-05)
for the Boulder facility to the Department of Commerce, National Bureau
of Standards on December 19, 1968. The license has been amended a total
of 29 times since it was issued. Amendment No. 28 added the special
nuclear material (e.g., plutonium) to the existing research and
development license and Amendment No. 25 authorized research and
development activities on the license using sealed sources. The most
recent amendment, Amendment No. 29, was issued to NIST on June 22, 2007
to increase the amount of Iron-55 and limit the amount of Nickel-63.
NIST is licensed to use solid, encapsulated plutonium in quantities
less than critical mass. Use of the material must be in accordance with
procedures. In the case of the NIST plutonium calibration source
involved in the June 9 event, the material was contained in a glass
vial. In addition, the glass vial was heat sealed in a plastic bag, and
the resultant package was heat sealed in a second plastic bag. This
package, composed of the sealed glass vial and the two heat-sealed
plastic bags, was in turn placed in a third plastic bag by the NIST
Radiation Safety Officer.
The NIST license includes a commitment that all individuals working
with licensed sources or those who frequent areas where licensed
sources are present shall receive radiation safety training at a level
appropriate for their assigned duties. It is the responsibility of the
licensee's management and RSO to ensure individuals who access those
sources or facilities receive the appropriate training.
NIST's license requires an RSO whose role is to ensure license
conditions are met and radiation safety practices are followed.
Radiation Worker Training is required for any individual where there is
a reasonable potential for an individual to receive doses greater than
100 millirem in a year. This training must be performed by the RSO or
an appropriately trained designee. The RSO must assure documentation of
Radiation Worker Training and maintain a list of trained and authorized
radiation workers. Individuals using special nuclear material must also
be trained pursuant to the conditions specified in NIST's letter dated
February 15, 2007. NIST license conditions state that refresher
training must be provided annually.
Radiation Worker Training covers fundamental practices and concepts
in radiation protection, including: (1) basic regulatory requirements
in 10 CFR Part 20 such as dose limits, posting and labeling, survey and
monitoring, radioactive material control and security, and incident or
emergency response; (2) radiation risks and protection strategies such
as time, distance, and shielding from the source, and contamination
control; and (3) general and job duty-specific training on the internal
policies and practices for implementing the radiation safety program.
THE JUNE 9, 2008 NIST EVENT AND RESPONSE
On June 9, 2008, the NIST RSO was notified that a via] containing
standard reference material was discovered broken in one of the
research laboratory suites. The reference material contained plutonium.
NIST's health physics personnel responded to the area and determined
that low levels of contamination were spread outside of the laboratory
suite into the adjoining hallway. The hallway was decontaminated and
the lab was isolated. Environmental sampling and bioassays and
urinalyses of individuals affected were initiated.
On June 10, 2008, NIST's Boulder, Colorado, facility reported the
plutonium contamination event to NRC. This event resulted in
contamination of certain areas within the facility and radioactive
contamination of at ]east two employees.
Once the initial significance of the event was understood by the
RSO, NIST's initial efforts were to protect workers and the public.
NIST restricted access to the lab suite, and began to evaluate the
extent of contamination to the lab and the potential for exposure to
workers and members of the public. NIST informed NRC of the event and
has cooperated with our agency staff and the other regulatory
authorities in support of inquiries and inspections.
Upon the initial inspectors' observations and consideration of risk
significance, complexity, and generic safety implications, NRC
determined, in accordance with our internal procedures, that a Special
Inspection Team (SIT) was warranted. The SIT process allows NRC to
assess an event and its causes and to quickly elevate the NRC response
if the findings reveal more significant concerns (e.g., an apparent
release of plutonium that results in an exposure to a member of the
public or a worker in excess of the allowable limit). As mentioned
earlier in this testimony, on June 29, a five-member SIT was dispatched
from NRC's Regional Office in Arlington, Texas, to conduct a more
detailed review of the event at the Boulder facility. The team consists
of the Region IV Division Director for Nuclear Materials Safety, a
Branch Chief, for Nuclear Materials Safety, and three health
physicists. On July 2, NRC staff executive management met with the SIT
and determined that additional escalation was not warranted at that
point in time. The team's inspection is continuing. A report
documenting the results of the special inspection team's work will be
issued within 45 days of the team completing their inspection effort.
On July 2, 2008, NRC issued a CAL to NIST confirming the agreed
upon actions that NIST took and planned to take as a result of the June
9 event in order to ensure safety and to adequately evaluate the event
in a timely manner. Pursuant to the CAL, NIST has agreed to take
several actions, including: (1) suspending use of the plutonium sources
pending NRC approval and determination of procedural adequacy for
safety and procedural compliance; (2) thoroughly determining the
radiation doses to all individuals potentially exposed by August; (3)
reviewing and assessing training and procedural adequacy prior to using
any licensed material; (4) providing NRC, for review and approval, a
written plan for stabilizing the contamination within the laboratory;
and (5) obtaining authorized services for the decontamination of the
facility and NRC approval of the licensee's decontamination plan.
Although our inspection team has not completed its work and we have
not finalized our inspection conclusions, the NRC staff is concerned
about a number of issues. These include: the amount of radiation dose
received by individuals as a consequence of the event; the amount of
radioactive materials released into the sewer; the use of procedures at
NIST's Boulder facility--particularly those related to the handling and
storage of radioactive material; and the training of the individuals
performing NRC-licensed activities.
SUMMARY
In conclusion, Mr. Chairman and Members of the Committee, it is the
policy of the U.S. Nuclear Regulatory Commission to ensure that
significant operational events involving reactor and materials
facilities licensed by the NRC are investigated in a timely, objective,
systematic, and technically sound manner; that the factual information
pertaining to each event is documented; and that the cause or causes of
each event are ascertained; and that corrective actions are implemented
to preclude recurrence.
I hope my testimony provides you with an understanding of NRC's
regulatory role with regard to facilities such as NIST, how the NRC
responds to events at these facilities, and the seriousness with which
we take our duty to protect public health and safety and the
environment.
Our assessment to this point has not identified any aspects of the
June 9, 2008 event which would result in significant impacts to public
and health safety, and we are continuing our investigation into the
circumstances of the event itself, including whether NIST's programs,
procedures, and policies may have contributed in some way to the event.
NRC's efforts will ensure that, if and where violations occurred, NIST
will be required to develop and implement effective and lasting
corrective actions.
Mr. Collins and I would be pleased to respond to your questions.
Biography for Charles L. Miller
Dr. Miller is the Director, Office of Federal and State Materials
and Environmental Management Programs. Prior to this appointment he was
the Director, Division of Industrial and Medical Nuclear Safety, in the
Office of Nuclear Material Safety and Safeguards (NMSS). Prior to that
appointment, he was the Deputy Director, Licensing and Inspection
Directorate in the Spent Fuel Project Office, NMSS.
Since joining the NRC in 1980, Dr. Miller also held a number of
positions in the Office of Nuclear Reactor Regulation, including:
Project Manger; Technical Assistant; Section Leader; Project Director,
Standardization Project Directorate; Project Director, Project
Directorate I-2; Chief, Emergency Preparedness and Radiation Protection
Branch; and Deputy Director, Incident Response Operations. He also
served as the Technical Assistant to former Commissioner Bernthal.
Prior to joining NRC, he worked for Science Applications
International Corporation (SAIC) for four years in various nuclear fuel
cycle and defense activities. He began his professional career at
Bechtel Power Corporation, where he spent two years working on the
design of nuclear power plants.
Dr. Miller received a B.S. degree in Chemical Engineering from
Widener University, and an M.S. and a Ph.D. in Chemical Engineering
from the University of Maryland.
Biography for Elmo E. Collins
Elmo E. Collins was assigned as the Regional Administrator for the
Region IV Office of the Nuclear Regulatory Commission (NRC) in
September 2007. NRC Region IV is one of four, large regional offices.
NRC Region IV is responsible for overseeing the inspection of 14
nuclear power plants in 22 States, overseeing the inspection and
licensing of medical, academic, and industrial users of radioactive
materials in Western United States, overseeing the Agreement States in
implementing the NRC's materials inspection and licensing programs in
16 of those 22 States, and overseeing the licensing of operators of the
controls of nuclear power reactors. Mr. Collins, originally from
Oklahoma, graduated from the U.S. Naval Academy at Annapolis, MD in
1976.
Mr. Collins has broad and extensive experience in the nuclear
industry. He served for six years in the U.S. Navy as a nuclear trained
submarine officer, serving on the USS Thomas A. Edison (SSBN 610). Mr.
Collins completed his qualification to serve as engineering officer on
nuclear powered submarines in May 1980. After leaving the Navy, Mr.
Collins worked in the commercial nuclear industry as a startup engineer
with General Electric from 1983 to 1987, receiving certification as a
Senior Reactor Operator.
Mr. Collins joined NRC Region I in 1987 as a resident inspector at
Oyster Creek, where he later became the Senior Resident Inspector. In
1991, Mr. Collins transferred to NRC Region IV as a Senior Project
Engineer. In Region IV, he subsequently held positions as Inspection
Team Leader, Senior Reactor Analyst, Reactor Projects Branch Chief, and
Nuclear Materials Branch Chief. Mr. Collins was appointed to Senior
Executive Service in May 2000 as the Deputy Director for the Division
of Reactor Projects. In February 2003, Mr. Collins was assigned the
position of Director, Division of Nuclear Materials Safety in Region
IV. In July 2004, Mr. Collins was re-assigned to NRC Headquarters
Office of Nuclear Materials Safety and Safeguards (NMSS) in Rockville,
MD. as the Deputy Division Director for the licensing and inspection of
the high-level radioactive waste repository at Yucca Mountain. In
October 2006, Mr. Collins was assigned to the Office of Nuclear Reactor
Regulation (NRR) as the Director, Division of Inspection and Region
Support.
During his career, Mr. Collins has been involved in inspection and
oversight of nuclear power plants, licensing and oversight of users of
radioactive materials, and licensing of the high-level radioactive
waste repository. In NRR, Mr. Collins was responsible for the operating
reactor inspection and assessment, operator licensing, and operating
experience programs. Mr. Collins has participated with the
International Atomic Energy Agency Teams evaluating the performance of
nuclear regulatory programs and assessment of nuclear plant operational
safety performance in other countries.
Chairman Wu. Thank you very much, Dr. Miller.
Dr. Collins, please proceed.
Dr. Miller. Mr. Chairman, Dr. Collins is with me today to
answer any questions that the Committee had but our testimony
at this time is complete, our oral statement.
Chairman Wu. Okay. Thank you, Dr. Miller. Dr. Collins, you
are temporarily spared until the Q and A period.
Dr. Rogers, please proceed.
STATEMENT OF DR. KENNETH C. ROGERS, FORMER COMMISSIONER, U.S.
NUCLEAR REGULATORY COMMISSION
Dr. Rogers. Chairman Wu, Ranking Member Gingrey, and
Members, because you have already heard a great deal about
this, I am going to confine my presentation to general findings
and recommendations. And they are preliminary. They are based
on one day there and a review of materials that was supplied to
us at that time and since then.
There is no uniform system supported at all levels of
management to nurture and support a culture of safety awareness
as a high priority in every NIST-Boulder activity. Policies and
personnel exist at NIST that might have prevented this
particular mishap, for example, the NIST administrative manual,
the NIST laboratory safety manual, the Safety, Health, and
Environment Division, the Division Safety Representatives, and
the Ionizing Radiation Safety Committee.
However, safety procedures have not been consistently
understood, applied, and enforced at both Gaithersburg and
Boulder. Some parts of the organization appear to have regarded
safety formalities as interfering with creativity and safety
activities as somewhat unwelcome competitors for scarce
resources.
The Boulder Safety Organization, particularly its training
activities, has been minimally supported and has had to
function with inadequate technical and human resources.
However, there has been some improvement in the last year or
so.
There were numerous instances in the evolution of this
incident in which important information should have been, but
was not, communicated up one level or down one level or
horizontally. People failed to ask essential questions. They
made incorrect assumptions and acted upon them.
Several persons we interviewed felt uncertain as to how the
safety organizations were supposed to work and one described
the safety culture at NIST as dysfunctional. The NIST-Boulder
Organization has not met a central leadership challenge to
successfully blend and maintain the enthusiasm of a collection
of very talented people for cutting-edge research, with a deep
respect for personal and community safety.
My preliminary recommendations are as follows: NIST must
proceed apace with the decontamination, and if necessary, the
decommissioning of all laboratory areas affected by the spill,
employing experienced, well-regarded professionals.
Consistent, open, and clear lines of communication
providing up-to-date, factual information about the incident
must be created and maintained to the NIST-Boulder staff and to
all interested government and concerned public interest
entities.
A comprehensive root causes and lessons learned analysis
must begin immediately and involve experienced, recognized
experts in such analyses from outside of NIST.
Use of radioactive material at Boulder should only take
place in laboratories specifically qualified for such purposes
in accordance with well-established standards and requirements.
Room 1-2124 in which the spill occurred did not meet those
standards.
A new cost benefits analysis should be carried out that
includes continuing conducting the research for the detector
program requiring plutonium or other special nuclear material
at laboratories well qualified to work with such materials.
The use of the plutonium sources, CRM 133, 138-1, and 138-
2, that are on site, should not resume in any research at NIST-
Boulder, and alternative, safer sealed sources must be used in
any further work at Boulder.
Resumption of the research project should only occur after
all staff connected with it are thoroughly trained and
qualified for the safe use of any radioactive or non-
radiological material or equipment to be used in their work.
The Radiation Safety Officer should be required to
routinely check on staff compliance with the Safety Procedure
Hazard Analysis Considerations that he lists in form 364 as
well as the practices planned and occurring in the relevant
laboratories.
A systematic study of all potential and actual hazards at
NIST should be carried out across the board as soon as
possible. On the basis of that analysis, a safe practices
protocol should be developed for the guidance of all users of
materials and equipment.
The NIST staff training policies and practices should be
thoroughly reviewed and modified to correct deficiencies. Staff
must understand the hazards and their potential consequences of
every new activity as well as ongoing projects and become
familiar with staff, with NIST administrative procedures as
well as the safety requirements related to their work.
All managers should be held accountable for promoting a
safety culture within their purviews, and management
performance reviews should include a consideration of how
effective they have been in that regard.
The functionality of the line management relationships at
NIST-Boulder to NIST-Gaithersburg should be examined as a
possible contributor to this unfortunate event. The study could
take place in parallel with the root causes analysis. Lines of
communication and authority clearly broke down.
Equally important is an examination of the functionality of
the relationships between the Boulder Safety Organization and
the other Groups, Divisions, and Projects at Boulder and
Gaithersburg. A clear understanding of how those relationships
are envisioned by NIST's top-level management has not been
successfully communicated to staff at Boulder and is a serious
weakness that should be corrected.
Thank you very much. I am happy to take on any questions.
[The prepared statement of Dr. Rogers follows:]
Prepared Statement of Kenneth C. Rogers
Chairman Wu and Members:
Before joining the U.S. Nuclear Regulatory Commission in 1987 as a
Commissioner, I spent thirty years in the academic world as a Physics
professor and as the President of an Institute of Technology.
During my ten years as a Commissioner, I had numerous occasions to
visit the NIST Center for Neutron Research. After leaving the NRC, I
have served, on a pro bono basis, on several review committees for the
Center. I am quite familiar with the activities and modes of operation
of the Gaithersburg Center, but until recently, I never had any
occasion to visit or learn about the work at the Boulder laboratory.
Sometime during the week of June 9, 2008 I received a call from
Patrick Gallagher, the Chair of the NIST Ionizing Radiation Safety
Committee, in which he asked me to serve with a small group of external
experts to look into the circumstances of the June 9 Plutonium spill at
the NIST-Boulder Laboratory and to provide comments and recommendations
for avoiding such an event in the future. I agreed to do so as did four
other independent experts in nuclear safety. The charge to the group
was to: identify the causes of the incident and any contributing
factors; evaluate the NIST response; evaluate the report on the
incident that will be produced by NIST; and provide to the Deputy
Director of NIST by June 30 our individual recommendations for
corrective actions to avoid future incidents and to improve NIST safety
performance and incident response.
We all worked from the same documents and testimonies, but we were
asked not to attempt to produce a consensus report.
On June 23 and 24 in Boulder we met as a group with ten different
people for approximately one hour each, and were given copies of
electronic mail exchanges as well as copies of any documents we
requested. There was a high degree of openness and cooperation in our
interactions with the NIST Staff.
I have given the Committee a copy of my report.
Because the Committee has already heard this morning about the
incident itself I will confine my presentation to general findings and
recommendations.
Preliminary Findings
There is no uniform system, supported at all levels of management,
to nurture and support a culture of safety awareness as a high priority
in every NIST-Boulder activity.
Policies and personnel exist at NIST that might have prevented this
particular mishap: for example, the NIST Administrative Manual, the
NIST Laboratory Safety Manual, the Safety Health and Environment
Division, the Division Safety Representatives, and the Ionizing
Radiation Safety Committee. However, safety procedures have not been
consistently understood, applied and enforced at both Gaithersburg and
Boulder. Some parts of the organization appear to have regarded safety
formalities as interfering with creativity and safety activities as
somewhat unwelcome competitors for scarce resources.
The Boulder Safety Organization, particularly its training
activities, has been minimally supported and has had to function with
inadequate technical and human resources. However, there has been some
improvement in the last year or so.
There were numerous instances in the evolution of this incident in
which important information should have been, but was not, communicated
up one level or down one level or horizontally. People failed to ask
essential questions. They made incorrect assumptions and acted upon
them.
Several persons we interviewed felt uncertain as to how the safety
organizations were supposed to work, and one described the safety
culture at NIST as dysfunctional.
The NIST-Boulder organization has not met a central leadership
challenge: to successfully blend and maintain the enthusiasm of a
collection of very talented people for cutting edge research with a
deep respect for personal and community safety.
Preliminary Recommendations
NIST must proceed apace with the decontamination and
if necessary the decommissioning of all laboratory areas
affected by the spill, employing experienced well-regarded
professionals.
Consistent, open and clear lines of communication,
providing up to date factual information about the incident,
must be created and maintained to the NIST-Boulder staff and to
all interested government and concerned public interest
entities.
A comprehensive Root Causes and Lessons Learned
analysis must begin immediately and involve experienced
recognized experts in such analyses from outside of NIST.
Use of radiological material at Boulder should only
take place in laboratories specifically qualified for such
purposes in accordance with well-established standards and
requirements. Room 1-2124, in which the spill occurred, did not
meet those standards.
A new Costs/Benefits analysis should be carried out
that includes continuing conducting the research for the
detector program requiring Pu or other SNM at laboratories well
qualified to work with such materials.
The use of the Plutonium sources CRM 133, CRM 138-1
and CRM 138-2 should not resume in any research at NIST-
Boulder, and alternative safer sealed sources must be used in
any further work at Boulder.
Resumption of the research project should only occur
after all staff connected with it are thoroughly trained and
qualified for the safe use of any radiological or non-
radiological material or equipment to be used in their work.
The Radiation Safety Officer should be required to
routinely check on staff compliance with the SAFETY PROCEDURE/
HAZARD ANALYSIS CONSIDERATIONS that he lists in Form 364 as
well as on the practices planned and occurring in the relevant
laboratories.
A systematic study of all potential and actual
hazards at NIST should be carried out across the board as soon
as possible. On the basis of that analysis a safe practices
protocol should be developed for the guidance of all users of
materials or equipment.
The NIST staff training policies and practices should
be thoroughly reviewed and modified to correct deficiencies.
Staff must understand the hazards and their potential
consequences of every new activity as well as ongoing projects
and become familiar with NIST administrative procedures as well
as the safety requirements related to their work.
All managers should be held accountable for promoting
a safety culture within their purviews, and manager performance
reviews should include a consideration of how effective they
have been in that regard.
The functionality of the line management
relationships at NIST-Boulder to NIST-Gaithersburg should be
examined as a possible contributor to this unfortunate event.
This study could take place in parallel with the Root Causes
Analysis. Lines of communications and authority clearly broke
down.
Equally important is an examination of the
functionality of the relationships between the Boulder Safety
Organization and the other Groups, Divisions and Projects at
Boulder and Gaithersburg. A clear understanding of how those
relationships are envisioned by NIST top-level management has
not been successfully communicated to staff at Boulder and is a
serious weakness that should be corrected.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Biography for Kenneth C. Rogers
OVERVIEW
I served as a Commissioner of the United States Nuclear Regulatory
Commission (NRC) for ten years. First appointed by President Reagan for
a five-year term I was reappointed for a second five-year term by
President George Bush. Both appointments were subject to Senate
confirmation. In my capacity as Commissioner, I was deeply involved in
a wide range of policy issues involving science and technology and
public policy. I represented the NRC for nearly ten years at the
National Association of Regulatory Utility Commissioners and was a
member of their Executive Committee. I have experience in working with
international organizations in nuclear safety matters; have met with
legislators of several foreign countries to assist them in formulating
national policies on nuclear safety, and served on a small
international group of experts to provide advice for the long-term to
the Secretary-General of the international Organization for Economic
Cooperation and Development (OECD).
In total, I have more than forty years experience in the conduct
and successful management of scientific, technological and educational
activities related to technology. I have had direct experience in the
oversight of nuclear power plants' operations from the standpoint of
strengthening their safety to the public. I have served on state-wide
commissions established to promote the public interest in educational
accountability and in the employment of technology to better serve the
needs of a state. I have had broad exposure to policy questions
relating to the control and use of science and technology for the
improvement of the human condition. I have constantly worked to
emphasize the necessity of including humanistic aspects in the
application of technology and have been and continue to be deeply
interested in the professional education of engineers and scientists so
as to heighten their concerns in this regard.
DATE OF BIRTH: March 21, 1929
PLACE OF BIRTH: Teaneck, New Jersey, USA
EDUCATION:
Columbia University, NY, NY; 1952-1956, Ph.D. (physics), date of
degree: 1956
Columbia University, NY, NY; 1950-1952, M.A. (physics), date of degree:
1952
St. Lawrence University, Canton, NY; 1946-1950, B.S. (physics), date of
degree: 1950
EMPLOYMENT
Government
2002-2006--Member, National Research Council Board on Assessment of the
National Institute of Standards and Technology (NIST) Programs
Sub-panel for the NIST Center for Neutron Research
2001-2004--Chairman, Screening Panels for new members of the Advisory
Committees on Reactor Safety and Nuclear Waste, U.S. Nuclear
Regulatory Commission
2001--Member, External Audit Panel of Energy Research Activities at the
Paul Scherrer Institute, Villigen, Switzerland
2000-2001--Chairman, Expert Advisory Group to the U.S. Nuclear
Regulatory Commission on The Role and Future Directions for
Nuclear Regulatory Research
2000-2002--Reviewer of Proposals to the U.S. Department of Energy in
nuclear energy programs: Innovations in Nuclear Infrastructure
and Education (INIE) and Nuclear Energy Research Initiative
(NERI)
1999-2000--Member, Blue Ribbon Advisory Panel to the Department of
Energy to Analyze the Future of University Nuclear Engineering
and Research Reactors
1997-1998--The U.S. Member of an international High Level Advisory
Group to the Secretary-General of the Organization for Economic
Cooperation and Development (OECD) on the Future Role of the
OECD Nuclear Energy Agency, Paris, France
1987-1997--Commissioner, U.S. Nuclear Regulatory Commission,
Washington, DC
Academic
1999-2002--Member of the Board of Visitors, A. James Clark School of
Engineering, University of Maryland
1971-1987--President and Chief Executive Officer, Stevens Institute of
Technology, Hoboken, NJ
1971--Provost & Dean of Faculty, Chief Academic Officer, Stevens
Institute of Technology, Hoboken, NJ
1998-1971--Head, Department of Physics, Stevens Institute of
Technology, Hoboken, NJ
1967-1968--Visiting Research Scientist, Princeton University, Plasma
Physics Laboratory, Princeton, NJ
1957-1967--Faculty Member, Teaching & Directing Research Teams in
Plasma &Particle Physics, Stevens Institute of Technology,
Hoboken, NJ
1955-1957--Research Scientist, Cornell University, Newman Laboratory of
Nuclear Physics, Ithaca, NY
Industry
2002-2006--AECL Technologies Inc. Mississauga, Ontario, Canada,
Consultant on U.S. Licensing Matters Pertaining to New Reactor
design certifications
2000--Nuclear Energy Institute, Washington, DC, Consultant on Nuclear
Regulatory Commission Policies and Procedures
1974-1986--Public Service Electric & Gas Co., Newark, NJ, Director &
Sole Director Member of Nuclear Oversight Committee
1986-1987--Public Service Enterprise Group, Newark, NJ, Director and
Chairman of Membership Committee of the Board of Directors
1973-1987--First Jersey National Bank, Jersey City, NJ, Director
1962-1970--Vitro Laboratories, West Orange, NJ, Consultant
1960-1963--Stanford Research Institute, Menlo Park, CA, Consultant
1962-1963--Grumann Aircraft Engineering Corporation, Bethpage, NY,
Consultant
1970-1972--Photochem Industries, Fairfield, NJ, Consultant
HONORS AND AWARDS
President Emeritus, 1987, Stevens Institute of Technology
Honorary Degrees
Doctor of Engineering, 1987, Stevens Institute of Technology
Doctor of Humane Letters, 1983, St. Lawrence University
Awards
Elected Fellow of the American Nuclear Society, 2001
Recipient of the Institute of Electrical and Electronic Engineers
Millennium Award Medal, 2000
Senior Member, Institute of Electrical & Electronics Engineers, 1989
Recipient of the first Hudson County (NJ) Humanitarian Award, National
Conference of Christians and Jews, 1985
Elected Fellow of the American Association for the Advancement of
Science, 1983
Elected Member of the Cosmos Club, Washington, DC, 1975
PROFESSIONAL MEMBERSHIPS
American Association for the Advancement of Science, Member & Fellow,
1968-Present
Institute for Electrical Electronics Engineers, Senior Member, 1978-
Present
American Physical Society, 1954-Present
American Nuclear Society (ANS), Fellow, 1988-Present. Vice Chairman
Public Policy Committee and of the Local Sections Committee,
2002-Present. Chairman Washington, DC Local ANS Section, 1999-
2000
Honorary Chairman, PSA '99 (International Conference on Probabilistic
Safety Assessment)
Assistant Chairman, Year 2000 Joint American Nuclear Society-European
Nuclear Society International Conference, Washington DC,
November 2000
The Food Safeguards Council (Treatment of Foods by Ionizing Radiation),
Board of Advisors, 1998-Present
National Association of Regulatory Utility Commissioners 1989-1997,
Member of the Executive Committee
Sigma Xi (Honorary Research Society), 1954-Present
Sigma Pi Sigma (Honorary Physics Society), 1949-Present
National Science Teachers Association, 1960-1970
American Association of Physics Teachers, 1960-1970
American Association for Higher Education, 1970-1980
American Society for Engineering Education, 1970-1990
Scientists & Engineers for Secure Energy, 1977-1987
NY Academy of Sciences, 1970-1988
Newcomen Society in America, NJ Coordinator, 1975-1988
MOST RECENT PUBLICATIONS AND TALKS
The Past and Future of University Research Reactors, SCIENCE 295, 2217
(2002)
Nuclear Power in a Regulatory Environment, Nuclear & Radiological
Engineering Graduate Seminar Talk, University of Cincinnati/The
Ohio State University, 2002
PUBLICATIONS (prior to 1988)
Approximately fifty refereed publications in Particle Physics,
Nuclear Instrumentation, and Plasma Physics and holder of two patents
on stabilized high electric current arc discharges.
MEMBERSHIPS (prior to 1988)
Appointed
Governor's Commission on Science & Technology (NJ), Chairman, Task
Forces on Telecommunications, 1983-1985
New Jersey Governor's Commission on Science & Technology, Commissioner,
1985-1987
New Jersey Commission on Academic Accountability in Higher Education,
Commissioner, 1979-1980
New Jersey Science & Technology Center, Advisory Board, 1980-1987
Regional Plan Association, Member of the New Jersey Committee, 1982-
1987
Research & Development Council of New Jersey, 1980-1987
Ex Officio
Association of Independent Technological Universities, President (1976-
1978), 1972-1987
Independent College Fund of New Jersey, Trustee, 1972-1987
Associated Colleges & Universities of New Jersey, Trustee, 1973-1982
Hudson County Community College Consortium, Trustee, 1972-1976
New Jersey State Chamber of Commerce, Director, 1976-1987
Christ Hospital Foundation, Jersey City, NJ, Trustee 1980-1986
Christ Hospital Foundation, Jersey City, NJ, Vice Chairman, 1980-1986
Hoboken Chamber Orchestra, Hoboken, NJ, Trustee, 1985-1987
Royal Society of Arts (London), 1970-1990
The University Club (of NY), 1972-1987
Other
Cosmos Club, 1975-Present
American Association of University Professors, 1958-1972
American Civil Liberties Union, 1970-1980, 2000-Present
Phi Sigma Kappa, Social Fraternity 1947-Present
Discussion
Chairman Wu. Thank you very much, Dr. Rogers.
It is traditional at this point for the Chairman to
recognize himself for the first five minutes of questioning. I
do so, and I now yield my time to Mr. Udall, the gentleman who
represents the Congressional District directly affected by this
spill. He is a Member of the Full Science and Technology
Committee and Chair of the Space Subcommittee.
Mr. Udall, please proceed.
Mr. Udall. Thank you, Chairman Wu, and welcome to the
panel. I want to thank you, Chairman Wu, for holding this
hearing today on this incident that occurred in my district in
Colorado. I am very disappointed, just like the Ranking Member
and the Chairman, that we are here today. This incident
shouldn't have occurred in the first place, and I am far from
satisfied with NIST's response, both initially and as the
situation has continued to develop. The apparent lack of an
adequate emergency response plan and clearly inadequate
protocols for handling toxic materials are just a few or the
first, I should say, of many serious problems that NIST must
resolve.
Now, let me just make it clear. NIST has done great work,
and I am proud to represent the labs and its employees here in
Congress. But I intend to see these problems addressed.
I want to turn my line of questioning, if I might, to Dr.
Turner. Dr. Turner, the communication from NIST to the public
and the State and local officials was inadequate. You didn't
contact the State or county officials until I specifically
asked you to a week and a half after the incident.
And I would like to find out more about your communication
with your employees. The incident occurred on the afternoon of
June 9, but for some reason NIST and the other Department of
Commerce employees were not informed until almost 24 hours
later. That makes no sense. Why did it take so long to inform
employees about the incident?
Dr. Turner. Yes, sir. First of all, let me say I fully
agree with you that our response was inadequate and was one of
the major failures that we had. There is no question about
that.
I have done several things. One, I have directed our head
of Emergency Services to prepare an emergency notification
checklist that would apply to Boulder. It would include things
like State and county officials on it, because I think during
an event is not the time to have to think about, you know, who
to call, when to call, and so forth, but to have that checklist
in front of them so they would know it right away. So we have
taken that step.
Also----
Mr. Udall. Dr. Turner, if I might, let me, I appreciate
what you are putting in place, but if I could just continue,
and I would welcome other additional information in that, along
that line. But I am just curious, why couldn't you just have
been frank with your employees, even a simple announcement that
a spill had occurred and that we are going to move to
understand what happened as soon as possible? That would have
been helpful.
Do you have a plan in place if something similar occurs?
Dr. Turner. Yes, sir. The whole incident was very slow to
evolve and----
Mr. Udall. If I could interrupt you one more time. What if
something happened tomorrow? Do you have a plan in place? A yes
or no answer would be sufficient.
Dr. Turner. Yes, sir. We have certainly streamlined our
communications. I have made, I have directed that changes be
made in our emergency communications process so that senior
managers like myself are immediately made aware of situations
as they occur that warrant our attention.
Mr. Udall. The reason I ask is that I have heard from a lot
of constituents in Boulder and those who work at NIST that they
are not confident that you have fixed all these communication
and safety problems. And after I hear Chairman Wu mention the
serious laser incident that occurred in Gaithersburg in
December, I would have thought that that would have made you as
the head of the agency aware that critical safety protocols
were not being followed at the NIST laboratory complex.
And on that note I would like to request that you provide
all e-mails between Boulder and Gaithersburg relating to how
and when employees, the press, and local and State government
will be notified and what needed to be clarified as you said.
Dr. Turner. Well, sir, let me answer your question in two
parts. First of all, one of the ways that we can assure
ourselves of whether we have fixed the problem or not, is to do
exercises. And so that is one of the things that we will plan
to do, and I will play in those exercises to make sure that,
you know, I am aware of what is going on and what is happening.
Mr. Udall. That is a yes? You are saying a yes that you are
going to put that all in place and----
Dr. Turner. Yes, sir. Absolutely. Because, again, I think,
as with anything else, the plans are only as good as the
execution.
Mr. Udall. Certainly.
Dr. Turner. And if our execution is flawed, you know, we
should find that, and if there are flaws in the execution or
lessons learned, doing an exercise is the venue where you can
find those things out before you, in fact, are in an actual
situation.
Mr. Udall. Let me move to another line of questioning. I
see my time is going to expire fairly soon.
I would like to know what you and the rest of the
leadership at NIST plan to do to restore the trust of the
employees given, in particular, that I have, since I have
learned that NIST is already planning to terminate certain
individuals in response to the incident?
Now, the investigation isn't even complete, yet it seems
like you are beginning to assign blame. Do you plan to make any
personnel changes before the analysis is complete?
Dr. Turner. Sir, let me first of all, if I could give a
fairly detailed answer to your question.
Mr. Udall. I know my time is running out, so maybe a yes or
no would be----
Dr. Turner. Well, first of all, there will be no personnel
actions against anyone until I have had an opportunity to make
sure that whatever--that the process is fair and consistent.
Mr. Udall. That is what I wanted to hear. Thank you.
Thank you, Mr. Chairman, for yielding.
Chairman Wu. I thank the gentleman and now the Ranking
Member, Dr. Gingrey.
Mr. Gingrey. Mr. Chairman, thank you.
Dr. Miller, let me go back to your testimony if I can. You,
I think, said that, I think I heard you say that the NRC, the
Nuclear Regulatory Commission, has inspections about every five
years or on a five-year basis.
First of all, I want to know if that is accurate, and when
the last inspection of NIST-Boulder occurred, and were there
any deficiencies found at that particular time, and if so, was
a corrective action plan submitted to NIST-Boulder?
Dr. Miller. Thank you, Congressman. I guess I would start
to answer your question in that the five-year inspection
frequency, we have a graded approach to our inspection
frequency based upon the--what we consider to be the safety and
the risk aspects of any licensee using materials. And that
ranges from: we have inspectors at certain facilities, they are
on site every day, to a five-year frequency. The quantities and
material that NIST was authorized to use were considered of low
safety risk, so the inspection frequency was five years.
The license by which they were given an amendment to get
the plutonium was only within the last couple years, and so the
inspection frequency hasn't triggered to actually go out there
yet. However, before that NIST had a license with the NRC for
doing small amounts of work that would not have required us to
actually do anything other than a telephone type of inspection
activity.
So they, when they changed their license, it triggered the
five-year frequency. So the NRC actually hadn't been to the
Boulder facility for a large number of years, I think going
back to some time in the 1990s.
Mr. Gingrey. In the light of--in light of this incident,
would you, any of you agree that possibly even with this
minimal licensee in regard to the amount of nuclear material
that they would be working with, obviously they don't have an
active reactor on-site----
Dr. Miller. Right.
Mr. Gingrey.--and I can understand that you, your
explanation of that, but would any of you think that maybe
every five years was not sufficient? I want you to answer that
question.
And then let me ask one last, which I think is particularly
important in light of what my colleague from Colorado was
saying in regard to the timeliness of the response of NIST-
Boulder and its Acting Director, you knew about, I think I
heard you testify that you were aware of this spill on June the
9th, and that an inspector was actually sent on June the 12th.
This is an occurrence on Monday, going to the site to inspect
on Thursday. If I am right on that timeline, that seems a
little bit slack, if I may say so. Can you explain that for me
as well?
Dr. Miller. I will start, and I will let Dr. Collins, who
was directly involved in dispatching the inspector augment, the
reporting requirements for an event of this type would require
that it be reported to the NRC within 24 hours, and this met
that obligation. So I believe that it was on June 10 that we
actually learned about it.
And Dr. Collins can tell you the deliberation that he took
in dispatching an inspector to the site.
Mr. Gingrey. Well, yes. You are saying that NIST met the
24-hour reporting requirement.
Dr. Miller. Right.
Mr. Gingrey. Now, what is the requirement for you to
physically respond to an incident, have somebody on site? Is it
more than 24 hours?
Dr. Miller. It depends on the incident, and it depends on
the travel arrangements, depending upon what we determine we
need with regard to the response.
Mr. Gingrey. Well, I would think travel arrangements, you
know, I can get a flight any time----
Dr. Miller. Right.
Mr. Gingrey.--day or night. I might have to wait awhile,
and you guys probably can attest about----
Dr. Miller. Dr. Collins can tell you his deliberative
process.
Mr. Gingrey.--transportation than I do.
Dr. Miller. Right. He can tell you his deliberative process
and how he chose to respond.
Dr. Collins. After we received notification of the incident
from NIST on June 10, we based our, I mean, we knew we needed
to send in an inspector, that we needed some on-site
confirmation of the circumstances. We based that at the time,
and that is all we have is the description of the event and the
extent and the existence of any immediately safety issues
associated with that event. We would not wait to get an
inspector on-site to make sure immediate safety issues are
addressed had they been described to us that day.
The description we got was that the rooms were isolated,
that people had been identified, and that NIST had initiated
actions to ensure that the radiation doses or potential
radiation doses for those people were determined.
So that became the basis for our timeline.
Mr. Gingrey. My time is about expired, Dr. Collins, but I
would say that since you extended or NRC extended this license
to NIST to be able to handle this low-level amount of
plutonium, there had not been a periodic inspection to make
sure that they were doing the job right, that they were
adequately trained and following all the protocol, guidelines
whatsoever. And so what they told you I don't think you, I
would be reluctant to rely on that, having no track record in
regard to their prior performance.
So I am just going to close by saying, you don't have to
respond but maybe later you can, that maybe your response
wasn't quite as timely as it should have been.
Chairman Wu. I thank the gentleman.
The gentlelady from California, Ms. Richardson, recognized
for five minutes.
Ms. Richardson. Yes. Thank you, Mr. Chairman.
First of all, let me start off with my question to Dr.
Turner. I am sorry. Dr. Turner. How long have you been Acting
Director?
Dr. Turner. I have been Acting Director since around Labor
Day of 2007.
Ms. Richardson. Okay. And do you agree with the
recommendations of Mr. Rogers, Dr. Rogers?
Dr. Turner. Yes, ma'am, I do. I am in substantial agreement
with him. I certainly would like to, I would welcome the
opportunity to discuss it with him further just to make sure
that we both have a similar understanding, but I have no, I see
nothing in his report that I would disagree with.
Ms. Richardson. Do you have the adequate funding to meet
those recommendations?
Dr. Turner. We will provide the funding, because safety is
going to be a priority for us, and that is one of the reasons
why we moved the Safety Office into the Office to report to the
Director so that we could make sure that they had the resources
they needed.
Ms. Richardson. Who oversees the safety personnel? How does
the recent reductions in funding for the Safety Division affect
their duties? And at the time when NIST's funding has been
increased significantly, why hasn't NIST devoted more resources
to environmental, health, and safety?
Dr. Turner. Well, the resources that they, they basically
have the same situation that all the rest of our labs were in.
We received a modest increase in fiscal year 2008, which did
not cover the salaries and raises for all our employees, and so
that covered--all our employees received the raises that they
were entitled to, but we had to take some of that out of the
base programs.
But, again, I would like to emphasize, though, that one of
the reasons why I moved the Safety Division to report now into
the Director's office is to assure that, one, we are aware of
what their needs are, two, they are properly prioritized, and
three, again, they have the adequate resources that they need.
Ms. Richardson. Are all your labs the same?
Dr. Turner. I am not sure if I----
Ms. Richardson. In terms of the work that is done. Are all
of your labs the same?
Dr. Turner. No. Our labs are quite different and diverse.
Ms. Richardson. Well, then, will you be evaluating the
difference in terms of--you said that, first of all, you said
they all got basically the same amount of money, and so if they
are not all the same, and if they are all doing different
duties, shouldn't it be somewhat different?
Dr. Turner. No. What I meant, what I intended there was,
that the amount of increase that we received in--we needed
about $13 million in fiscal year 2008 to cover the increase in
salaries and wages. We got about $6.5 million. And so everyone
took some of that out of their base and so that----
Ms. Richardson. I am not talking about the nuts and bolts
of if a person received a two percent increase. I am talking
about if a lab has a difference in terms of its responsibility
which has been discussed now in this committee, and so if now
you are doing work that you weren't doing before, have there
been changes done in terms of your safety personnel for those
labs appropriately is the question.
Dr. Turner. Well, first of all, we wanted to impress on all
of our laboratories that the responsibility of safety, for
safety starts with line management and that they are
responsible for that. Each lab has a Division Safety
Representative.
Ms. Richardson. Dr. Turner, I apologize. I don't know if
this is the first time you testified, but as Members we only
get five minutes to ask questions.
Dr. Turner. I am sorry.
Ms. Richardson. So my question is very specific to you. I
understand safety is important. I understand it all goes to
line management. I get all that. However, I just asked you the
question, are all the labs the same? You said, no. If the labs
are different and if they have different levels of
responsibility and danger, my question to you is has that now
been met at this particular lab and any other labs that might
have a unique situation? And have you appropriated the
appropriate funds to do so? That is my question.
Dr. Turner. Yes, ma'am, we have. We have done a hazards
analysis, and that has been done.
Ms. Richardson. Okay.
Dr. Turner. I apologize for that.
Ms. Richardson. I understand. I understand. When did you
learn of the incident?
Dr. Turner. I learned the morning of June 10.
Ms. Richardson. Okay. What process do you have in place to
rectify that?
Dr. Turner. I directed that some changes be made in our
emergency response capability for communication, that our 24-
hour, seven days a week Emergency Services Office in
Gaithersburg, if they received a call that should have been
forwarded to me, there would be a mechanism set up for the
office to patch them through.
Ms. Richardson. Are you now going to be notified
immediately?
Dr. Turner. Yes, ma'am, I am.
Ms. Richardson. Okay.
Dr. Turner. And the important thing is that there is one
number that anyone needs to remember.
Ms. Richardson. Okay. My last question is to Dr. Rogers,
and I think I have got about 15 seconds. You had an opportunity
to go to this location, do an evaluation. How often would you
recommend that inspections should incur so that that way we
don't have this same situation again.
Dr. Rogers. Well, I don't know how often. Regularly-
scheduled inspections should occur, but it does seem to me that
the license changes, the changes in the NRC license should have
triggered an inspection.
Ms. Richardson. Immediately or within----
Dr. Rogers. Yes. With the introduction of special nuclear
material and plutonium sources on-site, even though they were
small quantities, even though they were in encapsulated form,
and encapsulated is not a well-defined, technical term, it
seems to me that there should have been a question about, well,
now, this is something new. This is really a totally different
situation from what they were dealing with before in my
opinion.
The introduction of plutonium was totally new, and the type
of source that they were going to use was totally new, and in
my opinion NRC should have paid more attention to any possible
changes that were taking place in the laboratory and how those
materials were going to be used.
Ms. Richardson. Thank you, sir, and I appreciate your time,
Mr. Chairman.
Chairman Wu. I thank the gentlelady.
The gentleman from Nebraska, Mr. Smith, five minutes.
Mr. Smith. Thank you. Dr. Rogers, several of your
colleagues who provided independent reviews to Dr. Turner
singled out the Radiation Safety Officer for responding
commendably given the scope of the incident and the shortage of
resources. How would you characterize the containment and
cleanup effort by Boulder safety personnel?
Dr. Rogers. Well, first, let me say that my expertise
really lies in the general management of nuclear safety of
organizations. I have a technical background, and I know
something about these matters, but I would say that I would
have to really rely on my expert--the expertise of my
colleagues on whether the specific actions, one-by-one, day-by-
day, minute-by-minute, were the best or were appropriate. It
seems to me that they were a little slow, they were a little
confused, but they did get back on track and proceeded in a
reasonable way once that took place. But it did take a day or
two.
Mr. Smith. Okay. Thank you. In your testimony you, I wasn't
sure whether it was your own words or words of others that you
said the safety culture at NIST is dysfunctional. Were those,
was that your characterization?
Dr. Rogers. That was a quotation. That was not my own
analysis necessarily, but it was a quotation of one of the
people involved with safety at NIST.
Mr. Smith. Involved in safety at NIST and admitted to his
or her own dysfunction in relation to that?
Dr. Rogers. That this, that in other words--I think the
statement has to be interpreted in this way, that there were
pockets of very, very fine attention to safety at NIST, and
there were pockets of--where it was just the opposite, that the
safety organizational people had difficulty getting the
attention of some of the middle-level managers with regard to
safety issues with others they found very excellent
cooperation.
So I think the judgment of dysfunctional is perhaps to be
interpreted as not uniformly good.
Mr. Smith. But the individual did try to raise the issue
prior to the incident?
Dr. Rogers. I don't know about that. That was, that came
out in our interviews with people. I don't know to what extent.
I think there was a level of frustration.
Mr. Smith. I mean, if it was self-identified and nothing
was done about it, that would seem----
Dr. Rogers. Well, I have to, Congressman, all I can say is
that I did not have an opportunity to spend enough time to
pursue it in any depth but really took it to be a signal that a
hard look has to be taken at safety organization and how it is
responded to by the researchers at NIST.
Mr. Smith. But the comment was made that it was
dysfunctional, and you chose not to look into it further?
Dr. Rogers. Well, I didn't make any choice on this one way
or the other. We spent as much time as we had to and available
to us, and we interviewed ten individuals that day, each for an
hour. This was something that came out in one of the
interviews.
Mr. Smith. More anecdotal in nature?
Dr. Rogers. Yes.
Mr. Smith. Okay. Thank you.
Dr. Miller, back to my previous question. How would you
characterize the containment and cleanup effort by Boulder
safety personnel?
Dr. Miller. Dr. Collins has got a team on site. He can tell
you the current activities that are going on and how we
characterize that, sir.
Dr. Collins. I think the highest priority for the Special
Inspection Team was to make sure that NRC had a good
understanding and that the right actions were being taken to
evaluate the extent of the spread of contamination, understand
what the situation was, whether or not it was stable,
understand the radiation doses which could be associated with
that.
What we have found to date is while our work is still in
progress, NIST has reasonably determined the extent of the
plutonium spill. Rooms which are contaminated have been
isolated, and we have commitments from NIST in our confirmatory
action letter to present to the NRC a stabilization plan and
decontamination plan for approval before those activities
begin.
Mr. Smith. Okay. Thank you. Thank you, Mr. Chairman.
Chairman Wu. I thank the gentleman, and now in the regular
order it is appropriate to recognize the gentleman from
Colorado, Mr. Udall.
Mr. Udall. Thank you, Mr. Chairman. Again, I want to turn
back to Dr. Turner, and Dr. Turner, I was eager to get a number
of questions in, and I didn't, to confirm that you will provide
to use the e-mails that occurred after the incident here to the
Committee. Will you do that?
Dr. Turner. Yes, sir. Absolutely.
Mr. Udall. Thank you. Before I was elected to the Congress,
I served as the CEO and previous to that the COO of the
Colorado Outward Bound School. We had some 60,000 days a year
in the mountains of Colorado, the rivers, and in the canyon
country, and safety was bottom line, top line, it was
everything.
And you have to, as the leader, be ultimately responsible
for what happens----
Dr. Turner. Yes, sir.
Mr. Udall.--even if you aren't in the field yourself, and
you said this incident is unacceptable, and I wholeheartedly
agree with that.
But what do you mean? Are you taking full responsibility
for what happened?
Dr. Turner. Yes, sir, I am.
Mr. Udall. That is terrific. Specifically, where do health
and safety standards fit in your priorities, and what changes
are we going to see from your office? The initial reviews I
think clearly point out that the incident was the result of an
overall institutional failure----
Dr. Turner. Yes, sir.
Mr. Udall.--to properly train employees. That is your
responsibility.
Dr. Turner. Yes, sir.
Mr. Udall. The NIST safety operational system is your
responsibility. Have you read that document, and how does it
need to change to reflect the lessons learned in this incident?
Dr. Turner. Sir, I think there are gaps that certainly are
evident. There are some things in the operations and safety
manual that are good, other things are gaps; for example, the
fact that right now there is a, people have up to 30 days--I
guess new researchers have up to 30 days before they need to
get training. We need to close that gap and make that
appropriate. Then nobody works on anything until they are
appropriately trained for that.
So there are a number of things that we are going to do,
but we also want to take in and have the benefit of the
evaluations of the outside experts. The Department of Commerce
is also putting together a blue ribbon panel. The Inspector
General is also looking as there is feedback that we would get
from the NRC. So we want to be able to incorporate all that.
But let me assure you, sir, I, first of all, take
responsibility for this, and I am determined to fix it.
Mr. Udall. I also appreciate hearing that, number one, and
number two, I appreciate when Congresswoman Richardson talked
about budgets, that you made it clear, I believe you made it
clear that even though your agency has had some cutbacks, as
have all federal agencies, that you are going to find the
dollars, you are going to find the resources.
Dr. Turner. Yes, sir.
Mr. Udall. Because there is no excuse to jeopardize----
Dr. Turner. Yes, sir. Absolutely.
Mr. Udall. How many safety officials work the Boulder labs,
and who do they report to?
Dr. Turner. I don't know the exact number, sir. We can
certainly get that back to you, but they report to the head of
the Safety, Environment, and Health Division in Gaithersburg.
Mr. Udall. Gaithersburg. Why don't they report to someone
in Boulder? That doesn't really make sense to me as a long-time
safety officer in my old, my last career. I would encourage you
to look at changing that as NIST learns from the incident, and
I would like to also encourage you as I did a few weeks ago to
respond quickly and directly to requests by my staff and the
Committee staff. We still haven't received some simple things
we have requested like a timeline. It has been more than a
month since the incident.
Dr. Turner. Yes, sir. Let me just say that, first of all, I
apologize, you know, if we have been slow in responding, but
also, I have, I will be leaving for Boulder this evening, and
one of the things I want to do when I am there is to have a
discussion about the rules and responsibilities and reporting
structure that we have for our Site Director out there, because
quite frankly, I think that was a contributing cause for the
slowness of our responses, you know, the incommensurate
responsibility without authority. And that is one of the things
that we are looking to fix.
Mr. Udall. That may go to my point about maybe having a
Safety Officer on the ground in Boulder, but we want to pursue
that further as you, if you----
Dr. Turner. But let me just mention, I apologize for, I
hope, I didn't mean to cut you off, but we do have a Safety
Office there in Boulder. They report to the Safety Division in
Gaithersburg.
Mr. Udall. Who know that NIST has plutonium in the lab
before the incident? I have heard that some people that work
there didn't know, and I am just curious why. Did employees
fully understand what they were dealing with? I know a
Committee staff member was there a few weeks before, and she
was in that very room, and she was not aware that that was what
was being undertaken, that research with plutonium and the
other materials that were there.
Dr. Turner. Well, the plutonium was there to do work on
developing detectors that weapons inspectors could be using,
and as I understand it, NIST has about, in order of magnitude,
better capability for those detectors than anywhere else in the
country.
But clearly, it was a major failing that there was research
going on with plutonium in that laboratory, and other people
doing other business in that laboratory were not aware.
Mr. Udall. Can I ask that you will get us that information
for the record when it is available, and we can get the exact
questions to you after the Committee hearing.
Dr. Turner. Yes, sir.
Mr. Udall. Mr. Chairman, I thank you for the time and yield
back the time I have remaining, which is no time.
Chairman Wu. I thank the gentleman.
Mr. Smith.
Mr. Smith. Thank you, Mr. Chairman.
Dr. Miller and Dr. Collins, if you would, either of you, in
your testimony you state that the confirmatory action letters
document mutually agreed-upon corrective actions. How did the
NRC and NIST come to an agreement on the actions taken through
the July 2, letter, and how would you characterize NIST's
cooperation with the NRC since the event?
Dr. Miller. Dr. Collins will answer that question because
he was directly responsible in issuing the confirmatory action
letter to NIST.
Dr. Collins. We became aware of the need for a confirmatory
action letter. That is a mechanism we have to put in place
actions and commitments immediately when we feel they are
warranted to make sure that the situation is safe and remains
safe.
We became prompted to do that the more we became aware of
what appeared to be broad breakdowns in the procedures and
programmatic radiation safety program controls at NIST. We
began our discussions with NIST before the Special Inspection
Team arrived on site, and after that team arrived on-site and
began its initial work, we had continuing discussions and were
able to dialogue face to face with NIST officials to obtain
their commitments prior to the finalization of that letter on
July 2.
Mr. Smith. Okay. Thank you. And Dr. Rogers, other than
safety training and education, what else do you believe could
be done to insure that guest researchers certainly fully
appreciate the implications of their actions?
Dr. Rogers. Well, supervision certainly is an important
aspect there of their initial work. A guest researcher is
someone who comes with high credentials, but it has been my
long experience that an excellent technical credential does not
necessarily confer with it, either common sense or detailed
knowledge that is not involved with the work that is to begin.
So that it seems to me immediate supervision of any new
guest researcher by experienced people at the lab would be an
important addition to training and whatever else you mentioned.
Mr. Smith. Okay. Did you want to repeat, no, I am just
joking, what you said earlier.
And perhaps you kind of answered this partially, but would
there be any specific recommendations on how to insure that the
scientists at NIST facilities are adequately prepared for
dealing with the radioactive sources?
Dr. Rogers. Well, there is a great deal existing in the way
of policies, procedures, organizational structures, and so on
and so forth. They just haven't been used consistently. To me
the central question is developing an attitude of safety on the
part of every single person in the place. And that is a very
big challenge. It is not simply imposing a collection of new
requirements. It is something that has to come almost
automatically when people start to work, that they think of
safety along with whatever else they are doing.
And in this particular instance it seemed to me that
elementary questions were not asked. There wasn't sort of a
sense of intellectual curiosity on the part of key individuals
that they would understand what it is they were dealing with.
Maybe not having the training was important, an important flaw
but also not having an inquiring mind to ask, well, what is
this stuff I am dealing with? Is it dangerous or not? It is
plutonium. What is that?
And these are people with scientific backgrounds that
should sit down and go and do a little reading before they
begin working.
Mr. Smith. Well, I have a memo here that I think would be
particularly instructive based on what is at stake here, and I
appreciate the hearing today, and I would assume that most
folks would understand, especially those with excellent
credentials would understand the implications of what has
happened or what could happen.
So I appreciate that. Thank you.
Chairman Wu. I thank the gentleman. I understand the
gentlelady does not have any questions at this point in time.
Then the Chair recognizes himself for five minutes.
We are dealing with a situation with, about .25 grams of
plutonium. Dr. Miller, did I hear you correctly that the terms
of the license between the NRC and the NIST, and NIST would
potentially permit NIST to ask for up to any sub-critical
amount of plutonium?
Dr. Miller. I don't believe that I said that, Congressman,
but----
Chairman Wu. I thought I heard it.
Dr. Miller.--the terms of the license do have specific
provisions in them, and I can tell you, I can turn to the
license and tell you exactly what they are. But they are not
authorized critical amounts of material.
Chairman Wu. No. I said sub-critical. I thought you said--
--
Dr. Miller. But it is less----
Chairman Wu.--amounts----
Dr. Miller.--the terms of their license is, there is a
margin between the terms of their license and what would be
authorized for criticality. It is not right up to it.
Chairman Wu. But potentially it could be, it could have
been a much larger amount of plutonium that was----
Dr. Miller. The terms of their license not only restrict
them with regard to the total amount of plutonium they are
authorized to possess and use, but there is restrictions in the
license with regard to what each individual source that is used
can contain. So they could not contain that amount of plutonium
in any one given source given the terms of the license.
Chairman Wu. Okay. Well----
Dr. Miller. The total amount of plutonium that they were
authorized to possess on that license was significantly less
than what would be that critical amount.
Chairman Wu. It is bad enough when we are dealing with .25
grams. I am concerned about the terms by which the laboratories
may have multiple sources adding up to significantly more and
perhaps our staffs can get together to see precisely what those
amounts----
Dr. Miller. Yes.
Chairman Wu.--might add up to.
Dr. Miller. Yes. And we can certainly answer that
information. They have that information, and we can tell you,
you know, why the terms of the license for what they were given
the amounts that they were possessing.
Chairman Wu. Thank you, Dr. Miller. And you referred to a
five-year period of----
Dr. Miller. Yes.
Chairman Wu.--inspection. In either, it is either a NIST
internal rule or an NRC term of the license, I believe that
there is supposed to be annual trainings for personnel handling
these materials. Is that correct?
Dr. Miller. I can, the terms of the license require annual
training.
Chairman Wu. Yes.
Dr. Miller. The terms of the NRC license impose that
requirement on this through the license.
Chairman Wu. Okay. Well, Dr. Turner, Dr. Rogers, do you
have at hand the last time that the personnel involved were
actually trained?
Dr. Turner. I can get that for you, sir, but one of the
things I wanted to mention was that the, all work with
radioactive sources has been stopped at NIST in Boulder.
Chairman Wu. Yes. Yes.
Dr. Turner. Until we get assured that----
Chairman Wu. I understand.
Dr. Turner.--we are meeting all the terms of the license.
Chairman Wu. I understand that you have taken those steps,
cautionary steps appropriately going forward. I am looking back
now before this incident, and it is my understanding that there
was one training in 2007, and that prior to that the prior
training was in 2005, but no one has records as to the
intensity, duration, or the content of those trainings. At
least that is what I have been briefed on, and if you all have
any contrary information or supplemental information, I would
be interested in that.
Dr. Turner. I would be happy to provide it. I saw a list of
the training. Most of the training was, at least on the list
that I saw, up to date. There were a few cases, you know, for
example, the researchers involved in this situation where the
training had not taken place.
Chairman Wu. So other folks were up to date, but the
subject individuals were not up to date?
Dr. Turner. Yes, sir.
Chairman Wu. Okay. The consequence of this management
environment, if you will, there are a couple of things that I
saw in the train of events which at least to me seem like it
could have been prevented by adequate training. In one of the
documents prepared by NIST as a report to the NRC, I believe
that post-incident a number of the employees decided to stay in
a hallway and then one person suggested that they take their
shoes off.
It is commendable to not, to think about not tracking
materials around on their shoes, but net, net by taking the
shoes off, you expose socks and feet to the materials. The
other one was washing hands over an open drain.
Dr. Rogers, Dr. Turner, Dr. Miller, do you agree with me
that those are some of the things that are prevented by
adequate training and a complete program and culture of
training?
Dr. Turner. Yes, sir. I totally agree and also I think the
assumption of responsibility and leadership on the part of my
management, as well as having in place a firm, aggressive,
positive safety culture.
Dr. Rogers. Well, I quite agree that, you know, elementary
training would have avoided some of this. Information was not
conveyed to the person most directly involved with this
incident, that I would say could have been figured out by that
individual, but it was not transmitted to that individual.
So that you had a situation where the guest researcher, who
was unfamiliar with, one, the laboratory, general
administrative management requirements of the lab, and two, not
familiar with the details of the technical aspects of the work
involving radioactive materials which that person was going to
be engaged.
Chairman Wu. Thank you. I see that my time has expired. My
understanding is that Mr. Udall has a follow-up question.
Mr. Udall. I do. Thank you, Mr. Chairman, for yielding, and
before I ask my question, I would ask unanimous consent that a
letter from the city of Boulder be entered into the record. It
expresses the city of Boulder's concerns about the incident and
what they believe should be the path forward.
Chairman Wu. So ordered.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Udall. Thank you, Mr. Chairman.
I want to turn to both Dr. Miller and Dr. Turner and ask
you is there anything in the NIST protocols, anything in NIST
procedures that would prevent NIST from releasing a list of
radioactive and hazardous material at the labs to the city of
Boulder and the public in general?
Dr. Miller or maybe someone else here would be better
prepared to answer the question.
Dr. Miller. From the NRC's perspective traditionally NRC's
licenses have all been public except for aspects which are
security matters. Following the events of 9/11, we had to take
a look at what information would be public and what would not
be. And to some degree as a result of all that we have not
publicized those amounts.
However, that said, we certainly at every turn, the NRC has
always cooperated with State and local government officials to
make sure that they are fully informed and have access to that
information. Colorado itself is an NRC-agreement state. Because
this is a federal facility, we regulate it, but we have a
relationship with our State partners in the State of Colorado.
We certainly would be happy to share any information with them.
But there is a certain amount of what we are now doing that
is not made publicly available with regard to these types of
licenses. And, again, it goes back to national security
matters, Congressman.
Mr. Udall. What I hear you saying if there isn't a national
security concern, and that is important, we all----
Dr. Miller. Uh-huh.
Mr. Udall.--acknowledge, then there is nothing that would
prevent NIST from releasing the list of these radioactive and
hazardous materials? Depending on the state, depending where
the activity is occurring.
Dr. Miller. Yes. I mean, they certainly, certainly the
local officials should have access to that information. Okay.
Because of a number of reasons, including their duties as it
would relate to emergency response.
Mr. Udall. Uh-huh. Dr. Turner, you care to respond?
Dr. Turner. Yes, sir. I became aware of the letter this
morning, and I asked one of my staff in Boulder to see if they
could arrange a meeting between me and some of the city
officials so that we could discuss the content of that letter
and what an appropriate response would be. And also, you know,
we have had so many missteps because of lapses in
communication, and I really wanted to make sure that this was
not another situation where we had a misstep because of a lapse
of communication. That is why I wanted to meet directly with
city officials to make sure we had an agreement on exactly what
was being requested and what an appropriate response would be.
Mr. Udall. So what I hear you saying is you would be
willing to consider their request. You want to sit down and
talk with them. You want to complete your analysis, the various
reviews that are underway, and I would, and you will consider
that.
What I would add is we certainly have a tradition in the
world of public policy and public information, everything from
FOIA to other protocols of letting the public know as much as
we possibly can about materials that could affect the safety or
welfare or health of the public. And I think in the long run we
all agree this is, it is better to err on that side than----
Dr. Turner. Yes, sir.
Mr. Udall.--to keep these materials hidden from view or
lessen the awareness that communities may have of those
materials.
Dr. Turner. Yes, sir. We want to be a good, responsible
neighbor to the community that has been so good to us.
Mr. Udall. Yeah. Well, let me, I want to thank the Chairman
again for holding the hearing. Let me just end on this note.
This is a very serious incident. As I have said here today,
I am very disappointed in the way it has been handled.
Dr. Turner. Yes, sir.
Mr. Udall. And I have assurances from you that you are
going to move with dispatch, that you are going to be----
Dr. Turner. Yes, sir.
Mr. Udall.--open and that we are going to find out what
happened and then we are going to put protocols in place and
even take a look at the culture in this because----
Dr. Turner. Yes, sir.
Mr. Udall.--that may be a part of what has to change, and
NRC personnel who hear are very well versed in that. But I did
want to also emphasize the very important work that NIST does,
how proud we are to have you in our community, how proud we are
to have so many, all of the scientists and the engineers and
the great personnel there. And to underline the work you do in
a whole host of areas that make modern life what it is and the
important work that was being done in this situation, which is
to better understand how to prevent proliferation of nuclear
materials, nuclear weaponry. And we want that work to go ahead.
We want to understand how we can even be better at analyzing
and identifying people who are comporting with international
standards and those who aren't. So that is why it is so
important to get this figured out and get back on track,
because that work has to continue.
Dr. Turner. Yes, sir. Absolutely, and let me just say that
this has shaken NIST to its core. As you are aware, our
employees are fiercely proud, as am I, of being NIST employees,
and this has shaken all of us. I have been personally very
heartened by the response of our Laboratory Directors. Also I
met yesterday with the group that represents the researchers as
well as NIST fellows, and I really, I outlined to them the
importance of what we are doing and, you know, that we needed
their help. And I was really heartened by their response, that
they are taking this seriously and that they are committed, as
am I, to fixing this.
Mr. Udall. Thank you, Mr. Chairman, for holding this
important hearing.
Chairman Wu. I thank the gentleman from Colorado.
Mr. Smith.
Mr. Smith. Yeah. I was just wondering if it would be
possible for the minority to review the letter. I don't
necessarily want to object, but if it would be possible for the
minority to review the letter and then allow for the consent at
a later time.
Chairman Wu. Is the gentleman referring to the letter from
the city of Boulder?
Mr. Smith. The city of Boulder. Yes.
Chairman Wu. I would be happy to make the letter available
to the gentleman, but I believe that without a timely objection
it is entered in the record. But if you, if the gentleman has
any concerns about the letter, please enter that into the
record also.
Mr. Smith. Well, this is just the first I have seen it, and
I would like, you know, to review it a little further.
Chairman Wu. I would be delighted to make the letter
available to the gentleman.
Mr. Smith. Okay. Thank you.
Chairman Wu. I thank the gentleman, and the Chair
recognizes himself one last time.
Dr. Turner, you referred to an e-mail notice to you, which
I believe came in on a Monday night, and then you did not see
that e-mail until Tuesday morning. E-mail has terrific utility
in permitting us to time shift our communication, but there is
some things which I think we all agree, can rise above that and
need immediate attention. And you have referred to fixing these
communication systems within NIST.
Dr. Turner. Yes, sir.
Chairman Wu. And I am going to ask you just very briefly
that I assume that this form of e-mail communication for
exigent circumstances has been replaced by something which for
all of us in these jobs can reach us 7 by 24.
Dr. Turner. Yes, sir. That is why there is one number for
people to remember to call, and that is it.
Chairman Wu. And that number ultimately winds up at an
appropriate place in the chains of notification and command?
Dr. Turner. Yes. It goes directly to our Emergency Services
Office and then they, in turn, relay the call to, whether it is
me or whatever the appropriate official is, but there is one,
the important thing is there is one number to call and then
they will do the rest to contact us.
Chairman Wu. Well, this committee, this subcommittee, the
Full Committee, and the Committee staff will continue to work
with NIST to make sure that these, that the information is
reported appropriately, both within NIST, to other agencies,
and to oversight bodies such as this one.
Dr. Turner. Yes, sir.
Chairman Wu. I want to turn back to the laser incident in
Gaithersburg, and what is troubling to me about the laser
incident is that I did not know about the laser incident, and
it appears that no one in an oversight position was aware of
the laser incident until this plutonium incident came to light.
Did NIST take any steps to notify its own employees or
Congress or anyone else about the Gaithersburg laser incident?
Dr. Turner. Yes, sir. Let me describe the process that we
have done. One of the things that I did after I became the
Acting Director was to institute a standing policy at our NIST
leadership meetings where we begin each meeting with a five-
minute safety topic. Each one of our leaders has to report on
something, so, again, it is to infuse in them the idea that
they are responsible, as a line manager for safety. We also,
for accidents which occur, we also have the Lab Director who
was involved----
Chairman Wu. Dr. Turner, I am asking specifically about the
laser incident in Gaithersburg.
Dr. Turner. Yes, sir. And the Lab Director who was involved
gave a presentation to our leadership board because there are
lasers used throughout NIST, and so that way we are able to
make sure information is exchanged and also were changes made,
for example, in the set up at our facility that we shared with
the University of Colorado, because they had a very similar set
up. And so that information, lessons learned and information
sharing resulted in precautions being taken at other
laboratories as a result of hearing about and learning about
the causes and the actions taken in the laser----
Chairman Wu. You are saying that that did occur with
respect to the Gaithersburg laser incident. It is just that it
did not rise to the level that there would be any notification
of this committee or Committee staff?
Dr. Turner. Yes, sir. If we had a misstep in informing this
committee, I apologize for that, sir.
Chairman Wu. Now, these are different devices, but could
that first incident have had lessons learned beyond laser uses
that could have helped with the plutonium incident?
Dr. Turner. Yes, sir. I think this is one of the things
that we have done. Yeah. We are not looking at this situation
as a Boulder only. We are looking across NIST because of this.
We are not looking at this as a radiation safety issue only. We
are looking at radiation safety, hazardous materials. We are
also looking at equipment, we are also looking at machinery,
things which pose risks. You know, we are including that in our
comprehensive review of safety and safety policies.
Chairman Wu. Going forward, and Dr. Turner, you have made
many commitments today to start making changes appropriate in
procedure and in the culture of safety at NIST. What are your
expectations about the timeline? What are your expectations
about appointing appropriate panels in addition to the folks
that you have already appointed to look into this incident?
Dr. Turner. Well, first of all, I have made clear to
everyone that this is a high priority for us. Our highest
priority. I have also made it clear to everyone that this is
not a short-term problem. This, you know, changing cultures is
a long, difficult thing to do as Dr. Rogers referred to. So I
have made that clear that this is something that we are going
to be, you know, that is going to be on our radar screens for
quite some time to come and that I am determined to fix it and
make it right. And so, you know, people are aware of that.
People understand the enormity of the challenge that we face
and our determination to fix it, and I think our colleagues in
this share that same determination that it get fixed.
We wanted to make clear. This is not a temporary, fleeting
issue. This is something that we need to engrain and have
sustainable.
Chairman Wu. Dr. Rogers, since you are the one outside
representative group or Dr. Miller, if you would care to
comment, to this point in time should we be feeling good about
the steps that NIST has initially taken to change the safety
culture, or should we have further concerns or some combination
of each?
Dr. Rogers. Well, with respect to NIST it seems to me
everything I have heard has been very positive, very
professional. It is going to take some time, and there are
steps along the way. It does seem to me that Dr. Turner's
explanation of how NIST is viewing this incident is exactly
correct, that it is not just a small incident in one
laboratory. It is a manifestation of an underlying problem that
needs to be worked on.
But there is not going to be a quick fix totally. We are
talking here about a cultural issue. It is not just rules and
regulations, and culture is something that is engrained in
people. So that it is going to take some time to be absolutely
confident, if ever one can be, that this cultural change has
taken place. But it does seem to me that Dr. Turner's
explanation of the approach that is being taken is entirely
correct.
Chairman Wu. Thank you, Dr. Rogers.
Dr. Miller. Mr. Chairman, the NRC is very happy to hear Dr.
Turner's remarks and commitments. However, we were very
concerned about the nature of this event also. That is why we
responded in the way that we do.
As you know from our testimony we have currently suspended
NIST's authority through the confirmatory action letter to use
these materials, and we want to be convinced that they have
these things in place and gain our trust before we are going to
allow them to renew any use of that.
But the statements that Dr. Turner has made today and his
commitments are a beginning, convincing the NRC that NIST is
serious about doing this. I can assure you that the NRC will
stay on top of this until we feel comfortable and that they
have our confidence to renew any use of these materials.
Chairman Wu. Thank you very much. I want to touch on one
final topic, because I think we are all agreed, and Dr. Turner,
I am gratified to hear about the steps that you are taking and
as we all agree, this is a long-term process of cultural change
and building in, and educating for appropriate, prompt action.
I want to as forcefully as I can state in my own quiet way
that I would be deeply concerned about viewing this situation
as one where picking out one or a couple of wrong actions and
one or a couple of wrong actors and then taking punitive steps
in that direction would be viewed as, ``solving the problem.''
I think that that is something which would be demoralizing
to an excellent agency. You might lose good people that way.
The gentleman from Colorado, Mr. Udall, referred previously to
employee morale issues. I think that inculcating a culture of
learning from past mistakes and incorporating lessons learned
into a changed culture is the hallmark of a good or great
organization.
I have certainly appreciated the work that NIST has done
over many years. I am fond of saying that in economics or in
science if you can't measure it, it's not real, and NIST helps
us do that. NIST helps us standardize things, and without your
good work we would be doing things in faith where we need to be
doing things in technology or science. Nothing wrong with
faith. It is just it doesn't necessary move blocks where we
need to move blocks.
So this committee, this subcommittee and the Full
Committee, will continue to work with NIST, with the NRC, and
with outside review panels for, I believe, a good while to
come, to insure, Dr. Turner, that you and perhaps your
successors to come over many years, continue to build a better
culture of safety in addition to the intellectual and technical
excellence that you all have clearly built at NIST.
So as we bring this hearing to a close, I want to thank
each of the witnesses and Dr. Collins for being here today and
testifying before the Subcommittee. The record will remain open
for additional statements from Members and for answers to any
follow-up questions the Committee may ask, and there will be
further questions from me and from other Members and from
Committee staff for you all and the agencies that you all
represent.
And with that I thank you very much for being here on this
very important and very difficult subject. This hearing is
adjourned. Thank you.
[Whereupon, at 12:35 p.m., the Subcommittee was adjourned.]
Appendix:
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Answers to Post-Hearing Questions
Answers to Post-Hearing Questions
Responses by James M. Turner, Deputy Director, National Institute of
Standards and Technology, U.S. Department of Commerce
Questions submitted by Chairman David Wu
Q1. How do you believe an atmosphere developed at NIST where, as you
stated, ``line supervisors failed to take adequate responsibility for
safety issues, and safety personnel failed to assert a sufficient level
of authority to ensure compliance with existing procedures and
practices''?
A1. Several factors contributed. First, there are many NIST line
supervisors who take safety seriously. Obviously there are some who do
not. Some saw it, correctly, as line management's responsibility to
provide a safe workplace; others believed that it was the Safety
Division's job to make everyone safe. The Safety Division had not
always been paid attention to over the years and some in that division
felt that management did not fully support them. There is some
justification for this view. Thus they were not assertive in elevating
concerns.
Q2. In Dr. Rogers' testimony he stated that Room 1-2124, where the
spill occurred, did not meet standards and requirements to qualify a
lab space for use of radioactive materials. Did the management that
assigned the lab space consider that this research group would be
working with radioactive materials? When lab space is assigned at NIST,
how is safety and the adequacy of the workspace considered?
A2. The lack of a rigorous safety culture provided the atmosphere in
which neither line management nor safety officials took the necessary
steps to ensure that all appropriate officials knew what approved
materials were being used in laboratories, whether or not those
laboratories were appropriate for the materials being used, and what
training was or was not required and taken by the individuals handling
the materials and working in the immediate area. If there had been a
rigorous safety culture at NIST, then precautions to isolate the work,
to ensure appropriate training and preparedness measures, to restrict
traffic through and near the area, and to respond to the incident in a
safe manner should have been in force.
Once hazards are identified, steps should be taken to reduce the
risk-before the work begins. These steps could include protective
equipment, special handling instructions, access controls, work
procedures, training of all workers, and procedures for emergency
situations. Line Management, supported by the Safety Division, would
then take actions to assure that the lab space, including access
controls, was safe. Line Management is also expected to do
``walkdowns'' (announced and unannounced) to assure that work is being
done according to procedures and training and to question the workers
on their jobs, use of protective equipment, and what they should do in
an emergency. Line management last conducted a walkdown of Room 1-2124
in January of 2008 with the Safety Office. Clearly, the reviews
undertaken and communications between line management and the safety
division staff were inadequate.
Q3. Dr. Rogers suggested that performance reviews should hold managers
accountable for promoting a safety culture within their purview. Since
safety performance is already a required part of these reviews, how
will the criteria be changed to make sure it is prioritized and that it
provides factual and useful information? Please provide the current
safety related criteria used in performance reviews.
A3. As it currently appears in many employee performance plans, safety
is one of several activities under a broad critical element. The Chief
Human Capital Officer has recently been charged with developing a
separate, stand-alone critical element dealing with safety for all
performance plans for the 2009 rating year, which begins October 1,
2008. The new safety critical element will provide incentive and state
expectations for NIST staff to work safely, raise safety issues and
concerns promptly, and take appropriate actions to resolve unsafe
conditions or practices. The safety critical element will also provide
a basis for holding line managers and employees accountable for
increased safety awareness and performance through results-based
measures and outcomes that permit element ratings of exceeds
expectations, fully successful, minimally meets expectations, or
unsatisfactory.
The current safety related criteria vary by position and
organization. The table, below, contains typical criteria used in
performance reviews of NIST researchers.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Q4. Please provide the Committee with a full account of the laser
safety incident that occurred in Gaithersburg, as well as a description
any follow-up activities performed regarding the incident's
implications for health and safety at NIST.
A4. Laser Incident Overview
On March 5, 2008, there was an injury to the right
eye of a NIST research associate in the Atomic Physics Division
of NIST's Physics Laboratory. There were two NIST associates
involved in the incident. A third researcher was present in the
lab but in another area behind a curtain.
The injury was caused by a lack of communication
between the researchers present that resulted in the
associate's exposure to a laser. The second associate was not
experienced with the hands on procedures of this experiment and
was assisting. Normally, the injured associate performed the
entire procedure alone. At an undetermined point the laser was
left on when it should have been off. The injured research
associate was placing a slide onto a microscope stage and
putting a drop of immersion oil onto the objective lens. This
NIST associate believed the laser to be off and therefore
inadvertently exposed the right eye to the laser without
protective eyewear.
The incident occurred during the conduct of a joint
project between the Chemical Science and Technology Laboratory
and the Physics Laboratory. The goal of the project is to study
certain aspects of mitochondria, which are membrane enclosed
organelles found in the cells of most complex life forms. The
DNA of mitochondria is distinct from the DNA in the cell
nucleus and is inherited exclusively from the mother, which
means it can be used to trace maternal lineage far back in
time. Optical tweezers are used to isolate individual
mitochondria in order to quantify the variation of the genetic
information among mitochondria from a single cell.
Remedial Actions Taken in Response to Report on Laser Incident
Investigation
A detailed hazard and mitigation analysis of all of
the optical instruments (microscopes) that use Class 3B and
Class 4 lasers has been conducted. Revised standard operating
procedures have been developed, and, where possible,
engineering controls to eliminate the risk of exposure have
been implemented.
-- Each laser system has been inspected to ensure that
it is in proper working condition, that laser power
levels are as indicated on the devices, and that the
laser emission on/off switches are working properly.
-- A laser curtain has been installed to separate the
wet chemistry side of the laboratory from the optical
instrumentation side. This separation eliminates the
risk of laser exposure to any researcher on the wet
chemistry side of the laboratory, and also prevents any
researcher from inadvertently walking from the wet
chemistry area to the laser area without proper laser-
safety eyewear.
Under the recently adopted Health and Safety
Instruction for Laser Safety, NIST is working to ensure that
all optical instruments that use Class 3B and Class 4 lasers
have their own warning light indicating that the lasers are on.
-- The signs will be prominently displayed so that
they can be seen by any operator of a particular
instrument during normal use of that instrument.
-- Standardized signage and warning lights will be
prominently displayed to prevent entry into the laser
side without proper safety eyewear.
Interlocks have been installed on all optical
instruments where the condenser can be tilted back allowing
line-of-sight access to the objective lens. The interlocks
shutters or blocks the laser beam when the condenser is tilted
back.
Laser safety inspections have been--and will be
routinely--performed by the Group Laser Safety Representative
to ensure that necessary laser safety measures and standard
operating procedures are in place.
-- A laser safety inspection will be performed by the
Group Laser Safety Representative prior to any new
system being put into operation.
-- A laser safety inspection was made during the 3rd
week of April, 2008--and will be made annually--by the
Division Laser Safety Representative.
-- Occasional inspections by the Laser Safety Officer
of the Safety, Health, and Environment Division are
being scheduled.
Q5a. When will the Department of Commerce (DOC) appoint the Blue
Ribbon Panel to perform a review and analysis of environmental, health
and safety procedures and practices at the NIST labs?
Q5b. When will they begin their work and how long is the assessment
expected to take?
A5a,b. The Department of Commerce is working to establish the NIST Blue
Ribbon Commission on Management and Safety and have it complete its
work as expeditiously as possible. Attached is a Federal Register
Notice of the establishment of the Commission.
Q5c. Also, when will the DOC's Inspector General issue its report on
NIST management, training, safety and response operations?
A5c. The DOC OIG has requested that inquires regarding their report be
made to Mr. Dan Bechtel, the Assistant Regional Inspector General for
the Denver Region, 303-312-7660 or John Bunting, Regional Inspector
General for the Denver Region, at 303-312-7663.
Q6a. Prior to the June 9th incident, to whom did the Safety, Health,
and Environment Division (SHED) report at NIST's Gaithersburg and
Boulder Facilities?
A6a. SHED reported to the Chief Human Capital Officer.
Q6b. What have the operating budgets been for SHED and the Boulder
Safety Office for fiscal year 2004 through fiscal year 2008?
A6b. SHED and the Boulder Safety Office operating budgets for fiscal
year 2004 through fiscal year 2008 are reflected in the table below:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Q6c. How have budgets cuts impacted the number of staff employed by
these offices?
A6c. The number of staff has remained fairly constant as laboratory
programs grew, resulting in more work for the staff on hand. However,
NIST has decided to immediately add seven specialists to work under
contract for the next six months to supplement NIST's own safety and
health staff.
Q7. Committee staff learned that the initial medical tests done on the
affected personnel to determine if they had received internal exposure
to plutonium were either incorrectly performed or performed too late to
give useful results.
Q7a. Who was initially responsible for ensuring the medical safety of
these individuals?
A7a. It is always line management's responsibility to ensure medical
safety.
Q7b. When were radiation health experts contacted?
A7b. At 16:43 a call came into the Office of Safety, Health and
Environment. At 17:15 the NIST Boulder Radiation Safety Officer, who
was on annual leave, responded to a message left on his cell phone and
arrived on campus at 18:00 to provide additional support. The
Gaithersburg Radiation Health Physicist arrived in Boulder on
Wednesday, June 12th.
Questions submitted by Representative Phil Gingrey
Q1. On pages 9 and 10 of your testimony, you list five different
safety principles that you expect NIST personnel to embrace. These
include the need for effective safety oversight, requirements that
safety staff immediately stop questionable work, and that individuals
are responsible for their own safe behavior. Dr. Turner, can you
explain to the Committee who you would consider as ``safety staff''?
Does this include all line management or only those with specific
safety functions? Where does the responsibility of individual
researchers and that of ``safety staff'' begin?
A1. Safety staff would include all staff within the Safety, Health, and
Environment Division (SHED). Their role is to develop NIST-wide safety
policy and identify the means by which Line Management can show it is
complying with the policy. SHED also conducts annual site inspections
as required by 29 CFR 1960 and provides technical assistance and
support to Line Management in order to anticipate, recognize, evaluate,
and control hazards in their work areas. Line Management has the
primary responsibility for safety of work within their facilities.
Q2a. What functions are performed at the two NIST labs by the Safety,
Health, and Environment Division?
A2a. Functions performed: Occupational Safety and Health, Radiation
Safety, Environmental Management, Employee Assistance Program, Fire
Safety, Continuity of Operations Planning, Safety Engineering and
Industrial Hygiene.
Q2b. What is the annual budget for this division, and how many staff
do they have?
A2b. The annual budget for the Safety, Health, and Environment Division
in fiscal year 2008 is $5,041.7K and current staffing consists of 23.5
FTEs, of which there are currently three vacancies.
Q2c. Do you believe that this division has had the resources during
the past two years to effectively complete their responsibilities?
A2c. No. SHED has recently assessed its staffing and has submitted a
prioritized list of additional resources it needs. It is currently
under consideration by NIST.
Q2d. Do you believe it is appropriate for this division to be held
responsible for the safe design and execution of laboratory
experiments?
A2d. While SHED assists with safety design on individual experiments,
the line management in the individual labs is responsible for the
proper design and execution of experiments.
Questions submitted by Representative Mark Udall
Q1. Please provide the Committee with copies of all of the e-mails
between Boulder and Gaithersburg relating to how and when employees and
city, county and State officials would be notified of the incident.
A1. NIST is in the process of complying with this request.
Q2. Please provide the number of current full-time-equivalent
employees in NIST-Boulder's Safety Office. To whom does the Boulder
Safety Office report?
A2. Five employees are in the NIST Boulder Safety Office. The NIST
Boulder Safety Office reports to the Safety, Health, and Environment
Division which is headquartered in Gaithersburg, MD.
Q3. Please provide a list of all radioactive and hazardous materials
used at the NIST-Boulder facility.
A3. Lists provided to the Committee; deemed too lengthy to print.
Answers to Post-Hearing Questions
Responses by Charles L. Miller, Director, Office of Federal and State
Materials and Environmental Management Programs, U.S. Nuclear
Regulatory Commission; accompanied by Elmo E. Collins, Regional
Administrator, Region IV Office, U.S. Nuclear Regulatory
Commission
Questions submitted by Chairman David Wu
Q1. It was noted by several witnesses that no one at NIST seemed to
appreciate the difference between a sealed source and an encapsulated
source, which, as Dr. Rogers noted, is not a technical term.
Q1a. Was the failure to pursue precise information regarding the
source consistent with the lax manner in which NIST handled these
materials?
A1a. NIST did not procure the plutonium source in question until
approximately six months after the U.S. Nuclear Regulatory Commission
(NRC) approved NIST's license amendment request to use and possess
special nuclear material of less than a critical mass, including
plutonium in any solid, encapsulated form. The NRC is still reviewing
the circumstances associated with NIST's procurement of the plutonium
sources, including NIST's efforts to verify that the model numbers 137
and 138 plutonium sources met the conditions of its license. However,
the NRC preliminarily has determined that NIST personnel did not apply
the appropriate controls to which NIST committed in its license
amendment request and which are recommended by the source supplier
(U.S. Department of Energy New Brunswick Laboratory). Specifically, the
source supplier asked NIST whether or not the plutonium sources would
be removed from the outer cardboard tubes in order to conduct the
subject research. New Brunswick Laboratory staff understood that the
sources would not be removed from the outer cardboard tubes. The
supplier cautioned NIST in an e-mail message that if the plutonium
sources were removed, then the plutonium reference material sealed in
plastic bags should be considered contaminated and should only be
handled in a glove box. Similar written information was provided to
NIST in the form of a material safety data sheet. The NIST-Boulder
staff did not develop specific handling procedures for the plutonium
sources, contrary to its commitment to the NRC. At some point after
obtaining the plutonium sources in October 2007, one or more members of
the NIST-Boulder staff removed the sources from the outer cardboard
tubes. On June 6, 2008, NIST researchers removed the two plastic bags
that contained the plutonium source in question. A glove box was not
used, nor was a handling procedure or instruction provided for this
activity.
Q1b. How do you think this lack of distinction between sealed and
encapsulated contributed to this accident? Does the definition of the
term ``encapsulated'' need to be clarified?
A1b. The term ``sealed source'' is defined in 10 CFR Part 30.4,
Definitions, as ``any byproduct material that is encased in a capsule
designed to prevent leakage or escape of the byproduct material.'' The
definition requires the capsule to be designed to prevent contact with
and dispersion of the radioactive material under the conditions of use
for which it was designed. The term ``encapsulated'' is not defined in
the regulations. However, NRC maintains a database, NUREG/CR 5569
Health Physics Positions (HPPOS), of NRC staff positions on a wide
range of topics involving radiation protection, including encapsulated
sources. HPPOS-311 states that certain low energy and low activity
calibration and reference sources have been confined by using glass
vials for numerous years. The staff concluded that glass ampoules,
flame sealed to prevent leakage or escape of its contents, can be
considered ``sealed sources'' as long as the radionuclide content is
small and the impact on decommissioning of the facility, if one or a
few were to fail, is minor. While the NIST event is still under review,
the NRC's preliminary finding is that the plutonium sources in question
were unsealed material. This preliminary finding is made based on the
following: (1) the plutonium material was in a screw top micro-bottle
specifically designed to allow the material to be readily accessible
(e.g., poured out of the bottle); and (2) the material content was in a
configuration such that breakage of the micro-bottle could reasonably
be assumed to cause more than minor impact on decommissioning of a
facility. Consistent with our practices in reviewing the circumstances
surrounding an event or incident, the NRC plans to conduct a review of
agency guidance relative to this incident to determine whether
enhancements or clarifications are needed.
Q2. The NRC learned of the release at NIST-Boulder on Tuesday, June
10th, and sent inspectors to Boulder on Thursday, June 12th.
Q2a. What guidelines and requirements does the NRC follow to determine
when to dispatch inspectors?
A2a. NRC has guidance documents that address the course of action to be
taken in response to radioactive material incidents. The pertinent
documents for the plutonium contamination event at NIST-Boulder are
Management Directive 8.3, ``NRC Incident Investigation Program,'' and
NRC Inspection Manual Chapter 1301, ``Response to Radioactive Material
Incidents That Do Not Require Activation of the NRC Incident Response
Plan.'' Section 06.03 of Manual Chapter 1301 directs regional
management to evaluate the need to dispatch one or more regional
inspectors to conduct a special inspection of an incident site. Section
06.03.c.1. further defines ``immediate dispatch'' to be typically
within two days of a reported event. In this case, the NIST-Boulder
licensee discussed the circumstances with Region IV personnel and, at
the urging of the NRC staff, reported the event to NRC Headquarters
Operations Center late Tuesday afternoon, June 10, 2008. No on-going,
immediate safety issues were described on this call with the Operations
Center. Specifically, the licensee reported that the laboratory was
isolated, contaminated and potentially contaminated personnel had been
decontaminated, bioassay on these individuals was initiated, and there
was no indication that contamination had spread beyond the laboratory
building. Region IV management reviewed the event information and
decided to dispatch an inspector to gain first hand knowledge of the
event and to observe the licensee's response activities.
Regional management briefed the inspector on Wednesday, June 11. He
arrived on-site at NIST-Boulder the morning of Thursday, June 12. A
second inspector was dispatched the following week on June 19. After
reviewing the preliminary observations stemming from these two
inspection follow-up activities, in combination with additional
information obtained from NIST through telephonic briefings, the NRC
expanded its inspection follow-up to a five-person team, which was
dispatched to the site on June 29. This is consistent with Management
Directive 8.3 for operational events of this level of significance.
Q2b. When NIST first informed the NRC, did they appreciate the
magnitude of the incident? Was the description of the event presented
to the NRC accurate?
A2b. NIST first notified a Region IV materials license reviewer of the
event, which was immediately referred to regional management. NIST
described the event details that were known at the time, and indicated
that they were not certain whether the event was reportable. Regional
management advised NIST to immediately report the event to NRC
Headquarters Operations Center, which NIST did at 3:11 p.m. EDT on June
10, 2008.
The information provided in the initial notification to Region IV
management and the NRC Headquarters Operations Center was limited.
However, that information was generally consistent with our preliminary
observations during the initial on-site inspection. NIST provided
additional details of the event (e.g., that the associate researcher
washed his hands in the laboratory sink prior to notifying the
principal investigator that the source bottle was cracked) to Region IV
staff as information evolved during the progression of the licensee's
investigation.
Although their findings are preliminary, the NRC's special
inspection team has identified a number of elements required by the
NIST's license for the possession and use of special nuclear material
of less than a critical mass that were, in some cases, never developed
or implemented, or were not adequately implemented. Examples include:
insufficient training of occupational workers and laboratory
frequenters; procedures that were never developed or fully implemented;
security measures that were not implemented; safety modifications that
were not made to the laboratory where the plutonium sources were stored
and used; required audits of the radiation safety program that were not
conducted; not assigning a radiation monitoring device to personnel who
should have had one; personnel not wearing an assigned radiation
monitoring device; and inadequate emergency procedures. Additionally,
the scope of the licensee's efforts to bound the number of people that
were potentially contaminated and the extent of the spread of
contamination was insufficient. While the NRC agrees with the findings
and conclusions of the licensee's Ionizing Radiation Safety Committee
Initial Report of Plutonium Contamination at NIST-Boulder, other causes
and contributors of these apparent performance deficiencies are the
subject of NRC's ongoing special inspection.
Questions submitted by Representative Phil Gingrey
Q1. Your testimony describes a range of enforcement actions that are
available to the NRC that apply to a federal laboratory like NIST-
Boulder, including civil penalties.
Q1a. Can you elaborate on what enforcement tools the NRC has at its
disposal?
A1a. The NRC's enforcement authority is contained in the Atomic Energy
Act of 1954, as amended, and the Energy Reorganization Act of 1974, as
amended. These statutes provide the NRC with broad authority. The
Agency implements its enforcement authority through Subpart B of 10 CFR
Part 2 and as reflected in the NRC Enforcement Policy. The NRC
Enforcement Policy sets out the general principles governing NRC's
enforcement program and provides a process for implementing the
agency's enforcement authority in response to violations of NRC
requirements. The Enforcement Policy applies to all NRC licensees, to
various categories of non-licensees, and to individual employees of
licensed and non-licensed firms involved in NRC-regulated activities.
Because violations occur in a variety of activities and have
varying levels of significance, the NRC Enforcement Policy contains
graduated sanctions. Enforcement authority includes the use of Notices
of Violation (NOVs), civil penalties (current statutory maximum of
$130,000 per violation per day), Demands for Information (DFIs), and
Orders to modify, suspend, or revoke a license, Enforcement actions
against individuals include NOVs and Orders prohibiting the individual
from participating in NRC licensed activities. The NRC typically does
not issue civil penalties to individuals. Discretion may be exercised
in determining the appropriate final enforcement sanction to be taken.
Based on their safety and regulatory significance, violations are
categorized into one of four severity levels, with Severity Level I
being the most significant and Severity Level IV being the least
significant. Severity Level IV violations are considered very low
significance in nature and are not considered for escalated
enforcement. Severity Level I, II, and III violations are considered
for escalated enforcement and a civil penalty will be considered as
part of the final sanction. For violations at academic or research
facilities similar to NIST, a base civil penalty, currently $6500, is
considered when escalated enforcement action is taken. If a violation
is considered particularly egregious, an Order modifying, suspending,
or revoking a license may be issued. In determining the proper sanction
and severity level, the NRC will consider factors such as (1) was the
violation a result of a willful act by the licensee or an employee/
contractor of the licensee, (2) was the violation committed by an
official of the licensee, and (3) is it necessary to increase any civil
penalty to deter further recurrence of a serious violation.
Q1b. Can you fine a federal agency or individuals involved in a
mishap?
A1b. The NRC typically does not issue civil penalties to individuals.
However, discretion may be exercised in determining the appropriate
final enforcement sanction to be taken. The NRC has taken escalated
enforcement actions that included civil penalties against federal
facilities and research laboratories in the past.
Q1c. In the past, what type of actions has the NRC taken to respond to
research mishaps involving small amounts of regulated material?
A1c. Three examples of escalated enforcement taken against licensees
involving events similar to the event which occurred at NIST are
summarized below:
In 1996, the Department of Health and Human Services,
National Institute of Health (NIH) was issued a Severity Level
III NOV and a $2,500 Civil Penalty for failure to secure from
unauthorized removal or limit access to licensed materials that
were stored in unrestricted areas. In this case, an increase to
the base civil penalty for a Severity Level III violation was
not warranted because the licensee took effective corrective
action to prevent recurrence of the violation.
In 2000, Oklahoma State University was issued a
Severity Level III NOV without a civil penalty because the
licensee willfully used radioactive material in an unauthorized
location within the facility and the person using the material
was neither properly trained nor authorized to use the
material. Although the violation resulted in contamination of
areas not authorized for use of the licensed material, no
individual exposures greater than regulatory limits occurred.
Due to the low safety significance of the incident, this
violation would normally have been categorized as Severity
Level IV. However, since there was willfulness associated with
the violation, in accordance with the enforcement policy, it
was categorized as Severity Level III. Although the application
of the civil penalty assessment process would have typically
resulted in a civil penalty being proposed, the NRC decided to
exercise discretion and not assess a civil penalty based on the
licensee's effective corrective actions and the fact that the
violation involved the use of small amounts of tritium
representing a low risk to the health and safety of workers.
In 2001, a Severity Level I Notice of Violation and
an $11,000 civil penalty was issued to Southeast Missouri State
University for an event which resulted in a radiation dose to
the bone of a contract employee greater than the regulatory
limit of 50 rem. In accordance with the Enforcement Policy,
this overexposure was categorized as a Severity Level I
violation and discretion was used to increase the base civil
penalty for a Severity Level I violation by 100 percent because
of the particularly poor performance by the licensee.
Q2. How would you characterize the NRC's role and responsibility in
oversight of small laboratory research, as compared with facilities
with nuclear reactors? Does the NRC provide guidance for structuring
safety regimes in research environments? How do you foster a safe
operating regime in a complex and dynamic setting where prescriptive
rules may be insufficient or counterproductive to the underlying
research?
A2. The NRC regulates all facilities within its jurisdiction based on
the requirements within Title 10 of the Code of Federal Regulations
(CFR). Small laboratory research facilities are very different from
nuclear reactors and are licensed under a different part of these
regulations. Small laboratory research facilities use small quantities
of radioactive materials and the magnitude of risk is significantly
lower than for nuclear reactors. All NRC licensees are required to have
adequate equipment and facilities to protect the public health and
safety, and the environment. Additionally, licensees must be qualified
by training and experience to use the material for the purpose
requested.
It is the responsibility of the licensee to foster a safe working
environment. NRC regulations establish minimum radiation safety
requirements that are generally performance-based. Licensees have
flexibility in how to meet these regulations in developing their
programs and accomplishing their own specific activities. However, NRC
does provide guidance for applicants and licensees to use in developing
their radiation safety programs. This guidance is found in the multi-
volume technical guidance document series entitled, ``NUREG-1556:
Consolidated Guidance About Materials Licenses.'' Each volume in this
series is tailored to the radiation safety requirements for that type
of program and use of radioactive material. The guidance provides
information on all aspects necessary for the safe use of radioactive
material. For example, NRC's guidance includes information on topics
such as training, facilities and equipment, radiation safety program,
safe use of radioactive material, and emergency response. NRC
radioactive materials licensees are inspected by the agency on a
routine basis. The frequency of inspections is commensurate with the
risk to public health and safety posed by radioactive material that
licensees possess. NRC inspectors review a licensee's program against
its license, requirements in the regulations, and sound radiation
safety practices.
Answers to Post-Hearing Questions
Responses by Kenneth C. Rogers, Former Commissioner, U.S. Nuclear
Regulatory Commission
Questions submitted by Representative Phil Gingrey
Q1. On pages 9 and 10 of Dr. Turner's testimony, he lists five
different safety principles that he expects NIST personnel to embrace.
These include the need for effective safety oversight, requirements
that safety staff immediately stop questionable work, and, that
individuals are responsible for their own safe behavior. Dr. Rogers,
would you describe these principles as a sufficient starting point for
designing an effective safety program? In your opinion, what are the
strengths and weaknesses of these policies?
A1. The safety principles that Dr. Turner has listed are all good
starting points. He particularly emphasized training and specific steps
that the Safety Staff and Management must follow to build a safety
culture. He committed to a review of the training requirements that
will be imposed on new or transferred appointees. He stated that NIST
is reviewing the time period during which they could work before having
undergoing laboratory specific safety training, and also the
development by each laboratory/shop of a safety checklist. The current
thirty-day period that new employees can work without appropriate
training is too long in my opinion. These training requirements must
also apply to visiting researchers who are not NIST employees but are
afforded freedom to take scientific initiatives at the laboratories.
One important step that Dr. Turner has taken immediately is to move
the NIST Safety, Health, and Environment Division so that it now
reports directly to the NIST Deputy Director. This should elevate the
status of that Division and give it more authority. I hope that it will
be a permanent change.
The organizational structure, which treats NIST-Boulder as if it
were an integral part of NIST-Gaithersburg with the Boulder Laboratory
Director having no overall line management authority, may have some
useful features, but I failed to appreciate what they might be. The
Director title appears to be largely a ceremonial one. This arrangement
creates an unnecessary degree of uncertainty particularly in an
emergency situation. I would recommend that serious consideration be
given to reviewing and possibly revising the role of the Boulder
Laboratory Director.
In short, I believe that Dr. Turner has put in place an action
program that has the potential for creating a strong safety culture at
all of NIST, and I see no significant weaknesses. However, its success
will take time and continuity of leadership committed to emphasizing
safety in all of NIST's activities will be very important. I understand
that in the past changes in the NIST Director's office have sometimes
resulted in a loss of momentum in strengthening the Institute's safety
commitments. That should not happen again.
Q2. How would you characterize the effectiveness and applicability of
NRC's license requirements for small, research-oriented licensees?
A2. In general, NRC's extensive radioactive source material license
requirements are applicable and have been effective in protecting the
health and safety of the public and the users of the materials.
However, there are very many types of uses (approximately two million
devices use NRC licensed radioactive sources in the U.S.). The
licensing and oversight of these devices is carried out through NRC
Regional Offices not the Washington Headquarters. The Regional staff
required to perform the necessary oversight would be hard pressed to
inspect and follow up inspections at every single licensee unless a
strict priority system for these activities is established and
maintained, and unless licensees conscientiously obey the requirements
of their licenses. NRC has established such a priority system that
takes account of the potential as well as actual hazards posed by the
application of the radioactive material covered by the license.
However, judgment decisions have to be made in applying the priority
system and unless the NRC staff involved are well informed as to the
licensees intentions and capabilities, NRC may not be aware of the need
to reschedule an on site inspection or to explore more deeply the
written or verbal information submitted to them relative to the
license. I believe that lack of timely and complete information at NRC
was one of the problems that led to the Boulder incident.
Q2a. Do the requirements and guidelines provided by the NRC
realistically apply to a dynamic and innovative research setting?
A2a. I believe that they do and can be met without seriously hindering
the quality of the work and the enthusiasm of the researchers, provided
a culture of the importance of safety is established and valued
throughout the organization. However, NRC should take the Boulder
incident as an indicator that its guidelines should be reviewed for
precision and clarity. For example, there is too much imprecision in
the definition of encapsulated sources. Some individuals regarded
encapsulated as identical to sealed. This led to a false sense of
safety and was a contributor to the incident.
Q2b. How would you characterize the NRC's role and responsibility in
oversight of small laboratory research, as compared with facilities
with nuclear reactors?
A2b. In my opinion there are really three not two situations that
should be identified as different: [1.] Small Scale Research, Medical
and Commercial applications; [2.] Research and Test reactors and [3.]
Power reactors. The first and the third categories are the most
difficult regulatory challenges for NRC. The first because of the huge
number and diversity of licensees and the third because of the large
amount of nuclear material on site and the vital importance of
excellent well maintained and highly competent licensee staffs. Close
(essentially daily) regulatory attention must be maintained. I believe
that NRC has performed well in discharging its responsibilities in
situations [1.] and [3.] but needs to continue processes of self-
examination to ensure that its performance is sustained in both of
these. Situation [2.], Research and Test Reactors, poses a different
set of challenges to NRC for it is there that an overly heavy
regulatory hand can be seriously counter productive and stifling. NIST
has laboratories falling into Situation [1.] at Boulder, and Situations
[1.] and [2.] at Gaithersburg Center for Neutron Research. While
imposing licensing requirements appropriate to Situation [1.] across
the board on Gaithersburg poses no problem, simply carrying over
without modification, requirements appropriate to Situation [3.] could
negatively impact the research conducted at the Gaithersburg Center for
Neutron Research without any appreciable improvement in public health
and safety.