Lesson Learned Statement:Clear and timely Contractor-Subcontractor communication is vital to minimize the potential for violations of work permits and radiological worker exposures. Not only are safety and health consequences at risk, but failure to properly communicate performance expectations could lead to fines or other penalties to the company under Price-Anderson Amendments Act (PAAA) provisions. Additionally, the work control agreements between safety and health professionals familiar with Contractor protocols and Subcontractor personnel are essential to safe and efficient work performance.Discussion:On January 12, 1996, at Lockheed Martin Energy Research Corporation (LMER), a radiological work permit (RWP) was issued to manually remove large lead sheets from a contamination area behind Cell 2 of Building 3029. (NOTE: This was a Lockheed Martin Energy Systems (LMES) Environmental Restoration managed project.) The RWP's task description was as follows: 'Manual removal of large lead sheets from area behind Cell 2 and manual support of robot operations during remote lead removal.' The LMER radiological control technician (RCT) and the LMER Facilities Operations Representative approved the RWP based on the knowledge that the lead sheets themselves were not appreciably contaminated and the understanding that the more highly contaminated lead bricks underneath the lead sheets, which were shielding high levels of contamination on the floor, would be moved via a robot following the operating plans. The Subcontractor Engineer also approved the RWP. After the task had been completed (approximately one hour duration), Facility Management personnel (LMER RCT) noted that the more highly contaminated, lead- shielding bricks had been removed by the Subcontractor in addition to the lead sheets. The manual removal of these bricks violated the scope of the RWP, and manual removal of the lead bricks without using long handled tools also represented a departure from the ALARA Plan, the Site Specific Health and Safety Plan, and the Project Operating Plan. APPROVALS FOR THESE CHANGES HAD NOT BEEN OBTAINED, NOR WERE FACILITY OPERATIONS PERSONNEL INFORMED OF THE INTENT TO DEPART FROM THE APPROVED WORK PLANS. As a result of less than adequate radiological controls for the scope of work actually performed, unanticipated contamination of the area and company clothing resulted. Occurrence report ORO-LMES-X10ENVRES-1996-0001 was filed on January 17, 1996. On March 12, 1996, NTS report number NTS-ORO-LMES-X10ENVRES- 1996-001 was filed.Analysis:(Contamination Issues) The two Subcontractor employees involved in the job sustained intakes or suspected intakes of radioactivity, but doses were subsequently determined sufficiently low to be recorded as zero, per site (LMER) procedures. External exposures were small, but one worker exceeded the 20 mrem per entry limit specified in the ALARA Plan by about 5 mrem. Workers also entered areas that exceeded the 50 mrem/hour limit set during the planning for this job. During the work, which was beyond the scope of the RWP, radiation, contamination, and airborne radioactivity levels increased beyond those expected by the LMER RCT and Facility Operations personnel who approved the permit. Respirators with high efficiency particulate air (HEPA) filters were being worn for possible airborne lead protection, but were not required by the RWP for the purpose of radiological protection. High levels of airborne radioactivity were confirmed from both stationary and personal air samplers. Contamination was found in areas of the building that were previously uncontaminated. (Training Issues) An internal investigation determined that the Subcontractor RCT performed tasks for which task-based training had not been completed. The project team was notified by the Subcontractor prior to the beginning of work that all personnel were appropriately trained to the contract requirements. Verification of training received was initiated but not completed. No further additional task- based training had been scheduled at the time of the event. A fully qualified Subcontractor RCT was present during the job but it is apparent that this individual was not supervising tasks performed by the other RCT. Please note that unqualified RCTs may perform tasks for which they have not received training only if they are accompanied by and under the direct supervision of a trained RCT and the assignment is concurrent with training. Additionally, core radiological worker training requirements were not followed by the Subcontractor RCT which led to the spread of contamination. (Communication Issues) The internal investigation team reviewed the event and all of the documents related to the work that was to be performed. During interviews, it became clear that there was some confusion regarding the manual removal of lead bricks. This was caused by a rewrite of the RWP request submitted by the Subcontractor. The Subcontractor had written 'Remove lead shielding from outside cells...,' but the LMER RCT had approved 'Manual removal of large lead sheets from the area behind cell....' It was concluded that the LMER RCT who wrote the RWP and the personnel who performed the work did not have consistent agreement on what the scope of the work was to be. Overall mutual understanding of the work processes and contractual relationships between multiple parties was not clear, i.e., Contractor-Contractor, Contractor-Subcontractor, and Subcontractor-Subcontractor relationships. Roles and responsibilities and delineation of authority to make changes in the planned work scope were not well defined. Additionally, the flow-down of Price- Anderson Amendments Act (PAAA) requirements into subcontracts was not clearly conveyed after January 1, 1996, or understood. (Oversight Issues) It was determined that appropriate personnel did not attend the pre-job briefing prior to initiation of work, including the writer of the RWP. Based on the confusion of the scope of work to be performed, the LMER RCT was not present to oversee the beginning of work. This individual stopped work once it was later realized that the RWP had been violated. The level of oversight to be provided was not well defined. RESOLUTION/Recommended Actions:Due to PAAA implications of this event, all Lockheed Martin Energy Systems (LMES) divisions who request service subcontracts must respond that the recommended actions have been communicated with appropriate personnel. LMES Procedure PC-164, 'Safety and Health Service Subcontracts,' will be revised to underscore PAAA requirements, clearly defining roles and responsibilities, work-process change- control authorities, and levels of oversight to be provided for each job task. The procedure revision will formalize the following actions: (1) Include Contractor safety and health personnel in job planning, work-scope definition, and on-the-job coverage. (2) Give special consideration to assigning additional or enhanced oversight resources for first-time, infrequent, or unique activities, depending upon job scope and its associated hazard or risk level. (3) Hold daily, pre-job briefings at which the Subcontractor Project Manager, the Contractor Project Representative, the Facility Management Representative, and applicable safety and health personnel are in attendance, based on hazard or risk level. (4) Document Contractor and Subcontractor personnel training for the work activities to be performed. Maintain the documentation in the Contractor's Training Management System (database) or verify similar Subcontractor training records.Originator:Lockheed Martin Energy Systems, Central Safety and Health Organization, R. W. Oliver, 423/241-2097Validator:Susan Lowe, 423/574-8242Contact:J. L. McNelly, (423)574-7087Name Of Authorized Derivative Classifier:John W. KogerName Of Reviewing Official:P. L. McKenneyPriority Descriptor:Yellow / CautionKeywords:CONTAMINATION, OVERSIGHT, DEVIATIONS, RADIATION, CONTRACTOR, SUBCONTRACTOR, PAAA, PRICE-ANDERSON, TRAININGReferences:NTS-ORO--LMES-X10ENVRES-1996-001, final report April 12, 1996 Occurrence Report ORO-LMES-X10ENVRES-1996-0001, filed January 17, 1996 Radiological Work Permit 3047-96-0008A Radiological Event Report HAZWS-96-0002 Contract Statement of Work Subcontr.Information in this report is accurate to the best of our knowledge. As means of measuring the effectiveness of this report please use the "Comment" link at the bottom of this page to notify the Lessons Learned Web Site Administrator of any action taken as a result of this report or of any technical inaccuracies you find. Your feedback is important and appreciated. DOE Function / Work Categories:Conduct of Operations - GeneralRadiation Protection ISM Category:Hazard:Radiological Release
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