June 27, 2017

More than 30 US nuclear experts inhale uranium: think-tank exposes series of mishaps in Nevada

Nuclear Negligence examines safety weaknesses at U.S. nuclear weapon sites operated by corporate contractors. The Center for Public Integrity’s 4-part probe, based on contractor and government reports and officials involved in bomb-related work, revealed unpublicized accidents at nuclear weapons facilities, including some that caused avoidable radiation exposures. It also discovered that the penalties imposed by the government for these errors were typically small, relative to the tens of millions of dollars the NNSA gives to each of the contractors annually in pure profit.

Key findings

In April and May of 2014, a total of 31 scientists and technicians inhaled potentially cancer-causing uranium particles during laboratory experiments at the Nevada National Security Site, which supports the U.S. nuclear weapons program.
Annoyed by radiation alarms during these experiments, those conducting the experiments switched off electrical circuits also connected to a safety ventilation system. The particles then spewed throughout the room and an adjacent room where scientists congregated before and after the experiments.
The lab investigated the problem slowly, and more than a year passed before some of the affected personnel found out that they had been internally contaminated.
Due to the accident, the reactor that caused the personnel contaminations was switched off from July 2014 until Jan. 2016, delaying work meant to help improve nuclear safety and verify the potency of weapons in the U.S. nuclear arsenal.
A federal investigation after the exposures found safety deficiencies that had been previously flagged by oversight groups but went unfixed for years. But the private firms that operate the Nevada National Security Site received 90 percent or more of the profits available to them from 2013 to 2016.

Most were not told about it until months later, and other mishaps at the Nevada nuclear test site followed.

Not a clue.

The government scientists didn’t know they were breathing in radioactive uranium at the time it was happening. In fact, most didn’t learn about their exposure for months, long after they returned home from the nuclear weapons research center where they had inhaled it.

The entire event was characterized by sloppiness, according to a quiet federal investigation, with multiple warnings issued and ignored in advance, and new episodes of contamination allowed to occur afterward. All of this transpired without public notice by the center.

Here’s how it happened: In April and May 2014, an elite group of 97 nuclear researchers from as far away as the U.K. gathered in a remote corner of Nye County, Nev., at the historic site where the U.S. had exploded hundreds of its nuclear weapons. With nuclear bomb testing ended, the scientists were using a device they called Godiva at the National Criticality Experiments Research Center to test nuclear pulses on a smaller and supposedly safe scale.

The Device Assembly Facility at the Nevada Test Site, where the Godiva device is housed. NNSS.gov

But as the technicians prepared for their experiments that spring — under significant pressure to clear a major backlog of work and to operate the machine at what a report called Godiva’s “upper energy range”— they committed several grievous errors, according to government reports.

The machine had been moved to Nevada nine years earlier from Los Alamos, N.M. But a shroud, descriptively called Top Hat, which should have covered the machine and prevented the escape of any loose radioactive particles, was not reinstalled when it was reassembled in 2012.

Also, because Godiva’s bursts tended to set off multiple radiation alarms in the center, the experimenters decided to switch the alarm system off. But because the alarms were connected to the ventilation and air filter system for the room, those were shut off as well. The only ventilation remaining was a small exhaust fan that vented into an adjacent anteroom where researchers gathered before and after experiments.

On June 16, 2014, a month after the experiments were completed, technicians doing routine tests made an alarming discovery — radioactive particles were in the anteroom. They then checked the room holding Godiva, and found radiation 20 times more intense there. The Nevada site’s managers, who work for a group of private, profit-making contractors — like most U.S. nuclear weapons personnel — ordered the rooms decontaminated. But they didn’t immediately check exposures among the scientists and researchers who had gathered for the tests, many of whom had already gone back to their own labs.

None had any clue about the mishap until two months after the experiments, on July 17, when one of them — a researcher from Lawrence Livermore National Laboratory nuclear weapons lab in California — got the results from his routine radiation monitoring. His urine tested positive for exposure to enriched uranium particles.

National Security Technologies, LLC (NSTec), the lead contractor that runs the Nevada site, subsequently collected urine specimens from its own workers who’d been in the room with Godiva during the experiments. It discovered three of its technicians also had inhaled highly-enriched uranium.

News quickly spread, but only among the scientists and their bosses, who were accustomed to a shroud of official secrecy covering their work; no public announcement was made. According to an initial U.S. Department of Energy (DoE) investigative report dated April 28, 2015, calls eventually went out to test the 97 people present for the Godiva experiments. But for reasons that remain unclear the testing went very slowly, and not until 2016 did the DoE state that 31 were discovered to have inhaled uranium.

In a letter last summer to the Los Alamos and Nevada lab directors, National Nuclear Security Administration (NNSA) Administrator Frank Klotz suggested that the employees’ radiation doses were not large — at the high end, they were roughly equivalent to 13 chest x-rays. But once inhaled, uranium particles can keep emitting radiation for years, and so they pose an added cancer risk. Klotz’s letter deemed the exposures “safety-significant and preventable.” It could have been even worse, of course, given the absence of any timely warning.

“DOE views seriously any event in which workers received unplanned radiological uptakes.”
— August 31, 2016, letter from the DOE to Dr. Mark Peters, president of Battelle Energy Alliance LLC, and lab director at Idaho National Laboratory, addressing a release of Americium-241 that resulted in nine workers receiving small intakes. It was signed by Steve Simonson, Director of the Office of Enforcement, Office of Enterprise Assessments.

Lab operations riddled with errors

The four key national facilities involved in the underlying experimentation — Los Alamos National Laboratory, Lawrence Livermore, the Nevada Test Site and Sandia National Laboratory — are among the U.S.’s premier scientific labs. They collectively employ more than 26,000 people engaged in cutting-edge and often dangerous work, governed by myriad nuclear safety regulations, with two major contract enforcement mechanisms meant to inflict financial pain when needed on the private corporations that operate them.

And yet in this case, and in others like it, not only were the labs’ procedures and responses riddled with errors, but even after attention was called to these incidents, other safety mishaps occurred. And the financial penalties imposed by the government didn’t seem to have a major impact on the labs’ conduct.

A review by The Center for Public Integrity (CPI) of more than 60 safety mishaps at 10 nuclear weapons–related federal sites that were flagged in special, internal reports to Washington, along with dozens of interviews of officials and experts, revealed a protective system that is weak, if not truly dysfunctional: Fines are frequently reduced or waived while contractors are awarded large profits. Auditors say labs and production plants are overseen by an inadequately staffed NNSA and DoE, which as a result largely rely on the contractors to police themselves.

The CPI probe, partly based on documents obtained under the Freedom of Information Act, reveals a system in which extra profit is awarded under a rating profile that persistently places higher priority on the nuclear weapons labs’ national security “mission” than on worker protections, putting production far ahead of safety. Experts say it is a practice in keeping with a culture of urgent, no-holds-barred work that took root in the nuclear weapons complex during World War II. These production pressures flow down to the highly secured rooms where workers labor with special clearances, routinely handling highly toxic and explosive materials.

The DoE typically gives the private companies involved a financial bonus when they accomplish their missions on a deadline, notes Ralph Stanton, one of 16 workers exposed to radiation in an incident at Idaho National Laboratory in 2011. “When the [bonus] milestone is in play” — meaning on the occasions corporate lab operators gain extra pay by meeting production deadlines — some of the workers feel that “safety is completely gone.”

Tracy Bower, a spokesperson for the contractors that operate the Nevada Test Site, said its performance “scores” are high and that “our primary concern has been and continues to be the safety of our employees and our community.”

When the Nevada accident occurred, the Godiva experiments had considerable urgency. After being moved to Nevada from Los Alamos, the machine was originally supposed to resume operations in 2010, near three similar machines inside a tubular-shaped building about the size of two football fields, with a striking white top barely visible aboveground because it is swaddled in compacted earth.

But in August of that year the Defense Nuclear Facilities Safety Board, an independent federal safety agency that monitors nuclear weapons operations, warned in a letter to NNSA that it was concerned about “deficiencies” at the experimental facility housing Godiva, including potentially unreliable radiation alarms. Neither NNSA nor the site’s private contractor had “conducted sufficiently detailed design reviews of the facility,” the board’s chair, Peter Winokur, wrote.

Godiva’s operation was postponed, but the controlled bursts of radiation were finally restarted in September 2013. That same month the DoE’s Office of Inspector General warned that some safety issues persisted with Godiva, including flaws in some instrumentation related to safety and incomplete documents meant to guide workers safely through their tasks. The inspector general’s report also warned that more than a third of the time, when the contractors involved said they had fixed problems flagged by the government, they hadn’t actually done so. The inspector general blamed the delays and problems, in part, on “weaknesses in federal oversight.”

A workplace hazardous to whistleblowers

But inadequate supervision from Washington was only part of the problem. According to a separate August 2013 report by the DoE’s workplace health and safety office, the leaders of NSTec were generally inattentive to workers’ safety concerns and resentful of NNSA oversight. Amid a rise in workplace injury and illnesses at the site — which the report did not explain — the contractor had depicted the government’s inquiries about it as an “overreaction.”

The report said that because the contractor did not consistently encourage open communications, frontline workers feared retaliation if they complained to their supervisors about safety issues. It said two such cases of retaliation surfaced during the safety office’s inquiry. Overall, the report said, significant stresses existed on the site’s “safety and security culture” and there were “indications of a chilling effect” on worried workers.

It was against this backdrop that the Godiva contaminations played out over several months the following year. The device is an ugly stack of high-tech machinery, shelving and wires that stands as tall as a man. Inside are rings and blocks of highly enriched uranium, a key nuclear explosive; they are made to fission, just slightly, when they are delicately moved closer by at least two technicians.

The point is to generate modest bursts of radiation useful for researching nuclear power, training nuclear safety experts, predicting weapons effects and making bomb components less vulnerable to radiation storms in a nuclear war. Those who gathered for the experiments came from Los Alamos, which oversaw the work; Lawrence Livermore; Sandia; Pacific Northwest National Laboratory in Washington State; Oak Ridge National Laboratory in Tennessee; the Nevada Field Office of the National Nuclear Security Administration; and the U.K.’s Atomic Weapons Establishment.

In a push to make up for lost time, experimentation on Godiva was placed on an accelerated schedule. As a September 2016 report detailing the NNSA’s review of the contaminations noted, “During April and May 2014, there was an increased campaign of Godiva burst operations, some of which were in the upper energy range of Godiva’s capability.”

All the while, with radiation alarms silenced, the particles of uranium were being piped into the main Godiva room and an area where experimenters thought they’d be safe. Although the contamination started showing up in June, it was not until August 7, 2014, that the DoE’s Nevada Field Office at the site shut down Godiva’s operations.

Another 11 days passed before technicians noted even higher contamination levels inside the room that housed the machine. The contractors involved — from Los Alamos, Lawrence Livermore and the Nevada test site — didn’t determine that this incident merited a formal safety report to Washington for another two weeks.

A spokesperson for NNSA, Greg Wolf, wrote in an e-mail that all the exposure levels were below regulatory limits and posed minimal health risks. He wrote Godiva’s operations are now being closely monitored and that the contractors that run Nevada and Los Alamos “take any unexpected exposure seriously.”

Still, with those types of exposures, “there is some incremental risk that you might get cancer,” said Joel Lubenau, a certified health physicist, industry consultant and former senior adviser to a chair of the Nuclear Regulatory Commission. He said the degree of risk depended on how large the particles were and whether they were soluble enough to enter the bloodstream and reach key organs. He also said he was highly surprised to hear the alarms had been turned off and that the protective shroud was never installed.

No fines for repeated safety infractions

The fallout from the episode went on for years. On October 21, 2014, four months after the original Godiva leakage, technicians detected excess radioactive particle contamination outside the Flattop critical assembly device, another open-faced radiation-burst machine similar to Godiva, located in an adjacent building.

Contamination also showed up again in the Godiva equipment room. A week later workers shut down Flattop. But oddly, “no formal causal analysis was performed,” according to a 2016 settlement order summarizing DoE investigative findings on the Godiva incident. It was assumed that it was all related to Godiva, the order disclosed.

The settlement order called the Godiva room’s monitoring system inadequate, the hazard controls “insufficiently designed and implemented,” and the management response “slow” and “less than adequate.” But because the NNSA had docked contractors’ profits — $87,000 for NSTec and $500,000 for Los Alamos National Security, LLC — due to overall operational shortcomings, it levied no fines specific to the safety infractions.

And following a common pattern, these events amounted to only a portion of the documented mishaps at both labs during this period. In September 2013, for example, security personnel at the Nevada site unexpectedly found a trailer full of Los Alamos’s low-level radioactive waste sitting in a parking lot outside Gate 100 of the Nevada site. The trailer had been sent there for disposal but the site had refused to accept it because it lacked appropriate shipping papers describing the trailer’s contents, so it was left in the parking lot for a week.

After an investigation, Los Alamos voluntarily suspended its shipment of low-level waste to Nevada. Due to continuing problems with paperwork, Los Alamos wasn’t cleared to restart its waste shipments to Nevada until September 15, 2014, a full year after the trailer was discovered.

Read the full report here.