Nuclear Waste Leak Caused by a Typo

man-using-computer-mdThe title is a simplification. A drum of nuclear waste did leak after organic material was mixed with acidic waste because of a typo in a procedure. However, the fiasco began with pressure to meet a deadline related to renewal of a multi-billion dollar contract.

Los Alamos Laboratory was well on its way to meeting a mid-2014 deadline to ship radioactive waste to the Waste Isolation Pilot Plant (WIPP) in New Mexico when workers came across a batch of waste that was “extraordinarily acidic” (pH 0) and therefore unsafe to ship. Guidelines called for a rigid set of reviews to determine how to properly treat the waste before proceeding. That time-consuming process apparently jeopardized the deadline. Instead, neutralizer and kitty litter were added, and the drum was shipped to WIPP. The documents accompanying the drum made no mention of the original acidity, neutralizer, or type of kitty litter.

The campaign to clear waste from Los Alamos was more than 90 percent complete when the contents of the drum reacted and the drum’s lid breached in the underground WIPP disposal area. The exothermic reaction of the contents threatened dozens of nearby drums. One source says 21 workers “…were contaminated with what federal officials have described as low levels of radiation.” A statement from LANL “…said scientific testing has eliminated the explosive nature of the waste as the cause of the radiation leak.”

As a retired worker from Rocky Flats’ plutonium area, at this point I was thoroughly puzzled.  As long as neutralization was complete before sealing the drum, what could go wrong? Kitty litter – granulated clay – is commonly and successfully used in many industries to absorb liquids. Hmmmm? Why did the drum over-pressurize and breach the lid?

A procedural revision approved by LANL, effective August 1, 2012, directed waste packagers to “Ensure an organic absorbent (kitty litter) is added to the waste when packaging drums of nitrate salt.” Proof readers apparently didn’t notice that the word should have been “inorganic” and not “organic.” The correct kitty litter is “a clay-based material—not the more combustible organic variety that most chemists would have recognized as hazardous if mixed with wastes laden with nitrate salts… Officials at LANL declined to comment about whether a typographical error led to the switch to organic kitty litter.” But a news report says “The combination turned the waste into a potential bomb that one chemist later characterized as akin to plastic explosives.”

WIPP remains shut down “…as an estimated $500 million recovery effort expected to last several years gets underway, leaving thousands of containers of nuclear waste destined for WIPP stranded at national laboratories across the country.” That’s one expensive typo. But, as noted in this review, “‘trivial events in non-trivial systems’ can lead to significant problems. Some of these incidents sound ridiculous… blame may be placed on human error, but ‘the real problem lay deeply embedded within the technological systems… what appeared to be… a one-in-a-million accident was actually to be expected. It was normal.'”

Maybe a mindset of “organic is better” was out of control here, so workers missed the mistake. I doubt most cats care if their litter box is filled with old-fashioned clay or some sort of organic material. As for that multi-billion dollar contract – “The contractor, Los Alamos National Security, saw its fee reduced 90% because of the accident… also the duration of the management contract [reduced] by one year.”

Thanks to RF_alum for researching and drafting this post.


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