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Briefings & Information Aldermaston: Behind closed doorsSeptember 1999 IntroductionThe Atomic Weapons Establishment (AWE) at Aldermaston is at the heart of Britain's nuclear weapons production. It is here that nuclear warheads are designed, constructed, and later decommissioned. Aldermaston deals with some of the most dangerous materials known to humankind on a daily basis. Materials that require the highest levels of efficient management and effective health and safety procedures. Six years ago a report by Greenpeace entitled ‘Inside the Citadel’ revealed a shocking catalogue of accidents and extensive environmental contamination at Aldermaston. It concluded that many serious problems at the site, originally identified by a 1978 government commissioned report into safety, still existed. In response, Reading Borough Council established a community enquiry, whose chair, Helena Kennedy, QC, recommended that there should be "a full public enquiry into the health, environmental and safety aspects of AWE Aldermaston" and that this enquiry was "well overdue." Six years on this enquiry is even further overdue. Since then management of the AWE site has been taken over by Hunting BRAE plc. They have made efforts to increase transparency and established a ‘Local Liaison Committee’ to engage in dialogue with local councils and the community. But behind the glossy brochures and ‘dialogue processes’ has anything really changed? This report takes us once again inside the citadel to find out. The report is particularly timely, as the contract for managing AWE Aldermaston is currently up for review. It also coincides with the issuing of a consultative document by the Environment Agency looking at Aldermaston's environmental discharges. The information in this report is based on extensive research by CND, during which unprecedented access was gained to AWE's own internal documents, and official reviews of the site, via Parliamentary Questions. The back-up documentation is available on request Summary of report findingsAnalysis of official reviews of AWE • However, an analysis of reviews of the site undertaken between 1986 and 1998 by the Health and Safety Executive, Radioactive Waste Management Advisory Committee and National Audit Office indicate that many of the health and safety and environmental issues raised in the 1978 'Pochin Report' remain problems today. • Specifically, nuclear waste storage, accident/incident levels, risk assessments, safety training and implementation and controls to prevent 'criticality accidents' are ongoing problems. Poor worker safety • Repeat accidents: Between 1984 and 1996 there were four separate accidents involving leaking plutonium stores. In all, fourteen workers suffered internal contamination. Yet the problems of faulty plutonium stores is still not solved and as of December 1998 workers were boycotting work on them. • Repeat accidents:
failure to have adequate procedures to protect workers in areas where
hazardous tasks involving radioactive materials were underway has led
to seven workers being internally contaminated with plutonium, in two
separate incidents. • Following a 1993 leak of radioactive tritium, soil on site was contaminated with tritium one hundred and fifty times above normal levels. • The groundwater below the site is extensively contaminated with tritium, the source of which remains unknown to AWE management. • Since 1993 AWE illegally discharged heavily tritium-contaminated groundwater into the local stream; • Liquid waste
continues to be pumped out to the Thames down the ageing 'Pangbourne Pipeline'.
Flaking off of plutonium and uranium 'scale' that has built up on the
inside of the pipe over its forty years of use is causing a doubling in
intended discharge levels. Facilities called
for twenty years ago have still not been built: Inadequate nuclear
stores continue to be used: • AWE continues to use converted laboratories from the 1950's to store Intermediate Level nuclear waste, despite concerns of the HSE. • Plutonium sludge remains stored in tanks described as being of 'uncertain structural condition' by the HSE. The site is running
out of space for storing nuclear waste: Secrecy continues
to over-ride public interest: • The illegal tritium discharges into the local stream were not revealed to the regulators, according to the Environment Agency, until 1997. • Information regarding tritium contamination and increases in discharges from the site was omitted from environmental monitoring reports issued to the Local Liaison Committee, for reasons of 'national security'. • Accidents involving radioactive contamination of workers and the site were omitted from a 'comprehensive' list of accidents supplied to the Local Liaison Committee. RecommendationsCND believes that AWE Aldermaston should cease to produce nuclear weapons and turn its energies to decommissioning UK nuclear weapons and cleaning up the Aldermaston site. At the same time scientific work at Aldermaston should focus on developing technologies for nuclear disarmament verification that will be needed to implement a global nuclear weapons ban. CND calls for: • The government, through the Department of Environment, Transport and the Regions, to take back control of AWE and have direct responsibility for environment and health and safety matters. • A full and open independent public enquiry. • Genuine openness and accountability by the managers of AWE Aldernmaston. • The implementation of recommendations made by previous reports into health and safety and radioactive waste management. • Closure of the Pangbourne pipeline. • Construction of a size reduction facility and solid waste treatment facility. • Development of a realistic nuclear waste storage strategy, within the next twelve months, for public consultation. • Development of a five year plan to clean up the radioactive and toxic contamination on site. The Atomic Weapons Establishment Aldermaston (AWE): A brief history AWE Aldermaston sits on a former World War II airfield and over 1,000 buildings are sprawled over the 880 acre site. In the spring of 1951the first building was completed on site and in April of the following year the main warhead fabrication plant (A1.1) was completed. Six months later Britain carried out its first nuclear test. Throughout its 47 year history AWE has been beleaguered by management and health and safety problems and as a result a number of changes have been made to how the site is run. Aldermaston started off under the control of the Ministry of Supply, then by the United Kingdom Atomic Energy Authority, then in 1973 it was taken over by the Ministry of Defence with senior existing Aldermaston staff put in charge of the site. Ten years later the MoD Procurement Executive Controllerate of Research and Development Establishment took over control. Four year later, in 1987, when Royal Ordnance was being sold off, the two Royal Ordnance Factories that were the other legs of the nuclear weapons production complex triad, Burghfield and Llanishen, were renamed Atomic Weapons Establishment (AWE) and formed up with Aldermaston to create the AWE group. Two years after this, the Government announced it intended to employ a private company to come in and run Britain’s Atomic Weapons Establishments under an arrangement known as ‘GOCO’ (Government Owned/Contractor Operated). AWE was contractorised on 1 April 1993 and is currently managed and operated on behalf of MoD by Hunting BRAE Ltd. Hunting BRAE Ltd consists of three companies - Hunting Engineering (51%), Brown & Root (31%) and Atomic Energy Authority Technology (18%). One of their first acts was to ‘downsize’ the AWE complex to two sites, Aldermaston and Burghfield and to close AWE Foulness and Llanishen. Despite all these changes, the function of the Atomic Weapons Establishments at Aldermaston and Burghfield has little changed. These two sites remain at the heart of Britain’s nuclear weapons complex, staff there research, design, develop and manufacture nuclear weapons and when they reach the end of their life they dismantle and dispose of them. Hazardous material on site Tritium It is one of the least serious of the radioactive materials used on site, as it emits beta particles which are very weak and will not penetrate unbroken skin, also it has a short half life of just 12.2 years. However tritium is very reactive. It combines easily with other substances (such as air, water and many metals) releasing a great deal of heat. When it combines with metals the surface of the metal becomes radioactive. Tritium is most dangerous when combined with water or water vapour. Radioactive "tritiated water" is easily absorbed by the body via inhalation or absorption through the skin and is then mistaken for ordinary water and quickly distributed throughout the body. As a weak beta emitter, when absorbed, ingested or inhaled, tritium deposits all of its energy into the chromosomes in cell nuclei and can result in severe damage to a persons DNA macromolecule, the critical site for the effects of radiation. While researchers differ about the relative dangers of exposure to high levels of tritium, several studies have linked high tritium discharges to cancers and birth deformities including Down’s syndrome. Plutonium Nuclear weapons principally use plutonium 239 (Pu239) whose half-life is 24,365 years. Pu239 emits alpha particles which cannot penetrate the skin, so the main hazard to the body is when it is ingested, inhaled or taken directly into the blood stream through an open wound. If plutonium enters the bloodstream it concentrates in the bones and the liver. A few months after exposure 80 to 90 per cent of the total body burden of plutonium will be found in the skeleton, absorbed into the surface of newly formed bone. Such bone deposition may produce bone diseases (including cancer) many years later. Absorbed plutonium is held in the body for a lifetime and will continue to emit alpha particles and cause damage wherever it is in the body. A small dose of plutonium can result many years later in bone cancer, chronic anaemia, osteoporosis, and in bone necrosis which may produce spontaneous bone fractures. Such results may be expected 10, 20 or even 30 years after deposition, depending upon the size of the dose. [Extracted from "Nuclear Accident Procedures Course, the hazards of a nuclear weapon accident", The Royal Naval College, Greenwich, October 1987] Uranium The half life of uranium is 4.5 billion years. It is the amount of U235 which determines the economic and military value of uranium. For most nuclear reactor fuel the proportion of U235 must be increased to 3-4%. This is a process known as enrichment. A nuclear bomb, like the one dropped on Hiroshima would need have at least 60-90% U235. Uranium is an alpha emitter and causes similar radiation hazards to plutonium. In addition uranium can cause a form of heavy metal poisoning, with symptoms similar to lead poisoning, if it gets inside the body. As with plutonium, bringing together a critical mass of U235 will result in a spontaneous fission chain. Analysis of Reviews of AWE 1978-1998Pochin Report 1978 Pochin’s report delivered two months later was scathing and detailed 73 recommendations for changes at the site. The full report has never been publicly released. However, from the edited, declassified version the following information emerged: Pochin felt that the level of health protection for workers against inhaled plutonium was of "borderline adequacy".1 He concluded that "air concentration of alpha-emitting radionuclides, including plutonium, commonly exceed the limits… particularly in the Industrial Chemistry Group and in the laundry". Staff cutbacks and shortages at Aldermaston, particularly among health and maintenance staff, were identified as a major safety risk.2 Specifically a lack of ‘Health Physics’ staff meant that safety-related tasks such as checking contamination levels in buildings and glove boxes, investigating the causes of high levels of radiation and rehearsing emergency procedures were being left undone. Pochin also identified a "progressive reduction in maintenance staff" which was "erroneous".3 He stated "Operations as complex as some are at Aldermaston, and equipment that is as potentially hazardous if not carefully maintained, require a redundancy and not a shortage of maintenance effort". The report singled out the Waste Management Complex at Aldermaston for particular criticism. The buildings and the ground between them were found to be contaminated with radioactivity from past operations. The buildings were judged to be badly design and the area badly run. Criticisms included that buildings had ventilation systems that blew contaminants into workers faces, there was inadequate containment during the precipitation of radioactive sludge and the drumming of both radioactive sludge and solid waste and there were numerous dust traps which allowed contaminants to build up and made the buildings difficult to clean. Housekeeping in this area was found to be deplorable, for instance drums of waste were found abandoned in a process room inside the liquid effluent treatment plant and piles of waste dumped outside - "said to have been there for years".4 The liquid waste treatment plant was felt to be "unsuitable for use in a radiation process"5 and the solid waste treatment facility was "badly constructed, contained plant felt to be inappropriate for the work and in poor condition, employed bad work systems and had unsatisfactory ventilation".6 Overall, Pochin felt that problems in the Waste Management Complex were so severe that they could not be solved within the existing structures. In the immediate short term work could probably resume with extra maintenance support and careful monitoring of contamination levels. But in the longer term an adequate standard of safety could never be achieved by "a series of only partly adequate modifications"7 Pochin urged that "as soon as practicable… it would seem essential to relocate these difficult processes in buildings designed from the start to ensure good containment, efficient ventilation, and an adequate amount of mechanisation."8Specifically he said that a new facility was needed to process contaminated heavy equipment and that buildings where solid and liquid radioactive wastes were processed should be replaced. National Audit Office Report 1990In 1990 the National Audit Office (NAO) carried out an examination of the Ministry of Defence’s ability to plan, manage and control nuclear warhead research and support services carried out by AWE at Aldermaston. However, it also touched on areas of relevance to this report. Specifically the review stated that AWE suffered from "longstanding problems in working practices, attitudes, motivation and management, leading to inefficiency", but that although proposals had been made to implement various recommendations "action has been limited". The NAO noted that "staff shortages have limited the amount of routine preventive site maintenance undertaken, and the extent of the resultant backlog of maintenance work has not been identified…" The NAO were highly critical of management and "identified important inefficiencies and management weaknesses, particularly in the support services area, which continue to result in poor utilisation of the available manpower resources." Furthermore, that because of the massive new build programme on-site "there has been a build-up of decommissioning work" which coupled with manpower shortages was making this task more problematic. This review was one of many that led to the Government placing Aldermaston and the other Atomic weapons Establishments under private management. This NAO review remains classified and unavailable to the public. Inside the Citadel Report 1993In 1993 Greenpeace published an investigation into Aldermaston, which looked at whether Pochin’s recommendations had been implemented. Its conclusions were disturbing. It found that Aldermaston still had chronic staff shortages, particularly amongst health physics and maintenance staff. The report also found that of the new facilities that Pochin had called for in order for the site to deal more effectively with nuclear wastes were still not in operation. Specifically the building of a solid waste plant and a plant to process contaminated heavy equipment had not even been started. Furthermore the report revealed that almost 100 workers had been contaminated, injured or killed at Aldermaston since 1951. They also detailed 58 accidents and safety related incidents between 1955 and 1992. An inventory that included fires, explosions, leaks of radiation and worker contamination. Finally it concluded that standards of ‘housekeeping’ on site remained poor. The Health and Safety Executive Review of 1993Following close on the heels of privatisation, the Health and Safety Executive (HSE) announced that they were going to conduct a review of the Atomic weapons Establishments. The review took a year to complete and concentrated on health and safety management systems particularly focusing on high risk areas. Their conclusion was that "a number of areas referred to in the Pochin Report remain issues today… They include maintenance, communications, risk assessment and the training of managers".9 The details: The HSE Review Team did not paint a good picture of health and safety practices at the Atomic Weapons Establishments. HSE expressed the view that "A number of older facilities did not meet current design standards and equipment in new facilities were better. Nevertheless, taken as a whole, standards did not come up to those found elsewhere in high hazard industries, including the nuclear industry."11 The Review Team
found: 2 "Significant weaknesses" in AWE’s emergency planning and exercise arrangements; 3 An absence of "systematic assessments of the causes of plant and human failure"; 4 "Risk assessments of high hazard activities were not sufficiently comprehensive or systematic, and did not meet current standards on licensed nuclear sites and in other high hazard industries." 5 "AWE’s stated policy placed a welcome emphasis on giving safety priority over production in the event of a conflict, but the management arrangements to deliver this policy were inadequate in a number of respects." 6 "There were significant weaknesses in arrangements to manage the health and safety of maintenance workers, most of which reflected weaknesses across the rest of the organisation." 7 "Taken as a whole, control over safety during the design of new facilities and modifications fell short of good practice at licensed nuclear sites and in the high hazard chemical industry; this was particularly so in relation to the modification of existing plant." 8 "…significant shortcomings in risk control at the workplace which should have been picked up internally if effective monitoring had been in place. Examples included inoperative locks on explosives processing facilities and poor standards in facilities for handling toxic waste…" [Part 1, para 150] 9. "Criteria for internal reporting of abnormal events were not clear. Some of those interviewed said that events which were significant in relation to safety were not reported because they were not 'abnormal', but a relatively frequent occurrence (for example minor fires in glove boxes which did not lead to a radiation risk). Plant failures were generally logged locally rather than as part of the abnormal event system and so could not be examined centrally. When compared with other work places, the pattern of reporting at AWE suggested that there was probably under-reporting of non-injury events." [Part 1, para 155] 10 "There were significant shortcomings in risk assessment. The most important of these related to the organisation's approach to the assessment of risk from high hazard plant." [Part 1, para 114] 11 "In general assessment of general industrial risks was poorly covered. With few exceptions, the COSHH assessments examined by the team were inadequate…" [Part 1, para 117] 12 There were "serious inadequacies in plant records and drawings. In these circumstances the organisation could not demonstrate the adequacy of maintenance arrangements." [Part 1, para 119] 13 "Significant shortcomings and inconsistencies were identified in AWE safety documentation. Examples included work instructions on display which cross-referred to other documents which were not available; and a poorly structured site emergency plan, which was difficult to use and out of date in some respects." [Part 1, para 72] 14 "… the system for safety related training was fragmented… The review team considered that the inadequacy of health and safety management training was a serious shortcoming… The fragmented nature of AWE's safety training system was further weakened by poor communications…" [Part 1., paras 82-87] 15 "The review team found significant shortcomings in the design and use of AWE's permit to work systems. There was confusion about what the systems were intended to do and how they should operate. As a result, a number of situations were found where work was being carried out under a permit without the appropriate safeguards having been specified." [Part 1, para 121] 16 "The review team found evidence of significant weaknesses in management systems for controlling the important safety-related issues of the modification of existing plant and the design of new plant." [Part 1, para 122] The Reading Community Inquiry 1994This was established following the revelations contained in Inside the Citadel. In December 1993 Reading Borough Council’s Health and Environmental Services Committee, following AWE’s refusal to address the Committee, and following a resolution by Newbury District Council that an ‘independent inquiry’ should be established, decided that they would set up a ‘Community Inquiry’. Its terms of reference were: "To hear and evaluate the views and concerns of persons, groups or organisations regarding any immediate or future risks or threats in the wider area surrounding AWE and the environment, whether from routine operations or accidental affects, and to advise on how such views and concerns may be addressed." Helena Kennedy, QC, was asked to chair the inquiry and it took twelve hours of evidence over two days from 45 witnesses. A further substantial number of written submissions were also received. Representatives of AWE attended and gave public as well as private evidence. As Helena Kennedy stated in her report, published in mid April, 1994: "Having listened to the witnesses give their evidence to the Inquiry the main factor that rapidly became apparent was that there was a general lack of knowledge concerning AWE. This absence of any good quality information upon which people could rely and whose source they could trust inevitably meant that the workings of AWE and its health and safety levels became susceptible to rumour, misinformation, myth and exaggeration…" Her report concluded: "It is my opinion that a full public inquiry into the health, environmental and safety aspects of AWE Aldermaston and Burghfield is long overdue. The government should hold this inquiry before the end of 1994. . . such a move would be helpful to those living near to AWE as it would free anxieties and act as a pressure relief valve allowing for better communication between the AWE management and the public. The steps taken by AWE in giving the public more information are a step in the right direction. However, nothing other than the proposed inquiry will meet the criticisms of those potentially affected by AWE’s activities who must have a right to know just what risks, if any, they are being subjected to". Review by the Radioactive Waste Management Advisory Committee (RWMAC) 1994/5The purpose of this review was to assess the practice of radioactive waste management at MoD sites was carried out with the same degree of care as that at civil sites. Visits were made to MoD sites across the country from late 1994 till early 1995. On AWE Aldermaston the Committee felt that: "In general, the standards of radioactive waste management normally applied in the civil nuclear industry were being met. However, recognising that the origins of AWE lie with the large-scale use of radioactive materials in this country, and so standards might be expected to be at the forefront, aspects of practice were disappointing. There were too many incidents in 1993 for a well controlled site, and ILW storage and management were in part deficient…"12 On the storage of solid Intermediate Level nuclear waste (ILW) on site RWMAC expressed the view that "there was a significant space problem with regard to the provision of good quality, long-term storage comparable in type to that used in the civil nuclear industry." They also noted that "some of the ILW stores inspected were not constructed for long-term use, and did not permit regular monitoring and checking of ILW stocks." On the decommissioning of old facilities RWMAC felt that there would be "inherent difficulties in decommissioning facilities which had not been constructed with decommissioning in mind…" Regarding the treatment of liquid radioactive waste, mention was made of continuing problems with the new liquid waste treatment plant and that since 1984 plutonium bearing sludges had been accumulating on-site awaiting a treatment plant to be built. RWMAC painted a worrying picture of the state of the liquid waste discharge pipeline that runs from Aldermaston to the Thames. Apparently a layer of contaminated scale has built up in the pipe over the years and some of it is now flaking off into the discharges. According to RWMAC "an increase in activity along the line of the pipeline has been observed associated with scale leaching." Review by the Health And Safety Executive 1998Four years on from the RWMAC visit HSE reviewed AWE Waste Management Facilities. Regarding the plutonium bearing sludge tanks HSE expressed concern at their "uncertain structural condition". They felt that this waste "is not stored in a passive state", "is potentially highly mobile" and that "the tanks were not designed for their current function." HSE regarded it as a "matter of urgency" that this waste is retrieved and made safe and want a plant that will do so in operation by 2002. They revealed that of the nine ILW stores on site three were deemed to be unsuitable for use as long term stores because two of them were converted laboratories from the 1950s and the other was purpose built in the 1970s. All three of these stores are to be emptied and the waste moved to the six existing modern factory unit style construction nuclear waste stores. The review concluded that: "The solid ILW store structures may be suitable for a further 25 years. However, the ILW has not been conditioned for long term storage. Hunting BRAE needs to develop its plans to condition and reduce the volume of its solid wastes. More waste stores will be needed by 2005 if volume reduction is not carried out. Sludges are stored in unsuitable facilities of uncertain structural condition. Hunting BRAE needs to ensure that a sludge treatment facility is fully operational by the end of 2002and that a new store be provided for this waste." Poor worker safety Workers contaminated by plutonium due to substandard stores and poor management For fifteen years now AWE has had a problem with safes used to store plutonium being contaminated and with faulty packaging for the plutonium in these safes. This has lead to fourteen workers being contaminated in four separate incidents in the last fourteen years. As of December 1998, areas of the site were being embargoed by workers because this problem had yet to be resolved. The first serious plutonium contamination incident made public – 17 January 1984 Three pieces of plutonium, were first wrapped in aluminium foil, then stored in one heavy duty pvc bag inside another, which was then placed in a tin can fitted with a push-on lid. This can of plutonium was then stored in a safe in June 1983. In October the plutonium pieces were removed from their tin can and stored in another safe in an adjacent building. In January they were moved again and this is when the contamination incident occurred. Six workers were contaminated with plutonium, one extensively, as well as the safe, the trolley and the surrounding area. In the unclassified incident report it was noted that: "It was known that a number of safes contained ‘old’ packages which could leak inside safes which in themselves did not provide radiological containment. We believe there have been intermittent contamination problems at least since the routine survey on 21 October 1983, although there was no evidence that this was particularly associated with the ‘old’ packages. They must however be considered suspect at this time." Accidents are still happening Several incidents have occurred over the years since this problem was first noted in 1984. All appear to have been as a result of problems with plutonium packages in safe and/or intermittent contamination of safes due to leaking/faulty packages. Eight years later, on 8 December 1992, an incident occurred in a plutonium store at Aldermaston. During a routine surveying operation the packaging of a plutonium billet was found to be damaged. Much of the billet had oxidised into a fine powder and contamination was spread onto four workers and into the storage room. One of the recommendations of the Health and Safety Executive from this incident was that "The safety and suitability of safes for storing canned plutonium billets must be assessed and modifications made if necessary." Four members of the team were found to be contaminated. Other staff present withdrew in accordance with instructions and summoned assistance. Doses received were 7.1 mSv, 1.9 mSv, 0.7 mSv and 0.3 mSv. Contamination was contained within the storage area. According to the Health and Safety Executive: "The incident exposed significant weaknesses, both in the storage arrangements and in AWE’s ability to respond to the event. One of the fundamental weaknesses was the failure to recognise before the incident that contamination could occur in the store… the building ventilation system was not designed to control contamination spread. The design standard and quality control of the packaging were deficient, and systems for checking the state of stored material were inadequate." "Failings in the emergency arrangements included confusion in the initial assessment of the situation; restrictions imposed by the Ministry of Defence police (MDP) on the movement of key staff around the site during the emergency; and a lack of protective equipment for MDP use. Staff assigned to establish whether an environmental release had occurred could not carry out their job because they also did not have the protective equipment required." The HSE made a total of 24 recommendations which included: • Adequate, even if temporary, forced ventilation must be installed to maintain a negative pressure in the stores where the incident occurred; • As a matter of urgency, all cans containing certain plutonium billets must be inspected and if necessary repacked; • A regular surveillance regime must be established for all forms of packaged plutonium; • Standards of housekeeping must be improved; • Clear instructions and procedures must be issued to personnel carry out inventory surveillance; • A mechanism must be established for the more rapid assessment of the seriousness of any radiological incident; • Means of more rapidly confirming whether an environmental release has occurred must be established and practised; • The procedures for decontamination, monitoring and counselling of those affected by any radioactive release need to be reviewed, given the distress evident in those involved in the incident; • The airflow patterns in the building affected during the incident need to be more clearly established and documented. Eighteen months later, on 24 March 1994, two workers were contaminated when moving a safe for which authorisation had not been received. The two workers were not normally employed in the building and, according to AWE, they were unaware of the correct procedures to follow. According to Aldermaston,"The failure in this case was the system was not in place to ensure the safety of visiting staff working in the building. The staff normally resident in the building would have known not to move the safe." Presumably because they knew of the problems with safe contamination. Ignorance is no excuse, however. One would have thought that Aldermaston would have by now sorted out this continuing problem with twelve workers contaminated over a period of ten years because of the same problem. This has proved, however, not to be the case. Two years later, on 4 July 1996, a routine check of two containers was carried out. Two workers were found to have been contaminated because the container was damaged. "After an operation to check the contents of two metal containers of radioactive materials external monitoring of the five employees involved indicated that two of them were contaminated. Further tests carried out immediately afterwards then showed that only one person had inhaled measurable contamination. The team were provided with advice and counselling and sent home the same evening. Monitoring continued over a period of weeks on cumulative faecal samples from all five of the team. Final assessment confirmed a dose of 0.84 mSv for the person initially identified and 0.32 mSv for a second team member. Subsequent investigation showed that the contamination originated from a pinhole in the seam of one of the metal containers that was hidden by a label." According to Aldermaston other causes of this contamination incident were "inadequate monitoring for contamination" and "inadequate understanding of procedures for movement of a package". Two and a half years later in December 1998, at a routine meeting to discuss health and safety issues between Trade Unions and management the following note is made: "Unable to perform EMITs due to an embargo on the safes area" in a certain building "due to problems with containers in vaults. An action plan for the periodicity of EMIT checks is being developed based on risk. The meeting agreed that there was still some way to go to deal with this issue. [emphasis added]"16 Over fourteen years, fourteen workers, at least, have been contaminated with internal doses of plutonium. Yet the problem has still not been solved and evidently represents a continuing danger to the Aldermaston workforce. Workers contaminated due to inadequate safety zones On 12 February 1997, five workers were contaminated with uranium because there was an inadequate exclusion zone around the work being carried out whilst changing over a filter in a glovebox. An installed air sampler unit indicated a release of radioactive material had occurred during a filter change operation. An exclusion zone had been established and staff undertaking the work were using protective equipment. Staff in an adjacent area were wearing personal air samplers but were not required to wear additional protective equipment. Five of the six staff in the adjacent area were found to be contaminated. The recorded dose levels where in the range 0.15 mSv to 0.34 mSv. [This incident involved uranium] Other causes were that there was substantial material build up on the filter and the method statement for the task was not followed. Maintenance work on plant and equipment that have been in contact with nuclear materials has an inherent risk to it. There is always the possibility that nuclear materials may be released. Therefore sufficiently large, well-defined and controlled exclusion zones should be a basic health and safety procedure at sites like Aldermaston where such risk is an almost daily occurrence. An ‘exclusion zone’ is basically a strictly controlled and well-defined area where no one without the necessary protective clothing and training can enter. Its purpose is primarily to ensure that no one outside the exclusion can be contaminated if the worst were to occur and there was a release of nuclear material. Aldermaston clearly failed to establish such a zone in this incident and should have carried out immediate actions to ensure there would be no recurrence. This was not to be the case. Some ten months later in December 1997 two more workers were contaminated because, yet again, the ‘exclusion zone’ around the work being carried out was inadequate. This time the HSE acted because they now had the powers under the recently granted nuclear site license and prosecuted. AWE admitted its guilt and was fined a total of £22,000 plus £7,500 costs almost a year later. According to the prosecutor for the HSE the accident "was entirely avoidable and was the outcome of complacency". He also mentioned that inspectors called in to investigate the incident had "discovered widespread deficiencies in management supervision and safety at the establishment". Some of the opening remarks of counsel for the HSE in this case are worth quoting in full: "The Health and Safety investigation revealed widespread deficiencies in management, supervision and safety culture at the Establishment. In particular it seemed that the lessons to be learned from a very similar incident that had occurred in February 1997 were ignored. The accident that took place on 15 December was entirely avoidable."19 15 December 1997 accident: details On 15 December 1997, during the decommissioning of building A45 at Aldermaston a significant quantity of plutonium was accidentally released into the working environment contaminating two workers. A worker was removing a section of pipework attached to a glovebox that contained a filter during the Post Operative Clean Out (POCO) phase of decommissioning a redundant glove box. He removed the wrong part of the pipe and caused widespread plutonium contamination of the area. Two individuals working close by, but outside the ‘exclusion zone’ and, therefore, not wearing protective equipment, inhaled plutonium. Plutonium contamination was so severe that clean-up took some two months under controlled conditions and HSE investigators had to wait for the clean-up before they could view the area where the accident occurred. The HSE took the view that whilst the incident was initiated by the actions of the worker, he was not found to be at fault. Instead, the HSE investigation highlighted that some of the relevant management systems were either not followed or inadequate. Furthermore, HSE investigators believed that if the recommendations from the earlier incident in February 1997 in the same facility had been fully implemented, it would have been unlikely that any individual would have received an internal radiation dose. The Company’s own investigation reached similar conclusions. According to HSE: • AWE failed to "implement a safe system of work for the isolation of services to the glove box, hence the health and safety of their employees was not ensured so far as is reasonably practicable". • AWE failed to ensure that a safe system of work was in place for the persons remaining within the radiation/contamination controlled area, but outside the exclusion zone. • AWE "failed to ensure that an adequate safe system of work was specified for the work on the glovebox, hence all necessary steps to restrict exposure so far as reasonably practicable were not undertaken." • The extent of control and supervision exercised by the suitably qualified and experienced persons appointed for the work was considered to be inadequate for the tasks being undertaken on the glovebox. • There was little evidence of the licensees representatives taking an active role in ensuring that the corporate management systems were implemented within the facility. • Modifications to the plant were performed without approval of the licensee, the instructions for the work were not approved by the licensee and the appropriate supervisors did not visit the workplace prior to the incident. • Inadequate ‘exclusion area’ established, a recommendation of the February 97 incident. • The underlying cause of the incident was inadequate management control. • The use of contractors within the nuclear industry is widespread and the incident illustrated that the licensee was not sufficiently in day to day control of the operations at the site. • The incident could have been prevented if an adequate risk assessment had been undertaken and basic control measures implemented. • The radiation doses to the workers could have been avoided if the recommendations from a previous incident had been fully implemented. Undisclosed accidents The section below identifies several serious accidents which are not contained within the officially compiled list of accidents and incidents at Aldermaston prepared specifically for the Local Liaison Committee and Members of Parliament. This list is supposed to also be continually updated and the Local Liaison Committee are supposed to be kept informed. As the document states, "The attached reports are summaries of incidents since contractorisation of AWE 1 April 1993 when Hunting Brae took over the management and operation of the sites. These summary reports have been issued to the local liaison committee and the company has given an undertaken to update the committee at its quarterly meetings". It is curious that whilst this document claims to cover the period 1 April 1993 to 31 December 1998 it stops at 28 August 1998, thus omitting two serious accidents one in September 1998 the other in either November or December 1998 (see overleaf). A full list of accidents that are known to have occurred over the period 1988 to 1998 appear in the appendix to this document. These have been compiled using AWE internal documents obtained by CND, many of which the public have never seen. 28 June 1993 – on site tritium accident (outlined in detail earlier) The first full public account of this incident appears in the Consultation Document on the application by AWE plc for authorisation to dispose of radioactive waste of August 1999 produced by the Environment Agency. 3 September 1993 – HSE served two prohibition notices on AWE for a Machine coolant sump overflow in the A45 facility as a result of similar incidence to the one of four weeks previous in A37. Because they felt that "all necessary steps to restrict, as far as is reasonably practicable, exposure of employees to ionising radiation have not been taken". 11 November 1993 – The liquid waste treatment plant and the surrounding area were cordoned off for a time due to higher levels of radioactivity than expected being found in one of their ‘high activity sludge tanks. The incident occurred sometime on Thursday, 11 November. The immediate area was evacuated and the plant closed down. The incident occurred because a glob of nuclear material was dislodged from an old pipe that was being cleaned and flushed into the plant. As of Monday 15 November access was allowed to the immediate area and by Wednesday part of the treatment plant was reopened so it could continue to receive liquid waste. The sludge was removed to another area of the site where it will await disposal. 24 March 1994 – Accident outlined previously during which two workers were contaminated with plutonium when moving a safe for which authorisation had not been received. The two workers were not normally employed in the building and, according to AWE, they were unaware of the correct procedures to follow. "The failure in this case was the system was not in place to ensure the safety of visiting staff working in the building. The staff normally resident in the building would have known not to move the safe." 5 October 1996 – A glovebox line was exposed to full extract system pressure causing the gloves to balloon and one of the gloves to fail. The cause was identified to be failure of an air bleed damper motor. The motor was disconnected and the damper set manually to return the pressure to an acceptable level. Aldermaston failed to report the above incident to HSE inspectors who found out about it much later. HSE felt it "could have had potentially more serious consequences". They also noted that "other users of similar equipment at AWE had not been informed." 4 September 1998 – A process worker suffered a contaminated finger wound as a result of a sharp piece of glass or plastic penetrating the rubber glove. Interim assessment set the internal dose received at 2.91 mSv. All glove box work in the facility has been suspended and will restart only when risks have been reassessed and a safe system of work put in place. This same worker has the highest year-to-date dose of any worker put provisionally at 5.46 mSv. Sometime November/December 1998 – "Whilst carrying out an operation to repack RA contaminated Mercury waste packages, one bottle released a mist of powder. There were no known internal doses, however the area required decontamination. The incident is still under investigation, and the facility are developing plans for the recovery operation". Analysis of causes of all incidents, 1993-98 When one looks at the nature and causes of all accidents and incidents at AWE Aldermaston between 1993 and 1998 the conclusion CND reaches is that the management of AWE Aldermaston are still failing in the following areas: • Inadequate overall control of contractors in any or all areas of health and safety; • Inadequately defined and or designed safety procedures; • Inadequate safe design of systems; • Inadequate training of permanent workforce; • Inadequate management of health and safety on-site • Failure to adequately deal with problems arising from past incidents to stop them re-occurring; • Inadequate maintenance programme; • Inadequate criticality control of plutonium and uranium; • Inadequate radiation monitoring; • Inadequate records of status of ‘old equipment’; • Lack of knowledge of contents in stored nuclear waste; • Inadequate ‘safety cases’, and; • Bad housekeeping. |
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