Labeling mix-up, utility line cut cause two incidents at LANL plutonium facility

A federal safety board report documents two incidents at Los Alamos National Laboratory’s plutonium facility, PF‑4, late last month, including a Jan. 26 event in which a mislabeled reagent triggered an unexpected chemical reaction and left a worker with respiratory symptoms. The report, cited by the Santa Fe New Mexican and the Defense Nuclear Facilities Safety Board weekly report for the week ending Jan. 30, says hazardous‑material personnel performed the cleanup after the spill.

Workers on Jan. 26 were "loading a reactive reagent, that is, a material intended to kick off or facilitate a chemical reaction, into an aqueous nitrate process," the report summary states. The container carried two labels: a handwritten marker label listing hydroxylamine nitrate and a printed label identifying nitric acid. According to the report, the workers assumed the marker label listing hydroxylamine nitrate was the correct one, but the reagent matched the printed label, nitric acid, which the report describes as an "incompatible" substance that can cause heat and hazardous gas when used as it was on Jan. 26. The mixture overpressurized and caused a spill which, according to the safety board report, was cleaned up by hazardous material personnel.

The report ties the respiratory symptoms to the Jan. 26 chemical reaction. It does not provide hospitalization details or further medical outcome for the affected plutonium facility worker. LANL management told the safety board it would take corrective steps: "Management plans to review labeling practices and perform an extent‑of‑condition review on stored chemicals," the report states.

Two days earlier in the same PF‑4 area, the DNFSB weekly report documents a separate incident in which workers accidentally cut the wrong utility line while preparing to remove lines for glove box upgrades. The lab materials and the DNFSB summary use the phrasing "two days earlier" relative to the Jan. 26 event; the weekly report is for the week ending Jan. 30 and records the utility‑line cutting as a PF‑4 occurrence that same week. The DNFSB account does not specify which utility line was cut or whether any services were disrupted.

Those recent incidents come against a backdrop of earlier LANL safety lessons cataloged in DOE and lab documents. A separate incident record recounts paint particles from a water tank that stayed suspended in the air for 2 to 3 days, and notes that LANL Industrial Hygiene & Safety provided full‑face respirators and training after a contractor could not supply adequate protection; workers later used half‑face respirators and engaged in hygiene failures that included drinking and smoking while working, incorrectly using the decontamination facility, not showering, laundering work clothes at home, removing contamination with compressed air, and frequently breaking respirator seals. Historical monitoring cited in lab lessons shows lead machining air samples above the OSHA permissible exposure limit of 50 μg/m3, with breathing‑zone readings of 60.5 μg/m3 on one day and 302 μg/m3 on another (NA‑LASO‑LANL‑SHOPSFAC‑2009‑0001; ALO‑LA‑LANL‑PHYSTECH‑1995‑0004). An Energy Department Office of Inspector General report in 2018 also criticized LANL’s beryllium oversight.

The DNFSB weekly report for the week ending Jan. 30 and the federal summaries cited by the Santa Fe New Mexican are the primary official records of these PF‑4 events. Key open questions remain: the medical status of the worker who experienced respiratory symptoms, the volume and composition of the spill, which team performed the hazardous cleanup and what monitoring followed, and the timeline and findings for the lab’s promised review of labeling practices and extent‑of‑condition on stored chemicals.