Lessons to be learned from a tritium release

In December 1991, equipment breakdowns resulted in a tritium release at the Department of Energy's (DOE's) Savannah River K-Reactor. A description of the event is presented with emphasis of human factors lessons to be learned. The authors describe the changes in culture that are occurring within the DOE's nuclear complex as the DOE seeks to adopt the best knowledge within the world technical community. The lessons learned that are described provide a glimpse into over 40 years of experience that the DOE will share with the rest of the nuclear community.<>