The result, said the 62-page report by the NIST Ionizing Radiation Committee (pdf), was the spread of plutonium contamination at the lab and into the Boulder sewer system.
Specifically, the investigators found:
• Three plutonium sources were acquired without adequate hazard analysis or management approval.
• When the plutonium was received, all protective barriers were removed except the screw-topped glass bottle in a sealed plastic bag.
• Inexperienced and untrained researchers worked on the project.
• The work area was neither restricted nor controlled for radiological work and was in a busy, multi-use laboratory.