ORPS Operating Experience Report

1)Report Number:

EM--PPPO-LPP-PORTENVRES-2006-0004 After 2003 Redesign

Secretarial Office:

Environmental Management

Lab/Site/Org:

Portsmouth Gaseous Diffusion Plant

Facility Name:

Environmental Restoration

Subject/Title:

Sparks Blackened Shoe During Grinding

Date/Time Discovered:

04/27/2006 13:15 (ETZ)

Date/Time Categorized:

04/27/2006 15:02 (ETZ)

Report Type:

Notification/Final

Report Dates:

Notification	04/27/2006	17:47 (ETZ)
Initial Update	04/27/2006	17:47 (ETZ)
Latest Update	04/27/2006	17:47 (ETZ)
Final	04/27/2006	17:47 (ETZ)

Significance Category:

Reporting Criteria:

10(2) - An event, condition, or series of events that does not meet any of the other reporting criteria, but is determined by the Facility Manager or line management to be of safety significance or of concern to other facilities or activities in the DOE complex. One of the four significance categories should be assigned to the occurrence, based on an evaluation of the potential risks and the corrective actions taken. (1 of 4 criteria - This is a SC 4 occurrence)

Cause Codes:

ISM:

2) Analyze the Hazards

Subcontractor Involved:

Occurrence Description:

An employee was grinding on trip hazards on the floor of the X-3002. The rubber sole of his safety shoe got hot from the sparks. At one point flames were noted by the employee. He put the flame out with his leather glove. The fire watch was present with a fire extinguisher but did not discharge the extinguisher because the flame was already put out. The employee immediately removed his leather steel toe shoe and noted no discoloration to his white socks. The employee was not burned. The outside edge of the sole of his shoe was blackened. There was no damage to the leather top or the inside of the shoe. The work was being conducted under a hot work permit.

Cause Description:

Operating Conditions:

Normal routine maintenance

Activity Category:

Maintenance

Immediate Action(s):

--Grinding was stopped, shoe removed, noted no burn and employee exited area.
--LPP Management notified.
--Safety observed the job site.
--Plant Shift Superintendent (PSS) notified.
--Problem Report generated.
--An Occurrence Report was initiated.
--A Critique was held.

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Division or Project:

Waste Management/GCEP Operations

Plant Area:

System/Building/Equipment:

X-3002 Building, Safety Shoe

Facility Function:

Environmental Restoration Operations

Corrective Action 01:

Target Completion Date:05/31/2006

Tracking ID:20247

Evaluate the possibility of stopping this task and either painting or otherwise marking the remaining trip hazards.

Corrective Action 02:

Target Completion Date:05/15/2006

Tracking ID:20248

Evaluate the possibility of stopping this task and either painting or otherwise marking the remaining trip hazards.

Corrective Action 03:

Target Completion Date:06/15/2006

Tracking ID:20249

Incorporate into hot work permits the use of a fire retardant material to cover articles of clothing including shoes where sparks are present.

Corrective Action 04:

Target Completion Date:05/31/2006

Tracking ID:20250

Issue a lessons learned on this incident.

Lessons(s) Learned:

A formal lessons learned will generated as a corrective action.

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	Paul Kreitz
Phone	(740) 897-4568
Title	LATA/Parallax Portsmouth Project Manager

Originator:

Name	BOOK, JACQUELINE G
Phone	(740) 897-2569
Title	QUALITY PROGRAMS COORDINATOR

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/27/2006	17:16 (ETZ)	Dave Kent	PORTLPP
04/27/2006	17:27 (ETZ)	Paul Kreitz	PORTLPP
04/27/2006	17:33 (ETZ)	John Saluke	DOE-PORT

Authorized Classifier(AC):

Jim McCleery Date: 04/27/2006

2)Report Number:

EM-ID--CWI-WASTEMNGT-2006-0001 After 2003 Redesign

Secretarial Office:

Environmental Management

Lab/Site/Org:

Idaho National Laboratory

Facility Name:

ICPP Waste Management Activities

Subject/Title:

Discovery of a suspect/counterfeit 100 AMP 3 phase circuit breaker (not installed) at CPP-659

Date/Time Discovered:

04/25/2006 15:43 (MTZ)

Date/Time Categorized:

04/25/2006 16:05 (MTZ)

Report Type:

Notification/Final

Report Dates:

Notification	04/27/2006	13:11 (ETZ)
Initial Update	04/27/2006	13:11 (ETZ)
Latest Update	04/27/2006	13:11 (ETZ)
Final	04/27/2006	13:11 (ETZ)

Significance Category:

Reporting Criteria:

4C(2) - Discovery of any suspect/counterfeit item or material other than office supplies, office equipment, or household products.

Cause Codes:

ISM:

4) Perform Work Within Controls

Subcontractor Involved:

Yes
Warbonnet Electric

Occurrence Description:

On 4/26/2006, a suspect/counterfeit 100 amp, 3 phase circuit breaker was discovered prior to installation on the CPP-659 TRU waste handling project. A "Control of Nonconforming Items" report was completed, NCR number 100747.

The Idaho Nuclear Technology and Engineering Center (INTEC) is a U.S. Department of Energy (DOE) nuclear facility. The INTEC is located within the boundaries of the Idaho National Laboratory (INL). CH2M-WG Idaho, LLC (CWI) is the contractor for the INTEC. The mission of the INTEC is environmental cleanup, interim storage and disposition of nuclear material, and the processing and interim storage of waste for ultimate off-site disposal.

The NWCF CPP-659 is divided into two major functional areas, the calciner area and the decontamination area. The calciner area contains the process cells; the associated operating areas; the support control areas; and the maintenance area, which provides crane access for the process cells. Cells and cubicles that require frequent operating activities or contain high-maintenance equipment are provided with manipulators and lead-glass shielding windows.

The decontamination area provides equipment decontamination services for the NWCF and other facilities at the INTEC. In addition, the area contains the filter handling cell (309) for leaching and packaging high-efficiency particulate air (HEPA) filters from the NWCF and other INTEC facilities for disposal at the INEEL Radioactive Waste Management Complex (RWMC). Decontamination activities include debris treatment.

Cause Description:

Operating Conditions:

Modification Construction

Activity Category:

Construction

Immediate Action(s):

Suspect breaker was red tagged Non Conformance (NCR number 100747)

FM Evaluation:

To be determined

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Division or Project:

Liquid Waste Facility Closure

Plant Area:

INTEC

System/Building/Equipment:

New construction/CPP-659/Access Ramp Modifications

Facility Function:

Nuclear Waste Operations/Disposal

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	J. M. White
Phone	(208) 526-3862
Title	Liquid Waste Operational Close Department Manager

Originator:

Name	TEUSCHER, DENNIS R.
Phone	(208) 526-3100
Title	PLANT SHIFT SUPERVISOR

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/25/2006	16:05 (MTZ)	J. McNew	DOE-ID

Authorized Classifier(AC):

Teuscher, D.R. Teuscher Date: 04/27/2006

3)Report Number:

EM-OH-FCP-FFI-FEMP-2006-0015 After 2003 Redesign

Secretarial Office:

Environmental Management

Lab/Site/Org:

Fernald Environ. Mngmnt. Project

Facility Name:

Fernald Environ. Mngmnt. Project

Subject/Title:

Near Miss - Parked Tanker Trailer Rolls Over on North Haul Road

Date/Time Discovered:

04/26/2006 14:50 (ETZ)

Date/Time Categorized:

04/26/2006 15:00 (ETZ)

Report Type:

Notification

Report Dates:

Notification	04/27/2006	14:18 (ETZ)
Initial Update
Latest Update
Final

Significance Category:

Reporting Criteria:

10(3) - A near miss, where no barrier or only one barrier prevented an event from having a reportable consequence. One of the four significance categories should be assigned to the near miss, based on an evaluation of the potential risks and the corrective actions taken. (1 of 4 criteria - This is a SC 3 occurrence)

Cause Codes:

ISM:

2) Analyze the Hazards

Subcontractor Involved:

Occurrence Description:

--Occurrence Summary--

On Wednesday, April 26, 2006, at approximately 1450 hours, a tanker trailer parked on the north haul road rolled over onto its right side as contaminated water was being pumped into the tanker trailer. The tanker trailer rolled over when the right leg of the landing gear settled into the soil roadway and failed. Two personnel were at the rear of the tanker trailer (supporting the water pumping operation) when the tanker trailer began to roll over, but noticed that the trailer was moving and got to a safe distance from the trailer before it rolled over. This was the first time that the tanker trailer had been disconnected from the semi-tractor and placed on its landing gear in this area. Some contamination was detected in the soil after the tanker rolled over and the contaminated water spilled onto the soil, so the area was up-posted from a Category II Controlled Area/Radioactive Material Area to a High Contamination Area after the event.

--Background Information/Sequence of Events--

Over the past 2 weeks, Soil & Disposal Facility Project (SDFP) personnel have been using a tanker trailer attached to a semi-tractor (Ottowa) to haul contaminated water from the Soil Pile 7 (SP-7) run-off pond to the Converted Advanced Waste Water Treatment (CAWWT) Facility for processing. The tractor-trailer was driven by a Teamster to a position on the north haul road, just south of the run-off pond, which is a posted Category II Controlled Area/Radioactive Material Area, to receive water via a pump and hose. This operation had been performed successfully and without incident (on day and night shifts) about 6 times prior to this occurrence. But, in each of these instances, the tractor remained attached to the trailer during the evolution.

On April 26, 2006, at about 1130 hours, a Teamster parked the tractor-trailer in the normal location on the haul road for loading. About 2 hours later, the tractor was disconnected from the trailer because the tractor was needed to move a soil screener at another location on-site. When the Teamster disconnected the tractor from the trailer, a Laborer placed two 2" X 12" X 4' pieces of wood under the left and right landing legs of the tanker trailer and lowered the trailer onto the wood. The trailer was tilted slightly to right (the trailer was oriented from west to east, so it was tilting to the south) after the teamster lowered the trailer onto its landing legs because the road has a slight side-to-side slope in this location.

At about 1430 hours, SDFP personnel began filling the parked tanker trailer with contaminated water from the SP-7 run-off pond. A subcontractor Radiological Control Technician (RCT) and a Fluor Fernald Laborer were standing to the rear of the trailer as water was being pumped.

At about 1450 hours, with approximately 500 gallons of water loaded into the tanker trailer, the RCT stated that she was performing an alpha survey on the rear bumper of the trailer when she heard "a creaking or groaning sound" coming from the trailer. She informed the Laborer of this and asked him if the trailer was moving. The Laborer stated that he looked around the right side of the trailer and could see that it was starting to slowly tip over toward its right side. The Laborer told the RCT to move away from the trailer, farther to the rear. Both personnel (the Laborer and the RCT) moved to a safe distance behind the trailer.

Shortly thereafter, the trailer slowly rolled onto its right side and came to rest on the soil haul road, spilling water from the top fill port onto the soil. The pumping operation was suspended and notifications to Project Management, Project Safety, and the Fluor Fernald Assistant Emergency Duty Officer (AEDO) were made.

Cause Description:

Operating Conditions:

Does Not Apply

Activity Category:

Facility Decontamination/Decommissioning

Immediate Action(s):

The scene of the incident was secured by the Teamster Foreman, who was located in a pickup truck to the rear of the tanker trailer and witnessed the event. The Laborer and the RCT were a safe distance away from the tanker trailer by the time it rolled over onto its right side.

Due to the contamination levels of the water inside the tanker trailer, RCTs immediately up-posted the area from a Category II Controlled Area/Radioactive Materials Area to a High Contamination Area. Photographs of the scene were taken by a SDFP Safety & Health Representative. On the south side of the road (opposite from the SP-7 run-off pond), there is a containment ditch for a nearby Certified Area that is in the restoration phase. Earthen dams were placed on the east and west ends of that ditch to prevent the spilled water from spreading into the Certified Area. Preliminary contamination levels in the soil in the area of the spilled water revealed 210 dpm/100 cm2 alpha and 3,000 dpm/100 cm2 beta-gamma.

It was observed that the right landing leg of the tanker trailer had tension failures in both the lateral brace and the bolt flange to the trailer frame. This failure indicated the leg had settled vertically and the metal failed as the overturning trailer twisted to the leg from the soil. The timber that had supported the right landing leg had split longitudinally at the edge of the landing leg foot, reducing the surface area of the wood between 25 and 33 percent. After the longitudinal split, the remaining timber sheared laterally across the grain, leaving the foot with little or no additional support. The right leg sunk into the soil approximately 18 inches before the trailer overturned, which then pulled the leg and foot of the trailer back out of the ground.

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Yes.
Before Further Operation? No
By Whom: SDFP Management
By When: 06/10/2006

Division or Project:

Fluor Fernald, Inc./Fernald Closure Project

Plant Area:

North Haul Road

System/Building/Equipment:

Tractor-Tanker Trailer Operations

Facility Function:

Environmental Restoration Operations

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	Dan Powell
Phone	(513) 484-4150
Title	Soil & Disposal Facility Project Director

Originator:

Name	JOSEPH, RONALD L
Phone	(513) 484-2282
Title	INCIDENT INVESTIGATOR

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/26/2006	15:15 (ETZ)	Jeff Parkin	DOE-OH
04/26/2006	15:34 (ETZ)	Joe Desormeau	DOE-FCP

Authorized Classifier(AC):

4)Report Number:

EM-ORO--BJC-K25ENVRES-2006-0009 After 2003 Redesign

Secretarial Office:

Environmental Management

Lab/Site/Org:

East Tennessee Technology Park

Facility Name:

ETTP Facility D&D/K-25/K-27 Project

Subject/Title:

Load Drop - Self Dumping Hopper

Date/Time Discovered:

04/25/2006 12:30 (ETZ)

Date/Time Categorized:

04/25/2006 16:16 (ETZ)

Report Type:

Notification/Final

Report Dates:

Notification	04/27/2006	15:10 (ETZ)
Initial Update	04/27/2006	15:10 (ETZ)
Latest Update	04/27/2006	15:10 (ETZ)
Final	04/27/2006	15:10 (ETZ)

Significance Category:

Reporting Criteria:

Cause Codes:

ISM:

4) Perform Work Within Controls

Subcontractor Involved:

Occurrence Description:

At approximately 12:30 while transporting two (banded and stacked) new metal Wright self dumping hoppers to a work location, the ratchet type tie down strap used for retaining the hoppers on the flatbed truck tore into two pieces causing the hoppers to become unstable and fall from the truck onto the pavement (approximately a four foot drop). The two hoppers total combined weight is approximately 1000 pounds and were banded together at the time of the incident. There were no injuries associated with this event. There was no significant damage to the hoppers or pavement.

Cause Description:

Operating Conditions:

D&D

Activity Category:

Facility Decontamination/Decommissioning

Immediate Action(s):

ES&H took statements from employees, employees taken to medical for drug testing, truck removed from service for inspection, hoppers were inspected (no damage) and transported to their destination by forktruck.

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Division or Project:

K25/K27 D&D Project

Plant Area:

Central

System/Building/Equipment:

K-25

Facility Function:

Environmental Restoration Operations

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	G. Eidam
Phone	(865) 576-3393
Title	Manager of Projects

Originator:

Name	WYATT, LARRY O
Phone	(865) 574-3282
Title	SHIFT SUPERINTENDENT

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/27/2006	10:27 (ETZ)	Kelly Trice	Add. Not
04/27/2006	10:48 (ETZ)	G. Eidam	MOP
04/27/2006	10:48 (ETZ)	Greg Eidam	PM
04/27/2006	10:59 (ETZ)	Robert Stroud	DOE-FR
04/27/2006	11:00 (ETZ)	Donna Perez	DOE-OR
04/27/2006	11:36 (ETZ)	Brian Neal	DOE-ORO
04/27/2006	12:31 (ETZ)	Yvonne Horton	X-10 LSS
04/27/2006	12:32 (ETZ)	Rob Hughes	Y-12 PSS

Authorized Classifier(AC):

L. O. Wyatt Date: 04/27/2006

5)Report Number:

EM-RP--CHG-TANKFARM-2006-0010 After 2003 Redesign

Secretarial Office:

Environmental Management

Lab/Site/Org:

Hanford Site

Facility Name:

Tank Farms

Subject/Title:

Contamination Discovered Outside Radiological Area During Routine Survey

Date/Time Discovered:

04/25/2006 20:37 (PTZ)

Date/Time Categorized:

04/25/2006 21:30 (PTZ)

Report Type:

Notification/Final

Report Dates:

Notification	04/27/2006	13:58 (ETZ)
Initial Update	04/27/2006	13:58 (ETZ)
Latest Update	04/27/2006	13:58 (ETZ)
Final	04/27/2006	13:58 (ETZ)

Significance Category:

Reporting Criteria:

6B(4) - Identification of onsite legacy radioactive contamination greater than 10 times the total contamination values in 10 CFR 835 Appendix D and that is found outside of the following locations: Contamination Areas, High Contamination Areas, Airborne Radioactivity Areas, Radiological Buffer Areas, and areas controlled in accordance with 10 CFR 835.1102(c). For tritium, the reporting threshold is 10 times the removable contamination values in 10 CFR Part 835, Appendix D.

Notes:
(a) Legacy radioactive contamination is radioactive contamination resulting from historical operations that are unrelated to current activities.
(b) This does not apply to contamination from residual radioactive material meeting applicable DOE-approved authorized limits.
(c) The exclusion from reporting contamination in a Radiological Buffer Area applies only when the area has been established next to a Contamination Area, High Contamination Area or Airborne Radioactivity Area and its exit requirements have adopted guidance from Article 338.2 of DOE-STD-1098-99.

Cause Codes:

ISM:

6) N/A (Not applicable to ISM Core Functions as determined by management review.)

Subcontractor Involved:

Occurrence Description:

During routine radiological surveys outside of AZ Farm, a Health Physics Technician discovered contaminated tumbleweed fragments outside of an area established for contamination control. The highest reading was 60,000 dpm/100 cm2 beta/gamma total; no alpha detected.

Cause Description:

Operating Conditions:

Does not apply.

Activity Category:

Inspection/Monitoring

Immediate Action(s):

The contaminated tumbleweed fragments was picked up and disposed of.

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Division or Project:

CH2MHILL/Office of River Protection

Plant Area:

200 East

System/Building/Equipment:

241-AZ Tank Farm

Facility Function:

Nuclear Waste Operations/Disposal

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	Borrowman, J. E.
Phone	(509) 373-3056
Title	Manager, Day Shift Support

Originator:

Name	WATERS, SHAUN F
Phone	(509) 373-3457
Title	OPERATIONS SPECIALIST

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/25/2006	21:45 (PTZ)	Badden, J. J.	CH2MHILL
04/25/2006	21:48 (PTZ)	Sorensen, R. C.	ORP
04/25/2006	21:56 (PTZ)	Boyce, M. L.	ONC

Authorized Classifier(AC):

6)Report Number:

NA--LSO-LLNL-LLNL-2006-0017 After 2003 Redesign

Secretarial Office:

National Nuclear Security Administration

Lab/Site/Org:

Lawrence Livermore National Lab.

Facility Name:

Lawrence Livermore Nat. Lab. (BOP)

Subject/Title:

Near Miss to Electrical Shock

Date/Time Discovered:

04/25/2006 14:10 (PTZ)

Date/Time Categorized:

04/25/2006 15:30 (PTZ)

Report Type:

Notification

Report Dates:

Notification	04/27/2006	13:59 (ETZ)
Initial Update
Latest Update
Final

Significance Category:

Reporting Criteria:

Cause Codes:

ISM:

Subcontractor Involved:

Occurrence Description:

On April 25, 2006, in the process of troubleshooting non-functioning office equipment in Building 581 (NIF Site), it was discovered that an electrical circuit breaker was tripped after a hole was drilled into a wall and inadvertently through an electrical conduit.

Within the last few weeks, seismic anchors were installed into a wall to restrain a bookcase in an office area of Building 581. The anchors were being mounted to metal studs in a sheetrock wall. One of the holes drilled into the stud penetrated a conduit that runs perpendicular to and through the stud, severing one 120V energized wire and nicking the insulation of another energized wire.

In preparation for this work, a survey was completed to identify the location of studs and utilities inside the wall. However, at this time, it is unknown whether that survey identified the location of the conduit that runs perpendicular to and through the stud.

No electrical shock was reported. An investigation is in progress

Cause Description:

Operating Conditions:

Operating status was normal.

Activity Category:

Maintenance

Immediate Action(s):

The NIF Directorate Electrical Safety Officer applied a lock to the affected circuit breaker and barricaded the area.

The NIF Facility Manager suspended all work of this type in Building 581.

An investigation was initiated.

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Yes.
Before Further Operation? No
By Whom: Lee Kapit
By When: 06/08/2006

Division or Project:

NIF

Plant Area:

Site 200

System/Building/Equipment:

Electrical Wiring/B581/Electrical Conduit

Facility Function:

Balance-of-Plant - Offices

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	Ed Mosis
Phone	(925) /42-3-96
Title	NIF Programs Associate Director

Originator:

Name	MCGUFF, PAUL R
Phone	(925) 422-9547
Title	ENVIRONMENTAL SCIENTIST

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/25/2006	16:40 (PTZ)	Richard Scott	NNSA/LSO

Authorized Classifier(AC):

7)Report Number:

NA--LSO-LLNL-LLNL-2006-0018 After 2003 Redesign

Secretarial Office:

National Nuclear Security Administration

Lab/Site/Org:

Lawrence Livermore National Lab.

Facility Name:

Lawrence Livermore Nat. Lab. (BOP)

Subject/Title:

Personnel Injury During Earthquake Exercise

Date/Time Discovered:

04/27/2006 13:30 (PTZ)

Date/Time Categorized:

04/27/2006 13:30 (PTZ)

Report Type:

Notification

Report Dates:

Notification	04/27/2006	19:26 (ETZ)
Initial Update
Latest Update
Final

Significance Category:

Reporting Criteria:

2A(6) - Any single occurrence resulting in a serious occupational injury. A serious occupational injury is an occupational injury that:

(a) Requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received;

(b) Results in a fracture of any bone (except simple fractures of fingers, toes, or nose, or a minor chipped tooth);

(c) Causes severe hemorrhages or severe damage to nerves, muscles, or tendons;

(d) Damages any internal organ; or

(e) Causes second- or third-degree burns, affecting more than five percent of the body surface.

Cause Codes:

ISM:

2) Analyze the Hazards

Subcontractor Involved:

Occurrence Description:

On Tuesday, April 25, during an Earthquake Evacuation Exercise, an employee was walking along a narrow sloped path and slipped off of her high-heel shoe and twisted her foot. On Thursday morning, April 27, the employee went to Health Services and they discovered that the employee had a broken bone on the top of her left foot.

Cause Description:

Operating Conditions:

N/A

Activity Category:

Training

Immediate Action(s):

N/A

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Yes.
Before Further Operation? No
By Whom: Chris Holm
By When: 05/10/2006

Division or Project:

DNT

Plant Area:

Site 200, Block 300

System/Building/Equipment:

Superblock Yard (B331)

Facility Function:

Balance of Plant - Infrastructure (Other Functions not specifically listed in this Category)

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	Mark Martinez
Phone	(925) /42-3-75
Title	NMTP Program Leader

Originator:

Name	MCGUFF, PAUL R
Phone	(925) 422-9547
Title	ENVIRONMENTAL SCIENTIST

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/27/2006	15:30 (PTZ)	Richard Scott	NNSA/LSO

Authorized Classifier(AC):

8)Report Number:

SC--SSO-SU-SLAC-2006-0005 After 2003 Redesign

Secretarial Office:

Science

Lab/Site/Org:

Stanford Linear Accelerator Center

Facility Name:

Stanford Linear Accelerator Center

Subject/Title:

Occupational Safety and Health Administration (OSHA) Permissible Exposure Level (PEL) for Lead Exceeded by Subcontractor

Date/Time Discovered:

04/20/2006 11:00 (PTZ)

Date/Time Categorized:

04/26/2006 08:30 (PTZ)

Report Type:

Notification

Report Dates:

Notification	04/27/2006	18:28 (ETZ)
Initial Update
Latest Update
Final

Significance Category:

Reporting Criteria:

2A(5) - Personnel exposure to chemical, biological or physical hazards above limits established by the Occupational Safety and Health Administration (refer to 29 CFR Part 1910) or American Conference of Governmental Industrial Hygienists.

Cause Codes:

ISM:

Subcontractor Involved:

Yes
New World Environmental

Occurrence Description:

This event occurred during the day shift work (7:00 am to 3:30 pm) April 20, 2006 at the East end of the Final Focus Test Beam (FFTB) housing, Stanford Linear Accelerator Center (SLAC) building 64, in the SLAC research yard. A lead removal subcontractor was hired to remove bulk lead from the FFTB. Their protective gear included dust mask respirators, full body disposable Tyvek suits, gloves, safety glasses, and steel toed shoes. There was an OSHA compliant lead work sign posted, and the UTR verified that medical surveillance baselines for lead work were received by all subcontractor employees. The SLAC industrial hygienist, who was also the day shift FFTB safety supervisor, conducted air sampling to verify subcontractor compliance. The two air samples demonstrated exposure above the OSHA Permissible Exposure Level (PEL) of 50 micrograms per cubic meter of air. The 8 hour time weighted average exposures to lead were 84 and 86 micrograms per cubic meter.

Cause Description:

Operating Conditions:

Does not apply.

Activity Category:

Facility/System/Equipment Testing

Immediate Action(s):

On April 20, the SLAC Industrial Hygienist informed the lead work subcontractor that the possibility existed that laboratory results could demonstrate overexposure to lead and that a half mask respirator may be required to continue work. On April 21 the lead work subcontractors brought and wore half mask respirators with high efficiency cartridges. On April 24 prior to commencement of work, the SLAC Project Manager, the SLAC UTR, and the SLAC Industrial Hygienist met with the subcontractor to discuss the sample results and actions to be taken in order to comply with OSHA law. The subcontractor decided to limit total onsite work time including breaks to 4 hours per day and to continue to wear half mask respirators with high efficiency cartridges. This was agreed to by SLAC.

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Yes.
Before Further Operation? No
By Whom: SLAC Committee
By When:

Division or Project:

Operations Directorate

Plant Area:

B064, Beam Dump Area

System/Building/Equipment:

Final Focus Test Beam (FFTB)

Facility Function:

Accelerators

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	ROKNI, SAYED
Phone	(650) 926-3544
Title	FACILITY MANAGER

Originator:

Name	JOHNSON, HOPE E
Phone	(650) 926-4322
Title	FACILITY MANAGER ADMIN.

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/20/2006	16:00 (PTZ)	Sayed Rokni	SLAC
04/20/2006	16:40 (PTZ)	Donald Wilhelm	DOE SSO

Authorized Classifier(AC):