ORPS Operating Experience Report

1)Report Number:

EM-OH-WVDP-WVNS-UR-2006-0001 After 2003 Redesign

Secretarial Office:

Environmental Management

Lab/Site/Org:

West Valley Site

Facility Name:

Utility Room

Subject/Title:

Incorrect Conduit Cut during Boiler Demolition

Date/Time Discovered:

04/27/2006 09:40 (ETZ)

Date/Time Categorized:

04/27/2006 10:10 (ETZ)

Report Type:

Notification

Report Dates:

Notification	05/01/2006	16:10 (ETZ)
Initial Update
Latest Update
Final

Significance Category:

Reporting Criteria:

2C(2) - Failure to follow a prescribed hazardous energy control process (e.g., lockout/tagout) or a site condition that results in the unexpected discovery of an uncontrolled hazardous energy source (e.g., live electrical power circuit, steam line, pressurized gas). This criterion does not include discoveries made by zero-energy checks and other precautionary investigations made before work is authorized to begin.

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:

Subcontractor Involved:

Occurrence Description:

On April 27,2006, an operator cut the incorrect conduit during demolition work in preparation for removal of the old boilers from the Utility Room (UR). The four wires in the 3/4" diameter metal conduit were severed and at least one of the wires was energized by a 120 VAC power supply. The operator did not receive a shock nor observed any sparking when the conduit and wires were cut.

The operator was working on a step ladder at the North boiler and had just completed removal of a section of 2" diameter condensate pipe when he identified a length of conduit that was isolated (physically cut and wiring removed) and ready for removal. The conduit targeted for removal is located approximately 12 feet above the UR floor with three other conduits of the same size. He repositioned the ladder below the conduit, climbed up, visually traced the conduit from the cut point, placed his hand on it and proceeded to cut the conduit. When the pull string in the conduit became visible he realized that the incorrect conduit was cut. The operator stopped and contacted his supervisor.

The site maintenance electrical supervisor was notified and electricians went to the UR to determine if the severed lines in the conduit were energized. Inspection of the panels revealed that circuit breaker #9 in Panel #PPE4 was tripped for the 120 VAC power supply to a utility water makeup control valve actuator.

There was no personal injury or spread of radiological contamination as a result of this event.

Cause Description:

Operating Conditions:

Utility Room was in normal operating condition in parallel with old boiler demolition

Activity Category:

Facility Decontamination/Decommissioning

Immediate Action(s):

Operator immediately stopped work and notified the supervisor that the incorrect conduit had been cut.

A fact finding meeting was convened immediately following the event.

Electricians and Plant Systems Operations locked out and tagged circuit breaker #9 in Panel PPE4.

Facility Manager curtailed site utility demolition until controls are in place to positively identify lines.

Due to interruption in power to the control valve actuator, Plant Systems Operations increased cooling water basin system monitoring to ensure levels remain within system parameters.

Electricians were assigned for the planned restoration of the 120VAC power supply to the actuator for the automatic valve supplying water to the cooling water basin.

FM Evaluation:

The boiler utility line demolition is being performed adjacent to various operating utility service lines. Positive identification of adjacent service lines is imperative to the safety of the workers and to ensure the continuity of the utility system operations. The Utility Room Operator is responsible for systems operations and status in the UR and was not notified in a timely manner that a conduit was cut potentially interrupting power to a utility system. Interim system monitoring measures were put in place per the standard operating procedure until the electricians could complete the repair. Power was restored to the actuator before the end of day shift to permit the system to resume normal operations.

_______

This report is prepared solely to comply with the requirements of DOE Order 231.1A and DOE Manual 231.1-2. The descriptions used herein are intended to be consistent with both, are used solely for that purpose, and provide a summary of the subject event. Causes must be selected from those prescribed by DOE Guide 231.1-2

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Yes.
Before Further Operation? Yes
By Whom: P. J. Valenti
By When: 05/05/2006

Division or Project:

WVNSCO

Plant Area:

UTILITY ROOM

System/Building/Equipment:

Cooling Water System/Utility Room

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	CURCIO, JOSEPH P
Phone	(716) 942-2461
Title	SITE OPERATIONS MANAGER

Originator:

Name	SHERIDAN, ALISA A
Phone	(716) 942-2077
Title	SENIOR ENGINEER

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/27/2006	09:45 (ETZ)	D. C. Cook	DOE-FR

Authorized Classifier(AC):

2)Report Number:

EM-RL--PHMC-PFP-2006-0012 After 2003 Redesign

Secretarial Office:

Environmental Management

Lab/Site/Org:

Hanford Site

Facility Name:

Plutonium Finishing Plant

Subject/Title:

Cracked ceiling in Filter Room 315 represents a potential bypass route for unfiltered Zone 3 air (occupied radiological air space)

Date/Time Discovered:

04/27/2006 15:00 (PTZ)

Date/Time Categorized:

04/27/2006 15:35 (PTZ)

Report Type:

Notification

Report Dates:

Notification	05/01/2006	15:53 (ETZ)
Initial Update
Latest Update
Final

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 3 occurrence)

Cause Codes:

ISM:

Subcontractor Involved:

Occurrence Description:

On Thursday morning, 4/27/6, a maintenance team completed work in Filter Room 315 and was preparing to leave when one of the workers noticed that a section of the ceiling appeared to have separated and dropped slightly. Examination of the ceiling revealed that a section about 3-feet by 4-feet had cracked in several places and a small hole was formed when one part dropped about an inch. No pieces fell to the floor.

The damaged ceiling is on the downstream side of the HEPA filters, meaning that air can be drawn from Room 308 through the over-ceiling crawl space into the 292-Z-1 stack exhaust stream without being filtered. The initial evaluation could not determine the significance of the cracking, but PFP management decided the condition reportable as a management concern pending engineering evaluation and potential re-classification.

The filter room air space boundary after the HEPA filters is Safety Class to maintain a Leak Path Factor of 0.1 for accident scenarios affecting the Maximum Offsite Individual. The filtered air is Safety Significant to maintain a Leak Path Factor of 0.001 for accident scenarios affecting the Colocated Worker (pertinent when the filter room is in-service). Yet unclear is whether the 0.1 Leak Path Factor can be maintained in the as-found condition. Both Leak Path Factors will need further evaluation. Immediate actions are described in Section 19 below.

The filter room was already out-of-service for the maintenance work and will remain out-of-service until evaluation and repair is complete. The maintenance was routine, to replace Zone 3 HEPA filters in accordance with work package 2Z-05-03918 "Replace HEPA Filters in FR-315".

The ceiling appears to be modern gypsum-type wall board immediately under a corrugated metal decking. No water damage or stains are apparent. The decking forms the floor of the crawl space above the filter rooms. The decking is the same type that forms the Building 234-5Z roof decking and the floor of the duct level (between the first and second floors).

Access to the four-foot high crawl space between the roof and filter rooms is through one of two 3-foot square normally closed hatchways in Room 308 (a Zone 3 radiological air space). The crawl space is entered for inspection of heat detectors (but was not entered during the last heat detector inspection in Rooms 309, 313, and 316 in June 2005 under work package 2Z-04-07920). The ceiling crawl space is believed to be a stagnant, enclosed air space. This crawl space is a non-permit confined space accessed only for fire system inspections. Foot traffic in the crawl space cannot contact the filter room ceiling.

Cause Description:

Operating Conditions:

does not apply

Activity Category:

Maintenance

Immediate Action(s):

The cracked ceiling was discovered while the filter room was out of service for filter maintenance. The Room 308 and Room 320 air spaces were already under a fissile material movement restriction, the room dampers were closed, and a heavy curtain was in place to reduce flow. After examining and photographing the ceiling damage, everyone exited the room, and the two FR 315 access doors were closed and sealed with tape.

The filter room ceiling is being evaluated for repair.

A PISA screening was initiated.

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

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

Division or Project:

Plutonium Processing and Handling

Plant Area:

200 West

System/Building/Equipment:

Safety Basis/ Bldg 234-5Z/ filter room confinement

Facility Function:

Plutonium Processing and Handling

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	CJ SIMIELE
Phone	(509) 373-1519
Title	DIRECTOR

Originator:

Name	LUKES, JOHN M
Phone	(509) 373-3104
Title	OCCURRENCE INVESTIGATOR

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/27/2006	16:30 (PTZ)	JM Sondag	DOE-RL

Authorized Classifier(AC):

NA Date: 04/28/2006

3)Report Number:

EM-RP--CHG-TANKFARM-2006-0012 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:

04/27/2006 13:15 (PTZ)

Date/Time Categorized:

04/27/2006 13:20 (PTZ)

Report Type:

Notification/Final

Report Dates:

Notification	05/01/2006	18:08 (ETZ)
Initial Update	05/01/2006	18:08 (ETZ)
Latest Update	05/01/2006	18:08 (ETZ)
Final	05/01/2006	18:08 (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:

On 04/27/06, while performing routine radiological surveys near 244-A, a speck of contamination was discovered reading 250,000 dpm/100cm2 beta/gamma; no alpha detected.

As a result of identifying legacy contamination >50,000 dpm/100cm2 beta/gamma outside a radiological area, this event was categorized as a 6B(4) SC-4.

Cause Description:

Operating Conditions:

Does Not Apply.

Activity Category:

Inspection/Monitoring

Immediate Action(s):

The speck was picked up and properly 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:

244-A

Facility Function:

Nuclear Waste Operations/Disposal

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	Parnell, William L
Phone	(509) 373-2615
Title	Manager, Tank Farm Facility

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
04/27/2006	13:25 (PTZ)	Sorensen, R. C.	ORP
04/27/2006	13:29 (PTZ)	Badden, J. J.	CH2MHILL
04/27/2006	13:35 (PTZ)	Davis, K. W.	ONC

Authorized Classifier(AC):

4)Report Number:

NA--YSO-BWXT-Y12NUCLEAR-2006-0013 After 2003 Redesign

Secretarial Office:

National Nuclear Security Administration

Lab/Site/Org:

Y12 National Security Complex

Facility Name:

Y12 Nuclear Operations

Subject/Title:

PISA - Excessive Hold-up of Uranium Indicated in Induction Furnace Vacuum Filter

Date/Time Discovered:

04/27/2006 13:00 (ETZ)

Date/Time Categorized:

04/27/2006 16:00 (ETZ)

Report Type:

Notification

Report Dates:

Notification	05/01/2006	16:30 (ETZ)
Initial Update
Latest Update
Final

Significance Category:

Reporting Criteria:

3B(2) - Declaration of a potential inadequacy of the documented safety analysis (a potential positive USQ), per 10 CFR 830.203(g).

Cause Codes:

ISM:

4) Perform Work Within Controls

Subcontractor Involved:

Occurrence Description:

PISA - Nuclear Criticality Safety (NCS) Department was notified by the Uranium Holdup survey program (UHSP) lead on 4/24/06 that the gram quantity measurement point exceeded a prescribed limit. Upon further examination of the data and previous survey periods of the point, it was determined that the point had exceeded the action level point on several previous occasions. The NCS program places heavy reliance on the UHSP to detect such applicable accumulations (for mass control) of fissile material.

Cause Description:

Operating Conditions:

NORMAL OPERATIONS

Activity Category:

Normal Operations (other than Activities specifically listed in this Category)

Immediate Action(s):

The vacuum pump was de-energized
NCS wrote Memorandum of Criticality Concern (MOCC) identifying actions
The inlet valve to the vacuum system was shut
Administrative controls were put in place to control the area.
The drain valve for the system was opened. No liquid was present
NCS issued an additional MOCC to perform measurement in preparation for cleaning
Vacuum pump coolant system was de-energized
A USQD was initiated

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

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

Division or Project:

MANUFACTURING

Plant Area:

PROTECTED AREA

System/Building/Equipment:

9212

Facility Function:

Uranium Conversion/Processing and Handling

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	T. MORGAN
Phone	(865) 241-0548
Title	FACILITY MANAGER

Originator:

Name	LARGE, DENISE D
Phone	(865) 576-3952
Title	REPORTS AND DATA SPEC.

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/27/2006	16:05 (ETZ)	L. BROWN	PSS
04/27/2006	16:30 (ETZ)	F. KENDALL	NNSA FR
04/27/2006	17:00 (ETZ)	T. MORGAN	OPS MGR
04/27/2006	17:01 (ETZ)	L. REED	DIV MGR

Authorized Classifier(AC):

T. PAUL Date: 05/01/2006

5)Report Number:

NE-ID--BEA-CFA-2006-0004 After 2003 Redesign

Secretarial Office:

Nuclear Energy, Science and Technology

Lab/Site/Org:

Idaho National Laboratory

Facility Name:

Central Facilities Area

Subject/Title:

Worker Fractures Wrist During Material Unloading Activity - INL

Date/Time Discovered:

04/25/2006 15:00 (MTZ)

Date/Time Categorized:

04/26/2006 17:37 (MTZ)

Report Type:

Notification

Report Dates:

Notification	05/01/2006	18:38 (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:

Subcontractor Involved:

Occurrence Description:

On April 25, 2006 at approximately 1500 on the Idaho National Laboratory (INL) a Battelle Energy Alliance (BEA) Heavy Equipment Operator (HEO) was in process of releasing a chain binder on a load of jersey bouncers (concrete lane dividers) on an INL flatbed trailer when the handle of a chain binder struck the HEO on the right wrist area of his arm. The employee did not think the injury was serious at the time and continued to work. As the day progressed, and throughout the night his wrist pain worsened.

The HEO reported for work on April 26, 2006 and completed the work with the jersey bouncers. Later this day he reported to the Central Facilities Area (CFA) medical facility for evaluation. The CFA medical personnel evaluated the HEO, took an x-ray and informed the HEO that his wrist had been fractured and advised him to follow up with a orthopedic specialist. The HEO informed his supervisor of the dispensarys findings. The orthopedic specialist casted the right arm and the HEO returned to work with some restrictions on April 27, 2006.

The work was being performed between the security fences at the Idaho Nuclear Technology and Engineering Center (INTEC).

A critique is scheduled on May 2, 2006 when all involved employees can attend. Investigation is continuing.

On April 25, 2006, management did not know the HEO's arm was fractured. On April 26, 2006 at 1700 after the dispensary x-rayed the HEO's arm and determined the fracture, management then determined reportablity , thus the justification for not making timely categorization.

Cause Description:

Operating Conditions:

Normal

Activity Category:

Maintenance

Immediate Action(s):

April 26,2006 the employee's injury was evaluated at the INL dispensary. It was determined there was a fracture of the right radius. The physician at the INL dispensary advised the employee to follow up with an orthopedic specialist. The right arm was placed in a cast and the employee returned to work with restrictions.

April 26,2006 notifications made to line management and DOE-ID.

A critique of the event is scheduled for May 2, 2006 at 1000.

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Yes.
Before Further Operation? No
By Whom: Maintenance Management
By When:

Division or Project:

Facilities/Equipment Operations

Plant Area:

CFA

System/Building/Equipment:

Chain Binder

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	BRAUN, GARY W
Phone	(208) 533-4439
Title	Facility Manager - Site Wide Complex

Originator:

Name	LINDBERG, STEVEN
Phone	(208) 526-4007
Title	CONSULTING BUSINESS OPS SPEC

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/26/2006	17:00 (MTZ)	Gary W. Braun	BEA
04/26/2006	17:30 (MTZ)	Jerry L. McNew	DOE-ID
04/26/2006	17:37 (MTZ)	James P. Geringer	DOE-ID

Authorized Classifier(AC):

6)Report Number:

SC--PNSO-PNNL-PNNLBOPER-2006-0008 After 2003 Redesign

Secretarial Office:

Science

Lab/Site/Org:

Pacific Northwest National Laboratory

Facility Name:

Energy Research Programs (PNNL)

Subject/Title:

Management Concern Related to Ammonium Borohydride Flame

Date/Time Discovered:

04/27/2006 09:00 (PTZ)

Date/Time Categorized:

04/27/2006 13:00 (PTZ)

Report Type:

Notification/Final

Report Dates:

Notification	05/01/2006	14:19 (ETZ)
Initial Update	05/01/2006	14:19 (ETZ)
Latest Update	05/01/2006	14:19 (ETZ)
Final	05/01/2006	14:19 (ETZ)

Significance Category:

Reporting Criteria:

Cause Codes:

ISM:

5) Provide Feedback and Continuous Improvement

Subcontractor Involved:

Occurrence Description:

On Thursday April 27, 2006, at approximately 0830 hours, a small amount of ammonium borohydride ([NH4][BH4]), estimated to be less than 0.2 g., spontaneously burst into flame while being air dried in Hood #1 at PSL, lab 1520. The compound was on a watch glass (a concave, almost flat piece of glassware) when it ignited into a green flame. The flame lasted several seconds and grew to 3 inches and self quenched. A residue of white solid remained.

There were no injuries or chemical exposures.

Cause Description:

Operating Conditions:

N/A

Activity Category:

Research

Immediate Action(s):

The drying procedure of [NH4][BH4] on the watch glass had been used over ten times before without incident. The drying procedure of [NH4][BH4] is now changed to drying the solid under N2 without the use of metal spatulas (a glass rod will be used instead). This will remove a potential spark source (metal spatula) and an oxidant (O2 from air).

A critique will be scheduled for Monday May 1, 2006.

FM Evaluation:

DOE Facility Representative Input:

DOE Program Manager Input:

Further Evaluation is Required:

Division or Project:

Fundamental Sciences Directorate

Plant Area:

RCHN Area

System/Building/Equipment:

PSL / Lab 1520

Facility Function:

Laboratory - Research & Development

Corrective Action:

Lessons(s) Learned:

HQ Keywords:

HQ Summary:

Similar OR Report Number:

Facility Manager:

Name	Dupuis, M.
Phone	(509) 375-2617
Title	Director, Molecular Interactions & Transformations

Originator:

Name	POLLARI, ROGER A
Phone	(509) 376-2200
Title

HQ OC Notification:

Date	Time	Person Notified	Organization
NA	NA	NA	NA

Other Notifications:

Date	Time	Person Notified	Organization
04/28/2006	08:36 (PTZ)	Carlson, J. L.	PNSO

Authorized Classifier(AC):

Pollari, R. A. Date: 05/01/2006