1)Report Number:	EM-ID--CWI-RWMC-2006-0013 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Idaho National Laboratory
Facility Name:	Radioactive Waste Management Complex
Subject/Title:	Work Control Weaknesses
Date/Time Discovered:	07/07/2006 09:10 (MTZ)
Date/Time Categorized:	07/12/2006 19:00 (MTZ)
Report Type:	Notification/Final
Report Dates:	Notification 07/17/2006 16:17 (ETZ) Initial Update 07/17/2006 16:17 (ETZ) Latest Update 07/17/2006 16:17 (ETZ) Final 07/17/2006 16:17 (ETZ)
Significance Category:	4
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:	1) Define the Scope of Work 2) Analyze the Hazards
Subcontractor Involved:	No
Occurrence Description:	On July 7, 2006 Radioactive Waste Management Complex (RWMC) maintenance personnel were performing corrective maintenance activities on the excavator in ARP airlock #1 to repair the air conditioning system. As the repair progressed, maintenance personnel determined that there was interference from the nearby ammonia scrubber system. As the interference was removed, a small quantity of ammonia was released from a line that had not been fully evacuated. Maintenance personnel performing the task were in supplied air hoods, however the RCTs supporting the work were in powered air-purifing respirators (PAPRs.) The RCTs noted odor and experienced some eye and throat irritation. An immediate Stop Work was performed, notifications were made and the RCTs were taken to the Central Facilities Area (CFA) for medical evaluation and released to return to work with no restrictions. Industrial hygiene personnel determined exposure received was below the 8 hour threshold limit value (TLV) of 25 ppm; IDLH and ACGIH STEL 15 minute time weighted average of 35 ppm were not exceeded. The work was covered by maintenance work order. All hazards associated with the work were identified and were covered in a pre-job briefing prior to commencing the work activity
Cause Description:
Operating Conditions:	Warm Stand-by
Activity Category:	Maintenance
Immediate Action(s):	1.) All personnel were evacuated from the area. 2.) A formal Stop Work was declared in accordance with MCP-553. 3.) A hold was placed on further excavation work pending investigation. 4.) Line management notifications were made (Radiological Control, ARP Operations). 5.) Employees were excorted from the area, transferred to CFA medical, and monitored.
FM Evaluation:	Although the work being performed was covered by a maintenance work order and the hazards associated with the ammonia were identified, the controls identified failed to prevent the ammonia release. Following the ammonia release, work was appropriately stopped and the path forward was determined. The work to remove the ammonia system was then added to the maintenance work order. The work order change process was used to add the ammonia work to the work order. Upon completion of the work, a post-maintenance review determined that the work should not have been added to the work order but that a new design work order should have been developed and approved. The original work scope on the air conditioning system was appropriately covered in the work order, but the scope of work to remove the ammonia scrubber system was a change to the technical baseline for the facility and should have been done in accordance with the design control process. In a review of the work, several concerns were identified that require corrective action. 1. The operations, maintenance, safety, and engineering organizations failed to recognize the change in work scope required a design work order. 2. The original work order recognized ammonia has a hazard, but did not include controls to prevent working on the system or to ensure that the correct PPE would be used if work was to be performed. 3. The work order planner was rushed and felt there was a lot of pressure to get the work order approved for work. 4. The work order did not include appropriate post-maintenance testing. 5. The work order did not contain enough detail in the work steps to prevent work on the ammonia system. Hazards were identified, but the hazard control was less than adequate.
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	RWMC Cleanup Project
Plant Area:	ARP
System/Building/Equipment:	ARP/WMF-697/Excavator
Facility Function:	Nuclear Waste Operations/Disposal
Corrective Action 01:	Target Completion Date:08/31/2006 Tracking ID:101103
	Corrective Action Plan will be completed to address actions identified in ICARE 101103.
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Streepr, Kevin E. Phone (208) 526-6151 Title Nuclear Facility Manager
Originator:	Name BELNAP, GARY TREVER Phone (208) 520-0207 Title NUCLEAR FACILITY MANAGER
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/12/2006 19:00 (MTZ) Robert Knighten DOE-ID
Authorized Classifier(AC):
2)Report Number:	EM-ORO--BJC-K25ENVRES-2006-0013 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:	Violation of TSR Administrative Control
Date/Time Discovered:	07/13/2006 15:20 (ETZ)
Date/Time Categorized:	07/13/2006 15:30 (ETZ)
Report Type:	Notification
Report Dates:	Notification 07/17/2006 13:12 (ETZ) Initial Update     Latest Update     Final
Significance Category:	2
Reporting Criteria:	3A(2) - Any violation or noncompliance of a Hazard Category 1, 2, or 3 nuclear facility's Technical Safety Requirement (or Operational Safety Requirement) Limiting Control Setting, Limiting Condition for Operation, Administrative Control, or Surveillance Requirement. Exception: An event consisting solely of a surveillance test performed after the prescribed surveillance period, and in which the equipment was found to be capable of performing its specified safety function. (See separate criterion for late surveillance tests below).
Cause Codes:
ISM:
Subcontractor Involved:	No
Occurrence Description:	The K-25/27 Project implemented a Restricted Access Plan as part of the controls for Safety Evaluation Report for the Temporary Exemption Request of RCAAS Annunciation Requirements in the K-25 Building Immediate Evacuation Zones, SER-K25-RCAAS-ExReq-SBT-03-19 Revision 0. A requirement of the SER is for all employees to have a Personal Radiation Detection Instrument (PRDI) in contact with the body while in the Restricted Access Area during noise generating activities. During break an employee left their PRDI in a break room and returned to work. The break room is located inside the Restricted Access Area. Leaving the PRDI in the break room violated this requirement. The employee was with a work crew and all other members of the crew were equipped with PRDIs, so if a criticality would have occurred, the individual and their crew would have been notified and evacuated the area. K-25 is a Category 2 Nuclear Facility.
Cause Description:
Operating Conditions:	Normal
Activity Category:	Facility Decontamination/Decommissioning
Immediate Action(s):	The PRDI was returned to the employee, and the employee returned to work.
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:	K25/K27 D&D Project
Plant Area:	West
System/Building/Equipment:	K25 Process Building
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 LAWSON, DARRELL G Phone (865) 574-3282 Title SUPERINTENDENT
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/17/2006 11:10 (ETZ) Greg Eidam MOP 07/17/2006 11:15 (ETZ) Donna Perez DOE-OR 07/17/2006 11:15 (ETZ) Kelly Trice Addl Not 07/17/2006 11:17 (ETZ) Ken Jackson PM 07/17/2006 11:23 (ETZ) Carolyn Lawson DOE-ORO 07/17/2006 11:23 (ETZ) Robert Stroud DOE-FR
Authorized Classifier(AC):	Darrell Lawson      Date: 07/13/2006
3)Report Number:	EM-ORO--BJC-K25ENVRES-2006-0014 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:	Failure to Wear Required Personal Protective Equipment
Date/Time Discovered:	07/14/2006 11:15 (ETZ)
Date/Time Categorized:	07/14/2006 11:45 (ETZ)
Report Type:	Notification
Report Dates:	Notification 07/17/2006 16:51 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
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:
Subcontractor Involved:	No
Occurrence Description:	Two electricians were working in the K-25 Pipe Gallery, an area requiring fall protection, without wearing fall protection. The area in question was a permanently installed catwalk without hand rails. The catwalk was never provided safety features to meet current safety codes. Ten inches below each side of the catwalk there is corrugated metal heat shield. The heat shield material was previously evaluated by Structural Engineering and determined to be substantial enough to withstand a force of approximately 1500 foot-pounds, but had not been specifically evaluated for personal fall protection. If the employees had fallen off of the catwalk, they would have landed on the heat shield material.
Cause Description:
Operating Conditions:	Normal Operations - K-25 is a shutdown Category II Nuclear facility undergoing D&D
Activity Category:	Facility Decontamination/Decommissioning
Immediate Action(s):	Upon notification of the violation, the workers obtained the required PPE and returned to work. After Management review, work activities were suspended in all pipe gallery areas pending posting and barricade review. All work activities in the pipe gallery of K-25 and K-27 have been suspended pending a walkdown to verify postings in the areas requiring fall protection.
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:	K25/K27 Project at ETTP
Plant Area:	Central`
System/Building/Equipment:	K-25 Building
Facility Function:	Environmental Restoration Operations
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Greg Eidam Phone (865) 576-3393 Title Manager of Projects
Originator:	Name LAWSON, DARRELL G Phone (865) 574-3282 Title SUPERINTENDENT
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/17/2006 15:55 (ETZ) Greg Eidam MOP 07/17/2006 15:58 (ETZ) Donna Perez DOE-OR 07/17/2006 15:59 (ETZ) Kelly Trice Add. Not 07/17/2006 16:00 (ETZ) Cliff Hastings FM 07/17/2006 16:02 (ETZ) Janice Frost DOE-ORO 07/17/2006 16:02 (ETZ) Robert Stroud DOE-FR
Authorized Classifier(AC):	Bill McLendon      Date: 07/14/2006
4)Report Number:	EM-RL--WCH-RISS-2006-0001 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Hanford Site
Facility Name:	Reactor Interim Safe Storage
Subject/Title:	Contamination Discovered in Excavator While Outside Radioligically Controlled Area
Date/Time Discovered:	07/13/2006 13:05 (PTZ)
Date/Time Categorized:	07/13/2006 13:10 (PTZ)
Report Type:	Notification
Report Dates:	Notification 07/17/2006 19:57 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
Reporting Criteria:	6B(3) - Identification of onsite 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) This does not apply to contamination from residual radioactive material meeting applicable DOE-approved authorized limits. (b) This also does not apply to legacy radioactive contamination, which will be reported under a separate criterion below. (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:
Subcontractor Involved:	No
Occurrence Description:	On July 13, 2006, a Washington Closure Hanford (WCH) Radiological Control Technician (RCT) noted the radiological tag on a Linkbelt 4300 excavator was faded and unreadable. The excavator is being controlled as radioactive material and was recently relocated from 100-H to the 100-N Area in support of scheduled demolition activities. Due to the condition of the tag, the RCT conducted a radiological survey of the excavator. During the survey of the engine compartment, contamination was discovered up to 310,000 dpm/100cm2, beta/gamma, total contamination, with no alpha. The contamination appeared to be matrixed into soil that had become trapped in the engine compartment and battery box.
Cause Description:
Operating Conditions:	Does Not Apply
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	The excavator was taken out of service and Contamination Area (CA) postings were erected. Notifications were made to DOE and project management, and a fact finding investigation was initiated.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: Project Rad Controls By When:
Division or Project:	Reactor Interim Safe Storage
Plant Area:	100-N
System/Building/Equipment:	Linkbelt 4300 Excavator
Facility Function:	Environmental Restoration Operations
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Dennis Reese Phone (509) 373-7253 Title Project Director
Originator:	Name QUINN, TIM S Phone (509) 372-9439 Title MANAGER, SAFEGUARDS AND SECURITY
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/13/2006 13:15 (PTZ) Denis Reese WCH-PD 07/13/2006 13:15 (PTZ) Brian Biro DOE-FR
Authorized Classifier(AC):
5)Report Number:	EM-RP--CHG-TANKFARM-2006-0029 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Hanford Site
Facility Name:	Tank Farms
Subject/Title:	Contamination Discovered During Routine Radiological Survey
Date/Time Discovered:	07/12/2006 12:15 (PTZ)
Date/Time Categorized:	07/12/2006 16:35 (PTZ)
Report Type:	Notification/Final
Report Dates:	Notification 07/17/2006 14:21 (ETZ) Initial Update 07/17/2006 14:21 (ETZ) Latest Update 07/17/2006 14:21 (ETZ) Final 07/17/2006 14:21 (ETZ)
Significance Category:	4
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:	No
Occurrence Description:	On 07/12/2006, a Health Physics Technician performing routine surveys in A-Farm courtyard (outside of Farm) notified the Waste Feed Operations (WFO) Shift Office of discovery of 10 tumbleweed fragments reading up to 500,000 dpm/100cm2 beta/gamma; no alpha survey was performed. Assigned Responsible Manager: Bryce, J. H. at (509) 373-0584 Problem Evaluation Request (PER) 2006-1366 Timeline for delay in categorization: At 1215 hours, the on-duty WFO shift manager, per an Administrative Interface Agreement (AIA), attempted to contact the Fluor Hanford (FH) Integrated Biological Control Program point-of-contact (IBC) of the contamination discovery leaving a voice message requesting a return call. At 1300 hours, IBC was notified and a survey report faxed; occurrence reporting to be completed by FH. At 1625 hours, IBC contacts the on-duty WFO shift manager reporting their process is not in place to honor the AIA requesting CH2M HILL Hanford Group, Inc., report the event. At 1635, the on-duty WFO shift manager categorized the event completing required notifications.
Cause Description:
Operating Conditions:	Does not apply.
Activity Category:	Inspection/Monitoring
Immediate Action(s):	The courtyard area was posted as a Contamination Area.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	CH2MHILL/Office of River Protection
Plant Area:	200 East
System/Building/Equipment:	A-Farm Courtyard
Facility Function:	Nuclear Waste Operations/Disposal
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Sheriff, Marnelle L Phone (509) 376-2096 Title Manager, WFO Technical 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 07/12/2006 16:49 (PTZ) Badden, J. J. CH2MHILL 07/12/2006 16:49 (PTZ) Dodd, R. A. CH2MHILL 07/12/2006 16:49 (PTZ) Yasek, R. M. ORP 07/12/2006 16:50 (PTZ) Smithwick, R. L. ONC
Authorized Classifier(AC):
6)Report Number:	EM-RP--CHG-TANKFARM-2006-0030 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Hanford Site
Facility Name:	Tank Farms
Subject/Title:	Suspect/Counterfeit Bolts Found On Five KEVLOK Ratcheting Tie-Down Straps
Date/Time Discovered:	07/12/2006 17:53 (PTZ)
Date/Time Categorized:	07/12/2006 17:53 (PTZ)
Report Type:	Notification/Final
Report Dates:	Notification 07/17/2006 14:22 (ETZ) Initial Update 07/17/2006 14:22 (ETZ) Latest Update 07/17/2006 14:22 (ETZ) Final 07/17/2006 14:22 (ETZ)
Significance Category:	4
Reporting Criteria:	4C(2) - Discovery of any suspect/counterfeit item or material other than office supplies, office equipment, or household products.
Cause Codes:
ISM:	6) N/A (Not applicable to ISM Core Functions as determined by management review.)
Subcontractor Involved:	No
Occurrence Description:	On 07/12/2006, during a Bill of Material required inspection, Quality Assurance found five KEVLOK ratcheting tie-down straps, purchased for work package WFO-WO-06-000625, were found to have suspect counterfeit bolts as part of the assembly. The five bolt heads have six raised marks indicating a grade 8 bolt but have no manufacturers marking rendering them suspect per the DOE suspect fastener headmark list.
Cause Description:
Operating Conditions:	Normal parameters.
Activity Category:	Inspection/Monitoring
Immediate Action(s):	A hold tag was placed on the tie down straps and then transported the 2101HV building SC/I hold area. The SC/I Coordinator was notified and a nonconformance report (NCR CH-06-NCR-015) issued.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	CH2MHILL/Office of River Protection
Plant Area:	200 East
System/Building/Equipment:	Material Receiving/MO-997
Facility Function:	Nuclear Waste Operations/Disposal
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Jorgensen, Craig W Phone (509) 373-6593 Title Manager, DST System Engineering
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 07/12/2006 18:01 (PTZ) Smithwick, R. L. ONC 07/12/2006 18:06 (PTZ) Dodd, R. A. CH2MHILL 07/12/2006 18:10 (PTZ) Yasek, R. M. ORP 07/12/2006 18:28 (PTZ) Badden, J. J. CH2MHILL
Authorized Classifier(AC):
7)Report Number:	NA--LASO-LANL-BOP-2006-0004 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Los Alamos National Laboratory
Facility Name:	"at large" or Balance of Plant
Subject/Title:	Worker Sustains Foot Injury
Date/Time Discovered:	07/13/2006 17:30 (MTZ)
Date/Time Categorized:	07/13/2006 17:35 (MTZ)
Report Type:	Notification
Report Dates:	Notification 07/17/2006 19:51 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
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:	Yes CTSI
Occurrence Description:	MANAGEMENT SYNOPSIS: On July 11, 2006, at 0900, a Los Alamos National Laboratory (LANL) safety representative on the construction project at Technical Area 39, Building 98 observed a CTSI worker (W1) limping and questioned W1 about his condition. W1 stated that he injured his right foot when a one-inch long screw penetrated his safety boot sole and foot on July 7, 2006, at the TA39-98 job site while performing housekeeping duties. W1 thought that he had a rock in his boot and continued to work. After W1 got home and removed his safety boot, he observed that a screw had penetrated his boot and foot and broke through the skin. W1 self-treated the wound and did not seek medical attention, but over the weekend the wound became infected. On July 11, 2006, after the LANL safety representative and CTSI foreman observed W1's wound and became concerned with the severity of his injury, W1 was immediately taken to the Laboratory's occupational medicine facility for evaluation. Occupational medicine personnel referred W1 to the Los Alamos Medical Center (LAMC). At LAMC, the wound was cleaned and W1 transferred to the St. Vincent's hospital in Santa Fe, New Mexico, for further evaluation. At 1400, the CTSI supervisor transported W1 to St. Vincent's. W1 was evaluated and hospitalized for observation until his release on July 14, 2006. The attending physician noted that W1's injury was aggravated by a pre-existing medical condition. W1 is scheduled for a follow-up evaluation with his primary physician and instructed by the attending physician to stay home for two weeks. Upon notification on July 13, 2006, that W1 remained hospitalized for more than forty-eight (48) hours from the date he reported his injury, the Institutional Facilities and Central Services (IF&CS) facility operations director categorized the event as reportable under the injury reporting criteria. A critique was held on July 17, 2006, to collect additional facts surrounding the event. BACKGROUND: With oversight by the Project Management Facility, Infrastructure and Recapitalization Division Office (PMFIRP-DO) as a facility, infrastructure and recapitalization project FIRP, CTSI is the prime contractor tasked to remodel the TA39-98 shop bay into office spaces. The project uses various lengths and types of screws including one-inch long screws for the installation of steel framing and sheet rock. Several integrated work documents (IWDs) govern the construction work. The project required the standard personal protective equipment of safety glasses and safety boots with steel toes. W1 wore safety boots with steel toes.
Cause Description:
Operating Conditions:	Construction Activities
Activity Category:	Construction
Immediate Action(s):	W1 was immediately taken to occupational medicine for evaluation. Occupational medicine personnel referred W1 to LAMC. LAMC personnel treated the wound and transferred W1 to St. Vincent's hospital for further evaluation. At St. Vincent's, W1 was evaluated and hospitalized until his release on July 14, 2006. W1 is scheduled for a follow-up evaluation with his primary physician and is to remain out of work for two weeks. Before W1 is allowed to return to work, he will be evaluated at the Laboratory’s occupational medicine facility. CTSI management will review the accident/injury/event reporting requirements with all workers on the project emphasizing the importance of timely reporting and evaluation. In addition, CTSI management will remind workers of the need to continually maintain housekeeping on the job site.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: PMFIRP & QA-OA By When: 08/25/2006
Division or Project:	Project Management FIRP Division
Plant Area:	TA39-98
System/Building/Equipment:	TA39-98 Shop Area
Facility Function:	Balance-of-Plant - Machine shops
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Andrew Erickson Phone (505) 665-2272 Title IF&CS Facility Operations Director
Originator:	Name SISNEROS, ALVA M Phone (505) 664-0666 Title OCCURRENCE INVESTIGATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/17/2006 09:42 (MTZ) Ed Christie NNSA
Authorized Classifier(AC):	Patricia Vardaro-Charles      Date: 07/17/2006
8)Report Number:	NA--LASO-LANL-FIRNGHELAB-2006-0004 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Los Alamos National Laboratory
Facility Name:	Firing Sites and HE Lab.
Subject/Title:	Worker strikes 120v circuit within modular furniture power pole
Date/Time Discovered:	07/13/2006 15:15 (MTZ)
Date/Time Categorized:	07/13/2006 15:24 (MTZ)
Report Type:	Notification
Report Dates:	Notification 07/17/2006 18:11 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
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.
Cause Codes:
ISM:
Subcontractor Involved:	Yes KSL Services
Occurrence Description:	On July 13 at approximately 1445 a KSL Services employee cut into an energized 120v circuit while cutting through a plastic modular furniture power/communications pole. The employee, a sheetmetal foreman with 15 years experience at LANL, was tasked with replacing a missing acoustical ceiling tile in an office area that has a dropped ceiling and is outfitted with modular furniture. The replacement tile needed to be fitted around a plastic power pole rising from an island desk and projecting approximately 18 inches into the space above the dropped ceiling. The power pole was there in order to shroud a rigid metal conduit housing conductors that fed power to the island desk. The task on the work order was deemed low hazard and no IWD was required nor developed. The task instructions stated "Replace missing ceiling tiles in room 128 and 131." The Job Planning and Scoping Checklist indicated that there was no need for LO/TO, and no electric powered hand tools would be required. Start permission had been granted by the Facility Coordinator. When the employee arrived at the work site, he determined that if he were able to cut the power pole flush with the dropped ceiling, he could use a whole ceiling tile dropped into place for a better aesthetic effect versus trimming two partial tiles to fit around the power pole. He surveyed the area and saw no electrical outlets on the island desk (they were in fact present but located along the baseboard underneath the desk). He observed a safety cord cover running along the carpet from the main office area to the island desk and assumed that it was being used to cover an extension cord providing power to the desk, when in fact was for routing the phone and fax lines to the desk. The employee thought that the function of plastic power pole was merely to protect the corner of the desk, and reached into the ceiling area and felt the top of the power pole to ascertain whether it would be feasible to cut it off. He did not feel the flex conduit projecting from the top of the power pole and proceeded to cut the power pole with a hacksaw. When he noted that the cut was not going straight, he opted to use a battery powered reciprocating saw to complete the cut. When the pole was almost cut entirely through, he felt the saw blade contact something within, and stopped. Having ascertained that he had contacted a conduit within the power pole, he surveyed the immediate area, asked a nearby worker if there had been an interruption in power or communications, and completed the cut by hand from the opposite side of the power pole after incorrectly concluding that he had not penetrated the conduit. The employee did not feel a shock and observed no sparks, arcing or smoke. Once the power pole had been cut entirely through, the employee was able to see that the power pole housed electrical conduit, and that he had cut into the conduit. He immediately stopped his task and informed his supervisor. His supervisor, the KSL Maintenance Manager for Area 10, responded to the scene and with the assistance of a KSL electrician determined that there had been sufficient contact with the conductors inside the conduit to have tripped the 20-amp breaker at a nearby electrical panel. In coordination with the FOD-7 Maintenance Manager, they locked and tagged out the circuit pending repair.
Cause Description:
Operating Conditions:	Does not apply.
Activity Category:	Maintenance
Immediate Action(s):	- KSL electricians locked and tagged the tripped circuit. - KSL conducted a safety meeting with crafts to discuss lessons learned and review craft responsibilities and authority concerning STOP work. KSL management also emphasized craft responsibilities to perform work within the authorized scope.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: FME-WFO and QA-OA By When:
Division or Project:	FME Weapons Facilities Operations
Plant Area:	TA-8-21
System/Building/Equipment:	Dynamic and Energetic Materials Div. Office
Facility Function:	Balance-of-Plant - Offices
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name C. Mike Montoya Phone (505) 667-8052 Title FME-WFO Duty Officer
Originator:	Name RICHARDSON, JOSEPH B Phone (505) 665-4844 Title OCCURRENCE INVESTIGATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/13/2006 15:30 (MTZ) Edwin Christie NNSA
Authorized Classifier(AC):	Patricia Vardaro-Charles      Date: 07/17/2006