1)Report Number:	EM-ORO--BJC-K25ENVRES-2006-0015 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:	TSR Violation - Surveillance Frequency Exceeded
Date/Time Discovered:	07/14/2006 09:20 (ETZ)
Date/Time Categorized:	07/14/2006 09:45 (ETZ)
Report Type:	Notification/Final
Report Dates:	Notification 07/18/2006 12:17 (ETZ) Initial Update 07/18/2006 12:17 (ETZ) Latest Update 07/18/2006 12:17 (ETZ) Final 07/18/2006 12:17 (ETZ)
Significance Category:	4
Reporting Criteria:	3A(4) - 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.
Cause Codes:
ISM:	6) N/A (Not applicable to ISM Core Functions as determined by management review.)
Subcontractor Involved:	No
Occurrence Description:	During a routine Facility Manager review of TSR required surveillances for the Radiation Criticality Accident Alarm System (RCAAS), it was discovered that the allowable grace period for performing SR 4.1.1.3 was exceeded. SR 4.1.1.3 is a notification test of the RCAAS horns and visual signals. SR 4.1.1.3 for Cluster 46 (1 of 14) was not performed within the specified frequency. There are two semiannual surveillances for the RCAAS (SR 4.1.1.1 and 4.1.1.3). There are two frequencies applicable to the 4.1.1.1 and 4.1.1.3 Surveillances. The first applicable frequency is a semiannual requirement to complete the SR(s). The semiannual frequency was NOT exceeded. The second frequency tied to the SRs is in the form of a note embedded in the frequency column of the Surveillance Requirements table. The note states "SRs 4.1.1.1 and SR 4.1.1.3 shall be scheduled such that the Horns and associated relays are exercised QUARTERLY". This note has been interpreted as a TSR surveillance frequency. The quarterly frequency was exceeded by three days. There was seven days remaining on the semiannual frequency.
Cause Description:
Operating Conditions:	K-25 is a shutdown Category II Nuclear facility undergoing D&D.
Activity Category:	Facility Decontamination/Decommissioning
Immediate Action(s):	None - The review verified that SR 4.1.1.3 was conducted within the specified frequency except Cluster 46. Cluster 46 was successfully completed on 7/11/06 (prior to the time of discovery).
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
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 07/18/2006 08:50 (ETZ) Robert Stroud DOE-FR 07/18/2006 08:50 (ETZ) Cliff Hastings PM 07/18/2006 08:50 (ETZ) Kelly Trice Add. Not 07/18/2006 08:50 (ETZ) Greg Eidam MOP 07/18/2006 09:05 (ETZ) Carolyn Lawson DOE-ORO
Authorized Classifier(AC):	W. E. McLendon      Date: 07/14/2006
2)Report Number:	EM-RL--PHMC-ELEC-2006-0002 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Hanford Site
Facility Name:	Electrical Utilities
Subject/Title:	Personnel Injury
Date/Time Discovered:	07/13/2006 20:30 (PTZ)
Date/Time Categorized:	07/14/2006 10:00 (PTZ)
Report Type:	Notification
Report Dates:	Notification 07/18/2006 15:22 (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:	2) Analyze the Hazards
Subcontractor Involved:	Yes Contractor's Equipment Maintenance Company (CEMC)
Occurrence Description:	At approximately 1635 on 7/13/2006, a sub-contractor employee was injured while exiting his truck. The employee had parked the large "Belly Dump" truck on the 100 B/C cutoff road after completion of his daily work activities. The employee gathered his personal items (lunchbox, coffee mug, etc.) to exit the cab. He stepped out onto the fuel tank step, lost his balance, fell to the pavement, and landed on his hip. He was assisted by his co-workers to his car pool vehicle and was instructed by the foreman to have a medical evaluation performed. Subsequently evaluation, later that evening, revealed the hip was broken.
Cause Description:
Operating Conditions:	Normal operations
Activity Category:	Construction
Immediate Action(s):	Employee transported to Kennewick General by co-workers. Made notifications to Fluor Management and DOE-RL representatives. Evaluation by medical professional indicated a broken hip. Surgery was performed the following day on 7/14/2006.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	Closure Service & Infrastructure
Plant Area:	100
System/Building/Equipment:	100 B/C cutoff road
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 S. M. Baker Phone (509) 373-2028 Title Manager, Electrical Utilities
Originator:	Name SMITHWICK, RONALD L Phone (509) 376-3030 Title
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/13/2006 21:00 (PTZ) Randy Krekel RL/OOD
Authorized Classifier(AC):
3)Report Number:	EM-RL--PHMC-PFP-2006-0018 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Hanford Site
Facility Name:	Plutonium Finishing Plant
Subject/Title:	241-Z D-4 Tank Pit entry prior to completion of atmosphere sampling
Date/Time Discovered:	07/13/2006 19:40 (PTZ)
Date/Time Categorized:	07/13/2006 21:30 (PTZ)
Report Type:	Notification
Report Dates:	Notification 07/18/2006 12:08 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
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:	4) Perform Work Within Controls
Subcontractor Involved:	No
Occurrence Description:	SUMMARY: On Thursday evening (7/13/2006) entry was made into the Tank D-4 pit in 241-Z (permit required confined space) prior to completion of required air sampling and authorization. Also, the confined space entry log was not completed and approved prior to the entry. Personnel that had entered the pit were in appropriate personal protective equipment (clothing and hoods with supplied air) and sampling results that were completed prior to the entry were negative. NARRATIVE: On Thursday 07/13/06 at about 1700 hours, the 241-Z team was setting up for entry into the D-4 tank pit under work package 2Z-04-01447/M "D&D 241-Z: Tank D4: Remove Piping and Equipment." The crew consisted of the normal Q shift personnel, a Person-In-Charge (PIC), and PIC in training. The PIC in training was completing the second half of an all-day assignment and the Industrial Hygienist, while familiar with the safety requirements, was not the normally assigned Industrial Hygienist. The set up began with a pre-job briefing which addressed the following topics: 1) Scope of the work, 2) Job assignments, 3) hazards and controls (the confined space entry requirements were not discussed as this type entry has been performed many times), and 4) emergency response actions. The scope of the work was to reposition the ladder into the pit 90 degrees, lengthen and reposition the atmosphere air sampling tubes, and to enter the pit and prepare for waste loadout. At about 1815 hours, the crew proceeded to 241-Z and prepared for the ladder reposition and pit entry. The pit entry team proceeded to dress out for the entry. The Pit Entry Attendant (PEA) assigned at the pre-job briefing had a problem obtaining a proper mask, so the activity was reassigned. Similar problems with this person required a second reassignment. The new person assigned, while familiar with the task, had not performed this activity previously. The PEA is responsible for communicating with the personnel in the Pit and for maintaining awareness of these workers for safety and other issues. At about 1830 hours, the appropriately prepared personnel entered the access tent to modify the air sample hoses and to prepare for the pit entry. The pit cover remained in place during this evolution. The pit cover was then removed and the Station Operating Engineer (SOE) adjusted the pit ventilation as required by the work package, the ladder was untied at the top, and the atmosphere air sample hoses removed to be repositioned. Following this activity, the extended atmosphere air sample hoses were reinstalled into the cell (draped over the ladder) and an extension cord was put into the pit to provide temporary lighting. At about 1845 hours, the operator entering the Tank D-4 pit made a general call on his radio asking if everything was ready to enter the pit. A response was received that stated the entry was "10 minutes away" then "5 minutes away" on a subsequent call. During these calls, the Industrial Hygienist did not have a radio and the PIC in training did not hear these calls. These radio requests to confirm everything was ready for pit entry were made up until the time the hoods and air lines were installed and the first entry made around 1855 hrs. The first NCO entered the D-4 Tank pit and unfastened the ladder at the base which is resting on a grating at about the mid-point of the tank pit. The ladder was moved 90 degrees and refastened. Several minutes later, a second operator entered the pit. At about this same time, the Industrial Hygienist confirmed that the hoses were back into the pit and began to take the 3 required air samples. Each sample takes approximately 3 minutes per sample. The PIC in training went to see the Industrial Hygienist to sign the confined space entry log. The Industrial Hygienist asked the PIC at that time if people were in the pit and received a positive response. The Industrial Hygienist identified that only 2 of the 3 required samples were completed and that the confined space entry log was not filled out with the names of the entrants, nor the approval to enter the pit. At this time, the PIC in training directed a controlled egress from the D-4 Tank pit. The normal process for entry into a permit required confined space is to perform air sampling to verify proper atmosphere so the area can be reclassified to a non-permit required confined space. In the case of the 241-Z tank pits, the area above the grating is sampled via 3 sample tubes, and the area below the grating is sampled via 2 longer sample tubes. When the first entry is made into the pit (or following changing of the sample tubes as occurred in this instance), the upper area is sampled (3 samples), and the pit entered to allow the operators to extend the 2 longer sample tubes into the area below the grating. Then this area is sampled to allow access into the bottom of the cell. Once installed, all 5 sample points are sampled prior to each entry. Additionally, the requirement for entry into a confined space per HNF-RD-11258 "Confined Spaces" is to open the confined space, obtain and read the atmosphere samples, and to maintain a log of pit entries identifying those individuals who are authorized to make the entry. This is controlled under a confined space entry log, which also includes a location for the signature of the entry supervisor (PIC) to authorize confined space entry. Once approved, the Industrial Hygienist informs the PEA and the PIC that entry is authorized. A practice in use has been to have all the entrants sign the confined space entry log following the pre-job brief and the Industrial Hygienist would monitor access to the confined space until the samples were obtained and read, and the PIC signed the form. At this time, the Industrial Hygienist would inform the PEA and the PIC that entry was authorized.
Cause Description:
Operating Conditions:	Does not apply
Activity Category:	Facility Decontamination/Decommissioning
Immediate Action(s):	All personnel exited the Tank D-4 pit.
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 Finishing Plant Closure Project
Plant Area:	200W
System/Building/Equipment:	241-Z/Tank D-4 Pit
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 AMES, CHARLES P Phone (509) 376-6377 Title MANAGER, PFP PROJECT ASSURRANCE
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/13/2006 21:54 (PTZ) JM SONDAG DOE-RL
Authorized Classifier(AC):	N/A      Date: 07/18/2006
4)Report Number:	EM-SR--WSIS-SECFOR-2006-0001 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Savannah River Site
Facility Name:	Security Force Facilities
Subject/Title:	Failure to have Proper Work Package (Lockout/Tagout) Before Beginning Work
Date/Time Discovered:	07/17/2006 10:30 (ETZ)
Date/Time Categorized:	07/18/2006 10:00 (ETZ)
Report Type:	Notification
Report Dates:	Notification 07/18/2006 15:21 (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 Blackwater Target Systems LLC
Occurrence Description:	On 07/17/2006, Blackwater technicians were scheduled to replace air lines on a Rodgers Range Target System. After Blackwater personnel were badged to have access to SRS, a WSI-SRS Training Instructor escorted them to the SATA Range and left them unsupervised while they were completing the work. It was understood that electrical line leads to the air compressor for the Rodgers Range would be lifted (de-energized) by SR site personnel (WSRC/Bechtel), either Thursday (07/13/2006) of last week, or Monday morning by 0900. Prior to Blackwater beginning the work, they ensured that electrical line leads to the air compressor were de-energized; however, they were not familiar with SRS Lockout/Tagout procedural requirements. There should have been a Work Package completed, which would have included a Assisted Hazard Analysis (AHA)document, which would have been signed by both WSRC and Blackwater authorizing Blackwater to begin the work. The AHA should have then been reviewed with Blackwater. No injuries occurred as a result of this incident.
Cause Description:
Operating Conditions:	Does not apply.
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	When questioned by a WSRC representative, all operations being conducted by Blackwater was stopped and the DOE-SR representative issued a "Timeout" prior to Blackwater personnel starting back to work.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: Inquiry Official By When:
Division or Project:	Wackenhut Services, Inc.
Plant Area:	SATA Range
System/Building/Equipment:	Rodgers Range Target System
Facility Function:	Balance-of-Plant - Safeguards/security
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name SELMAN, CHARLES A Phone (803) 952-7789 Title Manager, Program Review & Analysis Department
Originator:	Name SELMAN, CHARLES A Phone (803) 952-7789 Title
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/17/2006 12:00 (ETZ) Rich Allen WSI-SRS 07/17/2006 12:00 (ETZ) Mark Bolton WSI-SRS 07/17/2006 12:00 (ETZ) Joe Cohen DOE-SR
Authorized Classifier(AC):	Henry Turner      Date: 07/18/2006
5)Report Number:	NA--PS-BWXP-PANTEX-2006-0068 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Pantex Plant
Facility Name:	Pantex Plant
Subject/Title:	Failure to Notify Operations Center Regarding Movement of Material Loads Exceeding 80,000 Pound Limitation
Date/Time Discovered:	07/14/2006 08:00 (CTZ)
Date/Time Categorized:	07/14/2006 15:21 (CTZ)
Report Type:	Notification
Report Dates:	Notification 07/18/2006 14:29 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
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:	Yes Page & Associates and subcontractor Grant Construction Co.
Occurrence Description:	On July 12, 2006, a contractor commenced with demolition and removal of the existing concrete approach, at Magazine 4-038. The contractor scheduled a CAT# 325C Track Excavator to break the existing concrete approach/apron and load the broken concrete into 20 cubic yard dump trucks to be hauled to the contractors recycling yard. The gross weight of the delivery vehicle and the track excavator was over 80,000 pounds. The excavator and delivery vehicle were moved in under the Justification for Continued Operations (JCO) for on-site transportation of loads exceeding 80,000 pounds. Once the equipment was at the work site, the contractor started breaking the concrete into pieces and loading the dump trucks for movement from the secured area to the plant weigh scales per the established Waste Management Plan. The weight is recorded by the truck driver for recycling purposes and hauled off plant to a recycling yard. The Contractor hauled eleven loads of broken concrete without contacting Operation Center for permission to travel on plant roads. Transportation movements had already been cancelled until the contractor stopped working the excavator; therefore, no collision could occur. Four of eleven loads (gross weight) were found to be over 80,000 pounds. However, movement of these loads had already begun when it occurred to the PSTR that the trucks could weigh more than 80,000 pounds. The PSTR accompanied a truck to the plant weigh scales, and verified that the truck was indeed over 80,000 pounds. When the PSTR discovered the overweight, he directed the contractor to decrease the size of the loads per dump truck. No injuries or equipment damage occurred as a result of this event and the event was not considered a TSR violation. The JCO does not address the need for notification of multiple movements greater than 80,000 pounds during the shut down of the Move Right System.
Cause Description:
Operating Conditions:	N/A
Activity Category:	Construction
Immediate Action(s):	1. Emergency Operations Center notified upon discovery of the occurrence, 07/14/06 @11:26 hours. 2. Occurrence investigation performed 07/14/06. 3. Critique scheduled and conducted at 1430 hours, 07/14/06 4. The event was categorized as a 10(2)SC3.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	BWXT
Plant Area:	Zone 4
System/Building/Equipment:	Magazine 4-038
Facility Function:	Balance-of-Plant - Site/outside utilities
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Richard Flodman Phone (806) 477-6463 Title Capital & Expense Projects Division Manager
Originator:	Name LEE, CYNTHIA R Phone (806) 477-4000 Title ADMINSTRATIVE SPEC III
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/14/2006 11:26 (CTZ) Carlos Alvarado PXSO
Authorized Classifier(AC):	Dennis Reed      Date: 07/18/2006
6)Report Number:	NE-ID--BEA-MFC-2006-0002 After 2003 Redesign
Secretarial Office:	Nuclear Energy, Science and Technology
Lab/Site/Org:	Idaho National Laboratory
Facility Name:	Materials and Fuels Complex
Subject/Title:	Potential Asbestos Exposure from Drilling Into a Door
Date/Time Discovered:	07/12/2006 13:00 (MTZ)
Date/Time Categorized:	07/17/2006 14:55 (MTZ)
Report Type:	Notification
Report Dates:	Notification 07/18/2006 16:35 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
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:	No
Occurrence Description:	On 07/12/2006 a Battelle Energy Alliance (BEA) Locksmith was installing a new lock on a door at the Materials Fuels Complex (MFC) building 752 on the Idaho National Laboratory (INL). The work was being performed under a Minor Maintenance Work Order and asbestos had not been identified as a potential hazard. While visiting with the Locksmith, an Idaho Cleanup Project (ICP) asbestos inspector who was doing non related work in the area, noticed a white plaster like substance inside the door where the old lock mechanism had been removed. He took a sample of the suspect material for analysis and made an informal comment that the material may be suspect asbestos and controls should be used. Based on these comments the Locksmith decided to use a different lock with a smaller hole that required less drilling, rather than drilling a 2 1/2 inch hole. The Locksmith proceeded with installing the new lock which required he drill two 1/4 inch holes in the door for the new lock mechanism. He had completed drilling and had vacuumed up the resulting debris when work was stopped at the request of the asbestos inspector and Industrial Hygenist (IH). The IH set up an air sampler to test for asbestos, the results identified 0.0036 fibers/cc which is well below the OSHA permissible Exposure Limit (PEL) of 0.1 fiber/cc. The results of the analysis on the sample taken from the door by the asbestos inspector identified the material to be 60 % asbestos. It is not known if the Locksmith received an asbestos exposure. The Locksmith was asbestos awareness trained but was not asbestos worker trained. This event was initially evaluated on 07/12/2006 and categorized as non ORPS reportable, after a critique of the event was conducted on 07/17/2006 it was upgraded to an ORPS reportable event under management concerns.
Cause Description:
Operating Conditions:	Normal Operations
Activity Category:	Maintenance
Immediate Action(s):	1. Took a sample of the suspect asbestos material from the door for analysis. 2. Stopped work. 3. Took air sample in the immediate area to test for asbestos. 4. Taped up the openings on the door to perevent any possible release.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: ES&H By When:
Division or Project:	FACILITY SUPPORT SERVICES
Plant Area:	MFC Laboratory and O
System/Building/Equipment:	MFC-752 Rm D6 Door
Facility Function:	Balance-of-Plant - Safeguards/security
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name PFANNENSTIEL, DARRELL F Phone (208) 533-7438 Title Manager Materials and Fuels Complex
Originator:	Name ALLEN, JEFFREY K Phone (208) 526-5320 Title OPERATIONS ASSISTANT
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/17/2006 15:00 (MTZ) Steve Winn BEA 07/17/2006 15:20 (MTZ) Robert C. Seal DOE-ID
Authorized Classifier(AC):
7)Report Number:	NE-ID--BEA-MFC-2006-0003 After 2003 Redesign
Secretarial Office:	Nuclear Energy, Science and Technology
Lab/Site/Org:	Idaho National Laboratory
Facility Name:	Materials and Fuels Complex
Subject/Title:	Discovery of Polychlorinated Biphenyl (PCB) Contaminated Material at MFC
Date/Time Discovered:	07/14/2006 14:00 (MTZ)
Date/Time Categorized:	07/18/2006 14:00 (MTZ)
Report Type:	Notification
Report Dates:	Notification 07/18/2006 19:08 (ETZ) Initial Update     Latest Update     Final
Significance Category:	2
Reporting Criteria:	5A(1) - Any release (onsite or offsite) of a hazardous substance, material, waste, or radionuclide from a DOE facility, that is above permitted levels and exceeds the reportable quantities specified in 40 CFR 302 or 40 CFR 355.
Cause Codes:
ISM:
Subcontractor Involved:	Yes Wheeler Electric
Occurrence Description:	On Wednesday, July 12, 2006, an electrical subcontractor to Battelle Energy Alliance(BEA) was performing work as part of an electrical upgrade project at the Materials Fuels Complex (MFC) on the Idaho National Laboratory (INL) when they encountered an oily substance while removing electrical cables from a conduit at the EBR-II Power Plant (MFC-768). Some electrical cables were removed to a gravel and asphalt area outside the building, and some were removed to a location inside the building for sizing and disposal. The subcontractor workers did not anticipate encountering PCB contaminated material during the project and continued to remove the cables from the conduit after they discovered the oily substance on some of the cables. A BEA electrical engineer recognized that a PCB contamination event had occurred in the same general area several years before, and on Thursday, July 13, he informed the appropriate BEA organizations that the oily substance could possibly contain PCBs. Immediate actions were taken to remove the workers from the area and to isolate and post the entire work area. One set of coveralls that showed signs of being contaminated with the oily substance, and the boots of all workers were collected and bagged as a precautionary measure. BEA notified the subcontractor that the oily substance encountered by their workers could possibly contain PCBs, and requested that any clothing worn home by the workers on Wednesday 07/12/2006, be collected and bagged. On Thursday 07/13/2006, BEA collected a sample of the oil for quantitative analysis at an INL laboratory. As a precautionary measure BEA placed the cables located outside into a waste box, collected the gravel from the area that was stained oil, and covered the oil stained asphalt area with a tarpaulin. On Friday 07/14/2006, additional cleanup activities were conducted inside the building to remove the PCB material from the floor. On Friday 07/14/2006 quantitative analysis of the sample indicated approximately 260,000 ppm PCB. However, the total quantity of PCB material that was released had not been determined. On Friday 07/14/2006 the event was categorized as non reportable since it was not known if the Environmental Protection Agency Reportable Quantity of 1-pound has been reached. On Monday 07/17/2006 at 1000 Facility Management made the determination to report the event under Management Concerns. On Tuesday 07/18/2006 conservative calculations were made and an estimated six lbs. of PCB may be contained in the conduit. Notifications were made to the appropriate agencies. The event was reclassified under Group 5, Sequence 1, Significance Category 2.
Cause Description:
Operating Conditions:	MFC electrical system is configured with only a single normal power feed to all facilities, all standby power feeds are operable.
Activity Category:	Construction
Immediate Action(s):	1. Work was stopped and workers evacuated from the area. 2. Area was secured and posted. 3. Potentially contaminated worker clothing was collected and bagged as a precaution. Requested that the subcontractor gather and secure any other potentially contaminated clothing. 4. Oil sample collected for analysis, analysis indicated approximately 260,000 ppm PCB. 5. Placed the cables which had been located outside into a waste box, collected the oil stained gravel, and covered the oil stained asphalt with a tarpauline. 6. DOE prompt notifications were made after reclassification on 7/18/2006 at 1400
FM Evaluation:	The potential extent of PCB contamination must be determined prior to the subcontractor returning to work.
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? Yes By Whom: FS&S By When: 08/24/2006
Division or Project:	Facility Support Services
Plant Area:	EBR-II Power Plant
System/Building/Equipment:	Electrical Distribution System MFC-768
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 PFANNENSTIEL, DARRELL F Phone (208) 533-7209 Title Manager Materials and Fuels Complex
Originator:	Name ALLEN, JEFFREY K Phone (208) 526-5320 Title OPERATIONS ASSISTANT
HQ OC Notification:	Date Time Person Notified Organization 07/18/2006 15:55 (MTZ) Operations Center DOE-HQ
Other Notifications:	Date Time Person Notified Organization 07/18/2006 14:00 (MTZ) Steve Winn BEA 07/18/2006 14:00 (MTZ) Robert C. Seal DOE-ID 07/18/2006 15:00 (MTZ) Id. Communications Center State 07/18/2006 15:00 (MTZ) National Response Center NRC
Authorized Classifier(AC):
8)Report Number:	SC-ORO--ORNL-X10CENTRAL-2006-0005 After 2003 Redesign
Secretarial Office:	Science
Lab/Site/Org:	Oak Ridge National Laboratory
Facility Name:	ORNL Central Complex
Subject/Title:	Service Representatives Enter Radiological Area Without TLD
Date/Time Discovered:	07/14/2006 09:00 (ETZ)
Date/Time Categorized:	07/14/2006 10:45 (ETZ)
Report Type:	Notification/Final
Report Dates:	Notification 07/18/2006 15:52 (ETZ) Initial Update 07/18/2006 15:52 (ETZ) Latest Update 07/18/2006 15:52 (ETZ) Final 07/18/2006 15:52 (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:	A3B1C01 - Human Performance Less Than Adequate (LTA); Skill Based Errors; Check of work was LTA -->couplet - A5B1C03 - Communications Less Than Adequate (LTA); Written Communication Method of Presentation LTA; Checklist LTA -->couplet - A6B2C01 - Training deficiency; Training Methods Less Than Adequate (LTA); Practice or "hands-on" experience LTA
ISM:	4) Perform Work Within Controls
Subcontractor Involved:	Yes T A Instruments
Occurrence Description:	-- Summary On July 14, 2006, an area radiological control technician (RCT) discovered that on the previous day, two service representatives who were installing software for a calorimeter had entered a posted radiological area without a thermoluminescent dosimeter (TLD) as required by the radiation work permit (RWP). Both contractors were wearing a Siemens alarming electronic personnel dosimeter (EPD) and recorded doses of 0.1 and 0.2 millirem. -- Background/Sequence of Events On 06/29/06, MSTD staff member 1 e-mailed a request for service representative access to the section secretary. This requests mentioned that the area was a radiological area. No specific request for a TLD was made. On 07/07/06, MSTD personnel entered a Personnel Access System (PAS) request for TA Instruments service representatives for the setup and installation of software for a new calorimeter in lab 139, Bldg. 4508, which is a radiological area. “Dosimeter required” was marked, “No” on the PAS request. An MSTD Division escort was given verbal briefing instructions by the laboratory space manager (LSM) on what to brief the service representatives. MST Division staff members were to provide safety instructions (Visitors Guide to Radiological Safety), PPE, assistance doffing and donning, and escort for the service representatives. On 07/11/06, the MSTD escort (MSTD staff member 2) was provided verbal instructions by the laboratory space manager on what to communicate and be cognizant of as an escort. On 07/12/06, the area RCT provided MSTD staff member 1 with radiation safety guide to be reviewed with service representatives. On 07/13/06, two TA Instrument service representatives arrived on site. At approximately 12:45, service representative 1 reviewed the RWP and Visitor’s Guide to Radiological Safety with MSTD staff member 1. MSTD staff member 1 assisted the service representative with donning the required PPE and provided a Siemens EPD. At 1300 hours, service representative 1 entered the controlled radiological area, where the escort was already present. At this point, the TLD or lack of TLD was not visible to the escort inside the radiological area because of the PPE worn by the service representative. At 1400 hours, service representative 2 reviewed the RWP and Visitor’s Guide with MSTD staff member 1, received assistance with donning the required PPE, and was provided a Siemens EPD. At 1500 hours, service representative 2 entered the radiological area to join service representative 1 and the MST escort. At 1630 hours, both service representatives and the escort exited the radiological area and surveyed out through the PCM1B. The EPD worn by service representative 1 indicated a dose of 0.2 mrem, and the EPD worn by representative 2 indicated 0.1 mrem. On 07/14/06 at approximately 0800 hours, the area RCT recognized that the service representatives may not have been wearing TLDs as required by the RWP. At 0900, the RCT verified that the service representatives were not issued TLDs, and the service representatives were not allowed entry into lab 139 to continue work.
Cause Description:	The cause "A3B1C01 Check of work LTA" was identified because not all requirements of the RWP were verified before the service representatives were allowed to enter into the posted radiological area. The requirements are identified on the RWP, and MSTD staff members reviewed the RWP with the service representatives, but concentrated on PPE use and contamination control. The couplet cause code "A6B2C01 Practice or hands on experience LTA" was identified for MSTD staff members 1 and 2 because the current Laboratory Space Manager (LSM) was out on medical leave and MSTD 1 was filling in and not as experienced in day-to-day operations usually handled by the LSM. MSTD 2 is a research staff member who was escorting for the first time. The couplet cause code "A5B1C03 Checklist LTA" was identified because the most reliable ways to prevent recurrence deal with aspects of the access and work control mechanisms such as the Personnel Access System (PAS) checklists and pre-job briefings for radiological work.
Operating Conditions:	Normal
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	On 07/14/06 at approximately 0900 hours, the service subcontractors were instructed to not enter the radiological area until further notification. At 0900, the RCT notified supervision and prepared Radiological Event Report RER 4508-06-3055. At 0927, RCT supervision notified MSTD Research Support Group Leader At 1005, LSS was notified. At 1005, a critiques was convened. At 1100, the event was classified as an ORPS reporable occurrence, 4B(5) SC4. On 07/16/06, the event was re-classified as a 10(2) SC4 occurrence after review with DOE-ORO personnel.
FM Evaluation:	This event resulted from not verifying all RWP requirements were met before entry into a posted radiological area. Additionally, dosimeters are not readily visible inside the radiological area because they are worn under PPE, so verification must be done before dressing out in the required PPE. The appropriate method(s) of reminding personnel to verify RWP requirements will be determined in conjunction with radiological protection management. Personnel were not subjected to increased radiological hazards as a result of this event. Doses were not higher or potentially higher because of the error.
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	Materials Science and Technology Division (MS&TD)
Plant Area:	Central Complex
System/Building/Equipment:	4508
Facility Function:	Laboratory - Research & Development
Corrective Action:
Lessons(s) Learned:	The probability of error increases when personnel take on new tasks as in filling in for off duty personnel or position turnovers.
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name F. K. Edwards Phone (865) 576-8568 Title ES&H Group Leader
Originator:	Name Bowers, Damien R Phone (865) 574-4880 Title OCCURRENCE REPORTING INVESTIGATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/14/2006 09:30 (ETZ) S. J. Zinkle MS&TD 07/14/2006 10:00 (ETZ) Lab Shift Superintendent ORNL/LSS 07/14/2006 10:27 (ETZ) Randy Smyth ORNL/DOE 07/14/2006 10:27 (ETZ) Bobby Davis ORNL/DOE 07/14/2006 10:27 (ETZ) Johnny Moore ORNL/DOE
Authorized Classifier(AC):