1)Report Number:	EM-OH-MCP-BWO-BWO05-2006-0004 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Mound Plant
Facility Name:	Utilities Facilities
Subject/Title:	NPDES Fecal Coliform Exceedance
Date/Time Discovered:	06/14/2006 09:30 (ETZ)
Date/Time Categorized:	07/12/2006 10:00 (ETZ)
Report Type:	Notification/Final
Report Dates:	Notification 07/24/2006 15:38 (ETZ) Initial Update 07/24/2006 15:38 (ETZ) Latest Update 07/24/2006 15:38 (ETZ) Final 07/24/2006 15:38 (ETZ)
Significance Category:	4
Reporting Criteria:	5A(4) - Any release (onsite or offsite) of a hazardous substance, material, waste, or radionuclide from a DOE facility that must be reported to outside agencies in a format other than routine periodic reports. (However, oil spills of less than 10 gallons and with negligible environmental impact need not be reported in ORPS.)
Cause Codes:
ISM:	2) Analyze the Hazards 3) Develop and Implement Hazard Controls 4) Perform Work Within Controls 5) Provide Feedback and Continuous Improvement
Subcontractor Involved:	No
Occurrence Description:	This occurrence is a continuation of the chlorine exceedance reported in EM-OH-MCP-BWO-BWO05-2006-0003 on June 13, 2006.The fecal coliform daily limit, 2000#/100ml, was then exceeded at Outfall 001 on June 14, 2006. The sample containing the high fecal coliform was taken at 9:30 a.m., June 14, 2006, at the sanitary treatment plant. The lab report was received late in the afternoon on July 6, 2006. Since this is a weekly grab sample and the plant was running in normal operation for the next two weeks, the exact extent or time of the exceedance is not easily determined. Steps are being taken to reduce, eliminate, and/or prevent exceedances of this nature. The manufacturer of the package plant has been on site and evaluated operation and maintenance procedures. Changes are being implemented to balance the chlorination/dechlorination content.
Cause Description:
Operating Conditions:	Does not apply
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	Evaluated the process for maintenance and loading of tubes in accordance with manufacturer's procedure. Identified the necessary changes Trained operator on changes Manufacturer of plant has been on site and evaluated operation and maintenance procedures. Changes are being implemented to balance chlorination/dechlorination content.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	CH2M Hill Mound, Inc.
Plant Area:	Plant Outfall 001
System/Building/Equipment:	Waste Water Treatment Plant
Facility Function:	Balance-of-Plant - Site/outside utilities
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name ZELLER, SHIRLEY E Phone (937) 865-4439 Title ORPS PROGRAM MANAGER
Originator:	Name ZELLER, SHIRLEY E Phone (937) 865-4439 Title ORPS PROGRAM MANAGER
HQ OC Notification:	Date Time Person Notified Organization 07/06/2006 16:30 (ETZ) R. Berry DOE/MCP
Other Notifications:	Date Time Person Notified Organization 07/06/2006 16:30 (ETZ) C. Friedman DOE/LM
Authorized Classifier(AC):	J. S. Stapleton      Date: 07/13/2006
2)Report Number:	EM-RL--PHMC-PFP-2006-0019 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Hanford Site
Facility Name:	Plutonium Finishing Plant
Subject/Title:	Solid Waste Box lid drop during handling - result of thread wear on re-useable swivel hoist ring screwed into lid
Date/Time Discovered:	07/21/2006 13:45 (PTZ)
Date/Time Categorized:	07/21/2006 13:50 (PTZ)
Report Type:	Notification
Report Dates:	Notification 07/24/2006 17:31 (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:	The flat lid of a Solid Waste Box (SWB) fell about 3-1/2 feet to the floor when the swivel hoist ring (a type of eye-bolt) threads failed. The lid grazed the right forearm (near the wrist) of a Solid Waste Operator who was stabilizing the lid when the swivel hoist ring attachment failed. The standard practice for handling SWB lids was followed in this event. The SWB is mounted on two piano dollies and rolled under the monorail hoist frame, the hoist hook is attached, and the lid is then lifted free of the SWB. After the SWB is rolled away for loading the lid is lowered onto a table under the hoist. The lid is flat sheet metal weighing 120-pounds with straight edges along the length and semi-circular ends. When the loaded SWB is returned, the lid is hoisted from the table high enough to clear the SWB and the SWB is rolled under. The swivel hoist ring failed after the lid was lifted off the table and as the Operator was holding the lid but before the SWB was rolled underneath. In falling, the lid scratched the operator's forearm before landing on the floor. As a standard practice, the operators were careful to ensure everyone was clear of the lid during handling. The SWB was also clear. The supervisor was present during the event and initiated notifications. The scratched operator received medical evaluation and was released for return to work. Alternate lid handling methods will be used pending resolution of the swivel hoist ring failure.
Cause Description:
Operating Conditions:	does not apply -
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	1. The SWB lid was inspected for damage and then manually re-installed with concurrence from PFP Industrial Safety. 2. The Solid Waste Operator whose forearm was grazed by the lid was evaluated at Advance Medical Hanford and released for return to work with no restrictions. 3. A critique meeting was held to establish the facts surrouding the event.
FM Evaluation:	The Actek brand swivel hoist ring is model 46100-SPE=.29". The threads on the ring in this event appeared to have been stretched. The PFP has no criteria for the number of times the swivel hoist rings are reused. Many dozens of SWBs have been handled in accordance with the standard practice with no previous ring failures. The swivel hoist ring has 1/4-20 threads and a thread projection of 0.29-inches. The ring carries a manufacturer stamp that lists the torque value of 6 pound-feet. When installed into the lid, the bolt is torqued to the stamped value. The manufacturer information states the swivel hoist ring is rated to have a 600-pound capacity and is tested to 200 percent of that value. The PFP practice is to install and torque the swivel hoist ring into the lid in advance (two days before in this event). The lid has a threaded hole in the center for the swivel hoist ring. The threads in the lid mount point did not appear to have significant damage. The SWB storage container is 36-3/16" high x 71" wide x 54-1/2" deep.
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:	200 West
System/Building/Equipment:	SWB Handling/ Bldg 234=5Z/ Swivel Hoist Ring
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 07/21/2006 14:00 (PTZ) JM Sondag DOE-RL
Authorized Classifier(AC):	NA      Date: 07/24/2006
3)Report Number:	EM-RL--WCH-ERDF-2006-0006 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Hanford Site
Facility Name:	Env.Restoration Disposal Facility
Subject/Title:	ERDF Truck Cable Breaks While Loading Full Container
Date/Time Discovered:	07/24/2006 10:00 (PTZ)
Date/Time Categorized:	07/24/2006 10:00 (PTZ)
Report Type:	Notification/Final
Report Dates:	Notification 07/24/2006 19:34 (ETZ) Initial Update 07/24/2006 19:34 (ETZ) Latest Update 07/24/2006 19:34 (ETZ) Final 07/24/2006 19:34 (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:	4) Perform Work Within Controls
Subcontractor Involved:	Yes Integrated Logistics Services, Inc.
Occurrence Description:	At 1800 hours on July 20, 2006, a cable broke on subcontractor shuttle truck #844 while loading a full container in the 100 F Remediation Container Transfer Area (CTA). There were no personnel in the area. The driver of the truck was in the cab operating the controls and was not in any danger from the container or cable. None of the container contents were spilled. The driver secured the equipment and contacted the Subcontractor's Second Shift Superintendent via the truck radio. The Subcontractor's Superintendent advised the driver to secure and hold his position. The Subcontractor's Superintendent and the Washington Closure Hanford (WCH) Second Shift Subcontract Technical Representative arrived at 100 F CTA at 1830 hours. The driver explained that while he was loading container # 347, the container hung up approximately six feet up the lift frame. He stopped and let the container back down about a foot. When he engaged the hoist cable again, the cable broke and the can rolled off the frame. The container traveled approximately six and one half feet on the ground and came into contact with container # 505. No damage to either container could be identified. During the investigation, track marks (deep gouges), from the cable, were found embedded on the passenger side of the lift frame. The third roller, from the rear of the lift frame, was also slightly bent upward. Based on the track marks found and the bent roller, the cable was under the roller when the attempt was made to load this container, causing the failure to the cable. On July 24, 2006, the truck was inspected by the Subcontractor's Project Superintendent, Maintenance Superintendent, Environmental Restoration Disposal Facility (ERDF) Operations Manager, and WCH Craft Supervisor. Based on these inspections, it was clear that the cable broke due to the cable being under the roller when the attempt was made to load this container. The incident was evaluated/reviewed with the Waste Operations Project Director, ERDF Operations Manager, and Subcontracts Manager. WCH Management decided to categorize the event as a Category 10(2). The event was categorized as an SC-4 because the clear cause of the event. The WCH Single Point of Contact (SPOC) was contacted on July 24, 2006 at 1050 hrs to begin the report notification. The DOE Facility Representative was notified on July 24, 2006 at 1105 hrs of WCH's decision to issue this report.
Cause Description:
Operating Conditions:	Normal
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	Photographs (negative type photos, e.g. no electronic photos to attach) were taken of the broken cable, damaged roller, cable tracks on the lift frame, and the two containers involved. Notifications were made to WCH Subcontract Technical Representative, ERDF Operations Manager, Subcontracts Manager, and the Acting Waste Operations Director. The WCH SPOC and DOE FR were also notified. The shuttle truck was returned to the Subcontractor's Maintenance Shop and placed out of service on July 20, 2006. Both containers were inspected by the mechanic and surveyed by the radiological controls personnel. No damage or indication of leakage was identified and the containers were placed back into service (transported to the ERDF for disposal).
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	Waste Operations
Plant Area:	100F
System/Building/Equipment:	ERDF
Facility Function:	Environmental Restoration Operations
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Jeff James Phone (509) 373-3228 Title Waste Operations Project Director
Originator:	Name BOND, SHAWN L Phone (509) 372-9252 Title EMERGENCY MANAGEMENT COORDINATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/24/2006 10:50 (PTZ) WCH SPOC WCH 07/24/2006 11:05 (PTZ) DOE FR DOE/RL
Authorized Classifier(AC):
4)Report Number:	EM-SR--WSRC-FCAN-2006-0004 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Savannah River Site
Facility Name:	F-Canyon
Subject/Title:	Performance Degradation of Stack Annulus Blower Breaker (U)
Date/Time Discovered:	07/20/2006 15:40 (ETZ)
Date/Time Categorized:	07/20/2006 15:40 (ETZ)
Report Type:	Notification
Report Dates:	Notification 07/24/2006 06:30 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
Reporting Criteria:	4A(1) - Performance degradation of any Safety Class or Safety Significant Structure, System, or Component (SSC) that prevents satisfactory performance of its design function when it is required to be operable.
Cause Codes:
ISM:
Subcontractor Involved:	No
Occurrence Description:	The stack blower breaker had been sent to breaker shop for 72 month scheduled calibration. Personnel from I & S received the breaker and installed it satisfactorily. A ground fault relay test was performed after the breaker was installed. During the test the relay functioned to interrupt the run circuit as it was designed. However, a step in the relay test procedure failed due to exceeding the voltage limit on the normally open contact. The expected voltage was 0-5volts alternating current (VAC) and the actual voltage was 18.8 VAC.
Cause Description:
Operating Conditions:	Normal operations
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	Personnel from I&S and F area engineering investigated the Ground fault relay. Several tests indicated that the ground fault relay works to provide proper interruption however, the cause of the excessive voltage could not be determined. The stack blower feeder breaker was danger tagged "Do not use" until a new Ground Fault Relay can be installed. A work order was initiated and sent to I&S to replace ground fault relay.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: G. Stallings By When: 08/31/2006
Division or Project:	WSRC/M&O/FAOP
Plant Area:	F-Area
System/Building/Equipment:	Stack Blower Breaker MCC-C-CB-1K
Facility Function:	Plutonium Processing and Handling
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name J. MARSHALL Phone (803) 952-4499 Title F-Area Operations Manager, M&O
Originator:	Name ABSHIRE, ROBERT Phone (803) 208-3026 Title OCCURRENCE INVESTIGATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/20/2006 15:50 (ETZ) D. Sanders TECHMGR 07/20/2006 15:50 (ETZ) S. Williams FMD 07/20/2006 15:50 (ETZ) J. Pennington PROCESSM 07/20/2006 15:55 (ETZ) J. Marshall FM 07/20/2006 15:56 (ETZ) M. Holloway SRSOC
Authorized Classifier(AC):	ABSHIRE, R.      Date: 07/24/2006
5)Report Number:	NA--LASO-LANL-BOP-2006-0005 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 Fractures Collar Bone and Ribs Resultant of Fall
Date/Time Discovered:	07/20/2006 12:45 (MTZ)
Date/Time Categorized:	07/20/2006 12:55 (MTZ)
Report Type:	Notification
Report Dates:	Notification 07/24/2006 16:12 (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:	No
Occurrence Description:	MANAGEMENT SYNOPSIS: On July 19, 2006, at 1400 CDT, as a National Security Office (NSO-DO) worker ascended temporary stairs to the podium, the stairs shifted and the worker fell off the stairs and hit the side of the stage. The worker was attending the Institute of Nuclear Materials Management (INMM) Annual Meeting in Nashville, Tennessee and was about to give his presentation when the injury occurred. He was immediately transported to a local hospital where he was treated and released. The worker fractured his collar bone and two ribs. On July 20, 2006, the worker returned home and received additional medical treatment at the Los Alamos Medical Center (LAMC). As of July 24, 2006, the worker has not returned to work. Upon his return to work, he will be evaluated at the Laboratory’s occupational medicine.
Cause Description:
Operating Conditions:	On Travel
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	The worker was transported to a local hospital where he was treated and released. On July 20, 2006, after his return home, the worker received additional medical treatment at the LAMC. As of July 24, 2006, the worker has not returned to work. Upon his return to work, he will be evaluated at the occupational medicine facility.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: NSO-DO & QA-OA By When: 09/01/2006
Division or Project:	National Security Division Office
Plant Area:	Off-Site
System/Building/Equipment:	Off-Site
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 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 07/20/2006 13:00 (MTZ) Ed Christie NNSA
Authorized Classifier(AC):	Linda Collier      Date: 07/24/2006
6)Report Number:	NA--PS-BWXP-PANTEX-2006-0070 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Pantex Plant
Facility Name:	Pantex Plant
Subject/Title:	Movement of Item Without Required Radiation Safety Monitoring.
Date/Time Discovered:	07/20/2006 16:30 (CTZ)
Date/Time Categorized:	07/20/2006 16:40 (CTZ)
Report Type:	Notification/Final
Report Dates:	Notification 07/24/2006 15:47 (ETZ) Initial Update 07/24/2006 15:47 (ETZ) Latest Update 07/24/2006 15:47 (ETZ) Final 07/24/2006 15:47 (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:	A5B3C02 - Communications Less Than Adequate (LTA); Written Communications Not Used; Not available or inconvenient for use
ISM:	4) Perform Work Within Controls 5) Provide Feedback and Continuous Improvement
Subcontractor Involved:	No
Occurrence Description:	On July 18, 2006 two items were removed from AL-R8 Sealed Insert containers (AL-R8 SIs) in order to complete require surveillance activities on the items. Removal of the items from the AL-R8 SIs and surveillance activities were performed utilizing Operating Procedure P7-0451. Once the surveillance activities were complete the items were placed into AL-R8s (interplant containers) also utilizing P7-0451. All radiation-monitoring requirements for the items were detailed in P7-0451 and were executed during the operations. The items were then moved from one 12-64 bay to another 12-64 bay utilizing Operating Procedure P7-5080 for repackaging into AL-R8 SIs. Following movement of the items, Radiation Safety was notified to perform monitoring of the items as required by P7-0549, which is the procedure that would be utilized to package the items in an AL-R8 SIs. After this notification Radiation Safety raised a question about the radiation-monitoring requirement that was not performed on the items during transit between facilities. There was no requirement in the approved operating procedure utilized for this operation (P7-5080) to monitor the items while being moved between facilities in the AL-R8s (interplant containers). A critique held on July 19 and reconvened on July 20 gathered pertinent information on the issue, which showed the in transit monitoring requirement of items in AL-R8s (interplant containers) is contained in an Engineering Instruction (PE04-015) that is referenced by Design Agency Document SIER 20041184LA. The items had been moved from originating 12-64 bay to 12-64 destination bay without this requirement for monitoring performed. Radiation Safety Technicians monitored the items following their arrival at the repackaging facility with no concerns detected. Operations were suspended with the items in a Safe and Stable configuration and there are no safety or quality concerns. Proper notifications were made to the Operations Center and NNSA Facility Representative. There were no personnel injuries or damage done to plant equipment as a result of this event.
Cause Description:
Operating Conditions:	The facility was operating normally.
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	BWXT Facility Representative was notified. NNSA Duty Officer and Facility Representative were notified. Generate a Problem Evaluation Report (PER) to assign specific actions on the event. Suspend use of the P7-0451 operating procedure pending Cause analysis report. Acquire approval From Design Agency to package items in Sealed Insert Container. Ensure there are no other Temporary Procedures that are not tied to an Operating Procedure. Initiate a Work Suspension Report/Restart Authorization for Off Normal Event. PX-4982
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	Manufacturing
Plant Area:	Zone 12 South MAA
System/Building/Equipment:	Zone 12 South
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 Tommy Leake Phone (806) 477-4566 Title Production Manager
Originator:	Name ASHLOCK, GARY G Phone (806) 477-4018 Title BUSINESS SUPPORT REP.
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/20/2006 16:41 (CTZ) B. Jones NNSA/ Fac. Rep. PXSO 07/20/2006 17:42 (CTZ) M. Blackburn NNSA/Duty Off PXSO
Authorized Classifier(AC):	Donald Gerber      Date: 07/24/2006
7)Report Number:	NA--SS-SNL-10000-2006-0009 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Sandia National Laboratory - SS
Facility Name:	SNL Division 10000
Subject/Title:	Suspect/Counterfeit bolts discovered on Manlifts during Inspection Campaign
Date/Time Discovered:	07/20/2006 12:43 (MTZ)
Date/Time Categorized:	07/20/2006 12:58 (MTZ)
Report Type:	Notification/Final
Report Dates:	Notification 07/24/2006 18:55 (ETZ) Initial Update 07/24/2006 18:55 (ETZ) Latest Update 07/24/2006 18:55 (ETZ) Final 07/24/2006 18:55 (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:	2) Analyze the Hazards
Subcontractor Involved:	No
Occurrence Description:	Between June 6, 2006 and July 20, 2006, six manlifts were found to have suspect/counterfeit bolts on them. All bolts which were determined to be either suspect or counterfeit were found during normal preventive maintenance inspections and have been collected for future final disposition by proper corporate compliance personnel. The IG has not been notified by Sandia National Laboratories personnel. There were not failures associated with these items. The bolts were found in a variety of applications on the manlifts. The bolts were found on the following manlifts, listed along with dates and times of initial notifications: Genie 1997, manlift -- original notification 6/6/2006 - 1610 Bolts found at castors; tile back platform; out rigger and mounting bolts; pot hole protection mounting; stabilizer mounting 1 ea - KS (Kosaka Kogyo) headmarking - 3/8" thread X 1" long - grade 5 6 ea - KS (Kosaka Kogyo) headmarking - 1/4" thread X 1 3/4" long - grade 5 2 ea - KS (Kosaka Kogyo) headmarking - 1/4" thread X 1" long - Grade 5 2 ea - no headmarking - 1/4" thread X 4 1/2" long - Grade 5 4 ea - KS (Kosaka Kogyo) headmarking - 1/4" thread X 2 " long - Grade 5 Tiger 1980 manlift -- original notification 6/14/2006 - 0949 Bolts found at Basket/bucket mounting; handrails/kick borads/gate/gate locks; platform/decking ; power track mounts; steer knuckles; rotating group/turntable/platform/basket/bucket; hoods/doors/swing out compartments; slides/hinges/wear pad mountings; all pin retainer bolts 1 ea - no headmarking - 1/4" thread X 1/2" long - grade 5 8 ea - no headmarking - 3/4" thread X 1 1/4" long - Grade 5 30 ea - no headmarking - 3/8" thread X 1 " long - Grade 5 9 ea - no headmarking - 3/8" thread X 1 1/4" long - grade 5 6 ea - no headmarking - 1/4" thread X 1 " long - grade 5 2 ea - no headmarking - 1/4" thread X 1 1/2" long - grade 5 4 ea - no headmarking 3/8" thread X 3/4" long - Grade 5 25 ea - no headmarking - 1/4" thread X 3/4" long - Grade 8 2 ea - no headmarking - 1/4" thread X 2 1/2" long - Grade 5 14 ea - no headmarking - 1/4" thread X 1 1/2" long - Grade 5 1 ea - no headmarking - 1/4" thread X 1 3/4" long - Grade 5 Skyclimber 1984 manlift -- original notification 6/14/2006 Bolts found at tank mounts/fuel/oil/ foilter mount; steer knuckles; hoods, doors, swing out compartments; all pin retainers; cylinder mounts, two piece wheel bolts; accumulator mounting bolts 2 ea no headmarking - 1/2" thread X 2" long - Grade 5 2 ea no headmarking - 3/8" thread X 1 1/4" long - Grade 5 12 eaKS (Kosaka Kogyo) headmarking - 1/4" thread X 2 " long - Grade 5 1 ea no headmarking - 1/2" thread X 5 3/4" long - grade 5 9 ea KS (Kosaka Kogyo) headmarking - 1/4" thread X 1" long - grade 5 4 ea no headmarking - 1/4" thread X 3/4" long - Grade 5 4 ea no headmarking - 1/4" thread X 1 1/2" long - grade 5 32 ea no headmarking - 3/8" thread X 1" long - Grade 5 4 ea no headmarking - 1/4" thread X 1/2" long - Grade 5 2 ea KS (Kosaka Kogyo) headmarking - 1/4" thread X 1 1/2" long - Grade 5 Hi-Ranger 1992 bucket truck -- original notification 6/22/2006 - 1502 Bolts found at basket/bucket mounting; chain/cable anchor points/pulley sleeve 2 ea - no headmarking - 3/4" thread X 2 1/2" long - Grade 5 2 ea - FM (Fastener Co. of Japan) headmarking - 3/4" thread X 5" long - grade 5 Versalift 1977 bucket truck -- original notification 7/20/2006 -- 0828 (Note: this Versalift unit was originally reported as a 1997 model.) Bolts found at basket/bucket mounting; handrails/kickboards/gate/gatelocks; platform/decking; power plant mounts AC/DC/Combustion 6 ea - no headmarking - 3/8" thread X 1 1/4" long - Grade 5 2 ea - no headmarking - 3/8" thread X 1" long - Grade 5 4 ea - no headmarking - 7/16" thread X 1 1/4" long - Grade 5 1 ea - no headmarking - 1/2" thread X 3 " long - Grade 5 Versalift 1983 bucket truck -- original notification 7/20/2006 Information on this unit not available at time of report.
Cause Description:
Operating Conditions:	Normal
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	When each manlift was originally found to have the potential of suspect/counterfeit bolts on them, all proper early notifications were immediately made to DOE and Sandia National Laboratories' management. As appropriate, the manlifts were placed out of service and, if necessary, removed from the field to replace the bolts. In other cases, the bolts were replaced either at the time of first observation or as maintenance operations allowed, but always in a manner to allow continued service in a safe manner. All bolts were collected for examination by a subject matter expert to confirm the nature of the bolts. (During earlier examination on a forklift from a similar inspection, other bolts which were initially thought to be suspect/counterfeit by the mechanics and other non-SMEs were determined to be proper, authorized fasteners). After examination by the SME, the bolts from the manlifts listed were determined to be actual suspect/counterfeit in nature. (Note: additional bolts which were also taken from the manlifts that were initially thought to be S/C and were determined to be proper authorized fasteners are not listed in this report. Also, three manlifts with bolts initially thought to be S/C were determined to be proper fasteners. These three manlifts are not listed in this report.)
FM Evaluation:	DOE/SSO Early Notification Date & Time: EOC - 6/06/06 - ? FR - Wayne Walker - 6/6/06 - 1618 Early notifications were made at each instance as follows: Event #18051 Genie 1997, manlift -- original notification 6/6/2006 - 1610 - Event #16855 Tiger 1980 manlift -- original notification 6/14/2006 - 0949 - Event #17032 Skyclimber 1984 manlift -- original notification 6/14/2006 - 0949 - Event #17032 Hi-Ranger 1992 bucket truck -- original notification 6/22/2006 - 1502 - Event #17273 Versalift 1977 bucket truck -- original notification 7/20/2006 - 0828 - Event #18034 Versalift 1983 bucket truck -- original notification 7/20/2006 - 0828 - Event #18034
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	10000/Fleet Services
Plant Area:	Tech Area I
System/Building/Equipment:	Manlift Maintenance Activity/Bldg. 876
Facility Function:	Balance-of-Plant - Machine shops
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Mark Crawford Phone (505) 845-9434 Title Fleet Services Manager
Originator:	Name LUCERO, JEWELEE A Phone (505) 845-4727 Title REPORTING ADMINISTRATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/20/2006 13:02 (MTZ) Mark Crawford 10265 07/20/2006 13:03 (MTZ) Wayne Walker, FR DOE/SSO 07/20/2006 13:04 (MTZ) Veronica Martinez, FR DOE/SSO 07/20/2006 13:05 (MTZ) Cynthia Schneeberger 10260 07/20/2006 13:07 (MTZ) Roy Fitzgerald 10300 07/20/2006 13:11 (MTZ) Lewis Marlman 10264 07/20/2006 13:12 (MTZ) Marc Evans 10300 07/20/2006 13:18 (MTZ) Bonnie Apodaca 10200
Authorized Classifier(AC):	William Plummer Jr.      Date: 07/24/2006
8)Report Number:	NA--SS-SNL-2000-2006-0003 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Sandia National Laboratory - SS
Facility Name:	SNL Division 2000
Subject/Title:	Defeat of Electrical Interlock
Date/Time Discovered:	07/20/2006 07:30 (MTZ)
Date/Time Categorized:	07/20/2006 08:15 (MTZ)
Report Type:	Notification
Report Dates:	Notification 07/24/2006 18:15 (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:	No
Occurrence Description:	Bye the end of August, an Electrical Safety Interlock was defeated and left in defeated condition for an extended period of time. Equipment owner was performing diagnostics on Mass Spec-2 under an Electrical Work Safety Plan signed by the Group Manager in August 2005. Defeat of the cabinet interlock was necessary to perform the diagnostic work, but was not specifically stated in the plan. The electrical safety by-pass was not returned to its safe condition until 12/2005, when the equipment manufacturer's representative was brought on site for further diagnostics. The back panel of the Mass Spec is located in a relatively inaccessible place, the back panel was closed, and a "Danger High Voltage" sign was posted during the time the interlock was by-passed. The area has controlled access via WebCAT.
Cause Description:
Operating Conditions:	Normal
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	1. System returned to safe condition. 2. Written and oral formal discipline given to three employees. 3. Performing an independent assessment of rad operations in Analytical Services. Define and implement corrective actions based on the recommendations of the independent group, with added attention to corrective actions that may affect this issue.
FM Evaluation:	DOE/SSO Early Notification Date & Time: EOC - 7/20/06 - 08:00 FR - Bill Wechsler - 7/20/06 - 08:30
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? Yes By Whom: Causal Analysis Team By When: 09/01/2006
Division or Project:	2000/Neutron Generator Facility
Plant Area:	Tech Area I
System/Building/Equipment:	Mass Spectrometer-2/Bldg. 870, Rm. 1206
Facility Function:	Laboratory - Analytical
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Max Saad Phone (505) 844-9338 Title ES&H Coordinator
Originator:	Name LUCERO, JEWELEE A Phone (505) 845-4727 Title REPORTING ADMINISTRATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/20/2006 08:15 (MTZ) John Sayre 2720 07/20/2006 08:30 (MTZ) Bill Wechsler, FR DOE/SSO 07/20/2006 09:00 (MTZ) Rich Antepenko 2736 07/20/2006 13:45 (MTZ) Max Saad 2733 07/20/2006 13:45 (MTZ) Melecita Archuleta 2000
Authorized Classifier(AC):	Bob Welberry      Date: 07/20/2006
9)Report Number:	NE-ORO--ORNL-X10HFIR-2006-0008 After 2003 Redesign
Secretarial Office:	Nuclear Energy, Science and Technology
Lab/Site/Org:	Oak Ridge National Laboratory
Facility Name:	High Flux Isotope Reactor
Subject/Title:	Cable Tray Hanger Pulled Out of Wall
Date/Time Discovered:	07/20/2006 17:30 (ETZ)
Date/Time Categorized:	07/20/2006 18:30 (ETZ)
Report Type:	Notification/Final
Report Dates:	Notification 07/24/2006 16:08 (ETZ) Initial Update 07/24/2006 16:08 (ETZ) Latest Update 07/24/2006 16:08 (ETZ) Final 07/24/2006 16:08 (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:	6) N/A (Not applicable to ISM Core Functions as determined by management review.)
Subcontractor Involved:	No
Occurrence Description:	On 7/20/06, during work to connect the Cold Source hydrogen transfer line to the test heater, a transfer line cable tray support became disconnected from the wall. The anchors that held the cable tray support to the alcove wall were pulled out of the concrete. The support and a short cable tray section slid approximately 3 feet down the transfer line. The support and the short cable tray section weigh approximately 125 lbs. No personnel were injured, and the transfer line, cable tray, and support were not damaged.
Cause Description:
Operating Conditions:	Reactor already shutdown for End of Cycle 407B.
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	A critique was held on 7/21/06 with personnel who were on the job. All aspects of the job were reviewed and a series of actions were established that led to an understanding of why the support became disconnected from the wall and to communicate lessons learned. A review of the drawings and the work package revealed that the length of the bolt specified for the anchor was inadequate. Installation of this and other hangers is still in the construction phase; therefore, not all post installation testing and reviews have been completed. A review of other similar anchor bolt installations will be conducted. This and any other inadequate bolt installations will be repaired. These actions will be tracked in the Laboratory's Assessment and Commitment Tracking System (ACTS). A lessons learned communication was promulgated on 7/21/06.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	Research Reactors Division
Plant Area:	7900
System/Building/Equipment:	7900
Facility Function:	Category "A" Reactors
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name D.J. Newland Phone (865) 574-1301 Title Facility Manager/Division Director
Originator:	Name SWENSON, JANET H Phone (865) 576-4943 Title OR ASSISTANT
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/20/2006 18:30 (ETZ) Rick Henry RRD 07/20/2006 19:15 (ETZ) Denny Newland RRD 07/20/2006 19:15 (ETZ) Doug Reed DOE-ORO 07/20/2006 19:18 (ETZ) Bill Eldridge ORNL-LSS
Authorized Classifier(AC):
10)Report Number:	RW--YMPO-BSYM-YMSGD-2006-0019 After 2003 Redesign
Secretarial Office:	Civilian Radioactive Waste Management
Lab/Site/Org:	Yucca Mountain Project Office
Facility Name:	Yucca Mountain Site-Geological Disp.
Subject/Title:	Finger Tip Amputation
Date/Time Discovered:	07/21/2006 16:00 (PTZ)
Date/Time Categorized:	07/21/2006 16:10 (PTZ)
Report Type:	Notification
Report Dates:	Notification 07/24/2006 18:09 (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 3) Develop and Implement Hazard Controls 4) Perform Work Within Controls
Subcontractor Involved:	Yes On-Site Maintenance
Occurrence Description:	At approximately 3:10 pm on July 21, 2006, an employee of OnSite Maintenance Center, LLC, a subcontractor of BSC, was performing maintenance activities on a paper shredder in the Bechtel SAIC, LLC (BSC) Human Resources offices located at 1160 Town Center Drive, (Building 13) when the sub contract employee suffered a finger tip amputation. 911 was notified immediately, the scene was secured by BSC personnel, and the employee was transported to UMC by ambulance. An investigation of this incident is currently underway.
Cause Description:
Operating Conditions:	Normal
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	911 was immediately notified Accident scene was secured
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: Facility Ops Deputy By When:
Division or Project:	Yucca Mountain Project
Plant Area:	Summerlin Campus
System/Building/Equipment:	Building 13/Paper Shredder
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 Lynch, Dee L. Phone (702) 295-6148 Title OPERATIONS ORPS COORDINATOR
Originator:	Name Lynch, Dee L. Phone (702) 295-6148 Title OPERATIONS ORPS COORDINATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 07/21/2006 16:19 (PTZ) Dean Stucker DOE 07/21/2006 16:19 (PTZ) John Arthur DOE
Authorized Classifier(AC):