1)Report Number:	EM--PPPO-PRS-PGDPENVRES-2006-0009 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Paducah Gaseous Diffusion Plant
Facility Name:	Environmental Restoration
Subject/Title:	Suspension of Subcontractor Work in Response to Radiation Protection Program Noncompliance
Date/Time Discovered:	08/01/2006 10:00 (ETZ)
Date/Time Categorized:	08/01/2006 14:00 (ETZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 19:23 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
Reporting Criteria:	4B(6) - A facility or operations shutdown (i.e., a change of operational mode or curtailment of work or processes) directed by management for safety reasons. 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:	1) Define the Scope of Work 2) Analyze the Hazards 3) Develop and Implement Hazard Controls 4) Perform Work Within Controls
Subcontractor Involved:	Yes EnergySolutions
Occurrence Description:	Subcontractor work activities at a scrap metal removal and disposal project were suspended by contractor management following discovery of events and conditions that were contrary to the requirements of the Radiation Protection Program (RPP). The suspension of work activities is limited to the scrap metal removal and disposal project and does not impact other site project activities, employees, or schedules. On 08/01/2006, the RPP Manager (RPPM) contacted the Environment, Safety, Health, Quality, and Training (ESHQ&T) Manager and the Remediation Projects Manager (RPM) regarding a series of events that had transpired following direction by the contractor Project Manager (PM) for work activities in a specific scrap metal yard area on 07/26/2006. During the time frame in question, radiological control personnel had observed that contamination area boundaries had been removed without evidence of radiological surveys required to down grade radiological protection area postings. Discussions with project management and subcontractor personnel confirmed that scrap metal work activities on 07/27/2006 removed material from a posted contamination area without radiological control personnel oversight in violation of the radiological work permit. The specific scrap metal yard area is designated as C-746-B Pad and is referred to as the B-Pad. As an area containing legacy items which have fixed contamination, the B-Pad area is posted as a Radioactive Material Area (RMA) with signs directing personnel to contact the Facility Owner and Health Physics prior to entry. Within the RMA smaller areas are posted as Contamination Areas (CA) where removable contamination has been detected and requires additional regulatory posting. The posted CAs in this scrap metal area had been created approximately one year ago, were noted on site radiological control maps and routinely monitored. Investigation into the removal of the CA postings did not reveal any documentation or authorization to down post the areas. Under the subcontractor scope of work, there are approved work control documents to perform work in scrap metal yard areas that are adjacent to and similar in material content to the B-Pad. However, the B-Pad area is not included in the approved work control documentation for the subcontractor. Based on personnel interviews and document reviews, there is sufficient evidence to indicate that subcontractor operations personnel used heavy equipment to remove material from three separate CAs without proper work authorization, failed to properly monitor equipment or material removed from the CA, did not sign the Radiological Work Permit (RWP), or contact a Radiological Control Technician (RCT) prior to entering the area or removing the material. This occurrence is submitted to ORPS under dual reporting criteria for contractor notification to the subcontractor of formal suspension of work 4B(6) as well as a management concern 10(2c) for the violation of established work control processes, procedures, and radiological protection program requirements.
Cause Description:
Operating Conditions:	Does not apply.
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	The suspect areas were surveyed based on existing survey map data and removable contamination was detected. The original contamination areas were immediately reposted as contamination areas. The heavy equipment grappler used to remove the material was resurveyed and no additional contamination found. Project operations and radiological control personnel were interviewed and submitted witness statements in an effort to establish the chronology of activities. A critique was initiated at 1730 hours ETZ on the day of discovery. The contractor procurement representative issued a formal suspension of work order to the subcontractor.
FM Evaluation:	A critique was initiated at the C-746-B Pad at 1130 on 08/01/2006, resumed at 1630, and reconvened on 08/02/2006. During these sessions, a walkdown of the site was conducted, witness statements and conflicts in the chronological description of events were evaluated with the participation of contractor and subcontractor management, subcontractor operations personnel, radiological control program and support personnel, quality assurance, and representatives from the Department of Energy. Subcontractor causal analysis and corrective actions were submitted for contractor quality assurance, radiological control, ISMS, and management review and approval. Contractor approval of the causal analysis as well as the competed and proposed corrective actions is required prior to restart of scrap metal removal and disposal project activities.
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? Yes By Whom: Chris Marshall By When: 08/15/2006
Division or Project:	PRS Paducah Environmental Restoration Project
Plant Area:	C-746-B Pad
System/Building/Equipment:	Northwest Scrap Metal Yards
Facility Function:	Environmental Restoration Operations
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Robert Daniels Phone (270) 441-5017 Title Remediation Projects Manager
Originator:	Name VALENTINE, LENIS C Phone (270) 441-5161 Title SENIOR QA ENGINEER
HQ OC Notification:	Date Time Person Notified Organization 08/01/2006 15:30 (ETZ) Bob Goldsmith HQ OC
Other Notifications:	Date Time Person Notified Organization 08/01/2006 10:00 (ETZ) Kelly Ausbrooks PRS 08/01/2006 10:15 (ETZ) Larry Payne PRS 08/01/2006 10:15 (ETZ) Chris Marshall PRS 08/01/2006 11:00 (ETZ) Robert Daniels PRS 08/01/2006 11:00 (ETZ) Len Valentine PRS 08/01/2006 13:45 (ETZ) Greg Bazzell DOE
Authorized Classifier(AC):	Montgomery R. Breneman      Date: 08/03/2006
2)Report Number:	EM-ID--CWI-RWMC-2006-0015 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Idaho National Laboratory
Facility Name:	Radioactive Waste Management Complex
Subject/Title:	Personel Injury at CPP-653
Date/Time Discovered:	08/02/2006 09:10 (MTZ)
Date/Time Categorized:	08/02/2006 09:18 (MTZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 19:39 (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
Subcontractor Involved:	No
Occurrence Description:	On August 2, 2006 a D&D Hazardous Reduction Technician was working on a Vulcan waste container inspection located in CPP-653. The waste container was staged in a rubber secondary containment approximately 15 Ft x 40 Ft long. The secondary containment is designed to contain solutions that might leak from containers. If a leak would occur the sides of the secondary containment would rise up containing the solution. Normally the containment sides lay flat to the floor surface. One area of the containment was raised because of a dividing wall. The technician had been working on the waste container but needed to exit the secondary containment to retrieve equipment needed for work being performed. The technician was stepping out of the secondary containment and tripped over the raised up side of the containment, falling forward onto the floor surface. With the assistance of a co-worker, also working in the containment, the injured technician was helped out of the area. The technician was taken to INTEC dispensary and then to CFA medical. It was determined at CFA medical that the technician had fractured the radial heads on both elbows. The technician was released by CFA medical to consult with a personal physician.
Cause Description:	Technician was working on a Vulcan waste container and needed to exit the secondary containment to retrieve equipment needed for work being performed. As the technician was stepping out of the containment area technician tripped over the raised side of the containment falling forward onto the floor surface. Technician chose the shortest route to exit the containment stepping over the raised side rather than a lower side.
Operating Conditions:	03 - Normal Operations
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	Technician was taken to medical for evaluation. Management notifications were made. Waste handling operations for CPP-653 were placed on hold.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: Facility Management By When:
Division or Project:	RWMC/INTEC Waste Processing Operations
Plant Area:	INTEC Waste Processi
System/Building/Equipment:	CPP-653
Facility Function:	Nuclear Waste Operations/Disposal
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:	1. EM-ID--CWI-RWMC-2006-0007
	2. EM-ID--CWI-RWMC-2006-0009
Facility Manager:	Name TROESCHER, PATRICK D. Phone (208) 526-6817 Title DEPARTMENT MANAGER
Originator:	Name LAYNG, JENNETTE E Phone (208) 526-1773 Title ASST. BUSINESS OPERATIONS
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 08/02/2006 09:18 (MTZ) Jerry L. McNew DOE-ID
Authorized Classifier(AC):
3)Report Number:	EM-RL--PHMC-PFP-2006-0020 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Hanford Site
Facility Name:	Plutonium Finishing Plant
Subject/Title:	Criticality Alarm System horn failure during routine quarterly audibility testing - partially de-terminated wire in horn
Date/Time Discovered:	08/02/2006 14:10 (PTZ)
Date/Time Categorized:	08/02/2006 17:30 (PTZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 19:10 (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:	5) Provide Feedback and Continuous Improvement
Subcontractor Involved:	No
Occurrence Description:	On Wednesday, August 2, 2006, routine quarterly testing was being performed to verify operability of Criticality Alarm System horns at the PFP. At approximately 1400 hours, horn CAH-Z1-8 located outside Room 149 was found to have failed. [Background in Room 149 was measured at 57-dBA before testing and the horn was measured from the room at 62-dBA during testing]. Fissile material movement was already stopped for the crit horn testing. Work steps were added to the horn test work package to repair the defective horn and return the system to service. The horn failure was the result of a partially de-terminated wire at a crimp on a spade lug connecting the power board to the horn amplifier. The wire was repaired and the horn retested under the same work package shortly after discovery that same day [room background was 60-dBA and the repaired horn from the room was 90-dBA].
Cause Description:
Operating Conditions:	does not apply
Activity Category:	Maintenance
Immediate Action(s):	1. The Building Emergency Director entered LCO 3.1.2 Condition K. Fissile material moves were restricted in areas requiring CAS coverage. [LCO 3.1.2 requires that the Criticality Alarm System (CAS) shall be Operable. A Required Action for inadequate alarm Condition K is to stop fissile material movements.] 2. The horn was repaired in accordance with an approved work plan.
FM Evaluation:	The reason for this failure was not apparent and the as found condition was likely unique. Some similar Occurrence Reports were listed for the interested reader but the loose wire could not have been discovered other than by the routine testing. All the other horns passed. The extended time for Categorization was due to the Building Emergency Director (Shift Operations Manager) and staff being occupied with competing priority activities.
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	Plutonium Finishing Plant Closure Project
Plant Area:	200 West
System/Building/Equipment:	Criticality Alarm System/ 234-5Z/ Criticality Alarm Horn
Facility Function:	Plutonium Processing and Handling
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:	1. EM-RL--PHMC-PFP-2004-0041
	2. EM-RL--PHMC-PFP-2002-0003
	3. EM-RL--PHMC-PFP-2002-0002
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 08/02/2006 19:30 (PTZ) SL Trine DOE-RL
Authorized Classifier(AC):	NA      Date: 08/03/2006
4)Report Number:	EM-SR--WSRC-HTANK-2006-0005 After 2003 Redesign
Secretarial Office:	Environmental Management
Lab/Site/Org:	Savannah River Site
Facility Name:	H Tank Farm
Subject/Title:	Failure of Tank 48 CLFL Analyzer
Date/Time Discovered:	08/02/2006 17:10 (ETZ)
Date/Time Categorized:	08/02/2006 17:45 (ETZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 11:22 (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:	Tank 48 CLFL analyzer (241-948-WTE-AIT-2081) hardwired alarm panel (7400B)alarm was received in 241-82H control room. This required entry into LCO 3.3.1(b) and completion of required LCO actions. Tank 48 was in "Operation" mode with no transfers in progress at time of failure. High ambient temperature conditions (temps exceeding 100F) also existed at time of analyzer failure.
Cause Description:
Operating Conditions:	Tank 48 was in "Operation" mode with no transfers.
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	No outside actions required - Facility will follow guidance in LCO 3.3.1(b) and obtain manual H2 samples every 4 hrs per Operations Management guidance.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: Occurrence Investigator By When: 09/16/2006
Division or Project:	Closure/HClosure
Plant Area:	HTANK
System/Building/Equipment:	Tank 48 CLFL analyzer (241-948-WTE-AIT-2081)
Facility Function:	Nuclear Waste Operations/Disposal
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name CLARK, JR, WYATT C Phone (803) 208-8592 Title FACILITY MANAGER
Originator:	Name YOUNG, HAROLD K Phone (803) 208-6588 Title ISSUE ADMINISTRATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 08/02/2006 17:46 (ETZ) G. Arthur HTF Eng 08/02/2006 17:50 (ETZ) F. Vick HTF OPS 08/02/2006 17:55 (ETZ) W. Clark HTF FM 08/02/2006 18:00 (ETZ) S. Nicholson DOE FR 08/02/2006 18:00 (ETZ) W. Johnson HTF QA 08/02/2006 18:05 (ETZ) K. Hauer Div Mgr
Authorized Classifier(AC):	N/A      Date: 08/03/2006
5)Report Number:	NA--LASO-LANL-ADOADMIN-2006-0009 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Los Alamos National Laboratory
Facility Name:	ADO Administration
Subject/Title:	Worker Fractures Foot
Date/Time Discovered:	08/01/2006 17:00 (MTZ)
Date/Time Categorized:	08/01/2006 17:10 (MTZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 15:26 (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 Protection Technology Los Alamos
Occurrence Description:	MANAGEMENT SYNOPSIS: On July 26, 2006, at 0740, a Protection Technology Los Alamos (PTLA) employee fractured the fifth metatarsal bone in her right foot resultant of an ankle twist when she stepped on a small rock in the parking lot of Technical Area 64, Building 1. The employee immediately notified her supervisor. The supervisor questioned the employee about going to the Laboratory’s occupational medicine facility for evaluation. The employee felt pain in her right foot, but did not feel it was necessary for an evaluation. After the employee got home at the end of the work day, the employee removed her shoe and observed swelling and bruising in her right foot. She self-treated the swelling in her foot that evening and did not seek medical attention. Upon arrival at work on July 27, 2006, the employee notified her supervisor of the condition in her right foot. The supervisor immediately sent the employee to the occupational medicine facility for evaluation. X-rays were taken; results indicated a fracture to her right foot. The employee was released to return to work with restrictions and referred to a specialist for further evaluation. The Institutional Facilities and Central Services (IF&CS) facility operations director was notified of the injury on August 1, 2006. Upon notification, the IF&CS facility operations director categorized the event as reportable under the injury reporting criteria. The NNSA facility representative was also notified of the injury and event categorization on August 1, 2006. A critique was convened on August 2, 2006. BACKGROUND: The TA64-1 parking lot is located at the end of a slope and to its north is a dirt lot containing debris, rocks, etc. After the critique, the IF&CS facility operations and the occurrence investigator conducted a visual inspection of the parking and dirt lots and identified soil erosion in the dirt lot due to the recent heavy rains in the Los Alamos area. As a result, it is suspected that contaminants (debris, rock, etc.,) from the dirt lot flowed into the parking lot. On the day of the event, the PTLA employee had just arrived to work. She parked her privately owned vehicle (POV) in the TA64-1 parking lot. The employee got out of her POV and started to walk between cars when she stepped on the rock causing her right ankle to twist. She experienced pain in her right foot, but continued to walk into the building. After she arrived in the building, the employee reported her injury to her supervisor. She then went to her work area and treated her right foot intermittently with an ice pack for the rest of the work day. She noted that she was carrying some documentation in one hand and a bag in her other hand. The employee did not see the rock because she was looking forward as she walked. She wore sandals with a flat heel. At the critique, the employee stated that she previously had surgery on her right foot and as a result did not have adequate support in her right ankle and foot.
Cause Description:
Operating Conditions:	Normal Operations
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	On July 27, 2006, the employee was evaluated at occupational medicine. X-ray results indicated a fracture to her right foot. The employee was released to return to work with some restrictions and referred to specialist for further evaluation. She is scheduled to see the specialist on August 2, 2006. After the event, the supervisor discussed the injury with the involved employee and emphasized the need to wear proper footwear in order to provide adequate support for walking activities. PTLA supervision will review the injury and lessons learned with employees at their next safety meeting emphasizing proper footwear and to be wary of walking surfaces. PTLA management notified the Associate Director for Security and Safeguards of the injury on July 27, 2006.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: QA-OA & PTLA By When: 09/15/2006
Division or Project:	Protection Technology Los Alamos
Plant Area:	TA64-1
System/Building/Equipment:	TA64-1 Parking Lot
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 08/01/2006 17:16 (MTZ) Ed Christie NNSA
Authorized Classifier(AC):	Linda Collier      Date: 08/03/2006
6)Report Number:	NA--LASO-LANL-GEOPHYSICS-2006-0001 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Los Alamos National Laboratory
Facility Name:	Geophysics, TA-21-210
Subject/Title:	Beryllium Contamination Found on Ductwork at TA-21 Building 210 and 150
Date/Time Discovered:	08/02/2006 08:30 (MTZ)
Date/Time Categorized:	08/02/2006 14:30 (MTZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 15:04 (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:	2) Analyze the Hazards
Subcontractor Involved:	Yes Environmental Restoration Group
Occurrence Description:	In preparation for decontamination/ demolotion of TA-21, environmental sampling of the site was undertaken by Environmental Restoration Group (ERG), a subcontracting organization. Results of the sampling yielded four locations within TA-21 building 210, and one location within TA-21 building 150, that were within the administrative action level of 0.2 to 3 micrograms/100 cm2 denoted in LIR (Laboratory Implementation Requirement) 402-560-01.2, Beryllium Use . Note that these samples are surface contamination levels on near ceiling ductwork and NOT airborne concentration levels. It is the airborne level that is used to determine health effects to personnel. There have been no airborne levels determined at this time. Per LIR-402-560-01.2, Section 5.2.6, "if swipe sample results are between 0.2 - 3 micrograms/100cm2, perform further evaluation and sampling as determined by a qualified industrial hygienist. Based on recommendations from the qualified industrial hygienist, the safety and environmental responsible manager/ supervisor shall either ensure that the area is cleaned to below 0.2 micrograms/100cm2 or post the area as a beryllium contamination area."
Cause Description:
Operating Conditions:	Facility Preparation for Deconstruction/ Demolition
Activity Category:	Facility Decontamination/Decommissioning
Immediate Action(s):	Personnel access to building will be limited to sampling personnel until sample verification is determined. Building will be posted as a Beryllium Contamination area pending the results of the sample verification. These activities are in compliance with the requirements of LIR-402-560-01.2, Section 5.2.6
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: QA-OA By When:
Division or Project:	Environmental Protection Division
Plant Area:	TA-21-210
System/Building/Equipment:	TA-21-210
Facility Function:	Environmental Restoration Operations
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 FOD-9
Originator:	Name FITZGERALD, MARK N Phone (505) 665-5187 Title OCCURRENCE INVESTIGATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 08/02/2006 16:50 (MTZ) DOE Duty Officer NNSA
Authorized Classifier(AC):	Mark Fitzgerald      Date: 08/02/2006
7)Report Number:	NA--LASO-LANL-HEMACHPRES-2006-0006 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Los Alamos National Laboratory
Facility Name:	HE Machining/Pressing Facils
Subject/Title:	Unauthorized boiler maintenance
Date/Time Discovered:	08/02/2006 15:15 (MTZ)
Date/Time Categorized:	08/02/2006 15:30 (MTZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 18:06 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
Reporting Criteria:	4B(5) - A facility operational event caused by deviating from a written procedure or using an inadequate procedure resulting in an adverse effect on safety, such as: an inadvertent facility or operations shutdown (i.e., a change of operational mode or curtailment of work or processes), facility or operations shutdown due to alarm response procedures, inadvertent process liquid transfer, or inadvertent release of hazardous material from its engineered containment. 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 KSL Services
Occurrence Description:	On August 1, 2006 the Engineering Facilities Operations (EFO) Director was informed that KSL Services personnel had performed boiler maintenance work that exceeded the scope of the approved Work Order and associated Integrated Work Document. EFO staff were reviewing cost reports with the local KSL Site Maintenance Manager on July 27 and noted that boiler water treatment costs seemed high. The Site Maintenance Manager requested additional information from his budget analyst and learned that costs for boiler maintenance at TA-16 are approximately double what had been projected. KSL Services held a fact-finding meeting on August 1 and learned that the local KSL boiler mechanic had performed certain boiler maintenance activities that were beyond the scope of the standing Boiler Relight work order that had been charged, and that the purchase of replacement valves and other fittings had been charged to the work order. KSL conducted at review of the boilers within EFO and found that 20 had been modified without appropriate review and authorization. Of those 20, one was found to have a brass valve replacing the original steel valve that did not conform to the LANL Engineering Standards. KSL issued a Nonconformance Report (NCR), an associated Corrective Action Report, and notified the EFOD. The EFOD convened a critique of the discovery on August 2. At the critique it was determined that there were no immediate safety issue due to the modifications, but as a precautionary measure the EFOD directed KSL to lock out the boiler. Although the boiler in questions, boiler B at TA-16-1492, was shut down at the time of the work and was under the control of the boiler mechanic, it was determined that lock-out/tag-out would have been appropriate for the work yet was not employed. Ultimately, it was determined that the work in question addressed a valid maintenance need but that appropriate work control measures were not employed to execute the work. At the critique it was also identified that there were two boilers at TA-9 that might have also had similar unauthorized maintenance. With the new information presented at the critique the EFOD determined that the condition rose to the level of a Management Concern, and re-categorized it as such.
Cause Description:
Operating Conditions:	Many (15) of the boilers were shut down for the summer.
Activity Category:	Maintenance
Immediate Action(s):	- KSL administratively locked out boiler B at TA-16-1492 with an orange lock and tag. - KSL and EFOD staff informed the TA-9 FOD staff of the discovery and recommended that the two similar boilers at TA-9-282 be inspected for unauthorized modifications. - NCRs have been issued for each of the boilers; disposition recommendations for each are pending.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? No By Whom: EFO and QA-OA By When:
Division or Project:	MSS-Engineering Facilities Operations
Plant Area:	TA-16 & 11
System/Building/Equipment:	Package plant boilers
Facility Function:	Explosive
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Robert Mason Phone (505) 667-7270 Title Engineering Facilities Operations Director
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 08/02/2006 15:30 (MTZ) Pradip Badheka NNSA 08/02/2006 15:30 (MTZ) David George NNSA
Authorized Classifier(AC):	Linda Collier      Date: 08/03/2006
8)Report Number:	NA--LASO-LANL-SIGMA-2006-0004 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Los Alamos National Laboratory
Facility Name:	SIGMA Complex
Subject/Title:	Fire Barrier Determined to be Less Than Adequate
Date/Time Discovered:	08/01/2006 14:30 (MTZ)
Date/Time Categorized:	08/01/2006 14:45 (MTZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 13:44 (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. 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:	3) Develop and Implement Hazard Controls
Subcontractor Involved:	No
Occurrence Description:	Management Synopsis: This event has been dual categorized based on the Materials & Chemistry (M&C) Facility Operations Director (FOD) management concern related inadequate documentation and resolution of a less than adequate fire barrier in the Beryllium Technology Facility (BTF). A wall, which separates a beryllium operations area and an office area, was credited as a safety related system with a 45-minute fire barrier rating in the Facility Safety Analysis (FSA). The BTF Fire Hazard Analysis (FHA) was submitted to DOE on June 30, 2005 and withdrawn on July 19, 2005 after the NNSA Fire Protection (FP) Program Manager determined the 45 minute fire rating was not appropriate. The NNSA FP Program Managers' decision was based on 1) the large size of two observation windows and 2) the lack of documentation to substantiate the fire rating of the sealants used for numerous penetrations from a hallway in the administrative area into the beryllium operations area. Background: The same issue had previously been identified by a Facility & Waste Operations (FWO) Fire Protection (FIRE) engineer during inspections of BTF conducted on May 31 and June 1, 2000. The issue was addressed and closed by BTF staff on September 18, 2000, without review or concurrence from FWO-FIRE.
Cause Description:
Operating Conditions:	Normal
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	1) The revised BTF FHA, addressing NNSA comments, was re-submitted to NNSA on March 10, 2006. 2) The hallway between the beryllium operations area and the administrative offices was cleared of combustible loading materials. 3) The hallway was posted and it is routinely monitored to ensure it is kept clear of combustible loading materials. 4) Shutters with a 1-hour fire rating will be installed over both observation windows. 5) Sealant around all penetrations will be removed and replaced 1-hour fire rated sealant. 6) Other equivalent measures will be taken, if needed, to provide the necessary fire rating (such as a drop ceiling with one hour fire rating).
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	Beryllium Technology Facility
Plant Area:	BTF
System/Building/Equipment:	Fire Protection/BTF
Facility Function:	Laboratory - Research & Development
Corrective Action:
Lessons(s) Learned:
HQ Keywords:
HQ Summary:
Similar OR Report Number:
Facility Manager:	Name Greg Fenner Phone (505) 665-3741 Title Facility Operations Director/Designee
Originator:	Name HAKONSON-HAYES, AUDREY C Phone (505) 667-9364 Title OCCURRENCE INVESTIGATOR
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 08/01/2006 14:45 (MTZ) Dave George NNSA 08/01/2006 17:10 (MTZ) Al Elliott PAAA
Authorized Classifier(AC):	Mark Fitzgerald      Date: 08/02/2006
9)Report Number:	NA--NVSO-NST-NTS-2006-0002 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Nevada Test Site
Facility Name:	Nevada Test Site
Subject/Title:	Ironworker Fractures Forearm
Date/Time Discovered:	07/28/2006 13:30 (PTZ)
Date/Time Categorized:	08/03/2006 12:15 (PTZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 20:00 (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:	4) Perform Work Within Controls
Subcontractor Involved:	No
Occurrence Description:	July 28, 2006, a National Security Technologies (NSTec) reinforcing ironworker, working on the slab for the new Shoot House, got his boot tip hooked on some in-place rebar. This caused the ironworker to fall with his left arm extended. He was transported to a local area medical facility for evaluation and referred to a orthopedic surgeon for further treatment. On August 3, 2006 the ironworker was diagnosed with three hairline, non-displaced, non-angular fractures of the left radius.
Cause Description:
Operating Conditions:	Does Not Apply
Activity Category:	Construction
Immediate Action(s):	Notifications to NSTec line management and Safety. Employee transported for medical attention. Management review scheduled.
FM Evaluation:	He has been placed on 10-pound limitation for lifting with left arm but is able to perform ironworker duties.
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	Yes. Before Further Operation? Yes By Whom: NSTec Zone 1 By When: 09/14/2006
Division or Project:	Shoot House Construction
Plant Area:	NTS-Area 23
System/Building/Equipment:	Does Not Apply
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:	1. EM--NVSO-BN-NTS-2004-0003
Facility Manager:	Name Rhyan Andrews Phone (702) 295-6460 Title Manager, Zone 1
Originator:	Name GILE, ANDREA L Phone (702) 295-7438 Title PROJECT OPERATIONS SPEC.
HQ OC Notification:	Date Time Person Notified Organization NA NA NA NA
Other Notifications:	Date Time Person Notified Organization 08/03/2006 12:30 (PTZ) Kathy Pepin NSTec 08/03/2006 12:35 (PTZ) Dennis Armstrong NSO/FR
Authorized Classifier(AC):
10)Report Number:	NA--PS-BWXP-PANTEX-2006-0075 After 2003 Redesign
Secretarial Office:	National Nuclear Security Administration
Lab/Site/Org:	Pantex Plant
Facility Name:	Pantex Plant
Subject/Title:	Cut 110 Volt, Three Conductor Wiring, Zone 4 Magazine
Date/Time Discovered:	08/01/2006 15:10 (CTZ)
Date/Time Categorized:	08/01/2006 17:18 (CTZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 17:00 (ETZ) Initial Update     Latest Update     Final
Significance Category:	2
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 2 occurrence)
Cause Codes:
ISM:	3) Develop and Implement Hazard Controls 4) Perform Work Within Controls
Subcontractor Involved:	Yes Page & Associates, Grant Construction Co.
Occurrence Description:	On July 31, 2006, the contractor commenced with demolition of an existing concrete apron, excavation of existing soil to new elevation and disposal of the excess soil and concrete off plant. There are underground utilities in the area including a 110 volt feeder to a receptacle mounted on a wood post which is to be removed and relocated by the contractor. The underground utilities and 110 volt feeder were marked. At approximately 2000 hours, the feeder was pulled apart by the track excavator being used for excavating activities. No arc resulted from cutting the cables and the breaker did not trip. There were no injuries or property damage resulting from this incident. The contractor had not requested lockout/tagout of the under ground feeder as required by the contract and work was not stopped by the Contractor or the PSTR. On 08/01/06, at 1000 hours, the PSTR called Construction Management and asked if someone could check the status of the cut cables. Construction Management requested the electrical subcontractor perform a checkout of the cables to determine their status. At 1300 hours, the electrical subcontractor verified that the cut cables in question were energized and requested electrical maintenance lockout the circuit. The electrical subcontractor and an alternate PSTR applied locks for safety until maintenance could respond. Construction Management reported the incident to the OC at 1510 hours.
Cause Description:
Operating Conditions:	N/A
Activity Category:	Construction
Immediate Action(s):	1. Emergency Operations Center notified upon discovery of the occurrence, 08/01/06, 1510 hours. 2. LOTO performed by PSTR and contractor. 3. Occurrence investigation performed 08/01/06. 4. Critique scheduled and conducted at 1430 hours, 08/01/06. 5. The event was categorized as a 2C(2)3. 6. BWXT management directed contractor to complete training on the following subject: a. Excavation Permit requirements b. Lock Out & Tag Out (LOTO) and Stored Energy c. Hand digging within 6 feet of a buried electrical line d. OSHA Competent Person responsibilities e. Activity Hazards Analysis knowledge and compliance f. Division I Safety related Specifications g. Utilities Marking and maintaining control of markings during construction. 7 Contractor directed to stop work on 08/01/06 at 1930 hours. 8 On 8/3/06, the event was recategorized, per the request of PXSO, to 10(3)2.
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input:
Further Evaluation is Required:	No
Division or Project:	BWXT Pantex, Capital & Expense Projects Division
Plant Area:	Zone 4
System/Building/Equipment:	Magazine 4-033
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 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 08/01/2006 15:10 (CTZ) Grady Rose PXSO
Authorized Classifier(AC):	Dennis Reed      Date: 08/03/2006
11)Report Number:	RW--YMPO-BSYM-YMSGD-2006-0021 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:	Summerlin Campus - Three Buildings Evacuated
Date/Time Discovered:	07/31/2006 09:50 (PTZ)
Date/Time Categorized:	07/31/2006 09:55 (PTZ)
Report Type:	Notification
Report Dates:	Notification 08/03/2006 18:39 (ETZ) Initial Update     Latest Update     Final
Significance Category:	3
Reporting Criteria:	4B(4) - Any facility evacuation, not including a precautionary evacuation, in response to an actual event. If the event fell under another reporting criterion, then evacuation should be reported as well by noting multiple reporting criteria for the single occurrence.
Cause Codes:
ISM:	3) Develop and Implement Hazard Controls
Subcontractor Involved:	No
Occurrence Description:	On Monday July 31, 2006 at approximately 0950 hours Building 9 in Summerlin was evacuated due to the smell of gas in the building. Building 8 and 9950 Covington Cross Drive were evacuated shortly after. All personnel were moved from the Normal Assembly area to Building 10 because of the high outdoor heat conditions. Southwest Gas was called to investigate the leak. After a thorough investigation Southwest Gas verified that nothing was leaking. At approximately 1300 hours, Southwest Gas gave Howard Hughes the all clear for occupants to return to the buildings.
Cause Description:
Operating Conditions:	Normal
Activity Category:	Normal Operations (other than Activities specifically listed in this Category)
Immediate Action(s):	Southwest Gas was called to determine location of gas leak Buildings 8, 9 and 9950 Covington Cross Drive were evacuated
FM Evaluation:
DOE Facility Representative Input:
DOE Program Manager Input: