1/23/76

1/24/76

2/4/76

3/11/76

3/24/76

S/19/76

5/28/76

6/29/76

6/30/76

TAS/T6

7/20/76

7/20/76
11/8/76

11/18/76

Appendix 1

147, can counter

149, Line 30

189

152B

149, Tank 452

114, Line 2, Tank 923

metal storage cab.
149, Line 21C

149, Line 21

110

from tank #453.

A one-gallon container filled with towels, used to

clean up nitric spill in a line, was found. Reddish

brown fumes were being emitted: sur-viv-air units
were used to investigate and move the container to
Line 3.

Cotton towels used to clean up nitric acid spill were
not thoroughly washed before discarded. Reaction
occurred. No injuries. No contamination released.

Deluge-valve bumped open on the incinerator
plenum. 10,290 liters of water in plenum. No
injuries.

PuQ? unaccounted for. Trip ticket not kept with
container. .

Employee punctured hand with tweezers while
working through glovebox gloves. Employee
restricted.

R&D experimented with high pressure press.
Electrical short took place when the two parts of the
press made contact. Someone had left the electrical
heaters in the on position. This resulted in
overheating of a Pu specimen. $13,857 loss.

Employee moving drums, hurt back.

Employee removing Raschig rings received acid
burn.

Contamination leaked from a process steam line.
(Steam condensate TK 923 put on vacuum 9" HG 15
liters of 12N nitric pulled into steam line out of Line
2.)

Opened bottle of paint stripper turned over and
splashed the front of an employee.

Contractors working overhead, weld stressed. 2000
sq. ft. floor contaminated. No injuries.

Leaking transfer line above Line 21. 7

Employee putting nuts on window popped shoulder.
Surgery required. Accident happened 2-3-76.

A2.5 gram sealed source fell on the floor and
subsequently leaked contamination in office area and
cafeteria, $14,334 loss.

1-19 4/21/92


4/1/70

4/13/70

4/15/70

4/30/70

5/5/70

5/6/70

5/8/70
5/12/70

S/14/70_
6/18/70
6/20/70
7/20/70
7/23/70
10/13/70
* 10/19/70

10/23/70

11/11/70
11/11/70

11/14/70
11/14/70

Appendix 1

149

106

149

148

148

114

149
182A

148
149
114

North Area

114

149

149

Fire escaped from fire box into adjacent material in
glovebox.

Paper jam in xerox machine.

Combustible fluid in plastic bottle ignited outside fire
box. Burned through bags and released
contamination to room. $820 loss.

Gasket failure resulted in loss of one block valve and
one induction coil. No contamination spread. $ 405
loss.

Gasket failure resulted in loss of block valve and
induction coil. No contamination spread. $1388
loss.

Three nitric acid valves in glovebox were open
releasing contamination to room. $2580 loss.

Material outside of fire box ignited.

Sparks from buffing operation ignited a glove.
Contamination. $550 loss.

Gasket failure on K-furnace. $1258 loss.
Chemieéal reaction within waste drum.
Materiai being dried on hot plate ignited.

Efectrical short in solenoid.

Material on hot plate ignited.
Pu skull ignited during recovery operation.

Fire escaped outside of fire box and ignited feed
material.

Gasoline fire in engine compartment of employee's
vehicle.

Pu skull ignited in recovery operation.

Vacuum line pressurized with 125 psi steam forced
contaminated material through wall of vacuum gage
coilar. This was done to unplug line. Contamination
spread. $1090 loss.

Gasket failure in K-furnace.

Unburned material in container of fly ash ignited.

1-13 4/21/92


2/1/83

3/17/83

3/25/83

4/21/83

5/19/83

6/13/83

6/22/83.
7/8/83

_ 718/83

713/83

7/25/83

8/2/83

Appendix 1

153, GB 1530

110, Cafeteen

149, Line 33

114, Line 5

146A, MT-1

149, Line 22

THA

149

Raschig rings became hyperventilated, which made
them dizzy.

NMSPI 83-2. Precipitator pot larger than 4-liters,
Posted limit stated no containers greater than 4-liter
capacity.

Ice cream freezer compressor exploded when
compressor failed to shut down after reaching
cooling set point.

Incinerator drum filtration line. Process water line
was contaminated with 3 molar caustic (KOH) and
plutonium at Line 33.

NMSPI 83-7. Line 5, parts in both the dissolver
vessel and the leaching vessel at same time - not .
allowed by limits.

Line MT-1. A bottle marked Freon was used to
degrease a batch of plutonium turnings/sludge. The
bottle actually contained aluminum nitrate which
reacted with the plutonium, the reaction oxidized and
dissolved some of the material

Overhead waste drain leaked contaminated 300 sq.
ft floor space, pipes, a wall, and a glovebox.

Contamination release to process area

NMSPI 83-12. West storage section of Line 22, one
can with 2062 g Pu and one can with 2109 g Pu.
Limit = 2500 g Pu.

Two air effluent samplers showed higher than
normal Pu concentrations. No cause could be
determined.

Waste drums were being moved from 771A to 776.
Next day, another driver and laborer used same truck
and their shoes became contaminated. Through
tracing, contaminated drums were found, 3 vehicles
were contaminated along with various areas on plant
site.

NMSPI 83-A. Bag found without proper slits cut in
it Plastic pen allowed to sag and form a reservoir
more than two inches deep while being
disassembled. Contaminated liquid accumulated in
the reservoir.

A waste collection tank was found to contain more
than the 200 g Pu limit

1-23 ; . 4f21jo2


12/20/63

12/22/63
1/7/64

1/21/64

1/22/64

1/24/64

1/28/64

2/4/64

2/4/64

2/10/64

2/17/64

2/19/64

3/17/64

4/5/64

4/11/64

Appendix 1

240

Parking Lot

Hallway

180

180, Line 3A

R & D Ceramics Lab

240

159, 160

180

166

148

Buming trash in incinerator caused filter plenum to
ignite. .
Employee slipped on ice—sprained back.

A hole was noticed in a contaminated waste bag and
was immediately taped shut. The bag was moved
down the hallway to be checked on a counter, thus
spreading contamination in the hallway. $110 loss.

Chip fire. Autoignition of metal in an open can. No
damage as metal was allowed to burn itself out in a
magnesium oxide crucible. No loss.

Pu explosion. No damage as the metal was not
tightly contained and the explosion blew the fire out.

No loss.

When furnace power was increased to 1/2 maximum
capacity, the copper electrode holder was consumed
by high temperature, releasing a small amount of
contaminated cooling water. $440 loss.

Burning of combustibles in incinerator caused filters
in plenum to ignite. Complete loss of first stage of
filters. $856 loss.

Welder cutting pipe caused paper wipes to ignite.
No damage.

Ignition of soot accumulation on face of first stage
filters in the incinerator filter plenum. Complete loss
of first stage of filters. $72? loss.

An attempt to free a plugged vacuum line with water
resulted in the release of contaminated water through
a pin hole in the line. $2056 loss.

Chip fire. Spontaneous ignition of a small quantity
of sodium and Pu granules in a glass beaker. No
damage or contamination, fire burned jtself out. No
loss.

Employee carrying a leaking sample carton of Pu
fluoride. Contamination spread. $214 loss.

Heat from reaction cracked reactor tube allowing hot
Pu hydride to become exposed to air and bum.
Contamination spread. $1071 loss.

Two 4liter bottles of liquid salvage leaked. $224
loss.

Gasket failure K-furnace.

i4 4/21/92


12/7/76
12/10/76

1/13/77
3/9/77
4/13/77

10/14/77
1/20/78

3/3/78
6/20/78
6/26/78
7/2/18
8/28/78

9/20/78

10/10/78
10/18/78

11/15/78

12/20/78

1/29/79

Appendix 1

Line 216

114; Line 3

114, Tank 177
147, can counter

181

180A.
114, Line 16

249, incinerator plenum

114, Line 1

249, incinerator plenum

181

Caustic overflowed. Crit drain. Liquid level sensor
in Line 216 malfunctioned.

Steam line valve above Line 3 leaked. Local area
contaminated.

Ring void. Crit. infraction.
Container to be counted leaked. Storage area.

Employee received electrical burn when a portable
down unit was unplugged.

Employee moving ladder, fell, cracked knee cap.

Puncture wound, contaminated rodding out calciner,
cable was frayed.

Gate valve on the sprinkler system was leaking. A
total of 5040 liters was transferred to Bldg. 774,
Level alarm in the incinerator was inoperative.

Employee playing volleyball. Sprained ankle.

Employee playing volleyball sprained ankle, also
later on sprained same ankle on stairs.

Employee walking outside, stepped ‘in hole, tumed
right ankle.

Contractor fiberglassing ducts, hose ruptured—cause
appears to be equipment.

Repacking 2 drums of salts. Bag of salt leaking. 5
possible inhalations. 3 initial counts were positive
west half of room 114 contaminated to 1,000,000
CPM.

Employee twisted wrist, surgery required.

Welding operation resulted in fire. First stage of
HEPA filters. No injuries.

Hoist gave way. 138 pound pipe fell to floor.
Cause—poor quality unistrut out Pipe hit one
employes on the foot

Fire outside of incinerator plenum. Welding
operation. No injuries. No contamination spread.

Employee wearing particulate filter only to remove
paint stripper. Became woozy and fainted.

1-20 4/21/92


10/12/84
10/14/84

11/7/84

12/14/84
1/8/85

3/26/85
3/28/85
6/13/85
6/27/85
TWLU8S

TALS

T/A9/85

7/23/85
8/25/85

9/19/85

Appendix 1

149, Line 42

R&D Crusher

Leach Part Cab.

164, Box 83
149

181

247

114

149

Utilities

181
247

149, Line 20

Anion Exchange. Two used FulFlo filter elements
on.a drying rack were spaced less than 12" from a
FulFlo cannister used for floor pickup solutions.

Aplastic bag was used to hold wet contaminated
Kim-wipes. The bag did not contain slits and could
have filled to 16 liters violating the 4-liter limit

The mass limit was exceeded for a storage shelf 3
parts were on shelf and only 2 are allowed.

213 g Pu was in Box 83 exceeding the 200 g limit.

Three filters were removed from line at one time
violating the proper procedure of removing only one
filter at a time.

Acontaminated bag port caused a SAAM alarm to
sound. An operator was contaminated - she had not
gone through the pre-glove check.

A tank containing nitric acid overflowed. The
operator left the room without turning off the transfer
valve. Automatic shutoff valve failed also.

Aciticality drain overflowed when a valve was
accidently left open.

A solution was to te transferred from a pencil tank to
a Raschig-ring filled tank. The wrong tank was
drained causing a violation of the accepted limit of
150 giliter Pu.

A FulFlo filter was spaced only 6" from a filter
cannister which was in use. This violated the
spacing requirements.

Package of impure PuO2 weighed 3861 g while limit
is 2500 g.

Water running into exhaust fan caused short circuit.
When attempt was made to restart fan, worker
received shock and fire started.

Contamination released when glove was being
removed from box.

Tank overflowing onto floor while operator was out
of room.

Floor sweepings in Line 20 were placed in a plastic
container and taken to the cold storage area near Line

1-26 4/21/92 >

—

i


6/26/82

7/13/82

TN 5/82

8/4/82

8/9/82

. 8/10/82

3/18,82

9/29/82

10/5/82

11/16/82
11/22/82

Appendix 1

114, tank 950

776 truck gate

148, Line 19

149, Line 22

238

114, Line 7

182, Box 226

110, Cafeteen
114

breached. Employee transported to medical.

A chem. operator was filling a 12M nitric acid tank
(tank #23) and left the room to take a sample to the
lab. The automatic shut-off valve failed and 100
gallons spilled onto the floor of the room and into the
hallway.

Waste of 2.58g. Pu per liter were transferred to a
tank whose limits are 3.7E-3g/liter. This caused a
total weight of 1250g in the tank exceeding the 200g
limit

Alarm technicians were installing conduit in a trench
using electric power tools. The fire dept. began
running tests of the sprinkler system in 776. Water
resulting from these tests filled the trench with 4" to
12! of water creating an electrical hazard.

Acchem. operator placed two containers of PuF4 next
to a K-furnace with product in the reduction vessel.

A can of material was introduced into the west burn
box that weighed 3483g (limit = 3000g), was the

~ third container added (limit = 2 containers) , and was
larger than the 1 liter limit for the box.

NMSPI 82-19 Three batches of material with Pu
contents of 366g , 675g, and 717g were'processed in
the glovebox, the established limit for each batch is
200g Pu metal.

Two machinists were installing a supplied air fan
using a hoist Small pieces of debris began falling so
the fan was lowered. Upon inspection, it was found
that the ceiling channel! was corroded causing the
hoist to fail

Six containers (approx. 2500g of oxide) were
bagged from a cart into Line 7. Temporary limit
allowed six containers to be bagged in provided each
was limited to a maximum of 1400g of PuO2 and
that the material being transferred came from Lines 8
and 9 only.

The wrong power button was pushed causing power
to flow to a furnace which was not in service. Asa
result, the induction coil overheated causing the
insulation to smoke, disintegrate, and ruin the coil.
Employee contaminated by cafeteen table.

Two chemical operators removing and packaging

1-22 4/21/92


11/13/72

12/22/72

1/5/73
1/21/73

3/15/73
3/19/73

4/11/73

3/3/73

6/26/73

8/14/73

8/24/73

SLITS

10/15/73

Appendix 1

114

249

149

149

149
141

149

146

281, Main plenum

114, Tank 952

contaminated liquid to leak into area. Overflowed
criticality drain into room. $1202 loss.

Maintenance was disassembling chemical pump,
when the pump face was opened, more liquid than
expected came out into try that was there to catch the
liquid. They also placed the mild steel bolts in tray
and the contaminate solution reacted with them.
$962 loss.

Welding on filter holding frames ignited Kim-wipes
on plenum roof.

Pu contaminated solution leaked onto room floor
when valve on tank sample device had matter lodged
under the valve seat. $772 loss.

Chemical reaction caused back pressure on check
valve. Threaded connections leaked under pressure
to cause spill $825 loss.

‘Burning waste fell to outside of glovebox.

Process liquid containing Pu solution entered a
vacuum pump causing overpressurization resulting in
a ruptured seal, allowing liquid to flow onto floor,
contaminating room and hallway. $3728 loss.

A window was being changed using sleeve method
inside a plastic house. One corner came off, causing
contamination of the room. $2285 loss.

Seal leak between balance and glovebox causing
contamination. $1112 loss.

Aq air activated valve was improperly installed and
when the line was activated, it leaked causing
contamination. $3078 loss.

Booster III temporary loss of supplied breathing air.
Cause unknown. No injuries. :

Valve left open, which allowed nitric acid to flow
from a chemical make-up tank to the tank in the
process acid, overfilling tank. This allowed liquid to
flow out a vent line which, in turn, flooded a
glovebox and liquid ran out the criticality drain.
$1600 loss.

Strange odors. Employees wearing full face
respirators became dizzy and nauseous. No other
problems. Source unknown.

This tank contains recycle solutions generated in

1-17 4/21/92


TAT/67 249 Glovebox—combustible waste incinerator
overheated, causing ignition of filters in plenum.

$457 loss.

7/18/67 249 Glovebox—combustible waste incinerator
overheated, causing ignition of filters in plenum.
$252 loss.

7(25/67 182 Ignition of chips inside lathe box.

8/10/67 114 Ignition of Pu while going through recovery

. operation.

8/11/67 149 Electrical cord on portable vacuum cleaner shorted
and ignited in a glovebox.

8/11/67 149 Overheated waste incinerator caused insulation on
exhaust duct to ignite in glovebox.

8/21/67 249 Glovebox—combustible waste incinerator
overheated, causing ignition of filters in plenum.

9/15/67 182 External radiation exposures-Type B. Foundry
operations involved with the ZPPR project. —~

10/11/67 249 Glovebox—combustible waste incinerator
overheated, causing ignition of filters in plenum.

10/12/67 153 Employee picked up small container of Pu and
bottom of container fell out. Pu ignited.

12/7/67 ll4 Pu ignition inside metal container.

1/9/68 149 Material inside of scrap pipe ignited.

1/15/68 114 Filter being dried ignited.

2/13/68 114 Filter being leached became dry and ignited.

2/21/68 114 Sparks from welding ignited filter in glovebox.

3/26/68 114 Welding sparks ignited filter in glovebox.

4/3/68 - il4 Material in leaching operation became dry and
ignited.

4/3/68 180A Accumulation of acetylene from welding ignited.
$898 loss.

4/19/68 East Dock 55 gal drum of hydrogen peroxide punctured. No

injuries. No environmental problems.

4/20/68 148 ~ Hot material ignited small brush.

Appendix 1 1-9 4/21/92


11/16/87

1/12/88

1/13/88

Appendix 1

114

149, Line 38

114, Line 16

from drum counter showed 823 g Pu, exceeding the
allowed limit of 500 g.

NMSPI 87-29, 55-gallon drum was taken to drum
counter and found to contain 608 g of Pu which
exceeded the allowed Pu limit of 500 g.

Operating personnel were conducting routine
monthly glove changes. Operator was unable to
maintain seal between the glove and glovebox and a
small amount of incinerator ash was released into
room contaminating operator, radiation monitor, and
area.

During re-assembly of calciner after inventory
teardown, personnel discovered a contaminated
glovebox glove. Contamination was released while
maintenance personnel were making a glove change
to replace the contaminated glove.

1-32 ‘ 4/21/92


9/2/86

9/25/86

10/12/86

10/27/86

10 27/86

10/27/86
11/6/86

11/6/86

12/10/86

1/28/87

2/5/87

3/1/87

Appendix 1

149, Line 23

clean up a 2" pan was heaped causing violation.

Too many containers containing fissile material were
found in Line 23 Batching area.

Grinnel Fire Alarms Criticality alarm panel was without emergency power when

114B, Line 17

114, Line 5

114, Line 15

Door 1

163, Box 115

148, Lines 19, 20

114, Line 7

147, Can Counter

114, Line 11, 15

electricians stripped out abandoned winng.

NMSPI 86-22. At shift change, personnel noticed
the free-metal canister in the line contained 628 g of
free-metal which is over the limit of 500 g.

NMSPI 86-24. An empty poly plastic bag-out bag
(18 x 24") was found open hanging undermeath a
fissile solution transfer line. No criticality drain slits
were cut in the bag.

NMSPI 86-23. .A dirty FulFlo filter cartridge was
removed from the FulFlo filter in Line 15. The
cartridge was then placed on the flange of 516A
digestor, causing a violation of the spacing limit
between containers containing fissile material

Locking mechanism on secured door failed.

Maintenance operations were in process of removing
items from a glovebox system, as workers were
removing a piece, plutonium contamination was
released to the area. .

Inadequate job review and lack of communication,
inadequate site preparation, and misapplication of
procedures resulted in release of plutonium oxide to
room atmosphere from glovebox. Five employees .
required body counts.

Smoke build-up, containing high levels of airborne
contamination, from the plasma arc cutting system
remained in supplied air house for short time after
cutting had ceased. Three employees became
contaminated while removing a breathing air

garment.

Smoke and fire inside glovebox apparently started by
a hot plate that was left on and turned upside down
near some combustibles.

NMSPI 87-3. NDA operator wrote 159 g instead of
259 g when transferring the gram value to package.
When package was placed in 55-gallon drum, drum
contained 1030 g which is over limit of 1000 g.

A glove on Line 11 and a glove on line 15 failed,
causing contamination of 3 personnel, equipment and

1-29 4/21/92


3/5/65

3/18/65
3/25/65

4/2/65
4/8/65
4/23/65
5/6/65

5/13/65
6/16/65

6/28/65

8/14/65
8/15/65
9/16/65
9/29/65
9/29/65

10/05/65

10/22/65
10/23/65
11/9/65

Appendix 1

182

149
180
180

Welding sparks from overhead work ignited fresh
paint material on floor.

Material in "trough" box ignited.

Acid feed line valve accidentally opened.
Contamination spread. $272 loss.

Electrical failure.
Acetone fire.
Electrical fault in powerstat ignited insulation.
Product feed sprayed out of loose flange on new
line. Line not checked after construction.
Contamination spread. $7557 loss.
Electrical fault in K-furnace.
Cyclohexane explosion in glovebox. Fumes from
spill. Cyclobexane ignited by electric motor. $300
loss.
1-1-1-trichloroethane explosion in drybox ignited by
burning metal chip during machining operation.
$4405 loss.

tothes left in dryer caught fire.
Dryer dire in laundry. $816 loss.
Gasket failure on K-fumace.
Sweepings and fines ignited.
Pu metal filing explosion, filings from coupons and
other sweepings were placed in styrene jar and
piaced on shelf in drybox when material exploded.
$214 loss. , .

Electrical failure ignited insulation and a cooling
water line.

Combustible waste outside incinerator ignited.
Ignition occurred while mixing materials.

Maintenance was preparing a drybox line for
removal Technician was using part of box to
complete work. Paint with 50% acetone was being
used for stripping and masking of paint and
contamination. Guillotine door in drybox line

1-6 . 4/21/92


4/20/64
4/24/64
4/28/64
5/5/64

6/18/64

6/24/64

6/25/64

713/64

75/64

8/17/64
9/18/64
9/19/64
9/25/64

9/26/64
10/20/64

11/2/64 ©
11/16/64

12/17/64
12/17/64
1/28/65
3/3/65

Appendix 1

_ 160

149

149

149

Hallway

149

166

146

180A

180A
148
149
149
149
148
149
181

Pu chip fire.

Sludge of fire in skull box.

Fire in "trough" box.

Potable water backed up in compressed air lines
because valve was left open. Equipment damage.
$308 loss.

Fire in sludge box.

Partial collapse of false ceiling (8 1/2 x 24 ft section).
$600 loss.

Open valve allowed escape of contaminated acid.
$960 loss.

Employee dropped sample vial he was carrying when
he bumped his arm on glovebox. Contamination
spread. $383 loss.

Hydrofluoric acid solution was pumped into
ammonia solution storage tanks by mistake as the
acid drum label had weathered away. $386 loss.
Chip fire.

Electrical short in vacuum got ignited wiring.

Fire in electrical transformer to Ajax converter.
Shipping container holding 5g of Am exploded. No
injuries (Time 7:41 a.m.) Contaminated room 180
and 180A. Loss 2.5g Am. Cause unknown. Could
be chemical explosion or slow pressure build-up.
$3700 loss.

Explosion inside shipping container.

Gasket failure K-furnace.

Chip fire in trough box.

Small chip fire.

Chip fire in graphite box.

Electrical arc in K-furnace ignited paper wipes.
Sludge ignited.

Sludge ignited.

1-5 4/21/92


11/17/73

2/18/74

4/15/74

724/14

W175

3/3/75

TN6/75

7/30/75

731/75

9/5/75

1/7/76

1/13/76

1/20/76

Appendix 1

148, Line 20

147

114, Tank 953

114

114, Line 1

114, Tanks 551-512

146

149, Line 41

114, Line 16

146A

149, Line 24

114, Line 3

---, Tank 453

toom 114. The criticality limit is 1 kg. of plutonium.
The sludge buildup contained 5.4 kg. Each
calibration compared to previous calibration instead
of original calibration.

An employee received an inhalation exposure when
he was being undressed at the completion of a
supplied breathing air operation.

Improperly installed blank in the supply duct
between rooms 141 and 147 had a 1/8" gap. When

* the reversed air flow occurred, Rm 114 became
contaminated. $3078 loss.

Raschig ring void discovered. Assumed it was
caused by incomplete filling, No injuries. No
problems. Nuclear safety infraction.

Poor construction of plastic house on Raschig ring
removal from tank caused contamination of area.
$833 loss.

Type C occurrence. External radiation exposure to
the hand.

Removing head tanks 551-512 in plastic house. One
employee received inhalation exposure. Employees
wearing FF respirators, exposure received during
undressing. : :

Process liquid came in contact with welding area, on
process liquid transfer line. This caused pressure
and loss of vacuum on the line allowing
contamination of area. $2200 loss.

During a grinding operation, an operator
unknowingly cut a glove while opening a bag of
residue for processing. Operator received more than
the permissible lung burden. $1609 loss.

Unplugging calciner, glove failure, 200 sq. ft. floor
contaminated.

Flowmeter ruptured, operator sprayed with
contaminated caustic and steam.

Criticality infraction. Wet ash heel in line. Crit limit
allows dry metal only.

One glove failed—four others contaminated, 200 sq.
ft. of floor contaminated. One employee body
counted—2nd count background.

Employee contaminated arm while removing sludge

1-18 4/21/92.


9/11/66

9/13/66

10/12/66

10/18/66

10/24/66 .

12/12/66

1/6/67
1/18/67

2/7/67
2/20/67

3/6/67

5/8/67

3/8/67

5/12/67

6/2/67

6/7/67

6/21/67

7/14/67

Appendix 1

281

249

249

114

249

149

114

249

149

148

181

148

Automatic sprinkler valve opened, flooding plenum
with 6" of water. Fire department was flushing
hydrants and told utility operators to disregard
alarms. $880 loss.

Sparks from waste incinerator ignited material on
filters.

Sparks from waste incinerator ignited material on
filters.

Sparks from waste incinerator ignited material on
filters. ,

Natural gas explosion occurred in waste incinerator,
blowing off bags and causing a window fracture.
$4630 loss.

Hot plate ignited plastic hose.

Burned out ballast in light fixture.

Glovebox combustible waste incinerator overheated,
igniting filters in plenum.

Pu ignition while being run through recover process.

' Spontaneous combustion of nitric acid and Kim-

wipes.

Spontaneous combustion of nitric acid and rubber
gloves inside glovebox.

Glovebox combustible trash incinerator overheated,
igniting filters in pleaum.

Pressurization of glovebox caused contamination
Filters were being removed in the incinerator
plenum. $2000 loss.

Ruptured gasket in K-2 furnace.

Spontaneous combustion of incinerator ash while
being reprocessed.

Ruptured gasket in K-2 furnace, causing ignition of
drybox glove.

Ignition of two small filters inside dissolver pot
Glovebox—combustible waste incinerator

overheated, causing ignition of filters in plenum.
$732 loss.

1-8 4/21/92


8/25/83

10/11/83

10/14/83

12/15/83

. 1/17/84

1/24/84

1/30/84

2/6/84

2/7/84

2/8/84

2/12/84

2/15/84

3/16/84

3/30/84

Appendix 1

114, Line 7

114

181A

114

182

149, Line 37

114, Line 3

148

149, Line 50

114, Line 3

Filter Plenum, 3rd stage FU-28. During supplied air
job filter technicians (3) reported getting sick from
acid fumes. Cause unknown.

NMSPI 83-19. Four position transfer cart had too
much shielding.

NMSPI 83-20. 55-gallon drum limit exceeded when
can was counted at can counter to be 300 g, then
placed in drum without being split and recounted.

NMSPI 83-23. Operator cleared plugged discharge
of fluorinator, 6500 g Pu fluoride (4530 g Pu) fell to
floor. Limit = 3500 g Pu. Classified report.

Five used FulFlo filter cartridges were found in the
line. Only four are allowed.

A 55 gallon drum was left unattended with the lid
off 55 gallon drums can only be left unattended
when the lid is on.

Pan Measuring 7 x 12 x 2" was used to collect
material from an offgas line. The accepted size is 6 x
91/2x2".

NMSPI 84-7. Bldg 771 and 707. Non-approved
furnace equipment (screens) used on top of funnels
during casting. All furnace equipment must be
approved by criticality engineer.

Incinerator fire. A fire occurred in the sorting box
next to the incinerator. Two gloves were burned off
of the box at the ring where they attach to the
glovebox. Apparent cause: Ignition of fumes
coming from the paint stripper-soaked wipes.

Criticality drain in a box was partially plugged with
tools.

NMSPI 84-11. Two container plus one-container of
floor sweepings were determined to contain total of
5974 g Pu. Limit = 5000 g Pu.

Burton Breakout. Electrician either bumped or
brushed up against the criticality drain flange.
Respirators were not worm Possible inhalation.

NMSPI 84-15. Caustic filtration. Solution greater
than discard level concenwation shipped to B774 on
pm shift.

NMSPI 84-16. Pan of fissile material less than 12"
edge-to-edge from other fissile material and greater

1-24 4/21/92


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2/7/69
2/17/69
3/28/69

4/10/69

5/11/69

5/19/69

6/25/69

7/10/69
TALLI69
7/30/69

8/14/69

8/21/69
8/27/69
9/6/69

9/8/69
9/9/69
10/3/69

Appendix 1

114

149

114

148

Tunnel

149

149

148

Tunnel

148,

ll4+
182

ll4

lid
148

Tunnel

Spontaneous combustion between leaded gloves and
acid inside paper boxes.

Door to fire box stuck in the open position, causing
rubber gloves to ignite.

Pu ignition inside container.

Gasket failure in K-2 furnace resulted in ignition of
glovebox gloves. Contamination spread. $3443
loss.

Major fire in B776. Started in glovebox system. All
of B776 and B777 contaminated. Some radioactive
material released to the environment. Smoke drawn
into tunnel by B771 ventilation system. (CD69-
6251/6252/6253/6254/6255/6256/7051/and CD71-
3740) $42,000,000 loss.

Filters in glovebox housing incinerator plugged up,
causing accumulation of heat, which ignited glove.
$1970 loss.

Ignition of filter while going through leaching
operation.

Gasket failure in K-2 furnace resulted in Pu ignition. _

Gasket failure in K-furnace. $370 loss.

Ignition of Pu in storage container. Contamination
spread. $20,000 loss.

Gasket failure in K-2 furnace resulted in ignition of
Pu.

Ignition of Pu during sorting operation.
Ignition of Pu chips inside storage container.

Operator opened wrong fill valve. Contamination
spread. $3180 loss.

. Chemical reaction inside Nash pump box.

Gasket failure in K-furnace.

The H&V operator replacing a valve in the pneumatic
control system. The system has an interlock designed
to sbut off the supply fans when the exhaust fans
stop. To replace the relief valve, it was necessary to
shut off air to the control system. It caused the
exhaust inlet damper to open-all the way, causing a

1-11 4/21/92


4/20/68
5/4/68
6/6/68
6/10/68
6/19/68

6/25/68

7/17/68

8/23/68
9/15/68
10/1/68
10/14/68

10/14/68
10/28/68
11/6/68

11/12/68
11/14/68
11/15/68
11/19/68
11/26/68

12/16/68
1/28/69
1/28/69

Appendix 1 ¢

148
114
114
114

249

281

114, Line 2

114
148
179

lid

114
148

148

114, Line 2
180D

149

181

114

114
114

180C

Gasket failed on K-furnace. $565 loss.
Filter ignition from welding operation.
Ignition of Pu and tumings.

Heater left on caused filters to ignite.

An employee in supplied air changing filter in
booster II suffered heat exhaustion.

The hose on a full face respirator came off while the
employee was in the main plenum. No inhalation
exposure.

Pu ignition while going through leaching operation.
$150 loss.

Possible explosion inside dissolving pot
Gasket failure in K-2 furnace. $875 loss.
Ignition of tank valve around Presto-lite torch.

Spontaneous combustion between nitric acid and
combustible waste.

Skull ignition’

Small fire in K-2 furnace.

Gasket failure in K-2 failure. Chemical explosion
caused over-pressurization of K-furnace due to
chemical reaction of lab waste mistakenly added to
process controlled metal for reduction. $1790 loss.
Pu ignition. No contamination spread. $125 loss.
Ignition of plastic funnel

Pu ignition in glovebox.

Ignition of electrical wiring due to welding operation.

Spontaneous combustion of nitric acid and
combustible waste.

Skull ignition.
Pu ignition while leaching operation was in process.

A spark ignited 50-50 mixture of methanol and
carbon tetrachloride.

1-10 4/21/92


7/29/87

8/13/87

8/19/87

8/25/87

8/31/87

O4/87

9/10/87

9/28/87

10/13/87

11/4/87

Appendix 1

146B

149, Line 29

114, Line 3

249

114B, Line 17

183

108A

Corridor A

149, Line 30

149, Line 42

slightly sagging telecommunication wires.

NMSPI 87-18. Cover of sump pump pit enclosure
was left open during the replacement of the sump
pump. The pit has unsafe dimensions and there are
fissile solutions in pipes located near the pit

NMSPI 87-20. Two 4-liter containers of laboratory
waste were placed in the ion exchange area,
approximately 8” from the tertiary column. This
violated the established nuclear safety limit allowing
a single 1-liter container and 12” spacing.

An operator moved a dirty FulFlo filter to the north
end of Line 3 to be bagged out. Dirty FulFlo filters
are not allowed in the north batching area of Line 3
violating a nuclear materials safety limit.

A sheet metal worker was grinding a weld on the
penthouse inside FU-1 filter plenum when his ladder
slipped. The workman released the grinder to catch
his balance and it struck his left wrist Five sutures
were required to close the wound.

A mix of water and hydrofluoric acid was introduced
into bydrofluorinator resulting in moist plutonium
tetrafluoride. The reaction between this moist
material and calcium metal pellets produced sufficient
heat to ignite and cause open hearth reduction. “

When opening the secondary containment on a
shipment of metallographic samples, the operators
realized the third inner bag was not sealed. 1400 sq.
fi of room was contaminated. Operators were
contamninated on their hands and arms.

Wiring on a hot plate in use in a glovebox began to
burn. A tygon hose lying on the floor next to the hot
plate had a hole melted in it and water leaked onto the
glovebox floor.

Asbestos contaminated dust, which had collected on
top of ceiling tiles became airbome when the ceiling
tiles were removed and contaminated two
individuals.

NMSPI 87-26. Night shift found two containers
containing buttons sitting next to each other ina 10x
72” O-ring bag. This was in violation of the 12”
spacing requirement for Line 30.

NMSPI 87-28. Resin was cleaned from the

glovebox floor, placed in Kraft tube, eluted,
removed from Line 42, and placed in drum. Results

1-31 4/21/92


3/2/87

4/10/87

4/13/87

4/14/87

4/23/87

5/8/87

3/19/87

71/87

7/23/87

Appendix 1

149, Line 24

Tanks 362, 363

114, Line 5

146A, Line MT-5

114

Outside

149, Line 37

Nitric Acid Dumpster

Maintenance Dock

the tracking of floor area. Entire operation was
shutdown until decontamination was complete.
None of the operators received body burdens.

Operator noticed material sparking and glowing in a
can of fines transferred to B771 from B707.
Reaction took place in a glovebox. Fines were not
burned twice as procedure calls for.

NMSPI 87-8. Drain valve on Tank 362 locked in
open position during approved transfer of solution
from tank 363 to B774. Approximately 40 liters of
unsampled solution from tank 362 were transferred
with solution from tank 363.

NMSPI 87-9. Midnight shift chemical operator
changed FulFlo filter in Line 5 and placed used filter
on drying stand, approximately 6” from another
filter. Limits specify that filters must be spaced 12”
or more from each other.

Acake pan (9 1/2 x 6 x 2”, 1.6 liter volume) was
used for blending enriched uranium oxide batches to
obtain a consistent mixture. The cake pan violated
the volume limit of 1 liter.

NMSPI 87-13. Stainless steel pump transfer
container of approximate dimensions 18 x 18 x 24”
was found with no lid. Container was placed under
a fissile solution transfer line violating the four liter
volume rule.

A light driver was transporting HF cylinders from
B130 to B771 HF storage area. As truck was
tuming comer and moving over rough road, one
strap loosened allowing cylinders to roll toward back
of truck. Forklift operator stopped cylinders from
rolling off One operator received slivers in arm.

Two employees entered supplied air and removed a
blank on incinerator. Air mover was taken out of
service to supply negative pressure. Negative
pressure was being lost so air mover were turned
back on to minimized contamination release.

Operator noticed a leaking hose on portable dumpster
which supplies nitric acid to chemical makeup area.
Approximately 35 gallons of nitric acid leaked from
hose to soil, Acid was neutralized with potassium
hydroxide flakes and sodium bicarbonate.

Heavy driver was transporting a 10 cu yd capacity

compactor box with the compactor trash truck. He
lifted the box up to see pedestrians and nicked

1-30 4/21/92


11/25/65
12/13/65
12/21/65
12/28/65
12/28/65

1/3/66
1/11/66
2/18/66
3/11/66

4/12/66
4/28/66
5/6/66

6/15/66
6/20/66
6/28/66
7/10/66
7/21/66

8/8/66
8/18/66

8/29/66

9/1/66

Appendix 1

149
181
152
114
181

181
152
248

114

149

148
148
149
149
249

148
149

249

181

between paint area and manufacturing test muffle
furnace was not completely closed. As painter put
second container of paint in air lock, a flash of fire
met him. $23,253 loss.

K-furnace failure ignited rubber hose.

Chips in carton ignited.

Electrical failure in furnace.

Storage vessel ruptured material ignited.

Container on hot plate boiled dry and ignited
material.

Welding ignited spray paint from aerosol can.
Ignition of combustible material near furnace.
Ignition of combustible waste material in barrel

Welding spark ignited 8" x 8" intake filter. $3054
loss.

Sparks from incinerator ignited material on Alters.
Soot on the face of both Ist and 2nd stages provided
fueL $764 loss.

Welding spark ignited combustible wasie in room.

Plastic oxygen supply hose to Pu burning experimeat
ignited.

Electrical coil failure on K-furnace.

Gasket failure on K-furnace.

Material being crushed ignited.

Combustibles in waste drum ignited by nitric acid.

Spark from incinerator ignited material on filters.
Four filters were bumed. $275 loss.

Gasket failure on K-furnace.

Heat from incinerator ignited oily waste at bottom of
box. :

Sparks from waste incinerator ignited material on
filters.

Material on dryer belt in calciner ignited.

1-7 4/21/92


5/4/79

6/17/79
6/19/79

TA3/19

8/10/79

9/5/19
n
6b

2/3/82

3/19/82

4/19/82

4/29/82
5/6/82

5/10/82

S/11/82

5/24/82

Appendix 1

Annex, so. drum
count -

180, Line C

181A, Line 46

146, Box MT-6

Corridor D

249 INA plevin,

149, Box 44

149, Line 24

247, chem. makeup

114, Line 5

114, Line 5

147A

114, Line 3

114

HEPA filter from plenum FU-2 was
punctured. Three employees body counted. One
initial positive.

Type "C" exposure—second half of month.

Glovebox leaked. Two persons body counted—one
positive. Leak due to maintenance operation on wall
of box.

Inlet filter installed cocked. Low box vacuum
(0.03") released contamination. Three employees
body counted—all three positive. Exhaust filter on
MT6 was plugged.

Employee put hand through window. West end
corridor D.

Employee moving drum—muscle sprain in hip.
Overheat condition reported by utilities ignited filters.

A needle valve was found to be leaking contaminated
nitrate solution. The valve was supposed to be
removed, but due to lack of communication, the
valve was forgotten.

NMSPI 82-5, a glovebox contained 3019g Pu,
exceeding the limit of 2500g.

An improperly positioned caustic fill valve caused the
overiilling of a vacuum system mist tank that resulted
in 11.65M KOH flowing onto the vacuum system
equipment and the floor of the area.

NMSPI 82-6, used FulFlo filter was placed too
closed to other fissile material which exceeded posted
spacing requirements.

NMSPI 82-9, placement of two leached parts in the
same spray hood. Only one part is allowed per hood
with no exceptions.

NMSPI 82-10. Overloading of a 55 gallon drum
with 524g of wet FulFlo filters. The limit is 500g.

NMSPI 82-13, dirty oxides were dried and then cut
out of the line. It was then determined that the oxides
contained 12% moisture and were therefore
considered wet Pu. The oxides weighed 1954g and
the limit for wet Pu is 400g.

During a supplied air operation, the docking ring
uniting the hood and suit separated and suit was

1-21 4/21/92


9/19/85

11/1/85

12/3/85

12/3/85

12/9/85

12/15/85
1/14/86

1/24/86

2/15/86

2/18/86

2/20/86

2/27/86

3/17/86

Appendix 1

149

164

East Annex

149

149

149

114, Line 11

249

114, Line 3

27. The container containing plutonium and
plutonium compounds pressurized and subsequently
released radioactive material to room.

Glovebox floor sweepings containing moisture were
added to sweepings of calcium metal The

" exothermic reaction caused a pressure build-up

which caused the can seal to break releasing
radiological contamination.

Liquid was transferred from a safe pencil tank to an
unsafe annular tank.

Employee mixed bleach, water, and a cleaning agent
together causing a gas that made the employee feel
sick.

Glovebox was undergoing cleanup and exploded
when acetone ignited from an operating hot plate.
Technician injured by window glass.

Two drums exceeded maximum amount of fissile
material of 500 g per drum.

High urine sample. Sensitive report.

Five containers containing fissile material were place
into glovebox violating limit of four containers.

Combustible material of over 1000 g was placed ina
glovebox violating the limit.

Contaminated employee. Sensitive report.

Two containers combined exceeded limit of 2500 g
Pu.

A vacuum trap would not drain. In an attempt to fix
the problem, an operator felt drops of liquid falling
on his head. He was found contaminated and taken
to medical It was determined that a weld in the neck
flange had failed, allowing steam and condensate to
leak out. A further inspection found four vacuum
traps with faulty welds.

Due to a lack of argon to a welding torch, it sparked
and fly ash began to smolder on a filter.

NMSPI 86-7. Operators introduced two cans of
material into Line 3, failing to observe mixed feed
left in a batch can on the batching table. The
combined weight was 5429 g which is over the limit
of 5000 g for the area.

1-27 4/21/92


2/18/63

3/1/63
3/25/63
3/27/63
4/23/63
5/17/63 ©

6/20/63

714/63
7/19/63

9/17/63

9/19/63 °

10/2/63

10/7/63

10/8/63

10/8/63

11/8/63

11/18/63

11/20/63

Appendix 1

148

180
149
114
181

148
147

149
771

149
188

148

146
148

148, 149, 165

148

148

Plastic fell off dryer into trough dissolver, causing it
to ignite.

Chip fire.

Metal fire in skull box.

Lighting ballast on fire.

Contaminated nitric acid spill. $5662 loss.

Gasket failure in K-furnace. Failure caused damage
to furnace heating coil and block valve. No fire or
contamination. $1081 loss.

Pin bole leak in stainless steel line over false ceiling,

line carries high Pu solution. Hole caused by
chemical reaction. $8364 loss.

: Metal fire,

A cracked electrode caused a hole to be bumed into
the mold weil of the furnace flooding the furnace
with cooling water. $330 loss.

Rag and glove fire in dissolver box.

A hangdown tube from a thermo microbalance fell
and broke spreading contamination. Contaminated
equipment placed in unsafe storage. $1500 loss.

Employee broke tygon sight tube with portable
ladder he was moving. Contamination spread.
$2500 loss.

Gasket failure in K-furnace.

Fire in K-furnace. No contamination release. $947
loss.

Fire in K-furnace due to gasket failure. No
contamination release. $1038 loss.

Cross connection valve between nitric acid supply
line and the distilled water system was left open and
acid migrated into the distilled water system. $1131
loss.

Gasket failure resulting in fire. No contamination
telease. $790 loss.

Gasket failure in K-furnace. No contamination
spread. $789 loss.

1-3 4/21/92


11/15/70
11/20/70
11/22/70
11/24/70
11/27/70
12/2/70

12/11/70
12/16/70
12/21/70
L2pa/70

12/26/70

1/22/71
2/2/71

2/8/71
220/71

3/14/71
4/12/71

d/19/71

A/19/71
4/22/71
5/3/71

Appendix 1

148
149
114
104
114
148

149

114

114

283

lit

148, Line 32

ll4
114

li4

149
148

476

114

Gasket failure in K-furnace. $526 loss.
Carton of sludge fell out of fire box.
Sludge ignited in recovery operation.
Paper jam in Xerox machine.

Pot boiled dry and material ignited.

Equipment failure. Gasket failure on K furnace.
$550 loss.

Bellows on incinerator off gas system deteriorated
and broke, releasing contamination. $3060 loss.

Wrong valve type was installed on acid line.
Stainless valve was replaced with Monel valve.
Contamination spread. $1640 loss.
Pu skull ignited in recovery operation.
Gas welding operation ignited oil drippings.
Tape and plastic bag ignited by hot plate.

Improper seal on dry box window at maintenance
change resulted in contamination spread. $817 loss.

FulFlo filter being dried ignited. No contamination
spread. $300 loss.

Spontaneous ignition of combustibles in waste drum.

2 kg Pu material in dissolver pot ignited. No
contamination spread. $155 loss.

FulFlo filter being dried ignited.

Asteam condensate line ruptured, spraying
contaminated steam into the room. Cause due to
galvanic corrosion of dissimilar metals.
Contamination spread. $5777 loss.

Gasket failed on reduction furnace.

Abnormal high pressure generated by reduction of
dirty fluoride. Contamination spread. $13,500 loss.

Water leaked through roof and shorted out wiring to
motor starter for x-ray unit. $1000 loss.

Material in dissolver pot dried and ignited.

1-14 4/21/92


2/8/72

2/20/72
2/26/72
2/28/72

3/2/72.

3/24/72
3/30/72
4/10/72
5/2/72

S/15/72
S/LT/12
6/21/72

WT2

7/24/72
9/6/72

10/3/72

Appendix 1

149

114

East Corridor

149
181, Line 45

149
149

149
149

149, Line 41

148

149

114

loss.

Pressurized incinerator glovebox due to unsafe
manner of punching aerosol glue can near burning

incinerator. $20,000 loss.
\

Unplugging drain line with steam caused tank to
become pressurized and contaminated room. $3931
loss.

Plastic bottle containing residue out of booster IIT ,
exploded. Nitric acid/metal reaction. Area
contaminated. No injuries.

Glovebox filter was being changed. The old filter
. Stuck, and as extra force was applied some oxide
was jarred loose and contaminated area. $2100 loss.

Waste ignited while loading incinerator.

Corroded steam condensate header leaked
contamination onto floor by Line 45. $1555 loss.

Oil sludge ignited on hot plate.

Spontaneous combustion of waste materials outside
of incinerator due to glovebox airflow reversal
$6000 loss.

Ice cream carton fell fom holder, spiiling Pu onto
floor. $4562 loss.

Pu sludge ignited while on hot plate.

While maintenance was cutting a piece of
contaminated exhaust pipe, a puff of dust came out
the end of the pipe. $1487 loss

Corroded steam supply header leaked contamination.
Cause was galvanic corrosion. $2711 loss.

Impure fluoride or possible impure calcium metal
charge caused overpressurization of reduction vesseL
Overtlowed criticality drains contaminating room.
$3871 loss.

Combustible waste burning around incinerator door.
Glove failure—old hydrofluorinator. nineteen
employees body counted, 3 with inhalation
exposures. Room 148, 149 contaminated. (Rodding
out operation being performed.)

Vacuum pump gasket ruptured, allowing

1-16 4/21/92


3/14/61
9/6/61
10/25/61
12/15/61
5/16/62
5/18/62
5/29/62
6/5/62
9/7/62
9/19/62

10/8/62
11/10/62
12/4/62

12/7/62

1/10/63

1/18/63

1/18/63
1/24/63
1/24/63
2/11/63

Appendix 1

166
166
771
147
180
166
148
148
149

Hallway

149
148

146

148

148
148
148
148

Alcohol ignition.

Ignition of filings.

Boiler exploded while it was being lit off
Electrical fire in transformer.

Chip and oil fire.

Acetone ignition outside box.

Metal explosion in furnace.

Gasket faiure (explosion) in K-furnace.
Chip fire—ignition caused by welders.

Spontaneous combustion rubber gloves and nitric
acid.

Chip fire.
Electrical—transformer to lathe on fire.

Combustible trash being bumed in incinerator caused
ignition of plenum.

Fire was caused due to inadequate seal between the ..
furnace top plate and the reduction vesseL The ,
inadequate seal resulted when a gasket from a
previous reduction stuck in the furnace causing
second gasket to cook during the vessel insertion into
the furnace. $250 loss.

Fire and contamination happened when the gasket on
the reduction vessel failed causing moltea metal to be
ejected from it, and pressurized the glovebox line and
failure of the gloves. $691 loss.

K-2 reduction furnace. Fire and contamination
happened when gasket failed. Failure caused molten
metal to be ejected from the furnace and pressurized
the glovebox line failing some of the gloves. $691
loss.

Paint ignited—caused by welders.

Oil fire in K-furnace.

Gasket failure in K-furnace. $441 loss.

Gasket failure in K-furnace. $715 loss.

1-2 4/21/92


3/31/84

3/31/84

4/5/84

4/6/84

6/6/84

711/84

7/13/84

7/22/84

7/25/84

8/6/84

8/7/84

8/27/84

9/17/84

10/4/84

Appendix 1

169, File Cabinet

114, Line 3

114, Line 3

148, Line 20

149, Line 42
114, Line 6
146A, B

149, Line 24

146, MT-1

Residue Process
164, Box 83

Tunnel

than 2" in depth in pan (heaped).

Nitrate solution dripped on employee from transfer
line. Leak due to poor welding job. Area and
employee contaminated.

A filing cabinet contained vials holding Pu of about
20 g. The vials were retumed to the glovebox in
Room 128.

NMSPI 84-18. North section of Line 3. Exceeded
both total mass limit and individual container mass
limit.

NMSPI 84-19. Line 3. Container on hotplate
spaced 7" from FulFlo filter cartridge. Limit requires
minimum 12" edge-to-edge spacing.

NMSPI 84-31. Line 20, Section 884, Button
Breakout. 2 1/2" diameter solid sample rack found
inside criticality drain.

Valve failure on tank 470 caused a four foot area to
be contaminated.

Criticality drain overflowed whea automatic
shutdown valve failed.

A 30-gallon bag, used to boid décontamination
supplies, had no slits cut in it to preveat
accumulation of solution.

Operating personne! were asked to bag wet
incinerator ash. The container used to bold the ash
exceeded the 4 liter limit

Two 30 gallon bags were underneath fissile solution
lines but did not contain slits to preveat accumulation
of solution. ,

A plastic bag of approximately 14-liters volume was
taped to a process line to hold surgeon's gioves. No
slit was in the bag to prevent build up of liquid.

Fumace fire caused by replacing initiators before
furnace had sufficiently cooled, starting a fire.

233 g fissile material accumulated in Box 83
exceeding the 200 g limit

NOx vapors were detected in 771/776 tunnel

Malfunction in the exhaust damper system was
apparently at fault.

1-25 4/21/92


9/30/55

6/14/57

9/11/57

6/9/58
6/20/58
1/7158
7/21/58
1/6/59
1/24/59
24/59
2/26/59
5/26/59
9/8/59

10/1/59
10/16/59
8/22/60
10/31/60
12/21/60
1/19/61

Appendix 1

Appendix 1

Chronology of Incidents Reported for Building 771

182

146

180

147
149
146
149

* 148

149

148

156 |

180
180
148
149

Fire resulted from metal briquette spontaneously
igniting Radioactive material became unconfined and
contaminated area. $9500 loss.

A peroxide tank chemical explosion occurred
showering employees with glass or metal fragments
and contaminated solution. Employee suffered a
minor laceration of right temple and lacerated tip of
the little finger of right hand. $30,936 loss.

Fire and contamination of all.B771. Burning plastic
released hydrogen which resulted in an explosion in
the building exhaust ducts and fire in the main
plenum. $818,000 loss. Report attached.
Electrical fire.

Electrical fire.

Rag fire inside skull box.

Metal fire inside K-4 furnace.

Combustible material ignition.

Metal fire.

Chip fire.

Flammable liquid ignition.

Electrical fire.

Catalytic decomposition of 50% peroxide in an
insulated storage tank. Catalyst in the form of
neoprene gasket material probably introduced
through faulty valve of piping. $1500 loss.

Spark inside skull box ignited paint

Chip fire.

Hot metal caused ignition of filter.

Pu ignition.

Overheated hot plate caused ignition of material

Sparks ignited rags.

Jel 4/21/92


4/24/86

4/28/86

3/3/86

5/6/86

5/16/86

5/23/86

6/21/86

6/27/86

T/LI/86

8/11/86

Appendix 1

114, Lines 13/14

114

114, Line 7

249

114, Lines 6/7

180D, Line 21C

148, Line 19

Residue Process

114

Two chemical operators were found to be highly
contaminated after working a drybox. 11 gloves
were found contaminated, but no holes in any gloves
were found. The procedure for self-monitoring after
working in gloveboxes was apparently not followed,
which caused spreading of contamination. .

Two carpenters were assigned to remove a handle on
ashield for decontamination. They left for lunch
before removing the handle and upon retuming
found the handle already removed.

NMSPI 86-11. Two containers were spaced less
than 12" apart and 2047 g Pu were present in an area
where only 2500 g are allowed.

Negative on the incinerator plenum airlock was non-
existent during undressing of person in supplied air
suit causing person to become contaminated. This
happened because both equalizer valves were closed
at the same time.

Two chemical operators found themselves
contaminated after using new gloves. Upon
inspection it was found that almost 70% of the new
gloves had cracks and minute tears in them. Upon
changing the gloves, contamination was released into

., the room.

NMSPI 86-12. Sludge material in a pan was dry,
but not placed in an 8801 can before being
introduced into the operating line.

NMSPI 86-14. Two buttons were produced,
weighing 2109 and 2111 g, respectively, in violation
of the 2100 g limit.

An operator was injured by a pressurized incinerator
feed drum when it was opened. The drum lid hold-
down mechanism was not resting atop the drum lid.
When the drum ring was removed, pressure form
inside the drum pried the unbolted drum ring off,
raising the lid. The operator's hand and hip were
struck by the drum ring when the pressure was
released from the drum.

Four used filter cartridges and one used filter found
in line thus exceeding nuclear materials safety limit of

four.

Plutonium material was heaped in a 2" pan in line
batching section. During routine maintenance of feed
auger material was spilled on floor, causing an
excess build-up of material on the floor. During

1-28 ‘42192


10/8/69
10/21/69
10/23/69
10/25/69
10/25/69
11/7/69

11/14/69
11/14/69
11/16/69

11/16/69

11/16/69

11/23/69
11/23/69
1/6/70

1/6/70

2/14/70

3/12/70

Appendix 1

148
148
182
148
148

Tunnel

114
148

148, Line 16

114, Line 3

148

lld
li4
ll4

li4

148

148
149
149
114

greater negative pressure in 771 tunnel than 776
exhaust system for the tunnel, pulled contamination
out of the ducts. $2688 loss.

Gasket failure in K-2 furnace.

Gasket failure in K-2 furnace.

Leak in hold caused Pu to fall on furnace floor.
Gasket failure in K-2 furnace.

Gasket failure in K-2 furnace.

Workers tried to remove a section of duct without
decontaminating it firs. $2488 loss.

Pu ignition during dissolving operation.
Gasket failure in K-2 furnace.

Gasket failure in K-2 furnace. Contamination
spread. $763 loss.

Line 3 pressurized due to a rapid reduction when
dissolving Pu tunings in nitric acid. Chemical
operators were making a bag cut on the other end of
the line. $1074 loss.

Reduction furnace gasket failure damaged block
valve and induction coil and released contamination.

Pu ignition while going through dissolving process.
Ignition of filters during leaching operation.
Material in dissolver ignited.

Rapid reaction whea dissolving Pu turnings in nitric
acid. Overflow and drain out criticality drain onto

floor. $995 loss.

Gasket failure in K-furnace. Contamination spread
to rcom. $531 loss.

Gasket failure in K-furnace.

Fire escaped to outside of fire box.

Material ignited outside of fire box.

Partially opened valve allowed water in process line

to overflow out the criticality drain onto the floor.
Contamination spread to room. $641 loss.

1-12 4/21/92


ST/71

5/22/71
6/1/71

O71

72/1

8/22/71

9/2/71

9/2/71

9/3/71

9/21/71
10/10/71
11/23/71

12/29/71

Appendix 1

149, Line 41

Parking lot
149, Line 41

Outside Bldg

164

179

149

149

149
149

114

114, Line 5

Pin hole leaks at the 304 elbow of the skull line
caused airborne contamination. $3352 loss.

Electrical fault caused ignition of wiring,

Maintenance changing dry box exhaust valve waste
bag was held to catch waste product. An abnormal
amount of condensation flowed out of the pipe.
Health physics monitor decided to dump the waste
bag because of possibility of a criticality incident
$2271 loss.

Power outage caused loss of glovebox negative
pressure and pressurized the work area with respect
10 the office area. No injuries, no contamination
spread. Caused by circuit overload.

Corrosion leak in non-line waste drum stored outside
on asphalt pad. Contamination on the pad. $3282
loss.

Exothermic reaction in a small produce can
containing some Pu material. Two employees
received reportable lung burdens. Pu contamination
spread. $60,000 loss.

Employee using lathe cut off end of finger when it
was caught between chuck jaw and side of cut off
tool. DI #26.

Hole in barrel lines allowed Pu oxide to escape into
room. Small Pu samples were placed in barrel with
combustibles. The Pu had ignited some time during
storage, causing breach of the barrel lines. $15,600
loss.

Free plutonium metal in a drum to be incinerated
bummed a hole in waste bag contaminating Room 149.
No injuries.

Waste outside of fire box was ignited.
Fiber pack material ignited outside of fire box.

Excess plutonium fluoride found in the
hydrofluorinator. Cniticality infraction. No injuries.

Chemical reaction accompanied by an explosion in a
Pu dissolution pot. The pot had contained Be-
contaminated Pu chips and fines were being
dissolved in nitric acid. Line 5 chemical reaction and
explosion. Blew out 3 sample plugs and caused’ 3
criticality drains to overflow. No injuries. $3770

1-15 4/21/92