Page No. 166
11/15/90

EVENT EVENT

‘SUMMARY OF EVENTS
1952 TO 1988

DATE NUMBER

40/09/87 IIR 87-40-777.3 707, MODULE A

10/15/87 SIR 86-10-460.1 460, WELDING SCIAKY DOOR

10/13/87 IIR 87-10-71.2 771, LINE 30
| 41/02/87 TR 87-92,371-7 37, RNS,

| V1/06/87 TER BI-9S-771.22 TN, LINE 42

11/05/87 EIR 87-93,707-19 707, RMI25A

DESCRIPTION

MNSPI 87-25. FOUNDRY PERSONNEL
EXAMINED CARRIERS CONTAINING
SCRAP MATERIAL AND FOUND 1T
EXCEEDED THE 3000 GRAMS LIMIT.

NMSPT 87-26. PH SHIFT FOUND
‘TWO CONTAINERS CONTAINING
BUTTONS SITTING NEXT TO EACH
OTHER IN A 10" X 72* O-RING
BAG. THIS WAS IN VIOLATION OF
THE 12° SPACING REQUIREMENTS
FOR LINE 30.

WHILE PLACING A FIXTURE INTO.
‘THE CHAMBER, THE LIFT TABLE
WAS RAISED, SUBSEQUENTLY
LIFTING THE DOOR OFF ITS
HINGES AND ALLOWING IT TO FALL
TO THE FLOOR.

RADIATION MONITOR SHEARED
FLOOR BY GLOVEBOX 14 AND NOTED
THE FLOOR WAS HIGHLY
CONTAMINATED, 25,000 COUNTS
PER MINUTE. ROOM WAS
DECCNTAMINATED AND MONITORS
DID A COMPLETE SURVEY OF AREA,
BUT COULD NOT FIND A SOURCE OF
CONTAMINATION.

WMSP] 87-28. RESIN WAS CLEANED
FROM THE GLOVEBOX FLOOR,
PLACED 5M KRAFT TUBE, ELUTED,
REMOVED FROM LINE 42, AND
PLACED IK DRUM. RESULTS FROM
DRUM COUNTER SHOWED B23 GRAMS
PU, EXCEEDING THE ALLOWED PU
LIMIT OF 500 GRAMS.

NMSPI 87-27. ASSEMBLERS
NOTICED TuO PC PARTS STORED
EDGE-TO-EDGE ON THE STAINLESS
STEEL WORK TABLE. THE LIMIT
REQUIRES 12" EDGE-TO-EDGE
STORAGE.

‘ABDTTTONAL NOTES



Page No. 1

12/21/90
SUMMARY QF 1989 EVENTS
®.. NUMBER EVENT OTHE NS Wee TIR/UOR Number Title
UESS-098 01/26/89 01/26/89 371 CAIRS N/A Employee Injury
UE89-101 01/02/89 01/02/89 881 SA N/A Buffer Zone |
UES89-102 01/03/89 01/03/89 556 CAIRS N/A Injuried Employee
UE89-103 01/04/89 01/06/89 372 IIR 89-025,371 Nuclear Material Safety |
Procedural Infraction 89-1 |
VE89-104 01/05/89 01/06/89 551 IIR 89-028,551 Radioactive Source |
Incident
UE89-105 01/05/89 01/05/89 551 NFI N/A Stuck Source |
UE89-106 01/09/89 01/09/89 RFP CAIRS N/A Injuried Employee |
UE89-107 01/09/89 01/10/89 RFP IIR 89-026, VW Non-Approved Life Line in |
UE89-108 01/06/89 01/06/89 443 ENV. N/A Caustic Tank |
UE89-109 01/10/89 01/11/89 371 NFI N/A Bypassing Safety System |
UE89-110 01/12/89 01/12/89 776 IIR = 89-034,776 Inadvertent Activation of |
Criticality Alarm |
UES9-111 01/11/89 01/13/89 331 TIR 89-029 ,331 Electric Wire Severed |
VE89-112 01/12/89 01/13/89 371 TIR 89-027,371-5 Posted Area Incident .
UE89-113 01/14/89 01/16/89 707 NFI N/A Building Evacuation |
UE89-114 01/14/89 01/16/89 779 NFI N/A Flooded Room |
UE89-115 01/10/89 01/17/89 707 HP N/A Contaminated Employee ;
VE89-116 01/17/89 01/17/89 707 HP N/A Contaminated Employee |
UVE89-117 01/17/89 01/17/89 865 TIR 89-031, 865 Drum Pressurization |
Incident |
UE89-118 01/18/89 01/18/89 750 NFI N/A Gas Odor |
UE89-119 01/10/89 01/10/89 RFP CAIRS N/A Injuried Employee

e.* 01/19/89 01/19/89 371 NFI N/A Incidents in 371 During

Radiograph Shots



Page No.
11/09/90

UE
NUMBER

1

EVENT — BUILDING
DATE

SUMMARY OF 1988 EVENTS
TITLE

UE88-000
UE88-000
UES8-001
UEB8-002
UE88-003
UE88-004
UESB-005
UE8S-006
UE88-007
UE88-008
UE88-009
VE88-010
UE88-011
UE88-012
UE88-013
UEss-014
UE88-015
UE8B-016
UE88-017
UE88-018
UE88-019
UEBS-020
UE88-021
UE88-022
UE88-023

03/09/88 776
06/04/88 771
09/01/88 771
09/14/88 771
09/19/88 331
09/18/88 559
09/19/88 PD904
09/21/88 778
09/22/88 PD750
09/23/88 778
09/23/88 RFP
09/23/88 779
09/23/88 774
09/24/88 778
09/28/88 771
09/26/88 779
09/28/88 779
09/29/88 778
09/29/88 771
09/30/88 776
10/01/88 444
10/04/88 371
10/05/88 444
10/06/88 PORTI
10/10/88 371

Non-conform to OSR

SAAM Mal function

Insufficient Procedure for Calibration

Nuclear Material Safety Procedural Infraction 88-25

Personnel Injury

_ Building 559 Security Incident

Pondcrete Spill @ 904 Pad
Personnel Injury
Pondcrete Spill at 750 Pad
Contamination

Injury

Contamination Incident in Building 779
Sludge Incident

Fire in Laundry

Unknown Source of Contamination

OSR - Surveillance Requirement

Water Supply Line Break

Injury

Inadverdent Entry into Respirator Area
02 Analyzer Problems

Injuried Employee

Possible Inhalation 61.0.

Be Contaminated Equipment Movement
Diesel Fuel Spill

Battery Explosion



Page No. 6
12/21/90
SUMMARY OF 1989 EVENTS
UE NUMBER EVENT DATE BUILDING TYPE IIR/UOR Number Title
DATE NOTTIETED INYS.
UE89-213 05/02/89 05/02/89 371 IIR 89-060,371 Nuctear Material Safety
Procedural Infraction 89-6
UES9-214 05/02/89 05/02/89 130 NFI N/A Motor 017 Spill
UE89-215 05/03/89 05/03/89 771 IIR 89-061,771-3 Asbestos Incident
UE89-216 05/03/89 05/04/89 374 NFI N/A Potassium Hydroxide Tank
UE89-217 05/04/89 05/04/89 707 TIR 89-062, 707-12 Nuctear Material Safety
Procedural Infraction 89-7
UE89-218 05/04/89 05/04/89 444 TIR 89-063, 444-5 Ludjum Damage
UES9-219-R 05/04/89 05/04/89 RFP NFI N/A Contractor Excavating
UE89-220 05/04/89 05/05/89 111 CAIRS N/A Injured Employee
UE89-221 05/05/89 05/06/89 776 IIR 89-065, 776-8 Water Leak
Qvi29-222 05/08/89 05/08/89 776 CR Power Loss in B/776 &
B/777
UE89-223 05/09/89 05/09/89 551 CAIRS N/A Back Hoe Rollover
UE89-224 05/09/89 05/09/89 776 HP N/A Contaminated Employee
UESS-225 05/09/83 05/09/89 460 NFL N/A Water Spilt
VES9-226 05/10/89 05/11/89 707 NFI N/A Contaminated Employee
UE89-227 05/11/89 05/11/89 707 HP N/A Injured Employee
UE89-228 05/11/89 05/11/89 707 NFI N/A Trichlor Spill
UE89-229-R 05/09/89 05/11/89 LANDFILL NFI N/A Methane Gas at Drill Site
VE89-230-R 05/09/89 05/11/89 460 NFI N/A Plenum Leakage Problems
UE89-231 05/16/89 05/16/89 771 HP N/A Employee Contamination
UE89-232 05/16/89 05/16/89 776 TIR  89-074,776-9 Improper Posted Rooms
UE89-233 05/15/89 05/16/89 779 HP N/A Roof Leak Causing Floor
Contamination
Daiss-231 05/17/89 05/18/89 777 HP N/A Clothing/Bag Contamination



Page No. 158

s”

SUMMARY OF EVENTS.
1952 TO 1988

EVENT EVENT
DATE NUMBER

07/07/87 SIR 87-7-GATE 9.1

07/07/87 SIR 87-7-776.1

07/07/87 SIR 87-7-707.1

07/16/87 SIR 87-7-BUFFER.+

07/20/87 SIR 87-7-776.3

BUILDING DESCRIPTION ADDETEORAL NOTES

900, NORTH & SOUTH GATES GATES WERE ACTIVATED FOR
CLOSING IN RESPONSE TO A
SCANNER ALARM, ALARMS WERE
APPARENTLY ACTIVATED BY AN
ELECTRICAL STORM. SOUTH GATE
WAS HIT BY A 1972 CHEVELLE AND
NORTH GATE WAS HIT BY A 1974
BLAZER.

776, SIZE REDUCTION VAULT TANK OPERATIONS CREW NOTICED
LIQUID AT BOTTOM OF TANK
DURING A RASCHTG RING
INSPECTION. LIQUID WASTE
OPERATIONS PUMPED OUT SOLUTION
IN TANK SR,

707, MODULE K, GLOVEBOX65 NMSPI 87-17. AN INGOT WAS CAST
WITHOUT THE USE OF WOLD CLANPS
CAUSING IT TO EXCEED THE
WAXIMUM THICKNESS IN ONE SHALL
AREA. ESTABLISHED LIMITS
REQUIRE THE USE OF CLAMPS.

BUFFER, WELL 65-86 GROUND WATER SAMPLING TEAM
VERE AT WELL 65-86, LOCATED
INSIDE THE FIRING RANGE FAN
AREA. WHILE: THE TWO-MAN
SAMPLING TEAM WERE WORKING,
OFFICERS BEGAN FIREARMS
QUALIFICATIONS. THE TWO MEN
WERE FORCED TO HIDE BEHIND
TRUCK FOR THREE STAGES.

776, RN134, GLOVEBOX642 THE PENCIL TANKS IN ROOM 134 LIQUID OVERFLOWING THE
WERE FILLED AND THE HIGH LEVEL CRITICALITY DRAIN.
ALARM IN ROOM 131 SOUNDED.
THE CLERK PACKER FOREMAN
ATTEMPTED TO CONTACT THE
METALLURGICAL OPERATIONS:
FOREMAN TO INFORM HIM TO EMPTY
‘THE TANKS BUT DID NOT MAKE
CONTACT. LATER, GLOVEBOX 642
HAD



Page No. 16
12/21/90
SUMMARY OF 1989 EVENTS
@,: NUMBER EVENT DATE BUILDING TYPE I1IR/UOR Number Title
DATE NOTIFIED. IN:
UES89-423 09/12/89 09/13/89 120 1&SSE N/A Injured Vendor
UE89-424 09/13/89 09/13/89 Hwy 93 T&SSE N/A Vehicle Accident Off Site
UES9-425 09/10/89 09/13/89 881 TIR 89-125,881-6 Electrical Shock
UEBS-426 09/12/89 09/14/89 777 TiR 89-126 777-7 Nuclear Material Safety
Procedural Infraction
89-19
UE89-427 09/13/89 09/14/89 566 NFI S&W Subcontractor Shutdown
UESS-428 09/14/89 09/14/89 779 NFL Construction Plans Error
UE89-429-R 09/15/89 09/15/89 991 TIR 89-128 991-2 Disregarded Building
Criticality Alarm Test
VE89-430-R 09/17/89 09/18/89 124 NFL N/A Fuel Line Break
UE89-431R2 09/15/89 09/18/89 707 NFI N/A Contaminated Wound
Qores-432 09/15/89 09/18/89 707 NFI N/A Out of Service Facility
UE89-433-R 09/16/89 09/18/89 374 VOR 89-14--374 89-1 Spray Dryer Malfunction
UE8S-434 09/19/89 09/19/89 250 NFI N/A Untreated Sanitary Waste
UE89-435-R 08/26/89 09/20/89 707 TIR 89-129 707-15 Nuclear Materials Safety
7 Procedural Infraction
89-20
VE89-436 09/19/89 09/20/89 123 NFI N/A Subcontractor Employee
UE89-437-R 09/19/89 09/20/89 460 NFI N/A Process Waste Solution
Spilt
UE89-438 09/20/89 09/21/89 553 CAIRS Personal Injury
UE89-439 09/21/89 09/21/89 887 TIR 89-130 881-7 Holding Tank Overflow
UE89-440 09/20/89 03/21/89 664 NFI Fire Sprinkler System
Bypass
UE89-441-R 09/22/89 09/22/89 991 NFL N/A Met Lab Spill
VE89-442 09/21/89 09/22/89 707 NFI N/A Fill Line Leak
UE89-443 09/23/89 09/25/89 T690 T&SSE N/A Vehicle Damage



Page No. 4
12/21/90
SUMMARY OF 1989 EVENTS
@.. NUMBER EVENT DATE BUILDING TYPE IIR/UOR Number Titte
DATE NOTIFIED INV.
VE89-381 08/15/89 08/16/89 RFP NFI N/A Broken Water Fitting
UE89-382-R 08/11/89 08/17/89 371 VOR 89-13--371 89-4 Stacker/Retriever Incident
UE89-383 08/20/89 08/21/89 444 NFI N/A Process Water Spill
UE89-384 08/20/89 08/21/89 881 NFE N/A Furnace Coolant Spill
UE89-385 08/18/89 08/22/89 865 CAIRS N/A Injured Employee
UE8S-386 08/19/89 08/23/89 707 TER 89-110 707-13 Nuclear Material Safety
Procedural Infraction
89-16
UE89-387 08/22/89 08/22/89 PD904 NFI N/A Asphalt Thinner Spill
VE89-388-R 08/23/83 08/23/89 776 NEI N/A Brine Spit}
UE89-389 08/18/89 08/18/89 RFP JiR 89-11) 000-11 Water Line Breaks
oe” . 08/23/89 08/24/89 439 CAIRS N/A Injured Employee
UESS-391 08/23/89 08/24/89 444 NFI N/A Safety System Bypass
VE89-392 08/24/89 08/24/89 RFP NFI N/A Hydraulic Fluid Leak
UE89-393-R 08/24/89 08/24/89 707 NFE N/A Fume Evacuation
UES89-394 08/24/89 08/25/89 PDS04 NFI N/A Smoldering Tar
VE89-395 08/24/89 08/25/89 PNDB5S CAIRS N/A Injured Contractor
UE89-396 08/25/89 08/25/89 776 TIR 89-112 776-11 Precautionary Building
Evacuation
UE89-397 08/24/89 08/25/89 569 TIR 89-113 569-2 Nuclear Material Safety
Procedural Infraction
89-17
UE89-398 08/12/89 08/14/89 776 NFI N/A Criticality Alarm System
Testing
UE89-399 08/14/89 08/15/89 460 NFI N/A Overheated Fuse
UE89-400-R 08/26/89 08/29/89 664 NFI N/A OSA Violation, Drum
Stacking
Bycss-101 08/30/89 08/30/89 779 NFI N/A Smal? Fire



Page No.
12/21/90

20

SUMMARY OF 1989 EVENTS

@., NUMBER EVENT DATE BUILDING TYPE IIR/UOR Number Title
DATE NOTIFIED INS.

UE89-507 10/24/89 10/24/89 770 NFI N/A Fire Alarms

UE89-508 10/24/89 10/25/89 707 NFI N/A Fire Alarms

UE89-509 10/24/89 10/25/89 776 NFI N/A Glovebox Overheat Alarm

UE89-510 10/25/89 10/25/89 444 VOR  89-15--444 89-2 Scrubber Leak

UES9-511-R 10/24/89 10/25/89 865 NFI N/A Furnace Leak

VE89-512 10/25/89 10/25/89 559 NFI N/A Glovebox Overheat Alarm

WES89-513 10/25/89 10/25/89 371 NFI N/A Multiple Building Fire
Alarms

UE89-514 10/25/89 10/25/89 T764 NFI N/A Fire Alarm

VE89-515-R 10/26/89 10/26/89 707 NFIT N/A Oxygen Analyzer Problems

UE89-516 10/26/89 10/26/89 566 NFI N/A Hazardous Material Spill

e Response

UE89-517-R 10/26/89 10/27/89 444 NFI N/A Contaminated Employee

UE89-518 10/27/89 10/27/89 883 TIR 89-142 883-1 Scrubber Spill

YE89-519-R 10/13/89 10/27/89 C-1 Pond NEI N/A Housekeeping/Storage
Problem

UE89-520-R 10/25/89 10/27/89 771 NFI N/A Suspect Supplied Breathing
Air Suits

UE89-521-R 10/26/89 10/27/89 774 NFI N/A Suspect Nuclear Material
Safety Procedural
Infraction

UE89-522 10/27/89 10/30/89 776 NFE N/A Criticality Beacon System
Power

UE89-523 10/29/89 10/30/89 460 NFI N/A Damaged Cylinder

UE89-524 10/29/89 10/30/89 771 NFL N/A Improper Orum Placement

UE89-525 10/29/89 10/30/89 771 NFI N/A Glovebox Overheat Alarm

UE89-526 10/30/89 10/30/89 779 NF] N/A Hydrogen Alarm

UE89-527 10/30/89 10/30/89 460 NEI N/A Injured Employee



Page No.
12/21/90

Wve vursee

UE89-337
UE89-338
UE89-339
UE89-340
UES89-341

UE89-342
UE89-343-R
UE89-344
UE89-345
UES9-346
UE89-347
UEBS-348-R

UE89-349
UE89-350
UE89-351
UE89-352-R

UE89-353
VE89-354
UE89-355
UE89-356
UE89-357

Qores9-258-n

12

EVENT BATE

SUMMARY OF
BUILDING TYPE

1989 EVENTS

LIR/UOR Number

Title

07/18/89 07/19/89
07/11/89 07/19/89
07/14/89 07/14/89
07/20/89 07/20/89
07/19/89 07/21/89

07/22/89 07/24/89
07/21/89 07/24/89
07/24/89 07/24/89
07/24/89 07/25/89
07/26/89 07/26/89
07/26/89 07/27/89
07/27/89 07/27/83

07/26/89 07/27/89
07/26/89 07/27/89
07/28/89 07/31/89
07/29/89 07/31/89

07/29/83 07/31/89
07/31/89 07/31/89
08/01/89 08/01/89
08/01/83 08/02/89
08/01/89 08/01/89

08/02/89 08/02/89

889
773
371
881
771

7
440
P0750
T690
W416
374
WiA3

TMm
718
wis
TMm

77
561
374
566
715

371

INYS.

NFI
IIR
NFI
NFIT
TER

TIR
NFI
NFY
NFE
NFI
NFT
VOR

NFI
CAIRS
IIR
IIR

cR
IIR
NFI
CAIRS
TIR

TIR

N/A
89-092,779-5
N/A

N/A
89-096,777-3

89-094,771-6
N/A

N/A

N/A

N/A

N/A

89-10--VV¥ 89-1

N/A
N/A
89-099, VW-4
89-101,771-9

nA
89-097,561-1
WA
N/A
89-102 000-9

89-103 371-21

Battery Acid Leak
Cooling Water Leak
Smoldering Shoe Cover
Nitric Acid Spill
Nuclear Material Safety
Procedural Infraction
89-15

Nitrogen Pressure Loss
Catalyst Spill
Saltcrete Destabilization
Smoking Air Conditioner
Loss of Air Mover

Brine Spill]

Electric Service
Interruption

NMSPI. 89-14 Supplemental
Laundry Fumes
Fuel Oi] Spil]

Hydrofluoric Acid (HF)
Alarm

Water Damage
Unauthorized Radiography
Bry Salt Spitt
Subcontractor Injury

Plant Power Feeder Line
Failure

Process Waste Spill, Tank
718



Page No. 168

11/15/90
SUMMARY OF EVENTS
1952 TO 1988
vER BUTtDING DESCRIPTION ‘ADDITIONAL NOTES
DATE NUMBER

01/28/83 11R 88-7, 707-1

62/02/88 LIR 88-13, 776-3

02/06/88 IIR 88-16,371~1

02/04/88 IIR 88-11, 707.5

O2/16/88 TIR BB-16, 464-1

707, NOD K RM 145

776, RM

371, RU2327

707, MoD ¢

4G6, RM 107

MONTTOR DISCONNECTED AIR HOSE
PRIOR TO REMOVAL OF SUIT AND
HOOD FROM ELECTRICIAN IN
SUPPLIED SREATHING AIR LEAVING
X-Y RETRIEVER. WITHOUT AIR FOR
2 MINUTES AND HAD 2 SPOTS OF
ALPHA CONTAMINATION ON NECK.
DECON AND BODY COUNTED
(BACKGROUND). NO THHALATION

TSA AUDITOR AND CRIT ENGINEER
WERE INSTRUCTED TO WERE HALF
MASK RESPIRATORS AS
PRECAUTIONARY MEASURE WHILE
AUDITING ROOM, SINCE ROOM HAD
MO SAAMS. TSA APPRAISERS, PER
HEALTR PHYSICS, INFORMED CRIT
ENGINEER THAT ADDITIONAL
PRECAUTIONS WERE REQUIRED.

A TIE IM OF A PROCESS LIQUID
TRASFER LINE WAS BEING
PERFORMED. THE 2" LIKE WAS CUT
AT THE Top TIE-IN AND THE
BOTTOM TIE-IN. A SMALL AMOUNT
OF LIQUID (1 LITER) WAS
DISCHARGED AT THE BOTTOM CUT.
BAG HAD SEEN CUT OVER PIPE BUT
‘A SMALL AMOUNT SPILLED TO AREA

BRIQUETTING. ONE BATCH
COMPLETED WITH NO PROBLEM.
AFTER RETRACTING PRESS ON
SECOND BATCH A SHALL AMOUNT OF
PU ON TOP OF RAM CAUSED
BINDING AND IGNITED PU. SMALL
AMOUNT OF CARBON TET CAUSED
LOUD WORSE. OXYGEH ANALYZER
READ 4.2% OXYGEN.

HIGH BE CONCENTRATION IN AIR.
VAC PICKUP NOT CLOSE ENOUGH TO
PART. RETRAIN OPERATOR.



Page No.
12/21/90

2

UE NUMBER EVENT

VE89-121
UE89-122
YE89-123
YES9-124

UE89-125
UE89-126
UE89-127
UE89-128
VE89-129
UE89-130
VE89-131
VE89-132
UE89-133
UE89-134
UE89-135
UE89-136
UE89-137
UE89-138
UE89-139
UE89-140
UE89-141
UE8S-142

Ques

UE89-144

01/20/89
01/18/89
01/20/89
01/20/89

01/24/89
01/25/89
01/26/89
01/27/89
03/30/89
02/02/89
01/26/89
02/03/89
02/05/89
02/06/89
02/06/89
02/08/89
02/07/89
02/08/89
02/09/89
02/10/89
02/15/89
02/16/89
02/03/89
02/22/89

SUMMARY OF 1989 EVENTS

DATE BUILDING TYPE IIR/UOR Number Title
2 ERYS
01/20/89 777 CAIRS N/A. 750 Glovebox Stripout
01/19/89 551 NFI N/A Personnel Scanner Alarms
01/20/89 PD904 NFI N/A Unauthorized Personnel
01/20/89 371 IR = 89-030,371-6 Loss of Instrument Air,
with Evacuation
01/24/89 371 NFI N/A Pressurized Drum
01/26/89 881 NFI N/A Smoldering Sme11
01/26/89 777 ue N/A Carbon Tet Spit]
01/27/89 707 HP N/A Carbon Tetrachioride
02/01/89 444 CAIRS N/A Injuried Employee
02/02/89 865 NFIT N/A Ventilation Supply
02/02/89 371 NFI N/A Personnel Evacuation
02/06/89 RFP CAIRS N/A Frozen Water Pipes
02/06/89 750 TIR 89-036, 750-1 Emergency Panel Power Loss
02/06/89 707 IIR 89-032,707 Static Pressure Upset
02/07/89 443 TIR 89-033, 443 Diesel Oi? Spill
02/08/89 460 IIR 89-037,460 High Pressure Leak
02/08/89 776 IIR 89-038,776-3 Cooling Water Loss
02/09/89 707 HP N/A Contaminated Employee
02/09/89 779 NEI N/A 480V Breaker
02/10/89 TK452 TIR 89-035, 443-6 Diesel O17 Spill
02/15/89 RFP TiR 89-039, Outrigger Collapse
02/17/89 777 NFI N/A Series Incidents
02/06/89 771 NFT N/A Water in Air ControT Line
02/22/89 371 NFI N/A Trash Can Fire



Page No. 149
21/15/98

‘SUMMARY OF EVENTS

1952 TO 1988

Event EVENT
DATE NUMBER

02/06/87 SER 87-2-707.1

02/09/87 SIR 87-2-123.1

02/14/87 SIR 87-2-886.1

02/17/87 IIR 88-19, 374-4

02/17/87 I1R 88-19, 374-1

02/20/87 SIR 87-2-776.1

BUILOING

DESCRIPTION

707, MODULE A, FURNACE AGS NMSPI 87-2. CASTING FURNACE

886, RMI01, SAT

376, EVAPORATOR

374, EVAPORATOR

WAS FOUND TO EXCEED THE LIMIT
BY 2663 GRAMS PLUTONIUM DUE TO
THE PRESENCE OF AN UNOBSERVED
MISPOUR. THE WORK AREA LIMIT
MAS ALSO VIOLATED WHEN A
CASTING AND THE MISPOUR
MATERIAL WERE PLACED IN THE
WORK AREA AT THE SAME TIME.

A LIGHT DRIVER WAS TRAVELING
WEST ON COTTONWOOD AND
PROCEEDED TO TAKE A RIGHT HAND
TURN ON DRIVE WAY, SOUTH OF
BLOG, 123. THE VAN BOX OF
‘TRUCK HIT THE OVERHEAD STEAM
AND PLANT AIR PIPES.
INSULATION AROUND THE STEAM
PIPES WAS ASBESTOS.

WHILE INSTALLING REACTIVITY
SHIMS, TWO SHEETMETAL WORKERS
FOUND URANIUM CONTAMINATION OW
THEIR BOOTIES, CLOTHING, AND
EXPOSED SKIN. SOURCE OF
CONTAMINATION 1S STILL
‘UNKNOWN.

RUPTURE DISK ON FIRST EFFECT
VAPOR BOOY RELEASED EVAPORATOR
FEED COVERING 5000 SQ FT OF
‘371 PARKING LOT. RELEASED
APPROX. 7.5 NCI PUL

RUPTURE DISK OW FIRST EFFECT
VAPOR BODY RELEASED EVAPORATOR
FEED COVERING S000 so FT OF
371 PARKING LOT. RELEASED
APPROX. 7.5 NET Pu.

776, StZE REDUCTION VAULT THE MAIN OUTSIDE WATER VALVE

WAS NOT TURNED OFF AT END OF
SECOND SHIFT. THE INSIDE VALVE
WAS TURNED OFF SUT FOUND TO BE
DEFECTIVE. THIS ALLOWED WATER
TQ SEEP OUT INTO SINK AND
EVENTUALLY OVERFLOW ON TO
VAULT FLOOR.

ADDITIONAL NOTES



Page Wo. = 179

09/13/88 IIR 88-11, W-2 VALVE VAULT

09/24/88 TR 88-119 778, RM 100

09/26/88 IIR 88-119 778, RM 100

09/30/88 IIR 88-123, 444-6 444, RM 107

49/15/90
SUMMARY OF EVENTS
1952 TO 1988
EVENT EVENT BUILDING DESCRIPTION. ADDU TLOWAL_ROTES $$$
DATE NUMBER
09/11/88 IIR 88-117, 000-4 — OUTSIDE EAST RANGE - VENDORS WERE = WHEN SHOKE WAS SEEN, FIRE

DEMONSTRATING SMALL EXPLOSIVE DEPARTMENT WAS CALLED AND
DEVICES ON TARGETS AND HAD PUT FIRE EXTINGUTSHED.

ONE ON A TARGET IM A GRASSY

AREA, W/O RANGE SAFETY

OFFICERS KHOWLEDGE, WHEN

DETONATED BY RIFLE FIRE, GRASS

WAS IGNITED BELOW TARGET AND

QUT OF SIGHT OF RANGE

PERSONNEL

‘A TEMPORARY BYPASS LINE SOUNDED IN 374 CONTROL ROOM.
SEPARATED AT A TYGON TUBE THE SOLUTION WAS BEING
CONNECTION AND FLOODED. VALVE TRANSFERRED FROM BLDG. 774
VAULT 12 WITH 1,700 GALS OF TO BLDG. 374

HIGR NITRATE SOLUTION. THE

BYPASS HAD BEEN USED SEVERAL

TIMES SUCCESSFULLY PRIOR TO

THE FAILURE. PUMPING WAS

‘STOPPED NHEM VALVE VAULT 12

ALARM

TRASH BAG IMADVERTAXTLY SET
UNDER ELECTRICAL OUTLET BEHIND
‘A WASHER EXTRACTOR OUTLET
SHORTED AND SPARKS SET FIRE TO
CONTENTS IN TRASH BAG. FIRE
WAS EXTINGUISHED BY BEST TEAM.
RF FIRE DEPT. RESPONDED AND
DID INVESTIGATE.

‘TRASH BAG INADVERTANTLY SET
UNDER ELECTRICAL OUTLET BEHIND
‘A WASHER EXTRACTOR OUTLET
SHORTED AND SPARKS SET FIRE TO
CONTENTS IN TRASH BAG. FIRE
WAS EXTINGUISHED BY BEST TEAM.
RF FIRE DEPT. RESPONDED AND
DID INVESTIGATE.

Be CONTAMINATED HOOD WAS
BAGGED OUT OF Be ROOH WITHOUT
RADIATION MONITOR SHEAR.
SMEAR WAS DONE LATER WITHOUT
CONTAHIMATION FOUND - WORKER
REPRAMANDED FOR KOT FOLLOWING
PROCEDURE.



Page No. 165
11/15/90

SUMMARY OF EVENTS
1952 TO 1988

EVENT
DATE WUMBER

19/07/87 IIR 87-96,374-1

19/16/87 31R 87-98,771-23

11/18/87 EIR 87-97,334-1

14/25/87 SIR 88-14,646-1

12/01/87 IIR 87-99,444-5

42/94/87 IIR 87-101,551-1

_surey

37%, RMBBI0

771, RMIIG

334, PIPE SHOP

464, RHIO7

466, RM103B

551, PU&D STORAGE YARD

DESCRIPTION

FOREMAN CLIMBED PORTABLE
‘SCAFFOLD OM MEZZANINE TO.
INSPECT HOIST RAIL. SCAFFOLD
TIPPED AND FELL WHILE THE
FOREMAN JUMPED 10 THE STEEL
DECK BELOW, FRACTURING HIS
LEFT FOOT.

WHSPI 87-29. 55-GRLLOM DRUM
WAS TAKEN 70 DRUM COUNTER AND
FOUND TO CONTAIN 608 GRAMS OF
PU WHICH EXCEEDED THE ALLOWED
PU LIMIT OF 500 GRAMS.

WELDING MACHINE WAS REWIRED
FOR 3 POLE RECEPTACLES. A
PHASE OF THE 3 PHASE CIRCUIT
WAS WIRED TO WIRE INSIDE THE
WELDER THAT WAS ATTACHED TO
GROUND, MAKING THE CASE AND
FRAME OF WELDER AT LINE
POTENTIAL TO GROUND. TWO
CRAFTSMEN RECEIVED SHOCKS.

DURING HAND FILING, THE HIGH
VAC HOSE WAS NOT CLOSE TO
PART, AND THE HOOD WAS LEFT
OPEN IW ORDER TO REACH THE
PART RESULTING IN A HIGH B.E.
HEAD COUNT,

EMPLOYEE CALLED FIRE
DEPARTMENT BECAUSE HE SMELLED
SMOKE. A TRASH CONTAINER WAS
LOCATED FULLY INVOLVED WLTH
FLAMES CONTACTING THE EAST
WALL OF 1038. PROBABLE CAUSE
OF FIRE WAS IMPROPERLY
DISPOSED OF CIGARETTE.

‘TWO TRUCKS FROM DENVER BARREL
& DRUM, INC. ARRIVED To PICK
THE EMPTY DRUMS THEY HAD
PURCHASED. GREEN POWDER
SPILLED FROM A BUNG-ROLE IN
ONE OF THE DRUMS AND WAS FOUND
TO BE RADIOACTIVELY
CONTAMINATED. EIGHT ADDITIONAL
DRUMS WERE FOUND TO
CONTAMINATED.

AODTTTORAL ROTES



Page No. 177

11/15/90
‘SUMMARY OF EVENTS
1952 TO 1988
EVENT ___EVENT BUILDING oe 7
DATE, NUMBER

04/15/88 11R BB-66-W9.1

04/20/88 IIR BB-44, 374-4

06/22/88 11R 88-36, 776-5

04/22/88 IIR 88-34, 776-4

06/27/88 IIR 88-48, 374-s

374, VALVE VAULT 9

376, RH 2805

DURING TRANSFER OF LICUID
WASTE, LEAK ALAR OCCURRED, NO
RESPONSE, LATER 3000 GAL
MESSING WAS FOUND BY THE
OPERATOR IN THE VALVE VAULT.
PREVIOUS DAYS MAINTENANCE WAS
NOT COMPLETED. REMAINDER
PUMPED THROUGH W8. NO
CONTAMINATION TO THE
ENVIRONMENT.

OFFSITE VENDER WAS REPAIRING
WOISY LUBE OLL PUKP OK
CHILLER. WAS SPLASHED IM FACE
AND EYES WITH A FREON AND OTL
MIXTURE. WAS NOT WEARING
SAFETY GLASSES, WAS GIVEN
ONSITE MEDICAL ATTENTION.
OFFSITE DOCTORER ON 4/21/88
EXAM SHOWED VISITOR WAS BACK
10

NORMAL.

776, SIZE REDUCTION VAULT BOTH DOORS OPENED AT SAME TIME

776, RM 1568

376, RM 3185

‘ON SRN AIR LOCK CAUSING
RELEASE TO ROOM 134, OPERATOR
ERROR. DOOR KEYS CHANGED SO
SUPERVISORS CONTROL ACCESS.

FOUR OPERATORS WERE TOLD TO

IN THE AREA AND ONE WAS SENT

SEAL A WINDOW OF BOX 499 WITH TO MEDICAL FOR FURTHER

PUTTY - BOX WAS MONITORED BY
RADIATION MONITOR AND WORK WAS COUNT.

DECONTAMINATION AND BODY

COUNT WAS NEGATIVE.

COMPLETED PER HSE 18.02 WHEN NO SOURCE OR CAUSE WAS

FINISHED MONITORING, SHOWED
30C TO 156,000 CPH ON HANDS OF
OPERATOR. THREE OPERATORS
WERE DECONTAMINATED

FOUND.

PIPEFITTERS WERE MOVING 12
NITROGEN BOTTLES FROM RM
3185-RM 3810, HAND NAS PINNED
BETWEEN TRANSFER CART AND
PROTRUDING STEAM SHUTOFF
VALVE, HAND WAS X-RAYED AKD 7
SONE WAS BROKEN. EMPLOYEE WAS

SENT TO PERSONAL DOCTOR
OFFSITE, 2 PINS PLACED IN THE
BONE



Page No. 167

11/15/90
‘SUMMARY OF EVENTS
1952 TO 1988
EVENT —EVENT BOTCDING DESCRIPTION ADDITEONAL NOTES
DATE NUMBER

01/12/88 EIR 88-3, 771-4

01/13/88 LIR 88-4,771-2

01/19/88 EIR 88-2,883-1

01/26/88 T1R 88-9,776-1

771, RMIGS, LINE 38

771, LINE 16

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
EHTO ROOM CONTAMINATING
OPERATOR, RADIATION MONITOR,
AND AREA.

DURING RE-ASSENBLY 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.

S.A. JONES CONSTRUCTION
‘SERVICES COMP. ELECTRICIANS
WERE INSTALLING NEW PANEL
BREAKER FOR 883 ADDITION.
PIECE OF BLANK FELL DOWN
INSIDE PANEL AND CAUSED SHORT.
SURGE WENT BACK TO MAIN PANEL
AND CONTINUED BACK TO
SUBSTATION. POWER LOSS LIMITED
TO 883.

776, SIZE REDUCTION VAULT AT COMPLETION OF COMPACTING

HEPA FILTER IM SIZE REDUCTION
BARREL CRUSHER, WASTE
TECHNICIAN REACHED IN
COMPACTOR TO REMOVE CRUSHED
FILTER AND A MAIL PUNCTURED
NEOPRENE GLOVE, SURGEONS
GLOVE, CLOTH GLOVE AND LEATHER
GLOVE BEFORE ENTERING HIS
RIGHT THUMB.



Page Ho. 180

11/15/90
SUMMARY OF EVENTS
1952 To 1988
EVENT EVENT BUILDING DESCRIPTION _. ADDITIONAL NOTES
DATE NUMBER
09/30/88 IIR 88-123, 444-6 444, RM 107 Be CONTAMINATED HOOD WAS

40/20/88 88-128, 121-3

Qo 88-128, 121-3

19/10/88 IIR 88-126, 779-6

11/19/88 IR 88-126, 779-6

OUTSIDE, FIRING RANGE

OUTSIDE, FIRING RANGE

779, RM 160

779, RM 160

BAGGED OUT OF Be ROOM WITHOUR
RADIATION MONITOR SHEAR.
SMEAR WAS DONE LATER WITHOUT
CONTAMINATION FOUND - WORKER
REPREMENDED FOR HOT FOLLOWING
PROCEDURE.

‘TWO CARTRIDGES WERE FOUND TO
BE EXPANDED BEYOND SIZE OF
CHAMBER OF GUN. ONE WAS ON
WIGHT FIRING THE 20TH THE
OTHER ON DAY FIRING OR THE
21ST, THE CARTRIDGES WERE
TAKEN TO THE ARMORY FOR
REMOVAL OFTHE BULLET. OX THE
FIRST ONE, A SECOND BULLET WAS
FOUN

TWO CARTRIDGES WERE FOUND TO
BE EXPANDED BEYOND SIZE OF
CHAMBER OF GUN. ONE WAS ON
RIGHT FIRING THE 20TH THE
‘OTHER ON DAY FIRING ON THE
21ST. THE CARTRIDGES WERE
TAKEN TO THE ARMORY FOR
REMOVAL OF THE BULLET. OM THE
FIRST ONE, A SECOND BULLET WAS
FOUND

VOLRATH CAN CONTAINING SITE
RETURN WAS SHIPPED FROM 777 TO
779 WITHOUT BELNG GAMHA
‘SCANNED

VOLRATH CAN CONTAINING SITE
RETURN WAS SHIPPED FROM 777 TO
779 WITHOUT BEING GAMMA
SCANNED

TO BE BEHIND THE FIRST
CAUSING THE EXPANSION OF THE
BRASS X-RAY OF THE SECOND
CARTRIDGE REVEALED THE SAME
PROBLEM.

TO BE BEHIND THE FIRST
CAUSING THE EXPANSION OF THE
BRASS EXRAY OFTHE SECOND
CARTRIDGE REVEALED THE SAME
PROBLEM.



Page No. 162
14/15/90

‘SUMMARY OF EVENTS
1952 TO 1988

EVvewt___ Event
DATE NUMBER

08/26/87 SIR 87-9-776.1 776, RMIZ7

08/31/87 SIR 87-8-771.5 71, RMVIGB, LINETT

Qh SIR 87-9-771.1 771, RMISS

09/09/87 SIR 87-9-371.1 371, RMI66C

09/09/87 SIR 87-9-707.1 707, MODULE 8, GBOX B105

DESCRIPTION —

NSPE 86-22. OPERATORS WERE
INSTRUCTED TO STACK AS MANY
DRUMS AS POSSIBLE, TWO HIGH
ONLY WITH A LIMIT OF 200 GRAMS
OF FISSILE MATERIAL PER DRUM.
ONE OF STACKED DRUMS WAS FOUND
JO CONTAIN 217 GRAMS.

AMIX OF WATER AND
HYDROFLUORIC ACID WAS
INTRODUCED INTO
HOROFLUORINATOR RESULTING IN
MOIST PLUTONIUM TETRAFLUORIDE.
THE REACTION BETWEEN THIS
WOIST MATERIAL AND CALCIUM
METAL PELLETS PRODUCED
SUFFICIENT HEAT TO IGNITE AND
CAUSE OPEN HEARTH REDUCTION.

WHEM OPENING THE SECONDARY
CONTAINMENT ON A SHIPMENT OF
METALLOGRAPHIC SAMPLES, THE
OPERATORS REALIZED THE THIRD
TMNER BAG WAS NOT SEALED. 1400
FI2 OF ROOM 183 WAS
CONTAMINATED. OPERATORS WERE
CONTAMINATED ON THEIR RANDS
AND ARMS.

NMSPI 87-23, RINE PACKAGES OF
OC 398 MATERIAL, WITH A
COMBINED VALUE OF 1063 GRAMS
OF FISSILE MATERIAL WERE
PLACED INTO ONE 55 GALLON
DRUM. THE LIMIT 1S 1000 GRAMS
OF FISSILE MATERIAL PER DRUM.

NMSPI 87-24. A METALLURGICAL
OPERATOR NOTICED THAT THE
INCLINE TROUGH AT THE SCRAP
SHEARER CONTAINED MORE SCRAP
METAL THAN WAS ALLOWED.

ADDITIONAL NOTES



Page No. 154

31/15/90
‘SUMMARY OF EVENTS
1952 70 1988
EVENT EVENT BUTEDTRG DESCRIPTION ADOT TYORAT NOTES
DATE NUMBER

04/14/87 SIR 87-04-559.1

04/14/87 SIR 87-4-771.3,

04/20/87 SIR 87-4-707.6

04/22/87 SIR 87-4-707.5

04/23/87 SIR 87-4-771.5

04/28/87 VOR 87-2-GAS 87-1

559, AIR TUNNEL

771, RMI6A, LINE MT-5

707, MODULE B, BOX 8-20

707, GLOVEBOX J-20

771, RMIIG

BUFFER ZONE, EAST GATE

TWO PROCESS WASTE PUMPS HAD
FAILED AND FLOAT CONTROL ON
SUMP PUMP 17WAS NOT WORKING
AUTOMATICALLY CAUSING BUILDUP
OF WASTE PROCESS WATER. SUMP
WAS STARTED MANUALLY TO START
TRANSFERRING WATER TO BUILDING
528.

A CAKE PAN (9 1/2TMx6"X2", 1.6
LITER VOLUME) WAS USED FOR
BLENDING ENRICHED URANIUM
OXIDE BATCHES TO OBTAIN A
CONSISTENT MIXTURE. THE CAKE
PAN VIOLATED THE VOLUME LIMITS
OF 1 LITER.

FIVE DEBRIMMED RINGS WEIGHING
5382 GRAMS IN GLOVEBOX 8-105,
EXCEEDED THE 3000 GRAMS LIMIT.
THE MACHINIST WAS ESTIMATING
THE WEIGHT OF THE BRIMS SINCE
‘A WEIGHT MEASURING SCALE WAS
NOT PROVIDED.

WHILE ATTEMPTING GLOVE
REMOVAL, PU OXIDE UNDER LIP OF
GLOVE WAS RELEASED IW MODULE
J NO DOWN DRAFT UNIT WAS
USED PRIOR TO LOOSENING ANY
PART OF THE GLOVE BOX GLOVES.

NMSPI 87-13. STAINLESS STEEL
PUMP TRANSFER CONTAINER OF
APPROXIMATE DIMENSIONS
18"X18"X26" WAS FOUND WITH NO
LID. CONTAINER WAS PLACED
UNDER A FISSILE SOLUTION
TRANSFER LINE VICLATING THE
FOUR LIFRE VOLUME RULE.

MAIN HIGH PRESSURE UNDERGROUND
GAS LINE (12") WAS RUPTURED BY
BULLDOZER DURING EXCAVATION
VORK CNE-HALF MILE SOUTHEAST
OF GATE 9 IN THE BUFFER AREA.
MINOR DAMAGE TO OVERHEAD POWER
LINES.



Page No. = 177

11/15/90
‘SUMMARY OF EVENTS
1952 To 1988
EVENT EVENT. BULLDING DESCRIPTION ADDLT-IGNAL-NOTES
DATE NUMBER
08/10/88 118 88-95, 000-2 — CUTSIDE CONTRACTOR STARTED EXCAVATION

08/14/88 TIR 88-99, POST 1

08/14/88 LIR 88-99, POST 4

08/17/88 11R-BB-103, 466-5

08/19/88 LIR 88-102, 779-5

08/23/88 88-98, 551-1

bob, RMT, 767B

‘TTS, ROOK 169

354

OPERATIONS IN NORTHEAST CORNER
OF BUFFER ZONE WITHOUT
CONTACTING CONSTRUCTION
MANAGEMENT OR THE
TELECOMMUNICATIONS DEPARTMENT

GUARD COULD NOT OPER DOOR TO LATCH PLATES WERE MODIFIED
EXIT GUARD POST. SEVERAL ON ALL GUARD POSTS TO ALLOW
PEOPLE OUTSIDE WITH KEYS COULD FOR SAGGING UNTIL REAVY DUTY
NOT OPEN DOOR. RF FIRE DEPT. HINGES CAN BE ORDERED.

CUT AWAY THE LOCK MECHANISM TO

FREE THE GUARD. FINDINGS WERE

THAT THE BINGES KAD SAGGED AND

WERE BINDING THE LATCH IN THE

LATCH PLATE.

GUARD COULD HOT OPEN BOOR TO’ LATCH PLATES WERE MODIFIED
EXIT GUARD POST. SEVERAL ON ALL GUARD POSTS TO ALLOW
PEOPLE OUTSIDE WITH KEYS COULD FOR SAGGING UNTIL HEAVY DUTY
NOT OPEN 000R. RF FIRE DEPT. HINGES CAN BE ORDERED.

CUT AWAY THE LOCK MECHANISM TO

FREE THE GUARD. FINDINGS WERE

THAT THE HINGES HAD SAGGED AND

WERE BINDING THE LATCH IN TRE

LATCH PLATE.

PROCESS WASTE TANK DRAIN WAS,
PLUGGED AND A WATER VALVE WAS
LEFT OPEN ON PROCESS DRAIN
FEEDING INTO PROCESS WASTE
TANK. TANK OVERFLOWED INTO
BASEMENT (2 TO 3 HUNDRED GALS)
= VALVE WAS CLOSED AND PLUG
REMOVED AND SYSTEM RETURNED TO
OPERATOR AFTER CLEAN UP

EMPLOYEE WAS CONTAMINATED
WHILE WORKING WITH CLAM SHELLS

WORTH OUTSIDE STORAGE YARD - 1 REQUIRE FACTORY REPAIR.
TRANSFORMERS STORED IN OUTSIDE OTHERS WERE FIXED HERE.
STORAGE WERE DAMAGED BY

UNKNOUN CAUSE. YARD WAS LOCKED

AND FACTORY REPS SUMMONED 70

EVALUATE DAMAGE, ON ARRIVAL

OF REPS, FURTHER DAMAGE WAS
DISCOVERED ON ONE TRANSFORMER.
THAT TRANSFORMER WI



Page No. 176

14/15/90
SUMMARY OF EVENTS
1952 TO 1988
EVENT EVENT BUILOING DESCRIPTION. DIT IONAL_-NOT
DATE NUMBER
06/02/88 IIR 88-58, 777-4 777, RM 415 TWO USED FILTERS WERE FOUND EXCEEDED CRIT LIMITS NO CRIT

06/02/88 IIR 88-63, 779-3

06/07/88 LIR 88-73, 707-5

06/09/88 UOR-88-5-779-88-1

06/10/88 IIR 88-68, 707-4

06/13/88 11R 88-69, 881-7

707, MOD J. 68 160

779, OUTSIDE

707, MOD & GB B-25

STACKED ONE ON TOP OF THE
OTHER 1H GLOVEBOX 305. HO
EXPLANATION OF WHO OR WHEN

LIMITS WERE POSTED DURING
THE MOVE NOR AT TIME OF
DISCOVERY OF FILTERS BY

THIS WAS DONE. BOXES HAD BEEN FILTER TECH.

MOVED FROM 771 TO 777.
FILTERS KAD BEEN REMOVED
WITHOUT A PROCEDURE Of
INFORMING THE FILTER TECH
PEOPLE. STACKING.

URANIUM METAL FOUND ON GROUND

NEXT TO DUMPSTER.

A CATCH PAN TO COLLECT PU
OXIDE FROM 4 CRUCIBLES OX

FUNNELS COLLECTED MORE OXIDE
PREVIOUS

THAN NHSL ALLOWED.
HISTORY INDICATED THAT
MATERIAL IN 4 WOULD NOT
VIOLATE LIMIT. PROCEDURE
CHANGED TO WEIGH MATERIAL
BEFORE BURN OUT.

CONTRACTOR EMPLOYEE RECEIVED

FLASH BURNS TO ARM AND FACE
WHILE WORKING ON LIVE POWER
LINE.

OPERATOR WAS LOADING PARTS

INTO THE WEBRER DEC MACHINE.
MSL LIMIT STATE ONLY TWO PART
IF OVER MAX SPECIFIED WEIGHT

FOUR OTHERWISE. OPERATOR
toapeD 3 OF 5, 2 PART
EXCEEDED MAX WEIGHT.

FAILED TO VERIFY WEIGHT.

INFRACTION FOUND BY 2D SHIFT.

EMPLOYEE FELL OFF DOCK AND
BROKE RIGHT WRIST

‘OPERATOR



Page No. 151

11/15/90
‘SUMMARY OF EVENTS
1952 TO 1988
VENT ‘BUELOTNG: DESCRIPTION ADOTTTORAC WOTES:
DATE NUMBER

03/06/87 SIR 87-3-707.1

03/05/87 SIR 87-3-371.1

r SIR 87-3-779.1

03/09/87 SIR 87-03-883.1

03/11/87 SIR 87-3-446.1

707, MOOULE C, BOX 8-70 GLOVEBOK B-70 WAS FOUND TO

371, RMIT11

779, RM137, BOX 106-6

CONTAIN 3 PARTS WHICH IS IN
VIOLATION OF THE ESTABLISHED
LIMITS THAT ALLOW A MAXIMUM OF
2 PARTS FOR THE MASSES
INVOLVED, THE OPERATOR
INCORRECTLY READ THE WEIGHTS.

MNSPI 87-5. A FURWACE FROM
GLOVEBOX 36 IN ROOM 3305 WAS
TRANSFERRED TO GLOVEBOX 70 IN
ROOM 1241. FURNACE CONTAINED A
CRUCIBLE AND MATERIAL
ESTIMATED AT 2754 GRAMS AND
GLOVEBOX CONTAINED 336 GRAMS
‘OF PLUTONIUM WHICH VIOLATES
THE LIMIT OF 1000 GRAS.

EMPLOYEE WAS EVAPORATING ONE
LITER OF OY LEACH SOLUTION,
97.2 GRAMS URANIUM PER LITER,
TN MICROWAVE OVEN FOR ONE HOUR
AT 100% POWER. ELECTRICAL
FIRE STARTED DUE TO A FAILURE
UN MICROWAVE WIRING THAT LED
TO A SHORT CIRCUIT.

883, RM109, H.P.M. PRESS SMALL PIECES OF TOOL STEEL

464, RM201, FURNACE 7

WERE EJECTED AT HIGH SPEED
FROM TWO COMPRESSING DIES.
THREE EMPLOYEES RECEIVED
INJURIES.

SILVER, BEING CAST INTO AN
INGOT, STARTED TO OUTGAS AT A
RATE HIGHER THAN THE VACUUM
SYSTEM COULD EVACUATE. VACUUK
SYSTEM OVERLOADED CAUSING
PUMPS TO SHUT DOW, AIR WAS
ALLOWED INTO FURNACE CAUSING
THE METAL TO OXID1ZE AND
PRODUCE FLAMES.



Page No. 150
44/15/90

SUMMARY OF EVENTS

1952 To 1988

TM EVENT EVENT BUILDING
DATE NUMBER

02/27/87 SIR 87-2-776.2 776, RMIS9

02/28/87 SIR 87-3-S8u.1 371, RM 3701

ee” SIR 87-3-771.1 771, RM114, LINE 15

03/02/87 UOR 87-1-771 87-1 Wt

03/02/87 UOR 87-41-71 87-1 771, RMIL9, BOX 26

DESCRIPTION

A PLASTIC BELL JAR HAD BEEN
UNDER A LOW VACUUM FOR
APPROXINATELY 10 MIRUTES WHILE
THE OPERATOR WAS PREPARING
MATERIALS TG BE INTRODUCED 10
PARTS WITHIN THE EVACUATED
BELL JAR WHEN 1T EXPLODED.

WYSPI SBM 87-4. A LEAK IN A
HOSE CARRYING WATER TO A
CONCRETE CUTTING SAW CAUSED
MINOR FLOODING. DURING
CLEANUP, IT WAS DISCOVERED
THAT THE VACUUM CLEANERS IN
USE WHICK WERE SUPPOSED TO BE
FILLED WITH RASCHIG RINGS WERE
NOT FILLED WITH RASCHIG RINGS.

A GLOVE OW LINE 14 AND A GLOVE
ON LINE 15 FAILED, CAUSING
CONTAMINATION OF 3 PERSONNEL,
EQUIPMENT AND THE TRACKING OF
FLOOR AREA. ENTIRE OPERATION
WAS SRUT DOWN UNTIL
DECONTAMINATION WAS COMPLETE.
NONE OF OPERATORS RECEIVED
BODY BURDEN.

A CAN OF FINES TRANSFERRED TO
BUILDING 771 FROM 707
UNDERWENT AN OXIDATION
REACTION. REACTION TOOK PLACE
INA GLOVEBOX, FINES WERE NOT
BURNED TWICE AS PROCEDURE
CALLS FOR.

OPERATOR NOTICED MATERIAL
SPARKING AND GLOWING AS IT WAS
BEING POURED INTO A SCREENING
PAN. UNBURNED NETAL MAY RAVE
BEEN PRESENT IN CANAND
UNDERGONE RAPID OXIDATION.

ABDITIONAL ROTES 1



Page No. 163

44/15/90
‘SURMARY OF EVENTS
1952 TO 1988
EVENT EVENT. BUILDING. SSERIPTION ADDITIONAL NOTES
DATE NUMBER

09/10/87 SIR 87-9-771.2

09/18/87 SIR 87-9-779.1

09/28/87 SIR 87-9-771.3

09/30/87 SIR 87-9-707.2

10/05/87 SIR 87-10-444.2

10/08/87 SIR 87-10-444.4

771, RMI80A, PSL GBOX

779, RM160

771, CORRIDOR A

707, EBH#6 WELDER

466, RM107

444, RH139

WIRING ON A HOY PLATE IN USE
IN A GLOVEBOX BEGAN TO BURN. A
TYGON HOSE LYING ON THE FLOOR
NEXT TO THE HOT PLATE HAD HOLE
MELTED IN IT AND WATER LEAKED
ON TO THE GLOVE BOX FLOOR.

A LECTURE BOTTLE OF CHLORINE
EAS WAS OPENED NEAR A ROOM
EXHAUST VENT TO DETERMINE IF
‘THE CYLINDER AS EMPTY. 4
CHLORINE ODOR WAS NOTED AND
THE VALVE CLOSED. CHLORINE GAS
WAS RLEASED INTO THE BUSLDING
VENTILATION SYSTEM. NO SERIOUS
INHALATION CASES.

ASBESTOS CONTAMINATED DUST,
WHICH HAD COLLECTED OM TOP OF
CEILING TILES, BECAME
AIR-BORNE WHEN THE CEILING
TILES WERE REMOVED AND
CONTAMINATED TWO INDIVIDUALS.

EMPLOYEE MAS WORKING IW
BREATHING AIR AND NOTICED
FRONT PART OF HOOD WAS OPEN.
INADEQUATE TENSION ON DOCKING
RING OR BAND WAS PLACED ON THE
THE LIP OF THE HOOD.

OM THE FINISH PASS, IT WAS
OBVIOUS THAT INSET HAD BROKE
DOWN, LEAVING A BAD FINISH.
THE PART WAS DIMENSIONALLY
CORRECT AND THERFORE HAD To BE
POLISHED TO MEET FINISH
REQUIREMENTS.

VARIAN MEV X-RAY EQUIPMENT HAD
BEEN ARCING AND EXPERIENCING
LOSS OF VACUUM. VENDOR REHOVED
BEAM CENTERLINE ASSEMBLY UNIT
AND PHOSGENE GAS WAS RELEASED
INTO AREA. GAS WAS DISSIPATED
BY ROOM AIR CIRCULATION
SYSTEM.



Page No. 153,

”

‘SUMMARY OF EVENTS:

1952 TO 1988

EVENT EVENT
DATE NUMBER

06/06/87 SIR 88-4-707.4

04/06/87 SIR 88-6-707.4

06/08/87 SIR 87-4-707.3

06/10/87 SIR 87-6-771.14

06/13/87 SIR 87-4-771.2

707, UTILITIES

707, UTILITIES

771, TANKS 362,363

771, RM144, LINE 5

DESCRIPTION

SUNDAYS MIDNIGHT SOE UNABLE TO
CALIBRATE OXYGEN ANALYZER ON
BREATHING AIR SYSTEM. MONDAY
‘DAY & PM SHIFT USED SREATRING
AIR. OM TUESDAY, OPERATIONS
STOPPED UNTIL OXYGEN ANALYZER
REPAIRED.

SUNDAYS MIDNIGRT SOE UNABLE TO
CALIBRATE OXYGEN ANALYZER ON
BREATHING AIR SYSTEM. MONDAY
DAN & PM SHIFT USED BREATHING
AIR. ON TUESDAY, OPERATIONS.
STOPPED UNTIL OXYGEN ANALYZER
REPAIRED.

707, MODULE J, BOX J35 -NMSPI 87-7, OPERATOR POINTED

QUT AN OPERATION INVOLVING THE
NELTING OF PLUTONIUM FROM A
TANTALUM CRUCIBLE OR FUNNEL
INTO A GRAPHITE CATCH PAN. IT
WAS DISCOVERED THAT ADEQUATE
LIMITS WERE NOT AVAILABLE AND
AN INFRACTION HAD OCCURRED.

NMSPI 87-8, DRAIN VALVE ON
TANK 362 LOCKED IN OPEN
POSITION DURING APPROVED
TRANSFER OF SOLUTION FROM TANK
363 TO BUILDING 774.
APPROXIMATELY 40 LITERS OF
(UNSAMPLED SOLUTION FROM TANK
362 WERE TRANSFERRED WITH
SOLUTION FROM TANK 363.

WHSPI 87-9. MIDNIGHT SHIFT
CHEMICAL OPERATOR CHANGED
FUL-FLO 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.

ADDITIONAL NOTES



Page No. 169

Ws145/90
e SUMMARY OF EVENTS
i 1952 TO 1988
SveMT__evens. SSTLOS OHANOF
DATE NUMBER

02/17/88 11R 88-20, 779-14

02/18/88 T1R 88-21, 460-1
03/01/88 11R 88-26, 559-1

03/04/88 IIR 88-28, 881-2

03/09/88 IIR 88-30, 779.2

03/10/88 118 88-33, 777-2

03/15/88 IIR 88-15, 462-1

03/19/88 IIR 88-32, 376-2

779, RM 228

460, CLEANING AREA

559, RM 103

881, RM 265

779, RM 107,208

777, RM 430

2

376, RM 3810

FINES AND CUTTING OIL IGNITED
TW GLOVEBOX. THE OVERHEAT
ALARM DID NOT SOUND. GLOVEBOX
WAS NOT INERTED.

‘TRICHLORNETHANE SPILLED AS A
OSE BLEW OFF.

AN OVERSIZED CONTAINER WAS
‘DISCOVERED 1% MA-11

SPRINKLER HEAD WAS BEING
REPLACED WHEN ROOM 265 WAS
FLOODED.

URANIUM FOUND IN DESKS

RESPONSE TO QUESTIONS RAISED SOURCE STILL UNKNOWN.

AFTER PREVIOUS ISSUANCE OF LIQUID TRAP IS BEING

THES TIR. ORIG. [IR DISCUSSED INSTALLED DOWN STREAM OF

LIQUID TH ARGON LINE LEADING  SWAMPING TANK ALTHOUGH

TO TRIT REMOVAL SYST NO SOURCE VOLUME OF SWAMPING TANK WAS

TO LIQUID WAS FOUND AND LIQUID LESS THAN AMOUNT IN LINE AND

SAMPLES SENT TO SS9 & 774 LABS SWAMPING TANK WAS NEARLY

WERE LOST AND NO ANALYSIS OF FULL AFTER INCIDENT.

SAME WERE DONE. UNKNOWN LIGUED WAS YELLOWISH
WHILE TANK HAS CLEAR WATER

FILTER TECHS WERE DOING A
REATED FILTER TEST - FILTER
IGNIGHTED AND WAS
EXTINGUISHED. AFTER TEST
SPARKS WERE SEEN COMING FROM
ROOF FILTER, FIRE DEPARTMENT
EXTINGUISHED FIRE. SPARK
ARRESTOR IS BEING PLACED
UPSTREAM OF ROOF FILTER.

FIRE STARTED WHEN CHECK VALVE
COVER WAS REMOVED, SOLUTION
SPLATTERED OM EXPOSED ENDS OF
HEAT TAPE CAUSING SHORT AND
FIRE. INSULATION WAS REMOVED
TO ENSURE FIRE WAS OUT.
LOCATION NEAR GTH EFFECT
EVAPORATOR PUMP.



Page No, 145
11715790
‘SUMMARY OF EVENTS

e 1952 TO 1988

EVENT BUILDING DESCRIPTION ADDITIONAL NOTES

11/12/86 SIR 86-11-123.1 WASTE ETHER BEING TRANSFERRED
WAS ACCIDENTALLY PLACED ON A
ROT PLATE IN AN ADJACENT HOOD.
CAUSING AUTOIGNITION
THE FORCE OF THE IGNITION
BLEW BURNING SOLVENT OUT OF
HOOD ONTO CART AND STOOL.

1122/86 SIR 86-11-371.2 371 AIOUID RAK OUT ON TO FLOOR DUE
‘TO OPEN LINE NOT HAVING BEEN
‘TAGGED OUT.

11/23/86 VOR 86-4-707 86-1 707, MODULES A,B,4,K DURING ROUTINE LOAD TEST OF
BUILDING 707 EMERGENCY
GENERATOR, THE CONTACTS
REMAINED OPEN RESULTING IN NO
POWER TO THE ECCS. A FUSE WAS
BLOWN IN THE UPS CIRCUIT
CAUSING FAILURE.  GLOVEBOX
PRESSURE IN HOOULES 4,8,4,K

@ FELL TO ZERO ALLOWING
CONTAMINATION.

11/25/86 SER 86-11-2071 207, A, SOLAR POND FORK LIFT OPERATOR STEERED HIS
FORK LIFT TOO CLOSE 10 SLOPE
OF POND 207-A AND THE LIFT
SLID- BACKWARDS INTO-THE POND.
THE BERM OF THE POND WAS WET
FROM SHOW WHICH WAS MELTING AS
IT FELL. OPERATOR RECEIVED
MIWOR INJURY ON ONE ARM AND
CONTAMINATED SHOES.

12/02/86 SIR 86-12-559.1 559, RN102, NEW B-BOX FOUR VIALS BEING PREPARED FOR
OFFSITE SHIPMENT WERE PLACED
ON THE FLOOR OF THE NEW B-BOX.
THE BOX WAS MARKED "NO FISSILE
MATERIAL”,

12/06/86 SIR 87-1-776.1 UNABLE 10 EXIT DOOR 39 IW
EMERGENCY DUE TO WELDS NOT
BEING REMOVED.



Page No. 8
12/21/90
SUMMARY OF 1989 EVENTS
7 ta NUMBER EVENT DATE BUILDING TYPE IIR/VOR Number Title
DATE NOTIFIED INYS :

UE89-255 05/27/89 05/30/89 707 HP N/A Gloveport Contamination -
Pinhole in Glove

YE89-256 05/26/89 05/26/89 RFP CAIRS N/A Motor Vehicle Accident

UE89-257 05/18/89 05/30/89 PL904 CAIRS N/A Parking Lot Incident

UE89-258 05/30/89 05/30/89 444 IIR 89-071, 444-6 Room 1 Spill

UE89-259 05/30/89 05/31/89 460 NFI N/A Water Accumulation

UE89-260 05/25/89 05/31/89 707 He N/A Positive Wound Count

UE89-261 06/01/89 06/01/89 PORT] CAIRS N/A Gate Closure, Vehicle
Damage

UES9-262 05/30/89 06/02/89 779 TER 89-073,779-2 Nuclear Material Safety
Procedural Infraction 89-9

UE89-263 06/01/89 06/02/89 371 NFI N/A Air Imbalance

3°" 06/02/89 06/05/89 RFP NEI N/A Storm Incidents

UE89-265 06/02/89 06/05/89 552 NFI N/A Liquid Nitrogen Tank

UE89-266 06/03/89 06/05/89 707 NFI N/A Monitoring Computer, B/707
Utilities

“UESS-267-R 06/03/89 06/05/89" 460 NFI N/A Valve Failure, Buitding
460

UE89-268 06/02/89 06/05/89 779 NFI N/A Malfunction of Heat
Detector

UESS-269-R 06/01/89 06/05/89 707 NFI N/A Helium Leak

UE89-270 06/01/89 06/05/89 707 HP N/A Clothing Contamination

UE89-271 06/01/89 06/05/89 707 HP N/A Clothing Contamination

VE89-272 06/05/89 06/05/89 776 CAIRS N/A Severed fingertip

UE89-273 06/01/89 06/06/89 N/A UOR 89-07--PTX 89-1 Contaminated Rail Car {

UE89-274-R 06/05/89 06/06/89 707 NFE N/A Process Waste Leak

on 06/07/89 06/07/89 130 NFL N/A Leaking Drum



Page No. 156

05/22/87 SIR 87-5-991.1

05/26/87 SIR 87-5-WE.1

r on SIR 87-5-707.2

05/30/87 SIR 87-6-371.1

6/01/87 SIR 87-6-W13.1

991, MEC~1D-9

374, VALVE VAULT 8

14/15/98
‘SUMMARY OF EVENTS
1952 TO 1988
}__event__evenz— DESCRIPTION ‘ADDITFONAL NOTES
DATE ‘NUMBER

TWO ELECTRICIANS WERE CHANGING
‘A BREAKER ON A MOTOR CONTROL
UNIT. WHILE REMOVING A SCREW,
THE CONTROL UNIT WAS PUSHED
BACK INTO COMPARTHENT,
CONTACTING THE VERTICAL BUS.
THIS ENERGIZED THE CONTROL
UNIT, PROOUCING AN ARC FLASH.

RADIOACTIVE ACIDIC SOLUTION
LEAKED FROM A TRANSFER
PIPELINE TO THE VALVE VAULT
ENVIRONMENT. THE BLIND COVER
WAS MILD STEEL AND HAD BEEN
CORRODED AWAY BY THE ACID THAT
IS TRANSFERRED THROUGH THIS
PIPELINE,

707, MODULE J, BOX J60 AT 325 C, GATE VALVES OPENED

TO ALLOW HOUSE AIR TO ENTER
AND BURNING TO BEGIN. HOWEVER,
GASES IGNETED AND GLOVEBOX
PRESSURIZED FORCING THE
CRITICALITY DRAIN TO EMPTY ON
THE FLOOR WITH SOME
CONTAMINATION.

PRIMARY SIDE OF UPS WAS
PURPOSELY DE-ENERGIZED TO
PERMIT WORK ON SEVERAL BUSES.
POWER WAS SUPPOSED 10 BE
SUPPLIED BY REVERSE SIDE BUT
THE BREAKER #3AR WAS IN OPEN
POSITION. INSTEAD BATTERY
POWER WAS USED UNTIL BATTERIES
WERE DRAINED.

OSBL WASTE TRANSFER SYS LEAK OF RADIOACTIVE ACIDIC

SOLTION FROM AN UNDERGROUND
TRANSFER PIPELINE TO THE SOIL
AND CULVERT BENEATH THE
PIPELINES.

SYSTEM SHUT DOWN CUTTING ALL
POWER TO UTILITIES CONTROL
ROOM ALSO CAUSING ALL
VENTILATION FANS TO SHUT
Dow.



Page Ho. 155
11/75/90

SUMMARY OF EVENTS
1952 TO 1988

| EVENT EVENT. BULLDING.

DATE NUMBER

06/28/87 VOR 87-2-GAS 87-1 IRRIGATION DITCH

05/01/87 SIR 87-5-776.1 776, 622 BOX

05/08/87 SIR 87-5-771.1 771, FLATBED TRUCK

05/14/87 SIR 87-6-371.3 371, NDASMC

05/19/87 SIR 87-5-771.2 77, RMIAS, LINE 37

—DESERIPTION- ROT TIONAL NOTES:

A LARGE TEAR OCCURRED IN THE
12" DIAMETER HIGR PRESSURE
NATURAL GAS PIPELINE DUE TO A
BULLDOZER CUTTING THE LINE
DURING EXCAVATION FOR AN
INSPECTION DITCH. NO PERSONAL
INJURIES. MINOR DAMAGE TO
OVERHEAD POWER LINES. FIVE
MELLION CU, FT. OF GAS
RELEASED.

NMSPI 87-14. A NEW PART
CARRIER WAS PLT INTO USE WITH
APPROXIMATELY 100-200 GRAMS
PLUTONIUM WHICH VIOLATED A
TEMPORARY LIMIT DATED 5/1/87
ESTABLISHED FOR TESTING
PURPOSES. FISSILE MATERIAL
SHOULD NOT BE USED UNTIL NEW
LIMITS ARE ISSUED.

‘A LIGHT DRIVER WAS FORKLIFT OPERATOR STOPPED
TRANSPORTING HF CYLINDERS FROM CYLINDERS FROM ROLLING OFF.
BUILDING 130 TO BUILDING 771 ONE OPERATOR RECEIVED

WF STORAGE AREA. AS TRUCK WAS SLIVERS IN ARM.

TURNING CORNER AND MOVING OVER

ROUGH ROAD, ONE STRAP LOOSENED

” ALLOWING CYLINDERS TO ROLL

TOWARD BACK OF TRUCK.

WMSPT 87-15. NUCLEAR MATERIALS
SAFETY LIMITS ALLOW ONLY
APPROVED SHIPPING CONTAINERS
ON FLATBED CARTS. A 2-LITER
CONTAINER (8802 VOLLRATH CAN),
WHICH JS MOT AN APPROVED
CONTAINER, WAS TRANSFERRED
FROM PROCESS AREA TO
LABORATORY ON A FLATBED CART.

TWO EMPLOYEES ENTERED SUPPLIED FOUR EMPLOYEES VERE
AIR AND REHOVED A BLANK ON CONTAMINATED.
INCINERATOR. AIR MOVER WAS

TAKEN QUT OF SERVICE TO SUPPLY

NEGATIVE PRESSURE. NEGATIVE

PRESSURE WAS BEING LOST SO AIR

MOVER WERE TURNED BACK OW TO

MINIMIZED CONTAMINATION
RELEASE.



Page No. 2i
12/21/90
SUMMARY OF 1989 EVENTS

@.. NUMBER EVENT DATE BUILDING TYPE IIR/UOR Number Title
DATE NOFIFIED INVS.

UES9-528 10/30/89 10/30/89 750 NFI N/A : 111 Employee

UE89-529 10/30/89 10/30/89 665 NFI N/A Grass Fire

VESS-530 10/30/85 10/31/89 331 NFL N/A Broken Water Main

UE89-531 =: 10/31/89 10/31/89 900 NFI N/A Damaged Vehicle

VES9-532 10/31/89 10/31/83 559 NFI N/A Glovebox Overheat Alarm

UE89-533 10/31/89 11/01/89 123 NFI N/A Nitric Acid Spill]

UE89-534-R 11/01/89 11/01/89 460 NFI N/A Mercury Spill

VE89-535 11/01/89 11/01/89 000 NFI N/A Multiple Vehicle Accident

VE89-536-R 11/02/89 11/01/89 VV-9 NFI N/A Confined Space Entry
Violation

UE89-537 11/01/89 11/01/89 371 NFI N/A Accidental Activation of a
Fire Alarm

UE89-538-R 11/01/89 11/02/89 566 NFL N/A Subcontractor Employee
Injury

UE89-539 11/03/89 11/03/89 444 NFI N/A Hydraulic Fluid Leak

UE89-540 11/03/89 11/03/89 119 NEI N/A. Battery Acid Leak

UE89-541-R 11/03/89 11/03/89 831 TIR 89-145 881-8 Elevator Capacity Exceeded

UE89-542 11/03/89 11/06/89 334 NFI N/A Manual Fire Alarm

UE89-543 11/06/89 11/06/89 000 NEI N/A Split Hydraulic Line

UE89-544 11/06/89 11/06/89 707 NEI N/A Injured Employee

UE89-545-R 11/07/89 11/07/89 995 NFI N/A Unknown Substance in Sewer

an

UE89-546 11/07/89 11/07/89 707 NFI N/A Glovebox Overheat Alarm

UE89-547 11/07/89 11/07/89 123 TIR 89-146 123-2 ie Scrubber Overflow -

UE89-548-R 11/08/89 11/08/89 707 TIR 89-164 707-18 Contaminated Area

VESS-543 11/08/89 11/08/89 WV 14 NFE N/A High Wind Damage



Page No. 4
12/21/90
SUMMARY OF 1989 EVENTS
UE NUMBER EVENT DATE BUILDING TYPE IIR/UOR Number Title
DATE NOTIFIED NYS.
UE89-167 03/14/89 03/14/89 771 uP N/A Locker Room Contaminated
UES9-168 03/10/89 03/20/89 123 TIR 89-048, 123 Counting System Miswire
VE89-169 03/20/89 03/21/89 460 IIR 89-049, 460-2 EB Welder Fire
YES89-170 03/17/89 03/21/89 776 TIR 89-052,776-5 spataninated Instrument
UE89-171 03/22/89 03/22/89 707 NFI N/A Work Order Request
UE89-172 03/21/89 03/22/89 707 IIR 89-056,707-11 Electrical Panel Incident
UE89-173 03/26/89 03/27/89 371 UOR 89-01--371 89-1 373 Pumphouse Fire
UE89-174 03/27/89 03/27/89 444 TIR 89-050,444 PCB Spit
UE89-175 03/28/89 03/28/89 RFP SPECL N/A Response to IG Request
UE89-176 03/29/89 03/30/89 883 ENV N/A Sodium Hyroxide Leak
<0. 03/30/89 04/04/89 RFP NFI N/A Fire Phone
UE89-178 04/01/89 04/03/89 707 CR Power Switch Problem
UE89-179 04/01/89 04/03/89 707 NFE N/A SAAM Calibration
UE89-180 03/31/89 03/31/89 774 TIR  89-051,774-1 Nitrate Solution Spill
VES9-18} 03/31/89 04/14/89 772 NFL N/A Red Tagged Equipment
VE89-182-R 04/04/89 04/05/89 559 CAIRS N/A Chemical Powder Inhalation
UE89-183 04/05/89 04/05/89 707 TIR 89-053, 707-10 Lithium Chloride Spil]
UES89-184 04/05/89 04/05/89 444 VOR 89-04--444 89-1 Exhaust Duct Fire
UES9-185 03/31/89 04/05/89 779 CRTD Vacuum Problem on SAAMs
UES9-186 04/04/89 04/06/89 886 HP N/A Procedure Violation
UE89-187 04/03/89 04/06/89 881 IIR  89-067,881 Carpal Tunnel
UE89-188 04/06/89 04/07/89 440 CAIRS N/A Injuried Employee
VESS-189 04/06/89 04/06/89 750 Env N/A Pondcrete
UE89-190 04/07/89 04/07/89 707 €AIRS N/A Injured Employee



Page No. 176
' 11715/90
SUMMARY OF EVENTS
1952 TO 1988
EVENT EVENT. BUILD IM DESCRIPTION ADDITIONAL NOT
DATE NUMBER

07/05/88 IIR 88-74, 460-2

07/08/88 IIR 88-83, 707-8

460

707, MOD 8 6B-6S

®... TSR 88-103, 121-001 OUTSIDE - FIRING RANGE

08/10/88 88-104, 121-2

08/10/88 IIR 88-95, 000-2

OUTSIDE - NIGHT FIRING

OUTSIDE

DURING NORMAL ACID PUMPING
OPERATION, A "T* JOINT CAP IW
THE OVERHEAD ACID LINE LEAKED
(APPROXIMATELY 1 GAL.) ON TO
THE FLOOR. ACID wAS
WEUTRALIZED AND CLEANED UP AND
LEAK REPAIRED. AN OPERATING
PROCEDURE WAS WRITTEN FOR THE
TRANSFER OPERATION.

3 PARTS FOUND ON INSPECTION
TABLE IN 68-68. NO EMPLOYEE
ADMITTED BEING INVOLVED. BOX
ALLONED A NUMBER OF PARTS IN
CARRIER 18 PLANER ARRAY,
TABLE CHANGED SO PART CANNOT
BE PLACED UNDER TABLE AND NEW
LIMIT WRITTEN TO ALLOW MORE
THAN 1 PART ON THE TABLE.

PISTOL WAS DAMAGED BY AN
OVER-CHARGED CARTRIGE
RESULTING IN AN EXPANDED.
CHAMBER IM THE CYLUMER.
REMAINING PORTION OF AMMO LOG
‘SENT BACK TO MANUFACTURER FOR
INVESTIGATION.

OVER~CHARGED CARTRIGE EXPANDED
CYLINOOR IN PISTOL AND
PRODUCED STINGING SENSATION IW
HAND OF USER, ALSO LOUDER THAN
NORMAL REPORT NOTED BY FIRE
ARMS INSTRUCTOR. TEST AND
EVALUATION OF AMMO AND PISTOL
‘ARE UNDER WAY.

CONTRACTOR STARTED EXCAVATION
OPERATIONS IN NORTHEAST CORNER
OF BUFFER ZONE WITHOUT
CONTACTING CONSTRUCTION
MANAGEMENT OR THE
‘TELECOMMUNICATIONS. DEPARTMENT



Page No.
12/21/90

e.: NUMBER

9

SUMMARY OF 1989 EVENTS

EVENT DATE BUILDING TYPE IIR/UOR Number Title
DA NOTIFIED INVS
VE89-276 06/07/89 06/07/89 707 NFI N/A Contaminated Wound
UE89-277 06/07/89 06/08/89 444 NF N/A Domestic Water Spit]
UE89-278 06/08/89 06/08/89 372 NFI N/A Hydraulic Fluid Spill
UEBS-279 06/08/89 06/08/89 RFP NFL N/A Gasoline Spilt
UE89-280 06/08/89 06/08/89 779 NFI N/A Nal Functioning Overheat
UE89-281 06/09/89 06/09/89 RFP NFI N/A Fume Inhalation
UE89-282 06/09/89 06/09/89 123 cR N/A Process Waste Tank Spill
UE89-283 06/09/89 06/09/89 444 NFL N/A Exhaust Fan
VESS-284 06/09/89 06/09/89 443 NFL N/A Fuel O77 Leak
UE89-285 06/08/89 06/12/89 774 NEI N/A Liquid Waste Leak
Qur29-286 06/09/89 06/09/89 559 UOR 89-08--559 89-2 Glovebox Overheat .
Detection System Failure
UE89-287 06/12/89 06/12/89 707 NFI N/A Steam Coil] Leak
UE89-288-R 06/12/89 06/13/89 707 NFI N/A Improper Storage of
: Pyrophoric Materials.
UE89-289 06/13/89 06/13/89 121 NFI N/A PELS Failure
UE89-290 06/13/89 06/13/89 771 NF N/A Possible Inhalations,
Subcontractors
UE89-291 04/25/89 06/13/89 v2 TIR 89-082, VV-3 Leak at Valve Vault 2
UE89-292 06/14/89 06/14/89 250 IIR = 89-075,000-8 Property Loss, Mowing
Incident
UE89-293 06/14/89 06/15/89 707 NFI N/A Oxygen Analyzer Limits
UE89-294 06/15/89 06/15/89 324 IIR 89-076,374-2 T-826 C Spill
UE89-295 06/18/89 06/19/89 771 HP N/A Nitrate Tank Sight Gauge
a
Gy e2s-286 06/15/89 06/19/89 882 TIR 89-077,881-4 Nuclear Material Safety

Procedural Infraction
89-10



Page Mo. 175,
11/15/98

e SUNMARY OF EVENTS
1952 To 1988 q
EVENT EVENT BUILDING DESCRIPTION. ADDITONAL NOTE:
DATE NUMBER:

06/15/88 IIR 88-64, 559-3 559, ROOM 103 MAINTAINING A CONTROL OF TOTAL
CONTAINER VOLUME IN THE VARIED
5 OPERATIONS PERFORMED IN E~16,
WAS A MAJOR CONTRIBUTOR TO THE
INFRACTION,

06/21/88 IIR 88-67, 776-5 776, SECOND FLOOR HOT WATER TANK LEAKED AND AN
INTERNALLY CONTAMINATED WET
VAC WAS USED TO PICK UP
UNCONTAMINATED WATER ON FLOOR.
WHEN DRAINING THE VACCUUM,
THREE WORKERS WERE
CONTAMINATED. CONTAMINATION
WAS DISCOVERED 30 MINUTES
LATER WHEN WORKERS MONITORED
THEMSELVES.

06/22/88 IIR 88-72, 000-1 EAST BANK DAM A-3 OPERATING TRACTOR ON SIDE HILL IDE RILL OPERATION.

G30’ SLOPE) RESULTED IN

r ROLE-OVER W/O INJURY WHEELS
WERE NOT REVERSED FOR SIDER
STANCE. OPERATORS HAVE BEEN
URGED TO USE GOOD JUDGEMENT
WHEN MOWING ON HILLSIDES.
RECOMMENDATION - PURCHASE THO.
WIDE TRAC MOWER TRACTORS FOR S

06/29/88 IIR 88-78, ‘707-6 7O7 MOD C #3 HEALD T-BASE EMPLOYEE WAS REMOVING BURR
FROM PART DURING 1.D.
OPERATION. USING A WORN
SCOTCHBRITE ABRASIVE CLOTH,
EMPLOYEE APPLIED PRESSURE.
HIS HAND SLIPPED FORCING THUMB
AGAINST SHARP EDGE OF THE PART
CAUSING A CUT.

07/05/88 IER 88-79, 440-1 460, MOD CENTER PERSONNEL WERE PREPARING TO
ROTATE A RAILCAR LID USING 5
TOM HOIST. USED HANDLE
INSTEAD OF PROPER CHAIN. WHEN
LID RAISED WELD BROKE ON
HANDLE AND LID FELL IN THE
FLOOR. NO INJURIES OCCURRED.



Page Ko. 152

eo”

‘SUMMARY OF EVENTS

1952 TO 1988

EVENT EVENT
DATE NUMBER

03/16/87 SIR 87-3-886-1

03/17/87 SIR 87-3-464.2

03/20/87 $1R 87-3-707.2

03/27/87 SIR 87-4-707.%

05/27/87 $1R 87-3-707.3

04/06/87 SIR 87-46-7074

BUILDING

886, RM101, SAT

44h, P.M.D. 0046-319

707, MODULE F, RMIZ6

707, MODULE J, BOK J60

707, MODULE C, BOX C-1

‘TOT, OXYGEN ANALYZER

DESCRIPTION

WHEN TRYING TO REMOVE LOWER
REACTIVITY SHINS, THE LOWER
SHIMS SLID DOWN ALLOWING THE
DRY URANIUM PONDER TO PUFF OUT
CONTAMINATING WORKERS AND ROOM
103.

OPERATOR, TAKING FINISH CUT OW
1/4" RAD, PRODUCED FINE CHIPS
THAT IGNITED AND DROPPED INTO
THE CHIP PAN, IGNITING OTHER
CHIPS IN THE PAN.

NMSPI 87-6. OPERATOR NOTICED
TWO PITS BEING STORED ON ONE
PUMPDOWN TABLE. THE LIMITS FOR
“APPROVED ASSEMBLIES" STATE
THAT EACH PUMPDOWN TABLE 1S
LIMITED TO ONE PIT.

460 GLOVEBOK BURN FACILITY
OVER PRESSURIZED DUE TO GAS
BUILD UP FROM MATERIAL BURNING
IN BURN CHAMBER WHICH DRAINED.
OTL FROM THE CRITICALITY
DRAIN. SOME CONTAMINATION WAS
RELEASED INTO MODULE J.

10 OPERATOR REMOVED FILTERS AND
CANISTERS FOR NORMAL INVENTORY
REPLACEMENT, HOWEVER, COULD
WOT LOCATE NEW FILTERS AND
LEFT FILTERS AND CANISTERS ON
FLOOR. NEXT SHIFT OPERATOR
STARTED PROCESS AND OIL
GRAVITY FED INTO FILTER BOX
AND OUT CRITICALITY DRAIN.

MIDNIGHT SHIFT SOE‘S NOT ABLE
TO CALIBRATE THE OXYGEN
ANALYZER ON BREATHING AIR
SYSTEM, DAY AND PH SHIFT
PEOPLE WERE ALLOWED TO GO INTO
BREATHING AIR WHILE THE
MONITORING INTRUMENT WAS OUT
OF CALIBRATION.

ADDITIONAL NOTES



Page No. 166

11/15/90

SUMMARY OF EVENTS
1952 To 1988

EVENT
NUMBER

EVENT
DATE

12/07/87 UOR 88-2--707 88-1

12/17/87 IIR 87-102,644-6

2/17/87 11R 87-103,707-20

12/22/87 11R 87-100, 76-11

01/07/88 11R 881-1, 881-1

BOTLDING

707, HOD B

446, RMIO7

707, MODULE 8

726, SA SYSTEM HEAT COIL

881

DESCRIPTION ADDITEONAL NOTES

ELECTRICIAN WAS RENOVING
WIRING IH POSTFORM ANNEAL
FURNACE CONTROL CABINET.
ELECTRICIAN ASKED SHEETMETAL
WORKER TO CUT WIRES HE
COULDN'T REACH. AN ELECTRICAL
ARC CAUSED TEMP BLINONESS.
WIRE WAS 480V BUT NO MARKINGS
‘ON CABINET OR ELECTRICAL
DRAWINGS.

BE DUST ADHERED TO TOOLS
DURING CUTTING OPERATION AND
WAS KNOCKED LOOSE BY THE
AUTOMATIC TOOL CHANGER AS THE
TOOLS WERE CHANGED. THE AIR
SAMPLE HEAD IS MOUNTED IN THE
NEAR VICINITY AND SUCKED UP
THE FREE FALLING BE DUST.

A SHEET METAL WORKER STEPPED
‘ON TO CABINET HOUSING AND WITH
‘A PAIR OF INSULATED WIRE
CUTTERS PROCEEDED TO SEVER THE
MIRES. A DIRECT SHORT CIRCUIT
BETWEEN WIRING OCCURRED
RESULTING IN AN ELECTRICAL
ARC. WORKER WAS TEMPORARILY
BLINDED.

WHEN REMOVING A HEATING COIL,
AN UNKNOWN SUBSTANCE CAME OUT
OF PIPING. {NOUSTRIAL HYGENE
RECOMMENDED TO PROCEED UNDER
ASBESTOS PROTECTION CONDITION.
SAFETY YAS OVERLOOKED IN
STARTING THE JOB.

WATER DAMAGE TO COMPUTER ROOM
WHEN SINK IN LAB OVERFLOWED
UPSTAIRS



Page No. 19
12/21/90
SUMMARY OF 1989 EVENTS

Ou NUMBER EVENT DATE BUILDING TYPE IIR/UOR Number Title
DATE——NOHIFIED EWS
VE89-486 10/18/89 10/19/89 771 NFI Precautionary Body Counts
UE89-487 10/20/89 10/20/89 776 NFI Oxygen Analyzer Alarm
VE89-488 10/20/89 10/20/89 771 TIR 89-14) 771-15 Air Supply Operations
UES9-489 10/20/89 10/20/89 877 NEI Fuel O71 Spill
UE89-490 10/20/89 10/20/89 904 Pad NFI Saltcrete Spill, 904 Pad
UE89-491 10/20/89 10/20/89 771 NFI Glovebox Overheat Alarm
VE89-492-R 10/20/89 10/20/89 566 NFIT N/A Construction Site Safety
Concerns
UE89-493 10/20/89 10/20/89 881 NFI Fire Alarm, Inadvertent
UE89-494 10/21/89 10/23/89 374 VOR 89-18--VV 89-2 Flooded Valve Vaults
UE89-495 10/20/89 10/23/89 776 NFI Glovebox Overheat Alarm
@ re 10/20/89 10/23/89 776 NFI Glovebox Overheat Alarm
UE89-497 10/21/89 10/23/89 778 NFI Contaminated Employee
UE89-498 10/22/89 10/23/89 707 NFI Fire Alarm System
Malfunction
~ UEGI-499° 10/23/89 10/23/89 776 NEL Glovebox Overheat Alarm
UE89-500 10/23/89 10/23/89 776 NFI N/A Waste Collection Tank
Spill, TIA & T1B
UE89-501-R 10/21/89 10/23/89 334 UOR 89-16--334 89-1 Suspected Contamination,
Maintenance Shop
UE89-502 10/24/89 10/24/89 790 NFI N/A Sub-contractor Crane
Incident
VEB9-503-R 10/23/89 10/23/89 000 VOR  89-17--000 89-1 Firing Range Incident
UE89-504 10/24/89 10/24/89 707 NFI N/A Fire Alarms
UES9-505 10/24/89 10/24/89 559 NFI N/A Glovebox Overheat Alarm,
B/559
i, SES9-506-R 10/24/89 10/24/89 561C NFI N/A Bulging Drums, RCRA
@ Storage



1709/90

. SUMMARY OF 1988 EVENTS

7 VE EVENT BUILDING TITLE

NUMBER. DATE
UE88-050 11/03/88 131 Injury
UE88-051 11/07/88 371 Nuclear Material Special Procedural Infraction 88-27
UE88-052 11/03/88 559 Nuclear Material Safety Procedural Infraction 88-28
UVE88-053 11/03/88 771 Nuclear Material Safety Procedural Infraction 88-29
UEB8-054 11/04/88 119 Vehicle Accidents, Steam Line
UE88-055 11/04/88 371 Control of Differential Pressure
VE88-056 11/10/88 777 Inadvertent Entry into DD Room
UE88-057 11/10/88 995 Unknown Substance
UE88-058 11/11/88 566 Injury
UE88-059 11/12/88 460 Injury

®@ UES8-060 11/14/88 707 Glove Failure with 2 Possible Inhalation
VES8-062 11/16/88 968 Injury
UE88-062 11/16/88 708 Injury
UE88-063 11/10/88 777 Deactivation of Criticality Alarm System
UES8-064 11/20/88 443 Fuel Leak :
VES8-065 11/19/88 776 Precautionary Building Evacuation
UE88-066 11/19/88 RFP Construction Vehicle Accident
UE88-067 11/19/88 443 Diesel Fuel Spill, Compressor Fuel System
UE88-068 11/18/88 776 Possible Inhalation
YE88-069 11/18/88 881 Transfer Valve
UE88-070 11/23/88 881 Employee Shock Incident
UES8-071 11/30/88 444 Fire Sprinkler Line Rupture
UE88-072 12/01/88 460 Injury

@ UE88-073 12/02/88 776 LCO Violation
UESS-074 12/02/88 444 High Voltage Shock



Page No.

4

11/98/90 SUMMARY OF 1988 EVENTS

UE EVENT BUILDING TITLE
NUMBER DATE
UEGE-075 12/03/88 707 Injury
UE88-076 12/03/88 RFP Gas Pipe Rupture
UE88-077 12/04/88 372 Injury
UE88-078 12/02/88 461 Live Ammunition in Drain
UES8-079 12/02/88 707 Crane Incident
VE88-080 12/05/88 551 Injured Employee
UE88-081 12/09/88 RFP Electric Service Interruption
UE88-082 12/08/88 664 Railcar Damaged Gate and Door
UE88-083 12/09/88 121 Injury
UE88-084 12/09/88 777 Contaminated Employee
UE88-085 12/13/88 334 Injury
UE88-086 12/14/88 RFP Vehicle Accident
UE88-087 12/17/88 707 Unplanned Evacuation
UE88-088 12/18/88 371 Emergency Generator Failure
UE88-089 12/17/88 371 Jones Stripout of Exhaust Duct
UE88-090 12/19/88 111 Unapproved Shipment Offsite
UE88-091 12/20/88 771 Injuried Employee
UE88-092 12/19/88 RFP Wall Collapse
UE88-093 12/21/88 776 Administrative Control
UE88-094 12/22/88 850 Open Flame
UE88-095 12/22/88 PD904 Pondcrete
UE88-096 12/22/88 707 Oxygen Rise In Inert System
UE88-097 12/27/88 371 Injuried Employee
UE8S-099 12/28/88 707 Glovebox Overheat
UE89-100 12/31/88 707 Site Gage Leak ¥-61



Page No. 15

12/21/90
SUMMARY OF 1989 EVENTS
e.. NUMBER EVENT DATE BUILDING TYPE IIR/UOR Number Title
DATE NOTIETED INVS.
UE89-402 08/30/89 08/31/89 771 IIR 89-115 771-10 Bing Change Incident -
UE89-403-R 08/31/89 08/31/89 707 TIR 89-116 707-14 Building Entry During
Evacuation
UE89-404 08/31/89 08/31/89 460 NFI Fan Oi] Fumes
UE8S-405 08/31/89 09/01/89 130 NFL Paint Spill
UE89-406-R 09/01/89 09/01/89 777 JIR 89-118 777-6 Welding Fire
UE89-407 08/31/89 09/01/89 777 JIR 89-117 777-5 Nuclear Material Safety
Procedural Infraction
89-18
UE89-408 09/01/89 09/05/89 664 NEI Damaged Shipping Crate
UESS-409 09/01/89 09/05/89 334 NFI Personal Injury
UE89-410-R 08/24/89 09/02/89 INEL TIR 89-124 664-2 Contaminated Shipment
UE89-411-R 09/05/89 09/05/89 779 HIR 89-121 779-7 Building Evacuation, 8/779
UE89-412-R 09/05/89 09/05/89 762 A NFI N/A Unauthorized Use of X-ray
Machines
UE89-413 09/06/89 09/06/89 566 NFI N/A Contractor Shutdown
UE89-414 09/06/89 09/06/89 374 IIR 89-120 374-3 Nitric Acid Burn
YES9-415 99/07/89 99/08/89 771 TIR 89-122 771-15 Employee Contamination
UE89-416 09/08/89 09/11/89 708 NFI N/A Loss of Air Pressure
UES9-417 09/09/89 09/11/89 707 NFI N/A Glovebox Overheat Alarms
UE89-418 09/10/89 09/11/89 761 T&SSE N/A Personnel Injury
UE89-419 09/10/89 09/11/89 111 TIR 89-123 111-1 Fire Alarm Malfunction
VE89-420 09/11/89 09/12/89 443 CAIRS Injured Employee
UES9-421-R 09/05/89 09/11/89 559 NFI N/A Chemical Inhalation
Qies-222 09/12/89 09/12/89 A-4 Pond NFI N/A Pump Leak



Page No. 172
11/15/90

EVENT EVENT

BUILDING

SUMMARY OF EVENTS

1952 To 1988

RODTT TONAL HOTE:

DATE NUMBER

05/02/88 IIR 88-62, 443-3

05/03/88 11R 88-62, 581-6
05/03/88 1IR BB-51, 881-4

05/06/88 IIR 88-37, 776.6

05/07/88 11R 88-53, 707-3

05/09/88 LR 88-47-777-3

464

881, RM 131

881, RN 144

776, RM 134

708

TG, GB 620

‘A SAWZALL BLADE BROKE WHILE
CUTTING A PIPE AND A PIECE OF
TRE BLADE SCRATCHED THE EYE OF
‘THE WORKER, EVEN THOUGH RE HAD
SAFETY GLASSES. RECOMMENDED
GLASSES WITH SIDE SHIELDS FOR
THIS TYPE OF WORK.

RESPIRATOR WAS PLACED IN
CONTAMINATED JAR, CAUSING
CONTAMINATION TO CABINET AND
RESPIRATOR

‘A SPARK HIT A RESPIRATOR, WORN
BY A J. A. JONES EMPLOYEE.
THE CARTRIDGE IGNITED AND
SMOKE WAS RELEASED.

BOTH SOUTH & EAST AIR LOCK
DOORS TO THE ASRF WERE OPENED
AT THE SAME TIME ALLOWING AIR
TO ESCAPE INTO ROOM 134. THIS
WAS IN VIGLATION OF OSA AND WO
4016 OPERATORS RETRAINED AND
REPRAMANDED.

VALMENT STATION LOST, 480V
SYSTEM BUMPED BUT HOT LONG
ENOUGH TO START EMERGENCY
GENERATORS. 2400V WAS LOST TO
7OB APPROX 31 MIN, TRIS
PROVIDED CONTROL POWER TO
‘START STANDBY DIESEL POMER
PUMPS FOR TOWER WATER OPERATOR
STARTED MANUAL APPROX 10 MIN.

SECOND PROCEDURAL INFRACTION WEIGHED BEFORE MOVING AND
AT THIS OPERATION. FAILURE TO FOUND 111 GRAM OVER WEIGHT
CONDITION ON 3,000 G LIMIT

FOLLO PROCEDURAL
REQUIREMENTS: WO WER WAS
INITIATED AMD WEIGHT WAS NOT
TAKEN OR RECORDED BEFORE SCRAP
MATERIAL WAS CUT UP AND PLACED
1M CONTAINER FOR TRANSFER,
PRODUCTION CONTROL HANDLER



Page No.
12/21/90

@.. NUMBER

UE89-465
UES9-466

UE89-467
UE89-468
UE89-469
UES89-470
UE89-471

UE89-472

UE89-473

eo"

UE89-475

UE8S-476

UE89-477-R

UE89-478
UE89-479
UE89-480
UE89-481

UE89-482
UVES9-483

VE89-484-R
UE89-485

18

SUMMARY OF 1989 EVENTS

EVENT = DATE

BUILDING

TYPE TIR/UOR Number

Title

B

10/10/89 10/11/89 750
10/10/89 10/11/89. 771

10/10/89 10/11/89 778
10/11/89 10/11/89 904 Pad
10/12/89 10/12/89 371C
10/13/89 10/13/89 130
10/14/89 10/16/89 778

10/13/89 10/16/89 707
10/13/89 10/16/89 778
10/13/89 10/16/89 460
10/13/89 10/16/89 771

10/14/89 10/16/89 771
10/14/89 10/16/89 707

10/15/89 10/16/89 250
10/16/89 10/16/89 771
10/16/89 10/16/89 881
10/16/89 10/17/89 559

10/17/89 10/17/89 881
10/17/89 10/17/89 778

10/17/89 10/17/89 551
10/18/89 10/19/89 850

ENVS

NFI
NFI

TIR
NFI

89-137 778-1

CAIRS
TIR 89-138 130-2

IIR 89-140 778-2

. NFI

NFI
NFI
NFI

NFI

NFI

NFI

89-14) 771-15

N/A

Battery Acid Spill

Vacuum Header Sotution
Spill

Pressurized Drum
Deformed Storage Drum Lid
Emptoyee Injury, Fall
Personal Injury, Burn

Unplanned Building
Evacuation

Oxygen Analyzer Problem
Litter Case, 11] Employee
Automobile Gasoline Leak

Glovebox Overheat Alarm,
Line 17

Glovebox Overheat Alarm,
180

Employee Injury, Puncture
Wound

Fire Water Flow Alarm
Oxygen Analyzer Problem
Cooling Water Spill

Glovebox Overheat Alarm,
C-28

Smoke Detector Alarm

Breathing Air Compressor
Alarm

Dioxane Removal

111 Contractor Employee



Page No. 9148
1415/90

EVENT EVENT

‘SUMMARY OF EVENTS
4952 TO 1988

BUILDING

DESCRIPTION

ADDITIONAL NOTES

DATE HUMBER

01/28/87 SIR 87-1-771-1

02/02/87 SIR 87-2-664.1

02/05/87 SIR 87-2-130.1

- 02/05/87 SiR: 87-2-664.2

02/05/87 SIR 87-2-771.1

771, RMII4, LINE 7

664, ATMX RAILCAR AREA

130, RMT80

684, NOA & HC COUNTERS

771, RMIS7, CAN COUNTER

SMOKE FIRE INSIDE GLOVEBOX
APPARENTLY STARTED BY A HOT
PLATE THAT WAS LEFT ON AND
TURNED UPSIDE GOWH WEAR SOME
CoMBUSTIBLES.

RATLCARS 611 AND 508 WERE
READY TO BE MOVED. AS BRAKE OV
517 WAS RELEASED, BOTH CARS
BEGAN TO HOVE SLOWLY DOW
TRACK DUE TO AW INCLINE, WAEEL
OF 608 RAN OVER A CHOKE.
BEFORE CARS STOPPED, END OF
RAILCAR 611 COLLIDED WITH
PARTIALLY OPENED ROLL-UP DOOR.

EMPLOYEE ATTEMPTED TO MOVE A
LARGE CRATE WETH A FORK LIFT
WHEN CRATE STRUCK A PALLET
WHICH IW TURN STRUCK A CART,
PUSHING THE CART INTO THE WEST
WALL OF ROOM 180 CAUSING
EXTENSIVE DAMAGE TO THE WALL.
CRATE WAS OBSTRUCTING DRIVER'S
VIEW.

FORK TRUCK WAS DRIVEN INTO
METAL CRATES STACKED 3 HIGH
AND THE TOP CRATES IN THE
FIRST TWO ROWS WERE PUSHED
OFF. A FIRE SPRINKLER SYSTEM
WATER SUPPLY CAME APART AT
COUPLING AFTER BEING STRUCK BY
FORK LIFT MAST.

NMSPI 87-3. NDA OPERATOR
WROTE 159 GRAMS INSTEAD OF 259
GRAMS WHEN TRANSFERRING THE
GRAM VALUE TO PACKAGE, WHEN
PACKAGE WAS PLACED 1N
SS-GALLON DRUM, DRUM CONTAINED
O30 GRAHS WRICH IS OVER LIMIT
OF 7000 GRAMS.



Page No. 7
12/21/30
SUMMARY OF 1989 EVENTS
= ba NUMBER EVENT = DATE BUILDING TYPE TIR/UOR Number Title
DATE NOTIFIED. ENVS
UESS-235 05/16/89 05/18/89 707 HP N/A Clothing/Glove
Contamination
VE89-236 05/16/89 05/18/89 707 HP N/A Clothing/Glove
Contamination
UE89-237 05/19/89 05/19/89 559 NFT N/A Hydraulic Fluid and
, Solvent Leak
UE89-238-R 05/18/89 05/18/89 881 TIR 89-068, 881-3 Process Waste Drain
UES9-239 05/19/83 05/22/89 707 NFI N/A Welder Incident
YE89-240 05/18/89 05/18/89 865 CAIRS N/A Injured Employee
VE8S-241-R 05/17/89 05/18/89 371 CAIRS N/A Flash Burns
UE89-242-R 05/19/89 05/19/89 777 CAIRS N/A Injury to Employee
UE89-243 05/22/89 05/22/89 371 HP N/A Inadvertent Entry into
Posted Room
Qoise-24 05/19/89 05/22/89 460 NEI N/A Water Accumulation
UE89-245 05/22/89 05/23/89 371 NFI N/A 371 Air Imbalance
UE89-246 05/23/89 05/23/89 371 TIR —89-069,371-10 Subcontractor
Contamination
UE89-247 05/18/89 05/23/89 371 HP N/A Contamination Lab
UEB9-248-R 05/24/89 05/24/89 374 TIR  89-072,374-1 HazMat Spill, Tank 805
UE89-249 05/24/89 05/25/89 777 IIR —89-070,777-2 Nuclear Material Safety
Procedural Infraction 89-8
BES9-250 05/22/89 05/25/89 707 HP N/A Scraped Elbow
UES9-251 05/24/89 05/26/89 707 HP N/A Positive Wound Count
UEB9-252 05/25/89 05/26/89 779 HP N/A Contamination Incident,
Maintenance
UE89-253 05/25/89 05/30/89 779 HP N/A Plutonium Oxide Release to
Lab
., UE89-254-R 05/27/89 05/30/89 444 NFI N/A Deionized Water Leak



Page No. 5
12/21/90
SUMMARY OF 1989 EVENTS
UE NUMBER EVENT DATE BUILDING TYPE TIiR/UOR Number Title
DATE NOTIFIED. INYS.
UE89-191 04/08/89 04/10/89 771 CAIRS N/A Contractor Injury
UE89-192 04/09/89 04/10/89 707 HP N/A Cooling Water Loss
VEB9-193 04/10/89 04/11/89 776 TIR  89-054,776-6 Pump Box Contamination
UE89-194 04/10/89 04/11/89 460 UOR  89-05--460 89-1 Clean Room Spill
UEB9-195 04/10/89 04/10/89 771 cR Tank 550 Incident
UE89-196 04/23/89 04/14/89 707 CAIRS N/A Cut Finger
UES9-197 04/13/89 04/14/89 371 CAIRS N/A Shoulder Injury
UE89-198 04/13/89 04/13/89 771 UOR  89-06--771 89-1 Acid Fume Inhalations
UE89-199 04/13/89 04/13/89 VV17 TIR 89-055, VV-2 Valve Vault #17 Incident
VE89-200 04/13/89 04/14/89 123 NFI N/A Phosphoric Acid Spill
Qve89-201 04/15/89 04/17/89 460 IIR 89-057, 460 NDT Waste Process Tank
UVE89-202 04/16/89 04/17/89 130 CR N/A Water Leak
VE89-203 04/17/89 04/17/89 PD903 IIR 89-064, 903-1 Unauthorized Access
VE89-204 04/19/89 04/19/89 460 NFI N/A Clean Room Tank Leak
YE89-205 04/19/89 04/20/89 881 NFI N/A Damaged Temporary Duct
jor!
UE89-206-R 04/20/89 04/21/89 995 NFI N/A Treatment Plant
VE89-207 04/19/89 04/20/89 778 CAIRS Employee Back Injury
UE89-208 04/23/89 04/24/89 371 TIR 89-066, 371-9 Contaminated
Subcontractors
UE89-209 04/22/89 04/26/89 991 TIR 89-058, 991 Dilute Chromic Acid
Incident
VE89-210 04/27/89 04/28/89 559 CAIRS N/A Employee ITIness
UE89-211 05/01/89 05/01/89 776 TIR 89-059,776 NucTear Material Safety
Procedural Infraction 89-5
@ices-212-2 04/26/89 05/01/89 777 HP N/A Cutting O%7 Spill



Page No. 159
44/15/90

SUMMARY OF EVENTS:
1952 TO 1988

07/23/87 SIR 87-8-771.4

Q7/24/87 YOR 87-3-776 87-1

07/29/87 SIR 87-8-771.2

07/31/87 SIR 87-8-121.1

08/01/87 SIR 87-8-776.1

BOTCDING

77%, MAINTENANCE DOCK

776, RM118, FBI CANYON

771, RM1G68

122, 1424 SHREDDER

776, ASRE

DESCRIPTION ADDITIONAL NOTES

HEAVY DRIVER WAS TRANPORTING A
10 CUBIC YARD CAPACITY
COMPACTOR BOX WITH THE
COMPACTOR TRASH TRUCK. HE
LIFTED THE BOX UP TO SEE
PEDESTRIANS AND NICKED
SLIGHTLY SAGGING
TELECOMMUNICATION WIRES.

A FIRE WAS OBSERVED AT THE WAS EXTINGUISHED IN THE
LOWER NORTHWEST PORTION OF THE SAME MANNER.
PRIMARY INCINERATOR R1 IN THE
AREA OF THE TRAMP METAL SCREW
AND PROGRESSING TOWARD THE
SOLID FEED SCREW. THE FIRE
BURNED FOR 20 MINUTES BEFORE
BEING EXTINGUISHED
10 MINUTES LATER IT REKINDLED
AND

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.

WHILE SECURITY INSPECTOR WAS
FEEDING HYLAR COMPUTER TAPE
INTO SHREDDER FOR DESTRUCTION,
AN ALLEN WRENCH FELL INSIDE
SHREDDER. SHREDDER BLADES WERE
BROKEN AND ROTOR SHAFT WAS
BENT.

REPLACED WELDING CABLES AND
PUT SHIELDING AROUND CABLE FOR
MACHNICAL PROTECTION. AFTER
ARC STARTER WAS ENERGIZED, A
FLASH WAS OBSERVED IN THE
GLOVE BOX DUE TO LEAKING GAS
CONNECTION AROUND FERRULE.



Page No. VV

12/21/90
SUMMARY OF 1989 EVENTS
Ou: NUMBER EVENT DATE BUILDING TYPE IIR/UOR Number Title
DAFE——NOTEFTED NYS
UE89-444 09/26/89 09/26/89 762 NFI N/A Government Property Damage
UE89-445 09/26/89 09/26/89 762 1&SSE N/A Property Damage 1
UE89-446 09/26/89 09/26/89 886 IIR 89-131 886-1 Leaking Vessel
UE89-447 = 09/26/89 09/27/89 707 NFE N/A Spilled Gasoline
“ure9-448 09/28/89 09/28/89 111 NFI Photo Lab Water Spilt
UE89-449 09/29/89 09/29/89 444 IIR 89-132 444-9 Room 1 Spit], Waste Pump
UE89-450-R 09/28/89 09/29/89 995 NFL N/A tow pH in Sewage Treatment
UE89-451 09/29/89 09/29/89 250 TER 89-143 250-1 Toxic Domestic Water Well
UE89-452-R 09/29/89 09/29/89 883 NFI N/A Process Water Line Rupture
UE89-453-R 09/29/89 09/29/89 444 NFI N/A Flevator Hydraulic Gasket
@ icscasa 10/02/89 10/02/89 WV 13 NFI Compressor Fire
UE89-455 10/03/89 10/03/89 771 NFI Titness, 2nd Stage Main
Plenum
UEBS-456-R 10/03/89 10/03/89 460 NEI N/A Copier Chemical Spil?
UE89-457 10/03/89 10/03/89 883 NEI N/A Personal Injury, Partial
Amputation
VESS-458 10/03/89 10/04/89 391 IIR 89-333 991-3 Unauthorized Painting
UE89-459 10/04/89 10/05/89 771 IIR 89-134 771-12 Nuclear Materials Safety
Procedural Infraction
89-21
UE89-460 10/04/89 10/05/89 771 NFI Hydrofluoric Acid
Evaporator Leak
UE89-461 10/04/89 10/05/89 771 TIR 89-136 771-14 Criticality Drain Overflow
UE89-462-R 10/05/89 10/05/89 904 Pad NFI N/A Gasoline Spill
UYES9-463-R 10/10/89 10/16/89 444 NFI N/A Uranium Chip Fire
Dosso-s64-n 10/09/89 10/10/89 771 NFI N/A Dilute Nitric Acid Spill,

T-452



Page No. 161
31/15/90

SUMMARY OF EVENTS

1952 To 1988

—-EVENT- ‘BUTLOTNE
DATE NUMBER

08/13/87 SIR 87-8-771.3 771, RMI49, LINE 29

08/19/87 SIR BT-2A-771.4 Tet, LINE 3

re SIR 87-8-881.1 88t, RMIO

08/25/87 SIR 87-08-S8W.1 TT, RM249

08/26/87 SIR 87-8-664.1 664, WAREHOUSE

DESCRIPTION

NHSPI 87-20. YWO 4-LITER
CONTAINERS OF LABORATORY WASTE
WERE PLACED IN THE ION
EXCHANGE AREA, APPROXIMATELY
8" FROM THE TERTIARY COLUMN.
THIS VIOLATED THE ESTABLISHED
NUCLEAR MATERIALS SAFETY LIMIT
ALLOWING A SINGLE 1-LITER
CONTAINER AND 12" SPACING.

AM OPERATOR MOVED A DIRTY
FUL-FLO FILTER TO THE NORTH
END OF LINE 3 TO BE BAGGED
QUT. DIRTY FUL-FLO FILTERS ARE
WOT ALLOWED IN THE NORTH
BATCHING AREA OF LINE 3
VIOLATING A XUCLEAR MATERIALS.
SAFETY LIMIT.

‘A S8OV FEEDER FROM THE
EMERGENCY GENERATOR WENT TO
GROUND DURING A SYSTEMS
OPERATIONAL TEST OF ATS 881-1.
A SHALL FIRE RESULTED WHEN
SPARKS FROM THE FAULT IGNITED
A PIECE (OF FOAM. THE FIRE WAS
EXTINGUISHED BY A S8W
ELECTRICIAN,

A SHEET METAL WORKER WAS
GRINDING A WELD ON THE
PENTHOUSE INSIDE F.U,-1 FILTER
PLENUM WHEN HIS LADDER
SLIPPED, THE WORKMAN RELEASED
THE GRINDER TO CATCH KIS
BALANCE AND IT STRUCK RIS LEFT
WRIST. FIVE SUTURES WERE
REQUIRED TO CLOSE THE WOUND.

ENGINEER AND FOUR WORKERS
MANUALLY LOWERED A 1250 18
LISTING ATTACHMENT TO A
HORIZONTAL POSITION ON A
PALLET. PART OF THE PALLET
SURFACE BROKE CAUSING THE
GUIDE PLATE ON ATTACHMENT TO
STRIKE THE FLOOR AND SEVERED
THE MIDDLE FINGER ON THE
ENGINEER'S HAND.

ADDITIONAL NOTES



Page No. 147
11/15/90
‘SUMMARY OF EVENTS.

e 1952 TO 1988

EVENT ‘EVERT BURLING DESCRIPTION ADDITIONAL NOTES
DATE NUMBER
12/21/86 SIR 86-12-331.1 331, 4TH AND SAGE BA TRANSPORTING DOZER, CHAIN

BROKE AND CAUGRT UNDER TRUCK
WHEEL AND DOZER FELL OFF.

12/21/85 SIR 86-12-331.4 331, SAGE STREET DURING TRANSPORT TO CANOFILL,
0-8 DOZER FELL OFF TRAILER
ALONG SIDE OF SAGE. STREET.

12/26/86 SiR 86-12-881.1 881 WATER OVERFLOWED WHEN HOSE
CLAMP FAILED ON TUBING
CARRYING COOLING WATER.
SPILLAGE CAUSED DAMAGE TO UPS
TH COMPUTER CENTER.

12/26/86 SIR 87-1-776.2 777, DOOR 30 TOP HINGE OF DOOR WAS BROKEN

ALLOWING THE DOOR ENOUGH
CLEARANCE FOR THE LOCKING
MECHANISM TO CLEAR THE JAMB
WITHOUT UNLOCKING. THIS
PERMITTED UNRESTRICTED ACCESS

e FROM THE OUTSIDE OF BUILOING.
DOOR WAS TEMPORARILY J-BARRED
WITH A LOCK AND CHAIN.

04/14/87 SER 87-1-569.1 369 BECAUSE OF A MISALIGNED PILOT,
GAS IGNITED 1N FURNACE BLOWING
OFF. THE -SHEETMETAL PAN.

01/15/87 SIR 87-1-460-1 469 A UNIT WAS BEING DRILLED FOR
DESTRUCTION WHEN A RELEASE OF

| GAS FROM WITHIN OCCURRED
(APPROXIMATELY S700 PSIG). THE

| RELEASE BLEW METAL CHIPS INTO
MACHINIST'S FACE, BUT No

| INJURY OCCURRED.

|

|

01/19/87 SIR B7-1-559.1 559, RM101, BOX E-23 THREE CONTAINERS OF FISSILE
SOLUTION CONTAINING & YOTAL OF
226.5 GRAMS OF PLUTONIUM WERE
STORED IW GLOVEBOX E-23. THE
GLOVEROX HAD A KUCLEAR
MATERIALS SAFETY LIMIT OF 200
GRAMS IN ANY FORM.



Page No.
11/09/90

UE

EVENT BUILDING

SUMMARY OF 1988 EVENTS
TITLE

NUMBER.

UES8-024
UE88-025
UES8-026
UE88-027
UE88-029
UE88-030
UE88-031
UE88-032
UE83-033
UE88-034
UE88-035
UE88-036
UE88-037
UE88-038
UES8-039
UE88-040
UES8-041
UE88-042
UE88-043
UESB-044
UES8-045
UE88-046
UE88-047
UE88-048
UES8-049

10/10/88 060
10/11/88 850
10/11/88 452
10/13/88 440
10/14/88 707
10/18/88 RFP
10/18/88 707
10/19/88 707
10/20/88 444
10/20/88 779
10/20/88 771
10/24/88 771
10/20/88 121
10/26/88 771
10/26/88 776
10/28/88 559
10/28/88 777
10/28/88 RFP
10/30/88 371
11/01/88 444
11/01/88 PD750
11/01/88 774
11/01/88 771
11/01/88 371
11/01/88 PD750

Building Evacuation - Natural Gas
Injuried Employee

Smoke Alarm

Cut Thumb

Cooling Water Spill

Car Crash - Injuried Employee
Contamination Incident
Contamination Incident
Injuried Employee

Unnecessary Radiation Exposure
Nuclear Material Safety Procedural Infraction 88-26
Injury

Faulty Ammo

Contaminated Employee
Possible Contamination

Natural Gas Smell]

Contaminated Incident
Excavating Incident

B Box Contamination

Acid Solution Spitt

Pondcrete Spill

Caustic Spill

Injury

Suspected Contaminted Drum

Pondcrete Spit] at 750 Pad



Page No. 170

11715790
SUMMARY OF EVENTS
r 1952 TO 1988
EVENT EVENT BUILDING DESCRIPTION ADDETL
DATE ‘WUMBER, |
03/21/88 88-75, 776-9 7% HISINTERPRETATION OF WHCSL
RESULTED IN PACKAGING RTVs TO
DRY SHIPPING LIMITS MAEN RTVs 1
FELL UNDER WET SKIPPING LIMITS
OF 2006, RECIPIENTS IN 371
FOUND CONTENTS TO BE IN EXCESS
OF 500 g AND REPORTED IT TO
THE AREA NUCLEAR CRITICALITY
ENGINEER
03/26/88 IIR 88-35, 374-3 374, RM 3809 PIPEFITTER WAS CUTTING UP HEAT

06/07/88 IIR 88-18, 446-2

06/08/88 UOR 88-1--776 88-1

06/12/88 LIR 88-38 123-1

04/16/88 TiR 88-39, 776-7

464, CAFETERIA

776, RM 456A

123, PARKING LOT

776, ROOK 154

EXCHANGER WITH PLASMA ARC
CUTTING MACHING, BLOW BACK
CAUGHT CLOTH HOOD ON FIRE. BY
STANDARD, PUT FIRE OUT. USE
OF LEATHER HOOD WILL NOW BE
USED.

SUSPECTED HIGH ASBESTOS FIBER
CONTENT IN CONSTRUCTION AREA
REPOSTED AFTER THE FACILITY
CLEANED AND NO ASBESTOS FOUND
~ RETRAINED EMPLOYEES ON
PROPER REPORTING OF INCIDENTS.

WIDE VARIATIONS OF OXYGEN
CANNOT BE DETECTED BY ANALYZER
‘TR COMMON EXHAUST OUST SYSTEM,
REDESIGN IS BEING CONSIDERED
NEW PROCEDURE REWRITTEN,

TOTAL LOSS OF VEHICLE DUE TO
ENGINE FIRE OF UNDETERMINED
ORIGEN. VEHICLE WAS PARKED
AND. RUNNING

FURNACE DEVELOPED A LEAK AND
DURING NORMAL PRESSURE PURGE,
CONTAMINATION ESCAPING INTO

ROOM SET OFF SAAMS. FURNACE

AND OTHER CONTAMIRATED
EQUIPMENT REPLACED WITH
UPGRADED UNITS.



Page No. 146

ee”

SUMMARY OF EVENTS

- 1952 To 1988

= EVENT EVENT BUILDING DESCRIPTION ADDITIONAL NOTES
DATE NUMBER
12/05/86 SIR 86-12-779.1 719, RATES NMSPI 86-26, A BATCH OF

12/06/86 SIR 85-12-707.1

: . SIR 86-12-68.1

12/10/86 SIR 86-12-771.2

12/11/86 SIR 86-12-707.2

707

100, WEST MAIN ACCESS

PLUTONIUM OXIDE, PACKAGED FOR
INTRAPLANT SHIPHENT, CONTAINED
WORE GRAMS WHICH EXCEEDED THE
50 GRAMS OF PLUTONIUM ALLOWED
JO SE SHIPPED IN A ONE GALLON
PAINT CAN.

OPERATOR LEFT WESTINGHOUSE
CLEANER WITH VAPOR HEATERS
OPERATING. THE COOLING WATER
FAILED TO CHANGE THE
TRICHLOROETHANE VAPORS BACK
TNTO LIQUID AND THE SAFETY
CONTROL DID NOT SHUT OFF THE
SYSTEM. AN OIL RESIDUE WAS
LEFT THAT CAUSED A VAPOR
FLASH.

RADTOMETRIC SCANNER ACTIVATED,
GUARD CLOSED GATE ON VEHICLE

INCIDENT CAUSED PROPERTY
DAMAGE.

771, RM148, LINES 19,20 SMOKE BUILD-UP, CONTAINING

RIGH LEVELS OF AIRBORNE
CONTAMINATION, FROM THE PLASHA
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.

707, MODULE C, BOX C-110 NMSPI 86-27. A BRIQUETTE

WEIGHING 1709 GRAMS PLUTONIUM
WAS FORKED IN GRIQUETTING
PRESS IN VIOLATION OF
ESTABLISHED LIMIT OF 1500
GRAMS PLUTONIUM. PERSONNEL
MAY NOT HAVE CHECKED IF CAN
WAS EMPTY BEFORE REUSING.



Page No. 10
12/21/90
SUMMARY OF 1989 EVENTS
@.. NUMBER EVENT DATE BUILDING TYPE IIR/UOR Number Title
DATE NOTIETED —NY:
UE89-297 06/19/89 06/20/89 774 NFI N/A Caustic Spill, Pump
Failure
UE89-298 06/21/89 06/21/89 PD750 NFI N/A Saltcrete Blocks Leaking
UE89-299-R 06/21/89 06/21/89 771 YOR 89-09--771 89-2 Nitric Acid Fumes
UE89-300 06/20/89 06/21/89 774 NFI N/A Clarifier Afftuent Spill
UE89-301 06/16/89 06/20/89 TK904 NFI N/A Contaminated Samples
VE89-302 06/21/89 06/21/89 331 NET N/A Excavation Policy
Violation
VE89-303 06/22/88 06/23/89 779 NFI N/A Firewater Accident
UES9-304 06/13/89 06/14/89 776 CR N/A Possible Fume Inhalation
UE89-305 06/25/89 06/26/89 443 NFI N/A Ethylene Glycol Spill
UE89-306 06/25/89 06/26/89 460 NFI N/A Uninterruptable Power
@ Supply Failure
UE8S-307 06/26/89 06/27/89 771 IIR = 89-078,771-4 Employee Acid
Contamination
UE89-308 06/26/89 06/27/89 LANDFILL CR N/A Asbestos Problem, Landfill]
UE89-309 06/26/89 06/26/89 771 NFI N/A Hydrofluoric Acid Leak
UE89-310 06/26/89 06/27/89 440 HR 89-080, 440-1 Contaminated Safe Secure
Trailer
UE8S-321 06/27/89 06/28/89 984 NFI N/A Hydraulic Line Rupture
UE89-312-R 06/28/89 06/29/89 779 IIR 89-079,779-2 Flammable Liquid (Ether)
in Storage Cabinets
UE89-313 06/29/89 06/30/89 771 NFI N/A Hydrofloric Acid
Evaporator Leak
YE89-314-R 06/30/89 06/30/89 666 NEI N/A Suspected PCB Storage
UE89-315 07/05/89 07/05/89 371 CAIRS N/A Falling Object, Injury
GE89-316 07/06/89 07/06/89 440 NFI N/A Fuel Oi7 Spill
@ vcos-si7-n 07/06/89 07/06/89 771 NFI N/A Possible LCO Violation



Page Ho. 178
11/15/90

eS SUMMARY OF EVENTS
1982 TO 1988

EVENT EVENT BUILDING DESCRIPTION ADDETIONAL_NOTES—

DATE NUMBER

08/27/88 UOR 88-8--779 88-2 79 HIGH VOLTAGE APPLIED ACROSS
CRITICALITY ALARM RESULTED IN
LACK OF COVERAGE OF THE ALARK.

08/29/88 88-99, POST-1 ‘762 - DOOR GUARD POST DOOR SAGGED,
BINDING LOCK AND TRAPPING
GUARD IN POST. RF FIRE DEPT.
SAWED LOCK OFF TO RELEASE
GUARD, HINGES WERE DETERMINED
10 BE INADEQUATE FOR DOOR
WEIGHT.

09/07/88 I1R 88-109, 000-3 OUTSIDE EAST OF LANDFILL, NORTH OF
POND A - TRACTOR OPERATOR
WOTICED SMALL FIRE WHILE
MOWING GRASS, CALLED IN FIRE
DEPT TO EXTINGUISH - CAUSE
UNKNOWN, BURNED 50 To 60
ACRES.

@ ve JIR 88-106, 121-002 NIGHT FIRING RANGE THE SECOND CASE IN TWO WEEKS, SENT TO SMITH & WESSOM FOR
OF AN OVERCHARGED SHELL FIRED REPAIR OR REPLACEMENT AS
IN A .38 SPECIAL HAND GUN. DEEMED NECESSARY BY THE
BOTH GUNS RECEIVED DAMAGE TO MANUFACTURER.
‘ONE CHAMBER IN THEIR
CYLINDERS. THE REVOLVER IS
BEING SENT TO THE AMMUNITION
‘MANUFACTURER FOR TEST AND
EVALUATION. THE REVOLVER WILL
BE

09/10/88 IIR 88-104, 121-002 WIGHT FIRING RANGE THE SECOND CASE IN TWO WEEKS, SENT TO SMITH & WESSON FOR
OF AN QVERCHARGED SHELL FIRED REPARI OR REPLACEMENT AS
IN A .38 SPECIAL HAND GUN. DEEMED NECESSARY BY THE
BOTH GUNS RECEIVED DAMAGE TO MANUFACTURER.
ONE CHAMBER IM THEIR
CYLINDERS, THE REVOLVER 1S
BEING SENT TO THE AMMUNITION
MANUFACTURER FOR TEST AND
EVALUATION. THE REVOLVER WILL
BE



Page No. 3
12/21/90
SUMMARY OF 1989 EVENTS
a UE NUMBER EVENT DATE BUILDING TYPE TIR/UOR Number Title
DATE NOTIFIED INYS

UE8S9-145 02/22/89 02/23/89 444 THR 89-044, 444-3 Vacuum Cleaner Fire

UE89-146 02/20/89 02/23/89 460 NFI N/A Poly Drum

YE89-147 03/17/89 03/17/89 121 UOR 88-15--12] 88-1 Defective .38 Caliber
Ammunition

VE89-148 02/27/89 02/28/89 707 IIR = 89-040,707 SAAM Malfunction

UE89-149 02/25/89 02/28/89 771 HP N/A Contaminated EmpToyee

UE89-150 02/28/89 02/28/89 776 HP N/A Contaminated Employees

UE89-151 03/01/89 03/01/89 707 CAIRS N/A Emptoyee Incident

UE89-152 02/23/89 03/01/89 995 TypeA Chromium Release

UE89-153 03/02/89 03/02/89 776 CAIRS N/A Contaminated Room

oe... 03/02/89 03/02/89 37] IIR 89-043,371 Air Imbalance

UE89-155 03/02/89 03/03/89 371 YOR 89-03--371 89-2 Utilities HVAC Occurrences

UE89-156 03/02/89 03/03/89 771 HP N/A Contaminated Employee

UE89-157 03/03/89 03/03/89 881 CAIRS N/A Demineralizer Tank

UE89-158 03/07/89 03/07/89 559 IIR  89-041,707 Nuclear Material Safety

- . . ° Procedural Infraction 89-2

VESS-159 03/07/83 03/07/89 559 VOR 89-02--559 89-1 Nuclear Material Safety
Procedural Infraction 89-3

UE89-160 03/07/89 03/07/89 707 NFI N/A Unusual Wrist Dosimeter
Reading

UE89-161 03/03/89 03/03/89 555 NFI N/A Main Breaker at Sub 555

UES9-162 03/09/89 03/09/89 750 NFI N/A Pondcrete

UE89-163 03/09/89 03/10/89 707 NFI N/A SAAM Alarm

VE89-164 03/10/89 03/10/89 130 TIR = 89-045,130 Dumpster Fire

UE89-165 03/09/89 03/13/89 707 IIR 89-046, 707 Nuclear Material Safety
Procedural Infraction 89-4

UES89-166 03/14/89 03/14/89 776 IIR = 89-047,776 Potential Violation of LCO



Page No. 173

11415/90
‘SUMMARY OF EVENTS
1952 TO 1988
EVENT ——EVEMT SUELD ING. DESCRIPTION ‘RODTT TONAL NOTE:
DATE NUMBER

05/10/88 IIR 88-50, 778-1 778, SHOWER & LOCKER

05/11/88 IIR 88-54, 561-1 561

05/12/88 1IR 88-31, 881-3 881, FILTER PLENUM

05/16/88 IIR 88-52, 850-1

05/17/88 LIR 88-56, 881-5 881, RM 115

05/20/88 IIR 88-60 559-2 559, RM 102

05/23/88 UOR-88-7-778 88-1 778

05/23/88 UOR 88-7--788 88-1 OUTSIDE 904 PAD

05/23/88 UOR 88-7--788 88-1

OUTSIDE 904 PAD

MIXENG OF BLEACH AND PC-100
PORCELAIN CLEANER O8 SHOWER
FLOOR LOW SPLATER SET OFF
TOXIC FUHES AFFECTING 3
CUSTODIAL PEOPLE. 3 REPORTED

CORRECTIVE ACTION RETRAIN
ALL CUSTODIAL PERSONNEL AND
IMPHASIZING HAZARD OF XIXING
CHEMICALS. TESTING FOR NEW
CHEMICALS THAT RELIEVE THE

TO MEDICAL AND ONE WAS SENT TO PROSLEM OF MIXING.

ST, ANTHONY'S NORTH HOSPITAL.

WASTE DRUM IN CARGO CONTAINER
LEAKED

FILTER PLENUN CONCERN
(POSSIBLE LEAK?). RESEALED
PLENUM.

850, S. CONF. ROOM 2ND FL ELECTRICIAN FELL WHEN

DEFECTIVE LADDER GAVE OUT.
RECEIVED MULTIPLE SPRAINS AND.
CONCUSSION.

JANLTOR POURED CHEMICALS INTO
WASTE DRUM. CHEMICAL REACTION
CAUSED SLIGHT SMOKING.

‘A NUCLEAR MATERIALS SAFETY
PROCEDURAL INFRACTION OCCURRED
AS A RESULT OF PLACING A
BALANCE ON TOP OF A
CRITICALITY DRAIN AKD LIMITING
THE DRAINS ABILITY TO FUNCTION
PROPERLY.

SPILL OF A BOX OF LOW LEVEL
MIXED RADIOACTIVE AND
HAZARDOUS WASTE, COMMONLY
CALLED "PONDCRETE”

PONDCRETE BOX FELL FROM FORK
‘TRUCK AND SPILLED WASTE ONTO
PAD

PONDCRETE BOX FELL FROM FORK
TRUCK AND SPILLED WASTE ONTO
PAD



Page No. 157

se”

SUNMARY OF EVENTS

1952 To 1988

EVENT EVENT
DATE ‘MURBER

06/01/87 SIR 87-6-460.1

06/03/87 SIR 87-6-776.1

06/21/87 SIR 87-6-707.1

06/22/87 SIR 87-6-776.1

07/01/87 SIR 87-7-771.1

BUELDING

460, FREIGHT ELEVATOR

DESCRIPTION

AFTER REHOVING TRASH, THREE
EMPLOYEES ENTERED THE FREIGHT
ELEVATOR TO RETURN TO THE
SECOND FLOOR. AFTER THE DOORS
CLOSED AND THE ELEVATOR
ASCENDED A FEW FEET, 27 LOST
POWER. THE EMPLOYEES WERE
EXTRACTED THROUGH THE CEILING
OF THE ELEVATOR VIA LADDERS.

776, RMI31, GBOX2O7-630 BRIQUETTING PRESS OPERATOR WAS

TAMPING PLUTONIUM CHIPS INTO
THE SILO OF THE PRESS. A FIRE
AND SMOKE OCCURRED. THE ONLY
ANOMALY PRESENT WAS WETTER
CHIPS.

707, MOD B, G8OX 258,880 NMSPI 87-16. WEBBER

77, 1-108

THERMALCYCLE AND. THERMALCYCLE
WHIT A WERE FOUND TO CONTAIN 4
PARTS IN ONE CHAMBER WHICH
EXCEEDED THE ALLOWABLE LIMITS
OF TWO PARTS FOR THE MASSES
INVOLVED.

BECAUSE OF FAULTY GASKET ON
CAUSTIC SUPPLY TANK LEVEL
INDICATOR, A FALSE TANK VOLUME
WAS INDICATED. TANK WAS
OVERFILLED AND GVERFLOWED INTO
THE BERM. CRACKS AND
DETERIORATION IN CONCRETE BERM
ALLOWED 1 TO 2 GALLONS OF
CAUSTIC TO SEEP ONTO ROADWAY.

771, NITRIC ACID DUMPSTER OPERATOR NOTICED A LEAKING

HOSE ON PORTABLE DUHPSTER
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 FLAKE
AND SODIUM BICARBONATE.

ADDITIONAL NOTES



Page No. i
12/21/90

0.: NUMBER EVENT
DATE

NOTIFIED

DATE BUILDING TYPE TIR/UOR Number
TNyS

SUMMARY OF 1989 EVENTS

Title

UE89-318 07/06/89
UE89-319 07/07/89

UE89-320-R 07/07/89
UE89-321-R 07/03/89

UE89-322 07/10/89
VE89-323 07/07/89
UE@9-324 07/11/89
VE89-325-R 07/11/89
UE89-326 07/10/89

UE89-327 07/03/89

UE89-328 07/03/89
UE89-329 07/11/89

UE89-330 07/12/89

UE89-331 07/12/89
YE89-332 07/13/89
UE89-333-R 07/17/89

UE89-334-R 07/16/89
UE89-335 07/14/89
YE89-336-R 07/17/89

07/06/89 779
07/10/89 444

07/10/89 460
07/10/89 771

07/10/89 130
07/12/89 444
07/12/89 444
07/11/89 367
07/10/89 569

07/10/89 776

07/11/89 771

07/12/89 38]

07/13/89 731

07/13/89 881
07/14/89 444
07/17/89 PD904

07/17/89 517
07/17/89 995
07/18/89 771

TIR
TIR

NFI

NFI
NFI
NFI
IIR
TIR

IIR

NFI

NFI

TER

IIR
TIR
IIR

NFI
IIR
TIR

89-081, 779-4
89-083 444-7

N/A
N/A

N/A
N/A
N/A
89-090, 367-2
89-085 , 569-2

89-086, 776-10

N/A

N/A

89-087, 731-1

89-088, 881-5
89-089, 444-8
89-093, 904-1

N/A
89-091, 995-2
89-095,771-7

Dislodged Glovebox Window

Smal} Process Solution
Spill

Acid Tank Overheat
Nuclear Material Safety
Procedural Infraction
89-11

Hydraulic Fluid Spill
Equipment Failure
Personal Injury
Chemica? Repetient Spill
Nuclear Material Safety
Procedural Infraction
89-13

Nuclear Material Safety
Procedural Infraction
89-12

Access Port Leak

Possible Injury
Sub-Contractor

Process Waste Storage Tank
Overflow

3/4" Water Line Break
Oxidation Reaction
(Saltcrete Spill) -
RETITLED: Saltcrete
Destabilization |

Power Outage

Downed Power Line

Nuclear Material Safety
Procedural Infraction
89-14



Page No. 3
12/21/90
SUMMARY OF 1989 EVENTS
Qu NUMBER EVENT PATE ep BUILDING We IIR/UOR Number Title
UE89-359-R 08/03/89 08/03/89 371 VOR 89-1]--37] 89-3 Hoist Incident
UESS-360-R 08/03/89 08/03/89 777 TIR = 89-104 777-4 Mismarked Electric Panel
UE89-361 08/03/89 08/04/89 443 IIR = 89-105 443-1 Smoke Inhalation
UE89-362 08/03/89 08/04/89 750 IIR 89-106 750-2 Cart Fire
UE89-363 08/04/89 08/04/89 562 NFI N/A Partial Loss of Building
. Fire Suppression System
UE8S-364-R 08/03/89 08/04/89 707 NFET N/A T-Based Lathe Sludge
UE89-365 08/05/89 08/07/89 Vv3 CAIRS N/A Heat Prostration
UE8S-366 08/05/89 08/07/89 528 HP N/A Contaminated Wound
UE89-367 08/07/89 08/07/89 980 CAIRS N/A Damaged Natural Gas
Tressel
UE89-368-R 08/06/89 08/07/89 RFP TIR 89-108 000-10 Electrical Failure to Sump
ip
© oss: 08/09/89 08/09/89 VVI3 NFI N/A No Top Side Observer
UE89-370-R 08/08/89 08/09/89 371 TIR 89-109 371-13 Radiography Source
Exposure
UES89-371-R 08/09/89 08/09/89 881 YOR 89-12--881 83-1 Employee Contamination
UE89-372 08/03/89 08/03/89 88] NFI N/A Sulfuric Acid Spill
UE89-373 08/08/89 08/09/89 371 NFE N/A Fume Inhalation I]Iness
UE89-374-R 08/09/89 08/10/89 707 NFI N/A Oxygen Analyzer Problem
UES9-375 07/13/89 08/14/89 T903A NFI N/A Incorrect Electrical Work
UE89-376-R 08/12/89 08/14/89 371 NFI N/A Pump Failure, Spill
UE89-377 08/14/89 08/15/89 707 TH N/A Loud SAAMs
UE89-378 08/14/89 08/14/89 371 CAIRS N/A Subcontractor Personal
Injury
UE89-379 08/09/89 08/10/89 559 NFE N/A Glove Port Problem
Qees9-320 08/16/89 08/16/89 777 NFI N/A Methyl Chloroform Odor



Page No. 160

11/15/90
SUMMARY OF EVENTS
1952 TO 1983
EVENT EVENT BUTLDING DESCRIPTION ADDITIONAL NOTES

DATE NUMBER

08/04/87 SiR 87-8-707.1

707, CHAINVEYOR LINE 7-S1 NHSPI 87-19. BIRDCAGE ON

08/05/87 SIR 87-B-LANDFILL.1 OUTSIDE SANIT. LANDFILE

08/06/87 SIR 87-8-BUFFER.1

08/07/87 SIR 87-8-777.1

08/07/87 SIR 87-8-707.2

NE BUFFER ZONE, SECTOR G

717, RMGS2

707, MODULES J & K

CHAINVEYOR 7-S3 WAS FOUND
SPACED APPROXIMATELY 36" FROM
ADJACENT BIRDCAGES. THE
ESTABLISHED SAFETY LIMIT 1S
54" BETWEEN BIRDCAGES.

WS2E PERSONNEL DISCOVERED THAT
PLANT SERVICES POSSIBLY
DISRUPTED TAREE SOLID WASTE
MANAGEMENT UBITS LOCATED SOUTH
AND EAST OF THE MEW LANDFILL
DURING EXCAVATION OF SURFACE
SOIL, THE EXACT LOCATIONS OF
‘SUMUS WERE UNCERTAIN

SWMUS WERE NOT DISTURBED.

THREE PERSONEL IN A VAN
TRAVELED THROUGH AN AREA WHERE
SOMEMONE HAD DUMPED CS TEAR
GAS POWDER IM THE ROADWAY. THE
POWDER ENTERED THE VERICLE AND
ALL THREE OCCUPANTS WERE
OVERCOME BY THE TEAR GAS.

MACHINIST WAS WORKING ON 18"
CINCINNATI LATHE LOCATED IN.8
BOX #206-543 USING
TRICHLOROETHANE AS TOOL
COOLANT. BE WAS WEARING
HALF-HASK RESPIRATOR BUT AIR
EXHAUST WAS NOT SUFFICIENT TO
CARRY THE TOOL COOLANT FUMES
AWAY AND RE INHALED THEM.

SOE’S STARTED TO RE-INERT
STORAGE VAULT. SAAM WENT OFF
IM MODULE K AND CONTAMINATION
WAS THEN FOUND IN MODULE.
REDUCTION OF NEGATIVE PRESSURE
OCCURRED FOR A FEW SECONDS BUT
REMAINED POSITIVE TO MODULE AT
ALL TIMES.