Page No. 103

44/15/90
‘SUMMARY OF EVEKTS
1952 To 1988
EVENT EVENT. sur png serpin AT TOMAL NOTES
DATE WUNBER

07/13/83 UOR 83-4--331 83-1 331, TRUCKING

07/13/83 SIR 83-07-331.1 T7Ik, 776

07/18/83 SIR 83-07-444,1 444, RMIOT

Quon SIR 83-07-371.2 371, 376

07/20/83 SIR 83-07-446.2 464, RMIOT

07/20/83 SIR 83-07-779.1 779, RMI37
07/25/83 SIR 83-10-S8W.1 teal

‘SIX CONTAMINATED DRUMS WERE
MOVED SPREADING CONTAMINATION
TO TWO TRUCKS, FOUR TRUCKERS,
AND TWO VARS.

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 OM PLANTSITE.

A HOT CHIP WAS, UNKNOWINGLY,
PUT INTO THE PAIL, IGNITING
JHE CHIP TBAT WAS 18 THE PAIL.

‘SYSTEM MALFUNCTION CAUSED
NEUTRON ALARM TO SOUND. NO
CRITICALITY HAD OCCURED.
CONTAMINATION SPREAD TO.
HALLMAY AND SOIL OUTSIDE
DURING EVACUATION. SOME
PERSONNEL WERE TAKEN TO
MEDICAL AND BOOY COUNTER,

FIRE IN CHIP BUCKET. CHIP
BECAME IGNITED DURING SHORT
INTERRUPTION OF COOLANT, THEN
FELL FROM TOOL AND FOUND ITS
WAY TO THE BUCKET OF CHIPS BY
MACHINIST'S FEET.

NMSPI 83-13. BOX 106-1 HAD 16
CONTAINERS TOTALING 16 LITERS
IN VOLUME. LIMIT = 20006 IW
MAX-SIZE 4-LITER CONTAINER.

NMSPI 83-A. BAG FOUND WITHOUT
PROPER SLITS CUT IN IT.
PLASTIC PEN ALLOWED TO SAG
AWD FORM A RESERVOIR MORE THAN
‘TWO INCHES DEEP WHILE BEING
DISASSEMBLED. CONTAMINATED
LIQUIO ACCUMULATED IN THE
RESERVOIR.



Page No. 126

11/15/90
— BUTTS

DATE NUMBER:

03/24/85 SIR 85-04-776.1 776, RMI?

03/25/85 SIR 85-03-559.2 559, RMIO2

03/26/85 SIR 85-04-771.1 771, RMIBT

03/28/85 SIR 85-03-771.1 771, RM2GT
371, RHB189

ee” SIR 85-04-3717.

04/03/85 UOR 85-01--371 85-t 371, RMS515

04/06/85 SIR 85-02-776.1 776, PLANT SERVICES

04/10/85 SIR 85-04-771.2 772, RAIGD

06/12/85 SIR 85-04-900.1 900, LUMP SUM, ELECT SHOP

04/15/85 SiR 85-04-559.1 559, R102

ad

SUMMARY OF EVENTS
1952 To 1988

DESCRIPTION ADDITIONAL NOTES

‘THREE DRUMS CONTAINED MORE
‘THAN TRE 200 G LIMIT.

‘A GLOVEBOX CONTAINED 11,855 ¢
PU EXCEEDING THE 8000 G LIMIT.

A CONTAMINATED BAG PORT CAUSED
‘A SAWM 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 TURWING OFF
THE TRANSFER VALVE. AUTOMATIC
SHUT OFF VALVE FAILED ALSO.

FOUR 55 GALLON DRUMS COKTALNED
MORE THAN THE 500 G PER DRUM
LIMIT.

A CHEMICAL OPERATOR INHALED
RADIOACTIVE MATERIALS DUE TO A
LEAKY SEAL ON A CRUCIBLE DROP.

‘A BOX THAT-WAS- NOT TO BE
STACKED WAS IMPROPERLY LABELED
AND A FORKLIFT OPERATOR
STACKED IT.

‘TWO PLASTIC BAGS DID NOT
CONTAIN SLETS TO PREVENT
LIQUID BUILD-UP OF OVER FOUR
LITERS.

EMPLOYEE SHOCKED WHEN WORKING
ON A DISCONNECT 80x.

‘A VEAL CONTAINED 47.3
EXCEEDING THE 25 G LIMIT.



Page No, 120
£15790

‘SUMMARY OF EVENTS

1952 TO 1988

EVENT EVENT
DaTE NUMBER

09/21/84 SIR 84-09-707.1

10/04/84

‘ 10/07/84 SIR 84~10-662.1

10/12/84 SIR 84-10-371,1

WW/1Z/B4 SIR B4-10-7714

10/16/84 SIR 84-11-7714

BUILDING

707, MODULE D

T711776, TWHNEL

DESCRIPTION

SANITORS WERE SWEEPING THE
FLOOR NEAR A LOVEBOX THAT,
UNKNOWN TO THEM, WAS LEAKING
CONTAMINATION. THE
CONTAMINATION WAS CONSEQUENTLY
SPREAD AROUND THE ENTIRE ROOM.

NOX VAPORS WERE DETECTED IN
TIVU776 TORNEL. MALFUNCTION
IN THE EXHAUST DAMPER
SYSTEM WAS APPARENTLY AT
FAULT.

ELECTRICIAN SET UP MOLD AND
LOAD A "CALDWELDTM CHARGE INTO
THE MOLD. WHEN THE CHARGE WAS
SGNITED, IT CAUSED A LARGE
FIREBALL A MOLTEN METAL TO
LAND ON THE ELECTRICIAN’S
RAND.

371, NDA & MC OPERATIONS A CAN CONTAINING 2389 G PU WAS

SHIPPED IN A 19 GALLON
CONTAINER WITH A CAN
CONTAINING 1569 G PU. THE
RULE STATES THAT NO. CAN
CONTAINING OVER 2250 G CAN BE
SHIPPED IN THE SAME 10 GALLON
CONTAINER,

T?1, LINE 42, ANION EXCH TWO USED FULFLO FILTER

‘771, R&D CRUSHER

ELEMENTS ON A DRYING RACK WERE
SPACED LESS THAN 12” FROM A
FULFLO CANNISTER USED FOR
FLOOR PICKUP SOLTNS.

A PLASTIC BAG WAS USED TO BOLD
VET CONTAMINATED KIM-WIPES.
TRE BAG DID NOT CONTAIN SLITS
AND COULD HAVE FILLED 70 16
LITERS VIOLATING THE 4 LITER
uit.

ADDITIONAL NOTES



A299

Page Ho.
11/15/90

‘SUMMARY OF EVENTS

10/03/85 SIR 85-10-374.1

10/04/85 SIR 85-10-886.1

10/11/85 SIR 85-10-G8.1

10/19/85 SER 85-10-371.4

oe SIR 85-10-68.2

10/27/85 SiR 85-10-371.2

10/31/85 SIR 85-11-707.1

11/01/85 SER 85-11-771.1

11/05/85

SIR 85-11-779.1

11/20/85 SIR 85-11-371.1

1952 TO 1988
BUILDING DESCRIPTION ADDITIONAL NOTES
374, WASTE TRANSFER SYSTE WASTE TRANSFERRED TO TANK

100,

an,

371,

37,

CML

GATE 8

PRODUCTION OPERATION

SOUTH GATE

SLUDGE PROCESSING

MODULE C, BOX 115

MANHOLE

RYB204

BEFORE ALL SIGNATURES WERE
OBTAINED.

AN ELECTRONIC MALFUNCTION OF A
SEMICONDUCTOR 1M A NEUTRON
PICOAMMETER CAUSED THE
CRITICALITY ALARM TO SOUND
CAUSING AN EVACUATION,

GATE CLOSED ON TRUCK GOING
THROUGH GATE. GUARD
ACCIDENTALLY HIT “FAST CLOSE"
BUTTON.

A TOTAL CHARGE TO A TILT
FURNACE EXCEEDED TRE LIMIT OF
4000 G.

FAULTY GATE CLOSED ON A
VEHICLE. THE STOP BUTTON WAS
REPLACED.

TWO HOBART POWER MIXING BOWLS
WERE PLACED INTO A GLOVEBOX.
THE LIMIT IS ONLY ONE MIXING
BOWL.

FIVE VIALS WERE FOUND TO
EXCEED THE LIMIT OF 30 6.

LIQUID WAS TRANSFERRED FROM A
SAFE PENCIL TANK TO AN UNSAFE
ANNULAR TANK. :

UNDERGROUND WIRING WAS
PARTIALLY SHORTED CAUSING
INSULATION TO BURK.

A JAR MILL USED TO PULVERIZE
ASH WAS USED TO CRUSH MATERIAL
SO IT MOULD FIT THROUGH A WIRE
MESH SCREEN. THE JAR MILL HAD
NO NUCLEAR MATERIAL SAFETY
LIMITS, HOWEVER.



12/17/82 SIR 82-12-381-1

12/17/82 SIR 82-12-559.1

12/18/82 SIR 82-12-750.1

12/21/82 SIR 82-12-886.1

12/28/82 SIR 82-12-444.1

01/03/85 SIR S3-01-WES.1

‘SUMMARY OF EVENTS
1952 TO 1988

BUILDING

381, FL. DISPOSAL TRAPS

559, M102, BOX C-4

750, POTABLE STEAM GEN.

886, 559

464, RM2O1, FURNACE 6

251, WIND SITE

DESCRIPTION ADDITICNAL NOTES

CHARCOAL FERE IN FLOURINE
DISPOSAL TRAPS. SPARKS FROM
SECONDARY TRAP WERE CARRIED TO
THE THIRD AND FOURTH TRAPS,
IGNITING THEM.

AMSPT #82-24. THE MAXINUM
ALLOWABLE NUMBER OF VIALS
ALLOWED OUT IN THE WORK AREA
WAS EXCEEDED. (LIMITS FROM GB
o-4)

WHILE ACID CLEANING THE
PORTABLE STEAM GENERATOR IN
BLDG. 750, WITH INHIBITED
HYDROCHLORIC ACID, FUMES WERE
GIVEN OFF WHICH GOT INTO THE
SUPPLIED AIR SYSTEM.

THE RTV SEALANT EN THE JOINT
OF THE OUTER CAN FAILED,
PROBABLY DUE TO HEAT AND/OR
RADIATION DAMAGE. THIS
ALLOWED SOME WATER TO ENTER
THE CAN. EVENTUALLY, THIS
MOISTURE BREACKED THE LID OF
THE INNER CAN, ALLOWING THE
WATER AND PU TO REACT.

MACHINE TURNINGS CONSISTING OF
BE, STAINLESS STEEL, AND
DEPLETED URANIUM WERE BEING
HEATED IN THE FURNACE TO
OXIDIZE THE URANIUM TURKINGS.
THE TURNINGS WERE HEATED TO
THE OIL'S IGNITION POINT
WITHOUT FLAME TO OXIDIZE THE
VAPORS AS THEY WERE GENERATED.

SHORT CIRCUIT IN 480 VOLTAGE
CABLE CAUSED A MINOR EXPLOSION
UNDERGROUND BENEATH
TRANSFORHER T-12.



Page No. 139
11/15/90
SUMMARY OF EVENTS
1952 To 1988

EVENT____EVENT DESCRIPTION
DATE NUMBER

06/28/85 SIR 86-07-218.1 218, NITRIC ACID FARM = AN OPERATOR WAS FILLING THE
771 PORTABLE ACID DUMPSTER
‘TANK WHEN THE AUTOMATIC
SHUTOFF LEVEL PROBE FAILED TO
SHUT THE PUMP OFF.
APPROXIMATELY 1 GALLON GF HNOS
SPILLED OUT OF THE SAFETY
OVERFLOW LINE OF THE DUMPSTER
‘ONTO THE GROUND.

96/30/86 SER 86-O7-218.1 218, NITRIC ACID FARM =A LIQUID WASTE OPERATOR WAS
ATTEMPTING TO HOOK UP THE
ELECTRICAL CONNECTOR WHICH
CONTROLS THE PUMP AND THE
LEVEL PROBE SYSTEM OF THE
DUMPSTER WHEN HE SUSTAINED AN
ELECTRICAL SHOCK.

9/30/86 SIR 86-07-RR.1 QUTSIDE, RUNAROUND TRACK A RAIL CAR WAS SITTING ON THE
¢ RUNAROUND RALL TRACK NEAR

BLDG, 664 ON JUNE 24. AT THAT
TIME THE HAND BRAKE WAS SET.
ON JUNE 30, THE CAR ROLLED OFF
THE TRACK DUE TO A HAND BRAKE
FAILURE. A MISSING BOLT IN
THE BRAKE BOTTOM ROD WAS THE
CAUSE.

07/07/86 SIR 86-07-G9.1 900, NORTH GATE THE WORTH GATE WAS OPENED TO
ALLOW A CAR THROUGH. THE
GUARD DID NOT NOTICE THAT THE
CAR HAD STALLED WHILE STILL IN
THE GATES PATH, AND,
THEREFORE, PRESSED THE CLOSE
BUTTON. THE GATE STRUCK THE
CAR ON THE RIGHT REAR FENDER

07/08/86 SIR 86-07-334.1 334, ELECTRICAL SYSTEM A PLANT SERVICES EMPLOYEE WAS
DIGGING A FENCE POST HOLE
USING THE LATEST SITE UTILITY
DRAWINGS WHICH DID NOT REFLECT
THE LATEST CONSTRUCTION

ADDITIONS. AT A DEPTH OF
TREE FEET, THE AUGER STRUCK A

e GROUND CABLE CAUSING POWER
LOSS TO BUILDING 334.

AODITIONAL NOTES



Page No. 137

15/15/90
SUMMARY OF EVENTS
 } 1952 To 1988
~ EVENT EVENT BUILDING DESCRIPTION ADDITIONAL ROTES:
DATE NUMBER

05/23/86 SIR 86-06-771.1

05/29/85 SIR 86-06-443.7

05/29/86 SIR 86-6-443.1

05/29/86 SIR 86-05-779.1

06/02/86 SIR 86-06-707.1

06/03/86 SIR 86-06-664.2

771, RMVB, LINE 21-C

423, STEAM PLANT

463, STEAM PLANT

779A, RM152, BOX 7268

WMSPT 86-12. SLUDGE MATERTAL
IN A PAN WAS DRY, BUT NOT
PLACED IN 8801 CAN BEFORE
BEING INTRODUCED INTO THE
OPERATING LINE.

A HEATED AIR TEST CONDUCTED ON
HEPA FILTERS RESULTED IN A
FIRE. THE FIRE WAS CONTAINED
WITHIN THE CHUCK ASSEMBLY.

THE FILTERS DID NOT PASS THE
TEST.

FILTER BEING SUBJECTED TO
HEATED AIR TEST CAUGHT OM FIRE
AND PRODUCED SMOKE IN SMALL
QUANTITIES WITHIN STEAM PLANT.

SWEEPINGS CONTAINING PUH2 WERE
PLACED IN AN AIR ATMOSPHERE © THE FLOOR BUT NONE WAS FOUND
GLOVEBOX IN A PAN, WHICH WAS ON THE BOX, THE FLOOR WAS
PLACED ON A HOT PLATE. DUE TO PROBABLY CONTAMINATED FROM A
THE THERMAL ENERGY FROM THE © BAG CUTTING OPERATION ON AN
HOT PLATE AND THE OXYGEN IN EARLIER SHIFT.

‘THE BOX, THE SWEEPINGS

OXIDIZED, EMITTING A SMALL

HYDROGEN FLAME.

CONTAMINATION WAS FOUND ON

707, MODULE B, BOX B-25A NMSPI 86-13. SPECIAL ORDER

664, GATE

PARTS BEING PROCESSED AT THE
DENSITY DETERMINATION WORK
STATION WERE FOUND TO BE ABOVE
‘THE ALLOWABLE WEIGHT FOR THE
THICKNESS OF THE PARTS IN THE
FREON TANK.

AN EMPLOYEE PARKED A TRUCK ON
AN INCLINE TO BE LOADED WITH
MATERIAL. HE DIDN/T SET TRE

EMERGENCY BRAKE BEFORE HE GOT
OUT OF THE TRUCK AND IT ROLLED
INTO THE GATE CAUSING MINOR
DAMAGE.



Page No. 143
11/15/90

SUMMARY OF EVENTS

1952 To 1988

EVENT EVENT
DATE NUMBER

10/08/86 SIR 86-10-559.1

10/12/86 SIR 86-10-7711

10/20/86 SIR 86-10-8861

10/22/86 SIR 86-10-444.2

10/26/85 SIR 86-10-71.

40/27/86 SIR 86-10-771.4

30/27/86 SIR 86-10-771.3,

BUILDING

777, SURVEILLANCE LAB

771, RM1148, LINE 17

DESCRIPTION

MHSPI 86-21. LAB TECHNICIAN
WAS TRANSPORTING A PRESSURE
COOKER TO RM 4318 FROM
TRANSFER CART IN RNG31.
‘TECHNICIAN RECEIVED ORDERS TO.
RETURN TO 559 AND LEFT COOKER
UNATTENDED ON STOOL IN RMA31B
HICH IS AN UNCONTROLLED
LOCATION.

WISPI 86-22. AT SHIFT CHANGE,
PERSONNEL NOTICED THE
FREE-METAL CANISTER IN THE
LINE CONTAINED 628 GRAMS OF
FREE-METAL WHICH 1S OVER THE
LIMIT OF 500 GRAMS,

886, ARIES AUTO. SCANNER CLAMP RING MOUNTING SYSTEM

a4

762, SOUTH GATE

771, AVIS, LINE 5

TT, RMMG, LINE 15

FAILURE DUE TO WELD SEPARATION
OF ONE OF TWO CLAMP RING
MOUNTING BOLTS

CRIPS LEFT OUT OF COOLANT
CAUSING FIRE IN CHIP PAN.

GATE WAS ACTIVATED FOR CLOSING
AND STRUCK GOVERNMENT FLAT BED
TRUCK. .

WHSPT 85-25. AM EMPTY POLY
PLASTIC BAG-OUT BAG (18"X24")
WAS FOUND OPEN HANGING
‘UNDERNEATH A FISSILE SOLUTION
TRANSFER LINE. NO CRITICALITY
DRAIN SLITS WERE CUT IW BAG.

WHSPI 86-25. A DIRTY FL-FLO.
FILTER CARTRIDGE WAS REMOVED
FROM THE FUL-FLO FILTER IX
LINE 15. THE CARTRIDGE WAS
THE PLACED ON THE FLANGE OF
516A DIGESTOR, CAUSING A
VIOLATION OF SPACING LIMIT
GETWEEM EQUIPMENT AND
CONTAINERS CONTAINING FISSILE
MATERIAL.

ADDITIONAL NOTES



Page No. 135

11/15/90
SUMMARY OF EVENTS
1952 TO 1988
———EvERT EVENT BHLBING DESCRIPTION ADDITIONAL NOTES

DATE NUMBER

03/28/86 SIR 86-06-776.1 776, RM2O9 NEWLY INSTALLED EXRAUST AND
RECIRCULATING FANS WERE
RUNNING BACKWARDS DUE TO AN
UT OF PHASE ELECTRICAL
‘MISTAKE.

04/08/86 SIR 86-04-779.1 779, 8N139 MMSPT#86-8. LAB PERSONNEL

04/15/86 SIR 86-04-M¥.1

04/24/86 SIR 86-05-771.5

04/26/86 SIR 86-4-776.2

04/28/86 SIR 86-05-771.1

OUTSIDE, MEYER WEDDLE

771, RAIS, LINES 13,14

776, RM154 MOLTEN SALT

771, RMIIS

CHANGED NMSL’S, POSTED THE
CHANGED LIMITS, AND FOWARDED A
COPY OF THE CHANGED LIMITS TO
CRIT. ENGINEERING FOR
APPROVAL, THE POSTING OF THE
ALTERED LIMIT RESULTED 18 A
PROCEDURAL INFRACTION.

MEYER WEDDLE TRAILER AREA. A
15 TOW CRANE WAS BEING
‘OPERATED WITHOUT RIGGERS AND
TEPPED OVER. THE CRANE
OPERATOR JUMPED AND FRACTURED
RIS LEFT ANKLE AND INJURED HIS
RIGHT KNEE.

‘TWO CHEM, OPERATORS WERE FOUND WHICH CAUSED SPREADING OF
TO BE HIGHLY CONTAMINATED CONTAMINATIOK..

AFTER WORKING A DRYBOX. 17

MORE GLOVES WERE FOUND

CONTAMINATED, BUT NO HOLES 10

ANY GLOVE WERE FOUND. THE

PROCEDURE FOR SELF MONITORING

AFTER WORKING IN GLOVEBOXES

VAS APPARENTLY WOT FOLLOWED,

MAXIMUM COMBINED VOLUME OF
CONTAINERS WERE EXCEEDED ON
NUCLEAR MATERIAL SAFETY LIMITS

‘TWO CARPENTERS WERE ASSIGNED
TO REMOVE A HANDLE ON A SHIELD
FOR DECONTAMINATION. THEY
LEFT FOR WINCH BEFORE REMOVING
THE HANDLE AND UPON RETURNING
FOUND THE HANDLE ALREADY
REMOVED.



Page No. 107

e¢”

‘SUMMARY OF EVENTS:

1952 TO 1988

EVENT EVENT
DATE NUMBER

14/17/83 SIR 83-11-881.2
VWs21/83 SIR B3-11-444.4

11/23/83 SIR 83-11-776.2

Dercsics SIR 83-12-707.1

12/09/83 SIR 83-12-79.

12/12/83 SIR 83-12-777.1

12/15/83 StR 83-12-71.1

BUILDING

DESCRIPTION

881, ASSEMBLY INSPECTION INSPECTOR INSPECTING PARTS WAS

we

176

‘707, BOX K-45

716, 777, 778

Tt, LINE 7

UNAWARE THE PARTS HAD LIVE
ACTUATORS INSTALLED.
POSSIBILITY FOR EXPLOSION WAS
6000.

URANIUM CHIP FIRE. MACHINIST
DID NOT KEEP PAEL HALF FULL OF
COOLANT TO SUBMERGE CHIPS IN.
FIRE WAS IMMEDIATELY PUT OUT
WITH COOLANT HOSE.

FIRE IN BRIQUETTING. 776, RM
131, BOX 630. FLAME AND SMALL
RELEASE OF ENERGY DURING THE
BRIGQUETTING OPERATION DUE TO
‘SOLID METAL BEING COMBINED
WITH TURNINGS.

NMSPI 83-24. CONTAINER
CONTAINED 1543 G PU METAL,
LIMIT = 1500 G.

‘A GLOVESOX WINDOW WAS BROKEN
DUE TO EXCESS VACUUM CAUSED BY
THE BOX ATMOSPHERE SAMPLING
SYSTEM LEAK AND THE ARGON GAS
BEING TURNED OFF TO THE BOK
PRESSURE CONTROLLER.

ALARM SYSTEM PERSONNEL WERE
STRIPPING OUT "J" BOXES AND
CONDUIT FROM THE OLD HONEYWELL
SYSTEM IN THE 700 AREA. WHILE
CUTTING OUT WIRING IN "J" BOX
778-4, THEY COT THE
CRITICALITY ALARM CABLES.
THIS CAUSED THE ALARMS TO GO
OFF.

NMSPI #83-23, OPERATOR CLEARED
PLUGGED DISCHARGE OF
FLUORINATOR, 65006 PU
FLUORIDE (45306 PU) FELL TO
FLOOR. LIMIT = 35006 PU.
CLASSIFIED REPORT.

ADDITIONAL NOTES.



Page No. 125

11/15/90
‘SUMMARY OF EVENTS
@ 1952 To 1988
VERT EVENT BUILDING DESCRIPTION

DATE NUMBER

05/08/85 SIR 85-05-371.% 1 A CRITICALITY ALARM SOUNDED
DURING AN UNANNOUNCED TEST.

05/16/85 SiR 85-05-779,1 TTSA, RMI6O (A VACUUM CLEANER BAG CAUGHT
FIRE IN A GLOVEBOX AFTER
SUCKING UP METALLIC SODIUM AND
POTASSIUM.

05/29/85 SIR 85-6-371.1 ‘371, RM3189 ‘TWO CANS OF MATERIAL WERE

06/10/85 SIR 85-06-371.2

@..0 SIR 85-06-771.1

06/14/85 SIR 85-06-559.1

06/15/85 STR 85-06-371.1

06/27/85 SIR 85-06-771.2

06/28/85 SIR 85-06-447.1

371, METAL PRODUCTION

559, RM102

371

UNACCOUNTED FOR DURING THE HAY
1985 INVENTORY. THE SUBJECT
CANS WERE LOCATED IN ROOM
3189, ENCLOSED IN A 10-GALLON
SHIPPING CONTAINER WHICH WAS
AMID AN ARRAY OF 24 EMPTY
10-GALLON CONTAINERS.

‘A FURNACE WAS LOADED TO 4182 G
EXCEEDING THE 4000 G LIMIT.

‘A CRITICALITY DRAIN OVERFLOWED
WHEN A VALVE WAS ACCIDENTALLY
LEFT OPEN.

‘A CAN CONTAINED 2139.4 G PUOZ
EXCEEDING THE 2000 G LIMIT.

TWO CANS WERE UNACCOUNTED FOR.
A SEARCH REVEALED THEY WERE
WITH EMPTY CONTAINERS. AN
EMPTY TAG HAD NOT BEEN REKOVED
FROM THE CANS PREVIOUSLY.

‘A SOLTW WAS TO BE TRANSFERRED
FROM A PENCIL TANK TO A
RASCHING-RING FILLED TANK.
THE WRONG TANK WAS ORAWED.
CAUSING A VIOLATION OF THE
ACCEPTED LIMT OF 150 G /LITER
PU.

447, RMB2, CHIP ROASTER A THERMALLY HOT OXIDE BARREL

WAS PLACED NEAR A PIECE OF
CARDBOARD WHICH THEN IGNITED.
‘THE SPRINKLER SYSTEM PUT OUT
THE FIRE,

ADDITIONAL NOTES



Page No. = 88

11/15/90

__EVENT___Evet_ surg
DATE NUMBER

04/29/82 SIR 82-04-707.2 707, HOOULE B

04/29/82 SIR 82-04-71.2 771, RWIS, LINE 5

05/06/82 SIR 82-05-WS.1

05/06/82 SIR 82-05-372.1

WIND SITE

05/06/82 SIR 82-05-771.1 771, RMIIG, LINE 5

05/10/82 SIR &2-05-707.2 707, MODULE A, BOX

95/10/82 SIR 82-05-771.3 771, RAIGTA

371, ANION EXCHANGE UNIT

‘SUMMARY OF EVENTS
1952 To 1988

DESCRIPTION

NMSPE 82-7, IN MODULE 6, FOUR
PART CARRIERS WERE FOUND ON
THE FLOOR OF CHAINVEYOR 7-SBA
AT THE TURNAROUND NEAR THE
1209 LINE. LIMITS ALLOW
FISSILE MATERIAL 10 BE IN
CARRIERS OW THE PENDANTS OF
THE CRAINVEYOR AND NOT ON THE
CHAINVEYOR FLOOR.

WHSP1 #62-6, A VSED FULFLO
FILTER WAS PLACED TOO CLOSE 70
OTHER FISSILE MATERIAL WHICH
EXCEEDED POSTED SPACING
REQUIREMENTS .

TILT-DOWN TOWER WITH WIND
MACHINE ATTACHED PIVOTED
UNRESTRAINED ABOUT ITS BASE
ALLOWING HACHINE TO CRASH INTO
GROUND.

USED FILTER CARTRIGES WERE
SPACED 12” FROM PUNP P+118.
THE LIMIT STATES A MINIMUM OF
24" IS NECESSARY.

NMSPL #82-9, PLACEWENT OF TWO
LEACHED PARTS IN THE SAME
SPRAY HOOD. ONLY ONE PART IS
ALLOWED PER HOOD WITH NO
EXCEPTIONS.
A-S5NMSPI #62-31, PU HETAL FROM
TWO APPROVED CASTINGS WERE IN
THE COOLING SECTION OF THE BOX
‘AT THE SANE TIME. ONLY ONE
APPROVED CASTING CAN BE IN THE
COOLING SECTION AT A TIME.

WUSPE #B2-10, OVERLOADING OF
ASS GALLON DRUM WITH 5246 OF
WET FULFLO FILTERS. THE LIMIT
Is 5006.

ADDITIONAL NOTES



Page No. 118

@””

SUMMARY OF EVENTS
1952 TO 1988

EVENT EVENT
DATE NUMBER

07/25/84 SIR 86-07-371.1

07/25/84 SIR 84-08-771.2

07/26/84 SIR 84-07-559.1

08/06/84 SIR 84-08-S8W.1

08/07/84 _SIR 84-08-771.3

08/08/84 SIR 84-08-371.2

08/09/84 SIR 84-08-707.2

BUILOTNS

DESCRIPTION

371, METAL PROD, FACILITY EMPLOYEE CLEANING TOP OF

771, LINE 26

359, RM102, HOOD CH-3

771, LINE BT-4

371, CSV INERT SYSTEM

707, NODULE B, BOX B-7D

GLOVEBOX FELL WEN DESCENDING
TRE LADDER. THE EMPLOYEE
SUFFERED A SEVERE INJURY TO
HIS LEFT WRIST AND A MINOR CUT
ON THE LEFT TEMPLE.

OPERATING PERSONNEL WERE ASKED
TO BAG WET INCINERTOR ASH.

THE CONTAINER USED TO HOLD THE
ASH EXCEEDED THE FOUR LITER
LIMET.

AN ANALYTICAL LAB TECHNICIAN
FASLED TO MAKE A CORRECT
VACUUM HOSE CONNECTION CAUSING
CERIC SULFATE SOLUTION TO
SPRAY INTO THE PERSON'S FACE.
EYES WERE FLUSHED WITH WATER.

TWO 30 GALLON BAGS WERE
UNDERNEATH FISSILE SOLUTION
LINES BUT DID NOT CONTAIN
SLITS TO PREVENT ACCUMULATION
OF SOLUTION

A PLASTIC BAG OF ~1% LITERS
VOLUME WAS TAPED TO A PROCESS
LINE TO HOLD SURGEON’S GLOVES.
NO SLIT WAS IN THE BAG TO
PREVENT BUILD UP OF LIQUID.

NEGATIVE PRESSURE IN CENTRAL
STORAGE VAULT VEXT TO
POSITIVE. WORKERS CORRECTED
PROBLEM WHEN SYSTEM WAS IN
AIR-PURGE MODE. THIS VIOLATED
PROCEDURE.

‘A WEW EQUIPMENT BOX WAS
INSTALLED NEXT TO A VERY
SIMILAR BOX, THE SAME LIMITS
WERE THEREFORE PLACED ON THE
NEW BOX. CRITICALITY ENG. HAS

TO SET THE LIMITS FOR A NEW
BOX.

ADDITIONAL NOTES


Page No. 104
oe”
eT ERT
DATE NUMBER

07/31/83 SIR 83-07-371.5

08/02/83 UOR 83-6--771 83-1

08/05/83 UOR 83-7--444 83-1

08/09/83 SIR 83-08-776.1

08/13/83 SIR 85-08-8811

08/25/83 SIR 83-08-771.2

08/25/83 SIR 83-08-883.1

08729783 SIR 83-08-365.1

883 83-1

BUTLDING

374

771, RMS

445, NORTH SIDE

776, RHI36

881, TEST CELL #6

TMm

833

SUMMARY OF EVENTS:
1952 To 1988

DESCRIPTION

LIQUID WASTE OPERATIONS.
AUNJURY FROM WASTE DRUM
MOVEMENT THROUGH A GUELLOTINE
DOOR.

HAND

A WASTE COLLECTION TANK WAS
FOUND TO CONTAIN MORE THAN THE
200 G PU LIMIT.

WORKERS INHALED GRAPHITE DUST
WHILE ATTEMPTING TO UNCLOG
HOPPER.

NMSPI 83-14. OFL TRAY IN
GLOVEBOX 752 EXCEEDED 2" DEPTH
SPECIFIED IN LIMITS.

DESTRUCTION OF PRODUCTION
UNIT, TOO MUCH PRESSURE
APPLIED TO LEFT SIDE OF UNIT
OURING TESTING.

FILTER PLENUM, SRD STAGE FUZS.
DURING SUPPLIED AIR JOB
FILTER TECHS (3) REPORTED
GETTING SICK FROM ACID FUMES.
CAUSE’ UNKNOWN.

4A" ROLLING MILL. EMPLOYEE
FELL FROM LADDER WHILE
ADJUSTING THE MILL THICKNESS
GAGE INDICATING POINTER.

INGOT BEING LOADED INTO MOLTEN
ZINC BATH HAD MOISTURE ON IT
AND CAUSED THE ZINC TO
SPLATTER. SOME LANDED ON
OPERATOR. OPERATOR INCURRED NO
BURNS.

A WORKER CRUSHED 2 FINGER TIPS
IN A ROLLING MILL. A FINGER

GUARD HAS BEEN INSTALLED.

ADDITIONAL NOTES



Page No. 198
31715790
‘SUMMARY OF EVENTS
1952 10 1988
— a
____- EVENT. EVENT. BUILDING DESCRIPTION ADDITIONAL NOTES
DATE ‘NUMBER

02/07/84 SIR 84-02-771.6 771, LINE 37

02/08/84 SIR &-02-447.1 447, LOADING DOCK

02/08/84 STR &4-02-771.3 7

02/12/86 SIR 84-02-771.5 771, LINE 3

02/15/84 SIR 8%4-02-559.1 559, RM1G3, HOOD MH-11

02/15/84 SIR 84-02-771.6 771, RMSE

02/15/84 SIR 84-02-991.7 997

INCINERATOR FIRE. A FIRE
OCCURRED IN THE SORTING BOX
NEXT TO THE INCINERATOR. THO
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.

‘A TRACTOR TRAILER WAS LOADED
NOSE HEAVY. WHEN THE TRACTOR
WAS PULLED OUT FROM UNDER THE
TRAILER, THE TRALLER PIVOTED
ON ITS LANDING GEAR AND ITS
NOSE STRUCK THE GROUND.

THE CRITICALITY DRAIN IN A BOX
WAS PARTIALLY PLUGGED WITH
TOOLS,

NMSPI 84-11. TWO CONTAINER +
ONE CONTAINER OF FLOOR
‘SWEEPINGS WERE DETERMINED TO
CONTAIN TOTAL OF 5976 G PU.
LIMIT = 5000 6.

WMSPI 84-10. BOX MH-44
CONTAINED A 20-LITER BATTERY
JAR. THIS GREATER THAN
4-LITER CONTAINER WAS NOT
APPROVED FOR THS HOOD.

BUTTON BREAKOUT. ELECTRICIAN
EITHER BUMPED OR SRUSHED UP
AGAINST THE CRIT DRAIN FLANGE.

RESPIRATORS WERE NOT WORN.
POSSIGLE INHALATION.

MACHINIST WAS REMOVING BELTS
BY TRYING TO ROLL THE BELTS
FROM THE SHEAVES. GLOVE OF
LEFT WAMD WAS PINCHED BETWEEN
BELTS AND PULLED FINGERS INTO
SHEAVES. AMPUTATION OF 4 AND
5 FINGER.



Page Ho. 106

oe”

‘SUMMARY OF EVENTS
1952 10 1988

EVENT EVENT
DATE NUMBER

10/14/83 SIR 83-10-771.2

40/17/83 SIR 83-10-707.1

40/25/83 SIR 85-10-646.2

10/25/83 SIR 83-10-865.1

40/26/83 SIR 83-10-707.2

11/09/85 StR 83-11-371.1

11/16/83 SIR 83-11-8841

* BUILDING

r

7O7, MODULE A

444, BASEMENT

707, MODULE ©

371

DESCRIPTION

NMSPT 83-20. 55-GALLON DRUM
LIMIT EXCEEDED WHEN CAN WAS:
COUNTED AT CAM COUNTER TO BE
300 G, THEN PLACED IN DRUM
WITHOUT BEING SPLIT AND
RECOUNTED.

NMSPI 83-21. MODULE A, A-25
CASTING FURNACE. MOLD CAST
WITH CHARGE EXCEEDING APPROVED
CHARGE BY ABOUT 643 G PUL

OTL FILLED CAPACITOR CONNECTED
TO 2300 VOLT SECONDARY OF
TRANSFORMER 444-3 EXPLODED.
GIL FOUND TO HAVE PCBS. AREA
HAD TO BE DECONTAMINATED.
THREE OTHER CAPACITORS REMOVED
AND SHIPPED TO WASTE
MANAGEMENT FOR DISPOSAL.

‘TWO MAINTENANCE ELECTRICIANS
WERE TROUBLESHOOTING LIGHTING
PANEL ANO TOUCHED A WIRE TO
‘THE RESET BREAKER CAUSING AN
ARC-FLASH INJURING THE TWO
ELECTRICIANS.

NMSP1 83-22. MODULE C, BOX
C-110 CONTAINED FIVE CANS.
LIMIT TS FOUR CANS.

TWO NCA DECTORS WERE TRIPPED
AS A RESULT OF RF WAVES FROM
TWO-WAY RADIOS IN USE OW A
NEARBY SUPPLIED AIR JOB. MINOR
CONTAMINATION WAS SPREAD
TWSIDE THE BLDG. FROM THE
‘SUPPLIED AIR JOB. NO
CRITICALITY HAD OCCURRED.

‘A PRESSURE RELIEF VALVE, WHICH OF THE TRANSDUCER AND
BLOWING THE CAP OFF THE
UNIT.

IS TO PROTECT A 500 PSIG
TRANSDUCER FROM
OVERPRESSURIZATION, WAS
REMOVED FROM TRE SYSTEM DUE TO
SUSPECTED LEAKS. THE PART WAS
PLUGGED AND THE SYSTEM
PRESSURIZED.
‘OVERPRESSURIZATION
INADVERTENTLY OCCURRED CAUSING

ADDITIONAL NOTES,



Page No. 119.

s 1/15/98

SUMMARY OF EVENTS.
1952 TO 1988

DATE NUMBER
08/10/84 SIR 84-08-371.1

08/16/84 SIR 84-08-371.3

08/27/84 SIR 84-08-771.4

08/29/84 SER 84-08-776.1

09/05/84 SIR 84-09-559.1

09/06/84 SIR 84-09-776.1

09/13/84 SIR &4-09-776.2

09/17/84 SER 84-09-7712

BUILDING

371, ELECTROREFINING

371, FLUORINE SUPPLY

771, RESIDUE PROCESSING

776, SIZE REDUCTION

559, R202, BOX C-4

776, SIZE REDUCTION.

7718

771, RMI66, BOX 83

DESCRIPTION

A TILT POUR FURNACE WS LOADED
TO 4149 G PU. THIS VIOLATED
LIMIT OF 4000 6 PUL

A FLUORINE PRESSURE REGULATOR
FAILED RELEASING 4.5 POUNDS OF
FLUORINE GAS.

FURNACE FIRE CAUSED BY
REPLACING INITIATORS BEFORE
FURNACE HAD SUFFICIENTLY
COOLED, STARTING A FIRE.

A DRUM CF TANTALUM METAL WAS
BEING REPACKED. WHEN ONE
PACKAGE WAS REMOVED FROM THE
DRUM, SPARKS AMD FIRE WERE
NOTED. THE PACKAGE WAS FOUND
‘TO CONTAIN CALCIUM AND SODIUM
METAL CAUSING THE PACKAGE TO
REACT WITH AIR.

A VIAL CONTAINING 118 G PU WAS
FOUND IN THE GLOVEBOX. THE
LIMIT FOR THIS VIAL IS 25 G.

A.VOLUME REGULATOR INSTEAD OF
APRESSURE REGULATOR WAS
INSTALLED ON A METAL WASTE BOX
IN WHICH PRESSURE EXPERIMENTS
WERE BEING CONDUCTED, AS A
RESULT THE BOX RAS
OVERPRESSURIZED.

CRITICALITY ALARM SOUNDED WHEN
BEING WORKED ON. THE WORKER
STOPPED THE ALARM BUT EVERYONE
EVACUATED.

233 G FISSILE MATERIAL
ACCUMULATED IN BOX 83
EXCEEDING THE 200 G LIMIT.

ADDITIONAL NOTES



Page Ho. 107
41/15/90
SUMMARY OF EVENTS
1952 To 1988

__ EVENT ___EVENT_______——-suitenig——— ESRI

05/17/83 SIR 83-05-883.1 883, RU 1, TANK A-25 EMPLOYEE WAS ON LADDER LEANING
OVER THE TOP OF THE TANK TO
CHECK THE LEVEL. THE LADDER
SLIPPED CAUSING THE EMPLOYEE
TO FALL CREATING A FRACTURE TO
THE LEFT ELBOW AND INJURING
HIS LEFT SHOULOER.

05/18/83 SIR 83-05-371.3 371 SPILL OF NON-CONTAMINATED
PROCESS WATER. A THREADED
UNION-HALF OF A PVC BALL CHECK
VALVE BROKE.

05/19/83 S5R 83-05-771.1 771, RMIS6A LINE HT-1. A BOTTLE HARKED

FREON WAS USED TO DEGREASE A
BATCH OF PLUTONIUM
TURNINGS/SLUDGE. THE BOTTLE
ACTUALLY CONTAINED ALUMINUM
NITRATE WHICH REACTED WITH THE

r PLUTIONIUA. THE REACTION
OXIDIZED AND OLSSOLVED SOME OF
THE MATERIAL.

05/07/83 SIR 83-06-776.1 776 INTERRUPTION OF AIR SUPPLIED
TO USERS. VALVE SET ON
EMERGENCY AIR RATHER THAN
HOUSE AIR.

06/13/83 SIR 83-07-7711 771, RM153 ‘OVERHEAD WASTE DRAIN LEAKED
CONTAMINATED 300 SO. FT. FLOOR
‘SPACE,PIPES, A WALL, AND A
GLOVEBOX.

06/20/83 SIR 83-06-460.7 OUTSIDE, FORK TRUCK FORK TRUCK #531-748. EMPLOYEE
RIDING OM THE FORK TRUCK
BECAME PINNED BETWEEN GAS TANK
FILLER SPOUT AND POWER POLE.
THE DRIVER THOUGHT HE WAS FAR
ENOUGH ANAY FROM THE POLE.

06/22/83 707, HOOULE ¢ HODULE ©. CONTAMINATION OF 25
GLOVES, 250 Sa FT. AND
CLASSIFIED DOCUMENTS. FAILED

TO SELF-HONITOR. SANE
@ EMPLOYEE REPEATED INCIDENT ON
7-5-83

S"RBDETIONAL NOTES:



Page Mo. =

715/90
‘SUMMARY OF EVENTS
1952 TO 1988
“EVENT —-EVENT BUTLDING DESCRIPTION ADDITIONAL NOTES
DATE NUMBER
08/18/82 SIR 82-08-8811 881, RUZES SODIUM NITRATE AND WATER WAS

USED AS AN ELECTROLYTE IN A
CHEMICAL KILLING MACHINE. AS
‘A PART WAS BEING RUN AN
EXPLOSION OCCURRED. THE FORCE
BLEW THE PLASTIC WINDOWS OFF
THEIR SCREWS AND BLEW
ELECTROLYTE TO THE CEILING.
NO INJURIES, NO KNOWN CAUSE.

08/20/82 SIR 82-08-444.7 ht, RMIOT A SPARK FROM A URANIUM CHIP
IGNITED THE COOLANT OIL VAPORS
ON THE LATHE.

08/22/82 SIR B2-08-127.1 121, RIFLE RANGE A BULLET BEING FIRED AT A

TARGET HIT THE METAL FRAME OF
THE TARGET AND RICOCHETED BACK
AND STRUCK AN OBSERVER IN THE

r LEFT FOREARM. THE WOUND WAS
WOT SERIOUS.
08/30/82 SIR 82-08-371.1 371, INCINERATOR A PUMP FAILED RELEASING 150

GALLONS OF WATER INTO ROOM
4125. THE VALVE HAD BEEN
INSTALLED IMPROPERLY CAUSING
THE UPPER COUPLING NUT TO BE

- STRIPPED FROM THE VALVE DURING
THE FAILURE.

08/30/82 SIR 82-08-LA.07 LAKE ARBOR MACHINE SHOP A MACHINEST CUT HIS LEFT HAND
ON A STAINLESS STEEL CHIP WHEN
OPERATING A 10" CINCINNATTE
LATHE.

08/31/82 SIR 82-08-865.1 865, HIGH BAY THE DOOR OF A LINDBERG FURNACE
WAS BEING OPENED TO REMOVE A
WOT PIECE OF STAINLESS STEEL.
PRIOR TO REMOVAL OF THE STEEL,
THE FURNACE DOOR SLAMMED SHUT
AGAINST THE STOPS. THE DOOR
LIFTING CHAIN HAD FAILED.



Page No. 116

eo 15/90

SUMMARY OF EVENTS.

1952 To 1988

DATE RUBBER

06/16/84 SIR 84-06-371.1

06/20/84 SIR 84-06-774.1

06/22/84 SIR 84-06-776.1

06/23/84 SIR 84-07-7761

07/03/84 SIR 84-07-707.2

07/03/84 SIR 84-07-707.1

07/07/84 SIR 84-07-771.4

07/13/84 SIR B4-07-707.3

37

77%,

776

17,

707,

707,

7,

707,

BUILDING

RM210

RHIGS

MODULE K

BOX K+55 FURNACE

RHIG9, LINE 42

BOX K-85 FURNACE

DESCRIPTION

FALSE ACTIVATION OF NCA SYSTEM
DUE TO RF WAVES FROM TWO-MAY
RADIOS.

HOIST FRAME FAILURE.
NOTICEABLE TORSIONAL
DEFLECTION OF THE BEAM COLUMN
CONNECTION OF THE GANTRY CRANE
USED 1M LIFTING A 4200 POUND
TANK. EXCESSIVE LATERAL FORCE
APPLIED.

‘A SLAB OIL CART WAS USED
WITHOUT THE PERMISSION OF
CRITICALITY ENGINEERING.

CRATE LOADED TO 597 GRAMS
EXCEEDING THE 350 GRAM LIMIT.
CRATE WAS REPACKED INTO TWO
CRATES.

NUCLEAR SAFETY MASS LIMITS
EXCEEDED IN K-45 BOX BY 46
GRAMS.

LEAKING CRUCIBLE CONTAINING
“ PLUTONIUM METAL WAS FOUND IN
FURNACE. IT WAS FOUND THAT
3076 GRAMS HAD DRIPPED FROM
THE CRUCIBLE, THE MATERIAL WAS
REDISTRIBUTED WITHOUT PROBLEM.

‘VALVE FAILURE OW TANK 470
CAUSED A FOUR FOOT AREA TO BE
CONTAMINATED.

‘A MOLD WAS CAST WHICH EXCEEDED
‘THE ACCEPTED LIMITS BECAUSE
THE WRONG MOLO WAS PLACED 1X
THE FURNACE. THE ACTUAL MASS
1W THE MOLD WAS NOT ABOVE THE
LIMits.

ADDITIONAL NOTES



Page No. 113

oe”

SUMMARY OF EVENTS
1952 TO 1988

veut ‘EVENT
DATE NUMBER

06/06/86 SIR 84-05-371.2
06/05/84 SIR 84-06-771,1

04/06/84 SIR 84-04-771.2

04/10/84 SIR 84-04-889.7

04/12/84 SIR 84-06-559.1

06/17/84 SIR B4-04-371.3

06/26/84 SIR 84-06-559.2

04/26/84 SIR 84-05-371.2

04/26/86 SIR 84-06-776.2

889,

559,

371,

559,

776,

BUTLDING

REITIZ:

ADE 3

LIne 3

RM102

RM2317, GB 78

RMI02

RM1105

RISE

DESCRIPTION

NMSPI 84-17. THREE 1-LITER
CONTAINERS WERE STACKED
LIMIT REQUIRES 12" EDGE TO
EDGE SPACING.

NMSPT 84-18. NO. SECTION OF
LIME 3, EXCEEDED BOTH TOTAL
MASS LIMIT AND INDIVIDUAL
CONTAINER MASS LIMIT.

NSP 84-19. LINE 3,
CONTAINER ON HOTPLATE SPACED
7 FROM FULFLO FILTER
CARTRIDGE. LIMIT REQUIRES
MINIMUM 12” EDGE-TO-EDGE
SPACING.

RAW PLANT WATER OVERFLOWED THE
‘TASK TO THE PROCESS LIQUID
WASTE SYSTEM. HOLDING TANKS
OVERFLOWED, ALLOWING WATER TO
RUN OUTSIDE ONTO THE ROOF AND
TO THE GROUND. BUILDINGS
DECONTAMINATED. NO RELEASE.

A PU SAMPLE IGNITED IN A
GLOVEBOK, =”

NMSPI 84-20. EIGHT USED
FULFLO FILTERS IM BOX. LIMIT
ALLOWS MAXIMUM OF FOUR USED
FILTERS.

MORE THAN 10 VIALS WERE
LOCATED IN THE WORK AREA,

NMSPI #84-26, A PLASTIC HOUSE
WAS CONSTRUCTED WHICH DID NOT
CONTAIN ENOUGH CRITICALITY
DRAINS.

OVERHEATING OF TEFLON RING
CAUSING GASEOUS FURNES.
MISUNDERSTANDING AS TO GVER
TEMPERATURE

WANTED 500 DEGREES FARENHEIT
AND OPERATOR THOUGHT
CERTIGRADE. SIX TRANSPORTED TO
MEDICAL.

ADDITIONAL NOTES



Page No. 90
11/15/90

‘SUMMARY OF EVENTS
@ 1952 To 1988

“DESCRIPTION “ABET TONAL NOTES

Ev BU LD es ———
DATE NUMBER

06/15/82 SIR 82-06-466.1 44, RM116, MACHINE SHOP A MACHINIST CAUGHT HER FINGER
BETWEEN THE MILLING CUTTER AND
THE FIXRURE OF A HORIZONTAL
BILL WHILE CLEANING THE
MACHINE. SHE RECEIVED SEVERE
LACERATIONS TO TRE MIDDLE
FINGER OF HER RIGHT HAND.

06/15/82 SIR 82-06-883.1 883, RM105 AN EMPLOYEE RECEIVED BURNS OW
THE BACK OF HIS NECK AND BACK
OF EARS WHILE REMOVING URANIUM
INGOT FROM FURNACE. THE BURNS
WERE A RESULT OF MOLTEN SALT
PRODUCING GASES THAT ESCAPED
FROM THE FURNACE AND BURNED
THE OPERATOR.

06/16/82 SIR 82-G6-889.4 889 URANIUM MACHINING CHIPS FROM
BLDG. 444 SPONTANEOUSLY
@ JGMITED IN A WASTE DRUM WHICH
HAD BEEN SENT TO BLDG. B89 TO
BE CEMENTED FOR SHIPMENT TO
THE NEVADA TEST SITE. ¥O
CONTAMINATION WAS RELEASED.

06/17/82 SIR 82-06-444.2 4bé, RMI01, TRACER LATHE A TRACER UNIT REMOVED FROM A

_ LATHE WAS NOT, BOLTED DOWN WHEN

a ‘STORED BECAUSE THE BOLTS WERE
MISSING. WHEN A MAINTENACE
MACHINIST BEGAN TO WORK ON THE
UNIT IT FELL, LANDING ON HIS
LEFT ARM. HE RECEIVED
LACERATIONS WHICH WERE CLOSED
BY SUTURES.

06/26/82 SIR 82-06-771.1 77, RM2G7 A CHEM. OPERATOR WAS FILLING A
42M WITRIC 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.



Page No. = 89
41/15/90
‘SUMMARY OF EVENTS
1952 To 1988

DESCRIPTION ADDITIONAL NOTES

Vent Even BUF
DATE NUMBER

05/11/82 SIR 82-05-771.2 771, RMING, LINE 3 NHSPE #82-13, DIRTY OXIDES
WERE DRYED AND THEN CUT OUT OF
THE LINE. IT WAS THEW
DETERMINED THAT THE OXIDES
CONTAINED 12% MOISTURE AND
WERE THEREFORE CONSIDERED WET
PU. THE OXIDES WEIGHED 1954G
AND THE LIMIT FOR WET PL IS
4006.

05/12/82 SIR 82-05-371.2 371, BOX 58 NMSPI #82-12, FIVE CONTAINERS
WERE IN BOX 58 AT SAME TIME
WHILE LIMIT IS FOUR.

05/13/82 SIR 82-05-782.1 782, VENTILATION SYSTEN THE SYSTEM SUPPORTING THE

DRIVE SIDE ASSEMBLY OF FAN 406
BROKE AWAY FROM THE FAN
ROUSING ALLOWING THE BEARING,
SHAFT, AND ROTOR ASSEMBLY TO

r SHIFT POSITION. DAMAGED
COMPONENTS INCLUDED BEARINGS,
SHAFTS, BLETS, DAMPER, AND
BELT GUARD.

05/17/82 SIR 82-05-371.3 ‘371, CRUSTIC TREATMENT AN EMPLOYEE BECAME
CONTAMINATED WHILE WORKING IN
ROONS 1117-1425. THE WORKER
WAS SENT TO TRE DECON. ROOM TO
DECONTAMINATE HIMSELF. HE DID
NOT HAVE HIMSELF MONITORED
AFTERWARDS AND WENT HOME. IT
WAS LATER DETERMINED THAT HE
WAS STILL CONTAMINATED.

05/18/82 SIR 82-05-707.3 ‘707, MODULE A, BOX A-SS  NMSP1 #82-14, A CASTING
CHARGE FOR A NOLD EXCEEDED THE
APPROVED LIMITS BY 6966 PU.

05/24/82 SIR 84-05-771.2 77h, RUIN DURING A SUPPLIED AIR
OPERATION THE DOCKING RING
UNITING TRE HOOD AND SUIT
SEPARATED AND SUIT WAS
BREACHED. EMPLOYEE
TRANSPORTED TO MEDICAL.



Page No. 102
31/15/90

‘EVENT EVENT
DATE NUMBER

06/22/83 SIR 83-06-771.1

06/27/83 SIR 83-06-464.1

06/27/83 SIR 83-07-444-1

07/01/83 SIR 83-07-375.1

‘ 07/01/83 SIR 83-07-371.3

07/06/83 VOR 83-5--371 83-2

07/06/83 SIR 83-07-371.4

07/08/83 SIR 83-07-771.2

07/08/83 UOR 83-8--771 83-2

‘SURMARY OF EVENTS
4952 TO 1988

BUILDING

77, RNING

4h6, RM106

7r

‘371, PLUTONIUM RECOVERY

374, DOCK 18T

371

371, 3%

771, RMIS9, LINE 22

77

DESCRIPTION ADDITIONAL NOTES

CONTAMINATION RELEASE TO
PROCESS AREA.

THE SIGHT GLASS PORTS ON HHC
#4 VACUUM SHATTERED CAUSING
WINOR DAMAGE TO THE LNTERIOR
OF THE CHAMBER,

ENERPAC HYDRAULIC PIPE BENDER.
A WIGH PRESSURE HOSE FITTING,
WHICH HAD BEEN MODIFIED,
RUPTERED SPRAYENG HYDRAULIC.
OIL APPROX. 50+ FEET. NO
INJURIES BUT POTENTIAL FOR
ONE.

IMADVERTENT CUTTING OF OWN
BREATHING ALR SUPPLY HOSE IH A
CONTAMINATED ATMOSPHERE BY
MAINTENANCE PERSONNEL.

MMSPT 83-14. TRUCKING
PERSONNEL STACKING 55-GALLON
DRUM OF RESIDUES INTO BACK OF
TRUCK, LIMITS DO NOT ALLOW
‘STACKING OF DRUMS.

A CRITICALITY ALARM SOUNDED
DUE TO A MALFUNCTION. SOME
CONTAMINATION OCCURRED DURING
EVACUATION.

PUBLIC ADRESS SYSTEM FAILURE.

NMSPI 83-12. EST STORAGE
SECTION OF LINE 22, ONE CAN
SMITH 2062 G PU AND ONE CAN
WITH 2109 G PU. LIMIT = 2500
6 PUL

‘TWO AIR EFFLUENCE SAMPLERS
SHOWED HIGHER THAN NORMAL PU
CONCENTRATIONS. WO CAUSE
COULD BE DETERMINED.



Page No. 92
15/90

EVENT EVENT
DATE NUMBER

07/28/82 UOR 82-336.03

08/06/82 SIR 82-08-771.1

08/09/82 SIR 82-08-774.2

erie SIR 82-08-71.3

08/11/82 SIR 82-08-707.2

08/14/82 SIR 82-08-707.1

08/18/82 SiR 82-08-771.4

SUMMARY OF EVENTS

BUILDING

334, ELECTRIC SHOP

771, RMIGB, LINE 19

T7t, RMI9, LINE 22

we

707, MODULE K

707, RM169, X-RAY UNIT

771, RM23B

1952 TO 1988

DESCRIPTION

ADDITIONAL NOTES

WORKER RECEIVED SHOCK WHEN
WORKING OM AN ARC WELDER. RIS
FINGER WAS BURNED.

A CHEM. 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 34346
CLIMIT=3000G), WAS THE THIRD
CONTAINER ADDED(LINIT=2
CONTAINERS), AND WAS LARGER
THAN THE 1 LITER LIMIT FOR THE
Box. -

NSPE 82-19. THREE BATCHES OF
MATERIAL WITH PU CONTENTS OF
366 &, 675 G, AND 717 G, WERE
PROCESSED IN THE GLOVEBOX.
THE ESTABLISHED LIMIT FOR EACH
BATCR 1S 200 G PU METAL.

TWO PART CARRIERS WERE PRESENT
IN THE TRANSFER AREA WHEW ONLY
ONE 1S ALLOWED. A CARRIER 1S
LIMITED TO 30006 PU AND EACH
CARRIER CONTAINED 38960.

X-RAY UNIT DID NOT FULLY
TERMINATE RADIATION OUTPUT AT
THE END OF PRESET EXPOSURE.
‘ONE PERSON RECEIVED A SMALL
AMOUNT OF PENETRATING
RADIATION OF UNKNOWN ENERGY
LEVEL.

JUO KACHINISTS 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.



Page No. 108

715/90
‘SUMMARY OF EVENTS.
- 1952 To 1988
= v BUILDING DESCRIPTION ADDITIONAL NOTES
DATE NUMBER
12721783 UOR 84-2-776 84-1 776 ‘AM ELECTRICIAN WORKED WITHOUT

A RESPIRATOR ON A PUMP WHICH
WAS CONTAMINATED. A BODY
COUNT REVEALED AN ELEVATED
LUNG COUNT.

01/06/84 SIR 84-01-779.1 ‘779, RMS, WAC #1 HIGH VOLTAGE INTERLOCK WIRING
WOT OPERATIVE. EMPLOYEE
ASSUMED POWER SUPPLY
DISCONNECTED AND RECEIVED
SHOCK AND BURNS.

01/12/86 SIR 84-01-777.1 777, RYG32 A WELDER WAS OVERCOME BY OZONE
DURING WELDING OPERATION. HE
WAS WEARING FULL FACE
RESPIRATOR. THE INTAKE FILTER
OW THE RESPERATOR WAS COW
ENOUGH 10 THE WELDING SURFACE
r TO CAUSE OZONE TO ENTER.

01/16/84 UOR 84-1--771 BA-1 774 CRITICALITY ALARM SOUNDED WHER
SET OFF BY RADIO FREQUENCY
NOISE" NEAR THE DETCTORS.

01/17/84 SIR 84-01-771.4 TH, RANG FIVE USED FULFLO FILTER
CARTRIGES WERE FOUND IN THE
LIME, ONLY FOUR ARE ALLOWED.

“01/26/84 STR 84-01-771,3 771, RMIBIA A535 GALLON DRUM WAS LEFT
‘UNATTENDED WITH THE LID OFF.
55 GALLON DRUMS CAN ONLY BE
LEFT UNATTENDED WHEN THE LID
IS ON.

01/30/84 SIR 84-02-371.3 ‘371, RM3189 NMSPI 84-4. 17 DRUMS EXCEEDED
THE 200 & LIMIT.

01/30/84 SIR 84-01-771.2 771, RMT A PAN HEASURING 7* X 12" X 2#
WAS USED TO COLLECT MATERIAL
FROM AN OFFGAS LINE. THE
ACCEPTED SIZE 18 6" xX 9 1/2" X
an,



Page Ho.
11/15/90

EVENT
DATE

06/17/80
07/02/80
11/06/80
1108/80

02/18/83

04/07/81

04/19/81

[

06/16/84
08/04/81
08/07/81
98/10/81

09/04/81

09/10/81

09/21/81

09/21/81

9

Bent Bus

NUMBER

883,

383,

881,

37,

tht,

881,

outst

865,

446

bbb,

‘SUMMARY OF EVENTS
1952 To 1988

RM101

RN269

RMIO7

RMAOT

RM26T

RMS809/3810,

RM245,

RM101

RM137

RMSO2

IDE, SO. OF GATE #9

RM136

RMIO1

RM182

RNIB

RMISIA

DESCRIPTION ADDITIONAL NOTES

CHIPS AND TURNINGS ON LATHE
IGNITED.

OVERHEAT CONDITION REPORTED BY
UTILITIES IGNITED FILTERS.

ELECTRICAL MALFUNCTION A”
PRESS SWITCH.

ELECTRICAL MALFUNCTION "A
PRESS SWITCH.

FIRE IN FILM DRYER.

SACK FILTERS IGNITED IN SALT
DRYER.

ELECTRICAL SHORT IN TANK
HEATER IGNITED PLASTIC TANK.

CHIPS IGNITED ON LATHE

SMALL TRANSFORMER OVERHEATED
AND IGNITED

BARREL OF CHIPS IGNITED WHILE
BEING LOADED INTO CHIP
ROASTER.

34% ACRE OF GRASSLAND BURNED
LATHE CHIPS IGNITED IN BARREL.

LATHE CHIPS IGNITED ON LATHE.

CUTTING TORCH SPARK IGNITED
WALL INSULATION.

MAGNESIUM CHIPS IGNITED ON
CUTTER.

MAGNESIUM IMPREGNATED BELT
SANDER IGNITED WHEN STEEL WAS
BEING SANDED ON THE SANDER.



Page No, 131

11715790
______ EVEN} EV88t§ ‘BUTEDING
DATE NUMBER

12/03/85 VOR 85-7-771 85-2 777

12/05/85 UOR 85-8--991 85-? 991

12/09/85 SIR 85-12-771.3 771, EAST ANNEX

12/15/85 SIR 85-12-771.2 mM

Oz: SIR 85-12-G9.4 900, CTR RD GUARD POST

SUMMARY OF EVENTS

1952 TO 1988

DESCRIPTION ADDITIONAL NOTES

A GLOVEBOX EXPLOSION INJURED A
TECHNICIAN WHEN THE WINDOW
STRUCK EMPLOYEE. EXPLOSION
CAUSED BY PRESENCE OF A
MIXTURE OF FLAMMAGLE SOLVENT
VAPORS BEING IGNITED BY A
SPARK FROM A HOTPLATE DURING
CLEANUP OPERATIONS.

‘A TRASH BAG CONTAINING
RADIOACTLVE WASTE WAS FOUND IN
THE "COLD" TRASH.

TWO DRUMS EXCEEDED MAXIMUM
AMOUNT OF FISSILE MATERIAL OF
500 G PER DRUM.

HIGH URINE SAMPLE. SENSITIVE
REPORT.

SCANNER ALARM SOUNDED CAUSING
GATE TO CLOSE. VEHICLE
SKIDDED INTO GATE. DRIVER WAS
PROBABLY SPEEDING.

01/06/86 SIR 86-01-69.1 900, CTR RD GUARD POST GATE ACTIVATED FOR CLOSING IN

01/09/86 SIR 86-01-707.1 707, PLANT AIR SYSTEM

01/13/86 SIR 86-01-P2.1

OUTSIDE, PORTAL 2

RESPONSE TQ SCANNER ALARM.
VEHICLE FAILED 10 BACK UP AND
‘WAS RIT BY GATE.

‘THE OPERATING PLANT AND
INSTRUMENT AIR COMPRESSOR
FAILED. THE AIR PRESSURE
DROPPED YO 30PSIG WITH ALL OF
THE AIR OPERATED EQUIPMENT
GOING TO THEIR FAILSAFE
POSITIONS.

‘A GATE YAS CLOSING WITH A CAR
IN ITS PATH. THE GUARD
DEPRESSED THE STOP BUTTON BUT
‘THE GATE CONTINUED, STRIKING
THE CAR.



Page Wo, 95

oe”

EVENT EVENT:
DATE RUMBER

10/10/82 SIR 82-10-371.1

10/14/82 SIR 82-10-8831

® SIR 82-10-371.2

10/28/82 YOR 82-371.06

10/28/82 SIR 62-11-750.1

49/05/82 SIR 82-41-782.4

11/09/82 SIR 82-21-8861

SUMMARY OF EVENTS

BUILDING

a7

371

371376

750

782, 779, 729, 779A

1952 Ta 1988

DESCRIPTION

NMSPI #82-22. PROCESS WASTE
SOLUTION WAS TRANSFERRED FROM
A CRITICALLY SAFE VESSEL TO A
CRITICALLY UNSAFE VESSEL
WITHOUT SOLUTION SAMPLE
ANALYSIS. SOLUTION WAS TO BE
CIRCULATING AND WAS
INADVERTENTLY TRANSFERRED TO.
374,

AM ELECTRICIAN WAS HOOKING UP
WIRING ON A BULLARD VERTICAL
LATHE, HE WAS STANDING OW AN
OILY MOTOR, SLIPPED AND FELL
ONTO THE FLOOR PLATES AROUND
THE MACHINE AND RECEIVED
LACERATIONS TO THE RIGHT HAND
AND LEFT CHEEK BONE.

CHEMICAL REACTION RESULTING IN
VAPORS BEING INHALED BY TWO
EMPLOYEES.

CRITICALITY ALARM SOUNDED FOR
AN UNKHOWN REASON. NOTHING
WAS FOUND WRONG WITH THE
ALARMS AND WO CONTAMINATION,
WAS FOUND.

NMPSE #82-23. ASSEMBLY
OPPERATIONS FOR A SPECIAL
DEVICE STARTED WITHOUT RAVING
WMSL AUTHORIZATION ON HAND.

ACTIVATION OF WEUTRON ALARM
CAUSED EVACUATION OF BLOGS.
179, 779A, 729, 782.
MALFUNCTION OF DETECTORS IS
ASSUMED TO GE THE CAUSE.

THE CRIT. ALARM OCCURED AT THE
INSTANT THAT A SCALE CHANGE
WAS MADE ON A REACTOR MONITOR
INSTRUMENT DURING A CRITICAL
MASS EXPERIMENT. NO
CRITICALITY RAD OCCURED. ALARH
WAS THE RESULT OF A FAILED
SOLDER JOINT AND A
QUESTIONABLE ELECTRONIC COAX
CABLE.

ADDITIONAL NOTES



Page No. = 9%

eo”

EVENT EVENT
DATE NUMBER

09/15/82 SIR 82-09-707.1

09/29/82 SIR 82-09-771.1

10/01/82 SIR 82-10-776.1

10/05/82 SIR 82-10-71.

10/06/82 SiR 82-10-707.1

‘SUMMARY OF EVENTS

BUILDING

‘707 MODULE A,B

776

771, RM1B2, BOX 226

707, MODULE 8

1952 TO 1988

DESCRIPTION ADDITIONAL NOTES

WMPSI #82-20. IN THE TRANSFER CARRIERS TO 8E PRESENT AT A
AREA BETWEEN CHAINVEYORS OF TIME IN EACH OF THESE AREAS.
MODULE A, FOUR PART CARRIERS

WERE FOUND PRESENT ON THE

GLOVEBOX FLOOR. ALSO, BETWEEN

THE CHAINVEYORS OF MODULE 8

FIVE PART CARRIERS WERE FOUND

ON THE GLOVEBOX FLOOR. LIMITS

ALLOW A HAX OF TWO PART

‘SIX CONTAINERS (APPROX 25006
OF OXIDE) WERE BAGGED FROM A
TART INTO LINE 7. TEMPORARY
LIMIT ALLOWED SIX CONTAINERS
TO BE BAGGED IN PROVIDED EACH
MAS LIMITED TO A MAX OF 14006
OF PUOZ AND THAT THE MATERIAL
BEING TRANSFERRED CAME FROM
LIMES 8 AND 9 ONLY.

SHEET METAL MAINTENANCE WAS
MORKING ON FAN SHAFT WITH
WELDER. A WORN CORD ON THE
WELDER SENT AN ARC OF
ELECTRICITY TO THE STEEL DECK
PLATE. THE CORO WAS WORN FROM
PEOPLE WALKING ON IT. THERE
WAS NO SHOCK HAZARD.

THE WRONG POWER BUTTON WAS
PUSHED CAUSING POWER TO FLOW
‘TO A FURNACE WHICH WAS NOT IN
SERVICE. AS A RESULT, THE
INDUCTION COIL OVERHEATED
CAUSING THE INSULATION TO
SWOKE, DISINTEGRATE, AND RUIN
‘THE COIL.

MOD SB. BYDRA-FORM PRESS.
ELECTRICIAN RECEIVED SHOCK
WHILE ATTEMPTING TO LOCATE THE
POWER SOURCES IN AN UNMARKED
CONTROL CABINET.


Page No. 144

14715798
r SUMMARY OF EVENTS
4952 10 1983 —
7 "EVENT EVENT BUILDING DESCRIPTION ADDITIONAL NOTES
DATE NUMBER
10/27/86 SIR 86-10-771.2 771, DOOR 1 LOCKING MECHANISM ON SECURED

41/05/86 SIR 86-11-460.1

11/06/85 UOR 86-3-771 86-1

19/06/86 VOR 86-3-771 86-1

11/10/86 SIR 86-11-707.1

41/71/86 SIR 86-11-69.1

11/41/86 SIR 86-17-69.

11/12/86 SIR 86-11-123.1

468, BLDG HI BAY AREA

774, RUI63, BOX 115,

707, DOCK SOUTHEAST

900, GATE 9

900, GATE 9, POWER GATE

123, ROOM 357

DOOR FAILED.

ACETONE FIRE NEAR WELDING
OPERATION

MAINTENANCE OPERATIONS WERE IX
PROCESS OF REMOVING ITEHS FROM
‘A GLOVEBOX SYSTEM. AS WORKERS
WERE REMOVING A PIECE,
PLUTONIUM CONTAMINATION WAS.
RELEASED TO AREA.

INADEQUATE JOB REVIEW AND LACK
GF COMMUNICATION, INADEQUATE
‘SITE PREPARATION, AND
KLSAPPLICATION OF PROCEDURES
RESULTED IN RELEASE OF
PLUTONIUM OXIDE TO ROOH
ATMOSPHERE FROM GLOVEBOX. FIVE
EMPLOYEES REQUIRED BOOY
COUNTS.

FORKLIFT PUNCTURED
TRICHLOROETHANE DRUM AT DOCK

EMPLOYEE ATTEMPTED TO DRIVE
THROUGH CLOSING NORTH GATE
WHICH HIT CAR ON REGHT SIDE
CAUSING EXTENSIVE DAMAGE.

RADIOMETRIC SCANNER ALARH
SOUNDED AT GATE 9 AND GUARD
DEPRESSED FAST CLOSE BUTTON TO.
POWER GATE. EMPLOYEE TRIED TO
PASS THROUGH CLOSING GATE

GATE HIT CAR RESULTING IN
EXTENSIVE DAMAGE TO 80TH THE
CAR AND THE POWER GATE.

HOT PLATE FIRE INVOLVING
SOLVENT 34 A HOOD.



Page No. 127
11415790
‘SUMMARY OF EVENTS
6 1952 To 1988
EVENT EVER BUILOING DESCRIPTION ADDITIONAL NOTES

DATE NUMBER

O7/31/85 SIR 85-09-707.4 707, MOOULE K SCREWDRIVER SLIPPED
PENETRATING WORKERS HAND
CAUSING A PLUTONIUM
CONTAMINATED WOUND.

08/02/85 SIR 85-08-707.1 707, MODULE J A CAN CONTAINED 2648 G PU
EXCEEDING THE LIMIT OF 2500 G.

08/05/85 SIR 85-08-707.2 707, HODULE A ‘A FEED INGOT WAS USED IN A DIE
CAST WORK AREA WHICH IS NO
LONGER ALLOWED.

08/12/85 SIR 85-08-371.1 371, RNS602 ‘TWO CANS OF MATERIAL WERE IN

98/18/85 SIR 85-08-121.1

08/25/85 SIR 85-08-771.1

08/27/85 SIR 85-09-776.1

08/29/85 SIR 85-09-G9.1
08/29/85 SIR 85-9-371.1

09/19/85 UOR 85-3-771 85-1

121, PISTOL RANGE

771, RM247

900, CTR RD GUARD POST

371

TTA, RMIGD

THE AIRLOCK AT ONE TIME
EXCEEDING THE LIMIT OF 3000
Pu.

‘A CYLINDER RUPTURED IN A .33
SPECIAL HAND GUN BEING USED ON
THE PISTOL RANGE.

TANK OVERFLOWING ONTO FLOOR
WHILE OPERATOR WAS OUT OF
ROOM,

WORKER EXPOSED TO RADIATION
DUE: TO & DEFECTIVE SUPPLIED

AIR SUIT, 20-25 MINUTES
PASSED BEFORE HE WAS NONTTORED
out.

GATE CLOSED ON VEHICLE BECAUSE
GUARD THOUGHT VEHICLE HAD
CLEARED.

INFRACTION OCCURRED WHEN A 10
GALLON DRUM WAS PLACED UNDER
GLOVEROX 48F.

FLOOR SWEEPINGS IN LINE 20
WERE PLACED IM A PLASTIC
CONTAINER AND TAKEN TO TRE
‘COLD STORAGE AREA NEAR LINE
27, ROOM 149. THE CONTAINER
CONTAINING PLUTONIUM AND
PLUTONTUM COMPOUNDS
PRESSURIZED AND SUSSEGUENTLY
RELEASED RADIGACTIVE MATERIAL
TO OOH.



SUMMARY OF EVENTS

1952 TO 1988

DESCRIPTION ADDITIONAL NOTES.

Page No. 9-113

1118190

EVENT __ EVENT BULLDEN

DATE HUMBER

05/17/84 SIR 84-05-371.4 371, RMIN17
05/21/84 SIR 84-05-3715 371, RMINIS
05/22/84 SIR 84-05-3716 371, RHB206, GB 42
05/26/84 UOR 84-3--FR 84-1127

@....

06/06/86
06/07/84
06711785

6/34/86

STR 84-05-707.3

‘SIR 86-06-771.4

SIR 86-06-371.2

SIR 84-06-583.1

SIR B4-06-707.1

707, MODULE H, RMI36

71, RAGE

‘371, RAS206

881, RUZ6

707

‘A SUPPLIED ALR HOOD AND A 55
GALLON BAG WERE LEFT OUTSIDE A
SUPPLIED AIR HOUSE, OPEN AND
‘UNDER LIQUID PROCESS LINES.

OVERFLOWING OF TANKS D-293 A/B
(CRIT DRAIN SYSTEM C) ONTO
FLOOR OF ROOM 1115.

WMSPI 84-29. TWO LARGE
PLASTIC BAGS WITHOUT SLITS
WERE PROPPED OPEN OM CART
UNDER FISSILE SOLUTION LINE.

‘A MACHINE GUN ROUND DETONATED
UPON FIRING SENDING SHRAPNEL
OUT OF THE EJECTION PORT.
THREE GUARDS AROUND THE GUN
WERE INJURED.

NMSPI 84-30. MOD H. STORAGE
RACKS LOADED WITH OY PARTS,
LIMIT = ONLY SPECIFIC APPROVED
ASSEMBLIES.

NSPL 84-31. LINE 20, SECTION
BBG, BUTTON BREAKOUT. 2.12"
DIA SOLID SAMPLE RACK FOUND
INSIDE CRIT DRAIN.

AMSPI 84-32. AL-17 CONTAINED
TWO I-LITER CANS OF FISSILE
MATERIAL. LIMIT ALLOWS MAXIMUM
OF ONE 4-LITER CONTAINER.

CHUCK JAW BROKE LOOSE AND
THROW INTO HOOD DAMAGING
MACHINE AND CAUSING SLIGHT ARM
INJURY TO EMPLOYEE.

MATERIAL IN WASTE DRUM
CONTAINED 583 G PU WHICH Is
OVER THE ACCEPTED LIMIT.



Page No. 132

oe”

‘SUMMARY OF EVENTS

1952 To 1988

DATE ‘HUMBER

01/14/86 SIR 86-01-3741
01/14/86 SIR 86-01-707.2
01/14/86 STR 86-01-71.1
01/14/86 SIR 86-01-G9.2
91/14/86 SIR 86-01-883.1
01/20/86 SIR 86-01-707.3

01/24/86 SIR 86-01-771.2

‘O1/31/86 SIR 86-02-707.2

01/31/86 SIR 86-02-707.2

BUILDING

37%, SALT CRETE

707, ELECTRICAL SYSTEM

771, RAIS

900, CTR RD GUARD POST

883, CONTROL ROOM CRAW!

707, WOD K, J-K CONVEYOR

771, RMAF

707, MOOULE J, BOK J-20

707, MODULE J, BOX J-20

DESCRIPTION ADDITIONAL NOTES

WORKERS CLEANING OUT MIX TANK
BURMED BY IRRITANTS FROM TANK,

AN EMERGENCY GENERATOR DID NOT *
START WHEN THE POWER WENT OUT.

FIVE CONTAINERS CONTAINING
FISSILE MATERIAL WERE PLACED
INTO GLOVEBOX VIOLATING LIMIT
OF FOUR CONTAINERS.

GATE CLOSED WHEN SCANNER ALARM
SOUNDED. VEHICLE IN PATH OF
GATE WAS AIT.

EA BLOCK OM A CRANE WAS BEING
LIFTED AND FAILED TO STOP AT
THE UPPER LIMIT. THE CABLE
KEPT WINDING UNTIL IT BROKE,
CAUSING THE BLOCK TO FALL. A
LIMIT SWITCR WAS FOUND
INOPERATIVE.

‘A CANON CONVEYOR WAS FOUND TO
EXCEED THE LIMIT OF 2500 6 PU
BY 475 G.

COMBUSTIBLE MATERIAL OF OVER
7000 G WAS PLACED IN A
GLOVEBOX VIOLATING THE LIMIT.

FOUR CANS OF OXIDE WITH ABOUT
22006 EACH WERE FOUND IN AN
AREA RESTRICTED TO A MAXIMUM
OF 60006 PU. IN ADDITION
THESE CANS WERE SPACED BETUEEN
6* AND 10" APART IN VIOLATION
OF THE 12" HINIMUM SPACING.

FOUR CANS OF OXIDE WITH ABOUT
22006 PU EACH WERE FOUND IM AN
AREA RESTRICTED TO 60006
MAXIMUM. THE CARS WERE ALSO
‘SPACED ONLY 6" APART IN
VIOLATION OF THE 42° LIMIT.



Page Wo. 114

eo”

ATE RUMBER

Q4/27/84 SIR &6-05-559.1

06/28/84 SIR &%-05-707.1

05/03/84 SIR 84-05-3711

05/03/84 SIR 84-05-776.2

95/04/84 SIR 84~05-371.3

05/04/84 SIR &%-05-707.2
05/09/84 SIR 84-05-559.2

05/09/84 SIR &4-05-776.1

05/16/84 SIR 84-05-881.1

‘SUMMARY OF EVENTS

1952 To 1988

BUILDING

559, RM102

707, MODULE C

371, RMT105

776, SIZE REDUCTION

371

707

559, RMIO1

776, RATES

881, ELEVATOR

DESCRIPTION

‘A VIAL CONTAINED 5S G PU. THE
LIMIT 18 25 G.

NMSPI 84-23. DRUM OF WET
COMBUSTIBLES LOADED BY 707 FAB
PERSOMNEL CONTAINED 79% G PU
(75S & AFTER SPLITTING).

LIMIT = 500 G PUL

ACIDIC SOLUTION SPILL
RESULTING IN MAJOR LEVELS OF
CONTAMINATION. OCCURRED
DURING ROUTINE MAINTEWANCE
WORK. THREE EMPLOYEES TAKEN
TO MEDICAL.

NMSPI 84-25. TWO CRATES LOADED
IW EXCESS OF MAX 350 G PU AND
5 G PU IN ANY CUBIC FOOT,

A TWO THCH PVC UNION BROKE.
APPROXIMATELY 500 GALLONS OF
WATER FLOWED. WO
CONTAMINATION WAS FOUND.

CHIP CAN EXCEEDED SPECIFIED
LIMIT,

WMSPE 84-21. BOX C-29
CONTAINED 120 SAMPLE VIALS.
LIMIT = MAXIMUM OF TEN VIALS.

EMPLOYEE RECEIVED A KNIFE
WOUND TO RIGHT THIGH MHEN
WORKING IN SUPPLIED AIR

OPERATOR DROVE A FORK LIFT OF
S800 LBS. ONTO AN ELEVATOR
WITH A MAXIMUM CAPACITY OF
2500 LBS. THE ELEVATOR WOULD
NOT MOVE WITH THIS AMOUNT OF
WEIGHT ON IT.

ADDITIONAL NOTES



Page No, = 9

715/90
SUMMARY OF EVENTS
4952 TO 1988
“Even VERT ~~ purto Tne DESCRIPTION ADDITIONAL NOTES
DATE NUMBER
06/29/82 SIR 82-06-376.1 376, RMGIO6 ‘A LEAK I THE PUMP DISCHARGE

VALVE OF A 12N NITRIC ACID
TANK WAS BEING FIXED. DUE TO
‘A LACK QF COMMUNICATION, THE
DISCHARGE VALVE WAS CLOSED
RATHER THAN THE TANK DRAIN
VALVE, APPROXIMATELY 600
LITERS OF ACID SPILLED ONTO
THE FLOOR.

07/07/82 SIR 82-07-371.1 an CONTARINATION SPILL DUE TO
RUPTURED PVC LINE.

07/13/82 SIR 82-07-771.1 771, RNI14, TANK 950 WASTE OF 2.586 PU PER LITER
WERE TRANSFERRED TO A TANK
WHOSE LIMITS ARE 3.7X10E-3
G/LITER. THIS CAUSED A TOTAL
WEIGHT OF 12506 IN THE TANK
@ EXCEEDING THE 2006 LIMIT.

07/13/82 SIR 82-07-865.1 B65, RMI0S AN EMPLOYEE WAS USING A LECO
MOUNTING PRESS AND WAS HOLDING
THE CAMLOCK CLOSURE BY ITS
HANDLE. THE HANDLE HAD WORKED
LOOSE OVER TIME AND CAME LOOSE
CAUSING THE OPERATORS FINGER
‘TOBE SEVERELY CUT ON THE
CAMLOCK CLOSURE.

07/16/82 VOR 82-707-02 707, MODULE J ‘AN OPERATOR LEFT A GLOVESOX
WITROUT MONITORING RIMSELF
OUT. HE LEFT THE BUILDING
CONTAMINATED. HIS TAR,
CARPOOL CAR, ANG HOUSE WERE
ALL CHECKED FOR CONTAMINATION.
NO CONTAMINATION WAS FOUND.
THE OPERATOR DID HAVE A
POSITIVE BOY COUNT.

97/15/82 SIR 82-07-776.1 TPUT76 TRUCK GATE ALARM TECHNICIANS WERE
INSTALLING CONDUIT 3M A TRENCH
USING ELECTRIC POWER TOOLS.
THE FIRE DEPT BEGAN RUNNING
TESTS OF THE SPRINKLER SYSTEM
r IM 776. WATER RESULTING FROM
THESE TESTS FILLED THE TRENCH

WITH 4* TO 1! OF HATER
CREATING AN ELECTRICAL BAZARD.



Page No. 105
”

EVENT EVENT
DATE NUMBER

09/12/83 SIR 83-09-371.1

09/15/83 SIR 83-09-707.1

09/16/83 SIR 83-09-707.2

09/21/83 VOR 83-10-111 83-1

09/29/83 SER 83-09-707.3

10/04/83 SIR 83-05-776.1

10/05/83 SIR B3-10-444.1

10/11/83 SER 83-40-771.1

SUMMARY OF EVENTS

BUTLDING

707, MODULE J

707, WODULE J

12t

707, MODULE B

776, SIZE REDUCTION

1952 To 1988

DESCRIPTION

CAN IN STACKER/RETRIEVER
CONTAINED 3300 G PUL LIMIT =
308 G PUL

NMSPI 83-15. MOD J, BOX J-35
FURNACE CHAMBER. A CASTING
WAS MADE WHICH EXCEEDED THE
APPROVED CHARGE OF THE MOLD
USED 1M THE FURNACE BY
APPROXIMATELY 730 G PU.

NUSPT 83-16. MOD J, BOX J-10,

CAN OF OXIDE IN CONNECTING
SECTION WEIGHED AT 3200 G PU
LIMIT = 2500 6 PU.

A CRITICALITY ALARM TONE.
FAMILIARIZATION TEST WAS
CONDUCTED BUT NOT EVERYONE
HEARD THE ANNOUNCEMENT AND
THEREFORE SOME PEOPLE
EVACUATED.

NMSPI 83-18, MOD B, BOX B-105.
FOUR G-LITER BOTTLES WERE
SIDE-BY-SIDE INSTEAD OF 12"
‘EDGE-TO-EDGE AS REQUIRED BY
POSTED TEMPORARY LIMIT.

NEW BARREL STORAGE AREA, DRUMS
WERE STACKED BY SIZE REDUCTION
BEFORE LIMITS APPROVED.

OPERATOR WAS CLEANING A
CRUCIBLE WHEN SOME SHOLDERING
URANIUM OXIDE WAS ACCIDENTALLY
SUCKED UP INTO THE HOUSE
VACUUM SYSTEM, CAUSING AN
OVERHEAT ALARM IW THE HOUSE
VACUUM HOPPER.

NMSPI 83-19. FOUR POSITION
TRANSFER CART HAD TOO MUCH
SHIELDING.

ADDITIONAL NOTES



Page No. = 142
11/15/90

@ SUISIARY OF EVENTS

- 1952 To 1988

p CEVENT EVENT BURLING “DESCRIPTION ADDITIONAL HOTES
DATE NUMBER

08/28/86 SIR 86-9-371.1 371, RMS3OS NMSPI 86-19. A 55-GALLOW DRUM
WAS LOADED WITH AN
ELECTROREFINING CRUCIBLE AND
SENT TO CALORIMETRY. DRUM
CONTAINED 1546 GRAMS IN
VIOLATION OF 1000 GRAM LIMIT
FOR DRY FISSILE MATERIAL IN A
55-GALLON DRUM.

08/28/86 SIR 86-8-374.1 374 SALT BRINE SPRAYED OPERATOR
(8/0 PPE) WHEN PLUGGED FILTER
WAS OPENED ON SPRAY DRYER
FEED.

09/02/86 SIR 86-9-771.1 TM ‘TOG MANY CONTAINERS CONTAINING
FISSILE MATERIAL WERE FOUND IW
LINE BATCHING AREA.

FISSTLE MATERIAL WERE FOUND IN
LINE 23 BATCHING AREA

ee” SIR 86-9-71.1 771, RMI49 TOO MANY CONTAINERS CONTAINING

09/04/86 SIR 86-9-707.1 707, PROCESS WASTE PROCESS WASTE TANK OVERFLOWED
WHEN PLENUM SPRINKLER SYSTEM
ACTIVATED (SLOW FLOW THAT DID
NOT SET THE ALARM OFF).

09/15/85 SIR 86-9-460.1 460, HIGH PRES. TEST CELL OVE TO A FITTING FAILURE A
PIPE CONNECTING COMPRESSOR
INLET LINE WITH EQUALIZING
VALVE AND RUPTURE DISC CAHE
LOOSE BENDING PIPE UP FROM ITS
ORIGINAL POSITION.

09/25/86 SIR 86-9-771.2 771, GRINNEL FIRE ALARMS CRIT ALARM PANEL WAS WITHOUT
EMERGENCY POWER WHEN
ELECTRICIANS STRIPPED OUT
ABANDONED WIRING.

10/01/86 SIR 86-10-371.1 374, DOCK 18-T REAVT DRIVER, REMOVING A WASTE

BOX FROM THE DOCK TO A
TRAILER, BACKED ITO ANOTHER
WASTE BOX SITTING O8 THE
GROUND. TRAILER HITCH PUNCHED

® HOLE TN THE BOX. WASTE BOK WAS
MOT RADIATION HONSTORED BEFORE
BEING MOVED. NO CONTAMINATION

OCCURRED.



Page Ho. = 122
41/15/90

DATE

12/19/84 SIR 85-01-707.2

01/03/85 SIR 85-01-371.1

61/08/85 SIR 85-01-644.4

@... SIR 84-08-442.

01/09/85 SIR 85-01-707.1

O1/15/8S SIR 85-C1-886.1

01/17/85 SIR 85-01-707.4

01/20/85 SIR 85-01-371.2

707, RMI7T

374

Glos, BASEMENT

771, RMIS9

707, MODULE J

371

‘SUMMARY OF EVENTS

1952 To 1983

DESCRIPTION ADDITIONAL NOTES

A PORTABLE NEUTRON DETECTOR
SOUNDED. PERSONNEL DID NOT
EVACUATE BECAUSE PRINARY
SYSTEM DID NOT SOUND. THE
CAUSE OF THE PORTABLE DETECTOR
ACTIVATING IS NOT KNOWN.

RADIO FREQUENCY WAVES SET OFF
CRITICALITY ALARM. ONE MAR
CONTAMINATED PARTS OF BUILDING
WHILE EVACUATING BECAUSE HE
HAD BEEN WORKING IN A
CONTAMINATED AREA.

EXHAUST FANS SHUT DOWN DUE TO
VOLTAGE DROP. THEY MUST BE
MANUALLY RESTARTED. THEY WERE
FORGOTTEN WHEN OPERATIONS
RESUMED.

THREE FILTERS WERE REMOVED
FROM LINE AT ONE TIME
VIOLATING THE PROPER PROCEDURE
OF REMOVING ONLY ONE FILTER AT
A TIME.

A BUTTON LOAD FOR FOUNDRY
OPERATIONS EXCEEDED THE WEIGHT
LIMIT OF 2500 G BY 58 G.

A PORTABLE NEUTRON ALARM
SOUNDED WHEN A MAN YORKING ON
IT ACCIDENTALLY SET 17 OFF.
ALL BUT FOUR PEOPLE EVACUATED
THE BUILOSNG,

TRREE BUTTON LOADS FOR FOUNDRY
OPERATIONS EXCEEDED THE 2500 6
utr.

TWO LOCK NUTS OW AN ATRLOCK
DOOR FAILED CAUSING THE DOOR
TO FALL ON A WORKERS HAND.
‘SRE WAS ALONE WHEN RULES
REQUIRE THAT TWO PEOPLE BE
TOGETHER. THEREFORE, SHE HAD

TO YELL FOR ASSISTANCE.



Page No. 123

oe”

‘SUMMARY OF EVENTS:
1952 10 1983

VERT EVENT
DATE NUMBER

01/22/85 SIR 85-01-776.1

01/26/85 SIR 85-02-371.1

01/31/85 SIR 85-12-7791

or SIR 85-12-334.1

02/22/85 SIR 85-5-371.2

02/28/85 SIR 85-03-559.1

03/16/85 SIR 85-03-371.1

03/16/85 SIR 85-03-750.1

03/18/85 SIR 85-3-PSZ.1

BUILDING

371

779A, RMI60

‘334, PLATE SHEAR

374, RHBGI2

589, RMTOZ

371, METAL PROOUCTIONN

559/779, CRIT. ALARMS

DESCRIPTION

LIQUID WASTE WAS TRANFERRED
FROM A CRITICALLY SAFE HOLDING
TANK TO A CRITICALLY UNSAFE,
HOLDING TANK.

ELECTRICIANS WERE PERFORMING
WORK OM THE BUILDING
ELECTRICAL POWER SYSTEK, AS
POWER WAS SHUT DOWN, IT WAS
DISCOVERED THAT THE PA SYSTEM
‘WAS NOT BACKED BY EMERGENCY
POWER.

TWO 5.2 LITER LEAD ENCASEMENTS
FOUND IR GLOVEBOX EXCEEDING
ESTABLISHED LIMITS OF FOUR
LITERS.

AN EMPLOYEE CRUSHED HIS FINGER
WHEN ADJUSTING A PLATE ON A
PLATE SHEAR.

NMSPI 85-5. INFRACTION
OCCURRED WHEN A CONTAINER WITH
1276 GRAMS OF PLUTONIUM OXIDE
WAS PLACED IN A GLOVEBOX WITH
A-LIMIT OF 200 GRaHS.

A VIAL CONTAINED 28 G PU
EXCEEDING THE 25 G LIMIT.

OPERATOR EXCEED 3000 & LIMIT
BY 223 G OR A CHARGE IN A
FURNACE.

CITICALITY ALARM WENT OFF
DURING TESTING.

BUILDING 779 CRITICALITY
DETECTION SYSTEH ACTIVATED, 21
SECONDS LATER, BUILDING 559
ALARMS SOUNDED. ALSO, SINGLE
DETECTORS ACTIVATED IN
BUILDING 776, COLUMN LINE D2W
AND BUILOENG 886. ALL ALARMS
WERE FALSE ALARHS.

ADDITIONAL NOTES



Page No. 138
11/15/90
‘SUMMARY OF EVENTS
r 1952 To 1988
_ BUILDING DESCRIPTION

DATE NUMBER

06/05/86 UOR 86-1-920 86-1 920, GUARD PosT A SECURITY INSPECTOR TOOK GFF
HIS GUN TO TUCK IN RIS SHIRT.
WHEN RE PICKED UP THE BELT,
THE GUN SLIPPED. HE GRABBED
IT AND TRE WEAPON DISCHARGED,
THE BULLET STRIKING THE FLOOR.

06/11/86 SIR 86-05-883.1 883 AK EHPLOYEE ACCIDENTLY BUHPED
THE EMERGENCY STOP ON A
ROLLING MILL. THIS CAUSED THE
BACK STOP TO LOWER, PINNING
THE MANS HAND FOR 25 SECONDS.
RE WAS NOT INJURED.

06/11/86 SIR 86-06-883.1 883, 8-ROLLING MILL EMPLOYEE WAS ADJUSTING A PIECE

06/12/86 SIR 86-06-886.1 ‘886, CRIT. ALARM SYSTEM

06/21/85 SIR 86-6-771.2 771, RMI48, LINE 19

96/27/86 SIR 86-O7-771.1 771, RESIOUE PROCESSING

OF METAL ON THE POWER TABLE
WHEN HE BUMPED AGAINST THE
STOP LINE. THIS KILLED POWER
TO THE SHEAR, INCLUDING POWER
TO THE HYDRAULIC PUMP THAT
HOLDS THE BACK STOP IM THE
RAISED POSITION. THE BACK
‘STOP LOWERED ONTO HIS RIGHT

THE CRITICALITY ALARM SOUNDED
WHILE MAINTENANCE WAS BEING
PERFORMED ON. THE SYSTEM. -NO
AMINOUNCEMENT HAD BEEN WADE
THAT TESTS WERE BEING
CONDUCTED ON THE SYSTEM AND,
CONSEQUENTLY, ALL EMPLOYEES:
EVACUATED.

NMSPI 86-14. TWO SUTTONS WERE
PRODUCED, WEIGHING 2109 AND
2111 GRAMS, RESPECTIVELY,
VIOLATION OF THE 2100 GRAM
Limit.

m

AM OPERATOR WAS INJURED BY A
PRESSURIZED INCINERATOR FEED
DRUM WHEN IT WAS IMPROPERLY
OPENED. THE DRUM LID

HOLD-DOWN MECHANISM WAS NOT
RESTING ATOP THE DRUM LID.
WHEN THE DRUM RING WAS
REMOVED, PRESSURE FROM INSIDE
THE DRUM PRIED THE UNBOLTED
ORUM RING

ADDITIGNAL NOTES

HAND PINNING IT THERE FOR
APPROXIMATELY 25 SECONDS.

‘OFF, RAISING THE LID. THE
OPERATOR'S HAND AND HIP WERE
STRUCK BY THE ORUM RING,
WHEN THE PRESSURE WAS
RELEASED FROM THE DRUM.



Page Ho. 117

eo”

‘SUMMARY OF EVENTS
1952 TO 1988

VERT —EVERT ——
DATE NUMBER

02/16/84 SIR &4-02-886.1

02/20/84 SIR 84-02-707.3

02/29/84 SIR 84-02-665.2

02/29/84 SIR 84-03-777.1

03/01/86 SIR 84-03-865.1

03/05/84 SIR 84-03-371.1

03/16/84 SIR 84-03-7714

03/20/84 SIR 84-03-776.1

BUILDING DESCRIPTION

886 A DELAYED CRITICAL FOR A
‘URANIUM EXPERIMENT IS SUPPOSED
TO LAST OVER ¢ MINUTE. DURING
THE EXPERIMENT IT BRIEFLY FELL
‘TO 45 SECONDS.

707, MODULE K ‘A MOLD WAS CAST EXCEEDING THE
ESTABLISHED LIMITS BY 1878 6.

646, TOOLGRIND SHOP OPERATOR WAS REMOVING BURR
FROM DRILL BIT OW GRINDER. HE
WAS USING AN INCORRECT
PROCEDURE AND THE BIT GOT
CAUGHT IN THE GRINDING WHEEL
CUTTING THE OPERATOR'S FINGER.

777, RM430 WMSPI 84-13. RED PART CARRIER
STORED WITHOUT REQUIRED 24"
SPACING FROM OTHER MATERIAL.

865 AN ELECTRIC WORKER WAS USING
(COZ GAS TO PROPEL A LINE
THROUGH A CONDUIT. HE WAS
OVERCOME BY THE COZ. THE
WORKER DID NOT HAVE CONFINED
SPACE ENTRY PERMIT.

371 WHSPI 84-14, 4-LITER
CONTAINER INTRODUCED INTO
GB40, ROOM 3206. LIMIT
SPECIFIED CONTAINER TO 2-LITER
MAXIMUM VOLUME.

771, RMI49, LINE 50 WSPI 84-15. CAUSTIC
FILTRATION. SOLUTION GREATER
THAN DISCARD LEVEL
CONCENTRATION SHIPPED TO BLDG
774 OW P.M. SHIFT.

776, UTILITIES PROCESS WASTE WATER WAS PUMPED
‘ONTO THE FLOGR. THE PUMP
COMES OM AUTOMATICALLY WHEN
‘THE LEVEL IN THE TANK BECOMES
‘700 HIGH.

ADDITIONAL NOTES



Page No. 164

11/15/90
‘SUMMARY OF EVENTS
1952 TO 19838
VERT EVENT ‘BUILDING DESCRIPTION ADDITIONAL NOTES:
DATE WUNBER

08/11/86 SIR 86-8-70.1

08/11/86 SIR 86-8-881.1
08/11/86 SIR 86-8-771.1
08/11/86 SIR 86-8-771.1

08/12/85 SIR 86-8-707.2

08/13/86 SIR 86-8-371.2
08/19/86 SIR 86~-8-771.2

08/22/86 SIR 86-8-464.1

707, MODULE C, BOX 45B

885, MAINT LUBE SHED

771, RM249

707, MODULE A

371, ROOM 3602

776-5, MAIN SUBSTATION

464, PRECISION SHOP

MMSPI 86-17, MACHINIST
WORKING AT GLOVEBOX 7-C-458
LOADED A CHIP CAN AND DID NOT
CHECK WEIGHT OF CHIPS ON A
SCALE. THE LIMIT OF 1500
GRAMS WAS EXCEEDED BY 36
GRAMS.

IWADVERTERT DUMPING OF
RADIOACTIVE CONTAMINATED OLL
SLUDGE INTO OPEN TOP DUMPSTER.

PLUTONIUM KATERIAL WAS HEAPED
1M 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 CLEAN UP A
2? PAN WAS MEAPED CAUSING A
VIOLATION

FURNACE COOLING BOX FOUND TO
CONTAIN A LOADED CRUCIBLE AND
‘CASTING IN ITS MOLD AT THE
SAME TIME THUS VIOLATING
ESTABLISHED SAFETY LIMITS OF
‘ONE.

DRUM LID RETENTION RING POPPED
OFF DRUM STRIKING LEFT THUMB
OF PERSONNEL

WORMAL POWER LOSS JO 771-3
‘SWITCHGEAR WHEN 776-5 MAIN
BREAKER FAILED

SWORT CIRCUIT 3% WIRING IM
NORTHSIDE JUNCTION BOX
ARCING ATE THROUGH WIRE AND
CONDUIT.



Page Ho, 87

71/15/90
EVENT EVEN]
DATE NUMBER

03/19/82 SIR 82-03-771.2

03/24/82 SER 82-03-371.1

06/07/82 SIR 82-84-707.1

Qe STR 82-06-881.1

04/19/82 SIR 82-04-771.1

04/29/82 SIR 82-04-123.1

SUMMARY OF EVENTS

BUILDING

771, RMIL9, LINE 24

371, NDA

1952 TO 1988,

DESCRIPTION

RMSPI #82-5, A GLOVEBOX
CONTAINED 30196 PU, EXCEEDING
THE LIMIT OF 25008.

NMSPI #82-4, A VOLLRATH CAN
OF PUO2 WAS TMADVERTANTLY
PLACED ON THE RIM OF A FULL 10
GALLON SHIPPING CONTAINER.

707, MODULE 8, BOX B-100 CCL4 SPILL. ROLLING HILL

881, RMZ96

OPERATOR LEFT SUPPLY LINE
VALVE OPEN AT END OF SHIFT.
SPRING LOADED DEMAND NOZZLE
FATLED OPEN ON OFF-SHIFT
FILLING GLOVE BOX, FLOWED
THROUGH CRIT. DRAIN AND
CONTAMINATED ROOM OVER 16
HOURS.

TWO SHEETS OF PLYWOOD FELL TO
THE FLOOR AFTER BEING
DISLODGED FROM THE SOUTH
OVERHEAD BRIDGE CRANE. A BOLT
SUPPORTING THE OVERHEAD
DUCTWORK BECAME ENTANGLED WITH
THE PLYWOOD DRAGGING THE
PLYWOOD FROM THE BRIDGECRANE,

771, RMZ47, CHEM. MAKEUP AN IMPROPERLY POSITIONED

123, ANALYTICAL LAB

CAUSTIC FILL VALVE CAUSED THE
OVERFILLING OF A VACIUK SYSTEM
MIST TANK THAT RESULTED IN
11.656 KOH FLOWING ONTO THE
VACUUM SYSTEM EQUIPMENT AND
THE FLOOR OF THE AREA.

AN EMPLOYEE TRANSFERRED 32N
NITRIC ACID TO A PLASTIC
BOTTLE AND CAPPED THE BOTTLE
SECURELY. LATER, THE
PRESSURIZED BOTTLE RUPTURED,
SPRAYING THE CORROSIVE
CONTENTS ONTO TWO EMPLOYEES.

ADDITIONAL NOTES



Page No. 130

15/90
SUMMARY OF EVENTS
1952 To 1988
—_—_——~fverr——— Even BUILDING ~ DESCRIPTION ADDITIONAL NOTES
DATE NUMBER
11/22/85 SUR 85-12-865.1 865, BERYLLIUM B-BOX —_SERYLLIUM RELEASED DUE TO POOR

HOUSEKEEPING, TURBULENCE
CAUSED BY NEG. PRESSURE, AND A
FLOW REVERSAL OF AIR. 100%
CLEAN-UP OF GLOVEBOK IS
IMPOSSIBLE WITH CURRENT DESIGN

OF GLOVES.

11/25/85 UOR 85-5--371 85-2 371/376 ‘A CRITICALITY ALARM SOUNDED
DUE TO A MALFUNCTION IN THE
ALARM.

11/26/85 UOR 85-6--707 85-2 707 A GLOVESOX BREECH RESULTED I

SAAMS ALARMING, POSTIVE
PRESSURE WAS NOTICED IN SOME
OF THE GLOVEBOXES. THE REASON

1S UNKNOWN.
oe UOR 85-6-707 85-2 707, MODULES J,K AN AIR REVERSAL OCCURRED IN TWELVE EMPLOYEES REQUIRED
HOOULE J DUE TO BREACH Tit BODY COUNTS.

GLOVEBOX SYSTEM. MODULE K ROOM
ATMOSPHERE WAS POSITIVE TO
HALLWAYS, CONTRARY TO UTILITY
INSTRUMENTATION READINGS.
INCIDENTS ARE NOT NECESSARILY
RELATED. MINIMUM CONTAMINATION
TW MODULE K. .

11/27/85 SIR 85-12-707.1 707, MODULE 8 ‘A PART CARRIER CONTAINED 3768
G OF MATERIAL, EXCEEDING THE
LIKIT OF 3009 6.

12/03/85 SIR 85-12-771.1 ral EMPLOYEE MIXED BLEACH, WATER,
AND CLEANING AGENT TOGETHER
CAUSING A GAS THAT MADE THE
EMPLOYEE FEEL SICK.

12/03/85 UOR 85-7-771 85-2 771, RMIGS ‘A GLOVEBOX WAS UNDERGOING
CLEANUP AND EXPLODED WHEN
ACETONE IGNITED FROM A SPARK
BY A HOT PLATE.



Page No. 128

11/15/98
SUMMARY OF EVENTS:
r 1952 10 1988
EVENT EVENT BODINE DESCRIPTION ADDITIONAL NOTES

DATE RUHRER

09/19/85 UOR 85-3-771 85-1 771, RMS

09720785 UOR 85-4-707 85-1 707

oe” VOR 85-4--707 85-1 707

09/21/85 VOR 85-4-707 85-1 707, MODULE C, BOX C-110 COOLING WATER HOSE RUPTURED PLUTONIUM CHIPS WERE ADDED

09/22/85 SIR 85-09-P1.1 762, PORTAL t

09/27/85 SIR 85-10-707.1 707

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.

MATER VAS RELEASED INTO PRESSURIZATION, ANO A
GLOVEBOX DUE TO COOLING WATER CONTAMINATION RELEASE.
HOSE RUPTURE. THE DISTILLED

WATER WAS PICKED UP AND

DISPOSED OF IM DEGREASER POTS

CONTAINING CCL4. NEXT SHIFT,

NORMAL DEGREASING RUN WAS MADE

IN THESE POTS. REACTION CAUSED

A FIRE OF CHIPS, GLOVEBOX

A RAPID EXOTHERMIC REACTION
BETWEEN CCL4/H20 AND PU
RESULTED IN A FIRE IN THE BOX
AND SOME CONTAMINATION TO THE
ROOM.

AND DISTILLED WATER LEAKED TO POTS AND UNDERWENT A
INSIDE GLOVEBOX. WATER WAS RAPID EXOTHERMIC CHEMICAL
REMOVED IN CCL4 DEGREASER REACTION WITH CCL4 AND #20.
POTS. POTS WERE NOT DRAINED

AND REFILLED WITH FRESH CCLG

FOR HEXT SHIFT. ON NEXT

SHIFT, POT WAS FILLED WITK

CCL4 UNAWARE THAT H20 WAS

‘PRESENT.

GATE CLOSED ON VEHICLE BECAUSE
GUARD THOUGHT VEHICLE HAD
ALREADY PASSED THROUGH.

WELD OVERPENETRATED A PIT
ASSEMBLY CAUSING THE INSIDE OF
THE CHAMBER TO BECOME
‘CONTAMINATED.



Page to. 98

rf 15/90

‘SUMMARY OF EVENTS

1952 TO 1988

EVENT EVENT
DATE NUMBER

01/13/83 SIR 83-01-121.1
01/24/83 SIR 83-01-707.1
02/01/83 SIR 83-02-771.1
02/08/83 SIR 83-02-447.1

02/15/83 SIR 83-02-371.1

02/15/83 SIR 83-02-883.1

03/01/83 SIR 83-05-707.1

03/06/83 SIR 83-03-707.2

BUILDING

721, PARKING LOT

707, MODULE B

771, RM153, GB 1530

467, RMSO1

371

883, "A" SIDE

707, MODULE B

DESCRIPTION ADDITIONAL NOTES:

AN M-116 TANK CRAWLED UP ON
THE RIGHT REAR CORNER OF AN
AUDI FOX, 2 DOOR SEDAN,

CAUSING EXTENSIVE DAMAGE TO

THE VEHICLE. NO DAMAGE To
TANK.
NMSPE 83-1, TWO PENDANTS ON

CHAINVEYOR 7DS6 (#324 AND
#325) SPACED 48" APART
LIMIT = 54" MINIMUM SPACING.

NMSPI 83-2. PRECIPITATOR POT
LARGER THAN 4-LITERS. POSTED
LIMIT STATED NO CONTAINERS

GREATER THAN 4-LITER CAPACITY.

URANIUM CHIP FIRE. SPARKS
FROM A GRINDING OPERATION WENT
INTO A PAN OF 0-38 CHIPS
IGNITING THEM.

NMSPI 83-3. CONTENTS OF TANK
D-152A APPROVED FOR TRANSFER
TO BLDG 374

TANK D-152BWAS BEING
RECIRCULATED AND VALVE
ALLOWING TRANSFER WAS STUCK
OPEN.

CINCINNATI 1/2 PLATE SHEAR.
OPERATOR HAD TIPS OF TWO
FINGERS SMASHED.

AN EMPLOYEE RECEIVED SECOND
DEGREE BURNS TO HIS RIGHT ARM
WHILE ATTEMPTING TO REMOVE AN
ITEH FROM MOD B PRESSURE
VESSEL.

TEST OF EMERGENCY POWER,
EMERGENCY GENERATOR STARTED
BUT DELIVERED NO POWER. LOSS
OF POWER TO CERTAIN GLOVEBOX
EXHAUST FANS RESULTED IN LOSS
OF NEGATIVE BOX PRESSURE AND
RELEASE OF CONTAMINATION.



Page No. 140

44/15/90
‘SUMMARY: OF EVENTS
r } 1952 TO 1988
EVENT EVENT BOTLDING ~ DESCRIPTION ADDITIONAL NOTES
DATE NUMBER

07/10/86 UOR 86-02-GATES 86-1 OUTSIDE, GATE 9

07/11/86 SIR 86-7-RANGE.1

07/11/86 SIR 86-7-771.2

97/26/86 SIR B7-7-P1.1

07/28/86 SIR 86-7-707.1

07/31/85 SIR 86-7-33546.2

08/01/86 SIR 86-8-371.1

EAST FIREARMS RANGE

771, RMIIG

762, NORTH VEHICLE GT

707

‘A CAR WAS SEEN GOING 42 MPH IN
‘A 25 MPH ZONE, A SECURITY
GUARD CHASED THE CAR AND
RADIOED THE GUARD AT GATE 9 TO
CLOSE THE GATE. THE GATE WAS
CLOSED AFTER THE CAR HAD GONE
THROUGH AND THE GUARD STRUCK
‘THE GATE CAUSING THE VEHICLE
TO ROLL OVER.

GRASS FIRE WAS STARTED BY
TRACER AHMUNITION BEING FIRED
BY & MACHINE GUN DURING RANGE
PRACTICE.

FOUR USED FILTER CARTRIDGES
AMO ONE USED FILTER FOUND IM
LINE THUS EXCEEDING NUCLEAR
MATERIALS SAFETY LIMITS OF
FOUR.

SECURITY INSPECTOR STATIONED
INSIDE BLDG 762 CLOSED GATE ON
GOVERNMENT VEHICLE.

INADVERTENT ACTIVATION OF
CRITICALITY DETECTION-SYSTEM
CAUSING AN UNPLANNED BUILDING
EVACUATION.

‘334, ARMORED PERSNL CAR, WHILE DRILLING A HOLE TO

3?1, RM 3713

INSTALL A BACKING GATE FOR
BATTERING RAM ON ARMORED
PERSONNEL CARRIER, INTERIOR
FUEL BLADDER WAS STRUCK WITH
DRILL AND PUNCTURED.

LOSS OF ROOM VENTILATION
DIFFERENTIAL PRESSURE CONTROL
1N THE BSA CANYON DUE TO
TAMPERING,



Page Wo. 100

1/15/90
r ‘SUNMARY OF EVENTS

1952 TO 1988

BUILDING ~ DESCRIPTION ADDITIONAL NOTES.

DATE WUNBER

04/21/83 SIR 83-04-771.1 771, RMI NMSP1 83-7. LINE 5, PARTS IN
BOTH THE DISSOLVER VESSEL AND
THE LEACHING VESSEL AT SAME
TIME - NOT ALLOWED BY LIMITS

06/22/83 SIR 83-04-707.1 707, MODULE K, GB K-45 —-NMSPI 83-8. MOD K. 2711 G PU
ON SCALE IN K-45. LIMIT =
4500 G PU MAX IN SCALE AND
‘WORK AREA.

04/23/83 SIR 83-04-371.2 371 NMSPI 84-9. CRIT DRAIN IN
SUBBASEMENT FOR GLOVEGOX 80
WAS TAPED UP.

06/26/83 SIR 83-06-371,3 37 MAINTENANCE WORKER RECEIVED
CONTAMINATED ACID BURN TO SKIN
WHILE YORKING IN SUPPLIED AIR.
ACID WAS DRIPPING FROM A
SWAGLOCK FITTING.

05/02/83 SIR 83-05-371.1 371 LEAK OF RADIOACTIVE
CONTAMINATED SOULTION TO
COMPRESSOR ROOM 2101, WHICH IS
A NONRADTOACTIVE CONTROL AREA,

05/09/83 SIR 83-05-371.2 eal WHSPL 83-10. TWO DRUMS WITH
LESS THAN 200 G WERE STACKED
ON THO DRUMS WITH HORE THAN
200 G. LIMITS ALLOW STACKING
ONLY WITH LESS THAN 200 G.

05/15/83 UOR &3-3--371 83-1 374 CONTAMSHATED NITRIC ACID
OVERFLOWED INTO CARBON STEEL
TANKS. ACID CORRODED THESE
TANKS SPILLING ONTO THE FLOOR.

05/17/83 SIR 83-05-463.1 403, CENTRAL STEAM PLANT AN ENGINEER WAS ATTEMPTING TO
LIGHT OFF BOILER #4 ON NATURAL
GAS UNDER ADVERSE WEATHER
CONDITIONS. EXPLOSION OCCURED
CAUSING THE OUTER SKIN AT A
CORNER SEAM TO RUPTURE.



Page No. 86
1415/90

eveut EVENT
DATE NUMBER

02/03/82 SIR 82-02-771.1

02/06/82 SIR 82-01-778.1

02/11/82

7 .. 03/05/82 SIR 82-03-883.7

03/17/82 SIR 82-03-776.1

‘SUMMARY OF EVENTS

BUILDING

771, RM 149, BOX 44

778, LAUNDRY

707, MODULE D

883, HEALTH PHYSICS

‘776, GLOVEBOX 630

1952 TO 1988

DESCRIPTION ADDITIONAL NOTES

A NEEDLE VALVE WAS FOUND TO BE
LEAKING CONTAMINATED NITRATE
SOLUTION, TRE VALVE WAS
‘SUPPOSED TO BE REMOVED BUT DUE
‘TO LACK OF COMMUNICATION, THE
VALVE WAS FORGOTTEN.

THE ADDITIONAL LOAD PLACED ON
JHE LAUNDRY PLENUM FACILITY
BECAUSE OF PLANT POPULATION
INCREASE APPARENTLY CAUSED
HEAT BUILDUP SUFFICIENT TO
IGNITE FINE LINT IN PRE-PLENUN
LINT SCREEN CHAMBER AND
ACTIVATE SPRINKLERS.

MODULE 0. BIRDCAGE FELL OFF
CHAINVEYOR TO RADIOGRAPHY.
CAUSE WAS NOT IDENTIFIED -
CONJECTURE: 1) SWAYING MOTION
FROM STARTING/STOPPING OF
CONVEYOR

2) CARRIER NOT PROPERLY
INSTALLED ON BIRDCAGE

OR 3) BIRDCAGE NOT PROPERLY

INSTALLED ON CHAIN. SIMILAR
INCIDENT OCCURRED ON 4-30-81
(RO REPORT).

‘A HEALTH PHYSICS VACUUM PUMP
WAS SHUT DOWN FOR REPAIRS.

THE DAMAGE TO TRE PUMP FROM
WORMAL WEAR WAS JUDGED
IMPOSSIBLE TO FIX. A NEW PUMP
HAD TO BE ORDERED. THERE IS.
NO BACK UP PUMP OR PORTABLE
PUMP TO TAKE ITS PLACE UNTIL A
NEW PUMP ARRIVES.

PIPEFITTERS WERE CLEANING OUT
TRE PRIMER CONTAINER , WHICH
CONTAINED A HARD MATERIAL LIKE
SLUDGE, WITH A BAR. DURING
THE CLEANING A SPARK AND FLASH
OF FIRE RESULTED. IT WAS
DETERMINED THAT THE BOX
CONTAINED OVER 10% OXYGEN.



Page No. = 127

11/15/90
SUMMARY OF EVENTS:
1952 To 1988
EVENT. EVENT. ELDING. DESCRIPTION ADDITIONAL NOTES.
DATE NUMBER

10/26/84 SIR 84-11-707-1

11/07/84 SIR 86-44-771.2

11/14/84 SIR 84-11-883.1

oe” SIR 86-11-6462.

: W2IT2/BA SIR 84-12-7771

T2s13/84 SIR 84-12-8811

T2/16 86 SIR B-12-771.2

12/17/84 SIR 85-01-707.3

707,

883,

MODULE K FURNACE

OY LEACH PART CABINE

PIT FURNACE

FILTER TEST FACILITY

RAI31, BOX 601

SPRINKLER SYSTEK

RHI6G, BOX 83

MODULE B

HATERIAL MEANT FOR A FIGURE 8
MOLD WAS POURED INTO A FEED
INGOT MOLD. THIS VIOLATED THE
LIMIT FOR INGOT HOLDS BY 681
s.

THE MASS LIMIT WAS EXCEEDED
FOR A STORAGE SHELF. 3 PARTS
WERE ON SHELF AND ONLY 2 ARE
ALLOWED.

WHILE CHECKING A CONTRO
CIRCUIT WITH A BECKHAN METER,
THE INTERNAL METER OR TEST
LEADS SHORTED AND BURNED THE
HANDS OF A MAINTENANCE
ELECTRICIAN.

‘A PENETROMETER, WHICH TESTS
LARGE BEPA FILTERS, OVERHEATED
AND WAS SHUT DOWN, BUT
OVERHEATING CONTINUED. THE
PENETROMETER’S AUTOMATIC
‘SHUT-OFF FEATURE BYPASSES THE
ELECTRICAL SOLENOID WHICH WAS
CAUSING THE OVERHEAT.

AN INGOT TO BE ROLLED WAS
THICKER THAN THE ALLOWABLE
LIMIT FOR ROLLING.

A DELUGE VALVE OPEMED WHER THE
FIRE DEPT. WAS WORKING ON A
DEFECTIVEHEAT DETECTION HEAD.
‘THE VALVE OPERATING THE
‘SPRINKLER SYSTEM SHOULDHAVE
BEEN CLOSED.

213 G PU WAS IN BOX 83
EXCEEDING THE 200 G LIMIT

A MAM LOST HIS BREATHING AIR
WHILE IN SUPPLIED AIR SUIT DUE
JO A KINK IN HIS HOSE, HE
REMOVED HOOD AND PLACED HIS
RESPIRATOR ON WITH A HOT GLOVE
CAUSING INTERNAL
CONTAMENATION.


Page No. 109

““

SUMMARY OF EVENTS

1952 TO 1988

- EVENT EVENT
DATE NUMBER

01/30/84 SIR 84-02-776.1

OT/31/84 SIR B4-O1-045.1

02/02/84 SIR 84-02-707.1

@.... SIR 86-02-371.1

02/06/84 SIR 86-02-371.4

02/06/86 SIR 84-02-707.2

02/06/84 SIR 84-02-771.2

* BUILDING

776, SIZE REDUCTION

ahh,

707

371

371

707, BOX C-60

DESCRIPTION

‘A MISLABLED DRUM OF MATERTAL
WAS PACKED INTO A MASTE BOX
WHICH EXCEEDED THE 350 G LIKIT
ON THE BOX.

AM NOT TECHNICIAN WAS REMOVING
SOME FILM WHEN HE NOTICED THE
GAMMA ALARMS FLASHING RED.
HEALTH PHYSICS CHECKED AREA
AND FOUND NO GAMHA RADIATION.
ALARM APPARENTLY
MALFUNCTIONED .

NMSPT 84-6. HS&E AREA MGR
GAVE VERBAL INSTRUCTIONS TO
PROD CONT EMPLOYEE WHICH
VIOLATED ESTABLISHED HANDCARRY
LIMITS.

ROOMS 1117, 1125, 1115, 1105.
2500 GALLONS OF POTASSIUM
HYDROXIDE WAS RELEASED WHEN
CPVC VALVE FAILED.

A SHIPPING CONTAINER WAS
LABELED AS EMPTY WHEN IT
ACTUALLY CONTATHED FLOURINE.
‘THE CONTAINER WAS TRANSFERRED
FROM 371 TO 771 BEFORE IT WAS
FINALLY NOTICED.

NMSPS 84-8. NUMBER 7 HEALD
AXIMATIC W.C."TTM BASE LATHE
BOX 70-60. OL PAM EXCEEDED
MAXIMUM 2" DEPTH.

771, RMI82, 707, A, J, K NNSPI 86-7. BLDG 71 AND 707.

NON-APPROVED FURNACE
EQUIPHENT (SCREENS) USED ON
TOP OF FUNNELS DURING CASTING.
ALL FURNACE EQUIPMENT MUST RE
APPROVED BY CRIT ENGR.

ADDITIONAL NOTES



Page No. 85

‘SUMMARY OF EVENTS
1952 To 1988

14/15/90
__ EVENT ____ EVENT

DATE NUMBER

09/21/81 QUTSIDE, NORTH OF PLANT

0702/81 OUTSIDE, PARKING LOT

10/29/81 865, RMIGS

94/03/81 447, RMGOEB

49725781 444, RATIOS

12/22/81 123, RM1Z6

rosie SIR 82-01-559.1

559, RM102, BOX C-19

01/20/82 $1R 82-01-371.1 371, ANALYTICAL LAB

01/28/82 SIR 82-01-123.7 123, RM131

ADDITIONAL NOTES

10 ACRES OF GRASSLAND BURNED.

LEAKING TRANSMISSION FLUID
OVERREATED AND IGNITED IN
ENGINE COMPARTMENT.

RIGH TEMPERATURE IN FURNACE
CAUSED VAPORIZATION OF ZINC.
TEMP. CONTROL CONTACTS STUCK.

METAL CHIPS IGNITED IN WOODEN
‘SHIPPING BOX.

METAL TURNINGS IGNITED ON
LATHE

TRANSFORMER ON BE ANALYZER
IGNITED.

‘A CRUCIBLE BEING REMOVED FROM
AN INDUCTION FURNACE FELL AND
ROLLED INTO A PLASTIC SAMPLE
RACK. THE EDGE OF THE SAMPLE
RACK THEN CAUGHT FIRE. THE
FIRE WAS OUT UPON THE ARRIVAL
OF THE FIRE DEPARTHENT.

TAPE, HOLDING SAMPLES OF
BARIUM AND CESIUM TOGETHER,
STUCK TO THE SLEEVE OF SOME
COVERALLS AND WAS THROWN INTO
THE LAUNDRY. THE “HOT
COVERALLS WERE RECOVERED ON
JAN. 21 WHEN THEY SET OFF THE
SURVEILLANCE INSTRUMENTS OF
‘THE RADIATION HONITORS..

‘A CARDBOARD BOX WITH 233
RADIOACTIVE SOURCES WAS
INADVERTANTLY DISCARDED AS
BUILDING TRASH. THE BOX WAS
SITTING ON THE FLOOR ALONG
WITH OTHER BOXES CONTAINING
BUILDING TRASA..



Page No. = 133

~

‘SUMMARY OF EVENTS
1952 10 1988

DESCRIPTION =

VERT

EVENT.
. ‘NUMBER

DATE
01/31/85 SIR 86-01-776.1
92/01/86 SIR 86-02-707.3
02/04/86 SIR 86-02-881.17

02/05/86 SIR 86-02-707.1

02/06/86 SIR 86-G2-559.%

®

02/15/86 SIR 86-02-444.2

02/15/86 SIR 86-02-7711
02/18/86 SIR 85-11-771.2

02/20/86 SIR 86-02-771.2

77%,

707,

707,

559,

466,

ral

SIZE REDUCTION

MODULE B

NEUTRON GENERATOR

MODULE B

RUIZ

FENCE PROJECT

RAMS

RMII4, LINE 19

ADDITIONAL NOTES

LOW AIR FLOW IN SUPPLIED AIR
SUIT CAUSED WORKER TO BECOME
TLL.

SCRAP METAL ON A BLANKING
PRESS EXCEEDED LIMITS OF 200 G
BY 152 G.

A NEUTRON GENERATOR ASSEMBLY
DROPPED 12 FEET WHEN THE HOIST
MECHANISM FAILED,

OIL IN FURNACE CAUGHT FIRE
WHEN PLASTIC LINE MELTED. PUT
OUT BY WORKERS.

A MATERIAL CONTROL CARD WAS
NOY FILLED OUT FOR A CONTAINER
AND THE CONTAINER WAS NOT
WEIGHED PRIOR TO THE ADDITION
OF MORE MATERIAL,

LADDER PROPPED AGAINST STEEL
POST SLIPPED CAUSING EMPLOYEE
TO FALL CUTTING HIS SIDE.

CONTAMINATED EMPLOYEE.
SENSITIVE REPORT.

‘TWO CONTAINERS COMBINED
EXCEEDED LIMIT OF 2500 G PU.

‘A VAC TRAP WOULD NOT DRAIN AND CONDENSATE TO LEAK OUT.
IW AN ATTEMPT TO FIX THE
PROBLEM, AM OPERATOR FELT
DROPS OF LIQUID FALLING ON HIS
HEAD. HE WAS Found
CONTAMINATED AND TAKEN TO
MEDICAL. IT WAS DETERMINED

THAT A WELD IM THE NECK FLANGE
HAD FAILED, ALLOWING STEAM

FURTHER INSPECTION FOUND 4
VAC TRAPS WITB FAULTY WELDS.



Page No. 117

T 5/90

SUMMARY OF EVENTS

O7/13/86 SIR 8-07-771.2

07/17/84 SIR 84-07-865.1

07/17/84 SIR 84-07-886.1

07/20/84 SIR 84-07-371.2

07/20/84 UOR 84-4-550 86-1

07/20/84 SIR 84-08-707.5

07/20/84 SIR 84-07-889.1

07/22/86 SIR 86-08-771.1

BUILDING

771, RMIN6, LINE &

865

886

371

550, TOWER B-3

707, BOX A-GS FURNACE

B89

771, RHISS A,B

1952 To 1988

DESCRIPTION

CRITICALITY DRAIN GVERFLOWED
‘WHEN AUTOMATIC SHUTOOWN VALVE
FATLED.

A HEATING FURNACE CONTAINING
URANIUM WAS DROPPED OFF A
TRUCK CAUSING CONTAMINATION TO
THE ROAD.

CRITICALITY ALARM SET OFF WHEN
BEING CHECKED BY TECHNICIAN.
HE IMMEDIATELY TURNED OFF THE
ALARM CAUSING A NEW EMPLOYEE
TO BE CONFUSED AND KOT
EVACUATE THE BUILOING.

10 GALLON AND 55 GALLON DRUHS
WERE MIXED IN A SHELF SECTION
WHICH IS NOT ALLOWED.

‘A GUARD ALTERING THE GRIP OF
HIS PISTOL WITH SANDPAPER
ACCIDENTALLY FIRED IT INTO.A
BULLET PROOF WINDOW.

THE PAPERWORK FOR MACHINING A
PART DID NOT AGREE WITH THE
PART LTSELF. 17 WAS
DISCOVERED THAT TRE WRONG MOLD
WAS USED DURING CASTING. THE
CHARGE DID NOT EXCEED WEIGHT
LIMITS, HOWEVER.

URANIUM CHIP FIRE IN A DRUM
CAUSED BECAUSE MATERIAL
IMPROPERLY PACKAGED FOR,
TRANSPORTATION. THE WATER
SURROUNDING THE CHIPS LEAKED
OUT EXPOSING THE CHIPS TO AIR.

A 30 GALLON BAG, USED TO HOLD
DECONTAMINATION SUPPLIES, HAD
NO SLITS CUT IN IT TO PREVENT
ACCUMULATION OF SOLTH.

ADDITIONAL NOTES



Page No. 126

11/15/90
‘SUMMARY OF EVENTS
1952 TO 1988 ee

EVENT eveNT BUILDING DESCRIPTION ADDITIONAL NOTES
DATE NUMBER
07/01/85 SIR 85-07-771.1 771, RING ‘A FULFLO FILTER WAS SPACED

ONLY 6" FROM A FILTER CANISTER

WAICH WAS IN USE, THIS

VEOLATED THE SPACING

REQUIREMENTS,
07/11/85 SIR 85-07-774.2 774, RBS PACKAGE OF IMPURE PUO2 WEIGHED

3861 G WHILE LIMIT IS 2500 G.
07/17/85 UOR 85-2-779 85-1 779, RMIEO ‘A RESEARCH FURNACE LEAKED

07/17/85 VOR 85-2-779 85-1

97/18/85 SIR 85-07-664.7

97/19/85 SIR 85-07-71.4

07/23/85 SIR 85-07-771.3

664, WASTE CRATES

771, UTILITIES

TP1, RMIBT

RADIOLOGICAL CONTAMINATION
WHEN IT OVERHEATED CAUSING A
FIRE, A SACK UP CAN USED TO
CONTAIN RADIOLOGICAL
CONTAMENATION LEAKS WAS NOT
USED.

A CONTROLLER OF FURNACE WAS
OPERATED IN- MANUAL MODE
CAUSING HEAT AT 99% OF MAXINUM
RATE. A CRUCIBLE RUPTURED AND
NO SECONDARY CONTAINMENT CUP
WAS USED. THE ALLOY BECAME
MOLTEN. THE GLOVEBOX
ATMOSPHERE WAS BREACHED
RELEASING CONTAMINATION TO
ROOM eben

A CRATE CONTAINED FILTERS
HAVING ~14 & PU IK A ONE
CUBIC FOOT AREA. THE
ALLOWABLE LIMIT IS 5 G PU INA
ORE CUBIC FOOT AREA,

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.



Page Wo. = 112

31/15/90
SUMMARY OF EVENTS
1952 70 1988
EVENT -—— EVENT BUT TG DESCRIPTION ADDITIONAL NOTES
DATE UMBER

93/26/84 UOR 84-02-76

03/28/84 SIR 84-03-444.1

03/30/84 SIR 86-03-771.2

Osx. SIR 86-06-750.1

03/31/84 SIR 84-03-771.3

03/31/84 SiR 86-05-771.4

04/04/84 SIR 84-04-371.1

7%

44

771, RMI16, LINE 3

707

77

AM ELECTRICIAN RECEIVED A LUKG
BURDEN. PROBABLY FROM
SERVICING A CONTAMINATED PUNP
WHICH HE BELIEVED TO BE
UNCONTAMINATED~

‘A CYLINDRICAL PART WAS PLACED
ON THE MAGNETIC CHUCK TO GRIND
SURFACES. IT CAME LOOSE AND
TRE EMPLOYEE REACHED FOR IT
WITH MIS RIGHT HAND, INJURING
HIMSELF.

NHSPI 84-16, PAN OF FISSILE
MATERIAL LESS THAN 12" E-€-
FROM OTHER FISSILE MATERIAL
AND GREATER THAN 2" IN DEPTH
IW PAN CHEAPED).

FISSILE MATERIAL OF OVER 200 G
WAS HAND CARRIED OUTSIDE OF A
BUILOIHG.

NITRATE SOLUTION DRIPPED ON
EMPLOYEE FROM TRANSFER LINE.
LEAK DUE TO POOR WELDING JOB.
AREA AND EMPLOYEE
* CONTAMINATED.

771, RM169, FILE CABINET A FILING CABINET CONTAINED

371, RMIT

VIALS HOLDING PU OF ABOUT 20¢.
THE VIALS WERE RETURNED TO
THE GLOVEBOX IN ROOM 128.

MAINTENANCE PIPEFITTER
INSTALLED TWO GASKETS RATHER
THAN LENGTHENING VALVE. THE
GASKETS BLEW OUT RESULTING IK
CONSIDERABLE AMOUNT OF LOW
LEVEL CONTAMINATED LIQUID OW
‘THE FLOOR.



Page No. 96
11/15/90

41/16/82 VOR 82-707.05

11/16/82 SIR 82-11-771.1

11/16/82 SIR 82-11-883.1

11/22/82 SIR 82-11-7712

oe” ‘WOR 82-883.06

12/08/82 SIR 82-12-3711

12/10/82 SIR 82-12-777.1

707, MODULE B

771, CAFETEEN

cal

883

Kias

A FURNCE OVERHEATED MELTING
THE LEAD SHIELD. THE
INSULATION IN THE FURNACE
CAUSED HEAVY SMOKE.

EMPLOYEE CONTAMINATED 8Y
CAFETEEN TABLE.

THE OPERATION IS A TIG WELD OF
DEPLETED URANIUM IN A WELDING
BOOTH. OPERATOR RECIEVED ARC
BURN TO HIS EYES.

TWO CHEMICAL OPERATORS
REMOVING AND PACKAGING RASCHIG
RINGS BECAME HYPERVENTILATED,
WHICH MADE THEM FEEL DIZZY.

AN EXHAUST FAN OVERWEATED
WHICH CAUSED THE BEARINGS TO
SEIZE, BENDING THE SHAFT AND
CAUSING THE FAN TO SELF
DESTRUCT. THE GEAR BOX
STARTED ON FIRE.

OPEN FLAME EMITTING FROM THE
BOTTOM OF ELECTROREFINING
TILT-POUR FURNACE #8. ARGON
SHUT OFF AND FURNACE ALLOWED
TO COOL.

AN OPERATION WAS BEING
PERFORMED TO MIX THE MOLTEN
SALT BATH IN THE BE
ELECTROREFINING CELL. AN
ARGON SUPPLY HOSE WAS BLOWN
OFF ITS CONNECTION TO THE
SPARGING TUBES. MOLTEN SALT
WAS FORCED OUT THE TUBES AND
‘SPRAYED TWO EMPLOYEES
RESULTING IN BURNS.

ADDITIONAL NOTES



Page No. 134

11/15/90
SUMMARY OF EVENTS
6 4952 To 1988
———--— EVENT ——— EVENT BUTUOTRG DESCRIPTION ADDITIONAL NOTES |

DATE NUMBER

02/27/86 SER 86-02-771.3 771, 200 FLR, INCINER FIL DUE TO A LACK OF ARGON TO A
WELDING TORCH, IT SPARKED AND
FLYASH BEGAN TO SMOLDER ON A
FILTER.

03/05/86 SIR 86-03-444.1 444, PRECISION SHOP ELECTRICAL INSULATION WAS WORN
‘OFF BY A CORNER OW A TRAY.
THIS CAUSED SPARKS, IGNITING
OIL IMPREGNATED LINT AWD DUST.

03/06/86 SIR 86-03-776.1 ‘776, FBI ‘SAMPLE WAS OPENED WITHOUT
RESPIRATORY PROTECTION OR A
RADIATION MONITOR PRESENT.
SAMPLE WAS CONTAMINATED.

03/10/86 SIR 86-3-664.1 664, CRATE COUNTER LSA WOODEN CRATE PUNCTURED BY
FORK LIFT

03/17/86 SIR 86-3-775.1 771, WMI16, LINE 3 NHSPT 86-7. OPERATORS

03/19/86 SIR 86-05-774.1 774, RMZO2
03/24/86 SIR 86-03-707.1 707, NCA SYSTEM
03/24/86 SIR 86-03-707.2 707

INTRODUCED THO 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 GRAMS WHICH IS OVER THE
LIMIT OF 5000 GRAMS FOR THE
AREA.

12 NORMAL NITRIC ACID WAS
SPILLED WHEN AN OPERATOR WAS
TRYING TO DESCALE A BUBBLER
TUBE. THE OPERATOR RECEIVED
BURNS ON HIS KNEES.

‘TWO NEW CRITICALITY ALARHS:
WERE INADVERTENTLY SET OFF IN
DT.

A CRITICALITY ALARH SOUNDED
AND THE UTILITY OPERATORS ON
DUTY DID HOT EVACUATE AND
REPORT TO THEIR ASSEMBLY AREA.



Page No. 136°

11/15/90
SUMMARY OF EVENTS
@ 1952 To 1988
EVENT EVENT BUILDING DESCRIPTION ADDITIONAL NOTES
DATE NUMBER,

05/05/86 SIR 86-05-771.2 771, RMITG, LINE 7

05/05/86 SIR 86-05-69.1 900, GATE
05/06/86 SIR 86-05-771.3 771, RH269
05/10/86 SIR 86-05-777.4 771, RM267

05/16/86 SIR 86-05-771.6 771, RMIIG, LINES 6,7

05/22/86 SIR 86-5-121.4 421, SOUTH PARKING LOT

NMSPT #86-11, TWO CONTAINERS:
WERE SPACED LESS THAN 12"
APART AND 3047G PU WERE
PRESENT IN AN AREA WHERE OWLY
25006 ARE ALLOWED.

GATE WAS ACTIVATED FOR CLOSING
BY A GUARD IW RESPONSE TO A
SCANNER ALARH, A DRIVER WAS
NOT PAYING ATTENTION AND RAN
INTO THE CLOSED GATE.

NEGATIVE ON TRE INCINERATOR
PLENUM AZRLOCK WAS NONEXISTENT
DURING UNDRESSING OF PERSON IN
‘SUPPLIED AIR SUIT CAUSING
PERSON TO BECGHE CONTAMINATED.

THIS HAPPENED BECAUSE BOTH
EQUALIZER VALVES WERE CLOSED
AT THE SAME TIRE.

AM OPERATOR WAS FILLING A
NITRIC ACID HOLDING TANK. THE
VALVE TO THE SIGHT GLASS, USED
TO OBSERVE THE LEVEL OF THE
TANK, WAS CLOSED AND THE TANK
OVERFLOWED. “THE OPERATOR
RECEIVED ACID BURNS OVER 12%
OF HIS BODY.

‘TWO CHEM. 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.

HOT GASES EMITTED BY MILES
{LASER GUN) EQUIPMENT DAMAGED
PAINT ON PARKED CARS DURING
SECURITY EXERCISES



Page No. = 9

oe”

event “EVENT
DATE HUMBER

03/06/83 SIR 83-03-WES.2

03/17/83 SIR 83-03-774.1

03/24/83 UOR 83-1--776 83-7

03/25/83 SIR 83-03-771.2

SUMMARY OF EVENTS.
1952 To 1988

BUILDING

250, WIND SITE

‘771, CAFETEEN

776, RM161 Nv CORNER

771, RMIS9, LINE 33

B05 UOR 83-2--SAGE 83-1 881, 374 TRANSFER

06/15/83 SIR 83-04-371.1

04/15/83 SIR 83-04-776.2

04/18/83 SIR 83-04-1883.1

04/19/83 SIR &3-04-707.2

Kia

776, SR-4 TANK

865, OUTSIDE

707, MODULE J, BOX J-10

DESCRIPTION

SHORT CIRCIUT 1M 480 VOLTAGE
CABLE CAUSED A MINOR EXPLOSION
UNDERGROUND BENEATH T-11
‘TRANSFORMER.

ICE CREAM FREEZER COMPRESSOR
EXPLODED WHEN COMPRESSOR
FAILED TO SHUT DOWN AFTER
REACHING COOLING SET POLNT.

A PRESS BREAKDOWN RESULTED IN
‘APU FIRE.

INCINERATOR DRUM FILTRATION
LINE, PROCESS WATER LINE WAS
CONTAMINATED WITH 3 MOLAR
CAUSTIC (KOH) AND PLUTONIUM AT
LINE 33.

WASTE BEING PUMPED INTO VALVE
VAULT ACCIDENTALLY, CAUSING
OVERFLOWING. ALARM SIGNALING
MOISTURE IN VAULT FAILED,

NHSPI 83-6. PLASTIC PEN
CONSTRUCTED AROUND TANK D-2938
was not 'suiT. 7”

NMSPI 83-5. MTCE OPRN ON TANK
‘SR-& HAD TEMP LIMIT FOR MAX
SIZE 1-LITER CONTAINER.
ACTUAL CONTAINER IN USE WAS
Two LITERS.

SEVERE ANKLE SPRAIN SUFFERED
BY SECURITY INSPECTOR WHO FELL
INTO AN EXCAVATION WHILE
RESPONDING TO AN ALARM.

WHILE BURNING SCRAP, BELIEVED
CONTAMINATED WITH CCLS, 18 THE
OXIDE FURNACE, EXPLOSION
OCCURRED SENDING SHRAPNEL
THROUGH THE GLOVE BOX HEPA
INTAKE FILTER CONTAMINATING
MODULE J.

ADDITIONAL NOTES