3.1.1 Define the Scope of Work

In regard to training, FESHM 7010 required all subcontractors to provide safety training, medical surveillance, and safety equipment for their employees. FESHM 7010 also required all subcontracts to contain a statement formally notifying the subcontractor and all sub-tier contractors that they were required to maintain records of training completed by all personnel working at Fermilab.

S. A. Healy was required to provide a job safety orientation to all subcontractor and sub-tier contractor employees, based upon the hazard assessment. Subcontractors performing work at the Laboratory were required to provide their employees with any ES&H training required by Federal, state, and Fermilab regulations, and as appropriate for their subcontracted operations. Examples of training deficiencies included:

• The S. A. Healy Safety Director did not meet the contractual minimum requirements specified for that position, which consisted of one of the following: (1) current registration as a professional engineer by the state of Illinois, (2) professional certification as a certified safety professional, (3) professional certification as a certified industrial hygienist and three years of underground professional experience in the area of safety, or (4) a minimum of 10 years of heavy underground construction experience in safety management in similar projects.

• A Competent Person was defined in the S. A. Healy-Fermilab contract as the designated subcontractor employee with knowledge of OSHA and other related safety standards, and who had the authority to enforce such standards. Fermilab also required the subcontractor Competent Person to have completed a 30-hour construction safety course, or equivalent. Neither Fermilab, S. A. Healy, nor Layne-Western ensured that Layne-Western employees assigned to the EAV-2/EAV-3 work were trained and qualified in accordance with the Competent Person training requirements. This situation was further evidenced by the employees’ inability to recognize some safety concerns at the job site.

• Layne-Western personnel were not adequately trained as required by 29 CFR 1926 or as necessary in accordance with all requirements pertinent to the hazards associated with the job, such as personal protective equipment, fall protection, hazard communication, hearing conservation, hoisting and rigging, and first aid.

• Layne-Western personnel were not adequately trained and qualified as Competent Persons to recognize safety hazards at the job site and perform hazard analyses, or to abate the several potential imminent-danger situations identified by the Board following the accident. Although recent efforts were made by Fermilab and S. A. Healy to increase subcontractor knowledge of hazard analysis, the information was not shared with Layne-Western employees since they were not included in the two safety stand-downs and the related training.

The Board concluded that the occupational safety and health policies, programs, and procedures for worker safety and health were not routinely implemented or enforced.

3.1.4 Perform Work Within Controls

Controls must be identified and implemented before starting work. Examples where necessary controls were not implemented on the Layne-Western EAV-2/EAV-3 drilling activity being performed at the time of the accident included:

• S. A. Healy did not impose controls equivalent to those specified by FESHM 7010 to assure that Layne-Western would operate safely. S. A. Healy did not require Layne-Western to perform a number of expected operations equivalent to Fermilab ES&H contract submittal requirements specified in FESHM 7010, before initiation of work.

• S. A. Healy did not require Layne-Western to summarize its past safety performance as required under "Qualification of Subcontractors." Layne-Western did not submit a copy of its ES&H Plan as required under FESHM 7010, "Safety Plan Review." Layne-Western did not complete a pre-construction checklist equivalent to ES&H Administrative Form #19.

• The hazard analyses included in the Layne-Western Safety and Health Manual were generic and not tailored to the specific drilling activity for EAV-2/EAV-3.

• The hazard analysis generated the day of the accident did not address either the hazards of the drilling operations or the appropriate controls, nor was it reviewed or approved.

• Layne-Western performed work from September 25, 2000, until the day of the accident without a hazard analysis.

• Fermilab procedures required current excavation permits and burn permits to be attached to the hazard analysis. These permits were not attached to the Layne-Western job hazard analysis. Although an excavation permit was issued for the EAV-2/EAV-3 drilling activity on October 6, 2000, the permit expired seven days after it was issued, and the permit was not extended or updated.

• Fermilab and S. A. Healy did not compare the work operations being conducted to the hazard analysis generated on the day of the accident to verify that safety hazards were adequately identified and appropriate controls established. Evidence indicated that neither the FAO, Fermilab, S. A. Healy, nor Layne-Western line and safety management had reviewed the work activity to evaluate occupational safety hazards, hazard control and abatement, or performance of work since Layne-Western began drilling operations on September 25, 2000.

• Pre-job briefings were informal, not documented, and not effective in conveying the extent of hazards. A work package with a step-by-step review process was not used.

• Work was not performed using appropriate controls, and actions that would be expected as a condition of formally authorizing initiation of work were not implemented.

The Board concluded that because the scope of work was not adequately defined, task-specific hazards could not be analyzed and work could not be performed within controls.

Feedback and improvement processes for Fermilab subcontractor construction projects consisted of the following mechanisms: assessment processes, analysis of performance information, reporting DOE accident/incident information, corrective action processes, and lessons-learned processes. These mechanisms formed the core of a continuing improvement process for Fermilab subcontractor construction projects.

The Office of the Deputy Assistant Secretary for ES&H Oversight had responsibility for performing independent ES&H oversight of DOE sites. This office had not performed oversight of Fermilab or the NuMI Project.

The Office of High Energy and Nuclear Physics in the Office of Science had the responsibility for the programmatic and technical overview of the NuMI Project. Since November 1998, the Office of Construction Management Support within the Office of Science had conducted six reviews of the NuMI Project, including ES&H. These reviews included ES&H recommendations to the Fermilab Director, although they were not communicated in ISM terms.

Subsequent reviews by the Office of Construction Management Support evaluated the effectiveness of the actions to address the recommendations of the previous review. However, corrective actions addressing recommendations made by the Office of Construction Management Support were not tracked in the Fermilab Environment Safety Health Tracking (ESHTRK) database, or in any other database.

No corrective action plans were developed, although some corrective actions were undertaken. For example, the draft May 22-24, 2001, review report indicated that the Fermilab organizational structure for the NuMI Tunnel and Halls Project was "complex and unwieldy," and that responsibilities and authorities were "confused, and a number of people involved do not have relevant underground construction experience." The review report also noted that the current management structure "is not effective for managing this critical stage of the S. A. Healy tunnels and halls construction contract." A reorganization was under way at the time of the accident.

The Chicago Operations Office Safety and Technical Services organization provided ES&H support to the FAO, as requested. The Chicago Operations Office Manager did not perform independent ES&H oversight of Chicago Operations Office line organizations. Since participating in the October 1999 combined Phase I and II ISM verification of Fermilab, Safety and Technical Services had not been asked to provide technical support to the FAO, or independent oversight on behalf of the Chicago Operations Office Manager. In particular, Safety and Technical Services had not been asked to provide support of safety oversight of NuMI Project construction operations or review of subcontractor safety management at Fermilab.

The Office of Science Functions, Responsibilities, and Authorities Manual, dated June 30, 2000, identified the Office of Science as primarily involved in providing direction and defining scope of work, while Operations Office managers oversee their contractors’ performance in analyzing hazards, developing and implementing controls, providing feedback, and pursuing improvement. The document noted that the Chicago Operations Office Manager had responsibility for "day-to-day" oversight of contractor operations, but that organizational elements of the Office of Science had responsibility for appraising the performance of the Chicago Operations Office Manager and maintaining "executive-level" awareness of contractor operational performance.

In describing how the Office of Science exercised the functions, responsibilities, and authorities for measuring the adequacy of line management oversight, the document noted that monitoring of the Chicago Operations Office Manager and associated contractors would be accomplished by (1) reviewing information provided by the Chicago Operations Office; (2) when appropriate, participating in Chicago Operations Office appraisals; and (3) conducting onsite reviews of Chicago Operations Office performance, including verification of appraisal of the contractors.

FAO had line management oversight responsibility for programs, projects, and facilities at Fermilab. For the NuMI Project, the FAO Manager assigned, with the approval of the Director of High Energy Physics, a project manager who was responsible for day-to-day execution of the project. The DOE NuMI Project Manager’s responsibilities included monthly project performance reviews and assurance that the NuMI Project complied with ES&H and contracting regulations. He performed bi-weekly inspections of the project using a standard form to document ES&H concerns. The concerns identified during each inspection were reviewed during subsequent inspections to ensure that corrective actions were implemented. Inspections conducted by the DOE NuMI Project Manager addressed general project safety, but lacked in-depth information on the status of compliance with 29 CFR 1926 and Fermilab requirements. Inspection forms were contained in project files but were not used as input to the ESHTRK system or any other project database. An FAO staff member performed two inspections of the EAV-2/EAV-3 job site, but these inspections concentrated on environmental protection issues and were not documented. FAO operational awareness reviews did not cover the NuMI Project. Figure 3-2 displays the DOE organizational relationships for management of the NuMI Tunnels and Halls Project.

Figure 3-2.  DOE NuMi Organizational Chart

Feedback and improvement processes at Fermilab were described in the Fermilab Integrated Safety Management Plan, Revision 3, August 2000. For subcontractor construction projects, performance evaluations and self-inspections were used as feedback mechanisms. The FESHM required that all subcontractors have their past safety performance evaluated and approved before award of any construction contract equal to or greater than $25,000. The fixed-price subcontract agreement executed by S. A. Healy and Layne-Western, effective September 13, 2000, exceeded $25,000 and therefore required a safety evaluation, but no evaluation was performed for Layne-Western. The Board requested safety statistics to evaluate Layne-Western’s safety performance before award of the Layne-Western contract, and was provided with incomplete information. The documentation provided indicated that the recordable injury rate for one year before award of the Layne-Western contract was 4.55.

S. A. Healy lacked a formal evaluation process for selecting subcontractors to perform work under their control. Selection of Layne-Western to perform drilling operations for the NuMI Project was based on S. A. Healy’s knowledge of Layne-Western. In addition, Fermilab had not used the evaluation process documented in FESHM 7010 to evaluate and approve Layne-Western’s past safety performance. Fermilab management considered it the responsibility of S. A. Healy to select its own subcontractors.

The Fermilab Self-Assessment Program Plan assigned the responsibility for performing assessments of ES&H performance to Fermilab divisions and sections. The Beams Division, which had responsibility for the NuMI Project, assigned management of civil construction to the Facilities Engineering Services Section. According to this plan, the assessments were to be conducted by comparing performance against established requirements. Findings were to be tracked in the ESHTRK system, and analyzed for root causes and trends. Action plans were to be prepared and tracked until all corrective actions were completed. The Facility Engineering Services Section had not conducted a construction safety assessment of the NuMI Project to evaluate the performance of S. A. Healy and Layne-Western against requirements contained in the Fermilab-S. A. Healy contract, FESHM, or 29 CFR 1926.

FESHM 7010 required construction subcontractor safety performance to be monitored using inspections performed by the construction coordinators in accordance with the Fermilab Subcontractor Construction Safety Program. The Subcontractor Construction Safety Program in FESHM 7010 required the ES&H Section and/or the Senior Safety Officer of the landlord division—in this case, the Facility Engineering Services Section—to perform oversight inspections of construction sites.

Program requirements stipulated that non-conformance with safety standards must be documented, along with the corrective actions determined by line managers. Inspections and surveillances of work performed by S. A. Healy and Layne-Western were conducted by both the NuMI Project construction coordinators and a safety engineer from the ES&H Section. The inspections of Layne-Western focused on environmental issues and not occupational safety. FESHM 7010 also required that random inspections of subcontractor owned tools may be performed by the construction coordinators and ES&H Section construction safety personnel. No inspections of contractor-owned tools associated with the Layne-Western drill rig were performed either by the construction coordinators or by Fermilab ES&H.

In accordance with their company safety manuals, both S.A Healy and Layne-Western assigned responsibilities to safety personnel to conduct job site safety inspections. The S. A. Healy Safety Officer had not recorded observations resulting from daily safety inspections. The Operator, who was the designated Competent Person and safety supervisor, documented two semi-annual inspections of the drilling rig. Layne-Western was unable to provide documentation of the required daily inspections, nor was there evidence that any inspections identified the existing safety deficiencies at the job site. Prior to the accident, Fermilab personnel had not documented any job site safety inspections of drilling operations by Layne-Western.

The Board analysis of feedback and improvement processes indicated that:

• The requirements for ES&H line management oversight by the Office of Science Functions, Responsibilities, and Authorities Manual were not being fully implemented.

• Since participating in the October 1999 combined Phase I and II ISM verification of Fermilab, Safety and Technical Services Support was not requested to provide technical support to the FAO, or to perform independent oversight on behalf of the Chicago Operations Office Manager.

• The Facility Engineering Services Section had not conducted any requirements-based assessments of the NuMI Project.

• The DOE NuMI Project Manager performed ES&H inspections and documented the results of the inspections of the NuMI Project, but the inspection results were not incorporated into the ESHTRK database or another system to show trends in the results of the inspections.

• Layne-Western’s past safety performance was not evaluated before awarding their contract.

• FAO, Fermilab, S. A. Healy, and Layne-Western inspections of work site safety at the EAV-2/EAV-3 job site were not rigorous, formal, or documented. Consequently, important safety information that would have provided indications of the degraded condition of the drill rig, safety and health noncompliance, and adverse trends was not collected, compiled, and provided to management.

The Board concluded that Department of Energy and Fermilab oversight programs had not been effective in identifying fundamental weakness in Fermilab subcontractor construction safety and health programs.

In evaluating how the site had analyzed performance information, the Board reviewed recent occurrences at Fermilab to determine whether precursor events existed before the accident. Fermilab had more than 20 occurrence reports between January 1, 1998, and the day of the accident, 6 of them related to construction operations (in one report there are two separate occurrences yielding seven construction safety occurrences). The Board identified similar underlying causes for all six construction occurrences, which are summarized in Table 3-2:

Table 3-2.  Analysis of Previous Fermilab Construction Occurrences

*    JHA      = Job Hazard Analysis
      MSDS    = Material Safety Data Sheet
      NA        =  Not Applicable
      PPE      =  Personal Protective Equipment

   

• Work planning and control processes were inadequate to perform work within controls.

• Inadequate hazard analyses were performed.

• Procedures were inadequate or not used to perform work.

• Corrective actions developed in response to previously identified events did not effectively prevent recurrence of similar problems.

The Board concluded that Fermilab had a series of construction safety events with similar systemic causes before the accident. Fermilab did not analyze available construction occurrences to identify trends and root causes. As a result, the systemic weaknesses underlying these events were neither identified nor addressed.

The Board evaluated how the site reported accident information. A majority of the Fermilab construction occurrences involved personnel injuries that required medical treatment and, in some cases, hospitalization. Even though most of these occurrences met the significance threshold for reporting in the DOE Computerized Accident/Incident Reporting System (CAIRS), none of these occurrences were found in the system.

In addition, the Board evaluated Fermilab Construction Subcontractor Lost Workday Case rates to identify reporting and construction trends associated with this data. The Board used CAIRS Lost Workday Case rates from March 1993 to June 2001. This time period includes construction of Fermilab’s two major tunneling projects, the Main Injector Tunnel and NuMI Tunnels and Halls. The Board compared the Lost Workday Case rate information for Fermilab Construction Subcontractors provided to the Board during the inbriefing to Lost Workday Case rate information in CAIRS for the period August 27, 1998, to September 15, 2000. Although Fermilab data shows 750 days without a lost workday case during this time period, the Board identified that a subcontractor pipe fitter dislocated his shoulder on November 11, 1998, resulting in 6 lost workdays. Additionally, for six months during the same period of time, Fermilab did not perform any fixed price construction work, thus minimizing the possibility that a lost workday case would have been experienced by subcontractors. Finally, a review of Lost Workday Case rates for the first six months of construction activities on each tunneling project indicated the Lost Workday Case rate approached 20 during the initial phases of construction as shown in Figure 3-3.

Figure 3-3.  Fermiilab Construction Subcontractors Lost Workday Case Rate

The Board concluded that Fermilab had not consistently and effectively reported accident and injury information pertaining to construction subcontractors into CAIRS.

To determine whether corrective actions were effective in preventing recurrence of similar problems, the Board reviewed a sample of Fermilab corrective action plans. The plans included two Type B accident investigations conducted by the Chicago Operations Office for accidents involving subcontractors that occurred on October 22, 1997, and September 4, 1998, and the Fermilab investigation report for the NuMI accident of March 12, 2001. Both Type B accident investigations identified causal factors that recurred in this accident as shown in Table 3-2. The site developed and implemented corrective actions for the causal factors for both Type B accidents, and by December 22, 2000, the FAO had verified that all were closed.

Fermilab had performed investigations of other safety events that occurred on the NuMI Project. The Board reviewed the report of the March 12, 2001, concrete placement-burn accident, and the January 31, 2001, accident where a subcontractor was struck by a falling rock in the NuMI Tunnel, to understand the process for identifying and implementing corrective actions for these investigations. The Fermilab accident investigation team’s report indicated that the safety plan: (1) was not being fully implemented or enforced, (2) lacked an effective written fall protection and scaling program, (3) did not address corrective actions and lessons learned, and (4) did not assign responsibility for a corporate safety auditing function.

In a memorandum to the Fermilab Director dated April 30, 2001, the Fermilab investigation team recommended that S. A. Healy implement corrective actions to address these deficiencies. Fermilab incorporated the corrective actions into the ESHTRK system. However, according to an ESHTRK report dated June 29, 2001, every action item related to this investigation still remained open.

A Harza consultant performed independent safety reviews and audits of underground construction work and aboveground work related to the tunnel construction, except for the Layne-Western drilling operations. Four audits of S. A. Healy during 2001 identified deficiencies in the company’s hazard analysis program. Reviews and audit reports documented general comments, deficiencies, and suggestions for improvement. One report dated March 19, 2001, to March 21, 2001, included a trend analysis evaluating project-related injuries. The consultant recommended that S. A. Healy develop a proactive program to address areas that contributed increased recordable injuries on the NuMI Project. Results of these reviews and audits were not input to the ESHTRK system, and no corrective action plan was developed to address the recommendations resulting from the trend analysis.

The causal factors identified in two previous accident investigations contributed to the June 21, 2001, accident. Recurrence of the causal factors in this accident indicated that Fermilab corrective action processes were ineffective and did not assure necessary improvement of construction subcontractor safety management systems.

The Board reviewed Fermilab mechanisms for communication, dissemination, and use of lessons learned involving construction subcontractors and sub-tier contractors. The Subcontractor Safety Subcommittee (S-3) and processes of FESHM 7010 and FESHM 7020, Subcontractor Safety – Other Than Construction (Interim), were used to provide an interface between Fermilab and the subcontractor for sharing lessons learned from both onsite and offsite incidents. The Board reviewed the minutes of the S-3 committee meetings from March 2000 to April 2001. The minutes indicated that the meetings were useful for facilitating communication between Fermilab divisions, but no subcontractors or sub-tier contractors attended the meetings. Additionally, the minutes indicated that there were no discussions of lessons learned from either onsite or offsite incidents, although numerous construction-related OSHA-recordable injuries occurred on the NuMI Project during this time period. The focus of these meetings indicates missed opportunities to discuss lessons learned.

The processes of FESHM 7010 and FESHM 7020 afforded subcontractors many opportunities to interface with Fermilab safety personnel while planning and executing work. However, these chapters lacked guidance and direction regarding the use of lessons learned for subcontractors.

Section 4.5 of the Fermilab ISM Plan addressed the core function "Feedback and Continuous Improvement." One of the mechanisms that Fermilab used to implement this core function was the Fermilab lessons- learned program. Central to this program was the use of the Fermilab ES&H website. The Board searched the website and found many construction-related lessons learned applicable to NuMI Project subcontractor construction safety management systems. Of particular note are February 23, 1998, lessons learned from the Idaho National Engineering and Environmental Laboratory discussing the use of formal joint collaborating safety surveillances to prevent accidents, increase communications between general and sub-tier contractors, and promote compliance with OSHA requirements. Use of this lesson learned by NuMI Tunnels and Halls line management would have assisted in identifying OSHA deficiencies, improving communications between organizations, and formalizing the process of obtaining safety information for tracking and trending.

Similarly, other safety lessons-learned information readily available to Fermilab from internal and external sources was never communicated to either Layne-Western or S. A. Healy.

The International Association of Drilling Contractors website contained public information that discussed safety measures to be employed for operating drilling equipment. The information addressed the proper positioning of a drilling crew when making or breaking pipe string. Use of this lesson learned might have mitigated or prevented the Operator injury.

The Board concluded that Fermilab processes were ineffective in ensuring that lessons learned were understood and applied by construction subcontractors and sub-tier contractors.

During the investigation, Layne-Western was unable to provide a variety of records and documents requested by the Board, indicating a lack of rigor and formality in managing safety documents. The following documents required by OSHA, DOE, and/or Fermilab were not generated or maintained:

• Hazard analyses

• Inspection records/equipment maintenance records

• Training records for training associated with Competent Persons, site orientation, hazard communications, personal protective equipment, fall protection, hazard assessment, and ladder safety

• Welding, cutting, and brazing permit requirements

• Fire watch training records

• Inspection requirements for slings

• Hazardous energy isolation records

• Work and excavation permits

• Welder qualification records

• Rigger qualification records.

The Board concluded that management had not enforced requirements for maintenance of records documenting the conduct of hazards analyses, inspections, training, and permitting.

3.1.6  Management Systems

Integrated safety management was first introduced at Fermilab in 1997, and the system has evolved since that time to incorporate improvements. The program was most recently changed in August 2000 to incorporate changes suggested by a combined Phase I and Phase II ISM verification review that was completed in October 1999. The verification team noted two key opportunities for improvement among those listed in the verification report, the hazard analysis process and feedback and improvement, and recommended that they be given high priority.

The Office of Science conducted a review of the NuMI Project in May 2001. That review characterized the management structure for the NuMI Project as not effective and concluded that responsibilities and authorities were "confused." The organizational structure for controlling the NuMI construction subcontractor provided several parallel lines of authority. The report provided a number of examples demonstrating that contract requirements were not followed and that ISM was not embodied in the safety culture. Moreover, the impact of not instituting an effective ISM program was highlighted by the series of injuries that occurred at the NuMI Project since January 2001. Those injuries, taken collectively, amounted to a breakdown in all of the ISM core functions and guiding principles.

The Board also noted deficiencies in all components of ISM as applied to the NuMI Tunnels and Halls Project. For example, responsibilities were not clearly assigned, safety training was insufficient, safety programs and procedures were deficient, and, oversight was inadequate to validate implementation of the five core functions of ISM.

Fermilab demonstrated a lack of clarity in contract requirements and their subsequent flowdown to construction subcontractors and sub-tier contractors. The absence of clarity was exemplified by the inconsistent responsibilities of construction coordinators. Under FESHM 7010, NuMI construction coordinators were assigned responsibilities for ensuring that construction operations were completed in accordance with the safety plan and the hazard analysis. This assignment of responsibility was inconsistent with Condition 4.2 of the Harza contract with Fermilab, which stated, in part, that Harza "shall not have control of and shall not be responsible for safety." However, Sections 2.4 and 2.5 and Exhibit A of the contract required Harza construction coordinators to accomplish safety audits. This dichotomy contributed to NuMI construction coordinators not having a clear understanding of their safety oversight responsibilities. The ability of management to effectively manage the NuMI Project, including the ability to enforce compliance with contracts, was compromised by unclear lines of authority in the project organization. Fermilab and S. A. Healy management had not clearly and properly communicated safety responsibilities to their staffs.

Fermilab and S. A. Healy management also failed to ensure that individuals involved with hazard analysis for the NuMI Project had the necessary knowledge and skills to perform their jobs safely. They failed to administer controls to ensure that effective hazard analysis would be performed on the NuMI construction operations. The S. A. Healy contract with Fermilab required hazard analyses for the operations of S. A. Healy and its subcontractors. Fermilab managers expected S. A. Healy and its subcontractors to administer hazard analysis programs in accordance with the requirements in FESHM 7010, but the Fermilab contract with S. A. Healy did not invoke this manual or make it clear that responsibilities and procedures in FESHM 7010 applied to subcontractors of S. A. Healy. The term subcontractor, as used in this document, was applicable to the construction contractors of Fermilab, but was not tailored to apply to contractors of S. A. Healy, such as Layne-Western.

The Chicago Operations Office Manager delegated line oversight responsibility as described in DOE Policy 450.5, Line Environment, Safety and Health Oversight, to the FAO Manager, but did not provide independent evaluations consistent with DOE oversight policy as described in DOE Order 414.1A, Change 1, Quality Assurance.

FAO and the NuMI Project management’s failure to correct previously identified deficiencies in management systems contributed to continuing performance deficiencies. Neither organization made sure that corrective actions were effective in preventing additional accidents, or that common causal factors related to the ISM core functions and guiding principles were effectively addressed. Specifically, neither organization identified that Layne-Western performed drilling operations from September 2000 until June 21, 2001, without a hazard analysis, or that responsibilities for preparation and approval of hazard analyses were not clearly assigned. The FAO did not assign a staff member to monitor the safety of Layne-Western drilling operations until June 2001, even though drilling had been in progress since the previous fall, and the review of Layne-Western operations by this staff member did not focus on safety. The S. A. Healy Safety Director and NuMI construction coordinator who had visited this site also failed to identify safety deficiencies.

Causal factors identified in the 1998 Type B accident investigation appear to be recurring. This situation was noted in the May 2001 semiannual safety performance reviews of the construction project by the Office of Science. Additionally, the same causal factors have been identified as weaknesses in more than 20 injury reports over the last 12 months, 2 of which prompted safety stand-downs.

The effectiveness of feedback and improvement processes applied to construction operations was reduced by documentation deficiencies. Results of safety inspections were not consistently documented and reported, and workplace injuries were not documented in CAIRS. Without such documentation, feedback to management was inaccurate and management decisions were based on incomplete safety information. Performance feedback processes were not adequate to support needed improvements in safety for the NuMI Project. The FAO did not perform sufficient oversight of safety practices at the job site, or of the safety program applied to Layne-Western by S. A. Healy, to identify significant deficiencies. Fermilab line management did not effectively monitor or control the operations of its subcontractor, S. A. Healy, to assure that S. A. Healy met the terms and conditions of its contract with Fermilab or the provisions of the Fermilab ISM Plan. Line management oversight was not adequate to identify significant safety deficiencies at the Layne-Western job site or to identify the poor condition of the drill rig.

Continuing weaknesses existed in the Fermilab ISM program, as it was applied to construction subcontractors on the NuMI Project. Specifically, Fermilab management had not established sufficiently formalized management systems or work control processes or procedures, but instead relied primarily on expert-based knowledge, skills, and abilities to assure that work was done safely. For example: (1) roles and responsibilities were not well understood, (2) qualifications were not commensurate with assigned duties, (3) the workforce was not held accountable for strict compliance with requirements, and (4) performance feedback systems were not adequate to support needed improvements.

The Board concluded that deficiencies in the construction safety management systems at Fermilab indicated a need for increased commitment by line management to ensure effective implementation of the ISM framework for all subcontractors and sub-tier contractors.

Guiding Principles of Integrated Safety Management

Core Functions of Integrated Safety Management

3.2  Barrier Analysis

Barrier analysis is based on the premise that hazards are associated with all tasks. A barrier is any management or physical means used to control, prevent, or impede the hazard from reaching the target (i.e., persons or objects that a hazard may damage, injure, or harm). The results of the barrier analysis are integrated into the events and causal factors chart to support the development of causal factors. Table 3-3 contains the Board’s summary of physical and management barriers that did not perform as intended and thereby contributed to the accident. Appendix D contains the complete barrier analysis.

Table 3-3.  Barrier Analysis Summary

3.3  Change Analysis

Change analysis examines planned or unplanned changes that caused undesirable results related to the accident. This process analyzes the difference between what is normal, or expected, and what actually occurred before the accident. The results of the change analysis conducted by the Board are integrated into the events and causal factors chart to support the development of causal factors. The results reinforced the barrier analysis results presented above.

3.4 Causal Factors Analysis

A causal factors analysis was performed in accordance with the DOE Workbook, Conducting Accident Investigations, Revision 2.

Causal factors are the events or conditions that produced or contributed to the occurrence of the accident and consist of direct, root, and contributing causes.

The direct cause is the immediate event or condition that caused the accident. The Board determined that the direct cause of the accident was the failure of the welded connection between the piston rod and the wire rope, releasing the stored energy of the breaking mechanism.

Root causes are events or conditions that, if corrected, would prevent recurrence of this and similar accidents.

The Board also identified contributing causes. Contributing causes are events or conditions that collectively with other causes increase the likelihood of the accident, but that individually did not cause the accident.

The root and contributing causes summarizing the Board’s causal factors analysis appears in Table 3-4.

Table 3-4.  Causal Factors Analysis Summary

    Judgments of Need

Judgments of need are managerial controls and safety measures believed necessary to prevent or minimize the probability of a recurrence. They flow from the causal factors and are directed at guiding managers in developing corrective actions. Table 4-1 summarizes the Board’s causal factors and judgments of need.

Table 4-1.  Judgments of Need