On April 3, 1995, I established a Type A Accident Investigation Board to investigate the fatal rappelling accident at the Savannah River Site Advanced Tactical Training Academy. The Board's responsibilities have been completed with respect to the investigation. The analysis, identification of root and contributing causes, and judgments of need reached during the investigation were performed in accordance with DOE 5484.1, "Environmental Protection, Safety, and Health Protection Information Reporting Requirements." I accept the findings of the Board and authorize the release of this report for general distribution.

Tara O'Toole, M.D., M.P.H.
Assistant Secretary
Environment, Safety and Health

EXECUTIVE SUMMARY

ACCIDENT INVESTIGATION BOARD

MAKEUP AND APPROACH

The Accident Investigation Board that conducted this investigation included individuals with experience and training in accident analysis, DOE accident investigation, safety, security training, rappelling, security operations, and management systems. The Board was assisted by representatives of Wackenhut Security Incorporated—Savannah River Site (WSI-SRS), United Plant Guard Workers of America, a DOE Savannah River Operations Office (SR) advisor, Westinghouse Savannah River Company (WSRC) security analysts, and several technical consultants. Appendix B describes the qualifications of the Board members and advisors.

During the investigation, the Board used various DOE accident analysis techniques, including MORT analysis. The Board also conducted extensive interviews and document reviews, and performed engineering and root cause analyses to determine the factors that contributed to the accident, including any operational, facility, equipment, and management deficiencies.

ACCIDENT SCENARIO

On April 3, 1995, at approximately 10:46 a.m., a WSI-SRS employee received fatal injuries as a result of a 27-foot fall during a rappel training exercise at the SRS ATTA Rappel Tower. The training exercise in progress at the time of the accident was a "Buddy Rappel" (two men on a single rope). This exercise was being conducted to prepare for a South Carolina State offsite Special Weapons and Tactics (SWAT) Team competition in Spartanburg, SC.

Initial training exercises consisted of building entry and clearing techniques on each level of the Rappel Tower and concluded with each competition team member executing a rappel from the top of the 40-foot tower with the recently installed safety gates open and the rope bearing on the edge of the top deck. These exercises were followed by practice of the Buddy Rappel technique. The Rappel Master, Team Coach, Rappeller, "Buddy," and another team member climbed to the top of the tower to prepare for the Buddy Rappel exercise.

The Rappeller asked "Do we go over or under the gate?" The Team Coach said "At Spartanburg, they go over the rail." The Buddy replied "Then we'll go over the gate." The Rappel Master then closed and locked the gates. The rope was routed over the top rail of the closed and locked gate and down to the ground. The Buddy attached his seat harness to the back of the Rappeller and prepared for the descent. The Rappeller said "On Rappel," and the Belayer on the ground responded "On Belay."

The Rappeller and the Buddy climbed over the gate and stood on the edge of the top of the tower. As they started their descent, the Rappeller experienced difficulty in establishing his body in the "L" position because of their combined weight of 484 pounds. As the Rappeller maneuvered his feet, the rope moved laterally and slipped approximately 8 inches down into the area between the gates where the gates were pinned together. This slippage enabled the rope to come in contact with the small radius edge of the lock-pin housing.

When the Rappeller and the Buddy were approximately 10 feet down the wall of the tower, the Belayer perceived that the Rappeller was descending too fast and was not in full control of the descent. His response was to apply a tension force to the rope to stop the descent. At about the same time, the rope separated where it had been in contact with the small radius edge of the gate lock-pin housing. The sound of the rope separating was described as a "crack" similar to a small- caliber rifle shot. At about 10:46 a.m., the Rappeller and the Buddy fell approximately 27 feet to the sawdust on the ground level. The Rappeller landed on top of the Buddy, causing severe chest compression to the Buddy.

The first response was from an Emergency Medical Technician (EMT) who was on the competition team. Cardiovascular pulmonary resuscitation (CPR) and rescue breathing were administered, but the victim was nonresponsive. He was transported to University Hospital in Augusta, GA, in an SR helicopter, where he was declared dead at 11:37 a.m.

ACCIDENT ANALYSIS AND FINDINGS

The Board conducted tests on the rope used in the rappel training exercise and concluded that it exceeded the tensile strength requirement of 4,500 pounds specified in the procurement specification. Test were also conducted to simulate the small diameter (relatively sharp) edge of the gate pin housing that caused the rope to separate. The test results were consistent with the dynamic (drop) tests conducted by rappel rope manufacturers, which show that 11mm rope will withstand seven drop tests over a 10mm diameter edge but will fail 100 percent of the time when routed over a 1mm diameter edge. The Board also concluded that the major findings indicated a breakdown of several management systems that could have prevented the accident, as follows:

• Lack of procedure or protocol for a nonroutine buddy rappel training activity;
• No risk analysis of unusual training on the recently modified tower;
• Basic principles of rappelling safety in the core training program do not ensure the recognition of unsafe conditions during rappelling;
• Poor communications between management and competition training team;
• Poor command and control of rappelling operation by leadership;
• Lack of safety management controls by DOE and WSI-SRS;
• Unclear assignment of safety responsibility in contractor organization;
• Lack of full utilization of lessons learned from prior rappelling accidents; and
• Lack of firm mission requirements for rappelling, and no reevaluation of changing needs.

Based upon the results of this accident investigation and a review of other security program safety issues, the Board recommends:

• Conduct a review of safety programs in security training and develop recommendations for improvement.
• Reassess the security mission requirements against DOE's programmatic needs and put in place a mechanism for continuous improvement.

DIRECT CAUSE

The direct cause of the fatal accident was the separation of the rappel rope caused by the combination of the rope coming in contact with the small radius edge of the gate lock-pin housing and the dynamic loading of the Rappeller and the Buddy on the rope.

PROBABLE CAUSES

The Board used several techniques to determine the probable causes of the accident, including events and causal factors analysis, barrier analysis, fault tree analysis, and destructive and nondestructive testing and analysis. These techniques identified the following areas as being less than adequate:

• Policy
• Design
• Procedures
• Conduct of Operations
• Training
• Experience
• Supervision
• Communications
• Lessons Learned
• Oversight

These areas were identified on the basis of inadequacies found in facility design, procedures development and implementation, Conduct of Operations, and policy communication and implementation.

ROOT CAUSES

The Board determined the following root causes of the accident:

• Management
• Training
• Policy Implementation
• Risk Assessment and Hazard Analysis
• Conduct of Operations
• DOE Oversight

JUDGMENTS OF NEED

The integration of the Board's analyses and findings resulted in the following major management system needs for DOE, WSI-SRS, and WSRC:

Wackenhut Services, Incorporated—

Savannah River Site (WSI-SRS) Actions

• WSI-SRS needs to expand the focus of its safety program, more effectively use lessons learned, and establish safety responsibilities at each level of the organization.
• WSI-SRS needs to ensure that its Conduct of Operations Program more effectively meets stated program goals, including facility safety analysis, management oversight, and procedural compliance.
• WSI-SRS needs to ensure that the fundamental principles of rappelling are included in training by more effectively utilizing the CTA-trained Rappel Instructors, and verify that all training is supported by up-to-date, approved lesson plans.
• WSI-SRS needs to ensure that management and supervisory responsibilities for SRT training and operations are understood and implemented.

Westinghouse Savannah River

Company (WSRC) Actions

• WSRC, in conjunction with WSI-SRS, needs to upgrade emergency response procedures on telephone discipline, standardization of emergency medical technician kits, and the use of SR helicopters in responding to medical emergencies.
• WSRC, in conjunction with WSI-SRS, needs to ensure that all noncompliances with OSHA requirements are identified, and that they are coordinated with WSI-SRS for facilities which they occupy.
• WSRC, in conjunction with WSI-SRS, needs to conduct a review of the Rappel Tower safety railings to establish a design that meets both the OSHA fall-protection and WSI-SRS training requirements.

Savannah River Operations

Office (SR) Actions

• SR needs to improve implementation of protective forces safety program, conduct of operations, and line management to include a full range of safety surveillance activities in addition to those conducted in support of the award fee process.
• SR needs to review, in conjunction with WSI-SRS, the requirement for rappelling at the SRS to determine its further use as an SRT technique.
• SR needs to justify that competitions are within the scope of WSI-SRS contract, satisfy the mission, desirable, and conducted safely.

Office of Environmental

Management (EM) Actions

· EM needs to place greater emphasis on occupational safety and conduct of operations in security and SRT operations at its sites by sponsoring job safety analysis and using other safety management tools to reduce occupational injury rates.

Office of Environment, Safety

and Health (EH) Actions

• EH needs to ensure that its safety program management, oversight, and assistant programs include protective forces operations and training programs, including a more comprehensive analysis of injury and illness statistics to identify areas that need improvement.
• EH needs to expand the scope of oversight to include occupational safety in safeguards and security activities, specifically in the protective force operations and training programs.

Office of Nonproliferation and

National Security (NN) Actions

• NN, in collaboration with the program offices, needs to develop and disseminate programmatic guidance on: Rappel Instructor/Master recertification; the dynamics of rappelling training criteria; and participation in high-risk competitions and similar events.
• NN, in collaboration with the program offices, needs to provide management control mechanism to reconcile protective force training requirements with documented site mission requirements (i.e., Site Safeguards and Security Plan).

TABLE of CONTENTS

• EXECUTIVE SUMMARY
• 1.0 INTRODUCTION
• 2.0 FACTUAL ACCOUNT OF FATAL ACCIDENT
  • 2.1 ACCIDENT DESCRIPTION
    • 2.1.1 Background
    • 2.1.2 Accident Chronology
  • 2.2 EMERGENCY RESPONSE
    • 2.2.1 SRT Medical Response
    • 2.2.2 EMT Response
    • 2.2.3 Related Emergency Response Action
  • 2.3 MISSION AND POLICY
    • 2.3.1 Mission Requirements
    • 2.3.2 Policy
  • 2.4 OPERATIONS
    • 2.4.1 DOE 5632.7A, "Protective Force"
    • 2.4.2 Contract
    • 2.4.3 Competition
  • 2.5 OCCUPATIONAL SAFETY AND HEALTH
    • 2.5.1 Rappel Tower Inspection and Safety Rail Installation
    • 2.5.2 Occupational Injury and Illness Experience
  • 2.6 TRAINING
  • 2.7 MANAGEMENT SYSTEMS
    • 2.7.1 Supervision
    • 2.7.2 Communications
    • 2.7.3 Management Control
      • 2.7.3.1 Management Control of the Special Response Team Competition Preparation
      • 2.7.3.2 Internal and External Management Control of WSI-SRS
      • 2.7.3.3 Headquarters Management Control of the Savannah River Operations Office
    • 2.7.4 Lessons Learned
    • 2.7.5 Conduct of Operations

• 3. ANALYSIS
  • 3.1 SYSTEM ANALYSIS
    • 3.1.1 Objectives and Methodologies
    • 3.1.2 Events and Causal Factors
  • 3.2 EMERGENCY RESPONSE
  • 3.3 MISSION AND POLICY
  • 3.4 OPERATIONS
    • 3.4.1 Contractual Requirements
    • 3.4.2 Competition
    • 3.4.3 Accident Scene
    • 3.4.4 Rappel Rope
  • 3.5 OCCUPATIONAL SAFETY AND HEALTH
    • 3.5.1 OSHA Inspections
    • 3.5.2 Safety Railing Installation
    • 3.5.3 Occupational Injury and Illness Experience
  • 3.6 TRAINING
  • 3.7 MANAGEMENT SYSTEMS
    • 3.7.1 Supervision
    • 3.7.2 Communications
    • 3.7.3 Management Control
    • 3.7.4 Lessons Learned
    • 3.7.5 Conduct of Operations
    • 3.7.6 Procedures
    • 3.7.7 Overall Summary
  • 3.8 SYSTEM PERFORMANCE ANALYSIS
    • 3.8.1 Change Analysis
    • 3.8.2 Barrier Analysis
    • 3.8.3 Fault Tree Analysis
    • 3.8.4 Root Cause Analysis

• 4. CONCLUSIONS
  • 4.1 MISSION AND POLICY
    • Findings
    • Probable Causes

• 4.2 OPERATIONS, TRAINING, AND EMERGENCY RESPONSE
  • 4.2.1 Operations
  • Findings
  • Probable Causes
  • 4.2.2 Training
  • Findings
  • Probable Causes
  • 4.2.3 Emergency Response
  • Findings
  • Probable Cause
  • 4.3 OCCUPATIONAL SAFETY AND HEALTH
  • Findings
  • Probable Causes
  • 4.4 MANAGEMENT SYSTEMS
  • Findings
  • Probable Causes
  • 4.5 CONDUCT OF OPERATIONS
  • Findings
  • Probable Causes

• 4.6 JUDGMENTS OF NEED

• BOARD MEMBER SIGNATURES

• BOARD MEMBERS, ADVISORS AND STAFF

• ACRONYMS

LIST OF APPENDIXES

Appendix A Accident Investigation Board Appointment Letter

Appendix B Board Members and Advisors Qualifications

Appendix C Medical Records Related to the Accident

Appendix D Occurrence Reports for Similar Incidents

Appendix E Emergency Response Chronology

Appendix F Rope Construction and Application

Appendix G Type C Accident Investigation Report of the Training Incident on February 25, 1994

Appendix H Documents Reviewed

Appendix I Individuals Interviewed

Appendix J An Evaluation of Rappelling Rope Capacity and Loading (U),

WSRC-TR-95-0194, Rev. 0, Dated April 26, 1995

Appendix K WSI-SRS Rappel Master Checklist

Appendix L WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2

Appendix M SRS Final Acceptance Inspection of New or Altered Facilities or Equipment

Appendix N Range Safety Officer Monthly OSH Inspection Checklist

Appendix O Integrated Accident Event Sequence

Appendix P WSI-SRS Rappel Master Training Outline

Appendix Q DOE-HQ Memorandums Suspension of Rappelling, Dated April 7 and 10, 1995

Appendix R Press Release

LIST OF TABLES

2-1 DOE and Contractor Injury and Illness Rates for Select Security Contractors 1992 through 1994

2-2 Injury and Illness Rates for Wackenhut Services, Inc., Savannah River Site and WSI-SRS Special Response Teams 1992 through 1994

2-3 DOE and DOE Contractor Occupational Injury and Illness Incidence Rates, 1994

3-1 Change Analysis

3-2 Performance of Barriers

3-3 Causal Factor Analysis

LIST OF FIGURES

2-1 Savannah River Site Map

2-2 "Figure 8" Mechanical Descender

2-3 Rappel Tower

2-4 View of Tower Showing Rappel Rope and Pipe Fulcrum

2-5 Rappel Tower and Rappel Ropes

3-1 Events and Causal Factors Chart - Summary Level

3-2 Rappel Tower and Tent

3-3 Top of Rappel Tower

3-4 Closeup of Rappel Rope

3-5 Lock-pin Housing

3-6 Impact Area as Seen from Top of Rappel Tower

3-7 Impact Area as Seen from Ground Level

3-8 Closeup of Impact Area

3-9 Closeup of Rope Break on Ground

3-10 Fault Tree Analysis

3-10-1 Fault Tree Analysis - System Operations Integrity

3-10-2 Fault Tree Analysis - Physical Systems Integrity

3-10-3 Fault Tree Analysis - Design System Integrity

3-10-4 Fault Tree Analysis - Safety Analysis

3-10-5 Fault Tree Analysis - System Design

F-1 Rope Manufacturing Process

Last Modified: Friday, 28-Feb-97 10:09:00