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This report is an independent product of the Type A Accident Investigation Board appointed by Tara O'Toole, M.D., M.P.H., Assistant Secretary for Environment, Safety and Health (EH-1). The Board was appointed to perform a Type A Investigation of this accident and to prepare an investigation report in accordance with DOE Order 225.1, Accident Investigations. The discussion of facts, as determined by the Board, and the views expressed in the report do not assume and are not intended to establish the existence of any duty at law on the part of the U.S. Government, its employees or agents, contractors, their employees or agents, or subcontractors at any tier, or any other party. This report neither determines nor implies liability. |
On January 23, 1996, I established a Type A Accident Investigation Board to investigate the electrical accident in Technical Area 21 of the Tritium Science and Fabrication Facility at the Los Alamos National Laboratory that resulted in serious injuries to a maintenance employee of Johnson Controls World Services, Inc. The Board's responsibilities have been completed with respect to this investigation. The analysis, identification of direct, contributing, and root causes, and judgments of need reached during the investigation were performed in accordance with DOE Order 225.1, Accident Investigations. 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
AL Department of Energy Albuquerque Operations Office
ANSI American National Standards Institute
CFR Code of Federal Regulations
CPR Cardiopulmonary resuscitation
DOE U.S. Department of Energy
EH Department of Energy Office of Environment, Health and Safety
EPA U.S. Environmental Protection Agency
ESA LANL Engineering Sciences and Applications Division
ESA-3 LANL Tritium Science and Technology Group
ESH LANL Environment, Safety, and Health Division
ESH-1 LANL Radiological Protection
ESH-3 LANL Facility Risk Management Group
ESH-5 LANL Industrial Hygiene and Safety Group
ESH-18 LANL Water Quality and Hydrology Group
ES&H Environment, safety, and health
FM Department of Energy Office of Field Management
FSS LANL Facilities, Security, and Safeguards Division
FSS-3 LANL Facilities Support Operations Group
FSS-6 LANL Facility Project Delivery Group
FSS-9 LANL Operations and Maintenance Services Group
JCI Johnson Controls World Services, Inc.
kV Kilovolt
LAAO Department of Energy Los Alamos Area Office
LANL Los Alamos National Laboratory
ML Management Level
OSHA Occupational Safety and Health Administration
NPDES National Pollutant Discharge Elimination Systems
PPE Personal protective equipment
SFE Santa Fe Engineering
TA Technical Area
TSE Tritium Science and Engineering
TSFF Tritium Science and Fabrication Facility
U of C University of California
UPCS Utilities Power Control Section
WSC Waste Stream Corrections
The electrical accident with injury at the Los Alamos National Laboratory (LANL) on January 17, 1996, resulted from failures of Department of Energy (DOE), contractor, and subcontractor management. Significant, sitewide, programmatic weaknesses in the Laboratory's safety management program and failure to correct them were the principal causes of the accident. This was particularly true of the inadequacies in work planning, authorization, and control procedures that contributed to the injury.
Neither applicable DOE standards nor LANL work control and project management procedures were followed. The use of more restrictive project controls and engineering reviews could have alerted supervisors and workers to the hazards. The support organization, inappropriately assigned responsibility for the work, did not have the internal procedures, experience using codes and standards, or expertise needed to perform complex facility modification work. A single Standing Work Order was used, an application not intended for large maintenance tasks, which did not provide for an adequate description of the facility and the work task hazards. As a result of a pervasive misinterpretation of LANL administrative requirements, personnel failed to take appropriate measures to determine the location of dangerous underground utilities and prevent the exposure of employees to hazards associated with those utilities. Finally, commitments and schedule pressures allowed the work to be performed on a work package that lacked sufficient detail and supervision. Although not a complete list of the serious problems, correction of any one of the previously mentioned conditions may have prevented the accident.
This accident highlights the importance of a comprehensive approach to safety that stresses clear goals and policies, individual and management accountability and ownership, implementation of requirements and procedures, and thorough and systematic oversight by contractor and Department management. There is also a need to ensure proper and uniform classification of work planning and control procedures, including reviews, approvals, and work supervision requirements.
In addition, Departmental and LANL management systems have not been effective at resolving longstanding, well defined programmatic issues or translating lessons learned into safe day-to-day operation. The numerous failures and longstanding weaknesses that led to the accident, their similarity with other precursor accidents at LANL, and the inadequate execution of corrective actions by Laboratory management indicate a lack of management accountability and ownership for safety.
An electrical accident was investigated in which a crafts person received serious injuries as a result of coming into contact with a 13.2 kilovolt (kV) electrical cable in the basement of Building 209 in Technical Area 21 (TA-21-209) in the Tritium Science and Fabrication Facility (TSFF) at Los Alamos National Laboratory (LANL). In conducting its investigation, the Accident Investigation Board used various analytical techniques, including events and causal factor analysis, barrier analysis, change analysis, fault tree analysis, materials analysis, and root cause analysis. The Board inspected the accident site, reviewed events surrounding the accident, conducted extensive interviews and document reviews, and performed causation analyses to determine the factors that contributed to the accident, including any management system deficiencies. Relevant management systems and factors that could have contributed to the accident were evaluated in accordance with the guiding principles of safety management identified by the Secretary of Energy in an October 1994 letter to the Defense Nuclear Facilities Safety Board and subsequently to Congress.
The accident occurred at approximately 9:34 a.m. on January 17, 1996, in Building TA-21-209, during the excavation of a sump pit in the floor of the building to correct a waste stream outfall deficiency. On that day, two mason tenders arrived at the job site at approximately 8:40 a.m. and resumed the excavation work, begun on the previous day. The mason tenders (crafts persons) were employed by Johnson Controls World Services, Inc. (JCI), the primary LANL subcontractor for construction and maintenance. The mason tenders alternately operated a jackhammer, pry bar, and shovel to loosen and remove the rubble from the sump pit. At about 9:34 a.m., at a depth of 39 inches, the mason tender operating the jackhammer pierced the conduit containing an energized 13.2 kV electrical cable. The accident victim was transported to the Los Alamos Medical Center, where cardiac medications were administered. At approximately 10:10 a.m., the accident victim resumed a normal heart rhythm and blood pressure. The accident victim remains in a deep coma.
Techniques used by the Board to determine accident causation produced evidence of significant deficiencies in the safety management program at LANL with respect to this accident.
The Board determined that the significant sitewide programmatic weaknesses that resulted in this accident have a high degree of similarity with weaknesses previously identified in other Type A accident investigations at LANL, external assessments by the U.S. Department of Energy (DOE) Los Alamos Area Office (LAAO) and the DOE Albuquerque Operations Office (AL), as well as internal oversight by LANL. LANL management has not ensured that identified corrective actions have been implemented in most of these cases. The Board found that management systems instituted at LANL have not been effective in resolving longstanding, well defined programmatic issues or translating lessons learned into safe day-to-day operations at the Laboratory. This is indicative of inadequate LANL line management accountability and ownership, as well as an inability to learn from previous incidents to prevent their recurrence.
The line managers who should have implemented the environmental modifications within their facilities did not do so. Instead, an environmental support organization was given responsibility for management of the project and proceeded to implement the modifications. Division level management was aware of this, but did not take action to restore responsibility to the appropriate facility operations organizations. The Waste Stream Corrections Project Team, led by the environmental support organization, indicated that field direction of the work would be simpler and more cost effective than using more restrictive project controls and engineering reviews that could have alerted supervisors and workers to the hazards. Thus, for this project, information was only passed on to JCI and was not subjected to an engineering review to determine the adequacy of information provided.
Because this construction work was being accomplished via a maintenance process, there was no mechanism in place to capture the facility design modifications that were being done to TSFF, a Category 3 nuclear facility. There was no plan to update the as-built drawings for this facility. The result was a loss of configuration control that would open the door for similar accidents in the future. The Board concluded that modifications to facility systems were not being captured or analyzed against the existing safety analysis report or other system design documents.
Many of the decisions relating to the Waste Stream Corrections Project, particularly the assumption of design responsibilities by the environmental support organization engineers in the project team, were due to cost and schedule pressures. The normal function of the organization (Water Quality and Hydrology Group) was to provide project support and oversight of environmental issues. It did not have the internal procedures, experience using codes and standards, or field construction expertise needed to perform complex facility modification work. Both the managers and the staff involved overestimated the capability of the project team to engineer and manage a construction project of this magnitude. The project team did not understand the processes required to implement design changes. As a result, the project team implemented an undocumented modification process that did not (1) adequately develop the designs, (2) require preparation of detailed work packages, (3) provide the guidance needed to assure adequate safety reviews, (4) manage changes to the work packages during installation, (5) document the completed work, and (6) formally turn over the new and modified systems to the facility operations organization. The overall process did not meet the requirements of the LANL Quality Assurance Management Plan or DOE orders. Although the decision to have a support organization assume the project lead and the decision to field-direct much of the work may not have been directly conveyed to senior LANL management, senior LANL management shares the responsibility because of its lack of involvement.
In implementing the facility modifications, neither applicable DOE design standards nor LANL work control and project management procedures (to the extent they were defined) were followed. LANL management has not communicated its expectation for, nor have LANL management programs emphasized use of, such procedures in conducting Laboratory activities. Consequently, Laboratory-wide procedures (1) have not been updated, (2) do not provide adequate guidance, and where they exist, (3) are not always followed by LANL or JCI personnel. Further, because Laboratory-wide procedures for many programs, including work control and planning and configuration management, are neither current nor comprehensive, multiple Division or Group-level procedures are being prepared and used. The standards and requirements in these procedures vary significantly among the different organizations at the Laboratory and do not necessarily reflect the requirements or expectations set by higher-tier documents within LANL, such as Director's Policies.
In this regard, Director Policy 102, "Formality of Operations," states that the Laboratory will establish programs and procedures to control conduct of operations, and that Laboratory personnel will be trained in the use of its procedures. It also states that management shall require all personnel to use applicable procedures and shall maintain oversight. The Board found multiple cases where the LANL management systems have failed to comply with this basic operating philosophy. The Director's Policies and lower tier Program Requirement Documents serve as guiding instructions, but no procedure, program, or process is in place to provide any assurance that these expectations are actually implemented on a sitewide basis.
The Board found that there are no Laboratory-wide operating procedures that implement the Program Requirements Documents for either configuration management or conduct of operations (a subset of which is work planning and control), and there is no plan to develop such procedures. Without specific implementing procedures, there is no assurance that higher-level policy and requirements documents are translated into actual implementation at the facility level. By not issuing sitewide operating procedures, LANL management has not achieved effective, consistent implementation of the requirements and expectations contained in Director's Policies at the working level. The Board believes that because of the lack of requirements and implementing procedures to control work and establish expectations, LANL's formality of operations must be strengthened.
The Board determined that the actions taken by LANL management in implementing the facility modifications related to this accident were being driven by time constraints. Ad hoc procedures were created to expedite the completion of the facility modifications needed to meet an Environmental Protection Agency Administrative Order deadline of October 1996. For example, for the work performed under the Waste Stream Corrections Project, the environment, safety, and health (ES&H) organization utilized a new process that used project summaries instead of the formal ES&H questionnaire process normally used under the LANL Administrative Requirement procedures. The project summaries are distributed to subject matter experts for review and comment; they are then are reviewed by the ES&H organization to ensure that all safety concerns are addressed. This ad hoc process, however, was never formally approved by LANL senior management. In addition, for this project, both the service request and the ES&H technical review were completed prior to completion of subject matter expert reviews, one of which addressed the fact that the complexity of the Waste Stream Corrections Project dictated more diligent controls and engineering reviews. The Board further determined that 16 Waste Stream Corrections Project subtasks were approved for work by the ES&H Division in the absence of detailed work packages and prior to completion of subject matter expert reviews. The failure of management to require LANL organizations to use formal, approved procedures contributed to the incomplete closure of identified safety concerns raised by the subject matter experts for the project on which the accident occurred.
A single Standing Work Order was used for the Waste Stream Corrections Project to correct over 2,000 waste stream deficiencies at all LANL sites, which contain many diverse facilities and buildings. Over 1,028 Standing Work Orders were being used at LANL at the time of the investigation. The purpose of Standing Work Orders is to allow routine activities, such as snow removal and lamp replacement, to be authorized, funded, and performed without the use of detailed work packages. In accordance with LANL Administrative Requirements procedures, Standing Work Orders do not need to have ES&H reviews because they are to be used for routine, repetitive, non-complex tasks. Standing Work Orders were not designed or intended to be used for large maintenance tasks, complex facility modifications, or major construction activities such as those encountered in the Waste Stream Corrections Project. Although an ES&H review was performed in the early stages of the Waste Stream Corrections Project, it was based on the very limited information provided in project summaries, which did not adequately describe the detailed facility and work task hazards to be encountered. The Board found that because the Standing Work Order format was too broad to permit the detailed work activities to be defined, ES&H reviews were completed without adequate understanding of the specific hazards associated with the work tasks. The Board considers the use of Standing Work Orders at LANL to be excessive, and their use may circumvent adequate ES&H reviews on the projects for which they are being used. This use of Standing Work Orders to capture the complex, non-repetitive work covered in the Waste Stream Corrections Project clearly exceeds their intended purpose.
Although LANL Administrative Requirement 1-12 clearly requires that excavation permits be obtained prior to any groundbreaking activities inside or outside buildings, a widespread misinterpretation by LANL and JCI personnel generally limited requests for excavation and penetration permits to areas located outside buildings. Board interviews with both LANL and JCI personnel found that the interpretation was common in both organizations, and knowledge of the specific requirements of Administrative Requirement 1-12 appeared limited. As a result of this incorrect interpretation, both LANL and JCI personnel failed to take appropriate measures to (1) determine the locations of dangerous underground utilities, (2) prevent the exposure of employees to hazards associated with those utilities, and (3) conduct work in a manner designed to avoid damage to the utilities, as required by 29 CFR 1926.
The Board had several concerns relating to the post-accident emergency response. Of major concern was the lack of a temporary power emergency plan for Building TA-21-209. Emergency power for critical needs was addressed several years earlier by LANL, and some TSFF critical systems were connected to the Tritium Systems Test Assembly emergency diesel generators. However, immediately after the accident in TSFF, LANL facility operating personnel and LAAO personnel determined that power to the building had to be restored as soon as possible. This decision was based on the possibility of tritium releases from the tritium effluent system and the possible need for freeze protection. Because there was no temporary emergency power plan for the facility, the generator capacity, power line size, and connection points to the existing Building TA-21-209 electrical panels were not known. To resolve these unknowns, LANL and JCI engineers used the biggest generator they could find; used "welding cables" because they were the largest conductor available; located and grounded the temporary diesel generator next to hydrogen bottles in clear view of a "caution explosive" danger sign; and routed (draped) cables over light fixtures and existing cable trays. The Board considers that a higher level of safety assurance could have been obtained had LANL developed, in advance, a well thought out temporary emergency power plan for the TSFF.
The Board had concerns involving the Facilities Management Unit concept at the Laboratory. Under this concept, the facility operating organizations are to be responsible for all work in their facilities and are to manage projects, such as the Waste Stream Corrections Project, through completion. However, procedures that implement the Facilities Management Unit program have not been issued, and not all LANL sites have adopted this approach. The Board generally endorses LANL's Facilities Management Unit concept purpose and policy. The assignment of facility operations and facility safety responsibility to a specific person within the facility management/operations organization helps in managing resources for optimum efficiency and effectiveness. However, the transition to the Facilities Management Unit model is not complete, even though it was conceived several years ago. The Board found that LANL senior management has not aggressively or formally endorsed the Facilities Management Unit transition process. This support is needed to bring about the changes in roles, responsibilities, authorities, and accountabilities that will be necessary to effectively implement the model throughout the Laboratory. The Board strongly believes that the success of this model will depend in large part on the ability of LANL senior management to clearly and formally state their expectations and hold individuals accountable for its implementation.
The direct cause of the electrical accident with injury was the chisel bit of the air-powered jackhammer coming into contact with the 13.2 kV energized electrical cable in the sump pit being excavated in the basement of Building TA-21-209.
Contributing causes of the accident are as follows:
Root causes of an occurrence are conditions that, if corrected, would prevent a similar occurrence. The root causes of this accident, as determined by the Board, are as follows:
During the accident investigation, the Board developed Judgments of Need that must be addressed in order to prevent a recurrence of similar accidents in the future. The following is a summary of the Judgments of Need, which have been categorized according to the guiding principles of safety management established by the Secretary of Energy.
On January 17, 1996, a worker at Los Alamos National Laboratory suffered severe burns and cardiac arrest when he contacted an electrical cable. He remains in a deep coma.
On January 17, 1996, at approximately 9:34 a.m., a crafts person received serious injuries as a result of coming into contact with a 13.2 kilovolt (kV) electrical cable in the basement of Building 209 in Technical Area 21 (Building TA-21-209) at Los Alamos National Laboratory (LANL). Building TA-21-209 houses the Tritium Science and Fabrication Facility, where lithium salt parts are fabricated for the underground nuclear test program. The work in progress at the time of the accident was the excavation of a sump pit in the floor of the building to correct waste stream deficiencies. The crafts person is an employee of Johnson Controls World Services, Inc. (JCI), which is the primary subcontractor to LANL for construction and maintenance work across the Laboratory.
The accident victim suffered severe burns and cardiac arrest. On-scene attempts to re-establish cardiac rhythm with a defibrillator were unsuccessful. The accident victim was subsequently transported to the Los Alamos Medical Center, where cardiac medications were administered. At approximately 10:10 a.m., the accident victim resumed a normal cardiac rhythm and blood pressure. The accident victim remains in a deep coma.
On January 23, 1996, Dr. Tara O'Toole, Assistant Secretary for Environment, Safety and Health (EH-1), appointed a Type A Accident Investigation Board to investigate this accident (see Appendix A). The Assistant Secretary's declaration of a Type A investigation was based on the serious nature of the incident, the recurrence of both electrical and conduct of operations incidents at LANL, and her concern for the need to develop programmatic lessons-learned to reverse this adverse trend in worker safety.
A Type A Accident Investigation Board was convened to find the causes of the accident and render judgments of need to prevent similar accidents in the future.
The scope of the Board's investigation included a review and analysis of the events leading up to the accident and identifying and analyzing the accident's direct, probable, and root causes. The investigation was conducted in accordance with DOE Order 225.1, Accident Investigations. In addition, the Board was charged with preparing a report of
the accident, and with providing judgments of need to prevent similar accidents from occurring in the future. The Board also observed and documented safety and health concerns that were not a direct cause of the accident.
During the investigation, the Board inspected and photographed the accident site and reviewed the events leading to the accident. The Board conducted extensive interviews and document reviews, and performed engineering and root cause analyses. Interviews were conducted with work participants, emergency responders, doctors, management, and other personnel. Document reviews included U.S. Department of Energy (DOE) orders, LANL policies and procedures, JCI policies and procedures, Santa Fe Engineering contractual documents, facility design and modification drawings, and related records. The Board evaluated relevant management systems and other factors that could have contributed to the accident, and performed an events and causal factor analysis and a change analysis of the events, causes, and safety systems related to the accident.
In support of the Board's efforts, JCI performed an electrical loads analysis of the fault caused by the accident, conducted compressive strength tests of both the concrete (surrounding the electrical cable conduit) and adjacent tuff soil (volcanic rock), and conducted an underground utility location survey (after electric power had been restored to the facility).
The Board's activities were consistent with Department of Energy concerns for worker safety and the significance of the accident.
The Accident Investigation Board consisted of a Chairperson; three Board Members, including one trained accident investigator; five advisors; and an administrative staff to coordinate the investigation and report preparation. The advisors provided expertise in accident analysis, electrical safety, work planning, construction safety, management systems, conduct of operations, materials testing, and medicine. Appendix B contains the qualifications and experience of the Board Members, advisors, and administrative support staff.
The Board's activities were consistent with the Assistant Secretary's concerns for worker safety at LANL and the overall significance of the accident relative to safety throughout the DOE complex. The basic objectives of the Board were to identify the facts pertinent to the accident, to determine the significance of the facts by analysis, to establish the direct contributors and root causes of the accident, and to identify the judgments of need to prevent a recurrence of a similar accident.
The Board also examined programmatic weaknesses that contributed to the accident. To achieve this objective, the Board conducted 63 interviews with workers, electrical safety specialists, supervisors, and management personnel. The Board also reviewed related procedures, work control documents, design drawings, safety program initiatives, and corrective actions taken in precursor events. The accident investigation was initiated on January 21, 1996, with a review of the accident scene and the damaged equipment, and a walkthrough of the events leading up to the accident. The Board concluded its investigation and conducted a closeout briefing at LANL on February 12, 1996.
Los Alamos National Laboratory's primary mission is application of scientific and engineering capabilities to assure national security.
LANL is operated by the University of California (U of C) under contract to DOE. Its primary mission is to apply scientific and engineering capabilities to assure national security through nuclear weapons technology. The complex is located in Los Alamos County in the mountains of north central New Mexico (Figure 1-1). The LANL facilities occupy 43 square miles and consist of 32 technical areas. Figure 1-2 shows Technical Area 21, the location at which the accident occurred.
The LANL organization, depicted in Figure 1-3, is a matrix of Divisions and Offices managed by Division or Office Directors (referred to in this report as the LANL Division management level) reporting directly to the Director and Deputy Director of the Laboratory (referred to in this report as senior LANL management). For the events leading up to this accident, three Divisions had major roles: the Environment, Safety, and Health (ESH) Division; the Facilities, Security, and Safeguards (FSS) Division; and the Engineering Sciences and Applications (ESA) Division. Within these Divisions are Groups such as the Water Quality and Hydrology Group (ESH-18), and the Operations and Maintenance Services Group (FSS-9). These organizations were assigned specific responsibilities for the work in Building TA-21-209 at the time of the accident.
The accident occurred during excavation operations in the basement of a tritium handling facility.
The Tritium Science and Fabrication Facility (TSFF) is a tritium research and development facility that is operated by the Tritium Science and Technology Group (ESA-3). The primary mission of the facility, which has been operating since 1974, has been the fabrication of lithium salt parts for the underground nuclear test program. The facility is located in Building 209 in Technical Area 21 (Building TA-21-209), and was designed to handle large quantities of tritium in the form of metal tritides or gas. The utilities for the TSFF, including electrical service, are located in the basement of Building TA-21-209, where the accident occurred.
Figure 1-1
Figure 1-2
Figure 1-3
The results of the Board's investigation, including facts, analysis, findings, probable causes, and judgments of need related to the electrical accident and injury that occurred in Building TA-21-209 are presented in this report. To clarify what occurred before, during, and after the accident, and to maximize the lessons learned from the accident, the Board has included appropriate photographs, diagrams, figures, tables, and copies of relevant documents. The corrective actions developed and implemented to address the results of this investigation will be evaluated and tracked to closure by the DOE's Office of Environment, Safety and Health (EH).
Last Modified: Friday, 28-Feb-97 10:09:00