On February 22, 1996, I established a Type A Accident Investigation Board to investigate the fall at the Transuranic Storage Area-Retrieval Enclosure of the Radioactive Waste Management Complex at the Idaho National Engineering Laboratory that resulted in the fatality of a construction Project Engineer. 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

TABLE OF CONTENTS

• ACRONYMS AND INITIALISMS
• PROLOGUE
• EXECUTIVE SUMMARY
• 1.0 INTRODUCTION
  • 1.1 BACKGROUND
  • 1.2 FACILITY DESCRIPTION
  • 1.3 SCOPE, CONDUCT, AND METHODOLOGY
• 2.0 FACTS AND ANALYSIS
  • 2.1 ACCIDENT DESCRIPTION AND CHRONOLOGY
    • 2.1.1 Background and Accident Description
    • 2.1.2 Chronology of Events
    • 2.1.3 Accident Response and Investigative Readiness
  • 2.2 PHYSICAL HAZARDS, CONTROLS, AND RELATED FACTORS
    • 2.2.1 Medical Surveillance
    • 2.2.2 Personnel Performance
    • 2.2.3 Management Systems
      • 2.2.3.1 Policies and Procedures
      • 2.2.3.2 Work Planning and Controls
      • 2.2.3.3 Supervision, Management, and Oversight
  • 2.3 BARRIER ANALYSIS
  • 2.4 CHANGE ANALYSIS
  • 2.5 PROBABLE CAUSAL FACTORS
• 3.0 CONCLUSIONS AND JUDGMENTS OF NEED
• 4.0 BOARD SIGNATURES
• 5.0 BOARD MEMBERS, ADVISORS AND STAFF
• Appendix B. PERFORMANCE OF BARRIERS
• Appendix C. CHANGE ANALYSIS

EXHIBITS, FIGURES and TABLES

Exhibit 1-1 Transuranic Storage Area-Retrieval Enclosure

Exhibit 2-1 View Looking South in TSA-RE

Exhibit 2-2 Gap and Leading Edge of Stack

Exhibit 2-3 Temporary Platform

Exhibit 2-4 Bottom View of Platform

Exhibit 2-5 Bottom of the Gap

Figure 2-1 Summary Events Chart and Accident Chronology

Figure 2-2 Barrier Analysis Summary

Figure 2-3 Events and Causal Factors Chart

Table 2-1 Causal Factor Analysis

Table 3-1 Conclusions and Judgments of Need

ACRONYMS AND INITIALISMS

CFR Code of Federal Regulations

DOE U.S. Department of Energy

EH DOE Office of Environment, Safety and Health

EM DOE Office of Environmental Management

ES&H Environment, Safety and Health

ID DOE Idaho Operations Office

INEL Idaho National Engineering Laboratory

LITCO Lockheed Idaho Technologies Company

M&O Management and Operating

OSHA Occupational Safety and Health Administration

RWMC Radioactive Waste Management Complex

TSA-RE Transuranic Storage Area-Retrieval Enclosure

The fatality at the Idaho National Engineering Laboratory on February 20, 1996, resulted from failures of Department of Energy (DOE), contractor, and subcontractor management, and the accident victim. The subcontractor, the employer of the accident victim, had a poor record of serious safety deficiencies and had never accepted the higher levels of safety performance required by the Department's safe work ethic.

Although all the appropriate contractual and procedural requirements were in place, the subcontractor failed to implement them and continued to allow violations of Occupational Safety and Health Administration regulations invoked by DOE orders. These serious deficiencies were recognized by the prime contractor, which was instituting progressively stronger sanctions against the subcontractor. However, because of the subcontractor's recalcitrance and the imminent danger conditions represented by the subcontractor's frequent violations of fall protection requirements, more aggressive measures, such as contract cancellation, could have been taken earlier.

The prime contractor's oversight was narrowly focused on selective aspects of the subcontractor's safety performance and did not identify the subcontractor's failure to implement its own procedures, the medical surveillance program, or fall protection. Thus, the implications and frequency of imminent danger hazards were not fully appreciated. Departmental oversight focused on the subcontractor's performance and did not identify the gaps in the prime contractor's oversight focus. As a result, hazards were not identified and barriers were not in place to prevent the accident, which could have been avoided.

This fatality highlights the importance of a complete approach to safety that stresses individual and line management responsibility and accountability, implementation of requirements and procedures, and thorough and systematic oversight by contractor and Department line management. All levels of line management must be involved. Contractual requirements and procedures, implementation of these requirements, and line management oversight are all necessary to mitigate the dangers of hazards that arise immediately in the workplace. Particular attention must be paid to individual performance and what is happening in the workplace. Sound judgment, constant vigilance, and attention to detail are necessary to deal with hazards of immediate concern. When serious performance deficiencies are identified, there must be strong, aggressive action to mitigate the hazards and reestablish a safe working environment. Aggressive actions, up to and including swift removal of organizations that exhibit truculence toward safety, are appropriate and should be taken.

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EXECUTIVE SUMMARY

INTRODUCTION

A fatality was investigated in which a construction subcontractor fell from a temporary platform in the Transuranic Storage Area-Retrieval Enclosure (TSA-RE) (Building 636) of the Radioactive Waste Management Complex at the Idaho National Engineering Laboratory (INEL). In conducting its investigation, the Accident Investigation Board used various analysis techniques, including event and causal factor analysis, barrier analysis, change analysis, and root cause analysis. The Board inspected and videotaped 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.

ACCIDENT DESCRIPTION

The accident occurred at approximately 11:20 a.m. on Tuesday, February 20, 1996, at the TSA-RE, when a construction subcontractor project engineer (Project Engineer), employed by Caddell Construction Company, Inc. (Caddell), fell approximately 17 feet from a temporary platform. [Caddell is a construction subcontractor to Lockheed Idaho Technologies Company (LITCO), the management and operating contractor for INEL.] The platform had been installed to catch falling tools and parts and to provide support for a transition piece to the ventilating system in the TSA-RE, but it was also used as a work platform for personnel activities when 100 percent fall protection was used. The Project Engineer was transported by helicopter to the Eastern Idaho Regional Medical Center in Idaho Falls, Idaho, where he died at 4:10 p.m. from severe head and neck injuries.

DIRECT AND ROOT CAUSES

The direct cause of the accident was the fall from an unprotected platform.

The root causes of the accident were (1) failure by Caddell to implement requirements and procedures that would have mitigated the hazards, and (2) failure by Caddell to effectively implement the Secretary's guiding principle mandating line management responsibility and accountability for safety performance.

CONCLUSIONS AND JUDGMENTS OF NEED

Conclusions of the Board and Judgments of Need as to managerial controls and safety measures necessary to prevent or mitigate the probability of a recurrence are summarized in Table ES-1. Investigative readiness is also discussed.

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