SRT operational and tactical response plans, which are required to be integrated within the SSSP, did not identify an aerial/building rappelling mission for the SRS SRT.
DOE 5632.7A, Protective Force Program, does not contain a prescriptive requirement for the Special Response Team (SRT) to have a rappelling capability; however, rappelling may be justified by site-specific conditions. The Site Safeguards and Security Plan (SSSP) documents the containment protection strategy and the associated risk acceptance for vital Savannah River Site (SRS) facilities, as approved by the Department. SRT operational and tactical response plans, which are required to be integrated within the SSSP, did not identify an aerial/building rappelling mission for the SRT.
The Office of Nonproliferation and National Security (NN) advised the Board that Department of Energy (DOE) sites are required to follow Central Training Academy lesson plans. Rappel training is required for the SRT Qualifications Course, unless an "exception" has been granted by NN. Since NN requires an exception for a capability (rappelling) that is not required by DOE 5632.7A, it fosters the belief that Central Training Academy lesson plans are Department policy and, therefore, implementation is required.
Interviews with Savannah River Operations Office (SR) and Wackenhut Services, Incorporated-Savannah River Site (WSI–SRS) management provided several explanations as to why SRT rappel operation requirements were contained in the WSI–SRS contract. One of the explanations was that because the Central Training Academy teaches a formal rappelling course, it was perceived as a Department policy requirement by SR and WSI–SRS senior security management and, therefore, required by contract.
Site-specific needs did not support the rappelling operations identified in the contract, regardless of how the status of Central Training Academy lesson plans was perceived.
The Board examined SR and WSI-SRS explanations and found them unsupported by site-specific needs as defined by the SSSP. Although some explanations had merit, based on NN interviews and DOE 5632.7A requirements, site-specific needs did not support the rappelling operations identified in the contract, regardless of how the status of Central Training Academy lesson plans was perceived. The need for the current SRT rappelling contractual requirement, first contained in the 1988 WSI–SRS contract, was not reassessed by SR management, despite changes to the DOE Design Basis Threat Policy, SRS mission requirements, and SSSP protection strategy.
The relevance of the buddy rappel technique to DOE or SRT operations is obscure. The Special Weapons and Tactics (SWAT) competition team viewed the buddy rappel technique strictly as a method of increasing their chances of winning the competition by descending two rappellers at one time to reduce the overall event completion time.
The competition team knew there would be a timed rappelling event at the Spartanburg SWAT competition and concluded that the buddy rappel might be a solution to reducing the event task time.
The competition team knew there would be a timed rappelling event at the Spartanburg SWAT competition and concluded that the buddy rappel might be a solution to reducing the event task time. Both WSI–SRS SRT management and WSI–SRS training management were presented with several opportunities to explicitly direct the exclusion of the buddy rappel technique from the competition training, but they did not.
The presence of a multi-faceted command and control structure at the Advanced Tactical Training Academy facility on the morning of the accident resulted in competition event training responsibilities being informally split among several SRT personnel. This fragmentation of command and control authority precluded any opportunity for a focused, carefully directed training and safety regimen overseen by a single leader. The absence of written SWAT competition training procedures that incorporated lessons learned from previous SRT competitions resulted in the team relying on experience and memory to drive their training and safety practices.
None of the members of the competition team were fully qualified to perform a buddy rappel.
A combination of several training-related factors were important contributors to the accident. The experience and training of the SRT appear to have been sufficient to meet the SRS requirements for performing normal duties. However, the competition team's buddy rappel training was discontinued in 1989, and the WSI–SRS Rappel Masters have not had the benefit of either refresher training or Central Training Academy instruction since that time. Therefore, none of the members of the competition team were fully qualified to perform a buddy rappel. There was no formal training program for the competition, and lesson plans had not been developed for buddy-rappel training. If lesson plans had been developed for the buddy rappel, SRT management would have had the opportunity to review the instructions during the training approval process and to determine the validity of the buddy rappel for SRS.
Revision 2 of WSI–SRS Standard Procedure 1-5600, Rappelling, did not contain changes concerning the use of the safety rails and gates that affected rappelling procedures. Updated procedures regarding the purpose and function of the Security Rappel Tower rails as related to rappelling could have deterred their use. Further, the current approach to safety training, which is a standard element of all rappel training, did not prepare otherwise skilled rappellers to consider, prepare for, and control all of the dynamics of buddy rapelling. Such dynamics include assessing how changes in the position of the rope impact safe rappel operations, recognizing that changes to the rappel facility impact rappel operations, and analyzing how changes to rappel techniques impact rappel operations.
There appears to have been a disparity between the intent of the Office of Nonproliferation and National Security concerning the application of Central Training Academy lesson plans and how the plans were perceived by SR and WSI-SRS officials.
Finally, the Board determined that NN had not effectively identified the appropriate application of Central Training Academy lesson plans pertaining to rappel requirements, nor had NN disseminated this information in DOE Orders to ensure clear understanding of the requirements and the process to receive relief from these requirements. Interviews with senior security management for NN, SR, and WSI–SRS established that there were differing views on the application of Central Training Academy lesson plans. These differing views led to WSI-SRS not ensuring that a rappel instructor trained by the Central Training Academy was present during rappel operations. There appears to have been a disparity between the intent of NN concerning the application of Central Training Academy lesson plans and how the plans were perceived by SR and WSI-SRS officials.
Conducting competition preparations without recent successful training on buddy rappelling, combined with a lack of Rappel Instructor/Master refresher training and enhanced safety training; the lack of information concerning the impact of the rails and gates on training at the Security Rappel Tower; and the lack of approved buddy-rappel lessons plans, were significant training-related contributors to the April 3, 1995, accident.
The current program direction for the protective force training program is not sufficient to ensure that either Central Training Academy training or the Rappel Instructors/Masters trained at the Central Training Academy will incorporate the necessary principles and facts about the operational safety and dynamics of rappelling that contributed to the April 3, 1995, accident into future training. The training program in effect at the time of the accident did not include such basic rapelling information as rope watching, load-bearing capacity under static and dynamic conditions, and the relationship between rope capacity and exposed-edge radius. The application of Central Training Academy lesson plans must be clarified and emphasized to ensure adherence to all Central Training Academy training requirements and to ensure the development of a clear process for obtaining relief from those training requirements that are not driven by site-specific protection program requirements.
Installation of new safety railings on the Security Rappel Tower to satisfy Occupational Safety and Health Administration (OSHA) fall-protection requirements was a factor in the accident. OSHA requires that this type of railing be designed to withstand a 200-pound force applied in any direction to the rail. The safety railings on the Security Rappel Tower were designed as gates to be opened for training exercises. After inspection of the tower by the SR Safety Division, the chains across openings were judged to be inadequate to meet the OSHA fall-protection requirements.
Neither WSRC nor WSI–SRS identified the need for fall protection on the Security Rappel Tower to meet the OSHA requirements.
Neither Westinghouse Savannah River Company (WSRC) nor WSI–SRS identified the need for fall protection on the Security Rappel Tower to meet the OSHA requirements. However, the SR Safety Division identified the need when conducting an inspection for an Occupational Safety and Health Program performance review of WSRC and WSI–SRS. After receiving a request from WSI–SRS, WSRC initiated actions to install the safety railings and exercised complete control of their design, fabrication, installation, and final inspection. Although, WSI–SRS was aware of the installation of safety railings on the Security Rappel Tower, the Board could find no evidence that they had participated in the design process.
WSI–SRS did not conduct a formal change analysis concerning the impact of the new gates on training activities.
The WSI–SRS Range Manager took the Security Rappel Tower out of service on March 6, 1995, for the installation of the safety railings and placed it back in service on March 29, 1995, at the completion of the job. Before placing the Security Rappel Tower back in service, the WSRC Area Safety Engineer inspected the handrail and gate installation and found it to be satisfactory for safe use as fall protection from the tower. This was just before the April 3, 1995, fatal rappel training accident. WSI–SRS did not conduct a formal change analysis concerning the impact of the new gates on training activities.
The Board examined the occupational injury and illness experience of WSI–SRS and other DOE security contractors to identify significant trends.
The Board examined the occupational injury and illness experience of WSI–SRS and other DOE security contractors to identify significant trends. In 1994, DOE had 31 security contractors with approximately 7,005 full-time employees. Table I-1 lists the 1992 to 1994 injury and illness rates for 8 of these contractors, with a total of 4,651 employees.
Table I-2 lists the total recordable and lost workday case rate of the SRT force versus the rate for all WSI–SRS and all Department protective forces. The WSI–SRS and SRT data in this table were obtained from WSI–SRS rather than from the Department's Computerized Accident/Incident Reporting System (CAIRS) database. The differences between Table I-1 and Table I-2 are due to the WSI–SRS information being more accurate and more current than that available from the CAIRS database. Table I-3 lists injury and illness rates for nine major sectors of DOE.
Line management of WSI-SRS was not effective and did not include all operations.
Some aspects of the management systems at SRS have been implemented effectively; however, there were shortcomings in the implementation of line management, program management, and independent oversight. Line management of WSI-SRS was not effective and did not include all operations. The focus of EM and SR line management of activities of WSI-SRS was on security planning and normal training and operations, respectively. Line management of WSI-SRS competition preparation was non-existent. This represents the most significant management systems failure. There were other failures within WSI-SRS. WSI–SRS oral and written communications did not prohibit the use of the unacceptable and unauthorized buddy rappel technique, nor did they ensure that personnel conducting operations on the Security Rappel Tower were informed of changes and their impact on operations. Breakdowns in the supervision and communication processes within WSI–SRS resulted not only in the buddy rappel technique being accepted for use, but also allowed the technique to be introduced as a training activity even though it was not authorized for the competition.
A number of shortcomings in program management systems contributed to WSI–SRS's use of an unacceptable rappel technique. These shortcomings include the lack of clear Department policy with regard to the appropriateness of the buddy rappel, not identifying shortcomings in the Rappel master qualifications during program management reviews, and the lack of understanding concerning the Central Training Academy's lesson plans.
DOE safety organizations did not provide managers with significant accident and illness data for SRTs across the DOE complex. Independent safety oversight by the Office of Environment, Safety and Health did not provide coverage for protective force operations and training.
Table I-2. Injury and Illness Rates for Wackenhut Services, Inc., Savannah River Site and WSI-SRS Special Response Teams 1992 Through 1994
|
1994 |
1993 |
1992 | ||||
|
TRC |
LWD |
TRC |
LWD |
TRC |
LWD | |
|
WSI-SRS* |
3.71 |
107 |
4.9 |
92 |
3.06 |
59 |
|
WSI-SRS SRT* |
8.78 |
102 |
26.4 |
912 |
14.5 |
51 |
|
All DOE Security** |
6.0 |
93 |
6.6 |
103 |
7.6 |
122 |
TRC = Total Recordable Case Rate
= Total Injuries and Illnesses X 200,000/ Employee Hours Worked
LWD = Lost Work Day Rate
= Total Days Lost X 200,000/ Employee Hours Worked
Source:
There were also numerous shortcomings in the conduct of operations program that led to training in rapelling being initiated on the Security Rappel Tower prior to full testing and without informing the SRT of the purpose and limitations of the newly installed gates. There are established procedures that are used for the analysis and testing of modifications to facilities prior to reinitiation of operations. Line management was complacent about ensuring that testing and change analysis requirements were completed prior to resuming operations at the Security Rappel Tower. Also, procedures were too broad in the assignment of safety responsibility during rappel training, even for authorized rappel techniques. In addition, lessons learned from previous accidents were not effectively utilized in all elements of WSI–SRS programs or operations.
There were also numerous shortcomings in the conduct of operations program that led to training in rapelling being initiated on the Security Rappel Tower prior to full testing and without informing the SRT of the purpose and limitations of the newly installed gates.
Last Modified: Friday, 28-Feb-97 10:09:00