Change or Difference

Analysis

Planned/Normal

Present

Difference

Analysis

Safety rail gates open

Safety rail gates closed

With gates open, the rappel is performed from the scuff pad on the tower floor. With gates closed, the rappel was done with rope on top of the safety rail.

The decision was made to Buddy Rappel with the rope on top of the safety rail and with the gates closed.

Scuff pads on edge of tower floor

Scuff pads were not used on top of safety rails

Rope contacted small radius edge of lock-pin housing.

The rappel rope received no protection from the small radius edge of the lock-pin housing.

Top belay

Ground belay

Only the ground belay was available as fall protection for the rappellers.

This condition resulted from the decision to conduct training simulating SWAT competition conditions.

Single Rappeller on rope

Buddy Rappel

Buddy Rappel increased static load on rope to 484 pounds. Rope actually separated on small radius edge with a dynamic load of 965 pounds.

Caused by team's desire to streamline rappelling activities for SWAT competition.

Two-rope rappel

Single-rope rappel

Single-rope rappel offers much less load support for Rappeller.

Two-rope rappelling is required at WSI-SRS for all rappelling activities except SWAT competition training. This exception is too broad and training requirements should be reviewed by Safety each year.

Chain and post fall protection

Safety rail/gates fall protection

Safety rail/gates fall protection present two hazards to tower users.

Created a climb over obstacle and potential for a rope pathway hazard.

Rope awareness and pathway

Lack of rope awareness and pathway

Rappeller unaware of rope pathway, fall line, and hazards.

Lack of awareness of rope pathway contributed to rope contacting small radius of lock-pin housing.

Rappel Master training discontinued

SRT not proficient in performing hazardous task (Buddy Rappel).

Management has not addressed the requirement for the Buddy Rappel as a useful rappel.

Buddy Rappel use is continued without regard to its hazard potential.

Risk Analysis - SPO III Core Curriculum 6/17/94

Risk analysis does not reflect new safety rails

The hazards involved in rappelling with the rope on top of the safety rail.

A risk analysis performed on the new fall protection should reveal the hazard to the rope caused by the small radius edge of the lock-pin housing.

Lesson plans for training

Lesson plans not required for SWAT competition training

Training is informal, not reviewed by Safety, and not approved by management.

SWAT competition training is informal, planning is insufficient, and hazardous activities are included.

Rappel practices well established in Procedure 1-5600 and SRT training procedures.

SWAT competition rappel practices not known by SRT members.

SRT members begin training using rappel practices that are illegal under competition rules.

The use of the hazardous buddy rappel was introduced into training because competition rules were not known by SRT members.

Rappel Procedure 3-6601 requires a visual inspection of the tower prior to each iteration of rappelling.

Inspection of safety rails not performed - procedures not followed.

Safety rails were not inspected for rope pathway hazards - small radius edge.

Lack of inspection led to hazardous rope pathway during SWAT competition training.

Procedure 1-3146 requires inspection of stationary rappel by appropriate safety personnel prior to each rappel training class.

Procedures not followed.

Safety rail fall protection not integrated with rappelling operation hazards.

Lack of inspection resulted in safety rail being used as a rappelling device and exposure of rope to pathway hazard.

Rappel rope placed on tower floor for rappelling from tower.

Rappel rope placed over top of safety rail.

Rope placement change to a more hazardous pathway.

Rope pathway change was made to simulate training under SWAT competition conditions.