Barrier

Purpose

Performance

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

To standardize procedures for all rappel operations and outline responsibilities for their safe conduct.

Barrier failed because procedure was not followed.

SPO III Core

Curriculum Risk Analysis

To determine the risk involved in conducting SPO III core curriculum training.

Barrier failed because the risk analysis does not address the types of rappel and does not address the hazards involved in Buddy Rappel.

ATTA Safety Analysis Report

To determine the risk involved in operating the ATTA range facilities.

Barrier failed because:

• Risk analysis does not cover the Rappel Tower and the two hazards associated with the fall protection.
• Risk analysis was not amended to address fall protection modifications (new handrails).

Training for Rappel Master

To provide Rappel Master with guidance to safely exercise overall control and coordination of rappelling activities. The emphasis is on providing safe and effective rappel operations.

Barrier failed because:

• Provisions were not made for refresher training for onsite Rappel Masters.
• Hazardous Buddy Rappel was not addressed as a training exercise to be continued or discontinued.
• Training does not specifically address safety responsibilities of Rappel Master or CTA Training Instructor.
• CTA-trained Rappel Instructors were not providing refresher training to SRS-certified Rappel Masters.

Communications

To provide SRT members with information required to conduct rappelling activities safely and efficiently.

Barriers failed.

Team Coach did not determine that two men on a rope resulted in disqualification at the SWAT competition. Lack of this information resulted in SRT members initiating training for Buddy Rappel.

Final Acceptance Inspection of Safety Rails

To determine that acceptance criteria for safety rail installation are satisfied including safety inspection.

Barriers failed because safety inspection did not reveal presence of small radius edge on safety rail gate pin-housing.

Two-Rope Rappelling

To provide a safe rope if the main rappel rope separates.

Barrier failed because single-rope rappelling was being used to simulate SWAT competition conditions.

Management Policy

To provide guidance and requirements for the development of the containment protection strategy and the associated risk acceptance for vital SRS facilities.

Barrier failed because SR and WSI-SRS did not properly implement policy requirements of DOE 5632.7A. This resulted in a contractual requirement for rappelling in the SR/WSI-SRS contract.

Knots and Anchors

Anchors are devices of sufficient strength to support loads on rope. Knots are used to fasten rappel ropes to anchors.

Did not fail.

Scuff Pads or Protective Mats

Protect ropes from damage by sharp objects.

Barrier failed because scuff pads were not used to cover safety rails or lock-pin housing.

Rappel Master Duties

Duties provide for ensuring safety of all personnel utilizing the Rappel Tower or helicopter rappel lanes.

Barrier failed because:

• Rappel Master did not stop unsafe act of placing rope on top of safety rails.
• Rappel Master inspection of handrail did not reveal small radius edge on lock-pin housing.
• Rappel Master did not ensure safe and orderly progression of training.

Dynamic Line Around Rappeller's Waist

Provide safety rope to support Buddy during Buddy Rappel.

Did not fail.

Rope Awareness

Provide awareness of rope pathway to avoid placing rope in a hazardous location.

Barrier failed because personnel involved with Buddy Rappel did not maintain proper awareness of rope position relative to small radius edge of lock-pin housing.

Top Belay

Provides slowing or stopping action of Rappeller from tower top.

Barrier was not used because of simulation of ground belay from SWAT competition.

Ground Belay

Provides slowing or stopping action of Rappeller from ground.

Barrier did not fail. Ground belay slowed and stopped rappellers; however, rope separated upon contact with small radius of lock-pin housing.

Rope

7/16-inch diameter nylon, 4,500-pound tensile strength provides support to Rappeller during rappelling activities.

Barrier failed. Rappel rope separated upon contact with small radius edge of lock-pin housing.

Warning Signs

Identification of safety rails as fall protection and forbids use in rappelling.

Warning signs were not present because design was not coordinated with Safety or WSI-SRS user.

Human Performance (Good Judgment, Training, and Qualifications)

Assists in interpretation of requirements to ensure safe execution, enhances ability to perform job, and guides on-the-job behavior.

Barrier failed. Task was undertaken for which lack of training did not provide qualifications; poor judgment in undertaking this task led to task performance errors.

WSI-SRS Procedure 1-811, "Facility/Equipment Repairs"

Establishes a procedure for the management of WSRC work requests for WSI-SRS facilities where there is a potential to degrade security or safety and health of employees.

Barrier failed because procedure did not require a safety review, risk analysis, and hazard identification of the Rappel Tower fall protection (handrails) modifications.

Conduct of Operation

To develop directives, plans, and procedures that, when implemented, will result in the improvement of quality and uniformity of operations.

The procedures and directives developed by WSI-SRS for the conduct of operations were not implemented in rappelling operations at the ATTA range.