On April 3, 1995, I established a Type A Accident Investigation Board to investigate the fatal rappelling accident at the Savannah River Site Advanced Tactical Training Academy. The Board's responsibilities have been completed with respect to the investigation. The analysis, identification of root and contributing causes, and judgments of need reached during the investigation were performed in accordance with DOE 5484.1, "Environmental Protection, Safety, and Health Protection Information Reporting Requirements." 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
The objectives of this investigation are twofold: to determine the cause and surrounding circumstances of this accident and to prevent the occurrence of similar accidents.
The accident under investigation occurred on April 3, 1995, at approximately 10:46 a.m. As a result of the accident, a Wackenhut Services, Incorporated–Savannah River Site (WSI–SRS) Special Response Team (SRT) member received fatal injuries from a 27-foot fall from the top of the Savannah River Site (SRS) Advanced Tactical Training Academy Security Rappel Tower. The accident took place during a rappel training exercise undertaken in preparation for an offsite Special Weapons and Tactics (SWAT) competition. A "buddy rappel," in which a rappeller carries a "buddy" on his back, was in progress, and a single rope was being used to descend from the top of the tower. The accident occurred when the rope separated during the rappel, and the Rappeller fell on top of the Buddy.
The Department of Energy (DOE) Accident Investigation Board (Board) assembled for this investigation was appointed by the Assistant Secretary, Environment, Safety and Health. The Board included both subject-matter and accident-investigation experts. Appendix A contains copies of the appointment letters. To determine the direct, probable, and root causes of the accident, and to identify judgments of need for correcting the deficiencies that led to the accident, the Board determined the most likely accident scenario and analyzed management structures, policies, procedures, and related practices at SRS.
The Board determined that the direct cause of the accident was the separation of the rope.
The Board determined that the direct cause of the accident was the separation of the rope, which was caused by the rope coming in contact with the small-radius, sharp-edged, lock-pin housing of the newly installed safety gate combined with the dynamic load of the Rappeller and the Buddy on the rope. Rope will separate under loads much smaller than those of its design strength when stretched under tension during an activity such as rappelling and over a small-radius diameter object like the gate lock-pin housing.
Savannah River Site management did not ensure that Special Response Team training requirements approved for the protective force mission were in accordance with the Site Safeguards and Security Plan.
The Board examined both the WSI–SRS mission and its protective requirements and found there was confusion about the necessity of the SRT's use of rappelling. The Site Safeguards and Security Plan (SSSP) did not include rappelling as a required SRT operational or tactical response technique. The Board found that Savannah River Operations Office (SR) management did not ensure that the SRT training requirements approved for the WSI–SRS mission were SSSP driven.
The Board also found that the DOE Headquarters Office of Nonproliferation and National Security (NN) exercised program management of the protective force and training programs in accordance with prevailing DOE orders. However, the Board determined that WSI-SRS viewed NN and their Central Training Academy rappel-training lesson plans as Department policy and, therefore, viewed the rappelling lesson plans as NN sanctioning rappelling, irrespective of site security requirements. In addition, the Board found that WSI-SRS and DOE policy regarding rappelling was inadequate to prohibit the use of the unacceptable buddy rappel technique.
DOE rappel policy was inadequate to prohibit the use of the unacceptable buddy rappel technique.
Two probable causes support these findings: SR did not make a comparison between the WSI-SRS mission and its training requirements; and the DOE Headquarters responsible program office, the Office of Environmental Management (EM), along with NN, which have security management responsibilities, did not ensure that SR clearly understood DOE's rapelling requirements and their appropriate application and effective implementation. In addition, EM was focused on security planning, not on safety and conduct of operations.
Several training-related factors combined to contribute to the accident.
Several training-related factors combined to contribute to the accident. The most important of these are: the SRT last conducted buddy rappelling in 1989; NN and WSI–SRS management reviews identified a need for Rappel Instructor/Master refresher training, but a training program was not developed; information concerning the impact of recently installed rails and gates at the Security Rappel Tower was lacking; and there were no buddy-rappel lesson plans. These factors led the Board to determine that WSI–SRS did not develop a training program that included all the necessary steps to conduct buddy rappelling safely and effectively.
The Board found that there was neither DOE nor WSI–SRS safety or training management of SRT competition preparation activities and that SR reviews of the WSI–SRS training program were not effective. The WSI–SRS safety program was primarily focused on facilities, not on operations and training, and WSI–SRS procedures did not assign safety responsibilities in a manner that ensured a progression of safety responsibility beyond the Rappel Master.
The Board determined that management controls were not provided because the operations office and the protective force perceived that competition preparations were outside normal operations and training requirements.
The Board determined that management controls were not provided because SR and WSI–SRS perceived that the competition preparations were outside normal operations and training requirements. WSI–SRS safety management controls were not accomplished at each organizational level because the procedures, position descriptions, and job task analyses for WSI–SRS managers and personnel involved in rappelling did not contain sufficient detail on safety responsibilities. In addition, DOE management controls were weak in that no line management reviews of rappelling operations had been conducted, no oversight by the DOE Headquarters Office of Environment, Safety and Health (EH) had been conducted, and there was no assurance that DOE rappelling training adequately covered the fundamental safety principles related to rappelling.
The Board also examined the injury and illness data for protective force operations and found that these operations are among the most hazardous in the Department. This finding indicates that greater emphasis needs to be placed on operational safety of SRT activities.
Based on the analyses and findings in this report, the Board identified the judgments of need listed below:
In addition to the judgments of need above, the Board has two broad recommendations for consideration based upon the results of this accident investigation and a review of other DOE security program safety issues. DOE should:
This is Volume 1 of a two-volume Type A Accident Investigation Board report on the April 3, 1995, Advanced Tactical Training Academy Security Rappel Tower fatality at the Department of Energy (DOE) Savannah River Site (SRS). This volume includes the Executive Summary, a description of the accident, an analysis of the pertinent facts, and the Board's conclusions and judgments of need. This volume also contains photographs of the accident scene; causal analysis diagrams; and Appendices A through H, which contain supporting documentation.
Volume 1 is designed to be a stand-alone document that provides the reader with a summary of the facts, analyses, and conclusions related to the accident. Volume 2 is also a stand-alone document and was designed to provide more-detailed information about the facts surrounding the accident, an expanded analysis of the facts, and the Board's conclusions and judgments of need. Volume 2 contains additional photographs, drawings, diagrams, and appendices.
SRS is a large industrial complex covering more than 300 square miles. The site borders the Savannah River and encompasses parts of three counties in western South Carolina. The Advanced Tactical Training Academy is in the northeast quadrant of the site, near the Barnwell-Aiken County line, as shown in Figure 1-1. The Advanced Tactical Training Academy consists of a pistol range, a 400-meter, known-distance range, a Security Rappel tower, a live-fire shoot house, and a stress course. The Security Rappel Tower is shown in Figure 1-2.
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The Board's investigation approach was twofold. First, the Board determined the accident scenario by examining the Security Rappel Tower and the rappelling equipment and by reviewing the actions taken by the Rappeller, the Buddy, and other Special Response Team (SRT) personnel present during the training exercise.
Programmatic breakdowns that could have contributed to the fatal accident were investigated.
The Board then analyzed management structures, policies, procedures, and related practices in effect at DOE Headquarters, the Department's Savannah River Operations Office (SR), Wackenhut Services Incorporated–Savannah River Site (WSI–SRS), and Westinghouse Savannah River Company (WSRC) that led to the SRT's use of rappelling at SRS. This line of investigation was pursued to determine if there had been programmatic breakdowns that could have contributed to the fatal accident.
The Board used various accident analysis techniques, including Management Oversight and Risk Tree (MORT) analysis, event and causal factors charting, analytical trees, barrier analysis, and change analysis. The Board conducted extensive interviews and document reviews and performed engineering and root cause analyses to identify the operational, facility, equipment, and management deficiencies that contributed to the accident.
Based on these analyses, the Board determined the direct, probable, and root causes of the accident. Root causes are those deficiencies that, if corrected, might have prevented this accident. In addition, the Board developed judgments of need for correcting the identified deficiencies. These can be used to prevent similar accidents throughout the Department.
The Accident Investigation Board and advisors assembled to conduct this investigation included individuals with experience and training in DOE accident investigation and analysis, occupational safety, training, rappelling, security operations, management systems, SRT operations, systems analysis, and engineering testing and analysis. Appendix B contains qualifications of the Board, advisors, and consultants. The Board was assisted by representatives of WSI–SRS, the United Plant Guard Workers of America, an SR advisor, WSRC personnel, and several technical consultants.
Rappelling is a tactic used by DOE protective forces and SRT personnel to gain access to facilities to thwart the theft, diversion, or sabotage of special nuclear material. DOE fire and rescue personnel also train in rappelling and use it during some of their missions and operations. Rappel training is conducted at the DOE Central Training Academy and at various Department field sites, including the SRS Advanced Tactical Training Academy.
Rappelling is a tactic used by DOE protective forces and SRT personnel to gain access to facilities to thwart the theft, diversion, or sabotage of special nuclear material.
Rappelling is the science of sliding down a rope in a safe, controlled manner, during which the rappeller has to support only a fraction of his or her total weight with the hands. Rappelling techniques have evolved from crude body rappels, in which a rope was wrapped around one or more parts of the body, to the mechanical descenders currently in use.
Mechanical descenders were used during both the single-person and the buddy-method rappel training exercises discussed in this report. The specific descender used during the buddy rappel was a "Figure 8" descender. Figure 2-1 illustrates this descender as it was observed after being unhooked from the Rappeller.
The Board identified the basic safety principles that should be used in rappelling. These principles are listed below.
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On April 3, 1995, at approximately 10:46 a.m., a WSI–SRS employee received fatal injuries as the result of a fall during a rappel training exercise at the SRS Advanced Tactical Training Academy Security Rappel Tower. The training was being conducted from the top of the 40-foot-high tower, which is shown in Figure 3-1.
Training in progress at the time was a buddy rappel (i.e., two men on a single rope). This exercise was being conducted to prepare for a South Carolina State Special Weapons and Tactics (SWAT) competition in Spartanburg, South Carolina.
Training in progress at the time was a "buddy rappel" (i.e., two men on a single rope). This exercise was being conducted to prepare for a South Carolina State Special Weapons and Tactics (SWAT) competition in Spartanburg, South Carolina.
Initial training exercises consisted of building entry and clearing techniques on each level of the Security Rappel Tower, concluding with each competition-team member executing a single rappel from the top of the 40-foot tower. The recently installed safety gates were open, with the rope bearing on the edge of the top deck, during regular rappel exercises. Following these exercises, the team practiced the buddy rappel technique over the top of the closed safety gates. The Rappel Master, Team Coach, Rappeller, Buddy, and another team member climbed to the top of the Security Rappel Tower to prepare for the exercise.
The Buddy replied, "Then we'll go over the gate."
The Rappeller asked, "Do we go over or under the gate?" The Team Coach said, "At Spartanburg, they go over the rail." The Buddy replied, "Then we'll go over the gate." The Rappel Master then closed and locked the gates. The rope was routed over the top rail of the gate and down to the ground. The position of the rappel rope prior to the buddy rappel is illustrated in Figure 3-2.
The Buddy attached his seat harness to the back of the Rappeller and prepared for the descent. The Rappeller said "On rappel," indicating a readiness to descend, and the Belayer on the ground responded "On belay," indicating a readiness to slow or stop the Rappeller's descent, if required.
The Rappeller and the Buddy climbed over the gate and stood on the edge of the top of the tower. As they started their descent, the Rappeller experienced difficulty in establishing his body in the "L" position because of his and the Buddy's combined weight of 484 pounds. As the Rappeller maneuvered his feet, the rope moved laterally and slipped approximately 8 inches down into the area between the gates where the gates were pinned together. This slippage enabled
the rope to come in contact with the small-radius edge of the gate lock-pin housing.
The Rappeller landed on top of the Buddy, causing severe chest compression to the Buddy.
When the Rappeller and the Buddy were approximately 10 feet down the wall of the tower, the Belayer perceived that the Rappeller was descending too fast and was not in full control of the descent. His response was to apply tension to the rope to slow or stop the descent. At about the same time, the rope separated where it had been in contact with the small-radius edge of the gate lock-pin housing. The sound of the rope separating was described as a "crack" similar to a small-caliber rifle shot. At about 10:46 a.m., the Rappeller and the Buddy fell approximately 27 feet to the sawdust on the ground level. The Rappeller landed on top of the Buddy, causing severe chest compression to the Buddy.
Emergency medical response was conducted by qualified Emergency Medical Technicians (EMT). Emergency medical response was provided by SRT EMTs, who were already at the scene of the accident, and by the WSRC Fire Department. All of these EMTs were qualified by the State of South Carolina. At the time of the accident, WSI–SRS sent requests by radio for SR helicopter assistance and by telephone to the SRS Operations Center for ambulance assistance. The Board examined each of these responses separately, in addition to reviewing related emergency-response actions.
The Buddy was transported by the Savannah River helicopter to University Hospital Emergency Room in Augusta, Georgia, where he was pronounced dead at 11:37 a.m.
The first, immediate medical response was from an SRT competition-team member who was a qualified EMT. The Rappeller and the Buddy were unhooked, and the Rappeller was rolled off the Buddy. The Rappeller complained of pain in his back and neck. The Buddy was nonresponsive, was not breathing, and his eyes were only partially open. Rescue breathing was administered. At first, a weak radial pulse was detected. Rescue breathing was continued, and, after several applications of the technique, no pulse was detected. At this point, cardiovascular pulmonary resuscitation was initiated.
The SR helicopter arrived at about 10:54 a.m. and departed the accident scene at about 11:00 a.m. with the Buddy. He was transported by the SR helicopter to University Hospital Emergency Room in Augusta, Georgia, where he was pronounced dead at 11:37 a.m.
The two WSRC Fire Department ambulances, Medic 1 and Medic 2, were dispatched at 10:49 a.m. En route, the crews discussed the quickest route to the accident to ensure they did not lose time and to ensure that Medic 1, the following ambulance, did not become disoriented in the dust-cloud created by Medic 2. Both crews discussed treatment requirements while en route. The crews arrived at the accident site within a minute of each other.
Medic 1 and Medic 2 arrived at the accident scene at approximately 11:04 a.m., which was about 4 minutes after the SR helicopter had departed with the Buddy. Although the primary emergency response was focused on the Buddy, the Rappeller, who reported numbness in his arms and legs, also received first-aid.
Medic 2, with the Rappeller on board, departed for the Medical College of Georgia Trauma Unit at 11:14 a.m and arrived there at 12:07 p.m. The Rappeller was treated and released the same day, with no apparent long-term effects.
Information obtained from tape recordings made by the SRS Operations Center during the accident time period indicated that conversations between WSI–SRS and individuals calling about the accident were transmitted over an open telephone line.
Interviews indicated that EMT emergency response kits were not standardized at SRS. The WSRC Medical Director recommended the contents to be included in WSRC's EMT kits and had oversight responsibility for them. The WSI–SRS kits were not necessarily standardized with those of WSRC, and there was no oversight of their contents.
The WSI–SRS EMTs provided a quicker response and transportation by helicopter than did the WSRC EMTs by ambulance due to the presence of WSI–SRS EMTs at the accident site. The WSI–SRT EMTs immediately called for the SR helicopter, which took only a few minutes to arrive and depart the accident scene carrying the Buddy.
A summary of the accident analysis, including discussions of the Security Rappel Tower, safety railings, rappel rope, rope testing, and analytical techniques, is provided in Appendix H. Operations analyses, including mission and policy, operations and training, occupational safety, management systems, and the direct cause of the accident, are summarized in Appendix I. The analysis described in the appendix was used to develop the conclusions discussed in the following section.
Last Modified: Friday, 28-Feb-97 10:09:00