4. CONCLUSIONS

4.1 Mission and Policy

Findings

The Site Safeguards and Security Plan did not include rappelling as a required capability.

• The SRS Site Safeguards and Security Plan (SSSP) was developed to provide formal DOE documentation of the protection strategy for vital SRS facilities. The SSSP did not include rappelling as an SRT operational or tactical response technique for achieving interdiction, interruption, neutralization, or recapture missions.
• SR did not ensure that SRT training requirements approved for the WSI–SRS mission were driven by the SSSP.
• Both SR and WSI–SRS senior management viewed Central Training Academy lesson plans as Department policy; however, NN stated that the plans were training criteria.

Probable Causes

· SR did not make a comparison between the WSI–SRS mission and its training requirements.

4.2 Operations and Training

Findings

• SR required WSI–SRS, by contract, to maintain an SRT that was "highly qualified and trained in aerial/building rappel techniques"; however, there was an absence of documentation to indicate how this capability was to be used.
• SR did not update the WSI–SRS contract to reflect changes in the design-basis threat policy and the evolving site mission. WSI–SRS participation in competitions was not a contract requirement, but SR authorized WSI–SRS participation as being within the perceived contractual scope of work. Success in offsite SWAT competitions was an assessment factor when SR determined award fees for WSI–SRS performance.
• SWAT competition rules were not clearly understood prior to the competition preparations for training. Competition team training did not include:

¾ use of the unapproved buddy rappel technique;

¾ a top belay safety line;

¾ formal rappel safety briefing; or

¾ formal assignment of responsibility to any one person; instead, these responsibilities were split informally among several SRT personnel.

Rappel Master/Instructor training on the safety risks and dynamics of rappelling was incomplete.

• There has been no WSI–SRS training in buddy rappelling since 1989, and no refresher training had been developed for the WSI–SRS Rappel Masters.
• The WSI-SRS rappelling lesson plan and standard procedure (1-5600, Rappelling, Revision 2) did not include references to the Security Rappel Tower gates in tower rappel training.
• Management of the WSI-SRS training program was inadequate to ensure that appropriate lesson plans were developed and that risk analyses were conducted for each type of rappel activity.
• Rappel Instructor/Master training on the safety risks and dynamics of rappelling was incomplete.

Probable Causes

• There was a lack of attention to detail by SR contract performance monitoring personnel, as they did not ensure that the statement of work for WSI-SRS was maintained accurately and reflected current mission requirements. In addition, SR did not clarify the specific correlation between WSI-SRS competition success and subsequent award fee determinations.
• WSI-SRS did not include buddy rappelling as a necessary technique, did not update either the rappelling lesson plans or the rappel procedures, and did not recognize the need to train personnel in the dynamics of rappelling.

WSI-SRS SRT personnel were unprepared to recognize all the potential dynamics of rappelling, unaware of the functions and limitations of the Security Rappel Tower rails and gates, and unprepared to conduct the buddy rappel because the WSI–SRS Training Division had not developed and validated a program for safe conduct of buddy rappel training.

4.3 Occupational Safety

Findings

· Neither WSRC nor WSI–SRS identified fall protection on the Security Rappel Tower as an Occupational Safety and Health Administration (OSHA) requirement. In addition, it appears that neither WSRC nor WSI–SRS was properly staffed with individuals qualified to conduct OSHA inspections. The gates on the Security Rappel Tower, as designed, were unsafe for the training purposes of the tower.

The SRT occupation is one of the riskiest and most hazardous occupations in the United States.

· The SRT occupation is one of the riskiest and most hazardous occupations in the United States, as indicated by injury an illness data.

Probable Causes

· Job safety analyses were not performed by WSI–SRS and other site security contractors to identify safety improvements that could be made in SRT activities. There was neither communication nor concurrence between WSRC and WSI–SRS on the design, fabrication, and installation of the Security Rappel Tower gates. Both the number of WSRC personnel conducting OSHA inspections at SRS and the qualifications of these personnel were inadequate.

4.4 Management Systems

The Department's rappel policy was not adequate to prohibit the use of the unacceptable buddy rappel technique.

Findings

• The Department's rappel policy was not adequate to prohibit the use of the unacceptable buddy rappel technique. SR line management of the WSI–SRS training program was not comprehensive. NN certification of WSI–SRS training did not identify shortcomings in Rappel Master knowledge.
• The Office of Environmental Management's (EM) line management did not focus on security planning and safety issues or on conduct of operations.
• The Office of Environment, Safety and Health (EH) Site Residents' safety oversight of WSI–SRS historically did not include operations and training activities. The EH safeguards and security oversight inspection program did not formally include safety until fiscal year 1995. Analyses of accident and illness statistics have not been comprehensive, and EH safety program management has not provided routine support to the Department's Safety and Security Program.
• SR line management of the WSI–SRS training program was not effective.
• The WSI–SRS safety program was primarily focused on facilities, not on operations and training.
• WSI–SRS supervisors did not meet their responsibility for ensuring that established procedures were followed, that lesson plans and safety analyses were developed for rappelling activities, and that the impact of changes to training facilities was communicated to WSI–SRS personnel.
• Neither SR nor WSI–SRS provided safety or training management of SRT competition activities. The WSI–SRS procedure for rappelling did not assign safety responsibilities beyond the Rappel Master, and the WSI–SRS safety program focused primarily on facilities, not on operations and training.

Probable Causes

• EM line management was focused only on security planning, not on safety and conduct of operations.
• EH safety program management and safety oversight of security operations had a low priority.
• NN certification activities of WSI–SRS training were too narrowly focused.

SR and WSI–SRS line management control was not provided for SRT competition preparations because they were perceived to be outside normal operational and training activities.

• SR and WSI–SRS line management control was not provided for SRT competition preparations because they were perceived to be outside normal operational and training activities.
• SR line management control of security training had a low priority.
• WSI–SRS safety management was ineffective because of a lack of sufficient details regarding safety management responsibilities.
• Ineffective communications and the failure of supervisors to meet their responsibilities led to unsuccessful line management within WSI–SRS.
• The WSI–SRS safety program did not focus on operations and training.

4.5 Accident Analysis Summary

Direct Cause

On the basis of its review, the Board concluded that the direct cause of the fatal rapelling accident was the separation of the rappel rope, which was caused by the combination of the rope coming in contact with the small-radius edge of the gate lock-pin housing and the dynamic loading of the Rappeller and the Buddy on the rope.

The Board concluded that the following major findings indicated a breakdown of several management systems that could have prevented the accident.

• Lack of procedures or protocol for nonroutine buddy rappel training activity;
• No risk analysis for performing unusual training on the recently modified tower;
• Recognition of unsafe conditions during rappelling not ensured by basic principles of rappelling safety in the core training program;
• Poor communications between management and competition training team;
• Poor command and control of rappelling operation by leadership;
• Lack of safety management controls by DOE and WSI–SRS;
• Unclear assignment of safety responsibility in contractor organizations;
• Lack of full utilization of lessons learned from prior rappelling accidents; and
• Lack of firm mission requirements for rappelling and no reevaluation of changing needs.

This page intentionally left blank.

5. JUDGMENTS OF NEED

The integration of the Board's analyses and findings resulted in the identification of the following major management system needs for DOE, WSI–SRS, and WSRC.

WSI-SRS Actions

• WSI–SRS needs to expand the focus of its safety program, more effectively use lessons learned, and establish safety responsibilities at each level of the organization.
• WSI-SRS needs to ensure that its Conduct of Operations Program more effectively meets stated program goals, including facility safety analysis, management oversight, and procedural compliance.
• WSI-SRS needs to ensure that the fundamental principles of rappelling are included in training by more effectively utilizing the CTA-trained Rappel Instructors, and needs to verify that all training is supported by up-to-date, approved lesson plans.
• WSI-SRS needs to ensure that management and supervisory responsibilities for SRT training and operations are understood and implemented.

WSRC Actions

• WSRC, in conjunction with WSI-SRS, needs to upgrade emergency response procedures on telephone discipline, standardization of emergency medical technician kits, and the use of SR helicopters in responding to medical emergencies.
• WSRC, in conjunction with WSI-SRS, needs to ensure that all noncompliances with OSHA requirements are identified and that they are coordinated with WSI–SRS for facilities which they occupy.
• WSRC, in conjunction with WSI-SRS, needs to conduct a review of the Security Rappel Tower safety railings to establish a design that meets both the OSHA fall-protection and WSI-SRS training requirements.

SR Actions

• SR needs to improve implementation of the protective forces safety program, conduct of operations, and line management to include a full range of safety surveillance activities in addition to those conducted in support of the award fee process.
• SR, in conjunction with WSI-SRS, needs to review the requirement for rappelling at SRS to determine its further use as an SRT technique.
• SR needs to justify that competitions are within the scope of WSI-SRS contract, satisfy the mission, and are desirable conducted safely.

EM Actions

· EM needs to place greater emphasis on occupational safety and conduct of operations in security and SRT operations at its sites by sponsoring job safety analysis and using other safety management tools to reduce occupational injury rates.

EH Actions

• EH needs to ensure that its safety program management, oversight, and assistance programs include protective force operations and training programs, including a more comprehensive analysis of injury and illness statistics to identify areas that need improvement.
• EH needs to expand the scope of oversight to include occupational safety in safeguards and security activities, specifically in the area of protective force operations and training programs.

NN Actions

• NN, in collaboration with the program offices, needs to develop and disseminate program guidance on Rappel Instructor/Master recertification, dynamics of rappelling training criteria, and participation in high-risk competitions and similar events.
• NN, in collaboration with the program offices, needs to provide management control mechanisms to reconcile protective force rappel training requirements with documented site mission requirements (i.e., the SSSP).

BOARD MEMBER SIGNATURES

The investigation of the Security Rappel Training Tower Fatality at the Department of Energy's Savannah River Site was conducted, and the report prepared, by the following Accident Investigation Board members:

BOARD MEMBERS, ADVISORS, AND STAFF

ACRONYMS

DOE U.S. Department of Energy

EH Office of Environment, Safety and Health

EM Office of Environmental Management

ES&H Environment, Safety, and Health

EMT Emergency Medical Technician

MORT Management Oversight and Risk Tree

NN Office of Nonproliferation and National Security

OSH Occupational Safety and Health

OSHA Occupational Safety and Health Administration

SR Savannah River Operations Office

SRS Savannah River Site

SRT Special Response Team

SSSP Site Safeguards and Security Plan

SWAT Special Weapons and Tactics

WSI Wackenhut Services, Incorporated

WSRC Westinghouse Savannah River Company

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