4.5 CONDUCT OF OPERATIONS

Findings

• ATTA SAR did not assess the safety or risk associated with the Rappel Tower.
• WSI-SRS Self-Assessment systems did not assess the Rappel Tower but instead concentrate on firearm safety and housekeeping.
• On-shift training was performed without procedure or lesson plan.
• On-shift training instructor did not evaluate the facility change and its potential impact on rappel operations.
• WSRC technical justification for the final safety acceptance was not documented for the facility modification.
• SRT unaware of job safety analysis and safety controls necessary for rappelling.
• Procedure was not utilized for the rappelling operation.
• WSI-SRS ESH did not conduct follow-on safety walkdowns after existing conditions changed.
• WSRC Safety review of WSI concentrated on B-Area facilities.
• DOE HQ (EM-25) and SR did not assess the conduct of operations of the security contractor.
• WSI-SRS ESH did not provide technical justification for allowing one-rope rappelling.

Probable Causes

• Safety risks of rappelling not recognized as a critical operation by SRT, ESH, Training, or Management.
• Firearm safety and general housekeeping was the main focus of management self-assessments.
• Verbatim compliance with procedures were not understood by SRT and Training Division.
• The need for change/risk analysis was not recognized for safe facility design, modification, operation, and acceptance.
• DOE has not recognized the security contractor as an organization performing work for the DOE under the requirements of DOE 5480.19.
• WSRC EH has not consistently assessed the safety aspects of ATTA in comparison to the large number of WSI B-Area facility assessments WSRC has performed.

4.6 JUDGMENTS OF NEED

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, 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 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 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 protective forces safety, 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 needs to review, in conjunction with WSI-SRS, the requirement for rappelling at the 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, desirable, and 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 assistant programs include protective forces 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 protective forces operations and training programs.

NN Actions

• NN, in collaboration with the program offices, needs to develop and disseminate programmatic guidance on Rappel Instructor/Master recertification; the 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 mechanism to reconcile protective forces training requirements with documented site mission requirements (i.e., Site Safeguards and Security Plan).

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