This is Volume 2 of the two-volume Type A Accident Investigation Board Report on the April 3, 1995, Security Rappel Tower Fatality at the U.S. Department of Energy (DOE) Savannah River Site (SRS). This volume of the report provides detailed information about the facts surrounding the accident, a full analysis of these facts, and the Board's conclusions and judgments of need.
Volume 2 contains accident scene pictures, diagrams of causal analysis, and appendices containing supporting documentation. The purpose of Volume 2 is to ensure that the probable causes of the accident are fully understood, and to assist in the development of corrective action plans to address identified judgments of need. It is designed to be a stand-alone document. Volume 1 of this report is also designed as a stand-alone document that provides a summary of the facts, analyses, and conclusions.
On April 3, 1995, a fatal accident occurred at SRS due to the separation of a rope used during a security training exercise at the Advanced Tactical Training Academy (ATTA) Rappel Tower. That same day, Dr. Tara O'Toole, Assistant Secretary for Environment, Safety and Health (EH-1) appointed a Type A Accident Investigation Board to investigate the accident (see Appendix A).
The scope of the Board's investigation was to conduct a review and analysis of the circumstances to determine the accident's direct, probable, and root causes. In addition, the Board was charged with preparing a report of the accident in accordance with DOE 5480.1, "Environmental Protection, Safety, and Health Protection Information Reporting Requirements," and with providing judgments of need to prevent similar accidents from occurring. The Board also observed and documented safety and health concerns that were not a direct cause of the accident, which are contained in this report.
During the investigation, the Board inspected the accident site and reviewed the events leading to the accident. The Board conducted extensive interviews and document reviews, and performed engineering and root cause analyses. Interviews were conducted with exercise participants, eyewitnesses, and other SRS personnel. Documentation reviewed included training exercise procedures, training records, certification requirements, facility design and modification records, and drawings. Appendix H contains a list of these documents.
The Board evaluated relevant management systems and other factors that could have contributed to the accident, and performed a Management Oversight and Risk Tree (MORT) analysis of events, causes, and safety systems related to the accident.
The Board's investigation included destructive testing and analysis of the separated rope. In addition, a test was conducted to determine the conditions required to produce the necessary force that caused the rope to separate and to confirm that the conclusions were credible and consistent with the accident scenario.
The Board completed the investigation of the accident on May 3, 1995, and submitted its findings to the Assistant Secretary for Environment, Safety and Health on May 4, 1995.
This page intentionally left blank.
SRS is a large industrial complex covering more than 300 square miles bordering the Savannah River and encompassing parts of three counties in western South Carolina. The ATTA is in the northeast quadrant of SRS near the Barnwell-Aiken County line, as shown in Figure 2-1. The ATTA consists of a pistol range, a 400-meter known distance range, a Rappel Tower, a live-fire shoot house, and a stress course.
Rappelling has been conducted as a part of the SRT Training Program since the start of the WSI-SRS contract in 1983. The first SRT training class was conducted in November 1983. Rappel training was initiated at SRS to prepare team members for SRT response to the tall multifloor structures located onsite. These tall structures include the reactors and canyons where internal or external building rappels might be required during a response. The SRT was allowed to practice helicopter rappels onto the reactor disassembly basin at the deactivated R-Reactor from 1985 to 1988.
Rappel Master Certification training, initially conducted onsite using WSI-SRS training resources, was discontinued in 1989 when sufficient site rappel masters had been trained. At the same time, the DOE CTA began formal training programs.
Rappelling is the science of sliding down a rope in a safe, controlled manner in which the rappeller has to support only a fraction of his/her total weight with his/her hands. The practice has evolved from crude body rappels, in which the rope was wrapped around one or more parts of the body.
The friction created by the rope sliding over the body and through the hands can be uncomfortable or painful. The effects of this friction and heat are typically reduced through the use of gloves and padding. In the middle of this century, mechanical descending devices were developed to control the descending process and dissipate the heat caused by friction between the rope and the descender. Mechanical descenders were used for both the single person and the Buddy Rappel training exercises discussed in this report.
The mechanical descender used during the Buddy Rappel was a "Figure 8." This descender is shown in Figure 2-2 as it was observed after being unhooked from the rappeller and dropped onto the ground at the base of the tower.
Basic safety principles recommended for rappelling from Appendix H, Reference 40 include one or more of the following:
· Applying a safety factor by requiring single rappel ropes to have a strength of least 15 times greater than the rappeller's weight;
On April 3, 1995, at approximately 10:46 a.m., a WSI-SRS employee received fatal injuries as a result of a fall during a Rappel Training exercise at the SRS ATTA Rappel Tower (Figure 2-3). The weather was sunny with a high temperature of 70 degrees Fahrenheit and a moderate wind out of the north at 9 mph.
The training exercise in progress at the time of the accident was a Buddy Rappel (two men on a single rope), which was being conducted to prepare for a South Carolina State SWAT Team competition to be held on April 14 and 15 in Spartanburg, SC. The Rappel Team members involved in the Buddy Rappel Training exercise consisted of a Rappel Master, a Rappeller, a "Buddy," and a Belayer, led by a Team Coach. The responsibilities of these individuals are defined in the following paragraphs:
The plan for WSI-SRS to enter a team in the State SWAT competition was coordinated with the SR prior to February 15, 1995. The WSI-SRS Travel Authorization request for the SWAT competition was approved on February 17, 1995.
WSI-SRS selected a Team Coach and a team of six SRT members for the upcoming competition. In preparation for the competition, the team reviewed videotapes of the 1994 event. The Buddy Rappel concept was discussed by the team members as a method for reducing the time for two team members to descend from the top of the tower during the competition. The SRT Commander was notified of the plan to conduct a SWAT competition training. The training date was established as April 3, 1995.
After Shift turnover at 7:00 a.m. on April 3, the Team Coach specified the training to be conducted. The Rappel Master and the SRT Sergeant assembled rappel equipment, ropes, an EMT bag, and range keys, then departed for the ATTA at about 7:25 a.m. They arrived at the ATTA at about 8:00 a.m. At about 8:10 a.m., they carried the rappel ropes to the top of the Rappel Tower. They performed a visual inspection of the rappel ropes and tied the left and right rappel ropes to the anchor points on the top of the tower.
Before tying off the ropes, the Rappel Master ensured that a rope pad was placed on the edge of the Rappel Tower. The Rappel Master and the SRT Sergeant inspected each other's knots and determined that both ropes were safely anchored. The rappel ropes were routed over the 6-3/4-inch diameter pipe fulcrum, as shown in Figure 2-4. The recently installed safety gates were unlocked and opened and the ropes were routed over the edge of the top of the tower from which they extended to the ground.
At approximately 8:40 a.m., the Rappeller, the Buddy, and an SRT member performed a three-man "Dead Hang Test" (static load test) by simultaneously hanging from first one rope and then the other. This test was performed to confirm the integrity of the rope and the anchor knots.
At 9:00 a.m., the Rappel Master conducted a safety briefing at the base of the tower for the team members. At 9:30 a.m., the Team Coach and the Belayer arrived. At 9:45 a.m., the Team Coach conducted a training briefing at the base of the tower.
Initial training exercises consisted of building entry and clearing techniques on each level of the Rappel Tower, and concluded with a single (one man at a time) rappel from the top of the tower with the recently installed safety gates open and the rappel rope bearing on the edge of the top deck. During the debriefing at the base of the tower after the second exercise, the Buddy Rappel technique was recommended and a briefing on the technique was held. The Team Coach then gave the Rappeller a sling rope to tie around his waist.
The Team Coach, Rappeller, "Buddy," and another Team Member climbed the tower to prepare for the Buddy Rappel exercise. The Rappel Master remained at the top of the Rappel Tower during the entire training period.
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 closed and locked the gates on the right rappel lane and ran his hand over the top rail to inspect for roughness. The rail was smooth and the preparation for the Buddy Rappel proceeded. The rope was placed over the top of the rail and extended to the ground. Figure 2-5 shows the position of Buddy
Rappel rope after the gates were closed and locked. The figure also shows a rappel rope routed over the edge of the top of the tower as it is normally configured for single-person rappelling.
The Buddy attached his carabiner (locking snap-link) to his seat harness, to the Rappeller's seat harness, and through the sling rope to provide additional confidence in the attachment. The Rappel Master inspected the attach points on the Rappeller and the Buddy.
When the inspections were complete, the Rappeller said "On Rappel" indicating readiness to descend. The Belayer on the ground responded "On Belay" indicating readiness to slow or stop the rappeller's descent if required. The two Rappellers started to maneuver over the gate, each moving one leg at a time in a coordinated manner. When both the Rappeller and the Buddy had crossed the gate, they were both standing on the edge of the top deck of the Tower. The rope was routed across the top rail of the right gate as the Rappeller started his descent.
Because of the combined weight of the Rappeller and the Buddy (approximately 484 pounds), the Rappeller experienced difficulty in establishing his body in the "L" configuration to initiate the Rappel. The Rappel Master was leaning over the edge of the tower watching the Rappel Team and did not observe the path of the rope. The Team Coach and the other Team Member were behind and to the left of the Rappel Master and were able to see only the Rappeller's initial descent.
No one observed the path of the rope. At some point, the rappel rope moved laterally and fell approximately 8 inches into the area between the gates where the gates were pinned together. This enabled the rope to come in contact with the small radius edge of the lock-pin housing.
The Rappeller and the Buddy were approximately 10 feet down the wall when the Belayer perceived that they were descending too fast to be in full control. The Belayer's response was to apply a tension force to the rope to stop their descent. At about the same time, the rope separated where it was 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 approximately 10:46 a.m., the Rappeller and the Buddy fell 27 feet to the sawdust on the ground. The Rappeller landed on top of the Buddy, causing severe chest compression to the Buddy. The first responder to the accident was an Emergency Medical Technician/Rappel Team Member who was at the scene. The Rappeller complained of back and neck pain. The Buddy was examined and found to be nonresponsive.
Both the SRT and the WSRC SRS Fire Department (FD) EMTs responded to the accident. At the time of the accident, requests for assistance were sent by radio to WSI-SRS for SR helicopter assistance and by telephone to the Savannah River Site Operations Center (SRSOC) for ambulance assistance. The Board examined each of these responses separately in addition to related emergency response actions. Appendix E contains the chronology of the emergency response.
As soon as the accident occurred, the Belayer called for the SR helicopter to be dispatched and for the spine board to be brought for the Buddy. The Belayer then ran to the range tower, picked up a breathing oxygen cylinder and face mask, and returned to the victim. An SRT instructor, who was observing the training, called 3-3911 to report the accident. He requested that an ambulance be dispatched to the ATTA Range.
The first responder at the accident scene was a WSI-SRS EMT who was a member of the Rappel Team and who was observing the Buddy Rappel training exercise. He immediately rushed to the Buddy.
The Rappeller complained of pain in his back and neck. The Buddy was nonresponsive, not breathing, and had eyes only partially opened. The Rappeller and the Buddy were unhooked and the Rappeller was rolled off the Buddy. The SRT EMT began providing first aid to the Buddy. At first, a weak radial pulse was detected. Rescue breathing was initiated; after several applications of the technique, no pulse was detected. CPR was immediately initiated on the Buddy.
The SR helicopter arrived about 10:54 a.m. and departed the accident scene at about 11:00 a.m. with the Buddy. Three SRT EMT members on board continued to administer CPR until the SR helicopter arrived at the University Hospital Emergency Room at 11:07 a.m., where the Buddy was turned over to trauma unit personnel. The Buddy was declared dead by University Hospital medical personnel at 11:37 a.m. (see Appendix C). The events presented in the accident chronology were taken from the Integrated Accident Event Matrix presented in Appendix O and from interviews with WSI-SRS employees present at the scene of the accident.
The two SRS FD ambulances, Medic 1 and Medic 2, were dispatched at 10:49 a.m. Both ambulances were at Station 1 in F-Area. 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 Medic 2's dust cloud. Both crews discussed treatment requirements while en route and both arrived within a minute of each other.
Medic 1 and Medic 2 arrived at the accident scene at approximately 11:04 a.m., approximately 4 minutes after the SR helicopter had departed with the Buddy. Although the primary emergency response was focused on the Buddy, the Rappeller also received first aid during this time period. While waiting for the ambulance to arrive, the Rappeller reported a numbness in his arms and legs.
Medic 2 departed for the Medical College of Georgia (MCG) Trauma Unit at 11:14 a.m. with the Rappeller on board, and arrived at MCG at 12:07 p.m. The Rappeller was treated and released the same day with no apparent long-term effects.
Information obtained from SRSOC tape recordings of the accident time period indicates that the activities of the WSI-SRS position in the response center were transmitted over an open telephone line to individuals calling about the accident. Interviews indicated that EMT emergency response kits are not standardized at SRS. The contents of the WSRC EMT kits are recommended and overseen by the WSRC Medical Director. The WSI-SRS kits are not necessarily standardized with those of WSRC and there is no oversight of their contents. The WSI-SRS EMTs provided a quicker response and transportation by SR helicopter than did the WSRC EMTs by ambulance.
The primary mission of WSI-SRS is to protect SRS nuclear materials against theft or diversion; vital facilities against sabotage; classified matter from unauthorized disclosure; Government-owned assets from loss; and SRS personnel from harm. As a SR management and operating contractor, WSI-SRS is required to provide paramilitary security services to meet this mission. The contract includes the requirement that WSI-SRS shall have an SRT that shall be highly qualified and trained in aerial/ building rappel techniques, but contains no provisions compelling WSI-SRS to participate in SWAT or Central Training Academy (CTA)-sponsored (i.e., Security Police Officer of the Year) competitions.
DOE 5632.7A, "Protective Force Program," prescribes policy, responsibilities, and requirements for the management, operation, training, and equipping of the Department's Protective Forces. The designation of responsibilities contained in this DOE order state that the "Director of Nonproliferation and National Security, through the Director of Security Affairs, provides management direction and coordination in the development, implementation, and oversight of the comprehensive Safeguards and Security Program." This policy also establishes the mission of an SRT as being trained and equipped to conduct interdiction, interruption, neutralization, and recapture operations against an adversary described in the "Design Basis Threat Policy for Department of Energy (DOE) Programs and Facilities."
Site-specific conditions can dictate the SRT to possess special skills (i.e., rappelling) to provide an effective and timely response as prescribed by site- or activity-specific vulnerability assessments. SRT operations and tactical response plans must be integrated into the Site Safeguards and Security Plan (SSSP), which contains vulnerability assessments and other related documents. The SSSP for SRS documents the DOE-approved protection strategy and associated risk acceptance for vital facilities.
DOE 5630.11B, "Safeguards and Security Program," dated August 2, 1994, state that the "Director of Nonproliferation and National Security ...through the Director of Security Affairs provides management direction and coordination in the development, implementation, and oversight of the policy for a comprehensive Departmental Safeguards and Security Program."
DOE 5630.15, "Safeguards and Security Training Program" dated August 21, 1992, state that the Director of the Office of Security Affairs (OSA) is responsible to "provide management direction and coordination in the development, implementation, and oversight of the comprehensive Departmental safeguards and security training program." This policy stipulates that the Director of Office of Safeguards and Security (SR-OSS) is responsible to "conduct annual reviews of safeguards and security training programs meet Departmental standards." SR-OSS is further required to conduct "initial and recurring reviews for training approval." The scope of the reviews "shall consist of a review of all aspects of local training programs to include such areas as program management and structure, course contents, training facilities, observation of course presentations for effectiveness, and evaluation of students."
Last Modified: Friday, 28-Feb-97 10:09:00