Identification and correction of Occupational Safety deficiencies on the Rappel Tower is a factor in the April 3, 1995, rappelling accident. In particular, the need for better fall protection, as required by the Occupational Safety and Health Administration (OSHA) in 29 CFR 1910.23, "Guarding Wall and Floor Openings and Holes," led to the installation of new safety railings on the Rappel Tower. OSHA requires that these railings be designed to withstand a 200-pound force applied in any direction to the rail. The Board could not determine if the safety railings on the Rappel Tower meet the 200-pound strength requirement because neither engineering calculations nor evidence of structural tests could be found. The safety railings on the tower were designed as gates to be opened for training exercises. Before the installation of the safety railings, fall protection was provided only by light chains that were inadequate to meet OSHA requirements.
Noncompliance with OSHA requirements is determined by individuals trained and qualified for that purpose. Three SRS organizations perform occupational safety inspections. One of these is WSRC, which in July 1994 entered into an agreement with WSI-SRS that WSRC will provide annual OSHA audits of WSI-SRS occupied facilities, including the Rappel Tower. According to the agreement, WSRC will also provide other industrial safety inspections on request. Under this agreement, the WSRC Facilities Evaluation Board conducted a February 10, 1995, evaluation of the B-Area facilities, which included the Rappel Tower. The evaluation identified only electrical protection deficiencies on the tower; it did not identify fall protection.
WSI-SRS is the second organization that can perform occupational safety inspections on the Rappel Tower, as identified in at least seven internal WSI-SRS Standard Procedures:
Under these procedures, the Range Safety Officer is responsible for the safety inspection of the tower and surrounding facilities. The Range Safety Officer conducts inspections using a checklist that has a simple format and does not include the complete OSHA or other industrial safety requirements that might be appropriate for the Rappel Tower, including safety railings and fall protection. The Board could find no evidence that WSI-SRS had identified the Rappel Tower fall protection deficiencies during its inspections.
The SR Safety Division conducts inspections in its OSH program performance reviews of WSRC and WSI-SRS. It identified the need for fall protection on the Rappel Tower to meet OSHA requirements during an unannounced OSHA-type inspection of the Rappel Tower and surrounding facilities on May 4, 1994. The results of this inspection were informally shared with the WSI-SRS Range Safety Officer and Safety Division personnel. On June 3, 1994, SR Safety Division forwarded these results to the WSI-SRS Security Management Division Facility Representative. On July 11, 1994, the WSI-SRS Security Management Division formally forwarded the results to the Director of the WSI-SRS Environment, Safety and Health (ES&H) Division.
The Director of the ES&H Division forwarded the results of the SR Safety Division inspection to the WSI-SRS Range Manager responsible for the Rappel Tower. However, the Range Manager had already sent a "Maintenance Request" memorandum on May 13, 1994, to the WSRC custodian at the ATTA site to have the safety railings installed. This request was in accordance with the general provisions and Appendix S of the WSRC-WSI-SRS July 1994 memorandum of understanding. Under the general provisions, WSRC agrees to "correct identified Occupational Safety and Health deficiencies for WSI-SRS occupied facilities." The noted appendix requires the submittal of written requests by WSI-SRS to WSRC custodians for modification, upgrade, or expansion to existing buildings occupied by WSI.
WSRC initiated actions to install the safety railings and controlled their design, fabrication, installation, and final inspection. WSRC had the railings designed by one subcontractor and fabricated and installed by a second subcontractor under Procurement No. SSD-CWE-943148. Even though WSI-SRS was aware of the installation of the safety railings on the Rappel Tower, the Board could find no evidence that they had participated in the design.
The WSI-SRS Range Manager took the tower out of service on March 6, 1995, for the installation of the safety railings, and placed it back in service on March 29, 1995, at the completion of the job. Before placing the Rappel Tower back in service, the WSRC Area Safety Engineer inspected the handrail and gate installation and found it to be satisfactory for safe use as fall protection from the tower. This was just before the April 3, 1995, fatal rappel training accident.
The Board examined occupational injury and illness experience of WSI-SRS and other DOE security contractors to identify significant trends. In 1994, DOE had 31 security contractors with approximately 7,005 full-time employees. Table 2-1 lists the 1992 to 1994 injury and illness rates for eight of these contractors with a total of 4,651 employees, which were obtained from the DOE Computerized Accident/Incident Reporting System (CAIRS).
Table 2-2 lists the total recordable and lost workday case rate of the SRT force versus the rate for all of WSI-SRS and all DOE protective forces. The WSI-SRS and SRT data in this table were obtained from WSI-SRS rather than from the DOE CAIRS. The differences between Tables 2-1 and 2-2 are due to the more accurate and current WSI-SRS information. Table 2-3 shows injury and illness rates for nine major sectors of DOE operations.
Three separate training activities and operations combine to describe the association of training to the rappelling accident; they are: (1) the specific aspects of SRT rappel training experience; (2) the programs and procedures of the WSI-SRS Training Division; and (3) the Rappel Training program and practices at the CTA.
· Interviews with various members of the WSI-SRS SRT and a review of training records indicate that all members of the SRT competition team had completed rappel training, and rappelled regularly during monthly training exercises.
Interviews indicated that WSI-certified Rappel Masters have varying levels of awareness of rappelling facts about individual equipment, ropes and their characteristics, edge padding needs and requirements, knots and their specific use, safety concerns and issues of rappelling, anchors and belays, and command and communication practices. However, the interviews also indicated a general lack of understanding of the combined technical dynamics of a rappel operations as discussed in "Rappelling" by Tom Martin (such as: watching the rope during a rappel, load bearing capacity two ropes, and adapting to changing conditions). In addition, those who were recently CTA-trained as Rappel Masters/Instructors have varying years of familiarity with some basic dynamics of rappelling, particularly rope stretching and wear.
|
1994 |
1993 |
1992 |
||||
|
TRC |
LWD |
TRC |
LWD |
TRC |
LWD | |
|
WSI-SRS* |
3.71 |
107 |
4.9 |
92 |
3.06 |
59 |
|
WSI-SRS SRT* |
8.78 |
102 |
26.4 |
912 |
14.5 |
51 |
|
All DOE Security** |
6.0 |
93 |
6.6 |
103 |
7.6 |
122 |
TRC = Total Recordable Case Rate
= Total Injuries and Illnesses X 200,000/ Employee
Hours Worked
LWD = Lost Work Day Rate
= Total Days Lost X 200,000/ Employee Hours Worked
Source:
Team members train and practice one-person, two-rope rappel as the standard for formal and shift training.
Four of the six team members successfully completed a WSI-SRS Rappel Master course between 1986 and 1989, which included two-person rappelling with two ropes and upper and lower belays, and qualified them to oversee rappel operations.
Buddy Rappelling has not been practiced at SRS since 1989.
Four of the 1995 competition team members had participated in the 1994 competition that required them to perform a single rope rappel over a fixed rail.
One competition team member who was present at the accident was an experienced and qualified WSI-SRS SRT Training Department instructor.
· Information on WSI-SRS Training Division responsibilities for training and safety was obtained through interviews with the Training Division staff and a review of various WSI-SRS standard procedures. The Training Division is responsible for all training facilities and operations, including the Rappel Tower at the ATTA and the Small Arms Training Academy (SATA).
WSI-SRS has based their SRT training curriculum on the CTA Security Policy (SPO) III core curriculum. A review of a WSI-SRS memorandum dated June 17, 1994, "SPO III CTA Core Curriculum - Risk Analysis Appraisal," indicates that the risk analysis is focused on the individual steps in rappelling and not the hazards relating to each type of rappelling or the potential dynamics of rappelling.
Before reopening the tower, the WSI-SRS Range Manager did not formally inform all personnel who had access to and used the Rappel Tower about the installation of rails and gates and their implications for use of the tower.
WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, was not updated to include the tower rails and gates.
WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, includes one rope rappelling for competition training, and recognizes both WSI-SRS and CTA Rappel Master/Instructor training as qualifications for conducting rappel operations.
The old training outline used until 1988 for the WSI-SRS Rappel Master training (see Appendix P) does not include a section on safety. It states that safety is the greatest concern of the Rappel Master and that "WSI-SRS safety requires a dual anchor point system...." The approved lesson plan for SRT rappel training includes equipment, knots, and other standard topics. Neither of these documents specifically includes safety training that presents the dynamics of all equipment and rappellers during the act of rappelling, or the need for the Rappel Master/Instructor or others to watch the rope during a rappel.
The Training Division had not developed an approved lesson plan for two-person rappelling, but not all SRT personnel were aware of this fact.
The Training Division is responsible for the conduct or support of training included in the approved 1995 Annual Training Plan, which does not include training to prepare for SRT team competitions. Training, in support of the Annual Training Plan, includes instruction by Training Division staff (referred to as quarterly training), and instruction by SRT shift lieutenants (referred to as monthly training).
The competition team training was coordinated before April 3, 1995, with the SRT Shift Lieutenant/Team Coach to parallel the training in the 1995 Training Plan that SRT conducts.
The SRT competition team preparation is planned, coached, and conducted by on-shift WSI-SRS operations personnel.
On-shift SRT training, including rappelling, is conducted by qualified WSI-SRS operations personnel with support from the Training Division, Special Operations Training.
On the day of the accident, the Team Coach was present when a team member and SRT Training Lieutenant discussed a Buddy Rappel as one way to reduce team performance time and increase their chances of winning the competition.
· Interviews with senior CTA personnel revealed that rappel training at CTA is done on a single Kernmantle rope, and does not include Buddy Rappelling or going over a rail or other obstacles before rappelling.
CTA provides a Rappel Instructor certification program, which includes the standard safety training on equipment, sharp edge padding, and individual techniques. The Rappel Master certification lesson plans (Sections 1.5 and 1.8) do not include explanations and demonstrations of the combined safety risks created by the system dynamics of knots, anchors, weight, ropes, other equipment, rope locations, and body movements during rappelling operations; nor do they include the need for the Rappel Master/Instructor or others to watch the rope during a rappel. In addition, there is no safety risk training that provides information on the load bearing capacity of ropes under both static and dynamic load conditions. There is also no information on the relationship between rope capacity for loads and exposed edge radius, or on the relationship between rope capacity for loads, rope temperature, and elasticity.
CTA reviewed and approved the SRT training program at SRS.
Three WSI-SRS SRT personnel have completed the CTA Rappel Master/Instructor course. A review of the course material reveals it is intended to assist sites in preparing SRT instructors to train SRT personnel in rappel techniques. The course material requires the presence of a Rappel Instructor at any location where rappel operations or training is to occur.
Interviews with Training Division staff indicated that WSI-SRS used its instructors, who were graduates of the CTA Rappel Instructor course, to update rappel lesson plans and perform rappel training. Title 10, Code of Federal Regulations, Part 1046, prescribes that local DOE training programs will be based on criteria established by CTA. CTA rappel lesson plans require that CTA trained rappel instructors be present during rappel operations. However, the Training Division does not recognize this requirement or believe these plans represent DOE policy. This was provided as the primary reason why CTA trained rappel instructors are not used during all WSI-SRS rappel operations. A review of DOE Order 5630.15, "Safeguards and Security Training Program," dated August 21, 1992, did not reveal any additional clarification on emphasis concerning CTA lesson plans. Further, 5630.15 does not provide a process for requesting relief from CTA training requirements that are not applicable to a specific site.
The need for refresher training for CTA-trained Rappel Instructors and WSI-SRS certified Rappel Masters has been recognized by NN and WSI-SRS. Though various groups have met to discuss methods of implementing refresher training for Rappel Masters, interviews with WSI-SRS and NN policy and training managers indicate that no refresher training programs have been developed at WSI-SRS or CTA.
The Board interviews with DOE Office of Defense Programs (DP) and Environmental Management (EM) personnel confirmed that neither Office is involved in the review and approval of WSI-SRS training programs.
Last Modified: Friday, 28-Feb-97 10:09:00