The Board interviewed SRT managers, SRT competition team members, and the WSI-SRS training staff to evaluate the awareness of supervisory/management personnel regarding the Buddy Rappel. Information from WSI-SRS procedures supports the information from these interviews.
The SRT Team Coach was aware that he and the other team members had not performed Buddy Rappels at SRS since 1989 and that no refresher training for Rappel Masters had been conducted at SRS. The WSI-SRS SRT training instructor, who recommended the Buddy Rappel, was also aware of this fact.
WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, was updated by the SRT Commander as a result of a helicopter rappelling accident that occurred in 1994. This procedure contains the requirement that all rappel activities be supported by approved lesson plans. An approved WSI-SRS lesson plan includes a safety review by the WSI-SRS Safety Division. The rappelling procedure also allows the use of one rope during competition training activities based on a 1991 safety analysis. Though the Buddy Rappel was performed during the WSI-SRS Rappel Master Training, a lesson plan for the Buddy Rappel has not been developed.
The SRT Training Lieutenant has completed the CTA Rappel Instructor course. The purpose of this course is to prepare site personnel to instruct other site personnel in appropriate rappel techniques. A review of the CTA Rappel Instructor course materials indicates that the Buddy Rappel is not taught. Interviews with the CTA senior rappel instructor revealed that CTA does not consider the Buddy Rappel to be an acceptable rappel technique for DOE organizations. Interviews with DOE OSA/NN rappel policy staff indicated that there is no DOE policy on the Buddy Rappel.
Several DOE Orders and WSI-SRS procedures (see Section 2.7.5) require a review of operations at facilities that have undergone maintenance or modifications. Interviews with WSI-SRS Training Division staff have established that the Manager, Firearms Training Department, is considered to be the facility manager of ATTA and SATA and has been designated the WSI-SRS Range Master. The Range Master and other members of the Training Division were aware of the changes that had been made to the Rappel Tower.
Interviews with WSI-SRS senior management, training and safety managers, and competition team members revealed the following information about communications prior to the April 3, 1995, accident.
Although various members of the Training and Safety Divisions and the Range Master were aware of the action to replace the safety chains on the Rappel Tower, this action was not coordinated with the Special Operations Division staff or SRT and the impact on rappel operations was not communicated to SRT.
Discussions between the Team Coach and the competition sponsoring organization (the Spartanburg County Detention Facility) did not include a full discussion of competition rules. The coach did not ask if Buddy Rappelling would be allowed during the competition. The sponsoring organization could not (and did not voluntarily) inform the Coach that such a rappelling technique was not allowed.
The morning of the accident, the Team Coach discussed with the SRT Training Lieutenant only the possibility of utilizing the Buddy Rappel and did not provide more specific details of the day's competition preparations. When asked for advice on the Buddy Rappel as a means to reduce the time for the rappelling event, the Training Lieutenant (who had been trained at CTA as a Rappel Instructor) did not inform the Team Coach that CTA did not recognize the Buddy Rappel as an authorized rappel technique, and did not remind the coach that WSI-SRS approved lesson plans did not support Buddy Rappelling.
Interviews conducted with the Team Coach and the SRT Commander indicate that there are conflicting statements regarding discussions between the coach and the commander that might not have fully communicated the coach's desire to use the Buddy Rappel technique. These interviews and a review of WSI-SRS procedures established that there is no formal mechanism to inform SRT management and WSI-SRS training managers of the specific nature of planned activities. However, the annual training plan provides such a mechanism for normal training activities.
The Board interviewed WSI-SRS training and safety managers and SRT personnel, SR training and safety managers and staff, and a member of the EH Resident, Office of Independent Oversight to develop information on management control of the SRT competition team. In addition, the Board reviewed applicable WSI-SRS and SR procedures. The following sections describe the results of interviews and document reviews.
There is no formal definition of whether SRT competition preparation is a training or operational activity. However, the managers of the WSI-SRS Training and Special Operations Divisions consider the activity to be training. A review of the WSI-SRS annual training plan revealed that it does not include SRT competition preparation.
The Board conducted an interview with SR-OSS and WSI-SRS managers and they believed that SRT participation in competition is within the scope of the WSI-SRS contract. However, these organizations did not perceive that this activity is in fact covered by the contract.
Specific interviews with the WSI-SRS Safety Office, the WSI-SRS Training Division, the SR Office of Safeguards and Security, and the EH Residents determined that none of these organizations provides management control of SRT preparation for competitions.
The Shift Lieutenant in charge of the competition preparation has safety and training oversight responsibilities, but those responsibilities have not been formalized. A review of WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, dated July 21, 1994, indicates that only the Rappel Master has specific safety and training management control responsibilities during any rappel operations. In addition, the position descriptions for the SRT Commander, SRT Shift Lieutenant, and SRT sergeant, and SRT job task analyses do not discuss specific safety responsibilities.
While the WSI-SRS Training Division does not provide management control of preparation activities, advice is provided on request. Conflicting statements indicate that advice provided by the SRT Training Lieutenant on the day of the accident included instruction on the proper hookup and a reiteration of the necessity to use a top belay or safety line as stated in the WSI-SRS Rappel Master course outline. The SRT Training Lieutenant stated that he did not believe that the competition team was actually going to use the Buddy Rappel, even though he provided the advice. Although the SRT Senior Instructor knew of the potential for Buddy Rappelling conducted without a lesson plan, as required by WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, he took no action.
Internal management control of WSI-SRS normal operations and formal training activities is conducted by the WSI-SRS Training, Safety, and Compliance Divisions. WSI-SRS Safety Division surveillance activities focus primarily on facilities and not operations or training. The coverage of training activities is not specifically scheduled, but coverage can occur during a facility safety surveillance.
The WSI-SRS Training Division has assigned safety management control responsibilities to a lieutenant in the Training Division and has given that person the title of Range Safety Officer. This individual accomplishes his responsibilities through the use of a checksheet (see Appendix N), which focuses primarily on facility safety; he does not review operations and training activities for safety concerns. An interview with the Range Safety Officer established that he had not completed any offsite formal training on how to conduct inspection activities.
A review of WSI-SRS Standard Procedure 1-3105, "Inspection Programs," revealed that individuals who conduct safety inspections follow a checklist and are not required to complete training on the conduct of safety inspections. However, WSI-SRS supervisors receive safety training during annual supervisor training sessions and during safety assistance reviews. As part of the conduct of operations programs, the WSI-SRS Compliance Division schedules surveillance, audits, and appraisals, which focus on training methodologies, content, and operation.
WSRC does not have any safety or training management control responsibilities over WSI-SRS. However, WSRC, under a July 1994 memorandum of understanding and WSI-SRS Standard Procedure 1-3105, "Inspection Programs," does conduct OSHA inspections of WSI-SRS facilities (see Section 2.7.5). The results of these inspections are forwarded to the applicable WSI-SRS facility manager. The WSI-SRS Safety Division does not take action on those results.
The current SR Line Management philosophy includes the establishment of line management's overall responsibility for facilities or programs with matrixed support to be provided through the Technical Assessment Program (Savannah River Implementation Procedure 5700.12A, signed September 15, 1994). Under the revisions of the new SR Line management philosophy, primary line and program management of WSI-SRS is the responsibility of SR-OSS, including safety, training, and conduct of operations. However, SR Manual 1100.6.X.X.1, "Organizations, Functions, and Delegations," dated March 25, 1994, does not reflect this management philosophy. In fact, the manual assigns safety management control responsibility of WSI-SRS to the Assistant Manager for Environment, Safety, Health, and Quality, and safety monitoring responsibilities to SR Office of Safeguards and Security. However, interviews determined that senior SR managers understand the current management philosophy.
Matrix safety management control support to SR-OSS is not provided through the technical assessment program. Some SR staff members expressed differing views on the roles of their respective organizations or themselves concerning safety management control; this is due to the current period of transition to a new management philosophy, and because a number of new procedures are being developed and implemented. SR-OSS meets most of its safety responsibilities of WSI-SRS through support provided by the Safety Division as part of the Award Fee Evaluation process. No other formal safety management control activities of WSI-SRS are conducted by SR. Until September 1994, the SR Safety Division had program management and line support for nuclear and nonnuclear safety programs and, during that time, traditionally placed primary focus on nuclear-related operations and hazards in its overall oversight activities. Interviews with managers of SR-OSS and the Safety Division revealed that both organizations believe safety support provided solely under the auspices of the Award Fee Process is inadequate to enable SR-OSS to meet all of its safety management control responsibilities.
A review of SR-OSS procedure 5482.1.1A, "Performing Safeguards and Security Appraisals," demonstrates how SR-OSS accomplishes assessment activities of normal WSI-SRS operational activities and the formal training program. A new draft SR-OSS procedure, 5700.6.4A, "OSS Technical Assessment Program," will replace SR-OSS 5482.1.1A, and bring the SR-OSS assessment program more in line with the SR Technical Assessment Program.
SR-OSS personnel interviewed stated that they have received verbal guidance from the SR-OSS Director to include safety in their interactions with WSI-SRS training and operational activities.
SR-OSS completes most of its day-to-day administrative Line management responsibilities of WSI-SRS through a resident Facility Representative. The SR-OSS Facility Representative stated that he is not part of the SR Facility Representative Program (SR Implementing Procedure 5480.19.1C, "Facility Representative Program"), which focuses on nuclear facilities.
SR-OSS management also indicated in interviews that the SRT operational point of contact has been assigned responsibility over SRT operations. The SRT point of contact stated that he is also expected to provide management of WSI-SRS training activities. However, the point of contact has not been asked to assist the SR-OSS Facility Representative and, therefore, has not routinely conducted surveillances of SRT training activities. The SRT point of contact has conducted two surveillances in 1995 (Law Enforcement Supervisor Training and Traffic Stops), both of which include training. Further, an SRT surveillance has been planned since December 1994; that surveillance is to include training.
Among program requirements levied on WSI-SRS by SR is Directive Implementation Instruction 5632.7B, which requires WSI-SRS to develop separate safety plans for potentially hazardous or high-risk activities.
Interviews with SR and WSI-SRS safety and training managers and staff indicate that they did not believe that the changes to the Rappel Tower required the completion of formal change analysis and performance testing before the reinitiation of rappelling operations. Some of these individuals stated that the changes were too insignificant to require the analysis.
SR-OSS has reviewed and NN and the CTA have approved the implementation of DOE 5630.15, "Training Approval Program (TAP)," and NN and the CTA have reviewed and approved the entire SRT Basic Certification course conducted at SRS. These reviews did not establish that WSI-SRS certified Rappel Masters had not received any refresher training, and had not identified shortcomings in Rappel Master knowledge. According to DOE Order 5630.15, "Safeguards and Security Training Program" dated August 21, 1992, the TAP is a formal program. The Order requires that review for training approval will include: program management course content, training facilities, observations of course presentations, and evaluation of students.
SR-OSS provides management control oversight over the WSI-SRS Conduct of Operations Program. The SR Assistant Manager for Environment, Safety, Health, and Quality (see Section 2.7.5) has the overall responsibility to implement the Conduct of Operations Program for SR and assists SR-OSS in meeting its oversight responsibility. Until 1995, the SR Conduct of Operations Program was focused entirely on WSRC.
A review of applicable DOE Orders establishes that there are three categories of Headquarters management control. The first category is Line Management that focuses on the implementation of various programs by DOE contractors. Line Management responsibilities flow from the Secretary, through the Secretarial Officers (which have facilities under their jurisdiction) to the Operations Office Managers. The application of Line Management is primarily in the form of program reviews, self-assessments, ES&H surveillance activities, and security and nuclear material's surveys. Another level of Headquarters management control is Program Management.
Program Management includes the development of program direction, and coordination in the development, implementation and "oversight" of the specific program. Program Management activities include certification of Field Element programs (such as training programs), supporting program implementation, and management of DOE facilities that provide Department-wide program support and assistance (such as the Central Training Academy). The final level of Headquarters management control is provided by the Office of Oversight, which is under the Assistant Secretary for Environment, Safety and Health. Independent oversight activities includes inspections, reviews, special studies, and site resident activities.
Interviews have revealed that EM, as the program office for SRS, has the lead Headquarters Line Management role for SR and WSI-SRS. EM management is focused on planning activities at SRS and not on Safety or Conduct of Operations.
The Board interviewed the Senior EH Resident at SRS to determine the Headquarters level of independent safety oversight of SR. EH Residents provide the day-to-day independent safety oversight of the SR Line Management of the WSI-SRS safety program. These Residents at SRS have expertise in radiological safety, worker safety, and industrial hygiene. They have not performed independent safety oversight activities of WSI-SRS, but rather on large WSRC operating facilities where hazards exist and present the greatest risk to a large number of workers and the public. Due to the limited number of EH Residents at SRS, the use of these resources has been prioritized focusing on safety issues with the greatest impact on the public, such as nuclear accidents. Nuclear operations at SRS have mostly changed from production activities associated with nuclear weapons to support activities for environmental restoration. Surveillances of WSI-SRS activities were recently incorporated into the EH Residents' 1995 surveillance schedule.
Additional safety and protective force independent oversight is provided by other EH elements. Starting in Fiscal Year 1995, the Office of Oversight, EH-2, has included some safety issues in Safeguards and Security inspection program activities for the Office of Security Evaluations (EH-21). Still other EH elements provide safety, health and environment Program Management Support. However, these elements have not provided routine Program Management of the DOE Safeguards and Security Program. There has not been an analysis of accident and illness statistics for the protective forces or SRT.
Protective force training policy and direction is provided by the Office of Security Affairs, under the Assistant Secretary for Nonproliferation and National Security (see Sections 2.4.1 and 2.6).
Line Management of the SR Conduct of Operations Program is provided by the Office of Operational Assessments (EM-25) (see Section 2.7.5).
The Board discussed formal and informal lessons learned programs at WSI-SRS, SR, and DOE Headquarters with a number of individuals, including the SRT Commander, WSI-SRS Safety Division Director, WSI-SRS Training Division staff, and EH Resident personnel. In addition, the Board reviewed the corrective action plans generated as a result of the 1994 helicopter rappelling accident, which are in Appendix G.
Within the SRT, accidents are reported promptly up the chain of command. WSI-SRS convenes an accident review board to determine the causes of less serious accidents. More serious accidents require the formation of an official accident investigation board. The results of these board actions and other information related to accidents within WSI-SRS and SRS are passed on to the WSI-SRS division directors (including the SRT Commander) during monthly safety meetings. Data on accidents that might be applicable to SRT operations is included in corrective action reports.
As a result of the February 1994 rappelling accident, WSI-SRS took several lessons learned actions. The rappelling procedure was placed under the purview of the SRT Commander and the procedure was updated to reinforce management oversight responsibilities. In addition, identified communications problems between the Rappel Master and the pilots were addressed. A review of WSI-SRS corrective action No. C 94-01-03 indicates that corrective action was taken in relation to the accident investigation board finding that the Rappel Master violated standard procedures and that each Rappel Master was to review applicable procedures. During the accident on April 3, 1995, procedures were again not followed for rappel operations and all surfaces in the rappel lane had not been padded. Another corrective action (No. C 94-01-02) dealt with the need for the development of written scenarios (similar to a lesson plan for training) prior to operations. This was accomplished through the revision of WSI-SRS Standard Procedure 3-5601, "SRT Static Display and Training Demonstration." During the accident on April 3, 1995, a lesson plan for Buddy Rappelling had not been prepared.
The Training Division staff provided data on other lessons learned actions. These included the building of an exit ramp from the rappel landing pit at ATTA to ensure that individuals participating in tactical proficiency evaluation training would not be injured while leaving the pit, and the reinforcement of the outrigger and top wire of the fence and preparation of a landing area to reduce the chance of injury at the climbing obstacle. Training Division managers also participate in DOE training quality panel meetings at which the results of investigations of accidents at other DOE sites are shared with panel members. On an informal basis, each training quality panel member routinely transmits accident information to the other panel members as it becomes available and the panel member feels that it would benefit the others.
The WSI-SRS Safety Division has implemented a formal lessons learned program that includes recordkeeping, reviews of Occurrence Reporting and Tracking System (ORPS) reports, and followup on actions taken. Followup includes the sampling of corrective actions to validate closure.
The Senior EH Resident provided additional information that indicates that accident and illness statistics for all occupational categories are available. SR uses these statistics as an indicator of performance during Award Fee evaluations. WSI-SRS has used these statistics through the Safety Program Integrated Oversight Policy Committee to assist management to focus on the WSI-SRS safety program, to address identified concerns, and to improve the overall performance of the WSI-SRS safety program. In addition, EH reviews ORPS reports at DOE Headquarters. The results of these reviews are shared with all DOE field elements in different written materials, one of which is the Operational Events Weekly. Although these statistics are averaged for some occupational groups, there are no indications that EH reviews accident/illness statistics for SRTs.
WSI-SRS has submitted to SR a DOE Order Compliance package for compliance with DOE 5480.19, "Conduct of Operations Requirements for DOE Facilities." WSI-SRS has categorized each requirement of DOE 5480.19 on a compliance review form, which also provides the appropriate procedure or documentation that effects requirement compliance. This is in conformance with the requirements for DOE 5480.19, Paragraph 5.
SR established an Operations Assessment Program to meet a commitment to EM-25, the Office of Operations Assessment, in Savannah River Implementing Procedure (SRIP) 5480.19.3A on February 6, 1995. This SRIP established a schedule for assessing the conduct of operations for all major SRS nuclear facilities and the nonnuclear powerhouses. The SRIP does not require a conduct of operations assessment of WSI-SRS, nor does the programmatic guidance from EM-25.
The following paragraphs discuss significant factors affecting the April 3, 1995, accident in relation to the proper conduct of operations.
The ATTA Safety Analysis Report (SAR), dated August 19, 1988, and approved by SR on October 24, 1988 (SR-WSI-88-3147), is required by DOE 5481.1B, "Safety Analysis and Review System." Chapter II, Paragraph 4.f(1) of this Order requires the SAR to be reviewed for changes in operating characteristics, design characteristics, or administrative controls in an operation that represents a significant modification. The SAR does not include the Rappel Tower; therefore, it was not reviewed after the modifications were completed.
WSI-SRS Procedure 1-3105, "Inspection Programs," establishes guidelines for a formal safety inspection for WSI-operated facilities. Supervisors are required to conduct formal and informal inspections of their respective areas, report the results, and correct any noted deficiencies. This is done primarily with a checklist for each WSI-SRS division (Law Enforcement, Zone Operations, SRT, etc). The SRT Supervisor's Inspection Checklist does not address inspection of the Rappel Tower. It also states that WSRC Industrial Safety Personnel will conduct annual OSHA Inspections of WSI-SRS facilities per a memorandum of understanding (Reference Protocol Document between WSRC and WSI-SRS). Inspections will be maintained in the WSRC database with a copy to WSI-SRS ES&H Division. WSRC will assume responsibility for the categorization of OSHA deficiencies and post deficiencies, and will ensure corrective actions occur. WSRC will provide WSI-SRS ES&H Division with a status report for OSHA deficiencies in WSI-SRS operating areas. Only one of nine WSRC inspections performed from 1992 to 1995 documented deficiencies at the ATTA facility. The deficiencies documented at ATTA were of a minor nature concerning the septic system. The other eight inspections were performed at B-Area facilities.
WSI-SRS Procedure 1-3113, "Risk Analysis Techniques," requires Operations Directors to ensure the performance of a safety risk assessment for new or significant modification of operations, so appropriate analyses can be conducted to minimize potential adverse effects. A risk analysis was not performed for the modification of the ATTA Rappel Tower.
WSI-SRS Procedure 1-3301, "Self-Inspection Program (SIP)," establishes for WSI-SRS organizational elements the opportunity to systematically and comprehensively evaluate their areas to enable the identification of deficiencies. This program utilizes prepared checklists for each division, which are categorized by command authority. The Training Division (48 checklist items), SRT Captain (25 items), SRT Lieutenant (119 items), and SRT Sergeant (106 items) each complete a compliance checklist semiannually. Only one item from the SRT Lieutenant checklist applies to rappelling, and concerns procedural knowledge of rappel training.
WSI-SRS Procedure 1-3304, "Management/Safety Oversight Walkdown," ensures compliance with safety program requirements, supports the implementation of the WSI-SRS Conduct of Operation Program, and enhances communications between management and employees. These walkdowns are performed on a weekly basis by management and documented via a walkdown report, which states the areas and facilities visited, the problems, concerns, and issues, and outstanding or notable achievements and observations. The 1994 walkdowns noted one deficiency at the ATTA Rappel Tower related to the chains prior to their replacement in March 1995.
WSI-SRS Procedure 1-3132, "Safety Meetings," establishes policy, assigns responsibilities, and defines procedures for monthly safety meetings and the distribution of safety meeting discussion materials. The ES&H Division is responsible for the routine distribution of safety and health information. Directors are responsible for distributing information provided by the ES&H Division to their employees. Managers, Captains, and other officers ensure that all employees under their cognizance have access to the information provided. Monthly safety meetings held during the last year included the following generic topics: lead exposure, waste minimization, heat stress, natural hazards, employee rights, hearing protection, carbon monoxide, holiday safety, OSHA awareness, ergonomics, and asbestos.
WSI-SRS Procedure 1-3307, "Environmental, Safety and Health and Quality Department Audit, Appraisal and Surveillance Program," establishes the methods to be used for the implementation of a comprehensive system of scheduled, planned, and documented audits, surveillances, and appraisals. Through examination of objective evidence, performance evaluations, and interviews, these evaluations are to verify that the applicable aspects of Quality Assurance (QA), and Environment, Safety and Health (ES&H) have been developed, documented, and implemented in accordance with established procedures and that they are effective. WSI-SRS assessments have been performed at ATTA for firearm safety and weapons cleaning.
WSI-SRS Procedure 1-3309, "Quality Assurance Surveillances," establishes the process for performing and responding to WSI-SRS Quality Department surveillances. These surveillances will be accomplished through direct observations to determine if an item, activity, system, or process is capable, reliable, and safe. The following methods are used during the surveillance: observing physical performance of work or functions, observing the workplace for the presence of suitable conditions and adequate housekeeping, reviewing or spot-checking documents governing the work or evaluating for compliance and adequacy, evaluating or verifying the presence and effectiveness of applicable controls, conferring with personnel performing or supervising the task or function, and evaluating documentation of functions to verify compliance and adequacy. WSI-SRS surveillances have been performed over the last two years for weapons cleaning.
WSI-SRS Procedure 1-6912, "Occupational Safety and Health (OSH) Inspections of SATA and ATTA," defines the activities of the WSI-SRS Training Division Range Safety Officer in conducting monthly OSH inspections at the ATTA and SATA facilities using a compliance checklist (see Appendix N). The checklist format to perform OSHA-type inspections includes OSHA Standard 1910.23(d)(1) criteria, such as "Are all stairways having four or more risers equipped with stair railings or handrails capable of withstanding 200 lbs. of force applied in any direction?" This procedural checklist is for compliance with DOE and OSHA requirements. It places no focus on any facility (Rappel Tower, shoot house, etc.), but rather it is a generic checklist used for the general ATTA and SATA areas.
The WSI-SRS Safety Program Integration Oversight Policy Council (SPIOPC) charter provides oversight for WSI-SRS ES&H programs. The Council will provide policy guidance and work to ensure that all elements of the organization contribute effectively to the establishment of a working environment in which awareness of safety requirements and compliance with these requirements are the accepted norms. The Council objectives are to ensure the integration of ES&H policies, programs, and procedures in the day-to-day operations of WSI-SRS through the periodic review of compliance efforts; to review identified ES&H deficiencies and corrective actions throughout WSI-SRS to ensure they are consistent with ES&H goals; to ensure the effective integration of all resources of WSI-SRS into the execution of the ES&H goals; and to provide strategic direction to ensure that WSI-SRS maintains a proactive ES&H program. SPIOPC minutes for the last two years indicate that the meetings are general topical discussions with no particular focus on ES&H field assessment activities related to safety oversight.
During the on-shift training related to this accident, the following items were noted in relation to the conduct of operations. DOE 5480.19 requires on-shift training adhere to established training programs to maintain instructional uniformity and to document on-shift training appropriately. The Order also requires that qualified operators supervise trainees so that unqualified personnel do not make mistakes that could affect safety. The Order also requires that on-shift instructors and evaluators be qualified for the activities they perform to ensure both correct operation and quality training. WSI-SRS Procedure 2-305, "On the Job Training Program," does not require the specific control of on-shift training.
This chapter requires that "administrative controls shall be established to document compliance with requirements of operational limits." This implies that a system shall be in place to prevent the operation or use of equipment, systems, or facilities above and beyond their operational capabilities. This procedure also requires that "security/safety equipment and systems shall be tested following maintenance," and that "equipment and systems checks shall be conducted prior to operations." It also requires that "modifications, temporary or permanent, to equipment or systems shall be controlled and approved."
WSI-SRS has a procedure for attaining maintenance and modification of its facilities through WSRC, yet throughout this process there is no identifiable detailed safety review by either WSI-ES&H or WSRC-ES&H. A completed form for "SRS Final Acceptance Inspection of New or Altered Facilities or Equipment" is required by WSRC Safety Manual 8Q, Procedure 51 (SMI-51), "Final Acceptance Inspection of New, Altered, or Discontinued Facilities or Equipment." This form is initiated by the Facility Administrator to record the final acceptance inspection of the new, altered, or discontinued facilities or equipment if the change might have created a potential hazard to personnel, equipment, or process.
The WSRC Facility Administrator, Area Safety Engineer, and Maintenance Engineer signed the form that provides the final acceptance inspection of the work request/project order for the new gates at the ATTA Rappel Tower. This inspection is dated March 29, 1995 (see Appendix M). The form stated that the items (handrails and gates) were inspected and found to be satisfactory for safe operation with a handwritten annotation that stated "safety representative approved the new gates, guardrails, and latching mechanism on the new gates." The instructions for completing the form include 31 inspection items, including examination for falling hazards, sharp edges, guards, identification, warning signs, operating procedures, and pinch points.
WSI-SRS 1-8100, "WSI-SRS Facility/Equipment Repairs," establishes a procedure for the proper management of WSRC Work Requests for facilities occupied or operated by WSI-SRS and to outline followup reporting requirements for facility maintenance items, including ES&H issues, which have the potential to degrade the overall security posture of critical facilities or the health and safety of WSI-SRS employees.
DOE 5480.19 requires the dissemination of equipment design changes, procedure changes, related industry and in-house operating experience information, and other information necessary to keep operations department personnel aware of current facility activities through a formal required reading program. WSI-SRS relies on two procedures to fulfill these requirements: Procedure 2-301, "Standardized Muster Checklist," and Procedure 2-305, "On The Job Training Program."
Attachment 3, "Conduct of Operations Requirements" of WSI-SRS Procedure 1-02, "WSI-SRS Written Directives System," establishes the policy that requires the development of procedures for anticipated operations, evolutions, tests, and abnormal or emergency situations. It also requires ES&H coordination of directives that address safety-related equipment.
As required in WSI-SRS Procedure 1-3157, "Job Safety Analysis," the JSA for Rappelling recognizes a hazard designated as "rope awareness," and presents the safety control for this hazard as follows: "Rappel Master or Rappel Instructor will point out the locations prior to the start of the evolution." This procedure also discusses "falls" as working conditions that need to be reviewed.
WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, requires the use of two ropes for all rappelling operations. A waiver was prepared in 1991 by WSI-SRS ES&H to provide a one-time exemption for the use of one rope for rappelling at a national SWAT competition in 1991. The procedure has been changed to note the exception for use of a single rope during SWAT Competition Team training based on this one-time waiver (see Appendix L). The technical basis for the waiver is "use of a single rope for descent with the equipment currently used does not present any increased risk." During the accident, only one rope was used. In addition, this procedure does not provide requirements for a Buddy Rappel. There was no training or lesson plan to support a Buddy Rappel operation. "WSI-SRS ES&H Division is responsible for conducting periodic assessment of the rappelling program. The ES&H Division will conduct an initial safety walkdown of any area to be used for routine rappelling prior to the activity. The results of the initial walkdown will remain effective unless existing conditions change, which will warrant a follow-on walkdown." The Rappel Master is required to perform an inspection of the tower; if discrepancies are found that cannot be resolved immediately, no rappelling will be performed. Other responsibilities of the Rappel Master include (1) ensuring the performance of proper rappel procedures as instructed in rappelling lesson plans, (2) conducting safety and operations briefings to rappellers, (3) controlling orderly progression on rappel, and (4) ensuring the safety of all personnel using the Rappel Tower.
DOE 5480.19 requires the establishment of an operator aid program to provide information useful to operators in performing their duties. The WSI-SRS compliance document for this requirement is Procedure 1-2612, "Bulletin Board Requirements (Official and Unofficial)." This procedure does not contain the required elements of DOE 5480.19 for the use of operator aids, nor does it discuss operator aids of any form.
Last Modified: Friday, 28-Feb-97 10:09:00