WSI-SRS does not have an organized program staffed with qualified individuals to conduct OSHA-type inspections on its facilities. WSRC, by agreement with WSI-SRS will perform this service on an annual basis along with other requested OSH inspections. However, the most recent WSRC inspection of the Rappel Tower failed to identify the deficiency of fall protection to meet OSHA requirements. It is also unlikely that WSI-SRS inspections would have identified this deficiency because its checklist does not include all OSHA-type hazards that would be found on the tower.
The tower was inspected by the Board for compliance with OSHA requirements. The gates appear to satisfy the OSHA requirements if they are properly closed and the connecting pin is properly inserted in the pin housing to keep the two halves of the gates together. However, the design of the gates installed at the various levels of the Rappel Tower presents a safety hazard in the following three ways:
Significant trends from the occupational injury and illness experience of WSI-SRS and other DOE security contractors listed in Section 2, Table 2-1, indicate that WSI-SRS has maintained one of the best corporate injury and illness rates of the DOE security contractors, even with the largest security workforce. Their rates for the 1992 through 1994 time period were at or below the DOE average.
Table 2-2 in Section 2 indicates that the WSI-SRS SRT had a total recordable and lost workday case rate (LWD) that exceeded the WSI-SRS and all DOE security contractors rates for injuries and illnesses for 1993 and 1994 (LWD). The SRT total recordable case rate (TRC) also exceeded, in some cases by a wide margin, the WSI-SRS and DOE security contractor rates for all three years. There is no DOE-wide SRT injury and illness data for comparison with the WSI-SRS SRT rates. In addition, Table 2-2 does not show the improvements in the WSI-SRS SRT rates, which include three years without a motor vehicle incident and 13 months without recordable personnel injuries.
Finally, Table 2-3 in Section 2 shows that the DOE security contractors injury and illness rates are the second highest of the nine major sectors of DOE. Only fixed fee construction contracting, which traditionally has high injury and illness rates, is higher than the DOE security contractors. The WSI-SRS SRT injury and illness rates for 1992 through 1994 shown in Table 2-2 are higher than most hazardous DOE operations of fixed fee construction contracting shown in Table 2-3.
Effective training programs contain a number of components, including a valid basis for their content, knowledgeable and qualified instructors, performance goals, testing and evaluation procedures, up-to-date and valid training materials, appropriate facilities, effective management, consistent procedures and communication, and appropriate resources.
A few exceptions to these requirements were identified in the WSI-SRS training program. The training program elements most related to the training aspects of the rappelling accident include knowledgeable and qualified instructors and personnel, the need for consistent procedures and communication, effective management, and in a lesser way, the need for up-to-date and valid training documents.
A combination of several training-related factors were important contributors to the accident, most important of which was a Competition Team with previous WSI-SRS Buddy Rappel training experience (which was discontinued in the late 1980s), and Rappel Masters who have not had the benefits of either refresher training or CTA instruction. These conditions came together in the context of the team's search for ways to improve team performance time. A contributing factor was the organizational separation of training conducted by the Training Division and the training conducted by the SRT shift lieutenants.
The experience and training of the SRT appear to have been sufficient to meet the SRS requirements for performing normal duties. Five of the six members of the team performing competition training received Rappel Master training when the Rappel Master course was taught at SRS. There has been no recent refresher training for those who completed the SRS Rappel Master course, and no Rappel Master refresher training program has been developed by WSI-SRS or CTA. A need for Rappel Master training at SRS since 1989 has been identified but no refresher training program has been developed. Three members of the SRT training staff had completed the CTA Rappel Instructor course; however, none of them were present during the competition training. Although CTA lesson plans establish DOE security training criteria and stipulate that only CTA-trained Rappel Instructors are qualified to perform Rappel Master duties, confusion on the status of CTA lesson plans by SRS personnel led to none of the personnel at the competition training, including the Rappel Master on top of the tower at the time of the accident, had been qualified by CTA to perform their duties. However, since WSI-SRS considers the Rappel Master training and recertification conducted at SRS in the 1980s to be valid, a qualified Rappel Master by the SRS standard was present during competition training.
Because Buddy Rappelling was taught as a minor part of the WSI-SRS Rappel Master certification course and none of the SRT members had refresher training on this hazardous activity, none of the members of the competition team were fully qualified to perform a Buddy Rappel. There was no formal training program for the competition and lesson plans were not developed for this training. If lesson plans had been developed for the Buddy Rappel, SRT management and instructors, in approving the training, would have had the opportunity to determine the validity of the Buddy Rappel for SRS. Furthermore, optional techniques, (i.e., one rope for competition preparation, and two ropes for all other rappelling) were being used at SRS, and WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, contained undocumented changes (use of rails and gates) that affected rappelling procedures. Updated procedures regarding the tower rail's purpose and function related to rappelling could have deterred their use.
The three SRT members who were CTA-certified as Rappel Instructors had not provided refresher training for the WSI-SRS Rappel Masters. Interviews with SRT members also indicated that even knowledge of some basic rappelling principles and facts about equipment was incomplete, and in a few cases incorrect. However, the CTA-trained Rappel Instructors who were interviewed indicated a greater awareness of the information. If lesson plans and refresher training for Rappel Masters had been developed, the absence of the Buddy Rappel as a rappelling activity taught at the CTA might have been revealed. This knowledge might have caused any rappelling activities in the competition training to either conform to the requirements of the CTA Rappel Instructor course or be separately reviewed and approved by WSI-SRS management, as was done in 1991 for single rope rappelling at the 1991 competition.
In addition, the current approach to rappel risk analysis and the current approach to safety training has not prepared otherwise skilled rappellers to consider, prepare for, and control all of the dynamics of Buddy or any other rappelling. This also is an important element of the training-related circumstances of the Competition Team practice session. Individuals who participate in training to further develop their rappelling skills should be able to fail without endangering themselves, as happened in this accident.
The usual specific and narrow emphasis of the formal, approved, and scheduled rappel training and exercises at WSI-SRS, as documented in the Training Division Annual Training Plan and lesson plans, were not the controlling conditions for the team practice session. For example, interviews with the team members made it evident that the idea to rappel over the rail was impromptu, because the team was unaware of the rails until that day. The presence of the rails reminded the team members of the 1994 competition, and offered an opportunity to practice an even closer approximation of possible requirements or scenarios to be encountered during the 1995 competition.
Conducting competition preparations without recent successful training on Buddy Rappelling, combined with a lack of Rappel Master refresher and enhanced safety training, a lack of information concerning the impact of the rails and gates on training at the tower facility, and the lack of approved Buddy Rappel lesson plans were significant training-related contributors to the April 3, 1995 accident. In addition, the current program direction for the protective force training program is not sufficient to ensure that CTA training and CTA-trained Rappel Instructors will incorporate the necessary principles and facts about the operational safety and dynamics of rappelling (including assessing how changes in the position of the rope impacts safe rappel operations, recognizing how changes to the rappel facility has an impact on rappel operations, and analyzing how changing from one man to buddy rappelling techniques impact rope load gearing capacity), which contributed to the April 3, 1995, accident. Finally, the training conducted by the Training Division and by the SRT shift lieutenants clouded the roles and responsibilities of the Training Division staff concerning training conducted by the SRT shift lieutenants. As discussed elsewhere in this report, this factor contributed to the guidance provided by the SRT Training Lieutenant being understood only as suggestions to the Competition Team. All of these conditions are missed opportunities to reduce the risks of training accidents.
On April 7 and 10, 1995, respectively, the Assistant Secretaries for Environmental Management and Defense Programs signed memoranda suspending all rappelling operations conducted for such purposes as training, initial qualification, requalification, certification, and competition at all EM sites (see Appendix Q). This suspension did not prohibit currently qualified individuals from rappelling during emergency lifesaving operations. The tower was examined by the Board as were all of the accident-related equipment, both on the tower and at the base of the tower.
As part of the analysis of the Management Systems, an Integrated Event Sequence is depicted in Appendix O. This sequence illustrates the interaction of those involved in the accident and provides a detailed account of the events preceding the accident scenario.
There were a number of deficiencies in the supervision of the SRT Competition Team.
The SRT Team Coach was deficient in his duties as a Shift Supervisor for allowing the introduction of the Buddy Rappel as a training activity for the team. He was aware that this rappelling activity had not been used at SRS since 1989 and should have realized that the team members were no longer qualified in the performance of the Buddy Rappel. The Team Coach was also aware that an approved lesson plan did not exist for the Buddy Rappel.
The SRT Commander was deficient as the supervisor of the SRT Team Coach in allowing the conduct of informal training on hazardous operations. The SRT Commander should have required the development of training lesson plans and a review of the SRT Core Curriculum Risk Analysis to be sure the hazards involved in SRT competition events were covered. The SRT Commander was also deficient for approving single-line rappelling for the SRT competition in WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, without an annual Safety Division review of the training activities.
The SRT Senior Instructor was deficient for not fully advising the SRT Competition Team that approved lesson plans had not been developed for the Buddy Rappel and that CTA does not recognize the Buddy Rappel as an accepted rappel technique. Thus, the SRT Senior Instructor did not meet his responsibilities as an advisor to the team and did not meet the intent of the training he had received at CTA while completing the Rappel Instructor course.
The Range Facility Manager was deficient for not ensuring that personnel utilizing the ATTA were fully informed about changes to the Rappel Tower that had an impact on rappel operations. This led to the misuse of the newly installed gates for a purpose for which they were not intended.
Communications were deficient in five specific situations during the preparation for SRT competition. These deficiencies resulted in the hazardous Buddy Rappel being introduced as a rappelling activity during the preparations and the inappropriate use of the gates.
Various WSI-SRS training and safety managers were involved in the replacement of the chains on the Rappel Tower with gates over a period of six months. However, SRT personnel were not consulted at any time about the design or purpose of the gates. Once the gates were installed, formal change analysis and performance testing was not completed because training and safety personnel did not to recognize the impact the gates had on rappelling and, therefore, the need to complete the analysis. Further, SRT personnel were not formally informed of the gate's purpose or limitations. This lack of communications contributed greatly to the SRT competition team's use of the gates in a manner for which they were not intended.
The SRT Team Coach discussed the SRT competition with officials of the sponsoring organization. However, the coach did not request a thorough discussion of the competition rules with the sponsoring officials and was not informed that Buddy Rappel would result in team disqualification from that event. The sponsoring officials did not voluntarily communicate this information to the Team Coach. As a result, the SRT Competition Team practicing for the competition did not have sufficient knowledge of the rules to properly plan training activities.
The members of the SRT training staff who had received Rappel Instructor training at CTA did not communicate the status of the Buddy Rappel as an unauthorized rappelling activity to the other training instructors. As a result, a member of the SRT Competition Team suggested the Buddy Rappel as an idea for streamlining the rappelling event. This suggestion was accepted since the team did not realize Buddy Rappelling is an unauthorized activity and would not be permitted under the rules for the competition.
The SRT Team Coach did not adequately brief the SRT Commander on specific plans for the competition training, and the SRT Commander did not require specific details on the training during the discussion. As a result, an unauthorized hazardous Buddy Rappel was included in the training.
The SRT Team Coach did not provide specific details of the SRT competition training and plans to use the Buddy Rappel to the SRT Senior Instructor. The SRT Training Lieutenant discussed the Buddy Rappel with the SRT Team Coach, but did not inquire into plans for its use in the competition. The SRT Training Lieutenant was deficient in his discussion with the SRT Team Coach because he did not forbid the use of the Buddy Rappel in the training as he should have due to his training as a CTA Rappel Instructor and his knowledge that there was no lesson plan for the Buddy Rappel. The SRT Team Coach was deficient for not specifically stating his intent to perform training using the Buddy Rappel.
DOE Headquarters safety and training management controls of SR and WSI-SRS is provided by EH (Program management and Independent oversight) and EM (Line management), respectively. NN is responsible for Protective Force policy, and has certified WSI-SRS training programs under the provisions of DOE Order 5630.15 and DOE Order 5632.7A. However, NN has not issued explicit policy on the types of rappelling. Line Management of the SR conduct of operations program is provided by the Office of Operations Line management Assessments (EM-25). Broad organizational responsibilities for Line Management (including safety, training, and conduct of operations) of WSI-SRS by SR have been formally assigned to SR-OSS.
The current SR Line Management philosophy is based on line management accountability supported by matrixed support. This philosophy has been effectively communicated to senior managers; however, SR staff has a lesser degree of understanding of the new philosophy. The continuing management philosophy transition period at SR is responsible for some of the lack of understanding. In addition, SR-OSS personnel have been verbally assigned safety responsibilities. Training Line Management of WSI-SRS has been assigned to a facility officer within SR-OSS and to the SRT operations point of contact.
WSI-SRS has much in the same way formally established organizational functions. The lead for safety is the Safety Division, and the Training Division administers the training program. Therefore, safety and training responsibilities have been established at each level, DOE Headquarters, SR, and WSI-SRS. However, given the number of different organizations and individuals responsible for management control and the organizational and individual confusion on their roles, there is uncertainty about whether sufficient clear guidance has been provided to ensure that all areas of management control will be performed for all WSI-SRS operations.
Guidance on the accomplishment of the assigned Line Management responsibilities is contained in numerous SR and WSI-SRS directives. SR has instituted the Technical Assessment Program to bring all assessment activities under one overall program to ensure consistency and eliminate duplication of effort. SR-OSS has developed its own procedures for conducting assessment activities that parallel the SR Technical Assessment Program. However, the SR-OSS assessment program does not include the same standards and qualifications, and might in fact be duplicative and not complementary to the overall SR assessment program.
Within WSI-SRS, a number of standard procedures have been developed concerning the conduct of operations (see Section 2.7.5) and formal training. Most of these SR and WSI-SRS procedures focus on contract-specified activities and training and exclude nonroutine activities, such as the competition preparations. Moreover, the existence of parallel assessment programs in SR and WSI-SRS might be a source of confusion and dilute the overall benefits of a unified assessment program.
Specific guidance for individual responsibilities is contained in position descriptions of the SRT Commander, Shift Lieutenant/SRT Team Coach, and SRT Sergeant and the job task analysis of the SRT. However, there was no discussion of specific safety responsibilities for rappelling in the position descriptions, job task analysis, and WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2.
This suggests that personnel and management officials assigned to these positions have no formal responsibility for safety. Because there is no formal assignment of responsibility for safety in the SRT, there is no direct progression of safety requirements through the ranks of the SRT members in the performance of their training duties. This was clearly demonstrated by the Team Coach when he did not stop the rappel training when presented with the fact that the conditions on the tower had changed and rappel procedures had not been updated.
Though organizational responsibilities have been formally established and guidance has been developed, the success or failure of oversight depends on whether the control mechanisms in place are uniformly implemented. Management control activities by WSI-SRS, SR, EH, and EM of WSI-SRS have tended to focus on the program/facility level and not the operational or training level. For instance, WSI-SRS safety inspectors (such as Range Safety Officer), who are not trained safety professional, must rely on facility-oriented checksheets. Further, EH Resident Independent oversight activities have historically centered on nuclear operations at WSRC and not on WSI-SRS. Independent oversight inspection of safety aspects of the protective force was initiated in Fiscal Year 1995 by the Office of Oversight. Had these inspections focused on safety in the past, shortfalls in safety integration into the DOE safeguards and security program might have been identified. In addition, other ES&H Program management organizations have not routinely focused on safeguards and security organizations or programs. Therefore, safeguards and security operations and associated training programs might not have fully received the benefits available from these organizations. EM has focused its Line Management activities on security plans and not on implementation of safety or conduct of operations programs. At SRS, safety support is provided to SR-OSS solely by the Safety Division through the Award Fee Evaluation Process. Senior SR managers from SR-OSS and the Office of Safety have stated that this level of support is not adequate. However, additional safety support for ongoing surveillance coverage of WSI-SRS operations and training has not been requested or offered. The confusion about organizational and individual roles and responsibilities and the existence of duplicate assessment programs have contributed to the lack of additional safety support.
Line Management of the WSI-SRS training program (excluding force on force training exercises) by SR was restricted to programmatic reviews and with no surveillance of actual training until Fiscal Year 1995. Safety management within WSI-SRS is comprised of facility surveillances that infrequently include actual operations or training. The WSI-SRS Training Division conducts assessments of classes given by their instructors, but does not monitor the Shift Lieutenants during on-duty training. The focus of the review and evaluation by NN of protective force rappel training was too narrowly concerned with the SRT training program to identify the shortcomings in the safety dynamics training for the Rappel Instructor/Master training. Further, Line Management of the WSI-SRS conduct of operations program by EM or SR-OSS has not been fully implemented.
While management control of operations and training is infrequent and too narrowly focused, control is nonexistent when the activity is perceived to be not part of the contract. Clearly, SR managers believe that approval of SRT participation in competitions is within the scope of the contract. However, there is no indication that organizations with management control responsibilities for WSI-SRS have recognized this fact and have initiated control activities. Without doing management control activities, none of the intended benefits of these programs can be realized.
Another control mechanism at SRS is found in numerous conduct of operations procedures (see Section 3.7.5). After the installation of the new gates, testing was required to ensure that the new devices functioned as required and to determine if any functions at the facility had been affected by the changes. This type of testing or risk analysis was not conducted nor were training requirements identified for those who must use the tower. Officials indicated that the changes were not important enough to warrant the analysis.
Active lessons learned programs have been implemented at WSI-SRS, SR, and DOE Headquarters. The lessons learned program at SRS includes the establishment of formal accident review boards and accident investigation boards and the analysis of local accident and illness statistics. These boards have determined the causes for accidents and have issued findings to WSI-SRS for corrective action. WSI-SRS has a detailed corrective action tracking system that includes management review and approval. The WSI-SRS Safety Division reviews the corrective action plans and validates that corrective actions have been accomplished through sampling of activities or review of procedures. Many examples were provided to this accident investigation board of past corrective actions taken as a result of the lessons learned programs at SRS. The analysis of the accident and illness statistics has been used in the Award Fee evaluation process of WSI-SRS and has been used by WSI-SRS management to reduce the accident rate of the protective force.
The review of the corrective action plans indicates that WSI-SRS has been largely successful in determining direct causes for accidents. However, the review of SR helicopter rappelling corrective action plans concerning the need to develop formal scenarios did not ensure that lesson plans for Buddy Rappel operations were also developed. Similarly, though the issue that the Rappel Masters were not following procedures during the SR helicopter rappelling accident was addressed, Rappel Masters once again did not follow procedures. The fact that these causes were similar to those identified during the SR helicopter rappelling accident indicates that corrective actions might not have fully addressed all concerns.
DOE Headquarters also has a lessons learned program that includes the review of accident and illness statistics. These statistics are available at EH and SR and some of these data have been analyzed. However, analysis of these data did not reveal the high rate of accidents experienced by the SRT (see Section 2.7.4). There appears to be no comprehensive plan to analyze all data. The failure to detect the fact that an occupational group within DOE had a high accident rate has denied DOE Headquarters and Field Managers access to significant data with which to make programmatic and operational decisions.
Programmatic guidance from the EM-25 Office of Operations Assessments does not specifically address the assessment of security contractor operations. The guidance provided is to ensure assessment of conduct of operations performance for all EM activities as defined by DOE 5480.19. EM-25 has conducted a review of the SR Operations Assessment Program and found it satisfactory. At present, the SR Operations Assessment Program does not assess the security contractor, WSI-SRS. Discussions with EM-25 after the accident conclude that EM-25 has not evaluated security contractors of the DOE complex for conduct of operations in the past.
The following paragraphs are an analysis of significant factors affecting the accident related to the applicable conduct of operations chapters of DOE 5480.19.
The ATTA SAR does not assess the safety and risks associated with the Rappel Tower. This SAR assesses only the safety and risks associated with the use of firearms at the ATTA. The installation of a new design gate (i.e., guardrails) should have prompted a review of the SAR.
The SRT Supervisors Inspection Checklist indicated that it does not address inspection of the ATTA Rappel Tower, but instead concentrates on firearm safety and general OSHA safety (e.g., fire extinguisher, hazardous chemicals, electrical, housekeeping, and personal protective equipment). The WSRC annual OSHA inspections have not effectively assessed the ATTA. Of the nine WSRC assessments reviewed, only one, the Facility Evaluation Board (FEB) report, dated March 18, 1995, documented a review of the ATTA. The two FEB findings at ATTA concerned minor deficiencies at the septic tank and septic field. The remaining WSRC OSHA reviews conducted for WSI-SRS were performed only at B-Area facilities.
A risk analysis was not performed for the replacement of the chains/stanchions with the new design gates by WSI-SRS. WSI-SRS memorandum OSHD-95-120, dated April 21, 1995, states that "Because the handrails were installed so that they could be opened for rappelling (like the chains they replaced), a change to the rappelling risk assessment was not initiated."
The Self-Inspection Program (SIP) indicates that only one checklist item concerns rappelling: SRT Lieutenant Checklist Item Number 109, "Are assigned personnel knowledgeable of procedures pertaining to Rappel Training for SRT?" This indicates a cavalier attitude toward WSI-SRS self-assessment of rappelling operations, considering the number of WSI-SRS checklist items that the WSI-SRS SIP utilizes.
The past year's WSI-SRS management safety oversight walkdown reports indicate that only one deficiency (dated March 8, 1994) was noted at the Rappel Tower, which was described as a "fastener was missing from one of the chains on top of the rappel tower, making it possible for someone to fall off." The major focus of the walkdowns is on firearm safety and general housekeeping.
WSI-SRS Monthly Safety Meetings have addressed primarily generic topics, such as lead exposure, waste minimization, heat stress, and natural hazards. This forum of communication would have been an excellent method to relay the changes to the Rappel Tower had the design changes been recognized as a concern by the ES&H Division.
WSI-SRS ES&H audits, appraisals, and surveillances performed at ATTA were for firearm safety and weapons cleaning, which includes a WSI-SRS inspection of ATTA that followed the SR OSHA inspection to reverify the 1994 SR findings to aid in establishing a WSI-SRS ES&H baseline for future inspections.
Quality Assurance surveillances conducted during the past two years indicate the only surveillance performed at ATTA was for evaluation of weapons cleaning.
WSI-SRS OSH Inspections of SATA and ATTA utilize a checklist format to perform OSHA type inspections. This generic procedural checklist is for compliance with DOE and OSHA requirements. There is no focus placed on any one facility (e.g., Rappel Tower, shoot house). The utilization of a checklist for these types of inspections does not provide an environment suitable for dynamic or changing operational situations or facility modifications.
The WSI-SRS SPIOPC meeting minutes for the last two years reveal general discussions of accident rates, medical questions, recordkeeping, performance indicators, ALARA, DOE feedback, and corrective action plans for deficiencies. There is no emphasis on ES&H field safety assessments being conducted on WSI-SRS facilities or training.
There is no identifiable training plan or lesson plan related to the use of a Buddy Rappel or the use of a single rope. Neither policies nor procedures were utilized to ensure that trainee personnel were aware of all operating limits and hazards. The Rappel Master, whose function was to serve as the qualified instructor, did not understand or evaluate the technical aspects of the facility modification and its potential impact on facility operation. In this case, the Rappel Master was not technically cognizant of the potential impact of the facility modifications and subsequent risks present and he did not display "rope awareness" during the training that might have prevented the accident.
There is no evidence to establish that the new gates (guardrails) were inspected or tested for safety to ensure that the design load (200 pounds) was adequate. Acceptance criteria was not established for the new gates before the Rappel Tower was reopened for safe operation after the facility modifications. The inspection form (SMI-51) does not technically validate the contents of the inspection committee review and why the modification is acceptable.
WSI-SRS Facility/Equipment modification procedures do not require a safety review of redesigned or newly design equipment and facilities to ensure that the modifications do not present additional risk or danger to the intended function of the equipment or facility. A safety review was not performed when a work request was sent to WSRC to modify the Rappel Tower. Neither WSRC nor WSI-SRS reviewed the adequacy of the configuration change to determine that the sharp edges of the gates could pose a possible risk to the rappelling equipment (i.e., the rope).
WSI-SRS relies on two procedures for a required reading program. One procedure addresses only the proper uniform, equipment, and professional appearance of the security force. It does not address equipment design changes, procedure changes, or operations. The other procedure discusses on-the-job training and does not address any of the required reading elements.
The JSA for rappelling recognizes a hazard designated as lack of "rope awareness" and a corresponding safety control to "point out locations prior to rappelling." Clearly there was a lack of awareness by the SRT of the JSA and its corresponding safety controls.
The rappelling procedure requires that two ropes be utilized for all rappelling operations, but during the accident only one rope was utilized. There is no technical basis provided by the waiver for use of a single rope that states that there is no increase in risk. This procedure does not provide requirements for a Buddy Rappel. There was also no training (or lesson plan) to support a Buddy Rappel operation. The WSI-SRS ES&H periodic assessments of the rappelling program as required by this procedure are blanketed by the inspections required by the Range Officer Inspections. The WSI-SRS ES&H Division did not conduct a follow-on safety walkdown after existing conditions changed, as required by the procedure. The Rappel Master did not recognize the potential hazard of the gates during his required inspection of the tower, did not ensure proper rappel procedures were utilized as instructed in rappelling lesson plans, did not conduct adequate safety and operations briefings to the Rappellers, did not control the orderly progression of the rappel, and did not ensure the safety of personnel utilizing the Rappel Tower.
WSI-SRS relies on a Bulletin Board Requirements procedure to meet the intent of DOE 5480.19. However, the procedure does not address operator aid postings or any of the requirements of DOE 5480.19 for operator aids. If the need for an operator aid had been addressed for the new gates, it would have been an obvious warning to the operators that certain precautions must be taken for proper use of the facility.
Rappelling operations at WSI-SRS on April 3, 1995, were controlled by WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, dated July 21, 1994. The purpose of the procedure is to standardize procedures for all rappel operations, outline responsibilities for their safe conduct, and provide procedural guidance that ensures safe and effective rappel operations are conducted. The Rappel Master is assigned responsibility for the safety of all personnel utilizing the Rappel Tower. However, the procedure does not formally provide for a progression of safety responsibility in the SRT ranks beyond the Rappel Master. The designation of the Rappel Master as the sole safety authority in charge of conducting rappel training and of the tower is a tremendous responsibility that would be better served by including provisions for assistance on safety-related matters.
The Rappel Master did not ensure a safe and orderly conduct of rappel training because the inspection of the handrail did not reveal the probable fall line of the rope when placed over the top of the handrail. The inspection performed by the Rappel Master did not reveal the sharp edge on the gate latching device. The Rappel Master did not properly control the number of personnel on top of the Rappel Tower. The SRT Team Coach and a team member were present on top of the tower when the Rappeller and Buddy began the Buddy Rappel training. The Rappel Master performed a safety briefing but did not mention the new handrail gates on top of the tower. Scuff pads were not used to protect the rope when placed on top of the handrail.
This procedure requires that two ropes be used simultaneously for all rappelling operations and improperly grants a broad exception to allow single-rope rappelling for all SWAT competition team training and does not recommend a coordination with Safety for each year's SWAT competition training. The procedure also provides an inconsistency between the 3,840-pound tensile strength nylon rope and the 4,500-pound tensile strength required in the rope procurement specification. The procedure does not address types of rappels that can be used and does not specifically address the hazardous Buddy Rappel.
Some of the aspects of the management systems have been effectively implemented. However, supervision allowed the introduction of the Buddy Rappel as a training activity. While procedures have established the requirements for the development of lesson plans and for analysis and testing of modifications made to facilities prior to the reinitiation of operations, they were not followed. Management did not ensure that required testing and change analysis was completed prior to resuming operations at the ATTA Rappel Tower. Procedures were also too broad in the assignment of safety responsibility during rappel training. Department policy did not clarify the appropriateness of the Buddy Rappel, and SRS communications did not prohibit the use of the Buddy Rappel, though it was not recognized as an accepted rappel technique and was not authorized for the competition. Further, management reviews of the training program did not identify shortcomings in rappel master qualifications, and a lack of understanding of the status of CTA lesson plans which contributed to the use of an unacceptable rappel technique. Management control activities did not include all WSI-SRS operations, and DOE safety organizations have not provided managers with significant accident and illness data for SRT. Lessons learned were not effectively utilized in all elements of WSI-SRS programs and operations to preclude repetition of earlier causes of accidents. In addition, there were numerous failures in the conduct of operations program that led to the initiation of Rappel Tower operations prior to full testing and without informing the SRT of the purpose and limitations of the gates.
Last Modified: Friday, 28-Feb-97 10:09:00