4. CONCLUSIONS

4.1 MISSION AND POLICY

Findings

• The SRS SSSP does not include rappelling as an SRT operational or tactical response to achieve an interdiction, interruption, neutralization, or recapture mission.
• WSI-SRS is contractually required to have an SRT that is "highly qualified and trained in...rappel techniques," but there was an absence of documentation that stated how this capability was to be applied.
• There was confusion on SRT training program requirements; SR and WSI-SRS senior security management viewed CTA lesson plans as Department policy and NN states that the plans are training criteria.
• NN has not formally established sufficient guidance on rappel operations to ensure safe operations.

Probable Causes

• SR management of WSI-SRS has not made a comparison between the WSI-SRS mission and its training requirements.
• DOE Headquarters (HQ) organizations with security management responsibilities have not worked collaboratively to ensure that field operations offices clearly understand HQ policy development/interpretation authority.

4.2 OPERATIONS, TRAINING AND EMERGENCY RESPONSE

4.2.1 Operations

Findings

Contract

• SR management has not updated the WSI-SRS contract to reflect the changing characteristics of the Design Basis Threat and the evolving SRS mission.
• WSI-SRS participation in competitions has not been a contract requirement but has been authorized by SR in a "performance direction" memorandum because participation was considered to be within the contract scope of work; SR has considered WSI-SRS success in offsite SWAT competitions as an assessment factor for determining award fees.

Competition

• Competition rules were not clearly understood beforehand to ensure appropriate safety analysis and preparation prior to the competition.
• Competition team training included the use of the unapproved Buddy Rappel technique.
• The competition team did not employ a top belay safety line during competition training.
• The required Rappellers Safety Brief Checklist was not used for the safety briefing before rappel training.
• Four different members of the competition team had responsibility to direct individual portions of the competition training.

Probable Causes

Contract

• There was a lack of sensitivity by SR contract oversight personnel that the WSI-SRS statement of work be accurate and reflect current mission requirements.
• SR has not clarified the specific correlation between WSI-SRS competition success and subsequent award fee determinations.

Competition

• There was a lack of adequate management control by WSI-SRS SRT training management for not directing the exclusion of the Buddy Rappel technique from competition training.
• There was a lack of adequate safety preparations and the use of an unapproved rappel technique by competition team members.
• The employment of a top belay safety line during competition training may have prevented the rappellers from falling.
• Command and control responsibilities during competition training were fragmented and not clearly defined.

4.2.2 Training

Findings

• Rappel Master/Instructor training about the safety risks and the implications of the total dynamics of rappelling is incomplete.
• No training had been conducted at SRS using a Buddy Rappel technique since SRS Rappel Master training ceased in 1989, and no refresher training has been developed for the WSI-SRS Rappel Masters.
• The WSI-SRS Training Division rappelling lesson plan and WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, were incomplete because they did not include references to the purpose and functions of the tower rails and gates in relation to the use of the tower for rappel training.
• The reviews of WSI-SRS SRT training program were inadequate to ensure that appropriate lesson plans were developed and that risk analyses of the core curriculum were conducted for each type of rappel activity or technique trained at SRS.
• The regulation status of CTA lesson plans has not been understood by SRS personnel, and this status has not been clarified or emphasized in DOE Orders.
• The WSI-SRS Training Division did not follow procedures to ensure that a lesson plan or guidance was available for the safety and effective conduct of Buddy Rappel training.

Probable Causes

• The absence of Buddy Rappel training, the lack of Buddy Rappel lesson plans, and the lack of Rappel Master refresher training was due to the fact that the WSI-SRS Training Division had not developed and validated a training plan that included all of the specific steps and sequence necessary to effectively oversee and safely train, and maintain the capability for buddy rappelling.
• WSI-SRS SRT personnel were unaware of the functions and limitations of the tower rails and gates prior to reopening the ATTA Rappel Tower because the WSI-SRS Training Division personnel did not update rappelling lesson plans or the WSI-SRS rappel procedure.
• Because the SRT core curriculum risk analysis has not included an analysis of the risk associated with each type of rappelling and safety training of Rappel Masters/ Instructors has been incomplete, WSI-SRS SRT personnel were not prepared to recognize all the potential dynamics of rappelling.
• The lack of understanding of the regulatory status of CTA lesson plans and the lack of reinforcement of that status in DOE Orders contributed to SRS personnel not ensuring that CTA trained rappel instructions were present during rappel operations.

4.2.3 Emergency Response

Findings

• The EMTs were qualified and provided adequate emergency medical assistance during the accident.
• An open telephone line at the SRSOC permitted the disclosure of information that might not have been appropriate for the caller to hear.
• Emergency medical technician kits were not standardized between the WSRC and WSI-SRS EMTs.
• The SR helicopter has not routinely used as a tool for WSRC EMTs for responding to emergencies at remote locations.

Probable Cause

· WSRC and WSI-SRS have not fully coordinated emergency response activities at SRS.

4.3 OCCUPATIONAL SAFETY AND HEALTH

Findings

• Neither WSRC nor WSI-SRS identified the lack of fall protection on the Rappel Tower as an OSHA deficiency and, therefore, appeared to not be properly staffed with qualified individuals to conduct OSHA inspections.
• The gates on the Rappel Tower were unsafe and not designed for the training purpose of the tower.
• The SRT occupation is one of the riskiest and most hazardous occupations in the United States.

Probable Causes

• The number or qualifications of WSRC individuals conducting OSHA inspections was inadequate.
• There were no communications or concurrence between WSRC and WSI-SRS on the design, fabrication, and installation of the gates.
• Job safety analyses have not been performed to identify safety improvements in SRT activities.

4.4 MANAGEMENT SYSTEMS

Findings

• There was no safety or training Line Management of SRT competition preparation activities.
• SRT competition preparations were perceived to be outside the scope of WSI-SRS operations and training activities.
• Supervisors did not meet their responsibilities because they did not follow established procedures and ensure that lesson plans and safety analyses were developed for rappelling activities.
• DOE rappel policy did not specifically prohibit the use of an unaccepted rappel technique.
• SR and WSI-SRS testing of the Rappel Tower after the installation of the gates did not include formal change analysis and performance testing of all functions that might have been affected by the maintenance.
• Communications within WSI-SRS did not prohibit personnel from using an unaccepted and unauthorized rappel technique, and did not ensure that personnel were informed of changes to the Rappel Tower.
• WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2, SRT position description and job task analysis did not assign safety responsibilities in a manner that will ensure a progression of safety responsibility beyond the Rappel Master.
• The WSI-SRS safety program was primarily focused on facilities and not operations and training.
• SR Safety Division support to SR-OSS was primarily under the auspices of the award fee process.
• SR review of the WSI-SRS rappel training program was not effective.
• Lessons learned from past accidents were not effectively used by WSI-SRS to prevent the reoccurrence of the causes of those accidents.
• NN certification of the WSI-SRS training program was too narrowly focused and did not identify shortcomings in Rappel Master knowledge.
• NN and WSI-SRS Program Management reviews have identified the need for Rappel Instructor/Master refresher training, but refresher training had not been developed.
• EM Line Management of WSI-SRS was focused on security planning issues and not on safety and conduct of operations.
• EH Resident safety oversight of WSI-SRS did not include WSI-SRS operations and training activities.
• The Office of Oversight (EH-2) safeguards and security inspection program did not formally include safety until Fiscal Year 1995.
• EH safety program management has not provided routine support to the DOE Safeguards and Security Program.
• Analysis of accident and illness statistics by EH has not been comprehensive.
• SR safety and security personnel have overlapping management control responsibilities and have differing perceptions on their oversight roles.

Probable Causes

• A lack of policy on rappel techniques, and a lack of Rappel Instructor/Master refresher training has decreased the effectiveness of NN's Program Management of the DOE protective force program.
• By focusing only on security planning, EM has not met its safety and conduct of operations Line Management responsibilities over WSI-SRS.
• EH safety Program Management and safety Independent oversight of DOE protective force programs has not been fully effective because of a lack of assistance in the development of the program, analysis of accident and illness statistics, and a lack of balance between nuclear and nonnuclear safety issues.
• SR and WSI-SRS Line Management has not provided for SRT competition preparations because they were perceived to be outside normal operational and training activities.
• Confusing and overlapping organizational and individual management roles and responsibilities have reduced the effectiveness of SR safety and training assessment programs for WSI.
• WSI-SRS safety management control has not accomplished at each organizational level because rappel procedures, position descriptions, and job task analyses for WSI-SRS managers and personnel involved in rappelling did not contain sufficient details on safety responsibilities.
• Ineffective communications and the failure of supervisors to meet their responsibilities led to unsuccessful line management within WSI-SRS.
• The WSI-SRS safety program has not fully effective due to the fact that it did not focus on operations and training and did not effectively utilize lessons learned.

Last Modified: Friday, 28-Feb-97 10:09:00