The activities that led to the accident were performed as part of a project to correct environmental deficiencies. An environment, safety, and health support management organization with no project experience and no direct facility operations responsibility was assigned as project lead.
The LANL National Pollutant Discharge Elimination System (NPDES) permit came up for renewal in 1991. During the renewal process, the Environmental Protection Agency (EPA) issued an Administrative Order to LANL management requiring an assessment of the Laboratory's facilities in accordance with the Clean Water Act and NPDES regulations and requirements. An assessment schedule was established and agreed upon by the EPA. The Water Quality and Hydrology Group (ESH-18) was assigned the responsibility to perform assessments to identify and correct NPDES deficiencies. A waste stream characterization assessment was conducted, and recommendations for corrective actions, including building modifications, were made over a three-year period by ESH-18 with assistance from an engineering firm, Santa Fe Engineering (SFE). Approximately 7,500 deficiencies were identified during the assessment.
Initially, the recommendations resulting from the waste stream corrections assessment were provided to LANL facility managers, who were expected to manage the modifications of their facilities resulting from corrective actions. By September 1995, approximately 50 percent of the deficiencies were corrected in accordance with the EPA Administrative Order deadline (October 1996). However, based on the rate at which the deficiencies were being addressed, the Administrative Order deadline to correct all deficiencies was not expected to be met. To expedite the corrective action process, ESH-18 grouped approximately 2000 deficiencies/corrective actions into a single Standing Work Order for its Waste Stream Corrections Project. Although ESH-18 had not previously functioned as a project manager for a project of this size, LANL management allowed ESH-18 to take the project lead in handling the Waste Stream Corrections Project because there was a perceived need at the LANL Division/Group level to have one central organization held responsible for correcting waste stream deficiencies. Since the decision was made at this level, the Director and Deputy Director, LANL, were not aware of this decision.
Several environment, safety, and health concerns were identified early in the project.
ESH-18 teamed with Facility Risk Management Group (ESH-3) early in the project to identify the environment, safety and health (ES&H) concerns relating to the project through its Project Summary process. A Project Summary (called an ESH Identification Process) was created and distributed to subject matter experts for review. The review of the ESH Identification Process by the subject matter experts identified several ES&H concerns associated with the project, including the lack of specific information to adequately scope the proposed work or assess all of the ES&H concerns.
In September 1995, ESH-18 implemented its own alternative work authorization process, which included a tailor-made administrative form that did not provide for further review of ES&H concerns. ESH-18 was budgeted approximately $3.4 M and, on October 1, 1995, established waste stream correction tasks, including major projects to be given to the Facility Project Delivery Group (FSS-6), which is normally responsible for coordinating major construction projects and identifying ES&H concerns. However, in early December 1995, a decision was made by ESH-18 to remove FSS-6 from the work authorization process and instead involve the Operations and Maintenance Services Group (FSS-9) in the flow of information to JCI.
The work authorization process that was developed for this project did not include some of the customary reviews of hazards and other environment, safety, and health concerns.
At approximately the same time that ESH-18 was receiving the subject matter experts' comments and concerns from their review of the ESH Identification Process involving safety and health issues, work packages associated with ESH-18's Waste Stream Corrections Project were authorized without prior resolution of these concerns. On December 20, 1995, the Waste Stream Corrections subtask FMU70-009 for work in Building TA-21-209 was approved. Another Waste Stream Corrections subtask was also approved for similar work at LANL Fire Station #1. Work packages for the subtasks were not prepared, and therefore further hazards assessments and ES&H reviews were not performed.
Lack of clarity about the need for permits limited the effectiveness of safety reviews at the site where the accident occurred.
On January 16, 1996, the day before the accident, the Waste Stream Corrections Project work began at LANL Fire Station #1 by JCI, the maintenance service contractor. A JCI pipefitter foreman (acting) was made responsible for the work, and two JCI cement mason tenders (one of whom was injured at Building TA-21-209 the next day) were directed by the JCI pipefitter foreman to begin cutting a concrete slab and excavating a sump pit. Two JCI safety engineers inspected the excavation work at separate times of the day and discovered that an excavation permit was not posted at the site. Both engineers cited the incident in reports. However, there was a significant discrepancy between the two reports. The first report stated that "Masons did not have an excavation permit on site," and the other stated "No violations noted. Hole was less than 5 feet in depth and appeared to be quite stable." The second safety engineer incorrectly conveyed to the mason tender and the foreman that no excavation permit was required. Although an excavation permit was not posted at the Fire Station #1 excavation, both safety engineers assumed that an excavation permit existed for the work being performed. However, it was later determined that no permit was ever issued. Neither the foreman nor the cement mason tender was provided with either of the construction inspection reports until after the accident in Building TA-21-209. Although the foreman was present at the fire station during the safety inspection, once he was informed by the second safety engineer that no excavation permit was required, he did not take further action to obtain a permit for similar excavation work at Building TA-21-209.
The accident victim was cutting concrete slabs and excavating under the floor in order to reroute the sanitary sewer. No detailed engineering drawings were provided to assist in selecting the location for cutting and excavation.
On January 10, 1996, preparations began in the basement of Building TA-21-209 for the Waste Stream Corrections Project work. The objective of the work was to reroute the floor sanitary sewer to the existing building sanitary sewer system. The work involved installing four sump pits by first cutting and removing concrete floor slabs approximately 36 by 36 inches, and then excavating the soil underneath to a depth of approximately 36 inches. JCI pipefitters were assigned to coordinate the project and determine the sump pit excavation locations using preliminary design drawings (Appendix G-1) prepared by SFE. The drawings provided were "one line" drawings, not dimensioned, and not drawn to scale. No detailed engineering drawings were provided specifying the sump locations. Based only on the preliminary design drawings, the pipefitters observed that one of the planned sump pits needed to be relocated due to its proximity to the basement doors. This request was approved verbally by ESH-18 without field-verifying the sump's proposed new location. Unknowingly, the pipefitters marked the sump location directly above the 13.2 kV electrical service to the building. An example of similar concrete markings photographed in the basement of Building TA-21-209 is shown in Figure 2-1. On January 11, 1996, a JCI cement mason foreman and his cement mason tender visited the Building TA-21-209 site to determine the scope of work. The mason tender was given primary responsibility for all cement slab cutting. His instructions were only verbally communicated to him by the pipefitters, without accompanying drawings or written specifications.
On the afternoon of January 16, 1996, the mason tender who had visited the work site previously and another mason tender proceeded to the Building TA-21-209 basement and cut the cement slab previously marked by the pipefitters. Once the cement slab was removed, the two mason tenders excavated approximately 12 inches of soil before the end of their shift. As at the fire station excavation, an excavation permit had never been obtained for the work being performed.
Figure 2-1
Uncertainty about the need for an excavation permit arose before the accident at both the accident site and another site.
On January 17, 1996, at about 8:40 a.m., the excavation work resumed at the Building TA-21-209 basement. The work was performed by the mason tender who cut the slab the previous day and by a cement mason who had not previously worked at Building TA-21-209. A general view of the work site is shown in Figure 2-2. Also on January 17, 1996, at approximately the same time that work commenced at the Building TA-21-209 basement, the pipefitter foreman approached the cement mason foreman about the safety inspections at Fire Station #1 the previous day to discuss whether an excavation permit was needed. The pipefitter foreman had been present at both Fire Station safety inspections and wanted clarification on whether an excavation permit was required there. Each foreman assumed that an excavation permit was not required for indoor use, and that if one was required, the other was responsible for obtaining it. The cement mason foreman called the JCI utility specialist who was responsible for locating underground utility lines. The utility specialist explained that an excavation permit was not required indoors, and that their electrical line locator equipment could not accurately locate indoor utility lines due to the high electromagnetic fields within the buildings. Although the utilities specialist had reinforced the contention that an excavation permit for indoors was not required, the cement foreman continued to seek a procedural reference excluding the requirement for indoor excavation because of the pipefitters' concern over the fire station construction safety inspection. Although the cement mason foreman had knowledge of the ongoing excavation work at Building TA-21-209 and was still uncertain as to the need for an excavation permit, he took no action to stop the work at Building TA-21-209.
The accident victim's jackhammer penetrated a 13.2 kV electrical cable, severely injuring him and cutting power to the building.
By 9:30 a.m. the masons at Building TA-21-209 had excavated to a depth of 39 inches (Figure 2-3) by using an air-powered jackhammer, a pry bar, and a shovel to loosen and remove the rubble from the sump pit. At 9:34 a.m., the jackhammer being used by the mason tender broke through a concrete-encased conduit containing a 13.2 kV electrical cable. The jackhammer bit penetrated the conduit several times before coming into contact with the cable, as illustrated in Figure 2-4. The accident victim was observed by the other mason tender to "shake" from the electrical contact, a buzzing sound like that of "an electric welder" was heard, and a bright flash of light was emitted, followed by an apparent explosion from within the sump pit. Power was apparently lost to Building TA-21-209 at approximately 9:34 a.m., as shown in Figure 2-5. Figure 2-6 shows the conduit that was struck by the jackhammer.
Personnel in the building called 911 and started cardiopulmonary resuscitation.
The accident victim slumped into the pit, and the mason tried without success to pull him out. Although an emergency telephone was located ten feet away, the mason tender then ran out of the basement, first to a back entrance south door which was locked, and then to the main entrance, where he met a facility person at the door and entered the
Figure 2-2
Figure 2-3
Figure 2-4
Figure 2-5
Figure 2-6
building to seek help. With power out at the building, it was necessary for building personnel to use flashlights to gain access to the stairway leading to the victim. The building's public address system was inoperative due to the power outage, and verbal communication was necessary to request help. Two building employees immediately called 911. Several personnel trained in cardiopulmonary resuscitation (CPR) went into the basement to assist the accident victim.
At 9:35 a.m. two separate calls were placed to 911 from the office area of Building TA-21-209. The emergency management system was activated at 9:35 a.m. Upon arrival at the basement excavation site, facility personnel observed that the victim apparently suffered burns mainly to his trunk and legs, was unresponsive and making gasping and gurgling sounds, and had no pulse. The victim was arched backwards within the pit with the jackhammer leaning against his legs. Facility personnel informally assessed the potential for electrical hazards based on the site's conditions (i.e., no lights or electrical sparks/sounds) and concluded that there were no such hazards. Immediately following this informal assessment, the victim ceased making gasping and gurgling sounds. The facility personnel then used a shovel handle to move the jackhammer away from the victim and immediately pulled him from the pit. Facility personnel began CPR at approximately 9:40 a.m.
Six Los Alamos Fire Department units responded to the scene and began treatment.
Between 9:36 a.m. and 9:40 a.m. six Los Alamos Fire Department units departed for the scene, including a rescue unit (Rescue 1), ambulance (Medic 1), Battalion Chief (Battalion 1), Fire Captain (Captain 3), training company (Station 2), and engine company (Engine 6). A Rescue 1 emergency medical technician arrived first at 9:41 a.m. and observed that two lay rescuers were attempting CPR. Lay rescuer 1 was performing chest compressions. The Rescue 1 emergency medical technician used a pocket mask and began performing ventilations. Lay rescuer 2 took over chest compressions. The Medic 1 ambulance arrived at 9:42 a.m., followed immediately by the Battalion Chief. At 9:42 a.m. Captain 3 and Station 2 personnel arrived, as well as Engine 6. Station 2 emergency medical technicians took over chest compressions, breathing, and airway management. The injured worker was administered oxygen via a bag valve mask. An initial attempt to insert a breathing and esophageal tube was unsuccessful. The Medic 1 emergency medical technician hooked up defibrillator leads and analyzed the rhythm, which was interpreted as fine ventricular fibrillation. A sequence of three shocks was administered, thirty seconds apart. After the third shock, the patient was observed to be asystolic (no cardiac electrical activity).
The victim was taken to the Los Alamos Medical Center emergency room, where normal pulse, blood pressure, and breathing were established.
A decision was made to immediately transport the injured worker to Los Alamos Medical Center. He was transported by gurney to the waiting Medic 1 ambulance. At the urging of Building TA-21-209 employees, the injured worker's co-worker, who was coughing and emotionally upset, was transported in the front of the ambulance (and later treated and released). Medic 1 departed the scene at 9:48 a.m. In transport, CPR was continued by two emergency medical technicians, and the breathing and esophageal tube was successfully inserted. A third emergency medical technician started an intravenous line. The ambulance stopped once en route in order to obtain an accurate rhythm reading, but the victim was still asystolic, and no additional shocks were administered. Medic 1 arrived at Los Alamos Medical Center at 9:54 a.m., traveling 2.9 miles in 6 minutes.
On arrival at Los Alamos Medical Center, the emergency room physician and nurses assumed care of the patient, with continued assistance from the emergency medical technicians. The injured worker was observed to be in fine ventricular fibrillation. He was intubated at 9:58 a.m. A second intravenous line was started, and the injured worker was administered cardiac medications consisting of bretylium, epinephrine, and lidocaine, in that order, between 10:00 a.m. and 10:05 a.m.
At 10:06 a.m. the patient's electrical rhythm reverted to sinus rhythm (normal rhythm pattern), but no pulse was detected—a condition referred to as electromechanical dissociation. After an additional dose of epinephrine, the injured worker had a palpable pulse beginning between 10:07 a.m. and 10:10 a.m., with normal blood pressure noted shortly thereafter. Spontaneous respiration was noted at 10:25 a.m. He then received calcium gluconate, magnesium sulfate, and potassium. He was admitted to the intensive care unit and attached to a ventilator at 11:05 a.m.
There was some urgency in restoring electrical power to the building where the accident occurred.
The accident scene was secured and controlled by LANL Emergency Management and Response Group personnel at approximately 9:45 a.m. on the day of the accident. A yellow and black plastic ribbon was placed around the accident site, and both still photographs and video pictures were taken of the scene.
The responsibility for the accident scene was turned over from the LANL Incident Commander to the Los Alamos Area Office (LAAO) Type B Accident Investigation Board Chairperson designated by the Albuquerque Operations Office (AL) at approximately 1:30 p.m. that same day. At that time, the LANL Tritium Science and Engineering Deputy Group Leader, his staff, and the Facility Manager expressed a sense of urgency to restore electrical power to the facility based on the assessment that the power outage could lead to small releases of tritium to the atmosphere from the tritium effluent system. This was discussed with LAAO and AL personnel, and verbal approval was given by the Type B Accident Investigation Board Chairperson to begin restoring normal electrical power to the area. A portable electrical generator was set up outside Building TA-21-209 by JCI maintenance personnel, and emergency power was restored at 3:00 p.m.
Excavation work in the sump pit resumed on January 18, 1996, in order to repair the damaged cable and restore normal electrical service. This excavation activity was also performed without an excavation permit or utility survey, although the power was locked out and tagged out. This excavation was performed in coordination with the LAAO designated Type B Accident Investigation Board Chairperson, who had initiated a Type B investigation of the accident.
Some lapses were noted in maintaining the chain of custody for evidence.
The physical evidence collected at the scene was turned over informally by LANL to LAAO on January 19, 1996, whereupon some of it was kept in a locked room (Room 121) in Building TA-21-209. Other items were kept in the trunk of an LAAO employee's government car. The victim's clothing and personal protection equipment (rubber gloves, rubber boots, and outer overalls) were collected by JCI Safety and were turned over to and retained by LANL Industrial Hygiene personnel in their offices. No chain of custody was established for the physical evidence pertinent to the accident by JCI, LANL, or LAAO until requested by the Headquarters Type A Accident Investigation Board on January 21, 1996.
The Type A Accident Investigation Board arrived at the accident scene on January 21, 1996. The Board observed the accident scene and some of the physical evidence, which was in Room 121 of Building TA-21-209 and controlled by LAAO. No inventory of the physical evidence was prepared by JCI or LANL or requested by LAAO at the time of turnover. The Board requested that a chain of custody be established before the physical evidence was delivered to the Board. On January 22, 1996, the physical evidence was turned over to the Board by LAAO with a note dated January 22, referencing a LANL memorandum, also dated January 22, containing a list of the physical evidence. Neither the note nor the memo included the personal protection equipment items or personal clothing items that were also turned over to the Board at the same time by LANL Industrial Hygiene.
The Laboratory uses a questionnaire that is sent to new project initiators to identify projects that may pose environment, safety, and health risks.
LANL Administrative Requirement 1-10, "Environment, Safety and Health Questionnaire," (August 30, 1991), requires that all new projects be assessed for ES&H concerns. The procedure identifies those projects requiring an ES&H review, the review process, and line management's resolution of ES&H concerns arising from the review. The ESH Division's Risk Assessment Group is responsible for gathering information from new project initiators, via a questionnaire, and distributing the information to the ES&H Questionnaire Committee for review. The ES&H Questionnaire Committee is composed of subject matter experts representing various ES&H disciplines.
LANL personnel initiating new projects are required to complete the questionnaire contained in Administrative Requirement 1-10 for projects that may include new construction and building modifications, groundbreaking, or soil disturbance, or for projects that may involve high energy sources. The Risk Assessment Group in ESH-3 then distributes the completed questionnaire to the Questionnaire Committee for review, evaluation, and comment on matters such as project siting, occupational safety, fire protection, industrial hygiene, and health physics. The Committee is also required to determine whether Federal, state, or local statutes and regulations apply to the proposed project.
If subject matter experts identify potential ES&H concerns during their review of the questionnaire, Administrative Requirement 1-10 requires the Risk Assessment Group to send the project initiator an ES&H checklist, which lists the possible ES&H concerns related to the project and the appropriate contact for each concern. The project initiator is responsible for contacting the personnel listed and for maintaining a permanent file to document the resolution of the concerns raised during the review. The permanent file is required to meet the DOE audit requirements specified in Administrative Requirement 1-5, "Environment, Safety, and Health Audits and Appraisals."
A project summary process was developed to supplement the questionnaire process.
In 1992, the LANL Associate Director for Operations designated the ESH Division as the office of primary responsibility for the ES&H Questionnaire process. In November 1993, a Quality Improvement Team was formed to identify needed improvements in the ES&H Questionnaire process. In December 1993, the Quality Improvement Team issued a report on the ES&H Questionnaire process, recommending process improvements for project-related data gathering and turnaround times for subject matter expert reviews.
In December 1993, the Facilities Review Section in ESH-3 developed the ESH Identification Process to (1) implement the Quality Improvement Team's recommendations, and (2) alleviate problems with poor response from project initiators who were responsible for completing the forms contained in Administrative Requirement 1-10.
The ESH Identification Process involves the Facilities Review Section conducting face-to-face interviews with project initiators to gather information for inclusion in a nested logic database. Following data collection, ESH-3 documents the data in an ESH Identification Project Summary, and distributes the Summary to subject matter experts for review. The Facilities Review Section forwards the results of subject matter expert reviews to the project initiator to address any ES&H impacts. Administrative Requirement 1-10 has not been revised to reflect the changes in the process, procedures, and practices that the Facilities Review Section implemented in the new ESH Identification Process and, as of the date of the accident, the new process was in direct conflict with Administrative Requirement 1-10.
For this project, initial reviews identified some potential hazards.
On August 24, 1995, ESH-18 initiated ESH Identification Process #95-0188 for the Waste Stream Corrections Project. The ESH Identification Project Summary was completed by ESH-3 technicians, and ESH-18 provided factual accuracy review/comments to ESH-3 on September 15, 1995. Information provided by ESH-18 characterized the Waste Stream Corrections Project as a construction-related activity and identified explosives, industrial hygiene, operational safety, and radiological safety as potential hazard areas that could be encountered during the project. Subject matter expert review comments were provided to ESH-18 via ESH-3 memorandum, "Project Summary Closure Letter," dated November 13, 1995.
On or about September 6, 1995, FSS-9 representatives completed Service Request #02447 for Waste Stream Corrections. This service request was later assigned Standing Work Order #06006, to "Provide labor and materials to perform modifications to drain systems within Laboratory buildings as directed by ESH-18 to correct environmental code deficiencies as recommended by the waste stream surveys schedules." The Standing Work Order noted that "manpower will be requested by the account controller as needed." The Waste Stream Corrections service request received final management approval on September 21, 1995. On September 28, 1995, ESH-3 Facility Safety personnel completed their ES&H review of the Waste Stream Corrections service request.
On October 5, 1995, JCI forwarded a "Request for Davis-Bacon Determination" for the Waste Stream Corrections Project to the LAAO Determining Official for review. The JCI transmittal specified, in part, "Perform modifications to original waste systems within the Laboratory to correct environmental deficiencies... This determination will be used on all Facility Management Unit standing work orders for this work." On October 10, 1995, the LAAO Determining Official responded that the Waste Stream Corrections Project was "uncovered" (maintenance) work.
Both the Waste Stream Corrections service request (September 21, 1995) and ESH-3's technical safety review of the service request (September 28, 1995) were completed before the subject matter expert reviews were completed for the Project Summary (November 13, 1995). The subject matter experts' safety input could have been useful in the other reviews.
There was concern about the lack of detailed information about some conditions.
In a November 1, 1995, memorandum to Distribution, "Update of ESH ID #95-0188, Waste Stream Corrections," ESH-3 stated that attempts had been made to address the entire Waste Stream Corrections Project on a Laboratory-wide scale, but because of this wide-scale approach, several subject matter experts were concerned about the lack of detail contained in the Project Summary. The memorandum outlined ESH-18's plans for organizing the project to address those concerns, including:
The project was performed as a series of small jobs that normally require radiological and risk management reviews.
The memorandum also noted that "Small job tickets, service requests, and work tickets, authorizing work by JCI are currently reviewed by ESH-3 or a facility management team. If identified risks or hazards cannot be adequately addressed on the ESH Review page of the small job ticket or service request, the ESH Identification Process can be initiated by ESH-3, the facility manager, or the project contact."
The small job ticket and work ticket forms normally used by LANL and JCI personnel allow for ESH-1 (Radiological Protection) and ESH-3 reviews. For the Waste Stream Corrections Project, ESH-18 developed its own tailored small job ticket form, whose purpose was to track project costs and NPDES permit compliance status. However, the tailored form did not include space for either ESH-1 or ESH-3 reviews. In addition to the ESH-3 reviews noted above, the JCI ES&H Manual, Procedure 12-21-112, "Hazard Assessment Requirements," dated November 7, 1995, requires JCI craft supervisors to conduct a preliminary hazard analysis prior to any work conducted by JCI personnel.
A lack of detailed design drawings allowed the excavation site to be placed directly over the electrical line.
Board interviews with ESH-18 project leaders and reviews of archived records indicate that ESH-18 began work on Waste Stream Corrections subtasks prior to completion of subject matter expert reviews of the Project Summary. Using the ESH-3 November 13, 1995, memorandum, "Project Summary Closure Letter, ESH ID #95-0188," as a baseline to determine completion of the ESH Identification Process, records indicate that between September 11, 1995, and November 8, 1995, ESH-18 issued 16 Waste Stream Corrections Project subtasks for work without detailed work packages. Some of the work packages involved hazards associated with plumbing and electrical modifications and installations.
No detailed reviews were performed.
ESH-18 provided the Board with information to indicate that, on December 6, 1995, project engineers from ESH-18 and SFE were in Building TA-21-209 to scope portions of the Waste Stream Corrections Project. Their written statements indicated they were approached by the building manager and informed by him of their activities in scoping out portions of the Waste Stream Corrections project.
On December 20, 1995, ESH-18 issued Waste Stream Corrections Project FMU70-009 to FSS-9. It was one of 15 subtasks under FMU70, and involved the work in the basement of Building TA-21-209. It had a target completion date of January 13, 1996. No detailed work package was prepared, and no further ES&H reviews were required. Concurrent with the release of the project for work, JCI pipefitters and masons scoped the job and laid out sites where excavation would be required to install sumps. The planned location of one sump appeared, on preliminary design drawings, to interfere with a door in the basement of Building TA-21-209. A JCI pipefitter contacted an ESH-18 representative to request approval for a deviation to relocate the sump. The ESH-18 representative contacted an SFE representative responsible for that subtask, who approved the change by telephone. The approval by ESH-18 to deviate from the preliminary design drawings was documented by JCI personnel on the FSS-9 Work Order Form. The approved sump relocation placed the sump location directly over an energized 13.2 kV electrical line.
The Laboratory has a hierarchy of documents governing operational activities.
LANL utilizes a hierarchial arrangement of documents designed to communicate the expectations of management and the methods by which Laboratory activities should be conducted. The highest-level documents are called Director's Policies. These documents define management expectations and delineate the goals and directions of the Laboratory. The middle-level documents are called Program Requirements Documents. These documents provide the basic information needed to implement programs established by the Director's Policies. The lowest-level documents in this procedural hierarchy are the Laboratory-wide and generic procedures. These describe the specific steps for conducting operational activities within the facility.
The LANL ES&H Manual presents the policies, requirements, and procedures needed to ensure health, safety, and environmental protection at the Laboratory. This is a controlled document that consists of Director's Policies, Committee Charters, Administrative Requirements, Technical Bulletins, and Support Services. The Administrative Requirements are the primary documents used to set forth Laboratory requirements for ES&H. This Manual also contains or references other program documents, such as Laboratory Manuals, Procedures, and Standards. While the general information section of the ES&H Manual does not describe or define the use and authority of the Laboratory Manuals, Procedures, and Standards, many of the Administrative Requirements are being replaced by the Laboratory Standards. The version of the ES&H Manual that was reviewed by the Board was dated January 31, 1995.
The JCI procedures system is governed by two primary documents: (1) Standard Practice Instructions, and (2) the JCI ES&H Manual. The Standard Practice Instructions are published with the intent of defining JCI policies and procedures.
Both the Laboratory and the construction and maintenance contractor have policies and procedures governing excavations, but they are not uniformly applied.
A list of the applicable LANL and JCI policies/procedures that were reviewed by the Board are provided in Appendix E. The following facts were obtained from the Board's review of the policies and procedures:
The Laboratory has no configuration management program to ensure that the physical configuration of its facilities is accurately documented.
The Laboratory's configuration management program is described in Director's Policy 112, "Configuration Management," dated September 1991. The purpose of the configuration management program is to ensure that the physical configuration of facilities is accurately reflected in the documentation used to operate and maintain the facility. Director's Policy 112 requires that all activities involving modifications in existing "designated" facilities must comply with this policy. Configuration management programs are not required for "non-designated" facilities. However, Director's Policy 112 does not provide any amplifying information on what criteria are used to classify facilities as "designated" or "non-designated."
Responsibility for the Laboratory's configuration management program resides with FSS-3. Program Requirements Document 112-01.1, "Configuration Management," dated September 1, 1995, describes a philosophy, not a detailed program. The configuration management program is not funded out of the LANL overhead budget. Facility-specific configuration management programs will only be developed and used if the facility requests and funds the activity through a specific charge account. The Tritium Science and Engineering Facility Management Group stated it is working on a Group-wide configuration management program, but there is no specific configuration management program at the present.
A contractor provided design support for facility modifications in conjunction with the project.
SFE was under contract from ESH-18 to perform four detailed tasks: (1) provide support to FSS, ESH-18, and operating Groups to evaluate and prioritize projects to correct deficiencies identified under the Laboratory's Waste Stream Characterization Program; (2) prepare preliminary design documents, in accordance with the Laboratory's Design Standards Manual, for piping, plumbing, and mechanical modifications to Laboratory buildings and wastewater systems for selected corrective actions and submit documents for finalization and approval to FSS and ESH-18 representatives; (3) in conjunction with FSS and ESH-18 personnel, provide field direction, observation, and verification of the adequacy of constructed modifications; and (4) provide other support as may be required to meet Waste Stream Characterization and NPDES Permit regulatory requirements related to non-complying waste streams and elimination of outfalls.
FSS-6 normally performs design reviews for facility modifications and construction projects. ESH-18, in consultation with JCI and FSS-9, made a decision not to utilize the design and project services of FSS-6 for the Waste Stream Corrections Project.
Electrical safety has been a concern within the Department of Energy, but there are no Departmental requirements for contractors to have an electrical safety program.
Electrical safety in the DOE complex has always been of considerable concern. A large number of electrical occurrences in 1992 prompted DOE to initiate a special task force to assess electrical safety throughout all its contractor sites. Several outcomes of that initiative directly or indirectly influenced electrical safety.
The information in these three documents offers the basis for investigating electrical accidents within the DOE. The information is DOE-specific; however, it is only guidance, because there are no Departmental requirements for contractors to develop an electrical safety program. Accident issues relating to electrical safety in the DOE complex can be readily compared to issues raised in these three documents. The documents serve as sound guidance for objectively ascertaining how electrical safety issues play a role in the events leading up to and following an accident. They also provide guidance in developing the analysis of facts, developing the findings, and determining judgments of need.
There was no formal guidance or written procedures for safely providing temporary power by portable generator.
The Board examined the issue of electrical safety for activities before, during, and after the accident. Factual accounts of events, procedures (or lack thereof), training, implementation of training or procedures and processes, and the interaction of safety (either JCI or LANL) were reviewed.
Formal guidance or written procedures do not exist to direct JCI Maintenance on how to evaluate, size, and safely provide temporary power by portable generator to sites that have experienced an unscheduled power outage. Formal guidance or written procedures do not exist to direct JCI maintenance in identifying the critical power needs that exist during the re-energization of a building being provided with temporary power from a portable generator.
It was recognized by LANL personnel that the effluent treatment system was not on the emergency power system. Emergency power procedures or plans were not developed or available to determine what would be needed to maintain the effluent treatment system in a safe condition during prolonged outages. For the TSFF, some critical emergency power needs were identified, such as power for the exhaust fans. However, not all critical systems were identified.
The JCI Utilities Power Control Section (UPCS) responded to the accident at Building TA-21-209 in accordance with formal procedures. However, the investigation revealed that emergency response by JCI UPCS takes a minimum of one hour during non-standard working hours in the event of an unexpected power loss.
A complete, formally written, comprehensive electrical safety program for LANL or JCI does not exist, although multiple components of a program have been developed and successfully implemented. LANL has defined and/or designated some elements of the program, such as an "Authority Having Jurisdiction," electrical safety inspections, and energized work permits, as required to be included in a programmatic planning document. However, this document should also include descriptions of the purpose, scope, ownership, objectives, responsibilities, interfaces, and implementation guidance for those elements.
Electrical safety training for the accident victim and other non-electrical crafts personnel was not conducted regarding safety-related work practices to recognize the electrical hazards from accidental contact (direct or indirect, above or below ground, passing through or near the job site). Additionally, the required use of electrical personal protective equipment was not procedure-driven for JCI employees who use jackhammers in work areas where the exact location of underground electric lines is unknown.
No determination was made as to whether the workplace contained hazards from electrical power circuits.
Before beginning work, the JCI ES&H personnel, the supervisor, or the foreman for the work at Building TA-21-209 did not ascertain by inquiry, direct observation, drawing review, physical walkthrough of the site, or instruments whether any part of an energized electric power circuit, exposed or concealed, could bring any person, tool, or machine into physical contact with the electrical power circuit.
Two previous incidents of electrical contact during concrete cutting led to corrective actions, which were not completed.
Occurrence report ALO-LA-LANL-HRL-1994-0004 involves two incidents of concrete cutting and penetrating energized cables at LANL Buildings TA-43-1 (October 26, 1994) and TA-46-161 (January 9, 1995). Based on the occurrence report and root cause analysis, two corrective actions were identified: (1) develop a JCI concrete sawing safety procedure(s) and provide personnel training, and (2) establish personal protective equipment requirements during concrete sawing. The referenced occurrence report was closed and finalized with applicable signatures. However, corrective actions to resolve all electrical safety issues discovered in the two incidents were not tracked by LANL to closure and therefore, not completed.
Because of these prior accidents, JCI changed its policy for the use of personal protective equipment when cutting concrete, but did not incorporate this change in its procedures or training. JCI did not implement the corrective action lessons learned from other similar reported incidents that required the preparation of procedures and improved training in the use of electrical personal protective equipment for cutting and/or jackhammering concrete or soil (Table 2-1). Because these procedures were not written, JCI did not provide personal protective equipment training to each employee in accordance with 29 CFR 1910.132 (f) (1-4) or JCI Procedure 12-29-040.
Table 2-1. Previously Reported Electrical Incidents
Precursor Electrical Safety DOE Order 5000.3B Reported Occurrences | |
|
Occurrence Report |
Activity |
|
· ALO-LA-LANL-TA55-1991-0027 Occurrence date August 6, 1991 |
· Masonry Saw Cuts Live Electrical Line |
|
· ALO-LA-LANL-ESHSUPT-1992-0003 Occurrence date March 6, 1992 |
· Hand Drill Cuts Live Electrical Line |
|
· ALO-LA-LANL-TRITFACILIS-1994- 0003 Occurrence date February 25, 1994 |
· Hand Drill Cuts Live Electrical Line |
|
· ALO-LA-LANL-HRL-1994-0004 Occurrence date October 26, 1994 |
· Masonry Saw Cuts Live Electrical Line |
|
· ALO-LA-LANL-HRL-1994-0004 Occurrence date January 9, 1995 (Involves TA-46-161) |
· Masonry Saw Cuts Live Electrical Line |
The cable conduit did not conform to specifications.
The original construction drawings and specifications for the conduit holding the 13.2 kV power feeder to Building TA-21-209 were reviewed. Specifications called for conduit of "rigid steel." The actual conduit used in the installation of the underground power feeder was made from an asphalt-impregnated fibrous material. The original specifications also required concrete encasement of the conduit, and this was incorporated into the final installation (Figure 2-7). Further, the electrical design portion of the SFE preliminary design work for Waste Stream Corrections did not comply with the design requirements of DOE Order 6430.1A. Finally, the work package for the Waste Stream Corrections Project was not supported with complete electrical engineering system design drawings or documentation.
Safety inspections of maintenance activities are not routinely performed.
The Board reviewed safety inspections for maintenance activities conducted by JCI, as well as pertinent JCI and LANL work forms and manuals related to electrical safety. JCI Safety and JCI Maintenance do not have a defined process to formally schedule safety inspections of maintenance activities. Many JCI safety inspections of maintenance activities are provided only as they are encountered by JCI Safety personnel in the performance of other duties. The JCI Roads and Grounds Pre-Job Safety Checklist does not address electrical hazards. In addition, the LANL "Small Job Ticket" and "Work Ticket" forms address electrical hazards in the ES&H review sections, only where the voltage exceeds 480 volts. The JCI ES&H Manual contains a "Pertinent Safety Sections" matrix. This matrix identifies different safety procedure sections of the manual and indicates the different crafts that require the use and knowledge of particular safety procedures and equipment. Many crafts persons, including masonry workers, are not included on the matrix for personal protective equipment and/or required to have electrical safety training.
The accident interrupted the power supply to the building. The public address system was not operational after the accident.
Fault current from line to ground at the time of the accident was calculated by JCI Utilities Power Control Section to be a maximum of 2600 amperes. In-line fuse links for phase A (contacted during the accident) vaporized on the utility pole outside Building TA-21-209 at 9:34 a.m. due to the magnitude of the fault. An electrical flash occurred from the vaporization of the phase A fuse link, resulting in a phase-to-phase fault. This caused phase B and C fuse links to clear and open within 244 milliseconds (Figure 2-8).
The public address system at Building TA-21-209 is not connected to emergency power (uninterruptible power source or generator) and was not operational after the power was interrupted due to the accident.
The accident victim was not using electrical personal protective equipment.
The accident victim at Building TA-21-209 was not using electrical personal protective equipment, such as rubber dielectric gloves, at the time of the accident on January 17, 1996. 29 CFR 1926.416(a)(3) requires that, in work areas where the exact location of underground electric power lines is unknown, employees using jackhammers, bars, or other hand tools that may contact an energized power line shall be provided with insulated protective gloves. Although not used during the accident, rubber dielectric gloves were used as electrical personal
Figure 2-7
Figure 2-8
protective equipment by the accident victim while he performed the concrete cutting work on January 16, 1996, at Building TA-21-209. However, outer leather gloves were not worn to prevent damage to the dielectric gloves.
JCI ES&H Manual procedure 12-25-008 "PPE For Electrical Work" (rev. June 17, 1994) under section 2.0.1 requires:
29 CFR 1910.137 (July 1, 1994) requires that rubber insulating personal protective equipment gloves be tested before first issue and every six months thereafter. The rubber insulating gloves worn by the accident victim while concrete cutting were last tested at 20 kV with a test date stamp of October 19, 1992. The JCI ES&H Manual nine-month rubber glove testing requirement was violated by JCI Maintenance. The JCI ES&H Manual 12-25-008 procedure, with regard to the nine-month rubber glove retest intervals, does not comply with the six-month testing interval requirement of 29 CFR 1910.137. In addition, JCI had no documented system for recalling personal protective equipment for retesting at planned intervals to meet requirements.
JCI ES&H Manual procedure 12-29-040, "PPE Training and Certification," describes how employees are to receive training on the identification of need, use, and care of personal protective equipment. JCI procedure 12-29-040 requires "Hands-on Training" for personal protective equipment and "When is Personal Protective Equipment Needed."
The electrical cable cut during the accident was identifiable by an underground utilities detector.
At the request of the Board, an underground utilities detector test was performed on January 25, 1996, to verify whether underground utilities can be located inside buildings. The test was witnessed by a member of the Board, as well as LANL and JCI personnel. The electronic utilities detector used in this test verified the presence of the 13.2 kV primary line that was penetrated during the accident on January 17, 1996. The readings on the detector when it was "swept" over the 13.2 kV line path, both through the concrete floor and directly over the excavated hole with the power lines exposed, were much higher than any "noise" readings due to the background sources inside Building TA-21-209.
The Board reviewed how emergency power was supplied to Building TA-21-209 following the accident. In providing temporary emergency generator power at Building TA-21-209, there was no emergency plan or procedure describing what critical power systems required temporary power. In addition, no plan or procedure describing what size generator was required, where and/or how to connect power, where to locate and ground the generator, how to introduce and route generator power cables into the building, or how long the building could be without power (i.e., for critical safety systems and/or freeze protection).
Policies and procedures relevant to the accident either did not exist or were not followed.
LANL and JCI have developed ES&H manuals that address DOE orders, Federal regulations, and standards. These manuals are recognized by, and applicable to, both organizations as official policy for performing work safely. They are also applicable to subcontractors contracted to perform work on all LANL projects and facilities.
There are no JCI or LANL policies or procedures for concrete cutting or for electrical safety involving concrete cutting operations, and therefore none were available for use on January 17, 1996, at Building TA-21-209.
Section 4.0(e) of JCI Procedure 12-22-006 (Rev. July 1995), "Excavations," requires that the JCI Utilities Department be contacted for location and marking of underground utilities prior to any excavation. JCI Utilities was not contacted for location of underground utilities prior to Waste Stream Corrections Project work at Building TA-21-209. However, on the morning of the accident, a JCI Utilities specialist was contacted and asked by the masonry foreman whether an excavation permit was required for excavation inside a building, specifically Fire Station #1. In relation to the Waste Stream Corrections Project, the JCI Utilities specialist indicated that, normally, a permit is not required for excavation inside a building, but if a requester wants one, a permit will be issued. JCI Utilities also indicated that the underground utilities detector is not reliable in locating utilities inside buildings. 29 CFR 1926.651 (B) requires the identification of buried utilities prior to any form of excavation. The intent of this regulation is to review drawings, physically examine the work site, or perform electrical measurements to determine whether electrical or other stored energy sources exist.
The JCI Utilities Power Control Section (UPCS) has developed job-specific procedures for all levels of electric utility work within the Section. Applicable UPCS procedures during the accident at Building TA-21-209 were implemented as written. JCI and LANL lockout/tagout procedures were exempt from being used on the 13.2 kV primary feeder into the basement of Building TA-21-209, because JCI UPCS has developed operating instructions satisfying JCI, LANL, and industry standards incorporating lockout/tagout (UOI 63-00-180, "Clearances"). Appropriate lockout/tagout actions by JCI UPCS personnel were implemented according to UPCS operating instructions during the de-energization and re-energization of the primary line feeder into the basement of Building TA-21-209 after the accident.
Last Modified: Friday, 28-Feb-97 10:09:00