The Accident Investigation Board focused on pre-accident work controls and management issues to determine the root causes of the accident.
The Board's analysis objectives were to identify and analyze root causes and factors resulting in the accident. The two main analysis objectives were (1) determining the most likely accident scenario leading up to the near fatal injury resulting from contacting a 13.2 kV electrical cable and associated response from facility and emergency medical personnel, and (2) analyzing management structure, policies, procedures, and common practices at LANL, its contractors, and the oversight of DOE Headquarters and field and area offices.
The first objective focused on the pre-event work control conditions and interactions of the cement mason tender, co-workers, foremen, and safety personnel during the excavation of a sump pit at Building TA-21-209. The second objective of the analysis was pursued to determine whether programmatic and procedural breakdowns resulted in the near-fatal accident.
The Board used several analytical tools and techniques to analyze the causes and effects of the accident. Based on these analyses, the Board determined the contributing and root causes (deficiencies that, if corrected, would prevent recurrence of this and similar accidents) of the accident.
A causal factors analysis was performed.
The events and causal factors chart is used to determine the sequence of events leading to the accident and to show the relationship between events and associated causal factors. A causal factors analysis is shown in Table 3-1, and an events and causal factors chart is depicted in Figure 3-1. Causal factors that arose from analysis of the events and causal factors chart are as follows:
A barrier analysis and a change analysis were performed.
Barriers and controls are the physical and administrative constraints that prevent an unwanted flow of energy. The barrier and control analysis looks at the barriers that management control systems have provided between the hazards and the person, place, or equipment, and then evaluates the effectiveness and presence of those barriers. Table 3-2 is the barrier and control analysis, and Figure 3-2 summarizes the performance of these barriers and controls in place during the accident.
Change analysis was performed to address the changes or departure from normal processes that led to the accident. The change analysis confirmed the results of the earlier events and causal factors analysis and the barrier analysis. The results of the change analysis are summarized in Table 3-3.
Table 3-1
Figure 3-1
Figure 3-1 cont
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Table 3-2
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Figure 3-2
Table 3-3
Restoration of electrical power took precedence over accident scene preservation.
The accident scene was not preserved until the Board arrived on site because of the assessment that restoration of normal electrical service to Building TA-21-209 was time-critical. This judgment was based on plant conditions immediately after the accident, as opposed to a safety-related requirement stated in the facility operations safety analysis report or in an emergency recovery plan associated with the loss of power for Building TA-21-209.
The chain of custody for evidence was not maintained.
The physical evidence pertinent to the accident was not gathered, inventoried, or controlled in a disciplined, documented manner.
At 9:30 a.m., on the morning of the accident, the outside temperature was 36 degrees F. The relative humidity was 70 percent. The wind speed was 6.4 miles per hour, out of the east southeast, and the sky was clear. No precipitation had been recorded in the previous hour.
The Board concluded that the meteorological conditions at the time of the accident did not influence the actions taken by the workers or responders and, therefore, did not contribute to the accident.
Tests on floor and ground materials indicate that the accident victim might not have been able to tell by "feel" that he was hitting the conduit.
The Board requested that JCI perform compressive strength tests on the concrete surrounding the 13.2 kV electrical cable conduit, and representative samples of undisturbed tuff material from the excavation. The preparation of the test specimen and the physical testing of the prepared samples was witnessed by a Technical Advisor to the Board. The results of the tests are contained in JCI Document EMT D 96.095, "Concrete and Tuff Examinations." The report is included in Appendix G-2.
The tests show that the average compressive strength of the concrete was approximately 1,130 pounds per square inch (psi), which is relatively low for concrete. Typical compressive strength values for concrete, based on the application, range from 2,500 psi to 4,000 psi. The average compressive strength for the tuff was 320 psi.
The Board concluded that, while there was a significant difference in the compressive strength values of the concrete and tuff (1,130 vs 320), the difference could easily have been overlooked by the JCI mason tenders performing the excavation work because of the quantity of rubble and dust in the excavation.
The Board developed an integrated accident event matrix.
An integrated accident event matrix was developed based on interview transcripts, emergency communication records, utility records, and observations by Board members. The event sequence depicted in the matrix allowed the Board to identify and understand the actions taken by the workers, the interactions between the workers prior to the accident, and the interactions between the emergency responders and the victim after the accident occurred. The matrix is included in Appendix G-3.
The Laboratory uses a questionnaire that is sent to all new project initiators to identify projects that may pose environment, safety, and health risks.
LANL policies and procedures require all new projects to be assessed for ES&H concerns. LANL Administrative Requirement 1-10, "Environment, Safety, and Health Questionnaire," August 30, 1991, identifies projects requiring an ES&H Questionnaire, discusses completion of forms, defines the review process, and mandates line management's resolution of ES&H concerns arising from the subject matter expert review. Elements of the Facility Risk Management Group (ESH-3) are responsible for gathering and distributing the information to support the ES&H Questionnaire.
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 appointed by the ESH Division Director to focus on improvements to the ES&H Questionnaire process. In December 1993, the Quality Improvement Team issued a report on the Questionnaire process, "Environment, Safety, and Health Questionnaire— Continuous Quality Improvement Team Report," and made recommendations for improving the overall process, including improvements in methods for data gathering and turnaround times for reviews by subject matter experts.
Initiators of new projects at LANL are required to complete the Administrative Requirement 1-10 Questionnaire for projects that may include new construction and building modifications, ground breaking and soil disturbance, or involve high energy sources. Administrative Requirement 1-10 requires Facility Risk Management (ESH-3) to distribute the completed questionnaire to the ES&H Questionnaire Committee members for reviews related to siting, occupational safety, fire protection, industrial hygiene, and health physics. The Committee, made up of subject matter experts, is also required to determine whether Federal, state, or local statutes and regulations apply to the project.
If ES&H concerns are identified by the ES&H Questionnaire Committee, Administrative Requirement 1-10 requires ESH-3 to send the project initiator a listing of such concerns, and the appropriate personnel to be contacted for each concern. Administrative Requirement 1-10 requires project initiators to then contact the personnel listed, and develop and maintain a permanent file that documents the resolution of the concerns raised by the ES&H Questionnaire Committee. The permanent file is required to meet DOE audit requirements as contained in Administrative Requirement 1-5, "Environment, Safety, and Health Audits and Appraisals."
A project summary process was developed to supplement the questionnaire process.
In lieu of the formal ES&H Questionnaire process implemented under Administrative Requirement 1-10, ESH-3 now utilizes the ESH Identification process, which involves face-to-face interviews with project initiators to obtain ES&H-related project data. Data outputs, namely ESH Identification Project Summaries, are distributed to subject matter experts for review, and comments are returned to ESH-3. ESH-3 then forwards comments to the project initiator for planning purposes and to address any ES&H impacts that have been identified during the subject matter experts review process. The ESH Identification process is ad hoc, was never formally approved by LANL senior management, and is inconsistent with the management-approved Administrative Requirement 1-10 procedure.
The Waste Stream Corrections Project was initiated through the ESH Identification process. The Waste Stream Corrections Project Summary, ESH ID #95-0188, dated August 24, 1995, characterized the Waste Stream Corrections Project as a construction-related activity, and identified potential safety hazards, including explosive safety, industrial hygiene, operational safety, and radiological safety. A copy of the Waste Stream Corrections ESH Identification is included in Appendix G-4.
For this project, initial reviews identified some issues that remained unresolved.
The Board confirmed statements by Water Quality and Hydrology Group (ESH-18) project managers that attempts were made to resolve subject matter expert comments via telephone and memoranda communications. However, they did not maintain a permanent file for subject matter expert comment resolution and, as a result, substantive ES&H comments from one subject matter expert with direct Waste Stream Corrections Project concerns were not resolved prior to initiation of the Waste Stream Corrections Project.
A service request was initiated for the work to be performed under the Waste Stream Corrections Project. The stated purpose of the service request for the Waste Stream Corrections Project was to "Provide labor and materials to perform modifications to drain systems within Laboratory buildings as directed by ESH-18 and to correct environmental code deficiencies as recommended by the waste stream surveys. Schedules and manpower will be requested by the account controller as needed."
Technical and management review processes did not fully address all safety information and potential hazards.
Both the service request (September 21, 1995) and the ESH-3 technical review (September 28, 1995) performed as part of the ESH Identification process were completed prior to completion of subject matter expert reviews of the ESH Identification Project Summary (November 13, 1995), where subject matter experts' inputs regarding safety aspects of the project could have been utilized. The ESH-3 technical review identified only noise as a hazard. The review did not require excavation permits or other similar approvals, and it did not require "as-built drawings" to be developed for the project. A copy of the ESH-3 technical review of the Waste Stream Corrections Project is included in Appendix G-5.
Following the technical review by ESH-3, there is no evidence that the Waste Stream Corrections ESH Identification Project Summary was referenced to obtain additional safety information regarding potential hazards. Consequently, the Project Summary was not used as a living document for preparing, evaluating, and controlling the Waste Stream Corrections Project at any level.
On October 5, 1995, JCI transmitted a "Request for Davis-Bacon Determination" for the Waste Stream Corrections Project to the LAAO Determining Official. The transmittal stated in part, "Perform modifications to original waste systems within the Laboratory to correct environmental code deficiencies. This determination will be used on all Facility Management Unit Standing Work Orders for this work." The LAAO Davis-Bacon Determining Official returned the Standing Work Order to JCI on October 10, 1995, with a determination that the work was "uncovered."
During Board interviews, the LAAO Determining Official stated that, based upon the information provided by JCI in their October 5, 1995, submittal, the work was uncovered, and therefore would be considered a maintenance activity, not a construction activity. During interviews with the Board, the Determining Official stated that Standing Work Orders may only include maintenance activities. In addition, the Determining Official stated that the information provided by JCI was insufficient to determine the content of the proposed work and, if the Waste Stream Corrections Project had been properly described, his determination would have been the work was "covered" (as construction).
The project was performed as a series of small jobs.
In a November 1, 1995, memorandum to Distribution, "Update of ESH ID #95-0188, Waste Stream Corrections," ESH-3 stated that attempts were made to address the entire Waste Stream Corrections Project on a Laboratory-wide scale. Because of this wide-scale approach, several reviewers (subject matter experts) were concerned about the lack of detail contained in the ESH-3 data (ESH Identification Project Summary). The memorandum presented the ESH-18 plans for organizing the project to address subject matter expert concerns, including:
The memorandum further 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 ES&H 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."
Commitments regarding worker safety and implementation of project and configuration management programs were not fulfilled.
The Board determined that commitments made by ESH-18 in the memorandum were never fully implemented for the Waste Stream Corrections Project. As a result, the processes outlined in the commitments that were necessary to ensure an adequate level of worker safety were never fulfilled. The implementation of project and configuration management programs never occurred.
For the Waste Stream Corrections Project, ESH-18 developed its own tailored small job ticket/work ticket form entitled "FSS-9 Work Order," which had been in use since September 13, 1995, and contained each Waste Stream Corrections subtask to be accomplished by JCI. The ESH-18 tailored form included information relevant to the project, and focused predominantly on tracking project costs and NPDES permit compliance. However, the tailored form did not require ESH-3 to review and approve the proposed work activity with regard to ES&H implications. As a result, no ESH-3 reviews were conducted for the work to be accomplished under specific subtasks assigned to JCI.
No preliminary hazard analyses were conducted.
In addition to the ESH-3 reviews required as part of the small job ticket/work ticket review and approval process, the JCI ES&H Manual, Procedure 12-21-112, "Hazard Assessment Requirements," November 7, 1995, paragraph 5(b), requires JCI project supervisors to conduct a preliminary hazard analysis prior to any work conducted by JCI personnel, including maintenance. No preliminary hazard analyses were conducted for any phase of the Waste Stream Corrections Project, nor were any conducted for any JCI maintenance activity in either organization at any time.
Board interviews and reviews of archived records indicate that ESH-18 issued work packages to FSS-9 for work on Waste Stream Corrections subtasks before the subject matter experts completed their reviews of the WSC ES&H ID Project Summary. The ESH-3 memorandum of November 13, 1995, "Project Summary Closure Letter, ESH ID #95-0188," was used 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.
The normal work authorization and control process is depicted in the flow diagram included as Figure 3-3. The work authorization and control process utilized for the Waste Stream Corrections Project is depicted in the flow diagram included as Figure 3-4.
The Building Manager did not receive specific information regarding project scope and time frame.
ESH-18 provided the Board with information indicating 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 that they were approached by the Building Manager, and they informed him of their activities. Based upon their statements, the information provided to the Building Manager was non-specific regarding the Waste Stream Corrections Project. It did not include discussions of the project's scope or the possible time frame for the modifications to take place in Building TA-21-209. Building TA-21-209 facility management personnel have stated that they recall no contact by either ESH-18 or SFE regarding the work in the basement of Building TA-21-209.
On December 20, 1995, Waste Stream Corrections Project FMU70-009, one of 15 subtasks under Facility Management Unit 70, was released for work in the basement of Building TA-21-209, with a
Figure 3-3
Figure 3-4
target completion date of January 13, 1996. Concurrent with the release of the project for work, JCI pipefitters and masons scoped the job and laid out sites where excavations would be required to install sumps.
A lack of detailed design drawings allowed the excavation site to be placed directly over the electrical line.
The planned location of one sump appearing on preliminary design drawings interfered with a door in the basement of Building TA-21-209. One JCI pipefitter contacted an ESH-18 representative to request approval for a deviation to relocate the sump. The ESH-18 representative contacted the SFE representative responsible for that Waste Stream Corrections subtask, who approved the change by telephone. The approval to deviate from the preliminary design drawings, which had been informally approved by ESH-18, was documented by JCI on the FSS-9 Work Order Form. ESH-18 and SFE personnel believed they were providing a deviation approval to relocate the sump above grade. This approved deviation, however, placed the sump location directly over an energized 13.2 kV electrical cable. No other LANL ES&H or engineering organizations were contacted or involved in the decision processes for this deviation. The work in Building TA-21-209 was similar in nature to work being conducted at Fire Station #1, where sump relocation deviations were also requested. The Board has identified confusion among individuals and Groups involved in the Waste Stream Corrections Project as to which deviations were actually being approved. This confusion relates to the informality established by ESH-18 for the approval of deviations, the informal communications and deviation approvals by telephone, the failure to rely on a paper trail to document the deviation approval process, and a general failure to field-verify deviation requests prior to approval.
Laboratory Director's Policies and Program Requirements Documents provide guidance but do not assure that expectations are met sitewide.
Director's Policy 102, "Formality of Operations," defines the basic requirements for establishing formality in Laboratory operations. It states that the Laboratory will establish programs and procedures to control conduct of operations, and Laboratory personnel will be trained on the use of its procedures. It also states that management shall require all personnel to use applicable procedures and shall maintain oversight. The Board found multiple cases where the LANL management systems have failed to comply with this basic operating philosophy. The Director's Policies and Program Requirements Documents serve as guiding instructions, but fail to provide any assurance that these expectations are actually implemented on a sitewide basis.
There are no Laboratory-wide procedures implementing Laboratory requirements for configuration management or conduct of operations.
There are no Laboratory-wide operating procedures that implement the Program Requirements Documents for either configuration management or conduct of operations (a subset of which is work planning and control), and there is no plan to develop such procedures. Instead, Laboratory efforts have been focused on compliance activities, "necessary and sufficient" programs, and the Integrated Standards Based Management System. Development of Laboratory-wide operating procedures is viewed as a compliance-based activity by the Laboratory, and the Laboratory is instead focusing on developing the new performance-based systems. With the development of the Integrated Standards Based Management System program and previous efforts, resources have been diverted from the existing procedures program. The result is that no Laboratory-wide implementing procedures for the conduct of operations and configuration management Program Requirements Documents have been issued.
The existence of the Director's Policies and Program Requirements Documents does not assure that these programs are actually implemented at the facility level. By LANL management's inaction to issue any sitewide operating procedures, management has effectively allowed the requirements and expectations identified in the Director's Policies to remain in the book instead of implementing them in the facilities.
Administrative Requirements are not up to date and are not uniformly implemented.
Problems were also noted concerning the Administrative Requirements. The Administrative Requirements do not reflect the reorganization of the Laboratory, which took place nearly three years ago. Because of this, the responsibilities and authorities of the various organizations are in question. LANL management has allowed Laboratory personnel to ignore or change the requirements without revising the applicable documented procedures (e.g., ESH-3 did not follow Administrative Requirement 1-10; ESH-18 began work prior to receiving an ESH final review; ESH-18, in coordination with Operations and Maintenance Services and JCI, developed a tailored work control form in lieu of approved work tickets/small job tickets).
Discrepancies involving the implementation of several Administrative Requirements, as well as the use of Standing Work Orders, were examined and analyzed by the Board. Administrative Requirement 1-10, "Environment, Safety, and Health Questionnaire," requires an assessment of all new projects for ES&H concerns. It also describes the process to be used to complete the forms. Personnel interviews and a review of the process indicated that ESH-3 has elected to utilize a new, informal process and procedures for ES&H hazard identification and forgo the use of Administrative Requirement 1-10. ESH-3 management has recognized this deviation from the defined, documented Administrative Requirement process and has allowed this condition to continue without requiring a formal procedure revision. A significant deficiency in the new informal procedures is that it does not address the actions to resolve the ES&H comments and concerns of subject matter experts. Failure of management to require its staff to use formal, approved procedures contributed to the incomplete closure of identified safety concerns with the Waste Stream Corrections Project.
An ES&H review at the early stage in the Waste Stream Corrections Project was very limited. The detailed facility and tasks hazards were not adequately identified in Waste Stream Corrections Project Summaries at this stage. Yet for a Standing Work Order, the ES&H reviews are based on the information provided in these project summaries. Further, the broad nature of the Standing Work Order format does not permit the detailed work activities to be described. Because of this process, ES&H reviews are being completed without adequate understanding of the specific hazards associated with the jobs.
The Board disagrees with the site's decision to treat the excavation work as a routine, non-complex task with minimal review requirements.
Administrative Requirement 1-11, "Work Request Review," is the primary document that defines the LANL work control process. Administrative Requirement 1-11 provides the definition of a Standing Work Order. The purpose of Standing Work Orders is to allow routine activities to be authorized, funded, and performed expeditiously. Such activities include snow removal, lubrication, and relamping. Standing Work Orders were not designed for performance of large maintenance tasks, facility modifications, or construction activities. A Standing Work Order is defined as a written work request for a defined period of time, for a specific scope, and that can be accomplished without a work ticket. Standing Work Orders are presently excluded from the ESH review requirements. The Board considers the use of Standing Work Orders to capture the complex, non-repetitive work covered in the Waste Stream Corrections Project as exceeding the intended use.
Personnel interviews and a review of other Standing Work Orders have indicated that Standing Work Orders are routinely used at LANL to accomplish complex activities. It is now routine for small job tickets and work tickets to be written as a Standing Work Order. Because Standing Work Orders are being used to complete more complex tasks, the ESH Identification process is being used improperly to capture some of the potential ES&H concerns that may result from the activity. The use of Standing Work Orders appears to be excessive and may circumvent the purposes of adequate ES&H reviews.
There are 1,028 Standing Work Orders currently in effect at LANL. These Standing Work Orders give blanket approval for all types of facility maintenance and modification activities. A review of the active Standing Work Orders indicate that they have been written for: (1) unspecified maintenance and modification actions for both nuclear and non-nuclear facilities; (2) security system upgrades; (3) asbestos abatement program work (a job in which a 480 V line was intentionally cut without using lockout/tagout); (4) electrical breaker maintenance; (5) correcting electrical deficiencies; and (6) exhaust stack monitoring system repairs and upgrades. Based on the lack of detail contained in the Standing Work Order description and the complexity of the task assigned to the Waste Stream Corrections Standing Work Order, a review of all Standing Work Orders is warranted.
Most of the major DOE sites (including Savannah River, Rocky Flats, and Hanford) have shifted away from using Standing Work Orders. The main reason for this shift is that the job conditions routinely do not meet the descriptions as annotated in the Standing Work Order. This results in either stop-work actions or unacceptable work conditions. Therefore, the sites have elected to use unique work orders for even what appear to be "routine" jobs.
Deviation from procedures appears to be an accepted practice at the site.
The only forms identified in Administrative Requirement 1-11 to be used for the work request reviews are the small job ticket/work ticket (Form 1336), the service request (Form 1337), and the service request supplement (Form 1338). There is no ESH-3 procedure that describes the method to be used to review these forms. Fabrication and utilization of alternate forms is not recognized by the Administrative Requirement. Several organizations (ESH-18, FSS-6, FSS-9, and JCI) were involved in the discussions about the generation of a new form, but none of them recognized that this activity was outside the approved work control process. There is an apparent attitude, as revealed by the numerous procedures violations, that deviation from procedures is an accepted practice at LANL. Director's Policy 102, "Formality of Operations," requires that personnel operate by approved procedures and, if necessary, formally revise those procedures. Acceptance of this philosophy by LANL personnel was not observed by the Board.
The site's determination that excavation permits are not needed for interior work led to incomplete recognition of hazards.
Although LANL Administrative Requirement 1-12 clearly requires that excavation permits be obtained prior to any ground-breaking activities inside or outside buildings, a longstanding and widespread interpretation generally limits requests for excavation and penetration permits to those areas located outside buildings. Board interviews with both LANL and JCI personnel found that the interpretation was common in both organizations, and knowledge of the specific requirements of Administrative Requirement 1-12 appeared limited. As a result of this incorrect interpretation, both LANL and JCI personnel failed to take appropriate measures to: (1) determine the locations of dangerous underground facilities, (2) prevent the exposure of employees to hazards associated with those facilities, and (3) conduct work in a manner designed to avoid damage to dangerous facilities, prior to the electrical shock accident at Building TA-21-209, as required by 29 CFR 1926.956(c).
29 CFR 1926.651(b) requires the employer to determine the estimated location of utility installations such as sewer, telephone, fuel, electric, and water lines, or any other underground installations prior to opening an excavation. Although the Board identified several instances where JCI and LANL personnel had questioned the need for an excavation permit for work in Building TA-21-209, it does not appear that Administrative Requirement 1-12 was consulted for guidance. Additionally, pre-accident telephone inquiries from the field to JCI organizations were documented and focused on the need for excavation permits. Witness statements indicate that callers were verbally informed that an excavation permit was not required for excavation activity inside buildings. As a result, LANL and JCI personnel failed to take appropriate action to determine whether utilities were present in the vicinity of the excavation in Building TA-21-209 where the electrical accident occurred.
Other issues involve utility location surveys, safety reviews, and use of design drawings.
Administrative Requirement 1-12, "Excavation and Fill Permit Review," details the procedures necessary to obtain and complete the ES&H review of all excavation/fill permits. It defines excavation as "any ground breaking with power equipment or hand tools." It also defines an excavation permit as "Permit required to begin any excavation (for example, exploratory boring, new facility construction, utility repair or installation, or penetration of slabs on grade inside buildings) or fill project on DOE property." It also describes the review process to be used in approving excavation permits. It states that an excavation permit is obtained from the Utility Services branch of JCI.
The actions that are performed by JCI are governed by Standard Practice Instruction 70-10-001, which involves performing a utility survey. However, there is no specific requirement for any review of the engineering drawings associated with the facility or work location, or for any walkdown of the facility to physically observe piping and electrical penetrations. Concurrent with the JCI utility survey, the excavation permit request is to be faxed to ESH-3 in order to undergo the required ES&H review.
Under Administrative Requirement 1-12, ESH-3 is responsible for distributing the permit through the "appropriate ES&H Groups." However, this distribution is not defined and is left up to the judgment of the ESH-3 staff. Administrative Requirement 1-12 states that the purpose of the ES&H review is to "ensure the proposed activity does not infringe on areas regulated or protected by the EPA or conflict with DOE orders or Federal and state statutes and regulations." While this statement does not preclude the use of inside excavation permits, it does indicate that the ES&H review process is focused toward the impacts that the excavation may have on outside areas. At the completion of the ES&H review, the permit is then returned to JCI. Administrative Requirement 1-12 states that "Upon completion of the review, the support services contractor returns the permit, either with comments necessary to proceed with the project, or with a disapproval." This procedure fails to provide a logical flow for completing reviews.
Procedures governing the use of the JCI excavation permit review process are: (1) JCI ES&H Manual Procedure #12-22-006, "Excavations," Rev. 3, dated July 27, 1995; and (2) JCI Standard Practice Instruction, 80-10-011, Excavation/Trenching: Protective Systems and Safety." While JCI ES&H Manual Procedure #12-22-006 does not prohibit excavation permits for inside work, all references made to work conditions are associated with outside excavation. The procedure does not specifically require excavation permits for masonry cutting of facility structures when it occurs inside. While the source of the widespread misconception that excavation permits are not required for inside work was not identified, the existence of this widespread belief was confirmed by the Board. Definitive improvements are needed in the methods that should be utilized to detect buried utilities, and clarification of the excavation permit policy is warranted.
Administrative Requirement 1-14, "ES&H Facility Design Review," specifies the ES&H facility design review procedures. The design review process described in Administrative Requirement 1-14 was not used to evaluate the quality of facility modifications being made by the Waste Stream Corrections Project. Failure to perform this review was associated with the fact that the Waste Stream Corrections Project was improperly classified as a maintenance activity, instead of a construction activity.
The contractor's safety review process is not documented.
JCI Standard Practice Instruction 12-02-010, "Work Order Review," describes the process that the JCI Safety Group must use to review work orders. This process establishes a single point of contact in JCI (Work Order Review Coordinator) who is responsible for ensuring that all work receives an adequate ES&H review. The process described in Standard Practice Instruction 12-02-010 is not being accomplished. Instead, different work packages are receiving different levels of review. For instance, all construction packages are sent to JCI Safety for review; however, none of the LANL Standing Work Orders are sent to JCI Safety. There is no procedure describing the logical flow of all work packages through the JCI system. This has resulted in an undocumented JCI safety review process. This also illustrates another case that is recognized by management that personnel are not complying with established procedures.
Communication of sitewide stop-work orders is not effective.
The Board became aware of cases in which a stop-work order issued by the Laboratory following the accident was not being observed. Some penetration work that had not undergone the specified ES&H review was still being performed. In addition, the LAAO Facility Representatives found multiple cases in which JCI workers were not aware of the stop-work order that was in effect.
Director's Policy 116 provides information associated with stop-work orders and restart actions. However, it does not provide any detailed information on how sitewide stop-work orders are communicated to all employees. The method that LANL management used to communicate the stop-work order following the accident at Building TA-21-209 was ineffective. This process utilized a master management e-mail system. This is an open-loop system. The stop-work order was sent to all Group leaders and above. There was no response required or verification that the order was received. It is the opinion of the Board that communication of vital information should require a formal confirmation that the order was received in the appropriate personnel. The Board also found that the Director's Policy 116 requirement to log this stop-work order in the Division Leader's office was not followed by any of the four divisions that were checked.
The interface between various organizations with work control responsibilities is not well defined.
The work control process at LANL is governed by multiple procedures. The interface among the different organizations (requestor; Facilities, Security, and Safeguards; and JCI) is not well defined. ES&H personnel incorrectly assumed that by inserting the comment "SSS-safety" in the ES&H review section of the Standing Work Order, JCI Safety would perform a task-level ES&H review. The responsibilities of the different organizations is also not well defined. The LANL work control process is complicated and detached. Because of a lack of process description and ineffective communication among the different organizations, these assumptions and expectations for ES&H reviews were not properly relayed. A single, comprehensive human-engineered process that defines the flow and responsibilities of each organization in LANL and JCI should be developed.
Configuration management is an optional process at the Laboratory.
The LANL configuration management program represents an optional process. There is no document describing the criteria for identifying designated facilities. The Program Requirements Document for configuration management also mentions the application of a graded approach. The Tritium Science Engineering Group's Review Board Procedure (dated March 28, 1995) describes a configuration management plan for its facilities. If used properly, this plan should maintain control of the facility configuration. However, the plan was not used for any of the work associated with the Waste Stream Corrections Project modifications.
Only preliminary design drawings were prepared for the work that led to the accident.
Interviews and memoranda confirm that the documents provided by SFE were preliminary designs. The drawings had no dimensions or approvals. While there was no specific tasking of SFE to develop and submit work packages for the jobs, "Scope of Work" documents were submitted to ESH-18. These scope-of-work documents were attached directly to the ESH-18-generated work order forms. The resulting work packages were reviewed by the ESH-18 technical reviewer and passed to JCI through FSS-9. The ESH-18 review and subsequent field validations focused on whether the modifications corrected the identified WSC deficiency, and did not provide an engineering design review as required by Administrative Requirement 1-14, "ESH Facility Design Review," or Program Requirements Document 110-01.0, "Quality Assurance Management Plan." FSS-9 only passed the information to JCI and did not perform an engineering review to determine the adequacy of the information provided.
When the work packages were received by JCI via FSS-9, they were considered "approved for construction." Because this construction work was being accomplished by a maintenance process, there was no mechanism in place to capture the facility design modifications that were being done to this Category 3 nuclear facility. There was no plan within ESH-18, FSS-9, JCI, or SFE to update the as-built drawings for this facility. The result was a loss of configuration control. Modifications to facility systems were not being captured or analyzed against the existing safety analysis report or other system design documents.
Because these designs were considered preliminary by SFE, no specific construction information was provided. SFE has stated that its piping design work was done to support plumbing code. However, there was no assurance that any of the sump pump installations would have complied with electrical, plumbing, or uniform building codes, because of the lack of specification associated with materials and installation.
To save on time and cost, control of the work was shifted to a group that had fewer requirements for formality and documentation.
Based on testimony and the review of documents, the Board has determined that expediency was the primary driver for shifting the work from FSS-6 to FSS-9. Work could be accomplished through FSS-9 by verbal field direction and would only require hand sketches. The FSS-6 process had a higher degree of formality and would require more elaborate documentation, thus increasing costs and extending completion time. When the decision was made not to utilize FSS-6, ESH-18 assumed the responsibility for performing or ensuring the completion of any design reviews associated with the Waste Stream Corrections Project—an action it was not prepared to perform.
The Board examined the issue of electrical safety for activities leading up to, during, and following the accident. Analyses of events, procedures (or lack thereof), training, implementation of training on procedures and processes, and interactions of safety activities (either at JCI or LANL) were examined.
There were no documented procedures for safely providing temporary power by portable generator.
Building TA-21-209 personnel did not have a documented procedure for restoring power by means of temporary generators and defining critical power system needs in the case of unexpected power loss to the building. The determination of where to connect temporary generator power into the facility electrical grid resulted from Group discussions between various LANL and JCI personnel on site immediately after the accident. Critical power systems were verbally defined by Building TA-21-209 personnel on site. These field determinations were made by individuals with several years' experience and knowledge of the building requirements. The power requirements of the building's critical systems were not previously known by any personnel on site or formally documented in an emergency plan or procedure.
Some safety concerns were noted in how the generator was connected and grounded.
JCI maintenance personnel delivered the highest capacity temporary generator (350 kilowatts) available to provide temporary electrical power to Building TA-21-209. Welding cables were used to provide power from the temporary generator to the transformer secondary power bus without any site personnel's specific knowledge of the cable's ampacity rating. Cables were introduced into the building through an existing penetration in the west wall (Figure 3-5), draped over existing cable trays (Figure 3-6), and draped over an existing chain link fence up to the transformer secondary load bus without regard for cable damage. Grounding of the generator was accomplished through connection to an existing ground pad adjacent to hydrogen gas cylinders and a nearby sign indicating ?Danger Hydrogen' (Figures 3-7 and 3-8). JCI personnel verified that the building transformer secondary power bus was disconnected from the switchbox, and the 13.2 kV electrical line was isolated from the building transformer and exterior utility pole (Figure 3-9). A proximity meter was used to test for any presence of voltage on the secondary circuit of the building transformer before initializing connection of the temporary generator.
Emergency power demand requirements were not known.
JCI maintenance personnel made all connections necessary to provide generator power to Building TA-21-209. Since emergency power demand requirements were not known, the current for initial generator startup was preset at 80 amperes. The generator was then adjusted to meet critical power system requirements. Critical power systems were powered up by energizing one circuit at a time. During routine generator maintenance and refueling, the building system was initially de-energized and re-energized at 80 amperes and then adjusted as necessary to full power requirements. There were no instructions or procedures for operating the generator. This work was accomplished safely by JCI maintenance personnel because of their several years' experience and their knowledge of portable generators.
The Board's primary concerns regarding the 480-volt secondary system re-energization after the accident were:
· Decision makers in the field had no guidance regarding the available fault current on the system or on the main breaker of the generator set.
Figure 3-5.
Figure 3-6.
Figure 3-7.
Figure 3-8.
Figure 3-9.
While the hazards associated with restoring power were kept at a low level through the experience and knowledge of the JCI and LANL personnel at the site, the capability to assure a higher level of safety while restoring power would have been facilitated by an established emergency power requirements plan. This issue should also be addressed at any other LANL buildings/facilities that may need temporary emergency power to satisfy critical system power requirements. In this particular case, JCI and LANL staff who had intimate knowledge of the building system were available in a short period. This may not always be the case.
Due to budget cuts, the electrical emergency crew cannot respond promptly to outages during off-shifts.
The response time for the JCI Utilities Power Control Section (UPCS) was approximately five minutes after notification of the power outage at Building TA-21-209. During an unscheduled outage of the electrical utilities distribution system, the response time for the UPCS is critically important. Timely site evaluation of the system conditions will ensure the best response for dealing with safety, facility, and re-energization. During the Board's investigation, it was discovered that, due to budget cutbacks, response time during non-standard working hours (4:00 p.m. to 7:30 a.m.) is a minimum of one hour due to the absence of a trouble crew on off-shifts. This has been the case for the past six months. This time is critical in controlling and containing hazards associated with the loss of electrical power to LANL buildings.
The site lacks a formal, comprehensive electrical safety program.
The lack of a formal, comprehensive electrical safety program to direct and plan electrical safety at LANL and JCI results in a "fire-fighting" approach to solving electrical safety problems. Beneficial development and utilization of a programmatic planning document allows for the incorporation of purpose; scope; ownership; authorities; interfaces; accountabilities; training; order, standard, and regulation implementation; and specific procedural documents to further guide the electrical safety process. Both the "DOE Report on the Electrical Safety Task Group" and the "DOE Electrical Safety Guidelines" provide for the development of a comprehensive electrical safety program at each DOE contractor site. The DOE has identified and provided a "Model Electrical Safety Program" and delivered seminars to further assist contractors in developing their own programs. It is the Board's understanding that LANL management began the process of developing an electrical safety program document, but redirected its efforts in dealing with electrical safety issues prior to completing the document. The appraisal report for the "Pilot Oversight Program for Line Environment, Safety and Health Management at Los Alamos National Laboratory," dated January 1996, further identifies the absence of a formal, overall electrical safety program document. Additionally, LANL's Industrial Hygiene and Safety Group (ESH-5) self-assessment effort identified this need in 1993. The LANL memo, dated January 14, 1993, identifying the final approval of Action Plan #4 for the Tiger Team findings (TSA-4) WS.4-3 (H1/C1) Cat. II, indicated "...Establish and Implement an Electrical Standards policy/program..." The required completion date was indicated as March 31, 1993. LANL Administrative Requirement 7-1, "Electrical Safety," is recognized by the Groups responsible for its implementation as "old," "out of compliance," and "needs revision." This policy does not adequately reference the electrical safety program elements that are currently required or being implemented.
The training provided is insufficient to prevent electrical accidents involving unqualified persons.
Incorporation of the 29 CFR 1910.333-.335, Safety-Related Work Practices, into the manner in which LANL and JCI train "unqualified persons" has not been adequately addressed. While the requirements of this OSHA electrical safety standard are being addressed for "qualified workers," serious electrical accidents are occurring involving "unqualified persons." LANL's self-assessment in January 1993 identified as one of its action needs to "Prepare a written guide detailing specific requirements and practical application of 29 CFR 1910, Subpart S, and 29 CFR 1926, Subparts K and V." There is no record that this guide was prepared, issued, or implemented.
The lack of an excavation permit allowed the electrical hazard to go unrecognized.
29 CFR 1926.416(a)(3) directs the employer, prior to work, to "...ascertain by inquiry or direct observation, or by instruments, whether any part of an energized electric power circuit, exposed or concealed, is so located that the performance of the work may bring any person, tool or machine into physical or electrical contact with the electric power circuit. The employer shall post and maintain proper warning signs where such a circuit exists. The employer shall advise employees of the location of such lines, the hazards involved, and the protective measures to be taken." This process would be supported by the JCI excavation permit procedure "Excavations-12-22-006, dated July 27, 1995" and the JCI excavation permit administered by the JCI Utilities Department. An excavation permit for the Waste Stream Corrections work at Building TA-21-209 was never issued, thus allowing the electrical hazard to go unrecognized. If the as-built drawings for Building TA-21-209 had been reviewed as part of the process for acquiring a permit, the location of underground utilities might have been determined. Appendix G-6 depicts the "as-built" facility drawing available from LANL's Facilities Support Operations Group (FSS-3) archives.
The identification of electrical hazards and the use and appropriate application of personal protective equipment to mitigate known or unknown hazards have been addressed in 29 CFR 1910.331 through .335, 29 CFR 1910.132, 29 CFR 1926.416, and 29 CFR 1910.651. These requirements are very specific in their meaning and intent. The recognition of shock hazards was additionally acknowledged by a JCI safety alert memo, dated March 10, 1992. The Board recognizes significant effort in meeting these requirements for "qualified persons." The applications to "unqualified persons" have not received the same attention. The OSHA standard requirements are not being met. JCI did not comply with this procedure. There is no evidence that the accident victim had ever been trained or certified according to JCI Procedure 12-29-040.
Corrective actions for electrical safety deficiencies are not always communicated or verified.
DOE occurrence reporting requirements are derived from DOE Order 5000.3B. The administration of this process at LANL appears to be well planned. However, tracking corrective action completion, and the understanding of what organizations are involved as to ownership and implementation, failed in a particularly significant occurrence at LANL (ALO-LA-LANL-HRL-1994-0004). The importance of this occurrence is directly related to the accident being investigated by the Board. Interaction between LANL and JCI management appears to need significant improvement in both communication and documentation. Verbal confirmations are the normal medium by which corrective action issues are closed. Specific identification of the responsible party did not occur in regard to the accident being investigated. The involvement of electrical safety specialists in dealing with electrical safety corrective actions, as well as the root cause analysis process, would enhance the effectiveness and quality of the occurrence reporting product.
Safety inspections of maintenance activities are not routinely performed.
JCI safety engineers responsible for inspection oversight maintenance work at LANL do not have a formal process for scheduling work that requires their inspection. Inspection schedules are based on an informal working agreement between the safety engineers and the maintenance schedulers, leaving the opportunity for work to be missed and safety issues to go unnoticed.
The drawings used to direct installation of electrical equipment were inadequate.
The SFE preliminary design drawings for the Waste Stream Corrections Project, which the JCI electricians in the field were to use for installing electrical equipment, did not reflect the requirements of DOE Order 6430.1A. The location of the circuit power source (power panel and circuit breaker number) was left to the electricians' judgment. The drawing for the Building TA-21-209 work reflected circuit breaker size, conduit size, and conductor size, but did not call out the equipment grounding conductor required by DOE Order 6430.1A. The order requirements exceed the National Electrical Code. This issue is important because of failures of the conduit system to provide an adequate ground path. The drawings simply directed the power to the "closest panel w/space." Decisions must rest with an engineer who has specific knowledge of the electrical system characteristics, in order to safely provide a finished installation.
Work documentation did not adequately address electrical hazards.
The recognition of electrical hazards can begin with the use of the appropriate work documentation in the pre-planning stages of a project. The LANL small job ticket or work ticket contains an ES&H review section. However, this section addresses electrical hazards only greater than 480 volts. 29 CFR 1910.333(a)(1) recognizes 50 volts or greater as hazardous, and requires the selection and use of safety-related work practices. The JCI Roads and Grounds Pre-Job Safety Checklist does not address electrical hazards at all. In both documents, electrical hazards are not adequately addressed.
The cable conduit did not conform to specifications.
Fault current at the time of the accident was calculated by JCI Utilities Power Control Section using generally approved methods. It was calculated at approximately 2,600 amperes at 13.2 kV. This value would estimate a worst-case analysis of current exposed to the accident victim at Building TA-21-209 on January 17, 1996. A review of the original construction drawings indicated that according to specifications, the conduit encasing the 13.2 kV electrical cable should have been rigid steel. However, the actual installation was an asphalt-impregnated fiber-based conduit. The steel conduit would have provided an additional barrier of protection against contacting the electrical cable.
The accident victim was not using electrical personal protective equipment.
Rubber dielectric gloves were used as electrical personal protective equipment while the accident victim performed concrete cutting work on January 16, 1996, at Building TA-21-209. However, the accident victim did not use these gloves during the jackhammer work on January 17, 1996, at Building TA-21-209. In addition, during the concrete cutting work, no leather protective gloves were worn over the dielectric gloves to prevent damage. JCI ES&H Manual procedure 12-25-008, "Personal Protective Equipment for Electrical Work" (rev. June 17, 1994), under Section 2.0.1 requires that:
29 CFR 1910.137 (July 1, 1994) requires rubber insulating gloves to be tested before first issue and every six months thereafter.
The rubber insulating gloves worn by the accident victim while cutting concrete on January 16, 1996, were tested at 20 kV with a test date stamp of October 19, 1992. The JCI ES&H Manual nine-month rubber glove testing requirements 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 29 CFR 1910.137 six-month testing interval requirement. In an appraisal report, dated January 1996, of the "Pilot Oversight Program for Line Environment, Safety and Health Management at LANL" (Assessment ID: LANL-PAD-95-01), a potential finding statement regarding JCI SPI 80-10-002 indicates inadequate implementation for periodic testing of rubber insulating gloves.
29 CFR 1926.416 (a)(3) requires that in work areas where the exact location of underground electric powerlines is unknown, employees using jackhammers, bars, or other hand tools which may contact a line shall be provided with insulated protective gloves. JCI ES&H Manual procedure 12-29-040, "Personal Protective Equipment Training & Certification," describes how employees are to be trained on the use and care of personal protective equipment. JCI Procedure 12-29-040 requires training for "Hands-on Training" of personal protective equipment and "When is Personal Protective Equipment Needed." JCI did not comply with this procedure. There is no evidence that the accident victim had ever been trained or certified according to Procedure 12-29-040. On the project on which the accident occurred, JCI was not in compliance with 29 CFR 1926.416 (a)(3).
The electrical cable cut during the accident was identifiable by an underground utilities detector.
On Thursday, January 25, 1996, at approximately 10:00 a.m., an underground utilities locator test was conducted at the accident site at Building TA-21-209. The locator tool used is a Power Line Detector, Model 50/60. The tool operates by detecting magnetic fields produced by current flowing through a live conductor. In previous statements made by those interviewed during the investigation, it was noted that this tool does not perform reliably inside buildings because of "noise" from magnetic fields produced by such things as power lines in walls, rebar in concrete, and interior lamps using power, all of which may cause the instrument to give inaccurate readings.
During the locator test indoors in the basement of Building TA-21-209, noise readings were present. However, when compared to locator tool readings at positions above the 13.2 kV electrical cable, above the concrete floor, and above exposed earth, it was obvious there was a magnetic field source dominating noise sources. These readings would have raised definite concern as to the existence of the underground power utility cable before excavation.
A second area in the basement of Building TA-21-209 that was marked for excavation was then monitored with the utilities locator tool. There was an operating pump motor and an electrical junction box nearby. High readings were measured by the locator tool, indicating either the existence of an underground utility and/or magnetic field noise generated by the pump motor and electrical junction box.
After the accident, the cable was appropriately isolated and re-energized.
The JCI Utilities Power Control Section (UPCS) has successfully developed and implemented utility operating instructions (UOI 63-00-180, "Clearances") satisfying JCI, LANL, and industry standards incorporating lockout/tagout requirements.
On January 17, 1996, following the electrical accident at Building TA-21-209, a JCI lineman isolated the 13.2 kV electrical cable. Clearance instructions require that clearance limits are to be used in conjunction with lock and clearance tags when isolating a circuit above 600 volts, to ensure that the circuit will not re-energize while working on it. Two clearance limits were used to isolate the removal of the 13.2 kV primary cutouts (blades) and circuit breaker. Cutouts were removed, phase lines were grounded, and a clearance limit tag was issued. The circuit breaker at the primary of the Building TA-21-209 transformer was "opened," grounded, locked, and issued a clearance limit tag.
Switching instructions for de-energization and re-energization of the 13.2 kV electrical cable incorporated all required safety procedures, including appropriate use of personal protective equipment by the lineman. Knowledge of applicable utility operating instructions by JCI UPCS line supervisors was evident.
In violation of procedures, no excavation permit was issued.
According to JCI ES&H Manual procedure 12-22-006, "Excavations," an approved excavation permit must be obtained and kept on site prior to any excavation work, except for emergencies as provided in JCI Standard Practice Instruction 70-10-001. This procedure was violated because an excavation permit was not issued. This JCI procedure was also violated in previous waste stream characterization projects where excavation permits were not issued and underground utilities were not located. JCI Procedure 12-22-006 and 29 CFR 1926.651 (B) require the identification of buried utilities prior to any form of excavation. JCI Utilities is the party responsible for these identification requirements. JCI Utilities was never contacted to locate buried utilities at Building TA-21-209 prior to the accident.
Corrective actions resulting from the occurrence reporting process were improperly closed.
There is no documentation that Occurrence Report ALO-LA-LANL-HRL-1994-0004 corrective actions were completed and implemented. The occurrence reporting process failed because certifying officials closed out corrective actions based on verbal confirmation. The final evaluation part of the occurrence reporting process did not take place.
Last Modified: Friday, 28-Feb-97 10:09:00