4.0 FINDINGS AND PROBABLE CAUSES

4.1 ACCIDENT SCENE PRESERVATION, EMERGENCY MEDICAL RESPONSE, AND INVESTIGATIVE READINESS Findings

  1. Employees are not encouraged to receive CPR training and certification or to get recertified.
  2. Employees were not knowledgeable about the indications for initiating CPR and about techniques of CPR.
  3. Lay rescuers demonstrated extreme bravery in proceeding with the rescue of the accident victim in the face of obvious danger.
  4. Lay rescuers did not positively ensure that all energy sources were de-energized before administering first aid.
  5. The current 911 system for LANL is not adequate to meet a demand of two or more calls at the same time.
  6. Emergency medical technician personnel did an exemplary job of transporting the accident victim as rapidly as possible to the Los Alamos Medical Center and in administering appropriate treatment on the scene and en route.
  7. Los Alamos Fire Department emergency medical technicians are not currently trained or certified in the administration of cardiac medications.
  8. LAAO did not require LANL personnel to preserve the scene of the accident until the Board arrived at the scene.
  9. The physical evidence pertinent to the accident was not gathered, inventoried, and controlled in a disciplined, documented manner.
  10. LAAO did not require JCI, LANL, and the Type B Accident Investigation Board to establish a documented chain of custody for the physical evidence pertinent to the accident.

Probable Causes

  1. The Los Alamos Fire Department's concern for the cost of training emergency medical technicians to administer cardiac medications versus the number of cardiac patients who would need such services has prevented the technicians from receiving this training.
  2. Resource constraints have reduced the capability of Protective Technologies-Los Alamos to receive 911 calls and radio dispatch assistance simultaneously.
  3. CPR training does not provide sufficient practice in the indicators of cardiac arrest and application of CPR techniques.
  4. Deficiencies in emergency response training exist in regard to positively identifying the absence or disconnection of stored energy sources prior to administering first aid.
  5. LAAO did not recognize the need to preserve and document the physical conditions of the accident scene.
  6. LAAO personnel were not trained in DOE accident investigation techniques, processes and procedures.
  7. There is no procedure requiring LAAO to train accident investigation team leaders.

4.2 ELECTRICAL SAFETY

Findings

  1. Emergency response time by the JCI Utilities Power Control Section is a minimum of one hour during non-standard working hours.
  2. A JCI job-specific procedure identifies the use of personal protective equipment to be used during jackhammering.
  3. Personal protective equipment training and certification, as prescribed in JCI ES&H Manual Procedure 12-29-040, provides for the basic (but not all) requirements of 29 CFR 1910.132 (f) (1-4).
  4. Safety training for the accident victim, as required by JCI ES&H Manual Procedure 12-29-040, was not completed prior to the accident.
  5. 29 CFR 1926.416 (a)(3) requirements were not met by JCI at the accident work site in Building TA-21-209.
  6. The JCI Utilities Power Control Section has developed formal Utility Operating Instructions, which were implemented accordingly by all JCI Utilities Power Control Section electrical workers on the day of the accident.
  7. The JCI Utilities Power Control Section has developed job-specific lockout/tagout procedures (UOI 63-00-180, "Clearances") for high-voltage work that satisfy industrial standards and which were appropriately implemented the day of the accident.
  8. The rubber gloves worn by the accident victim during concrete cutting work on January 16, 1996, at Building TA-21-209 did not comply with the JCI Procedure 12-25-008 or 29 CFR 1910.137 testing requirements for such gloves.
  9. The public address system in Building TA-21-209 is not connected to any form of uninterruptible power supply.
  10. The design drawings for the Waste Stream Corrections Project did not comply with the design requirements of DOE Order 6430.1A, Section 16.
  11. Adequate electrical engineering design support was not provided for the Waste Stream Corrections Project.
  12. LANL Occurrence Report ALO-LA-LANL-HRL-1994-0004 was officially closed without JCI completing the required corrective actions.
  13. The JCI Roads and Grounds Pre-Job Safety Checklist does not address electrical hazards.
  14. The LANL small job ticket/work ticket addresses electrical hazards in the ES&H review section only where the voltage exceeds 480 volts.

Probable Causes

  1. An emergency plan for critical power needs does not exist to provide guidance to JCI maintenance personnel responding to unscheduled power outages and providing temporary electric power by portable generators to meet building-critical needs.
  2. Backshift support for emergency electrical utilities service was eliminated because of funding.
  3. A formal, complete, comprehensive electrical safety program document for LANL or JCI is not in place.
  4. JCI did not recognize the need to prepare a procedure to reflect the requirements of 29 CFR 1926.416(a)(2).
  5. JCI did not incorporate all the requirements of 29 CFR 1910.132(f)(4) into its procedure.
  6. The JCI procedure requiring certification and training involving personal protective equipment did not appear in the JCI ES&H Manual until November 28, 1995.
  7. JCI personnel misinterpreted the excavation permit requirements.
  8. JCI Utilities Power Control Section personnel at all levels have accepted their job-specific operating instructions as procedures and requirements.
  9. JCI Safety and Maintenance personnel do not routinely perform safety inspections of maintenance activities.
  10. JCI ES&H Manual Procedure 12-25-008 does not satisfy the requirements of 29 CFR 1910.137 for rubber glove testing.
  11. The JCI Maintenance organization does not have a systematic program for keeping track of rubber glove test dates, retest due dates, or inventory control.
  12. LANL policies and requirements are not factored into JCI procedures and policies.
  13. The validation process for closure of corrective action items identified in LANL occurrence reports is not effectively implemented.
  14. Lessons learned from previous electrical incidents have not been effectively implemented into LANL or JCI procedures or training programs.

4.3 WORK PLANNING, AUTHORIZATION, AND CONTROL

4.3.1 Work Planning

Findings

  1. Administrative Requirement 1-10, "Environment, Safety, and Health Questionnaire," has not been revised to reflect the use of the ESH Identification process.
  2. The ESH Identification process is ad hoc, was never approved formally by LANL senior management, and is inconsistent with the management-approved Administrative Requirement 1-10 procedure.
  3. All subject matter expert comments on the ESH Identification Project Summary were not resolved prior to the initiation of the Waste Stream Corrections Project, in accordance with the requirements contained in Administrative Requirement 1-10, "Environment, Safety, and Health Questionnaire."
  4. The Risk Assessment Group review of the Waste Stream Corrections service request for ES&H concerns did not identify all hazards associated with the Waste Stream Corrections Project.
  5. Procedures are not in place to define the ES&H requirements to be accomplished by Risk Assessment Group in its review of service requests, small job tickets/work tickets, or other documents used to authorize and/or control JCI work activities.
  6. Although the Water Quality and Hydrology Group made commitments regarding plans for organizing the Waste Stream Corrections Project to address ES&H issues, those commitments were never fully met or implemented.
  7. In utilizing a tailored small job ticket/work ticket form for the Waste Stream Corrections Project, LANL ES&H staff omitted the ES&H review section, with no reasonable assurance that ES&H reviews would be accomplished either by the LANL Risk Assessment Group or JCI.
  8. JCI craft supervisors did not conduct a preliminary hazard analysis for the work in Building TA-21-209, as required by JCI procedures.
  9. JCI craft supervisors were not familiar with the requirement, procedure, or form for conducting preliminary hazard analysis prior to any work activities involving JCI personnel.
  10. JCI craft workers involved in the accident had not been provided with formal documentation on the scope or safety review/ requirements for the work they were to perform.

Probable Causes

  1. Administrative Requirements have not been kept up to date to reflect changes in LANL organizations, procedures, and practices.
  2. Laboratory-wide procedures have not been developed to establish performance expectations and define the requirements for conducting work planning and control within various LANL organizations.
  3. LANL does not have a good internal assessment process to discover deviations from procedures.
  4. There is neither enforcement of safety requirements by LANL or JCI management, nor accountability for poor safety performance.

4.3.2 Procedures

Findings

  1. Laboratory-wide operating procedures have not been written for a majority of the Administrative Requirements, which is in violation of Director's Policy 102. Specific to this incident, there are no Laboratory-wide operating procedures to implement the Director's Policies for (1) conduct of operations, (2) configuration management, (3) work planning and control, and (4) ES&H design reviews.
  2. LANL management has allowed Laboratory personnel at the Division and/or Group level to ignore or change requirements without revising applicable procedures.
  3. Line managers did not ensure that Administrative Requirement 1-11 was met. Forms other than the "approved" work control forms were used to issue work. Standing Work Orders were being used for non-routine, non-repetitive tasks, in direct conflict with Administrative Requirement 1-11 and with their intended purpose.
  4. LANL and JCI staff were not aware that an excavation permit was required by Administrative Requirement 1-12.
  5. The Administrative Requirements contained in the LANL ES&H Manual are not well understood or complied with by either the staff or management levels within LANL.
  6. The requirements of SPI 12-02-010, "Work Order Review," were not complied with.
  7. There is no single, comprehensive work control procedure that describes the flowpaths and requirements for submitting, approving, and issuing work through LANL and subcontractors contracted to perform work (JCI in this case).
  8. The stop-work order notice was not on file, as required by Director's Policy 116, in any of the four Division offices that were checked nearly one week after its issuance.
  9. There was no verification that all appropriate personnel received the stop-work order notice.
  10. Procedures did not exist for many of the processes needed to support the Waste Stream Corrections Project, and where procedures did exist and were available for use by LANL and JCI personnel, they were considered as optional guidance and were not generally followed.

Probable Causes

  1. Administrative Requirements do not reflect the current LANL organization, and confusion exists as to specific organizational responsibilities.
  2. High-level procedures are written and requirements are directed to line managers without adequate infrastructure, responsibility, and accountability to implement the numerous requirements.
  3. LANL senior management does not enforce the requirements described in the Administrative Requirements, Director's Policies, and other procedures, thereby permitting Division and Group level management to interpret, change, or violate procedures when the need exists.
  4. There was a widespread misconception within both LANL and JCI organizations that excavation permits were only required for outside activities.
  5. The excavation permit procedures only require the performance of a utility survey and Risk Assessment Group review. There is no requirement for a review of drawings or a physical check for electrical or piping penetrations at the work sites.
  6. Standing Work Orders are being used for complex, non-repetitive, non-routine work.
  7. The master management e-mail method used to promulgate the sitewide stop-work order does not incorporate message receipt confirmation. The process is "open loop" and does not assure the stop-work order notice is received and placed in effect.

4.3.3 Design and Configuration Management

Findings

  1. Preliminary design documents were used for construction activities.
  2. Design reviews for the Waste Stream Corrections Project work did not comply with the design review requirements contained in Administrative Requirement 1-14 and the Quality Management Plan for 10 CFR 830.120.
  3. The process for obtaining approval for design changes is informal and does not require field verification of changes requested prior to approval.
  4. The LANL configuration management program is ineffective at maintaining configuration control of facilities.
  5. As-built drawings are not required to be updated for facility modifications, particularly those "modifications" being handled as maintenance activities.
  6. The Water Quality and Hydrology Group did not recognize its responsibilities for design review after assuming the project lead role.
  7. The graded approach in the configuration management program does not require controls for non-vital systems.

Probable Causes

  1. LANL management has not instituted Laboratory-wide procedures outlining organizational responsibilities and authorities governing the conduct of design reviews.
  2. High-level procedures are written, and requirements are directed to line managers without adequate infrastructure, responsibilities, and accountability to implement the numerous requirements.
  3. Management does not uniformly enforce the requirements described in Administrative Requirements and Director's Policies.
  4. There is no Laboratory-wide configuration control procedure.
  5. Modifications to facility systems are not being captured or analyzed against the existing safety analyses or system design documents.

4.4 PERSONNEL RESOURCES AND TRAINING

Findings

  1. JCI did not provide job-specific electrical safety-related work practice and personal protective equipment training commensurate with DOE orders, OSHA regulations, or its own procedural requirements.
  2. Oversight by LANL to measure the contractual requirement deliverables for training at JCI evaluates only high-level programmatic issues.
  3. The training process at JCI for critical courses and activities is not completely directed and implemented as required by the JCI Training Manual and JCI Standard Practice Instructions.
  4. Training requirement principles that appear in DOE Order 5480.20 and the training requirements of DOE Order 4330.4B are not completely implemented in all critical training courses and activities at JCI.
  5. JCI crafts personnel and union stewards have concerns about raising safety issues to foremen and supervisors because they fear recrimination.

Probable Causes

  1. The training oversight measurement metrics established for LANL are broad and vague.
  2. The JCI safety and training organizations do not fully integrate their respective procedure requirements.
  3. JCI resource constraints have prevented the complete implementation of the training requirements commensurate with DOE orders.
  4. Supervisors and foremen are not being held accountable or being disciplined by JCI management for trying to subvert the workers' rights to raise safety issues on construction or maintenance jobs.

4.5 MANAGEMENT SYSTEMS

4.5.1 Johnson Controls World Services, Inc.

Findings

  1. Failure to categorize the work as construction resulted in removing the administrative barrier of an independent safety review by the JCI construction safety engineer, as well as conduct of both a preliminary hazard analysis and an activity hazard analysis.
  2. Failure to prepare as-built drawings of electrical and other stored energy system changes due to past facility modifications resulted in the loss of configuration control of a potentially life threatening system.
  3. JCI does not have a documented process for work package assignment and/or for detailing supervisor or foreman accountability to assure technical and safety adequacy of the information provided in the work package.
  4. JCI does not routinely prepare design drawings for modifications to existing buildings, particularly for work packages that flow from LANL through the JCI Maintenance Division.

Probable Causes

  1. The Standing Work Order system does not require a safety review for individual tasks performed under the work order.
  2. The Standing Work Order system is used as a convenient method for performing work without preparing a job ticket.
  3. The safety-related implications of maintaining configuration control of stored energy systems is not recognized.

4.5.2 Santa Fe Engineering

Findings

  1. SFE preliminary drawings did not consider electrical system tie-in requirements.
  2. SFE preliminary drawings were not adequate as a basis to perform construction activities in a safe manner.
  3. SFE provided guidance/concurrence on sump pump relocation informally without considering engineering or safety significance.
  4. SFE preliminary drawings did not identify all potential hazards identified in existing facility drawings which were available.

Probable Causes

  1. The SFE "field engineer" was not a degreed engineer with electrical system knowledge and experience.
  2. The LANL contract with SFE did not reflect the need for detailed drawings or level of engineering safety expertise needed to support the expectations of LANL management.

4.5.3 Los Alamos National Laboratory

Findings

  1. The LANL processes used in managing the modification of the building systems did not comply with the LANL Quality Plan or DOE Order 6430.1A.
  2. Management is allowing the Standing Work Order system to be used for non-routine, non-repetitive tasks without adequate safety review.
  3. The current use of the Standing Work Order system is in conflict with the original intent of the concept.
  4. Conduct of operations at LANL does not comply with DOE Order 5480.19; there is insufficient formality of operations to assure that management's expectations are being met.
  5. The implementation of a Laboratory-wide conduct of operations program at LANL has not received sufficient management attention.
  6. Design processes are not uniform throughout LANL, and the management-level controls applied in these processes do not ensure that worker safety and operational needs are being met in the design processes.
  7. The Engineering Sciences and Applications Division did not meet its line responsibility for managing changes to the facility.
  8. The Facility Management Unit process is in a transitional state where roles, responsibilities, authorities, and accountabilities are not well understood throughout LANL organizations.
  9. Administration of the Waste Stream Corrections Project corrective actions did not comply with Director's Policy 124.
  10. The processes for determining and assigning work management-level classifications do not provide consistent results at LANL.
  11. The work being performed at the accident site should not have been classified as Management Level 4 by the Facilities Support Operations Group, because of the type of work involved, the complexity, and the necessity to comply with EPA regulations.
  12. The design controls required by the assigned Management Level 4 classification do not require adequate configuration management, design, and turnover of systems.
  13. The lessons learned from previous significant accidents have not been implemented at LANL to eliminate programmatic deficiencies that have repeatedly been identified as either root or contributing causes to the accidents.
  14. LANL management programs have not been effective in holding individuals accountable for completing assigned tasks, particularly those involving corrective actions related to programmatic deficiencies identified during assessments.
  15. The Laboratory Director has not formally promoted the Facility Management Unit model to the management team.
  16. LANL management is not ensuring that the rights of LANL subcontractor employees to a safe work environment are being protected.

Probable Causes

  1. Responsibility for the design and construction of NPDES modifications was transferred to a support organization that did not have the necessary and sufficient engineering or project management tools and experience to perform the required tasks to assure safety during field construction.
  2. The Standing Work Order process does not require a safety review for individual subtasks performed under the overall Work Order.
  3. The Standing Work Order process is utilized by LANL personnel as a convenient method of performing work without a job ticket and work package, allowing most work to be field directed.
  4. The Facility Management Unit responsible for Building TA-21-209 did not take an active role in the design, development, or field implementation of the Waste Stream Corrections modifications being managed by the Water Quality and Hydrology Group.
  5. The decision supported by LANL Division and Group level management to "fast track" Waste Stream Corrections modifications in an undocumented process seriously reduced the margin of safety for the accident victim by eliminating engineering and safety reviews and by not providing sufficient details in the field work package.
  6. LANL management has not placed a high priority on the implementation of conduct of operations.
  7. Management is not directing program or procedure compliance in a top-down approach; consequently, organizations create their own systems in order to accomplish their assigned functions.
  8. Management has not adequately considered the importance of providing appropriate detail in work packages and preparing modifications to as-built drawings for subsequent safe operations and maintenance of facility systems.
  9. There are different criteria for establishing work management level classifications in the two procedures reviewed, and the guidance for assigning risk in each of the LANL work classification procedures is too vague to assure consistent classification of work management level classifications between organizations.
  10. The LANL Facility Management Unit model has not received formal direction from LANL senior management and, as a result, is not fully implemented across the Laboratory.
  11. LANL management does not assign adequate priority to the implementation of corrective actions that are needed to improve safety at the Laboratory, and does not hold individuals accountable for safety performance.
  12. LANL managers have not recognized the importance of implementing formal processes to ensure consistent operations.
  13. LANL managers have not provided an environment that encourages subcontractor employees to raise safety issues.

4.5.4 Los Alamos Area Office

Findings

  1. LAAO management reassigned the Facility Representative from Technical Area 21 to other activities for most of the 1995 calendar year.
  2. LAAO Facility Representative personnel do not understand the "teaming concept" and whether or not it affects their responsibilities and accountabilities for line management safety oversight of LANL.

Probable Causes

  1. LAAO management reassigned the Facility Representative to Technical Area 55 and to other temporary assignments in an attempt to allocate scarce resources in a priority manner. Technical Area 55, Readiness Assessments and Accident Investigations, was given priority over day-to-day oversight at the Tritium Facilities, which included Building TA-21-209.
  2. The scope of the "teaming concept" has not been adequately defined and explained to LAAO personnel to ensure that it does not inhibit the performance or objectivity of day-to-day line management oversight.

4.5.5 Albuquerque Operations Office

Findings

  1. The Functional Area Appraisal Procedure developed by AL to implement the pilot oversight program requires agreement from the contractor on all findings.
  2. The Functional Area Appraisal Procedure reduces the independence and effectiveness of the assessment team.

Probable Cause

The Functional Area Appraisal Procedure is not consistent with the definition of the program provided by the Deputy Secretary of Energy.

4.5.6 DOE Headquarters

Findings

  1. The EH Resident Office was not staffed to the level originally planned.
  2. The EH Resident's surveillance duties have been reduced because of other priorities.
  3. The single Los Alamos EH Resident does not possess all of the education and experience required to provide effective oversight of all of the major activities at LANL.

Probable Causes

  1. Staffing constraints did not allow the EH Resident Office to be fully staffed as originally planned.
  2. Work priorities for the Los Alamos EH Resident are not well defined or understood.

4.6 OCCUPATIONAL SAFETY AND HEALTH

Findings

  1. LANL and JCI personnel did not correctly characterize the Waste Stream Corrections Project as a construction activity.
  2. LANL and JCI personnel did not conduct surveys, or make other reasonable efforts, to determine the location of underground utility installations prior to opening the excavation in the basement of Building TA-21-209.
  3. JCI did not ensure that a hazard assessment was conducted prior to work on elements of the Waste Stream Corrections Project and, in particular, prior to work in the basement of Building TA-21-209.
  4. LANL and JCI management did not ensure the establishment of adequate industrial hygiene control measures for the protection of employees during the mechanical removal of tuff in the basement of TA-21-209.

Probable Causes

  1. LANL and JCI personnel incorrectly interpreted the scope of work involved in the Waste Stream Corrections Project.
  2. LANL and JCI personnel were unfamiliar with procedural requirements and, consequently, failed to ensure the enforcement of procedural requirements during the conduct of work.
  3. Inadequacies existed in LANL and JCI ES&H organizational reviews of work packages that could have identified potential hazards in the workplace.
  4. There was a lack of LANL facility line management involvement in planning and execution of the Waste Stream Corrections Project.
Please send comments to support@tis.eh.doe.gov

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