Table 3-1. Causal Factors Analysis

Causes

Discussion

Management Systems

LANL management has not instituted a Laboratory-wide work control procedure that formalizes the work control process for construction and maintenance tasks. The following deficiencies exist:

• Management fostered an attitude that allowed multiple Groups to go outside the bounds of the established work control process for the sake of expediency.
• LANL management allowed project schedule to take precedence over established procedures.
• Management allowed deviations from the approved ES&H review process.
• Policy was in place that stated if no ES&H subject matter expert (SME) response was received, concurrence was assumed.
• Management allowed the project lead to be accomplished by a Group which was inexperienced in project management.
• The Water Quality and Hydrology Group (ESH-18) failed to follow the work process plan that was disseminated to multiple lab organizations.
• A sitewide misperception existed as to the requirements for indoor excavation.
• Facility management did not have access control to their facility.

Conduct of Operations—Work Control

LANL and JCI conduct of operations processes relating to work control were deficient because of the following:

• ESH-18 design review processes were not procedurally governed.
• ESH-18 approves and issues preliminary design documents for construction.
• Work is authorized to commence prior to resolving SMEs' comments.
• Inaccurate description of work tasks leads to Davis-Bacon determination on non-covered work.
• Lack of formality existed in the approval process for modifications.
• Informal communication (verbal) was used to direct work activities pertaining to modifications.
• Work packages were not provided to craft personnel.
• Workers did not obtain approval of the Facility Manager.
• Maintenance failed to inform JCI safety prior to starting work.

Occurrence Reporting System

LANL management did not ensure that adequate actions were taken resulting from previous occurrences, internal and external assessments, and accident investigations. Corrective actions to precursor events were not completed.

Hazards Analysis

A preliminary hazard analysis (PHA) was not provided for the "maintenance" work in Building TA-21-209, and the JCI foreman was not aware of the requirements for a PHA to be performed. The attention JCI provided to safety for maintenance activities was not as rigorous as that provided for construction. A PHA and an activity hazard analysis are required for construction activities, while maintenance activities only require a PHA.

Conduct of Operations— Procedures

LANL and JCI conduct of operations relating to procedures were deficient because of the following:

• Excavation procedures were not implemented.
• Preliminary task scoping procedure was not followed.
• Resolution of ES&H SME comments was not accomplished.
• ESH-18 developed and utilized a unique tailored work form.
• Facility Risk Management Group (ESH-3) failed to identify all associated hazards during the review process.
• The Standing Work Order process was not used properly.
• A required preliminary hazard analysis was not performed.
• Approval for lateral relocation of sump was not obtained.
• Workers failed to inform the Facility Manager prior to starting work.
• JCI did not have in place a formal procedure to identify the required personal protective equipment for specific tasks exposing "unqualified" workers to electrical hazards.

DOE Oversight

DOE oversight at all levels has not been effective at correcting known deficiencies. Corrective actions from recurring incidents related to similar work activities and assessment have not been corrected or elevated to management.

Supervision

JCI supervisors do not have a comprehensive knowledge of work control and work from verbal instructions and direction. JCI supervisors were not aware of several procedures in such areas as excavations, personal protective equipment, and hazards analysis.

Training

Training implementation was informal, was not based on appropriate structured development, delivery, or measurement of learning. Implementation of performance based training for critical training and activities did not meet the requirements of DOE Order 5480.20, the maintenance training requirements from DOE Order 4330.B, and the requirements of JCI procedure 12-29-040, PPE Training and Certification Program.

Electrical Safety

JCI crafts personnel did not receive training on or implement the specific requirements for work by "unqualified workers" as specified in 29 CFR 1910.331-335. There is no formal procedure in place identifying the need for this hazard awareness type training.