Table 3-2. Barrier and Control Analysis

Hazard

Direct Barrier or Control Failure

Possible Contributing Factors to Barrier or Control Failures

Possible Root Causes of Failures

Loss or Potential Loss Event

Evaluation

Contact with 13.2 kV electric cable

Failure of design to identify electrical cable at sump location

Architect/engineering firm was not tasked to provide engineering drawings or specifications

The design was only intended to provide preliminary information

As-built drawings were not used by ESH-18 to identify utility lines

Water Quality and Hydrology Group (ESH-18) was not knowledgeable in project management to request engineering designs or specifications

Contact with 13.2 kV line

A planning organization was given responsibility for the project in no order to meet Environmental Protection Agency (EPA) schedule commitments

Failure of mason to detect electrical cable during excavation

Color and texture of concrete and tuff are similar

Compressive strength are similar for concrete and tuff

Job specific hazard awareness training

Hazard awareness was not adequately provided to the cement mason foreman

Failure of excavation procedure to identify electrical cable

Confusion among JCI crafts personnel, foremen, and supervisors on requirements for an excavation permit indoors

Facility Risk Management Group (ESH-3) review fails to identify the need for an excavation permit during the service request process

ESH-18 did not know of excavation permit requirement of Administrative Requirement 1-12

Implementation and training on procedures

Lack of understanding of responsibilities

Implementation of procedures were not enforced

ESH-3 personnel assumed a more detailed specific safety and health review would be performed

Contact with 13.2 kV electric cable

Failure to assess potential construction hazards

The Waste Stream Corrections tasks were classified as a Standing Work Order (SWO) and not subject to the same safety and health assessment as a construction project

Lack of oversight and conduct of operations

Contact with 13.2 kV line

Implementation of conduct of operation and training was not conducted

A Preliminary Hazard Analysis was not performed as required by JCI procedures

The JCI Roads and Grounds Safety checklist was completed but does not address all hazards

JCI safety inspection was not conducted at Building TA-21-209

Failure of a utility survey to identify an electrical cable

The utilities survey group did not believe that an excavation permit was required for indoor excavations and that a survey could not be conducted indoors because of the background noise

Implementation and training on procedures

Procedures were not enforced

Failure of physical barriers to isolate contact with electrical cables

JCI mason was not wearing personal protective equipment (PPE) as required by 29 CFR 1926.416(a)(3)

Implementation of JCI procedures

Procedures were not enforced

Contact with 13.2 kV electric cable

Failure of conduit material to conform to specifications

Conduit was made of an asphalt material. The original building specifications required the installation of rigid steel conduit

Tests performed showed that the conduit encasement was of low strength concrete, 1130 psi

Inspections/engineering modification

Contact with 13.2 kV line

Failure of supervision and management oversight

LAAO/AL have not been effective at correcting known deficiencies

Management system is not effective in correcting change

Lack of management attention to close out corrective actions

LANL management allowed ESH-18 to have project lead

Established policies and procedures were not implemented

LANL management allowed project schedule to take precedence over established procedures

LANL management allowed a preliminary design package to be used for construction

LANL management allowed deviations from Administrative Requirements 10, 1-11, 1-12, and 14 and the Quality Management Plan

Contact with 13.2 kV electric cable

Lessons learned process failure

JCI did not ensure that crafts personnel were aware of work place hazards (preliminary hazard analysis, excavation, and worker training)

JCI Safety did not review "Maintenance" work package

Contact with 13.2 kV line

LANL management did not ensure that adequate actions were taken resulting from previous occurrences

The corrective action process was not implemented

Between 1991 and the present there were 5 similar occurrences which referenced the need for training and proper personal protective equipment

Failure of configuration control

ESH-18 allowed relocation of sump pit without a modification review

Facility Managers were not aware of modifications to facility

ESH-18 was not experienced in project management