A subcontractor project engineer died from a fall at the Idaho National Engineering Laboratory on February 20, 1996.
On February 20, 1996, at approximately 11:20 a.m., a construction subcontractor project engineer (Project Engineer) working at the Idaho National Engineering Laboratory (INEL) fell approximately 17 feet from a temporary platform. The platform was built to catch falling tools and parts and to provide support for a transition piece being installed as part of the ventilating system in the Transuranic Storage Area-Retrieval Enclosure (TSA-RE) (Building 636) at the Radioactive Waste Management Complex (RWMC). The Project Engineer was transported by helicopter to the Eastern Idaho Regional Medical Center in Idaho Falls, Idaho, where he died at 4:10 p.m. from severe head and neck injuries.
On February 22, 1996, Tara O'Toole, M.D., M.P.H., Assistant Secretary for Environment, Safety and Health, U.S. Department of Energy (DOE), appointed a Type A Accident Investigation Board to investigate the accident, in accordance with DOE Order 225.1, Accident Investigations (See Appendix A).
Contractor activities at INEL are managed by the DOE Idaho Operations Office (ID). The facility in which this accident occurred is under programmatic direction of the Office of Environmental Management (EM).
Contractor activities are consolidated under Lockheed Idaho Technologies Company (LITCO) and managed by the Idaho Operations Office.
In October 1994, contractor activities at INEL were consolidated under a single management and operating (M&O) contract
awarded to Lockheed Idaho Technologies Company (LITCO),1 which included member companies of Lockheed, RUST, Duke, Babcock and Wilcox, Parsons, and Coleman.
Since 1970, defense-generated transuranic waste has been received at the RWMC, placed on asphalt pads, and covered with soil. The plan was that these containers would all be retrieved within 20 years and shipped to the Waste Isolation Pilot Project near Carlsbad, New Mexico, which is the intended disposal site.
The facility where the accident occurred is used to store transuranic waste in stacked drums and boxes.
The TSA-RE structure is 97 percent completed and provides a weather-tight enclosure in which the waste can be retrieved year- round. The structure also helps to prevent the spread of any contamination that could be released from breached or deteriorated waste packages, or from a material handling accident during retrieval operations.
The transuranic waste stored at TSA-RE consists principally of stacked metal drums and fiberglass-reinforced plywood boxes covered with a vinyl-coated, geo-fabric tarpaulin (originally provided for weather protection), and then covered with approximately four feet of earth, except for the south end of the stack which has no earthen cover (see Exhibit 1-1).
The Board commenced its investigation on February 22, 1996, completed the investigation on March 18, 1996, and submitted its findings to the Assistant Secretary for Environment, Safety and Health on March 21, 1996.
The scope of the Board's investigation was to review and analyze the circumstances to determine the accident's causes. During the investigation, the Board inspected and videotaped the accident site, reviewed events surrounding the accident, conducted extensive interviews and document reviews, and performed causation analyses.
The purposes of this investigation were to determine the nature, extent, and causation of the event and any programmatic impact, and to assist in the improvement of policies and practices, with emphasis on safety management systems.
The Accident Investigation Board was convened to determine why the accident happened and how similar accidents can be avoided in the future, with emphasis on safety management systems.
The Board conducted its investigation, focusing on management systems at all levels, using the following methodology:
1With the recent merger between Lockheed and Martin-Marietta, the operating company was renamed Lockheed-Martin Idaho Technologies. However, because official contractual documents have not been modified to reflect this change, LITCO is the acronym used to refer to the joint venture in this report.
2Five guiding principles are identified in the Secretary's letter: line management responsibility for safety, comprehensive requirements, competence commensurate with responsibilities, independent oversight, and enforcement. The first three are applicable to management systems related to this investigation. The Secretary's letter included a comprehensive description of the functions that the Department deems necessary to fulfill its mandate under enabling legislation to provide "reasonable assurance that the safety and health risk of operating personnel and the public be minimized."
3Charting depicts the logical sequence of events and conditions (causal factors) that allowed the events to occur.
4Barrier analysis reviews hazards, the targets (people or objects) of the hazards, and the controls or barriers that management control systems put in place to separate the hazards from the targets. Barriers may be procedural, physical, or human.
5Change analysis is a systematic approach that examines failures in barriers and controls that result from planned or unplanned changes in a system.
Last Modified: Friday, 28-Feb-97 10:09:00