Figure 2-1 summarizes the chronology of significant events.
Site response to the accident was good.
Response by site personnel from the inception of the incident through transport to medical treatment facilities in Idaho Falls was good. During the accident investigation, the following facts were noted regarding investigative readiness by LITCO and Caddell:
Contractor procedures were insufficient to perform or support all actions required for an accident investigation.
·Procedures for accident investigations did not address accident scene management or evidence handling, processing, preservation, and control. Nevertheless, timely personnel access controls to the accident scene were instituted, and scene configuration was maintained. Evidence control, accountability, and chain of custody were not effectively accomplished or timely. A composite record specifying the origin of the evidence, custodianship, and dates of transfer was not established by LITCO. In addition, the Project Engineer's personal effects and body were released before the Board arrived. No autopsy was performed, and no blood samples were taken prior to treatment.
·Provisions to support Type A and B accident investigations were not included in the LITCO subcontract with Caddell. As a result, the Board required the services of ID legal counsel and a LITCO contract administrator to obtain the Project Engineer's employment, work restriction, and medical records from Caddell. Further, the Project Engineer's employment- related medical records, fitness for duty report, and last medical examination were not furnished to the Board until nine days after the request was made.
Some items of evidence that could have facilitated the investigation were unavailable or incomplete.
Evidence presented to the Board by LITCO and Caddell consisted of the Project Engineer's personal protection equipment (hard hat and safety glasses), eyeglasses, and photographs of the accident scene. The personal effects were not available; they could have given insight into his medical condition at the time of the accident, and assisted in reconciling evidence presented to the Board. Evidence was collected and photographs were taken by various site personnel, stored at assorted locations, and provided to the Board over a 12-day period without accompanying chain of custody receipts. There were no procedures for these activities or for accident scene management. Photographs did not contain complete identification data (i.e., time, date, photographer's name) or a scale of reference to indicate the dimensions of the objects and distances in the photographs. The prolonged time that Caddell took to provide documentation necessary to the investigation indicates that Caddell was contractually unnecessarily reluctant in supporting the Board's requirements.
Although in this case an autopsy would not have affected the conclusions of the investigation (because the emergency medical treatment obscured the essential conditions), it is generally a good idea to conduct an autopsy for fatal accidents to confirm clinical diagnosis, or to identify contributory conditions or an unrecognized cause (e.g., head trauma vs. heart attack). If a blood sample had been taken prior to emergency medical treatment, it could have provided diagnostic information to assist the Board in determining the exact medical condition of the victim.
The contractor's procedural deficiencies diminished the efficiency of the investigation, but did not affect is outcome.
DOE Order 225.1 mandates that contractor requirement documents contain provisions for supporting Type A and B accident investigations and that contractor staff establish and maintain an accident investigation capability. Although the procedural deficiencies indicated above did not affect the ultimate outcome of the investigation, they did impact its efficiency.
The investigation revealed the following facts regarding the Caddell medical surveillance program:
·Caddell has a documented medical surveillance program that consists of annual comprehensive physical examinations, "fitness for duty" reports by the examining physician, designation of any resulting work restrictions, and execution of the work restriction(s) through the safety engineer, in conjunction with the employee's immediate supervisor.
·The medical surveillance program was referred to by Caddell staff interviewed during the investigation as a "wellness program."
·In the case of the Project Engineer, Caddell management received a work restriction report dated January 10, 1995,
from a contracted occupational physician, but failed to execute the medically recommended work restrictions.
The subcontractor's medical surveillance program had issued work restrictions on the project engineer because he suffered from diabetes.
The project engineer knew of these restrictions, but his managers stated that they were not aware of them.
A comprehensive medical surveillance program for construction personnel that complies with 29 CFR 1910.120 (Hazardous Waste Operations and Emergency Response) consists of (1) an occupational work history evaluation completed by the employee, (2) an annual employee medical evaluation for members of the workforce, (3) medical diagnosis and analysis of disabilities or limitations considering the framework of the workplace, (4) reporting of recommended work restrictions to each employee and his/her supervisor, (5) implementation of work restrictions by the supervisor, and (6) recordkeeping.
Caddell's medical surveillance program was not effective in communicating the work restrictions and enforcing compliance in this case. In addition, Caddell safety management did not exercise its responsibility to be aware of and execute work restrictions.
The project engineer's failure to comply with the restrictions, and the subcontractor's failure to implement the medical surveillance program, contributed to the accident.
The Project Engineer's failure to execute his personal responsibilities under the program by abiding by the work restrictions was a contributing factor in the accident. The failure of Caddell to fully implement its medical surveillance program (poor communications of restrictions and insufficient enforcement of compliance with work restrictions) contributed to the accident, because non-compliance with the established program contributed to the Project Engineer's presence at the scene.
Facts relating to personnel performance at the time of the accident are:
The project engineer had a reputation for safe work practices, but that day he failed to follow a number of procedures.
6Diabetic neuropathy is a slow, progressive loss of function of the sensory nerves in the limbs that causes numbness, tingling, and discomfort on both sides. It occurs after many years of diabetes, especially if the diabetes has not been controlled. The feet are often the first part of the body to be affected.
Caddell training records indicate that the Project Engineer was trained in the requirements of the Caddell ES&H Program Plan, which specifies the use of fall protection equipment for work at heights above six feet. Although Caddell's ES&H Program Plan identifies three progressive fall protection levels, in practice sole reliance was typically placed on the choice of last resort, which was the use of personal protective equipment and 100 percent tie- off.
His uncharacteristic failure to follow procedures may have resulted from impaired judgment and balance due to his medical condition.
Documentation and interviews did not indicate that Caddell or LITCO safety personnel were aware of the existence of the platform, and indicated that the Project Engineer was exhibiting uncharacteristic behavior on the day of the accident (i.e., entering into an obviously hazardous situation without the required fall protection equipment). Because of the Project Engineer's preexisting medical condition and evidence that he may have not eaten on the day of the accident, he may have unknowingly
7Hypoglycemia is a condition characterized by abnormally low blood sugar level. Some patients who require insulin become unaware of their hypoglycemia; that is, they can no longer recognize its symptoms and counterregulate it. When a patient is unaware of hypoglycemia, the blood sugar concentration continues to decrease and must reach a very low level before the patient experiences symptoms such as headache, uncoordination, double vision, inappropriate behavior, and confusion.
suffered a hypoglycemic event that may have affected his judgment. Also, the diabetic neuropathy in his feet and legs could have affected his ability to maintain his balance. Thus, it appears likely that his medical condition may have contributed to his fall, and impaired judgment may have contributed to the accident.
The subcontractor was contractually required to implement Departmental safety policies and standards, including requirements for fall protection and medical surveillance.
Review of the contract articles and the MK-Ferguson subcontract documents incorporated in the TSA-RE construction contract confirm that clear and appropriate safety policy and standards exist in the subcontract awarded to Caddell. Specifically, comprehensive construction safety requirements addressing full coverage for scaffolding and fall protection, including use of personal protective equipment, are clearly delineated and contractually incorporated from the OSHA standards (29 CFR 1910 and 1926) through applicable DOE orders, the MK-Ferguson construction management contract documents, the Caddell construction subcontract, and subtier subcontracts awarded by Caddell.
Caddell, as required by its subcontract, submitted its ES&H Program Plan for RWMC in November 1993, for review and acceptance by MK-Ferguson prior to start of work. The Caddell ES&H Program Plan adequately reflects INEL safety policy and OSHA standards invoked by DOE orders.
Explicitly incorporated in Caddell's subcontract (Special Condition Clause 17 "Construction Health and Safety," paragraph A, Attachment 7 and the MK-Ferguson Site Health and Safety Plan) is the requirement for 100 percent fall protection. This fall protection policy duplicates the tiered approach defined in the OSHA standards using (1) engineered barriers, (2) administrative restraints and signs, and (3) personal protective equipment. This fall protection policy was contractually passed down to Caddell, and subsequently through Caddell to its subtier subcontractors, and was clearly reflected in Caddell's ES&H Program Plan for the RWMC which was accepted by MK-Ferguson.
Furthermore, Special Conditions Clause 17, Paragraphs E and I (the latter invoking the MK-Ferguson "INEL Safety Work Control Procedures," WCP S-5 "Scaffolding," and WCP S-6 "Job Safety Analysis Plan") require submission of a plan for scaffolding and job safety analysis for the TSA-RE project. These safety submittals were provided by Caddell and its subtier subcontractors during the project.
Special Condition Clause 17 (Construction Health and Safety) of Caddell's subcontract, Paragraph J (Site Health and Safety Plan), invokes a medical surveillance program requiring Caddell and its subtier subcontractors to implement a program for all personnel "involved in onsite execution of construction activities." Diabetes is noted as one of the special medical conditions that must be reported to the safety engineer and supervisory personnel.
Facts relating to hazards analysis are as follows:
The subcontractor failed to follow Departmental requirements and its own procedures pertaining to hazards analysis
·Interviews revealed that neither a Job Safety Analysis nor a Construction Safe Work Permit (ID-F-5480.1H),8 as required by the Caddell ES&H Program Plan and DOE Order 5480.9A, was completed and implemented for the transition piece installation and platform construction.
8DOE Order 5480.9A, Construction Project Safety and Health Management, now refers to these analyses as a Preliminary Hazards Analysis and an Activity Hazard Analysis, respectively.
·Interviews with ID, LITCO, and Caddell line management and safety personnel revealed that the radiological control barrier discouraged personnel from inspecting the stack area for hazards. Thus, they did not approach near enough to adequately see, in the existing lighting conditions, the edges of the stack or the platform. They were therefore unable to recognize the safety deficiencies.
Failure to follow existing procedures for completing the required Job Safety Analysis or a Construction Safe Work Permit led to conditions in which hazards were not identified and were left unmitigated prior to the accident.
A Job Safety Analysis or Construction Safe Work Permit is required to identify specific hazards and appropriate control measures. The Job Safety Analysis need not be complex, but must specify, in advance, the actual work practices and protective measures to be implemented. This practice mitigates potential impacts to safety and health, project cost, and schedule. Further, the Job Safety Analysis includes the timely planning of abatement strategies for imminent danger situations. Alternatively, a Construction Safe Work Permit may be completed. It provides a detailed job description, including the erection of any temporary structures, and informs workers and supervisors of the hazards and protective measures in effect in areas requiring performance of hazardous tasks.
Meeting the requirement for completing a Job Safety Analysis or a Construction Safe Work Permit for the transition piece installation and the platform would have identified specific safety hazards and mitigation strategies, such as the required safety measures and warnings on or near platform. Following these procedures would have reduced the platform's potential as an attractive nuisance.
The radiological control barrier discouraged safety personnel from entering the area to inspect for hazards, and the light was too dim to allow them to see the hazards from outside the area.
ID, LITCO, and Caddell safety and line management personnel expressed the view that the principles of As Low As Reasonably Achievable for radiological protection precluded direct inspection of the area in which the platform was located. Consequently, these inspections were conducted only from outside the radiological control barrier. Although the principles of As Low As Reasonably Achievable apply, they should not be interpreted as precluding the necessity for such inspections. The lighting conditions also contributed to the inability to make an accurate and timely assessment of the safety hazards in the area of the stack from the radiological control barrier. Thus, the platform or other hazards on the stack were never identified.
There were no permanent fall protection systems in the area of the accident, and there were no safety barriers or warnings to keep people away from the edge of the stacks.
On the day of the accident:
Occupational Safety and Health Standards for the Construction Industry (29 CFR 1926) require that, when working from an area greater than six feet in height or near unprotected edges or sides, personal protection in the form of a fall protection system be in place during all stages of active work. Violations of fall protection requirements usually constitute an imminent danger situation. Lighting in the area was less than the minimum of 5 foot-candles prescribed by the OSHA standards (29 CFR 1926.56). This level of illumination may have contributed to the accident, taking into consideration the visual adjustment when moving from a brighter area to a progressively darker area, as was the case in the area where the accident occurred. There were no permanently installed fall protection systems, barriers, or warnings; each subtier contractor was expected to identify the fall hazards and provide its
The combination of insufficient barriers, warning lines or signs, fall protection, and illumination was a contributory cause to the accident.
own fall protection system as they saw fit. The combination of these circumstances was a contributory cause to the accident.
The contractor had repeatedly directed the subcontractor to improve safety performance, and had taken steps to enforce safety compliance.
The subcontractor's poor safety record is well known to the contractor and the Operations Office.
Numerous evaluations have noted deficiencies in implementation and execution of requirements.
While some deficiencies in documentation, policy, and procedures were noted, Caddell's major shortcoming has been inadequate implementation and field execution of requirements described in its ES&H Program Plan and procedures. Important examples, directly pertinent to this investigation, are:
The Board encountered numerous other indications of Caddell management's attitude toward safety. A recent example is a Caddell corporate office letter of February 5, 1996, denouncing LITCO's order to replace the Project Superintendent and characterizing LITCO's approach to safety as "heavy handed." Caddell's deficient safety program implementation is contributory to the conditions that led to the accident.
The Board examined the adequacy and timeliness of LITCO's actions to influence Caddell's behavior. Given the long record of correspondence with Caddell based on deficiencies observed in the field, the increasing severity of actions taken, and the perceptions by most people interviewed that the actions were resulting in improvement, LITCO's actions were generally adequate. However, four significant deficiencies were noted in LITCO oversight:
The prime contractor's actions were generally adequate.
Roles, responsibilities, and authorities within ID are clearly defined and understood. The RWMC Facility Manager used performance indicators and trends effectively to highlight areas of contractor performance requiring improvement. These areas received increased oversight, and deficiencies were frequently communicated to LITCO. Pressure exerted by ID to correct deficiencies in Caddell's safety program was resulting in improved performance. The award fee process and incentives negotiated with LITCO in the area of ES&H are focusing LITCO's attention on improved performance in this area. However, ID oversight did not recognize that LITCO was not assessing Caddell's compliance with all contractual ES&H obligations, and therefore the medical surveillance program deficiencies went undetected. ID oversight focused heavily on performance in the field and generally did not assess how well LITCO was doing in overseeing other aspects of the Caddell contract.
Operations Office oversight focused more on field performance than on the compliance issues that pertain to this accident.
There are no issues relative to oversight by EM that have a bearing on this accident.
There are no issues of technical competence that have a bearing on this accident.
Successful performance of administrative, physical, and management barriers would have prevented the accident.
A barrier analysis was performed that identified three types of barriers germane to the accident: (a) administrative controls, (b) physical barriers, and (c) management barriers. Successful performance by any of these types of barriers would have prevented the accident. The barriers that failed are summarized in Figure 2-2. Appendix B provides the details of this analysis.
Barriers that failed or were not used were industrial safety postings and fall protection requirements. The safety and health plans and fall protection procedures identified a hierarchy of actions to be taken, with personal protective equipment as a last resort. These procedures were not followed because of the work activity level in the area, the radiological posting, the low lighting levels, and the strong emphasis on 100 percent tie-off for fall protection.
Furthermore, a Job Safety Analysis or Construction Safe Work Permit was not completed to specifically address the temporary platform from which the Project Engineer fell, and construction management was not aware that the platform was left in place. Controls were not in place to keep the platform from being improperly used as a work surface. Additionally, safety surveillance was not increased in the area as work activity levels increased, since individuals believed that they could see enough of the area to assess any safety hazards without crossing the radiological control barrier. However, lighting was below standards for work activities at the accident scene, and the platform was not clearly visible from the radiological control barrier.
Occupational medical program requirements were not emphasized, so medical information on individual employees was not being used by Caddell management, and work restrictions were not enforced. The Project Engineer had work restrictions against working at unprotected heights, working alone, and working around high speed machinery. In addition, his Fitness for Duty Form indicated that "hearing protection was required." The Crane Vendor was being escorted by the Project Engineer at the
time of the accident, and was always escorted in the construction area. Therefore, he was not trained in stop work authority, and did not stop the Project Engineer from approaching the elevated edge of the stack and the platform.
A change analysis was performed to determine points where changes are needed to correct deficiencies in the safety management system and to pinpoint changes and differences that may have had an effect on the accident. The results of the analysis are in Appendix C.
Changes resulting from failure to follow procedures directly contributed to the accident.
Changes directly contributing to the accident were failure to execute established procedures for fall protection, signs and barricades, and Job Safety Analysis/Construction Safe Work Permit; unsafe use of the temporary platform; insufficient lighting in the platform area; and unenforced work restrictions for the Project Engineer. No Job Safety Analysis and/or Construction Safe Work Permit was performed on the platform, leading to a failure in the hazard analysis process and unidentified and uncorrected hazards. Deficiencies in the medical surveillance program and failure to enforce work restrictions allowed the seriously diabetic Project Engineer to be present on the platform. Deficiencies in the management of the safety program within Caddell are also related to failures in the medical surveillance program.
Changes brought about by Caddell management failures resulted in a deficient worker safety program. Caddell management failed to implement the contractual safety requirements necessary to prevent the accident and avoid deficiencies in the worker safety program.
The prime contractor's approach to improving subcontractor safety performance did not address imminent danger situations.
LITCO's progressive approach to improving Caddell's compliance with safety requirements was successful to a degree, but failed to prevent recurrence of imminent danger situations.
Figure 2-3 depicts the logical sequence of the events and causal factors for the accident. It indicates, in a time-sequenced flow, factors that allowed the accident to occur.
Direct, contributing, and root causes for the accident were identified.
The direct cause of the accident was the fall from an unprotected platform. However, there were also contributing causes (causes that, if corrected, would not, by themselves, have prevented the accident but are important enough to be recognized as needing corrective action) and root causes (the fundamental causes that, if corrected, would prevent recurrence of this and similar occurrences). Causal factors are identified on Table 2-1, with a short discussion of each cause.
Contributing causes for the accident were:
Other possible contributing factors were the impaired judgment and physical condition of the Project Engineer. These causes could not be substantiated.
Root causes of the accident were:
Failure by Caddell to implement requirements and procedures that would have mitigated the hazards. The implementation of comprehensive and appropriate requirements is the second of DOE's safety management principles. Caddell failed to implement its medical surveillance program and to enforce work restrictions for the Project Engineer. A hazards analysis, required by DOE Order 5480.9A and the Caddell ES&H Program Plan, was not conducted; consequently, the hazards associated with the platform were not identified, and no countermeasures were implemented. The absence of fall protection, physical barriers, and warning signs in the vicinity of the platform, along with inadequate lighting, violated DOE requirements that invoke Federal safety standards. Furthermore, the contractual requirements for safety, as prescribed in Caddell's ES&H Program Plan and the subcontract with LITCO, were not implemented. Finally, failure to ensure that comprehensive requirements are fully implemented represents a fundamental flaw in the safety management program of Caddell and exhibits failure to meet the management requisites for the second of DOE's safety management principle's requiring that comprehensive and appropriate requirements be established and effectively implemented to counteract hazards and assure safety.
·Failure by Caddell to implement the principle of line management responsibility and accountability for safety. Line management responsibility and accountability for safety is the first of DOE's safety management principles. Caddell has clear safety policies and well-defined responsibilities and authorities for safety. However, Caddell line management has failed to appropriately analyze and manage hazard mitigation and, when faced with adverse consequences for poor safety performance, has refused to accept accountability. Caddell consistently failed to implement effective safety policies and practices as reflected in DOE, ID, and LITCO policies and industry standards. In addition, Caddell failed to foster a safe work attitude throughout its organization and in its lower tier subcontractors. Caddell did not meet contractual requirements for safety and its own safety policy. The result has been routine use of poor safety practices by both Caddell and its subtier subcontractors, reflected in Caddell's poor safety performance record. Finally, Caddell failed to ensure that findings resulting from reviews, monitoring activities, and audits were resolved in a timely manner. Caddell's approach and numerous safety program failures reflect less than full commitment to safety and directly led to the accident.
Last Modified: Friday, 28-Feb-97 10:09:00