CONCLUSIONS

JUDGMENTS OF NEED

· Comprehensive safety requirements exist, are contractually invoked, and are appropriate for the nature of TSA-RE construction work.

None

· Caddell failed to follow procedures required by its contract and by its ES&H Program Plan, including:

Caddell line management and safety personnel need to implement existing safety requirements and procedures, including the full requirements of the medical surveillance program.

·Caddell failed to adequately implement a medical surveillance program, thereby permitting an individual with medical restrictions, including not working at heights, to work in violation of those restrictions.

·The Project Engineer had several medical restrictions, including not working alone, not working at heights, and not working around high speed machinery.

·Caddell failed to adequately implement fall protection requirements contained in its ES&H Program Plan for the TSA-RE project, including enforcement of a three-tiered approach to fall protection. The third tier (choice of last resort) requires anchor points, lanyards, shock absorbers, and full-body harness.

·Although the Project Engineer had a reputation for adhering to applicable safety regulations, on the day of the accident, he did not follow prescribed procedures. He was not wearing any fall protection equipment and did not obtain a direct reading dosimeter before entering the radiological control area.

·The Project Engineer's preexisting medical condition, which was the source of his medical restrictions, may have impaired his judgment and may have contributed to the accident.

§ Caddell and LITCO did not fully implement the hazard inspection requirements of the TSA-RE contract and Caddell's ES&H Program Plan, and therefore did not sufficiently identify or analyze hazards and institute protective measures necessary due to changing conditions.

There is a need for Caddell and LITCO to ensure than an adequate hazards analysis is performed prior to changes in work tasks that affect the safety and health of personnel.

·A radiological control barrier discouraged access to the area, and made it difficult for line management and safety personnel to recognize and analyze safety hazards in the surrounding area, including hazards associated with the platform.

LITCO needs to carefully evaluate, post, and control radiological control boundaries so that access to areas for safety and management walkdowns is not discouraged, or access made unnecessarily restrictive.

·Neither a Job Safety Analysis nor a Construction Safe Work Permit was completed for the transition piece installation and temporary platform construction in accordance with contractual requirements.

·Caddell management at all levels, including the corporate office, was unresponsive to demands for improved safety performance for a significant portion of the construction project.

·LITCO failed to assess Caddell's compliance with all contractual ES&H obligations and thus did not recognize that the medical surveillance and fall protection programs were not being executed as described in the Caddell ES&H Program Plan.

LITCO and Idaho Operations Office oversight programs need to be better balanced between field verifications and assessments of all aspects of Caddell's ES&H program.

·Idaho Operations Office oversight focused almost exclusively on the performance of Caddell and its subtiers in the field. As a result, the Operations Office failed to recognize that LITCO was not assessing all aspects of Caddell's ES&H contractual obligations.

· A temporary platform, used as a work surface for personnel activities when employing 100 percent fall protection, did not have guardrails and was left in place without barriers or other warning devices.

Caddell and LITCO need to ensure that safety personnel inspect changing work conditions for previously unidentified safety and health hazards, and implement protective measures.

·Caddell failed to post adequate warning signs and establish barriers on the stack to warn personnel that they were approaching within six feet of the edge of a fall hazard, as required by Occupational Safety and Health Administration regulations and Caddell's ES&H Program Plan.

·LITCO failed to recognize that warning signs and barriers were not in place in the work area on top of the stack.

· Although response by site personnel to the accident was good, Caddell's and LITCO's actions in the wake of the accident demonstrated little understanding of investigative readiness capabilities.

ID needs to develop contractual requirements and modify existing contractual requirements for accident investigation readiness capability to ensure timely responsiveness to the needs of future investigations, in accordance with DOE Order 225.1.

·Caddell failed to provide the Board, in a timely manner, the Project Engineer's employment, work restrictions, and medical records. Caddell also failed to recognize the Board's investigative needs before releasing the Project Engineer's personal effects.

·LITCO failed to develop an accident investigation readiness capability addressing evidence preservation, control, accountability, and chain of custody.

· The Board was unable to determine the exact medical condition of the Project Engineer at the time of the accident, since a blood sample was not obtained prior to administering treatment, nor was an autopsy performed.

There is a need for the Assistant Secretary for Environment, Safety and Health to consider a policy for taking blood samples before intravenous solutions are administered in serious accident situations that occur on DOE property.

There is a need for the Office of General Counsel to develop a Departmental policy for performing autopsies on fatal accident victims when the accident occurs on DOE property.

There is a need for the Office of General Counsel to determine whether a policy is needed for "impounding" any personal property and contractor records (i.e., medical) of accident victims, until the Accident Investigation Board has had an opportunity to review their relevance to the circumstances of the accident.