EH-9212 Issue No. 12, December 1992 Occupational Safety Observer
DECEMBER 1992
Occupational Safety OBSERVER
This edition of Occupational Safety Observer represents the first in
a series of monthly compendiums that will be prepared by the Office of
Safety and Quality Assurance (EH-30) for DOE-wide dissemination. The
purpose of the publication is to raise the awareness of the DOE community
to occupational safety incidents and issues.
We hope to achieve this objective by establishing a forum to exchange
pertinent information to assist all of us, both DOE and operating
contractor staff and management, in the appreciation and recognition of
occupational safety-related hazards in our work environment. The review of
operational experience and presentations of lessons learned in this forum
will contribute to continual safety program improvement with a goal of
preventing or mitigating occupational safety incidents.
In each edition of the Observer, you will find articles dealing with
such topics as 1) lessons learned from selected occupational
safety-related incidents throughout the complex, 2) DOE-wide trending and
analysis of occupational safety performance, and 3) lessons learned from
private industry practices and experience.
The success of this compendium depends on your involvement and
support. We welcome your comments and any suggestions for Observer
articles or topics for future publication. Please forward your comments
and suggestions to Rebecca Hansen, Operations Management Division,
EH-32.1, U.S. Department of Energy, 1000 Independence Avenue, S.W.,
Washington, D.C. 20585.
Joseph E. Fitzgerald, Jr.
Deputy Assistant Secretary
Safety and Quality Assurance
Plant Fire Ä Commercial Coal-Fired Plant
Fire During Plant Maintenance Results in Three Deaths
Maintenance outages at large plants involve the simultaneous
performance of varied work activities, often by several different
contractor organizations. Concern for fire prevention and safety is an
issue that all organizations and workers have in common. Fires do
not discriminate Ä victims are not necessarily those persons involved
in work that is related to the cause of the fire.
What Happened
A commercial coal-fired power plant in Indiana was shut down
for annual maintenance. The maintenance activities included manual
washing of the interior fiberglass liner of the 740-foot smokestack and
welding work in a de-sulfurization scrubber unit.
On October 5, 1992, contract workers, including three workers
on a platform at the 275-foot level, were inside the smokestack
performing the washing operation. Workers employed by another
contractor were welding a metal plate on the lower section of the
scrubber unit. Hot slag (molten metal debris) produced by the
acetylene welding of the plate fell onto plastic filter material about 20
feet below the welders. The slag ignited the filter material. Workers
attempted Ä but failed Ä to extinguish the flames with a hose. The
fire, fed by flue gases in the scrubber unit, spread and could not be
Page 2 Occupational Safety OBSERVER
extinguished. Smoke and gases from the fire followed the designed
flow path for plant exhaust gases þ out the scrubber unit and up
through the smokestack.
Workers at the scene, including the welders, escaped. About
fourteen workers fled the smokestack to the roof of the building and
were rescued by the combined use of a maintenance crane and a
rescue helicopter. The three workers inside the stack at the 275-foot
level were overcome by smoke and died.
The Investigation
Investigations by the company and Indiana Occupational Safety
and Health Administration (OSHA) have not been completed. Indiana
OSHA has yet to determine whether the power company or the
contractors violated workplace safety and health regulations. It is not
known whether the smokestack workers were equipped with
respirators or other life-saving equipment.
Applicable OSHA Standards
OSHA General Industry Standard 29 CFR 1910.252(a) covers
fire prevention and protection requirements associated with welding.
Section (a)(1) of the standard outlines basic precautions, which
include removing mobile fire hazards from the welding area, and
using guards to confine the heat, sparks, and slag produced from the
welding. Section (a)(2) contains more specific precautions and
requires fire watches for welding that takes place in locations where
serious fires could develop. This section also requires that immobile
combustibles be protected with flameproof covers during welding and
places responsibility for the safe conduct of welding on management.
Lessons Learned
Lessons learned regarding fire safety are equally applicable to
both private industry and the DOE complex. Based on preliminary
information, several lessons are to be learned from this incident:
o The potential for fire associated with welding operations must be
recognized and appropriate precautions must be taken.
o Planning and scheduling of the multiple work activities during a
plant outage or other large-scale operation must include
coordination and safety awareness among all worker groups.
o Work within a normally unoccupied or uninhabitable space (not
necessarily a "confined space" per se) must include safety
considerations such as communication, ventilation, and method
of egress.
o Workers must be properly trained in the use of manual fire
fighting equipment.
o Rote compliance with safety requirements (OSHA Standards,
NFPA Standards, DOE Orders, etc.) does not guarantee safety.
Awareness of the þbig pictureþ and application of common
sense are key ingredients of worker safety.
Procedures Violations
Occupational Safety OBSERVER Page 3
Electrical Incidents Ä Major DOE Concern
Accidents involving electrical currents are extremely serious
because of the potential for serious injury or fatality. Two recent
electrical shock incidents at DOE facilities illustrate the seriousness of
electrical shock incidents. Preliminary reviews of these incidents
indicate that both were caused, fully or in part, by non-compliance
with procedures and OSHA regulations.
What Happened
One incident occurred on September 9, 1992, at Rocky Flats
when two electricians were performing maintenance work on switch
gear. While one electrician was tightening a ground lead with an
allen wrench, the other electrician was holding the wire in place from
the bottom. The allen wrench slipped and made contact with an
energized buss bar located behind the insulating blankets. When that
contact was made, the electricians witnessed a flash and immediately
withdrew their hands from the panel. Both employees received flash
burns and small lacerations to their hands. They were treated on site
and at a local hospital, and returned to work later that day.
Ten days later, at Grand Junction, CO, a master electrician was
nearly electrocuted while changing fuses in a 480-volt fused
disconnect. A faulty switch mechanism had failed to disconnect the
power to the fuses, though the handle position indicated þoff.þ The
electrician proceeded with his work unaware that the fuses were
energized. While replacing the fuses, his right hand came in contact
with the bottom current Ä carrying section of the fuse, causing an
electrical arc through his hand to the adjacent fuse and knocking him
unconscious. A superintendent at the scene knocked the electrician
away from the fused disconnect, sent a nearby operator for help, and
began administering CPR to the electrician who had stopped
breathing. The electrician regained consciousness before the
emergency medical team arrived. He was hospitalized in the burn
unit for burns to his left hand and more severe burns on his right
hand. He was released the following day.
What Do These Incidents Have in Common?
Both incidents appear to have been caused by a violation of
OSHA requirements and site procedures.
In the September 9 Rocky Flats incident, both electricians were
performing "hands on" work in violation of the site Health and Safety
Practices Manual (H&SP). H&SP Section 15.00, Electrical Safety
Practices, states that when one person is working on exposed
energized electrical equipment at 480 volts or higher, a second person
is required as a standby for assistance. The second worker is not to
be assigned þhands onþ tasks or duties. In this case, one electrician
was torquing the allen wrench while the other was holding the ground
wire.
Preliminary investigation of the September 19 Grand Junction
incident suggests that a primary cause of the incident was a violation
of requirements designed to prevent personnel exposure to electricity.
The electrician placed the fused disconnect in the "off" position prior
to opening the panel, but failed to verify that the fused disconnect was
deenergized, as required. The electrician did not perform a voltage
test to ensure that the electrical current was disconnected. He also
did not use either insulated tools or gloves.
Page 4 Occupational Safety OBSERVER
Applicable OSHA Regulations
The actions taking place at the time of these incidents are
covered by the OSHA General Industry Standard 29 CFR 1910.333,
which covers electrical safety-related work practices. Several specific
subparts should be noted by all personnel involved in work on
electrical equipment.
OSHA General Industry Standard 29 CFR 1910.333(b) covers
working on or near exposed deenergized parts, including equipment
not yet locked or tagged. Subpart 1910.333(b)(2)(i) requires written
procedures for work on deenergized equipment to be available to all
workers. Section 1910.333(b)(2)(ii) requires that the circuits and
equipment to be worked on be disconnected from all electric energy
sources. Subpart 1910.333(b)(2)(iv) requires that before work begins
on any deenergized equipment, a qualified person must test and
confirm the deenergized state.
A verification that contacts have been disengaged is required by
29 CFR 1926.416 and was apparently not performed in the Grand
Junction incident. The requirements for locking and tagging circuits
that have been deenergized and are being worked on are described in
29 CFR 1926.417, and were apparently not followed in the Grand
Junction incident.
Protective equipment, including the use of fuse handling
equipment, is specified in 29 CFR 1910.335. Compliance with this
requirement could have mitigated the injuries suffered in the Grand
Junction incident.
Corrective Actions
A Type A Investigation of the Grand Junction incident is
currently being conducted as required by DOE Order 5484.1. The
incident at Rocky Flats prompted a termination of the work package
pending a review for electrical safety implications. Several sections
of the site Health and Safety Practices Manual have also been revised
to more explicitly describe the two-man "hands on" rule and what
constitutes its use.
DOE Response
Electrical safety is a high priority for DOE and actions are being
taken to address this significant safety concern. At the direction of
the Under Secretary, EH-1 has established a Task Group on Electrical
Safety, which will examine electrical safety and the adequacy of
existing procedures throughout the DOE complex.
How Can Accidents Like This Be Prevented?
There are several things that all DOE managers and staff can do
to help prevent similar electrical incidents at their facilities. First,
all sites should stress the importance of careful adherence to all work
procedures and requirements. Second, those procedures should be
reviewed and revised as appropriate, to ensure that they are sufficient
to prevent incidents of this kind. Third, managers should provide
written guidance to work crews clarifying work processes and safety
issues. Fourth, managers should ensure that all staff have the proper
training and experience necessary to perform tasks safely. Finally,
the fact that one of these cases was caused by equipment failure as
well as a procedural violation suggests a need for preventive
maintenance on all electrical systems.
Occupational Safety OBSERVER Page 5
These incidents illustrate the need for tighter administrative and
physical controls on energized electrical work. The set of corrective
actions resulting from the September 9 incident includes the provision
that all work orders involving work on or near energized equipment
must include a justification documenting why the work must be
performed in the energized state. This may lead to fewer occasions
for energized electrical work.
Protective Equipment
Protective Equipment Could Have Mitigated Chemical Spill
Incidents
On October 22, 1992, at the Industrial Wastewater Pretreatment
Facility at the Kansas City Plant, an experienced operator was
conducting a routine treatability test on a waste developer solution to
determine an appropriate method to recover silver. While conducting
this test, the reagents he was using (sodium hydroxide, calcium
chloride, and a commercial sodium hypochlorite preparation) reacted
violently and sprayed the operator's face, neck, and arms. Safety
glasses worn by the operator prevented injury to his eyes. (He was
also wearing a rubber apron.) However, he received second degree
burns to his nose and first degree burns to his wrist, arm, and
forehead. The facility was evacuated immediately and promptly
cleaned and decontaminated by a spill team dressed in protective gear.
Operations recommenced shortly thereafter.
In a separate incident at the Idaho Chemical Processing Plant on
October 16, 1992, an operator received minor injuries because he was
not wearing personal protective equipment (PPE) while performing
maintenance on nitric acid piping. The operator was purging a line
used to transfer nitric acid from a storage area to process makeup
tanks in a main building. A 20 psig air hose was connected to the
acid line at the storage area to purge the line to the main building.
The operator assumed that the purge was complete when the
liquid level in the receiving vessel stopped rising. However, some
acid remained in the transfer line. Since the work area had been
determined to be unsafe because an adjacent line was leaking acid, the
line purge work was conducted under a written Hazardous Work
Permit, requiring that the operator wear an acid suit, including a face
shield and rubber boots. The operator was apparently not wearing
any of the required PPE. When the operator disconnected the hose,
he was sprayed with 13 Molar nitric acid. He promptly used the
eyewash and an emergency shower and was taken to the site medical
center. He was examined later at a local hospital and released.
Applicable OSHA Regulations
Several OSHA regulations are pertinent to these incidents and
should be reexamined by all personnel engaged in work which
presents hazards that might require PPE.
The use of eye and face protection is discussed in 29 CFR
1910.133, which requires the use of appropriate protective equipment
whenever there is a risk of injury without such protection. Although
the operator at Kansas City who was wearing safety glasses did not
receive any injury to his eyes, he should have been wearing splash-
proof chemical goggles or possibly a full face shield for the type of
Page 6 Occupational Safety OBSERVER
operations he was performing.
Specific requirements for the design, construction, testing, and
use of devices for eye protection are contained in the American
National Standard for Occupational and Educational Eye and Face
Protection Z87.1 1968. The use of other personal protective equipment is
described in 29 CFR 1910, Subpart I.
Requirements for the communication of hazards posed by
chemicals in the workplace are contained in 29 CFR 1910.1200.
They include requirements for Material Safety Data Sheets and
training of employees in the use of personal protective equipment.
Corrective Actions
An investigation of the October 22 incident is currently being
conducted to determine the specific causes of the incident. As an
interim measure to the findings and recommendations of the
investigation, testing similar to that in the incident will be conducted
under a protective chemical hood.
In the October 16 incident, the area was immediately isolated to
prevent re-entry until clean-up had been conducted and the facility
could be returned to normal status. An investigation is currently
being conducted on the incident and the events surrounding the
incident.
Findings and further analysis of both incident reviews will be reported
in future editions of Occupational Safety Observer.
Lesson Learned
Routine tasks are often so familiar to us that they become
predictable. However, unexpected events, as illustrated here, can and
do occur. Therefore, proper use of PPE must become habitual in the
performance of our work tasks.
Fortunately, the personnel injuries in both of these incidents
were relatively minor. Either event could have resulted in serious
harm. Injuries similar to these can be prevented in the future with
the proper and consistent use of the appropriate PPE. PPE should
become another component of the "right tool for the job" philosophy.
Hoisting & Rigging
Monorail Trolley Falls Ä Near Miss to Worker
On September 29, 1992, a monorail trolley and chain hoist in
the C Reactor Stack area at Savannah River rolled off the end of a
monorail beam and fell to the floor. Six employees were reportedly
in the general area, including one individual who had passed under
the trolley only moments earlier and was approximately 8 feet away
when the trolley fell. Fortunately, no one was injured in the incident.
Because of the potential for injury, work in the C Reactor Stack area
was immediately stopped pending evaluation of the occurrence.
Recognizing the safety significance of the near miss, contractor
management upgraded the incident to an Unusual Occurrence.
Moreover, the September 29 incident appears to be a recurrence of a
similar January 1992 event, again with potential for severe personnel
injury.
Occurrence Evaluation Findings
Occupational Safety OBSERVER Page 7
A section of the monorail beam that supports the trolley was
removed to allow the non-routine movement of a 120-ton overhead
crane. Although the trolley was not in service at the time, some
unplanned activity, possibly a worker brushing against the chain hoist
hanging from the trolley, caused the trolley to move along the
monorail toward the removed section. Because no temporary rail
stops were installed at the rail ends when the monorail section was
removed, the trolley and hoist were able to roll off the unguarded
end.
One of the apparent causes of the trolley fall, as reported in the
10-day occurrence report, was the inadequacy of the Westinghouse
Savannah River Company (WSRC) Hoisting and Rigging procedure
that allowed the rail section to be removed without requiring rail stops
to be attached to the open rail ends. The contractor has identified a
need for hoisting and rigging training modules to include requiring the
installation of rail stops on an open rail system.
Corrective Actions
The contractor identified each of the following actions as means
of preventing a recurrence and disseminating the lessons learned:
o Evaluate the safety inspection program for the monorail system.
Identify the frequency that the monorail is inspected and whether
or not the inspection program includes evaluation of the chain
hoist and trolley, including the travel range of the trolley.
Verify that the inspection frequency is appropriate and that the
trolley travel range, without the beam section in place, is
evaluated. Revise the safety inspection criteria or define/adjust
the inspection frequency as required to ensure the safety of the
system.
o Review and evaluate the previously completed work package
that allowed disengagement of the removable monorail section.
Verify that the work package includes the proper instructions for
installing the rail stops or for otherwise restricting the trolley
from unplanned movement during times when the monorail
beam section is removed. Further consideration should be given
to the load-carrying capability of the monorail trolley and hoist
when the beam section and its supports are removed. Revise the
work package as required to ensure that the rail stops are
properly installed and the trolley is secure from movement or
service, as indicated by the evaluation.
o Determine if the splice plates that join the monorail at the
removable section joints would have prevented the trolley from
rolling off the beam end if they had remained attached to the
stationary ends of the rails. If these are found to act as effective
end stops, modify the subject work package to include leaving
the splice plates in place on the stationary beam ends.
o Evaluate the January 1992 occurrence to determine the status of
documented corrective actions and applicability to this event.
The contractor is pursuing the completion of these corrective
actions. Further evaluation of the occurrence will continue.
Page 8 Occupational Safety OBSERVER
Applicable OSHA Regulation
The requirements for inspection of overhead cranes are
contained in 29 CFR 1910.179(j)(1-2). The inspection should have
included the range of travel and condition of the rails.
In addition to the corrective actions implemented by the site,
another important consideration is the review of all work packages
before they are issued to the field. Specifically, if the work package
used to remove the section of monorail had been reviewed, it may
have come to the attention of the reviewer that a rail stop had not
been installed, and that the unsafe condition existed. The unsafe
condition could then have been rectified with the installation of the
rail stop.
Vehicle Safety
Potential for Vehicle-Slide Incidents Always Present
Two recent, potentially serious incidents at the Nevada Test Site
(NTS) serve as important reminders about the safe use of vehicles on
unusual terrain. The incidents both involved vehicles being operated
on or near slopes in soil that was previously disturbed. Although
both accidents could have resulted in serious injuries to the vehicle
operators, fortunately neither operator was hurt.
The first incident involved a water truck that was being used for
dust control on work performed at one of the NTS's radioactive waste
dumps. Dirt that was to be hauled into the subsidence to cover
recently deposited waste packages was stockpiled and sprayed to
minimize the amount of dust raised during the transfer. As the water
truck proceeded up the haul road along the top of the pile and began
spraying water, the dirt gave way under the truck's weight. The
truck slid a distance of approximately three feet down the slope on the
right side of the temporary road. Although there were no injuries and
the truck was not damaged, recovery of the water truck required the
use of heavy equipment.
Less than a week later at another site at NTS, a second incident
occurred that shared similar characteristics. At the time of the
incident, dirt banks around evaporation ponds were being
reconstructed using a roller-compactor equipped with roll over
protective structures. Apparently, the roller-compactor hit a soft spot
in the dirt, slid on the bank's slope, and rolled over onto its side.
The driver unfastened his seat belt quickly and jumped from the cab
before it completely rolled over. Although the driver was not
injured, the event had the potential to be much more serious.
An investigation is being conducted into the roller-compactor
accident, and no root causes have yet been established for either of
the vehicle slide incidents. However, no matter what the cause of the
incidents, they are a striking reminder of the delicate nature of
operating equipment on unusual, previously disturbed or potentially
unstable terrain. Operators and all personnel can help prevent injury
and equipment damage by being aware of the operating environment
and its potential dangers, and by maintaining familiarity with the
capabilities and safe operating envelope of the equipment they are
using.
Applicable OSHA Regulations
Occupational Safety OBSERVER Page 9
In the water truck incident, the edge-to-edge stability of the
access road is unclear. OSHA General Industry Standard 29 CFR
1926.602 outlines the requirements for moving equipment on access
roadways or grades, directing that vehicles be maneuvered only on
access roads or grades that can accommodate the vehicle.
OSHA General Industry Standard 29 CFR 1926.21 (b) (2)
requires that all personnel be trained to recognize and avoid unsafe
conditions. Both incidents may suggest an opportunity for improved
training in hazard recognition.
Mining Accident
Lock Out/Tag Out Violation
Kills UMTRA Employee
Sometimes taking a shortcut can save time and effort when
performing routine work tasks. However, when shortcuts violate
established safety procedures, the potential for a serious injury or
fatality multiplies. A Uranium Mill Tailings Remedial Action
(UMTRA) site employee was killed last May as a result of such a
violation.
What Happened
On May 1, 1992, a maintenance mechanic at the UMTRA site
near Grand Junction, CO, was fatally injured when he failed to shut
down heavy motorized equipment properly before entering the
adjacent area to perform a routine work inspection. The accident
occurred at a rock screening plant in an area beneath a large coarse
rock classifier, known as a grizzly. The area also contained a feeder
belt conveyor located directly below the grizzly and an inclined belt
conveyor.
Apparently, the mechanic decided to investigate some facet of
the grizzly or belt conveyor operation. He entered the small area
while both belt conveyors were in operation without telling the
screening plant operator of his intentions. The specific details of
what happened are unclear; however, it is known that the mechanic
was working alone and probably stood on a small, unstable pile of
crushed rock beneath the feeder belt to get a better view of the
operating equipment. He somehow got caught in a pinch point
between the feeder belt and its bottom return (or carrier roller). The
heavily loaded belt conveyor continued to pull him in, passing his
entire body, except for one foot, through the roller pinch point. He
died of multiple traumatic injuries. He was discovered by coworkers
within approximately ten minutes.
Several checks of vital signs revealed no pulse, but because of
the severe bleeding observed, CPR was not performed.
What Caused the Accident?
A Type A accident investigation was performed. It identified
several causes that ultimately led to the accident; however, one cause
stands out above all others. Because the cursory maintenance
inspection required the mechanic to enter a confined area, placing him
in close proximity to the moving belt conveyors, it would have been
prudent for the mechanic to either stay out of the area with the
equipment in operation or to shut down the operating machinery
Page 10 Occupational Safety OBSERVER
before entering. The UMTRA site maintenance and operating
contractors both have established Lock Out/Tag Out (LOTO)
programs in effect.
Corporate policies specifically state that, in this case,
particularly while working alone, the LOTO procedure should have
been followed. That is, the equipment should have been shut down
and the appropriate electrical isolation switches disconnected with
locking devices placed on their operating mechanisms. However, it
was determined that in recent practice, screen plant supervision
frequently condoned violations of the corporate LOTO policy, and
that the screen plant operations and maintenance crews had become
accustomed to taking safety shortcuts, including entering the area
beneath the grizzly without following the LOTO procedure.
Lesser causes that may have contributed to the accident include
the following:
o failure to implement a two-man work rule, which would have
provided another worker at the scene to respond by shutting off
the feeder belt;
o failure of the mechanic to notify anyone that he was going to
enter the area prior to making the inspection;
o failure to provide approved guards on pulleys and rollers, as
required by Mine Safety and Health Administration (MSHA)
policy;
o failure to remove the rocks and other operating debris
periodically from beneath the grizzly, thus providing additional
head space below the feeder belt;
o failure to provide conveyor start-up warning alarms on the belts
for remote equipment start-up;
o failure to develop and implement standard operating procedures
for the screen plant, including safety procedures for entering
inspection areas; and
o contractor management's failure to provide periodic training in
safety procedures to reinforce LOTO.
Applicable MSHA Regulations
Operations at the UMTRA site are conducted under the
jurisdiction of MSHA. The actions taking place at the time of the
accident are covered by the following MSHA regulations for metal
and non-metal surface mining, 30 CFR 56:
MSHA 30 CFR 56.14105, Procedures during repairs or
maintenance...repairs or maintenance of machinery shall be
performed only after the power is off....(NOTE: this is
comparable to the OSHA regulation for Lock Out/Tag Out
found in 29 CFR 1910.147.)
MSHA 30 CFR 56.14107, Moving machinery parts (a).... shall
be guarded to protect persons from contacting....drive head, tail,
Occupational Safety OBSERVER Page 11
and take up pulleys...and similar moving parts that can cause
injury: (b) guards shall not be required where the exposed
moving parts are at least seven feet away from walking or
working surfaces.
MSHA 30 CFR 56.14201, Conveyor start-up warnings (b) when
the entire length of the conveyor is not visible from the starting
switch, a system which provides visible or audible warning shall
be installed and operated to warn persons that the conveyor will
be started.
MSHA 30 CFR 56.14112, Construction and maintenance of
guards (b) guards shall be securely in place while machinery is
being operated....
Lessons Learned
Many contributing causes could have been prevented. However,
the most regrettable circumstance is that adequate LOTO procedures
were already developed and in place. UMTRA contractor
management and supervision should have emphasized adherence to
these procedures and provided periodic training in their use.
DOE Order 5483.1A, dated June 1983, requires DOE compliance
with OSHA regulations, including those listed in the Observer.