EH-9402 Issue No. 02, February 1994 Occupational Safety Observer
FEBRUARY 1994
Occupational Safety Observer
Special Protection Required:
PROTECTING ELECTRIC UTILITY WORKERS FROM FALLS
Falls from power transmission structures are among the most serious
hazards faced by electric utility workers. Yet, when the Western Area Power
Administration (WAPA) began to increase its efforts to prevent falls, it found
that fall protection for utility workers was a new concept in the electric
power industry. Nevertheless, for the past 3 years WAPA has been working to
demonstrate that a variety of techniques, including an emphasis on employee
involvement, can be used to help prevent falls.
Background
In January 1991, the Secretary of Energy requested an extensive
investigation of and renewed emphasis on fall protection. Records from WAPA's
inception in 1977 show that employees had already reduced falls from
transmission structures (towers and poles). However, in response to the
Secretary's request, WAPA and its employees began increasing their efforts to
improve safety for workers, including formation of (1) the Ad Hoc Fall
Protection Task Force, (2) the Fall Protection Steering Committee, and (3) the
Engineering Design Group. Since 1991, only three WAPA employees have fallen
from elevated surfaces (such as stairs, step ladders, and the tops of vehicles
or other equipment), compared with 15 falls from these types of surfaces
during 1988-91. WAPA credits employee motivation for the improvement.
Employees participate extensively in WAPA’s safety program. For example, the
Ad Hoc Fall Protection Task Force, made up primarily of employees, is
responsible for analyzing work practices and recommending fall protection
measures. These recommendations are eventually adopted and implemented by the
Fall Protection Steering Committee and the Engineering Design Group.
Elements of the fall protection program
WAPA identified several elements of a successful fall protection
program. In addition to the standard physical work positioning system, which
typically consists of a harness and safety strap (see "Fall Protection for
Iron Workers," Observer, July 1993), good climbing skills are crucial.
Equipment and tower design factors are also important. For example, nonskid
walking surfaces must be used on equipment and ladder rungs, and communication
towers can be retrofitted to ensure that workers are anchored to the structure
at all times.
The Fall Protection Task Force recommended a variety of safety measures
that collectively embody the elements of a good fall protection program. One
of the most important of these measures is a process that considers whether
climbing is necessary to complete specific tasks. (WAPA supervisors found
that climbing towers to perform routine inspections was often unnecessary.)
Other measures include testing anchorages before climbing, changing substation
designs to accommodate aerial devices (such as lifts) to protect workers,
working with fall arrest equipment manufacturers and suppliers to improve
equipment reliability, adding ladders and rails to new steel pole designs, and
requiring rails and nonskid surfaces on new equipment.
WAPA employees are developing fall prevention training, and vendors have
significantly improved equipment over the past 3 years. WAPA is also
cooperating with industry leaders and OSHA to develop fall protection
standards, but further work is needed to improve structural designs, work
procedures, and equipment and training for fall protection systems.
Lessons learned
The WAPA experience indicates that ensuring worker safety on elevated
structures requires identification of hazards and development of plans to
resolve these problems. WAPA uses integrated teams of managers and employees
to focus on the problem of fall prevention. These teams attribute their
success to (1) employee and management commitment to safety first; (2) worker
motivation, knowledge, and skill; and (3) empowerment of workers to make the
job site safe.
Preventing falls requires that employees and managers work jointly
toward the goal of eliminating falls. John Bomar, Director of the WAPA
Division of Safety, notes that he has often heard that working in the
electrical utility industry is inherently hazardous. Accidents are regarded
as an inevitable part of the job. Bomar challenges this attitude: "If we
change our expectations as we approach a hazardous work situation with
improved planning, training, and hazard recognition, we can eliminate the
suffering and costs of accidents. Working together, we can identify and
eliminate unsafe attitudes and conditions from our workplace."
$6-Million Fine Imposed:
OSHA Investigates Plant Explosions
On June 3, 1993, in the early hours of the morning, four explosions
struck a gunpowder plant in Kenvil, New Jersey. The plant stretched over 6
square miles and included 40 buildings. Four buildings were destroyed by the
explosions, and five were damaged in the subsequent fire. Windows were broken
over a 6-mile radius, and 80 percent of the businesses in a nearby town were
damaged. Because the incident occurred on a weekend, only 50 employees were
on site--12 of whom were injured, 3 of them seriously.
Results of OSHA investigations
The OSHA investigation found two root causes that relate to the DOE
complex: (1) failure to exercise good housekeeping practices when dealing
with hazardous substances, and (2) failure to comply with regulations
affecting safety. The initial investigation concluded that the explosions
could have been minimized or prevented if production equipment had been
routinely cleaned.
OSHA inspectors have returned to the plant several times since the
initial inspection, but the company has not addressed their findings. In
September 1993, OSHA levied $6 million in fines against the company for 71
violations. Twenty-one of the violations were considered :willful," and 48
were considered "serious." Among these were failure to provide adequate
ventilation for a chemical storage area and failure to address chemical
decontamination procedures in the emergency response plan for the plant.
The regulations
The explosions at this site were caused by the generation of heat and by
failure to clean equipment properly, two issues addressed in 29 CFR 1910.109,
which includes the following requirements:
-- Equipment should be subject to regular and periodic flushing, cleaning,
dismantling, and inspection.
-- A collection system for dangerous residues should be provided in areas
where these residues may accumulate.
-- Daily visual inspections should be conducted, and a program should be
implemented for conducting systematic maintenance according to a regular
schedule.
-- Equipment must be designed to minimize the possibility of frictional
heating.
OSHA regulations stipulated in 29 CFR 1910.22 include general
housekeeping requirements affecting all work areas, passageways, storerooms,
and service rooms. OSHA requirements related to the production, storage, and
use of explosives also stress cleanliness, order, and sanitation:
-- 29 CFR 1910.109(c)(5)(iv) requires that magazine floors be swept
regularly; kept clean and dry; and maintained free of grit, paper, and
rubbish.
-- 29 CFR 1910.109(g)(2)(vi){b} requires that the floors and equipment of the
mixing and packaging room be cleaned regularly and thoroughly to prevent
accumulation of oxidizers, fuels, or other sensitizers.
-- 29 CFR 1910.109(g)(5)(iv) requires that the interior of warehouses used
for storing blasting agents be kept clean.
In addition, 29 CFR 1910.109 (k)(2) specifically states that
manufacturers of explosives must meet the requirements of 29 CFR 1910.119, the
Process Safety Management Standard, which specifies that hazards and
procedures must be analyzed to prevent or mitigate recognized hazards.
Lessons learned
The accident at the gunpowder plant suggests the following lessons
learned, which apply to all industrial settings:
-- This accident was caused by failure to maintain work areas that were free
of hazardous accumulations. DOE facilities often work with substances that
present either an explosive or radioactive hazard. Such materials necessitate
good housekeeping practices.
-- Identified workplace hazards must be corrected. Management must develop
and implement formal plans to resolve identified hazards. Failure to comply
with this requirement can result in fines and criminal penalties.
-- The hazards of any process must be identified and addressed when
facilities are designed and procedures are developed. Plant design and
operating procedures must be periodically assessed and modified to ensure the
continued safety of both workers and the surrounding community.
Pre-Lift Inspection Identifies Defective Crane:
Good Lift Plans Promote Safe Hoisting and Rigging Operations
Hoisting and rigging operations are inherently dangerous. Because of
this fact, the DOE Hoisting and Rigging Manual requires that "critical lift"
plans be prepared and approved by management before work involving cranes
commences. The following incident relates how implementation of one good lift
plan helped to avoid a potential accident.
The incident
On August 18, 1993, workers at the FUSRAP (Formerly Utilized Sites
Remedial Action Program) site near Aliquippa Gap, Pennsylvania, were preparing
to remove two large turret exhaust units from the roof of a building
contaminated with radioactive material. Because the removal of the structures
involved the use of a crane, a detailed lift plan was drafted for the
operation. The lift plan included a requirement to conduct a visual
inspection of the crane before the operation began.
The crane, which had been rented from a local equipment agency, arrived
on schedule and was inspected against the checklist provided in the lift plan.
The inspection identified a number of safety defects that had apparently been
caused by improper operation of the crane and lack of appropriate maintenance.
These defects included damaged welds on the jib gantry sheave, excessive
lateral play in the jib hook retaining pin, and an inoperative anti-two block
safety device. Based on the results of the inspection, the site
superintendent rejected the crane and notified the equipment rental agency.
The rental agency immediately designated the defective crane as
out-of-service and replaced it with a newer model, which was inspected and
found to be acceptable. Although the removal operation was delayed for
several hours, the work was conducted without further problems.
Lessons learned
In this incident, a well-developed and implemented lift plan was
instrumental in avoiding a potentially serious accident. Proper lift planning
promotes a deliberate, disciplined approach toward lifting operations, while
focusing on the identification of unsafe conditions. When implemented by
trained and knowledgeable personnel, a formal lift plan is an effective way to
prevent incidents and personnel injuries.
[Editor's note: An upcoming issue of The Safety Connection, a quarterly
publication of the Office of Safety and Quality Assurance, will include an
article on the development of plans and procedures for "critical lifts."]
Letter to the Editor
As a followup to the Observer's November 1993 feature article, it should
be noted that the crane operator's attention was focused almost completely on
maneuvering the load suspended from the auxiliary hook. As a result, he did
not notice the two-blocked condition of the primary hook cable, which
eventually snapped. Also not mentioned in the article were the mispositioning
of the signal worker, who should have been directly in line with the boom and
in the operator's line of sight, and the absence of a tag line, which the
signal worker could have used to assist in maneuvering the load. These
procedural failures contributed to the accident.
Information regarding what constitutes proper operator training, load
rigging, and signal worker positioning can be found in the DOE Hoisting and
Rigging Manual.
Edward Patigalia
DOE Hoisting and Rigging Program Manager
(301) 903-3972
Danger From Above:
Hard Hats Protect Workers
In two recent incidents, workers were struck and injured by falling
objects that were dislodged from loads hoisted overhead. In both cases, hard
hats worn by the workers prevented more serious injuries from occurring.
The incidents
The most recent incident occurred at the Super-Conducting Super Collider
Site on October 13, 1993, when workers were preparing to lower two conveyor
belt rollers down the personnel shaft at the N35 Site. The rollers were
secured in a sling. When a worker pulled the tag line to adjust the load, the
line slid along the roller and dislodged a 10-pound bearing on the end. The
bearing fell 200 feet down the shaft, ricocheted off the lower shaft wall, and
bounced into an adit (a nearly horizontal mine shaft), hitting a worker
standing 10 feet inside the adit. The bearing struck the worker's hard hat,
which he was wearing backwards, and hit him on the forehead, knocking him to
the ground.
An earlier incident occurred at the Nevada Test Site on May 5, 1993,
while a flagpole was being raised. An ironworker steadying the base of the
pole was struck on the head and shoulder by a piece of wood that came loose
when the crane operator inadvertently released tension on the choker. The
worker initially declined medical attention but received treatment for
cervical injury the next day. He underwent neck surgery about 2 months after
the incident.
Lessons learned
These two incidents suggest a shared lesson learned regarding the use of
hard hats:
-- Wear your hard hat, and wear it properly. Hard hats are vital pieces of
personal protective equipment. They should be worn near hoisted loads and in
all other situations for which they are required. Workers who wear their
equipment improperly do not receive the maximum benefit of its protection.
Whenever loads are hoisted overhead, there is always a danger that
something will fall. To mitigate this danger, the following precautions
should be taken:
-- Stay clear of hoisted loads. Workers should take all reasonable
precautions to avoid placing themselves beneath a hoisted load.
-- Always pay attention to your surroundings. In the incident at the Nevada
Test Site, the crane operator's momentary distraction allowed the choker to
become slack.
-- All loads must be thoroughly checked before they are moved. Loose items
must be properly secured or removed and hoisted separately. Rigging should be
appropriate for the lift.
OSHA regulations cited in 29 CFR 1926.100 and 29 CFR 1910.135 require
that workers wear hard hats whenever there is a danger of head injury
resulting from impact, falling or flying objects, electrical shock, or burns.
Hard hats should meet the requirements of ANSI Z89.1-1969.
References
HQ--URA-SSLL-1993-0021
NVOO--REEC-OMD2-1993-0001
Soldering, Welding, and Vacuuming:
Inadequate Work Controls Cause False Alarms
In three recent incidents, repair or maintenance workers inadvertently
initiated fire alarms when their activities generated smoke or airborne dust.
In each case, the work control process was inadequate because no actions were
taken to prevent false alarms.
The incidents
The first incident occurred at the Oak Ridge Institute of Science and
Education on September 20, 1993. A worker was soldering joints during the
installation of an air conditioner in the Energy Building. Smoke caused by
the soldering work activated a nearby smoke detector, which sounded a fire
alarm. The building was evacuated, and the Oak Ridge Fire Department
responded. After it was determined that there was no fire, people returned to
work, the alarm was deactivated, and a fire watch was established until the
soldering was completed.
The second incident occurred on September 21, 1993, in the Defense Waste
Vitrification Facility at Savannah River Site. Construction workers operating
a vacuum in the 292-S West Electrical Room raised enough dust to activate the
room's smoke detector. Work was halted while the building was evacuated.
When the cause of the alarm was determined, the building was returned to
normal operation.
The third incident occurred at the In-Tank Precipitation Facility at
Savannah River Site on September 23, 1993. A welder was working on the door
to the 241-96H laboratory, and a fire watch was posted. Both the welder and
the fire watch were aware that there was a smoke detector in the laboratory's
vestibule, but they believed it was out of range. When smoke from the welding
operation activated the alarm, the building was evacuated.
Lessons learned
Maintenance and construction activities will routinely generate dust or
smoke that can activate smoke detectors. A crucial part of the work planning
process involves taking steps to anticipate these situations.
The work order process should include provisions to evaluate the
likelihood of a false fire alarm, and specify what preventive actions should
be taken. If there is a high probability of a false fire alarm, the alarm
system should be temporarily removed from service and a fire watch should be
posted. DOE 5480.7A requires that workers take special precautions when fire
alarms are out-of-service.
False fire alarms are not uncommon, and they are not benign. False
alarms tend to desensitize personnel to the need to respond quickly and
appropriately to alarms. In addition, there is always the danger of an
accident while fire equipment speeds to the scene. Building evacuations can
also cause security and safety problems. False alarms can be prevented by
examining the work environment to identify sources of dust and smoke and by
modifying the work plan accordingly.
References
ORO--ORAU-ORISE-1993-0011
SR--WSRC-WVIT-1993-0090
SR--WSRC-ITP-1993-0036
FEATURE ARTICLE
Know Your System:
OPEN GAS LINE GOES UNDETECTED
Personnel working with potentially dangerous substances and energy
sources must take extra care to ensure that they follow established procedures
and to notify other workers in the area that these activities are in progress.
The incident
In May 1993, modifications were under way at Lawrence Berkeley
Laboratory to divide a research laboratory into two rooms. As part of this
effort, a fume hood was removed. This meant that utility lines servicing the
hood had to be disconnected, including natural gas lines. The Facilities
Maintenance and Operations organization was tasked to shut off and tag out a
branch of the gas manifold so that the contractor assigned to the remodeling
project by the Architect-Engineering organization could proceed with its work.
The project was completed by the contractor and accepted by
Architect-Engineering in September 1993, when Maintenance and Operations was
tasked to restore the natural gas supply for one of the two labs. A visual
inspection of the area was conducted to verify the position of the gas valves;
the tag on the gas manifold was removed; and the manifold valve was opened to
start the flow of gas. On returning to the lab, a technician smelled gas.
After finding--and subsequently closing--a partially opened valve, the
technician assumed that the problem had been identified and resolved.
Several minutes later, a lab technician entering the area smelled the
odor of natural gas. He immediately notified the building manager, who
initiated a general evacuation of the building. Maintenance and Operations
shut off the gas at the manifold. During an inspection of the lab, workers
found a second gas line that was hidden behind a stack of boxes. The control
valve had been removed from the line.
The investigation
Investigators determined that the second line had been overlooked when
gas service was restored to the lab. They concluded that communication and
coordination between the Architect-Engineering and Maintenance and Operations
organizations had been inadequate. The investigation found that the on/off
valve at the end of the second gas line had been disconnected to permit
removal of the fume hood; however, the valve had not been replaced and the
line remained open.
The investigation indicated that Maintenance and Operations personnel
did not work from an accurate set of drawings showing all utility lines that
were affected by the remodeling effort. In addition, the investigation found
that no written procedures had been established for restoring natural gas
service. The planning package included directions for handling hazardous
materials such as chemicals and asbestos, but it did not cover the potential
hazards associated with natural gas.
Lessons learned
This incident suggests several lessons related to modification control,
in general, and lockout/tagout procedures for handling natural gas, in
particular:
-- Develop a detailed project plan. All organizations responsible for
operating and maintaining a facility should be involved in the facility
modifications. During the planning stage, all affected utilities must be
identified and reported to the appropriate organizations. The completed plan
should require thorough inspections of all utility lines. After the project
is finished and before locks and tags are removed, each organization must
ensure (1) that utility modifications have been completed as specified in the
project plan and (2) that the configuration and location of all utility
services are known.
-- Conduct a walkdown before restoring service to a system. Personnel
responsible for restoring or installing utility services should conduct a
thorough walkdown of the system to ensure that all components have been
identified.
-- Provide warnings and cautions about potentially hazardous energy sources.
Work order packages should contain specific procedures for removing or
restoring utility services. Such procedures should include requirements
related to performing leak checks and using special tools or equipment.
Workers should be trained to use these procedures, and work orders should
clearly identify the person responsible for ensuring that procedures are
followed.
-- Update as-built drawings. As an integral part of any project, facility
drawings and other documents must be updated to reflect the as-built
configuration of all utility lines.
-- Use appropriate equipment to identify leaks. Don't rely on your nose to
detect substances (such as natural gas and propane) that contain aromatic
additives. Even a brief exposure to these substances can cause the sense of
smell to become desensitized.