EH-9501 Issue No. 1, January 1995 Occupational Safety Observer
January 1995, Vol. 4 / No. 1
In This Issue
Steel Frame Collapses ...................................1
Truck Carrying Low-Level Waste Overturn .................2
Unsecured Steam Supply Involved in Two Near Misses ......4
Puget Sound Shipyard Fatality ...........................5
Chemical Accidents ......................................5
Worker Escapes Eye Injury ...............................7
Follow Industry Standards
Steel Frame Collapses
On September 9, 1994, the steel frame of a building under construction
at the Idaho National Engineering Laboratory (INEL) collapsed during a
windstorm. The building, designed to be a Type II storage module, had
65 percent of its frame in place. Unsure about the safety of the
incomplete structure during the high winds, the subcontractor had
suspended work only 18 minutes before the collapse.
Immediately after the incident, the DOE Idaho Operations Office
convened an accident investigation committee to conduct a Type B
investigation. The effects of wind load on the unsecured structure
were analyzed. In addition, certified metallurgists and experts from
the American Welding Society conducted a survey for evidence of faulty
welds, counterfeit bolts, or improper workmanship--none of which was
found. The results obtained by these outside experts coincide with
DOE's preliminary findings, which suggest that the structural design
was adequate.
The investigation found, however, that the structure had not been
erected in compliance with standard industry practices. In this
instance, wind forces on the frame exceeded the load capacity of the
structure's temporary 3/4-ton cable supports, which were insufficient
in both number and strength to prevent failure under prevailing wind
conditions. Once the cables broke, the wind force exerted on the
structure caused the roof to bow and move the structure off center,
ultimately leading to the collapse.
Because prefabricated buildings are made of lighter components, the
effects caused by wind and other loads on partially completed
structures must be carefully considered. Some of the individual
components may be relatively weak, but when they are connected with
other components, however, they establish the building's overall
integrity.
Three other buildings at INEL have designs similar to that of the
collapsed structure--two of which have stood for more than a year with
no reported problems. Nonetheless, concern for the integrity of these
buildings prompted another in- vestigation by DOE, which con- cluded
that no correlation exists between the collapsed frame and the other
buildings.
Lessons Learned
Suspension of work because of suspected dangerous conditions is often
the best way to protect worker safety and health. In this case, a
knowledgeable supervisor recognized the hazard, suspended work, and
removed his crew from a dangerous situation.
Standard industry practices should always be followed when a building
is being constructed. Implementing a detailed construction plan based
on guidance provided by the designer and using properly trained
professionals can mean the difference between success and failure.
In this instance, site investigators recommended formal communication
between the designer, fabricator, and builder, which might assist
management in anticipating such problems and taking steps that could
prevent an accident of this magnitude.
References
ID--MKF-MKEM-1994-0006
Effective Response
Truck Carrying Low-Level Waste Overturns
At 5:45 p.m. on October 1, 1994, a tractor-trailer transporting
low-level waste from the Fernald Environmental Management Project
(FEMP) to the Nevada Test Site overturned near St. Louis, Missouri.
FEMP personnel responded appropriately to the accident, even though it
occurred more than 500 miles away.
The Incident
The tractor-trailer, traveling on Interstate 44 west of Rolla,
Missouri, was transporting a large metal container on a flatbed
trailer. The container was filled with construction debris classified
as low-level waste.
When the driver pulled into the left lane to pass a slower car, he
failed to follow the curve of the lane because his attention was
focused on the right-hand mirror. The left front tire of the truck
went off the road. The driver managed to bring the tire back on the
road, but in doing so, he lost control and the truck overturned. The
chains securing the container broke, allowing the container to slide
upside down into the median. The tractor and trailer came to rest on
their sides in the road. The driver was not injured.
The Response
A state hazardous materials (HAZMAT) team from Fort Leonard Wood
responded to a call from the Missouri Highway Patrol. The HAZMAT team
performed a preliminary radiological survey and found no evidence of
contamination.
When informed of the accident at about 6:00 p.m., FEMP activated its
emergency operations center (EOC). Reasoning that FEMP personnel would
be better trained and equipped to handle a potential container breach
during the cleanup operation, the EOC requested that the accident scene
be secured until the FEMP response team could arrive.
The response team consisted of two radiation technicians, the
low-level-waste shipping manager, and the Acting DOE Branch Chief for
waste management. An airplane was chartered to transport the team. The
EOC also developed a radiological assessment plan, a container
integrity assessment plan, and a lifting and rigging plan.
Meanwhile, EOC personnel maintained constant contact with emergency
responders at the scene of the accident. The Phelps County Sheriff's
office maintained a perimeter at a radius of 100 feet, and the tractor
and trailer were safely righted at 7:36 p.m.
The FEMP team arrived about 7 hours after the accident occurred and
immediately conducted a radiological survey of the container and the
path it had taken across the median. Like the HAZMAT team, the EOC
team found no evidence of contamination.
The team decided to wait until dawn to turn the container right side
up. Police blocked traffic as the operation began. Two cranes were
used to roll the container off its roof and onto its side. It was
again evaluated for integrity, and no contamination breach was found.
The container was then righted and loaded onto the original trailer,
which was relatively undamaged. The container was transported to a tow
yard, where it was moved to another trailer and transported back to
Fernald without further incident.
The Cause of the Accident
The police report attributed the accident to driver error. There were
no indications that the driver had been abusing controlled substances
or that he suffered from fatigue, but police consider the stretch of
road on which the accident occurred to be dangerous.
According to Traffic Safety Facts 1992: Large Trucks, published by the
U.S. Department of Transportation, "failure to keep in lane or running
off road" is one of the main causes of fatal accidents involving large
trucks.
In this case, the road had an 8-inch "crown" (or drop-off designed to
facilitate drainage), which apparently caused the driver to lose
control.
Lessons Learned
DOE is committed to ensuring the safe transport of its materials. When
accidents do occur, however, effective transportation emergency plans
such as the one developed at FEMP protect the health and safety of the
public and the environment. Offsite accidents involving hazardous
materials pose a special challenge because civilian responders may not
be trained to deal with these materials or because they may not be as
well trained as DOE personnel. Despite the logistical problems
associated with this accident, FEMP's response was quick and effective
because the response plan had been developed long before the accident
occurred.
Several factors must be considered when developing such a plan:
o Access to a team with a broad range of skills. FEMP had access to
experts in diverse fields, such as health physics and public
relations.
o Ability to contact team members at any hour of the day or night. Use
pagers or cellular phones as necessary, and be sure to provide backup
personnel for people who will be unavailable because of vacation,
travel, or illness.
o Assurance that the team has a place to work. Team members should have
easy access to telephones, fax machines, radios, and computers.
Administrative support should also be readily available.
o Preparation to deal effectively with the press and next of kin in the
event of a fatal accident.
o Indepth preparation through practice drills and exercises. The EOC
should know that the emergency response system will work before the
team reports to an accident scene.
Reference
ORO--FERM-FEMP-1994-0074
Isolation Errors
Unsecured Steam Supply Involved in Two Near Misses
In two separate incidents in October 1994, an unsecured steam supply
created hazardous situations that almost resulted in serious injury.
At the Idaho National Engineering Laboratory (INEL), a worker
replacing part of a heating system was burned when he inadvertently
opened the supply line upstream of the isolation valve. At Rocky
Flats, a worker was splashed with acid after opening an inspection port
on a tank with a misaligned steam bypass valve.
The INEL Incident
A pipefitter narrowly escaped serious injury while replacing a leaking
section of steam supply line. The local steam supply valve had been
tagged and locked out, and the trap bypass valve was closed to provide
single isolation of the work area from the steam supply.
In an effort to drain the leaking line before beginning the replacement
operation, the pipefitter loosened a union downstream from the closed
valve. Condensate in the line quickly filled a 3-gallon bucket. At
that point, the pipefitter decided to use a hose to drain the line. He
located a capped drain on the line and removed the pipe cap to fit a
hose bib on the opening. As soon as the pipe cap was removed, it was
evident that pressure in the line was too high either to attach the
hose bib or to replace the pipe cap. As the pipefitter prepared to
leave the work area, live steam began to blow through the opening in
the line. The main steam supply was quickly shut down to stop the
leak. Although the pipefitter was sprayed with cold condensate, there
were no injuries.
An investigation found that the uncapped section of the line was
upstream of the closed valve. Investigators determined that the
facilities engineer who authorized the job had instructed the
lockout/tagout crew to isolate the wrong valves--and none of the valves
in the work area were labeled. Further, the crew failed to obtain a
hot work permit, which would have provided the pipefitter with better
information about valves and hot lines in the work area and about any
unusual isolation problems.
The Rocky Flats Incident
A slightly different problem with steam supply occurred at Rocky
Flats. In this instance, night shift workers began heating a solution
used to descale heat exchangers. For proper operation, the tank must
be 82 percent full. Thirty minutes after work began, an alarm
indicated that the tank level was at 100 percent.
Operations personnel responded to the alarm. After determining that
all tank inlet valves were properly set, the crew found no obvious
explanation as to why the tank filled completely. An operator climbed
on top of the tank to remove the inspection port. When he released the
last clamp holding the port in place, pressure inside the tank forced
the inspection port off the tank and the operator was sprayed with a
small amount of acid solution. The worker received second-degree
thermal burns on the back of an arm and a leg. His arm and leg were
rinsed with water, and he was transported to a local hospital, where he
was treated and released.
A subsequent investigation indicated that a steam supply bypass valve
to the heating coil was misaligned, which increased the amount of steam
going to the coil. The valve was also mislabeled. In all, about 85
gallons of acid solution escaped from the tank.
This situation violated at least two Federal Regulations. First,
management failed to provide a safe working environment as required
under the OSHA General Duty Clause [U.S.C. 654(a)]. Further, the
operator failed to comply with the provisions of U.S.C. 654(b), which
establishes standards for the safe operation of equipment. Finally,
the tank should have been subject to the lockout/tagout requirements
set forth in 29 CFR 1910.147(d), "Control of Stored Energy."
Lessons Learned
These incidents can be attributed to poor work planning due to
inadequate configuration management. As specified in 29 CFR
1910.147(d)(6), isolation of a work area must be verified before the
task begins. For single isolation, a full review of flow diagrams,
connect diagrams, and permit requirements should ensure that the
correct valves are identified to secure the work area. These
assurances cannot be made without a full and accurate set of as-built
drawings.
It is imperative to exercise extreme care when working with steam and
other high energy sources. In the Rocky Flats incident, a series of
errors at different times caused a potentially serious accident. When
working with steam, double-checking repairs and labeling is crucial.
Removing a port in a pressurized tank is a high-risk maneuver. All
requirements stipulated in 29 CFR 1910.147 must be carefully followed.
References
ID--LITC-LANDLORD-1994-0001
RFO--EGGR-LIQWASTE-1994-0022
Crane Accident
Puget Sound Shipyard Fatality
Proper training could have prevented a fatal accident at the Puget
Sound Naval Shipyard on August 24, 1994. The incident took place
aboard the aircraft carrier U.S.S. Nimitz, which is currently
undergoing an 11-month overhaul.
A crane rigger was working near a Lorain 45 T rough terrain crane with
a two-blocked cable when the cable broke, dropping a 200-pound metal
ball on his head. Both the hook and the ball fell nearly 40 feet
before striking the victim. The crane, which was not carrying a load,
was being positioned to make a lift when the accident occurred. The
reason the cable broke was unknown at press time.
According to OSHA investigators, the accident was caused by improper
operation of the crane. Further investigation indicated that other
workers also lacked proper training and were unfamiliar with the load
charts or the computerized indicators controlling the anti-two-block
device. Moreover, workers were permitted to operate machinery without
fully understanding the operating instructions, thereby creating an
unsafe working environment.
On September 16, 1994, OSHA issued a citation to the Puget Sound Naval
Shipyard for violation of 29 CFR 1915.117(b), stating that "employees
who did not understand the signs, notices, and operating instructions,
were permitted to operate a crane, winch, or other power-operated
hoisting apparatus."
Procedural Errors
Chemical Accidents
In separate incidents at Pacific Northwest Laboratory (PNL), Fermi
Laboratory, and Westinghouse Hanford Company (WHC), inattention to
detail combined with inexperience and failure to follow routine
procedures produced a series of chemical accidents.
The PNL Incident
At PNL, on July 16, 1994, a fire occurred in an open chemical hood
during routine distillation of 1.5 grams of tetrahydrofuran (THF)
benzophenone and 1.5 grams of potassium metal. Warming was done under
positive nitrogen atmosphere in a 1-liter, three-neck flask equipped
with a water-cooled condenser/solvent collector, nitrogen gas source,
and pressure relief bubbler. As the sample was warmed to the reflux
temperature (65.3 oC), an increase in pressure dislodged a ground glass
stopper in the three-neck flask. THF and potassium metal escaped. The
vaporized THF was ignited by the potassium, which in turn set fire to a
portion of the remaining THF, several rubber laboratory gloves, and the
rubber vacuum hoses.
Laboratory workers activated the fire alarm and evacuated the
building. The fire was not intense enough to activate the sprinkler
system, but some floor tiles near the hood were scorched. A building
security worker put out the blaze with a hand-held extinguisher. No
injuries resulted.
The distillation procedure was performed by an inexperienced worker who
was not properly supervised. Thus, management's failure to ensure that
established procedures were followed led to faulty implementation of
the distillation process, which in turn caused the fire.
The Fermi Incident
On August 4, 1994, two workers at Fermi were exposed to nitrogen
dioxide (NO2) while removing piping from a tank. Before work began,
the tank discharge line was flushed to the pump suction valves, which
were then locked and tagged shut. The workers assigned to the task
wore personal protective equipment, but they did not use NO2 monitoring
equipment.
When the workers cracked the first bolts on the downstream side of the
valve, as expected, a small amount of green liquid drained into a catch
bag. As the workers continued to loosen bolts on the valve, a larger
quantity of green liquid was discharged. At this point, one worker
experienced a burning sensation in his eyes and lungs. He quickly
retightened all bolts and left the area. After reporting the incident
to his supervisor, he reported to the medical service unit. No other
workers were exposed. An industrial hygienist surveyed the work area
and found an NO2 reading of 1.4 parts per million (ppm) around the
catch bag. The maximum short-term exposure allowed by OSHA is 1.0
ppm. The exposed worker was treated and suffered no ill effects.
After the incident, an investigation determined that the worker had
loosened the bolts on the wrong side of the locked and tagged valve.
Root causes included a poorly developed work plan, inadequate briefings
for workers, failure to obtain required permits, and lack of adequate
equipment at the job site.
The WHC Incident
On August 9, 1994, a nuclear process operator at WHC was sprayed during
the release of about a half-gallon of liquid from a 55-gallon drum
containing soil sludge. The sludge, containing about 1 ppm carbon
tetrachloride, had been packed by another Hanford contractor and sent
to WHC for shipment to the non- radioactive hazardous waste storage
facility. The accident occurred when, in accordance with published
procedures, the operator adjusted a drum-locking ring to align the lids
and rings with the labels. The drum lid blew about a foot into the
air, and the liquid splashed onto his left leg.
The operator removed his coveralls and was transported to the first-aid
unit for evaluation. The Hanford Hazardous Materials Response Team was
called to the accident scene, where responders released pressure in 11
more drums by puncturing a small hole in each lid.
Built-up pressure in the drum was the result of inadequate headspace.
When liquids are packed in a container, 49 CFR 173.24(h) requires that
sufficient headspace be left to allow the liquid to expand. Liquids
must not fill any receptacle completely at a temperature of 55 oC (131
oF) or less. Further, the drum lids, rings, and labels had not been
aligned in accordance with local procedures and standards. The shipper
had not complied with published procedures and Federal regulations.
Lessons Learned
Each of these incidents was caused, at least in part, by failure to
follow procedures, failure to ensure that workers were properly
trained, or failure to obtain proper permits and use appropriate
equipment. In all three cases, the accident could have been avoided if
existing procedures had been followed. Other items for managers
include the following:
0 Management must make certain that workers are aware of even the most
routine procedures before they are allowed to work without
supervision.
0 Management must ensure that work is carefully planned and implemented.
Pre-job planning and obtaining appropriate equipment for each task are
key elements of a successfully planned and implemented job.
0 First-line managers should be knowledgeable about the status and
condition of equipment being used by workers under their supervision.
0 Managers must ensure that workers are trained to all required
procedures. Errors can be caused either by ignorance or by disregard
for established procedures.
References
RL--PNL-PNLBOPER-1994-0040
ORO--FERM-FEMP-1994-0052
RL--WHC-TPLANT-1994-0023
Vehicle safety experts
. . . cite several other factors that can contribute to an accident
like the one described in this article:
Weather can play a role by obscuring the view of the car being
overtaken. Mirrors can fog up or spray from the truck's tires can
obscure the view.
Drivers of conventional tractors, which have long hoods, are less prone
to these types of accidents because the driver does not have to look as
far away from the road to see the mirror. Cab-over tractors, on the
other hand, have no hood; the driver must look at right angles to the
road to see the right-hand mirror.
Drivers who wear glasses are more prone to these types of accidents
because their peripheral vision is weak.
Note
The Occupational Safety and Health Observer is a publication of the
Office of Environment, Safety and Health.
Joseph E. Fitzgerald, Jr., Deputy Assistant Secretary
Editor-in-Chief, Rebecca F. Smith
Coordinating Editor, Douglass Abramson
Editorial Board, Oliver D.T. Lynch, Jr., Richard M. Tuggle, PhD, CIH,
Jeffrey Finch, Charles G. Bruch, PE, David Johnson, Ashok Kapoor, John
Teske, CIH
The descriptions of the incidents included in this compendium are based
on information available at the time of publication. Articles
regarding DOE incidents are drawn from Occurrence Reporting and
Processing System (ORPS) reports, accident investigation reports, and
interviews with site personnel.
DOE 5483.1A, dated June 1983, requires DOE compliance with the OSHA
regulations cited.
If you would like more information about an article in this issue, have
a correction for an article, or would like to submit an article, please
contact the coordinating editor at: Office of Oversight Analysis and
Planning Support, U.S. Department of Energy, Telephone: (301) 903-7328
The Observer's Internet address is: observer@battelle.org
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