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The Recovery Process from the October 11, 2004

Electrical Arc Flash Accident at SLAC

Mike GrissomAssistant AssociateDirector (ES&H)

Stanford LinearAccelerator CenterMenlo Park, CA

April 11, 2005

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Director’s Statement

Your safety, and that of the environment, is of the utmost importance to SLAC. I know that we achieve our goals with the power of our collective effort. Let’s continue our efforts to make SLAC as safe and protective a workplace as we possibly can.

- Jonathan Dorfan

Controls

Scope

HazardsCauses

Work

CheckImprove

Integrated Safety

ManagementSystems

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Safety Philosophy

We believe that:

•Accidents are preventable•Managers create safe work environments•Supervisors ensure that everyone understands the safety expectations and work controls.•Safety is our most important day-to- day consideration.•You are responsible for your own safety.

SLAC must “integrate safety and environmental protection into its management and work practices at all levels so that the mission is accomplished while protecting the worker, the public, and the environment.” This objective is the foundation of the SLAC ES&H Program.

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SLAC Safety Goal

SLAC’s goals with respect to ES&H are to assure that ES&H requirements are made an integral part of program planning and are not subordinated to program goals.

If it can’t be donesafely – don’t do it!

Ultimately, the Lab’ssafety goal is to continuously strive fora healthy, accident-free, and environmentally sound workplace andcommunity whilepursuing scientific and technical excellence.

Of course the principle of “safety comes first!” extends to all areas of the workplace. I urge you to again read the “Values and Expectations” document found at http://www-group.slac.stanford.edu/esh/eshvalues.html which discusses how we balance our priorities to ensure that safety comes first even as we achieve outstanding science.

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Post-Type A Accident Chronology

• October 11, 2004 – Accident at Sector 20 B002• October 18, 2004 – Suspension of Work• October 18 to November 6, 2004 – DOE Type A Accident

Investigation Board at SLAC• October 18, 2004 – All Hands: “Safety Comes First”• November 12, 2004 – Return to Normal Work• January 14, 2005 – Corrective Action Plan Issued• Restart Process

– SSRL: Validation Team Review (January 3 to January 19, 2005)– B-Factory: Validation Team Review (January 26 to February 23, 2005)

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DOE Type A Report – JONs 1-4

The first 4 JONs focused onelectrical safety.

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DOE Type A Report – JONs 5, 6, 10 and 12

Four of the judgments of need were directed at the DOE Stanford Site Office.

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DOE Type A Report – JONs 7, 8, 9 and 11

The remaining judgments ofneed were focused on contracting,balancing priorities, improving thesafety culture, and establishingfrom the highest levels of theSLAC organization that “SafetyComes First.”

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Corrective Action PlanCAP Team: December 14, 2004 to January 14, 2005

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Many Specific Corrective Actions Were Identified

One or more correctiveactions were identified foreach of the 12 judgments ofneed in the DOE Type AAccident InvestigationReport.

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Safety Comes First – Suspended Work

Safety Comes First Director’s Guidance for Week Beginning October 18, 2004, Memo

#1

Phased approach:My memorandum, issued late Friday afternoon, October 15, calls for another suspension

of regular work beginning on Monday, October 18, 2004. With the guidance provided herein, and, using the SLAC Safety Management System as a starting point, we will begin

the careful, deliberate, and in some cases, protracted process that will allow us to eventually return to our regular work. Initially, we will be working in an envelope of

allowed activity that has severe restrictions on certain work. As we progress in our quest for an improved safety culture, this envelope will be judiciously expanded until we finally

reach a state where everyone has returned to normal work. The stages of progression through this envelope are:

Suspension - Effective Today - ALL normal activities of SLAC workers (except for critical services) are suspended.

Restricted - resumption of normal activities by some, but those activities may be impacted by the continued suspension of activities

elsewhere in the Laboratory. Normal – New processes and procedures are in place for all suspended

activities and it has been determined that it is prudent and safe to resume all normal work activities.

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3

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All Employees Complete “Safety Comes First

Checklist”

SLAC supervisors were required to validate completion of all the reading and actions on the checklists before their employees could resume office level duties.

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Safety Comes First – Suspended to Restricted

WorkTransition from Suspended Work to Restricted Work

October 19, 2004Groups can move from a state of Suspended Work into a state of Restricted Work once the members of the group have completed all of the safety work listed under “Specific Group Implementation” and “Specific Individual Implementation” in the

Safety Comes First: Director’s Guidance for Week Beginning October 18, 2004 Memo #1.

Each Division will communicate the process for validating that this safety work has been done, but, at minimum, it will involve each person signing a statement that they have read and

completed all of the safety work required by the Director’s Guidance Memo #1. Attached is a checklist that could be used for this purpose although other means that can be verified and

documented are acceptable.Based on the vulnerability of the work environment and technical complexity of the work requirements, groups around the Laboratory will be moving to Restricted Work in varying

amounts of time. We anticipate that desk workers will transition to a restricted status this week. In areas whose work involves the prohibited activities (Hot Electrical and Hoisting and Rigging)

the change to a restricted status may take much longer.For people whose work is primarily at a desk, the restricted work status may be much like regular

work. The difference will be defined by the status of the groups with which they interact.Specific guidance about the transition from Restricted to Normal work will come at a future time.

We greatly appreciate your continued strong support as we move forward in this challenging time.

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Return to Normal Work

By mid-November 2004, most staffhad their hazards identified, trainingspecified, and mandatory trainingcompleted allowing them to return tonormal work except for certain higherrisk activities and restart of theaccelerators.

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Training Status for October – December 2004

Nearly 7,000 individual ES&H training records were processed in thefirst 3 months of the post accident period.

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Subcontracting Delays

Although subcontracted work was not specifically prohibited,the process of ensuring that subcontractors adequately developedand implemented their health and safety plans and that SLACprovided adequate oversight resulted in substantial delays incompleting work for the first 4 months of FY05 (October 2004through January 2005). Subcontracted work proceeded on veryfew projects during this period.

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Restart Process - SSRL

SSRL staff prepared a 117-page documentsupporting restart of the SPEAR3 synchrotron.

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SSRL Restart Validation Team – Pre-restart

A number of pre-restartrecommendations were identifiedby the Validation Team such as:

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SSRL Restart Validation Team – Post-restart

A number of post-restartrecommendations were identifiedby the Validation Team such as:

The SSRL acceleratorfacilities are now inoperation.

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Restart Process – B Factory

Operations staff prepared a 181-page documentsupporting restart of the B-Factory HEP facility.

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B-Factory Restart Validation Team – Pre-

restartA number of pre-restartrecommendations were identifiedby the Validation Team such as:

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B-Factory Restart Validation Team – Post-

restartA number of post-restartrecommendations were identifiedby the Validation Team such as:

The B-Factory acceleratorfacilities are now inoperation.

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What was the impact of the event of October 11,

2005?• Is located on 426 acres of land leased by the DOE

from Stanford University through the year 2012• Has over 2M square feet of facilities• The major active experimental facilities are:

– LINAC– PEP II / BaBar– SSRL (SPEAR)– End Station A– NLCTA– Final Focus Test Beam

• Comprises an international research facility where more than 3000 scientists from approximately 25 nations conduct their research

Approximately 1,300employees; perhaps 100sof subcontractors; up to3,000 users; and manyvisitors were impactedby the Type A event for 3-6months.

The next facility restart effort isfocused on the NLCTA.

Validated

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Some Background on the SLAC ES&H Program

• ISMS = Integrated Safety Management System• ISMS Terms• SLAC Safety Organization• ES&H Division• Safety Officers• Safety Inspectors• ES&H Divisional Coordinators• Citizen Committees

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ISMS

Integrated Safety Management System. This is how we protectemployees and the community. This training will introduce youto the SLAC Safety Management System (SMS), which is thelab’s version of ISMS.

Following the precepts of the SMS program will allow you towork safely and efficiently while at work and at home. SLAC’sexperiences with Type A and Type B accidents have madethe need to do this even more apparent.

The main responsibility for the safe return to work will have to be borne by the Associate Directors, their divisions and their staffs. The “line”, from myself down to where the work is implemented, must take ownership of a safe workplace. As I affirmed during my recent all-hands meeting, we are all responsible for our safety and the work we do: the “buck” stops at every one of us. Accordingly, I am charging the Associate Directors and their respective supervisors to plan our return to work in a careful and deliberate manner.

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ISMS Terms

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SLAC Safety Organization

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ES&H Division

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Safety Officers

Perry Anthony, ElectricalSafety Officer

Sayed Rokni, RadiationSafety Officer

Ted Fieguth, LaserSafety Officer Richard F. Boyce, Pressure &

Vacuum Vessel Safety Officer

• Directly report to the Director for their specialty areas• Get advice from Citizen Committees• May direct provision of services• May stop work/activities

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Safety Inspectors

Brett Groussman, Crane Inspector

Jerry Pfefferkorn, OSHA Inspector

Jack Fry, Construction Safety Inspector

• Have special competency as defined by OSHA• Can stop work/activity and lock out an area/system to prevent use• Maintain inventories and records for areas/systems inspected

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ES&H DivisionalCoordinators

Ian Evans, SSRL

Michael Scharfenstein, LCLS

Janice Dabney, TDRick Challman, BSDFrank O’Neill, RD

Mike Grissom, ES&HDSandy Pierson, RD/PEP-II

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Citizen Committees

• Members come from throughout the SLAC organization• Have special knowledge of SLAC and some knowledge of functional area• Can be advisory and/or authorizing