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FINAL REPORT
Type BAccident Investigation Board Report
Of the November 1, 1999Construction Injury
At theMonticello Mill Tailings Remedial Action
SiteMonticello, Utah
Albuquerque Operations Office
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Type BAccident Investigation Board Report
Of the November 1, 1999Construction Injury
At theMonticello Mill Tailings Remedial Action Site
Monticello, Utah
December 1999Albuquerque Operations Office
U.S. Department of Energy
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DISCLAIMERDISCLAIMERDISCLAIMERDISCLAIMER
This report is an independent product of the Type B accident investigation board appointedby R. E. Glass, Manager, Albuquerque Operations Office.
The board was appointed to perform a Type B Investigation of this accident and to preparean investigation report in accordance with DOE Order 225.1A, Accident Investigations.
The discussions of facts, as determined by the board, and the views expressed in the reportdo not assume and are not intended to establish the existence of any duty at law on the partof the U.S. Government, its employees or agents, contractors, their employees or agents, orsubcontractors at any tier, or any other party.
This report neither determines nor implies liability.
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APPOINTING OFFICIAL’S ACCEPTANCE STATEMENTAPPOINTING OFFICIAL’S ACCEPTANCE STATEMENTAPPOINTING OFFICIAL’S ACCEPTANCE STATEMENTAPPOINTING OFFICIAL’S ACCEPTANCE STATEMENT
On November 5, 1999, I established a Type B Accident Investigation Board to investigatethe Accident at the Monticello Mill Tailings Remedial Action Site that resulted in the Injuryof a worker. The Board’s responsibilities have been completed with respect to thisinvestigation. The analysis, identification of direct, contributing, and root causes, andjudgments of need reached during the investigation were performed in accordance withDOE Order 225.1A, Accident Investigations. I accept the findings of the Board and authorizethe release of this report for general distribution.
Signed,
R. E. Glass, ManagerAlbuquerque Operations Office
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TABLE OF CONTENTS
PROLOGUEACRONYMSEXECUTIVE SUMMARY1.0 INTRODUCTION
1.11.11.11.1 BackgroundBackgroundBackgroundBackground1.21.21.21.2 Facility DescriptionFacility DescriptionFacility DescriptionFacility Description1.31.31.31.3 Scope, Purpose, and MethodologyScope, Purpose, and MethodologyScope, Purpose, and MethodologyScope, Purpose, and Methodology
2.0 FACTS AND ANALYSIS2.1 Accident Description and ChronologyAccident Description and ChronologyAccident Description and ChronologyAccident Description and Chronology
2.1.1 Background and Accident Description2.1.2 Accident Reconstruction and Analysis2.1.3 Chronology of Events2.1.4 Emergency Response and Investigative Readiness2.1.5 Medical Analysis2.1.6 Interim Corrective Actions
2.22.22.22.2 Hazards, Controls, and Management SystemsHazards, Controls, and Management SystemsHazards, Controls, and Management SystemsHazards, Controls, and Management Systems2.2.1 Management Systems2.2.2 Work Planning and Controls2.2.3 Equipment Safety
2.32.32.32.3 Barrier AnalysisBarrier AnalysisBarrier AnalysisBarrier Analysis2.42.42.42.4 Change AnalysisChange AnalysisChange AnalysisChange Analysis2.52.52.52.5 Causal FactorsCausal FactorsCausal FactorsCausal Factors
3.0 CONCLUSIONS AND JUDGEMENT OF NEEDS4.0 SIGNATURES OF BOARD MEMBERS5.0 LISTING OF BOARD MEMBERS, ADVISORS, AND STAFFAPPENDIX A – TYPE B INVESTIGATION BOARD MEMORANDUMAPPENDIX B - EVENTS AND CAUSAL FACTORS ANALYSIS SUMMARY
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ACRONYMSALBLMCERCLA
CIDCFRDOEEMEPAERDOE-GJOHSPMPPOHMOSHAOUPPEQC
Albuquerque Operations OfficeBureau of Land ManagementComprehensive Environmental Response,Compensation and Liability ActConstruction Interface DocumentCode of Federal RegulationsDepartment of EnergyOffice of Environmental ManagementEnvironmental Protection AgencyEnvironmental RestorationDOE-Grand Junction OfficeHealth and Safety PlanMonticello Peripheral PropertiesOhio Hazardous MaterialsOccupational Safety and Health ActOperable UnitPersonnel Protective EquipmentQuality Control
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EXECUTIVESUMMARY
IntroductionIntroductionIntroductionIntroduction
On November 1, 1999, a serious accident at the Departmentof Energy Monticello Mill Tailings Remedial Action Site inMonticello, Utah was investigated in which a truck driver wasstruck by a bar when attempting to pry open stuck gates of abelly dump truck while unloading rock. Additionally, onSeptember 14, 1999, two scrapers were involved in a head-oncollision at a limited visibility area. Two workers werehospitalized. One driver was hospitalized over five days. Thecontractor, with participation from the Department of Energy(DOE) Grand Junction Office (GJO), conducted an accidentinvestigation of the scraper collision and a report was finalizedon October 21, 1999.
On November 5, 1999, R. E. Glass, Manager, DOEAlbuquerque Operations Office (AL), appointed a Type BAccident Investigation Board to investigate the accident inaccordance with DOE Order 225.1A, Accident Investigations,since the injury resulted in a hospital stay over five days. Thescope of the Board’s investigation was to identify relevantfacts; analyze facts to determine the direct, contributing, androot causes of the accident; develop conclusions; anddetermine the judgments of need that when implemented,would reduce the probability of a similar recurrence.Additionally, the Board was to review the recent scraperincident and report to determine common causes, if any,between the two incidents.
In conducting its investigation, the Accident InvestigationBoard (the Board) used various analytical techniques thatincluded: 1) barrier analysis, 2) change analysis and (3) eventand causal factor analysis. The Board inspected andphotographed the trailer involved in the incident and areawhere the accident occurred, reviewed the events surroundingthe accident, and conducted interviews, and revieweddocuments to determine the facts that contributed to theaccident.
After the November 1, 1999 accident, constructionmanagement implemented the following interim correctiveactions: increase in safety awareness through the daily safetymeetings, increasing postings and notifications, establishing acheck-in area for visitors and vendors, and notifying all listed
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vendors and subcontractors concerning entry requirements.
The project is scheduled to be completed in December 1999.After being briefed by the Board, the AL Manager directed theAssistant Manager responsible for EnvironmentalManagement and the Grand Junction Office Manager, bymemorandum dated November 23, 1999, to take immediateaction on the areas that the Board identified as needingattention. These areas included:
• Safety requirements clearly identified and communicated• Unsafe acts evaluated• Clear roles and responsibilities• Job hazard analysis• Clear delineation of the construction area
These immediate actions were developed to ensure safecompletion of the Monticello Project while waiting for theissuance of the Type B Accident Investigation Report. Also,the Manger’s memorandum required that DOE-GJO workwith AL to ensure that the Integrated Safety Managementprinciples are implemented at Grand Junction this year.
Accident DescriptionAccident DescriptionAccident DescriptionAccident Description
On November 1, 1999 at 11:18 am, a truck driver was struckby a metal bar while attempting to pry open stuck gates on abelly dump. The driver’s injury resulted in a fractured skull.He underwent surgery and is expected to make a full recovery.The driver was hired by a local truck owner to haul rock forriprap material to be used in completion of the repository cellat Monticello. This truck owner was hired by a materialsupply vendor, Crowley Construction because the vendor didnot have enough equipment to complete the activities on twocontracts that had been awarded.
Causal FactorsCausal FactorsCausal FactorsCausal Factors
The Board identified root causes for the accident, theelimination of which could have prevented the serious injury:
• Site workers and subcontractors were not following siteprocedures and contract requirements.
• The responsibilities of project and constructionmanagement for safety and health on construction siteswere not clearly defined.
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In addition, contributing causes that may have increased thelikelihood of the accident, without individually causing theaccident, were identified as follows:
• Construction contract management did not ensuresubcontractors were meeting contractual requirements.
• Occurrence investigations were not thorough enough todevelop effective actions to prevent similar occurrences.
• Various construction tasks were not fully analyzed forhazards.
• Vendors were not subject to the same safety and healthrequirements as construction contractors.
• Truck driver was impaired; however, the Board could notdetermine to what degree this contributed to the accident.
Conclusions and Judgments of NeedConclusions and Judgments of NeedConclusions and Judgments of NeedConclusions and Judgments of Need
Table ES-1 presents the Board’s Conclusions and Judgmentsof Need. The Board’s Conclusions are those consideredsignificant, based upon facts and pertinent analytical results.From the Conclusions the Board developed Judgments ofNeed to guide managers in developing follow-up actions.Follow-up actions should include safety and managementcontrols and practices necessary to resolve the conditionsidentified in the Conclusions for each Judgments of Need.
Table ES-1: Conclusions and Judgments of Need
ConclusionsConclusionsConclusionsConclusions Judgment of NeedJudgment of NeedJudgment of NeedJudgment of NeedThe construction workers, subcontractors,and vendors were not following therequirements established in the Health andSafety Plan or in the contract documents.For example, Driver 1 appeared to be unfitfor duty that was a violation to 49 CFR382.201, Alcohol concentration and OHM’srequirement 5.2.17, Alcohol Prohibited Conduct.Crowley failed to inform OHM of the hiringof the truck drivers.
MACTEC needs to review currentrequirements and procedures to ensureapplicability and consistency. Based on thisreview, MACTEC needs to disseminatethese requirements and procedures to theworkers, subcontractors, and vendors.
DOE-GJO needs to ensure that theircontractors adhere to contractualrequirements relating to safety and health.
Roles and responsibilities for safety andhealth on construction sites for projectmanagement and construction managementwere not clearly defined.
DOE-GJO needs to clarify roles andresponsibilities for safety and healthinvolving project management and ensurethese responsibilities are understood andaccomplished.
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MACTEC needs to clarify roles andresponsibilities for safety and healthinvolving construction management andensure these responsibilities are understoodand accomplished.
Crowley did not inform OHM of the use ofindependent truck owners.
MACTEC needs to ensure the contractor’srequirements are met by subcontractor andlower subtier subcontractors, includingvendors.
Occurrence and accident investigations tendto identify personal error as root cause forthe incident. Potential management andprogram system errors are not identified
MACTEC needs to conduct occurrence andaccident investigations to determine rootcauses that focus on program andmanagement systems and develop andimplement corrective actions to address theidentified causes.
DOE-GJO needs to ensure that theircontractors are conducting accident andoccurrence investigations to identifymanagement and program system errors andensure that their contractors areimplementing effective corrective actions toaddress the causes.
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1.0INTRODUCTION
1.1 Background1.1 Background1.1 Background1.1 Background On November 1, 1999, at approximately 11:18 a.m., a truckdriver for a material supplier was seriously injured as he wasunloading rock from a belly dump truck at the Monticello MillTailings Remedial Action Site in Monticello, Utah.
On November 5, 1999, R. E. Glass, Manager, Department ofEnergy (DOE), Albuquerque Operations Office (AL),appointed a Type B Accident Investigation Board toinvestigate the accident in accordance with DOE Order225.1A, Accident Investigations, since the injury resulted in ahospital stay over five days. The appointment memorandumis attached in Appendix A.
1.2 Facility Description1.2 Facility Description1.2 Facility Description1.2 Facility Description The Monticello Mill Tailings Remedial Action Site comprisesseveral tracts of land, including the old Monticello millsite and34 Monticello Peripheral Properties (MPPs) surrounding themillsite The millsite is a 110-acre tract located alongMontezuma creek on the south side of the city of Monticello,San Juan County, Utah. Uranium and vanadium mill tailingsand other by-product materials produced during milloperations contaminated the Monticello Mill TailingsRemedial Action Site, the MPPs and the Monticello VicinityProperties.
The Environmental Protection Agency placed the millsite andvicinity properties on the National Priorities List under theComprehensive Environmental Response, Compensation andLiability Act (CERCLA) because of significant risk to humanhealth and the environment associated with the contaminationof the tailings. Remedial activities on the millsite began in1995. Figure 1-1 is a photo of the Monticello Mill TailingsRemedial Action Site.
Contractor activities are managed by the DOE-GJO, whichreports to the DOE Albuquerque Operation’s Office ofEnvironmental Operations and Services. The cognizant DOEsecretarial office is the Office of Environmental Management.The DOE-GJO’s construction manager is MACTEC-ERS(MACTEC) and the prime contractor for the Monticello MillTailings Remedial Action project is Ohio Hazardous Materials(OHM). OHM conducts most of the work; however, OHMdoes contract out to other subcontractors and suppliers.Crowley Construction is a supplier to OHM as well as asubcontractor to MACTEC.
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1.3 Scope, Purpose, and1.3 Scope, Purpose, and1.3 Scope, Purpose, and1.3 Scope, Purpose, andMethodologyMethodologyMethodologyMethodology
The Board began its investigation on November 8, 1999,completed the investigation on November 16, 1999, andsubmitted its report to the Manager of AL on December 10,1999.
The Scope of the Board’s investigation was to identifyrelevant facts; analyze facts to determine the direct,contributing, and root causes of the accident; developconclusions; and determine the judgments of need that whenimplemented, would reduce the probability of a similarrecurrence. Additionally, the Board was to review a recentscraper incident and report to determine common causes, ifany, between the two incidents.
Figure 1-1 Monticello Mill Tailings Remedial Action Site
AdministrativeAdministrativeAdministrativeAdministrativeBuildingsBuildingsBuildingsBuildings
Disposal CellDisposal CellDisposal CellDisposal Cell
Material StockpileMaterial StockpileMaterial StockpileMaterial StockpileAreaAreaAreaArea
MonticellMonticellMonticellMonticello
Hwy. 191Hwy. 191Hwy. 191Hwy. 191
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The purposes of the investigation were to determine thecause of the accident, identify any safety managementdeficiencies, and generate lessons learned, which can beapplied to similar situations to avoid potential accidents.
The Board conducted the investigation using the followingmethodologies:
• Interviews and document reviews• Visual inspections of equipment• Factual analyses using event and causal factors chartingplus barrier and change analysis techniques to identify thecauses of the accident and develop judgments of need forcorrective actions to prevent recurrence
2.0 FACTS ANDANALYSIS
2.1 Accident Description2.1 Accident Description2.1 Accident Description2.1 Accident Descriptionand Chronologyand Chronologyand Chronologyand Chronology
2.1.1 Background andAccident Description
Onsite activity on the Monticello Mill Tailings RemedialAction Project started in November 1995. The project hasvarious milestones for completion with a final completiondate of June 30, 2000. On June 17, 1999, the projectexperienced a significant safety and health record of 1.5million man-hours without a lost workday. The project isapproximately 90% complete. The contractor is behindschedule, but contracts were put in place to avoid anotherwinter shutdown, which would result in carrying the workover into another construction season. These remainingtasks include completing the dirt cover on the repository andout-slopes, re-contouring of a private property adjacent tothe millsite, and hauling and placing the rock (riprapmaterial). Final seeding and restoration will conclude byJune 30, 2000, if these tasks are completed.
On May 4, 1999 OHM awarded a purchase order to Crowleyto haul rock and sand. On October 19, 1999, Crowley wasalso awarded a contract to complete a MPP re-contouringproject. As a condition of the re-contouring subcontract,Phase IV project, assurances were required of Crowley not toadversely impact any other tasks on the site. Since Crowleydid not have enough trucks to complete both contract tasks,he hired trucks and drivers from four local truck owners tocontinue rock hauling.
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2.1.2 AccidentReconstruction and
Analysis
The accident occurred at approximately 11:18 am during rockdelivery to the stockpile area at the Monticello Mill TailingsRemedial Action Site. The driver of a belly dump truck,Driver 1, delivered two loads of rock to the site earlier in themorning. Typically, the gates of a belly dump truck areoperated from the inside of the truck cab, but on both tripsDriver 1 had to stop, get out of his truck and manually pryopen the belly dump gates using an iron bar approximately1.25 inches x 4.5 feet. In order to pry open the gates, Driver1 squatted between the rear tires and behind the belly dumpgates, then placed the bar between the partially-opened metalgates and pried open the gates using his own strength. (SeeFigure 2-1)
On the second trip, Driver 1 and an OHM operator of afront-end loader working in the same area discussed theoption of using the front-end loader to assist in the openingof the gates. However, neither had access to a chain to pullthe gates apart, and Driver 1 proceeded to open the gates byusing the iron bar. The OHM front-end loader operatorcontinued with his work. Although there is a Health andSafety Plan requirement to stop work when equipmentmalfunctions, neither individual exercised this responsibility.
On both the first two loads, Driver 1 had been successful inopening the gates using the iron bar. Another belly dumptruck driver, Driver 2 (hauling for a second truck owner),witnessed Driver 1 prying the gates and did not stop work.
Figure 2-1 Reenactment of AccidentFigure 2-1 Reenactment of Accident
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On the third load, Driver 1 once again attempted to open thebelly dump gates by using the iron bar. It was during thisload that the gates opened and the weight of the rocks forcedthe iron bar upward, striking the truck driver on the rightside of the head above the eye.
Driver 1 was found within minutes of the accident by aQuality Control (QC) Inspector who was also in the area, andby Driver 2 who was unloading his truck on the other side ofthe stockpile area from where Driver 1 was located. Both ofthese men found the injured driver unconscious lyingadjacent to the truck. Figure 2-2 shows a similar truck at theapproximate location of the accident.
2.1.3 Chronology ofEvents
Following is the chronology of significant events and Figure2-3 Map of Accident Area:• On May 4, 1999, Crowley received purchase order from
OHM to produce and deliver sand and rock.• On October 19, 1999, Crowley received contract from
MACTEC to re-contour a MPP adjacent to the millsite.• On October 25, 1999, Crowley hired trucks and drivers
from four truck owners, since Crowley did not haveenough equipment to perform both jobs.
• On October 25, 1999, a truck owner hired Driver 1 andprovided a belly dump truck. The belly dump trailer hadbeen idle for one year.
Figure 2-2 Belly Dump Truck at Accident Scene
Approximate locationApproximate locationApproximate locationApproximate locationOf Driver 1 after accidentOf Driver 1 after accidentOf Driver 1 after accidentOf Driver 1 after accident
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• On November 1, 1999, Driver 1 delivered threetruckloads of rock. Belly dump truck gates stick on eachload.
• On November 1, 1999, Driver 1 opened gatessuccessfully on first two loads using an iron bar.
• On November 1, 1999, on third load, at approximately11:18 a. m., Driver 1 attempted to pry gates open usingthe metal bar and was struck by the iron bar as the gatesopened.
• On November 1, 1999, at 11:23 a.m., a guard called 911.• On November 1, 1999, at 11.28 a.m., an ambulance
arrived at the accident scene.
2.1.4 EmergencyResponse and
Investigative Readiness
At 11:20 a.m., the OHM QC Inspector used his radio to callthe OHM Site Safety Officer for assistance. After severaltries without any response, the OHM QC Inspector askedDriver 2 to stay with Driver 1 while he went for help. TheOHM QC Inspector drove to the office compound to getassistance from the OHM Site Safety Officer. The OHMQC Inspector was able to locate the alternate OHM SiteSafety Officer and they both drove toward the accidentscene. As they passed the guard shed, the alternate OHMSite Safety Officer asked the guard to call 911 for ambulanceassistance.
Upon arriving at the accident scene, the OHM QC Inspector
Hwy. 191
Construction Road
By-pass Road
Material Stockpile Area
Guard Shack
Parking Lot
Administrative Buildings
MaterialStockpiles
Primary Access Road
Former Exclusion Zone Fence
ApproximateLocationof Accident
Belly DumTruck
Monticello
Figure 2-3 Map of Accident Area
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and alternate OHM Site Safety Officer witnessed that theinjured driver had regained consciousness and had stood upwith assistance from Driver 2. Driver 2 was physicallysupporting Driver 1 who was leaning against the truck.Driver 1 was convinced to lay back down until theambulance arrived. The ambulance arrived approximatelyfive minutes after the guard made the call. The EmergencyMedical Technicians treated Driver 1 at the scene and thentransported him to San Juan Hospital in Monticello, Utah.Upon examination by the local physician, the physiciandetermined at approximately 3:30 p.m., that Driver 1 shouldbe air lifted to St. Mary’s Hospital in Grand Junction,Colorado.
The OHM Site Safety Officer requested that the truck ownerget an alcohol and drug screen on Driver 1 since there wassome indications from the initial personnel on scene thatDriver 1 appeared unfit for duty (several witnesses stated thatDriver 1 smelled of alcohol). The accident scene was notsecured since the injury was first determined to be minor.Also, during interviews, it was stated that the scene was notsecured or photographed since the equipment involved in theincident was not damaged. During the transporting of theinjured driver to Monticello and on to Grand Junction, thetruck owner moved the belly dump truck off site, therefore,removing physical evidence from the accident scene.
After discovering that the injury to Driver 1 was more severe,DOE-GJO and the prime contractor, MACTEC initiated anaccident investigation and arrived at the construction site onNovember 3, 1999. Witness statements were recorded byDOE-GJO on November 3, 1999. The investigation wasinterrupted on November 4, 1999 while a formal AL Type BBoard was being established.
The Board was established on November 5, 1999 and arrivedat the construction site on November 9, 1999. The Boardconducted its on-site investigations of the accident onNovember 9 and 10, 1999 and concluded investigations atDOE-GJO on November 12, 1999.
2.1.5 Medical Analysis The admission diagnoses included: an open head injury, rightfrontal-orbital skull fracture, and a right frontal lobecontusion. The laboratory results also showed a residualblood alcohol concentration of 34 milligrams per deciliter or0.03% at the time of admission. Surgery was conducted onNovember 5, 1999 with no complications. Driver 1 was
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released from the hospital on November 8, 1999 and isexpected to return to work.
Several personnel on the scene of the accident informed theBoard that Driver 1 appeared to be unfit for duty per theirvisual contact with Driver 1. 49 CFR 382.201, Alcoholconcentration, states, “no driver shall report for duty whilehaving an alcohol concentration of 0.04 or greater.” Also,OHM Procedure HS101, 5.2.17, Alcohol Prohibited Conduct,reiterates this requirement for subcontractors. The Boardconcluded that the effects of alcohol might have been afactor in this accident, but the degree to which it contributedcould not be determine.
2.1.6 Interim CorrectiveActions
While awaiting the results of this investigation, MACTECimplemented the following list of corrective actions since theaccident on November 1, 1999:
• Increased worker awareness of hazardous operationsaround them, questioning any unsafe operation, reportingit to supervision and checking for proper personalprotective equipment being worn. Presented at the dailytailgate meeting.
• Immediate stopping of all subcontractor and vendordelivery trucks at the guard shack to assure that theproper briefings have been completed, and properpersonal protective equipment is available.
• The posting of restricted access signs on roadways thatare accessible prior to the guard shack, and additionally atthe millsite entrance.
• OHM notified, to all listed vendors and subcontractors,that first time entry requires stopping at the guard shackat the support area.
In addition, MACTEC is implementing the followingcorrective actions:
• Establish definite physical perimeter boundaries for thesite with proper postings.
• Post a map outlining boundaries for each individualcontrolled area, listing the required proper personalprotective equipment for that area.
• Post a notification board at the highway access indicatingthat all visitors, first-time vendors and subcontractorsmust stop at the guard shack.
• Establish a route with physical boundaries that directs all
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incoming traffic to the guard shack area for checking in.• Continue worker awareness to safety of not only their
individual tasks, but to those around them, and if anunsafe act is observed, it should be reported tosupervision.
• Emphasis to all operators that if a piece of equipment isnot working properly, stop and report it to supervision.
As a result of the short construction period remaining on theproject, the AL Manager directed the Assistant Managerresponsible for Environmental Management and the GrandJunction Office Manager, by memorandum dated November23, 1999, to take immediate action on the areas that theBoard identified as needing attention. These areas include:
• Safety requirements, including identifying and ensuringcontractual requirements flow down to vendors andsubcontractors
• Safety systems should evaluate unsafe acts as well asunsafe conditions and results should be trended todetermine possible management and programmaticfailures
• Clear defined roles and responsibilities (both contractorand federal staff)
• Current or new construction activities should beanalyzed, hazards identified, and appropriate controlsestablished for safety and health (i.e., reevaluate theReconstruction Task in the Health and Safety Plan)
• Clear identification and communication of theconstruction area to include traffic patterns and sitetraffic rules
The Manger’s memorandum required that the GrandJunction Office work with AL to ensure that the IntegratedSafety Management principles are implemented this year.
2.2 Hazards, Controls,2.2 Hazards, Controls,2.2 Hazards, Controls,2.2 Hazards, Controls,and Managementand Managementand Managementand Management
SystemsSystemsSystemsSystems2.2.1 Management
SystemsThe following facts address management issues that relate tothe accident:
Responsibility
DOE-GJO is a DOE office funded under theEnvironmental Management (EM) Program. EM’s Office of
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Site Closure is specifically responsible for the funding andscheduling of environmental restoration (ER).
Through the delegation of the Operations Officeresponsibility, ER activities in the DOE-GJO are delegatedfrom EM to the Manager of AL. Within AL, overallmanagement of the DOE-GJO is the responsibility of theOffice of Environmental Operation and Services. The directday-to-day management responsibility for ER Projectsassigned to the DOE-GJO, for environment, safety andhealth oversight, resides within the DOE-GJO federal team.
Within DOE-GJO there are two teams; one focusing onproject management and the other on environment, safetyand health. The health and safety oversight flows down tothe Technical Assistance and Remediation Contractor,MACTEC. MACTEC is responsible to ensure thatremediation projects are conducted safely and in anenvironmentally compliant manner.
Safety Program Requirements
Under contract number DE-AC13-96GJ87335, MACTEC iscontractually obligated to adhere to the constructionmanagement requirements of DOE Order 5480.9A,Construction Safety Management and DOE Order 5480.4,Environmental Protection Safety and Health Protection Standards(both replaced by DOE Order 440.1A Worker ProtectionManagement for DOE Federal and Contractor Employees whichreferences 29 CFR 1910, Occupational Safety and HealthStandards and 29 CFR 1926, Safety and Health Regulations forConstruction). Since this was an environmental restoration site,a Health and Safety Plan (HSP) was required, by 29 CFR1910.120. Initially there were two health and safety plans,one for MACTEC and another for its subcontractor, OHM.To ensure consistency with MACTEC and OHM, acombined HSP, Monticello Projects Health and Safety Plan, MAC-MRAP 1.3.4 was issued on September 22, 1998, after reviewand concurrence by the DOE-GJO Project Coordinator. Inaddition to the HSP, each organization has corporate healthand safety policies and procedures. Workers are providedinformation about the HSP and other safety topics in aninitial site briefing and daily tailgate meetings. Although theHSP treats vendors as visitors, OHM's Health and SafetyPolicies and Procedures Manual states that vendors are treated assubcontractors. The major difference between vendor andsubcontractor site requirements is that the equipment and
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vehicles for subcontractors were to be initially inspectedprior to coming on site.
In the HSP, specific procedures and hazard controlrequirements are specified in Appendix B, Task-SpecificRequirements for Monticello Projects. However, most of theseprocedures relate to industrial hygiene and radiationprotection hazards. In the Reconstruction Task section ofthe HSP, which closely relates to the hauling and stockpilingof rock activities, there is no listing of hazard controlrequirements such as traffic procedures, signs, traffic plans,etc. In the HSP, Appendix D refers to site traffic rules.Heavy Equipment and Vehicle Traffic Control Plan refers to sitetraffic rules. Also, in the HSP it states, “equipment that isdefective or not operating must be reported immediately tothe supervisor.”
OHM and its lower tier subcontractors are contractuallyobligated to comply with all Occupational, Safety and HealthAdministration (OSHA), DOE, and other Federal, State andlocal agency regulations by the Monticello Remedial ActionProject Construction Specifications, Terms and Conditions,GJPO-PROC-111 and the HSP. OHM is also responsiblefor all lower tier subcontractors’ compliance with thesehealth and safety requirements. OHM is responsible toidentify procedures to ensure lower tier subcontractors arecompliant with OSHA Standards. Health and SafetyRequirements, E0292601 states, “Subcontractor shall performinitial safety inspections of heavy equipment prior tocommencement of work,” and “Subcontractor shall provideappropriate safety barricades, signs in accordance with 29CFR 1926 Subpart G and 29 CFR 1910.144.”
Crowley was contractually obligated to MACTEC for thePhase IV re-contouring project, and to OHM for PurchaseOrder 111871 and OHM Terms and Conditions for sand androck production and delivery. The purchase order identifiedCrowley as a vendor thus avoiding liability in the event ofloose rocks falling from the trucks and damaging othervehicles on the highway.
There were verbal contracts between Crowley and four localtruck owners to haul rock and sand to the Monticello site.Crowley gave no information to the truck owners concerningsite safety and health requirements. One of the truck ownershired a temporary driver, Driver 1, to haul the rock, but nosafety and health information or directions to the site weregiven to Driver 1.
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Safety Oversight
DOE-GJO Project Management determined that there wasduplication of safety oversight by MACTEC and OHM.Roles and responsibilities were clarified such that OHMsafety personnel would be responsible for industrial safety,and provide the day-to-day safety inspections; whereas,MACTEC would provide safety oversight on the project, butmaintain the day to day industrial hygiene and radiationprotection responsibility support. To ensure thatprofessional safety oversight was available, a directive wasissued, on June 15, 1998, as part of Construction InterfaceDocument (CID), Number 175, MRAP OU1. In thisdocument it states, “OHM shall provide on-site corporatehealth and safety support and mentoring at a minimumquarterly or more often as agreed with the contractor. OHMshall also provide one additional on-site Health and SafetyTechnician.” In the first year, after implementation of CID175, corporate heath and safety was present; however afterInternational Technologies acquired OHM, corporate healthand safety support has had a minimal physical presence onthe site. The industrial safety oversight is comprised ofOHM conducting daily inspections and MACTEC and OHMconducting weekly joint inspections.
At the Monticello site, DOE-GJO has a Site Project Managerand a Construction Inspector who is a federal employee fromthe Bureau of Reclamation. The coordination of theseconstruction activities is challenging and has kept the DOE-GJO Site Project Manager’s workload at a high level. ADOE-GJO Safety & Health Manager stationed at GrandJunction visits the site every three to four weeks. Both theSite Project Manager and the Project Coordinator, located atDOE-GJO, stated that the responsibility for health andsafety was assigned to the contractor. Although, theConstruction Inspector would oversee the safety and healthof workers on the site, the majority of his responsibilitieswere for overseeing the construction progress. The DOE-GJO Safety and Health Manager oversees safety and heathand any deficiencies are brought to MACTEC and OHM'sattention. The DOE Project Coordinator has reduced hisparticipation on the Monticello Project due to otherassignments. The responsibilities for safety and healthoversight are not clearly delineated for the ConstructionInspector and Safety and Health Manager by the either theProject Manager or the Project Coordinator. Based on the
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above interviews, roles and responsibilities for safety andhealth are not clearly delineated and understood by thefederal and contractor staff.
Construction Activities
Prior to the current activity, the main construction task wasto excavate and haul mill tailings into the constructedrepository cell. At that time, strict access control and specificradiological procedures were in place for the safety and heathof the workers, public and environment. Radiologicalpostings and fences were erected to define the exclusionaryboundaries.
The construction schedule for completion of the repositoryis behind schedule. To avoid another winter shutdown,additional funds were provided by DOE-GJO to obtainadditional scrapers and earth-moving equipment. With thisadditional equipment, the cap of the repository cell could becompleted by December 1999. At the same time, MACTECand DOE-GJO decided that Phase IV MPP Re-contouringProject would be contracted to ensure completion while theMontezuma Creek was low and to meet the commitmentsmade to the landowner.
To ensure that there was sufficient equipment to completeboth activities, the contract for Phase IV was issued with thestipulation that the contractor awarded the project could notimpact the activity on the repository. Crowley (successfulawardee of Phase IV) indicated that he would obtain otherequipment to avoid any impacts to the repository activities.There was no follow-up by MACTEC to verify how Crowleywas obtaining the equipment. Although OHM was aware ofCrowley's new contract, OHM assumed that Crowley wouldmake the rock hauls without subcontracting.
During this final activity in completing the cell, a knoll wasbeing removed with scrapers and other earth-movingequipment. This activity was adjacent to the fence line thatwas used to secure the site and also to demarcate theconstruction and exclusion areas. Both MACTEC and OHMobserved traffic congestion problems with the scrapers andmaterial supply equipment delivering sand and rock to thestockpiles nearby. A by-pass was constructed to keep thehaul equipment away from the earth-moving equipment. Nofurther measures were taken to establish a fence, erect signsor restrict travel on the new by-pass. MACTEC Safety
14
Coordinator noted that the fences and signs were not inplace, but these controls were not erected since there weredifferences in the definition of a construction area. Someindividuals felt that the construction area extended toHighway 191, which was bounded by barbwire fencing. Thecontractors did not perform an integrated job hazard analysisto identify and mitigate hazards for the above constructionactivities.
Previous Incidents and Accidents
On March 23, 1999, there was a structural deformation of a1,000-gallon diesel fuel tank because of actions performed bya fuel delivery vendor. MACTEC conducted an investigationand determined that the root cause of the accident was a lackof compliance with existing procedures. Although recordsshow the vendor was trained, the vendor stated that he wasnot trained. One of the corrective actions was to re-train thefuel vendor on the established refueling plan and the HSP.
Between June 1, 1999 and September 8, 1999, the siteexperienced four incidents involving scrapers; however, theseincidents did not result in personnel injury or equipmentdamage. The following lists the incidents and root causes:
• On 6/1/99, three scrapers bumped while loading radonbarrier material. The root cause was determined to beoperator error.
• On 6/7/99, the road sank which caused the scraper tohigh center. The root cause was lack of management’sawareness of the road condition.
• On 6/29/99, the throttle mechanism of the scraper stuckin the open position. The direct cause was mechanicalmalfunction.
• On 9/8/99, a scraper rolled off the edge of an earthenberm. The root cause was personnel error.
On September 14, 1999, two scrapers were involved in ahead-on collision at a limited visibility area. Two workerswere hospitalized. One driver was hospitalized over fivedays. The contractor, with participation by DOE-GJO,conducted an accident investigation and a report wasfinalized on October 21, 1999. The accident investigationteam concluded that the root cause was personnel errorbecause the worker was aware of the limited visibility andpotential danger but did not stay on the outside lane. Nocontributing causes were identified. Judgments of Need were
15
identified as part of a continuous safety improvement effort.This report was issued on 11/22/99 and no correctiveactions were taken at that time prior to the current accident.These Judgments of Need are as follows:
• Performance of field supervisors should be evaluated toensure work activities are adequately monitored.
• The equipment maintenance system should be evaluatedto ensure that the highest priority is given to repair ofdeficiencies that effect safe operation of equipment.
• The training and qualification practices for equipmentoperators should be reviewed for adequacy.
• Shift changes should be continually evaluated for safetyimpact
• Management should assign responsibility for trackingcorrective actions and perform oversight to ensureeffectiveness of the system.
2.2.2 Work Planningand Controls
The Board's analysis of work planning and controls focusedon the site activities and whether the contractor's andsubcontractor’s implementation resulted in effective projectplanning and anticipated hazard control. The framework foranalysis consisted of the five core safety managementfunctions described in DOE Policy 450.4:
• Define the scope of work• Identify and analyze the hazards associated with the work• Develop and implement hazard controls• Perform work within controls• Provide feedback on adequacy of controls andcontinuous improvement in defining and planning work
These five core safety management functions provide thenecessary structure for any work activity that could affect thepublic, the workers or the environment. The rigor inaddressing these functions depends on the type of workactivity and the hazards involved. An analysis of severalactivities leading to the iron bar accident in relation toapplicable core functions is presented in the followingsubsections:
Define the Scope of Work
Several activities that were significant and contributed to theaccident over a period of time are listed below:
16
• Elimination of the Exclusion Area• By-pass Road Construction• Phase IV Contract Execution• CID 175 Implementation
These activities were not effectively communicated andintegrated into the overall project and were not disseminatedto various subcontractors and vendors.
Identify and Analyze the Hazards Associated with theWork
The following hazards were not adequately identified andanalyzed by the contractor and subcontractor safetypersonnel:
• Elimination of Exclusion Construction Area - As theradioactive material control zone was removed, theconstruction hazards and associated controls were notthoroughly identified. There was much confusion onwhat constituted the construction area boundaries andtherefore, PPE requirements were not consistentlyenforced.
• By-pass Road Construction - Decisions were made toconstruct a by-pass road to alleviate a traffic safetyconcern; however, postings, traffic patterns and rules,and communications to other subcontractors werelacking. Without these hazard controls, Driver 1 was notaware of the construction site boundaries and its rulesand requirements.
• Phase IV Contract Execution- Additional re-contouringwork on an adjacent MPP was deemed necessary and anew short duration contract was awarded to Crowley forrock hauling. This new work required belly dump trucksin addition to Crowley's rock hauling trucks. As a resultCrowley acquired more belly dump trucks and driversfrom local truck owners. These new truck owners anddrivers were not used to the rigor of safety and healthrequired on the Monticello Project.
• CID 175 Implementation – The change instituted adifferent approach to implementing industrial safety.The day to day responsibility for industrial safety andhealth implementation was transferred from MACTECto OHM. This caused some confusion on roles andresponsibilities and weakened verification and oversightof safety.
17
Develop and Implement Hazard Controls
The September 1998 HSP was used to develop the controlsfor the Monticello Mill Tailings Remedial Action Project.This project was divided into numerous tasks that are definedin the HSP. Task hazards were identified along with thelocation of the task, PPE prescribed, additional training,monitoring, permits, associated procedures, and task specifichazard control requirements. These task hazards focusedmainly on radiation and industrial hygiene. Since thedevelopment of the HSP there has been no updates exceptfor the page change for a traffic plan.
For the Reconstruction Task, REC.1, which includes materialhauling, the task specific hazard control requirementsincluded: dust suppression; spotters (if necessary); eyecontact (operator/worker); back-up alarms; and groundpersonnel out of operating area. In addition to these taskrequirements, the HSP also included Recommended HazardControls and Protective Equipment and Traffic ControlPlans. This information included rules and instructions forusing equipment and vehicles on the site. Theseadministrative controls were provided to the worker duringthe initial briefing and during daily tailgate safety meetings.
Perform Work within Controls
Monitoring of performance consisted of site inspections andaccident/injury statistics. OHM conducted daily inspectionsand on a weekly basis, both MACTEC and OHM performedsite inspections. Based on reviews of the inspectiondocuments, these inspections concentrated on unsafeconditions, such as, housekeeping, condition of roads, etc.Unsafe acts or failure to follow procedures were notdocumented. Based on interviews, if procedures were notbeing followed, the worker was alerted of the fact. Withoutthe documentation of the unsafe acts, trending ofperformance could not be conducted.
Provide Feedback on Adequacy of Controls andContinuous Improvement in Defining and Planning Work
MACTEC and its subcontractor had experienced variousincidents in the past year that were investigated andcorrective actions taken. However, the incidents were notevaluated to with respect to management systems or program
18
failures. Several incidents in the past had similarities to thisrecent incident. For example, the two scrapers that collidedresulted in a corrective action to establish two-way trafficcontrol by the use of cones. The rock hauling by-pass did notget any management focus on two-way traffic control.Another example was the incident involving a fuel vendorand the structural deformation of a fuel tank. The correctiveaction was taken to re-train the fuel vendor but othervendors were not evaluated to determine if they needed re-training.
2.2.3 Equipment Safety According to the truck owner, the belly dump trailer was idlefor the past year prior to being used for this hauling activity.OHM relied on the fact that Crowley was familiar with thesite procedures, since the company had worked on the siteand other peripheral properties. However, OHM was notinformed that other subcontractors to Crowley were hired.
2.3 Barrier Analysis2.3 Barrier Analysis2.3 Barrier Analysis2.3 Barrier Analysis A barrier analysis was conducted to identify conditions that ifin place, would have isolated the driver from the hazardsassociated with the stuck gates of the belly dump truck. Theanalysis addresses both the management and physical barriersthat should have been used or were not in place prior to theaccident. The barriers are summarized in Fig. 2-4 BarrierAnalysis Summary.
Physical Distance from Gates
From interviews with Driver 1 and the front end loaderoperator, there was a conversation about using the front endloader and a chain to free the stuck gates so that Driver 1would not have to pry open the gates with the bar. However,since there was no chain available, Driver 1 made thedecision to use the iron bar. Although the use of heavyequipment to open the belly dump gates would have kept thedriver from using the bar to open the gates, the properprocedure would have been to stop work and makeequipment repairs.
Operational Equipment
The belly dump truck used by Driver 1 was idle for about ayear. This inactivity may have contributed to the failure ofthe pneumatic system to open the gates fully. Crowley didnot own this vehicle. Crowley was also awarded anothercontract for earth- moving at the site, and so Crowley's in-use belly dump trucks were pulled from the material supply
19
purchase order work to the earth-moving contract work.Local truck owners were hired to compensate for theincreased work demand. The truck involved in the accidentwas not inspected or checked for operational readiness. Acheck for operational readiness may have prevented the truckmalfunction.
PPE
To work in a construction area or when alighting from avehicle in a construction area, workers were required to weardesignated PPE including hard hats, safety glasses, reflectivevests, and safety shoes at a minimum. Crowley did notcommunicate the requirement for PPE to the truck owner orto Driver 1. A hard hat, in this case, may have prevented orreduced the seriousness of the injury.
Signs and Barricades
Signs were not posted at the construction site boundary (siteentrance from Highway 191) alerting workers and visitors of
20
PPE requirements or check-in requirements. Signs were inplace alerting workers of PPE requirements before enteringthe former exclusion zone. When the by-pass wasconstructed, a sign or posting was not in place for the rockhaulers to alert them of PPE requirements. Also, fencingwhich was used to secure the construction site or exclusionzone was removed, so earth-moving activities could beperformed along the fence line. Without this fence oradditional postings, workers could not define theconstruction site boundaries.
Fitness for Duty
According to the medical records, there were indications thatDriver 1 may not have been fit for duty. Driver 1 was notdirectly employed by Crowley, but was hired by a local truckowner to deliver rock. Therefore, Driver 1 was not subjectto company fitness for duty requirements. Assuring thatDriver 1 was fit for duty would have lessened the possibilityof performing unsafe acts because of poor judgement.
Procedures with Training
Neither Crowley nor the truck owner provided instructionsto Driver 1 concerning PPE requirements, stop workprocedures, reporting of defective equipment, traffic patternsor traffic rules. Training on these procedures, requirementsand safety rules may have prevented the accident or injury.
Roles and Responsibilities
Roles and responsibilities for safety from the workers to thesafety and project managers were not clearly understood orcommunicated.
• Workers: If roles and responsibilities were properlycommunicated and followed, work would have beenstopped when workers noticed that the belly dump truckgates were malfunctioning. Driver 1 would not haveresumed hauling until the equipment was safely andproperly repaired. On-site trained workers were requiredto notify appropriate officials in the event of equipmentfailure so repairs could be performed in accordance withthe HSP. This responsibility was not followed since itwas not communicated by the truck owner to Driver 1.
• Vendor: Vendors were, for the most part, not informedof site safety roles and responsibilities. Not knowing
21
their roles and responsibilities or the roles andresponsibilities of the on-site workers, significantlycontributed to the failure of Driver 1 to properly handlethe malfunctioning belly dump truck. If roles andresponsibilities were properly understood, Driver 1would have stopped work and the truck would have beenrepaired properly.
• Safety Personnel, Contractor Managers, and DOEProject Managers: Each of these individuals claimed tobe the overall responsible person for safety on theMonticello Project. However, without full integration ofsite activities (constructing the by-pass, removing thefence, and the Phase IV task), there was no overallevaluation of the project with regards to health andsafety. Also, previous accidents and incidents were notassessed for trends and lessons learned to ensure thatsubcontractors met their respective contractrequirements. The project over the last year experiencedseveral incidents. The most recent accident may havebeen prevented if previous accidents were thoroughlyinvestigated an appropriate corrective actionsimplemented. For example, the accident with the dieseltank deformation revealed a training issue with a vendor.The corrective action was taken to re-train the fuelvendor but other vendors were not evaluated todetermine if they needed re-training.
Lessons Learned
There were numerous site incidents and accidents that wereinvestigated. The majority of the root causes were identifiedas personal error or not following procedures. In one case,the corrective action was to retrain vendors on a specificprocedure, yet it was not identified that other vendors mayneed training on the procedures established at the site. Lackof thorough root cause analysis and subsequent lessonslearned implementation resulted in the failure of this barrier.If lessons learned were properly implemented all vendors(including Crowley) would have received proper site safetytraining.
2.4 Change Analysis2.4 Change Analysis2.4 Change Analysis2.4 Change Analysis A change analysis was also conducted to analyze any changesor differences to determine causal factors in this accident.These changes and the effect of these changes are presentedin summary form in Table 2-1 Change Analysis.
22
Table 2-1 Change AnalysisTable 2-1 Change AnalysisTable 2-1 Change AnalysisTable 2-1 Change AnalysisChange or DifferenceChange or DifferenceChange or DifferenceChange or Difference AnalysisAnalysisAnalysisAnalysis
Planned or Normal Condition Condition at time of Accident Difference or Change EvaluationChain and Operating Equipmentare used to open the belly dumptruck gates.
Iron bar is used to open thegate
When using the bar, the driverwas exposed to the hazards ofthe gates opening and causingthe bar to strike him.
Although the driver and theoperator of the front-end loaderidentified the need for the chain,neither of these workers stoppedthe work to get the rightequipment.
Driver 1 is fit for duty. Driver 1 is possibly impaired. Driver 1 used the bar to openthe gates, since his judgementmay have been impaired.
Driver 1 is a temporary workerfor the Truck Owner. TheTruck Owner did not use formalhiring policies and procedures toensure the drivers are fit forduty. Although OHM has arequirement for AlcoholProhibited Conduct, thisrequirement was not passed tothe truck owner, since Crowleydid not inform OHM of thehiring of other truck owners.
Vendors meet the samerequirement as subcontractors.
Vendors do not meet siterequirements.
Subcontractors must complywith more stringentrequirements than vendors,and must have training.
Vendor status was established toeliminate liability claims shouldrocks fall from trucks anddamage other vehicles. Althoughthe HSP treats vendors as visitor,the Health and Safety Policiesand Procedures Manual of OHMstates that vendors are treated assubcontractors.
23
Table 2-1 Change AnalysisTable 2-1 Change AnalysisTable 2-1 Change AnalysisTable 2-1 Change AnalysisChange or DifferenceChange or DifferenceChange or DifferenceChange or Difference AnalysisAnalysisAnalysisAnalysis
Planned or Normal Condition Condition at time of Accident Difference or Change EvaluationWorkers are trained and informedabout health and safetyrequirements
Workers are not retaininginformation provided during thetailgate meetings.
Safety procedures, instructionsand policies are not followed
Stop work, working withdefective equipment, andwearing PPE was notcommunicated to the driver sinceOHM was not informed of thenew drivers. But in otherincidents, the root causes wereidentified as personal errors,although workers received thetraining. The safety requirementsat the site consist of the HSP andcorporate requirements, andunless brought to the attentionof the worker, theserequirements are onlydisseminated in tailgate meetingsand site briefings.
Good operating equipment Pneumatic system on the dumpgates was apparently faulty.
The gates did not open andDriver 1 used a bar.
Safety inspections were notperformed on vendor equipment.
Adequate and quality equipmentavailable
Limited quality and amount ofequipment
Additional equipmentcontracted from local truckowners
Although MACTEC identifiedthis change when awarding thecontract for Phase IV, there wasno verification as to whatequipment was going to be used.
Qualified Material SupplyContractor available to performwork
Material Supply Contractorsubcontracts his work to localTruck Owners.
Truck Owners were not awareof the procedures to befollowed at the project site.
Contractor did not inform OHMof the new truck subcontractors;therefore OHM did not provideappropriate training.
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Table 2-1 Change AnalysisTable 2-1 Change AnalysisTable 2-1 Change AnalysisTable 2-1 Change AnalysisChange or DifferenceChange or DifferenceChange or DifferenceChange or Difference AnalysisAnalysisAnalysisAnalysis
Planned or Normal Condition Condition at time of Accident Difference or Change EvaluationSecure construction site Undefined construction area
boundariesPPE is required in constructionareas.
Since the fence securing the areawas removed, the constructionsite was no longer defined so theuse of PPE was also not defined.Also, some workers believed thatthe material storage area was nota construction area.
A defined 29 CFR 1910.120 wasteremediation site
Final stages of construction During the remediationactivity, radiation and healthprotection was emphasized.This emphasis on health issuesalso influenced overall safety.
The exclusion area boundarieswere removed because therewere no longer health hazards.Additional posting or barricadesto alert the worker of safetyhazards did not augment the lossof this physical control.
Fenced access to constructionarea
By-pass constructed around site There are no longer signsposted on the fence to alertworkers to wear PPE.
The by-pass was constructed toreduce the cross traffic betweenthe scrapers and the supplytrucks; however, there was nofurther analysis to determine theconsequences of the change.
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2.5 Causal Factors2.5 Causal Factors2.5 Causal Factors2.5 Causal Factors The direct cause of the accident was that an iron bar used forprying the belly dump gates struck the head of Driver 1. Thebelly dump gates released causing the iron bar to be ejectedtoward the driver.
The root cause of the accident is the fundamental cause that, ifeliminated or modified, would prevent reoccurrence of thisand similar accidents. There were also contributing causesthat individually did not cause the accident, but increase thelikelihood of the accident and are important enough to berecognized as needing corrective action. The causal factorsare identified on Table 2-2, Root Causes, with a discussion foreach cause. Appendix B, Events and Causal Factors AnalysisSummary includes the summary of the events and causal factorschart.
Table 2-2 Root CausesTable 2-2 Root CausesTable 2-2 Root CausesTable 2-2 Root CausesRoot Causes Discussion
Site workers and subcontractors are notfollowing site procedures and contractrequirements.
Procedures and requirements are found inthe Health and Safety Plan along withcorporate safety manuals. Unless thecontractor and subcontractor review thesedocuments, the workers and subcontractorsmay only receive the important informationduring one-time safety briefing or at informaltailgate meetings. Crowley’s new TruckOwners and drivers did not receive anybriefings prior to entering the site. Inaddition DOE-GJO has a responsibility toensure that contractual requirements are metfor safety and health.
Roles and responsibilities for safety andhealth oversight by project and constructionmanagement were not clearly defined.
The ES&H oversight by DOE-GJO andMACTEC was limited. The Project Managerand Coordinator were focused onproduction tasks and relied on MACTEC foroversight. One of the items required underCID 175 was to delegate industrial safetyimplementation to OHM. Oversightconsisted of inspections without evaluationsof program and management systems.Consequently, some site workers andvendors were not aware of roles andresponsibilities on site, for example, thefront end loader operator did not performaccording to assigned responsibilities and
26
Driver 1 was not aware of PPE requirementsor site check-in requirements. In addition, itwas apparent through the interviewingprocess that what position (or whichindividual) was responsible for overall sitesafety was not clearly understood by mostsite personnel.
Contributing Causes DiscussionAccident and Occurrence investigations werenot thorough to develop effective correctiveactions to prevent similar occurrences.
Investigations conducted by the contractorand its subcontractors have in most casesidentified the cause of the incident aspersonal error. Occurrence investigations didnot identify programmatic failures,management failures, or contributing causesthat if corrected could prevent similaroccurrences. In one case, the correctiveaction was to retrain vendors on a specificprocedure, yet it was not identified that othervendors may need training on the proceduresestablished at the site.
Various construction tasks were not fullyanalyzed for hazards.
The following tasks: elimination of theexclusion zone, By-pass road construction,Phase IV contract execution, and CID 175implementation were not fully analyzed forthe possible hazards associated with thesechanging site activities.
Vendors were not subject to the same safetyand health requirements as the constructionsubcontractors.
Although OHM procedures do notdifferentiate between suppliers andsubcontractors, OHM established adistinction in order to reduce liability issues.
Construction management did not ensuresubcontractors were meeting contractualrequirements.
Both OHM and its subcontractors did notmeet their respective contractualrequirements. OHM was requested toprovide safety barricades and signs, whichwere not present, when the exclusion fencewas removed. OHM was also required toperform industrial safety inspections ofsubtier contractor equipment. Crowleyfailed to report to OHM that he had hiredadditional the truck owners.
Truck driver was possibly impaired. Based on interviews, several personnelindicated Driver 1 appeared to be unfit forduty. The Board concluded that the effectsof alcohol might have been a factor in thisaccident, but the degree to which itcontributed could not be determined.
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3.0CONCLUSIONS
AND JUDGMENTSOF NEED
ConclusionsConclusionsConclusionsConclusions Judgment of NeedJudgment of NeedJudgment of NeedJudgment of NeedThe construction workers, subcontractors,and vendors were not following therequirements established in the Health andSafety Plan or in the contract documents.For example, Driver 1 appeared to be unfitfor duty that was a violation to 49 CFR382.201, Alcohol concentration and OHM’srequirement 5.2.17, Alcohol ProhibitedConduct. Crowley failed to inform OHM ofthe hiring of the truck drivers.
MACTEC needs to review currentrequirements and procedures to ensureapplicability and consistency. Based on thisreview, MACTEC needs to disseminatethese requirements and procedures to theworkers, subcontractors, and vendors.
DOE-GJO needs to ensure that theircontractors adhere to contractualrequirements relating to safety and health.
Roles and responsibilities for safety andhealth on construction sites for projectmanagement and construction managementwere not clearly defined.
DOE-GJO needs to clarify roles andresponsibilities for safety and healthinvolving project management and ensurethese responsibilities are understood andaccomplished.
MACTEC needs to clarify roles andresponsibilities for safety and healthinvolving construction management andensure these responsibilities are understoodand accomplished.
Crowley did not inform OHM of the use ofindependent truck owners.
MACTEC needs to ensure the contractor’srequirements are met by subcontractor andlower subtier subcontractors, includingvendors.
Occurrence and accident investigations tendto identify personal error as root cause forthe incident. Potential management andprogram system errors are not identified
MACTEC needs to conduct occurrence andaccident investigations to determine rootcauses that focus on program andmanagement systems and develop andimplement corrective actions to address theidentified causes.
DOE-GJO needs to ensure that theircontractors are conducting accident andoccurrence investigations to identifymanagement and program system errors andensure that their contractors areimplementing effective corrective actions toaddress the causes.
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4.0 BOARDSIGNATURES
29
5.0 BOARDMEMBERS,
ADVISORS, ANDSTAFF
Board MembersBoard MembersBoard MembersBoard Members
George J. RaelAccident Investigation Board ChairpersonAlbuquerque Operations Office
Ralph FevigAlbuquerque Operations Office
John CormierAlbuquerque Operations Office
Patricia ArmijoAlbuquerque Operations Office
Site AssistanceSite AssistanceSite AssistanceSite Assistance
Vernon CromwellSafety OfficerGrand Junction OfficeAlbuquerque Operations Office
APPENDIX ATYPE B INVESTIGATION BOARD MEMORANDUM
A-1
A-2
A-1
APPENDIX BEVENTS AND CAUSAL FACTORS ANALYSIS SUMMARY
Tank DeformationIncident
03/22/99
Materials SupplyContractor hired to
deliver rock05/4/99
Numerous accidentsoccurred (ORPS)
Accident with twoscrappers
9/17/99
Exclusion (boundary)fences are removed
9/30/99
Monticello projectidentified behind
schedule
Work schedulechanged
mid-October
Materials SupplyContractor
awarded new contract10/19/99
Materials SupplyContractor hires trucks& drivers from 4 local
Truck Owners10/25/99
OHM/IT generatesfinal traffic problem
routes
10/27/99
By-pass to material stockpile area became
operational
10/25/99
Legend
Event
Conditions
CausalFactor
AccidentEvent
AssumedCondition
Approved verballyby OHM/IT
No traffic controlon by-pass
Traffic patternnot identified for new
area/materialunloading
Vendor not informedof new route
Doesn’t includematerial stockpile area
CID 175 issued
06/15/98
Reservationsabout roles andresponsibilities
No verification ofimplementation;
oversight is lacking
Increase in amountof heavy equipment
10/21/99
Focus oncompletion by winter
Verbal agreementwith drivers; Pay is by
number of loads
Hired on to meetcommitments of newcontract for phase IV
work
OHM/IT not aware ofnew trucking companies;for subcontractors-yes,
vendors-no
Truck Owners/drivers do not receiveany safety information
Current workcan’t be impacted by
this new work
OHM/IT is awareof new contract
Materials SupplyContractor doesnot have enough
trucks to meet newrequirements
Materials SupplyContractor pulls trucks
off of current workto meet newrequirements
No verificationof statement of “no
impact”
Informal Operationby OHM
Subsequentconstruction site
not identified
No more exclusion zoneor focus on rad
Construction safetyreceives less priority
Assumption thatsince Hwy 191is boundary, no
need to post
Root cause ofinvestigation is
found to beoperator error
Other causalfactors not properly
identified
Personal oroperator error frequently
cited as cause
False sense of safety securityfrom previous
successes
Investigationsdid not determine
root cause
Hired with apurchase order
References99 page terms and
conditions
Required driversto perform safety checksand follow routing and
traffic directions
Use of vendorsto avoid liability issues
Vendor accident report4/30/99
Root cause isthat procedures
were not followed
Recommendedthat all vendors receive
training on HSP
Resulting correctiveaction implementation
was done only forspecific vendor
Accident Investigationsnot thorough
Vendors do notmeet HSP requirements
No analysis ofchange
Violation of contractrequirements
No analysis ofchange
Not a dedicatedconstruction site
Focus onproduction and
schedule
Focus onproduction and
schedule
No analysis of change
RootCause
Connector
A
Procedures and contractual requirements arenot effectively communicated to workers and subcontractors
Role and responsibilities are not clearly defined
Events and Causal Factors Summary
B-1
Driver 1 delivers1st load of the day;
by-pass used11/1/99
Belly dump jams;Driver 1 uses iron bar
to free gates11/1/99
Belly dump jamsagain on 2nd trip;
by-pass used
11/1/99
Driver 1 makes3rd trip of the day;
by-pass used11/1/99
Belly dump gatesjam again
Driver 1 gets outof truck
11/01/99
Driver 1 uses iron barto open gates
11/01/99
Bar use is Improper;Unsafe practice
Air pressure notsufficient to operate
pneumatic gates
No notice givenof traffic patterns
Not recognizedas a construction
area
Considered a vendorand not generallyinformed of safety
11/1/99
Driver 1 and front end loader operator discuss
proper method of freeing the gates;Iron bar is used to
free gates
Operator of frontend loader did not
have a chain
Front end operatordid not notify proper
authorities of equipmentfailure
Work not stopped
Truck Ownerhires Driver 1
10/29/99
Driver 1 deliversone belly-dumpload to the site
10/30/99
Doesn’t get directions
OHM doesn’t know ofnew Driver 1 orof new Truck
Owner
Driver 1 doesnot receive a site briefing
Driver 1 notwearing PPE; violation
of HSP
No safety informationor training of employees
No safety program
Belly dumptrailer has been unused
for one year
Driver 1 deliversto wrong side of material
pile
11/1/99
3rd malfunctionof the day No PPE worn
Violation of HSPrequirements
Driver 1 not aware ofHSP or requirements
Bar use is Improper;Unsafe practice
Gatesopen and
iron bar strikesDriver 1
~11:18am11/01/99
Driver 1 may havebeen unfit for
duty
Violation of contractrequirements Violation of safety
and healthrequirements
Vehicle Malfunctions
Supervisor notcalled
Driver 1 doesn’treceive site & procedure
info from TruckOwner
Driver 1 doesn’treceive site & procedure
info from TruckOwner
~11:23am11/01/99
QC Inspector andOHM alternate Site Safety Officer direct
guard to call 911
Ambulance arrives
~11:28am11/01/99
Scene not secured
A
B-2