Office of Environment, Safety and Health

Type A Accident Investigation

Subcontractor Fatality at the Pond B Dam Upgrade Project on July 26, 2004 at the Savannah River Site Aiken, South Carolina

September 2004 September 2004 This page is intentionally blank. TABLE OF CONTENTS

EXECUTIVE SUMMARY ...... ES-1 1.0 INTRODUCTION ...... 1-1 1.1.Background ...... 1-1 1.2.Facility Description ...... 1-1 1.3.Scope, Conduct, and Methodology ...... 1-2 2.0 THE ACCIDENT ...... 2-1 2.1.Background and Accident Description ...... 2-1 2.2.Emergency Response and Medical Treatment...... 2-6 2.3. Investigative Readiness and Accident Scene Preservation ...... 2-8 2.4.Accident Reconstruction and Analysis ...... 2-9 3.0 ACCIDENT FACTS AND ANALYSIS ...... 3-1 3.1.Line Management Roles and Responsibilities...... 3-1 3.2.Procurement and Contractual Requirements ...... 3-4 3.3.Work Planning and Controls ...... 3-6 3.4.Safety Oversight ...... 3-8 3.5.Feedback and Improvement ...... 3-10 3.6.Personnel Training and Qualifications ...... 3-13 3.7.Change and Barrier Analysis...... 3-14 3.8.Causal Factors Analysis ...... 3-14 4.0 JUDGMENTS OF NEED ...... 4-1 5.0 BOARD SIGNATURES ...... 5-1 6.0 BOARD MEMBERS, ADVISORS, AND STAFF...... 6-1 Appendix A – Appointment of Type A Accident Investigation Board...... A-1 Appendix B – Analysis of Previous Savannah River Near-Miss and Industrial Operations Occurrences ...... B-1 Appendix C – Change Analysis ...... C-1 Appendix D – Events and Causal Factors Analysis ...... D-1

iii Figures and Tables

Table ES-1. Causal Factors and Judgments of Need ...... ES-1 Figure 1-1. South end of Pond B Dam...... 1-2 Figure 1-1. Accident investigation terminology ...... 1-3 Figure 2-1. The accident scene ...... 2-1 Figure 2-2. Lowboy after removing excavator……………...... 2-3 Figure 2-3 The recommended arm configuration for lifting tracks ...... 2-4 Figure 2-4. Approximate arm configuration the teamster used ...... 2-4 Table 2-1. Event chronology...... 2-5 Figure 2-5. The scene immediately following the accident...... 2-7 Figure 3-1. Relevant DOE organizational chart ...... 3-1 Figure 3-2. WSRC, BSRI, subcontractor, and vendor line management and functional relationships ...... 3-3 Figure 3-3. WSRC categories of subcontracted work ...... 3-5 Figure 3-4. Reproduction of Grade South’s hazard analysis for mobilization ...... 3-7 Table 3-1. Causal Factors Analysis ...... 3-15 Table 4-1. Conclusions and Judgments of Need ...... 4-1 Table B-1. Analysis of Previous Savannah RiverNear-Miss and Industrial Operations Occurrences ...... B-3 Table C-1. Change Analysis ...... C-3 Figure D-1. Events and Causal Factors Chart ...... D-3

iv Release Authorization

On July 28, 2004, I appointed a Type A Accident Investigation Board (Board) to investigate the July 26, 2004, subcontractor fatality that occurred at the Savannah River Site Pond B Dam. The Board’s responsibilities have been completed with respect to this investigation. The analyses and the identification of the contributing causes, the root cause, and the Judgments of Need resulting from this investigation were performed in accordance with DOE Order 225.1A, Accident Investigations.

I accept the report of the Accident Investigation Board and authorize release of this report for general distribution.

This report is an independent product of the Type A Accident Investigation Board appointed by John Spitaleri Shaw, Acting Assistant Secretary, Environment, Safety and Health, U.S. Department of Energy.

The Board was appointed to perform a Type A investigation of this accident and to prepare an investigation report in accordance with DOE Order 225.1A, Accident Investigations.

The discussion of facts as determined by the Board and the views expressed in the report do not assume, and are not intended to establish, the existence of any duty at law on the part of the U.S. Government, its employees or agents, contractors, their employees or agents, or subcontractors at any tier, or any other party.

This report neither determines nor implies liability.

v ACRONYMS

AHA Automated Hazard Analysis Board Type A Accident Investigation Board BNFL British Nuclear Fuels, Limited BSRI Bechtel Savannah River, Incorporated CFR Code of Federal Regulations DAR Daily Activity Report DEAR Department of Energy Acquisition Regulation DOE Department of Energy EMS Emergency Management Services EMR Experience Modification Rate ES&H Environment, Safety and Health ES&HP Environment, Safety and Health Provisions FEB Facility Evaluation Board FERC Federal Energy Regulatory Commission FRAP Functions, Responsibilities, and Authorities Procedure FSSBU Field Support Services Business Unit ISM Integrated Safety Management ISMS Integrated Safety Management System MCG Medical College of Georgia METRAC Metropolitan Tractor Company OA Office of Independent Oversight and Performance Assurance OBU Operations Business Unit ORPS Occurrence Reporting and Processing System OSHA Occupational Safety and Health Administration OSS Office of Site Services PVC Polyvinyl chloride RFP Request for Proposal SR Savannah River Operations Office SRS Savannah River Site SRSOC Savannah River Site Operations Center STARRT Safety Task Assignment Risk Reduction Talk STR Subcontract Technical Representative TRC Total Recordable Case TSP Task-Specific Plan WPP Worker Protection Plan WSI/SRS Wackenhut Services, Incorporated/Savannah River WSRC Westinghouse Savannah River Company, LLC Executive Summary

The Accident Carolina. With the exception of facilities operated for the National Nuclear Security On July 26, 2004, at approximately 3:15 p.m., a Administration, many of the original production truck driver (driver) was critically injured at the facilities within the site are being Savannah River Site, while loading a rented decommissioned, and major waste treatment excavator onto a lowboy trailer for return to and management activities associated with that the rental company. The accident occurred effort are conducted under the cognizance of when a teamster from GradeSouth, Inc., a the U.S. Department of Energy’s (DOE) Office construction sub-tier contractor, and a truck of Environmental Management. Local DOE driver from Guthrie Grading and Hauling management is provided by the DOE-Savannah attempted to reposition an outrigger plank on River Operations Office (DOE-SR). the lowboy trailer. The plank had become dislodged when the excavator was being In December 2003, Bechtel Savannah River, Inc. positioned on the trailer. The teamster used the (BSRI) awarded a construction subcontract to excavator’s boom to lift one of the excavator GradeSouth, Inc., to make necessary repairs to tracks off the trailer so that the driver could the Savannah River Site’s Pond B Dam to bring reposition the plank under the track. The the dam into compliance with guidelines issued excavator dropped (moved) while the driver was by the Federal Energy Regulatory Commission. repositioning the plank, and the driver suffered Part of the work GradeSouth performed critical and subsequently fatal injuries. The required the use of a rented excavator. The direct cause of the fatality was crushing injuries deceased driver was an employee of Guthrie resulting from movement of the excavator Grading and Hauling, which had been hired to during loading operations. return the excavator to the rental company, Metropolitan Tractor. The driver’s fatal injuries On July 28, 2004, the Acting Assistant Secretary occurred at the Pond B Dam Upgrade Project for Environment, Safety and Health appointed during the final phases of the project. a Type A Accident Investigation Board (Board) to analyze causal factors, identify root causes, Results and Analysis and determine Judgments of Need to preclude similar accidents in the future. The Chairman The Board conducted numerous interviews, and some Members of the Board arrived at the reviewed relevant documents, and had elements Savannah River Site July 28, 2004, and the full of the excavator’s performance evaluated Board convened onsite on August 2, 2004. The (tested). Results from these efforts were used to Board completed the investigation on perform a causal factors analysis in accordance September 1, 2004. with the DOE Workbook, Conducting Accident Investigations. Causal factors are events or conditions that produced or contributed to the Background occurrence of the accident and consist of root, direct, and contributing causes. The Savannah River Site is located approximately 25 miles southeast of Augusta, The root cause of the accident is the Georgia and 22 miles south of Aiken, South fundamental cause that, if corrected, would

ES-1 prevent reoccurrence of this and similar The Board also identified contributing causes accidents. The direct cause is the immediate and conclusions related to this accident. Based event or condition that caused the incident. on those conclusions, the Board determined the Contributing causes are events or conditions appropriate Judgments of Need in responding that, collectively with the other causes, increase to this accident. Judgments of Need are the likelihood of the accident but individually managerial controls and safety measures did not cause the accident. necessary to prevent or minimize the probability or severity of a recurrence. They are also The Board concluded that the following are the directed at guiding managers in developing root causes of the accident that should be corrective measures. Table ES-1 summarizes the corrected to prevent similar events from Board’s conclusions and Judgments of Need. occurring. Summary – DOE, WSRC and BSRI were inattentive to programmatic deficiencies in the The Accident Investigation Board concluded communication and implementation of that this accident was preventable. The Board safety requirements for subcontracted identified weaknesses in the site’s construction work at the Pond B Dam implementation of integrated safety Project. management policy through work practices as – The subcontractors’ unstructured approach it relates to the subcontractor and vendors to work did not ensure that safety and performing work at the Pond B Dam Upgrade health requirements were translated into Project. WSRC did not ensure that the work controls, did not take those actions subcontractor met basic requirements imposed necessary to enforce compliance with by the Department, the site, and the fundamental safety requirements during the Occupational Safety and Health Administration. work, nor did they define their safety and Although internal and external oversight health expectations for the activity prior to activities and a series of operational occurrences work. identified construction safety-related issues and concerns with similar systemic causes, a lack of – WSRC failed to fully address the causal rigorous causal analysis prevented identification factors for previous operational occurrences of lessons-learned and systemic weaknesses and through the corrective action processes at implementation of effective corrective actions. the site. The DOE-SR and WSRC need to intensify their The Board further determined that the direct efforts and commitment to ensure that all the causes of the accident resulting in the excavator elements associated with ISM are promptly and falling onto the driver are as follows: effectively addressed for all construction – The driver was working under or near the subcontractors and sub-tier contractors and excavator. vendors to prevent additional accidents. – The GradeSouth teamster was not qualified to operate the excavator. – GradeSouth failed to exercise control over its employee and vendor. – Stop-work authority was not effectively utilized.

ES-2 Table ES-1. Causal Factors and Judgments of Need

ES-3 Table ES-1. Causal Factors and Judgments of Need (continued)

ES-4 1.0 Introduction

1.1 Background River National Laboratory. Major subcontractors to WSRC include Bechtel On July 26, 2004, at the Savannah River Site Savannah River, Incorporated (BSRI), which is (SRS) Pond B Dam, a truck driver suffered fatal responsible for environmental restoration, injuries when he was crushed by an excavator. project management, and engineering and On July 28, 2004, John Spitaleri Shaw, Acting construction activities; British Nuclear Fuels, Assistant Secretary for Environment, Safety and Limited Savannah River Corporation, which is Health, U.S. Department of Energy (DOE), responsible for the site’s solid waste program; appointed a Type A Accident Investigation CH2 Savannah River Company, which is Board (Board) to investigate the accident in responsible for decommissioning and accordance with DOE Order 225.1A, Accident demolition; and Polestar Savannah River Investigations (see Appendix A for appointment Company, which provides the services of the memorandum). Chief Closure Officer. Security, protective services and special response capability are 1.2 Facility Description provided by Wackenhut Services, Incorporated/ Savannah River Site (WSI/SRS). 1.2.1 Savannah River Site Savannah River Site covers 310 square miles, 1.2.2 Pond B Dam encompassing parts of Aiken, Barnwell, and Figure 1-1 shows an aerial view of Pond B. The Allendale Counties in South Carolina, bordering Pond B Dam, the scene of this accident, was the Savannah River. The site is located constructed in 1960 as a simple earthen dam approximately 25 miles southeast of Augusta, with a sandy-toe drain system that was typical Georgia, and 22 miles south of Aiken, South of that period. The dam is operated and Carolina. Many of the original production maintained using the Federal Energy Regulatory facilities within the site are being Commission (FERC) guidelines as set forth decommissioned. Major waste treatment and under Title 18 Code of Federal Regulations management activities associated with that effort (CFR) Part 12, Safety of Water Power Projects are conducted under the cognizance of the DOE and Project Works. WSRC and FERC Office of Environmental Management (EM), inspections confirmed that the pre-repair state with local DOE management provided by the of the Pond B structure did not comply with Savannah River Operations Office (DOE-SR). FERC guidelines and required repair. A fixed- Also located within the site are operating price construction contract was awarded to and facilities associated with tritium processing and executed by GradeSouth, Inc., a sister company handling under the cognizance of the National to Beam’s Contracting. The scope of the Pond B Nuclear Security Administration. Upgrade Project included the installation of a filter and drainage system consisting of coarse The site is operated by an integrated team led gradation sand, fine gradation sand, and a by Westinghouse Savannah River Company, compacted-earth fill berm; installation of a rock LLC (WSRC), which is responsible for the site’s riprap collection ditch; installation and removal nuclear facility operations, environment, safety, of a temporary sediment basin; and installation and health (ES&H), and quality assurance; all of four piezometers. At the time of the accident, site administrative functions; and the Savannah GradeSouth was completing punchlist activities

1–1 Figure 1-1. South end of Pond B Dam after receiving a Certificate of Mechanical 1.3 Scope, Conduct, Completion from BSRI on June 23, 2004. These and Methodology activities included excavation and earth- moving work. The Board began its activities on July 29, 2004, and completed its investigation on September 1, 2004. The scope of the Board’s investigation was to identify and analyze all relevant facts to determine the direct, contributing, and root causes of the event; to develop conclusions; and to determine Judgments of Need that, when

1–2 implemented, should prevent recurrence. See Figure 1-2 for an explanation of accident A causal factor is an event or condition in investigation terminology. the accident sequence that contributes to the unwanted result. There are three types The Board conducted its investigation in of causal factors: direct causecause, which is accordance with DOE Order 225.1A, the immediate event or condition that Accident Investigations, using the following caused the accident; root causecause, which is the causal factor that, if corrected, would methodology: prevent recurrence of the accident; and – The Board gathered relevant facts through the contributing causescauses, which are the interviews and by reviewing documents and causal factors that collectively, with the evidence. other causes, increase the likelihood of an accident but that did not cause the – The Board inspected the accident scene, accident. tested equipment, conducted an engineering analysis, and reviewed Event and causal factors analysis includes photographs of the scene. charting, which depicts the logical sequence of events and conditions (causal – The Board identified causal factors using factors that allowed the accident to occur) event and causal factor analysis, barrier and the use of deductive reasoning to analysis, and change analysis. determine the events or conditions that contributed to the accident. – Using these causal factors, the Board developed Judgments of Need for corrective Barrier analysis reviews the hazards, the actions to prevent recurrence. targets (people or objects) of the hazards, and the controls or barriers that management systems put in place to separate the hazards from the targets. Barriers may be physical or administrative.

Change analysis is a systematic approach that examines planned or unplanned changes in a system that caused the undesirable results related to the accident.

Figure 1-2. Accident investigation terminology

1–3 This page is intentionally blank. 2.0 The Accident

2.1 Background and the driver was repositioning the plank, the Accident Description excavator dropped (moved), critically injuring the driver. Figure 2-1 shows the position of the 2.1.1 Accident Overview excavator and lowboy immediately following On the afternoon of July 26, 2004, a GradeSouth the accident. teamster employee and a truck driver from Guthrie Grading and Hauling, Inc. (Guthrie) 2.1.2 Background were loading a John Deere Model 790E-LC On August 15, 2003, BSRI sent a Request for excavator onto a lowboy trailer. The accident Proposal (RFP) for the Pond B Dam Upgrade occurred at approximately 3:15 p.m. as the Project to four construction contractors. The teamster and driver attempted to reposition an scope of work included soil excavating and outrigger plank on the lowboy trailer that trenching, earth filling, installing polyvinyl became dislodged while the excavator was being chloride (PVC) drainage pipes, and setting positioned on the lowboy. The teamster used the precast reinforced-concrete manholes and weir excavator’s boom to lift one of the excavator boxes. It also included drilling monitoring wells tracks off the lowboy trailer so that the driver and setting piezometers and monitoring well could reposition the plank under the track. As components. This work involved operating

Figure 2-1. The accident scene

2–1 heavy earthmoving equipment and drilling rigs Metropolitan Tractor Company (METRAC), and performing rigging activities at a remote delivered the excavator to the project site on onsite location. July 15. A qualified operating engineer from GradeSouth unloaded the excavator. The Of the four contractors, GradeSouth was the METRAC driver informed the operating only prospective bidder to respond to the RFP. engineer that the excavator had a hydraulic leak. The company had previously worked at SRS GradeSouth repaired the leak by tightening with demonstrated safety performance for three hydraulic line fittings. On July 19, while using years, based on the Minimum Performance the excavator to load a dump truck, the Eligibility Factors of the RFP. These factors operating engineer noticed that it was losing included an Experience Modification Rate hydraulic pressure and that the boom gradually (EMR) of 1.0 or less and a Total Recordable Case lowered into the truck bed. After adding about (TRC) rate of 7.9 or less. In December 2003, 5 gallons of hydraulic fluid, the operating GradeSouth was awarded a fixed-price engineer completed the fieldwork that required construction contract to execute the work at the the long-boom excavator. The following day, a Pond B Dam and started mobilization activities. GradeSouth mechanic made repairs that BSRI issued a Notice to Proceed on January 7, included replacing an O-ring on a hydraulic line 2004. After completion of a pre-job briefing, to the operating cylinder for the arm and tested GradeSouth started construction work the week the excavator to confirm that there was no of January 19, 2004. detectable leak. The excavator was parked. GradeSouth notified METRAC of the repairs and During the execution of the project, two requested that the equipment be transported off incidents occurred. On February 19, 2004, a site. METRAC then contacted Guthrie and GradeSouth employee bent a drill auger when requested that the excavator be transported to he rotated the equipment boom while the auger their Augusta office. was still in the hole. The operator believes he may have blacked out due to a medical condition 2.1.3 Accident Description that was not previously disclosed to GradeSouth. At approximately 2:00 p.m. on July 26, 2004, a On April 23, 2004, BSRI issued a safety citation GradeSouth teamster was assigned to meet a to GradeSouth for an incident in which a Guthrie truck driver at the New Ellenton GradeSouth driver overturned a dump truck security gate and escort him on site to retrieve equipped with a 1,000-gallon, skid-mounted the excavator. The teamster used a GradeSouth water tank while backing onto an adjacent slope company vehicle to travel to the gate. Records to make a turn. The dump truck and water tank indicate that the truck driver signed in at the were being used to wet down a road for dust New Ellenton security gate at 2:35 p.m. The control, and the tank had not been secured to teamster led the truck driver to the Pond B Dam prevent lateral shifting within the body of the Project area and parked the company vehicle dump truck. near the excavator. The truck driver positioned the lowboy trailer he had brought for loading On June 23, 2004, BSRI issued a Certification of the excavator and disconnected the trailer from Mechanical Completion, with a punchlist of its gooseneck trailer hitch, which remained items to be completed, to GradeSouth for the attached to the truck cab. Pond B Dam Upgrade Project. As one of the punchlist items, GradeSouth had to rework the The lowboy trailer, shown in Figure 2-2, is 8 sediment pond and needed a long-boom feet, 6 inches wide. Outriggers are available for excavator to reach across the pond while on the trailer to extend it an additional 1 foot on level ground. GradeSouth’s vendor, each side, resulting in a total width of 10 feet, 6

2–2 inches. The trailer body supports the weight of the excavator toward the front of the trailer and the excavator, and the outriggers support the signaled the teamster by hand when the tracks, which sag if not supported. The excavator excavator was positioned where he wanted it. is 11 feet, 1 inch wide, which means the The teamster also stated that the truck driver excavator track will hang over the outriggers told him that the plank on the outrigger on the about 3 to 4 inches when the excavator is driver’s side of the lowboy was cocked and that centered on the lowboy. the driver asked him to use the boom to lift the track on that side of the excavator so that he The driver positioned the outrigger and plank could reposition the plank correctly on the on the driver’s side of the lowboy, and the outrigger. Post-accident statements by the teamster assisted the driver in positioning the teamster indicate that neither he nor the truck outrigger and plank on the passenger side (post- driver considered stopping work or backing the accident visual examination indicated that excavator off the trailer and starting over when outriggers were missing on the lowboy – three the plank became cocked. on the passenger side and two on the driver’s side). The outrigger plank on the driver’s side The teamster raised the excavator boom and spanned six outrigger positions, including one swung it about 90 degrees to the right so that it of the missing positions. The teamster drove the was nearly perpendicular to the excavator excavator onto the lowboy trailer from the front tracks. He positioned the boom and the arm to end of the trailer. He stated that he loaded the place the bucket on the ground about 10 to12 excavator as a courtesy to the driver. The feet from the trailer. In this position, the arm is GradeSouth employee is a teamster, not an at an approximate 45-degree angle to the operating engineer. ground. John Deere recommends that the arm should be at a 90- to 110-degree angle to the The excavator was initially positioned as far back boom, allowing the track to be elevated by on the lowboy as it would go. The teamster applying downward force on the boom only, stated that the truck driver asked him to move rather than operating in “two-stick” control

Figure 2-2. Lowboy after removing excavator

2–3 (illustrated in Figures 2-3 and 2-4). The teamster that he did not have a sensation that the then used the excavator controls to push down excavator was sliding but that the bucket was on the boom and out on the arm to raise the sliding. track (i.e. “two-stick” control). He stated that the truck driver verbally directed him at least When the teamster heard the truck driver twice to raise the track higher. During this scream out in pain, he applied pressure and activity, the driver was in the teamster’s line of boomed back up in order to keep the tracks off sight. The driver then squatted down near the the driver or the bucket from getting to the excavator and trailer, and he then disappeared driver. He did this by pushing down on the from the teamster’s line of sight. boom and out on the arm. The teamster asked the driver if he was okay and was told that he The teamster stated that shortly afterwards he needed some help. felt the excavator budge, like it dropped. He then focused his attention on the excavator The teamster stated that he locked down the bucket and the ground and a short time later hydraulic controls on the excavator, ran off the saw the excavator drop again. He believed he back of the trailer without looking at the injured could feel the bucket bleeding down and, from driver, got into the company vehicle, and drove where the pressure had been applied to raise across the dam (0.4 miles) to the GradeSouth the track, it was releasing the pressure, allowing construction office trailer to get help. He met the track to come back down. He then began his foreman, general superintendent, and calling to the driver to get out, that the excavator another GradeSouth employee and told them was coming down. The teamster stated that the the driver was pinned. The four of them truck driver told him to hold on a minute and returned to the scene of the accident in two not do anything. The teamster said that he took vehicles; the foreman and superintendent in one his hands completely off the controls so he and the teamster and employee in the other. wouldn’t accidentally bump the bucket, but the When they arrived at the accident scene, they bucket was continuing to slide in. He reported found the driver lying on his stomach,

Figure 2-3. (left) The recommended arm configuration for lifting tracks

Figure 2-4. (below) Approximate arm configuration the teamster used.

2–4 somewhat parallel to the track of the excavator, The GradeSouth employees wedged lumber with his feet near the edge of the track. The from the lowboy under the track to prevent it foreman determined that an ambulance was from dropping further. Table 2-1 below provides required, and the superintendent used his an event chronology. company-issued cell phone to call the GradeSouth onsite office in H-Area, informing The Board concludes that there were a number of them of the accident and requesting an opportunities to utilize stop work and it was not ambulance. The GradeSouth onsite office then exercised. notified the SRS Emergency Duty Officer that an accident had occurred at the Pond B Dam and that medical assistance was required.

Table 2-1. Event chronology

Date Event 8/15/2003 BSRI issued the RFP. 9/8/2003 BSRI issued Addendum 1 to the RFP. 12/3/2003 BSRI awarded the subcontract to GradeSouth. 1/7/2004 BSRI gave GradeSouth the Notice to Proceed. 6/23/2004 BSRI issued the Certificate of Mechanical Completion, with punchlist. 7/15/2004 GradeSouth received the excavator from METRAC. 7/21/2004 GradeSouth requested METRAC to pick up the excavator. 7/26/2004 The Guthrie driver entered the site to pick up the excavator . 2:35 p.m. GradeSouth teamster escorted the driver to the Pond B Dam Project area. The driver positioned the lowboy for loading. The teamster rotated the boom and raised the excavator. The driver asked the teamster to raise the excavator higher using the boom. The driver repositioned the outrigger plank. ~3:15 pm The excavator fell on the driver. The teamster drove to the other side of the Pond B Dam to get help at the construction office trailer. GradeSouth employees drove back to the accident site and found the driver lying on his stomach somewhat parallel to the excavator track, but not under it. 3:27 pm The supervisor called the GradeSouth H-Area Office by cell telephone. A GradeSouth employee in H-Area called the Savannah River Site Operations Center (SRSOC) using the site telephone and requesting an ambulance. 3:28 pm GradeSouth H-Area Office employee made a follow-up call to the SRSOC. 3:28 pm The SRSOC dispatched Squad 3/Medic 3. 3:40 pm Unit 91 arrived as first responder Emergency Medical Services and provided a critical assessment of the driver. 3:40 pm Squad 3/Medic 3 arrived at the scene. 3:55 pm Medic 3 departed the scene for the Medical College of Georgia Trauma Center. Medic 3 picked up an additional paramedic while en route. 4:40 pm Medic 3 arrived at the Medical College of Georgia. 6:18 pm The Medical College of Georgia reported this as the time of death.

2–5 2.2 Emergency Response with an accurate description of the accident when they first arrived. and Medical Treatment The first responders noted that the driver’s feet Although GradeSouth reported that they had were near the track and that his body was BSRI remote worker radios in the work trailer positioned at approximately the same angle as at the worksite, and the teamster told them that the lumber (Figure 2-5) that was placed under the driver had been pinned, the initial call for the track by GradeSouth personnel to prevent medical assistance was not made until the the tracks from falling onto the driver. They GradeSouth foreman and superintendent drove also noted that the driver’s pants were torn and to the accident scene and determined that an that his right leg and pelvis were injured. The ambulance was required. The GradeSouth driver could not provide the first responders superintendent used his company-issued cell with an accurate description of the accident. phone to call the GradeSouth office in H-Area During the first responders’ initial assessment, at SRS, informing them of the accident and the driver’s blood pressure decreased and heart requesting an ambulance. At 3:27 p.m., the and respiratory rates increased. The driver was GradeSouth employee located in H-Area called given oxygen by non-rebreather mask and the Savannah River Site Operations Center placed on a Reeves Sleeve for transport. (SRSOC) and reported that they had a man down that was non-responsive and that an ambulance Testimony from emergency responders was needed. The employee reported that the indicates that consideration was given to using man (driver) was at the Pond B Dam Upgrade the WSI helicopter for MEDEVAC transport. Project. In a follow-up phone call from H-Area Several of the first responders stated that if they to SRSOC at 3:28 p.m., the employee reported had known that the driver had been crushed by that the man was non-responsive, and they were the excavator, they would have put the not sure if he fell off something. SRSOC had no helicopter on standby. One of the first direct communication with the employees at the responders (a paramedic) stated that they would accident scene to obtain information for the first not have been able to effectively secure, treat, responders. and transport the driver using the MEDEVAC. The Board’s inspection of the MEDEVAC At 3:28 p.m., SRSOC dispatched fire department helicopter and interviews with the pilots personnel, emergency medical technicians, and indicated that there is room for the patient to a paramedic from Savannah River Fire be securely strapped in the helicopter, along Department Station 3 to the accident scene. At with two attending medical personnel and their 3:32 p.m., while en route to the accident scene, equipment. The approved SRS Medical these first responders radioed SRSOC to request Protocols dated September 25, 2001, indicate additional information on the driver’s condition. that the driver exhibited at least three of the The dispatcher responded that all that was anatomic and physiologic criteria that may known indicated that he was conscious, but warrant a MEDEVAC transport. The Medical incoherent. The first responders, along with SRS Protocols also indicate that ground travel to the law enforcement personnel, arrived at the Pond Medical College of Georgia is approximately 50 B Dam at 3:40 p.m. Personnel arriving at the minutes and air travel is 7 to 8 minutes. accident scene found the driver conscious, lying face down, responding to questions, and The ambulance departed the accident scene at complaining of leg pain. The first responders 3:55 p.m. for the nearest Level I Trauma Center stated that no one at the scene provided them at the Medical College of Georgia in Augusta. A paramedic and an emergency medical

2–6 Figure 2-5. The scene immediately following the accident technician both attended the injured truck The ambulance arrived at the hospital’s driver in the back of the ambulance. The emergency department at 4:40 p.m. The driver ambulance driver declared a Code 3 (lights and was taken to the trauma room, where the siren) and Signal 24 (multiple trauma and shock) hospital’s trauma team managed his injuries. The and radioed the hospital to report that they were team’s physical examination revealed bruises transporting the driver. The emergency medical and abrasions on the driver’s left thigh and an technician and paramedic had difficulty open fracture of the right femur. The driver controlling the injured driver, who was, at could not move his lower extremities and had times, combative and uncooperative. The no sensation in either leg up to the level of the ambulance driver radioed Savannah River Fire umbilicus. X-rays showed an extensively Department Station 1 to request that a second comminuted intertrochanteric fracture of the paramedic meet the ambulance en route to help right femur, multiple pelvic fractures (right and in controlling the injured driver and assisting left superior and inferior pubic rami, right the paramedic and technician. Subsequently, the sacrum with widening of the right sacroiliac second paramedic assisted in giving the driver joint) and fracture of the right transverse process oxygen and intravenous fluids. During of vertebra L5. Orthopedic Surgery personnel transport, the paramedics noted that the driver wrapped the driver’s pelvic area in a bed sheet stopped breathing for several seconds and to stabilize the pelvis and applied a traction administered oxygen using a bag valve mask. device to the right leg to reduce the femur The injured driver quickly resumed breathing fracture. The driver displayed respiratory spontaneously. distress and was placed on mechanical ventilation. He was then transported to the

2–7 angiography suite to determine the extent of The Board concludes that the emergency medical suspected vascular injuries and to embolize response was hampered by the lack of an accurate affected blood vessels, as needed. As the patient description of the incident due to poor was transferred to the angiography table, he communications. experienced a cardiopulmonary arrest and could not be resuscitated. The time of death was The Board also concludes that the emergency recorded as 6:18 p.m. medical services (EMS) responders did not precisely follow the approved SRS Medical Forensic pathologists performed an autopsy on Protocols for trauma transport. MEDEVAC could July 27, 2004, at 10:00 a.m. The probable cause have decreased transport time to the Medical and mechanism of death were determined to College of Georgia by 30 minutes or more. be hypovolemic shock due to fracture of the pelvis and right femur and blunt trauma to the In addition, the Board concludes that GradeSouth pelvis and legs from being crushed by an failed to meet the requirements established by excavator. Significant findings on examination WSRC for the Remote Worker Notification included: Program. 1. Much contusion of the medial aspects of both right and left thighs. 2.3 Investigative Readiness 2. Fracture of the right mid-femur. and Accident Scene 3. A quarter-inch puncture wound on the Preservation upper right lateral thigh. 4. An irregular abrasion over the mid lateral Initial investigative activities related to this left thigh extending to the back of the thigh. accident began after the injured driver was transported to off-site medical facilities and 5. Contusions over the right and left buttock were managed by a law enforcement officer areas. employed by WSI/SRS. Law enforcement 6. Examination of the internal organs revealed personnel and investigators dispatched to the bilateral fractures of the pelvis with scene ensured that first-person written separation of the symphysis pubis. Much statements were collected from personnel hemorrhage was present in the pelvis. The involved directly or indirectly with the accident right femur, tibia, and fibula were also or the subsequent response. The investigators fractured. also conducted a preliminary interview with the GradeSouth teamster who was operating the The forensic pathologist reported that there was excavator during the accident, and the results no evidence of injury to the major blood vessels of that interview were documented. The in proximity to the pelvic or femoral fracture. investigators performed preliminary inspections The South Carolina Law Enforcement Division of the excavator, the lowboy trailer, and the Forensic Services Laboratory analysis of blood tractor. Digital pictures of the accident scene and ocular fluid was negative for volatiles, and environs were collected and maintained. including ethanol, amphetamine/metamphe- Fire department and emergency medical tamine, barbiturates, benzodiazepines, cocaine, personnel also conducted a critical incident and opiates. Five postmortem digital photo- critique of the accident and their response. graphs were provided to the Board’s physician advisor. WSI/SRS was notified by the Barnwell County Coroner on July 26, 2004, that the driver was deceased as a result of the injuries received from

2–8 the accident. The accident scene was secured at performed on the excavator. The testing was 5:52 p.m., and at 8:21 p.m., a WSI/SRS Security performed under the oversight of the Board and Officer was posted at the scene. The DOE-SR was witnessed by representatives of several Safety and Radiation Protection Division companies. The Board inspected the lowboy Director was notified of the fatality by the trailer, tractor, and the surrounding area for any SRSOC at 8:36 p.m. The DOE-SR notified WSI/ additional evidence, then released the lowboy SRS at 9:25 p.m. to restrict access to the scene trailer and tractor to WSRC, which pending a DOE Type A Accident Investigation. subsequently allowed Guthrie to remove it from The accident scene was controlled as a crime the accident site. On August 11, 2004, the Board scene by WSI/SRS, and access controls were returned control of the accident site to WSRC, established at the opposite (east) end of the Pond with the exception of the excavator. On August B Dam, approximately 0.4 miles from the 16, 2004, the Board determined that no accident scene. The only access to the accident additional analysis of the excavator was required scene was the road across the dam. Crime scene and released it to WSRC. tape was erected around the excavator and trailer to demarcate the scene control The Board concludes that the actions taken by boundaries. All personnel allowed entry to the DOE-SR, WSRC, and WSI/SRS were effective in accident scene were logged into the area by preserving the accident scene. WSI/SRS at the access control point at the east end of the Pond B Dam. 2.4 Accident Reconstruction

On July 27, 2004, at approximately 12:00 p.m., and Analysis DOE-SR representatives from the Safety and Radiation Protection Division visited the site of The Board’s inspection of the accident scene the accident, and coordinated the activities to determined that the excavator was initially preserve the scene from heavy rains forecast for driven all the way to the back end of the lowboy that evening. A large protective enclosure was trailer with the boom facing the rear of the installed over the accident scene as much as trailer. Asphalt and mud on the back end of the practical to preserve the scene. Also, sandbags trailer indicated that the excavator was centered were placed to prevent loss or alteration of on the trailer at the back end. The excavator evidence. Small diversion trenches were was then moved forward on the trailer. Again, installed to channel water away from the deposited material from the tracks indicated that accident site. Additional protective covering was the excavator was centered on the trailer. The installed on July 29, 2004, to fully enclose the teamster stated that he was asked to swing the accident scene. Access to the site was controlled boom around and lift up one track so that the by WSI/SRS, with access permission granted outrigger plank on the driver’s (accident) side initially by DOE-SR and subsequently by the could be repositioned. The teamster raised the Type A Accident Investigation Board boom and swung it to the right, placing it at Chairperson. approximately a right angle to the track. He stated that he positioned the bucket 10 to 12 The Accident Investigation Board assumed feet from the track and used the boom and arm control of the accident site on August 3, 2004. controls to raise the track. This is not the WSI/SRS officers maintained direct control of configuration recommended by the the accident scene, with the Board approving manufacturer, John Deere, to raise the track. In all entries. On August 6, 2004, the Board allowed post-accident interviews, the teamster stated WSRC to remove the excavator from the lowboy that he didn’t think he could raise the excavator trailer so that operability tests could be track with the angle between the boom and arm

2–9 at 90 to 110 degrees (as recommended by John seals. Based on these simulations and supporting Deere) because of the long boom. He noted that engineering evaluation input, the Board a regular excavator could be raised in that determined that, as the excavator bucket and manner but with a long-stick excavator, there track slipped, the excavator fell onto and is a chance of bending the piece of equipment critically injured the Guthrie driver. or not picking it up at all. The Board believes the teamster’s assumption was incorrect. The Board also attempted to determine the driver’s actions when he was out of sight of the The Board conducted engineering analysis and teamster while attempting to reposition the calculations, and simulated the accident outrigger plank. The outrigger plank was conditions in the field to assist in analyzing the approximately 18 inches off the ground and accident. Engineering analysis indicate that under the excavator track. The track extended initially, the excavator configuration was stable about 3 to 4 inches beyond (over) the plank with about 16,000 pounds of force on the bucket width. The plank was 11 feet long and, based and 35,000 pounds of force on the stationary on 3.7 pounds per foot for dried oak, weighed track. The Board determined that, while the approximately 40 pounds. Considering the track was elevated, a leak on the hydraulic line physical stature of the driver and the to the arm cylinder (caused by a loose fitting) manipulations required to adjust the plank, the relieved hydraulic pressure from the arm Board determined that he was lying on his side cylinder. The gradual loss of pressure in the on the ground under or near the raised cylinder resulted in a redistribution of loads (suspended) track, contrary to Occupational within the excavator structure, which caused a Safety and Health Administration (OSHA) 29 buildup of lateral loads at the excavator support CFR 1926.600(a)(3)(i). The medical reports points (the stationary track and the bucket). identified multiple fractures of the pelvis, After the lateral loads built up to a level that fractures to the right femur, fibula, and tibia, exceeded the frictional holding capability at the and abrasions that support this conjecture. The excavator supports (between either the Board also determined that after the teamster stationary track and trailer or the bucket and heard the driver scream out in pain and raised ground), slippage occurred, until sufficient the track up again, the driver managed to move pressure was built up in the cylinder to re- out from under the track to the position he was support the load. This action occurred in when the teamster and the other GradeSouth repeatedly, causing either the bucket or the employees returned. Medical personnel at the track to slip, until the suspended track was again accident scene reported that the driver had a resting on the trailer bed. layer of dirt on him and that his pants were pulled down slightly, which is consistent with The simulation of the accident conditions using crawling on his elbows. the excavator involved in the accident, with the existing hydraulic leak present, confirmed the The Board concludes the following: Board’s engineering analysis. Both bucket – The driver placed himself in an unsafe slippage and track slippage were noted with a position under a suspended load in order to similar pre-accident excavator configuration. adjust the plank. The simulation was re-performed after repair of the hydraulic leak by tightening the loose – The teamster was not qualified to operate the fitting. No bucket slippage or track slippage was excavator. noted. However, the raised track did lower – In the configuration that the teamster was slowly over the next 20 minutes, probably from using to lift the excavator track, the leak in slow internal leakage around the cylinder piston the hydraulic line to the arm cylinder contributed to the accident.

2–10 3.0 Accident Facts and Analysis

This section addresses the facts related to the and maintain clear lines of authority and accident, along with the results of the Board’s responsibility for ensuring safety. These analysis. When analyzing the facts, the Board responsibilities apply to activities conducted by considered the core functions and guiding DOE, WSRC, BSRI, and GradeSouth for the principles of Integrated Safety Management, Pond B Dam Upgrade Project. which comprise the fundamental DOE safety and health policies that should be incorporated 3.1.1 DOE Roles and Responsibilities in all phases of the work, from work planning Figure 3-1 illustrates the relevant portions of through execution and feedback. the DOE organization from the Program Secretarial Office (EM-1) to the Pond B Dam 3.1 Line Management Roles Upgrade Project. DOE-SR describes its and Responsibilities organizational roles and responsibilities in the Functions, Responsibilities, and Authorities Line management is directly responsible for the Procedure (FRAP), which was updated in April safety and protection of the public, workers, and 2004. The DOE-SR FRAP states that the DOE- the environment. In order to be effective, the SR Manager has overall responsibility for Department and its contractors must establish ensuring the development and maintenance of

Figure 3-1. Relevant DOE organizational chart

3–1 safety management systems so that work is organizations to plan and execute the work and carried out in a manner that assures the safety to bring the tools necessary to complete their and health of the public and workers. assigned activities. The team for the Pond B Dam Upgrade Project consisted of a project The DOE-SR Office of Site Services (OSS) manager, assistant project construction manages the programmatic and technical manager, safety engineer, subcontract technical activities associated with logistics, support representative (STR), subcontract specialist, and services, and non-nuclear infrastructure at SRS; personnel from other disciplines as necessary consequently it is the line management office for project completion. These staff personnel for the Pond B Dam Upgrade Project. The OSS have line management responsibility for safety project managers and field representatives and take day-to-day direction from the WSRC manage the field activities of DOE-SR and its project manager. contractor, WSRC, by performing periodic surveillances, assessments, and walkthroughs. The project manager is required to develop a The OSS line management responsibility applies Construction Execution Plan and delineate staff only to WSRC. OSS does not provide oversight assignments and responsibilities. The of subcontractors, such as BSRI, or lower-tier Construction Execution Plan for the Pond B subcontractors, such as GradeSouth. Moreover, Dam Upgrade Project gives overall the DOE-SR FRAP does not address oversight responsibility for planning, organizing, of work being carried out by subcontractors to controlling, and directing the project effort to WSRC. the Project Manager, with the assistant project construction manager responsible for The DOE-SR Office of Environment, Safety and performance of the construction team. It Health and the Assistant Manager for Closure delineates staff assignments and responsibilities Projects (Figure 3-1) provide subject matter accordingly. experts and technical support to construction project line management when requested. The Board concludes that WSRC/BSRI line management roles and responsibilities for The Board concludes that the current DOE-SR ensuring safe execution of the project were FRAP does not clearly define roles and established. responsibilities for activities related to ES&H oversight of WSRC subcontractors. 3.1.3 GradeSouth Roles and Responsibilities 3.1.2 WSRC/BSRI Roles and The GradeSouth Worker Protection Plan (WPP) Responsibilities contains line management roles and Figure 3-1 presents the WSRC line management responsibilities for corporate positions, organization responsible for the execution of including senior managers, supervisors, and work at Pond B Dam. WSRC subcontracts with employees. Figure 3-2 also depicts the specific BSRI for construction activities, and the GradeSouth line management organization for subcontract is implemented using jointly the Pond B Dam Upgrade. The Secretary/ developed policies and procedures for safety and Treasurer, as the senior manager for the project, project management. The BSRI organization, as is responsible for application of the company’s a unit, reports to the WSRC President. WSRC safety program. As stated in the GradeSouth uses a matrix management organization to WPP, the senior manager establishes field establish a project team to execute construction personnel safety goals and objectives, and projects. A project team is formed by assigning delegates the responsibility for accident personnel from appropriate functional

3–2 Figure 3-2. WSRC, BSRI, subcontractor, and vendor line management and functional relationships and vendor BSRI, subcontractor, Figure 3-2. WSRC,

3–3 prevention to the supervisors, holding them Workplace Safety and Health, using the accountable for positive action within their area. anticipated scope of work to be performed at the Pond B Dam. Completion of the checklist The GradeSouth onsite Project Manager, as permitted BSRI to categorize the work, establish supervisor for the Pond B Dam Upgrade Project, whether the work was hazardous or non- is responsible for completing the work within hazardous, and determine worker protection schedule and budget. The Project Manager is plan requirements for the subcontractor responsible for safety, obtaining equipment awarded the contract. The Pond B Dam needed for the job, and for employee training. Upgrade Project was classified as Category C The Superintendent and his direct reporting work. It was deemed hazardous work due to Foreman are also considered supervisors. The the operation of forklifts or other heavy Superintendent has responsibilities for multiple equipment, rigging, soil excavation or trenching, projects onsite, and the Foreman is responsible and construction. Non-hazardous activities for a single job; in this case, the Pond B Dam included material and supply delivery services. Upgrade Project. WSRC/BSRI categorizes subcontracted work to As stated in the WPP, these supervisors are determine the level of ES&H compliance required to have a thorough knowledge of the required and the amount of safety oversight hazards involved in every operation within their WSRC/BSRI will provide (see Figure 3-3). The craft and a knowledge of controls for those level of oversight and type of safety hazards. They must also insist on proper use of documentation required can vary based on machinery, equipment, and tools to avoid scope, hazards, proximity of the job to site accidents, complete a job safety analysis for personnel, and subcontractor’s knowledge, operations that are likely to produce accidents, compliance and commitment to employee and perform daily inspections of their safety. The categories are delineated in WSRC accountable areas. The WPP states that 8Q-15 and are based on the SRS Workplace GradeSouth employees are to incorporate safety Safety and Health Policy, dated August 21, 1998. in every job procedure, know and obey safe This policy was developed jointly by DOE-SR practices, and report unsafe conditions to a and WSRC. supervisor. The RFP for the Pond B Dam Upgrade Project The Board concludes that the line management was issued in August 2003, shortly after the roles and responsibilities for the GradeSouth purchase requisition was approved, as a fixed- personnel were clearly documented and price construction bid. Several general ES&H understood. and key ISM requirements were incorporated in the RFP. They include: 3.2 Procurement and – Subcontractor must maintain complete Contractual Requirements control over its employees and all of its lower-tier suppliers and subcontractors. The procurement process for the Pond B Dam (BSRI procurement personnel consider Upgrade Project began with the approval of a vendors, such as Guthrie, as lower-tier purchase requisition in July 2003. Also that suppliers.) month, the requisition preparer completed the – Documentation in the subcontract will Subcontract Safety Checklist, found in describe how the subcontractor will procedure WSRC Manual 8Q, Procedure 15 implement ISM core functions. (WSRC 8Q-15), Subcontracted Services

3–4 – In performing work, implement the – The subcontractor will comply with OSHA General Provisions of the contract. and all other applicable federal, state and – Before performing work, evaluate the local regulatory requirements. (However, hazards and establish an agreed-upon set of BSRI personnel stated that they had no standards; tailor controls to the work. jurisdiction over vendors or suppliers to subcontractors for flow-down of ISM requirements.) Category A – BSRI will provide to subcontractor Subcontract work that requires employees copies of the Subcontractor subcontractor and site personnel to Safety Handbook, which complies with jointly perform manual work in the DOE Order 440.1A, Worker Protection same job or project. This category of Management. work requires compliance with applicable WSRC procedures and a – The subcontractor will submit a WPP that subcontractor safety and health policy. implements OSHA requirements. For hazardous Category A work, the minimum safety interface is monthly. Four companies were invited to bid on the project and were required to meet the following Category B minimum performance eligibility factors for Subcontract work that does not require ES&H: 1) a three-year average experience the subcontractor and site personnel to modification rate (EMR) of 1.0 or less, and 2) a jointly perform manual work, and the three-year average total recordable case (TRC) work is located in close proximity and rate of 7.9 or less. may or may not result in risk to site personnel safety. Hazardous Category B During an August 2003 pre-proposal conference work requires compliance with the for the Pond B Dam Project, BSRI distributed subcontractor’s corporate WPP, which the SRS Davis-Bacon Construction is aligned with OSHA, to include a task- Subcontractor Safety and Health Information specific plan and a minimum of weekly Handout, which provided information on 36 interface with WSRC safety oversight. items related to safety. Of these, Item 3 required subcontractors to submit a task-specific plan Category C (TSP), a supplement to the WPP, that included Subcontract work that does not require a breakdown of tasks, hazards, and controls. the subcontractor and site personnel to However, the RFP contained no requirements jointly perform manual work. The to develop a TSP. BSRI also distributed at the work is isolated, and the work does not pre-proposal conference, guidance for reasonably result in risk to site developing a TSP and the checklist that would personnel safety. This category of work be used to evaluate the WPP. Additionally, to requires the subcontractor to comply clarify questions from the pre-proposal with its corporate WPP, which is conference, Addendum 1 to the RFP was issued aligned with OSHA. WSRC oversight, and stipulated that a BSRI field radio was at a minimum, consists of incident required to be with the subcontractor every day review, consultation, or as requested by work was performed at the job site. the funding division. GradeSouth was the only company to submit a Figure 3-3. WSRC categories of subcontracted work proposal for the Pond B Dam Project. The contract for the Project was awarded to

3–5 GradeSouth in December 2003, after final • Documentation in the subcontract will negotiations. The subcontractor received a describe how subcontractor will Notice to Proceed on January 7, 2004, and began implement the five core functions of ISM. construction work during the week of January • Subcontractor shall comply with OSHA 19, 2004. and shall implement site-specific ES&H requirements when specified in the The Board concludes that the subcontract for the contract. Pond B Dam Upgrade Project was adequate in that ISM and worker protection requirements • Subcontractors perform daily documented were included. safety inspections and observations of working craftsmen. 3.3 Work Planning • Subcontractors complete Equipment Declaration Forms prior to equipment and Controls being used on site.

Work planning and execution at SRS is, in part, At the pre-proposal conference in August 2003, governed by Department of Energy Acquisition BSRI issued a checklist for subcontractors to use Regulation (DEAR) 970.5223-1, Integration of to develop a WPP. This checklist required a TSP Environment, Safety and Health into Work (task-level hazards analysis and controls) for Planning and Execution, in the WSRC contract only Category B work, consistent with WSRC through Section H.16. This DEAR clause Manual 8Q, Procedure 15. However, BSRI requires that the contractor exercise a degree notified potential bidders at the pre-proposal of care commensurate with the work and the conference that a TSP would be required for the associated hazards; and that ES&H be an integral Pond B Dam Upgrade Project, and guidance for and visible part of work planning and execution. developing a TSP was distributed. The guidance provided did not contain sufficient details to The RFP and the ensuing subcontract for the prepare a hazards analysis at the task level as Pond B Dam Upgrade Project contained required by the RFP. flowdown requirements related to ISM, and specifically required that subcontractors and GradeSouth submitted its corporate Safety their lower-tier subcontractors implement the Program Policies and Procedures as evidence of listed guiding principles and core functions of their WPP. The WPP is the document that ISMS when performing work. The RFP also GradeSouth uses to establish and communicate stipulated that: safe work practices to workers. While their • Subcontractors possess and maintain a corporate document addresses many of the corporate-level WPP that implements the OSHA requirements of 29 CFR 1926, it fails to OSHA requirements. meet minimum requirements of the contract. For example, the WPP does not address • BSRI will provide guidance on employee guidance on task hazards relevant to preparation, content, review, and the full scope of work nor designate a safety and acceptance of the WPP. health professional. Additionally, the WPP does • The WPP shall provide employee not emphasize stop work authority, but states guidance on task hazards, engineering that the employee’s responsibilities are to controls, precautions, and requirements caution fellow workers when they perform on personal protective equipment. unsafe acts and to refrain from taking chances.

3–6

Figure 3-4. Reproduction of GradeSouth’s hazard analysis for mobilization

GradeSouth submitted a TSP that identified The TSP does not include demobilization as part potential hazards, hazards controls, and of the work scope to be analyzed for hazards. A feedback mechanisms for six major work areas: generic approach to hazards analysis was also 1) mobilization; 2) pollution control and erosion used for other major work areas, instead of a control, 3) dewatering (well points), 4) grading, task level hazard evaluation. excavating and earth filling, 5) installing PVC drainage pipes and manholes, and 6) seeding and On January 5, 2004, the BSRI safety engineer mulching. documented that the GradeSouth WPP and TSP met the requirements of the contract, and a However, the TSP does not evaluate hazards at Notice to Proceed was issued on January 7, 2004. a task level as required by the BSRI guidelines. For example, the hazards analysis for Although not required by WSRC procedures, mobilization (shown in Figure 3-4) uses a on January 13, 2004, the BSRI STR completed generic approach instead of a task-specific an automated hazard analysis (AHA) for the approach to hazards analysis. It does not Pond B Dam Upgrade because there were no consider loading and unloading of heavy other tools in place to effectively prepare for equipment or transporting wide loads on site. and document the pre-job briefing or to identify It does, however, require that operators and task-specific hazards. (The AHA is an internal employees be trained, qualified, and fit for duty. WSRC tool to identify and analyze hazards and

3–7 replaced the job hazard analysis process. The clarity in how the various documents — the STR used the AHA to brief GradeSouth WPP, TSP and AHA — interface with one employees at a pre-job briefing, and BSRI and another. Each contains important controls that GradeSouth safety and management personnel the subcontractor needs to execute ISM and signed the AHA. Although the AHA analyzes mitigate hazards; however, these controls are some hazards at the task level for the Pond B not consolidated in the subcontractor’s WPP or Dam Project, it does not consider the full scope TSP, which are used to perform work. The of work, including mobilization and WSRC procedures and guidance documents do demobilization activities or loading and not clarify the hierarchy of the various safety unloading heavy equipment. It also does not documentation involved in this project and incorporate the transportation of wide loads on contain conflicting requirements for completing site and the operation of heavy equipment on and developing the safety document. This sloping ground as hazardous tasks. contributed to the ineffectiveness of the BSRI work planning and execution process, as The AHA does, however, identify a number of required for Davis-Bacon Category C other hazards and controls that are not construction subcontractors. considered in the GradeSouth WPP and TSP. For example, it considers the remote location The Board concludes the following: of the job site as a hazard and reinforces the need – BSRI imposed additional, and sometimes to notify the SRSOC using BSRI-issued remote conflicting, requirements on GradeSouth that radios prior to and after working each shift per were over and above those in the contract. Procedure MRP 4.03. It also requires a qualified first-aid person at the work site when – BSRI failed to provide sufficiently detailed performing any work. The AHA invokes several guidance for developing a task-level hazards site procedures as additional requirements, analysis, and safety oversight failed to identify including: the weaknesses of the hazards analysis. – OSR 18-125, Excavation/Trenching – Both hazards analyses — the TSP and AHA Checklist; — for the Pond B Dam Upgrade Project did not adequately address the full scope of work – 8Q, Procedure 34, Excavations and (i.e., demobilization) or identify hazards at a Trenches; task or activity level, including the loading – 8Q Procedure 9, Barricades, and TM-90-7, and unloading of heavy equipment. SRS Hoisting and Rigging Manual; – 8Q, Procedure 12, General Site Safety Requirements; 3.4 Safety Oversight – MRP 4.03, Savannah River Site Remote 3.4.1 GradeSouth Oversight Worker Notification; and GradeSouth’s contract requires that a safety and – 8Q, Procedure 117, Hand and Portable health professional be designated in the WPP, Power Tools. along with his or her associated qualifications As a result, the subcontractor had two separate and duties. It also requires that the safety hazard analyses — a TSP and an AHA — both representative conduct, at a minimum, of which failed to consider the full scope of work documented 30-minute daily safety inspections or analyze hazards at a task level. These at the job site and 30-minute observations of documents identified different hazards and working craftsmen. The WPP does not controls. The Board noted that there is a lack of delineate who has responsibility for oversight

3–8 and for executing the requirements and terms and above the contractual requirements of the contract, and it fails to designate the safety were being imposed. and health professional. The Board determined that a safety and health professional was A corrective action plan was submitted in assigned to the job. However, the Board found August 2001. no 30-minute daily safety inspection reports or 30-minute observations of work. Daily Activity In March 2004, the WSRC FEB Project Review Reports (DARs) were submitted to the STR; Team conducted a performance-based however, entries under “Safety” were noted evaluation of the Pond B Upgrade Project. The either as “Weekly” or “N/A.” evaluation identified the assessment area of Environmental, Safety, Health and Quality In addition to the daily safety oversight activities Assurance as “Below Average.” The report notes to be accomplished, the contract requires “improvements were needed in the control and GradeSouth to ensure that all major equipment conduct of activities within the prescribed is inspected, operated, and maintained by contract and permit conditions.” The report competent personnel and to complete a Major further notes that “Safety walk-downs Equipment Declaration Form prior to using performed at the site were not sufficiently equipment onsite. An Equipment Declaration thorough to identify and correct unsafe Form was not submitted for the excavator conditions.” A corrective action plan was involved in this accident prior to its use. submitted in August 2004.

The Board concludes that GradeSouth failed to BSRI routine oversight of subcontractor safety provide control and oversight of its activities at is provided through the safety engineers/ the Pond B Dam Upgrade Project. representatives and STRs as part of the project team’s line management organization. The 3.4.2 WSRC/BSRI Oversight safety engineers are responsible for providing WSRC provides independent oversight of primary occupational safety and health support subcontractor safety through periodic project and field oversight of subcontractors, reviewing reviews and evaluations conducted by the and accepting the subcontractor’s WPP, and Facility Evaluation Board (FEB). In April 2001, coordinating stop-work actions. The STRs the WSRC FEB completed a Focused Integrated performed their safety oversight through daily Safety Management Evaluation of Subcontractor walkthroughs of the project to identify and Safety at the request of the WSRC President. document safety concerns in Daily Activity The evaluation identified the following two Reports. This level of oversight is greater than relevant core issues: required in WSRC Manual 8Q, Procedure 15 for Category C work, where the STR is only – The mechanism for the identification of required to provide oversight for incident WSRC requirements tailored to a specific reviews. task for categories of work A, B, and C was not clearly and uniformly understood by all The Board concludes that WSRC and BSRI’s stakeholders, STRs, and subject matter oversight activities were not effective in ensuring experts from the initial development phases that subcontractor safety issues were adequately of the subcontract to field implementation. identified and resolved. – Conflicting requirements were found in the following WSRC manuals: 11B, 7B, 3E, 8Q. As a result, additional requirements over

3–9 3.4.3 DOE Oversight 3.5 Feedback and DOE line management for the Pond B Dam Improvement Upgrade Project is provided by the OSS, which reports to the Deputy Manager for Business. This Feedback and improvement processes should be organization carries out oversight responsi- designed and utilized to provide information on bilities through the field representatives, who the adequacy of work controls, to identify and manage the prime contractors’ activities through implement opportunities for improving the periodic surveillances, assessments, and definition and planning of work, and to utilize walkthroughs. There were no surveillances or line and independent oversight processes to assessments completed by a field representative provide information on the status of safety. Line for the Pond B Dam Upgrade Project. management is directly responsible for establishing and implementing feedback and DOE-SR is responsible for ensuring protection improvement programs and processes to of the environment, workers, and public from facilitate a culture that promotes ongoing hazards posed by DOE facilities, operations, and examination and learning, while connecting the cleanup activities. Within the DOE-SR Office practical experiences of work that has been of Environment, Safety and Health, the Safety conducted to the planning for future work. The and Radiation Protection Division provides feedback and improvement function is intended direct oversight of prime contractors’ safety and to identify and correct processes or deviations health programs through scheduled and reactive that lead to unsafe or undesired work outcomes, assessments as well as trending of safety data. confirm that the desired work outcomes were No assessments of subcontractors’ safety and obtained safely, and provide managers and health programs, including BSRI’s, have been workers with information to improve the performed by this Office. However, an quality and safety of subsequent, similar work. assessment of the prime contractor’s oversight of subcontract work in high-level waste was In evaluating how DOE, WSRC, and BSRI had performed in 2003 by an employee of the line analyzed performance information as part of management organization for high-level waste. lessons-learned, feedback, and improvement, That assessment concluded that the the Board reviewed previous accident subcontractor management program provided investigation reports, the feedback provided by sufficient guidance and oversight to ensure DOE and WSRC assessments, GradeSouth proper implementation of subcontract incident reports that were generated during the requirements and flowdown of contract project, and site Occurrence Reporting and requirements. Two weaknesses were noted in Processing System (ORPS) reports. the implementation of the WSRC Manual 8Q, Procedure 15 requirements, specifically in the use of Equipment Declaration Forms and 3.5.1 Daily Safety Meetings documented TSPs aligned with modified tasks. Information collected during this investigation suggests that the STR for the Pond B Dam The Board concludes that DOE-SR provided no Upgrade Project routinely provided GradeSouth direct oversight of subcontractor construction supervision with information to be shared with activities on the Pond B Dam Upgrade Project. craft personnel during daily tailgate safety and plan-of-the-day meetings on the project. Copies of safety topics collected and cataloged at GradeSouth’s work trailer at the job site indicated that a wide variety of topics were

3–10 discussed, including heavy equipment safety, and“Since there could be circumstances in the heat and cold stress, and biological hazards. future where an inadequate JHA [Job Hazard Analysis] process could fail to identify a less 3.5.2 Feedback from DOE, WSRC, obvious hazard or where a unique control and BSRI Assessements strategy could be beneficial, these observations about Bell’s JHA process were referred to the As discussed in Section 3.4.2 of this report, the appointing official for appropriate follow-up WSRC Facility Evaluation Board completed a with BSRI and Bell.” Focused Integrated Safety Management Evaluation of Subcontractor Safety, in April 2001. This review identified two core issues: 1) While Judgments of Need were not identified the mechanism for the identifying WSRC for the April 2002 accident investigation, that requirements tailored to a specific task for A, B report clearly indicated “areas for improvement” and C categories of work was not clearly and requiring consideration by DOE and WSRC uniformly understood by all stakeholders, and related to possible future accident scenarios. 2) conflicting requirements were identified in a Those areas for improvement were forwarded number of WSRC manuals, resulting in to DOE for consideration; the Board found no additional requirements over and above evidence that DOE or WSRC took specific contractual requirements being imposed. actions to address the identified construction safety deficiencies. In April 2002, a Type B accident investigation was conducted following a worker’s fall from a In January 2004, WSRC completed a Phase I and shoring/scaffolding structure at the SRS Tritium II reverification of the WSRC integrated safety Extraction Facility construction site. While the management program. The report concluded Type B Investigation Board did not identify that ISMS was implemented at SRS but Judgments of Need associated with this accident, identified opportunities for improvement Areas for Improvement were referred to the related to the AHA process contained in WSRC Appointing Official. In the referral, the Board Manual 8Q, Procedure 120. The WSRC report stated: “During the course of this investigation, noted that the level of detail provided in AHAs the Board noted some areas for improvement. varied and indicated that additional training and These areas were determined not to have a mentoring was necessary to ensure further causal relationship to this accident, but might improvement in the AHA process. play a role in potential future events. These matters were noted in the report and were During January and February 2004, DOE referred to the Appointing Official for Headquarters Office of Independent Oversight consideration.” Two of the referred areas for and Performance Assurance (OA) conducted an improvement were applicable to the accident inspection of environment, safety and health at the Pond B Dam Upgrade Project, and are management and emergency management at presented below: SRS. OA’s Summary Report stated, in part, that safety controls were not always effectively “Training requirements similar to those in the communicated to the workers and effectively scaffolding and fall protection standards apply implemented by the workforce, and that WSRC to workers such as powered industrial truck had not established adequate mechanisms to operators, crane operators, and electricians. Lack ensure that controls identified in the AHA were of appropriate training could be a factor in a implemented and effectively integrated into variety of potential future accident scenarios,” work activities. The report also noted that construction and subcontractor personnel were

3–11 not always rigorously and consistently DOE, WSRC, and BSRI managers were provided implementing construction safety requirements, with information from a variety of sources over resulting in potentially unsafe conditions and a number of years to indicate there were practices. programmatic deficiencies in the communication and implementation of safety While a corrective action plan was developed requirements for subcontracted construction and submitted for the OA ES&H inspection six work across the Savannah River Site. months after the inspection was completed, there was no evidence to indicate that DOE, The Board concludes that effective recurrence WSRC, or BSRI took compensatory action to controls for identified deficiencies were not assess or evaluate the construction safety issues established. that were identified by the OA team. 3.5.3 Operational Occurrences In February 2004, during drilling of well points The Board also reviewed recent construction at the Pond B Dam, a GradeSouth operator related occurrences in ORPS at SRS to determine blacked out and rotated the equipment boom whether precursor events had occurred before while the auger was still in the hole, resulting the accident on July 26, 2004. As a result of this in minor damage to the auger. An investigation review, the Board identified similar underlying was conducted by BSRI personnel; however, no causes for the incidents, which are summarized causal factors and corrective actions were in Appendix B. Many of the corrective actions identified. were to stand down, change, or clarify procedures and to retrain the workers. The In March 2004, the WSRC Facility Evaluation Board determined there were a number of Board Project Review Team conducted a common causes for these occurrences, as well performance-based evaluation of the Pond B as the ineffective corrective action processes: Dam Upgrade Project and identified the assessment area of environment, safety and – Workers failed to recognize hazardous health as “Below Average.” The report noted conditions in their assigned work areas; that improvements were needed in the control – Workers were unaware of other personnel and conduct of activities within the prescribed in the work surroundings; contract and permit conditions, and that safety – Although job conditions changed, stop- walkdowns performed at the site were not work authority was not utilized, nor was sufficiently thorough to identify and correct the efficacy of reanalyzing the hazards or unsafe conditions. controls considered;

In April 2004, during dust control activities, a – There was an over-reliance on the skill of dump truck rolled onto its side when the operator the craft assigned to accomplish the task; was backing the vehicle, and one of the rear tires and backed onto a slight incline. The water tank – There was inattention to detail by operators, shifted, causing the truck to roll onto its side. An or operators were less experienced and/or occurrence report was generated, and the untrained in the work they were assigned subsequent investigation indicated weaknesses in to accomplish. two ISM Core Functions: analyzing the hazards and developing and implementing hazard controls. The Board concludes that WSRC failed to fully Corrective actions were developed to address the address the causal factors for the occurrences incident, but did not include supplier/vendor- through the corrective action processes in place owned equipment. at the site.

3–12 3.6 Personnel Training and has significant experience with heavy Qualifications equipment operation. The individual that loaded the excavator on the 3.6.1 Equipment Operators lowboy trailer the day of the accident is a Subpart C, General Safety and Health teamster and not an operating engineer. Provisions, to the OSHA Safety and Health Teamsters do not receive formal training in Regulations for Construction, 29 CFR heavy equipment operation. Although he had 1926.20(b)(4) states: “The employer shall permit previous experience operating similar only those employees qualified by training or equipment at another jobsite for GradeSouth, experience to operate equipment and he did not have any experience operating the machinery.” The SRS Davis-Bacon Construc- long-boom excavator that was involved in the tion Subcontractor Safety and Health accident. There was an operating engineer at Information Handout (part of the pre-bid Pond B at the time the excavator was being package for the Pond B Dam Upgrade Project) loaded, but he was operating another piece of states: “Heavy equipment operators shall be equipment at the job site. The foreman for the qualified and knowledgeable with the Pond B Dam Upgrade Project at the time of the equipment being operated according to the accident stated that he assigned the teamster to manufacturer’s guidelines and warnings found meet and escort the Guthrie driver to the job in the operating manual.” The Mobilization site but that they did not specifically assign him section of the TSP submitted by GradeSouth for to load the equipment. the Pond B Dam Upgrade Project states: “Operators and employees shall be trained, The Board concludes that GradeSouth failed to qualified and fit for duty.” GradeSouth does not ensure that heavy equipment operations were have a formal or documented process for conducted by qualified operators. verifying that employees are trained and qualified. These decisions are made by 3.6.2 Safety Personnel supervision based on the firsthand knowledge and Subcontract Technical of the individual’s ability and/or a review of Representatives previous training, experience, or possession of the journeyman card in the applicable craft area. BSRI Construction Management Procedure CMP 04-01.01 establishes the qualification At a union construction site such as the Pond B requirements for STRs. The procedure requires Dam Upgrade Project, operating engineers are candidates to have a minimum of six education the craft that are trained and qualified to operate and experience credits before consideration as heavy equipment. A review of the Local 470 a potential STR. Guidance is included in the operating engineer training program indicates procedure for determining the applicability of that it provides both classroom and hands-on education and experience and how that equates training related to heavy equipment operation, to credits or partial credits. Potential STR including excavator operation. When METRAC candidates must also complete a structured and delivered the excavator to the job site, it was documented interview with the Construction offloaded by one of the GradeSouth operating Subcontracts Manager (CSM) or designee to engineers, not the METRAC truck driver. The challenge the candidate’s technical and operating engineer operated the equipment to administrative procedure knowledge level. The perform the required work at the job site. He CSM also reviews the candidate’s previous has been an operating engineer since 1977 and training and required reading requirements and determines if it was adequate. When all of these

3–13 requirements are complete, the CSM approves A barrier analysis was also conducted to identify a letter of qualification for the candidate. barriers associated with the accident. This analysis addressed physical systems and management There were three STRs assigned to the Pond B systems in place to isolate and avoid the hazards. Dam Upgrade Project over the duration of the The results of the barrier analysis validated the project. A review of the training and results in the change analysis. The results of the qualification records of the three STRs indicates barrier analysis is not included in the report. that they each had over 20 years of relevant experience and that they met the STR 3.8 Causal Factors Analysis qualification requirements stated in CMP 04-01.01. The Board performed a causal factors analysis in accordance with the DOE Workbook, A review of the training and qualification Conducting Accident Investigations. Causal records for the two people assigned as safety factors are events or conditions that produced engineers to the Pond B Dam Upgrade Project or contributed to the occurrence of the accident indicates that they both possess adequate and consist of direct, root, and contributing training and experience for that position. causes.

3.6.3 Truck Driver A direct cause is the immediate event or The driver of the Guthrie tractor and lowboy condition that caused the incident. The Board trailer did have a commercial driver’s license concludes that a direct cause of the accident was that covered driving a tractor and trailer of the the excavator falling onto the driver. size involved in the accident. Guthrie management personnel stated that driving the The root causes of the accident are the lowboy was his primary responsibility and that fundamental causes that, if corrected, would he was not trained or utilized by them as an prevent reoccurrence of this and similar equipment operator. They also stated that accidents. The Board has also identified although he may have loaded smaller equipment contributing causes. Contributing causes are on trailers in the past (e.g., backhoes and small events or conditions that, collectively with the dozers), he was not qualified and never loaded other causes, increase the likelihood of the a piece of equipment the size of the excavator accident but individually did not cause the on the lowboy trailer. accident. The causal factors are identified in Table 3-1. 3.7 Change and Barrier Analyses

Change analysis examines changes planned or unplanned that cause undesirable results related to the accident. This process analyzes the difference between what is normal, or expected, and what actually occurred before the accident. The results of the change analysis conducted for the accident at Pond B Dam were integrated into the events and causal factors chart to support the development of causal factors. Appendix D contains the change analysis.

3–14 Table 3-1. Causal Factors Analysis

3–15 Table 3-1. Causal Factors Analysis (continued)

3–16 4.0 Judgments of Need

Conclusions are synopsis of those facts and or severity of a recurrence. They flow from the analytical results that the Board considers conclusions and are directed at guiding especially significant. Judgments of Need are managers to developing corrective measures. managerial controls and safety measures Table 4-1 summarizes the Board’s conclusions necessary to prevent or minimize the probability and Judgments of Need.

Table 4-1. Conclusions and Judgments of Need

4–1 Table 4-1. Conclusions and Judgments of Need (continued)

4–2 5.0 Board Signatures

5–1 This page is intentionally blank. 6.0 Board Members, Advisors, and Staff

Board Members

Chairperson Raymond J. Hardwick, Jr., DOE Office of Environment, Safety and Health

Member Patrice M. Bubar, DOE Office of Environmental Management

Member Ralph A. Fevig, DOE Sandia Site Office

Member Michael J. Thomas, DOE Office of River Protection

Advisors

Advisor William T. Cooper, Jr., DOE Office of Environment, Safety and Health

Advisor Michael Montopoli, M.D., Occupational Health, DOE EH

Advisor Amy B. Poston, DOE SRS

Advisor Mark A. Smith, DOE SRS

Consultants

Consultant Tom Bolton, BSRI

Consultant Pat Casey, MAS Consultants, Inc.

Consultant H.E. Flanders, P.E., WSRC

Consultant Margie Lewis, Parallax, Inc.

Consultant R.R. Rothermel, WSRC

Consultant Mike Schoener, MAS Consultants, Inc.

6–1 Technical and Administrative Support

Coordinator/Technical Editor Elaine Merchant, Parallax, Inc.

Coordinator Karen Brown, Parallax, Inc.

Court Reporters Cathy T. Pirtle, Culpepper Reporting, Inc. Pamela N. Pope, Culpepper Reporting, Inc.

6–2 Appendix A — Appointment of Type A Accident Investigation Board

A–1 This page is intentionally blank. A–3 This page is intentionally blank.

This page is intentionally blank. Appendix B — Analysis of Previous Savannah River Near-Miss and Industrial Operations Occurrences

B–1 This page is intentionally blank. Savannah River Near-Miss and River Savannah Industrial Operations Occurrences Table B-1. Appendix B — Analysis of Previous Table

B–3 This page is intentionally blank. Appendix C — Change Analysis

C–1 This page is intentionally blank. Table C-1. Change Analysis Table

C–3 Table C-1. Change Analysis (continued) Table

C–4 Table C-1. Change Analysis (continued) Table

C–5 This page is intentionally blank. Appendix D — Events and Causal Factors Analysis

D–1 This page is intentionally blank. Figure D-1. Events and Causal Factors Chart

No effective lessons learned program Grade South did not exercise control of its workers A J

Contract documents are confusing GradeSouth did not implement safety controls B K

GradeSouth did not implement contract safety Teamster was not qualified to operate the excavator C requirements L

BSRI requirements were not in the WPP Strong stop work authority not in GradeSouth WPP D M

GradeSouth did not implement ISMS Stop work authority not used E N

WSRC and BSRI failed to oversee Hydraulic leak present F O

BSRI construction work planning documents Driver working on or near the elevated excavator – G are confusing P OSHA violation

BSRI did not provide thorough oversight No accurate description of the accident is provided H of GradeSouth Q

GradeSouth does not meet contract requirements EMS did not precisely follow the SRS protocols I R for trauma transport

D–3 Figure D-1. Events and Causal Factors Chart

B

OSHA B requirements only I

Hazard Work is identified in isolated; TSP but not remote Qualified in WPP A location operator is required

Identifies Work does not require Construction Three operation of heavy moving subcontractor Contains subcontract ISMS and site ISMS tenets ES&H issues equipment as hazardous personnel to of DEAR information identified work jointly work 970.5223-1 presented

FEB issues ISMS Requisition preparer Category C work A Request for BSRI conducts Evaluation Report of signs subcontract classification is Proposal is issued pre-bid meeting Subcontractor Safety safety checklist assigned 08/15/03 A 05/08/01 7/23/03 7/30/03

D–4 Figure D-1. Events and Causal Factors Chart

A A G A

Identifies safety Finding Additional controls to work indicates oversight of Requires a instructions, details in the AHA AHA construction, and AHA varied should be AHA issues considered

WSRC conducts ISMS DOE-SR self assessment BSRI prepares construction OA issues report on B Phase I/II reverification of ISMS conducted execution plan ESH Management C 01/13/04 01/15/04 01/26/04 02/04

D–5 Figure D-1. Events and Causal Factors Chart

A

Long I boom excavator required

Corrective actions from dump truck A Dirt work AI were not required in effective punchlist E

Operating Issues engineer had No several hydraulic identified, not 30 items wearing hard equipment No task fittings identified declaration analysis tightened hat, defective on choker form performed 07/19/04 punchlist submitted

BSRI conducts general Certification of Grade South receives Grade South operator plant weekly safety mechanical completion excavator from Metrac engineer off loads Metrac driver informs assessment operating engineer of leak D 06/23/04 07/15/04 excavator E 05/13/04 07/15/04 07/15/04

D–6 Figure D-1. Events and Causal Factors Chart

N

M J

L M J N

Improper use of N equipment, J OSHA 1926 N P

Teamster Equipment does not Unsafe act backoff the L in improper L position to on driver’s trailer to behalf reattempt lift track

Driver tells teamster to swing to side Teamster rotates boom Driver asks teamster to raise Teamster loses visual contact Driver’s side board & boom up to lift driver’s side track so misaligned outrigger board can & raises track, full visual track higher. Visual and with driver while repositioning G becomes contact with driver. verbal contact with driver. plank H misaligned be repositioned

D–7 Figure D-1. Events and Causal Factors Chart

C

C Q

GradeSouth 0.4 miles had not from scene Dunnage reported in as to office placed remote under trailer workers excavator

No site Site radios Teamster radio GradeSouth in does not present, Q notices GradeSouth look at Remote driver is not trailer driver worker pinned

Teamster drives pickup Superintendent calls GradeSouth Teamster notifies foreman Superintendent, foreman safety officer located in H-Area Teamster locks down across dam to and superintendent and hydraulic controls in GradeSouth Office/trailer and both teamsters go office by cell phone to call I another teamster that driver J the excavator cab to get assistance back to accident scene in SRSOC for emergency response is injured pickup trucks

D–8 Figure D-1. Events and Causal Factors Chart

Q R

Critical Medic 3 assessment of does not driver is made. request Q Injuries to leg MEDEVAC and pelvis helicopter

Grade South Safety SRSOC dispatches Unit 91 arrives at scene Squad 3/Medic 3 Medic 3 departs scene for Officer calls SRSOC Engine 3 3:40 pm 07/26/04 arrive at scene MCG Trauma Center J 3:27 pm 07/26/04 3:28 pm 07/26/04 3:40 pm 07/26/04 3:55 pm 07/26/04 K

Additional medic is needed to assist with injured

Medic 3 picks up Medic 3 arrives at MCG MCG reports time of death K additional medic in route 4:40 pm 07/26/04 6:18 pm 07/26/04 L at F-Area

D–9 This page is intentionally blank.