U.S. Department of Energy Office of Fossil Energy Accident Investigation Report Scissor Lift Accident in the West Hackberry Brine Tank-14 Resulting in Injury on February 7, 2013 June 2013 Strategic Petroleum Reserve West Hackberry Storage Site Cameron Parish, Louisiana Scissor Lift Accident in the West Hackberry Brine Tank-14 Resulting in Injury Disclaimer This report is an independent product of the Accident Investigation Board appointed by Christopher A. Smith, Acting Assistant Secretary, Office of Fossil Energy. The Board was appointed to perform an Accident Investigation and to prepare an investigation report in accordance with Department of Energy (DOE) Order 225.1B, Accident Investigations. The discussion of the 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. Scissor Lift Accident in the West Hackberry Brine Tank-14 Resulting in Injury Scissor Lift Accident in the West Hackberry Brine Tank-14 Resulting in Injury Release Authorization On February 15, 2013, an Accident Investigation Board (the Board) was appointed to investigate an accident that resulted in serious injuries caused when a scissor lift tipped over in Brine Tank- 14 (WHT-14) at the Strategic Petroleum Reserve, West Hackberry, Louisiana, site on February 7, 2013. The Board’s responsibilities have been completed with respect to this investigation. The analysis and the identification of the direct cause, root causes, contributing causes, and judgments of need resulting from this investigation were performed in accordance with the Department of Energy (DOE) Order 225.1B, Accident Investigations. The report of the Accident Investigation Board has been accepted and the authorization to release this report for general distribution has been granted. Christopher A. Smith Acting Assistant Secretary Office of Fossil Energy Scissor Lift Accident in the West Hackberry Brine Tank-14 Resulting in Injury Scissor Lift Accident in the West Hackberry Brine Tank-14 Resulting in Injury Table of Contents Legend ........................................................................................................................................... iv Acronyms ........................................................................................................................................v Executive Summary ................................................................................................................ ES-1 1.0 Introduction ........................................................................................................................1 1.1 Appointment of the Board ...................................................................................... 1 1.2 Facility and Organization ........................................................................................ 1 1.2.1. Strategic Petroleum Reserve ....................................................................... 1 1.2.2. West Hackberry Site ................................................................................... 1 1.2.3. Office of Fossil Energy ............................................................................... 2 1.2.4. SPR Project Management Office in New Orleans, LA ............................... 3 1.2.5. Operating Contractor Organization............................................................. 3 1.2.6. Construction Contractor Organization ........................................................ 3 1.2.7. Subcontractor Organization ........................................................................ 3 1.3 Scope, Purpose and Methodology of the Accident Investigation ........................... 3 2.0 Facts and Analysis..............................................................................................................5 2.1 Description of Work Activity ................................................................................. 5 2.2 Accident Description .............................................................................................. 8 2.2.1. Accident Scene Analysis and Reconstruction............................................. 9 2.2.1.1. Force Analysis ........................................................................ 10 2.2.2. Chronology of Events ............................................................................... 12 2.3 Implementation of Integrated Safety Management System .................................. 16 2.3.1. Define the Scope of Work......................................................................... 16 2.3.2. Identify and Analyze Hazards Associated with the Work ........................ 19 2.3.3. Develop and Implement Hazard Controls ................................................. 25 2.3.4. Perform Work within Controls ................................................................. 30 2.3.4.1. PBC ......................................................................................... 30 2.3.4.2. AGSC ...................................................................................... 42 2.3.4.3. DM .......................................................................................... 44 2.3.4.4. DOE ........................................................................................ 44 2.3.5. Provide Feedback and Continue to Improve Safety Management ............ 45 2.4 Emergency Response ............................................................................................ 48 2.4.1. DOE and DM Responses .......................................................................... 49 2.4.2. Investigative Readiness and Scene Preservation ...................................... 50 2.4.2.1. Scene Preservation .................................................................. 50 i Scissor Lift Accident in the West Hackberry Brine Tank-14 Resulting in Injury 2.5 Barrier Analysis .................................................................................................... 51 2.6 Change Analysis ................................................................................................... 52 2.7 Event and Causal Factors Analysis ....................................................................... 52 3.0 Conclusions and Judgments of Need ..............................................................................55 4.0 Board Signatures ..............................................................................................................63 5.0 Board Members, Advisors and Consultants ..................................................................64 5.1 Biographies of Accident Investigation Board Members and Support .................. 65 Appendix A: Appointment of an Accident Investigation Board .................................. A-1 Appendix B: Barrier Analysis .......................................................................................... B-1 Appendix C: Change Analysis .......................................................................................... C-1 Appendix D: Event and Causal Factor Analysis ............................................................ D-1 Appendix E: Force Calculations on Scissor Lift ............................................................. E-1 ii Scissor Lift Accident in the West Hackberry Brine Tank-14 Resulting in Injury Figures Figure 1: West Hackberry Site, Cameron Parish, Louisiana ......................................................... 2 Figure 2: Accident Investigation Terminology .............................................................................. 4 Figure 3: WHT-14 at the SPR West Hackberry Site ..................................................................... 5 Figure 4: Skyjack SJIII 3226 Scissor Lift ...................................................................................... 6 Figure 5: Dimensional Specifications and Dimensions of the Skyjack SJIII 3226 ....................... 7 Figure 6: Overturned Scissor Lift in Tank ..................................................................................... 8 Figure 7: 3-D Rendering of Scissor Lift and Hose Prior to the Accident ...................................... 9 Figure 8: Manufacturer-Applied Label shows 0 wind and 90 lb side force ................................ 24 Figure 9: Breathing Air Filtration System ................................................................................... 29 Figure 10: Warning Label inside Scissor Lift Identifying Side Force Limitations ..................... 35 Figure 11: Position of the scissor lift in relation to work completed. .......................................... 39 Figure 12: Control Box with three-way switch pointing to the drive position ............................ 40 Figure E-1: Board Examining inside of WHT-14 and Scissor Lift ............................................ E-6 Figure E-2: WHT-14 and Scissor Lift in Relation to Manhole .................................................. E-7 Figure E-3: Scissor Lift in WHT-14 ........................................................................................... E-8 Figure E-4: Base of Scissor Lift in WHT-14 .............................................................................. E-9 Figure E-5: Outside Manhole of WHT-14 ...............................................................................