September 2004

Office of Environment, Safety and Health

Type A Accident Investigation

at theSavannah River Site

Aiken, South Carolina

Subcontractor Fatality at thePond B Dam Upgrade Project

on July 26, 2004

September 2004

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TABLE OF CONTENTSEXECUTIVE 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-1Appendix 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

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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 IndustrialOperations Occurrences ..................................................................................................B-3

Table C-1. Change Analysis .............................................................................................................. C-3

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

Figures and Tables

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Release Authorization

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

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

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

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

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

This report neither determines nor implies liability.

ACRONYMSAHA Automated Hazard AnalysisBoard Type A Accident Investigation BoardBNFL British Nuclear Fuels, LimitedBSRI Bechtel Savannah River, IncorporatedCFR Code of Federal RegulationsDAR Daily Activity ReportDEAR Department of Energy Acquisition RegulationDOE Department of EnergyEMS Emergency Management ServicesEMR Experience Modification RateES&H Environment, Safety and HealthES&HP Environment, Safety and Health ProvisionsFEB Facility Evaluation BoardFERC Federal Energy Regulatory CommissionFRAP Functions, Responsibilities, and Authorities ProcedureFSSBU Field Support Services Business UnitISM Integrated Safety ManagementISMS Integrated Safety Management SystemMCG Medical College of GeorgiaMETRAC Metropolitan Tractor CompanyOA Office of Independent Oversight and Performance AssuranceOBU Operations Business UnitORPS Occurrence Reporting and Processing SystemOSHA Occupational Safety and Health AdministrationOSS Office of Site ServicesPVC Polyvinyl chlorideRFP Request for ProposalSR Savannah River Operations OfficeSRS Savannah River SiteSRSOC Savannah River Site Operations CenterSTARRT Safety Task Assignment Risk Reduction TalkSTR Subcontract Technical RepresentativeTRC Total Recordable CaseTSP Task-Specific PlanWPP Worker Protection PlanWSI/SRS Wackenhut Services, Incorporated/Savannah RiverWSRC Westinghouse Savannah River Company, LLC

ES-1

The Accident

On July 26, 2004, at approximately 3:15 p.m., atruck driver (driver) was critically injured at theSavannah River Site, while loading a rentedexcavator onto a lowboy trailer for return tothe rental company. The accident occurredwhen a teamster from GradeSouth, Inc., aconstruction sub-tier contractor, and a truckdriver from Guthrie Grading and Haulingattempted to reposition an outrigger plank onthe lowboy trailer. The plank had becomedislodged when the excavator was beingpositioned on the trailer. The teamster used theexcavator’s boom to lift one of the excavatortracks off the trailer so that the driver couldreposition the plank under the track. Theexcavator dropped (moved) while the driver wasrepositioning the plank, and the driver sufferedcritical and subsequently fatal injuries. Thedirect cause of the fatality was crushing injuriesresulting from movement of the excavatorduring loading operations.

On July 28, 2004, the Acting Assistant Secretaryfor Environment, Safety and Health appointeda Type A Accident Investigation Board (Board)to analyze causal factors, identify root causes,and determine Judgments of Need to precludesimilar accidents in the future. The Chairmanand some Members of the Board arrived at theSavannah River Site July 28, 2004, and the fullBoard convened onsite on August 2, 2004. TheBoard completed the investigation onSeptember 1, 2004.

Background

The Savannah River Site is locatedapproximately 25 miles southeast of Augusta,Georgia and 22 miles south of Aiken, South

Carolina. With the exception of facilitiesoperated for the National Nuclear SecurityAdministration, many of the original productionfacilities within the site are beingdecommissioned, and major waste treatmentand management activities associated with thateffort are conducted under the cognizance ofthe U.S. Department of Energy’s (DOE) Officeof Environmental Management. Local DOEmanagement is provided by the DOE-SavannahRiver Operations Office (DOE-SR).

In December 2003, Bechtel Savannah River, Inc.(BSRI) awarded a construction subcontract toGradeSouth, Inc., to make necessary repairs tothe Savannah River Site’s Pond B Dam to bringthe dam into compliance with guidelines issuedby the Federal Energy Regulatory Commission.Part of the work GradeSouth performedrequired the use of a rented excavator. Thedeceased driver was an employee of GuthrieGrading and Hauling, which had been hired toreturn the excavator to the rental company,Metropolitan Tractor. The driver’s fatal injuriesoccurred at the Pond B Dam Upgrade Projectduring the final phases of the project.

Results and Analysis

The Board conducted numerous interviews,reviewed relevant documents, and had elementsof the excavator’s performance evaluated(tested). Results from these efforts were used toperform a causal factors analysis in accordancewith the DOE Workbook, Conducting AccidentInvestigations. Causal factors are events orconditions that produced or contributed to theoccurrence of the accident and consist of root,direct, and contributing causes.

The root cause of the accident is thefundamental cause that, if corrected, would

Executive Summary

ES-2

prevent reoccurrence of this and similaraccidents. The direct cause is the immediateevent or condition that caused the incident.Contributing causes are events or conditionsthat, collectively with the other causes, increasethe likelihood of the accident but individuallydid not cause the accident.

The Board concluded that the following are theroot causes of the accident that should becorrected to prevent similar events fromoccurring.

– DOE, WSRC and BSRI were inattentive toprogrammatic deficiencies in thecommunication and implementation ofsafety requirements for subcontractedconstruction work at the Pond B DamProject.

– The subcontractors’ unstructured approachto work did not ensure that safety andhealth requirements were translated intowork controls, did not take those actionsnecessary to enforce compliance withfundamental safety requirements during thework, nor did they define their safety andhealth expectations for the activity prior towork.

– WSRC failed to fully address the causalfactors for previous operational occurrencesthrough the corrective action processes atthe site.

The Board further determined that the directcauses of the accident resulting in the excavatorfalling onto the driver are as follows:

– The driver was working under or near theexcavator.

– The GradeSouth teamster was not qualifiedto operate the excavator.

– GradeSouth failed to exercise control overits employee and vendor.

– Stop-work authority was not effectivelyutilized.

The Board also identified contributing causesand conclusions related to this accident. Basedon those conclusions, the Board determined theappropriate Judgments of Need in respondingto this accident. Judgments of Need aremanagerial controls and safety measuresnecessary to prevent or minimize the probabilityor severity of a recurrence. They are alsodirected at guiding managers in developingcorrective measures. Table ES-1 summarizes theBoard’s conclusions and Judgments of Need.

Summary

The Accident Investigation Board concludedthat this accident was preventable. The Boardidentified weaknesses in the site’simplementation of integrated safetymanagement policy through work practices asit relates to the subcontractor and vendorsperforming work at the Pond B Dam UpgradeProject. WSRC did not ensure that thesubcontractor met basic requirements imposedby the Department, the site, and theOccupational Safety and Health Administration.Although internal and external oversightactivities and a series of operational occurrencesidentified construction safety-related issues andconcerns with similar systemic causes, a lack ofrigorous causal analysis prevented identificationof lessons-learned and systemic weaknesses andimplementation of effective corrective actions.

The DOE-SR and WSRC need to intensify theirefforts and commitment to ensure that all theelements associated with ISM are promptly andeffectively addressed for all constructionsubcontractors and sub-tier contractors andvendors to prevent additional accidents.

ES-3

Table ES-1. Causal Factors and Judgments of Need

ES-4

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

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1.1 Background

On July 26, 2004, at the Savannah River Site(SRS) Pond B Dam, a truck driver suffered fatalinjuries when he was crushed by an excavator.On July 28, 2004, John Spitaleri Shaw, ActingAssistant Secretary for Environment, Safety andHealth, U.S. Department of Energy (DOE),appointed a Type A Accident InvestigationBoard (Board) to investigate the accident inaccordance with DOE Order 225.1A, AccidentInvestigations (see Appendix A for appointmentmemorandum).

1.2 Facility Description

1.2.1 Savannah River SiteSavannah River Site covers 310 square miles,encompassing parts of Aiken, Barnwell, andAllendale Counties in South Carolina, borderingthe Savannah River. The site is locatedapproximately 25 miles southeast of Augusta,Georgia, and 22 miles south of Aiken, SouthCarolina. Many of the original productionfacilities within the site are beingdecommissioned. Major waste treatment andmanagement activities associated with that effortare conducted under the cognizance of the DOEOffice of Environmental Management (EM),with local DOE management provided by theSavannah River Operations Office (DOE-SR).Also located within the site are operatingfacilities associated with tritium processing andhandling under the cognizance of the NationalNuclear Security Administration.

The site is operated by an integrated team ledby Westinghouse Savannah River Company,LLC (WSRC), which is responsible for the site’snuclear facility operations, environment, safety,and health (ES&H), and quality assurance; allsite administrative functions; and the Savannah

1.0 Introduction

River National Laboratory. Majorsubcontractors to WSRC include BechtelSavannah River, Incorporated (BSRI), which isresponsible for environmental restoration,project management, and engineering andconstruction activities; British Nuclear Fuels,Limited Savannah River Corporation, which isresponsible for the site’s solid waste program;CH2 Savannah River Company, which isresponsible for decommissioning anddemolition; and Polestar Savannah RiverCompany, which provides the services of theChief Closure Officer. Security, protectiveservices and special response capability areprovided by Wackenhut Services, Incorporated/Savannah River Site (WSI/SRS).

1.2.2 Pond B DamFigure 1-1 shows an aerial view of Pond B. ThePond B Dam, the scene of this accident, wasconstructed in 1960 as a simple earthen damwith a sandy-toe drain system that was typicalof that period. The dam is operated andmaintained using the Federal Energy RegulatoryCommission (FERC) guidelines as set forthunder Title 18 Code of Federal Regulations(CFR) Part 12, Safety of Water Power Projectsand Project Works. WSRC and FERCinspections confirmed that the pre-repair stateof the Pond B structure did not comply withFERC guidelines and required repair. A fixed-price construction contract was awarded to andexecuted by GradeSouth, Inc., a sister companyto Beam’s Contracting. The scope of the Pond BUpgrade Project included the installation of afilter and drainage system consisting of coarsegradation sand, fine gradation sand, and acompacted-earth fill berm; installation of a rockriprap collection ditch; installation and removalof a temporary sediment basin; and installationof four piezometers. At the time of the accident,GradeSouth was completing punchlist activities

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after receiving a Certificate of MechanicalCompletion from BSRI on June 23, 2004. Theseactivities included excavation and earth-moving work.

Figure 1-1. South end of Pond B Dam

1.3 Scope, Conduct,and Methodology

The Board began its activities on July 29, 2004,and completed its investigation on September1, 2004. The scope of the Board’s investigationwas to identify and analyze all relevant facts todetermine the direct, contributing, and rootcauses of the event; to develop conclusions; andto determine Judgments of Need that, when

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implemented, should prevent recurrence. SeeFigure 1-2 for an explanation of accidentinvestigation terminology.

The Board conducted its investigation inaccordance with DOE Order 225.1A,Accident Investigations, using the followingmethodology:

– The Board gathered relevant facts throughinterviews and by reviewing documents andevidence.

– The Board inspected the accident scene,tested equipment, conducted anengineering analysis, and reviewedphotographs of the scene.

– The Board identified causal factors usingevent and causal factor analysis, barrieranalysis, and change analysis.

– Using these causal factors, the Boarddeveloped Judgments of Need for correctiveactions to prevent recurrence.

A causal fcausal fcausal fcausal fcausal factactactactactororororor is an event or condition inthe accident sequence that contributes tothe unwanted result. There are three typesof causal factors: direct causedirect causedirect causedirect causedirect cause, which isthe immediate event or condition thatcaused the accident; rrrrroooooooooot causet causet causet causet cause, which isthe causal factor that, if corrected, wouldprevent recurrence of the accident; andthe contributing causescontributing causescontributing causescontributing causescontributing causes, which are thecausal factors that collectively, with theother causes, increase the likelihood of anaccident but that did not cause theaccident.

EvEvEvEvEvent and causal fent and causal fent and causal fent and causal fent and causal factactactactactororororors analysiss analysiss analysiss analysiss analysis includescharting, which depicts the logicalsequence of events and conditions (causalfactors that allowed the accident to occur)and the use of deductive reasoning todetermine the events or conditions thatcontributed to the accident.

Barrier analysisBarrier analysisBarrier analysisBarrier analysisBarrier analysis reviews the hazards, thetargets (people or objects) of the hazards,and the controls or barriers thatmanagement systems put in place toseparate the hazards from the targets.Barriers may be physical or administrative.

Change analysisChange analysisChange analysisChange analysisChange analysis is a systematic approachthat examines planned or unplannedchanges in a system that caused theundesirable results related to the accident.

Figure 1-2. Accident investigation terminology

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2.1 Background andAccident Description

2.1.1 Accident OverviewOn the afternoon of July 26, 2004, a GradeSouthteamster employee and a truck driver fromGuthrie Grading and Hauling, Inc. (Guthrie)were loading a John Deere Model 790E-LCexcavator onto a lowboy trailer. The accidentoccurred at approximately 3:15 p.m. as theteamster and driver attempted to reposition anoutrigger plank on the lowboy trailer thatbecame dislodged while the excavator was beingpositioned on the lowboy. The teamster used theexcavator’s boom to lift one of the excavatortracks off the lowboy trailer so that the drivercould reposition the plank under the track. As

2.0 The Accident

the driver was repositioning the plank, theexcavator dropped (moved), critically injuringthe driver. Figure 2-1 shows the position of theexcavator and lowboy immediately followingthe accident.

2.1.2 BackgroundOn August 15, 2003, BSRI sent a Request forProposal (RFP) for the Pond B Dam UpgradeProject to four construction contractors. Thescope of work included soil excavating andtrenching, earth filling, installing polyvinylchloride (PVC) drainage pipes, and settingprecast reinforced-concrete manholes and weirboxes. It also included drilling monitoring wellsand setting piezometers and monitoring wellcomponents. This work involved operating

Figure 2-1. The accident scene

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heavy earthmoving equipment and drilling rigsand performing rigging activities at a remoteonsite location.

Of the four contractors, GradeSouth was theonly prospective bidder to respond to the RFP.The company had previously worked at SRSwith demonstrated safety performance for threeyears, based on the Minimum PerformanceEligibility Factors of the RFP. These factorsincluded an Experience Modification Rate(EMR) of 1.0 or less and a Total Recordable Case(TRC) rate of 7.9 or less. In December 2003,GradeSouth was awarded a fixed-priceconstruction contract to execute the work at thePond B Dam and started mobilization activities.BSRI issued a Notice to Proceed on January 7,2004. After completion of a pre-job briefing,GradeSouth started construction work the weekof January 19, 2004.

During the execution of the project, twoincidents occurred. On February 19, 2004, aGradeSouth employee bent a drill auger whenhe rotated the equipment boom while the augerwas still in the hole. The operator believes hemay have blacked out due to a medical conditionthat was not previously disclosed to GradeSouth.On April 23, 2004, BSRI issued a safety citationto GradeSouth for an incident in which aGradeSouth driver overturned a dump truckequipped with a 1,000-gallon, skid-mountedwater tank while backing onto an adjacent slopeto make a turn. The dump truck and water tankwere being used to wet down a road for dustcontrol, and the tank had not been secured toprevent lateral shifting within the body of thedump truck.

On June 23, 2004, BSRI issued a Certification ofMechanical Completion, with a punchlist ofitems to be completed, to GradeSouth for thePond B Dam Upgrade Project. As one of thepunchlist items, GradeSouth had to rework thesediment pond and needed a long-boomexcavator to reach across the pond while onlevel ground. GradeSouth’s vendor,

Metropolitan Tractor Company (METRAC),delivered the excavator to the project site onJuly 15. A qualified operating engineer fromGradeSouth unloaded the excavator. TheMETRAC driver informed the operatingengineer that the excavator had a hydraulic leak.GradeSouth repaired the leak by tighteninghydraulic line fittings. On July 19, while usingthe excavator to load a dump truck, theoperating engineer noticed that it was losinghydraulic pressure and that the boom graduallylowered into the truck bed. After adding about5 gallons of hydraulic fluid, the operatingengineer completed the fieldwork that requiredthe long-boom excavator. The following day, aGradeSouth mechanic made repairs thatincluded replacing an O-ring on a hydraulic lineto the operating cylinder for the arm and testedthe excavator to confirm that there was nodetectable leak. The excavator was parked.GradeSouth notified METRAC of the repairs andrequested that the equipment be transported offsite. METRAC then contacted Guthrie andrequested that the excavator be transported totheir Augusta office.

2.1.3 Accident DescriptionAt approximately 2:00 p.m. on July 26, 2004, aGradeSouth teamster was assigned to meet aGuthrie truck driver at the New Ellentonsecurity gate and escort him on site to retrievethe excavator. The teamster used a GradeSouthcompany vehicle to travel to the gate. Recordsindicate that the truck driver signed in at theNew Ellenton security gate at 2:35 p.m. Theteamster led the truck driver to the Pond B DamProject area and parked the company vehiclenear the excavator. The truck driver positionedthe lowboy trailer he had brought for loadingthe excavator and disconnected the trailer fromits gooseneck trailer hitch, which remainedattached to the truck cab.

The lowboy trailer, shown in Figure 2-2, is 8feet, 6 inches wide. Outriggers are available forthe trailer to extend it an additional 1 foot oneach side, resulting in a total width of 10 feet, 6

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inches. The trailer body supports the weight ofthe excavator, and the outriggers support thetracks, which sag if not supported. The excavatoris 11 feet, 1 inch wide, which means theexcavator track will hang over the outriggersabout 3 to 4 inches when the excavator iscentered on the lowboy.

The driver positioned the outrigger and plankon the driver’s side of the lowboy, and theteamster assisted the driver in positioning theoutrigger and plank on the passenger side (post-accident visual examination indicated thatoutriggers were missing on the lowboy – threeon the passenger side and two on the driver’sside). The outrigger plank on the driver’s sidespanned six outrigger positions, including oneof the missing positions. The teamster drove theexcavator onto the lowboy trailer from the frontend of the trailer. He stated that he loaded theexcavator as a courtesy to the driver. TheGradeSouth employee is a teamster, not anoperating engineer.

The excavator was initially positioned as far backon the lowboy as it would go. The teamsterstated that the truck driver asked him to move

the excavator toward the front of the trailer andsignaled the teamster by hand when theexcavator was positioned where he wanted it.The teamster also stated that the truck drivertold him that the plank on the outrigger on thedriver’s side of the lowboy was cocked and thatthe driver asked him to use the boom to lift thetrack on that side of the excavator so that hecould reposition the plank correctly on theoutrigger. Post-accident statements by theteamster indicate that neither he nor the truckdriver considered stopping work or backing theexcavator off the trailer and starting over whenthe plank became cocked.

The teamster raised the excavator boom andswung it about 90 degrees to the right so that itwas nearly perpendicular to the excavatortracks. He positioned the boom and the arm toplace the bucket on the ground about 10 to12feet from the trailer. In this position, the arm isat an approximate 45-degree angle to theground. John Deere recommends that the armshould be at a 90- to 110-degree angle to theboom, allowing the track to be elevated byapplying downward force on the boom only,rather than operating in “two-stick” control

Figure 2-2. Lowboy after removing excavator

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(illustrated in Figures 2-3 and 2-4). The teamsterthen used the excavator controls to push downon the boom and out on the arm to raise thetrack (i.e. “two-stick” control). He stated thatthe truck driver verbally directed him at leasttwice to raise the track higher. During thisactivity, the driver was in the teamster’s line ofsight. The driver then squatted down near theexcavator and trailer, and he then disappearedfrom the teamster’s line of sight.

The teamster stated that shortly afterwards hefelt the excavator budge, like it dropped. Hethen focused his attention on the excavatorbucket and the ground and a short time latersaw the excavator drop again. He believed hecould feel the bucket bleeding down and, fromwhere the pressure had been applied to raisethe track, it was releasing the pressure, allowingthe track to come back down. He then begancalling to the driver to get out, that the excavatorwas coming down. The teamster stated that thetruck driver told him to hold on a minute andnot do anything. The teamster said that he tookhis hands completely off the controls so hewouldn’t accidentally bump the bucket, but thebucket was continuing to slide in. He reported

that he did not have a sensation that theexcavator was sliding but that the bucket wassliding.

When the teamster heard the truck driverscream out in pain, he applied pressure andboomed back up in order to keep the tracks offthe driver or the bucket from getting to thedriver. He did this by pushing down on theboom and out on the arm. The teamster askedthe driver if he was okay and was told that heneeded some help.

The teamster stated that he locked down thehydraulic controls on the excavator, ran off theback of the trailer without looking at the injureddriver, got into the company vehicle, and droveacross the dam (0.4 miles) to the GradeSouthconstruction office trailer to get help. He methis foreman, general superintendent, andanother GradeSouth employee and told themthe driver was pinned. The four of themreturned to the scene of the accident in twovehicles; the foreman and superintendent in oneand the teamster and employee in the other.When they arrived at the accident scene, theyfound the driver lying on his stomach,

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

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

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somewhat parallel to the track of the excavator,with his feet near the edge of the track. Theforeman determined that an ambulance wasrequired, and the superintendent used hiscompany-issued cell phone to call theGradeSouth onsite office in H-Area, informingthem of the accident and requesting anambulance. The GradeSouth onsite office thennotified the SRS Emergency Duty Officer thatan accident had occurred at the Pond B Damand that medical assistance was required.

Table 2-1. Event chronology

The GradeSouth employees wedged lumberfrom the lowboy under the track to prevent itfrom dropping further. Table 2-1 below providesan event chronology.

The Board concludes that there were a number ofopportunities to utilize stop work and it was notexercised.

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 2:35 p.m.

The Guthrie driver entered the site to pick up the excavator .

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.

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2.2 Emergency Responseand Medical Treatment

Although GradeSouth reported that they hadBSRI remote worker radios in the work trailerat the worksite, and the teamster told them thatthe driver had been pinned, the initial call formedical assistance was not made until theGradeSouth foreman and superintendent droveto the accident scene and determined that anambulance was required. The GradeSouthsuperintendent used his company-issued cellphone to call the GradeSouth office in H-Areaat SRS, informing them of the accident andrequesting an ambulance. At 3:27 p.m., theGradeSouth employee located in H-Area calledthe Savannah River Site Operations Center(SRSOC) and reported that they had a man downthat was non-responsive and that an ambulancewas needed. The employee reported that theman (driver) was at the Pond B Dam UpgradeProject. In a follow-up phone call from H-Areato SRSOC at 3:28 p.m., the employee reportedthat the man was non-responsive, and they werenot sure if he fell off something. SRSOC had nodirect communication with the employees at theaccident scene to obtain information for the firstresponders.

At 3:28 p.m., SRSOC dispatched fire departmentpersonnel, emergency medical technicians, anda paramedic from Savannah River FireDepartment Station 3 to the accident scene. At3:32 p.m., while en route to the accident scene,these first responders radioed SRSOC to requestadditional information on the driver’s condition.The dispatcher responded that all that wasknown indicated that he was conscious, butincoherent. The first responders, along with SRSlaw enforcement personnel, arrived at the PondB Dam at 3:40 p.m. Personnel arriving at theaccident scene found the driver conscious, lyingface down, responding to questions, andcomplaining of leg pain. The first respondersstated that no one at the scene provided them

with an accurate description of the accidentwhen they first arrived.

The first responders noted that the driver’s feetwere near the track and that his body waspositioned at approximately the same angle asthe lumber (Figure 2-5) that was placed underthe track by GradeSouth personnel to preventthe tracks from falling onto the driver. Theyalso noted that the driver’s pants were torn andthat his right leg and pelvis were injured. Thedriver could not provide the first responderswith an accurate description of the accident.During the first responders’ initial assessment,the driver’s blood pressure decreased and heartand respiratory rates increased. The driver wasgiven oxygen by non-rebreather mask andplaced on a Reeves Sleeve for transport.

Testimony from emergency respondersindicates that consideration was given to usingthe WSI helicopter for MEDEVAC transport.Several of the first responders stated that if theyhad known that the driver had been crushed bythe excavator, they would have put thehelicopter on standby. One of the firstresponders (a paramedic) stated that they wouldnot have been able to effectively secure, treat,and transport the driver using the MEDEVAC.The Board’s inspection of the MEDEVAChelicopter and interviews with the pilotsindicated that there is room for the patient tobe securely strapped in the helicopter, alongwith two attending medical personnel and theirequipment. The approved SRS MedicalProtocols dated September 25, 2001, indicatethat the driver exhibited at least three of theanatomic and physiologic criteria that maywarrant a MEDEVAC transport. The MedicalProtocols also indicate that ground travel to theMedical College of Georgia is approximately 50minutes and air travel is 7 to 8 minutes.

The ambulance departed the accident scene at3:55 p.m. for the nearest Level I Trauma Centerat the Medical College of Georgia in Augusta. Aparamedic and an emergency medical

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Figure 2-5. The scene immediately following the accident

technician both attended the injured truckdriver in the back of the ambulance. Theambulance driver declared a Code 3 (lights andsiren) and Signal 24 (multiple trauma and shock)and radioed the hospital to report that they weretransporting the driver. The emergency medicaltechnician and paramedic had difficultycontrolling the injured driver, who was, attimes, combative and uncooperative. Theambulance driver radioed Savannah River FireDepartment Station 1 to request that a secondparamedic meet the ambulance en route to helpin controlling the injured driver and assistingthe paramedic and technician. Subsequently, thesecond paramedic assisted in giving the driveroxygen and intravenous fluids. Duringtransport, the paramedics noted that the driverstopped breathing for several seconds andadministered oxygen using a bag valve mask.The injured driver quickly resumed breathingspontaneously.

The ambulance arrived at the hospital’semergency department at 4:40 p.m. The driverwas taken to the trauma room, where thehospital’s trauma team managed his injuries. Theteam’s physical examination revealed bruisesand abrasions on the driver’s left thigh and anopen fracture of the right femur. The drivercould not move his lower extremities and hadno sensation in either leg up to the level of theumbilicus. X-rays showed an extensivelycomminuted intertrochanteric fracture of theright femur, multiple pelvic fractures (right andleft superior and inferior pubic rami, rightsacrum with widening of the right sacroiliacjoint) and fracture of the right transverse processof vertebra L5. Orthopedic Surgery personnelwrapped the driver’s pelvic area in a bed sheetto stabilize the pelvis and applied a tractiondevice to the right leg to reduce the femurfracture. The driver displayed respiratorydistress and was placed on mechanicalventilation. He was then transported to the

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angiography suite to determine the extent ofsuspected vascular injuries and to embolizeaffected blood vessels, as needed. As the patientwas transferred to the angiography table, heexperienced a cardiopulmonary arrest and couldnot be resuscitated. The time of death wasrecorded as 6:18 p.m.

Forensic pathologists performed an autopsy onJuly 27, 2004, at 10:00 a.m. The probable causeand mechanism of death were determined tobe hypovolemic shock due to fracture of thepelvis and right femur and blunt trauma to thepelvis and legs from being crushed by anexcavator. Significant findings on examinationincluded:

1. Much contusion of the medial aspects ofboth right and left thighs.

2. Fracture of the right mid-femur.3. A quarter-inch puncture wound on the

upper right lateral thigh.4. An irregular abrasion over the mid lateral

left thigh extending to the back of the thigh.5. Contusions over the right and left buttock

areas.6. Examination of the internal organs revealed

bilateral fractures of the pelvis withseparation of the symphysis pubis. Muchhemorrhage was present in the pelvis. Theright femur, tibia, and fibula were alsofractured.

The forensic pathologist reported that there wasno evidence of injury to the major blood vesselsin proximity to the pelvic or femoral fracture.The South Carolina Law Enforcement DivisionForensic Services Laboratory analysis of bloodand ocular fluid was negative for volatiles,including ethanol, amphetamine/metamphe-tamine, barbiturates, benzodiazepines, cocaine,and opiates. Five postmortem digital photo-graphs were provided to the Board’s physicianadvisor.

The Board concludes that the emergency medicalresponse was hampered by the lack of an accuratedescription of the incident due to poorcommunications.

The Board also concludes that the emergencymedical services (EMS) responders did notprecisely follow the approved SRS MedicalProtocols for trauma transport. MEDEVAC couldhave decreased transport time to the MedicalCollege of Georgia by 30 minutes or more.

In addition, the Board concludes that GradeSouthfailed to meet the requirements established byWSRC for the Remote Worker NotificationProgram.

2.3 Investigative Readinessand Accident ScenePreservation

Initial investigative activities related to thisaccident began after the injured driver wastransported to off-site medical facilities andwere managed by a law enforcement officeremployed by WSI/SRS. Law enforcementpersonnel and investigators dispatched to thescene ensured that first-person writtenstatements were collected from personnelinvolved directly or indirectly with the accidentor the subsequent response. The investigatorsalso conducted a preliminary interview with theGradeSouth teamster who was operating theexcavator during the accident, and the resultsof that interview were documented. Theinvestigators performed preliminary inspectionsof the excavator, the lowboy trailer, and thetractor. Digital pictures of the accident sceneand environs were collected and maintained.Fire department and emergency medicalpersonnel also conducted a critical incidentcritique of the accident and their response.

WSI/SRS was notified by the Barnwell CountyCoroner on July 26, 2004, that the driver wasdeceased as a result of the injuries received from

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the accident. The accident scene was secured at5:52 p.m., and at 8:21 p.m., a WSI/SRS SecurityOfficer was posted at the scene. The DOE-SRSafety and Radiation Protection DivisionDirector was notified of the fatality by theSRSOC at 8:36 p.m. The DOE-SR notified WSI/SRS at 9:25 p.m. to restrict access to the scenepending a DOE Type A Accident Investigation.The accident scene was controlled as a crimescene by WSI/SRS, and access controls wereestablished at the opposite (east) end of the PondB Dam, approximately 0.4 miles from theaccident scene. The only access to the accidentscene was the road across the dam. Crime scenetape was erected around the excavator andtrailer to demarcate the scene controlboundaries. All personnel allowed entry to theaccident scene were logged into the area byWSI/SRS at the access control point at the eastend of the Pond B Dam.

On July 27, 2004, at approximately 12:00 p.m.,DOE-SR representatives from the Safety andRadiation Protection Division visited the site ofthe accident, and coordinated the activities topreserve the scene from heavy rains forecast forthat evening. A large protective enclosure wasinstalled over the accident scene as much aspractical to preserve the scene. Also, sandbagswere placed to prevent loss or alteration ofevidence. Small diversion trenches wereinstalled to channel water away from theaccident site. Additional protective covering wasinstalled on July 29, 2004, to fully enclose theaccident scene. Access to the site was controlledby WSI/SRS, with access permission grantedinitially by DOE-SR and subsequently by theType A Accident Investigation BoardChairperson.

The Accident Investigation Board assumedcontrol of the accident site on August 3, 2004.WSI/SRS officers maintained direct control ofthe accident scene, with the Board approvingall entries. On August 6, 2004, the Board allowedWSRC to remove the excavator from the lowboytrailer so that operability tests could be

performed on the excavator. The testing wasperformed under the oversight of the Board andwas witnessed by representatives of severalcompanies. The Board inspected the lowboytrailer, tractor, and the surrounding area for anyadditional evidence, then released the lowboytrailer and tractor to WSRC, whichsubsequently allowed Guthrie to remove it fromthe accident site. On August 11, 2004, the Boardreturned control of the accident site to WSRC,with the exception of the excavator. On August16, 2004, the Board determined that noadditional analysis of the excavator was requiredand released it to WSRC.

The Board concludes that the actions taken byDOE-SR, WSRC, and WSI/SRS were effective inpreserving the accident scene.

2.4 Accident Reconstructionand Analysis

The Board’s inspection of the accident scenedetermined that the excavator was initiallydriven all the way to the back end of the lowboytrailer with the boom facing the rear of thetrailer. Asphalt and mud on the back end of thetrailer indicated that the excavator was centeredon the trailer at the back end. The excavatorwas then moved forward on the trailer. Again,deposited material from the tracks indicated thatthe excavator was centered on the trailer. Theteamster stated that he was asked to swing theboom around and lift up one track so that theoutrigger plank on the driver’s (accident) sidecould be repositioned. The teamster raised theboom and swung it to the right, placing it atapproximately a right angle to the track. Hestated that he positioned the bucket 10 to 12feet from the track and used the boom and armcontrols to raise the track. This is not theconfiguration recommended by themanufacturer, John Deere, to raise the track. Inpost-accident interviews, the teamster statedthat he didn’t think he could raise the excavatortrack with the angle between the boom and arm

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at 90 to 110 degrees (as recommended by JohnDeere) because of the long boom. He noted thata regular excavator could be raised in thatmanner but with a long-stick excavator, thereis a chance of bending the piece of equipmentor not picking it up at all. The Board believesthe teamster’s assumption was incorrect.

The Board conducted engineering analysis andcalculations, and simulated the accidentconditions in the field to assist in analyzing theaccident. Engineering analysis indicate thatinitially, the excavator configuration was stablewith about 16,000 pounds of force on the bucketand 35,000 pounds of force on the stationarytrack. The Board determined that, while thetrack was elevated, a leak on the hydraulic lineto the arm cylinder (caused by a loose fitting)relieved hydraulic pressure from the armcylinder. The gradual loss of pressure in thecylinder resulted in a redistribution of loadswithin the excavator structure, which caused abuildup of lateral loads at the excavator supportpoints (the stationary track and the bucket).After the lateral loads built up to a level thatexceeded the frictional holding capability at theexcavator supports (between either thestationary track and trailer or the bucket andground), slippage occurred, until sufficientpressure was built up in the cylinder to re-support the load. This action occurredrepeatedly, causing either the bucket or thetrack to slip, until the suspended track was againresting on the trailer bed.

The simulation of the accident conditions usingthe excavator involved in the accident, with theexisting hydraulic leak present, confirmed theBoard’s engineering analysis. Both bucketslippage and track slippage were noted with asimilar pre-accident excavator configuration.The simulation was re-performed after repairof the hydraulic leak by tightening the loosefitting. No bucket slippage or track slippage wasnoted. However, the raised track did lowerslowly over the next 20 minutes, probably fromslow internal leakage around the cylinder piston

seals. Based on these simulations and supportingengineering evaluation input, the Boarddetermined that, as the excavator bucket andtrack slipped, the excavator fell onto andcritically injured the Guthrie driver.

The Board also attempted to determine thedriver’s actions when he was out of sight of theteamster while attempting to reposition theoutrigger plank. The outrigger plank wasapproximately 18 inches off the ground andunder the excavator track. The track extendedabout 3 to 4 inches beyond (over) the plankwidth. The plank was 11 feet long and, basedon 3.7 pounds per foot for dried oak, weighedapproximately 40 pounds. Considering thephysical stature of the driver and themanipulations required to adjust the plank, theBoard determined that he was lying on his sideon the ground under or near the raised(suspended) track, contrary to OccupationalSafety and Health Administration (OSHA) 29CFR 1926.600(a)(3)(i). The medical reportsidentified multiple fractures of the pelvis,fractures to the right femur, fibula, and tibia,and abrasions that support this conjecture. TheBoard also determined that after the teamsterheard the driver scream out in pain and raisedthe track up again, the driver managed to moveout from under the track to the position he wasin when the teamster and the other GradeSouthemployees returned. Medical personnel at theaccident scene reported that the driver had alayer of dirt on him and that his pants werepulled down slightly, which is consistent withcrawling on his elbows.

The Board concludes the following:

– The driver placed himself in an unsafeposition under a suspended load in order toadjust the plank.

– The teamster was not qualified to operate theexcavator.

– In the configuration that the teamster wasusing to lift the excavator track, the leak inthe hydraulic line to the arm cylindercontributed to the accident.

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3.0 Accident Facts and Analysis

Figure 3-1. Relevant DOE organizational chart

This section addresses the facts related to theaccident, along with the results of the Board’sanalysis. When analyzing the facts, the Boardconsidered the core functions and guidingprinciples of Integrated Safety Management,which comprise the fundamental DOE safetyand health policies that should be incorporatedin all phases of the work, from work planningthrough execution and feedback.

3.1 Line Management Rolesand Responsibilities

Line management is directly responsible for thesafety and protection of the public, workers, andthe environment. In order to be effective, theDepartment and its contractors must establish

and maintain clear lines of authority andresponsibility for ensuring safety. Theseresponsibilities apply to activities conducted byDOE, WSRC, BSRI, and GradeSouth for thePond B Dam Upgrade Project.

3.1.1 DOE Roles and ResponsibilitiesFigure 3-1 illustrates the relevant portions ofthe DOE organization from the ProgramSecretarial Office (EM-1) to the Pond B DamUpgrade Project. DOE-SR describes itsorganizational roles and responsibilities in theFunctions, Responsibilities, and AuthoritiesProcedure (FRAP), which was updated in April2004. The DOE-SR FRAP states that the DOE-SR Manager has overall responsibility forensuring the development and maintenance of

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safety management systems so that work iscarried out in a manner that assures the safetyand health of the public and workers.

The DOE-SR Office of Site Services (OSS)manages the programmatic and technicalactivities associated with logistics, supportservices, and non-nuclear infrastructure at SRS;consequently it is the line management officefor the Pond B Dam Upgrade Project. The OSSproject managers and field representativesmanage the field activities of DOE-SR and itscontractor, WSRC, by performing periodicsurveillances, assessments, and walkthroughs.The OSS line management responsibility appliesonly to WSRC. OSS does not provide oversightof subcontractors, such as BSRI, or lower-tiersubcontractors, such as GradeSouth. Moreover,the DOE-SR FRAP does not address oversightof work being carried out by subcontractors toWSRC.

The DOE-SR Office of Environment, Safety andHealth and the Assistant Manager for ClosureProjects (Figure 3-1) provide subject matterexperts and technical support to constructionproject line management when requested.

The Board concludes that the current DOE-SRFRAP does not clearly define roles andresponsibilities for activities related to ES&Hoversight of WSRC subcontractors.

3.1.2 WSRC/BSRI Roles andResponsibilitiesFigure 3-1 presents the WSRC line managementorganization responsible for the execution ofwork at Pond B Dam. WSRC subcontracts withBSRI for construction activities, and thesubcontract is implemented using jointlydeveloped policies and procedures for safety andproject management. The BSRI organization, asa unit, reports to the WSRC President. WSRCuses a matrix management organization toestablish a project team to execute constructionprojects. A project team is formed by assigningpersonnel from appropriate functional

organizations to plan and execute the work andto bring the tools necessary to complete theirassigned activities. The team for the Pond BDam Upgrade Project consisted of a projectmanager, assistant project constructionmanager, safety engineer, subcontract technicalrepresentative (STR), subcontract specialist, andpersonnel from other disciplines as necessaryfor project completion. These staff personnelhave line management responsibility for safetyand take day-to-day direction from the WSRCproject manager.

The project manager is required to develop aConstruction Execution Plan and delineate staffassignments and responsibilities. TheConstruction Execution Plan for the Pond BDam Upgrade Project gives overallresponsibility for planning, organizing,controlling, and directing the project effort tothe Project Manager, with the assistant projectconstruction manager responsible forperformance of the construction team. Itdelineates staff assignments and responsibilitiesaccordingly.

The Board concludes that WSRC/BSRI linemanagement roles and responsibilities forensuring safe execution of the project wereestablished.

3.1.3 GradeSouth Roles andResponsibilitiesThe GradeSouth Worker Protection Plan (WPP)contains line management roles andresponsibilities for corporate positions,including senior managers, supervisors, andemployees. Figure 3-2 also depicts the specificGradeSouth line management organization forthe Pond B Dam Upgrade. The Secretary/Treasurer, as the senior manager for the project,is responsible for application of the company’ssafety program. As stated in the GradeSouthWPP, the senior manager establishes fieldpersonnel safety goals and objectives, anddelegates the responsibility for accident

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prevention to the supervisors, holding themaccountable for positive action within their area.

The GradeSouth onsite Project Manager, assupervisor for the Pond B Dam Upgrade Project,is responsible for completing the work withinschedule and budget. The Project Manager isresponsible for safety, obtaining equipmentneeded for the job, and for employee training.The Superintendent and his direct reportingForeman are also considered supervisors. TheSuperintendent has responsibilities for multipleprojects onsite, and the Foreman is responsiblefor a single job; in this case, the Pond B DamUpgrade Project.

As stated in the WPP, these supervisors arerequired to have a thorough knowledge of thehazards involved in every operation within theircraft and a knowledge of controls for thosehazards. They must also insist on proper use ofmachinery, equipment, and tools to avoidaccidents, complete a job safety analysis foroperations that are likely to produce accidents,and perform daily inspections of theiraccountable areas. The WPP states thatGradeSouth employees are to incorporate safetyin every job procedure, know and obey safepractices, and report unsafe conditions to asupervisor.

The Board concludes that the line managementroles and responsibilities for the GradeSouthpersonnel were clearly documented andunderstood.

3.2 Procurement andContractual Requirements

The procurement process for the Pond B DamUpgrade Project began with the approval of apurchase requisition in July 2003. Also thatmonth, the requisition preparer completed theSubcontract Safety Checklist, found inprocedure WSRC Manual 8Q, Procedure 15(WSRC 8Q-15), Subcontracted Services

Workplace Safety and Health, using theanticipated scope of work to be performed atthe Pond B Dam. Completion of the checklistpermitted BSRI to categorize the work, establishwhether the work was hazardous or non-hazardous, and determine worker protectionplan requirements for the subcontractorawarded the contract. The Pond B DamUpgrade Project was classified as Category Cwork. It was deemed hazardous work due tothe operation of forklifts or other heavyequipment, rigging, soil excavation or trenching,and construction. Non-hazardous activitiesincluded material and supply delivery services.

WSRC/BSRI categorizes subcontracted work todetermine the level of ES&H compliancerequired and the amount of safety oversightWSRC/BSRI will provide (see Figure 3-3). Thelevel of oversight and type of safetydocumentation required can vary based onscope, hazards, proximity of the job to sitepersonnel, and subcontractor’s knowledge,compliance and commitment to employeesafety. The categories are delineated in WSRC8Q-15 and are based on the SRS WorkplaceSafety and Health Policy, dated August 21, 1998.This policy was developed jointly by DOE-SRand WSRC.

The RFP for the Pond B Dam Upgrade Projectwas issued in August 2003, shortly after thepurchase requisition was approved, as a fixed-price construction bid. Several general ES&Hand key ISM requirements were incorporatedin the RFP. They include:

– Subcontractor must maintain completecontrol over its employees and all of itslower-tier suppliers and subcontractors.(BSRI procurement personnel considervendors, such as Guthrie, as lower-tiersuppliers.)

– Documentation in the subcontract willdescribe how the subcontractor willimplement ISM core functions.

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Category ASubcontract work that requiressubcontractor and site personnel tojointly perform manual work in thesame job or project. This category ofwork requires compliance withapplicable WSRC procedures and asubcontractor safety and health policy.For hazardous Category A work, theminimum safety interface is monthly.

Category BSubcontract work that does not requirethe subcontractor and site personnel tojointly perform manual work, and thework is located in close proximity andmay or may not result in risk to sitepersonnel safety. Hazardous Category Bwork requires compliance with thesubcontractor’s corporate WPP, whichis aligned with OSHA, to include a task-specific plan and a minimum of weeklyinterface with WSRC safety oversight.

Category CSubcontract work that does not requirethe subcontractor and site personnel tojointly perform manual work. Thework is isolated, and the work does notreasonably result in risk to sitepersonnel safety. This category of workrequires the subcontractor to complywith its corporate WPP, which isaligned with OSHA. WSRC oversight,at a minimum, consists of incidentreview, consultation, or as requested bythe funding division.

Figure 3-3. WSRC categories of subcontracted work

– In performing work, implement theGeneral Provisions of the contract.

– Before performing work, evaluate thehazards and establish an agreed-upon set ofstandards; tailor controls to the work.

– The subcontractor will comply with OSHAand all other applicable federal, state andlocal regulatory requirements. (However,BSRI personnel stated that they had nojurisdiction over vendors or suppliers tosubcontractors for flow-down of ISMrequirements.)

– BSRI will provide to subcontractoremployees copies of the SubcontractorSafety Handbook, which complies withDOE Order 440.1A, Worker ProtectionManagement.

– The subcontractor will submit a WPP thatimplements OSHA requirements.

Four companies were invited to bid on theproject and were required to meet the followingminimum performance eligibility factors forES&H: 1) a three-year average experiencemodification rate (EMR) of 1.0 or less, and 2) athree-year average total recordable case (TRC)rate of 7.9 or less.

During an August 2003 pre-proposal conferencefor the Pond B Dam Project, BSRI distributedthe SRS Davis-Bacon ConstructionSubcontractor Safety and Health InformationHandout, which provided information on 36items related to safety. Of these, Item 3 requiredsubcontractors to submit a task-specific plan(TSP), a supplement to the WPP, that includeda breakdown of tasks, hazards, and controls.However, the RFP contained no requirementsto develop a TSP. BSRI also distributed at thepre-proposal conference, guidance fordeveloping a TSP and the checklist that wouldbe used to evaluate the WPP. Additionally, toclarify questions from the pre-proposalconference, Addendum 1 to the RFP was issuedand stipulated that a BSRI field radio wasrequired to be with the subcontractor every daywork was performed at the job site.

GradeSouth was the only company to submit aproposal for the Pond B Dam Project. Thecontract for the Project was awarded to

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GradeSouth in December 2003, after finalnegotiations. The subcontractor received aNotice to Proceed on January 7, 2004, and beganconstruction work during the week of January19, 2004.

The Board concludes that the subcontract for thePond B Dam Upgrade Project was adequate inthat ISM and worker protection requirementswere included.

3.3 Work Planningand Controls

Work planning and execution at SRS is, in part,governed by Department of Energy AcquisitionRegulation (DEAR) 970.5223-1, Integration ofEnvironment, Safety and Health into WorkPlanning and Execution, in the WSRC contractthrough Section H.16. This DEAR clauserequires that the contractor exercise a degreeof care commensurate with the work and theassociated hazards; and that ES&H be an integraland visible part of work planning and execution.

The RFP and the ensuing subcontract for thePond B Dam Upgrade Project containedflowdown requirements related to ISM, andspecifically required that subcontractors andtheir lower-tier subcontractors implement thelisted guiding principles and core functions ofISMS when performing work. The RFP alsostipulated that:

• Subcontractors possess and maintain acorporate-level WPP that implements theOSHA requirements.

• BSRI will provide guidance onpreparation, content, review, andacceptance of the WPP.

• The WPP shall provide employeeguidance on task hazards, engineeringcontrols, precautions, and requirementson personal protective equipment.

• Documentation in the subcontract willdescribe how subcontractor willimplement the five core functions of ISM.

• Subcontractor shall comply with OSHAand shall implement site-specific ES&Hrequirements when specified in thecontract.

• Subcontractors perform daily documentedsafety inspections and observations ofworking craftsmen.

• Subcontractors complete EquipmentDeclaration Forms prior to equipmentbeing used on site.

At the pre-proposal conference in August 2003,BSRI issued a checklist for subcontractors to useto develop a WPP. This checklist required a TSP(task-level hazards analysis and controls) foronly Category B work, consistent with WSRCManual 8Q, Procedure 15. However, BSRInotified potential bidders at the pre-proposalconference that a TSP would be required for thePond B Dam Upgrade Project, and guidance fordeveloping a TSP was distributed. The guidanceprovided did not contain sufficient details toprepare a hazards analysis at the task level asrequired by the RFP.

GradeSouth submitted its corporate SafetyProgram Policies and Procedures as evidence oftheir WPP. The WPP is the document thatGradeSouth uses to establish and communicatesafe work practices to workers. While theircorporate document addresses many of theOSHA requirements of 29 CFR 1926, it fails tomeet minimum requirements of the contract.For example, the WPP does not addressemployee guidance on task hazards relevant tothe full scope of work nor designate a safety andhealth professional. Additionally, the WPP doesnot emphasize stop work authority, but statesthat the employee’s responsibilities are tocaution fellow workers when they performunsafe acts and to refrain from taking chances.

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

GradeSouth submitted a TSP that identifiedpotential hazards, hazards controls, andfeedback mechanisms for six major work areas:1) mobilization; 2) pollution control and erosioncontrol, 3) dewatering (well points), 4) grading,excavating and earth filling, 5) installing PVCdrainage pipes and manholes, and 6) seeding andmulching.

However, the TSP does not evaluate hazards ata task level as required by the BSRI guidelines.For example, the hazards analysis formobilization (shown in Figure 3-4) uses ageneric approach instead of a task-specificapproach to hazards analysis. It does notconsider loading and unloading of heavyequipment or transporting wide loads on site.It does, however, require that operators andemployees be trained, qualified, and fit for duty.

The TSP does not include demobilization as partof the work scope to be analyzed for hazards. Ageneric approach to hazards analysis was alsoused for other major work areas, instead of atask level hazard evaluation.

On January 5, 2004, the BSRI safety engineerdocumented that the GradeSouth WPP and TSPmet the requirements of the contract, and aNotice to Proceed was issued on January 7, 2004.

Although not required by WSRC procedures,on January 13, 2004, the BSRI STR completedan automated hazard analysis (AHA) for thePond B Dam Upgrade because there were noother tools in place to effectively prepare forand document the pre-job briefing or to identifytask-specific hazards. (The AHA is an internalWSRC tool to identify and analyze hazards and

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replaced the job hazard analysis process. TheSTR used the AHA to brief GradeSouthemployees at a pre-job briefing, and BSRI andGradeSouth safety and management personnelsigned the AHA. Although the AHA analyzessome hazards at the task level for the Pond BDam Project, it does not consider the full scopeof work, including mobilization anddemobilization activities or loading andunloading heavy equipment. It also does notincorporate the transportation of wide loads onsite and the operation of heavy equipment onsloping ground as hazardous tasks.

The AHA does, however, identify a number ofother hazards and controls that are notconsidered in the GradeSouth WPP and TSP.For example, it considers the remote locationof the job site as a hazard and reinforces the needto notify the SRSOC using BSRI-issued remoteradios prior to and after working each shift perProcedure MRP 4.03. It also requires a qualifiedfirst-aid person at the work site whenperforming any work. The AHA invokes severalsite procedures as additional requirements,including:

– OSR 18-125, Excavation/TrenchingChecklist;

– 8Q, Procedure 34, Excavations andTrenches;

– 8Q Procedure 9, Barricades, and TM-90-7,SRS Hoisting and Rigging Manual;

– 8Q, Procedure 12, General Site SafetyRequirements;

– MRP 4.03, Savannah River Site RemoteWorker Notification; and

– 8Q, Procedure 117, Hand and PortablePower Tools.

As a result, the subcontractor had two separatehazard analyses — a TSP and an AHA — bothof which failed to consider the full scope of workor analyze hazards at a task level. Thesedocuments identified different hazards andcontrols. The Board noted that there is a lack of

clarity in how the various documents — theWPP, TSP and AHA — interface with oneanother. Each contains important controls thatthe subcontractor needs to execute ISM andmitigate hazards; however, these controls arenot consolidated in the subcontractor’s WPP orTSP, which are used to perform work. TheWSRC procedures and guidance documents donot clarify the hierarchy of the various safetydocumentation involved in this project andcontain conflicting requirements for completingand developing the safety document. Thiscontributed to the ineffectiveness of the BSRIwork planning and execution process, asrequired for Davis-Bacon Category Cconstruction subcontractors.

The Board concludes the following:

– BSRI imposed additional, and sometimesconflicting, requirements on GradeSouth thatwere over and above those in the contract.

– BSRI failed to provide sufficiently detailedguidance for developing a task-level hazardsanalysis, and safety oversight failed to identifythe weaknesses of the hazards analysis.

– Both hazards analyses — the TSP and AHA— for the Pond B Dam Upgrade Project didnot adequately address the full scope of work(i.e., demobilization) or identify hazards at atask or activity level, including the loadingand unloading of heavy equipment.

3.4 Safety Oversight

3.4.1 GradeSouth OversightGradeSouth’s contract requires that a safety andhealth professional be designated in the WPP,along with his or her associated qualificationsand duties. It also requires that the safetyrepresentative conduct, at a minimum,documented 30-minute daily safety inspectionsat the job site and 30-minute observations ofworking craftsmen. The WPP does notdelineate who has responsibility for oversight

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and for executing the requirements and termsof the contract, and it fails to designate the safetyand health professional. The Board determinedthat a safety and health professional wasassigned to the job. However, the Board foundno 30-minute daily safety inspection reports or30-minute observations of work. Daily ActivityReports (DARs) were submitted to the STR;however, entries under “Safety” were notedeither as “Weekly” or “N/A.”

In addition to the daily safety oversight activitiesto be accomplished, the contract requiresGradeSouth to ensure that all major equipmentis inspected, operated, and maintained bycompetent personnel and to complete a MajorEquipment Declaration Form prior to usingequipment onsite. An Equipment DeclarationForm was not submitted for the excavatorinvolved in this accident prior to its use.

The Board concludes that GradeSouth failed toprovide control and oversight of its activities atthe Pond B Dam Upgrade Project.

3.4.2 WSRC/BSRI OversightWSRC provides independent oversight ofsubcontractor safety through periodic projectreviews and evaluations conducted by theFacility Evaluation Board (FEB). In April 2001,the WSRC FEB completed a Focused IntegratedSafety Management Evaluation of SubcontractorSafety at the request of the WSRC President.The evaluation identified the following tworelevant core issues:

– The mechanism for the identification ofWSRC requirements tailored to a specifictask for categories of work A, B, and C wasnot clearly and uniformly understood by allstakeholders, STRs, and subject matterexperts from the initial development phasesof the subcontract to field implementation.

– Conflicting requirements were found in thefollowing WSRC manuals: 11B, 7B, 3E, 8Q.As a result, additional requirements over

and above the contractual requirementswere being imposed.

A corrective action plan was submitted inAugust 2001.

In March 2004, the WSRC FEB Project ReviewTeam conducted a performance-basedevaluation of the Pond B Upgrade Project. Theevaluation identified the assessment area ofEnvironmental, Safety, Health and QualityAssurance as “Below Average.” The report notes“improvements were needed in the control andconduct of activities within the prescribedcontract and permit conditions.” The reportfurther notes that “Safety walk-downsperformed at the site were not sufficientlythorough to identify and correct unsafeconditions.” A corrective action plan wassubmitted in August 2004.

BSRI routine oversight of subcontractor safetyis provided through the safety engineers/representatives and STRs as part of the projectteam’s line management organization. Thesafety engineers are responsible for providingprimary occupational safety and health supportand field oversight of subcontractors, reviewingand accepting the subcontractor’s WPP, andcoordinating stop-work actions. The STRsperformed their safety oversight through dailywalkthroughs of the project to identify anddocument safety concerns in Daily ActivityReports. This level of oversight is greater thanrequired in WSRC Manual 8Q, Procedure 15 forCategory C work, where the STR is onlyrequired to provide oversight for incidentreviews.

The Board concludes that WSRC and BSRI’soversight activities were not effective in ensuringthat subcontractor safety issues were adequatelyidentified and resolved.

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3.4.3 DOE OversightDOE line management for the Pond B DamUpgrade Project is provided by the OSS, whichreports to the Deputy Manager for Business. Thisorganization carries out oversight responsi-bilities through the field representatives, whomanage the prime contractors’ activities throughperiodic surveillances, assessments, andwalkthroughs. There were no surveillances orassessments completed by a field representativefor the Pond B Dam Upgrade Project.

DOE-SR is responsible for ensuring protectionof the environment, workers, and public fromhazards posed by DOE facilities, operations, andcleanup activities. Within the DOE-SR Officeof Environment, Safety and Health, the Safetyand Radiation Protection Division providesdirect oversight of prime contractors’ safety andhealth programs through scheduled and reactiveassessments as well as trending of safety data.No assessments of subcontractors’ safety andhealth programs, including BSRI’s, have beenperformed by this Office. However, anassessment of the prime contractor’s oversightof subcontract work in high-level waste wasperformed in 2003 by an employee of the linemanagement organization for high-level waste.That assessment concluded that thesubcontractor management program providedsufficient guidance and oversight to ensureproper implementation of subcontractrequirements and flowdown of contractrequirements. Two weaknesses were noted inthe implementation of the WSRC Manual 8Q,Procedure 15 requirements, specifically in theuse of Equipment Declaration Forms anddocumented TSPs aligned with modified tasks.

The Board concludes that DOE-SR provided nodirect oversight of subcontractor constructionactivities on the Pond B Dam Upgrade Project.

3.5 Feedback andImprovement

Feedback and improvement processes should bedesigned and utilized to provide information onthe adequacy of work controls, to identify andimplement opportunities for improving thedefinition and planning of work, and to utilizeline and independent oversight processes toprovide information on the status of safety. Linemanagement is directly responsible forestablishing and implementing feedback andimprovement programs and processes tofacilitate a culture that promotes ongoingexamination and learning, while connecting thepractical experiences of work that has beenconducted to the planning for future work. Thefeedback and improvement function is intendedto identify and correct processes or deviationsthat lead to unsafe or undesired work outcomes,confirm that the desired work outcomes wereobtained safely, and provide managers andworkers with information to improve thequality and safety of subsequent, similar work.

In evaluating how DOE, WSRC, and BSRI hadanalyzed performance information as part oflessons-learned, feedback, and improvement,the Board reviewed previous accidentinvestigation reports, the feedback provided byDOE and WSRC assessments, GradeSouthincident reports that were generated during theproject, and site Occurrence Reporting andProcessing System (ORPS) reports.

3.5.1 Daily Safety MeetingsInformation collected during this investigationsuggests that the STR for the Pond B DamUpgrade Project routinely provided GradeSouthsupervision with information to be shared withcraft personnel during daily tailgate safety andplan-of-the-day meetings on the project. Copiesof safety topics collected and cataloged atGradeSouth’s work trailer at the job siteindicated that a wide variety of topics were

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discussed, including heavy equipment safety,heat and cold stress, and biological hazards.

3.5.2 Feedback from DOE, WSRC,and BSRI AssessementsAs discussed in Section 3.4.2 of this report, theWSRC Facility Evaluation Board completed aFocused Integrated Safety ManagementEvaluation of Subcontractor Safety, in April2001. This review identified two core issues: 1)the mechanism for the identifying WSRCrequirements tailored to a specific task for A, Band C categories of work was not clearly anduniformly understood by all stakeholders, and2) conflicting requirements were identified in anumber of WSRC manuals, resulting inadditional requirements over and abovecontractual requirements being imposed.

In April 2002, a Type B accident investigationwas conducted following a worker’s fall from ashoring/scaffolding structure at the SRS TritiumExtraction Facility construction site. While theType B Investigation Board did not identifyJudgments of Need associated with this accident,Areas for Improvement were referred to theAppointing Official. In the referral, the Boardstated: “During the course of this investigation,the Board noted some areas for improvement.These areas were determined not to have acausal relationship to this accident, but mightplay a role in potential future events. Thesematters were noted in the report and werereferred to the Appointing Official forconsideration.” Two of the referred areas forimprovement were applicable to the accidentat the Pond B Dam Upgrade Project, and arepresented below:

“Training requirements similar to those in thescaffolding and fall protection standards applyto workers such as powered industrial truckoperators, crane operators, and electricians. Lackof appropriate training could be a factor in avariety of potential future accident scenarios,”

and“Since there could be circumstances in thefuture where an inadequate JHA [Job HazardAnalysis] process could fail to identify a lessobvious hazard or where a unique controlstrategy could be beneficial, these observationsabout Bell’s JHA process were referred to theappointing official for appropriate follow-upwith BSRI and Bell.”

While Judgments of Need were not identifiedfor the April 2002 accident investigation, thatreport clearly indicated “areas for improvement”requiring consideration by DOE and WSRCrelated to possible future accident scenarios.Those areas for improvement were forwardedto DOE for consideration; the Board found noevidence that DOE or WSRC took specificactions to address the identified constructionsafety deficiencies.

In January 2004, WSRC completed a Phase I andII reverification of the WSRC integrated safetymanagement program. The report concludedthat ISMS was implemented at SRS butidentified opportunities for improvementrelated to the AHA process contained in WSRCManual 8Q, Procedure 120. The WSRC reportnoted that the level of detail provided in AHAsvaried and indicated that additional training andmentoring was necessary to ensure furtherimprovement in the AHA process.

During January and February 2004, DOEHeadquarters Office of Independent Oversightand Performance Assurance (OA) conducted aninspection of environment, safety and healthmanagement and emergency management atSRS. OA’s Summary Report stated, in part, thatsafety controls were not always effectivelycommunicated to the workers and effectivelyimplemented by the workforce, and that WSRChad not established adequate mechanisms toensure that controls identified in the AHA wereimplemented and effectively integrated intowork activities. The report also noted thatconstruction and subcontractor personnel were

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not always rigorously and consistentlyimplementing construction safety requirements,resulting in potentially unsafe conditions andpractices.

While a corrective action plan was developedand submitted for the OA ES&H inspection sixmonths after the inspection was completed,there was no evidence to indicate that DOE,WSRC, or BSRI took compensatory action toassess or evaluate the construction safety issuesthat were identified by the OA team.

In February 2004, during drilling of well pointsat the Pond B Dam, a GradeSouth operatorblacked out and rotated the equipment boomwhile the auger was still in the hole, resultingin minor damage to the auger. An investigationwas conducted by BSRI personnel; however, nocausal factors and corrective actions wereidentified.

In March 2004, the WSRC Facility EvaluationBoard Project Review Team conducted aperformance-based evaluation of the Pond BDam Upgrade Project and identified theassessment area of environment, safety andhealth as “Below Average.” The report notedthat improvements were needed in the controland conduct of activities within the prescribedcontract and permit conditions, and that safetywalkdowns performed at the site were notsufficiently thorough to identify and correctunsafe conditions.

In April 2004, during dust control activities, adump truck rolled onto its side when the operatorwas backing the vehicle, and one of the rear tiresbacked onto a slight incline. The water tankshifted, causing the truck to roll onto its side. Anoccurrence report was generated, and thesubsequent investigation indicated weaknesses intwo ISM Core Functions: analyzing the hazardsand developing and implementing hazard controls.Corrective actions were developed to address theincident, but did not include supplier/vendor-owned equipment.

DOE, WSRC, and BSRI managers were providedwith information from a variety of sources overa number of years to indicate there wereprogrammatic deficiencies in thecommunication and implementation of safetyrequirements for subcontracted constructionwork across the Savannah River Site.

The Board concludes that effective recurrencecontrols for identified deficiencies were notestablished.

3.5.3 Operational OccurrencesThe Board also reviewed recent constructionrelated occurrences in ORPS at SRS to determinewhether precursor events had occurred beforethe accident on July 26, 2004. As a result of thisreview, the Board identified similar underlyingcauses for the incidents, which are summarizedin Appendix B. Many of the corrective actionswere to stand down, change, or clarifyprocedures and to retrain the workers. TheBoard determined there were a number ofcommon causes for these occurrences, as wellas the ineffective corrective action processes:

– Workers failed to recognize hazardousconditions in their assigned work areas;

– Workers were unaware of other personnelin the work surroundings;

– Although job conditions changed, stop-work authority was not utilized, nor wasthe efficacy of reanalyzing the hazards orcontrols considered;

– There was an over-reliance on the skill ofthe craft assigned to accomplish the task;and

– There was inattention to detail by operators,or operators were less experienced and/oruntrained in the work they were assignedto accomplish.

The Board concludes that WSRC failed to fullyaddress the causal factors for the occurrencesthrough the corrective action processes in placeat the site.

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3.6 Personnel Training andQualifications

3.6.1 Equipment OperatorsSubpart C, General Safety and HealthProvisions, to the OSHA Safety and HealthRegulations for Construction, 29 CFR1926.20(b)(4) states: “The employer shall permitonly those employees qualified by training orexperience to operate equipment andmachinery.” The SRS Davis-Bacon Construc-tion Subcontractor Safety and HealthInformation Handout (part of the pre-bidpackage for the Pond B Dam Upgrade Project)states: “Heavy equipment operators shall bequalified and knowledgeable with theequipment being operated according to themanufacturer’s guidelines and warnings foundin the operating manual.” The Mobilizationsection of the TSP submitted by GradeSouth forthe Pond B Dam Upgrade Project states:“Operators and employees shall be trained,qualified and fit for duty.” GradeSouth does nothave a formal or documented process forverifying that employees are trained andqualified. These decisions are made bysupervision based on the firsthand knowledgeof the individual’s ability and/or a review ofprevious training, experience, or possession ofthe journeyman card in the applicable craft area.

At a union construction site such as the Pond BDam Upgrade Project, operating engineers arethe craft that are trained and qualified to operateheavy equipment. A review of the Local 470operating engineer training program indicatesthat it provides both classroom and hands-ontraining related to heavy equipment operation,including excavator operation. When METRACdelivered the excavator to the job site, it wasoffloaded by one of the GradeSouth operatingengineers, not the METRAC truck driver. Theoperating engineer operated the equipment toperform the required work at the job site. Hehas been an operating engineer since 1977 and

has significant experience with heavyequipment operation.

The individual that loaded the excavator on thelowboy trailer the day of the accident is ateamster and not an operating engineer.Teamsters do not receive formal training inheavy equipment operation. Although he hadprevious experience operating similarequipment at another jobsite for GradeSouth,he did not have any experience operating thelong-boom excavator that was involved in theaccident. There was an operating engineer atPond B at the time the excavator was beingloaded, but he was operating another piece ofequipment at the job site. The foreman for thePond B Dam Upgrade Project at the time of theaccident stated that he assigned the teamster tomeet and escort the Guthrie driver to the jobsite but that they did not specifically assign himto load the equipment.

The Board concludes that GradeSouth failed toensure that heavy equipment operations wereconducted by qualified operators.

3.6.2 Safety Personneland Subcontract TechnicalRepresentativesBSRI Construction Management ProcedureCMP 04-01.01 establishes the qualificationrequirements for STRs. The procedure requirescandidates to have a minimum of six educationand experience credits before consideration asa potential STR. Guidance is included in theprocedure for determining the applicability ofeducation and experience and how that equatesto credits or partial credits. Potential STRcandidates must also complete a structured anddocumented interview with the ConstructionSubcontracts Manager (CSM) or designee tochallenge the candidate’s technical andadministrative procedure knowledge level. TheCSM also reviews the candidate’s previoustraining and required reading requirements anddetermines if it was adequate. When all of these

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requirements are complete, the CSM approvesa letter of qualification for the candidate.

There were three STRs assigned to the Pond BDam Upgrade Project over the duration of theproject. A review of the training andqualification records of the three STRs indicatesthat they each had over 20 years of relevantexperience and that they met the STRqualification requirements stated in CMP04-01.01.

A review of the training and qualificationrecords for the two people assigned as safetyengineers to the Pond B Dam Upgrade Projectindicates that they both possess adequatetraining and experience for that position.

3.6.3 Truck DriverThe driver of the Guthrie tractor and lowboytrailer did have a commercial driver’s licensethat covered driving a tractor and trailer of thesize involved in the accident. Guthriemanagement personnel stated that driving thelowboy was his primary responsibility and thathe was not trained or utilized by them as anequipment operator. They also stated thatalthough he may have loaded smaller equipmenton trailers in the past (e.g., backhoes and smalldozers), he was not qualified and never loadeda piece of equipment the size of the excavatoron the lowboy trailer.

3.7 Change and BarrierAnalyses

Change analysis examines changes planned orunplanned that cause undesirable results relatedto the accident. This process analyzes thedifference between what is normal, or expected,and what actually occurred before the accident.The results of the change analysis conducted forthe accident at Pond B Dam were integrated intothe events and causal factors chart to support thedevelopment of causal factors. Appendix Dcontains the change analysis.

A barrier analysis was also conducted to identifybarriers associated with the accident. This analysisaddressed physical systems and managementsystems in place to isolate and avoid the hazards.The results of the barrier analysis validated theresults in the change analysis. The results of thebarrier analysis is not included in the report.

3.8 Causal Factors Analysis

The Board performed a causal factors analysisin accordance with the DOE Workbook,Conducting Accident Investigations. Causalfactors are events or conditions that producedor contributed to the occurrence of the accidentand consist of direct, root, and contributingcauses.

A direct cause is the immediate event orcondition that caused the incident. The Boardconcludes that a direct cause of the accident wasthe excavator falling onto the driver.

The root causes of the accident are thefundamental causes that, if corrected, wouldprevent reoccurrence of this and similaraccidents. The Board has also identifiedcontributing causes. Contributing causes areevents or conditions that, collectively with theother causes, increase the likelihood of theaccident but individually did not cause theaccident. The causal factors are identified inTable 3-1.

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Table 3-1. Causal Factors Analysis

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Table 3-1. Causal Factors Analysis (continued)

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4.0 Judgments of Need

Conclusions are synopsis of those facts andanalytical results that the Board considersespecially significant. Judgments of Need aremanagerial controls and safety measuresnecessary to prevent or minimize the probability

or severity of a recurrence. They flow from theconclusions and are directed at guidingmanagers to developing corrective measures.Table 4-1 summarizes the Board’s conclusionsand Judgments of Need.

Table 4-1. Conclusions and Judgments of Need

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

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5.0 Board Signatures

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6.0 Board Members, Advisors, and Staff

Board MembersBoard MembersBoard MembersBoard MembersBoard Members

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

Member Patrice M. Bubar, DOE Office of EnvironmentalManagement

Member Ralph A. Fevig, DOE Sandia Site Office

Member Michael J. Thomas, DOE Office of River Protection

AdvisorsAdvisorsAdvisorsAdvisorsAdvisors

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

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

Advisor Amy B. Poston, DOE SRS

Advisor Mark A. Smith, DOE SRS

ConsultantsConsultantsConsultantsConsultantsConsultants

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.

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Technical and Administrative SupportTechnical and Administrative SupportTechnical and Administrative SupportTechnical and Administrative SupportTechnical 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.

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Appendix A — Appointment ofType A Accident Investigation Board

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A–3

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Appendix B — Analysis of PreviousSavannah River Near-Miss and

Industrial Operations Occurrences

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Tabl

e B

-1. A

ppen

dix

B —

Ana

lysi

s of

Pre

viou

sSa

vann

ah R

iver

Nea

r-Mis

s an

dIn

dust

rial O

pera

tions

Occ

urre

nces

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C–1

Appendix C — Change Analysis

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C–3

Tabl

e C-

1. C

hang

e An

alys

is

C–4

Tabl

e C-

1. C

hang

e An

alys

is (c

ontin

ued)

C–5

Tabl

e C-

1. C

hang

e An

alys

is (c

ontin

ued)

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D–1

Appendix D — Events and Causal Factors Analysis

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D–3

Figure D-1. Events and Causal Factors Chart

A

G

B

C

D

E

No effective lessons learned program

Contract documents are confusing

GradeSouth did not implement contract safety requirements

BSRI requirements were not in the WPP

GradeSouth did not implement ISMS

BSRI construction work planning documents are confusing

K GradeSouth did not implement safety controls

L Teamster was not qualified to operate the excavator

M

N

Strong stop work authority not in GradeSouth WPP

Stop work authority not used

F WSRC and BSRI failed to oversee O

P

Q

Hydraulic leak present

Driver working on or near the elevated excavator – OSHA violation

No accurate description of the accident is provided

R EMS did not precisely follow the SRS protocols for trauma transport

J Grade South did not exercise control of its workers

H BSRI did not provide thorough oversight of GradeSouth

I GradeSouth does not meet contract requirements

D–4

Figure D-1. Events and Causal Factors Chart

Requisition preparer signs subcontract safety checklist

7/23/03

Category C work classification is

assigned 7/30/03

Identifies operation of

heavy moving equipment as

hazardous work

A Request for Proposal is issued

08/15/03

Work does not require

subcontractor and site

personnel to jointly work

Work is isolated; remote location

Contains ISMS tenets

of DEAR 970.5223-1

FEB issues ISMS Evaluation Report of Subcontractor Safety

05/08/01

Three ISMS issues

identified

Hazard identified in TSP but not

in WPP

OSHA

requirements only

BSRI conducts pre-bid meeting

Construction subcontract

ES&H information presented

Qualified

operator is required

A

B

B

I

A

D–5

Figure D-1. Events and Causal Factors Chart

WSRC conducts ISMS Phase I/II reverification

01/13/04

Finding indicates details in

AHA varied

DOE-SR self assessment of ISMS conducted

01/15/04

Additional oversight of

the AHA should be

considered

BSRI prepares construction execution plan

01/26/04

Requires a

AHA

OA issues report on ESH Management

02/04

Identifies safety controls to work

instructions, construction, and

AHA issues

A A G A

B C

D–6

Figure D-1. Events and Causal Factors Chart

Certification of mechanical completion

06/23/04

30 items identified

on punchlist

Dirt work

required in punchlist

BSRI conducts general plant weekly safety

assessment 05/13/04

Issues identified, not wearing hard hat, defective

choker

Long boom

excavator required

Grade South receives excavator from Metrac

07/15/04

Corrective actions from dump truck AI were not

effective

No equipment declaration

form submitted

Grade South operator engineer off loads

excavator 07/15/04

No task analysis

performed

Metrac driver informs operating engineer of leak

07/15/04

Operating engineer had

several hydraulic fittings

tightened 07/19/04

A

A

I

E

D E

D–7

Figure D-1. Events and Causal Factors Chart

Driver tells teamster to swing to side & boom up to lift driver’s side track so misaligned outrigger board can

be repositioned

Teamster rotates boom & raises track, full visual

contact with driver.

Equipment in improper position to lift track

Improper use of

equipment, OSHA 1926

Driver asks teamster to raise track higher. Visual and

verbal contact with driver. Driver’s side board

becomes misaligned

Teamster does not

backoff the trailer to

reattempt

Teamster loses visual contact with driver while repositioning

plank

Unsafe act on driver’s

behalf

J

L

L

N

L

J

M

P

N

J

N

G H

N

M

D–8

Figure D-1. Events and Causal Factors Chart

Teamster locks down hydraulic controls in the excavator cab

Teamster drives pickup across dam to

GradeSouth Office/trailer to get assistance

Teamster notifies foreman and superintendent and

another teamster that driver is injured

No site radio

present, Remote worker

Teamster does not look at driver

0.4 miles from scene

to office trailer

Superintendent, foreman and both teamsters go

back to accident scene in pickup trucks

Superintendent calls GradeSouth safety officer located in H-Area

office by cell phone to call SRSOC for emergency response

Site radios in

GradeSouth trailer

GradeSouth notices

driver is not pinned

Dunnage placed under

excavator

GradeSouth had not

reported in as remote workers

C

Q

Q

C

I J

D–9

Figure D-1. Events and Causal Factors Chart

Critical assessment of driver is made. Injuries to leg

and pelvis

Grade South Safety Officer calls SRSOC

3:27 pm 07/26/04

SRSOC dispatches Engine 3

3:28 pm 07/26/04

Unit 91 arrives at scene 3:40 pm 07/26/04

Squad 3/Medic 3 arrive at scene

3:40 pm 07/26/04

Medic 3 departs scene for MCG Trauma Center

3:55 pm 07/26/04

Medic 3 does not request

MEDEVAC helicopter

Q

Q R

J K

Medic 3 picks up additional medic in route

at F-Area

Medic 3 arrives at MCG 4:40 pm 07/26/04

MCG reports time of death 6:18 pm 07/26/04

Additional medic is

needed to assist with

injured

K L

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