How NOT to Perform a First Time, High Risk Evolution

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How NOT to Perform a First Time, High Risk Evolution

Brian Anderson, DOE-Idaho

Nuclear and Safety Performance Division

September 13, 2011

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Biographical Information – Brian S. Anderson• Employer: U.S. Department of Energy / Idaho Operations Office • Position: Team Leader, Safety Performance Team• Education: BS / Electrical Engineering, U. S. Naval Academy – 1977• Experience:

– 33 Yrs. Nuclear Operations (Submarines, Reactors, Nuclear Facility Operations)– Quality Assurance, ES&H, Construction, Maintenance, Training …– ORR, RA, Accident Investigation, ISMS Verification - Team Lead or member

• Certifications:– ANSI/ASME NQA-1 Lead Auditor – 1985, 2009– U. S. Navy Nuclear Program, Qualified Submarine Officer

& Nuclear Engineer 1982 & 1984– DOE TQP – Senior Technical Safety Manager - 1999

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What Happened …

• On October 4, 2010 at 0930 hours, workers were up-righting a 7,800 lb. shield door, 104 in. high × 52 in. wide × 30 in. deep

• Using a hydraulic telescoping gantry system (HTGS) to support and raise the door into a vertical position

• The load shifted causing the door and HTGS to tip • The HTGS’s fall was arrested as the top of the HTGS

contacted pipe supports attached to a structural steel I-beam• The shield door came to rest against the pipe supports at about

a 15-degree angle from vertical• Three workers were in close proximity, none were injured• Immediate actions taken to isolated and preserve the scene

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How it Happened … Work Planning

• Work package CWCP # 100145, Install the Concrete Filled Shield Plugs in the 4 Pack (WP), was planned in February 2010

• Engineering did not identify the applicable hoisting and rigging standard for this type of a lifting device (DOE-STD-1090) * … but considered a construction aid• Default determination can be performed as “Skill-of-the-Craft”

• However, WP Step 200 is a hold point which requires an engineered lift plan be developed for each door

• WP Job Hazard Analysis (JHA) and Job Safety Analysis (JSA) did not identify and mitigate hazards *

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How it Happened … Work Planning (Cont’)

• URS procurement rented the HTGS and requested certifications for the HTGS … – but did not request an operation/maintenance manual– which was not available during CWCP development

• Work package planner did not specify a formal pre-job briefing in the CWCP *

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How it Happened … Worker Training• HTGS considered a construction aid, so no training was

required * or provided *– "Identify equipment requiring technical expertise for producing

acceptable results or precautions for avoiding injury" – "Personnel performing work that requires special skills or abilities shall

be qualified and certified prior to performing work.“

• Supervisory and Safety Support staff unfamiliar with HTGS– Superintendents– Field supervisors– General Foremen & Foremen, – Safety personnel, and – Work Package planners

• Workers reverted to “Skill of the Craft”

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• A formal process for releasing work to the field is not in place• IWTU work is coordinated using

– a plan of the week meeting– a prioritized work list, and – daily meetings where work being done that day is discussed

• Both ironworker and millwright superintendents not at work• At the daily meeting, no oversight of the HTGS activity was

specified (complex equipment and first-time use) *• Construction manager/superintendent and general foreman /

foreman did not review the work packages daily *

How it Happened … Work Control

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• Work activity pre-job brief was LTA • Construction Engineer / General Foreman / Foreman conducts *• with all stakeholders (users, craft, supervisors, & support staff) *• to review every part of the work package *• to ensure a thorough understanding of the job *

• WP not checked out for use at the work site *• and not reviewed by personnel at Pre-job briefing*• and not used to control the work

• resulting in a missed hold point - rigging engineer prepare lift plan *

How it Happened … Work Control (Cont’)

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• Emphasis on schedule exceeded emphasis on methods – Schedule pressure lead to “Get it Done” mindset

• Supervision oversight was less than adequate – Superintendent not familiar with use of the HTGS– Foremen and supervisors not familiar with use of the HTGS– Safety personnel not familiar with use of the HTGS

• Improvement in using work documents in the field as a result of corrective actions taken in May of 2010

• OE at IWTU has shown an increased potential for errors for first time evolution/equipment use, Cranes & “Skill-of-the-Craft”– April 2008 dropped Crane Jib boom– April 2009 dropped butt section of the crane boom

How it Happened … Management & Oversight

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• Task execution errors in …– Use of WP to control work *– No lift plan *– Cross bar leveling, – Free travel of the towers, – Centering load on the cross bar between the towers, and – Use of the Hilman rollers.

• Failure to “Step back” when questions arose *• Ironworker Foreman not familiar with WP use• Posted operating instructions on the HTGS were not used or

followed:– NOTE statement directs the operator to ensure the gantry is free to

center itself over the load during the lift

How it Happened … Task Execution

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Lift Execution

• The HTGS was received, assembled and functionally checked using “Skill-of-the-Craft”

• The specification sheet provided by the equipment owner was available and used

• Two Hillman rollers were set under the opposite end of the door to allow the bottom of the door to roll as needed

• Millwright foreman conducted a pre-job brief w/millwrights and iron workers even though ironworkers performed lift– did not identify the hazards or training & operating requirements

• The iron workers decided to chock the wheels using wood wedges, ½-in. plywood & small metal plates

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Gantry TruckShield Door

HilmanBlock

Sling

Cross Beam

Chocked Wheels

Side View of Initial SetupDiagram 2

N

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• Attached a come-a-long from bottom of door to building structural column to control door movement

• Stationed workers to operate come-a-long and adjust rollers

Lift Execution (Cont’)

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Shield DoorSlings

Gantry Truck

Gantry Truck

Cross Beam

Hilm

anRol

lers

Top View of Initial SetupDiagram 1

N

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Initial Configuration

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Hillman Rollers

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Gantry Truck Come-a-longTail line

HilmanChocked Wheels

Side View ½ Way Through LiftDiagram 3

Slings

N

Cross Beam

Tele

scop

ing

Sec

tions

of

Tow

er

• Stop periodically to tap the east Hillman roller into alignment• Observer gave the door end a push to be sure it was moving• Visually determined if the cross beam on the HTGS was level*• Stopped the lift few times to re-level the HTGS cross beam

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Lift Execution (Cont’)

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Cross Beam

Top Section of Telescopic Jack

Slings

Gantry Truck

Chocked WheelsChocked Wheels

Hilman Rollers

Come-a-long Tail line

Side View Just Before IncidentDiagram 4

N

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Lift Execution (Cont’)

• When the door reached vertical, the center of gravity of the door shifted South away from the line between the Hillman rollers and the slings to the center of the door

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Lift Execution (Cont’)

Shield Door

Gantry Truck

Gantry Truck

Cross Beam

Hilm

an

Rol

lers

Diagram 5Top View of Setup Just Before Incident

Tail Line

Come a long Operator

HTGSOperator

N

3rd Iron worker

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The Event …

• As the door reached vertical, it rocked through the HTGS uprights (towers) and slightly to the South

• At the same time the East Hillman roller appeared to stop• HTGS moved 1 to 2 ft to the South and East, tipping and

contacting the structural steel I-beam• Door stopped by Unistrut supporting conduit and cables• The iron worker operating the HTGS retreated to the West

• The iron worker operating the come-a-long on the South noticed the tipping and pushed the 3rd iron worker, by the South end of the shield door, to the West and followed him out of the way

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Suggested Actions for LL Program Improvement – Complex-wide

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Corrective Actions

33 Corrective Actions Developed

Examples:• Changed work control• Trained on equipment and validate training• Supervision present for first time events• O&M manual present for all lifting equipment• Retrain crafts on need for CWCP in field

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What Do You Think… ?

• Could this happen at your site?

• How does work as performed compare with work as imagined?

• What should have been done to prevent this?

• Agree with Causal Analysis?

• Corrective Actions appropriate?

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Preventing an Accident is the best thing you’ll never realize you did

• It’s better to Prepare and Prevent than to Repair and Repent• If we do this right, there may be dozens of accidents that were

prevented• We’ll never really know what they were, because they didn’t

happen• It doesn’t happen by “Accident”

– A questioning attitude needs cultivated– Organizational learning must be embraced– Safety must undergo constant examination

• Examine :Work as Performed” vs. “Work as Imagined”• Start “ Preventing Accidents”