EH-9307 July 1993 Occupational Safety Observer
JULY 1993
Occupational Safety Observer
The Occupational Safety Observer
a publication of the
Office of Environment,
Safety and Health
Joseph E. Fitzgerald, Jr.
Deputy Assistant Secretary
Editor-in-Chief
Rebecca Hansen
Coordinating Editor
Tom Kyriakakis
Editorial Board
Oliver D. T. Lynch, Jr.
Michael E. Wangler
Richard M. Tuggle
Jeffery Finch
Charles G. Bruch
John Stone
The descriptions of the incidents included in this compendium are based on
information available at the time of publication. Articles regarding
DOE incidents are drawn from Occurrence Reporting and Processing System
(ORPS) reports, accident investigation reports, and interviews with site
personnel.
DOE 5483.1A, dated June 1983, requires DOE compliance with the OSHA
regulations listed.
If you would like more information about an article, or would like to
submit an article, please contact the Coordinating Editor at:
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(EH-32.1)
U.S. Department of Energy
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Occupational Safety OBSERVER Page 2
Rental Equipment
Manlift Basket Malfunction
Workers must know more about their equipment than just how to
manipulate the controls. They must also be knowledgeable about the
equipment's capabilities and limitations. The following incident can be
attributed, at least in part, to insufficient operator training on rented
equipment. Fortunately, no one was injured during this incident; however,
the potential for serious injury or death was present.
The incident
On April 2, 1993, two workers at the Weldon Springs Site Remedial
Action Project were using a rented manlift to remove asbestos from a
building scheduled for demolition. The workers had received training on
the equipment from the project management contractor and were certified as
operators. Both workers were wearing appropriate personal protective
equipment, including safety harnesses.
The workers were removing asbestos near the building's roof line,
approximately 20 feet above ground level. During this process, the
workers found that they could not maneuver the manlift basket to reach a
particular area because the roof extension blocked the manlift boom. They
were able, however, to maneuver the basket closer by tilting it forward
using the manlift's hydraulic leveling mechanism. When they attempted to
stop the basket at a tilt angle of approximately 45 degrees, the workers
found that the basket no longer responded to the controls. The basket
continued to tilt forward, eventually stopping in a nearly horizontal
position. At this point, unable to return the basket to level, the
workers called for help.
Coworkers on the ground raised a ladder against the building and
positioned it next to the basket. The first worker exited the basket onto
the ladder and climbed down without further incident. When the second
worker prepared to exit, however, the basket unexpectedly tilted sharply
sideways. The second worker was jolted but managed to remain inside the
basket. He was able to exit the basket successfully and climb down. The
manlift was then lowered using a remote control and was removed from
service.
Results of the investigation
The direct cause of this incident was human error in that the two
workers were operating the equipment beyond its design capacity. The
manlift involved in the incident, a Grove model AMZ 50 XT, comes equipped
with a closed-loop hydraulic leveling system designed to keep the basket
approximately level during boom movement. The adjustment control in the
basket is designed to allow minor level corrections by occupants: it is
not intended as a mechanism to extend the occupant's reach. This fact is
not specifically stated in the manlift operator's manual.
When the workers used the hydraulic tilt control to position the
basket at an extreme angle, the manlift's hydraulic holding valve was
overloaded. The excessive tilt rendered the leveling system inoperative
and caused the basket to continue forward.
Occupational Safety OBSERVER Page 3
The sudden movement that occurred when the second worker attempted to
exit the basket resulted from an accidental disengagement of the locking
handle on the mechanical rotation system. The mechanical rotation system
operates independently of the hydraulic leveling system and allows workers
to rotate the basket and lock it into position. A Grove representative
speculated that the second movement may have occurred either because of
the sharp angle of the basket or because the handle that locks the basket
was bumped during the incident.
Lessons learned
OSHA 1910.67(c)(2)(ii) states that "only trained persons shall
operate an aerial lift." The most significant lesson learned from this
incident is that such training must cover more than just the mechanics of
operation. To be properly trained, operators must also know the
capabilities and limitations of their equipment. Management should be
particularly attentive to operator training and certification whenever
rented equipment is used, as there is an increased likelihood that
extensive training may not be conducted. It is also worth noting
that characteristics of similar equipment can vary from manufacturer to
manufacturer, as well as among models of equipment produced by the same
manufacturer.
Reference
ORPS #ORO--MK-WSSRAP-1993-0011
Four in 10 Days
Excavation Incidents Continue
The March 1993 Observer discussed excavation hazards at DOE sites.
This article reiterates the importance of being careful while conducting
excavation activities by focusing on a series of four recent excavation
incidents that occurred during a single 10-day period.
The incidents
All four of these incidents involved backhoes or trackhoes:
o March 22, 1993 -- an 8-inch sanitary sewer line was damaged by a
trackhoe.
o March 25, 1993 -- a backhoe broke a 230-volt electric power
line.
o March 26, 1993 -- an effluent pipeline was ruptured by a
backhoe.
o March 31, 1993 -- an underground electrical line was severed by
a trackhoe.
Occupational Safety OBSERVER Page 4
Although only one of these incidents can be traced to an apparent
violation of excavation requirements, all are linked by a common cause --
carelessness.
The first incident was caused by a trackhoe operator violating
excavating requirements. While excavating beneath a partially uncovered
sewer line, the operator maneuvered the trackhoe bucket in a manner that
exerted upward pressure on the pipe, causing it to rupture.
In the second incident, contractors were excavating buried power
lines when the front tire of the backhoe slipped into the excavation hole,
severing the power line. The direct cause of the incident was failure of
the backhoe operator to ensure an adequate margin of safety.
In the third incident, a subcontractor working near an effluent
pipeline was digging by hand, as required by the excavation permit,
because of the proximity of the pipeline. The subcontractor then used a
backhoe to remove debris, however, and damaged the pipe. Again, the
direct cause of the incident was lack of attention.
In the fourth incident, the location of an underground line had been
marked with florescent orange paint. The equipment operator had been
briefed on the location and energized status of the underground electrical
line, and he was directed to restrict mechanical excavation to areas at
least 3 feet away from the line. As he worked toward the line, he
apparently forgot where the line was buried. Stakes or flags had not been
used to call his attention to the location of the line.
Lessons learned
The clearest lesson that emerged from this string of incidents is
that careful attention is crucial when performing excavation work.
Workers must ensure an adequate margin of safety.
It is also essential to be aware of the location of hidden lines and
other buried hazards, and to maintain safety limits that are designed to
prevent accidental damage or injury. OSHA regulations (29 CFR 1926.651)
require that underground installations (such as sewer or electric lines)
be identified before excavation. These regulations further require that
when excavation activity nears the estimated location of underground
installations, the exact location of these hidden hazards must be
determined by safe, acceptable, and effective means. Specific
guidelines for performing safe excavation operations include the
following:
o Review excavation procedures to ensure that techniques for
dealing with known potential hazards are understood.
o When working in close proximity to fixed objects, use a second
person to guide the equipment operator if depth perception is
limited from the operator's position.
o Use drawings and electronic sensors, when appropriate, to locate
hidden hazards.
Occupational Safety OBSERVER Page 5
o When drawings don't seem to match as-built conditions, take the
time to submit a request for a review of the drawings and the
site.
References
March 22 incident: ORPS #ORO--MKFO-K25CENTENG-1993-0001
March 25 incident: ORPS #RL--WHC-WHC200EM-1993-0014
March 29 incident: ORPS #ORO--MK-WSSRAP-1993-0010
April 1 incident: ORPS #ALO--GEO-GJO-1993-0002
Good Practices
Fall Protection for Ironworkers
After two construction workers fell to their deaths at the new Denver
International Airport, the staff of OSHA's Region VIII established
rigorous fall protection requirements. These requirements affected the
DOE's National Renewable Energy Laboratory. Fortunately, one construction
contractor at the National Renewable Energy Laboratory has been involved
in the development of a fall protection system that both meets Region
VIII's tough standards and is welcomed by workers.
Two systems
The potential for falls has always existed in the construction
industry. Some of this risk can be attributed to the nature of the work
itself; however, many personnel work without benefit of protective systems
that might greatly reduce this danger. Ironworkers, in particular,
frequently walk along beams suspended high above ground. Their sense of
balance is often their only protection. Approximately 50 ironworkers fall
to their deaths each year. Ironworkers have been exempted from OSHA fall
protection standards because there are few stable structures to which they
can safely secure themselves and because safety harnesses and lifelines
tend to interfere with their work. Lifelines can in fact be hazards --
lifelines can trip workers or be caught by moving equipment.
The latest fall protection systems may change all this. LPR
Construction, which is performing the steel erection work at the National
Renewable Energy Laboratory, has helped to develop a system that protects
ironworkers from falls without interfering with their work. This system
complies with DOE Orders and meets OSHA's strict fall protection
requirements. The system, known as the SINCO Beam Walker, consists
of two stanchions that clamp to a standard I-beam. A 40-foot line, to
which workers can attach their lifelines, runs between the stanchions.
The Beam Walker is installed while the beam is on the ground. Patents for
this design are pending. A similar product will be offered by another
company, Miller Equipment, within a few months.
Occupational Safety OBSERVER Page 6
DOE's Golden Field Office reports that ironworkers like this type of
system because it protects them without unduly restricting their
movements. It also allows them to dispense with an unpopular safety
precaution -- the uncomfortable, inefficient practice of walking on
the lower flanges of the beams.
Overcoming the culture
Despite the advantages of systems such as the Beam Walker, their
manufacturers could face a hard sell. Similar fall protection systems
have existed for 20 years without gaining widespread acceptance. A
spokesman for Miller Equipment acknowledges that the "macho" culture of
ironworkers may lead them to discount the value of such protective
systems. Nevertheless, the Beam Walker's safety record argues for its
effectiveness: the system has already successfully arrested the falls of
several ironworkers. Also, economic pressure is being brought to bear on
the steel erection industry to operate more safely; for example, there are
strong incentives to reduce workers' compensation claims.
The Beam Walker also anticipates stricter national OSHA standards on
fall protection for ironworkers. Steel erection regulations in 29 CFR
1926 Subpart R concerning fall protection are somewhat ambiguous and have
created confusion in the construction industry. OSHA has recently
announced its intent to establish a negotiated rulemaking committee on
steel erection. One of the primary mandates for this committee is to
address fall protection issues. The rulemaking effort is currently on
hold, however, because of the Clinton Administration's desire to reduce
the number of rulemaking committees.
The Golden Field Office agrees that the time has come to use advanced
fall protection systems. Industry appears to be following suit.
According to a press release from the Golden Field Office, the Beam Walker
and similar systems "are quietly gaining momentum with progressive steel
erectors concerned with protecting their people the best way they can,
100% of the time."
The information in this article does not constitute an endorsement of any
particular brand of product or manufacturer by the U.S. Department of
Energy.
Piper Alpha: Part 2
Inadequate Training and Leadership Hinder Evacuation
Last month, the Observer described how an explosion struck the Piper
Alpha oil platform in the North Sea when explosive hydrocarbons leaked
into work spaces. Primary causes of the initial explosion, as explained
in Part 1, were informal shift turnover and lockout/tagout practices.
This month we look at the way in which the disaster unfolded,
concentrating on the failure of efforts to evacuate the platform.
Although the magnitude of the disaster hindered evacuation efforts, the
lack of leadership and inadequate training also contributed to the death
toll -- many workers were unfamiliar with evacuation procedures,
evacuation routes, or even the layout of the platform, and no one led them
to safety.
Occupational Safety OBSERVER Page 7
This tragedy provides valuable lessons for DOE facilities in the area
of emergency response and evacuation plans.
The disaster unfolds
Because it was 10:00 p.m. when the first explosion struck, most
workers on Piper Alpha were off duty and in the accommodation (living)
area. Although no alarm sounded and no announcements were made over the
public address system, the workers immediately recognized the seriousness
of the situation and realized that Piper Alpha would have to be evacuated.
Approximately 100 men assembled in the galley, where they were advised
that others were searching for a way off the platform. The workers
waited. At first, conditions were not too bad, but the emergency lighting
failed and smoke began to fill the compartment. The men began to panic.
The Offshore Installation Manager (OIM) for Piper Alpha arrived in
the galley but failed to take charge of the situation. The British
government's inquiry revealed a frightening scene. One survivor described
how "people were shouting at the OIM and asking him what was going on and
what procedure to follow. [The survivor] did not know whether the OIM was
in shock or not but he did not seem to be able to come up with an answer."
Another survivor testified that the OIM was standing on a table, "trying
to assume some kind of command. This was virtually impossible due to
panic, commotion, and heckling." The smoke thickened; men crouched low to
avoid it as they waited for rescue or leadership.
There was, unfortunately, no organized evacuation or rescue aboard
the platform. Piper Alpha did radio a distress call just after the first
explosion, but personnel were forced to abandon the radio room almost
immediately thereafter. The distress call did not include a request for
helicopters, the preferred means of evacuating the platform. Even if
helicopters had been requested, they would have been unable to land
because of the smoke and fire. The ships standing by Piper Alpha launched
their rescue craft within minutes of the explosion and began pulling men
from the water, but rescuers were unable to board the platform.
At 10:20 p.m., a second explosion struck the platform and some
workers, acting on their own initiative, decided to leave the galley,
although few had any idea of where to go. The inquiry's report describes
their motives: "Some left the galley because there was no point in
staying there. Others realized that if they did not get out they would
have died there. Others took the view that they had nothing to lose by at
least attempting to save themselves." Yet, many stayed behind.
Fire raged through the platform, fueled by oil stored aboard Piper
Alpha, by oil from the wellhead, and by oil and gas piped from neighboring
platforms. At 10:50 p.m., the third explosion struck and the platform
began to collapse. At 11:18 p.m., a final explosion occurred, perhaps the
largest. The collapse continued. By 12:15 a.m., the north end of
Piper Alpha, where the accommodation area and galley were located, had
fallen into the sea.
Those who stayed behind in the galley or elsewhere on Piper Alpha did
not survive. Of the 61 survivors, all were rescued from the water or from
levels of the platform near the water. Altogether, 167 others died.
Occupational Safety OBSERVER Page 8
Inadequate training
The high death toll aboard Piper Alpha was caused by several factors.
However, it was clear during the inquiry that a lack of training on
emergency procedures contributed significantly to the loss of life.
Occidental Petroleum, which operated Piper Alpha, did have training
policies. When a newcomer arrived aboard the platform, he was required to
receive a safety induction. Since Occidental made extensive use of
contractors and turnover was high, such arrivals occurred frequently.
Newcomers were also provided with a safety handbook. This information
supplemented a generic course administered ashore. In addition,
evacuation drills were to be conducted aboard Piper Alpha on a weekly
basis.
In practice, however, this training was cursory and did not meet the
intent of Occidental's policy. Some contractors had not completed the
course that was given ashore, and the safety induction aboard the platform
was often brief or nonexistent. Moreover, the safety handbook contained
errors. Instead of conducting one evacuation drill per week, Piper
Alpha averaged one drill every 2 weeks. A full-scale emergency drill had
not been held during the 3 years preceding the disaster.
As a consequence, many victims aboard Piper Alpha were ill trained in
those actions that could have saved their lives. Many personnel were not
familiar with the platform beyond the accommodation area and their own
work spaces. They did not know the evacuation routes, the location of
lifeboats, or how to launch or inflate life rafts. Some believed that
they could not survive the 100- to 175-foot plunge from the upper decks of
Piper Alpha into the ocean, although many who were trapped by the fire
made this leap and survived.
Occidental made extensive use of contractors aboard Piper Alpha.
These contractors, who are comparable with DOE subcontractors, came and
went. There was no system in place to ensure that they were properly
trained. In the absence of leadership during the catastrophe, the
unfortunate result was that contractors did not have the knowledge they
needed to save their own lives. The inquiry found that "the abnormally
high casualty rate among those on Piper who, for reasons of their
employment were not fully familiar with the platform layout, was
striking."
Lessons for DOE
The shortcomings on Piper Alpha suggest the need for a two-pronged
approach for ensuring worker safety during emergencies in general and
evacuations in particular: all workers should be trained to deal with
emergencies, and key workers should receive special training that will
enable them to act as leaders during emergencies.
Other Observer articles have emphasized the importance of training.
OSHA requirements repeatedly emphasize the importance of training on
emergency procedures, notably in 29 CFR 1910.119 (Process safety
management of highly hazardous chemicals), 29 CFR 1910.120 (Hazardous
waste operations and emergency response), and 29 CFR 1910.147 (The control
of hazardous energy [lockout/tagout]). Remember that it is not enough
simply to have policies that require training -- Occidental had such
policies. It is crucial that management be aware of the actual training
Occupational Safety OBSERVER Page 9
occurring on site and that managers take action when actual training
practices deviate from required training practices.
It may not be feasible, in the face of high turnover, to provide
thorough training for all employees to deal with every emergency. In
fact, such a comprehensive training program may not even be desirable.
Instead, it may make more sense to ensure that certain key individuals
have comprehensive training and that all others are trained to obey
those individuals during an emergency -- that's where leadership can make
a difference.
Training for all personnel should account for the way people tend to
behave during emergencies. In particular, allowances must be made for the
fact that people do not always make correct decisions during an emergency
-- witness the OIM aboard Piper Alpha. A key method for overcoming this
deficiency in human nature is to establish an emergency response
plan that prescribes the routines that must be followed during an
emergency. Such routines greatly simplify the decision-making process.
Leaders should be trained to assess a situation and to select the course
of action best suited to that situation. The other personnel should be
trained to follow these leaders.
All workers should participate in drills that cover all aspects of
their respective emergency response plan and the plan should be routinely
revised to address any weaknesses that are revealed during the drills.
Such an approach, where leaders are chosen in advance and trained to
follow predetermined courses of action during an emergency, is based on
research into the way people behave during emergencies and is further
reinforced by the hard lessons of the Piper Alpha disaster.
Elevator Repair
Alert Workers Identify Violation
The lessons learned published in the Observer are normally drawn from
unusual or dramatic incidents. It is worth remembering, however, that
valid lessons can also be learned from less spectacular incidents. For
example, consider the following incident, in which workers identified an
unsafe practice before any harm occurred. It serves as an example of
the value of a good "safety culture."
The incident
On April 28, 1993, an offsite repairman arrived to troubleshoot an
elevator located inside a building at Rocky Flats Plant. The repairman
had been dispatched to the site by the elevator company in response to a
routine trouble call. On arrival, the repairman checked in with the
Operations Section and received authorization to perform the necessary
work. The repairman was then assigned a security escort and taken to the
work site.
During the process of troubleshooting the elevator, the repairman
identified what he thought was the source of the problem. He proceeded to
disassemble the elevator control panel and remove a suspect electrical
wiring harness. The repairman acted without notifying the Operations
Section of a change in the scope of the work and without implementing
Occupational Safety OBSERVER Page 10
lockout/tagout procedures required at the site.
Workers passing the elevator noticed that electrical repair work
appeared to be in progress without the required warning notices being
prominently displayed. After confirming this to be the case, the workers
reported the situation to a proper authority and a "stop work" notice was
subsequently issued. When questioned, the repairman said that commercial
practices do not require lockout/tagout warnings as long as the electrical
breaker panel is in sight at all times during the repair operation.
Lessons learned
OSHA regulations addressing electrical work practices and electrical
circuit lockout/tagout (29 CFR 1910.333 and 29 CFR 1910.147, respectively)
are explicit in requiring the locking and tagging of electrical circuits
during repair operations. The repairman's understanding of lockout/tagout
requirements was incorrect.
Management is responsible for ensuring that all subcontractors,
whether permanently or temporarily assigned to the site, comply with
appropriate standards and practices. It cannot automatically be assumed
that the standards and practices of offsite contractors, even those
performing warranty or other work on specialized equipment, are
acceptable. For instances in which offsite contractors are performing
short-term work of this nature, the assignment of a knowledgeable escort
is advised.
Reference
ORPS #RFO--EGGR-NONPUOPS1-1993-0008