Type B Investigation Worker Injury at the Canister Storage Building Construction Site

U.S. Department of Energy
Richland Operations Office

DOE/RL 97-58

Type B Investigation

Worker Injury
at the
Canister Storage Building
Construction Site

June 1997

This report is an independent product of the Type B Accident Investigation Board appointed by Lloyd L. Piper, Acting Manager, Richland Operations Office.

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

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

This report neither determines nor implies liability.

Executive Summary

Introduction

On May 7, 1997, an ironworker suffered a fractured pelvis while performing lifting and rigging activities at the Canister Storage Building (CSB) construction project, Hanford Site. On May 8, 1997, Lloyd Piper, Acting Manager, U.S. Department of Energy (DOE), Richland Operations Office (DOE-RL), formally appointed a Type B Accident Board of Investigation to investigate the accident in accordance with DOE Order 225.1, Accident Investigations. The Board began the investigation on May 8, 1997, completed the investigation on May 27, 1997, and submitted findings to the Acting Manager, DOE-RL, on June 13, 1997.

Accident Description

Under contract to the DOE-RL, Fluor Daniel Hanford (FDH) through its contractor, DE&S Hanford (DESH), was constructing the CSB. DESH used Fluor Daniel Northwest, Inc. (FDNW) to provide construction management and safety oversight services and Mowat Construction Company to construct the CSB.

The CSB will provide interim storage for spent nuclear fuel. The fuel will be stored in a below-grade vault portion of the building in vertical through-the-floor surface tubes. The deck over the vault was complete and construction of the above-grade portions of the building was in progress. This included the placement of several large steel columns. The two columns involved in the accident were 15.85 meters (52 ft.) long and weighed about seven metric tons.

After completing a design change which involved rolling and welding on four of the columns, the ironworkers were moving a column to the deck of the CSB when the accident occurred. This was at approximately 1505 hours on Wednesday, May 7, 1997.

As the column was lifted, it swung out from the crane, and a vertical gusset plate attached to the column knocked some of the supporting dunnage away. The ironworkers then began setting the column down to readjust the rigging.

When the column was being lowered, the end near the crane came to rest on the ground, on the gusset at an angle slightly away from the ironworker. The ironworker entered between the column being lowered and a second, stationary column.

As the far end of the column settled, the column rotated around the point where the gusset contacted the ground. The ironworker felt with his hand the column rotating toward him, but he did not think it would continue to the point where he was in danger. As soon as he realized he was being pinched between the columns, he attempted to free himself. It was too late, and the result was a fractured pelvis. The ironworker foreman and crane operator saw this occur. The ironworker foreman signaled the crane operator who was already taking actions to lift the column. The injured ironworker was taken to Kadlec Medical Center hospital, Richland, Washington, where he was admitted and diagnosed as having a fractured pelvis. He was released on May 12, 1997, to convalesce at home, and should be fully recovered in four to six months.

Root and Contributing Causes

The Board identified three root causes for the accident. Eliminating these would have prevented the serious injury.

Failure to have adequate task safety analysis -- The safety analysis did not address the hazards that led to the accident.
Failure to have adequate personnel training -- The personnel were experienced, but their experience was not reinforced by specific training required by the safety program.
Failure to have adequate oversight -- Contractor inspections and DOE-RL oversight did not identify the hazards that led to the accident.

In addition, seven contributing causes were identified:

The dunnage was not in place when the load was lowered.
An adequate supply of dunnage material was not available at the work site.
The area was too congested.
An insufficient number of workers were involved in rigging the columns.
The rigging was set too far from the ends of the column.
The ironworker did not understand his role as rigger during the pre-job briefing.
The ironworker was not attentive during the pre-job briefing.

Judgements of Need

The Board identified judgements of need for the CSB project and for all Hanford construction projects. These included actions to:

Reevaluate job safety analyses (JSAs) to assure that all hazards are identified;
Reevaluate the JSA approval process to assure all hazards are systematically identified;
Assure that all fixed-price contractors are meeting training and qualification requirements for rigging; and
Reevaluate the safety inspection process to assure that hazards are identified and corrected.

Conclusions

The lessons learned from this accident point to the pressing need to fully and rapidly implement the DOE commitments made in response to DNFSB recommendation 95-2, the Integrated Safety Management Program, and the DOE Enhanced Work Planning program. These initiatives emphasize a disciplined analytical and collaborative approach to work planning, hazards analysis, and hazard control, instead of the focus on fulfilling paper requirements. If DOE is to minimize worker injuries and possible fatalities during the changing mission, then emphasis must be placed on a multi-disciplinary approach to pre-job planning where each step of the work is reviewed for the hazards expected and appropriate control is established.

Table of Contents

Executive Summary
Signature Page
Board Signatures
Acronyms
1.0 Introduction

1.1 Brief Description of the Accident
1.2 The Canister Storage Building Project
1.3 Scope, Purpose, and Methodology of the Investigation

2.0 Facts and Analysis

2.1 Accident Description and Chronology
2.2 Physical Hazards, Controls and Management Systems
2.3 Analyses
2.4 Causal Factors
2.5 Safety Management Template

3.0 Conclusions and Judgements of Need
4.0 Board Members, Advisors, and Staff

Appendix 1 Technical Advisor Reports
Appendix 2 Barrier Analysis
Appendix 3 MORT Analysis
Appendix 4 Event and Causal Factors Analysis
Appendix 5 Reason Analysis
Appendix 6 Safety Management Template
Appendix 7 Appointment Memorandum 40

Photos and Sketches

Photo 1. Aerial Photograph of the Scene Taken 2 Hours Before the Accident
Photo 2. The Column as it Was Rigged, Taken Shortly After the Accident. When lifted, the column had not rotated properly. Note fallen dunnage material
Photo 3. Inadequate Dunnage
Sketch 1. Dunnage Arrangement Prior to Accident
Sketch 2. Rigging Arrangement to Roll Columns
Sketch 3. Rigging Arrangement to Move Column
Sketch 4. Accident Scene Just Prior to the Accident
Sketch 5. Estimated Positions of Columns Prior to the Accident
Sketch 6. Accident Sequence Depiction
Sketch 7. As the column was lowered, it rotated in an arc around the gusset plate

Acronyms

CESH

CSB

DESH

DNFSB

DOE

DOE-RL

FDH

FDNW

HFD

JHA

JSA

MORT

Mowat

Contractor Environment Safety and Health Program

Canister Storage Building

DE&S Hanford

Defense Nuclear Facilities Safety Board

Department of Energy

Department of Energy, Richland Operations Office

Fluor Daniel Hanford

Fluor Daniel Northwest, Inc.

Hanford Fire Department

Job Hazards Analysis

Job Safety Analysis

Management Oversight and Risk Tree

Mowat Construction Company

Type B Investigation

Worker Injury
at the
Canister Storage Building
Construction Site

1.0 Introduction 1.1 Brief Description of the Accident
On May 7, 1997, an ironworker was injured when he was pinched between two large, steel I-beams (columns) during construction of the Hanford Canister Storage Building (CSB). The accident occurred when the ironworker, an ironworker foreman, and a crane operator rigged one of the columns in preparation for placing it on the CSB deck. The workers were lowering the column temporarily to adjust the rigging sling. The column was setting on a protruding gusset on one end and settling on dunnage on the other end when the ironworker stepped between it and another column. The column they were lowering rolled toward the ironworker, pinching his pelvis between the two columns. The load was lifted immediately, but the ironworker's pelvis had been fractured. Because the column rigging accident involved a hospitalization that was expected to exceed five days, the Acting Manager, DOE Richland Operations Office (DOE-RL), directed a Type B accident investigation be conducted. This decision was based on the requirement of DOE Order 225.1, "Accident Investigations," Attachment 2, Section 2.b.(1), which requires a Type B investigation for any accident resulting in hospitalization of one or more employees for more than five days.			On May 7, 1997, an ironworker fractured his pelvis while rigging a structural steel column.
This accident occurred one day after a carpenter on the same project was injured during a fall. The carpenter was protected by his safety harness and lanyard, but was knocked momentarily unconscious when he hit his head during the fall. The carpenter was dismantling some shoring at the time of the accident.			The day before the rigging accident another worker fell and injured his head.
1.2 The Canister Storage Building Project
The Canister Storage Building will be a new facility intended for the interim storage of spent nuclear fuel. The vault structure had been completed and was covered by the deck. Columns were being placed on the deck for construction of the CSB building. Construction was on schedule. Work was being performed one shift per day with little overtime. Under contract to the DOE-RL, Fluor Daniel Hanford (FDH), through their contractor, DE&S Hanford (DESH) was constructing the CSB. DESH used Fluor Daniel Northwest, Inc. (FDNW) to provide construction management and safety oversight services. Mowat Construction Company was under contract to DESH to actually construct the CSB. 1.3 Scope, Purpose, and Methodology of the Investigation The investigation focused on the events leading to the personal injury accident, in order to identify the cause(s). It also evaluated the fall accident to the extent necessary to identify any common causes. In addition, the investigation reviewed the safety programs of Mowat, DESH, FDNW, FDH, and DOE-RL. The Board of Investigation (Board) examined the scene of the rigging personal injury accident and interviewed witnesses to both accidents. It also interviewed the injured employees and cognizant line and safety managers within the several contractors and RL. The Board used the information gathered to analyze the accident and identify root and contributing causes. The Board used Management Oversight and Risk Tree (MORT) analysis and barrier analysis to identify the root and contributing causes, and represented its findings in an event and causal factor analysis. It supplemented these traditional accident investigation tools with a computer-based root cause analysis program called Reason.¹ 2.0 Facts and Analysis 2.1 Accident Description and Chronology The CSB Project is located in the 200 East Area of the Hanford Site. The purpose is to store spent nuclear fuel for later disposal. The fuel will be stored in a below-grade vault portion of the building.			The CSB is a new facility under construction at the Hanford Site.
The construction of the operating deck over the vault was complete. Mowat had begun construction of the above-grade steel superstructure of the building. Workers were beginning to place large steel columns on the deck over the vault. The columns were staged in a laydown area adjacent to the CSB. The columns were 15.85 meters (52 ft.) long and weighed about seven metric tons. Photo 1. Aerial Photograph of the Scene Taken 2 Hours Before the Accident			Construction of the CSB basement was complete. Seven metric ton columns were being placed to construct the superstructure.
On April 16, 1997, a design change (DCN-081) was issued which required that a series of attachments be welded to columns before they were placed on the CSB deck. This work was performed in the laydown area.			A design change required modification of the columns in the laydown area.
The columns were rotated in place to facilitate welding. The columns had been placed on wood dunnage and a crane was used for lifting and rotating. The dunnage was a stack of railroad ties, but 4"x4" and some 2"x4" lumber was used to support the column involved in the accident. Sketch 1. Dunnage Arrangement Prior to Accident			The columns were supported by railroad ties and lumber.
Rotation of the columns was accomplished by installing a sling on chokers that were off center. When the crane lifted the column, the position of the chokers induced the rotation. The column was then lowered onto the dunnage in its rotated position. Sketch 2. Rigging Arrangement to Roll Columns			A crane was used to rotate the columns during welding.
At 0700 hours on the morning of the accident, the entire crew of the construction site met for a daily safety meeting. One topic discussed in the meeting was the fall accident from the previous day. The Mowat safety officer reminded employees that most accidents occur shortly before lunch or shortly before quitting time. After the meeting, three ironworkers and one crane operator went to work welding on the columns. Welding was completed by about 1200 hours before the crew broke for lunch.			On the morning of the accident the crew attended the daily safety meeting.
After lunch, the crew was to lift the columns and lay them on the CSB deck. Later, they would be connected together and lifted upright. Because of the need for properly orienting the columns, the rigging was to be installed to induce rotation. The rotated columns were to be lowered by the rigging onto the dunnage in the laydown yard for a final adjustment, then moved to the CSB deck. Each column would then be in its proper orientation when set on the CSB deck. However, a carpenter pointed out to the ironworkers that there was a camber on the CSB deck, and additional support would be required for the columns when they were lowered onto the deck.			The welding was complete at noon. Columns were to be moved in the afternoon.
To lift and rotate columns the ironworker foreman and the ironworker attached the rigging, then held it while the crane operator tightened the line. This was necessary to assure that the chokers remained in the correct position while the line was tightened. To reach the chokers, both workers had to walk between the column to be moved and an adjacent column. When the rigging was tight, the ironworker and the ironworker foreman moved out from between the columns. Sketch 3. Rigging Arrangement to Move Column The ironworker foreman served as the signalman for the crane operator. The ironworker stood at the east end of the column which was nearest to the crane, but facing away from the crane. The ironworker foreman stood at the west end of the column facing the crane, looking down the length of the column. Sketch 4. Accident Scene Just Prior to the Accident The ironworker foreman communicated with the crane operator using hand signals. The ironworker foreman communicated with the ironworker verbally. While they were about 17 meters (56 ft.) apart, there did not appear to be any communications difficulty between the ironworker and the ironworker foreman.			Riggers had to walk between columns to adjust rigging.
The first column was rotated at about 1400 hours, the rigging was adjusted, the column was lifted from the laydown area, and it was placed on the CSB deck. This operation was conducted by an ironworker, the ironworker foreman, and the crane operator. Rigging activities such as attaching slings and signaling are skills of the ironworker trade. The ironworker who helped rig the first column was not the ironworker who was later injured. When the first column was moved, the ironworker who was later injured was on the CSB deck placing dunnage to compensate for the camber in the deck. After the first column was laid on the CSB deck, the ironworker who assisted with rigging the column stayed on the deck. The ironworker who was on the deck went to the laydown area. About 1500 hours, the ironworker foreman asked the ironworker in the laydown area if he thought there was time to move a second column to the CSB deck. The ironworker checked his watch and noted a time of 1505 hours. The ironworker agreed there was time, since quitting time was 1530 hours. Sketch 5. Estimated Positions of Columns Prior to the Accident			The first column was moved to the CSB deck at about 1400 hours.
When the ironworker and the ironworker foreman were in position, the crane operator began the lift. However, the rigging was not properly offset, and the column did not rotate sufficiently (Photo 2). Also, when the column was lifted, it swung out from the crane one or two meters. This caused the gusset to knock the lighter dunnage away. Photo 2. The Column as it Was Rigged, Taken Shortly After the Accident. When lifted, the column had not rotated properly. Note fallen dunnage material. When the ironworker saw the dunnage material fall, he realized that there was not a level surface for the column. He stepped between the two columns and kicked the fallen 2"x4" and 4"x4" lumber dunnage out of the way, leaving the railroad ties in place. This left a level surface, but it was lower than the surface that had existed. A gusset plate on the column would now protrude into the dirt and prevent the east end of the column from settling onto the dunnage. When the full set of dunnage was in place, the column was supported higher above the ground and the gusset plate would not reach the ground (Sketch 1). The ironworker understood the east dunnage would not support the column when it was lowered. He believed that the column would be sufficiently stable with both flanges of the column settled on the west end dunnage. He was concerned, however, when the column was eventually rotated it would need stable dunnage when the rigging was adjusted for the final move to the CSB deck. After the column was rotated the gusset plate would no longer be a problem because it would protrude horizontally from the column instead of down into the ground.			The second column was lifted, but it did not rotate properly. The column swung one or two meters and knocked down some dunnage.
The ironworker foreman signaled the crane operator to lower the load so they could re-adjust the rigging. Because of the offset rigging, the column was partly rotated and the gusset plate contacted the ground at angle. The crane operator continued to lower the column and the north flange of the column contacted the dunnage at the west end, closest to the ironworker foreman. Because of the column's angle, the south flange had not yet contacted the west dunnage. At this point, the ironworker saw the rigging line closest to him begin to slacken, which he interpreted to mean that the load was stable. He stepped forward to begin adjusting the rigging on his end of the column. However, the ironworker foreman had not ordered the crane operator to stop, and the crane operator was continuing to lower the load. Due to the partial rotation of the column, the north column flange had touched the west dunnage, the south flange had not. The ironworker stepped between the column being rigged and the adjacent column sitting on its dunnage. The adjacent column was resting on dunnage such that the north column flange was presented on a plane perpendicular to the ground. The columns were separated by a space of about 46 centimeters (18 in.). The crane operator continued to lower the load and the column was rotating so that the flange closest to the ironworker moved toward him. The ironworker was standing close to the end of the column, and placed his hand on it to feel it settle. The rotation occurred as the south flange of the column was settling on the west dunnage (closest to the ironworker foreman). The axis of rotation was now along a line that ran from the point where the gusset settled on the ground to the point where the north flange settled on the west dunnage. At the east end of the column, where the ironworker was standing, the gusset created a moment arm so that the column itself was moving in an arc.			Because dunnage was missing, the east end of the column landed on a gusset plate. As the west end settled, the column rotated to ward another column.
The ironworker felt the column rotating toward him. He thought the column would stop before it would injure him. When he found he was being squeezed between the two columns, he tried to turn but was unable to get out. The ironworker foreman and the crane operator saw this occur. The ironworker foreman immediately signaled the crane operator who was already lifting the column. The ironworker turned around, stepped away, and collapsed. The crane operator sounded his horn, signaling other workers of the accident. The ironworker foreman ran immediately to the ironworker, and other workers also arrived quickly. They calmed the ironworker and called for an ambulance. The Hanford Fire Department dispatch log indicates that the ambulance was dispatched at 1507 hours, and arrived at the scene at 1511 hours.² Hanford Fire Department (HFD) emergency medical technicians provided initial medical attention. Sketch 6. Accident Sequence Depiction Sketch 7. As the column was lowered, it rotated in an arc around the gusset plate. The ironworker was transported by the Hanford Fire Department ambulance to Kadlec Medical Center hospital where he was admitted. An examination found a fractured pelvis. He was released on May 12, 1997, to convalesce at home, and should be fully recovered in four to six months.			The ironworker stepped between the moving column and a stationary column, and was pinched.
The Fall Accident³ On May 6, 1997, a carpenter, a carpenter foreman, and a laborer were dismantling shoring in the CSB basement. The shoring was installed to support the installation of concrete forms. The three individuals were working near the east end of the CSB. The carpenter was removing pieces of shoring and passing them to the carpenter foreman. The carpenter foreman passed the pieces to the laborer who stacked them in a pile. The carpenter was on the shoring, about eight meters (25 ft) above the CSB floor. He was wearing a safety harness with a lanyard. Shortly before the accident, the laborer noted the time was 1515 hours.			A carpenter fell when his foot slipped. He was working eight meters above the floor, but his lanyard caught him.
While moving the hook for one of his safety lines, the carpenter's foot slipped on a rung of the shoring. The second carpenter and the laborer heard a sound followed by a grunt. They looked up and saw the carpenter hanging by his lanyard. The lanyard had extended about 1.5 m (five feet). They immediately used a portable radio to request an ambulance. The carpenter foreman and another worker climbed the shoring to get the carpenter down. The carpenter was unconscious and had a laceration on the back of his head. They lowered the carpenter to the laborer. The carpenter regained consciousness as he was lowered but was groggy. 2.2 Physical Hazards, Controls and Management Systems
All personnel involved in the accident had extensive construction experience. This included the injured worker, his coworkers, the ironworker foreman, and the structural superintendent. For example, the ironworker foreman, who was serving as signalman during the rigging accident, had been an ironworker since 1960, and the injured ironworker had 20 years of experience. Journeyman ironworkers are proficient in hoisting and rigging operations.			All of the workers were experienced.
The Mowat safety program was described in the "Mowat Construction Company Safety and Environmental Manual." This documents company policies and administrative procedures, but does not include site specific processes and procedures. DESH imposed the "Contractor Environmental Safety and Health Program" (CESH) on Mowat. This program is described in a manual which includes procedures, for example: Pre-job safety planning; Safety and health meetings/inspections; Cranes, hoisting and rigging; Steel erection and assembly; and Scaffolds.			Several safety programs governed the work.
The chapter on hoisting and rigging (CESH-18) reflected many of the requirements and practices specified in the "Hanford Site Hoisting and Rigging Manual," DOE-RL-92-36. For example, it included a requirement that training be documented for personnel who direct or perform rigging work. The CESH program included requirements for preparation of a job safety analysis (JSA). These were described in procedure CESH-3. Section 2.0 of CESH-3 required JSAs be prepared to describe the hazards associated with work activities and specific measures applied to eliminate or control the hazards. Mowat had a full-time safety officer assigned to the CSB construction project. Among other duties, this individual: Coordinated preparation and approval of JSAs; Conducted daily safety meetings; and Conducted routine safety inspections. Oversight of the Mowat construction safety program was conducted by FDNW, DESH, and DOE-RL.
Mowat, FDNW, DESH, and DOE-RL performed routine safety inspections and oversight of the construction site. During the several months preceding the accident, Mowat and FDNW conducted weekly inspections, while DOE-RL conducted oversight visits on a monthly basis. The purpose of the DOE-RL oversight was to assure that the Mowat and FDNW safety management processes were achieving acciptable results. This is specified in DOE Order 440.1, "Worker Protection Management for DOE Federal and Contractor Employees." The Mowat safety officer accompanied FDNW and DOE-RL on their inspections and oversight visits. The DESH and DOE-RL visits were conducted during one of the weekly FDNW inspections. Weekly inspections by the Mowat safety officer were conducted independent of the FDNW weekly inspections.			Some safety inspectors found problems, but others did not.
The Mowat, FDNW, and DOE-RL inspections and oversight visits were documented and the reports reflected follow-up on issues from previous inspections. The Mowat safety officer conducted daily undocumented inspections. The following are examples of issues from inspection reports:
Eyewash station needs to be put back out	Mowat	May 6, 1997
Housekeeping needs work	Mowat	April 22, 1997
Pair of 10' chokers removed from service	Mowat	March 24, 1997
Improper use of extension cord	FDNW	January 30, 1997
Housekeeping needs improvement	DOE-RL	February 21, 1997
The Board reviewed 13 Mowat inspection reports and 11 of the reports noted deficiencies. These 13 inspections were conducted over a three month period, between January 28 and May 6, 1997, and no deficiencies were noted concerning column spacing and dunnage.
The Board reviewed 30 DESH and FDNW inspection reports. Only three of the reports noted deficiencies. These inspections were conducted over a one year period, from March 21, 1996 to April 17, 1997, and no deficiencies were noted concerning column spacing and dunnage. The Board reviewed four DOE-RL monthly oversight visit reports, two of which noted non-specific problems with housekeeping. These inspections were conducted from January through April 1997. Regulations, Requirements, and Safety Practices Associated with the Accident			None of the inspections identified hazards of inadequate dunnage and inadequate column spacing.
The Board requested the DOE-RL Hoisting and Rigging Program Manager and three other safety experts to review the DOE-RL Hoisting and Rigging Manual, OSHA regulations and the Construction Safety Association of Ontario⁴ Rigging Manual and Crane Handbook for relevant regulations, requirements, and good practices. The experts visited the accident scene as part of their reviews. The reviews are documented in Appendix 1. The main points are: Training and qualification of personnel performing the rigging operation were not documented in accordance with the DOE-RL Hoisting and Rigging Manual. The designated leader (the ironworker foreman) had too many duties. This is inconsistent with the designated leader's role as described in the DOE-RL Hoisting and Rigging Manual. The load was not set on adequate dunnage as described in the Construction Safety Association of Ontario Crane Handbook. The rigging operating would have been conducted more safely if the chokers had been set at the ends of the column. The Job Safety Analysis			Several safety experts found nonconformances to safety standards and regulations.
The requirement to prepare a JSA was included in the general provisions of the Mowat contract as well as in the CESH manual. Section 55 of the Mowat contract, "Health and Safety Requirements," included the following requirement: "Within thirty (30) days after award of this contract, but no later than ten (10) days prior to commencing onsite work, the contractor and lower tier contractors shall submit a "Job Safety Analysis/Job Hazard Analysis" (JSA/JHA) acceptable to DESH. A JSA/JHA is the breaking down into component parts of any project or activity to: (1) determine the hazards connected therewith and the requirements of qualifications of those who are to perform the work; (2) identify hazards associated with each step or task; (3) implement solutions to eliminate, nullify, or reduce to a minimum of consequences of such hazards."			The construction contract required a JSA to identify hazards of each step or task.
Section 2.2 of CESH-3, "Pre-Job Safety Planning" includes the following requirement: "Ensure that the pre-job plan is communicated to all affected personnel before starting work." The approved JSA did not explicitly address the workers' activities at the time of the accident. The Mowat JSA MCC-1, "Erecting Structural Steel and Related Work," did not address rotating the columns and dunnage requirements.
The injured ironworker did not sign the attendance record for training on the JSA, although he did sign a JSA continuation sheet that was specific to man-basket attachments for forklifts. The JSA training on erecting structural steel was conducted on March 17, 1997, and workers signed the forklift man-basket attachment sheet on April 2, 1997. No one, including the injured worker, recalled if the injured worker had attended the March 17, 1997 training on the JSA for erecting structural steel.			The injured ironworker did not attend JSA training.
Regardless of what training was conducted on the material in the JSA, the Mowat structural superintendent told the Board that he walked through the rigging operation with all participants. This was during the pre-job briefing, which the structural superintendent said he conducted on April 28, 1997. The structural superintendent was present the first few times the columns were rolled to facilitate welding for the design change. Records of these walkthroughs were not maintained. It is not clear whether the walkthroughs addressed adequacy of the dunnage, hazards associated with walking between the columns, or spacing between the columns.
The injured ironworker recalled the walkthrough conducted by the structural superintendent but said that he had not paid attention to the rigging discussion. He believed that his role in the work was limited to welding, and the rigging discussion did not apply to him. Column Spacing Most of the contractor personnel interviewed by the Board believed the columns were too close for welding and rigging operations. The injured ironworker had noted this but said nothing to his supervision or management. Another ironworker said that he had mentioned his concern to the ironworker foreman, but action had not been taken. The issue was not discussed in the morning safety meetings or the pre-job briefing.			The structural superintendent walked workers through the rigging operation, but the injured ironworker was inattentive.
The safety experts, requested by the Board to evaluate the area, all agreed the columns were placed too close together (Appendix 1). However, there were not any regulations, standards, or written practices which specified a spacing requirement. Therefore, spacing adequacy is largely a matter of judgement. The safety professionals were concerned workers would have to enter "pinch points" where they could be caught between moving columns. During the work the ironworkers were required to stand between the columns holding the chokers while the crane brought the sling taught. However, no one expected the workers to be standing between the columns when the columns were actually moving.			The safety experts found columns were not properly spaced. Column spacing in the laydown area was inadequate, creating "pinch points."

In the view of the Board, a proper JSA would have evaluated the column spacing issue and should have required the columns to be more widely spaced. This analysis should have been performed when the original JSA was prepared and when the need for welding on the gusset plates was identified. It would have been necessary to move the columns from the laydown area if the gusset plate welding was not required. The Board believes the JSA MCC-1 should have addressed issues such as the spacing between the columns. Dunnage The workers involved in the accident told the Board they recognized the dunnage used to support the weight of the columns was inadequate. The safety professionals reached the same conclusion (Appendix 1). While 9"x7" railroad ties made up the foundation of the dunnage, 4"x4"s and 2"x4"s were also used. Some of the 2"x4"s were crushed by the weight of the columns. Because they were so light and narrow, they were easily knocked over by the gusset.
To reconstruct the dunnage, the ironworker would have to work under the suspended load to stack the crushed lumber. The load could have been temporarily moved out of the way, but this would extend the job past the end of the shift. The ironworker chose instead to allow the column to land on the gusset plate. OSHA regulations and the Construction Safety Association of Ontario Crane Handbook state material must be adequately supported, but there is not specific guidance on how to do this. For example, 29 CFR 1926, Section (a) (1) states that material must be "racked, interlocked, or otherwise secured to prevent sliding, falling or collapse." How to accomplish this is a matter of judgement. However, the Board believes the dunnage should have been substantial enough that it would not crush under the weight of the columns. The JSA addressed unloading steel from trucks to the ground, but did not address dunnage. Photo 3. Inadequate Dunnage Training and Qualification of Workers in Hoisting and Rigging			Some dunnage material was too light and was crushed. When knocked down, it was too hard to reconstruct.
The DOE-RL Hoisting and Rigging Manual requires employers train workers in rigging practices and safety requirements. Training must be documented and include written tests and performance evaluations. There are provisions for accepting properly documented training from previous employers. Mowat did not provide or ensure the training described in the Hoisting and Rigging Manual.			Mowat did not follow training requirement of the DOE-RL Hoisting and Rigging Manual.
For column rolling and lifting, Mowat walked through the operation with the ironworkers. This was done by the structural superintendent who watched the first operation in which a column was rolled for welding. The walkthrough was not documented. The ironworker foreman and the injured ironworker said they were relatively experienced in rigging, but it was generally limited to moving rebar. Before the walkthroughs, the ironworker foreman told the structural superintendent he was uncomfortable during rigging operations. The injured ironworker did not realize he would be functioning as a rigger and did not pay attention to the rigging instruction. He did not sign the JSA for erecting structural steel and related work. He did not recall reading or being oriented on the JSA. The structural superintendent told the Board that he wanted additional, more experienced personnel for rigging operations. This was difficult to justify because rigging operations were sporadic. The structural superintendent told the Board that Mowat management was unwilling to hire additional workers for rigging who would not be fully occupied. The structural superintendent was unwilling to hire people for a few days and then lay them off. Mowat was depending on the workers' extensive experience as ironworkers, but their experience was more with rigging rebar and with other duties of the ironworker trade. Staffing
The workers involved in the accident told the Board that staffing of the rigging operation was inadequate. In particular, the ironworker foreman was filling the roles of designated leader, signalman, and rigger. The Hoisting and Rigging Manual does not prohibit the designated leader from serving other functions. However, the Board concluded he could not serve effectively in all three roles.			The "designated leader" of the rigging operation had too many duties and could not do his job correctly.
The Board found there were enough workers available to relieve the designated leader of his additional duties. During the lift of the first column, the ironworker who was later injured was away from the laydown area preparing the deck to receive the column. During the second lift (when the injury occurred), the other ironworker was on the CSB deck attending to other duties. If work on the CSB deck was completed before beginning the lifts, additional personnel would have been available to help fill the rigger and signalman roles. The Ironworker's Judgement Error
The injured ironworker and the Board agreed that poor judgement was used when stepping between the columns. He had 20 years of experience in construction work and was familiar with this type of hazard. However, he and the other workers wanted to show more progress on the job before they stopped for the day.			The ironworker made a judgement error when he stepped between the columns.
The workers agreed management had not placed any pressure on the crew, but among themselves wanted to move a second column before the end of the day. Everyone involved with the work told the Board there was enough time to do this. The Mowat Safety Policy
While all workers must be held accountable for working safely, there are many things that management must do to keep workers focused on safety. Mowat was doing many (but not all) of these things. The workers interviewed by the Board judged the CSB construction work to be safely run in comparison to other projects they had worked. The workers all said they had authority to stop work for unsafe conditions. However, the workers and ironworker foreman did not exercise this authority. Accident Response			Management must reinforce safe work practices.
When the ironworker was injured, Mowat and HFD personnel responded promptly. The load was pulled immediately from the injured ironworker and the crane operator sounded his horn. The injured ironworker received immediate attention from his coworkers, one of whom called 911. The HFD ambulance was on the scene within minutes of the accident. The ironworker was transported by the HFD ambulance to Kadlec Medical Center hospital where he received medical care.
Immediately after the accident, Mowat, FDNW, and DESH management judged the columns in the laydown area were unsafe. They ordered the columns to be moved so they were all set on dunnage and appropriately spaced. While some stabilization of the material may have been in order, the Board concluded the accident scene was unnecessarily disturbed by this action. Moving the material made investigation of the accident more difficult. Contractors are required to maintain accident scenes undisturbed by paragraph 2, Attachment 1 of DOE Order 225.1, "Accident Investigations."			After the accident, the contractors rearranged the accident scene to improve safety. This complicated the investigation.
2.3 Analyses The Board used barrier analysis (Appendix 2), MORT analysis (Appendix 3), event and causal factors analysis (Appendix 4), and the Reason analysis process (Appendix 5) to establish root and contributing causes of the accident. Barrier Analysis A barrier is defined as anything used to control, prevent, or impede process or physical energy flows and intended to protect a person or object from hazards. The barrier analysis addressed three types of barriers associated with the accident: administrative, management, and physical. These barriers either failed or were missing. Successful performance by any of these barriers could have prevented or mitigated the severity of the accident (Appendix 2). Administrative Barriers
Two administrative barriers failed to prevent the accident. These were: the JSA and training.			Administrative barriers that failed were the JSA and training.
The JSA did not address the following: adequacy of dunnage, adequacy of column spacing, required minimum number of participants during rigging, avoidance of pinch points, and adequacy of staffing during rigging operations. If the JSA had adequately analyzed the rigging operations, it would have prohibited the ironworker foreman from trying to serve simultaneously in the roles of rigger, signalman, and designated leader. When the ironworker foreman attempted to fill all three roles, he did not serve adequately in the role of designated leader. A properly attentive designated leader would not have permitted the ironworker to step between the columns before motion had stopped.
When the design change was issued, fabrication work had to be performed in the laydown area. The JSA was not reevaluated to identify new hazards. Mowat did not follow the training requirements of the Hoisting and Rigging Manual and failed to assure workers understood how to properly rig the column. The injured ironworker was allowed to participate in rigging operations even though he had not attended the JSA training on raising structural steel.			The JSA was not reevaluated when the design change required fabrication work in the laydown area. Mowat did not follow the training requirements of the Hoisting and Rigging Manual.
The Hoisting and Rigging Manual required Mowat to either train the workers in rigging operations or obtain documentation of proficiency from previous employers. This was to include testing and demonstration of proficiency. The ironworkers were not tested and the injured ironworker did not demonstrate proficiency. The structural superintendent said that he walked the ironworkers through the column rigging process and watched the first few column rolling activities. However, the injured ironworker said he believed his role was limited to welding and did not pay attention during the rigging instruction. The injured ironworker did not attend instruction on the JSA because he did not sign the attendance sheet and did not recall attending.			The injured ironworker thought his only role would be as welder and was inattentive during the pre-job briefing.
The injured ironworker was sufficiently experienced to understand and avoid the hazard. Training on hoisting and rigging safety and training on the JSA would have refreshed his understanding and discouraged the unsafe act. Training on hoisting and rigging should have reinforced workers' understanding of what constituted adequate dunnage. Management Barriers The management barriers which failed were: the safety surveillance program and the line management oversight process.
While Mowat had an active safety inspection program, it did not identify either inadequate dunnage or inadequate column spacing. FDNW and DESH inspection programs did not identify these problems. Mowat and DESH had line management oversight responsibilities. These organizations did not identify the problem of inadequate dunnage or column spacing. DOE-RL oversight reviews did not identify the inadequate JSA or hazards in the laydown area. Physical Barriers Two physical barriers failed to protect the ironworker. These were: dunnage and spacing of the columns in the laydown area. If the ironworker had replaced the dunnage after it was knocked out the column would not have rotated on the gusset to pinch the ironworker.			Management barriers that failed were the safety surveillance program and the line management oversight process.
			The physical barriers that failed were the dunnage and spacing between the columns.
If the columns were more widely spaced a pinch point would not have been created. The ironworker could have moved out of the way of the moving column. MORT Analysis The MORT analysis evaluated the components of an idealized safety management system and identified those parts of the system that failed. This analysis found three root causes: The task safety analysis was less than adequate, Personnel training was less than adequate, and Inspection was less than adequate. The results of the MORT analysis are presented graphically in Appendix 3. Task Safety Analysis Less Than Adequate The task safety analysis was documented in the JSA. However, the JSA did not address the specifics of the rigging operation and did not require mitigation of the hazards. The Board concluded that task safety analysis was less than adequate. Personnel Training Less Than Adequate The Board evaluated training required by the Hoisting and Rigging Manual and the JSA. The workers were not trained or training was ineffective. In addition, the effectiveness of training was not adequately evaluated. Even though journeyman ironworkers are expected to understand and avoid the hazards associated with rigging operations, periodic reinforcement is necessary. Training provides this reinforcement. Based on these considerations, the Board concluded that personnel training was less than adequate. Inspection Less than Adequate The Board evaluated inspections made by the Mowat line management and safety officer, FDNW, and DESH. These inspections failed to identify problems of inadequate dunnage and inadequate column spacing. Based on this, the Board concluded that inspection was less than adequate. Reason Analysis The Reason analysis is described graphically in Appendix 5. It identified the following causes: The ironworkers did not understand it was safer to set the chokers at the ends of the column. The JSA did not prescribe minimum staffing requirements for rigging operations. The ironworker foreman was occupied with too many collateral duties. The injured ironworker did not understand he had rigging duties. (This refers to the time of the pre-job briefing.) The ironworker foreman did not realize the ironworker had been inattentive at the pre-job briefing. The JSA did not specify spacing requirements for the columns. The safety oversight organizations inspections were inadequate because they did not identify the dunnage and column spacing hazards. The line organizations inspections were inadequate because they did not identify the dunnage and column spacing problems. The JSA did not address dunnage requirements. 2.4 Causal Factors Summary of Root and Contributing Causes
The Board found three root causes of the accident. These are stated using the MORT and Reason rubric. Task safety analysis less than adequate Personnel training less than adequate Inspection less than adequate			Root causes were inadequate task safety analysis, training, and inspection.
The Board found the following contributing causes. The dunnage was not in place when the load was lowered. An adequate supply of dunnage material was not available at the work site. The area was too congested. An insufficient number of workers were involved in rigging the columns. The chokers were set too far from the ends of the column. The ironworker did not understand his role as rigger during the pre-job briefing. The ironworker was not attentive during the pre-job briefing. Root Causes Task safety analysis less than adequate. The JSA did not address several important factors, the elimination of which could have prevented the accident. These were: proper dunnage to support the columns in the laydown area, proper spacing of the columns to prevent creation of pinch points, and minimum staffing during rigging operations. Personnel training less than adequate. Personnel training did not satisfy the requirements of either the Hoisting and Rigging Manual or the Contractor Environmental Safety, and Health Program manual. Training activities would have reminded workers to stay out of pinch points, assured columns were adequately supported, and addressed proper spacing between columns. Inspection less than adequate. Management, safety, and oversight inspections failed to identify problems of inadequate dunnage and column spacing. These problems should have been identified and corrected prior to performing lifting and rigging operations. Contributing Causes The dunnage was not in place when the load was lowered. Mowat incorrectly used 4"x4" and 2"x4" lumber to support the seven metric ton column. This material crushed and broke under the weight of the column, then was easily knocked out when the column swung. The ironworker could not easily reassemble the dunnage before lowering the column. Nationally recognized standards and regulations specify that loads must be adequately supported. Adequate dunnage material was not available at the work site. An inadequate quantity of railroad ties was provided for supporting the columns. In the absence of the railroad ties, workers used 4"x4" and 2"x4" lumber for dunnage. When this material was knocked out, the workers set the column down in a way that caused the column to roll into the ironworker. The area was too congested. The columns in the laydown area were not adequately spaced for fabrication work. While the spacing may have been adequate for storage, it should have been reevaluated while planning for the design change work. Hazard from inadequate spacing during the column rolling should also have been evaluated. An insufficient number of workers was involved in rigging the columns. The rigging operation was conducted with the ironworker foreman trying to fill the roles of the designated leader, rigger, and signalman. He was unable to properly perform the function of designated leader. Additional workers would have allowed the ironworker foreman to properly perform the function of designated leader. The chokers were set too far from the ends of the column. If chokers were near the ends of the column, the ironworker would not need to step between the columns to adjust them. While placing chokers near the ends of the column would have increased the stress on the rigging, calculations showed the rigging would still have been adequate for the lift. Contractor line and safety management did not perform adequate inspections of the dunnage. Despite daily inspections and visits to the work site, neither the line nor the safety organizations identified safety hazards that led to the accident. These were the inadequate dunnage and the inadequate spacing between columns. The ironworker did not understand his role as rigger at the time of the pre-job briefing. When the ironworker attended the pre-job briefing, he believed his role in the job was limited to welding. As a result, he did not pay attention to the portion of the briefing that dealt with rigging. He did not sign the training attendance sheet for the JSA on raising structural steel. The ironworker did not pay attention during the pre-job briefing. The ironworker was inattentive during the pre-job briefing because he thought his role on the job was limited to welding. As a result, he was not concerned with the rigging safety discussion. 2.5 Safety Management Template The applicable fundamental principles for an effective safety management program are discussed in relation to this accident in Appendix 6.

3.0 Conclusions and Judgements of Need

Conclusions are a synopsis of those facts and analytical results the Board considers especially significant. Judgements of need are managerial controls and safety measures believed necessary to prevent or mitigate the probability or severity of a recurrence. They flow from the conclusions and causal factors and are directed at guiding managers in developing follow-up actions. The following table summarizes conclusions of the Board and judgements of need regarding managerial controls and safety measures necessary to mitigate the probability of a recurrence.

CONCLUSIONS	JUDGEMENTS OF NEED
The JSA did not adequately assess the hazards of the job. In particular, it did not address proper support for the columns, or minimum staffing during rigging operations.	1.a. There is a need for FDH to reevaluate all JSAs for the CSB Project to assure they meaningfully address the hazards associated with the job.
	1.b. There is a need for FDH to reevaluate FDNW's approval process to assure that JSAs adequately address hazards before each JSA is approved.
	1.c. There is a need for FDH to assure there is a JSA for rigging at the CSB project which addresses each of the following issues: Adequate dunnage; Adequate spacing between columns; and Adequate staffing during rigging operations.
	1.d. There is a need for FDH to assure all applicable fixed price contractors have JSAs which adequately address hoisting and rigging operations.
The JSA was not reevaluated when the design change required new welding in the laydown area. A reevaluated JSA should have addressed spacing of the columns during welding and rigging operations.	2.a. There is a need for FDH to institute a process which assures the CSB project adequately reassesses existing JSAs whenever the scope of a job changes.
	2.b. There is a need for FDH to assure all fixed price contractors reevaluate their JSAs whenever the scope of a job changes.
Training was inadequate. The requirements of the Hoisting and Rigging Manual for training, testing, and performance evaluation were not followed. The injured ironworker was allowed to serve as a rigger even though he had not been trained on the JSA for structural steel. While journeyman ironworkers are expected to be familiar with the hazards of rigging operations, training provides necessary reinforcement of safe work practices.	3.a. There is a need for FDH to assure all personnel involved in rigging operations on the CSB project have been trained in accordance with the requirements of the Hoisting and Rigging Manual.
	3.b. There is a need for FDH to assure that all fixed price contractors have functioning processes which assure all personnel involved in rigging operations have been trained in accordance with the Hoisting and Rigging manual.
Line and safety organization inspections of the work site were inadequate. This included Mowat and FDNW inspections. None of these inspections identified the inadequate dunnage or inadequate column spacing. DOE-RL oversight did not identify the inadequate JSA.	4. There is a need for FDH and DOE-RL to reevaluate CSB project line and safety inspection processes. This should determine why inspectors overlooked the column spacing and dunnage problems, and programs should be revised to correct the causes.
The FDNW safety inspections identified very few problems and were of questionable value. Safety inspectors said they did not document issues which were promptly corrected by Mowat. This practice does not assure that safety inspections are properly disciplined nor does it provide trending information.	5. There is a need for FDH to reevaluate policy regarding documentation of safety inspection issues identified by FDNW. Issues identified by safety inspectors should be documented and formally closed.
The dunnage used to support the columns was inadequate. This was due partly to the fact that an adequate supply of the proper material was unavailable.	6. There is a need for FDH to assure adequate dunnage is available for storing and staging material at the CSB project.
During the pre-job briefing the ironworker did not understand he would be called on to perform the function of rigger. The Mowat training process did not assure he understood his role and absorbed the necessary training.	7. There is a need for FDH to reevaluate the CSB project training process to assure all training which addresses safety issues is effective. This should include clearly establishing the roles of workers, as well as checks to assure that workers absorbed the necessary information.

4.0 Board Members, Advisors, and Staff

Chair Accident Investigator Member Member Member	Frederick T. Daniels, DOE-RL David H. Brown, DOE-RL Burton E. Hill, DOE-RL Scott K. Potter, DOE-RL S. J. Veitenheimer, DOE-RL
Editorial and Clerical Support	Ofelia T. Gloria, DOE-RL
Technical Advisor Technical Advisor Technical Advisor Technical Advisor Technical Advisor Technical Advisor Technical Advisor Technical Advisor	James J. Allen, DOE-RL Chris J. Bosted, DOE-RL Kenneth L. Harris, DOE-RL Larry G. Musen, DOE-RL Noble J. Atkins, DOE-RL Michael C. Humphreys, DOE-RL Dana L. Morgan, FDNW Ray Pope, FDNW

Appendix 1
Technical Advisor Reports

Appendix 2
Barrier Analysis

Appendix 3
MORT Analysis

Appendix 4
Event and Causal Factors Analysis

Appendix 5
Reason Analysis

Appendix 6
Safety Management Template

Appendix 7
Appointment Memorandum

_______________

¹Reason is a trademark of Decision Systems, Inc.

²The times stated in the log are earlier than would be expected from the 1505 start time recalled by the foreman. This disparity could have occurred if the ironworker's watch was a few minutes fast.

³The Board reviewed the fall accident to determine if any precursors were evident which could have precluded the injured worker accident. None were found.

⁴The Construction Safety Association of Ontario issued manuals and construction safety good practice standards that are used in the American construction industry.

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