Barrier

Purpose

Performance

WSI-SRS Standard Procedure 1-5600, "Rappelling," Rev. 2

To standardize procedures for all rappel operations and outline responsibilities for their safe conduct.

Barrier failed because procedure was not followed.

SPO III Core

Curriculum Risk Analysis

To determine the risk involved in conducting SPO III core curriculum training.

Barrier failed because the risk analysis does not address the types of rappel and does not address the hazards involved in Buddy Rappel.

ATTA Safety Analysis Report

To determine the risk involved in operating the ATTA range facilities.

Barrier failed because:

• Risk analysis does not cover the Rappel Tower and the two hazards associated with the fall protection.
• Risk analysis was not amended to address fall protection modifications (new handrails).

Training for Rappel Master

To provide Rappel Master with guidance to safely exercise overall control and coordination of rappelling activities. The emphasis is on providing safe and effective rappel operations.

Barrier failed because:

• Provisions were not made for refresher training for onsite Rappel Masters.
• Hazardous Buddy Rappel was not addressed as a training exercise to be continued or discontinued.
• Training does not specifically address safety responsibilities of Rappel Master or CTA Training Instructor.
• CTA-trained Rappel Instructors were not providing refresher training to SRS-certified Rappel Masters.

Communications

To provide SRT members with information required to conduct rappelling activities safely and efficiently.

Barriers failed.

Team Coach did not determine that two men on a rope resulted in disqualification at the SWAT competition. Lack of this information resulted in SRT members initiating training for Buddy Rappel.

Final Acceptance Inspection of Safety Rails

To determine that acceptance criteria for safety rail installation are satisfied including safety inspection.

Barriers failed because safety inspection did not reveal presence of small radius edge on safety rail gate pin-housing.

Two-Rope Rappelling

To provide a safe rope if the main rappel rope separates.

Barrier failed because single-rope rappelling was being used to simulate SWAT competition conditions.

Management Policy

To provide guidance and requirements for the development of the containment protection strategy and the associated risk acceptance for vital SRS facilities.

Barrier failed because SR and WSI-SRS did not properly implement policy requirements of DOE 5632.7A. This resulted in a contractual requirement for rappelling in the SR/WSI-SRS contract.

Knots and Anchors

Anchors are devices of sufficient strength to support loads on rope. Knots are used to fasten rappel ropes to anchors.

Did not fail.

Scuff Pads or Protective Mats

Protect ropes from damage by sharp objects.

Barrier failed because scuff pads were not used to cover safety rails or lock-pin housing.

Rappel Master Duties

Duties provide for ensuring safety of all personnel utilizing the Rappel Tower or helicopter rappel lanes.

Barrier failed because:

• Rappel Master did not stop unsafe act of placing rope on top of safety rails.
• Rappel Master inspection of handrail did not reveal small radius edge on lock-pin housing.
• Rappel Master did not ensure safe and orderly progression of training.

Dynamic Line Around Rappeller's Waist

Provide safety rope to support Buddy during Buddy Rappel.

Did not fail.

Rope Awareness

Provide awareness of rope pathway to avoid placing rope in a hazardous location.

Barrier failed because personnel involved with Buddy Rappel did not maintain proper awareness of rope position relative to small radius edge of lock-pin housing.

Top Belay

Provides slowing or stopping action of Rappeller from tower top.

Barrier was not used because of simulation of ground belay from SWAT competition.

Ground Belay

Provides slowing or stopping action of Rappeller from ground.

Barrier did not fail. Ground belay slowed and stopped rappellers; however, rope separated upon contact with small radius of lock-pin housing.

Rope

7/16-inch diameter nylon, 4,500-pound tensile strength provides support to Rappeller during rappelling activities.

Barrier failed. Rappel rope separated upon contact with small radius edge of lock-pin housing.

Warning Signs

Identification of safety rails as fall protection and forbids use in rappelling.

Warning signs were not present because design was not coordinated with Safety or WSI-SRS user.

Human Performance (Good Judgment, Training, and Qualifications)

Assists in interpretation of requirements to ensure safe execution, enhances ability to perform job, and guides on-the-job behavior.

Barrier failed. Task was undertaken for which lack of training did not provide qualifications; poor judgment in undertaking this task led to task performance errors.

WSI-SRS Procedure 1-811, "Facility/Equipment Repairs"

Establishes a procedure for the management of WSRC work requests for WSI-SRS facilities where there is a potential to degrade security or safety and health of employees.

Barrier failed because procedure did not require a safety review, risk analysis, and hazard identification of the Rappel Tower fall protection (handrails) modifications.

Conduct of Operation

To develop directives, plans, and procedures that, when implemented, will result in the improvement of quality and uniformity of operations.

The procedures and directives developed by WSI-SRS for the conduct of operations were not implemented in rappelling operations at the ATTA range.

Change or Difference

Analysis

Planned/Normal

Present

Difference

Analysis

Safety rail gates open

Safety rail gates closed

With gates open, the rappel is performed from the scuff pad on the tower floor. With gates closed, the rappel was done with rope on top of the safety rail.

The decision was made to Buddy Rappel with the rope on top of the safety rail and with the gates closed.

Scuff pads on edge of tower floor

Scuff pads were not used on top of safety rails

Rope contacted small radius edge of lock-pin housing.

The rappel rope received no protection from the small radius edge of the lock-pin housing.

Top belay

Ground belay

Only the ground belay was available as fall protection for the rappellers.

This condition resulted from the decision to conduct training simulating SWAT competition conditions.

Single Rappeller on rope

Buddy Rappel

Buddy Rappel increased static load on rope to 484 pounds. Rope actually separated on small radius edge with a dynamic load of 965 pounds.

Caused by team's desire to streamline rappelling activities for SWAT competition.

Two-rope rappel

Single-rope rappel

Single-rope rappel offers much less load support for Rappeller.

Two-rope rappelling is required at WSI-SRS for all rappelling activities except SWAT competition training. This exception is too broad and training requirements should be reviewed by Safety each year.

Chain and post fall protection

Safety rail/gates fall protection

Safety rail/gates fall protection present two hazards to tower users.

Created a climb over obstacle and potential for a rope pathway hazard.

Rope awareness and pathway

Lack of rope awareness and pathway

Rappeller unaware of rope pathway, fall line, and hazards.

Lack of awareness of rope pathway contributed to rope contacting small radius of lock-pin housing.

Rappel Master training discontinued

SRT not proficient in performing hazardous task (Buddy Rappel).

Management has not addressed the requirement for the Buddy Rappel as a useful rappel.

Buddy Rappel use is continued without regard to its hazard potential.

Risk Analysis - SPO III Core Curriculum 6/17/94

Risk analysis does not reflect new safety rails

The hazards involved in rappelling with the rope on top of the safety rail.

A risk analysis performed on the new fall protection should reveal the hazard to the rope caused by the small radius edge of the lock-pin housing.

Lesson plans for training

Lesson plans not required for SWAT competition training

Training is informal, not reviewed by Safety, and not approved by management.

SWAT competition training is informal, planning is insufficient, and hazardous activities are included.

Rappel practices well established in Procedure 1-5600 and SRT training procedures.

SWAT competition rappel practices not known by SRT members.

SRT members begin training using rappel practices that are illegal under competition rules.

The use of the hazardous buddy rappel was introduced into training because competition rules were not known by SRT members.

Rappel Procedure 3-6601 requires a visual inspection of the tower prior to each iteration of rappelling.

Inspection of safety rails not performed - procedures not followed.

Safety rails were not inspected for rope pathway hazards - small radius edge.

Lack of inspection led to hazardous rope pathway during SWAT competition training.

Procedure 1-3146 requires inspection of stationary rappel by appropriate safety personnel prior to each rappel training class.

Procedures not followed.

Safety rail fall protection not integrated with rappelling operation hazards.

Lack of inspection resulted in safety rail being used as a rappelling device and exposure of rope to pathway hazard.

Rappel rope placed on tower floor for rappelling from tower.

Rappel rope placed over top of safety rail.

Rope placement change to a more hazardous pathway.

Rope pathway change was made to simulate training under SWAT competition conditions.