Type B Accident Investigation Board Report; Subcontractor Employee Personal Protective

119 Pages·2003·1.72 MB·English

DOE/ORO-2151

RTM ENTOFE U. S. Department of Energy
A N
P E
DE RGY Oak Ridge Operations Office
U A
NITEDSTA TESOF A MERI C
Type B
Accident Investigation
Board Report
Subcontractor Employee
Personal Protective Equipment
Ignition Incident
on February 18, 2003
Bechtel Jacobs Company LLC,
East Tennessee Technology Park,
Oak Ridge, Tennessee
March 2003
CRCC 845
DOE/ORO-2151

Type B Accident Investigation Board Report of the
Subcontractor Employee Personal Protective
Equipment Ignition Incident on February 18, 2003
Bechtel Jacobs Company LLC,
East Tennessee Technology Park,
Oak Ridge, Tennessee

March 2003

Oak Ridge Operations Office
U.S. Department of Energy
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INDEPENDENT REPORT

Th is report is an independent product of the Type B Accident Investigation Board
(Board) appointed by Gerald Boyd, Manager, Oak Ridge Operations Office, U.S.
Department of Energy (DOE). The Board was appointed to perform a Type B
investigation of the incident and prepare an investigation report in accordance with DOE
Order 225.1A, Accident Investigations.

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

This report neither determines nor implies liability.
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TABLE OF CONTENTS

TABLE OF CONTENTS....................................................................................................i
TABLES AND FIGURES.................................................................................................iii
ACRONYMS.....................................................................................................................v
EXECUTIVE SUMMARY..............................................................................................vii
1.0 INTRODUCTION.................................................................................................1-1
1.1 Background..................................................................................................1-1
1.2 Facility Description......................................................................................1-1
1.3 Scope, Conduct, and Methodology..............................................................1-2
2.0 FACTS..................................................................................................................2-1
2.1 Event Description and Chronology...............................................................2-1
2.1.1 Event Description..............................................................................2-1
2.1.2 Chronology of Events......................................................................2-11
2.1.3 Previous Events...............................................................................2-16
2.2 Integrated Safety Management ...................................................................2-17
2.2.1 Define the Work..............................................................................2-21
2.2.2 Analyze the Hazards........................................................................2-24
2.2.3 Develop and Implement Controls....................................................2-26
2.2.4 Perform Work Safely.......................................................................2-29
2.2.5 Feedback and Improvement............................................................2-33
3.0 ANALYSIS..........................................................................................................3-1
3.1 Barrier Analysis ...........................................................................................3-1
3.2 Change Analysis..........................................................................................3-1
3.3 Events and Causal Factors Analysis ............................................................3-1
3.4 Integrated Safety Management ....................................................................3-2
4.0 CONCLUSIONS AND JUDGMENTS OF NEED...............................................4-1
5.0 BOARD SIGNATURES.......................................................................................5-1
6.0 BOARD MEMBERS, ADVISORS, AND STAFF...............................................6-1

APPENDICES:
Appendix A – Appointment of Type B Accident Investigation Board.........................A-1
Appendix B – Barrier Analysis......................................................................................B-1
Appendix C – Change Analysis ....................................................................................C-1
Appendix D – Events and Causal Factors Analysis......................................................D-1
Appendix E – Events and Causal Factors Chart.............................................................E-1

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