# Presentation: 582158

## Table Saw InjuryType B Accident Investigation

**Presentation to the **
**2006 Facility Representative Conference**
**Knoxville TN**
**Mike Goriup**
**DOE-ID Facility Representative**

## The Accident

- At about 9:15 a.m., January 11, 2006, an electro/mechanical technician, on his second day on the job, sustained a serious injury to his right hand while operating a table saw at the INL Integrated Defense Systems Facility (also referred to as the Heyrend Way Facility).

## The Accident

- The Technician’s right hand contacted the blade of a table saw resulting in amputation of his little finger and a wound that extended across the palm of his hand between the base of his little finger to the web between his thumb and index finger. Extensive reconstructive surgery was required to                    repair damage associated with the                         remaining three fingers.  His little                           finger could not be reattached.                                  He has not yet regained use of                                his remaining three fingers.

## CAUSAL FACTORS

- The Board identified three root causes, one local and two systemic, for the accident, the elimination of which would have prevented the injury:
- Local Root Cause – **Failure to ensure the blade guard assembly was in place** when required for the specific cutting operation.
- Contractor Systemic Root Cause – BEA was **inattentive** to a number of **deficiencies in work control processes** and **allowed informality in execution of the integrated safety management (ISM) program**, including competence commensurate with responsibility.
- DOE Systemic Root Cause – **DOE-ID did not ensure oversight activities were sufficient** to identify deficiencies in the contractor’s implementation of integrated safety management system (ISMS).

## Causal Factors?

- Failure to ensure the blade guard was in place!
- Seems simple - Improper action by one person (the victim)
- How could oversight prevent this?
- Are we suggesting we need one-to-one DOE coverage?
- Perhaps a deeper look into the conditions surrounding the event would be helpful...

## What was he doing?

- The Chemical, Biological, Radiological, Nuclear and High Yield Explosives (CBRNE) Systems Integration project is funded by the U.S. Army, and encompasses a number of activities, including design and procurement of custom storage containers. The custom storage containers are made at the Heyrend Way Facility (IDSF).

## Slide 7

## Integrated Safety Management System

- Five Core Functions
- 1. Define the scope of work
- 2. Identify and analyze hazards associated with work
- 3. Develop and implement hazard controls
- 4. Perform work within controls
- 5. Provide feedback on the adequacy of controls
- Eight Core Principles
- (INL added one for “Worker Involvement”)
- Competence Commensurate with Responsibilities
- Line Management Responsibility for Safety

## Work Control – With a Twist

- R&D Work Control Process (MCP-3571)
- MCP-3571 was created in 1999 with the intention of providing controls for the safe conduct of research by establishing defined, peer reviewed **boundaries** within which the researcher had latitude to work, **rather than imposing specific controls** on each research task.
- The procedure’s scope section specifically stated that it **only applied to activities that had an R&D component**.
- R&D was defined as work undertaken to acquire new knowledge or improve existing knowledge, with the distinguishing criterion being the **presence of a scientific or technological uncertainty to be resolved**.
- Revision 3 of MCP-3571, dated October of 2000, contained a new term: “**R&D Related Activities**.” The definition of this term included “prototypical shop activities performed at R&D facilities.”

## “acquire new knowledge or improve existing knowledge”

- The Risk Identification Checklist in the Project Execution Plan for the CBRNE Systems Integration project answered “no” to the following questions:
- Is the technology new?
- Is the technology unknown or unclear?
- Is this a new application of an existing technology?
- Does the project modernize or advance technology in an existing application?
- The activity of manufacturing the shipping containers did not involve scientific investigation or development of new scientific knowledge.
*The Board concluded that the work being performed (fabrication of an equipment storage box) by the Technician under the CBRNE project did not meet the definition of a R&D-related activity, based upon the Project Execution Plan checklist.*

## Problems With MCP-3571

- On the day of the accident, the technician was working under the MCP-3571 R&D work control process as an “R&D Related activity.”
- Per MCP-3571, work involving R&D or R&D-related activities was assigned to a Principal Investigator (PI) who was the central point of contact and coordination for all aspects of the project.
**A PI was not formally assigned to this project.** The project manager and the laboratory manager at various points in the procedure made decisions in a PI capacity.
- Step 4.1 of MCP-3571 was titled “Define Scope of Work,” but **neither of the two sub-steps provided scope definition**.
- Sub-step 4.1.1 determined if the research was administrative in nature and, therefore, exempted from work control.
- Sub-step 4.1.2 read, “Determine if identified hazards are ordinary laboratory hazards and can be mitigated by skill of the researcher.”

## Slide 12

## Failures in Job Safety Analysis

- In MCP-3571, Analyzing Hazards (for R&D Related work) begins in step 4.9 with the development of a **Job Safety Analysis (JSA)**.
- The first step (4.9.1) was to Complete Form 420.05, Independent Hazard Review, Hazard Mitigation Worksheet, to identify any potential hazard(s) and to identify appropriate SMEs to review the form and JSA.
**This form was not generated for the CBRNE project**.
- A determination was made between the Laboratory Manager and the Project Manager that the existing JSAs in effect in the Heyrend Way Facility appropriately covered the CBRNE work to be performed and that a new or revised JSA was not required.
**This was the standard way of doing business.**

## The Blanket JSA

- The *Job* Safety Analysis is supposed to analyze the hazards of a particular *Job.*
- The JSA in use was for activities throughout the facility.
- The JSA had been borrowed without modification from another R&D machine shop when the Heyrend Way facility was leased.
- The borrowed JSA didn’t address the one piece of equipment the Heyrend Way facility had that the other facility did not – a table saw.

## Competence Commensurate with Responsibility

- According to the INL ISMS Description document (PDD-1004), the CCR process should begin with the line manager filling out an Employee Position Description (EPD) that **defines the required skills, experience, and education required of the position**.
- This EPD should then be used to hire an appropriate candidate for the position.

## Recruiting 101

- The EPD for the Technician described the position’s role to include the following:
- “Support a variety of multi-disciplined, technical and innovative tasks in electrical and/or electronic, mechanical, or other physical disciplines to support sophisticated and complex laboratory programs, tests, and engineering or scientific projects.”
- The “Special Requirements” block of the EPD listed
- “Strong skills and work experience in electronics and electro-mechanical design, fabrication, and installation.”
- “Must be computer literate and have good typing skills.”

## Training Can Make the Difference

- The technician had no work history of carpentry work.
- How many of us actually do the jobs we were hired for?
- Training can be used to change or improve job skills.

## Individual Training Plan

- Per procedure, **managers were responsible for identifying training requirements** and needs within their area that might have been necessary for their personnel to work safely and effectively.
- Per procedure, the manager establishes new employee competency by developing an **Individual Training Plan** (ITP) for the employee.
- An ITP describes the required training pertaining to an employee’s job function and included facility-specific training requirements. Any facility specific training requirements applicable to an employee’s job function should be identified.
**The Technician did not have an ITP.**

## Training Missed

- The technician had received some initial employee training (policies, employee benefits, security) but was missing 6 of 10 “required” initial employee training items.
- The technician had been informed that he had stop work authority and could stop work if he thought it was unsafe.
- He received a briefing from the shop foreman on equipment operation and safety.  He read the JSA.
- He was turned loose to work.

## Making Cuts

- The technician cut some plywood using the table saw with the guard in place.
- To make dado cuts, the guard needed to be removed.
- He asked for help removing the guard
- He made the Dado cuts
- He **remembered being told he could not cut foam with the guard in place**. He started rip cutting the foam without the guard.
- The foreman checked on him and noted he had safety glasses and gloves on.
**The foreman didn’t notice the guard was removed.**

## Something Happened

- The foam was not cutting like wood
- It was floppy and tended to bind in the blade
- It was hard to control with a push stick
**The technician was uncomfortable performing the work and considered stopping work.**
- He was **reluctant to stop** or ask for help since it was only his second day on the job, he was trying to make a good impression, and he had already had to ask for help once before.
- “Something Happened” the foam twisted or kicked back
**His hand went into the blade**

## Call for Help

- There were **no first aid kits** in the facility
- They had been removed to force workers to go to the company nurse to help with injury reporting
- The nurse is in a different facility several miles away
**The workers calling 911 knew the facility only as the “Heyrend Way facility” and did not immediately know the street address.**
- The building did not have an address number on it.
- First aid training was not required for anyone in the building (OSHA requirement)
- Fortunately two other workers were first aid trained and provided good fist aid assistance using cleaning rags to stop the bleeding.

## How could this be?

- A worker was hired to do a job he wasn’t qualified to do, and once hired wasn’t trained to do the job
- The job was not performed to any work procedure, was not analyzed for hazards, and wasn’t covered by any approved company documents
- A new worker was let loose with little supervision (and the supervision provided was poor.)
- Medical assistance provided by luck, not planning

## Contractor Oversight

- Self Assessment Program in place including monthly topical reviews with topics including ES&H, training, and quality assurance.
- One assessment looked specifically at **machine guarding** and was checked as **“ok.”**
- One assessment specifically included **first aid kits** and was marked **“not applicable.”**
- One **self-assessment of JSAs** was performed
- It **only verified that the JSAs in the facility were up-to-date** (within the five year period allowed).
- Two BEA senior management assessments were documented from organizations **outside** the R&D organization.
**Inconsistent standards of training, qualification, and tracking of personnel who use machine shop equipment.**
- Minimal facility supervision and the minimal work authorization and control protocols. (OK by procedure)

## DOE Oversight

**National Security Team** was **program line management** with responsibility for overall program management activities such as cost, schedule, and scope, in addition to project safety.
- The **Quality and Safety Division (QSD)** was primarily responsible for oversight of quality and safety programs.  In addition to ES&H program oversight, **SMEs** were available at request of line management for targeted assessments or technical consultation.
**Facility Representatives** (FacReps) **performed oversight of their assigned facilities/activities** to ensure that the contractor was operating facilities safely and in accordance with contractual and regulatory requirements.  *They reported to the facility line management, not to the program management.*

## The Role of the Facility Representative

- When the Heyrend Way Facility was first leased in April 2000, the FacReps responsible for oversight of the Heyrend Way Facility (and the other Idaho Falls laboratories) reported to the Science and Technology Complex/ Infrastructure (STC/I) Team and were, in part, performing safety oversight of National Security program work activities.
- During this time, **FacReps and SMEs raised issues** with work/hazard controls in laboratory facilities, including the Heyrend Way Facility and **including significant concerns regarding use of JSAs.  **
- This management arrangement led to **DOE-ID internal tension** as FacRep oversight was perceived by the program as interference with program work, and NS security issues with FacReps (need-to-know, etc.) were perceived by FacReps and their line management as an attempt to restrict safety oversight.

## Safety Oversight Turned Over to Program

- In June of 2003, the jurisdictional issues were resolved by an **informal agreement between facility line management and NS program management that excluded FacReps and SMEs from certain NS activities unless their assistance was specifically requested by the NS Program.**
- FacRep staffing analysis did not require FacRep coverage at a non-nuclear facility unless the facility contained a high non-nuclear hazard (biological, high energy, chemical, etc.)
- One of two FacReps left DOE, the other transferred to higher hazard facility. No FacReps left in labs.
- It was determined that **NS Program Team personnel would provide the safety oversight** that was previously performed by FacReps and SMEs.
- One of the NS program/project managers was a previously qualified DOE-ID FacRep and another had an OSHA inspector and laboratory safety background.

## Safety Oversight Stops

- The time and effort required to manage the more than **300 projects/programs left little time for in-house safety oversight. **
- There was no documented evidence of safety oversight at the Heyrend Way Facility from June 2003 until October 2005.
- One visit each month to the Heyrend Way Facility was recorded in a personal logbook by an NS Team project manager for October, November, and December 2005.
- The sole entry regarding safety oversight was recorded on October 26, 2005, stating, “Observed subcontractor interaction and ES&H approach.”

## Recovery Begins

- The need for FacRep coverage in lower hazard industrial facilities was recognized by DOE-ID in the fall of 2004.
- The FacRep staffing analysis was revised in January 2005
- In November 2005 an FacRep was assigned to labs again with “unimpeded access”
- The Lab FacRep did not make it to the Heyrend Way facility before the accident.

## Root Cause Review

- Local Root Cause – **Failure to ensure the blade guard assembly was in place** when required for the specific cutting operation.
- Contractor Systemic Root Cause – BEA was **inattentive** to a number of **deficiencies in work control processes** and **allowed informality in execution of the integrated safety management (ISM) program**, including competence commensurate with responsibility.
- DOE Systemic Root Cause – **DOE-ID did not ensure oversight activities were sufficient** to identify deficiencies in the contractor’s implementation of integrated safety management system (ISMS).

## Conclusion

- Do we need one-to-one coverage to prevent this type of accident?
- Do you need to see the machine guard on the floor to know there’s a problem?
**No.**
- Even an accident as seemingly simple and straight forward as this one has systemic precursors that can be identified without having to witness the “Local Root Cause.”
**If all a FacRep looks for is the Local Root Cause, the odds of preventing an accident drop to near zero.** (my opinion)

## sawstop