# Presentation: 868111

## July 2004 Hanford Fall Fatality Accident

**2005 Facility Representative Workshop**
**Rob Hastings, Director**
**Operations Oversight Division**

## Double-wide trailer excessed to Community Reuse Organization (CRO)
Trailer sold by CRO to commercial company
Buyer contracted another small company to disassemble and transport trailer to new location in the community
During disassembly worker fell from ladder suffering serious head injury - no witnesses
Worker had medical issues and hot weather may have contributed to fall

**Trailer sold by CRO to commercial company**
**Buyer contracted another small company to disassemble and transport trailer to new location in the community**
**During disassembly worker fell from ladder suffering serious head injury - no witnesses**
**Worker had medical issues and hot weather may have contributed to fall**

**July 15, 2004 Fatal Accident**

## Accident Scene

## Type A Accident Investigation

**Type A accident investigation was immediately initiated**
**Ted Wyka board chairman**
**Five board members - EH, ID, and 3 from RL including an FR**
**Report completed August 23, 2004**

## Causes of Accident

**Private Contractor**
**Owner did not ensure worker was fully aware of hazards and controls**
**Owner did not take advantage of available FHI resources**
**Roles and responsibilities for self-reporting of medical conditions not established**
**Improper ladder use may have contributed**

## Causes of Accident

**FHI**
**Failed to understand roles and responsibilities for non-government contract work on the Site**
**Did not provide safety oversight for non-government work**
**Did not ensure task specific hazards analysis was performed**
**Did not ensure proper training of work crew - treated them as visitors**
**Other site employees did not fully recognize the physical condition of the worker and did not stop work**

## Causes of Accident

**DOE**
**Failed to understand roles, responsibilities and accountabilities for non-government work on the Site**
**Did not provide safety oversight for non-government work**
**Allowed excessed property to be dispositioned in-place**
**Did not ensure proper training of visitors performing work**

## Actions

**Immediate**
**Stopped excess property transfers**
**Directed contractors to review all industrial work performed by any subcontractor or vendor to ensure adequate flow-down of requirements and oversight**
**Follow-up**
**Reviewed all RL instruments - contracts, agreements, grants, leases, etc. to determine full scope of work and site access opportunities**
**Performed a self-assessment to capture all opportunities for improvement not captured in the Type A Accident Report**

## Actions

**Ensured all contracts have appropriate safety provisions**
**Established CRO excess location offsite - site contractors deliver excess equipment to CRO site**
**Stop work policy renewed and flowed down to all subcontracts**
**Site access controls and visitor training improved**
**Established RL procedures to ensure proper review and coordination of future instruments**

## Safety Oversight-Specific Actions

**FRs performed site-wide assessment of subcontractor ISMS implementation**
**FRs performed oversight of previously unknown small RL-direct contractors**
**SMEs performed assessment of Job Hazard Analysis process**
**Evaluated work control processes - job specific work instructions versus skill of the craft**
**Evaluated all near miss events for FY04**
**Revised contracts to require root cause analysis and corrective actions for all near miss events and provided a better definition of a near miss**

## Conclusions

**Need to ensure you are aware of all DOE contracts and instruments that allow work to be performed on your site**
**Understand your CRO processes**
**Change oversight focus as necessary to ensure industrial hazards have adequate safety oversight**
**Periodically assess all contractors no matter how small**
**Ensure appropriate flow-down of requirements to subcontractors**
**Ensure hazard identification and control processes are sound, even for subcontractors and small contractors**
**Revised contracts to require root cause analysis and corrective actions to prevent recurrence for all near miss events**