# Presentation: 023025

## Lessons Learned Report

**Lessons Learned Report**
**Four Incidents**
**at **
**Lawrence Berkeley Laboratory**
**Warren Yip**
**Facilities/Federal Project Manager**
**October 24, 2002**

**DOE Berkeley Site Office** **• Lawrence Berkeley National Laboratory**

## Table of Contents

- Background
- Detailed description of the incidents
- Common factors
- Recommendations

## Background

**	**This presentation summarizes the four safety incidents that took place in a relatively short period of time, August 6 to September 10 of 2002.  Following the fourth incident, Director Shank initiated a one-hour safety stand down for Facilities on September 12, 2002 and communicated his concerns about maintaining a safe environment for Laboratory Employees.  During his safety discussion Director Shank tasked Facilities to do a lessons learned review and to identify the events and common causes that led up to the four incidences.

## Detailed Description of Incidents	

**1.****	****Contact with 480-volt Line by Jackhammer**** **
- On 6 August 2002, a construction subcontractor was performing cutting and removal of sidewalk concrete outside LBNL building 70.  Work supported the installation of an electrical generator, with six conduits to be added alongside an existing concrete electrical ductbank contained within a section of the concrete stairway/sidewalk between the new generator and the electrical room #130 of building 70.  There was a dig permit for work within the entire area authorizing the saw cutting of the concrete based on the contractor’s field painted outline of each area for excavation.
- Concrete saw cutting was performed during the morning hours of the day and the use of the jackhammer began at approximately 12:00 noon.  Visits to the job site by supervision visually confirmed the use of a jackhammer.  A postponement of work was agreed to by LBNL and the contractor until approximately 5:00 p.m. due to the building 70 occupant's complaints of noise.
- At about 8:35 p.m., the operator using the jackhammer punctured a rigid galvanized conduit and made contact with the 480 Volt energized conductors. The operator, excavation contractor supervisor, electrical journeyman and electrical contractor supervisor all present and within a few feet witnessed sparks from the jack hammer penetration of the conduit.  The work was stopped and the operator removed his hands immediately leaving the jackhammer upright in the conduit. No workers received any electrical shock or injury.

## Detailed Description of Incidents	

**2.****	****Dump Truck Rollover**
- On 14 August 2002 at approximately 9:30 a.m., a dump truck owned and operated by a subcontractor overturned onto the driver’s side during on-site road construction.  The overturning occurred on an extension of Calvin Road uphill and west of building 85 where the new roadway is under construction.  The dump truck was stationary and the truck bed was being raised to dump its load of material at the time of the accident.
- The driver suffered only minor bruises, exited the vehicle himself and there were no resulting lost workdays.  There were no other passengers or affected bystanders.  Approximately two gallons of diesel fuel and a small amount of anti-freeze were spilled into the ground.  Most of the hauled material spilled from the truck onto graded landscape. The on-site Fire Department was notified.  The subcontractor arranged for a tow truck to right the dump truck and tow it off-site.  The contaminated soil was collected and transported to the Building 51 Waste Accumulation Area.

## Detailed Description of Incidents	

**3.****	****Gas line struck by backhoe**
- On 28 August 2002 at approximately 9:45 a.m., An existing 3” natural gas line was struck by a backhoe while excavation work for the installation of a new water line was in progress in Lawrence Road.  The work was planned and scheduled, and a dig permit had been issued for the work. The existence and location of the gas line was reviewed with the work crew supervisor prior to the start of the work by the laboratory Operations and Maintenance personnel responsible for issuing dig permits.  The existing 3” gas line was shown on the construction drawings and was shown on the drawings to cross the path of the new water line in the location where the gas line was struck and broken.
- The LBNL Fire Department responded, as did appropriate LBNL operations and maintenance personnel and the gas line was secured. The gas line was repaired and servicewas restored at approximately 4:00 p.m. Construction work under the subcontract was stopped by a written directive.

## Detailed Description of Incidents	

**4.****	****ISAH Table Disassembly**
- On 10 September 2002 at approximately 1:20 p.m., a subcontract worker working with the LBNL rigging team was disassembling part of the remnants of the "ISAH (Irradiation Stereotaxic Apparatus for Humans) table" in building 51B. Bolts connecting a positioning jack to the floor were being removed.  Three of four bolts had been removed from the first positioning jack when the remaining bolt broke in tension. When the bolt failed, the ISAH dropped to the floor causing the positioning jack to move vertically upward.  A corner of the positioning jack hit the worker, grazing the side of his head causing two shallow lacerations. The worker was transported to the hospital as a precautionary measure to ensure there was no head trauma and was released the same day. The worker reported to work the next day

## Common Factors	

- 	The following table summarizes the causes (Direct, Contributing and Root) that were identified for each of the incidents:

## Recommendations

**Do more up front work to identify the locations of underground **
**utilities prior to contractors starting work on-site**
**Clearly communicate safety requirements/expectations to contractors**
**Review internal Policies Procedures and Staffing levels**
**Increase day to day communication with contractors**