Validation vugraphs

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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
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Table of Contents

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

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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.

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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 contractors
  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 1200 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 500 p.m. due
  to the building 70 occupant's complaints of
  noise.
• At about 835 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.

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Detailed Description of Incidents

• 2. Dump Truck Rollover
• On 14 August 2002 at approximately 930 a.m., a
  dump truck owned and operated by a subcontractor
  overturned onto the drivers 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.

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Detailed Description of Incidents

• 3. Gas line struck by backhoe
• On 28 August 2002 at approximately 945 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 400 p.m. Construction work under
  the subcontract was stopped by a written
  directive.

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Detailed Description of Incidents

• 4. ISAH Table Disassembly
• On 10 September 2002 at approximately 120 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

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Common Factors

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

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Recommendations

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