Type: DOE OPEX
Publisher: U. S. Department of Energy, Strategic Petroleum Reserve - DOE
Published As: Public
At approximately 9:54 a.m. Central Standard Time (CST), Blaster 1 and Blaster 2 entered WHT-14 to perform elevated abrasive blasting operations. PBC Blaster 1 and PBC Blaster 2 were connected by separate blast hoses to a common sand pot and began blasting the upper four feet (the 28 to 32 foot level above the floor of the tank) of the interior tank wall. PBC Blaster 1 was working, in a counterclockwise direction with the scissor lift fully extended, and was visible from the location where the PBC Tank Entry Watch (PBC Hole Watch) was monitoring the activity. The PBC Hole Watch reported that PBC Blaster 1 was making good progress and that he had experienced few problems with his equipment.
At approximately 10:42 a.m., the PBC Hole Watch felt the blast hose supplying air and grit to Blaster 1 pulse, an indication that the nozzle had been opened to begin blasting, looked up, and observed the scissor lift and PBC Blaster 1 falling toward the center of the tank. PBC Blaster 1 and the scissor lift came to rest on the floor of the tank with PBC Blaster 1 lying partially out of the work platform, still connected to the work platform by a lanyard attached to his fall protection harness.
The Board concluded the direct cause of this accident was lateral forces exceeded the capability of the scissor lift to remain upright.
The local root cause was that SPRPMO, DM, AGSC, and PBC failed to recognize, understand, and manage operating conditions within the safe operating limits specified by the equipment manufacturer.
The systemic root cause of this accident was that SPRPMO, DM, and AGSC failed to adequately implement several of the guiding principles of Integrated Safety Management: Clear Roles and Responsibilities; Competence Commensurate with Responsibilities; Identification of Safety Standards and Requirements; and Hazard Controls Tailored to Work Being Performed.
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