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February 6, 2013
Ms. Alicia Fenrick
Director, Litigation and Claims
245 Market Street
San Francisco, California 94105
Via e-mail: AWF9@pqe.com
Bureau Veritas Project No. 33112-012262.00
Subject: Root Cause Analysis of Fatal Injury at Kern Power Plant
2401 Coffee Road
Bakersfield, California
Dear Ms. Fenrick:
Bureau Veritas North America, Inc., Health Safety and Environmental Services, is pleased to provide you
with a copy of the Root Cause Analysis of Fatal Injury report from the Kern Power Plant facility at 2401
Coffee Road, Bakersfield, California, 93301.
Should you have questions in regard to the enclosed report, or need assistance with other industrial
hygiene issues, please contact me all Redacted I
Please take a minute to share your opinion with us regarding the consultant's service by completing our
web-based quality survey. Click on the following link or copy and paste it into your web browser to access
the site.
http://www.us.bureauveritas.com/wps/wcm/connect/BV USNew/Local/Home/Our-
Services/Health Safety Environmental/Webinars C Technical%20Traininq/hse customer satisfaction s
urvev content
Thank you again for the opportunity to be of service.
Very truly yours,
Redacted
Senior Managing Consultant
Bureau Veritas North America, Inc.
Health, Safety, and Environmental Services
Bureau Veritas North America, Inc.
Jdea/'h, Safely and HuvironwenlalSamc 2430 Cammo Ramon, Suite 122 Fas : (925) 426-0106
San Ramon, CA 94583 www.RureauVeritasHSE.corn
SB GT&S 0768592
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Root Cause Analysis of Fatal Injury at Kern Power Plant
Completed At: Kern Power Plant
2401 Coffee Road
Bakersfield, California 93301
Bureau Veritas Project Number: 33112-012262.00
Report Date: February 6, 2013
Prepared for: Ms. Alicia Fenrick
Director, Litigation and Claims
AWF9@pqe.com
Redacted
Prepared by:
Senior Managing Consultant
San Ramon, California
Redacted
FINAL REPORT
This purpose of this Industrial Hygiene assessment and report is to assist you, the client, in your responsibility to establish and
maintain a loss control program to prevent illness and injury to your employees and others. Our activities and recommendations are a
supplement to and not a substitute for, any part of your own responsibilities and activities. These services are based upon
information supplied by client management and conditions that are readily observable, and should not be relied upon exclusively to
prevent all possible illnesses, injuries or losses.
SB GT&S 0768593
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Table of Contents
SECTION PAGE
1.0 INTRODUCTION 1
2.0 BACKGROUND 1
3.0 ACCIDENT DESCRIPTION AND TIMELINE 2
4.0 ROOT CAUSE ANALYSIS METHODOLOGY 8
5.0 POTENTIAL ISSUES FOR EXAMINATION 9
6.0 ROOT CAUSE ANALYSIS 10
7.0 RECOMMENDATIONS FOR POSSIBLE PGE PROGRAM AND/OR
MANAGEMENT SYSTEMS IMPROVEMENTS 29
8.0 QUALITY ASSURANCE 31
APPENDIX A
LOSS CAUSATION MODEL - USING "WHY?" ANALYSIS
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1.0 INTRODUCTION
Ms. Alicia Fenrick, Director, Litigation and Claims, with Pacific Gas and Electric Company (PGE), retained Bureau
Veritas North America, Inc. (Bureau Veritas) to conduct a root cause analysis (RCA) of the fatal accident at the
Kern Power Plant located at 2401 Coffee Road, Bakersfield, California 93301 in order to assess potential
improvements in PGE's relevant (contractor) safety management systems in place at the time of the accident. The
scope of work for this project was described in Bureau Veritas' Proposal No. 3303.12.365 dated November 5, 2012,
and Proposal No. 3303.12.776 dated December 18, 2012 both addressed to Ms. Alicia Fenrick. The project was
completed in accordance with the Master Services Agreement (MSA # 4400005800, effective 2-2-12) established
between BVNA and Pacific Gas and Electric. While on-site at KPP Mr. WH was Bureau Veritas' primary
contact.
CSP. CIH, CHMM, CPEA Senior Managing Consultant with Bureau Veritas, completed the
RCA on January 11, 2013.
Bureau Veritas performed the following tasks for this project:
? Prepared a list of requested PG&E and Cleveland Wrecking Company (CWC) documents to be
reviewed.
? Prepared a list of key PG&E personnel (by job function) to be interviewed.
? Prepared a list of questions for PGE's Generation Procurement group
? Prepared a list of questions for CWC
? Conducted a physical inspection of the work site
? Reviewed key documentation provided by CWC to PGE
? Reviewed key documentation provided by PGE
? Interviewed key PGE personnel associated with the KPP demolition project
? Interviewed key PGE personnel associated with the procurement process for hiring contractors for
the KPP demolition project
? Interviewed three experienced tank demolition professionals
? Reviewed video recordings of the tank demolition process immediately before and during actual
incident
? Performed a root cause analysis of the incident based on the available information
? Identified potential improvements to PGE's relevant (contractor) safety management systems
? Reviewed plans for completing the demolition of the tanks
2.0 BACKGROUND
The former Kern Power Plant (KPP) was comprised of two (2) main generating units, Unit 1 and Unit 2; 4 boilers
two (2) house generating units; and a heavy fuel oil tank farm. KPP was removed from the roles of the country's
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generating facilities in 1996. The facility was retired in 1985, (designated as in "cold standby"), and has been un -
staffed since the late 1980's.
The Kern Power Plant Demolition Project is a "turn -key" project, whereby the contractor was given care, custody
and control of the site and the Contractor has full responsibility for the dismantling, demolition and disposal of all
the structures and equipment at the site and the safety of the people on the site.
3.0 ACCIDENT DESCRIPTION and TIMELINE
The following account of the accident was excerpted from CWC's accident investigation report provided to
Location of Incident: Kern Power Plant, Bakersfield, California
Date of Incident: Tuesday, June 19, 2012, approximately 9:20
a.m.
Type of Incident: Worker fatality; struck by collapsing tank wall
Executive Summary:
On June 19, 2012, a four-person team was in the process of dismantling a large (approximately 40 feet high and
120 feet in diameter) fuel storage tank when a section of the steel wall unexpectedly collapsed and struck the boom
lift one of the employees was working from. Due to the position of the boom lift, the force of the impact dcve the lift
backward until the entire unit overturned causing the basket the employee was riding in to strike the ground. Co­
workers immediately suspended their activities and rushed to aid the injured employee. Emergency services (via
911) were summonsed and the employee was transported by ambulance to a local hospital. Tragically the
employee's injuries were too severe and he did not survive.
Investigation Methodology:
Information included in this report was obtained from on-site evaluation of the accident scene; from interviews of
CWC employees who either witnessed the incident or who had first-hand knowledge of the events leading to and
immediately following the incident; and from project documents including the site health and safety plan, employee
training records, daily tailgate meeting notes, and equipment inspection records.
Background Information:
In March 2012, Pacific Gas and Electric (PG&E) contracted CWC to dismantle the Kern Power Plant (KPP) located
at 2104 Coffee Road in Bakersfield, CA. The facility includes four boilers with associated control rooms and smoke
stacks, four above ground, heavy fuel storage tanks with associated piping and equipment, administrative building,
hazardous waste storage building and other smaller tanks and support structures. The plant ceased operation in
the mid-1980s and the site has been idle ever since.
Due to the age of the facility, a number of structures (including the boilers and above ground tanks) contained
asbestos insulation. In accordance with State ofCalifornia regulations, the asbestos insulation needed to be
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removed prior to the initiation to the demolition of these structures. Because CWC does not normally conduct
asbestos abatement work, a specialty subcontractor was retained by CWC to perform this work. The abatement
activities on the four above ground tanks were completed in mid-June. Demolition activities on the four tanks
began the week of June 18, 2012.
Incident Review:
The team assigned to demolish Tank 1 consisted of FIELD SUPERINTENDENT (field superintendent), THE DECEDENT
and LABORER/TORCHMAN, (torch men/laborers) and HEAVY EQUIPMENT OPERATOR (heavy equipment
operator). This same team had worked together on a previous CWC project where numerous fuel tanks of similar dimensions
to the four at the Kern facility were dismantled.
At the time FIELD SUPERINTENDENTS crew started to work on the four fuel tanks, other work ers were completing
the task of emptying the fuel drain lines that were present on either side of the tanks. Once the fuel lines were empty and
cleaned, the lines could be disassembled.
On June 18, the crew cut "doors" in the side of the four tanks to provide access for the laborers and equipment.
Prior to cutting the doors, FIELD SUPERINTENDENT, LABORER/TORCHMAN and THE DECEDENT discussed the
size of the opening and where the door should be cut. The factors bearing on this decision included the location of fuel lines
and the terrain
surrounding the tanks. The door to Tank 1 was the cut between the fuel lines and on the side where tie pieces of
the tank could be easily processed and removed from the site. After the door was cut, the floating lid on the interior
of the tank was demolished and taken outside of the tank with the excavator.
On June 19, 2012, FIELD SUPERINTENDENT led a safety tailgate meeting to discuss the work that would be completed
that day, including the demolition of Tank 1. During the meeting, the entire CWC crew discussed the days' work
assignments, JSA's and PPE requirements for their respective tasks. After the meeting, FIELD SUPERINTENDENTS crew
went to Tank 1 and again reviewed the specific steps for dismantling the tank.
FIELD SUPERINTENDENT and his crew had previously determined that the torch men would cut the tank walls from boom
lifts positioned inside the tank. This decision was driven by the surface conditions surrounding the tank. The ground
outside the tank is uneven and sandy. And with a tank height of 40 feet, the crew was concerned about the
difficulties of maneuvering their boom lifts to allow them access to the upper portions of the tank. In addition, other
obstacles such the existing fuel lines would impede efficient work from the outside.
Working from the inside of the tank eliminated these problems. The tank floor was flat, stable, and free of
obstructions. With a tank diameter of 120 feet, the crew concluded they had ample room to maneuver the lifts
without compromising worker safety. The same approach had been successfully used by this same crew to
demolish tanks of similar size over the past 10 years.
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As had been the practice on similar jobs, the plan was to cut the top half of the tank in 20' x 20' sections and then
use a Link Belt 700 excavator (operated by HEAVY EQUIPMENT OPERATOR) to fold the cut section in to the interior
of the tank. FIELD SUPERINTENDENT marked the initial four cut locations, spaced approximately 20 feet apart, with
orange spray paint on the exterior base of the tank walls. These marks identified locations where the two torch men
(LABORER/TORCHMAN and THE DECEDENT), working from S-60 Genie boom lifts, would make cuts.
When the torch men were set up to cut the first piece, they alerted FIELD SUPERINTENDENT, who was stationed on
the ground outside of the tank. FIELD SUPERINTENDENT then directed the torch men where to line up their cuts. Once
they were aligned to FIELD SUPERINTENDENTS satisfaction, the torch men commenced cutting.
As the torch men cut the tank walls, they would leave "stickers" on both the horizontal and vertical cuts. A sticker is
a short (2"-3" long) uncut section of wall which keeps the cut wall section in place until it is ready to push in by the
excavator operator.
FIELD SUPERINTENDENT frequently entered and exited the tank while the cuts were made to verify the cuts were
made in the proper locations, monitor the position of the boom lifts, assist the torch cutters with their equipment (such as
moving hoses), and coordinate communication with the excavator operator working outside the tank.
Once the section was cut and with the "stickers" intact, the tordi men would signal to FIELD SUPERINTENDENT that
the cuts had been completed. At this time, the torch men would move their boom lift back and to the center of the tank.
FIELD SUPERINTENDENT would look outside the tank to determine whether the area was clear. FIELD
SUPERINTENDENT would then contact the excavator operator by radio and direct him to make the push. As directed,
the operator would extend the boom of the excavator and tap the cut section of wall, breaking the "stickers". Once
pushed, the weight and momentum of the cut section would allow the steel to fold squarely into the tank. The operator
would then flatten the cut section of steel against the intact portion of the wall, thus reducing the height of the tank wall
by roughly half.
Following each cut, FIELD SUPERINTENDENT returned to the exterior of the tank and, using the orange paint as his
guide, confirmed the desired location for the next cut. Due to the respirators worn by the torch men, FIELD
SUPERINTENDENT used hand signals rather than a radio to communicate where the next cut would be made. In order
for the torch men to see his signals, they needed to raise their baskets above the rim of the tank to gain line of sight with
FIELD SUPERINTENDENT
Once the first section was down, the crew, under FIELD SUPERINTENDENTS direction and using the same
process described above, took down wall sections 2 and 3.
After the third section was down, FIELD SUPERINTENDENT noticed that THE DECEDENT lift was located
approximately 25-30 feet from the tank wall. FIELD SUPERINTENDENTwanted the boom lift carriage approximately 45
feet from the tank wall. Lifts with 60' booms (rather than standard 40' booms) had been obtained for this project to allow fa
greater distances between the tank walls and the lift carriages.
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In addition, FIELD SUPERINTENDENT noticed that THE DECEDENT had his boom extended perpendicular to the
carriage (which happened to position the carriage wheels parallel to the tank wall). Instead, FIELD SUPERINTENDENT
wanted the boom extended over the length of the carriage to afford greater stability when extended (which would also
change the wheel alignment to be perpendicular to the tank wall). FIELD SUPERINTENDENT communicated his
concern to THE DECEDENT and directed him to reposition the lift.
At the time that FIELD SUPERINTENDENT was instructing THE DECEDENT to reposition his lift, he received a
telephone call that required him to go to the front gate. Prior to leaving, FIELD SUPERINTENDENT gave each torch
cutter a bottle of water and told them to rest (conditions at the time were hot and dry and FIELD SUPERINTENDENT
was concerned about heat stress). As he left, he told the torch cutter: "I'll be right back." The torch men nodded asFIELD
SUPERINTENDENT turned toward the front gate, which was about 500 yards from the tank.
As he left, FIELD SUPERINTENDENT assumed the torch men would suspend their activities until he returned because:
(1) This crew had worked together for over 10 years and their practice had been to wait for FIELD SUPERINTENDENTS
direction before starting new tasks; (2) it would take a few minutes for the torch men to drink their water; (3)THE
DECEDENTwould need to a few minutes to reposition his lift; (4) FIELD SUPERINTENDENTthought he would return
from the front gate before they had finished their water.
For reasons not known, THE DECEDENT repositioned his lift and began his next cut above the tank door (note: unlike
the pervious sections, the location of this cut had not been identified by orange spray paint). Upon finishing his cut,
THE DECEDENT raised his bucket above the rim of the tank and motioned to the excavator operator. Using hand
signals, THE DECEDENT indicates to the operator that he was ready for the newly cut section to be pushed into the
tank. The operator then extended the excavator boom and taps the freshly cut section.
Unlike the 3 previous wall sections, this section did not fold squarely into the tank. Instead, because approximately
2/3 of this section extended above the doorway (and therefore was not supported), the bottom, unsupported corner
of this section dipped downward, causing the upper corner to tip toward the urt-cut wall. The top corner of the cut
section then hung up momentarily on the urt-cut wall, causing it to bend in toward the interior of the tank.
The newly cut wall section continued its downward descent, pulling the corner of the urt-cut section down with it.
The weight and momentum of the sagging steel drove the un-cut wall further into the tank interior. The collapsing
steel struck the boom of THE DECEDENT lift and pushed the entire unit backward. Because the carriage was aligned
parallel to the wall, the wheels were not positioned to allow the carriage to roll backward. As a result, the force of
the sagging steel drove the boom lift upward until it passed its center of gravity. At this point, the entire lift
overturned and the basket, along with THE DECEDENT, fell to the ground. Because the entire lift overturned, the fall
protection gear worn by THE DECEDENT could not prevent his devastating injuries.
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On his way back from the gate, FIELD SUPERINTENDENT heard the crash of the lift overturning. Other crew members,
including THE DECEDENTs step brother, rushed to the scene and tended to THE DECEDENT. Work was
immediately suspended and emergency services (911) were called. THE DECEDENT was transported to the hospital by
ambulance. Tragically, THE DECEDENT passed away as short time later.
Incident Analysis:
The fatality at the Kern facility is confounding for a number of reasons:
? The crew assigned to the Kern project were some of CWC's most experienced and talented workers; many
with 10 or more years with the company.
? Over the past 5 years, the 4-person team involved in the Tank 1 incident had dismantled numerous tanks
of similar size without serious incident using similar procedures. CWC management considered this crew to be
their "A team" for dismantling elevated structures.
? FIELD SUPERINTENDENT is an experienced field superintendent, fluent in both English and Spanish, and is well
respected and liked by his field crews.
? The Tank 1 team reviewed the written JSAs for this assignment during the June 19 tail gate meeting. In
addition, the team had physically inspected the tank prior to the initiation of site activities and had discussed their
specific steps for cutting the tank.
? THE DECEDENT was wearing the required personal protective equipment including:
-Fall protection harness with attached lanyard -Disposable coverall, gloves, ear plugs, and safety glasses-M> face
respirator with HEPA cartridges -Hard hat and work boots
? The Tank 1 team was not under any time pressure to remove the tank. In fact they were assigned the
Tank 1 task while waiting for the completion of the asbestos abatement work elsewhere in the facility.
THE DECEDENT was an excellent employee. He was known as hard worker who was diligent about following health
and safety requirements. He was very well liked by other members of the crew and was considered to be a mentor
to many.
It is not possible to know why THE DECEDENT decided to make his next cut without waiting for direction from the Field
Superintendent (FIELD SUPERINTENDENT). Clearly THE DECEDENT assumed that this section of wall would fold
into the tank like the previous 3 sections. However, crew members interviewed for this investigation expressed surprise that
DECEDENT would make a cut near the door because they believed that a cut in this location could jeopardize the
structural integrity of that section of the tank wall.
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Several crew members mentioned that THE DECEDENT had "not been himself during the days leading up to the
incident. THE DECEDENT was normally an outgoing person, very talkative, and enjoyed joking with coworkers. However,
prior to the accident, he had apparently become quiet and reserved.
This was so unusual that on Monday (June 18) before the incident, FIELD SUPERINTENDENT pulled THE
DECEDENT aside to ask if there was something wrong. During this conversation, THE DECEDENT mentioned that he
was seeing a doctor about a
health condition. THE DECEDENT apparently had been having A MEDICAL ISSUE and on the Friday before the
incident, his doctor prescribed a new medicine for the condition.
THE DECEDENT had a work mandated physical last March and was cleared for duty. THE DECEDENT apparently
indicated
that he was OK and was able to continue to work. According to FIELD SUPERINTENDENT and other members of the
crew, DECEDENT did not exhibit signs of impairment, he just seemed quite and a bit distracted. Note: the coroner's report
did
not indicate the presence of illegal or recreational drugs.
Kern Power Plant Fatality Event Timeline - 6/19/2012:
0600: Daily safety tailgate meeting
0620: Crew assignments are made and work begins
0730 - 0846: First 3 section of the tank are successfully cut
-0850 - 0855: Superintendent FIELD SUPERINTENDENT is notified that he needs to meet a contractor at the front
gate.
Superintendent FIELD SUPERINTENDENT gives the 2 laborers bottles of water and informs
his crew that he will
return shortly
0855 - 0907: Laborer DECEDENT begins to cut unmarked tank wall section above doorway
Laborer DECEDENT signals to equipment operator HEAVY EQUIPMENT OPERATOR to push in
freshly cut wall section
0908: Newly cut wall section snags top, left corner (as viewed from outside the tank) of un-cut wall and
bend it down into the tank toward the DECEDENT boom lift.
Force of collapsing wall drives boom backward causing the carriage to overturn.
-0910 - 0920: Co-workers come to the aid of DECEDENT. Emergency services are called. Site operations are
halted
-0920 - 0930: Emergency personnel arrive, tend to DECEDENT, and transport him to hospital
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4.0 ROOT CAUSE ANALYSIS METHODOLOGY
A modified Systematic Causal Analysis Technique (SCAT) was used to perform a root cause analysis (RCA) of the
accident. SCAT is an accident investigation tool developed by Frank Bird at the International Loss Control Institute
(ILCI) and first published in 1985. Based on ILCI's Loss Causation Model (see Appendix A), it uses a familiar "5
Whys" approach that starts out by identifying the types of substandard acts and/or conditions that were immediate
causes of the loss event (accident). Effective corrective actions focus attention on eliminating these immediate
causes.
Asking why each substandard act or condition occurred helps identify the underlying types of personal and/or work
environment factors (root causes) of the loss event. Eliminating t hese root causes contributes to effective long term
preventive actions.
Asking why these factors were present helps identify program failures and management system weaknesses.
Addressing these failures and weaknesses produces permanent improvements in the organization's management
and control of risk.
For example:
An employee slipped and fell to the floor injuring his wrist.
Investigation shows that an immediate cause of the fall was an unsafe condition, oil on the floor.
Cleaning up the oil was a corrective action.
Asking why there was oil on the floor resulted in discovering that a root cause of the accident was inadequate
maintenance, (a forklift was leaking oil).
Fixing the leaky forklift was a preventative action.
Asking why the forklift was leaking resulted in discovering a forklift program flaw: forklift maintenance was on a "run
until failure" schedule.
Changing to a preventive maintenance schedule for forklifts was a program improvement.
Asking why forklift maintenance was on a "run until failure" schedule resulted in discovering a management system
problem: that the maintenance department was understaffed due to a Fluman Resources department backlog in
filling open positions.
Developing a system of prioritizing the hiring process for Human Resources was a management systems
improvement for the company.
Note:1 ILCI was bought by Det Norske Veritas (DNV) in 1991.
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5.0 POTENTIAL ISSUES FOR EXAMINATION
After reviewing the documents provided, inspecting the accident site, and interviewing key personnel and outside
experts, and viewing the videos of the accident, the following observations / potential issues were noted and used
to help populate the tables.
Note: Given the circumstances surrounding this incident and the inability to directly interview and interact with CWC
employees, the words "possible," "potential," and "proposed" are used liberally throughout this RCA in describing
observations, immediate causes, and root causes.
1 PGE Procurement did not validate CWC safety data.
2 Experience Modification Rates (EMRs) reported for CWC and their 2 main subcontractors for 2010 and 2011
do not corrolate with reported OSHA rates for the same time period (reported as zeros). This can be possible
if all workers compensation costs for all 3 companies over the 2 year period were due to non-OSHA
recordable cases, i.e. first aid) but such conditions seem unlikely given the nature of the business operations..
3 PGE Procurement did not validate CWC compliance with required safety programs
4 CWC elected to not follow their agreed upon demolition work plan method for demolishing tanks
5 CWC elected to use manual means with manlifts and cutting torches instead of purely mechanical means to
demolish tanks when mechanical means were available.
6 PGE's Representative did not approve nor object to CWC's change in method for demolishing tanks
7 CWC's use of manlifts and cutting torches is an obsolete approach and carries a higher safety risk and is no
longer general industry practice now that taller excavators with shears are available
8 Victim's behavior was noticeably out of character on the day of the accident
9 Victim informed superintendent that he was taking a new medication
10 CWC Superintendent accepted victim's answer that he was okay to work and took no further action
11 Victim, an experienced employee, positioned his manlift in an unsafe location: too close to the talk wall with
the manlift's wheels parallel to the tank wall
12 CWC Superintendent instructed victim to reposition the manlift before continuing work
13 CWC Superintendent was called away from the worksite temporarily, expecting the work crew to wait until his
return before restarting work
14 Victim resumed working while superintendent was still away
15 Victim ignored superintendent's instruction to safely reposition the manlift
16 Victim finished cutting section over doorway (not the correct section)
17 Victim raised manlift over tank wall to signal excavator operator to push tank wall in
18 CWC Excavator operator did not wait for superintendent to return and proceeded to push on tank wall
19 CWC Superintendent, safety officer, and work crew did not stop work each time excavator pushed tank wall
into tank while workers were inside the tank
20 CWC's method for testing the Integrity of tank floor to insure its ability to support men and equipment before
they entered the tank is to use a "tracked vehicle" first.
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6.0 ROOT CAUSE ANALYSIS
The following descriptions refer to and expand upon the color coded: observations, substandard acts and
conditions (immediate causes), and personal and work-environment factors (root causes) that appear in the
root cause analysis table.
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RCA BY: MODIFIED - SYSTEMATIC CAUSAL ANALYSIS TECHNIQUE ?
Proposed Observation 1.0 Manlift was parked too close to and parallel to the tank wall
1.1 Improper Position for Task
Potentially Substandard Potentially Substandard Potentially Substandard
1.2 Improper Placement
Acts Acts Acts
1.3 Using Equipment Improperly
1.01 Inadequate Mental or Psychological Capability -emotional disturbance
1.02 Inadequate Mental or Psychological Capability - mental illness
1.03 Mental or Psychological Stress - mental illness
1.04 Mental or Psychological Stress - preoccupation with problems
Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors
1.05 Mental or Psychological Stress - emotional overload
1.06 Physical or Psychological Stress - injury or illness
1.07 Physical or Psychological Stress - blood sugar insufficiency
1.08 Physical or Psychological Stress - drugs
Proposed Observation - Black font Potential Immediate Cause - Blue font Possible Root Cause - Green font
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Proposed Observation 1.0
Manlift was parked too close to and parallel to the tank wall.
Potentially Substar proper Position for Task
Potentially Substar proper Placement
Potentially Substandard Act 1.3 - Using Equipment Improperly
Victim was an experienced employee who would be expected to be familiar with the proper positioning of a manlift for maximum stability. Instead, he parked with
the wheels parallel to the tank wall. When the lift was extended towards the tank wall it was perpendicular to the direction of the wheels. Consequently, when the
tank wall collapsed and fell against the extended manlift, the wheels could not roll back away from the wall. Instead the lift truck was tipped over.
Possible Personal Factors 1.01 -1.08
Victim's health issues are not known at this time.
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RCA BY: MODIFIED - SYSTEMATIC CAUSAL ANALYSIS TECHNIQUE ?
Victim did not follow superintendent's instructions to reposition manlift (with wheels
Proposed Observation 2.0
perpendicular to tank wall) before resuming work
2.1 Failure to React - Correct
Potentially Substandard Potentially Substandard Potentially Substandard
2.2 Failure to Follow Procedure - Policy - Practice
Acts Acts Acts
2.3 Using Equipment Improperly
2.01 Inadequate Mental or Psychological Capability -emotional disturbance
2.02 Inadequate Mental or Psychological Capability - mental illness
2.03 Mental or Psychological Stress - mental illness
2.04 Mental or Psychological Stress - preoccupation with problems
Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors 2.05 Mental or Psychological Stress - emotional overload
2.06 Physical or Psychological Stress - injury or illness
2.07 Physical or Psychological Stress - blood sugar insufficiency
2.08 Physical or Psychological Stress - drugs
2.09 Lack of Knowledge - misunderstood directions
2.10 Improper Motivation - improper performance is rewarded
Possible Work-Env Factors Possible Work-Env Factors Possible Work-Env Factors 2.11 Improper Motivation - inadequate discipline
2.12 Inadequate Work Standards - inadequate communication of standards
Proposed Observation - Black font Potential Immediate Cause - Blue font Possible Root Cause - Green font
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Proposed Observation 2.0
Victim did not follow superintendent's order to reposition the manlift (with wheels perpendicular to tank wall) before resuming work.
Potentially Substandard Act 2.1 - Failure to React - Correct
Potentially Substandard Act 2.2 - Failure to Follow Procec licv - Practice
Potentially Substandard Ac inq Equipment Improperly
Victim was using the manlift in an unsafe manner contrary to good practice, and did not respond to superintendent's instructions to correct the situation. This was
apparently unusual behavior for the victim.
Possible Personal Factors 2.01 - 2.08
Victim's reasons for failing to follow superintendent's instructions may have been related to health issues which are not known at this time.
Possible Personal Factor 2.09 - Lack of Knowledge - misunderstood directions
Victim may have misunderstood the superintendent's instructions.
Possible Work Env. Factor 2.10 - Improper Motivation - improper performance s rewarded
Victim may have ignored instructions to save time. Company culture may reward productivity over safety.
Possible Work Env. Factor 2.11 - Improper Motivation ? inadequate discipline
Inadequate disciplinary policy and/or practice may not discourage rule breaking.
Possible Work Env. Factor 2.12 - Inadequate Work Standards - inadequate communication of standards
It's possible that the victim was not aware of the right/safe way to position the manlift's wheels.
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RCA BY: MODIFIED - SYSTEMATIC CAUSAL ANALYSIS TECHNIQUE e
Torch cutting and excavator pushing on tank wall took place w/o site superintendent
Proposed Observation 3.0
present
Potentially Substandard Potentially Substandard 3.1 Operating Equipment Without Authority
Acts Acts 3.2 Failure to Follow Procedure - Policy - Practice
3.01 Inadequate Mental or Psychological Capability -emotional disturbance
3.02 Inadequate Mental or Psychological Capability - mental illness
3.03 Mental or Psychological Stress - mental illness
3.04 Mental or Psychological Stress - preoccupation with problems
Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors Possible Personal Factors 3.05 Mental or Psychological Stress - emotional overload
3.06 Physical or Psychological Stress - injury or illness
3.07 Physical or Psychological Stress - blood sugar insufficiency
3.08 Physical or Psychological Stress -drugs
3.09 Lack of Knowledge - misunderstood directions
3.10 Improper Motivation - improper performance is rewarded
Possible Work-Env Factors Possible Work-Env Factors Possible Work-Env Factors 3.11 Improper Motivation - inadequate discipline
3.12 Inadequate Work Standards - inadequate communication of standards
Proposed Observation - Black font Potential Immediate Cause - Blue font Possible Root Cause - Green font
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Proposed Observation 3.0
Torch cutting and excavator pushing on tank wall took place w/o site superintendent present.
Potentially Substandard Act 3.1 - Operating Equipment Without Authority
Potentially Substandard Act 3.2 - Failure to Follow Procec Icy - Practice
CWC superintendent could see both the inside and outside of the tank putting him in a position to decide if he felt the manlift was in a safe position, far enough
away from the tank wall, before signaling the excavator operator to push in the tank wall. CWC company procedure calls for supervision during tank demolition.
With the superintendent called away to the front gate, the victim raised the manlift cage higher than the edge of the tank and signaled the excavator operator to
push in the tank wall. In doing so, the victim increased the likelihood of tipping over and the severity of falling from a greater height. The excavator operator was
not in a position to judge the distance of the manlift from the tank wall, and should have waited for the superintendent to return before pushing the wall in.
Possible Personal Factors 3.01 -3.08
Victim's reasons for failing to wait for the superintendent to return may have been related to health issues which are not known at this time. Excavator operator's
actions could be grounds for disciplinary action.
Possible Personal Factor 3.09 - Lack of Knowledge - misunderstood directions
Victim and excavator operator may have misunderstood the superintendent's instructions.
Possible Work Env. Factor 3.10 - Improper Motivation - improper performance is rewarded
Victim and excavator operator may have ignored instructions to save time. Company culture may reward productivity over safety.
Possible Work Env. Factor 3.11 - Improper Motivation - inadequate discipline
Inadequate disciplinary policy and/or practice may not discourage rule breaking.
Possible Work Env. Factor 3.12 - Inadequate Work Standards - inadequate communication of standards
It's possible that the company has not communicated rules regarding work while not under direct supervision of the superintendent.
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RCA BY: MODIFIED - SYSTEMATIC CAUSAL ANALYSIS TECHNIQUE e
Victim was said to be acting sufficiently strangely, out of character, (but not apparently
under the influence), for co-workers to take notice, and for the site superintendent to ask
him if everything was all right. Victim reported that he felt ok to work and that his doctor
had very recently given him a new prescription. Autopsy did not detect the presence of
Proposed Observation 4.0 alcohol or illegal drugs. CWC reports that their company program requires employees to
report the use of prescription medications that may affect their ability to work safely. CWC
also reported that the victim followed company policy in this regard. Given these facts it is
unclear why the superintendent allowed the victim to continue to perform his normal duties
on the day of the accident.
Potentially Substandard
4.1 Under The Influence of Alcohol or Other Drugs
Act
4.01 Inadequate Mental or Psychological Capability -emotional disturbance
4.02 Inadequate Mental or Psychological Capability - mental illness
4.03 Mental or Psychological Stress - mental illness
Possible Personal Possible Personal Possible Personal Possible Personal Possible Personal Possible Personal Possible Personal Factors Factors Factors Factors Factors Factors Factors 4.04 Mental or Psychological Stress - preoccupation with problems
4.05 Mental or Psychological Stress - emotional overload
4.06 Physical or Psychological Stress - injury or illness
4.07 Physical or Psychological Stress - blood sugar insufficiency
- inadequate identification and evaluation
Possible Work Env. Factor 4.08 Inadequate Leadership and/or Supervision
of loss exposures
Proposed Observation - Black font Potential Immediate Cause - Blue font Possible Root Cause - Green font
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Proposed Observation 4.0
Victim was said to be acting sufficiently strangely, out of character, (but not apparently under the influence), for co-workers to take notice, and for the site
superintendent to ask him if everything was all right. Victim reported that he felt ok to work and that his doctor had very recently given him a new prescription.
Autopsy did not detect the presence of alcohol or illegal drugs. CWC reports that their company program requires employees to report the use of prescription
medications that may affect their ability to work safely. CWC also reported that the victim followed company policy in this regard. Given these facts it is unclear why
the superintendent allowed the victim to continue to perform his normal duties on the day of the accident.
Potentially Substandard Act 4.1 - Under The Influence of Alcohol or Other Drugs
It is not known what prescription drugs the victim was taking or their potential effect of the victim's ability to perform his duties safely. It is also not known if the
victim had a medical condition that was causing him distress at the time of the accident.
Possible Personal Factors 4.01 - 4.07
Victim's reasons for acting out of character may have been related to health issues which are not known at this time.
Possible Work Env. Factor 4.08 - Inadequate Leadership and/or Supervision - inadequate identification and evaluation of loss exposures
Superintendent may not have the training, skill, or knowledge to assess the victim's condition.
Superintendent's assessment of the victim's condition may have been inaccurate.
Superintendent may not have considered the severity of the consequences of allowing the victim to proceed with work on the day of the accident.
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RCA BY: MODIFIED - SYSTEMATIC CAUSAL ANALYSIS TECHNIQUE e
CWC was using manual means with hand-held cutting torches (manual labor) to take apart
Proposed Observation 5.0
the tanks - (in conflict with the methods stated in their Demolition Work Plan)
Potentially Substandard Potentially Substandard 5.1 Failure to Identify Hazard/Risk
Acts Acts 5.2 Failure to Follow Procedure - Policy - Practice
- inadequate assessment of loss
5.01 Inadequate Engineering
exposures
Possible Work Env. Possible Work Env. Possible Work Env. - inadequate identification and evaluation
Factors Factors Factors 5.02 Inadequate Leadership and/or Supervision
of loss exposures
5.03 Inadequate Tools & Equipment - inadequate availability
Proposed Observation - Black font Potential Immediate Cause - Blue font Possible Root Cause - Green font
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Proposed Observation 5.0
CWC used men on elevated work platforms (manlifts) with cutting torches performing manual labor to cut apart the tanks - (in conflict with the methods stated in
their Demolition Work Plan - see italicized text below)
Demolition of all buildings and structures at the facility will be performed by mechanical means utilizing heavy equipment with specialized demolition attachments.
Cl/I/C's track excavators wili be equipped with specialized attachments such as hydraulic breakers, shears, grapples, and pulverizers. As a rule, CWC will use heavy
equipment to complete the demolition and site clearing on this project for a majority of the structures and buildings. CM/C's procedures will limit the use of labor to the
most controlled and safe conditions and rely upon mechanized means of removal wherever possible.
PG&E Contract No. 3500927058 Pago 37 of 122
Potentially Substandard Act 5,1 - Failure to Identify Hazard/Risk
Three independent experienced tank demolition practitioners were consulted by Bureau Veritas to comment on the methods as planned and as deployed by CWC,
They are:
Alia' a ' ? ' - r ' , ? i', oowledgeal 1 i ' >, _ jnd nc -M , C ank d < ? / ? - ' ?; the torch
cutting method employed by CWC is outdated and is no longer an accepted industry best practice. All three agreed that as equipment improved to work at greater
heights the accepted industry best practice is to use mechanical means (excavators with shears for example) exclusively to dis-asseruble tanks avoiding manual
labor, and the hazards inherent in torch cutting (burns, fumes, lead exposure, etc.), and working at height (falls). Further, on the specific topic of demolition of
floating top tanks, each agreed that tank height was irrelevant, since shearing could be initiated from the bottom of the tank rather than the top. It is unclear why
CWC continues to use a work method acknowledged by experts to be more hazardous.
Possible Work Env. Factor 5.01 - Inadequate Engineering ? inadequate assessment of loss exposures
Possible Work Env. Factor 5.02 - Inadequate Leadership and/or Supervision - inadequate identification and evaluation of loss exposures
The risks of torch cutting and working at height have contributed to making this method no longer an industry best practice, now that other safer mechanical
methods are available. It is not known why this change in proposed work method was allowed to proceed in the manner that it did without an additional assessment
of hazards and risks.
Potentially Substandard Act 5.2 - Failure to Follow Procedure - Policy - Practice
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The mechanical method for cutting up tanks (described in the Demolition Work Plan) that was agreed to as part of bid process was not being followed.
It is not known why CWC decided to change the method of cutting up the tanks after committing to using mechanical means and minimizing manual labor in their
Demolition Work Plan, This decision was directly responsible for putting employees at risk.
Possible Work Env. Factor 5.03 - Inadequate Tools and Equipment - inadequate availability
It's not clear whether CWC had the right equipment available to do the job mechanically. Evidence was presented by the PGE site representative that excavators
(Link Belt 5800) with a shears capable of shearing at heights up to 35 feet, according to manufacturer specifications, were on site. Excavators capable of shearing
up to 40 feet high, according to manufacturer specifications was on site (Link Belt 700) but did not have shears attached. Their operational readiness at the time of
the incident are not known at this time.
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RCA BY: MODIFIED - SYSTEMATIC CAUSAL ANALYSIS TECHNIQUE ?
Excavator pushed tank wall in while workers were "working at height" inside the tank -
Proposed Observation 6.0
(in the line of fire)
Potentially Substandard Potentially Substandard 6.1 Failure to Identify Hazard/Risk
Acts Acts 6.2 Failure to Follow Procedure - Policy - Practice
6.01 Lack of Knowledge - lack of experience
- inadequate identification and
6.02
evaluation of loss exposures
- lack of supervisory/management job
6.03 Inadequate Leadership and/or Supervision Inadequate Leadership and/or Supervision Inadequate Leadership and/or Supervision
knowledge
Possible Work Env. Possible Work Env. Possible Work Env. Possible Work Env. Possible Work Env. - inadequate instructions, orientation
6.04
Factors Factors Factors Factors Factors and/or training
- inadequate assessment of loss
6.05 Inadequate Engineering
exposures
6.06 Inadequate Tools and Equipment - Inadequate availability
Proposed Observation - Black font Potential Immediate Cause - Blue font Possible Root Cause - Green font
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Proposed Observation 6.0
Excavator pushed tank wall in while workers were "working at height" inside the tank - (in the line of fire).
Potentially Substandard Act 6.1 - Failure to Identify Hazard/Risk
Accident prevention during this procedure relies on the CWC superintendent's presence and unfailing ability to accurately judge how far away the man lifts must be
before the tank wall can be safely pushed in. While this may not have resulted in an accident in the past, it seems an unnecessary (and therefore unacceptable) risk-
to allow workers to be working at height inside the tank when the tank wall is being pushed in.
Possible Work En v. Factor 6.01 - Lack of Knowledge - lack of experience
Possible Work Env. Factor 6.02 - Inadequate Leadership and/or Supervision - inadequate identification and evaluation of loss exposures
Possible Work Env. Factor 6.03 - Inadequate Leadership and/or Supervision - lack of supervisory/management job knowledge
None of the employees and/or people in an oversight role recognized the unnecessary risk involved and the simple solution of having workers leave the tank each
time a section of the cut tank wall was about to be pushed into the tank.
Potentially Substandard Act 6.2 - Failure to Follow Procedure-Policy-Practice
CWC superintendent could see both the inside and outside of the tank putting him in a position to decide if he felt the manlift was in a safe position, far enough
away from the tank wall, before signaling the excavator operator to push in the tank wall. CWC company procedure calls for supervision during tank demolition.
With the superintendent called away to the front gate, the victim raised the manlift cage higher than the edge of the tank and signaled the excavator operator to
push in the tank wall. In doing so, the victim increased the likelihood of tipping over and the severity of falling from a greater height. The excavator operator was
not in a position to judge the distance of the manlift from the tank wall, and should have waited for the superintendent to return before pushing the wall in.
Possible Work Env. Factor 6.02 - Inadequate Leadership and/or Supervision - inadequate identification and evaluation of loss exposures
None of the people in an oversight role recognized the unnecessary risk involved
Possible Work Env. Factor 6.04 ? Inadequate Leadership and/or Supervision - inadequate instructions, orientation and/or training
While leaving the work area the superintendent may not have told the excavator operator to wait until his return before restarting work.
Possible Work Env. Factor 6.05 - Inadequate Engineering - inadequate assessment of loss exposures
CWC management condoned the practice of allowing employees to be working at height inside the tank when the tank wail is being pushed in.
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Potentially Substandard Condition 6.3 - Inadequate Preparation - Planning
It is not known why CWC did not follow the Demolition Work Plan, Inadequate preparation and planning are plausible components.
Possible Work Env. Factor 6.06 - Inadequate Tools and Equipment - inadequate availability
It's not clear whether CWC had the right equipment available to do the job mechanically. Evidence was presented by the PGE site representative that excavators
(Link Belt 5800) with a shears capable of shearing at heights up to 35 feet, according to manufacturer specifications, were on site. Excavators capable of shearing
up to 40 feet high, according to manufacturer specifications were on site (Link Belt 700) but did not have shears attached. Their operational readiness at the time of
the incident,, are not known at this time.
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RCA BY: MODIFIED- SYSTEMATIC CAUSAL ANALYSIS TECHNIQUE .
Contractors' in-house safety programs required by regulation for the kind of work
they perform were not evaluated against established criteria prior to their being
accepted as an approved vendor and being allowed to bid on proposals. Contractor
Proposed Observation 7.0 self-reported safety performance data is not checked for accuracy. Experience
Modification Rates (EMRs) reported for CWC and their 2 main subcontractors for 2010
and 2011 do not match OSHA rates for the same period (which were zeros). This is
possible but very unlikely.
7.1 Failure to Identify Hazard/Risk
Potentially Substandard Acts Potentially Substandard Acts
7.2 Failure to Check/Monitor
Potentially Substandard
7.3 Inadequate Information or Data
Condition
Possible Personal Factor 7.01 Lack of Knowledge - lack of experience
- inadequate identification and
7.02 Inadequate Leadership and/or Supervision
Possible Work-Env. Factor evaluation of loss exposures
7.03 Inadequate Purchasing - inadequate contractor selection
Proposed Observation - Black font Potential Immediate Cause - Blue font Possible Root Cause - Green font
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Proposed Observation 7.0
Contractors' in-house safety programs required by regulation for the kind of work they perform were not evaluated against established criteria prior to their being
accepted as an approved vendor and being allowed to bid on proposals. Contractor self-reported safety performance data is not checked for accuracy. Experience
Modification Rates (EMRs) reported for CWC and their 2 main subcontractors for 2010 and 2011 do not match OSHA rates for the same period (which were zeros).
This is possible but very unlikely.
Potentially Substandari ilure to Identify Hazard/Risk:
Procurement process does not identify risks associated with hiring contractors whose in-house safety programs are sub-standard.
Possible Personal Factor 7.01 - Lack of Knowledge - lack of experience:
In-house staff may not posses the knowledge or experience to evaluate contractors' compliance with regulatory requirements for contractors' in-house safety
programs.
Possible Work-Env. Factor 7.02 - Inadequate Leadership and/or Supervision - inadequate identification and evaluation of loss exposure:
Procurement leadership did not identify and evaluate the risks associated with hiring contractors whose in-house safety programs may be sub-standard.
Possible Work-Env. Factor 7.03 - Inadequate Purchasing - inadequate contractor selection:
There is a lack of in-house capability to accomplish the task of evaluating a contractor's compliance with regulatory requirements, during the qualification process.
An outside contractor specializing in this area should be considered to accomplish the task.
Procurement process does not check/monitor the accuracy or validity of the safety information provided by prospective contractors during the qualification process.
Possible Work-Env. Factor 7.02 - Inadequate Leadership and/or Supervision - inadequate Identification and evaluation of loss exposure:
Procurement leadership did not identify and evaluate the risks associated with hiring contractors whose safety qualification data may be inaccurate or false.
Possible Work-Env. Factor 7.03 - Inadequate Purchasing - Inadequate contractor selection:
There is a lack of in-house capability to accomplish the task of validating the safety data provided during the qualification process An outside contractor
specializing in this area should be considered to accomplish the task.
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Potentially Substandard Condition 7,3 - Inadequate Information or Data
Procurement process does not evaluate the safety programs of prospective contractors.
Procurement process does not have established criteria to evaluate the safety programs of prospective contractors.
Procurement process does not have adequate information to evaluate prospective contractors' safety programs.
Procurement process does not validate the safety qualification data provided by prospective contractors.
Procurement process does not have adequate information to evaluate prospective contractors' safety programs.
Possible Personal Factor 7.01 - Lack of Knowledge - lack of experience:
[n-house staff may not posses the knowledge or experience to evaluate contractors' compliance with regulatory requirements for contractors' in-house safety
programs.
Possible Work-Env. Factor 7.02 - Inadequate Leadership and/or Supervision - inadequate identification and evaluation of loss exposure:
Procurement leadership did not identify and evaluate the risks associated with hiring contractors whose in-house safety programs may be sub-standard.
Possible Work-Env. Factor 7.03 - Inadequate Purchasing - inadequate contractor selection:
There is a lack of in-house capability to accomplish the task of evaluating a contractor's compliance with regulatory requirements, and/or validating the safety
qualification data provided by the contractor during the qualification process. An outside contractor specializing in this area should be considered to accomplish the
task.
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RCA BY: MODIFIED - SYSTEMATIC CAUSAL ANALYSIS TECHNIQUE
It is conceivable (though unlikely) that during the several years that the site was dormant
the ground under the tank might have subsided. CWC's effort to insure the integrity of the
tank floor before workers and equipment went in the tank by having "tracked vehicles"
Proposed Observation 8.0
enter the tank first might not have detected smaller problems because the vehicle's tracks
spread the weight of the vehicle over a large surface. They might have detected larger
problems by have the tracked vehicle fall through the floor into a hole.
8.1
- inadequate assessment of loss
Possible Work Env. Factor 8.01 Inadequate Engineering
exposures
Proposed Observation - Black font Possible Root Cause - Green font
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Proposed Observation 8.0
It is conceivable (though unlikely) that during the several years that the site was dormant the ground under the tank might have subsided, settled, or become
unstable. CWC's effort to insure the integrity of the tank floor before workers and equipment went in the tank by having "tracked vehicles" enter the tank first might
not have detected smaller problems because the vehicle's tracks spread the weight of the vehicle over a large surface. They might have detected larger problems
by have the tracked vehicle fall through the floor into a hole. Although this did not prove to be an issue on this project, better methods of testing the floor for
problems, (e.g. inspection and tapping by a competent person, or ground penetrating radar) are available.
Potentially Substandard Act 8.1 - Failure to Identify Hazard/Risk
Possible Work En v. Factor 8.01 - Inadequate Engineering - inadequate assessment of loss exposures
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7.0 RECOMMENDATIONS FOR POSSIBLE PGE PROGRAM AND/OR MANAGEMENT SYSTEMS
IMPROVEMENTS
The contract between CWC and PGE clearly states that CWC has full responsibility for the safety and safety
oversight of any and all activities that take place on the site. Under these circumstances, PGE's ability to prevent an
accident would largely be limited to their choice of contractor to perform the demolition. Therefore the following
recommendations focus mostly on possible improvements to PGE's management systems for procuring services.
These recommendations are suggestions for improvements to PGE's management systems and programs based on
best practices and should not be construed in any way to suggest a failure of any due diligence on PGE's part in
hiring CWC.
RECOMMENDATION #01
APPLICABLE CAUSES/FACTORS-2.10. 2.11. 3.10. and 3.11
CONTRACTOR QUALIFICATION
PGE's procurement process should examine disciplinary policies as part of contractors' safety qualification.
In California a company's disciplinary policy should be found in the company's Injury - Illness Prevention Program.
(Note: CWC has a disciplinary policy.)
RECOMMENDATION #02
APPLICABLE CAUSES/FACTOR - 1.08. 2.08. 3.08 and 4.1
CONTRACTOR QUALIFICATION
Procurement process should examine and put a high value on contractor's policies regarding prescription drugs and
drug testing as part of contractors' safety qualification. (Note: CWC has a policy regarding prescription drug use.)
RECOMMENDATION #03
APPLICABLE CAUSES/FACTORS - 6.1. 6.01. 6.02. and 6.03
CONTRACTOR QUALIFICATION
The formal safety training and safety certifications of contractors' proposed site safety officers should be evaluated
before they are accepted in that role during the bid process.
(Note: CWC's site safety officer at KPP has training in asbestos and hazardous waste, an undergraduate degree in
construction technology, and five years experience as a site safety officer. It is possible his lack of certification
and/or formal training in safety management and risk assessment may have been contributing factors to his not
recognizing and addressing the hazards involved in the events leading up to the accident.)
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RECOMMENDATION #04
APPLICABLE CAUSES/FACTORS 5.2
CHANGE MANAGEMENT
When significant changes in the work methods agreed upon during the bidding process are proposed, there should
be a risk assessment conducted on the proposed new process including a discussion of additional hazards and
risks, necessary mitigation, and potential costs. It is unclear why such an assessment did not happen when CWC
chose to change the agreed upon process for demolishing tanks. It is also unclear why CWC chose to change the
agreed upon process for demolishing tanks. PGE's on-site representative should raise a red flag when aware of
such changes so that the change can be evaluated for new hazards and risks.
RECOMMENDATION #05
APPLICABLE CAUSES/FACTORS - n/a
CONTRACTOR QUALIFICATION
The role and responsibilities of any PGE on-site representative should be clearly defined in writing and
communicated to all on-site and project staff and contractors, in future similar projects, The qualifications of
candidates performing that role should be carefully evaluated, especially as it pertains to any assigned safety
responsibilities.
(Note: Although it was clearly understood that the PGE on-site representative at KPP has no assigned safety
responsibilities since the contract unambiguously places the full responsibility for all site safety matters with CWC,
the exact role and responsibilities of the PGE representative on site were not clearly defined. It was noted that his
diligence in tracking the progress of the project is why we have a video record of the accident to review.)
RECOMMENDATION #06
APPLICABLE CAUSES/FACTOR - n/a
TRAINING and LEARNING FROM EVENTS
To maximize and capture learnings from events to foster continuous improvement in the training of future site
representatives there should be a written record of the takeaway lessons learned during projects.
(Note: Contractors hired for their existing expertise, usually require little training to perform their work, beyond a
general orientation to the company. For this reason, PGE's training management systems were not examined in
detail as part of this RCA. However, it was noted that the current on-site representative received some orientation
benefit by spending a limited amount of time working with the previous incumbent before he left that role. Also, there
is an ongoing daily teleconference of on-site representatives from several projects that is used to discuss issues and
share solutions. Lastly, the on-site representative at KPP benefits from weekly one or two day visits from his PGE
manager.)
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RECOMMENDATION #07
APPLICABLE CAUSES/FACTOR - 7.0
CONTRACTOR QUALIFICATION
Procurement should consider employing a 3rd party specializing in assessing contractors' safety programs and
validating/tracking/ contractors' safety and insurance data. Pacific Industrial Contractor Screening (PICS) and
ISNetWorld are two well respected vendors of these services. (Note: PGE's Procurement group has also identified
this potential improvement as part of their review.)
RECOMMENDATION #08
APPLICABLE CAUSES/FACTOR - N/A
LEARNING FROM EVENTS
Future tank demolition should follow the agreed upon contract language and use mechanical means avoiding the
use of manual labor whenever possible.
(Note: CWC's proposal for future tank demolition reduces risks significantly by prohibiting workers from being inside
the tank while mechanical means are employed.)
8.0 QUALITY ASSURANCE
As a world leader in providing services that our clients depend on, we continually strive to provide the highest quality. This
report has been reviewed as a part of our quality process.
This report was prepared bv: This report was reviewed by:
Redacted Redacted
Senior Managing Consultant Director, Management Consulting
Bureau Veritas North America, Inc. Bureau Veritas North America, Inc.
San Ramon Office San Ramon, CA Office
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APPENDIX A
LOSS CAUSATION MODEL - USING "WHY?" ANALYSIS
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LOSS CAUSATION MODEL* USING "WHY?" ANALYSIS
Because of Because of Because of Because of
People Contact With: Sub-standard Adverse: Inadequate:
Or At-risk:
Property Energy Acts Job Factors Program
Or and/or and/or
Production Substance Conditions Personal Factors Program
Exceeding Standards
Planet A Threshold Compliance To
(Environment) Standards
Public
Relations
PROFITS
?Reference:IRerlac li-Modified ILCI Less Causation Model
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SB GT&S 0768629

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