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Friday, 19 September 2014 12:05
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SB_GT&S_0768630.pdf
SB_GT&S_0768633.pdf
SB_GT&S_0768658.pdf
Content:

---------------------Page 1---------------------
Root Cause Analysis Report:
Worker Fatality
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Business Confidential
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 drove the lift backward until tie 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:
Cleveland Wrecking Company (CWC) utilized the "Why Tree" methodology for conducting this
investigation. The Why Tree approach is a logic -based model for evaluating an undesired event
(in this case, a worker fatality) to determine the underlying root cause(s) leading to the event.
The investigation team was led by HS&E managers from the URS Infrastructure and
Environmental (IE) Division and included representatives from CWC operations management
and the URS IE Legal Department.
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.
The Incident Timeline is provided in Figure 1. The "Why Tree Analysis" Diagram is provided
in Figure 2. The Program Enhancement plan is provided in Appendix A.
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
---------------------Page 2---------------------
Root Cause Analysis Report:
Worker Fatality
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Business Confidential
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 of California regulations, the
asbestos insulation needed to be removed prior to the initiation to the demolition of these
structures. Because CWC does not normally conduct asbestos abatement work, a specialty subĀ­
contractor 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 Kem
facility were dismantled.
At the time FIELD SUPERINTENDENTS crew started to work on the four fuel tanks, other workers
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 fectors
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 the 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.
---------------------Page 3---------------------
Root Cause Analysis Report:
Worker Fatality
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Business Confidential
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.
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 Lin k 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 torch 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
3
SB GT&S 0768635
---------------------Page 4---------------------
Root Cause Analysis Report:
Worker Fatality
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Business Confidential
section of wall, breaking the "stickers". Once pushed, the weight and momentum of thecut
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 SUPERINTENDENT wanted 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 for greater distances between the tank walls and
the lift carriages. 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 as FIELD 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 DECEDENT would need a few
minutes to reposition his lift; (4) FIELD SUPERINTENDENT thought he would return from the front
gate before they had finished their water.
---------------------Page 5---------------------
Root Cause Analysis Report:
Worker Fatality
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Business Confidential
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 un-cut wall. The top corner of the cut section then hung up momentarily
on the un-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 un-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 ofTHE 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.
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.
---------------------Page 6---------------------
Root Cause Analysis Report:
Worker Fatality
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Business Confidential
? 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
- Vi 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 k nown 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 THE 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.
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, THE
DECEDENT.
6
SB GT&S 0768638
---------------------Page 7---------------------
Root Cause Analysis Report:
Worker Fatality
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Business Confidential
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.
Corrective Actions/Program Enhancement:
As previously stated, it not possible to know precisely why THE DECEDENT proceeded to cut the
tank wall above the door while Superintendent FIELD SUPERINTENDENT was away. Regardless,
CWC was shocked
and greatly saddened by this event and has made a number of changes in our operations to
prevent similar incidents from ever happening again. Those changes include the following:
? A Senior Management Steering Committee has been established to provide safety
oversight of all CWC operations. The Committee will focus on enhanced CWC Health
and Safety management, program enhancement & development, employee training, and
program assessments. Corrective actions and recommendations will be documented and
assigned to a Responsible Party for resolution.
? Work plans will include diagrams or photos of the structures to be demolished with the
sequence of steps that will be employed to accomplish the task. Work plans will be
reviewed and approved by the CWC Director of Operations, Project Manager, and Health
and Safety Manager. A Registered Professional Engineer will also review plans that
involve demolition activities that could impact the stability of the structure.
? Changes to Work Plans will be reviewed and approved by the CWC Director of
Operations and the CWC Safety Manager. Changes that may impact the structural
integrity of the facility being demolished will also be reviewed and approved by a
Registered Professional Engineer.
? Field crews have been instructed to engage only in tasks that have been evaluated and
approved by the Superintendent.
? A CWC superintendent will be present for all tank demolition activities. Tank demolition
activities will be suspended if the superintendent is call away.
? Crews will not initiate cuts on tank walls until the locations have been approved and
identified by the superintendent.
? Field crews have also been instructed to suspend their work activities if they are unsure
of the proper procedure for safely completing the task or if they encounter changing
conditions that could impact the safety of the crew, client, or members of the public.
7
---------------------Page 8---------------------
Root Cause Analysis Report:
Worker Fatality
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Business Confidential
Please refer to Appendix A "Kern Power Plant Demolition Program Enhancement Plan" for
additional details.
Attachments:
Figure 1: Event Timeline
Figure 2: PG&E Kern Fatality "Why Tree" Diagram
Appendix A: Kern Power Plant Demolition Program Enhancement Plan
Appendix B: Tank 1 Work Plan
SB GT&S 0768640
---------------------Page 9---------------------
Figure 1
PG&E 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: (approximately)
? 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 comer (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: (approximately)
? Co-workers come to the aid of DECEDENT
? Emergency services are called
? Site operations are halted
---------------------Page 10---------------------
0920 - 0930: (approximately)
? Emergency personnel arrive, tend to THE DECEDENT, and transport him to hospital
SB GT&S 0768642
---------------------Page 11---------------------
SB GT&S 0768643
---------------------Page 12---------------------
APPENDIX A
Kern Power Plant Demolition Program Enhancement Plan
SB GT&S 0768644
---------------------Page 13---------------------
Appendix A
Program Enhancement Plan
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Program Responsible Si a ri 1: n d
hlemeni Program 1: nliancemcni Dale Dale
reuduieu
Leadership Leadership Leadership A Senior Management Steering In Ongoing
Committee will provide safety progress
oversight of CWC operations. The
Committee will focus on CWC Health
and Safety management, program
enhancement & development,
employee training, and program
assessments. Corrective actions and
recommendations will be documented
and assigned to a Responsible Party for
resolution.
A full time Health and Safety Manager Redacted 7/30/12 End of
will be assigned to the Kern Project. field
This person will report to the CWC activities
Director of Operations and work
closely the project superintendents.
This person will have intimate
knowledge of demolition industry and
have training in:
? Hazard recognition
? The URS Behavior Based Safety
programs with emphasis on 4-Sight.
? Emergency procedure.
? URS reporting requirements for
safety observations, near miss, and
incidents.
Health and safety structure will be Redacted 7/25/12 8/17/12
reorganized to include a foil time
HS&E manager.
Training Continue to provide BBS training to all Redacted Ongoing
field staff with added focus on the
fundamentals of 4-Sight including:
? Hazard identification and analysis
? Change management
? Stop work authority
? Fitness for duty
i
SB GT&S 0768645
---------------------Page 14---------------------
Appendix A
Program Enhancement Plan
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Program Re*poiiMhle Si a ri i ?; n d
Piemen l P ro e ra m 1 ? n li a nee men l Pane Dale Dale
Training Training Training Training This training will be provided to new
(Cont.) (Cont.) (Cont.) (Cont.) staff within the first week of
employment.
Training status of field staff will be
reviewed monthly to verify completion.
Redacted 8/6/12 8/10/12
CWC field supervisors and project
managers will receive additional
training on the fundamentals of project
execution, staff communication, and
changed conditions management. The
training will include the concept of
"critical conversations" as related to
safety.
Work plans will be reviewed and Redacted 7/16/12 Ongoing
approved by the CWC Director of
Operations, Project Manager, and
Health and Safety Manager. A
Registered Professional Engineer will
also review plans that involve
demolition activities that could impact
the stability of the structure.
The Health and Safety Plan (HSP) will Redacted 7/16/12 Ongoing
be modified to incorporate the
requirements for Safe Work Plans and
to provide additional focus on:
? Roles & responsibilities
? Emergency response procedures
? Observation, near miss, and incident
report procedures
? In-field hazard analysis (4-Sight)
? Change management procedures
? Fitness for duty expectations
2
SB GT&S 0768646
---------------------Page 15---------------------
Appendix A
Program Enhancement Plan
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Program Responsible Siari 1: n d
Piemen i Program F nhaneemeni Pariv Dale Dale
Training Training Training The HSP will be incorporated into the
(Cont.) (Cont.) (Cont.) Project Management Plan as a standĀ­
alone appendix to enhance
compatibility and consistency with the
2 documents.
Future projects will have a project -redacted
kick-off meeting and will be conducted H&S Manager
with all project staff prior to the
initiation of field activities and will
include identification of appropriate
Safe Work Plans required. At a
minimum, this meeting will include:
A brief review of the project work
plan
? Focused review of the FISP and
associated TFIAs.
Review of employee qualifications
and training
General project requirements
PPE requirements
Stop work authority
Change management procedures.
Fitness for duty expectations
Confirmation that employees with
English as a second language fully
understand the Plan.
Review of Safe Work Plans.
The daily tail gate safety meeting will Redacted 7/25/12 Daily
include:
Review Safe Work Plans that may
be performed.
Assignments and anticipated work
schedule for the day
Confirmation that employees with
English as a second language fully
3
SB GT&S 0768647
---------------------Page 16---------------------
Appendix A
Program Enhancement Plan
PG&E - Kern Power Plant Demolition
Bakersfield, CA
Program Responsible Siari 1! n d
I- lemeni Program I- nhancemeiu Pariv Dale Dale
Training understand the topics.
(Cont.)
? Review applicable JSAs
? Other issues or hazards that may
develop during the work day (bad
weather, other contractor activities,
fatigue, etc.)
THAs will be reviewed again if crew
composition changes during the day
(ie: if a crew is assigned to a particular
task and it is determined later that day
that additional workers are needed to
complete the tasks, applicable JSAs
will be reviewed again to verify all
team members understand task hazards
and controls).
Audits Audits A field audit will be conducted by URS Redacted 8/12 End of
H&S staff within the first two weeks of field
initiation (or resumption) of significant activities
field activities and each month
thereafter. Audit reports will be
submitted to the Senior Management
Steering Committee.
H&S manager (to be assigned) will Redacted 8/12 Ongoing
perform weekly audits (or as level of
work activities dictate)
4
SB GT&S 0768648
---------------------Page 17---------------------
APPENDIX B
SB GT&S 0768649
---------------------Page 18---------------------
Tank #1 Work Plan
SB GT&S 0768650
---------------------Page 19---------------------
"COAST TO COAST
628 E Edna Place
Covina, CA 91723
Phone: 626-967-9799
FAX: 626-967-1479
TANK #1 WORK PLAN
1. Back drag and level tank perimeter areas for boom lift operations using a track loader
2. Torch man will work from a boom lift positioned outside the tank cutting 3 strips of the cantilevered
portion of section #1 of the tank finishing with cut #4, felling the section within the tank(see photo
#1)
3. A grapple mounted excavator will remove fallen section #1 to a processing area.
4. The excavator will then re-position to the interior of the tank and secure the grapple to the stiffener
plate as indicated in photo #6. This will stabilize section #2 while the curvature is removed by
torching.
5. Torch man will work from boom lift positioned outside section #2 of the tank and begin torch
cutting along cut line 1 down to ring #3 of the tank.
6. Torching will continue laterally along ring #3 as illustrated with line 2 of photo ft6 through to the
north end of the section.
7. The excavator will relocate to the outside of the tank to support the removal of the remainder of
the tank.
Normal tank removal activities will resume working from the outside of the tank as detailed in photo ft5 and
the tank removal plan enclosed
---------------------Page 20---------------------
SB GT&S 0768652
---------------------Page 21---------------------
SB GT&S 0768653
---------------------Page 22---------------------
SB GT&S 0768654
---------------------Page 23---------------------
SB GT&S 0768655
---------------------Page 24---------------------
SB GT&S 0768656
---------------------Page 25---------------------
SB GT&S 0768657

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