Doe hanford hoist drop from monorail

Root Cause Analysis Report
Version as of May 6, 2004
Hoist Drop from Monorail 21 at K West
Spent Fuel Pool
March 10, 2004
Sponsor: D. M. Busche
Root Cause Analysis Team
W. J. Leonard, Team Leader
W. R. Corcoran, Senior Advisor
J. M. Lukes
M. E. Poole

Root Cause Analysis: Hoist Drop at K West Spent Fuel Pool on March 10, 2004
Page 2 of 117
Table of Contents
Executive Summary ........................................................................................................ 4
Glossary.......................................................................................................................... 5
Narrative.......................................................................................................................... 7
Eight Question (Phoenix) Analysis ................................................................................ 15
Missed Opportunity Matrix............................................................................................. 23
Influence-Consequence Matrices.................................................................................. 29
Hoist Drop .................................................................................................................. 30
Non-Notification.......................................................................................................... 31
Barrier Analysis Matrix .................................................................................................. 32
Discussion of Design Vulnerabilities.............................................................................. 38
Discussion of Process Vulnerabilities............................................................................ 38
Procedures................................................................................................................. 38
Training ...................................................................................................................... 39
Safety Vulnerability Audits.......................................................................................... 39
Discussion of Process Strength .................................................................................... 39
Discussion of Influences................................................................................................ 40
Corrective Action Recommendations ............................................................................ 42
Analysis of Expected Effectiveness of Recommended Corrective Action ..................... 47
Conclusions................................................................................................................... 47
Attachments .................................................................................................................. 48
Comparative TimeLine ©......................................................................................... 49
Why Staircase Trees............................................................................................... 73
Extent of Condition and Cause Matrix..................................................................... 83
Cause Codes .......................................................................................................... 92
Documents Reviewed ........................................................................................... 103
Personnel Contacted............................................................................................. 106
Analysts Comments .............................................................................................. 108
Structural Analysis Report..................................................................................... 111
Calculations........................................................................................................... 113
Unanswered Questions......................................................................................... 117

Page 3 of 117
Table of Figures
Figure 1 - Fuel Storage Monorail System........................................................................ 8
Figure 2 - Locking Arm & Weighted Safety Arm.............................................................. 9
Figure 3 - Flexible Transfer Crane................................................................................... 9
Figure 4 - Hoist Trolley Stopped Against Weighted Safety Arm.................................... 10
Figure 5 - Weighted Safety Arms In “UP” Position ........................................................ 11
Figure 6 - Hoist/Trolley Assembly Lying on Grating ...................................................... 11
Figure 7 - WSA Clearance ............................................................................................ 12

Page 4 of 117
Executive Summary
On March 10, 2004 at about 11:17 P.M. a monorail hoist fell from its monorail in the K-
West Basin Spent Fuel Pool and came to rest on a grating over the pool. There were no
personnel injuries, no radiological releases, and no significant equipment damage. It
was, however, a near miss because if workers had been in the fall trajectory of the hoist
they could have been injured, perhaps severely.
The Facility Manager and the Multi-Canister Overpack (MCO) Production Manager were
promptly notified, but the Department of Energy Facility Representative (DOE-FR) was
not promptly notified. This episode received press coverage and was the subject of a
letter from the DOE Richland Operations Office (RL) Manager to the Fluor Hanford (FH)
President.
The hoist fell because it was moved by a Radiological Control Technician (RCT) to
facilitate his regular duties and because the monorail hoist stop (Weighted Safety Arm)
that should have stopped the hoist was stuck in the up position. The causes of the
mispositioned Weighted Safety Arm are not fully known, but are believed to include
distortion of the Weighted Safety Arm or shaft by some kind of impact combined with
the failure to perform checks that would have identified the improper Weighted Safety
Arm conditions.
The prompt notification to the DOE-FR was not done because the personnel involved
incorrectly applied procedural requirements and failed to recognize the “near miss”
nature of the event shortly after it occurred. In the opinion of the team, the letter from
RL would not have been written had prompt notification of the event occurred.
Both RL and FH management have shown keen interest in this event and its
investigation.
Recommended corrective actions for the primary event include enhanced preventative
maintenance and enhanced operating requirements. Recommended corrective actions
for the reporting irregularity include clarification of the procedure and re-emphasis of
managements’ expectation for strict adherence to the contractual and procedural
requirement to notify the DOE-FR of any adverse events or conditions that are worthy of
being reported to the FH Facility Manager.

Page 5 of 117
Glossary
Item Description / Meaning
Contracts
Requirements
Document (CRD)
Contractual requirement with which Fluor Hanford must comply.
Specifically, the requirement that the DOE Facility
Representative must be promptly notified of non-reportable bad
news when the Facility Manager is notified. (CRD M 231.1-2
(Rev. 1), “Occurrence Reporting and Processing of Operations
Information”.)
Crane Inspection
Team (CIT)
Team formed by Spent Nuclear Fuel Project to evaluate crane
issues and make recommendations. Also called the Crane
Committee. (Letter 03-SNF-JKM-024, dated June 9, 2003,
“Establishment of the Spent Nuclear Fuel Crane Inspection
Team”)
Fuel Storage
Monorail System
(FSMS)
Extensive system over the K Basins for transporting spent
nuclear fuel stored under water. Components of the FSMS are
Hoists, WSAs, and FTCs. (See Figure 1)
Flexible Transfer
Crane (FTC)
Double rail trolley circling the perimeter of the fuel storage pool.
Used for transporting Spent Nuclear Fuel under water from one
parallel monorail to another. (See Figure 3)
Weighted Safety
Arm (WSA)
Safety Device for stopping errant hoist trolleys. Also called
Receiver Latch, Latch, and Rail Stop and Stop. WSAs are
mounted in parallel on a pivot shaft and hang from the top of the
monorail. When the FTC is latched with a monorail, the Locking
Arms automatically align the FTC and the WSAs rotate up so a
hoist can be rolled onto or off of the FTC. (See Figures 2, 4, and
5)
Locking Arm An extension of the WSA to align and secure an FTC to the
monorail. The Locking Arm is brazed to the top of the WSA. If
an FTC is not fully stopped before it is engaged with the
monorail, the Locking Arm may be bent outward from impact.
This results in inward bending of the WSA which can then
become stuck in the up position against the monorail. (See
Figures 2 and 7)
Non-Reportable
Event
An event or condition that does not require an occurrence report
in accordance with HNF-PRO-060, “Occurrence Reporting and
Processing of Operations Information”. RL has repeatedly
indicated that it wants to be notified of non-reportable events and
conditions that are the subjects of notifications to the Facility
Manager.

Page 6 of 117
Item Description / Meaning
Stand-Down Described in HNF-PRO-060 Appendix C “Occurrence Reporting
Categories and Criteria”, Group 4 “Facility Status”, Subgroup B
“Operations” (7) SC-4: “A facility or site stand-down resulting
from safety reasons reportable as an occurrence or occurrences.
NOTE: This is a secondary reporting criterion, and does not
require a separate occurrence report.” Compare with the next
higher level criterion, (6) SC-4*, ”A facility or operations
shutdown (i.e., a change of operational mode or curtailment of
work or process) directed by management for safety reasons.”
The latter is “reportable” (requires an occurrence report).
Production Pause A work stoppage not considered a stand-down, not defined in
HNF-PRO-060.

Page 7 of 117
Narrative
This event is the conjunction of two parallel developments, one having to do with
notifications and the other having to do with equipment. The ultimate consequence was
a letter of concern from DOE-RL to Fluor Hanford regarding delayed notification of
events and other issues.
Over the last few years, RL has become increasingly dissatisfied with the promptness of
notification of low-level “non-reportable” events that are sufficiently significant to require
informing facility management. This dissatisfaction eventually manifested itself by RL
imposing a change to the contract with FH. The Contract Requirements Document
(CRD) was implemented by FH in a change to its reporting process procedure, HNF-
PRO-060, “Reporting Occurrences and Processing Operations Information”.
The need for the change to HNF-PRO-060 was identified after the procedure was
through the review cycle. The need for the change was urgent and the time pressure
was sufficient that the CRD related addition was not sent back through the review cycle.
Thus, the reviewers were not afforded the opportunity to identify certain human factors
issues that would later turn out to be important.
The human factors issues involved are:
1) The use of the exact words from the CRD, and
2) The location of the change in a portion of the procedure called “Reportable
Occurrences”.
The wordy descriptions and location of the requirement in HNF-PRO-060 made it highly
likely that a person not specifically trained in the intent of the procedure change would
not perceive the basic simplicity of it. The basic simplicity of the intent is to have the
Facility Representative (FR) promptly notified of all non-reportable bad news that is
reported to the Facility Manager.
The FH Emergency Preparedness (EP) department had the responsibility to make and
implement the changes to HNF-PRO-060. There was no process to ensure that all
personnel who needed to change their notification behaviors would be trained to the
new requirements. In addition, there was no process to check that the new behaviors
would, in fact, take place. Thus, the Shift Operations Manager (SOM) who was on duty
when the hoist dropped had not been trained to the new requirements.
There was, however, a presentation by the EP Director to the Facility Managers Forum
covering the new requirements. Unfortunately, the person who was the K West Basin
Facility Manager (FM) on the night of the event was not in attendance because he was
not the K West Basin FM at the time of this presentation. In addition, the EP Director
did not cause checks to be made to ensure compliance with the new contract
requirements as listed in HNF-PRO-060.
Meanwhile, FH personnel had difficulties in recognizing and labeling “near miss”
(personnel injury) situations. Personnel are reluctant to declare near misses. This
reluctance is manifested in prolonged discussions as to whether or not a particular
event was a near miss.

Page 8 of 117
The K West Basin Fuel Storage Monorail System dates from the mid-1950s (Figure 1).
Recently the equipment has been used more frequently to support facility closure. The
use and misuse of this equipment has resulted in material deficiencies including tilted
monorails and distorted components.
Figure 1 - Fuel Storage Monorail System
The monorail Latch Assembly is made up of two key parts, the Locking Arm (Figure 2)
that engages a Flexible Transfer Crane (FTC) to the monorail (Figure 3), and the
Weighted Safety Arm (Figure 2) that acts as a rail stop when the FTC is not coupled.
“Normal” use of FTCs has included engaging the locking mechanism to the monorails
while the FTCs are still moving. This action causes the monorail’s Latch Assembly
Locking Arm to be impacted, likely bending the Locking Arm such that the Weighted
Safety Arm is bent in the opposite direction. This results in the WSAs contacting and
sticking in the up position on the monorail upper flange

Page 9 of 117
Figure 2 - Locking Arms & Weighted Safety Arms
Figure 3 - Flexible Transfer Crane
(Photo taken in passageway at south end of Monorail 21, about where the hoist landed,
looking east)
The Weighted Safety Arms (WSAs) are engineered safety devices for preventing a
hoist/trolley assembly from falling off the end of a monorail (Figure 4). “Normal” use of
the hoist trolleys has included allowing the hoists to collide with the WSAs. The Root
Cause Analysis (RCA) Team considers that this is a use of a safety device for
operational purposes. There are two disadvantages to this practice. First, the collisions
Locking
Arms
Weighted
Safety
Arms

Page 10 of 117
could damage the hoist trolley assembly, the WSAs, or the WSA shaft. (Note: For the
rest of this report, when we refer to bending to the WSA, please understand that the
same effects could have been caused by a bent shaft.) Second, if, for some reason, the
WSA is missing or stuck in the up position, the hoist trolley would not collide, but rather,
continue off the end of the monorail and fall in an area where personnel could be.
Figure 4 - Hoist Trolley Stopped Against Weighted Safety Arm
The annual Preventive Maintenance (PM) of the K West Basin monorail system was
completed in February, 2004, and did not result in the recording of any safety
discrepancies. Unfortunately, the records are not sufficient to provide adequate detail.
It is not clear whether discrepant conditions existed and actions were taken to correct
those conditions or whether no discrepant conditions existed. A recording of “No
Discrepancies” was made on the work record of the PM.
A variety of job classifications are needed in the K West Basin. Some, such as
Radiological Control Technicians (RCTs), do not receive hoisting and rigging training.
Many people, nevertheless, move hoists in order to do their assigned jobs unless they
are told to stop and get a qualified person.
On the night of March 10th
, 2004, an RCT moved a hoist on Monorail 21. Monorail 21
was tilted down toward the south. The RCT did not do any pre-use checks for this
seemingly trivial evolution. The RCT elected to push the hoist to the south (in the
direction of downward tilt). For unknown reasons, the WSA at the south end of Monorail
21 was stuck in the up position and was therefore unavailable to stop the traveling hoist
(Figure 5).

Page 11 of 117
Figure 5 - Weighted Safety Arms Stuck In “UP” Position
The hoist fell off the end of the monorail and landed on a grating in a spot that is
sometimes occupied by workers. Fortunately, at the time of the impact, there were no
workers and no equipment in the trajectory of the hoist (Figure 6).
Figure 6 - Hoist/Trolley Assembly Lying on Grating
The hoist casing was damaged. No other physical consequences resulted.
The personnel in the area, the RCT and four Nuclear Chemical Operators (NCOs),
heard the sound of the impact and verified the source. They stopped work and
informed the SOM.

Page 12 of 117
The SOM sent an Operating Engineer (OE) and an NCO to investigate the fallen hoist.
They found that the WSA at the south end of Monorail 21 was inexplicably in the down
position. They also found that when the WSA was pushed up, could become stuck in
the up position. The WSA was left in the up position for further evaluation on dayshift.
The OE cordoned off the area. The hoist drop into the area sometimes occupied by
people was not considered to be a near miss personnel injury event.
Figure 7 - WSA Clearance
The scrap processing crew received permission from the SOM to re-enter the basin to
complete process work.
The SOM reviewed HNF-PRO-060 for reportability, but found no guidance that
prompted him to notify the FR or to advise the FM that the FR should be notified. The
SOM notified the FM about the event and the near miss aspect of the event was
discussed (determined not to be a near miss), but notification to the FR was not. The
SOM then notified the Multi-Canister Overpack (MCO) Production Manager. Again,
neither notification to the FR nor the near miss was discussed.
The next morning, March 11, 2004, at the K West Basin Plan of the Day management
meeting, the hoist fall was discussed and determination was made for the Crane
Inspection Team to investigate. The Crane Inspection Team investigated K West and
found 9 damaged WSAs. Action was taken to correct the identified discrepancies.
There was no overt evidence that the Crane Inspection Team (CIT) realized that their
activities were affecting root cause analysis evidence. This could have been particularly
significant since the possibility of sabotage would later be considered and the WSAs
were potentially criminal evidence. The CIT did take photographs of some of the
damaged WSAs. They did not, however, record “as found” dimensions of the distorted
WSAs prior to making adjustments (straightening).
Normal
Clearance:
described by
Structural
Engineer as
“almost zero.”
Wear caused by
engagement with
moving FTC.

Page 13 of 117
Meanwhile, the FR called the FM and discussed a number of production issues. During
this conversation, the FM mentioned that the hoist fell off the monorail.
Later that morning, following the CIT investigation of the stuck WSA, the Fuel Storage
Monorail System (FSMS) Design Authority and the Engineering Manager met with the
SNF Project Deputy Director. No certain cause for the WSAs to become bent was
determined. Additionally, no certain cause for the WSA having been moved up was
determined. However, one of the people who had been involved in the investigation
disclosed to the Deputy Director that the WSAs may have been damaged intentionally.
Following this meeting the CIT inspected the K East Basin and confirmed (based on a
list provided by operators) that several WSAs were capable of sticking in the up
position. The Crane Inspection Team straightened the bent WSAs, breaking one in the
attempt.
The Deputy Director notified the SNF Vice President of the event, stating that the CIT
thought the WSAs were bent on purpose. The SNF Vice President then notified the FH
Vice President. Subsequently, the FH President and the DOE-RL Manager were
notified. The RL Manager called the Facility Representative Manager, who notified the
K West Basin FR. The FR had not been aware that the hoist fall was a result of a bent
WSA stuck in the up position or that it was a suspected act of sabotage.
At about 2:00 in the afternoon, the FH Executive Vice President directed the
implementation of a “Production Pause”. Also, the SNF Vice President notified site
security and security notified local law enforcement.
The only evidence obtained by the RCA Team was a seven line hand written, undated
personal statement. Some interviews were conducted prior to the critique meeting;
however, there does not appear to be any formal record of these interviews.
A Critique Meeting was scheduled for 6:30 that evening. The event and corrective
actions were discussed, but no probable causes were determined. Security and law
enforcement personnel were present at the meeting.
The hoist fall event was determined reportable as a Near Miss Occurrence following the
Critique Meeting.
The next day, March 12, 2004 the Tri-City Herald printed an article titled “Hanford
Officials Investigate K Basin Accident”. The newspaper article stated that work was
stopped throughout Hanford’s K Basins after an accident lead to an investigation that
found mechanical problems at both the K East and K West Basins. Discussion of
possible sabotage was mentioned, however, the article went on to state that the
evidence was inconclusive.
The same day, the DOE-RL Manager sent the letter of concern to the FH President
stating that RL was “extremely concerned about the degradation of hoisting safety
equipment and subsequent hoist drop off the monorail to the basin grating, which was
initially identified as a purposeful act”. They went on to state that they were “particularly
dissatisfied with the response actions from the time the hoist fell on Wednesday night,
March 10, 2004, until RL was notified of issues on Thursday afternoon, March 11,
2004”.

Page 14 of 117
On March 15, 2004 at about 8:00 in the morning, the SNF Deputy Director informed the
FH Executive Vice President that corrective actions had been completed. The
Production Pause was terminated based on a restart plan that had been approved by
the Executive Vice President.
On March 18, 2004 the FH VP of Regulatory Compliance appointed an “Independent
Review of Recent Near Miss at SNF”, headed by the Manager of Assessments. The
review team was convened to gather information about the event for a response to the
RL letter of concern. No formal report was issued from this review.
On April 2, 2004, The Tri-City Herald printed an article titled “K Basins accident
concerns DOE”. The newspaper article described the RL letter and the FH response to
the letter. The article indicated that FH now believes that the problem was not caused
by worker sabotage, but was caused by wear and tear on the equipment at the end of
its life cycle.
On April 5, 2004, a Root Cause Analysis Team was chartered to investigate two primary
issues of concern:
1) The near miss event involving the falling hoist, and
2) The delayed notification to RL personnel.
The items to be included were:
• Determine the facts associated with the event;
• Analyze the causes for the event;
• Identify the potential for similar events to occur at the SNF Project and rest of the
site, and;
• Provide recommendations for corrective action to the SNF Project and the rest of the
site.

Page 15 of 117
Eight Question (Phoenix) Analysis
This analysis provides summary answers to the Eight Questions for Insight and is a
brief high-level summary of the entire episode.
Eight Question (Phoenix) Analysis of Hoist Drop
Impact
1. Consequences
(Tangible and intangible
adverse effects)
o Actual:
1) Adverse letter from RL to FH.
2) Adverse press coverage.
3) Costs of a Production Pause of several days.
4) On-site investigation Costs.
5) Costs incurred in interfacing with RL over this incident.
6) Reduced employee moral due to accusations of
wrongdoing.
o Expected:
1) Increased RL scrutiny of FH activities and associated
costs.
2) Probable withholding of fees to FH.
3) Costs of repairing/replacing distorted Weighted Safety
Arms.
o Potential Consequences:
1) Severe personnel injuries and an extensive production
pause or shut down.
2. Significance (What
does this mean for the
future of the facility?)
o Precursor to:
1) More serious personnel, economic or customer
satisfaction consequences. (The behaviors and conditions
involved in this one would, if not corrected, be capable of
causing a much more serious event.)
2) Potential breakdown of the Occurrence Reporting
element of the Safety Management Program.
o Temporal and Spatial Extent:
1) Monorail problems: Several cases of distorted
Weighted Safety Arms were found in both K West and in
K East.

Page 16 of 117
Impact (continued)
2) Notifications: There have been other notification
shortfalls in the past. These prompted changes in contract
requirements, including requirements that were
specifically not met in this instance.
3) Previous failures to declare near misses.
4) Other safety device precursors.
5) Other departures from ISMS.
6) Other difficult administrative procedures.
7) Other problems caused by not using SAT.
o Barriers that did not succeed:
See items 3, 4, and 5 below.
o Remaining barriers:
1) Good fortune (There were no personnel in the fall
trajectory of the hoist).
o Campaign issues:
1) Personnel safety hazards
2) Notifications.
3) Near Miss calls.
4) Promptness and effectiveness of Critique Meetings.

Page 17 of 117
Influences on Consequences
3. Vulnerability (What
set us up for this
event?)
o Elevated monorail.
o Hoist rides on monorail.
o Hoist pendant, chain and chain bucket hang down
obstructing activities below.
o Monorail 21 is tilted toward the south end.
o Monorail 21 and hoist have low friction.
o Weighted Safety Arms prevent hoist dropping off end of
monorail when FTC not present.
o Single failure vulnerability.
o Weighted Safety Arm bent slightly causing interference
with Monorail 21:
1) Probably caused by repeated collisions of the
hoist/trolley assembly with the WSA and,
2) The impact of the FTC when coupling with the
monorail.
o WSA in the up position potentially caused by long tools
striking the WSA.
o Adverse impact of tool strikes not recognized.
o RCT not trained on hoist vulnerability to dropping off end
of monorail.
o RCT not trained to avoid relying on safety devices, e.g.,
WSAs.
o Practice of relying on Weighted Safety Arms to stop hoist.
o Practice of moving hoists without safety checkout.
o Practice of moving FTCs while coupling to monorails.
o ISMS not applied to routine RCT tasks.
o Collisions between hoist and Weighted Safety Arms not
considered as precursors.
o Collisions between FTCs and Locking Arms not
considered as precursors.
o PMs don’t find Weighted Safety Arm problems.

Page 18 of 117
Influences on Consequences (continued)
o Previous history of notification shortfalls.
o Previous history of “near miss” declaration shortfalls.
o Non-User-Friendly guidance on notification.
4. Trigger (What put the
ball in motion?)
o Radiological Control Technician moved hoist.
5. Exacerbation (What
made the
consequences as bad
as they were?)
o RCT did not keep positive control of the hoist trolley.
o Monorail elevation.
o Failure to notify Facility Representative.
o Previous FH performance issues (notification
deficiencies).
o Lack of questioning attitudes of managers.
o Imprudent references to “intentional act” and “sabotage”.
6. Mitigation (What kept
the consequences from
being a lot worse?)
o No personnel in fall trajectory.
o Prompt FH response to RL letter.

Page 19 of 117
Close Out
7. Lessons to be
Learned (What skills,
rules, and knowledge
should be added or
reinforced?)
o Notifying Facility Representative when Facility Manager is
notified of non-reportable “bad news” is not optional.
o Routinely using and relying on Weighted Safety Arms to
stop moving hoists is a bad practice.
o Routinely coupling moving FTCs with monorails is a bad
practice.
o Using safety devices as operational controls is a bad idea.
o Interviews and interview-assisted personal statements
should be obtained before the involved personnel leave
the site at shift end.
o Inflammatory words, such as “sabotage”, should be used
prudently and only when necessary.
o Professionals hate to find out bad news about their areas
of responsibility from their superiors (e. g., SNF DOE-FR
notified by DOE-RL FR Manager).
o Criminal investigations and Root Cause investigations
have different objectives and should not be combined.
o Every event should be scrutinized to determine the extent
to which it was a near miss to something much more
serious.
o Managers who receive bad news reports should exhibit a
questioning attitude toward the information received. In
particular, the caller should be queried about potential
circumstances that would make the bad news more
significant.
8. Corrective Actions
(What conditions and
behaviors should be
changed?)
o Interim compensatory measures:
1) Implemented a Production Pause (The Production
Pause was lifted following completion of actions 2, 3, and
4 below).
2) The Crane Inspection Team completed an evaluation
of the monorail system and adjusted other WSAs into
their proper position and verified proper operation.
3) Implemented a Long Term Order requiring a shiftly
check to verify WSAs are in the down position; to verify
WSAs are in the down position while performing
operations; and, to prohibit the hanging of tools off of the
WSAs.

Page 20 of 117
Close Out (continued)
4) Conducted management briefings on the event to
SNFP employees.
5) FH VP of Regulatory Compliance issued an e-mail to
all Project Vice Presidents to disseminate to their Facility
Managers the expectations for compliance with the
requirement to notify the FR whenever the FM is notified
of “non-reportable” bad news.
6) Provide stop-gap training on near miss identification
and FR notification expectations for all personnel involved
in the notification process.
o Corrective actions for symptoms and effects: (Complete)
1) “Straightened” the Weighted Safety Arm on Monorail
#21 and verified proper operation.
2) Replaced the cracked casing on the Hoist HOI-440 and
verified proper operation.
o Corrective actions for causes:
1) Change monorail hoist system operating procedures to
require that persons moving hoists must maintain positive
control of the hoist, and must not cause collisions
between the hoist and the WSAs.
2) Change monorail hoist system operating procedures to
require that before beginning evolutions involving hoists,
all monorail system safety features must be checked.
3) Change the FTC operating procedures to require that
persons moving FTCs do not cause collisions with the
monorail system (Locking Arms).
4) Rewrite HNF-PRO-060 to meet appropriate procedure
standards, including human factors.
5) Revise HNF-PRO-060 to require that every event be
suspected to be a near miss for something more serious
(e.g., would people normally work in an area that was in
the line of fire?)

Page 21 of 117
6) Revise training policy to require all training for new
requirements meets the intent of the SAT.
o Corrective actions for generic implications:
1) Examine other PM procedures for weaknesses similar
to the ones found in the monorail system procedures.
2) Check all PM procedures to assure that they require
returning the system to a reference condition after the
evolution.
3) Share this report with other facilities.
o Corrective actions for self-assessment deficiencies:
1) Change the text of the monorail system PM instructions
to clearly specify what needs to be checked and what the
acceptance criteria are.
2) Change the text of the monorail system PM instructions
to clearly specify the safety significance of the items being
checked.
o Disposition of Extraneous Conditions Adverse to Quality:
1) Management and the Bargaining Unit should agree on
the union’s role in investigations so that union leadership
does not obstruct.
2) Interviews of involved personnel should be conducted
before the end of the shift.
3) Experienced interviewers should assist personnel in
preparing personal statements.
4) Personal statements should be dated and signed, and
completed before the end of the shift.
5) Personnel who have not been trained in evidence
preservation should be barred from the scene of an
accident.
6) Any physical work on evidence should be done under
the work control process and the work control instructions
should include measures to prevent spoliation.

Page 22 of 117
7) The basis for both imposition and lifting of work
interruptions (Production Pause) should be documented.
8) Private deals to abrogate contractual requirements
must be discouraged (prompt notifications from FMs and
FRs).
9) The adherence to the intent of ISMS and SAT should
be transparent in work instructions and other documents.
One should be able to pick-up one of these documents
and tell that ISMS and/or SAT has been applied.
10) Personnel in high hazard environments should not
take action without ensuring that they posses the
qualifications/training. It is not acceptable for a person to
assume that the action they are about to take is trivial.
11) Criminal investigations should take precedence over
organizational learning investigations (critiques). If law
enforcement personnel are present, critiques should be
suspended.
12) FH Senior Management needs to ensure that bad
news that will be communicated to DOE-RL Senior
Management is first reported to the project Facility
Representative.
13) All investigative activities should result in written
documentation.
14) Subsequent chartered investigation teams should be
provided with all reports of previous investigative
activities.
15) Unintended and unanalyzed impacts between
equipment should be treated as abnormal events and
should be stopped pending engineering approval (e.g.,
impacts of long tools against overhead components.)
16) The effectiveness of corrective actions should be
checked some time after implementation.
o Follow-up plans:
1) Audit this facility and all facilities with similar
vulnerabilities to confirm that they accommodate the
lessons to be learned and corrective actions of this
incident.

Page 23 of 117
Missed Opportunity Matrix
This Matrix is a summary of the most significant situations in which ordinary people could have prevented the event or
made its consequences less severe by doing ordinary actions ordinarily well. The matrix is not intended to capture brilliant
insights or out-of-the-box thinking.
Who Situation Opportunity (action) Expected Result Impact on
Consequences/Remarks
EP Dissemination of
CRD requirements
Train all personnel
whose behaviors
needed to change, in
accordance with SAT
Personnel needing to
change their previous
behavior relating to prompt
notification to FR would
have done so
All the personnel involved in
notifying FRs of non-reportable
bad news would have been
trained to the CRD requirements.
It is more likely that notifications
would have been made.
EP During or after
dissemination of
CRD requirements
Trainees’ knowledge
should have been
checked both during
and after the training.
The behaviors of the target
population would have
been checked to ensure
prompt notifications were
being made and the
training would have been
modified if necessary
properly trained to the CRD
requirements.
EP Dissemination of
CRD requirements in
PRO-060
Plan the training in
order to accomplish a
specified result
have done so
trained to the CRD requirements.

Page 24 of 117
FM Dissemination of
CRD requirements in
PRO-060
Disseminate the
information provided in
the Facility Manager’s
Forum related to
prompt notification to
FR when FM is notified
of “bad news”
have done so
informed of the CRD
requirements.
EP Procedure Review
Process
Obtain peer review of
PRO-060 after CRD
requirements were
incorporated
Human factor issues would
have been identified
have done so
Procedure would have been more
user friendly
EP Dissemination of
CRD requirements
in PRO-060
Provided supplemental
information/continuing
training to personnel
who had been
previously trained
when CRD requirement
was added (not all
personnel received
training to the new
requirement).
have done so
informed of the CRD
requirements.
EP Procedure change
process
Verification and
validation of
administrative
procedures
Human factor issues would
have been identified
Procedure would have been more
user friendly

Page 25 of 117
FM Dissemination of
PRO-060 for prompt
notifications to FR
Provided information
from the Facility
Manager’s Forum on
prompt notifications to
the FR to their project
personnel.
have done so
informed of the CRD
requirements.
QA
Operations
Engineering
Safety
Performance of
periodic audits,
assessments, and
JHAs for K West
Basin Operations,
including the use of
hoists
Audits, assessments,
and JHAs should have
noticed the single point
failure vulnerability.
The event is aborted by
identifying the problem and
establishing additional
controls.
No event, however, the prompt
notification vulnerability remains in
place.
An example of a control would be
to hang caution tags on the hoists
when they are on slanted
monorails to say: CAUTION: Keep
positive control while moving hoist.
Monorail is tilted and hoist will
continue to travel on its own.
QA
Operations
Engineering
Safety
Performance of
periodic audits,
assessments, and
JHAs for K West
Basin Operations,
including the use of
hoists
Audits, assessments,
and JHAs should have
noticed the routine
repeated use of the
safety device to stop a
hoist.
controls.
No event

Page 26 of 117
Design
Authority
Thinking about
failure modes and
safety vulnerabilities.
Identify safety
vulnerabilities related
to the single point
failure and the
challenging of a safety
device (Weighted
Safety Arms).
controls.
No event.
Millwright
Supervisor
Preventative
Maintenance
Discrepancies (bent or
sticking Weighted
Safety Arms) should
have been found.
The discrepant condition of
the Weighted Safety Arm
would have been identified
and corrected.
No event
Operators Thinking about
impact in the
overhead from use of
long tools
Recognize that long
tools are impacting
overhead hoist system
equipment
Areas would be inspected
for damage and repairs
initiated if necessary
Potentially prevented event
Comment: The long tool may
have bent the Weighted Safety
Arm, or caused it to stick in the up
position. Evidence is inconclusive.
Operators Routine movement
of the hoist
Pre-use hoisting and
rigging checks should
identify safety
anomalies including the
Weighted Safety Arm
on Monorail 21 being in
the up position.
The pre-use checks would
have aborted the event by
identifying the Weighted
Safety Arm in the up
position.
No event
Operators Routine movement
of the FTC
Recognize that FTCs
are impacting Locking
Arms
FTCs would be stopped
before coupling with the
Locking Arm on the
monorail.
Potentially prevented event
Comment: The FTC impact may
have bent the Weighted Safety
Arm.

Page 27 of 117
SOM Compensatory
actions from hoist
fall.
Implement controls to
ensure other hoists
don’t fall off monorails
before resuming
normal operations.
Controls would have been
implemented.
Mitigation of RL concerns for
worker safety described in Letter
of Concern to FH.
SOM Found out that hoist
fell off monorail and
impacted an area
where workers
sometimes are
present.
SOM should have
recognized that this
was a near miss
personnel injury.
Reportability would have
been clearly established
and SOM would have
made notifications to FM
and FR
The prompt notification issue
would not have occurred.
FM Found out that hoist
fell off monorail.
FM should have asked
questions to reveal that
this was a near miss
personnel injury.
and SOM would have
made notifications to FR
MCO
Production
Manager
Found out that hoist
fell off monorail.
MCO Production
Manager should have
asked questions to
reveal that this was a
near miss personnel
injury.
and SOM would have
made notifications to FR
K West
Management
Chain (SOM &
FM)
Notification process FR should have been
notified in accordance
with SNF Notification
Guidelines and HNF-
PRO-060 for events
meeting the threshold
for notification of the
FM.
The FM or SOM would
have promptly notified the
FR.

Page 28 of 117
K West
Management
Chain (SOM &
FM)
Notification process FM and SOM should
have been aware of RL
concern for receiving
prompt notification.
The FM or SOM would
have promptly notified the
FR.
VP S&H Escalating customer
dissatisfaction with
prompt notification of
non-reportable bad
news
Find out about
escalating
non-reportable bad
news
Assure that EP understood
the purpose of the changes
to PRO-060 to
accommodate CRD
requirements
Change would have been better,
training would have been better
and the notification issue would
not have happened
Collective
Feedback
Community
Escalating customer
non-reportable bad
news
Take instances of
customer
prompt notifications,
record them, analyze
them, implement
corrective actions, and
disseminate lessons to
be learned
Notifications would have
been done as required by
the CRD
would not have occurred

Page 29 of 117
Influence-Consequence Matrices
Explanation of Influence-Consequence Matrices
See one of the two matrices on the next two pages. These matrices display important influences on the consequences
and how the removal of a single influence would have impacted the consequences.
In the Influence-Consequence Matrix for the Hoist Drop, for example, the upper part of the left hand column lists important
influences on the consequences of the hoist drop. The lower part of the left hand column lists the types of consequences.
The next column indicates that in the actual case all of the influences were present and the actual consequences resulted.
The remaining columns relate to hypothetical cases in which, respectively, certain influences are assumed to have been
negated. At the bottom of each of these hypothetical case columns one sees the consequences that would have resulted
from the hypothetical case.
One sees readily from that matrix that there were seven individual influences (causes) that, if it had not been there the
hoist would not have dropped.

Page 30 of 117
Hoist Drop
Influences Actual
Case
Case 1
WSA
straight
Case 2
WSA
down
Case 3 MR
level
Case 4 RCT
pushes
hoist N
Case 5 RCT
holds onto
hoist
Case 6 Pre-
use check of
WSA
Case 7
PM ID’s bent
WSA
Case 8
Person
under end of
MR
WSA is bent Yes No Yes Yes Yes Yes Yes Yes Yes
WSA is up Yes No, WSA
would
drop
No Yes Yes Yes Yes Yes Yes
M 21 is tilted to
S
Yes Yes Yes No Yes Yes Yes Yes Yes
RCT pushes
hoist to S
Yes Yes Yes Yes No Yes Yes Yes Yes
RCT does not
maintain +Ctrl
Yes Yes Yes Yes Yes No Yes Yes Yes
No pre-use
check of WSA
Yes Yes Yes Yes Yes Yes No Yes Yes
PM does not ID
bent WSA
Yes Yes Yes Yes Yes Yes Yes No Yes
No person
under end of
MR
Yes Yes Yes Yes Yes Yes Yes Yes No
Consequences
Hoist Dropped,
casing
broke
None None Probably
None
None None None None Dropped,
casing not
broken
Personnel None None None None None None None None Injury or
death

Page 31 of 117
Non-Notification
Influences Actual
Case
Case 1
Previous
notification
success
Case 2 No
CRD
Case 3
Mgmt
chooses
effective
wording
Case 4
PRO-060
is human
factored
Case 5
PRO-060
training
per SAT
Case 6
Realistic
“near miss”
sensitivity
Case 7
Questioning
attitude by
FM
Case 8
Questioning
attitude by
MCO Mgr
RL unhappy w/
notifications
Yes No Yes Yes Yes Yes Yes Yes Yes
CRD on
notifications
Yes Yes No Yes Yes Yes Yes Yes Yes
PRO-060 uses
CRD wording
Yes Yes Yes No Yes Yes Yes Yes Yes
PRO-060 LTA
human factored
Yes Yes Yes Yes No Yes Yes Yes Yes
Ineffective PRO-
060 training
Yes Yes Yes Yes Yes No Yes Yes Yes
Inadequate “near
miss” sensitivity
Yes Yes Yes Yes Yes Yes No Yes Yes
Inadequate
challenge by FM
Yes Yes Yes Yes Yes Yes Yes No Yes
Inadequate
challenge by
MCO Mgr
Yes Yes Yes Yes Yes Yes Yes Yes No
Consequences
FR not promptly
notified per CRD
Yes FR not
promptly
notified per
CRD
FR not
promptly
notified
per CRD
FR
promptly
notified
per CRD
FR
promptly
notified
per CRD
FR
promptly
notified
per CRD
FR promptly
notified per
“near miss”
requirement
FR promptly
notified per
CRD
FR promptly
notified per
CRD
Letter of concern
from RL
Yes Probably no
letter
Letter of
concern
from RL
Probably
no letter
Probably
no letter
Probably
no letter
Probably no
letter
Probably no
letter
Probably no
letter

Page 32 of 117
Barrier Analysis Matrix
The Barrier Analysis Matrix is an implementation of the Threat-Barrier-Target Model,
which has been a mainstay of the DOE approach to Root Cause Analysis for many
decades. The matrix below evaluates the principal barriers in terms of their
effectiveness during this episode only. Failed, missing, and ineffective barriers are often
causes of adverse events. The Barrier Analysis Matrix does not provide analysis of the
causes of the problem barrier conditions.
Barrier Analysis Matrix ©
Barrier Target
Protected
Threat Effectiveness
in this case
Significance
Note: In Barrier Analysis a 'barrier' is a device, measure, entity, or the like that has the
effect of reducing the probability or consequences of a 'threat' to a 'target'. Devices that
could have or are intended to have the same effect are also called 'barriers'.
Note: Barriers that did work can be retained and reinforced. Barriers that did not exist can
be deployed. Barriers that existed, but did not work, can be strengthened.
SNF Project
Notification
Guideline
Compliance
with
notification
requirements
Notifications
not made
Not Effective:
Guideline did not
ensure the FR
would be notified
when the FM is
notified of bad
news.
Missed
Opportunity:
Notification to
FR not made
FH sensitivity
to RL
requirement
that prompt
notification was
required for
non-reportable
bad news
Customer (RL)
satisfaction
Customer
(RL) finds out
they have not
been notified
as required
Not Effective:
Despite a history
of customer
dissatisfaction in
this area, FH did
not take effective
steps to rectify the
situation
Missed
Opportunity:
FH not sensitive
to RL
dissatisfaction
with lack of
prompt
notification.
FH Feedback
Systems (i.e.,
LL, RCA)
RL satisfaction
with prompt
notification
Lack of
awareness of
problems
Not Effective:
These processes
were not triggered
because there
was no
documentation of
customer
dissatisfaction –
required to initiate
feedback
processes
Missed
Opportunity:
The feedback
system did not
recognize an
emerging
escalating
problem

Page 33 of 117
Barrier Target
Protected
in this case
Significance
HNF-PRO-060 Compliance
with prompt
notification
requirement
for non-
reportable bad
news.
Non-
compliance
with prompt
notification
requirement
Not Effective:
Human Factors
not considered.
May have
prevented non-
notification
Review
process for
change to
HNF-PRO-060
Compliance
with prompt
notification
requirement
for non-
reportable bad
news.
Non-
compliance
with prompt
notification
requirement
Not Effective:
Procedure change
was not reviewed.
Missed
Opportunity :
CRD
requirements in
PRO-060 were
not implemented
Review cycle
could have
corrected human
factors
deficiency.
Procedure
verification and
validation of
HNF-PRO-060
Compliance
with CRD
Procedural
defects that
impede user
understanding
of
requirements
Not Effective:
Did not happen,
not required.
Missed
Opportunity:
V&V is always
available for
complex
processes.
Failed Barrier:
Systematic
Approach to
Training
(A post
training
knowledge
check is a
barrier against
continued
ineffective
knowledge.)
Training to
PRO-060
Ineffective
training
Not used. Missed
Opportunity:
Target
population was
not identified and
effectiveness of
training was not
verified.

Page 34 of 117
Barrier Target
Protected
in this case
Significance
PRO-060
Training
Compliance
with
requirement to
notify RL of
non-reportable
bad news.
Non-
compliance
with
requirement
Not Effective:
Training to notify
RL of non-
reportable bad
news was not
performed. (SOM
& FM not trained
to revision.)
Missed
Opportunity:
Personnel were
not trained to the
change.
FM
Communication
of Facility Mgr
Forum
information
Compliance
with
requirement to
notify RL of
non-reportable
bad news.
Non-
compliance
with
requirement
Not Effective:
Not consistently
applied across
site
Missed
Opportunity:
Not all personnel
received
communication
Audits,
assessments,
and JHAs
Weighted
Safety Arm
(safety device)
Unrecognized
use of a
safety device
as an
operational
control
Not Effective:
If use of the safety
device as an
operational
control was
recognized,
additional controls
would have been
implemented.
Missed
Opportunity:
Did not
recognize the
use of Weighted
Safety Arms as
operational
controls.
Audits,
assessments,
and JHAs
Weighted
Safety Arm
(safety device)
Failure to
control for
condition that
sloping
monorails
could cause
hoist to strike
Weighted
Safety Arms.
Not Effective:
If the sloped
monorails were
appropriately
identified (even if
not re-leveled),
then additional
controls could
have been
implemented.
Missed
Opportunity:
An example of a
control would be
to hang caution
tags on the
hoists when they
are on slanted
monorails to say:
CAUTION: Keep
positive control
while moving
hoist. Monorail is
tilted and hoist
will continue to
travel on its own.

Page 35 of 117
Barrier Target
Protected
in this case
Significance
Audits,
assessments,
and JHAs
Weighted
Safety Arm
(safety device)
Unrecognized
impact on the
locking arms
from moving
FTC during
coupling to
the monorail
Not Effective:
If damage caused
by the moving
FTC was
recognized,
additional controls
would have been
implemented.
Missed
Opportunity:
Did not
recognize
damage was
being caused by
FTC.
Preventive
Maintenance
procedure
Functional
Weighted
Safety Arm
Non-
functional
Weighted
Safety Arm
Not Effective:
Did not find the
bent/ sticking
Weighted Safety
Arm.
Missed
Opportunity:
Did not
incorporate
procedural steps
to ensure bent/
sticking latches
were identified.
Millwright Functional
Weighted
Safety Arm
Non-
functional
Weighted
Safety Arm
Not Effective:
Did not find the
bent/ sticking
Weighted Safety
Arm.
Missed
Opportunity:
Skill of the craft
could have
identified the
bent/ sticking
Weighted Safety
Arm.
Procedure OP-
14-002
“Perform Pre-
Use Test on
Hoist”
The Hoist. Damage to
Hoist.
Not Effective:
Did not require the
performance of a
pre-use test for
relocation of the
hoist AND, if a
pre-use test had
been required for
this activity, there
was no
requirement to
ensure the
Weighted Safety
Arm was in the
down position.
Missed
Opportunity:
The operating
procedure could
have required
the operator to
ensure the
Weighted Safety
Arm was in the
down position.

Page 36 of 117
Barrier Target
Protected
in this case
Significance
Procedure OP-
07-113W
“Position and
Secure
Irradiated Fuel
at 105-KW”
The Hoist. Damage to
Hoist.
Not Effective:
Not intended to be
effective.
However, neither
this procedure nor
OP-14-002 would
have prevented
the hoist from
falling from the
monorail.
Missed
Opportunity:
The procedure
could have
required the
operator to
ensure the
Weighted Safety
Arm was in the
down position.
FTC operating
procedures
Safe operation Damage to
the Locking
Arms
(subsequently
damaging the
Weighted
Safety Arm -
bending it)
Not Effective:
Did not ensure
that FTCs were
not moving while
coupling to the
monorail
Missed
Opportunity:
The procedure
could have
required that the
operator ensure
that FTCs were
stopped prior to
coupling to the
monorail
Training for
hoist/monorail
system
operation
Safe operation Repeated use
of Weighted
Safety Arms
as operational
controls (to
stop the
hoist).
Not Effective:
Weighted Safety
Arms are used as
operational
controls.
Missed
Opportunity:
Train people to
keep positive
control of hoist
when moving it.
Training for
FTC operation
Safe operation Repeated
practice of
coupling
FTCs to
monorails
while FTCs
are still
moving
Not Effective:
Did not ensure
that FTCs were
not moving while
coupling to the
monorail
Missed
Opportunity:
The training
could have
required that the
operator ensure
that FTCs were
stopped prior to
coupling to the
monorail

Page 37 of 117
Barrier Target
Protected
in this case
Significance
SOM, FM,
MCO Mgr, and
Deputy Director
Questioning
Attitude with
respect to near
misses
Compliance
with near miss
reporting
requirements
and correction
of unsafe
conditions
Unidentified
near miss
situations
Not Effective:
Conversations
between SOM on
one hand and FM,
MCO Mgr, and
Deputy Director
respectively did
not surface the
near miss
Failed Barrier:
Questioning
attitude was not
exhibited.
Missed
Opportunity:
People at this
level often
exhibit
questioning
attitudes
Exacerbating
Factor:
If this barrier had
been successful,
the whole
episode would
have been much
less significant.
Operators Safe operation Continued
unsafe
operations
Success:
Workers stopped
work and notified
management
Without this, the
opportunity to
evaluate and
correct the
unsafe condition
would have been
missed.

Page 38 of 117
Discussion of Design Vulnerabilities
At the time of this hoist fall event, the K Basin Fuel Storage Monorail System was old.
The design was probably current at the time of construction. Comments on the design
vulnerabilities should be taken in that context. They are intended not as criticisms of the
design, but as possibilities for learning.
Discussion of Process Vulnerabilities
By process vulnerabilities, we mean vulnerabilities associated with the way evolutions
are conducted, i.e., the process for moving hoists. In this case one single adverse
contingency, a mis-positioned WSA, together with process issues, allowed the hoist
drop to occur. This discussion applies to the design the way it was at the time of the
hoist drop event.
Procedures
The procedure for operating hoists contained precautions and notes associated with the
upper limit switch on the hoist. This is appropriate since upper limit switches should not
be relied upon to stop the “UP” travel of the hoist. Conversely, similar steps were not
included to caution operators on not utilizing the WSA as a normal means for stopping
the trolley. Similarly, steps were not included to verify the WSA position prior to moving
the trolley or to ensure positive control of the hoist/trolley assembly is maintained during
movement to avoid challenging the WSA.
Procedures that direct the operation of FTCs do not contain steps to ensure that FTCs
are stopped prior to attempts to engaging the FTC to a monorail. No caution
statements or other steps warn operators of the damage that can occur to the Locking
Arm and WSA should an FTC be moving while engaging it to a monorail.
The procedure for performing preventative maintenance does not ensure that
deficiencies associated with the WSAs are identified. The procedure does not specify
any acceptance criteria and does not require recording “as found” conditions, actions
taken, and “as left” conditions.
The procedure used for defining and declaring Near Miss events does not ensure that
Near Miss events are recognized and reported. This problem exists not only here at
FH, but across the DOE Complex. Also, this same procedure is used to ensure prompt
notification of reportable and non-reportable occurrences to the DOE FR. However, the
steps in the procedure are not well placed to ensure that when FMs are notified of non-
reportable events (bad news), the FR is promptly notified of the same. The wording is
essentially the same as the CRD, but it does not need to be. Simple words that clearly
state that whenever the FM is notified of non-reportable “bad news”, the FR shall be
promptly notified of the same bad news are all that is required.

Page 39 of 117
Training
The training on the new CRD requirement for prompt notifications (as codified in the
Occurrence Reporting procedure) was not adequate to ensure compliance with the
CRD and customer expectations. While both the procedure and training did contain this
information, the recently inserted requirement was not clear to most personnel who
received this training. Many believed that the information was merely more of the same
(notify the FR of abnormal events), without recognizing the significance of the change
(FR shall be promptly notified anytime the FM is notified of “bad news”).
In addition to the training content, the SAT did not appear to be used. No knowledge
check was used to ensure the objectives of the training were met and no follow-up
reviews were conducted to ensure the new requirement was being implemented. Also,
while most of the applicable personnel were originally identified that needed this
training, it does not appear that actions were taken to ensure they were scheduled,
attended, or that it was added to their Training Matrix as required training to perform
their assigned duties.
Hoisting and Rigging training is provided to operators who use hoists. Specifically, the
monorail hoist training contains information regarding the checking of upper limit
switches and the need to ensure that operators due not use upper limit switches as a
normal means to stop the “UP” travel of the hoist. No information could be found
regarding the need to check the position of WSAs and to ensure positive control is
maintained when moving the hoist/trolley assembly so that it does not collide with
WSAs. Similarly, it would appear the training for operating FTCs does not warn against
moving FTCs while engaging them to monorails. This practice has been witnessed in
the past and is believed to be a probable cause for the damage being done to WSAs.
Safety Vulnerability Audits
Safety audits and assessments have failed to recognize “normal” operations as
potential event precursors. The practice of allowing hoist/trolley assemblies to collide
with WSAs, and the practice of engaging FTCs to monorails while they are still moving,
was known by many within the SNF Project. The fact that these practices have been
known, but allowed to continue points to a less than adequate sensitivity towards single
vulnerability safety devices such as the WSAs.
Discussion of Process Strength
As soon as the scrap processing crew personnel were aware that the noise was caused
by the fallen hoist, they stopped work and investigated the scene. The personnel then
notified the SOM, who sent other personnel to investigate the fallen hoist. The use of
“Stop Work” by the crew upon discovery of an abnormal event is encouraging. The
prompt notifications made to the SOM and attempts to secure the scene were also
encouraging.

Page 40 of 117
Discussion of Influences
Although the definitive cause(s) for the bent WSA is not known, the WSA was likely bent
as a result of the hoist/trolley assembly colliding with the WSA and/or the FTC colliding
with the Locking Arm while it was moving and engaging to the monorail. The influence
the bent WSA had on this event is that it stuck when moved to the up position.
The definitive cause for the WSA being moved to the up position is unknown. However,
one possible scenario is that long tools may have contacted the WSA, moving it to the
up position. It is not clear to what extent hanging tools from the WSAs might contribute
to it being moved to the up position. The influence of the WSA being in the up position
is that it no longer provided that “rail stop” function it was designed to provide. Thus,
when the hoist/trolley assembly was pushed to the south, it continued to roll until it
passed the bent WSA in the up position and fell to the grating below.
The cause for monorail 21 being tilted to the south is likely the result of a combination of
aging/old equipment whose preventative maintenance program does not inspect and/or
correct for this condition. The influence this tilted monorail had on this event is that
once the hoist/trolley assembly was pushed to the south, it continued to roll down grade
until it reached the end of the monorail, passing the bent WSA stuck in the up position,
and fell to the grating below.
The cause for the RCT to push the hoist to the south is not significant. However, it is
important that if RCTs and other non-qualified personnel are permitted to move
hoists/trolley assemblies out of their way, they need to understand that they must have
positive control and have verified the position of WSAs. The influence the RCT had on
this event is the creation of the momentum necessary to cause the hoist/trolley
assembly to roll south on the monorail until it fell to the grating below.
The fact that no pre-use check of WSA positions is required had an influence on this
event. Had personnel been trained, and the procedure directed the performance of this
check prior to movement of the hoist/trolley assembly, the WSA would have been
discovered in the up position and the event would have been avoided.
The cause for the less than adequate preventative maintenance (PM) for WSAs
appears to be due to the lack of recognition that this equipment performs a vital safety
function. The influence this had on this event is that the PM (as currently written) did
not ensure that the bent WSA (safety device) was identified and corrected.
Although the area where the hoist fell is a normal traffic area, no personnel were in the
vicinity of the end of the monorail when the hoist fell. This had a beneficial influence on
this event since the result was no personnel were injured (Near Miss).
The cause for the RL concern regarding prompt notifications (or the lack there of) is a
result of a lack of sensitivity (past and present) to this issue by FH. The RCA Team
believes that this condition alone likely influenced the customer to issue a formal letter
of concern.
The CRD wording incorporated into HNF-PRO-060 had a significant influence in the
prompt notification issue reflected in this report. The fact that the wording was “overly
wordy” likely contributed to a lack of recognition that this was a change from past

Page 41 of 117
practice (FH has always been required to notify the FR of abnormal events). Also, the
fact that the change was not human factored when incorporated into HNF-PRO-060
was significant because personnel following the procedure would not reach this step
since the section it is listed in deals with “Reportable Occurrences”.
Training to the new requirement (HNF-PRO-060) for prompt notification to the FR
whenever the FM is notified was ineffective. The influence this had on personnel is a
lack of sensitivity to a historical concern from RL and an inability to recognize the need
to promptly notify the FR whenever the FM is notified of “bad news”. This training also
failed to correct a long standing problem of identifying Near Miss events. Not
surprisingly, this problem still exists throughout the DOE Complex and FH has yet to
satisfy the customer’s concern regarding a perceived lack of sensitivity to this issue.
The inability of management and others to apply a “questioning attitude” to some events
may influence others to not recognize them as near misses. Despite the design,
process, administrative, and operational issues, the application of a “questioning
attitude” alone would have prevented this event or made it less consequential at many
junctures.

Page 42 of 117
Corrective Action Recommendations
The Corrective Action Table addresses the principal influences on the consequences of
this episode. It not only includes recommended corrective actions, but also provides an
assessment of the expected impact of the corrective action, if implemented. The table
also addresses the expected impact on the episode being investigated if the corrective
action had been in place before the event. For each corrective action recommended,
the team provides its advice on the priority of the corrective action.
Corrective Action Table
Consequence
Influence
Corrective
Action
Expected
Impact
Impact on
Current Event
if pre-
implemented
Remarks
Not keeping
positive control
of the hoist
when moving it.
Procedure
change:
positive control
of hoist when
moving it.
High Priority
Hoist does not
hit WSA and
does not fall
off a monorail
when there is
no WSA.
None on this
event (since
RCT does not
follow
operating
procedures.)
Need corrective
action related to
RCT
performance.
RCT moved
hoist without
proper
precautions.
Procedure
change: all
activities in high
hazard areas to
be done by
qualified
individuals.
High Priority
People moving
hoists and
doing other
potentially
hazardous
activities will
act safely.
RCT either
would have
been properly
qualified or
would have
asked for a
properly
qualified
individual to
move the hoist.
Maintaining
positive control
would be one of
the proper
precautions.
Tilted monorail. None: Residual
risk
None. None. Previous
corrective
actions would
make tilted
monorail non-
significant.
Need USQE.

Page 43 of 117
Consequence
Influence
Corrective
Action
Expected
Impact
Impact on
Current Event
if pre-
implemented
Remarks
Distorted WSA
hardware.
PM instruction
change:
Effective
checking and
condition
recording of
WSA hardware.
Medium Priority
WSA hardware
problems
would be
identified.
WSA hardware
problems
would have
been identified
a month before
the event, and
the event
would not have
happened.
PM leaves a
time window for
adverse
conditions to
remain
undetected.
This barrier is
not 100%
effective.
Distorted WSA
hardware.
Procedure
change: Pre-
use operational
checks of WSA
hardware on
monorails to be
used.
High Priority
WSA mis-
positioning
would be
identified and
corrected
before moving
hoists.
None on this
event (since
RCT does not
follow
operating
procedures.)
Need corrective
action related to
RCT
performance.
Distorted WSA
hardware.
Procedure
change:
Operational
controls to
ensure FTCs
are not moving
when coupling
with monorails
High Priority
FTC does not
impact Locking
Arm
Locking Arm
and
subsequent
WSA damage
may not have
occurred
Reduces
potential for
damaging the
locking arms
and subsequent
WSAs

Page 44 of 117
Consequence
Influence
Corrective
Action
Expected
Impact
Impact on
Current Event
if pre-
implemented
Remarks
Numerous
conditions
adverse to
safety
associated with
operation and
material
condition of the
FSMS.
Apply ISMS to
FSMS
operation and
maintenance.
Low Priority
Operational
and material
hazards will be
identified and
controlled.
WSA distortion
issues would
have been
identified.
Safety device
precursor
issues would
have been
identified.
Positive control
issues would
have been
identified, and
so forth.
There was no
evidence that
FSMS operation
and
maintenance
had received the
benefit of ISMS.
SOM does not
recognize near
miss.
FH Senior
Mgmt establish
and enforce
their
expectations for
near miss
recognition by
FH personnel.
High Priority
Reduced
likelihood of
mis-
identification of
near miss
situations.
SOM would
have
recognized
near miss.
Near miss
would have
been reported.
No opportunity
to
misunderstand
CRD
requirements.
Without Senior
Mgmt
reinforcement of
good near miss
declaration
performance,
this corrective
action will be
useless.
Inadequate
challenge of
SOM telephone
notification
results in
situation not
being fully
described to
FM.
Questioning
attitude
workshop
training for all
mgmt personnel
whose duties
include
receiving
notifications
from Shift
Managers.
High Priority
Shift
Management
personnel will
receive
collegial
assistance
from the senior
managers to
whom they
make
notifications.
FM would have
led SOM
through the
proper logic to
identify that
only luck stood
between the
hoist drop
situation and
an injury.
All new
managers in this
situation must
be trained
before taking on
duties involving
receiving
notifications.

Page 45 of 117
Consequence
Influence
Corrective
Action
Expected
Impact
Impact on
Current Event
if pre-
implemented
Remarks
Inadequate
challenge of
SOM telephone
notification
results in
situation not
being fully
described to
MCO
Production Mgr.
Questioning
attitude
workshop
training for all
mgmt personnel
whose duties
include
receiving
notifications
from Shift
Managers.
High Priority
Shift
Management
personnel will
receive
collegial
assistance
from the senior
managers to
whom they
make
notifications.
MCO
Production Mgr
would have led
SOM through
the proper
logic to identify
that only luck
stood between
the hoist drop
situation and
an injury.
This is a repeat
corrective
action; it only
needs to be
done once.
HNF-PRO-060
contained
human factors
defects.
Subject HNF-
PRO-060 to
validation and
verification that
includes
consideration of
human factors
effectiveness.
Medium Priority
On-shift
personnel
involved in
occurrence
response will
be able to pick
up the
procedure and
succeed.
SOM would
have
understood
that “non-
reportable” bad
news given to
the FM should
be given to the
FR. No
notification
issue would
have arisen.
HNF-PRO-060
is probably not
the only
administrative
procedure that
is a human
factors problem.
HNF-PRO-060
training was
ineffective in
that it did not
result in the
desired
performance.
Retrain
personnel on
this procedure
meeting the
intent of the
Systematic
Approach to
Training.
High Priority
On-shift
personnel
involved in
occurrence
response will
be able to pick
up the
procedure and
succeed.
SOM would
have
understood
that “non-
reportable” bad
news given to
the FM should
be given to the
FR. No
notification
issue would
have arisen.
SAT is just good
business.
Training that
does not meet
the intent of
SAT is not
effective.

Page 46 of 117
Consequence
Influence
Corrective
Action
Expected
Impact
Impact on
Current Event
if pre-
implemented
Remarks
There was no
post-training
effectiveness
check on HNF-
PRO-060
training.
Conduct post-
training
effectiveness
checks on
future HNF-
PRO-060
training.
High Priority
Any significant
performance
issues caused
by HNF-PRO-
060 training
will be
detected.
Significant
performance
issues would
have been
identified and
corrected.
SOM would
have
understood
that “non-
reportable” bad
news given to
the FM should
be given to the
FR. No
notification
issue would
have arisen.
This would be
included in
meeting the
intent of SAT.

Page 47 of 117
Analysis of Expected Effectiveness of Recommended
Corrective Action
The RCA Team has concluded that if FH implements the corrective actions marked
“high priority”, FH will not have another event like the hoist drop event and will not have
another notification shortfall. It is important that the effectiveness of these corrective
actions be periodically confirmed.
Conclusions
The RCA Team completed all four objectives of its charter.
In the context of high hazard industry events, this one is of rather low consequence.
However, its significance is high because it is a result of behaviors and conditions that
could be ingredients of much more consequential events.
The team believes that the implementation of the recommended corrective actions and
the dissemination of the lessons to be learned will likely result in the saving of lives,
pain, assets, and careers at Fluor Hanford.
The three main areas for improvement are:
1. Conduct of Operations and Maintenance.
2. Handling of Adverse Event Information
3. Rapid Investigative Response

Page 48 of 117
Attachments
Comparative TimeLine ©......................................................................................... 49
Why Staircase Trees............................................................................................... 73
Extent of Condition and Cause Matrix..................................................................... 83
Cause Codes .......................................................................................................... 92
Documents Reviewed ........................................................................................... 103
Personnel Contacted............................................................................................. 106
Analysts Comments .............................................................................................. 108
Structural Analysis Report..................................................................................... 111
Calculations........................................................................................................... 113
Unanswered Questions......................................................................................... 117

Page 49 of 117
Comparative TimeLine©
The Comparative TimeLine©
is a convenient method of capturing the behaviors and conditions that made up the episode.
The resources required to carefully construct a Comparative TimeLine pay for themselves many times over in making it
easier to do the Why Staircase Trees, the Barrier Analysis Matrix, the Missed Opportunity Matrix, and other tools.
When What did happen What should have
happened
Immediate Result
(Consequence)
Significance (Impact on
Final Consequences)
Earlier FH management chose not
to notify RL of certain “non-
reportable” bad news that
was reported to Facility
Managers (FMs).
FH management should
have determined RL needs
and complied.
RL becomes dissatisfied. Set-up Factor:
This sets the stage for the
notification consequence.
About
2003_09
Paul Golan (DOE-HQ)
established metrics that
were drivers for RL
notifications to HQ.
OK RL identifies what types of
things it wants to be notified
of. These included “non-
reportable” bad news
usually reported to FMs.
Set-up Factor:
Creates additional need for
Facility Representatives
(FRs) to get the types of
information they wanted
anyway.
Prior to
2003_11_03
RL drafted Contracts
Requirements Document
(CRD) asking for
notification to FR of bad
news reported to FM.
OK FH has to change PRO-60
to implement this
requirement.
Set-up Factor:
Creates formal requirement
for notifying the FR of non-
reportable bad news.
Prior to
2003_07
A revision of HNF-PRO-060
not including the CRD was
in the review cycle. It had
been reviewed by many
reviewers.
OK Created opportunity to
change PRO-60 after it had
been reviewed.
The post-review addition of
the CRD provisions meant
that some early reviewers
thought they knew what
was in PRO-60, but didn't.

Page 50 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
Prior to
2003_11_03
Shift Managers,
Occurrence Reporting
personnel, and others were
trained on the Revised
PRO-060 (with CRD
provisions). The K West
Basin Operations Shift
Manager (SOM) was not
trained.
The SOM should have
received this training.
The SOM was not aware of
FR notification
requirements for non-
reportable bad news.
Set-up factor:
Creates a condition for non-
compliance with CRD.
2003_11_03 CRD provisions for non-
reportable bad news were
inappropriately placed in a
section on reportable
occurrences.
CRD provisions for non-
reportable bad news should
have been appropriately
placed in a section on non-
reportable occurrences that
are reported to FM’s,
placed in a table, or
otherwise presented in a
human factored way.
Increased the probability of
non-compliance.
Set-up factor:
2003_11_03 HNF-PRO-060 Revision 7
issued with CRD
provisions.
Revised PRO-60 should
have gone back through
the review cycle.
Reviewers did not have the
opportunity to comment on
the human factors
deficiencies in how CRD
provisions were
incorporated.
Failed barrier:
Review cycle could have
corrected human factors
deficiency.

Page 51 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
After
2003_11_03
Director of Emergency
Preparedness briefs Facility
Managers’ Forum on CRD
provisions in PRO-060.
Only the FMs received this
CRD training.
The appropriate target
audience should have been
trained on the CRD
provisions in PRO-060 in
accordance with the
Systematic Approach to
Training (SAT). The K
West Basin FM did not
receive this training.
Not all the personnel
involved in notifying FRs of
non-reportable bad news
are trained to do so.
Missed Opportunity:
All personnel involved in
notifying FRs could have
been trained to do so.
Failed Barrier:
- SAT is a barrier against
ineffective training
Set-up factor:
After
2003_11_03
The Director of EP does not
check to see that the
training was effective, i.e.,
that personnel involved in
notifying FR’s of non-
reportable bad news know
they are supposed to do so.
In accordance with SAT,
trainees’ knowledge should
have been checked.
The training deficiency is
not noticed by FH.
Missed Opportunity:
A check of the training
would have found that it
was ineffective - Leaves
set-up factors in place.
Failed barrier:
A post training knowledge
check is a barrier against
continued ineffective
knowledge.
Set-up factor:

Page 52 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
After
2003_11_03
The FMs who attended the
Forum did not tell facility
personnel about the
requirement to notify the
FR about non-reportable
bad news when the FM is
notified.
The FMs should have
informed facility personnel
about the requirement to
notify the FR
Not all the personnel
involved in notifying FRs of
non-reportable bad news
are informed of the
requirement to do so.
Missed Opportunity:
All personnel involved in
notifying FRs could have
been informed to do so.
Failed Barrier:
- Communications LTA –
The FMs did not
communicate the new CRD
requirement to facility
personnel AND the PRO-
060 author did not
communicate the new CRD
requirement to all of the
procedure users.
After
2003_11_03
Non-reportable bad news is
reported to FMs, but not to
FRs.
Non-reportable bad news
reported to FMs should
also have been reported to
FRs.
FH Management not
sensitive to Increased RL
dissatisfaction
Set-up Factor:
Increases level of FR
dissatisfaction.
After
2003_11_03
FR complaint about not
being told about non-
reportable bad news
reported to FMs.
OK FH management not
sensitive to RL
dissatisfaction
Set-up Factor:
Problem continues

Page 53 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
After
2003_11_03
FH management does not
reinforce expectation for
CRD compliance, that FRs
be notified when FMs are
notified.
FH management should
have noted that previous
training was LTA and fixed
it.
Conditions for non-
compliance continue.
Missed Opportunity:
FH management could
have aborted the
notification portion of this
event by correcting a
known condition adverse to
business.
Failed barrier:
Management failed to
correct the non-compliant
condition (via training
improvement and
reinforcement of
expectations)
Set-up Factor:
Leaves the previous set-up
factors in place.
The Fuel Storage Monorail System (FSMS) is designed such that a single barrier prevents a hoist from dropping off the monorail. This
single barrier is the Weighted Safety Arm (safety device). Training does not sensitize users of this single failure vulnerability. The
combination of the design and the way it was used is an example of using safety protection for operational control.
Earlier Workers routinely rely on
Weighted Safety Arms to
stop moving hoists during
normal operations (passive
safety devices used as
operational controls).
Workers should not have
been using WSAs as hoist
stopping devices.
Repeated hoist drop
precursors (the Weighted
Safety Arm safety device
was repeatedly
challenged).
Set-up Factor:
If the hoist is moved to the
end of the Monorail and the
Weighted Safety Arm is up
or breaks, the hoist will fall.

Page 54 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
Earlier Audits, assessments, and
Job Hazards Analyses
(JHAs) of the FSMS do not
notice the single failure
vulnerability of the
Weighted Safety Arms.
Audits, assessments, and
JHAs should have noticed
the single failure
vulnerability and required
that procedures be
changed to either
frequently verify the
condition of the Weighted
Safety Arms, or prohibit
challenging them.
Set-up Factor is not
corrected.
Missed Opportunity:
Any of these safety audits
could have aborted the
event by establishing
additional controls.
Failed Barrier:
JHAs are barriers that
guard against safety
vulnerabilities.
ISMS infraction.
Earlier Audits, assessment, and
JHAs of the FSMS do not
notice the routine repeated
use of the WSA (safety
device) to stop a hoist.
JHAs should have noticed
the routine repeated use of
the safety device to stop a
hoist.
The recognition of the use
of WSAs to stop hoists
should have resulted in PM
and Operating procedures
that ensure their position
and operability.
The precursor continues. Missed Opportunity:
Any of these could have
aborted the event by
identifying and correcting
the unsafe behavior.
Failed Barrier:
JHAs are barriers that
guard against safety
vulnerabilities.
ISMS infraction.

Page 55 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
2003_02_03 100K monorail inspection
procedure (annual
inspection) SP-14-005
changed to add rail stops
(Weighted Safety Arms) to
Step 4.1.2 to ensure they
were checked for
looseness and alignment.
OK Missed Opportunity:
The procedure change
acknowledges the need for
Millwrights to check
Weighted Safety Arms, but
many Weighted Safety
Arms were not in proper
alignment.
2003_06_09 The Crane Inspection
Team was chartered as a
work place improvement
initiative for the K Basins.
The charter was to evaluate
reported issues and make
recommendations for
resolution.
OK
The FSMS was first built in 1954, and has become worn out over the years, requiring extensive repair to restore “normal” operation.
Although some FTCs have been replaced with new ones, original FTCs are worn to the point that alignment is not possible with many of
the monorails. Additional damage results from the increased forces necessary for the workers to align FTCs with monorails during hoist
transport of fuel loads exceeding 700 pounds. Worker frustration resulting from difficult FSMS operations with worn-out equipment may
have contributed to equipment abuse.

Page 56 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
2004_02_19 FSMS Maintenance
completed the annual
preventive maintenance
inspection on the Weighted
Safety Arms in the K West
Basin. No discrepancies
were noted in the work
package.
Discrepancies (bent or
sticking Weighted Safety
Arms) should have been
found.
No problem was found with
on the south end of
Monorail 21. The bent
WSA was not identified and
corrected.
Missed Opportunity:
The bent or sticking
condition of Weighted
Safety Arms -
FSMS Maintenance does
not provide adequate
documentation of any
repairs in the work
packages to provide data
for trending.
Failed Barrier:
No problems with Weighted
Safety Arms were identified
by performing the PM.
Set-up Factor:
Problem continues.
2004_02_19 FSMS preventative
maintenance was
performed to a procedure
that did not require that an
FTC be installed when
inspecting WSA
functionality.
The PM procedure should
have required that an FTC
be engaged to the
monorail.
No problem was found with
on the south end of
Monorail 21. The bent
WSA was not identified and
corrected.
Missed Opportunity:
The bent or sticking
condition of Weighted
Safety Arms.
Failed Barrier:
Because the FTC was not
engaged to the monorail,
no problems with Weighted
Safety Arms were identified
by performing the PM.
Set-up Factor:
Problem continues.

Page 57 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
Before
2004_03_10
Personnel had been
working in the basin pool
under the south end of
Monorail 21 using long
tools.
OK Created opportunity for
personnel to strike
Weighted Safety Arm with
long tool during work.
Set-up Factor:
Possible inadvertent
contact with Weighted
Safety Arm causing it to
travel beyond its normal
range of motion, and
allowing it to become stuck.
Missed Opportunity:
Long tools were known to
strike or become stuck in
the overhead during use.
Before
2004_03_10
Personnel had been
working in the basin pool
under the south end of
Monorail 21.
OK Created opportunity for
personnel to be injured if
the hoist falls on them.
Exacerbating Set-up
Factor:
This converts a potential
equipment event into a
personnel safety event.
Personnel working in the basin use long poles to retrieve empty fuel canisters. The canisters are hooked to a chain on the hoist, so the
hoist can lift the canister in the water, and the canister can be transported along the monorail. The hoists roll by manual operation, but
lift by means of an electric motor. The monorail system is approximately seven feet above the grating over the water. The grating is
approximately 22 feet above the bottom of the pool. In use, long poles are reported to often strike into the overhead.
Before
2004_03_10
The Weighted Safety Arm
was bent.
should not have been bent.
The bent Weighted Safety
Arm became stuck in the
up position.
Set-up Factor:
If the Weighted Safety Arm
had not been bent, it would
have been in the down
position.

Page 58 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
2004_03_10 The south-end Weighted
Safety Arm on Monorail 21
is in the up position.
should have been in the
down position.
could not perform its
intended function. If the
hoist travels to the end of
the monorail, it will fall off.
Set-up Factor:
in the up position will allow
a hoist traveling to the end
of the monorail to fall off.
Missing Barrier:
in the down position
(barrier) was missing.
Before
2004_03_10
rigging checks do not
identify the Weighted
in the up position.
rigging checks should
identify safety anomalies
including the Weighted
being in the up position.
Set-up Factor allowed to
continue.
Missed Opportunity:
The pre-use checks could
have aborted the event by
identifying the Weighted
position.
Missing Barrier:
The pre-use checks did not
require checks of the
Weighted Safety Arms.
2004_03_10_
2317
Radiological Control
Technician (RCT) who is
part of a waste processing
crew needs to move hoist.
OK The RCT moves the Hoist. Triggering Factor.
2004_03_10_
2317
(before)
Monorail 21 was tilted
downward to the south. (A
number of monorails in the
K West Basin were known
for many years to have “a
long glide path”.)
Monorail 21 should have
been level.
Created vulnerability to
continued hoist motion
once the hoist is started.
Set-up Factor.

Page 59 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
The Weighted Safety Arms were verified in the down position three weeks preceding this event by personnel working at the south end of
Monorail 21.
2004_03_10_
2317
RCT, following normal
practice, does not request a
Qualified Operator to move
hoist.
RCT should have
requested Qualified
Operator to move the hoist.
A non-qualified operator
moved the hoist.
Extraneous Condition
Adverse to Quality
2004_03_10_
2317
Procedure OP-14-002
“Perform Pre-UseTest on
Hoist” did not require pre-
use testing when relocating
hoist.
The procedure should have
required visual inspection
to verify the Weighted
Safety Arms (safety device)
were in the down position.
was not visually inspected.
Set-up Factor
Missing Barrier:
The procedure did not
require a pre-use check
before the hoist was
relocated.
Procedure OP-14-002 “Perform Pre-UseTest on Hoist” precautions and limitations stated the following: “Limit switches are safety
devices for protection of personnel and equipment. Limit switches shall not be used as a controller to stop the upward travel of the
hoist.” Section 4.2 includes the following note: “The up limit switch is a back-up; its use should be avoided during normal operation.”
The pre-use test procedure does not recognize the Weighted Safety Arms as safety devices and does not call out pre-use inspection.
The team could not find any safety principle that allowed treating mechanical safety devices less rigorously than electrical safety
devices.

Page 60 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
2004_03_10_
2317
RCT pushes hoist to south. A Qualified Operator should
have moved it.
(Note that if the hoist had
been moved to the north
this event would not have
happened.)
Hoist begins moving to the
south. (We do not know
whether the Qualified
Operator would have
behaved differently. E.g., a
Qualified Operator may
have intuitively moved the
hoist northward or may
have noticed the Weighted
position, or may have
moved it south more
carefully.)
Final Triggering Factor.
2004_03_10_
2317
The hoist rolls southward
and travels off the end of
the monorail.
OK (given the existing set-
up factors)
Hoist is in free-fall. Natural outcome of prior
behaviors and conditions.
2004_03_10_
2317
No personnel or sensitive
equipment are in vicinity of
the hoist trajectory.
OK: Fortuitous condition No personnel or equipment
consequences (except to
hoist casing).
Mitigating Factor. This
non-robust barrier
prevented this near miss
from being a consequential
Safety Event.
2004_03_10_
2318
The five involved personnel
(1 RCT and 4 Nuclear
Chemical Operators
(NCOs)) went to the fallen
hoist and confirmed the
Weighted Safety Arm was
in the down position. The
immediate inspection found
no obvious problems with
the hoist or monorail.
OK Inexplicable condition
discovered.

Page 61 of 117
happened
Immediate Result
(Consequence)
Final Consequences)
2004_03_10_
2330
An NCO notified the K
West Basin SOM that a
hoist had fallen off the
south end of Monorail 21
onto the grating; no
personnel were in the area
of the fallen hoist.
OK Notification sequence starts
2004_03_10_
2330
SOM does not declare that
the hoist drop was a near
miss for personnel injury.
Because the hoist dropped
in an area where people
work, the drop should have
been recognized as a near
miss.
The hoist drop is not
treated as a near miss and
near miss notifications are
not made.
Missed Opportunity:
First Failed Barrier to CRD
non-compliance.
2004_03_10_
2330
Discussion between the
personnel and the SOM led
to determination that, other
than the hoist pre-use
operational check, no
specific check of the
Weighted Safety Arms is
required; also, that no
Flexible Transfer Cranes
(connecting to Weighted
Safety Arms on the
monorails) had been in use
along the south part of the
basin.
OK
2004_03_10_
2330
Interviews of involved
personnel were not
conducted.
Interviews should have
been obtained as soon as
possible after the event.
Adverse to Quality
Adverse to Quality:
Real-time recording of the
facts at the event scene did
not occur.

Doe hanford hoist drop from monorail

Doe hanford hoist drop from monorail

Recommended

Recommended

More Related Content

What's hot

What's hot (6)

Similar to Doe hanford hoist drop from monorail

Similar to Doe hanford hoist drop from monorail (8)

More from William R. Corcoran, Ph.D., P.E.

More from William R. Corcoran, Ph.D., P.E. (9)

Recently uploaded

Recently uploaded (20)

Doe hanford hoist drop from monorail