Tupe A Accident Investigation of the July 15, 2004 Hanford 200 East Area Fall Facility

摘要

On July 15, 2004, an employee of All Mobile Transporting & Repairs (AMTR) was found motionless at the bottom of a ladder with a serious head injury. There were no eyewitnesses to the apparent fall. The evidence indicated the employee was standing on the ladder approximately five to six feet off the ground, removing sheet metal screws from the aluminum trim of a mobile office that was being prepared for transport off the Hanford Site. On July 12, 2004, the AMTR employee underwent out patient surgery with general anesthesia and reportedly collapsed twice the next evening. The AMTR employee had medical conditions, which may have contributed to the apparent fall. The Type A Accident Investigation Board specifically reviewed the authorities, accountability, and roles and responsibilities of the DOE and contractor organizations, and management systems as they may have contributed to the accident. The Board determined both DOE-RL and FHI believed they had only very limited accountability, roles and responsibilities for work performed by non-government contractors on the Hanford Site beyond providing safe access. The work giving rise to this incident was performed by non-government workers as a result of DOE-RL transfer of title to an excess mobile office to the Community Reuse Organization (CRO). The CRO sold the mobile office to a commercial company prior to CRO accepting possession. The commercial company then contracted with AMTR to retrieve the mobile office from Hanford (DOE property) and transport it to a new location in the community.