RLUOB Toppled Load: Near Miss to Personnel Injury (Incident Investigation Final Report)
On Monday, February 25, 2019, at approximately 1430, the Logistics Central Shop (LOG-CS) Hoisting and Rigging (H&R) crew moved an anti-vibration table on the first floor of Technical Area 55 (TA-55), Building 400, Radiological Laboratory/Utilities/Office Building (RLUOB). The table was designed to be anchored to the facility floor on pedestals to provide vibration dampening for an electron microscope (SEM/TEM). The table was approximately 86 inches wide by 56 inches tall, an asymmetrical load. It weighed approximately 2,300 pounds. The crew was transporting the load using a lifting device, specifically a Vere Optical Table Hoist. The work control package (Integrated Work Document [IWD] and H&R Ordinary Lift Plan) included staging the table, moving the load from the loading dock through corridors into a laboratory, and installing the table. During the table move, the riggers made adjustments to the lifting device to enable the load and device to pass through security double doors. After the crew successfully passed through the security double doors, three riggers moved the load approximately ten linear feet further at which point the lifting device and load fell to the RLUOB facility floor. No injuries were sustained as a result of the toppled load and frame. The rigging crew immediately notified supervision who then notified the TA-55 Facility Operations Director (FOD). After further review, the TA-55 FOD categorized the event as a near miss to personnel injury. The scene was preserved and all H&R operations within the TA-55 directorate were paused pending a review of all lift plans with the rigging supervisor and the Chemistry and Metallurgy Research Replacement (CMRR) Construction Manager. All lift plans were to be reviewed prior to resumption of H&R lifts within the directorate. Additionally, all newly generated lift plans will be reviewed by the TA-55 FOD, the H&R supervisor and the affected manager. The Associate Laboratory Director for Weapons Production (ALDWP) appointed a team to investigate the event, identify all relevant facts, and determine the direct, contributing, and root causes. The team was also charged with reviewing other similar events to identify common causes for multiple recurring events and the organizational and management weaknesses that have led to failure to correct recurring events. (See Appendix A: Memo, Appointment of Accident Investigation Board.)