K-25 Accident Information

[Douglas.Minnema@dp.doe.gov]

    Dear RADSAFEr's,
    
    There appears to be continuing interest in the unfortunate accident 
    at K-25, and understandably so.  However, the investigation team 
    report has not been issued yet, and normally no information is 
    released or confirmed until that time.  Therefore, we have no 'firm' 
    information as to the cause of the accident or the precursors.  
    However, due to the universal interest and the general nature of 
    some relevant details of the accident, the team did take the 
    somewhat unusual step of issuing a preliminary statement through the 
    Office of the Assistant Secretary for Environment, Safety, and 
    Health, Dr. O'Toole.  It was distributed a couple of weeks ago, but 
    I am attaching it below for those who did not get it.
    
    While K-25 was not a Defense Programs facility, we too have a strong 
    and active interest in the accident and the multiple concerns it 
    raises for our operations.  As more factual information becomes 
    available, we will try to share it with you.
    
    Douglas Minnema, CHP
    Radiological Control Program Advisor 
    Defense Programs
    Department of Energy
    
    Douglas.Minnema@dp.doe.gov
    
    
    
    
On March 7, 1997, Dr. Tara O'Toole, Assistant Secretary, Environment, Safety 

and Health, issued the following memorandum.  This information is being 
provided via the DOE Lessons Learned list server in response to numerous 
requests for information associated with the DOE Type A Investigation.  If 
you 
have any questions, please contact the person identified in the memorandum.
    
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 
Department of Energy
Memorandum
    
Date:     March 7, 1997
    
Reply to
Attn of:  EH-2: Office of Oversight: Podonsky: 3-3777 
    
Subject:  Safety Alert - Preliminary Accident Investigation    
          Findings from Oak Ridge Accident
    
To:       Operations Office Managers 
    
As you are aware, the Office of Environment, Safety and Health established a 

DOE Type A Accident Investigation Board to determine the causal factors and 
root cause of the welding/cutting fatality at the Oak Ridge K-25 site. 
Because it may be several weeks before the Board's final report will be 
issued and because of the significance of this accident to similar work 
being 
conducted throughout the Department, I want to alert you to some personnel 
safety issues you should address at sites under your cognizance. 
    
The accident at the Oak Ridge K-25 site involved welders working outside a 
fixed shop area removing equipment from a facility in a high contamination 
area 
using oxygen/acetylene cutting torches.  Because the work was being 
performed 
in a radiological area, the welders were required to wear anti-contamination 

clothing in addition to full face respirators and a welder's mask.
    
Preliminary analysis of the accident has indicated that sparks and/or molten 

metal (slag) from the cutting operations ignited the welder's 
anti-contamination clothing.  Based on preliminary input from the Board, the 

flammability of the clothing, the worker's inability to see that his 
clothing 
was on fire, and the lack of a designated/dedicated fire watch for the 
operations appear to be contributing factors to the accident.  In this 
accident, fire consumed the clothing being worn by the welder in a very 
short 
period of time (approximately 3 minutes or less).
    
The anti-contamination clothing provided was 100% cotton and not treated 
with flame retardant.  Although some DOE sites have flame retardant 
anti-contamination clothing available for use by workers, there are no 
regulatory, industrial, or Departmental requirements for the use of such 
clothing in operations similar to that ongoing at the K-25 site at the time 
of the accident.  Personnel safety responsibilities for the fire watch are 
similarly not specifically defined or required.
    
Therefore, you should review the following personnel safety issues at your 
sites, for work involving similar hazards, involving the adequacy of:
    
*  Fire watch procedures in covering personnel safety as well as property 
loss 
control (e.g. maintaining line of sight).
    
*  Fire watch training in regard to personnel safety and emergency 
aid/response.
    
*  Fire mitigation equipment, for personnel and property, available to the 
fire 
watch to carry out his/her responsibilities.
    
*  Existing policy/requirements at your sites for the use of flame retardant 

treated anti-contamination clothing by workers involved in operations with 
similar hazards.
    
Copies of the Board's final Accident Investigation Report, which will 
identify the Judgments of Need to help prevent recurrence not only at the 
Oak Ridge K-25 site but throughout the Department, will be made available to 

you in several weeks after it is accepted by EH-1. Should you have any 
questions on this matter, please contact Ms. Barbara Stone of my staff at 
(301)903-5895.
    
    
/s/ Tara O'Toole
Tara O'Toole, M.D., M.P.H.
Assistant Secretary
Environment, Safety and Health
    
cc:
S-3
EM-1
ER-1
NE-1
DP-1
FM-1
    
Cynthia M. Eubanks
(423)576-7763; FAX=(423)241-6539
Mgr. Issues Management Staff
Lockheed Martin Energy Systems, Inc.