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U.S.DepartmentofEnergyOfficeofHealth,SafetyandSecurityAccidentInvestigationReportFallfromFixedLadderatBuilding830atBrookhavenNationalLaboratoryonJune29,2012August2012BrookhavenSiteOfficeU.S.DepartmentofEnergyUpton,NewYorkFallfromFixedLadderatBuilding830atBrookhavenNationalLaboratoryThispageisintentionallyblank.FallfromFixedLadderatBuilding830atBrookhavenNationalLaboratoryDisclaimerThisreportisanindependentproductoftheAccidentInvestigationBoardappointedbyFrankJ.Crescenzo,ActingSiteManager,BrookhavenSiteOffice,U.S.DepartmentofEnergyonJuly11,2012.TheAccidentInvestigationBoardwasappointedtoperformaninvestigationofthisaccidentandtoprepareaninvestigationreportinaccordancewithDepartmentofEnergyOrder225.1B,AccidentInvestigations.Thediscussionoffacts,asdeterminedbytheAccidentInvestigationBoard,andtheviewsinthereportdonotassume,andarenotintendedtoestablish,theexistenceofanydutyatlawonthepartoftheU.S.Government,itsemployeesoragents,contractors,theiremployeesoragents,orsubcontractorsatanytier,oranyotherparty.Thisreportneitherdeterminesnorimpliesliability.FallfromFixedLadderatBuilding830atBrookhavenNationalLaboratoryFallfromFixedLadderatBuilding830atBrookhavenNationalLaboratoryFallfromFixedLadderatBuilding830atBrookhavenNationalLaboratoryExecutiveSummaryOnJune29,2012,atapproximately2:35p.m.,aBrookhavenSciencesAssociatesmaintenancemetalsworkerwasclimbingafixedladderlocatedontheexteriorofBrookhavenNationalLaboratoryBuilding830.Theworkerlostthree-pointsofcontactwiththefixedladderandfellfromaheightofapproximately15-feetlandingonasphaltpavement.Becauseoftheseverityoftheresultinginjuryandtheprognosisofhospitalizationoftheworkerinexcessoffivedays,onJuly11,2012,theDepartmentofEnergy’sOfficeofScienceBrookhavenSiteOfficeActingManagerformallyappointedaDepartmentofEnergyAccidentInvestigationBoard.TheBoardwastaskedwithidentifyingallrelevantfactstodeterminethedirect,root,andcontributingcausesoftheaccident;developingconclusion;anddeterminingJudgmentsofNeedthat,whenimplemented,shouldpreventrecurrenceoftheaccident.TheBoardinitiatedtheaccidentinvestigationonJuly17,2012.TheBoardconcludedthisaccidentwaspreventable.Thedirectcauseoftheaccidentwastheworkerfallingfromthefixedladderafterlosingthreepointsofcontactandthenstrikingasphaltpavement.UnfortunatelytheinjuredworkerwasnotavailabletotheBoard.TheworkerdidnotrespondtorepeatedrequestsmadebytheBoardforaninterview,nordidtheworkerrespondtoawrittenrequestforinformation.Assuchthefactsofthisaccidentarelimitedtothephysicalevidencefoundatthesceneandwitnessstatements.TheBoardidentifiedtherootcauseofthisaccidenttobetheBrookhavenScienceAssociates(BSA)hazardrecognitionprocessfailingtoidentifytheinherentriskassociatedwithelevatedworkwhenclimbingafixedladder.Fivecontributingcauseswerealsoidentified:BSAfailedtosatisfy29CFR1910fixedladderrequirementsasrequiredby10CFR851;theBSATier1safetyinspectionprocessisinadequatefortheidentificationofunsafeconditionsandpractices;theBSAemployeeconcernsprogramisnotbeingutilizedasameansofchallengingunsafeconditions;theBSAworkplanningandcontrolprocesswasnotfollowedforidentifyingworkhazardsanddevelopingcontrolsforthistask;andtheBSAworkplanningandcontrolprocessfailedtoprovideadequatehazardrecognitionwhichledtoafalsejudgmentthatelevatedworkislowhazardwork.TableES-1containsthesetofconclusionsderivedfromtheanalyticalresultsperformedduringthis...