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Federally Led Accident Investigation Reports

Includes Pre-March 2011 Type A Reports

March 26, 2014
Accident Investigation of the February 5, 2014, Underground Salt Haul Truck Fire at the Waste Isolation Pilot Plant, Carlsbad NM

The U.S. Department of Energy (DOE) Accident Prevention Investigation Board was appointed to investigate a fire at the Waste Isolation Pilot Plant that occurred on February 5, 2014. An aged EIMCO 985-T15 salt haul truck (dump truck) caught fire in an underground mine.

March 16, 2014
Accident Investigation of the December 11, 2013, Integrated Device Fireset and Detonator Accidental Discharge at the Sandia National Laboratory Site 9920, Albuquerque, NM

The U.S. Department of Energy (DOE) Accident Investigation Board investigated an accident at Sandia National Laboratories, Site 9920 on December 11, 2013. Site 9920 personnel were testing an integrated explosive device, containing a fireset and detonator when the IED unexpectedly went off during handling, causing injury to the firing officer’s left hand.

November 22, 2013
Accident Investigation of the October 1, 2013, Tice Electric Company Employee Fatality near Patrick's Knob Radio Station, Bonneville Power Administration

The purpose of the investigation was to determine the cause of the accident and to develop recommendations for corrective actions to prevent recurrence

August 6, 2013
Accident Investigation of the June 1, 2013, Stairway Fall Resulting in a Federal Employee Fatality at DOE Headquarters Germantown, Maryland

On June 28, 2013, an Accident Investigation Board was appointed to investigate an accident at the Department of Energy Germantown Headquarters facility, on June 1, 2013 that resulted in a fatality on June 24, 2013.

July 30, 2013
Accident Investigation of the July 30, 2013, Electrical Fatality on the Bandon-Rogue No. 1 115kV Line at the Bonneville Power Administration

This report is an independent product of the Level I Accident Investigation Board appointed by Brad Bea, Chief Safety Officer, Bonneville Power Administration. The Board was appointed to perform a Level I Accident Investigation and to prepare an investigation report in accordance with Bonneville Power Administration Manual, Chapter 181, Accident Investigation and Reporting.

June 21, 2013
Accident Investigation of the February 7, 2013, Scissor Lift Accident in the West Hackberry Brine Tank-14 Resulting in Injury, Strategic Petroleum Reserve West Hackberry, LA

On February 15, 2013, an Accident Investigation Board (the Board) was appointed to investigate an accident that resulted in serious injuries caused when a scissor lift tipped over in Brine Tank-14 (WHT-14) at the Strategic Petroleum Reserve, West Hackberry, Louisiana, site on February 7, 2013. The Board’s responsibilities have been completed with respect to this investigation. The analysis and the identification of the direct cause, root causes, contributing causes, and judgments of need resulting from this investigation were performed in accordance with the Department of Energy (DOE) Order 225.1B, Accident Investigations.

November 30, 2012
Accident Investigation of the September 20, 2012 Fatal Fall from the Dworshak-Taft #1 Transmission Tower, at the Bonneville Power Marketing Administration

This report is an independent product of the Level l Accident Investigation Board appointed by Brad Bea, Chief Safety Officer, Bonneville Power Administration. The Board was appointed to perform a Levell Accident Investigation and to prepare an investigation report in accordance with Bonneville Power Administration Manual, Chapter 181, Accident Investigation and Reporting

September 18, 2012
Accident Investigation of the August 21, 2012, Contamination Incident at the Los Alamos Neutron Science Center at the Los Alamos National Laboratory

On August 25, 2012, radioactive contamination was identified on Flight Path 04 of the Lujan Center, an experimental area that is part of the Los Alamos Neutron Science Center at the Los Alamos National Laboratory in New Mexico. Los Alamos National Laboratory is operated by Los Alamos National Security, LLC. The Operating Contractor quickly determined that the contamination had spread offsite, and response teams were immediately brought in.

August 24, 2012
Accident Investigation of the June 17, 2012, Construction Accident - Structural Steel Collapse at The Over pack Storage Expansion #2 at the Naval Reactors Facility at the Idaho National Laboratory, Idaho Falls, Idaho

This report documents the Naval Reactors investigation into the collapse ofa partially-erected spent fuel storage building, Overpack Storage Expansion #2 (OSE2), at the Naval Reactors Facility. The Accident Investigation Board inspected the scene, collected physical and photographic evidence, interviewed involved personnel, and reviewed relevant documents to determine the key causes of the accident. Based on the information gathered during the investigation, the Board identified several
engineering and safety deficiencies that need to be addressed to prevent recurrence.

August 1, 2012
Investigation of the June 29, 2012, Fall from a Fixed Ladder at Building 830, at the Brookhaven National Laboratory Brookhaven National Laboratory

On June 29, 2012, at approximately 2:35 p.m., a Brookhaven Sciences Associates maintenance metals worker was climbing a fixed ladder located on the exterior of Brookhaven National Laboratory Building 830. The worker lost three-points of contact with the fixed ladder and fell from a height of approximately 15-feet landing on asphalt pavement.

January 1, 2012
Investigation of the November 8, 2011, Plutonium Contamination in the Zero Power Physics Reactor Facility, at the Idaho National Laboratory

On November 8, 2011, workers at the Idaho National Laboratory (INL) Materials and Fuels Complex (MFC) Zero Power Physics Reactor (ZPPR) Facility were packaging plutonium (Pu) reactor fuel plates. Two of the fuel storage containers had atypical labels indicating potential abnormalities with the fuel plates located inside. Upon opening one of the storage containers,
the workers discovered a Pu fuel plate wrapped in plastic and tape. When the workers attempted to remove the wrapping material, an uncontrolled release of radioactive contaminants occurred, resulting in the contamination of 16 workers and the facility

November 1, 2011
Investigation of the September 13, 2011, Fatality at the Strategic Petroleum Reserve Bryan Mound Site

On September 13, 2011, a recently-hired, untrained subcontractor employee struck three large elevated pipes while operating a front deck mower at the Cavern 5 area of the Strategic Petroleum Reserve Bryan Mound (SPR-BM) site.

August 8, 2011
Investigation of the July 1, 2011, Fall Injury at the Savannah River Site

On July 1, 2011, a worker fell from portable scaffolding during facility modifications in the Purification Area Vault (PAV) of Building 105-K at the Savannah River Site (SRS). The worker required hospitalization due to sustained head injury and numerous broken ribs. This accident meets Accident Investigation Criteria 2.a.2 of Appendix A of DOE Order 225.1B, Accident Investigations (i.e. hospitalization of the injured worker for more than five calendar days, commencing within seven calendar days of the accident).

May 25, 2011
Independent Review of the July 8, 2010 Fatality at the Strategic Petroleum Reserve Bryan Mound Site - May 25, 2011 Addendum closing the Investigation based upon the Galveston County Medical Examiner's Report

In consultation with the Assistant Secretary for Fossil Energy (FE), the Chief Health, Safety and Security Officer appointed an Independent Review Board (IRE3) on July 20,201 0, under the provisions of the Department of Energy (DOE) Order 225.1 A, Accident Investigations, that represented a modified Type A accident investigation.

April 1, 2011
Investigation of the March 5, 2011, Building 488, Brookhaven National Laboratory, Tree Felling Injury

On Saturday, March 5, 2011 at approximately 10:20 a.m., a Brookhaven National Laboratory Building and Grounds Utility Worker was felling a pine tree while elevated in a 60-foot articulating and telescoping boom lift approximately 20-feet above the ground on the south side of Building 488. As the gas-powered, 20-inch chainsaw being used by the employee cut through the tree trunk, an approximately 8-foot long, 18-inch diameter, 520 pound section of tree trunk fell toward the aerial lift, striking the employee’s right forearm, and compressing it against the top railing of the aerial lift basket.

March 31, 2010
Level 1 Accident Report of the March 1, 2010 Bobcat Fatality at BPA's White Bluffs Substation

On March 2, 2010 at the request of the Bonneville Power Administration (BPA) Chief Safety Officer, a Level I Accident Investigation was convened to investigate an accident in which a supplemental labor contractor was fatally injured in a Bobcat/backhoe accident at the White Bluffs Substation near Richland, Washington on March 1, 2010.

October 1, 2009
Type A Accident Report of the June 26, 2009 Vehicle Fatality at Lawrence Livermore National Laboratory

This report is an independent product of the Type A Accident Investigation Board appointed by Thomas P. D’Agostino, Administrator, National Nuclear Security Administration, U.S. Department of Energy and Glenn S. Podonsky, Chief Health, Safety and Security Officer, Office of Health, Safety and Security.

August 29, 2008
Type A Accident Investigation Board Report on the July 1, 2008, of the Vehicle Fatality Accident-Western Area Power Marketing Administration

This report is an independent product of the Type A Accident Investigation Board (Board) appointed by Anthony H. Montoya, Chief Operating Officer, Office of the Chief Operating Officer, Western Area Power Administration.

November 15, 2004
Type A Investigation of the Electrical Arc Injury at the Stanford Linear Accelerator Complex on October 11, 2004

On October 11, 2004, at approximately 11:15 am, a subcontractor electrician working at the Stanford Linear Accelerator Center (SLAC) received serious burn injuries requiring hospitalization due to an electrical arc flash that occurred during the installation of a circuit breaker in an energized 480-Volt (V) electrical panel.

October 1, 2004
Level 1 Accident Investigation Report of August 17, 2004, Fatal Aircraft Accident on the Grand Coulee-Bell No.6, 500 kV Line

On August 17, 2004, at approximately 0940, a Bonneville Power Administration (BPA) pilot was killed in the crash of a Bell 206BIII helicopter while stringing "sock line" to enable the subsequent stringing of new conductors and static wire on the Grand Coulee-Bell #6 500-kV line between tower 84/2 and BPA’s Bell Substation in Mead, Washington. (See Appendix 7, Site Map.)

September 14, 2004
Type A Investigation - Subcontractor Fatality at the Savannah River Site Pond B Dam Upgrade Project, July 26, 2004

On July 26, 2004, at approximately 3:15 p.m., a truck driver (driver) was critically injured at the Savannah River Site, while loading a rented excavator onto a lowboy trailer for return to the rental company.

August 1, 2004
Type A Accident Investigation of the July 15, 2004, Hanford 200 East Area Fall Fatality

On the morning of Thursday, July 15, 2004, a non-government contractor employee of All Mobile Transporting & Repairs (AMTR) was found motionless at the bottom of a ladder with a serious head injury.

August 8, 2001
Type A Accident Investigation of the June 21, 2001, Drilling Rig Operator Injury at the Fermi National Accelerator Laboratory, August 2001

On June 21, 2001, at approximately 9:40 A.M., a construction sub-tier contractor employee (the “Operator”) at the Fermi National Accelerator Laboratory (Fermilab) received serious head injuries requiring hospitalization when he was struck by part of the drilling rig (a “tong”) that he was operating.

July 1, 2000
Type A Accident Investigation of the March 16, 2000, Plutonium-238 Multiple Intake Event at the Plutonium Facility, Los Alamos National Laboratory, New Mexico

On March 16, 2000, at approximately 2 p.m., a radiological release of plutonium-238 occurred near a glovebox in the Plutonium Processing and Handling Facility (TA-55) of the Los Alamos National Laboratory. At least seven of the eight workers who were in the room at the time received confirmed intakes of plutonium-238.

June 1, 1999
Type A Accident Investigation Board Report on the April 19, 1999, Special Agent Fatality at the Southeast Courier Section, Oak Ridge, Tennessee

On April 19, 1999, a fatality occurred at the Albuquerque Operations Office (AL) Southeast Courier Section (SCS). A Special Agent had finished his 1-mile qualification run on a treadmill, walked out of the building and suffered an acute myocardial infarction resulting in death.