TABLE OF REVISIONS. Rev. Page Date Description. 0 N/A Initial revision. 2 of 18

Transcription

1

2 TABLE OF REVISIONS Rev. Page Date Description 0 N/A Initial revision. 2 of 18

3 TABLE OF CONTENTS TABLE OF REVISIONS... 2 EXECUTIVE SUMMARY CONDITIONS BEFORE THE INCIDENT SEQUENCE OF EVENTS PERSONNEL PERFORMANCE PROBABLE CAUSE IMMEDIATE ACTIONS NOTIFICATIONS REPORTABILITY AND POTENTIAL SIGNIFICANCE EXTENT OF CONDITION INTERIM ACTIONS TEAM SUGGESTED ACTIONS FITNESS FOR DUTY (FFD) FINDINGS REPORT ATTACHMENTS of 18

4 EXECUTIVE SUMMARY On July 30, 2013 at approximately 1440 CDT, TVA (Tennessee Valley Authority) Energy Delivery personnel were in the process of replacing a conductor on the Trinity - Browns Ferry 161 kv line when the cable used during installation failed, allowing the conductor to fall into the waters of the Tennessee River. TVA crews took immediate actions to minimize the risk to public safety. The immediate actions included contacting the USCG (United States Coast Guard) to close the Tennessee River to traffic and establishing a patrol on each side of the downed conductor. However, at approximately 1730 CDT, a recreational boat made contact with a downed conductor from the Trinity - Browns Ferry 161 kv (kilovolt) line, resulting in a fatality to one of the occupants of the boat. Following the fatality event, TVA Police, in cooperation with the State of Alabama Marine Police, and the TVA OIG (Office of the Inspector General), began an investigation into the events surrounding the fatality. TVA Safety & Health began an independent parallel investigation into the public safety aspects surrounding the event. The independent Safety & Health investigation team scope was defined as follows: Review of the public and employee safety plans associated with the work activities over the Tennessee River Review of the contingency plans for actions in the event that a conductor was dropped into the waters of the Tennessee River Review of the actions taken by TVA personnel in response to the July 30, 2013 event that resulted in a fatal injury to a member of the general public Key Findings Within the above defined scope, employee actions leading up to and following the incident were in keeping with established work practices. The boat pilot s notifications and coordination related to river traffic following the conductor drop were thorough. Safety plans did not contain specific written guidance for handling river traffic and additional actions to be taken if the conductor fell in the river. TVA has no official authority to control water traffic. Recommendations Workers should be provided specific written safety plans for waterway traffic patrol when waterway crossing is involved. Guidelines for patrol of waterway traffic should be established to ensure consistency in development of waterway traffic patrol plans. Additional analysis should be performed to understand the condition and failure mode of the pull cable. 4 of 18

5 1.0 CONDITIONS BEFORE THE INCIDENT 1.1 Scope of Work On July 08, 2013, TVA Energy Delivery personnel began a project, consisting in scope of replacing the conductors on the Trinity - Browns Ferry 161 kv line, crossing the waters of the Tennessee River, approximately 1.75 miles in width. All required clearances and applicable safety measures were in-place. Figure 1, Line Crossing the Tennessee River (dsc_0033.jpg). Aerial view of the Trinity - Browns Ferry 161 kv line (right side of the right tower), looking north towards Athens As work continued, the TVA Energy Delivery crew determined that a larger puller 1 was needed to effectively complete the task, and a new puller was procured on July 25, The new puller had a maximum working force of 40,000 and a manually set safety limit of 22,000 pounds. The rated tensile strength of the pulling cable was greater than 50,000 pounds. Pulling of the line continued with no significant adverse issues identified until the pulling cable broke allowing the 161kV conductor to fall into the water at approximately 1440 on July 30, Work Documentation The replacement of the conductors on the Trinity - Browns Ferry 161 kv line was performed utilizing 2 separate JSAs (Job Safety Analysis) to provide safety information. An ESP Pre-plan Checklist for Stringing Operations was utilized for the determination of precautions associated with the work scope. The ESP Pre-plan Checklist for Stringing Operations was completed prior to work beginning on the Trinity - Browns Ferry 161 kv line project. A spreadsheet of Line Crossings was included with the work scope documentation to ensure that in the event of a dropped conductor, all energized lines had been identified with needed actions to secure any voltage incurred by contact. Additionally, the work documentation package included a drawing, Line Clearance Diagram, of the transmission grid. 1 The piece of equipment, used by TVA Energy Delivery personnel, that pulls the associated overhead conductor into position. Maximum working force on the original puller was 20,000 pounds. 5 of 18

6 Pre-job briefings were conducted daily to address the scope of work for the planned activities. Pre-job briefings included a discussion of safety precautions. 1.3 Meteorological Conditions Review of the weather conditions on July 30, 2013 indicated that skies were clear with visibility approximately 10 miles. High temperature was around 90 degrees with winds less than 10 mph (miles per hour). Scattered clouds moved into the area around 1900 with light rain around Patrol of River Traffic TVA ESS (Equipment Support Services) personnel were contacted to assist with the patrol of the area involving overhead work. ESS personnel supported the activities with two boats to assist in patrol of the area. One boat, designated TVA Boat 1, was positioned near the southern shore (Decatur side) of the Tennessee River to patrol the area from southern shore to the midpoint of the river. Another boat, designated TVA Boat 2, was positioned near the northern shore (Athens side) of the Tennessee River to patrol the area from the northern shore to the mid-point of the river. Areas of coverage overlapped and both boats relocated as needed within their respective area to support activities as needed. Prior to the spring of 2012, the patrol of river traffic, involved TVA Police and the use of official TVA Police boats equipped with blue strobe lights and siren/public address units. During this activity, TVA ESS boats were neither marked with any official TVA markings, nor did they utilize blue lights or sirens 2. However, each ESS boat was manned with a minimum of two people. One of which was tasked with flagging river traffic utilizing an orange flag. During the time leading up to the event, over 200 boats were stopped and successfully warned of the line work. 2.0 SEQUENCE OF EVENTS 2.1 Event Narrative On the morning of July 30, 2013, work began at 0545, with show up 3 on the south (Decatur) side of the project. Following show up, crews dispersed to their respective work locations for the day with specific pre-job briefings held from TVA ED (Energy Delivery) personnel were tasked with removal and re-installation of the 161 kv conductor. ESS personnel were tasked with patrol of the area and providing foreman support. At 0830, work began on removing the last existing (old) conductor. During the removal process, the two TVA boats were located on the water, patrolling the area where work was being performed overhead. Work on the removal of the old conductor was completed around 1100, and the workers suspended work for lunch. Work reconvened around 1130 and the re-installation of the conductor began around 1230 with the pulling of the three (3) new wires for the bottom phase of the Trinity line. At approximately 1440, the pulling cable failed allowing the new conductor to fall into the Tennessee River. 2 TVA ESS boats were not serving in a law enforcement capacity, thus the use of blue or red warning lights and the use of a siren was prohibited by law. 3 Show up is the overall plan of the day meeting for TVA Energy Delivery personnel. 6 of 18

7 Figure 2, Failed Pulling Cable (dsc_0014.jpg). Image of the cable that failed during the July 30, 2013 conductor re-installation. At the time of the conductor fall, TVA Boat 2 was covering its assigned area with a USCG qualified boat pilot, an additional ESS person, and the lineman foreman onboard. TVA Boat 2 returned to the boat ramp on the north (Athens) side of the river for the lineman foreman to assist in conductor recovery efforts. TVA Boat 2 then relocated to the west (downstream) side of the downed conductor to patrol the area spanning the width of the river, from the northern shore to the southern shore. TVA Boat 1 was also covering its assigned area at the time of the conductor fall. Additionally, TVA Boat 1 adjusted its area of coverage on the east (upstream) side of the downed conductor to patrol the area spanning the width of the river, from the northern shore to the southern shore. See Attachment B, Event Diagram, for further details. Following the conductor fall, the TVA Boats successfully warned recreational boats, providing notice of the downed conductor. Additionally, the pilot of TVA Boat 2 displayed quick thinking and foresight by taking immediate actions to notify the appropriate authorities of the fallen cable. See section 5.0, Immediate Actions, for details. At 1730, a fishing tournament began, departing from Ingalls Harbor, approximately 5 miles to the east (upstream). 4 Prior to 1733, TVA Boat 2 made contact with a recreational boat (Identified as Recreational Boat 4 on the Event Diagram, Attachment B) with four (4) occupants, successfully providing warning of the downed conductor. Upon clearing from warning the recreational boat, the pilot of TVA Boat 2 noticed a boat 5 (Identified as Recreational Boat 1 on the Event Diagram, Attachment B) 4 Ingalls harbor is located in Decatur, Alabama, a distance of 5-6 miles upstream of the river crossing work. Travel time figured at 70 mph: 5 miles = 4.31 minutes, 6 miles = 5.17 minutes. 5 Boat was identified as a Ranger, Z21, 21.2 ft in length with a 250 horse power mercury engine, with a top rated speed of approximately 70 mph. Source: Main.aspx?lp_id=396&t=BOAT-TEST&Videoid=942&p=0&s= 7 of 18

8 heading westbound (downstream), at a high rate of speed. The pilot of TVA Boat 2 attempted to move into position to warn the operator of the boat of the downed conductor. Upon a closer look, there were three boats traveling westbound (identified as Recreational Boat 1, Recreational Boat 2, & Recreational Boat 3 respectively). The pilot of TVA Boat 2 observed the lead boat come to a stop. The pilot of TVA Boat 2 proceeded over to Recreational Boat 1 to verify that the occupants were aware of the downed conductor and discovered that the passenger had come in contact with the downed conductor and had received severe injuries. The pilot asked the operator of Recreational Boat 1 where he had launched the boat and called 911 to report the event. The pilot of TVA Boat 2 then directed the operator of Recreational Boat 1 to return to Ingalls Harbor and relayed the message to the 911 dispatcher. Recreational Boat 1 returned to Ingalls Harbor and met with EMS (Emergency Medical Services). The injuries sustained by the passenger of Recreational Boat 1 proved to be fatal. 2.2 Detailed Sequence of Events (Source references are related to the Document Control Log, Attachment C) Date / Time Details Source 12/05/12 Project planning begins for conductor replacement on the Trinity - BF 161 kv Line (3 scoping workshops in Dec.) /08/13 Conductor replacement project begins (Phase 3) /11/13 ESS contacted for support of the conductor replacement project (1 boat for helicopter support) 07/15/13 Setup begins to pull conductor over water - Pulled top phase with original 20k puller /15-29/13 Pulling top and middle phase conductors over the river / /22/13 Second boat arrived to support the conductor replacement project TVA ED / /25/13 Swapped to larger puller procured for the conductor replacement project /30/ Employees arrive at show up on south side of river Decatur, McEntire Lane /30/ Overall Morning Meeting in Decatur /30/ Specific pre-jobs conducted on North & South side of river /30/ Begin removal of the existing conductor (2 boats in the water) /30/ Completed removal of the existing conductor /30/13 LUNCH /30/ Begin pulling 3 new conductors (bottom phase) /30/ Cable used for pulling the new conductor fails allowing the conductor to fall into the waters of the Tennessee River of 18

9 Date / Time Details Source 07/30/13 (Sequence of events related to mitigation of hazards) Pull stopped Calls were made by pilot of TVA Boat 2 Stay clear issued / Live Dead Live ordered Meter test (LDL) conducted Absence of energy confirmed Discovered cable had struck distribution feeder Notified distribution center Placed grounds Recovery of plan of distribution feeder implemented Reconnected cable for pull TVA boat #2 takes North Foreman to North shore of river when cable struck the water. TVA Boat #2 returns to downstream side /30/ Decatur railroad bridge notified of the dropped conductor, request made to lower the railroad bridge, thereby blocking the channel of the river to commercial vessel traffic /30/ Notified the ESS River Services Manager of the dropped conductor /30/13 Pilot of the east bound tow boat notified of the dropped conductor /30/ Wheeler Lock notified of the dropped conductor, request made to close the lock /30/ U. S. Coast Guard notified of the dropped conductor /30/ U. S. Coast Guard broadcast released (VHF Channel 16 - hourly; announcing condition and closing the river to traffic) /30/ Pull restarted. U. S. Coast Guard notified /30/13 Conductor running board binds up /30/13 TVA Boat #1 moves into position for better view of conductor running board /30/ Recreational fishing boats in water at Ingalls boat launch in preparation for a fishing tournament TVA Police 07/30/ Shotgun start to fishing tournament TVA Police 07/30/13 Fishing boats were observed upstream by North shore foreman /30/13 North shore foreman radios South shore foreman (on TVA Boat #1) of fast approaching fishing boats. 07/30/13 TVA Boat #2 sees oncoming fishing boats and attempts to intercept (waving flags during route) of 18

10 Date / Time Details Source 07/30/ EVENT OCCURS, 911 notified of the conductor strike and injury by Marine Pilot of Boat # /31/ OSHA notified of the fatality (non-required notification) TVA Safety 2.3 Investigation Team Findings Within the defined scope of this investigation, employee actions leading up to and following the incident were in keeping with established work practices. The boat pilot s notifications and coordination related to river traffic following the conductor drop were thorough. Safety plans did not contain specific written guidance for handling river traffic and additional actions to be taken if the conductor fell in the river. o The roles & responsibilities with respect to river traffic patrols were unclear. o The employees had to rely on their knowledge and experience. o The boats used for traffic patrol also had some other responsibilities. o The boats used did not have TVA identifying markings. TVA has no official authority to control water traffic. 3.0 PERSONNEL PERFORMANCE No human errors were identified during the investigation into the subject event. However, a latent organizational weakness was identified in that ED personnel were required to revert to knowledge space to respond to an event involving a dropped conductor into open navigable waters. Written guidance related to water crossings were not available at the time of the event. During the subject event, the pilot of TVA Boat 2 s performance was extraordinary. The pilot displayed quick thinking and made sound decisions related to making notifications of the dropped conductor, going well above and beyond what was required. The USCG was contacted to close the Tennessee River to river traffic. Additionally, the pilot displayed the foresight to not only notify the downstream lock (Wheeler), but also to notify the railroad bridge at Decatur to secure the area. The pilot then determined that there should be only one commercial vessel between the two obstructions. He then obtained the personal phone number of the operator of the commercial vessel and made notification to the operator by phone. 4.0 PROBABLE CAUSE Due to the public safety and law enforcement aspects, probable causes associated with the subject event are not included in the scope of the investigation. The circumstances regarding the use, condition, and breaking of the failed pulling cable were not within the scope of this investigation and require separate investigation and analysis to consider the failure mode of the cable. Personnel error has not been identified as a contributor to the event. 5.0 IMMEDIATE ACTIONS Immediate actions, as related to the fatality, began at approximately 1440 when the wire used in pulling the conductor failed, resulting in the conductor falling to the water below. Recovery efforts for the conductor started immediately following the line drop. During the recovery efforts, the pilot of TVA Boat 2 notified the USCG of the incident and requested they close the Tennessee River to traffic. Additionally, the pilot notified the 10 of 18

11 downstream lock (Wheeler) and the railroad bridge at Decatur to secure the area. The pilot then phoned the operator of the only commercial vessel in the area to provide warning of the downed conductor. Patrols on both the upstream and downstream area continued. 6.0 NOTIFICATIONS The following notifications were made following the conductor falling into the Tennessee River: 7/30/13, Decatur railroad bridge notified of the dropped conductor, request made to lower the railroad bridge, thereby blocking the channel of the river to commercial vessel traffic 7/30/13, Notified the ESS River Services Manager of the dropped conductor 7/30/13, Wheeler Lock notified of the dropped conductor, request made to close the lock 7/30/13, U. S. Coast Guard notified of the dropped conductor 7/30/13, U. S. Coast Guard broadcast released (VHF Channel 16 - hourly; announcing condition and halting (closing) the river to traffic) 7/30/13, Pull restarted, U. S. Coast Guard notified 7/30/13, notified of the conductor strike and injury 7/31/13, OSHA notified of the fatality (not required) 7.0 REPORTABILITY AND POTENTIAL SIGNIFICANCE Multiple agencies 6 are conducting investigations into the fatality associated with the Trinity - Browns Ferry 161 kv line work. Regulatory impact is minimal; however, ensuring public safety is priority for TVA. Although not required, OSHA (Occupational Safety and Health Administration) was contacted by TVA and no further actions were required by them. 8.0 EXTENT OF CONDITION EOC (Extent of Condition) for the associated event has been bounded to other conductor installation or removal activities that could potentially impact public safety. For the purposes of the event in question, the investigation team has limited the EOC to work activities involving overhead conductor installation or removal, in which the associated conductor work involves crossing the travel path of vessels, motor vehicles, and rail components. Conductor installation or removal activities that cross open navigable waters have been identified as a potential vulnerability for TVA. These activities do not have procedural controls related to the control of river traffic. Additionally, conductor installation or removal activities that cross active railroads have been identified as a potential vulnerability for TVA. Risk associated with these activities is mitigated with the inclusion of an engineered safety plan in accordance with railroad administrator standards. Finally, conductor installation or removal activities that cross public roadways have been identified as a potential vulnerability for TVA. Risk associated with these activities is mitigated with the inclusion of a safety plan in accordance with the Federal Highway Administration standards. 6 TVA Police, TVA Office of the Inspector General, and the Alabama Marine Police are all conducting investigations into the event in parallel to the TVA Safety & Health investigation. All information that is not Law Enforcement Restricted has been shared with the TVA Safety & Health investigation team. 11 of 18

12 The ESP Pre-Plan Checklist for Stringing Operations includes a checkbox to prompt the individual completing the checklist to consider public roadway and railroad crossings; however, there is no prompt for the consideration of open navigable waters. All recommendations from the Trinity - Browns Ferry 161 kv line are potentially applicable to the EOC and a graded approach to implementation should be taken. 9.0 INTERIM ACTIONS Following the fatality, TVA took the following interim actions to ensure the safety of the general public: Additional reviews of work scope that involves the crossing of open navigable waters by TVA Safety & Health, TVA Management, and TVA Executives Additional safety planning Addition of written water crossing contingency plans Additional water presence by TVA to provide patrols of areas with overhead work 10.0 TEAM SUGGESTED ACTIONS The following recommendations are provided based on team findings following the conductor falling into the Tennessee River resulting in a fatality to a member of the general public. Workers should be provided specific written safety plans for waterway traffic patrol when waterway crossing is involved. o This plan should be developed in advance as part of the work package and should be specific to the waterway to be crossed. o The work group responsible for performing the work should have responsibility for developing and implementing the waterway traffic patrol plan. o Contingency plans should be provided to address additional actions and notifications to be taken in the case of an incident. Guidelines for patrol of waterway traffic should be established to ensure consistency in development of waterway traffic patrol plans. Additional analysis should be performed to understand the condition and failure mode of the pull cable FITNESS FOR DUTY (FFD) FINDINGS All personnel that were considered as supervision, personnel operating the cable puller and tensioner, and all personnel that were tasked with control of river traffic required FFD testing by TVA process. A total of eleven individuals were tested with no positive test results. 12 of 18

13 12.0 REPORT ATTACHMENTS Number Name List of Attachments Attachments Attachment A Attachment B Attachment C Attachment D Investigation Scope / Charter Event Diagram Document Control Log Incident Facts 13 of 18

14 Attachment A Trinity - Browns Ferry 161kV Event Investigation Scope A team has been formed to investigate the public safety aspects surrounding the fatal injury of a member of the public that occurred on the Tennessee River on July 30, 2013 during Energy Delivery work on the Trinity - Browns Ferry 161kV line. The following items are in scope: Public and employee safety plans associated with work activities over the river Contingency plans for dropping a conductor in the river Employee actions to address public safety when the conductor fell The following items are not in scope: Employee safety plans for land based work activities Conductor pull setup and technical details The team will review associated documentation, conduct interviews, and establish a timeline of relevant events. Based on review of event data, the team will identify any process and performance gaps and provide suggested improvement actions. Team Members Dana White - Director, Safety & Health - Lead Anthony Cameron - Safety Manager, Energy Delivery Joey Howell - Safety Manager, Generation West Joel Landers - Safety Consultant Robert Lee - Safety Consultant Mitch Collier - Safety Consultant Keith Ridgeway - Engineering Coordinator, Browns Ferry Keith Elder - General Manager, Transmission Line Projects Walter Hutcherson - Sr. Manager, Transmission Line Construction 14 of 18

15 Attachment B Event Diagram N W S E 4 Cowford Boat Ramp 46 Tennessee River Wheeler Lake RB Wheeler Lock kv line 161 kv line 47 Pulling cable for the BF Trinity 161 kv line broke and the conductor fell into the waters of the Tennessee River. Ingalls Harbor Approximate Point of Impact X 10 6 Legend Recreational Boat (RB) Travel Direction Approx. Speed 70 mph RB1 RB2 RB3 50 X X Tower Number Events Involving TVA Boat 1 Events Involving TVA Boat X Other Events Event Details: 1. TVA Boat 1 was patrolling the area involving overhead work. Area of responsibility began at the southern shore of the Tennessee River and extended to the approximate mid-point of the river, overlapping TVA Boat TVA Boat 2 was patrolling the area involving overhead work. Area of responsibility began at the northern shore of the Tennessee River and extended to the approximate mid-point of the river, overlapping TVA Boat Location of TVA Boat 2 at the time of the conductor fall. 4. Upon seeing the conductor fall, TVA Boat 2 returns to the boat ramp to deliver the Lineman Foreman to assist with recovery. 5. Following the delivery of the Lineman Foreman, TVA Boat 2 moves to the west (downstream) side of the downed conductor to patrol the area from the northern to the southern shore of the Tennessee River (Apx 1.75 miles). 6. Following the conductor fall, TVA Boat 1 remains on the east (upstream) side of the downed conductor to patrol the area from the northern to the southern shore of the Tennessee River (Apx 1.75 miles). 7. TVA Boat 2 provides warning of the downed conductor to RB4. 8. Following the warning of RB4, TVA Boat 2 sees a boat (RB1) traveling westward toward the downed conductor at a high rate of speed. Starts relocation to attempt to provide warning to RB1. 9. Location of TVA Boat 1 when RB1 is spotted traveling towards the downed conductor. 10. Passenger in RB1 makes contact with the downed conductor incurring fatal wounds, RB1 comes to a stop. 11. TVA Boat 2 sees RB1 stop and continues relocation to ensure that passengers in the boat had seen the downed conductor. 12. TVA Boat 1 makes contact with RB2 & RB3, successfully warning and stopping before contact with the conductor. 13. Pilot of TVA Boat 2 calls 911 and then directs the operator of RB1 to Ingalls Harbor to meet EMS (emergency medical services). 15 of 18

16 Attachment C Document Log Trinity Browns Ferry 161 kv Line Event Control Number Description Pages 0001 Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Interview Notes of EX 5, Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, Statement of EX 5, 6 + Interview Notes Statement of EX 5, Statement of EX 5, Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Statement of EX 5, 6 + Interview Notes Interview Sign in Sheet Follow up Interviews Conducted on Photos Taken on Photos Taken on Alabama Marine Police Report (from waff.com) ESP TLC CS , R ED TI , R JSA LC006, R Rope Invoice Scheduling Info Job Brief Meterological Data Follow up Interviews Conducted on JSA LC005, R Follow Up Interviews w/forman Photo's Taken on of 18

17 Attachment D Incident Facts The approximate distance across the river is 1.75 miles land miles. The approximate distance from Ingalls boat ramp to the point of impact is 5.6 land miles (4.9 nautical miles). If the bass boat were traveling at a speed of 70mph, it would take approximately 5 minutes to reach the cable area from Ingalls boat ramp (where the fishing tournament started). Alabama Marine Police obtained statements from two ESS employees, and involved recreational boaters. The TVA Police has copies of these statements. JSA LC006 was used for conductor rigging. While it does mention that conductor rigging may cross highways or waterways, it does not provide specific safety guidance for these situations. If a roadway will be crossed when pulling conductors, the design package contains an engineered safety plan in accordance with Federal Highway Administration Safety Standards. The design package for this job did not contain safety guidance specific to crossing a waterway. Interviews and review of pre-job brief documentation indicates crews discussed that the conductor could fall in the river, and a contingency plan was discussed. Two TVA boats with boat operators and a marine pilot from ESS were assigned to patrol river traffic. The ESS boat operators and pilot participated in the ESP pre-job briefs on the Athens side. The ESS boat operators and pilot indicated they were supporting the ESP work. ESP personnel indicate it was ESS responsibility to patrol the river and alert boat traffic to the ongoing work. Prior to the 2012 reorganization, TVA police were used to patrol waterways and assist Energy Delivery with traffic control. Their boats were equipped with blue flashing lights, sirens, and public address systems. TVA police received formal training to qualify them to be marine officers. TVA ESS boat operators do not get training for waterway traffic patrol. Their traffic patrol approach was based on knowledge and experience. The TVA ESS boats used are unmarked boats. They do not have sirens or PA systems. They used orange fluorescent flags for visibility. 17 of 18

18 Attachment D Incident Facts (continued) Boat operators and ESP workers indicate they stopped over 200 boats during the 2 week period the work had been ongoing. They did not maintain records of the boats and drivers stopped. Following the conductor being dropped, the boat operators stopped approximately 10 to 13 boats prior to the boat coming in contact with the low conductor. Coast Guard notifications of river closure following the conductor drop went out via marine radio. Commercial watercraft are required to have marine radios. However, radios are not required for most recreational watercraft. Follow up work was required on Friday and Saturday following the incident. With 6 boats in the river for waterway traffic control including Morgan County Rescue and the Coast Guard, a boat and 2 personal watercraft still broke through the water traffic control boundaries. 18 of 18