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Report Number
NHAOE-102820214417
Event Start / End
07/15/2021 12:30 pm - 07/15/2021 1:00 pm
Event Duration
Less than 12 hours
Functional Area
Safety
Functional Area Subclass
Employee
Classification
Minor
Impact of Event
Other
Human Performance
Yes

Boat Drifting in the Boat Restricted Zone with Open Spillway

October 28th, 2021

Minor

Part I: Report of Events

Description of Event:

A contractor was performing bathymetry in the boat restricted zone (BRZ) of the plant forebay.  The work boat was not equipped with a kicker motor, so a second boat was used as a safety/tow boat.   The safety boat’s motor ran aground, and the boat required a tow from the work boat.  The work boat was unable to overcome the flow of the partially open spillway and generating units while towing the safety boat from the rear.  The flow from the spillway and units pulled the boats towards the dam.

The plant operators closed five spillgates and reduced plant output by approximately 100MW.  Plant crews were dispatched to aid the two contractor boats.  The contractor was able to get the safety boat re-connected and towed away from the dam before the boats drifted into the dam face.  The two contractor boats tied up to the work barge and a stop work was executed.

Actions Taken:

Contractor’s boats were secured and spill and plant operations resumed.



Part 2: Cause Analysis

Method & Findings:

The contractor’s boats were operating in the BRZ.
Critical Factors:

  • There was no spotter on the contractor’s safety boat.
  • The contractor was unfamiliar with the underwater topography of the BRZ.

System Gaps:

  • The operating plan for working in the BRZ was insufficient.

Failed Barriers:

  • Safety boat had no backup motor

Causal Factors:

  • Primary boat had a lack of a sufficient kicker motor, requiring a safety boat
  • Single motor on safety boat

Critical Controls:

  • Safety boat ran aground – failed
  • Communication with control room – failed safe

Supporting Materials:



Part 3: Corrective Actions Plan

Corrective Actions:

Boat operators will always have an observer on the boat in the BRZ.
All watercraft in the BRZ to have a sufficient kicker motor.
The Standard Operating Procedure (SOP) for the BRZ will be updated with additional information.

Sequence & Completion Dates for Actions Listed:

Boats were secured at the end of the event.  The SOP revision is complete and awaiting management approval.



Part 4 – Lessons Learned

Lessons Learned:

  • Risk is created by working in the forebay near active spill and operating units.
  • Boats in the BRZ should have an observer to watch for hazards; no boat should be occupied by fewer than two people.
  • Boats in the BRZ should have backup motors capable of overcoming the expected current due to plant flow.

Recommendations:

  • Restrict boat operation near active spill.
  • Boats in the BRZ should have sufficient kicker motors and two or more occupants.
  • No more boats than necessary should be in the BRZ.
Download PDF
Report Number
NHAOE-102820214417
Event Start / End
07/15/2021 12:30 pm - 07/15/2021 1:00 pm
Event Duration
Less than 12 hours
Functional Area
Safety
Functional Area Subclass
Employee
Classification
Minor
Impact of Event
Other
Impact of Event - Other
change in operations
Human Performance
Yes