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Sector 30 PVC Pipe Incident Investigation Final Report

On September 13, 2007, a pipe exploded at Sector 30 along the SLAC linac. Very fortunately, no one was seriously injured in this incident. To determine what led up to this accident and to help ensure that such an accident does not happen again, Acting Director Persis Drell appointed a committee to investigate the causes of the incident. The final report of this committee has now been released.

The committee conducted a rigorous review to find the causes of the incident and how such incidents can be prevented in the future. One of the main goals of the investigation was to find the "root cause:" The most fundamental condition that, if fixed, would have prevented the accident and probably a whole class of similar situations.

The committee determined that the root cause of the accident was poor planning at several critical junctures. A part of the job, the installation of a pressure gauge on the steel pipe, was overlooked, and a last-minute fix went awry. If the work on the pipes had been well planned from the beginning and through to completion, the event would almost certainly have been prevented. Planning and thought are needed prior to all work, not just this specific case.

Insufficient planning is a recurring theme at SLAC, and outside reviewers have told us before that we need to pay more attention to work planning and control. We have made a lot of progress, but we clearly need to do more.

There are four other causal factors described in the report. Together they refer to how SLAC communicates requirements with subcontractors for work, communicates to other members of the SLAC community also doing work, and over-relies on “skill of the craft” for catching a subtle hazard.

A two-page Executive Summary and the full report are available on the ES&H website. The report also contains recommendations for moving forward.

—Harvey Lynch, SLAC Today, November 9, 2007

Above image: The PVC pipe (right) that exploded at Sector 30 on September 13, 2007. At left is a neighboring pipe that was damaged by the explosion. (Please note that the time stamp is off by one hour.)


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