Information Notice 2013-15, Willful Misconduct / Record Falsification and Nuclear Safety Culture
| ML13142A437 | |
| Person / Time | |
|---|---|
| Issue date: | 08/23/2013 |
| From: | Marissa Bailey, Laura Dudes, Kokajko L, Mark Lombard Office of Nuclear Material Safety and Safeguards, NRC/NMSS/FCSS, Division of Construction Inspection and Operational Programs, Division of Policy and Rulemaking |
| To: | |
| King M | |
| References | |
| TAC MF1836 IN-13-015 | |
| Download: ML13142A437 (8) | |
UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR REACTOR REGULATION
OFFICE OF NEW REACTORS
OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS
WASHINGTON, DC 20555-0001 August 23, 2013 NRC INFORMATION NOTICE 2013-15: WILLFUL MISCONDUCT/RECORD
FALSIFICATION AND NUCLEAR SAFETY
CULTURE
ADDRESSEES
All holders of an operating license or construction permit for a nuclear power reactor or a
non-power reactor under Title 10 of the Code of Federal Regulations (10 CFR) Part 50,
Domestic Licensing of Production and Utilization Facilities, except those who have
permanently ceased operations and have certified that fuel has been permanently removed
from the reactor vessel.
All holders of and applicants for a power reactor early site permit, combined license, standard
design certification, standard design approval, or manufacturing license under 10 CFR Part 52, Licenses, Certifications, and Approvals for Nuclear Power Plants.
All contractors and vendors that supply basic components to U.S. Nuclear Regulatory
Commission (NRC) licensees under 10 CFR Part 50, Domestic Licensing of Production and
Utilization Facilities or 10 CFR Part 52, Licenses, Certifications, and Approvals for Nuclear
Power Plants.
All holders of, or applicants for a fuel cycle facility license under 10 CFR Part 70, Domestic
Licensing of Special Nuclear Material.
All holders of and applicants for a specific source material license under Title 10 of the Code of
Federal Regulations (10 CFR) Part 40, Domestic Licensing of Source Material.
All holders of and applicants for a transportation package certificate of compliance or for a
specific approval for transport of radioactive material shipping containers under 10 CFR Part 71, Packaging and Transportation of Radioactive Material.
All holders of and applicants for an independent spent fuel storage installation license or a
certificate of compliance under 10 CFR Part 72, Licensing Requirements for the Independent
Storage of Spent Nuclear Fuel, High-Level Radioactive Waste and Reactor-Related Greater
Than Class C Waste.
All holders of and applicants for a gaseous diffusion plant certificate of compliance or an
approved compliance plan under 10 CFR Part 76, Certification of Gaseous Diffusion Plants.
PURPOSE
The NRC is issuing this information notice (IN) to inform addressees of recent willful misconduct
and record falsification incidents at U.S. nuclear sites and to emphasize the importance of
establishing and maintaining an effective safety-culture by applicants, licensees and their
contractors. The NRC expects that recipients will review the information for applicability to their
facilities and consider actions, as appropriate, to avoid similar problems. Suggestions contained
in this IN are not NRC requirements; therefore, no specific action or written response is
required.
DESCRIPTION OF CIRCUMSTANCES
Described below are seven recent willful misconduct incidents including record falsification that
took place at U.S. nuclear facilities. The NRC enforcement policy states: Licensees are
expected to take significant remedial action in responding to the willful violations commensurate
with the circumstances, such that the action reflects the seriousness of the violation, thereby
creating a deterrent effect within the licensee organization. Therefore, licensees often take
significant actions including the potential for employment termination for the individuals involved
in willful misconduct or record falsification. The NRC may issue escalated enforcement actions
to the individuals involved. Licensees establishing and maintaining an effective safety-culture is
essential in helping prevent willful misconduct by ensuring that expectations and consequences
are clearly stated and understood by all their employees, contractors and agents.
Record Falsification - Travelers for Field versus Design Drawings - Shaw AREVA Mixed Oxide
(MOX) Services Fuel Fabrication Facility Construction Project - In 2009 a contract employee, a
senior structural engineer, directed or allowed a junior engineer to sign his signature on
travelers, contrary to an Engineering directive. Travelers are used as part of the process to
signify that field drawings match design drawings. Thirty-seven travelers were identified in
which the signature may not have been provided in accordance with requirements. The
licensee completed an investigation which included an extent of condition review. Corrective
actions included procedural revisions, several nuclear safety-culture initiatives and related
training and communications to MOX Services personnel and contractors to preclude similar
incidents. Additional information appears in the NRC confirmatory order available on the
agencys public Web site in Agencywide Documents Access and Management System
(ADAMS Accession No. ML093280757).
Record Falsification - Work Order Packages - Tennessee Valley Authority, Watts Bar Nuclear
(WBN) Unit 2 Construction Project - In 2010 two subcontractor employees, one craft and one
craft foreman, at WBN Unit 2 deliberately falsified micrometer readings identified in work order
(WO) packages for primary containment penetrations, and falsely annotated on the WOs that
micrometer readings had been performed for cables in these penetrations, when they had not
been completed. Additionally, the craft foreman falsely attested that a WO review, field
walkdown, review of craft documentation, and the scope of work had all been completed.
Corrective actions included a prompt cessation of all containment electrical penetration work
activities, the initiation of an internal review of the incident, a root cause and extent of condition
review, procedural revisions, training related to the importance of 10 CFR 50.9 Completeness
and Accuracy of Information, and procedural compliance, the addition of language in major
contracts stressing the importance of procedural compliance and the consequences of
noncompliance, as well as various site-specific and fleetwide communications. Additional
information is available in Enforcement Action (EA-12-021), and the NRC Confirmatory Order
package (ADAMS Accession No. ML12202A260). Record Falsification - Fire Drill Forms - Dominion Energy Kewaunee, Inc, Kewaunee Plant - A
fire brigade trainer deliberately failed to conduct announced fire drills in accordance with
applicable procedures and license condition and falsified the Fire Drill Evaluation/Critique
Forms required by the site Fire Protection Program Plan quarterly announced fire drills (from
at least August 2009 through December 2011). The announced fire drills were performed as
training sessions instead of actual fire drills. The NRC issued a final significance determination
on April 30, 2013, determining this to be a white finding, along with a Severity Level-III willful
violation of License Condition 2.C.(3), Fire Protection and a violation of 10 CFR 50.9(a),
Completeness and Accuracy of Information. Corrective actions by the licensee included
initiating an internal investigation into the fire brigade trainers activities, taking disciplinary
actions for both the trainer and the individuals supervisor and conducting fire drills correctly, with no major deficiencies noted. Additional information is available in EA-12-266 Final
Significance Determination of a White Finding with Assessment Followup, Notice of Violation
and Proposed Imposition of Civil Penalty - $70,000: NRC Inspection Report Number
05000305/2013008; Kewaunee Power Station (ADAMS Accession No. ML13121A317).
Record Falsification - Shift Check Forms - Southern Nuclear Operating Company, Vogtle
Electric Generating Plant (Vogtle) Units 3 and 4 Construction Project - In 2012 a subcontracted
employee falsified a concrete laboratory shift check form, at the Vogtle Units 3 & 4 construction
project. Investigations substantiated that the subcontracted employee deliberately falsified the
form and failed to identify to management or to correct equipment conditions adverse to quality.
The employee listed the temperature recorder for safety-related concrete testing as operable
and in range despite knowing the recorder was inoperable. The experimental safety-related
concrete mix design in question was never used. Additional information appears in NRC
Integrated Inspection Reports 05200025/2012-005 and 05200026/2012-005 section 4OA7 Licensee Identified Violations, (ADAMS Accession No. ML13030A390).
Record Falsification - Hourly Fire Watch Patrols - Southern Nuclear Operating Company, Farley Nuclear Power Plant (Farley) - Between September and December 2011, four contract
employees willfully failed to complete fire watch rounds required to ensure that Farley remained
in compliance with 10 CFR 50.48 Fire Protection. In addition, these same employees falsified
fire watch logs by annotating that hourly fire watches were completed when in fact they had not
been performed. These actions caused Farley to be in violation of 10 CFR 50.48 and 10 CFR
50.9(a). Corrective actions included the prompt initiation of an investigation into the matter, an
extent of condition review, the conduct of stand down meetings with the contractor to ensure
that performance expectations were clearly understood, and other licensee fleet activities to
strengthen oversight of supplemental personnel. Additional information is available in the NRC
Notice of Violation; (ADAMS Accession No. ML13063A274).
Record Falsification - Radiation Training Examinations - NRC Issues Confirmatory Order to
Southern Nuclear Operating Company, Farley Nuclear Power Plant - On May 7, 2013, the NRC
issued News Release No: II-13-031 to inform the public of an NRC confirmatory order to Farley
nuclear power plant. The order addresses a violation that involved a Farley security officer
helping other security officers during radiation worker training exams or actually taking the exam
for them and falsifying the associated records. The licensee has agreed to a series of corrective
actions related to the companys failure to ensure that radiation worker training exams for
security officers were not compromised. Corrective action steps include fleetwide actions such
as evaluating the testing environment and compliance with applicable training procedures at
corporate and operating sites and communicating messages throughout the fleet regarding
willful misconduct and its incompatibility with safe nuclear construction and operations. The
licensee also held fleetwide stand-down to address and discuss integrity and trustworthiness. Southern Nuclear Operating Company has committed to conducting an effectiveness review of
all actions taken under the confirmatory order, and to evaluating and implementing actions to
reinforce communications involving willful misconduct, integrity and trustworthiness annually
until 2015. Additional information is available in the NRC Confirmatory Order, EA-12-145, (ADAMS Accession No. ML13127A144).
Misrepresentation - Display Serial Numbers - Pentas Controls, LLC (Pentas) - In 2010, the
owner/president of Pentas directed one of his employees to switch a broken display on a Peach
Bottom Atomic Power Station steam leak detector monitor with a working display unit from the
Brunswick Nuclear Plant site. Before its shipment, the owner/ president also instructed an
employee to file down the serial number on the substitute display to conceal its identity and to
ship the working display to Peach Bottom without informing that site of the switch. On March
15, 2011, the owner/president made false statements to NRC investigators by repeatedly
denying that the unrepairable Peach Bottom display had been substituted with a working display
from Brunswick site.
Because of the egregiousness of the owner/presidents actions, the U. S. Department of Justice
(DOJ) prosecuted the case in Federal district court in Phoenix, AZ. The president pled guilty to
making false statements to NRC investigators, a felony, and was sentenced on February 11,
2013. In exchange for his guilty plea, the president will serve a 5-year probation during which
time he will complete several conditions that the NRC developed and included in the DOJs
global settlement agreement. The NRC will monitor these conditions. As part of the agreement, the owner/president was required to notify his employees of his violation and its consequences
and Pentas was required to conduct training on safety-related activities and hire an outside
contractor to conduct employee protection training. The owner/president was banned from
safety-related decision making for 1 year and from quality-assurance oversight activities
indefinitely. Additional information is available in Judgment in Department of Justice prosecution
of President of Pentas Controls, Inc., including Terms of Probation (ADAMS Accession
No. ML13213A376) and in the NRC Enforcement Program Annual Report, Calendar Year
2012, on page 16; (ADAMS Accession No. ML13079A446).
BACKGROUND
10 CFR 50.9, 10 CFR 52.6, and 10 CFR 70.9, as applicable, all titled Completeness and
Accuracy of Information, state that information required by statute or by the Commission's
regulations, orders, or license conditions to be maintained by the applicant or the licensee, shall
be complete and accurate in all material respects. Regulations in 10 CFR 50.5, 10 CFR 52.4 and 10 CFR 70.10, as applicable, all titled Deliberate Misconduct, have more detailed
requirements and specifically prohibit deliberate misconduct.
Related NRC Generic Communications and Website Information
The NRC has previously issued numerous generic communications related to safety-culture, deliberate misconduct and issues involving proper oversight of contractors or subcontractors.
The following represents some of the recent related NRC generic communications:
NRC Bulletin 2007-01, Security Officer Attentiveness, dated December 12, 2007. This bulletin
requested information on licensee administrative and managerial controls to deter and address
inattentiveness and complicity among licensee security personnel including contractors and
subcontractors; (ADAMS Accession No. ML073400150). NRC Regulatory Issue Summary (RIS) 2006-13, Information on the Changes Made to the
Reactor Oversight Process to More Fully Address Safety Culture, dated July 31, 2006. This
RIS documented changes made to the reactor oversight process (ROP) to more fully address
safety-culture; (ADAMS Accession No. ML061880341).
NRC RIS 2005-18, Guidance for Establishing and Maintaining a Safety Conscious Work
Environment, dated August 25, 2005. This RIS provided licensees, applicants for a license, holders of certificates of compliance, and their contractors guidance on establishing and
maintaining a safety-conscious work environment; (ADAMS Accession No. ML052220239).
NRC IN 2002-36, Incomplete or Inaccurate Information Provided to the Licensee and/or NRC
by Any Contractor or Subcontractor Employee, dated December 27, 2002. This IN reminded
addressees of the importance of diligently ascertaining the accuracy of educational background
and professional qualifications of any contractor or subcontractor employees subject to such
qualification requirements and alerted them about the potential penalties that could result from
intentionally providing incomplete or inaccurate information to the NRC; (ADAMS Accession
No. ML023650299).
NRC RIS 12-01, Availability of Safety Culture Policy Statement, dated January 17, 2012. This
informs addressees of the availability of the Commissions safety-culture policy statement;
(ADAMS Accession No. ML112940226).
The NRC Safety Culture Policy Statement was issued in the Federal Register on June 14, 2011 (ADAMS Accession No. ML111650336). The NRC policy statement defines nuclear
safety-culture as: The core values and behaviors resulting from a collective commitment
by leaders and individuals to emphasize safety over competing goals to ensure
protection of people and the environment. Note: This policy statement applies to all
licensees, certificate holders, permit holders, authorization holders, holders of quality assurance
program approvals, vendors and suppliers of safety-related components, and applicants for a
license, certificate, permit, authorization, or quality assurance program approval subject to NRC
authority. Nuclear safety-culture program information is available (in both English and Spanish)
at the NRC public Website link:
http://www.nrc.gov/about-nrc/regulatory/enforcement/safety-culture.html#programs
DISCUSSION
As stated in the NRC Enforcement Policy (on page 9, section 2.2.1.d): Willful violations are of
particular concern because the NRCs regulatory program is based on licensees and their
contractors, employees, and agents acting with integrity and communicating with candor. The
Commission cannot tolerate willful violations. Therefore, a violation may be considered more
significant than the underlying noncompliance if it includes indications of willfulness.
An effective safety-culture is essential to nuclear safety at all phases of design, construction and
operation and can help prevent willful misconduct by ensuring expectations and consequences
are clearly stated and understood. Construction activities present additional challenges as new
employees join the nuclear workforce for the first time. Often, these new employees lack
familiarity with the nuclear safety-culture expectations needed to conduct their work activities in
accordance with regulatory requirements and may require extra guidance. For example, they
may not understand and recognize the significance of their signatures as they relate to
complying with the requirements (10 CFR 50.5, 10 CFR 50.9, 10 CFR 52.4, 10 CFR 52.6, 10 CFR 70.9, and 10 CFR 70.10, as applicable). In addition, employees new to the commercial
nuclear industry may wrongly believe based on previous non-nuclear experience, that they can interpret certain work procedure steps or have more latitude in deviating from procedural
guidance.
Key behaviors of a healthy safety-culture need to be continually reinforced. These behaviors
include personal accountability, including admitting mistakes, demonstrating a questioning
attitude and a willingness to raise concerns and engaging with management in problem
resolution. Trust and respect need to permeate each organization while communications
maintain a focus on nuclear safety and leaders demonstrate a commitment to safety in their
decisions and behaviors.
CONCLUSION
The above willful misconduct issues and discussion highlights the need for applicants, licensees, contractors and suppliers involved in construction, fabrication activities, and
operations of nuclear facilities, to establish and implement an effective nuclear safety-culture.
This includes training, adequate oversight, and frequent communications especially for workers
new to the nuclear industry. Safety-culture weaknesses have been identified as one of the
causes of major accidents and incidents such as the Fukushima nuclear accident in Japan in
2011, the Davis-Besse reactor vessel head degradation near-miss incident discovered in 2002, the Chernobyl accident in the former Soviet Union in 1986, and the Three Mile Island Unit 2 accident in 1979.
The NRC continually looks for signs of wrongdoing (willful misconduct, deliberate violations and
careless disregard) when inspecting, evaluating inspection findings, reviewing licensee
corrective action programs, reviewing licensee employee concerns programs, and responding to
allegations. Wrongdoing (e.g., falsification of records) may be referred to the U.S. Department of
Justice for prosecution and may result in civil fines, criminal penalties, or Orders being issued to
licensees, as well as to the individuals involved.
The NRC expects that recipients will review the information in this information notice for
applicability to their facilities and consider actions, as appropriate, to avoid similar problems.
CONTACT
S
This IN requires no specific action or written response. Please direct any questions about this
matter to the appropriate technical contacts listed below or the appropriate project manager.
/RA/ /RA/
Laura A. Dudes, Director Lawrence E. Kokajko, Director
Division of Construction Inspection Division of Policy and Rulemaking
and Operational Programs Office of Nuclear Reactor Regulation (NRR)
Office of New Reactors (NRO)
/RA/ /RA/
Mark Lombard, Director Marissa G. Bailey, Director
Division of Spent Fuel Storage Division of Fuel Cycle Safety and Safeguards
and Transportation Office of Nuclear Material Safety
Office of Nuclear Material Safety and Safeguards
and Safeguards
Technical Contacts: Alfred Issa, NRO Mark King, NRR
301-415-5342 301-415-1150
E-mail: Alfred.Issa@nrc.gov E-mail: Mark.King@nrc.gov
Note: NRC generic communications may be found on the NRC public Web
site, http://www.nrc.gov, under NRC Library/Document Collections.
ML13142A437 *via e-mail TAC MF1836 OFFICE NRO/DCIP/CAEB Tech Editor NRO/DCIP/CAEB NRR/DLR/RAPB/BC
NAME AIssa QTE - CHSU RLukes SBloom (acting)
DATE 7/18/13
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NAME DSieracki DSolorio CHawes MKing
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NAME DPelton SBahadur
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