ML20093N790
| ML20093N790 | |
| Person / Time | |
|---|---|
| Site: | University of Missouri-Columbia |
| Issue date: | 09/29/1995 |
| From: | Mckibben J, Rhyne J MISSOURI, UNIV. OF, COLUMBIA, MO |
| To: | Hughes G, Klein D, Remick F AFFILIATION NOT ASSIGNED, TEXAS, UNIV. OF, AUSTIN, TX |
| References | |
| NUDOCS 9510270382 | |
| Download: ML20093N790 (35) | |
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F e Research Reactor Center Research Park II Columbia. Missouri 6521t Telephone (314) 882 4211 FAX [314] 882-3443 UNIVERSITY OF MISSOURI-COLUMBIA September 29,1995 Dr. Dale IOein College of Engineering Mail Code C2100
. The University of Texas at Austin Austin, TX 78712-1080 Dr. Forrest Remick p -gh
.305 E; Hamilton Ave,
' State College, PA 16801 5413 Dr. Gary Hughes 7101 Sycamore Creek Rocheport,MO 65279 Gentlemen:
Thank you again for your review and assessment of the safety environment at MURR. This opportunity to gain from your collective experiences and insights is immeasurable. We have carefully studied your findings and recommendations, and with the assistance of all groups at MURR have implemented a major portion of your recommendations. We continue to work on the remainder.
The attached " Report of Progress" explains where MURR stands regarding each of your findings and recommendations. This report of progress will be sent also to NRC Region III. We welcome your evaluation of our responses for adequacy and effectiveness of addressing each issue.
Sincerely,
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ames J. Rhyne J. Charles McKibben Director Associate Director enc xc:
Regional Administrator, NRC Region III T. Reidinger, NPR Project Engineer, NRC Region III S. Weiss, Chief-NRR/ONDP, NRC h
COLUMBIA KANSAS CITY ROLLA ST. LOUIS
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REPORT OF PROGRESS ON RECOMMENDATIONS OF THE INDEPENDENT SAFETY ASSESSMENT TEAM (ISAT) q I
The recommendations ofISAT were provided under two headings, Climate For i
Safety and Chilling Effect and Fear of Retalintion. This report will use the same format as the ISAT report. To keep the findings, recommendations, and MURR responses in context each ISAT finding will be followed by the ISAT recommendations
' and MURR response. The response will include actions taken where there is agreement on particular findings and recommendations and a measure of the progress on action items that are on going or planned.
A. CLIMATE FOR SAFETY Finding #1: Although most individuals indicated that they did not have a concern about mporting safety issues, twelve individuals indicated that they did have concerns about the ability to report and to address safety issues. Although these concerns wem l
expressed predominately in the Nuclear Analysis Program (NAP), there were four additional areas from which such concerns wem expressed.
Recommendation #1: The Center management must continuously communicate, demonstrate, and encourage openness for employees to mport safety issues. Further, the University Administration should clearly communicate its desim and expectation that employees will raise safety issues, ifdiscovered, with a commitment that there will be no mtaliation for raising such issues.
i MURR Resnonse to Recommendation #1:
4 MURR management has communicated and encouraged openness for employees to 19 port safety issues and demonstrated that there will not be retaliation for raising such issues.
In August 1994, the annual indoctrination /re-indoctrination training (emergency response, radiation and general safety and security) was revised to increase the emphasis on each persons responsibility to raise safety concerns and how this can be
- done both internally and externally (and anonymously). In late 1994, this revised indoctrination brochure was mailed to each individual granted access to MURR.
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Additionally, to reinforce the importance of this issue, the indoctrination questionnaire was revised to include a question on both the internal and external ways to address unsafe conditions.
The annual seminars presented by licensed operators and health physics personnel, which have focussed on emergency response for persons not in the Facility Emergency Organization, have been _ expanded to include training on general safety
~ issues,10CFR50.7_ issues and safety reporting channels.
Instructions for reporting safety issues are included in a policy (C4:016), Safety Concern Reporting. This policy established a center wide MURR Safety Oversight Committee (MSOC) which consists of Safety Representatives from each of seven -
groups in the center. Each group _was allowed to design its own safety reporting and tracking system and has its own safety concerns subcommittee. Safety issues may
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be brought before a person's own safety committee or directly to the MSOC. These safety concern reports can be made anonymously.
The MU administration has communicated its policy on safety reporting in letters (attached) to each person at MURR from the Interim Vice Provost for Research, dated February 8,1995 and the Chancellor, dated February 10,1995.
The mechanisms are in place to reinforce and remind all persons at MURR of 4
their responsibility to report safety concerns, the channels to make safety concerns
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known and the University commitment that retaliation for reporting safety concerns will not be tolerated.
Finding #2: Then is a lack ofproactive response in addressing safety issues. For example, following the Department ofLabor Administrative Law Judge's
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Recommended Decision and Order, them appeared to be hesitancy on the part ofMURR management to be proactive in assuring MURR personnel that they should come forward with any safety issue 3 without fear of retaliation. There was a tendency to
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await action by the upper University administration and the outcome of the Independent Safety Assessment Team's (ISAT) mport. Perhaps the traditionalpast culture and experience ofopenness in reporting such issues caused MURR management to consider it unnecessary to take immediate pmactive efforts to assum personnel of managements expectations for continued openness and (medom of mtaliation for Importing safety concerns. Efforts such as modifying indoctrination literatum, Director's 2
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a memos and Director's and supervisor's meetings where undertaken following ISAT recommendations to be more proactive.
Reconunendation #2: Center management and cognizant University personnel should take immediate pmactive actions when actual orpotential safety or regulatory concerns or violations become evident. MURR and the University personnel should not await outside advice or NRC action before undertaking a response to mitigate and correct such concerns or violations.
MURR Resnonse to Recommendation #2:
MURR management promotes taking immediate corrective action when actual or potential safety or regulatory concerns become evident. This has been a long standing policy at MURR and has included instances of self reporting the events or issues and their associated corrective actions to the NRC that were not required to be reported by regulation.
In this particular case, MURR management erred in not appreciating the potential chilling effects that can result from even a claim of discrimination involving protected activity.
Part of the difficulty in the DOL case is that personnel action (promotions, demotions, etc.) and the reasons for such actions are considered confidential for personal privacy reasons. It makes it harder to actively reduce a perception of retaliation or discrimination when management is not free to publicly divulge the reasons for such actions or to explain such actions to staffin general.
The Vice Provost for Research & Dean of the Graduate School,in a letter to NRC dated Oct. 28,1994, established that a written communication will be sent to all employees at MURR in the event of any subsequent allegations of discrimination related to protected activities of which MURR management became aware. This communication will advise them 1) an allegation has been made,2) that the filing of such allegations is a right under federal law, and 3) that federal law prohibits retaliatory actions against an individual exercising such right, and 4) that any retaliatory action in violation of such f-seral law will subject the retaliator to disciplinary action. This commitment will be incorporated into the MURR Policy &
Procedure Manual.
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MURR management recognizes that better documentation ofits personnel I
actions, and evaluation of such actions to assure there are no elements of 10CFR50.7 4
- protected activities involved, can provide MURR staff confidence that discrimination or retaliation for such protected activities will not be tolerated. Two policies have I
been written to this end,' one regarding disciplinary action and the other regarding personnel promotions (attached).
uThe policy for disciplinary action'(P7:020) provides progressiw liscipline for all employees, including exempt level personnel. A requirement for written warnings for
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- exempt level personnel is implemented at the Reactor Center and is not required by
_ eneral policy of the University. The written warning is designed to provide each g
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employee ample opportunity to respond to the constructive criticism and to assure that employees are aware of their rights to file a grievance through University
" established procedures.
The policy for promotions for Research Scientists (P3:021) requires all promotion requests to be made in writing to the Director with complete justification regarding the evaluation criteria. The promotion request will then be reviewed by an i
administrative supervisor at least one level above the immediate supervisor before an approval or denial of the promotion requestis issued. The individuals making these reviews are also charged with evaluating the request with specific attention to the protection afforded by 10CFR50.7. A similar policy for promotion cf non-scientific staffin exempt positions (e.g., managers)is being developed.
Finding # 3: ' There is no integrated safety policy and pmcedure manual. This i
leads to a lack ofconsistent understanding ofsafety policy andprocedums. For example, too fmquently there was a lack ofconsistent indication by those interviewed as to whom one would mport a safety concern beyond one's immediate supervisor. This was true even afer mcent memos and meetings intended to clarify such mporting paths.
Recommendation #3: Develop a safety policy and procedure manual on a
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timely basis with staffinput and participation.
MURR Resnonse to Recommendation #3:
A MURR Policy and Procedure manual was issued December 1,1994. This g
included a Safety policy (C4:015) and a Safety Concern Reporting policy (C4:016)
' that provide guidelines for reporting safety concerns, the avenues available to make 4
- w such reports and the information that such reporting is protected by University policy and NRC regulation.
Assurance that such safety reporting will not result in retaliation or discrimination are included in a new discrimination policy committing to zero tolerance for discrimination or retaliation. Additionally, a policy (P1:030) has been issued to not tolerate hostile aggressive behavior in the center and provides protection for any person who is subjected to such behavior.
- Staffinput was solicited for new policies / procedures and revision of those issued December 1,1994. The policy and procedure manual continues to be revised to incorporate changes or additions recommended by staff.
Finding #4: ^ Then is an inadequate written process for ensuring that safety issues, when identilied, are prioritized, corrected, and tracked and to ensure that feedback is pmuided to the individual that raised the issue. Although them is an incident mporting system in Service Applications, it appears ineffective, needs further development, and.
has not been utilized Center wide.
Recommendation #4: Develop a Center wide policy for prioritizing, correcting, and tracking identilied safety issues and ensuring that feedback is provided to the individual that raised the issue. While encouraging a climate where individuals feel fue to openly identify safety issues, a mechanism should be provided for those individuals that might pmfer to remain anonymous.
MURR Resnonse to Recommendation #4:
A center-wide policy (C4:016) [ attached] has been developed for prioritizing, 4
correcting, and tracking safety concerns. The policy provides for feedback to the individual who raised the concern and includes several mechanisms for anonymous submittals.
The policy, Safety Concern Reoorting. Tracking and Resolution, includes formation of a MURR Safety Oversight Committ ze (MSOC) and seven Safety Concern Subcommittees, one for each of seven g~oups at MURR. This structure encourages safety reporting at the group level for possible rese ion with review by MSOC. Direct reporting to the MSOC is also available to persons with safety concerns. Safety reporting at each level can also be done anonymously.
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3 L The implementation of the MSOC and the safety concern subcommittees was
.j inspected by NRC June 19-22,1995 with the observation that the MSOC process
- was adequately implemented to provide MURR employees a program to address.
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. safety concerns while preventing potential retaliation against employees. The l
inspectors felt that the MSOC representatives could use additional training in order.
for them to clearly recognize and address discrimination issues that may.be raised by MURR personnel. As a first step to this training process, each MSOC member has been asked to read NUREG -1499, Reassessment of the NRC's Program for Protactina Allerem Against Retaliation, to get additional understanding of10CFR50.7 and definitions of protected activity and discrimination.
Finding #5: There is no formal root cause analysis pmgram. For example, there Jhas been considerable attention given to the recent shipping pmblems; however, it appears ihat the symptoms am being treated rather than ihe fundamental cause.
Becommendation #5: Development and implement a formal root-cause analysis pmgram, of scope appmpriate for the activities conducted at MURR, for significant problems that have been identified.
l MURR Resnonse to Recommendation #5:
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We have had a long term practice of doing root cause analysis of safety issues in i
license related activities associated with Reactor Operations (e.g., License Event L
Reports). These analyses have not, however, been done by a formal program or procedure. A formal root cause analysis procedure has been implemented as part of Service Applications Quality Procedures, in Section 4.5 of SAQ 2, Incident Renorts.
This procedure currently is used to address Service Applications safety issues.
When we have gathered experience and feedback from Service Applications use of this procedure, we will revise it to a center-wide procedure.
[ Attach copy ofSAQ 2, Se'ction 4.5]
Finding #6: Considerable independent authority resides in Service Applications such that pmssums to meet service mquiremenis might override safety and ALARA i ~
considerations. For example, Service Applications can develop income producing service clients, authorize the irradiation ofclient's targets (within a generically approved envelope), as well as ship irradiated targets to clients.
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Recommendation #B: Develop a check and balance structure for areas in which single, independent authority exists. For example, stmng consideration should be given
- to moving all (i.e., LLW, HLW, and target) shipping functions to Reactor Operations when them exists a culture for compliance with regulatory mquimments andprocedum V
' adhemnce.
MURR Response to Recommendation #6: -
We do not agree that Service Applications has independent authority which
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makes it more likely to override safety and ALARA consideration. There is no question that Service Applications takes its customer service role seriously and that customer' demand or the need for medicalisotopes create some pressure while adhering to established procedure. The key pointis to have a shipping group where
'there exists a culture for compliance with regulatory requirements and procedure L
adherence. The personnel within the shipping group have developed this culture and respect for regulatory requirements and procedure adherence.
The Safety Subcommittee reviewed this issue at the October 26,1994 meeting and the subcommittee felt Reactor Operations should maintain their focus on safe i
operation of the reactor and not assume the shipping role. The subcommittee felt persons in shipping are being trained to be as disciplined as Reactor Operations with respect to procedure compliance.
The Service Applications shipping group is composed of the persons with the j
highest level of expertise in the area of transportation of radioactive and other hazardous material.
Certified shippers attend off site training to develop the expertise needed to meet NRC, DOT and IATA (International Air Transportation Associates) regulations. The certified shippers review all shipments that leave the center.
Finding #7: Training pmgrams appear weak in certain amas. For example, several individuals indicated that the.m is a lack of adequate training ofpersonnel in shipping and in the use ofpneumatic tubes. Further, mactor operator requalification tmining is primarily limited to self mading and on-the job training.
Recommendation #7: Evaluate the training needs in all amas of the Center, including the need for a Center wide training coordinator. Develop and implement
. training programs where appropriate.
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l MURR Rennonse to Recommendation #7:
.l Group leaders and managers were sent a questionnaire (attached)in July 1995
- asking each group to identify specific training needs and specific training deficiencies.
. The completed questionnaires are used to target new areas of training for i
development, to improve existing training and combine training for groups with common training needs. The responses from group leaders and managers identify
- three major areas where training needs improvement: 1) general laboratory safety;
- 2) hazardous material (e.g., chemical) use, storage and disposal; and 3) general fire safety.
The Reactor Manager and Health Physics Manager will evaluate these identified I
L training deficiencies and solicit assistance from Environmental Health and Safety Department to upgrade the training in these areas. The training may include lectures, demonstrations, video tapes and literature. We will try to schedule common
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training needs for large groups of personnel when possible (e.g., fire extinguisher -
i training). Some of the training will need to be performed or coordinated by each group leader or manager to assure relevance to each groups needs.
The answers to the questionnaires from the various groups at MURR did not identify pneumatic tube user training or shipper training as areas of deficiency in training. From the Reactor Manager and Health Physics Manager's perspective, as the persons who must interview prospective p-tube users prior to their authorization, 4
the training of pneumatic tube operators has been adequate.
The training of shippers has been significantly upgraded ow - 'he last three years.
Shippers receive off site training in DOT and IATA regulations regarding shipment of radioactive and other hazardous material. Shipper trainees are trained to perform or inspect specific tasks associated with a transportation package. Qualified shippers have demonstrated ability and training to perform or inspect all tasks on specific 1
packages. Certified shippers are certified to perform all aspects of shipping.
The Reactor Safety Subcommittee discussed the finding regarding the operator requalification program. The program has met or exceeded NRC requirements and is inspected by NRC to assure that it does. Several upgrades in training have been done in the last several years, including reactor theory training at the Rolla Reactor and more extensive training with health physics staff.
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The subcommittee inquired into an outside assessment of Operator.
J Requalincations. The Reactor Manager suggested having the next Reactor i
Operations' Audit focus on Operator Requalineation.' A Reactor Operations Audit,
- with emphasis on the operator requalineation program, was performed March 24-26,-
1995 by Rich Holm, Reactor Manager of the University ofIllinois Nuclear Reactor g
Laboratory. This audit was reviewed by the Safety Subcommittee at a July 25,1995 meeting. The audit indicated that training met the regulatory requirements and recommended some areas ofimprovement. These recommendations are currently being evaluated by the Operations Engineer, Operations Training Coordinator and the
. Reactor Man'ager.
- The need for a center wide training coordinator has been discussed for a number l
'of years at group leader meetings and Reactor Advisory Subcommittee meetings with no clear consensus on the need for a center-wide coordinator. The training needs of each group need to be identiSed by each group leader or manager and they should
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accept responsibility for providing or coordinating the training.
d Finding #8: Them is a need to reinforce the importance of adhering to safety rules andpractices. For example, some individuals have exited the building when their use of the hand and foot monitor resulted in an alarm. (we note that these individuals were called back by other MURR personnel.) Further, there was a recent case in which l
equipment was operated when tagged out. (We note that recent mtraining has covend this topic ofequipment tag out.)
Recommendation #8: Enhance the communication of management's
~ expectation of and insistence on adhemnce to safety rules and practices by strengthening
. periodic training and supervisory involvement.
l MURR Resnonse to Recommendation #8:
The examples cited are isolated cases. Each time an incident such as these L
occurs both the individual and his sponsor / supervisor are counselled regarding the j
safety implication of their actions and warned of the consequences of a second incident.-
We have tried to learn from each such incident and each case that is relevant to i
the entire center is incorporated into our training or is communicated by
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memorandum to all staff. The training regarding danger tags has bien added to the annual indoctrination /re-indoctrination literature and is covered as part of the -
training seminars for persons not in the Facility Emergency Organization (FEO).
The Center policy on Safety and Safets Reporting was discussed earlier in MURR Resnonne to Recommendation #3 and #4.
Finding #9: : Them is a need for improvement in the general ama ofindustrial safety. For example, concerns were expressed about chemical storage, fire safety, work
. practices (including the movement of sample containers over the reactor; see sample
' letter in Appendix E),' and stability of some heavily loaded lab benches.
Recommendation #9: Establish a permanent industrial safety advisory group that includes Center, UMCpersonnel, and outside industrial experts to evaluate the current practices at the Center and pmvide mcommendations for improvement, as appropriate.
MURR Response to Recommendation #9:
The MURR has an annual inspection by an Industrial Hygienist from the
- University department of Environmental Health and Safety to identify areas of industrial safety concern. Reactor Operations staff perform monthly audits of safety equipment at MURR (fire extinguishers, emergency lights, exit lights, fire loading / housekeeping, etc.)
The concern regarding movement of sample containers over the reactor was evaluated by Reactor Operations staffin November / December 1994 and was determined to not present a reactor safety problem. An NRC inspector reviewed the safety analysis during the Routine Safety Inspection October 31 through November 4,1994.
The areas of training discussed in MURR Resnonse to Recommendation #7 include upgrading general laboratory safety training, which includes industrial safety.
Several other recommendations related to industrial safety were identified by the questionnaire process that bear consideration as MURR policy. That,e areas are chemical inventory and control and control oflaboratory use.
The recommendation about chemical inventory and control involves designating a
- secure storage area for laboratory chemicals in general and restricted access to the -
- MURR flammable storage locker.
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The recommendation about control oflaboratory usage involves developing a
. policy that requires a person, from other than the group responsible for a laboratory.
to request use prior to use. This will allow the group responsible for.the lab and the requestor or requestor's supervisor to determine any training needs for the individual specific to the use of the laboratory prior to the use.
Fintling #10: Them is no formalpmoess to captum andfor to addmss safety concerns fmm outside review gmups or mgulatory bodies. For example, the mport pmuided by Dr. Marcus Voth raised issues about the target certification concerns and shipping pmcess that, if acted upon pmmptly, potentially could have solved some of the
- significant shipping issues. Them wem also two action items lost when the Central.
Radiation Safety Committee (CRSC) disbanded, which were not transfermd to the
' Reactor Advisory Committee (RAC). The two action items were a CRSC recommendation ofALARA training for Center wide statf and CRSC concern about MURR Alcohol / Drug program ineffectiveness.
Recommendation #10: Implement a pmcedum to identify, to mspond in a timely manner, and to track safety issues raised by outside mulew groups as well as by the RAC. The University should pmuide leadership in developing an cffective alcoholIdrugpolicyfor MURR.
huse to Recommendation #10:
MURR has developed a tracking system for open items brought before the Reactor Advisory Committee (RAC) for safety issues from outside review groups or regulatory bodies.
The tracking of safety issues and follow up will be done similar to how the Reactor
-Manager and Health Physics Manager respond to audits, by identifying items they intend to address with proposed actions. These items will then be reviewed by the
. relevant reactor subcommittee to assure all significant issues are identified. The Subcommittee can request specific dates for final action or feedback on particular L items if necessary. This method is similar to what was used by the Shipping Task Force to track commitments.
. The MURR Alcohol and Drug Use Policy was issued by memorandum to all persons with unescorted access to MURR on May 17,1993. In July 1993, an alcohol u
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' breath analyzer ~was purchased and staff have been trained in its use. The policy has l
been incorporated into the MURR Policy and Procedure Manual and includes an objective means for testing persons to verify or refute suspected impairment from alcohol.
B. CHILLING EFFECT AND FEAR OF RETALIATION-F Finding #1:. Our assessment is that there is a significant chilling efect and a fear i
of retaliation. Of the individuals interviewed, thirty-one reported a chilling efect and of
. those, seventeen reported a fear ofretaliation. The chilling efect and the fear of retaliation, while highly evident in the NAP, were widespread and included individuals in almost allgmups. (We note that the Indoctrination Program has recently been strengthened to clarify management's expectation ofsafety and that management's
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' expectations Ofsafety have been communicated verbally and in writing to various gmups. This action should mitigate a perceived chilling efect for reporting safety issues.)' While the assessment was being conducted, articles appeared in the localpaper in which remarks attributed to the University Chancellor had a considerable chilling efect on a number ofemployees. (We note that the Chancellor attempted to clarify remarks attributed to him in the localpaper; however, it is our assessment that this attempt was not entirely successful.) Other causes include the " demotion"ofDr. Steven Morris, and comments attributed to the Vice President for Human Services that c
University stagmembers are "at will" employees. There is also employee anxiety related to the activities surrounding the Department ofLaborproceeding, as well as the actual and veiled threats ofemployee lawsuits by one employee against another.
Further, past use ofrecording conversations by employees without other employees' knowledge has caused some employees to be less open.
Recommendation #1: On a regular schedule, reinforce communication of MURR management's expectation that safety issues will be reported and its commitment that those making the reports need not fear retaliation. This should be l
. conveyed verbally and in writing. Clarify the expectations of the UMC Chancellor
_regarding raising safety issues so that it is clear that there will be no retaliation against ^
employees that raise safety issues. While staKmay be "at will" employees from the University's employment perspective, the University should indicate the importance of MURR staWin enabling the Center to reach its goals.
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MURR Response to Recommendation #1:
This recommendation is partially' addressed in MURR Resnonse to CHmate for 4
T Safety Recommendation #1. The Chancellor's position was clarified by a letter to each person at MURR dated February 10,1995. The Chancellor's letter reiterated
. that "all employees should recognize their responsibility to be aware of safe practices and to report any instances that may be considered unsafe." He and the Vice Provost for Research (in his letter of Feb. 8,1995) assured the persons at MURR that'retallation for safety reporting would not be tolerated. A copy of the Chancellor's letter is posted on the' bulletin board near the safety reporting instructions.
We will stress in indoctrination /reindoctrination training the responsibilities of radiation workers in 10CFR19.12 Instructions to Workers. This regulation (in part) states that radiation workers "shall be instructed of their responsibility to report promptly to the licensee any condition which may lead to or cause a violation of Commission regulations and licenses or unnecessary exposure to radiation or radioactive material." This responsibility is directed towards radiation safety, but can be generalized to each worker's responsibility to report unsafe conditions or practices of any kind.
Our goal in this area is to keep the following two needs in mind in determining our actions and training. We need to not only encourage reporting concerns, but create the consequence that nat reporting or covering up concerns or safety issues willlead to disciplinary action. We need to create the expectation that a person should be
" chilled" if or when they don't report safety concerns or issues.
Finding #2: All individuals interviewed indicate that they were aware of the recent claims of retaliation for raising safety issues. Most individuals indicated that they received their information from rumors and from the newspaper account, in
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contrast to any official MURR management notification. During the interviews, the
" Assessment Team asked for the individual's assessment of these claims in order to
- assess theirperception as to whether the personnel actions taken were related to raising safety issues. Ifan assessment was offered, most, but not all, individuals indicated that it was theirpersonal opinion that the actions taken were not in response to raising safety issues. However, it was not the intent of the Assessment Team to evaluate the correctness i
of the Department ofLabor's finding or the University's position on the matter.
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E Recommendation #2: Post the pmcedures for reporting safety issues so it is
' extremely clear to whom safety issues should be reported. This pmcedum should also L
articulate the process to follow if the safety issue has 'not been sufficiently addmssed fmm the mporting individual's perspective.
4 MURR Resnonne to Recommendation #2:
j The procedures for reporting safety issues are posted near the entrance to the MURR laboratory. The same procedures are part of the Policy and Procedure l
Manual described in MURR Resnonse to Climate for Safety Recommendation #3.
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- These procedures have also been distributed to all center staff via memos and the MURR Newsletter.
l MURR management developed a policy, Staff Access to Information (C1:051) to improve access to information concerning the MURR Center (attached). This policy established an information library in the front lobby. This library consists of
. notebooks which contain correspondence to and from regulatory agencies, committee meeting minutes, reports, research abstracts, etc. These materials were placed in a location that provides maximum access and allows for use of the copy machine if persons are interested in their own copy of certain information.
In order to alert staffin the event of any subsequent allegations of discrimination related to protected activities of which MURR management becomes aware, a written communication will be sent to all employees of MURR advising them 1) an allegation has been made,2) that the filing of such allegations is a right under federal law, 3) that federal law prohibits retaliatory actions against an individual exercising
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such right, and 4) that any retaliatory action in violation of such federal law will subject the retaliator to disciplinary action. A policy to this effect is being developed for the MURR Policy & Procedure Manual.
Finding #3: Several individuals indicated that the DOL hearing, the Adminis-tmtive Law Judge's Recommended Decision and Order, and the Secutary ofLabor's
' Pmliminary Order had a positive elfect inasmuch as it demonstrated that ifretaliaticn were to ' occur in response to raising a safety concern, pmtection would be pmuided.
-However, some individuals seeked assurance fmm the ISAT that a safety concern did
' not have to be ultimately proven valid before such pmtection would be provided.
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Becommendation #3: Because of the apparent lack offamiliarity at many levels
. within the University, the continuing uncertainty amongst some Center and University personnel about the 'Whistleblower" protection afforded by ihe Energy Reorganization Act of1974 and the changes made as part of the Comprehensive National Energy Policy Act of1992, as well as the separate and distinct implementation responsibilities of the Department ofLabor and the NRC, consideration should be given to further training in the pmvisions of the Act and its implementation at various levels at the University.
MURR Resnonne to Recommendation'#3:
1 NRC staff from Washington, D.C. and Region III have met with the MU Chancellor. Recommendations have been made to conduct training for Universny administrators above the Director of MURR.
As a starting point for training of MURR managers and group leaders, ten copies of NUREG-1499, Reassessment of the NRC's Program for Protecting Allerers Against Retaliation, were ordered and are in routing to group leaders / managers for their information.
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- O Of6ce of Research Umversirv of Missouri-Columb.
205 Jesse Hall
- Columoa. MO eCM
- Telepnone 014} BE* 'M
- FAX m4) SH 5454 February 8,1995 To:
Research Reactor Center Personnel
. From:
John McCormick Interim Vice Provost for Research and Dean of the Graduate School
Subject:
.Open Climate for Raising Issues I was pleased to have the opponunity to join you at the recent meeting of Research Reactor Center personnel. What panicularly impressed me was the professionalism and strong commitment to success of the Reactor Center that was consistently obvious from your comments. It was also clear that there is an appreciation of recent efforts to improve communication. Let me join the effon that Dr. Rhyne and others are making along this line. The focus mainly was on knowing about planning and in general"what's happening",
but there's another important aspect of communication that I'd like to emphasize as well: I want to assure all of you that institutional policy encourages personnel to raise any issues concemed with conforming to University, State, and federal policy, regulations and law.
Safety issues are of particular importance at the Reactor Center.
In fact, together with several representatives from the Reactor Center, I met with NRC officials in Lisle, Illinois, in relation to the issue of ensuring a climate of openness. I'm enclosing copies of the remarks I presented that addressed this matter. It's imponant to me and to this institution that you all know of our firm commitment to ensuring that all not only feel free and comfortable about raising concerns relating to safety, but that they also accept it as a responsibility. I hope the commitment I emphasized in my remarks to the NRC offer whatever reassurance you might need.
You're justifiably proud of the accomplishments at the Reactor Center, which is poised to " move to the next level"in capabilities and achievements. A commitment to safety, an atmosphere of openness, and a spirit of all pulling together will be imponant.
You have both my congratulations for your accomplishments and best wishes for success!
enclosure c: Chancellor Kiesler an equa! crpertu s) / ADA uwtN*aen
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NRC July 22,1994 Enforcement Conference Text Relating to Openness I am John McCormick, Interim Vice Provost for Research and Dean of the Graduate School at the University ofMissoud-Columbia. I'm pleased to take this opportunity to let you know that at the
. University and at the Research Reactor Center it has been and is very important that policies and practices ensure existence of an emironment in which everyone feels free to raise issues regarding.
safety.
The University recognizes that in this enforcement conference the NRC is carrying out its responsibility to ensure that the Research Reactor Center promotes an emironment that encourages everyone to raise safety issues. As the responsible Ursversity official here in the spirit of full cooperation with this responsibility of the NRC, I can provide assurance that the University, as well
- as the management of the Research Reactor Center, is fully committed to this goal The Universiiy understands, respects, and fully suppons the protections accorded under 10CFR50.7 with regard to dghts of an individual to challenge and report practices that are perceived to be unsafe or not in accord with regulations. The ability to freely report such incidents and the guarantee of no repdsal or retribution against the individual is a cornerstone of such legislation. These are also the principles under which the University ofMissouri, including the Research Reactor Center, operates. Multiple avenues are available to individuals to take complaints, concerns, and grievances to a hearing by higher administrative officials. The Research Reactor Center has placed and continues to place a strong emphasis on self-reporting to the NRC and other agencies of any problem, even if not specifically required to do so by the applicable regulations.
Dr. Rhyne, who is with us today, can desedbe fully the past, current and future actions that are
' designed to ensure that neither the events related to Dr. Morris and Dr. Zinn nor any other events establish an atmosphere that suppresses the feeling of complete freedom to raise any safety issue at the Research Reactor. I will summarize them bdefly: (1) We have taken immediate steps to comply fully with the Secretary of Labor's order; (2) Reactor management has arranged for a survey, just completed, by an extemal expert to assess whether there is any " chilling effect" as a result of the Monis/ Zinn case; and (3) Reactor management has taken several specific steps to promote, and to test, an atmosphere that both educates and encourages everyone at the Research
- Reactor Center to be knowledgeable about safety issues and responsibilities at the Reactor; and (4) the Reactor Advisory Committee has involved itselfin these discussions and policy matters and has strongly encouraged the University's upper administration to stay informed about and shape policy to take into account all forms of protected activity within the University.
The presence of seven ofus here today is evidence that we take this responsibility seriously and an indication that we wish to have available for this discussion today all who might usefully sen e as information resources.
Thank you.
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Office of the Chancellor W inn Hal:
- coirma Me e':::. Teiernone '.94 Sf: ?F
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Febmary 10,1995 To:
Research Reactor Center Personnel From:
Charles A. Kiesler, Chancellor
Subject:
Institutional Policy on Safety and Reporting Conversations I have had with representatives from the NRC and with the three members of the Independent Assessment Team made me aware that there is some i
uncertainty about campus administrative commitment to safety matters, including the raising of safety concems by individuals. I write now to dispel any uncenainty and to assure you about, and commitment to, an open and safe environment and freedom of expression on such matters..
We seek to have a climate that encourages all employees to raise concerns about safety without fear of reprisal or retribution. Indeed, all employees should recognize their responsibility to be aware of safe practices and to report any instances that may be considered unsafe or in some way out of compliance with University, State, or federal policy. I was pleased to learn that the Research Reactor Center recently has placed added emphasis on ensuring that all know the alternatives for raising safety issues. If for some reason you believe that you need to use routes beyond your supervisor, there are multiple avenues available to individuals to take concerns, complaints, and grievances. You are welcome to bring safety concems to my attention. Further, self reporting to the h7C, or other appropriate agencies, is an cption that everyone is &ce to pursue.
The University is fully committed to fostering a safe and open environment. The Research Reactor Center has accomplished much, ofwhich you all can be proud. Future success will be dependent on a continued strong emphasis on safety. Working together as a team, coupled with an emphasis on individual responsibility, I am confident that the Center will enjoy continued success.
University of Missouri Columbia an equal opportururr/ ADA uuorunon L
MURR Policy and Procedure Manual 9
DISCLIPINARY ACTION P7:020 Management guidelines for disciplinary actions are given in PE801. The introduction states that "Where problems with employee behavior or performance arise, a supervisor will seek to correct the problem with the least amount of disruption to the work environment. Discipline is a means to correct inferior employee behavior and performance."
Progressive discipline is the least severe action necessary to correct a performance or behavior problem. Progressive discipline may include oral warning, written warning, suspension and ultimately discharge. The MURR Center supports progressive discipline for all ofits employees, and requires written warnings for all, including exempt level personnel. This goes beyond the general policy at the University of Missouri, which states that exempt employees are not usually subject to progressive discipline.
In the event of serious incidents, summary suspension or discharge may occur without prior warnings or attempts at progressive discipline. Another exception to using progressive discipline is with performance problems that are determined to be due to skill deficiency rather than rule violations or neglect of duty. In cases where reasonable attempts at training fail to correct the problem, the employee may be discharged without prior disciplinary action.
If disciplinary action is recommended, the written comments and intended disciplinary action are to be reviewed by an administrative supervisor at least one level above the immediate supervisor before the disciplinary action can be taken.
Because all MURR Center employees are engaged in protected activities, the individuals making these reviews are charged with evaluating the request with specific attention to the protection afforded by 10CFPJ50.7. The written communication is to provide the employee ample opportunity to respond to the -
constructive criticism. The procedure will also assure that employees have sufficient knowledge to exercise their rights to file grievances throught he established University grievance procedures.
April 15,1995 Page1of 1
MURR Policy and Procedure Manual 9
PROMOTION GUIDELINES FOR RESEARCH SCIENTISTS P3:021 The usual promotion track for MURR scientists is from Research Scientist to Senior Research Scientist. This promotion normally is accompanied by a supplernentary salary increment. Senior Research Scientists who have long-term established and well-funded research efforts, and who show scientific leadership potential, can be conridered for appointment to Group Leader or Program Coordinator Group Leader and Program Coordinator are internal titles at the Center and do not automatically resuit in salary increments. The associated administrative duties fulfill the service component expected of all scientists.
As defined by MU, Research Scientist positions are non regular appointments; however, promotions are to be evaluated with the same criticality as equivalent prornotions for regular faculty.
Promotion from Research Scientist to Senior Research Scientist (see belowhvill be considered using similar criteria of research competence, accomplishments, service, etc. as applied to promotion from Associate to Full Professor.
The promotion process to Senior Research Scientist normally will start with a request memo from the candidate's group leader to the Director. After preliminary review and concurrence, the Director will appoint a small advisom,r committee of MURR senior scientists and outside senior researchers in the candidate's field to evaluate the CV of the candidate, solicit external letters of recommendation, and to consider other factors as appropriate. The candidate will receive notice of the make-up of the committee and be given an opportunity to comment before formal appointment of the committee.
The suitability of a candidate for promotion should be entirely performance driven and not be subject to bias based on number of years in his/her present position.,
CRITERIA FOR PROMOTION FROM RESEARCH SCIENTIST TO SENIOR RESEARCH SCIENTIST
.Normally the promotion committee will be asked to evaluate each of the three major components of a MURR Research Scientist's appointment separately-Basic or Applied Research, MURR service, and MU MURR Collaborative interactions.
Example evaluation criteria in each of the three job components are:
L Basic or Applied Research-50%
a.
Development of an independent research program
- b. Evidence of an international reputation in the field c Securing of peer reviewed external funding d.
Publication in major journals Invited presentations, national committees, review panels, etc.
e.
April 15,1995 Page 1 of 2
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' MURR Policy and Procedure Manual.
- PROMOTION GUIDELINES FOR RESEARCH SCIENTISTS P3:021
- 2. MURR Service -25%
a.
Serving on internal committees
. b. Service work for other groups c.
General use instrument development
- d. Contributions to income generation for the Center
- 3. MU MURR Collaborative Service-25%
- a. Development of collaborative research programs
- b. Classroom teaching Supervisor or committee member of PhD or MS students c.
. d. University wide or departmental committees i
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MURR Policy and Procedure Manual SAFETY i
C4:015 Safety and security are the two foremost concerns of everyone at the MURR Center. It is crucial that the MURR Center maintain a safe environment for employees and the community. Every member of the staff should feel free to raise safety concerns. In fact, we have an obligation to point out concerns. Any questions relating to security / emergency procedures / health physicc should be directed to the appropriate member of the staff, as defined below.
If you have a safety concern or believe that a violation of NRC regulations has occurred, you should report it immediately to your supervisor, Reactor Control Room staff or Health Physics staff. If they do not address the problem, you should bring it to the attention of the MURR Center management or University adminis-tration. If you still believe that adequate corrective action is not being taken, you may report this to an NRC inspector or the NRC Region III ofUce, telephone number 708/829 9500.
To help ensure that radiation workers feel free to voice their concerns, federallaw prohibits an employer from firing or otherwise discriminating against you for bringing safety concerns to the attention of your employer or the NRC. Your protection from discrimination and the avenues open to you to seek protection from discrimination are outlined in the Code of Federal Regulations 10CFR50.7. A copy of these regulations may be obtained in the Health Physics Office.
j Additional information on your rights and responsibilities as a radiation worker can be found on NRC Form 3 posted on the bulletin board located near the film j
badge racks.
Supervisors are to reinforce the principle of open reporting of safety concerns and the mechanisms for reporting inside and outside of MURR, free of any real or l
i potential discrimination or reprisal by employees or supervisors at any level.
The Center is in the process of developing and implementing a Center wide safety concern reporting and tracking system that will provide for an evaluation of the concern, assign a priority, provide feedback to personnel until the issue is closed, and allow for anonymous reporting. (See SAFETY CONCERN REPORTING, TRACKING AND RESOLUTION, c4:015.]
An employee may choose to make an anonymous report of a safety concern.
Computer generated documents allow for a considerable degree of anonymity.
i Such reports may be placed in a supervisor's or Director's Office mail box, or ofUce if unoccupied. There is a drop box on the north side of the laboratory building corridor leading to the personnel airlock that is checked regularly by a member of j
the MURR Safety Oversight Committee (MsOC).
)
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April 15,1995 Page 1 of 2
MURR Policy and Procedure Manual.
SAFETY C4:015 Every member of our staff has an obligation to himself, to the facility and to the general public to ensure a safe environment at MURR. Please do not let fear of discrimination or retaliation prevent you from reporting a safety concern. Federal law prohibits such discrimination or retaliation, and the MURR Center is committed to an open safety environment and a climate free of any inhibitions to report safety
- issues.
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9 MURR Policy and Procedure Manual 9
SAFETY CONCERN REPORTING, m
TRACKING AND RESOLUTION C4:016 Safety, security and regulatory compliance are foremost concerns of everyone at the MURR Center. Itis crucial that the MURR Center maintain a safe environment for employees and the community, and that every rnember of the staff feels free to raise concerns regarding these issues, indeed, we have an obligation to be aware of safety at all times, and to point out concerns or suggestions. Personnel are encouraged to bring questions, suggestions and concerns to their supervisors and other appropriate members of the staff (see Safety, C4:015).
This procedure should notinterfere with or replace the normalinteractions between employees and supervisors in addressing safety concerns, or the normal coordination between MURR groups that has resulted in a safe working environment over the years.
This program provides stafimembers who feel their safety concerns were not addressed adequately in the normal workplace channels of communication with a method to give their safety concern more visibility and ensure their safety concerns are addressed formally. The procedure covers raising a safety concern, coordination of the efforts of the subcommittees and MURR Safety Oversight Committee (MSOC), reviewing concerns and directing them to the responsible person, review of proposed solutions, tracking progress on all concerns submitted, providing timely feedback, and accommodating anonymous reporting.
Because of the scope and complexity of the MURR Center programs and the importance of timely consideration of safety concerns, seven groups representing all of the MURR Center personnel have been designated to develop procedures for reporting, tracking and resolving their own groups' safety concerns. Each group will designate a Safety Representative and may create a Safety Concern Subcommittee (SCS). A centerwide MURR Safety Oversight Committee (MSOC) has been established as a clearinghouse for safety concerns handled by the Subcommittees as well as concerns submitted directly to the Oversight Committee. Any employee who feels that a safety concern has not or cannot be addressed adequately through normal channels may submit a report to any Safety Concern Subcommittee or to the MSOC. The seven Subcommittees represent the following staff divisions:
Service Applications Facility Operations Reactor Operations Neutron Materials Science Program Biomedical Program Nuclear Analysis Program Computer Development, Health Physics, Ira rument Development, Nuclear Engineering, Director's Office (CHIND)
SAFETY CONCERN REPORT Each of the seven groups as well as the Oversight Committee is responsible for designing its own report form for safety concerns. Any of the eight forms may be used to report a concern. The Oversight Committee's Safety Concern Report provides space for April 15,1995 Page 1 of 6
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MURR Policy and Procedure Manual SAFETY CONCERN REPORTING, TRACKING AND RESOLUTION C4:016 the concerned individual (the initiator) to give the date, a description of the concern and
)
suggested solution,if applicable. Signing the formis optional.
Using a Safety Concern Report is preferred, not mandatory, but all concerns to be considered by the Committee should be made in writing. The concern should be clearly ~
described and its safety significance indicated. Suggestions for resolution are welcomed and encouraged. The completed report, signed or unsigned, may be submitted to the i
MSOC or to any of the Subcommittees (in person to one of the members, via the Center mail boxes, electronic transmission, etcJ.
4 Avenues for anonymous reporting are an essential element in this system. An initiator who chooses not to sign the form may deliver it to the Oversight Committee anonymously via the dropboxlocated at the northeast corner of the hallway leading to the containment building, the MSOC mailbox in the MURR mail room, or through the US mail:
MURR Safety Oversight Committee Research Reactor University of Missouri-Columbia Colu:nela,MO 65211 Blar: report forms will be kept near the drop box and in the black forma cabinet in the lobby,:op drawebleft. hand side.
SAFETY CONCERN SUBCOMMITTEES 1
Each of the seven groups has developed procedures for reporting,tri king and resolving its own safety concerns. These procedures will be kept on file in the %bby Library."
MSOC and Subcommittee procedures will be revised as necessary to meet the needs of the MURR Center and its staff. Groups will designate a Safety Representative and may form a Safety Concern Subcommittee from members within their groups. Membership, 4
meeting frequency, method of handling safety concerns, etc., are at the discretion of the groups as long as they allow for anonymous reporting, timely action, staffinvolvement and feedback. They will report actions to the Oversight Committee as defined below.
1 Each Safety Concern Subcommittee is responsible for ensuring that an updated procedure and copies of resolved safety concerns are placed in the safety concern book in the " Lobby Library."
OVERSIGHT COMMITTEE Each of the seven groups / Subcommittees will select a representative to serve on the Oversight Committee. The seven representatives will serve on a rotating basis, with the schedule to be determined based on the Committee's activity / demands and input from members in the seven groups. The groups / Subcommittees may designate alternates to serve on the Committee when their representative is absent. The Committee will elect a Chairperson and/or Secretary to coordinate the workload and maintain records. A simple majority will constitute a quorum.
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MURR Policy and Procedure Manual 9
SAFETY CONCERN REPORTING, a
TRACKING AND RESOLUTION C4:016 Because timely action is critical, the Committee will meet as necessary to address the concerns submitted, and any member may cali a meeting. A designated member will routinely check the Committee's mailbox and dropbox for reports. The Committee will perform an initial review of safety concerns within 10 working days of their receipt (filing) to verify the safety significance and to assign a priority for resolution. Timely feedback will be provided to the initiator and wil be made available to other Center personnel. The Reactor Manager and RSO/ Health Physics Manager will be notified of safety concerns involving potential or actual regulatory violations as early in the resolution process as possible.
The Committee will review the safety concern to determine the validity and priority of the concern. Then the Committee will direct the safety concern to the appropriate MURR staff member (s), based on job responsibilities, for resolution. The Committee may reference requirements (regulations, standards, etc.) and possible solutions for consideration in resolving the concern, and set a desired response time. If possible, those individuals closest to or most affected by the safety concern should be involved in the resolution process-including the initiator whenever appropriate. Staff from other University departments or outside consultants may also be appropriate resources.
It may be necessary to solicit further information from the initi stor of the safety concern.
In the case of an anonymous report, questions from the Committee or responsible personnel may be posted in the case on the west wall outside the breakroom. It is expected that the initiator will respond promptly. Anonymity can be maintained via the avenues mentioned earlier, including the dropbox and US mail. Action toward resolution of the safety concern will proceed as effectively as possible with or without a response.
The responsible person will present proposed resolution (s) to the Oversight Committee, who will evaluate whether or not they consider the safety concern adequately resolved.
The Committee may accept the proposal es adequate, or may request modification or further consideration of the issue. They should indicate specific reasons whenever a proposal is viewed as insufDciently addressing a valid safety concern. The Committee may find it necessary to direct the concern to a higher levelin the organization until a satisfactory resolution is achieved.
Proposed corrective actions accepted as adequate by the Committee will be attached to the Safety Concern Report. Distribution willinclude the initiator (if the form is signed) and the Director's Office, and may include the Reactor Advisory Committee or one ofits Subcommittees, and other MURR personnel. Corrective actions for anonymous reports will be posted on the bulletin board outside the breakroom. Due to budget limitations, alternate solutions may need to be considered for recommendations that require significant resources and/or allocations. Copies of final reports will be available in the
" Lobby Library."
The Oversight Committee's responsibilities willinclude review and tracking of all safety concerns dealt with by the seven Subcommittees, as well as those concerns submitted l
directly to the Committee. Subcommittees will forward to the Oversight Committee the l
following:
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MURR Policy and Procedure Manual SAFETY CONCERN REPORTING, TRACKING AND RESOLUTION C4:016
' safety concerns that have been resolved safety concerns that are in appeal (the appeal may come directly from an initiator)
- - safety concerns referred to the Committee for resolution:. anonymous concerns outside the Subcommittee's purview, those failing resolution at the Subcommittee level, and coneerns thatinvolve several MURR groups or require significant resources and/or allocations The Oversight Committee will review the Subec,mmittees' resolutions for thoroughness, 1 consistency, and applicability to other groups within the Center. When appropriate, the
' Committee may reopen a (resolved) safety concern ifit determines that further corrective actions may be warranted.
. APPEALS 4
Initiators or other concerned parties may appeal a Subcommittee's actions to the
]
Oversight Committee. The Conamttee will review appeals within 10 working days,
' following the same process de scribed for directly submitted reports.
RECOURSE Resolutions that are unacceptable to the initiator or other concerned parties may be 1
appealed directly to the MURR Director's Of!1ce or University Administration (Campus RSO,Vice Provost for Research, Provost, etc.). The University's Grievance Procedure (UM Personnel Policy Manual PE105)is another available avenue. Anyone who feels he/
she or others have been subjected to intimidation or hostile-aggressive action at MURR due to raising safety concern questions should report immediately to the appropriate level of authority in accordance with MURR Policy P1:030, Intimidation and Other Hostile Aggressive Behavior.
If at any time an individual believes that adequate corrective action is not being taken, he/she may report this to an NRC inspector or the NRC Region III office, telephone number 708/829 9500. To help ensure that radiation workers are free to voice their concerns, federallaw prohibits an employer from firing or otherwise discriminating against an individual for bringing safety concerns to the attention of the employer or the NRC. Protection from discrimination and the avenues available to seek such protection are outlined in the Code of Federal Regulations 10CFR50.7. A copy of these regulations may be obtained in the Health Physics Office.
4
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MSOC Tracking ID #
MURR SAFETY CONCERN REPORT DATE 1
I SAFETY CONCERN (use additional sheet if necessary) l l
I SUGGESTIONS FOR RESOLUITON (use additional sheet if necessary) l Initiator's name (optional) l 1
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DateimidalSCS acdon
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_ RE DISTRIBUTION / POSTING i
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MURR-SAQ-00002 Service Appilcations: Incident Report i
l 4.4 INCIDENT REVIEW TEAM (IRT) RESPONSIBILITIES 4
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. At this point of the process, the Incident Review I-Team (IRT) is responsible for the Root Cause Analysis 1.
and for devising Long Term Corrective Action (s); Steps I
-4.5 through 4.6.2.
4.5'
' ROOT CAUSE ANALYSIS i
. NOTE:
IF APPROPRIATE, USE THE FOLLOWING METHODS IN ORDER TO OBTAIN ALL THE APPARENT CAUSES:
STEP BY STEP AhMYS1S WALK THROUGH ANALYSIS 4.5.1 Root cause criteria:
Incident would not have occurred if the causes were not present.
Incident would not recur if the cause(s) are eliminated.
Elimination of the cause(s) will prevent repetition of the incident.
4.5.1.1 If a probable Root Cause catisfies all three criteria, it is a valid Root Cause.
4.5.1.2 Root Cause Analysis Investigators should be Subject Matter Experts (SMEs) and have a thorough knowledge of this procedure and it's systematic methods to ensure effective root cause determination.
1 M
Date: 09 Feb.1995 MURR SAQ;00002 page 13 of 17 1 SA
-Rev.02 REFERRAL USE PROCEDURE l
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MURR-SAQ-00002 Service Applications: Incident Report 4.5.2 Sten Bv Sten Analysis 4.5.2.1 Systematically evaluate each acdon until a cause is established which can be corrected in order to prevent recurrence of the incident.
Continue to ask the question WHY7 until the question can not be answered.
For example: Use Pool Pumo P508 Analvsis Flow Chart
( Attachment 4); Pool pump became inoperative.
Investigator:
WHY7 Originator:
Investigated; Pump main breaker tripped - could not " Reset".
Investigator:
WHY7 Originator:
Investigated; P508 motor is " locked-up".
Investigator:
WHY?
Originator:
Inspected motor; shaft bearings froze.
d Investigator:
WHY7 l
Originator:
Inspected bearings; no grease in bearings.
Investigator:
WHY7 Originator:
Verified recent scheduled lubrication from pump Machinery History.
Investigator:
WHY7 Originator:
On investigation, discovered improper grease was used during lubrication.
j Investigator:
WHY7 Originator:
On further investigation, it was determined that the original entry into the Machinery History as to the type of grease to be used for P508 was incorrect.
Investigator:
WHY7 Originator:
There is not a systematic method to review Machinery History data.
Investigator:
WHY7 Originator:
Due to lack of structured approach.
Investigator:
WHY7 Originator:
Due to lack of dedicated manpcNer.
b Date: 09 Feb.1995 MURR-SAQ;00002 page 14 of 17 Rev.02 SA REFERRAL USE PROCELURE V
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q MURR-SAQr00002 Service Applications: Incident Report 4.5.2.2 From the preceeding example (Step 4.5.2.1), it can be seen, an equipment malfunction occurred due tu a human performance 3
deficiency.
4.5.2.4 Consider the Root Cause Criteria of Step 4.5.1.
4.5.3 Walk throuah Analvsis This method is a reenactment of the task as it was performed, using the personnel involved when the incident occurred.
The investigator should be knowledgeable of the incident.
4.5.3.1 Use the MURR Incident Reoort Form (Attachment 2) and Service Acolications Incident Review Form (Attachment 3) to obtain the preliminary information as to the incident.
4.5.3.2 If available, obtain the references / drawings, etc. required to aid in the reenactment.
4.5.3.3 Investigators are to specify.which tasks will be investigated.
4.5.3.4 Have the individual (s) walk through the sequence slowly, using the appropriate procedure, reconstructing the j
occurrence.
4.5.3.5 The investigator should stop the walk through to ask questions, then continue the process.
4.5.3.6 Record all facts concerning the event.
4.5.3.7 Summarize all information collected.
4.5.3.8 Identify all probable problem areas; to include unclear, indirect effects.
4.5.3.9 List the most probable causes.
a 4.5.3.10 Consider the Root Cause Criteria of Step 4.5.1.
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UNIVERSITY OF MISSOURI COLUMBIA INTRA-DEPARTMENT CORRESPONDENCE TO: Gro Leaders, Managers
<}.
e, Charb( '
h FROM: '
DATE: 7/14/95
SUBJECT:
ISAT Recommendations to Evaluate Training Needs The ISAT committee recommended that MURR evaluate the training needs for the Center. To accomplish this evaluation we need each of you to identify your group's specific training needs and specific training deficiencies. We will use the information
-to target new areas of training for development and combine training for groups with common training deficiencies. Please answer the following questions and return to the, l.
Director's Office by July 31,1995.
1.
What training do individuals in your group receive beyond the standard
' indoctrination? Who provides this trairing?
'2.
Identify specific deficiencies in trainmg for individuals in your group. Who would you2ecommend provide the training?
' 3.. _ Ifindividuals n your group need additionallab safety / industrial safety training, what specific a eas of this type training would be most valuable (i.e., chemical use and storagt, fire safety)?
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o MURR Policy and Procedure Manual 9
STAFF ACCESS TO INFORMATION C1 :051 To improve the access to information concerning the MURR Center, an information library will be maintained in the front lobby. The library will contain notebooks of the following types ofinformation:
Correspondence to and from regulatory agencies (NRC, DOE, etc.)
Committee meeting minutes (RAC, RSC, etc.)
Reports (Annual, Review Groups, NRC, etc.)
Preprints of current research work The materials contained in the library need to remain in the lobby so they will be available to anyone wanting to review them. You may use the copier to make your own copy of any of the materials kept in this library.
Additionally a bulletin board near the front entry will be used to post new and current information. The following types ofitems will be posted:
Recent letters between MURR and regulatory agencies New minutes from committee meeting.
a Notice of new items in the MURR library that are difficult to post.
Long term goals and current priorities.
New University and Center policies and procedures We welcome your suggestions concerning improving access to information that can benefit all of us in doing our jobs.
i J
April 15,1995 Page1of 1