ML20137S233
| ML20137S233 | |
| Person / Time | |
|---|---|
| Site: | Fort Saint Vrain  |
| Issue date: | 12/31/1994 |
| From: | STIER, E.H. |
| To: | |
| Shared Package | |
| ML20137S172 | List: |
| References | |
| FOIA-96-434 NUDOCS 9704150067 | |
| Download: ML20137S233 (290) | |
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No. 5 4
4 5 REPORT OF INDEPENDENT COUNSEL INVESTIGATION CONCERNING ISSUES AT THE FORT ST. VRAIN NUCLEAR GENERATING STATION DECOMMISSIONING PROJECT
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l l PUBLIC SERVICE COMPANY OF COLORADO PREPARED BY l STIER, ANDERSON & MALONE S
DECEMBER 1994 CASEND. 4-94-010 EXHIBlT A Page / Of- N9
' I 9704150067 970407 -
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TABLE OF CONTENTS l
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L - INTR O D U CTI O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... ..... 1 !,
A. . Origin 'and Purpose 'of Investigation . . . . . . . . . . . . . . . . . . . . .... 1 l 2
B. Conduct of Investigation . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . 3 _
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- 1. : Investigative Staff . . . . . .............. ..... ...... :)
, 2.- ' investigative Process. . . . . . . ...................... 3 l 1
Analysis of Evidence . . . . . . . . . . . . . . . ............... 4 i 3. l
- 4. Organization of this Report . ........................ 5 !
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+: End notes . . . . . . . . . . . . . . . . . . . . . .. . ... ... ... ... .. .... 6 t,
.11. I SSU E S ~ . . . . . . . . . . . . . . . . . . . . . . .. ........ ............. 8 111.
SUMMARY
OF CONCLUSIONS . . . . ...........................9 l
A. Whether an Atmosphere Existed in Which Workers
. Were Reluctant to Raise Safety Concerns . . . . . . . . . . . . . . . . . . . . 9 B.. Whether SEG Employees Used the ROR Process to intimidate and Harass MKF Personnel . . . . . . . .............. 13 C. Whether SEG Supervisors and RPTs Falsified Radiation Survey Documentation .... .................. . 14
- 1. 1992 Release Survey Forms .......... . .. . ... 14
- 2. Radiation Work Permit Survey Forms
.for Early 1993 and Survey Forms Related to Release of Hot Service Facility _ Plug from Reactor Building in September 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 15 IV. - ' BAC AGROU N D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 LA.; 0verview . . . . . . . . . . . . . . . . .... ..... ........ . . . 20 l t
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B. Significant Events Preceding investigation . . . . . . . . 22 i
- 1. Prior NRC Inspections . . . . . . . . . 22
- a. Fuel Handling Machine Event . . . . . . . . . . . . . 22-
- b. Crane Overload Event . . . . . . . . . . . 25 l 1
- 2. NRC Intimidation and Harassment Investigation . . . . . . . . 26
- a. Layoff of MKF Workers . . . . . . . . . . . . . 26 .
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- b. Verbal Threat Made to RPT . . . . . . . . . . . 26 C .- Identification of Possible Falsification of Radiation Survey Records . 27 Endnotes . ................. . . . . . . . . . . . . 30 i V. DISCUSSION OF ISSUE: WHETHER AN ATMOSPHERE -
EXISTED IN WHICH WORKERS WERE RELUCTANT TO RA!SE SAFETY CONCERNS . . . . . . . . . . . . . . 33 j A. Applicable Standards . . . . . . . . . . . . . . . . .. . . . 35
- 1. MKF Policies . . . . . . . . . . . 36
- 2. Federal Standards . . . . . . . . . . 36
- a. General Standards . . . . . . 37
- b. Allocation of Burden of Proof . . . . . . . 41
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- 3. SEG Standards: Radiological Occurrence Reports . . . . . . 45 l
- a. Decommissioning Plan . . . . . . . . . . . . . . . 45
- b. PSC Procedures . . . . . . . . . . . . . . . 47
- c. SEG Procedures . . . . . . . . . . . 48 B. Perceptions of MKF and SEG Workers . . . . . . . . . . 49
- 1. MKF Craft Workers . . . . 51 ii i
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- 2. SEG Workers .... . .. . . . ... . . .. .. . . . 54 l C. Effects of Certain Conditions and Events on Workers' Perceptions . ...... . .. ..... ...... . .. . . . . 56 l 1. March 1993 Layoffs of Four MKF Workers . . . . 57
- c. Description of Allegation . . . ...... . .......58
! MKF Response to Allegation . . 61
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- c. Analysis . . . . . ... .. . ... ... .. . . . 66 .
- d. Conclusion . . ..... ........... . . . . . . . . 76
- 2. ' Perceived intimidating Behavior by MKF Supervisors .. . . 76 -
- a. Perceived Intimidation of RPTs . . ... . . . . 77
- b. Perceived intimidation of MKF Craft Workers . . . 88
- c. Conclusion . . . . . . . . . . . . . . . . . . . . .. ... . . 96 t
- 3. Other incidents involvir'g Actions of MKF Supervisors . . . 97
- a. Crane Overload incident . . . .. ... . . 97 t
- b. Asbestos incidents . . . . . .... . . .. . . 100
- c. Allegations Concerning Carpenter Foreman . . 109
- 4. Effect of Certain MKF Policies on MKF Worker Perceptions . . . . . . . . . . . . . ... . ... . . . . . . 114 ,
- a. "Open-Door" Policy . . . . . .... .. . . . . . 115
- b. Disciplinary and Layoff Policies . . . . ... . . 117
- 5. Effect of Certain SEG Policies on RPT Perceptions . . . . 118
- b. Perceived ineffectiveness of ROR Program . . . . 120 iii s
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D. l Summary and Conclusion .......... ...... ........ . 133- d
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-Endnotes . . . . . .............. ......... ..........,. .138: ,
VI. DISCUSSION OF ISSUE: WHETHER SEG EMPLOYEES USED' l i THE ROR PROCESS TO INTIMIDATE AND HARASS MKF i 4- ' WOR KER S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
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- -A. Nature and Origin of Perception . . . . . . . . . . . . . . . . . . . . . . . . 164 1 y
, 1. General Perception of ROR Program . . . . . . . . . . . . . . . . . 164
- 2. Specific Instances of Alleged Harassment . . . . . . . . . . .. 167- $
. B.' Factual Basis for Perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _168 j C. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........ .171 End notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -172 l Vll. DISCUSSION OF ISSUE: WHETHER SEG SUPERVISORS i AND AN RPT FALSIFIED RADIATION SURVEY l I
DOCUMENTATION RELATING TO RELEASE OF MATERIALS FROM THE SITE DURING 1992 ............................. 174 A. ' Introduction . . . . . . . . . . . . . . ..................... . . . 174 B. Standards - Radiation Protection Program . .... ...... . . . . 176
- 1. Organization of FSV Radiation Protection j Prog ram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176 i
- 2. FSV Decommissioning Plan ......................178 ,
- 3. Applicability of PSC Procedure to Survey Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .180 j 4.' Applicability of SEG Procedure to Decommissioning Activities . . . . . . . . . . . . . . . . . . . . . . 181 C. Release of Materials From FSV for Unrestricted Use . . . . . . . . . . 182 '
- 1. The Decommissioning Plan - Release Criteria . . . . . . . , , 183 e
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- 2. - The Contracts Release Standards - ...... . . . . . . . . . . . 184- t I .
PSC Release Procedures . . . . . . . . 185-
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- 4. ' SEG Release Procedures . . . . . . . . . . . . . . ... ...... 187- )
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- 5. Survey Technique ~for Conducting Radiation j Contamination Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 j D. Backdated Release Survey Forms - Discovery of j the Problem ' . . . . . . . . . -. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 :
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- 1. Possible Survey Documentation irregularities $
Identified during investigation . . .' . . . . . . . . . . . . . . . . . . . 190 j f
2.' Genesis of the Backdated Release Survey Forms . . . . . . 193 i
- a. Zahrt's Account about Discovering I the Problem . . . . . . . . . . . . . . . . . . . . . . . .. . 193 l i
- b. Bixby's Account of the Preparation of l the Backdated Release Survey Forms . . . . . . . . 197 .
- c. Sawyer's Account Regarding the Backdated Release Survey Forms . . . . . ..... . . . . . . . . 200 !
E. Analysis of 14 Backdated Release Survey Forms . . . . . . . . . 201 !
- 1. Overview - Blain's Review of Backdated Release Survey Documentation ................. . . . . 206 .
- 2. Misleading Nature of Backdated Release Survey Forms . . . . . . . . . . . . . .. ........ . . . . . . . 207 m 3. Zahrt's Accountability for Backdated Release .
Survey Documentation ....... . ....... . . . . . . . 209 i
- a. Zahrt's Failure to initiate an ROR . . . . . . . . . . . . . . 21 0
- b. Zahrt's Awareness of Audit Activity at FSV . . . . . . . . 212 f
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- 4. Similarity of Approach - Bixby's Backdated Release [
Survey Forms and Backdated RWP Survey Forms . . .. 213 j
- 5. Zahrt's Explanation for the Survey Document l Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . ....... 215 )
F. SEG Management's Knowledge . . . . . . . . . . . . . . . . . . . . . . . . 22 3 l G. . Analysis of Safety implications of Backdated Release Survey Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 j l
H. Conclusion - Backdated Release Survey Forms . . . . . . .... 226 ;
. E ndnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ............ 227 .
Vill, DISCUSSION OF ISSUE: WHETHER SEG l SUPERVISORS AND RPTs FALSIFIED RADIATION WORK PERMIT SURVEY DOCUMENTATION . . . . ... . . . . . . . . 255 !
-6 A. Introduction - Falsification of Radiation ;
Work Permit Survey Forms . . .. ... . .... . . . . . . 255 ;
B. Discovery of Missing Surveys - D. Parsons' informal Audit . . . . . . . . . . . . . . . ...................... 259 i
. i C. Investigation into Backdating of RWP i Survey Forms . . . . . . ....... . . . .. .. .. .. .261 j e
- 1. Identification of Suspect RWP f
< S u rvey F o rm s . . . . . . . . . . . . . . . . . . . . . . . . . . ... .. 262 ;
- 2. Additional Relevant Document Analysis . .. . .. .. 264 .
- a. Response Test Records . . ....... . . . 265 .
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- b. Maintenance Records . . . . . . .. .. .. . . . . . 266 i t
- c. Equipment lasue Log . . . . . . . . . . . . . . ... .... 267
, 'd. Fastrak Computer Printouts . . . . . . . . . . . . . . . . 268 i
- D. Analysis of Suspect RWP Survey Forms . . . . . ..... . . . . . . 268 .
- 1. RPT Robert Rankin . . . .... .... ... . ... 272 i vi .
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- 2. RPT'Craig Thorp . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 1
- 3. RPT David Hatch . . . . . .. . . . . . . . . . . . . . 276 i a
4; RPT James Bixby . . . . . . .......... . ........ 278- l 1
- 5. RPT Brent Daniel .........................-......-279_ ;
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- 6. RPT Daryl Deringer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 1
. 7. RPT Roland " Chip" Sawyer . . . .......... ... ..... 283- i t ;
- a. Backdated RWP Survey Forms . . . . . . . . . . . . . . . . . 283 f
- b. Sawyer's " Distribution" of Routine RWP 'i
. Survey Forms to Satisfy the Requirements :
of Other RWPs . . . . . . ............. . . . . . . 285 !
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- 8. RPT Joseph Trujillo ...... ....... . . . . . ... . . . . 287 a l s . 9. RPT Dennis Beierle . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 90 ,
- 10. RPT Robert Dale . . . . . . . . . . . . . . . . . . . . . .. . . . . . 293 i-4 E. Conclusion - Backdated RWP Survey Forms . . . . .. ....... 294 f Endnotes . . . . . . .. . . . . . . . ..................... ...... .. 297 i 1
IX. DISCUSSION OF ISSUE: WHETHER SEG SUPERVISOR l
. SAWYER FALSIFIED A SURVEY FORM FOR THE HOT SERVICE FACILITY BLOCK . . . . . . . . . . . . . . . . . . . ..... . .307 4- A. Introduction - Falsification of Hot Service Facility Block Survey Form . . . . . . ..... .... . .. . . .307 B. Decontamination and Survey Activity of the H SF Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... .309
- 1. Initial Release of the HSF Block ................. . 309
- 2. Discovery of Contamination of the HSF Block ......... .311
- 3. Additional Decontamination and Surveying of the HSF Block . . . . ............. ... .. . .. 312 1 VH j
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~ C. Sawyer's Account . . . . . . . . .. . . . . . . . . . . . . . .
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D. Analysis of Sawyer's Survey Form 4503 .................... 315 i
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E.' Conclusion : . . . . . . . . . . . . . . . . . . . . . . . . . . . . - ... . . . . . . . . . 319 .j i
. Endnotes . . . . . . . . .- .. . . . . . . .. ........... ................. 321 i
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- l. INTRODUCTION L . !
'A. Oriain and Puroose of Investiaation This report presents the results of an investigation that was initiated at the request .
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of Public Service Company of Colorado (PSC) and the Westinghouse Decommissioning j Project Team (Westinghouse Team) as a result of events occurring at the Fort St. Vrain l i
Nuclear Generating Station (FSV) in early 1994. j
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FSVs reactor was permanently shut down in August 1989. In November 1989 l
.i PSC submitted a proposed decommissioning plan to the Nuclear Regulatory Ccmmission j (NRC). To carry out the decommissioning, PSC pursued a fixed price bidding process j which led to the selection of a contractor and subcontractors, collectively referred to as !
- the Westinghouse Team. Under an agreement signed in April 1991, Westinghouse !
Electric Corporation was the contractor responsible for project management, while l Scientific Ecology Group, Inc. .(SEG), a wholly owned subsidiary of Westinghouse, had j the responsibilities of radiation protection and radwaste preparation and shipment l support. Construction services were to be furnished by Morrison Knudsen Ferguson f Corporation (MKF). j Prior to the start of our investigation, the NRC had initiated an investigation into
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intimidation and harassment allegations surrounding the discharge of four MKF workers.
While the NRC investigation was underway, an MKF superintendent who had just received his fourth Radiological Occurrence Report (ROR) - a SEG-Procedure j generated report documenting violation of radiological protection rules - threatened the l
SEG radiation protection technician (RPT) who wrote the ROR. When PSC leamed of l 1
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[ ' this incident. its management requested the Westinghouse Team to investigate and take .j I
corrective action and develop an overall action plan to address the possible " chilling" 4
cffects of the incident. An action plan was then developed and implemented. !
The threatening of an RPT by an MKF superintendent and the allegations that. ;
MKF workers had been harassed and intimidated caused PSC and the Westinghouse Team to develop concerns about whether the objective of the ROR program at FSV was ,
equally understood by all facets of the workforce: whether RPTs were subjected to 1 intimidation and harassment for enforcing proper radiation protection practices; and ;
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whether employees in general felt free to speak out about safety issues. !
There were indications that at least some FSV workers were reluctant to express I s;fety concerns because they felt there was an atmosphere in which production and scheduling considerations took precedence over safety. At the same time, some I
construction supervisors countered with the assertion that RPTs used the ROR program abusively, to harass them.
In late February 1994, PSC, in conjunction with the Westinghouse Team, retained our firm to determine whether an atmosphere of intimidation and harassment existed.
The Stier. Anderson & Malone independent investigation began during the week of March 7,1994. Shortly after our investigation commenced, an additional issue of j
potential falsification of survey documentation surfaced. SEG, in turn. contracted with a former NRC inspector to perform an independent assessment. The preliminary results 4 of this assessment concluded that SEG personnel had failed to follow survey ,
documentation procedures and that there had been falsification of survey documents.
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B. Conduct of Investication l
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- 1. Investiaative Staff The investigative staff of Stier. Anderson & Malone included three attorneys with cxtensive investigative experience. all of whom had participated in previous ;
investigations in the nuclear utility industry.' During the investigation, Darrel Blain, a member of PSC's health physics oversight group, assisted in a comprehensive review l of the ROR program. He also participated in analyzing selected radiation survey documentation, took part in numerous interviews of witnesses, helped obtain documents, cnd provided technical expertise on health physics issues. However, all decisions with.
I r:spect to the conduct of the investigation, analysis of the evidence, and conclusions i
were within the exclusive control of Stier, Anderson & Malone.
- 2. Investicative Process During an "all hands" meeting on March 10,1994. PSC and the Westinghouse i Tcam management introduced members of Stier, Anderson & Malone's investigative staff 1
to the site employees. The investigators then began gathering and analyzing documents and interviewing witnesses. Most of the interviews were completed by the cnd of May 1994.
We initially conducted informal interviews of PSC personnel to determine the scope of the problem and familianze ourselves with operations and site personnel.
During this process, we also interviewed a witness who was introduced to us by PSC management. The witness raised the issue of potential falsification of radiation survey j forms, which we investigated as described below.
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' During the analysis of the facts and in the preparation of.this report inferences :
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were drawn solely from the evidence gathered. When possible, the strength'of.the .
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? inferences drawn from that evidence is indicated. Where conflicts in the e'vidence were ;
i relevant to the issues,'every effort was made to resolve them.
'In ~ resolving . conflicts in~ witnesses' statements 1 then following factors were j i
- consioered of primary importance: the access of the witness to firsthand knowledge of. .l t
the relevant facts; possible bias or self-interest the witness may have had in presenting j i
a particular version of the facts; the extent to which a statement was corroborated by !
other witnesses or documentary evidence; and the plausibility of the statement under all -l the circumstances. l 4
1 In weighing the evidence, it was important to consider the nature of the evidentiary l
- 1 conflict. Where inaccuracies in recollection were insignificant or the record did not j
. indicate that the inaccuracies were intentional, the conflicts did not detract from the
, . overall assessment of the credibility. of the witness. Finally, in no case was the -l J
J cvaluation of the credibility or weight arsched to information supplied by witnesses 1 b sed upon investigators' observations of the witnesses' demeanor during interviews.
- 4. ' Oraanization of this Report i This report is organized into nine main sections. The sections are: Introduction, issues. Summary of Conclusions, Background, and five sections containing detailed
- discussions of the issues. Additionally, Appendices A, B and C contain further details
- . conceming document falsification issues. Appendix D contains comments to the final draft of this report and responses to those comments.
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- 3. Of the 105 witnesses whose statements were taken,46 returned their interview I transcripts. Where a witness statement is cited as source, reference will be made !
in an endnote to the name of the witness, and the date and page of the interview i statement. In the endnote references to witness statements. we specify whether i or not the witness has sworn to the truthfulness of the statement. l I
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1 II, : ISSUES . '
I The primary issues addressed in this report are:
A. Whether an atmosphere existed in which workers were reluctant to raise safety concerns. ;
- 8. Whether SEG employees used the ROR process to intimidste and harass MKF personnel. :
C. Whether SEG supervisors and RPTs falsified radiation survey )
documentation in three areas:
- 1. 1992 survey forms for unconditional release of materials from the i
, plant; ,
- 2. Radiation Work Permit (RWP) survey forms for early 1993; and )
- 3. A survey form related to the release of the hot service facility plug from the reactor building in September 1993. !
These issues are discussed in detail in Sections V. VI, Vil, Vill, and IX, and our conclusions regarding each of them are summarized in Section ill below.
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SUMMARY
OF CONCLUSIONS .
A. Whether an Atmosohere Existed in Which Workers Were Reluctant to Raise Safety Concerns A significant cross section of the workforce at FSV perceived that workers who -
cppeared to int _erfere with production goals by raising safety . concerns wou!d displease their. supervisors and thereby endanger their jobs. This perception existed despite the efficial policies set forth in writing or articulated by upper management which encouraged workers to express safety concerns and did not condone retaliation against persons who rcised such can'cerns, in part the perception that workers who express concerns risk their jobs resulted !
I from conditions unrelated to the decommissioning project, such as the attitudg.s_aod -
i cxpectations many .MKF employees had developed from their previous experience in the construction industry. NumRIOMLWOIkets desenbed a culture in that industry in which it is generally accepted that expressing safety concerns or developing a reputation as !
l s meone who questions the actions of supervisors or who slows production, can 1
-: l cndenger one's job securg As one worker put it. "if there's going to be a layoff and if you are a bitcher or griper . . you can bet the first layoff, you're going to be en _'
That's the way construction works." However, some supervisory actions and inactions during the decommissioning project contributed to or reinforced the perception.
First, there were patterns of conduct among mid-level SEGMKE supfervisors cnd superintendents that fostered triis. perception by creating the appearance of an d -
imbalance between appropnate concems for production and scheduling on the one hand, cnd safety and procedural compliance on the other. No one event created the 9
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.' cpp_earance that production and scheduling took precedence over safety _and procedural: j
- compliance. However, supervisory actions related to the following events created or ^ - ,
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i r inforced~ an impression .among segments of SEG's and MKF's workforce that their
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' respective' management teams were more interested in moving the project along than ?
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in'seeing that it was performed ' properly: ,
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'An instance in which ' expression of safety concerns by four MKF workers !
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was perceived to have influenced the decision to lay them off. .;
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- - Several instances where plant or worker safety was potentially 2
compromised, including an incident involving' the overloading of a crane 1 and several incidents where, workers were possibly exposed to' asbestos. J 4 o ~
- - Two instances where' RPTs were subjected to threatening or abusive _
o language by MKF supervisory personnel following their having raised radiation protection or work place safety concerns.
l - A number _of violations of radiation protection practices were committedtby )
MKF supervisory personnel. Some of these violations seemed flagrant to .
the RPTs. In their view, however, no strong corrective action was taken ,
by SEG site management.
- A number of RORs were issued against MKF personnel for willful violations of radiation protection procedures. Many RPTs felt that management failed l to take meaningful disciplinary action against the violators. This fostered ;
an attdude among the RPTs that the ROR program was ineffective.
I Second, while these events did not reflect MKF and SEG policies, they did s
cvidence flaws in the management of those organizations at the FSV site. Upper . /
managers in some cases were totally unaware of the perceptions of their workers and the actions of some of their supervisors and superintendents that helped shape those 1 ;
perceptions. For example, shortly after the March ~1993 layoff of four laborers, a e
J significant number of MKF workers had at least heard the allegation that the layoffs were 4 .
- caused by the laborers' expression of concerns, and a segment of the workforce tended-10
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- to believe the allegation. 'In contrast, upper level MKF mangers stated they were ,
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- unaware even that the' allegation had been made until the NRC' began its investigation' in late 1993. ~ln other cases, managers were generally aware of tensions in the work
. place. butIfa_iled to obtain an adequate understanding' of the conditions underlying them7 / I
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! The RPTs' dissatisfaction with SEG management's corrective action on the RORs, for .l
- cxample,' could be traced tc3pper SEG site manlagement not havino a complete picture R 4 :
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- of conditions in thafeactor building.! These SEG managers were not aware of the almost ;
, i Ldrily friction between one of the MKF superintendents, Danny Hicks, and many of the i RPTs. l Third, some MKF and SEG policies that on their face did not favor production over ;
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7 % s;fety.were administered in a way that fueled that perception. For example, MKF's
. 'open-door" policymbv which it encourmand workara in enmmunicata safety copearns p v'
) ~ u; i directly to too manaaersTwas undermined when a supervisor reprimanded workers fot ,
t; king a safety concern to MKF's general superintendent.f When these same workers ,
were laid off not long thereafter, they and others perceived a relationship between the j
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1:yoff and their having gone to MKF's general superintendent pursuant to the "open- :
door" policy. Similarily, the conduct of SEG's ROR program led some to believe that it !
I w:s being administered in a way that favored production. / .
Thehorkforce imic+Etions th='--- a --M ar r=L ' ==a == a"*linari =have hari the effect of makina at 5-=.+ =ame workarn _more rainetant than they otherwise would h ve been to express safety conearand However, the evidence did not indicate that :
! Lh:7.ardous' conditions remained uncorrected because of such reluctance, indeed, the !
11 i
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- -project as a whole has had a good safety record. Even some witnesses who perceived -
s
( .
cn atmosphere ofintimidation and harassment stated that they would not hesitate to take =
i A
]
i
- .whatever sMps were necessary to correct a serious safety problem. !
- As problems'were identified during our investigation, the Westinghouse Team and i
.PSC management began taking corrective actions'. With confirmation of the records; .
[- falsification issue in late March 1994, the Westinghouse Team issued a stop work order i i cnd shortlyLthereafter PSC issued.its own stop work order. SEG undertook additional 'j i
tr ining of the RP,Ts and commissioned a management review. Additionally, SEG placed ,
)
that two supervisors suspected of involvement in survey record falsification on
', administrativ' 'enve. PSC set up an employee concerns hotline; significantly increased ,
l its oversight activities, especially in the area of unconditionsi release of materials; and set forth comprehensive corrective action requirements for the Westinghouse Team to accomplish prior to restart.
We hr.ve not undertaken an analysis of these corrective actions or their impact l on the cor,ditions described in this report. We note, ho,vever, that major elements of the atmosphere of intimidation and harassment described by witrcases were no longer i= factors _by the time the Westinghouse Team and PSC issued their stop work orders.
Hicks and two othe[MKF superintende ts;were frequently identified as the major
, contributors to the intimidation and harassment atmosphere. By March 1994 however,
~
6 Hicks had been transferred from the site, and even before our investigation began,
. accordi,ngito the RPTs, the behavior of the other two superintendents had improved 1
~s ignificantly.
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' On LSEG's-i s'de_ of the ledger, the evidence showed that Kenneth Zahrt. the !
~
Radiation Protection Operations Supervisor (RPOS), controlled the flow of information !
to upper SEG site management concerning three key matters: Hicks' violations of !
radiation protection practices. the behavior of jiinothe~rYK7 su'pirintendent[who .a threatened an RPT, and the failure of 'some RPTs to document their survey activities. !
Following the Westinghouse Team's and PSC's stop work orde=, SEG removed Zahrt ;
~
from the RPOS position and placed him on administrative leave.
f (The issues related to intimidation. harassment, and reluctance of workers to raise -
safety concerns are discussed in detail in Section V of this report.)
.i B. Whether SEG Emolovees Used the ROR Process to intimidate and Harass ;
MKF Personnel ;
The{ perception \that the ROR program was intended for punitive purposes can be
.treced to comments made early in the decommissioning project by Westinghouse Team ,
)
- m::nagement. At that time, the craft workers were told that if they received three RORs r .
th ;y would be discharged. This led the craft workers to describe the program as a "one, I two three, you're'out" program. Additionally, two MKF superintendents expressed the view that some RPTs enforced the ROR program in a discriminatory manner, and one of the superintendents, Hicks, contended that the RORs were used for harassment
. purposes.
The evidence, however, does not support the conclusion that the program was
!- ' used in a punitive way. Two MKF employees. one a superintendent and the other a craft
{ . worker, each accumulated four RORs. The craft worker's violations involved activities i'
~ with a significant potential for contamination of himself and others. Eventually, this craft
-13 1
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worker was terminated by MKF, but for reasons which did not relate directly to the ROR . !
(1 I
- cctivity. 'As for the MKF superintendent, Hicks, his access to the radiological control f crea was temporarily restricted following the issuance'of a fourth ROR. Hicks' action in' l vbrbally threatening the ROR's author ultimately led to a decision by his employer to l
' transfer Hicks to another MKF location. !
[ i 4+_
None.of the MKF workers interviewed complained that.the ROR process was 1 cbused,; and the evidence did not support the view that the program was enforced in a - !
I discriminatory m,anner, or used for harassment purposes.
l J(This issue is discussed in detail in Section VI of this report.) !
- . 1
[ C. Whether ~ SEG Supervisors and RPTs Falsifiet Radiation Survey '
- . Documentation !
! The evidence supports the conclusion that during 1993, five SEG RPTs and three
[' supervisors participated in falsifying radiation survey documentation in the following )
crcas. l
- 1. 1992 Release Survey Forms
[ Fourteen release survey. forms covering the period September 8,1992 through e
.' December 7,1992 were falsified. These survey forms dealt with the unconditional i rclease of portions of the dismantled steam generator system from the reactor building.
r The 14 faladied survey forms reflected that they. wore prepared by an RPT and reviewed
( ' by.an SEG supervisor on various dates between September and December 1992. The investigation, however, showed that all 14 survey documents were created in February 1993. The RPT involved in this backdating was directed to prepare the documentation 14 i
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i No.5 l l
l by an SEG supervisor. SEG's RPOS then reviewed and signed each of these 14 l 1 l backdated survey documents. ]
Although the evidence demonstrated that this 1992 release survey documentation was falsified, the investigation did not disclose any instance where the steam generator j system materials covered by the backdated survey forms were improperly released from ,
the site. Witness accounts and the circumstances surrounding the dismantling of the !
I steam generator system strong!y suggest that these materials were properly surveyed 4
prior to their release. l (The falsification of these 14 survey forms is discussed in detail in Section Vil and '
,, 1 Appendix A to this report). )
- 2. Radiation Work Permit Survey Forms for Early 1993 and Survev Forms Related to Release of Hot Service Fa .i!ity Pluo from Reactor l Buildina in September 1993 Twenty turvey forms covering radiation work permit (RWP) surveys performed in ;
i
. i J nuary, Februaq/, and the first week in March 1993 were falsified in that the survey and r; view dates listed on them were backdated and the backdating was not disclosed on th3 documents. Each of the twenty falsified RWP survey forms indicated it was prepared j l
by an RPT and reviewed by an SEG supervisor on various dates in January, February, I cnd early March 1993. The investigation, however showed that these survey documents came into existence substantially after the survey and review dates contained on the survey forms.
y (The falsification of these twenty survey forms is discussed in detail in Section Vill ./
cnd Appendix B to this report).
15 l
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Two of the RPTs responsible for backdating RWP survey documents admitted
(.. * '
their actions. The remaining six individuals involved either denied the backdating or declined to participate in an interview.
l 1
Circumstantial evidence suggests that another 10 RWP su.vey forms were backdated in March 1993. The investigation, however, could not rule out the possibility I th:t some of these documents were initially created on the dates written on the survey form. but were then misplaced until early March 1993, when they were located and i cntered into the SEG 1993 survey log. In the case of two survey forms we investigated, the evidence showed these forms were actually misplaced for over two months.
The investigation disclosed two cases in which the evidence showed that RWP 4
survey documentation was falsified in that the activity described on the survey forms was not performed on the date and time indicated on the suivey document. One of the survey forms in question documented a comprehensive survey of the hot service facility (HSF) block on September 27,1993 at 1600 hours0.0185 days <br />0.444 hours <br />0.00265 weeks <br />6.088e-4 months <br />. The survey documentation was pr: pared by SEG's day shift supervisor. Records show that for most of the afternoon of September 27,1993, he attended training and could not have performed the time-consuming survey he documented.
(The f2sification of the HSF block survey form is discussed in detail in Section !
IX and Appendix C to this report). ,
. :. 9 The seennd instance of falsification of an RWP survey form where the survey l could not have been performed on the date and time indicated involved 1 of the 30 backdated RWP survey forms. A February 16,1993 RWP survey form listed a survey {
i 16
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i time of 1030 hours0.0119 days <br />0.286 hours <br />0.0017 weeks <br />3.91915e-4 months <br />. Plant records, however. show that the RPT was only in the plant i .
for eight minutes between 1543 and _1551 hours and he was not active on an RWP at cny time during the day.
Analysis of relevant records -including instrument calibration dates, computerized RWP entry,-instrument response testing, gate entry and- equipment issue logs --
corroborated that . survey documents were falsified. The evidence -supports the conclusion that often the instrument usage and calibration data listed on the backdated survey forms twere fabricat<A. In some instances, the backdated RWP survey documentabon cited the use of a type of survey instrument that had to be issued and returned on a daily basis. The 'SEG instrument equipment issue log, however, contained no entry of any su2 instrument having been signed out or returned on the dates in question. In other instances, SEG's records lacked any entry showing that survey instruments were response tested as required on the date of the alleged survey activity.
In still other instances, the instrument calibration date listed on the backdated survey form .was plainly in conflict with the scheduled calibration date based on SEG's m:intenance records. In still other instances, the analysis showed that the 3urvey instrument listed on backdated survey forms was out-of-service.
The weight of the evidence supports the conclusion that the backdated RWP survey forms were intended to mislead. The key ingredients that made the documents misleading were the matching survey dates and review dates, combined with the omission of any notation advising a reader that the documents were created at a much f later time. . Although each of the RPTs involved in the backdating denied receiving any 17
No.5
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\ specialinstruction on preparing the backdated documentation, each RPT and supervisor 1 i
i~ involved approached the problem in an identical manner. The RPTs backdated the ,
a purported survey date, either th'e RPTs or the supervisors backdated their review date, 4 1 cnd the reviewers knowingly affixed their signatures to a document containing a l
)
beckdated review date. Neither the RPTs who prepared the backdated survey forms nor j
- the supennsors who reviewed them made any notation that would have alerted an l cutside observer that the documentation came into existence at a much later date than I
e the alleged survey activity described on the forms. The' similarity in approach to the :
- i. . problem adopted by all of the participants in backdating survey forms suggests concerted ;
I ection. l
- The evidence did not show whether surveys were backdated to accommodate the int:; rest of production and scheduling over procedural compliance. The evidence did ,
l show a connection, however, between the backdating of RWP survey documentation in c:rly 1993 and a pending audit review of the radiation protection program. In the case of the HSF . block survey form, the evidence showed a connection between_an .
! inadequate survey of the HSF block and the desire to exoedite production.
No discemible impact on public and worker health and safety could be identified in connection with either the release of materials from the steam generator system or the RWP surveys for which documentation was backdated. The ALARA* exposure reports for FSV and individual worker exposure records provide objective evidence that overall 3
'ALARA ("as low as Reasonably Achievable") refers to a doctrine in the nuclear industry
, designed to minimize worker exposure to radioactivity.
18 e' W *V een We - T myer+m- m p 2 f wwa -
1 L No.5 i
- worker and public health and safety have been meintained. . None of the witnesses, 1_'
including the RPTs and the craft' workers'who expressed concerns or perceived'that an - l atmosphere of intimidation and harassment existed, had knowledge of any improper. l release of materials. With the exception of the release of the HSF plug from the reactor l i
- building to a fenced in area within the site perimeter, the investigation did not disclose
' ~
- that any other materials were improperly released. 1 The evidence does not indicate that PSC, Westinghouce Team or higher level l l
SEG managers.were, aware of the above-described document. falsification when it ~ .j occurred; Upper SEG site management first received indications of survey document i
-irregularities in early March 1994, and a week later, the concern that survey documents - i
- . msy have been falsified surfaced in our investigation. Shortly thereafter, PSC and the.
- Westinghouse Team management were advised of the possible falsifications. ]
)
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.IV. IBACKGRDUND.
! Overview -
A.-
?
The FSV Nuclear Generating Station began initial power generation in .1976. j T '
While in operation, it was the only high temperature, gas cooled commercial reactor in l r
the country.' Primarily for economic reasons, FSVs reactor was permanently shut down -
i in August 1989.2 PSC then began formulating and implementing plans to defuel and I
dismantle the reactor and to terminate its license from the NRC.' l p -
- In' Novembpr 1990, PSC submitted a proposed decommissioning plan to the NRC. l PSC also pursued a fixed price bidding process for decommissioning services, which led ;
f j
I to the, selection' of a contractor and subcontractors, collectively referred to as the i
- . Westinghouse Team, to accomplish the decommissioning.'
- in April 1991, Westinghouse Electric Corporation, MKF, and PSC signed an cgreement to provide services for FSVs decommissioning. Westinghouse was responsible for providing project management for the decommissioning process while I
SEG, a wholly owned subsidiary of Westinghouse, provided radiation protection support and radiation waste shipping services. Construction services were to be furnished by .)
MKF.5 ,
in May 1991. PSC received a possession only license from the' NRC. Defueling
. cf the reactor commenced in December 1991 and was completed by June 1992.' In August.1992 the Westinghouse Team commenced decommissioning work with SEG utilizing PSC procedures for implementation of the radiation protection program.' Then in December 1992, following the NRC's decommissioning plan approval, SEG began 20 l
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1 using its own radiation protection procedures,for decommissioning.' 'The projected
[' '
-l completion date for the decommissioning is November 1995.' PSC plans for the site to _ ' -!
be released for unrestricted use and anticipates that in the future the site will probably:
be used as an electric generating facility." ;
. Prior to the start of our investigation, the NRC had initiated an investigation into intimidation iand ~ harassment allegations surrounding the discharge. of four MKF - 'I workers." While the NRC intimidation and harassment investigation was underway, an <
MKF superinton'dent who had just received his fourth ROR was accused of threatening - f an.SEG RPT who had just written the ROR." In early February 1994, when PSC b:rned of the alleged threat to the RPT, PSC management requesteo the Westinghouse Tsam to investigate, take corrective action, and develop an overall action plan to l
' address the possible " chilling" effects of the incident. An action plan was then developed ;
and implemented." i In' late February 1994, PSC, in conjunction with the Westinghouse Team, retained i
our firm to determine whether an atmosphere of intimidation and harassment existed."-
. As desenbod above, shortly after our investigation commenced, the issue of polontial l f:Isification of survey documentation surfaced. SEG, in tum, contracted with a former :
NRC inspector to perform an independent assessment of the possible falsification of l survey. forms. ' The preliminary results of SEG's assessment concluded that SEG l personnel had failed to follow survey documentWon pre ,edures and that there had been l
- falsification of survey documents." ;
k 21 E
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~ On_ March 25,1994, the Westinghouse Team ceased all work in radiation control '
9 ,
areas. PSC then issued a confirmatory stop work order which required a number'of' cctions to be completed by the Westinghouse Team prior to resuming workc !These
{
cctions included retraining personnel in procedural and regulatory requirements,.
completity an overall technical assessment of :the radiation protection ' program,
' developing an' action plan for assessing and documenting the release of material for j I
unrestricted'use, and providing PSC with an assessment of any safety implications I
associated with,the findings of failure to follow procedures and falsification of records.
! .B. Sionificant Events Precedina investiaation l
- 1. Prior NRC Insoections In two 1993 NRC inspection reports reviewing incidents at FSV, the NRC l cxpressed the view that production was emphasized over safety. The incidents involved l L
th) fuel' handling machine and the reactor building crane, respectively. (As described
- more fully below, the theme that production was emphasized over safety was later l
l echoed by a segment of the FSV decommissioning workforce.)
- _ a. Fuel Handlina Machine Event
[
[ The fuel handling machine (FHM) was used in the decommissioning process to l rcmove intemal core components of the Prestressed Concrete Reactor Vessel (PCRV).'
-The FHM is located on Level 11 in the reactor building.' It is more than forty-five feet tall. - i
- weighs approximately one hundred sixty-five tons, and is desigrWed to withstand certain i i
sarthquake activity - a " design basis seismic event" - without toppling if attached to the i
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!' r=ctor building crane while sitting on a reactor isolation valve, or if it is bolted down in [
,I
- , oneLof the seismically qualified locations in the plant. j
. On' February 10,1993, MKF was supervising activities involving the removal of_
l radioactive core components from storage well number five, which is not a seismically ;
quslified location. Under MKF's supervision, the FHM was detached from the reactor. !
building crane for approximately one hour." The event ~ placed the plant -in an -
4
.i unanalyzed condition.' PSC then notified the NRC and submitted a Licensee Event l Report.." -
, j L On May 5,1993, the NRC issued a Notice of Violation in contiection with the FHM i
' being placed in an unanalyzed configuration." In response, PSC concluded that the cv:nt did not. compromise safety because the integrity of the reactor building ,
confinement was maintained at all times. While recognizing that the likelihood of a l l
[ d:: sign basis seismic event was quite small, PSC acknowledged that for a one hour period this condition existed:
However, had such an event occurred, it is conceivable that the FHM could have toppled, and either fallen through the Reactor Building exterior wall, or fallen in some other manner that, with its 165 ton weight, would have rendered the Resctor Building structural integrity indeterminate. The i activated graphite blocks locartd within the Fuel Handling Machine may have been exposed during:such a fall, that
- would have created a radiological hazard.
- In an inspection report addressing.the FHM being placed in an unanalyzed configuration.-the NRC concluded that the " circumstances surrounding this event
_ indicated an emphasis on production or continuation of work activities at some expense
-to safety. 2' The NRC also concluded, however, that the initial responses of PSC a'nd -
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No.5 ;
,I personnel questioned the configuration resulting from the FHM being disconnected from -
~
the crane, but did not exercise their stop work authority. ' The NRC further noted that p cithough the contractor supervisor claimed the work package procedure in effect at the !
4 time did not preclude such a configuration, in fact it did.24 .'
PSC admitted that NRC license requirements had been violated in disconnecting i i the reactor building crane from the FHM and moving the FHM to a location not included j
. in the seismic design analysis for the plant.2s PSC attributed the violation to human error l in that the MKF superintendent in charge of activities misinterpreted pertinent procedural !
i requirements. PSC further conceded that its own oversight personnel did not stop the {
r - activities, even though they had questioned detaching t-4 FHM from the crane.2e An earlier incident involving the FHM also caused the NRC to question whether ,
1 a proper balance between safety and production was being maintained. During {
operations to remove dummy fuel blocks from the PCRV with the FHM, two events i
occurred on January 6,1993, which resulted in two dummy blocks ending up in a tipped )
i
[ position. According to the NRC, after the first block tipped no evaluation was made as l 1
't3 the cause of the event before a decision was made to continue removing the dummy !
- 1 blocks. The next thirteen blocks were removed without any problem. While attempting i .
, ts remove the final block, the FHM again experienced a mechanical failure which l- ultimately led to the block tipping over.27 The NRC questioned PSC's decision to continue with the block removal process without determining the cause for the first tipped
- block.' The NRC observed that the events surrounding the tipped blocks caused "some 24
._ Li
7 No.5 4
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]^1- concern over whether too much emphasis was being placed on maintaining production or: schedules at the expense oi s;;fety. 2: The NRC also questioned "the level of
$ involvement and effectiveness' of PSC oversight of the contractors."2e
- i. b. Crane Overload Event 1 ,
L .- In issuing the May 5,1993 Notice of Violation for the February 10,1993 FHM cvent, the.NRC also said ~it was concerned that the circumstances of that' incident o ;
- indicated an emphasis _-on production "at some expense to safety" in light of a
~
i subsequent crane overload incident. On February 23,1993, during an effort to remove the PCRV top head access penetration plug, "the auxiliary hoist on the reactor building .j crcne was overloaded." As a result, three eyebolts attached to the plug were sheared
{
i i 1 off and rigging attached between the crane hook and the plug was damaged. The NRC l noted that PSC's " assessment of this event concluded that procedural inadequacies, lack ,
. of adherence to procedures, insufficient engineering ' support, improper utilization of f
l equipment, and an emphasis on scheduling concerns over safety were all contributing
. causes."'8
~
The auxiliary hoist on the crane was rated at 17.5 tons. The NRC's inspection e
I report stated that it was calculated that approximately 25.5 tons of force was required i' to shear the three eyebolts. The report further noted that the Westinghouse Team i
responded with a' program that included efforts "to place safety ahead of production or ,
schedul[ing) concerns."
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No.5-t As more fully discussed later in this report, the crane incident coninouted to a a
I . ~!
i production goals were being stressed by MKF management at the expense of safety.
c 2. - NRC Intimidation and Harassment investication l i
- a. Lavoff of MKF Workers ;
i f Another critical event leading up to our investigation was related to the termination
, i
- 'of four MKF laborers in March 1993. In December 1993, PSC received a letter from the j NRC advising ttat t the NRC had received some allegations conceming environmental !
conditions at the plant." It was alleged, for example, that some workers were issued j i
i r;Ispirators while others were denied their use. Shortly after PSC received the NRC's letter PSC was called by an investigator from NRC Region IV, who advised of a possible
- investigation' involving intimidation and harassment. Subsequently, in early 1994 the p
f - NRC investigator arrived on site and advised PSC personnel that the four laborers who
. had been laid off had alleged they had raised safety concerns about environmental conditions and were subsequently denied the use of respirators. They further claimed they were laid off because they raised safety concems." While at the site, the NRC investigator intervewed two RPTs and advised PSC that he would return the following
- ' week.
I'
- b. Verbal Threat Made to RPT
. On February 3,1994, an MKF Superintendent, Danny Hicks, was issued his fourth ROR by an RPT. The RPT had told Hicks to exit the area of the rotating work platform cn'the refueling floor (RFF), Level 11, after repeatedly telling Hicks to stop touching his 26 1
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[ face, because such touching was a violation of safety rules while in a radiologically
- protected area. After leaming about the ROR the next day, Hicks, according to the RPT, threatened him.
i ~ PSC learned of the verbal threat on February 8,1994, and asked Westinghouse i
Team management to investigate the incident and report back to PSC with details and a correchve action km to address the situation and remedy any possible " chilling" ,
. i effect. in late February 1994, MKF management transfercad Hicks away from the FSV
- ~s ite. ' .
I On February 9,1994, the NRC Region IV investigator retumed to FSV and continued his investigation. Some RPTs advised PSC that they wished to speak with the NRC~ investigator, and arrangements were made for two of them to do so On February 14,1994, the NRC investigator advised PSC that based on the interviews with E
the RPTs, the NRC felt it had to conduct more in depth interviews that would focus on ;
l SEG personnel.'2 1
In late February, as indicated earlier, our firm was retained to determine whether l 4
cn atmosphere of intimidation and harassment existed at the site.
C. Ide,aircstion of Possible Falsification of Radiation Survev Records l
On March 17,1994, shortly after the beginning of our investigation, we leamed i that radiabon survey records related to the radiation protection program may have been j falsified.'8 PSC was immediately advised of this preliminary information, and, in turn, notified of5cers of Westinghouse, MKF and SEG. SEG, whose employees were implicated in the possible falsification of survey records, hired a consultant who was a
, 27 l
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,- No.5 i
[ , former NRC supervisor / inspector, to perform a preliminary assessment of the records-
,f'
- management area. During the week of March 21,1994, the consultant reviewed records - l I
rdlating to the' release of materials from the site for unrestricted use, as well as survey
{ forms relating to radiation work permit activity within the reactor building." j i On March 24,1994, SEG's consultant reported the preliminary results of the
! cssessment. The consultant concluded there had been a failure to follow procedures - .
l cnd apparent falsification of records with intent to mislead."
~
- ln response, the Westinghouse Team ceased all work in the radiological control
- crcas (RCAs) beginning March 25,1994, including stopping the release of materials from the RCAs." On the same date, PSC and the Westinghouse Team met to assess the
. situation. Based on available information, they concluded as a preliminary matter that
-pub!ic and worker safety were not jeopardized as a result of the alleged document irregularities. PSC also endorsed the Westinghouse Team's decision to stop work and provided it with a verbal outline of requirements that would have to be met prior to A
restait. On that same date, PSC and the Westinghouse Team telephoned NRC Region IV and briefed the NRC on their preliminary findings, conclusions regarding the safety 1-significance, and the decision to stop work." As for the safety implications arising from the possible falsification of release survey forms related to materials from Level 1 of the )
l R: actor Building, review of the Level 1. logbook, combined with an awareness of PSC )
oversight activities in that area, resulted in PSC's concluding that although there had been procedural violations, no' material was inappropriately released from the site.
'Concoming the suspected irregularities in the RWP survey forms during the early part I
!r 28 i
. I i
, - . . .- _ . . - - - i
No.5 t
cf 1993, .a review of' radiation protection- monitoring records, including 1
thermoluminescence dosimeters' -(TLD's)' and digidose . records, ' disclosed no i
cverexposures of personnel, no reported unusual contamination events, and no i contamination uptakes. PSC therefore concluded, preliminanly, that although there had
-been procedural violations, public and worker health and safety were not affected in. j connechon with the possible falsification of RWP survey forms."
The following Monday, March 28,1994, PSC issued a confirmatory stop work! !
order which required a number of schons to be completed by the Westinghouse Team prior to resuming work. These included retraining personnel on procedural and -!
regulatory requirements, completing an overall technical assessment of the radiation. ,
~
protection program, developing an action plan for assessing 'and documenting the release of material for unrestricted use, and providing PSC with an assessment of any ;
safety implications associated with the findings of failure to follow procedures and I falsification of records.si ( PSC also notified the NRC in writing of the apparent f Isification of radiation survey documentation.s2 ) {
l i !
)
l i
l 29
~.
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No.5 ENDNOTES r
l
- 1. DN 803-52 at 806.'
i
- 2. DN 803-52 at 808-09,817.
- 3. Egg DN 803-52 at 810-39.- j i
- 4. DN 803-52 at 815-17. i
'5. DN 803-52 at'816! DN 2117-291. Agreement among PSC and Westinghouse and !
MKF, 4/1/91. l l
- 6. DN 803-52 at 817,819.'
);
7.' DN 803-52 at 817; Swom Interview' Statement of Lester C. Hutchins, May 16, )
1994, pp. 49-50 [ hereinafter cited as "Hutchins (5/16/94)"). j
- 8. DN 3-15 at 12-13; Sworn Interview Statement of J. Edward Parsons,~ May 11, 1994, p. '16 [ hereinafter cited as."E. Parsons (5/11/94)"]; Unswom Interview q Statement of Roland E. Sawyer, Jr., Mar. 29,1994, pp.12-13 [ hereinafter cited j
as " Sawyer (3/29/94) (Unswom)"]; Unswom intennow Statement of Kenneth L. i Zahrt Mar. 28,1994, pp. 26-27 [ hereinafter cited as "Zahrt (3/28/94) (Unswom)"J. l
- 9. DN 803-52 at 817.
' 10. DN 803-52 at 822; Swom Interview Statement of Donald W. Warembourg, May 12,1994, p. 6 [ hereinafter cited as "Warembourg (5/12/94)").
- 11. DN 82-72 at 62-64; Warembourg (5/12/94), p. 75; DN 73-76 at 73. The NRC's i
' intimidation and harassment inquiry was preceded by a December 1993 inquiry into the " occupational work environment" at FSV, DN 113-45.
, .12. DN 82-72 at 63; DN 73-78; ama ROR 94-003, DN 55-61; Swom Interview l
Statement of Rick Neely, Apr. 5,1994, pp. 21-23 [ hereinafter cited as "Neely (4/5/94)"). l l
- 13. DN 82-72 at 63-68. r
- 14. DN 82-72 at 67. -
- 15. DN 2292-315 at 2293,2300-01,2313-15.
{
l 30
i No.'5 - !
- 35. DN 113-14.
- 36. .DN 73-74 at 73. ;
i
- 37,-
DN 74 at 73; ROR 94-003, DN 54-61. )
138.- Neely (4/5/94), pp. 21-23.
, 39.0 : DN 73-74; att DN 2292-315 at 2295; Warembourg (5/12/94), pp. 27-38. !
- 40. Swom Interview Statement of William J. Hug,' May 18,1994, p.120 [ hereinafter i cded as " Hug (5/18/94)"]. j
- 41. 1DN 73-74 at 74. I
- 42. DN 73-74 at 74; DN 2292-315 at 2296. .
j
. 43. DN 2292-315 at 2300.
1
- 44. . DN 2292-315 at 2301. ;
- 45. DN 2292-315 at 2307; DN 12405, FSV Decommissioning Project - NRC Region .
IV Meeting,' August 4,1994 (Briefing Document), p. 6.
~
- 46. DN 2292-315 at 2303. Egg Ring DN 12405, FSV Decommissioning Project - NRC Region IV Meeting, August 4,1994 (Briefing Document), p. 6.
~
- 47. DN 12405, FSV Decommissioning Project - NRC Region IV Meeting, August 4, 1994 (Briefing Document), p. 6.
~
- 48. DN 12405, FSV Decommissioning Project - NRC Region IV Meeting, August 4
' 1994 (Briefing Document), p. 6; Warembourg (5/12/94), p. 54.
- 49. . DN 2292-315 at 2302.
. 50.- DN 2292-315 at 2307; DN 12405, FSV Decommissioning Project - NRC Regen !
IV Meeting, August 4,1994 (Briefing Document), p. 7. I
- 51. DN 2292-315 at 2304.
l
. 52. DN 2292-315 at 2293.
} , )
32
]
f a
nx _. . - .
i No.5 l
- 16. DN 272-79 at 274; 33g alag DN 272-79 at 278; Sworn interview Statement of Sam I W. Chesnutt, Apr. 12,1994, p. 24 [ hereinafter cited as "Chesnutt (4/12/94)"]; ,
~
Swom interview Statement of Rick Neely, Apr. 6,1994, p. 52 [ hereinafter cited as "Neely (4/6/94)"].
- 17. DN 272-79; Chesnutt (4/12/94), p. 25. MKF's General Superintendent, Thomas .
l Dieter, recalled that at the time the FHM was located over the HSF. MKF wanted to use the HSF and he wanted the FHM moved onto the shield adaptor on the equipment wall. Unsworn interview Statement of Thomas J. Dieter, May 17 and .
18,1994, pp. 201-02 [ hereinafter cited as " Dieter (5/17/94) (Unswom)"). Dieter ,
recalled a DSC' individual advising him that PSC had done this in the past. ?
Therefore,Jeter said he took it for granted that it was alright to again do it. Id.
- 18. DN 272-79 at 275.
l
- 19. DN 16-28 at 19.
- 20. DN 272-79 at 276. Sag glag Chesnutt (4/12/94), p. 24.
- 21. DN 16-28 at 16.
- 22. DN 16-28 at 16.
- 23. DN 16-28 at 23.
- 24. DN 16-28 at 23.
- 25. DN 29-33 at 30.
- 26. DN 29-33 at 30-31.
- 27. DN 3-15 at 10.
- 28. DN 3-15 at 11.
1
- 29. DN 3-15 at 11.
- _ _ 30. DN 16-28 at 16.
- 31. DN 16-28 at 24.
- 32. DN 16-28 at 24.
1 j- 33. DN 16-28 at 24, i
- 34. DN 16-28 at 24. !
, 31 l l
l 1
N3. 5 - l V. DISCUSSION 6F ISSUE: WHETHER AN ATMOSPHERE EXISTED IN WHICH 3 f WORKERS WERE RELUCTANT TO RAISE SAFETY CONCERNS l
' At.the beginning of the investigation, we learned that some MKF and SEG
- personnel believed there was a general atmosphere at the FSV site in which workers ;
. i
. were reluctant to express safety concems for fear of jeopardizing their jobs. Additionally, l
)
certain specific events were identified in which workers contended they or others had !
been harassed and intimidated by supervisors because they had raised safety concems.
One was the March 1993 layoff of four MKF laborers, which, as noted, was being investigated b[the NRC to determine whether the' layoffs resulted from the workers' j cxpression of safety concerns. Another series of events centered around the rslationship between MKF supervisory personnel and RPTs employed by SEG; some -l i
RPTs alleged that MKF supervisors acted abusively towards them when they tried to cnforce radiological protection rules.
As the investigation progressed, a pattern emerged: charges that raising safety concems led to intimidation and harassment were closely linked to a perceived ctmosphere in which production and scheduling were emphasized over safety and procedural compliance. For example, the MKF workers who alleged their March 1993 IEyoffs were caused by their having raised safety concems viewed MKF managers and supervisors as driven by production goals and resentful of workers who raised safety concems if that might slow production.' Thus, in addition to investigating the facts and 4
circumstances surrounding specific events, we sought to determine whether any actual or perceived harassment reflected in those events resulted from or evidenced an overall policy or practice that emphasized production over safety.
33 r
-No.5 i 1
During the' investigation,'we sought to determine how widespread were the
't .
. I perceptions:related to intimidation and harassment and the extent to which these j 1
perceptions had a basis in fact. We also inquired into what and when the various layers 1 of supervision and management knew about the perceptions and the events underlying 1
$ them, and how supervisors and managers responded to complaints of intimidation or ~ j
.\
h rassment. Additionally, we tried to determine whether perceived harassing behavior j reflected management or supervisory policies or practices:- and if not, what factors, including supervisory and management actions or inactions, contributed to the perception i i 1
byl some that an atmosphere existed in which production and scheduling. took precedence over safety and procedural compliance, and in which raising safety concerns could lead to retaliation.
As will be discussed more fully below, the evidence showed: ,
i
. A perception existed among a cross section of both MKF and SEG employees that an atmosphere of intimidation and I
harassment prevailed at FSV. Especially among MKF
' workers, this atmosphere reinforced the existing belief of L many persons that expressing safety concems could i endanger one's job.
n ,
The perception of intimidation and harassment and the concomitant reluctance to express safety concems reflected ;
- attitudes rooted in the culture of the construction industry, and were not caused solely by events or conditions unique to i
!. the FSV decommissioning project.
L Certain events and conditions that did occur during the J decommissioning project contributed to the perception of L intimidation and harassment and reinforced . the general reluctance many workers already felt about expressing safety concems. These included the March'1993 layoffs of four i
. MKF laborers and behavior by an MKF superintendent toward ,
, RPTs that was perceived as threatening. :
I y.
l !
u _
1 L
No.'5 l l
I l
'~
-. . While the official policies of PSC, Westinghouse, MKF, and j j SEG did not sanction intimidation and harassment of employees and gave appropriate emphasis to safety considerations, patterns of conduct among mid-level SEG )
' and MKF supervisors / superintendents tended to undermine i the official policies by creating the appearance that their }
respective managements were more interested in moving the l project along than in seeing that it was performed properly. ]
q
- In some cases, most notably the March 1993 layoff of four MKF laborers, the evidence disclosed a rational basis-l underlying the perception of some workers that expressing ]
safety concerns led to layoffs or other intimidation and ;
. harassment.
NIKF and SEG upper managers were not aware of key i percophons among their workers or the actions of some of j their supervisors / superintendents that helped shape those :
perceptions, j
- Some MKF and SEG policies that on their face did not favor production over safety were administered in a way that fueled that perception.
-The subsections below begin with a discussion of the standards we used to evaluate the intimidation and harassment issues. Next is a description of MKF and SEG workers' perceptions relating to intimidation and harassment. This is followed by detailed discussions of the most significant events contributing to those perceptions.
A. ADDicable Standards Standards for evaluating the perception that expressing safety concems could jeopardize one's job can be found in MKF's own corporate policies as well as in federal standards applicable to the decommissioning project. In discussing these standards, we da not suggest that a legally cognizable violation occurred with respect to any of the incidents under review. We refer to. legal and regulatory standards to illustrate the 35
.j g neral parameters 1within which the conduct at issue must be evaluat$d. and not to -f I
[ ccstablish that any specific law was violated. !
- 1. MKF Policies
- - Although MKF_ does not have a forma'l, written policy forbidding harassment of- f i
" persons who express safety concerns, such a policy is implicit in a number of MKF's written standards relating 'to job safety. For example. MKF's general safety and health I i
guidelines encourage employees-to report "all unsafe and unhealthy practices and
- - conditions" to their supervisors at once.2 MKF supervisory personnel assigned to the l
' ~
I FSV decommissioning project confirmed their understanding that it would be against- !
-7
^
company policy to penalize workers for reporting safety concerns.' As one put it: I.
.. t i> .
l would say we have a very strong policy for people to speak up and express their feelings
-- and concerns." The same supervisor added: " Safety is the number one priority with
- our corporation and from the top on down we have strong support."5
- 2. Federal Standards Contentions that expressing safety concerns led to harassment or other adverse consequences - such as the March 1993 layoffs of four MKF workers - can also be cvaluated under the "whistleblower protection" standards applicable to licensees and contractors regulated by the NRC. In the case of the four MKF laborers. the allegation !
l did not arise in the context of a formal complaint or legal proceeding, and we did not
~
seek to determine whether, had there been such a complaint or proceeding, the laborers' contentions would have met all of the jurisdictional and other requirements specified in
' applicable regulations. In analyzing the perception of intimidation and harassment, 4
36 M
y + 'c- >-w , 4 --
^
~
No.5 however.-weLdid draw upon the accumulated body ~of ' standards and precedents cpplicable to the many _"whistleblower" cases that have been litigated in various forums.
. prrticularly those that have occurred in nuclear settings. In particular, we were cognizant : f of the standards used to determine whether employees in facilities licensed by the NRC {
i had _been retaliated against for expressing safety concems; and, more broadly,' the ;
~
standards applicable to licensees and their contractors with respect to maintaining an ' i
' ctmosphere free of 'ntimidation i and harassment for expressing safety concerns.
t
- a. General Standards ]
- 1
~
In 1978 Congress amended the Energy Reorganization Act of 1974 (ERA) to add -
a whistleblower protection provision, Section 210.8 This section was furthar amended i
~
in 1992, and renumbered as Section 211,' Section 211 currently protects' whistleblowers I whose employer (1) is licensed by the NRC, (2) has applied for a license, (3) is a j.
L contractor or subcontractor of an NRC licensee or applicant, or (4) is a contractor or subcontractor of the Department of Energy (DOE) that is indemnified by the DOE under tha Atomic Energy Act (AEA) of 1954.8 Section 211 prohibits employers from discharging or otherwise discriminating "against any employee with respect to his compensation, terms, conditions, or privileges of employment" because the ernployee engaged in certain protected whistleblowing activities.' Discrimination encompasses m:ny forms of adverse action taken by employers, and the remedy provided by Section 211 is not limited to employees who have been fired." Protected activities include
. notifying the employer of an alleged violation of the ERA or the AEA," refusing to f
cngage in any practice made unlawful by either statute, testifying before Congress or
, '37 s.
No.5 ;
'l i
Tcny federal or state proceeding regarding any provision of either statute, commencing . ,
it or. causing to be commenced a proceeding under either statute, testifying in any such. ,
t ,
=!
proceeding, and assisting or participating in any manner in any other action'to carry out
~ the purposes of either statute.'2 l In addition to the specific protection of individual "whistleblowers," wh'o can file . j i
cirims for relief with the Department of Labor (DOL), NRC regulations have addressed
- the general " chilling effect" that can' result from management actions or inactions, and ;
thit can stifle the flow of safety-related information. Under the ERA and'the'NEA, the l
NRC is charged with ensuring that its licensees' operations do not threaten the public ;
f[ herith and welfare. This includes taking action against licensee practices which do not - j
. . riss to the level of Section 211 " retaliation," but which are nevertheless detrimental to a s2f;ty-conscious work environment.
In particular, the NRC'has promoted a policy that "looks unfavorably upon any
. restriction on the free flow of information to the NRC,"" and it has expressed concern ovsr licensee practices which operate to prevent or dissuade employees from raising i -.
. safety issues. This so-called " chilling effect" is a source of concern for the NRC because 4
- of the important role employees play in maintaining a quality-conscious environment and
- because of the possible impact such;a " chilling effect" could have on overall plant sLfety." According to agency rationale, on-site workers are often the best situated to identify safety concerns, and nuclear facilities will be safest where employees feel free to provide timely.' notification to the proper authorities, who in turn can take action to t prevent safety or health accidents.' While employee reluctance to raise safety concerns
' I 1
38 l
d
e .. ;
No.5 !
does not necessarily call into question'the safety of a plant "the persistence of such a
(- '
. condition can erode the quality consciousness of the workplace, and thereby affect. f i
. facility safety."" ' .
- Consistent with this policy, the NRC has taken a variety of actions in cases where licensees were found to have engaged in conduct which can create a " chilling effect." - ,
'One case, for example, in the Matter of Arizona Public Service Company. involved an: . ,
.7 NRC investigation prompted by allegations of a "' hostile work l environment.'"" The :
1
. investigation revpaled that two percent of the employees felt "some reluctance to bring significant safety issues to the attention of their immediate supervisors."" Six percent .
f;lt free to bring significant safety concerns to their immediate supervisor,' but felt "some reluctance to raise the issues higher."" The NRC was concemed with ar)y perception
' thrt an employee might suffer discrimination for raising safety concems and it asked the licensee to " advise (the NRC).of the steps being taken to resolve this perception problem.""
There are indications that the NRC may, in the future, pursue a stricter policy to correct the so-called " chilling effect." The NRC recently appointed a review team to
~
ev luate NRC programs for protecting employees who raise safety concems from retaliation and to determine if the NRC has taken " sufficient steps within its authority to create an atmosphere within the regulated community where individuals with safety concems feel free to engage in protected activity without fear of retaliation."2" The review team found that 'the existing NRC/ DOL procedures for Section 211 violations are themselves insufficent to create an environment in which workers feel free to voice their -
h
- 39 :
l
..-e- 4 -y-.. er- w .v ,,w 6 *,, .% -- -. .w... . .- , . se = , - -m- 1 w r , , w -.
mw. v v
l No.5 -l u
' safety concerns.; The review team stated that these proceedings should not be viewed
[ as the exclusive avenue by which the NRC ensures the safety of its _ licensees' facilities.2i c in particular. DOL proceedings often involve expsnsive and time consuming litigation,
- and force employees to " accept the full risk involved in raising a concern."22 i The review team advised the NRC to tak's action that "would more. visibly )
Emphasize the rosponsibility of licensees to maintain a retaliation-free workplace."2s One such action would be to issue a statement.of policy that " clearly states [the NRC's] !
. l l cxpectations regarding the proactive approach licensees and their contractors should l
l t"ke in ensuring that all employees are free (and feel free) to raise concerns both ro their -
mrnagement and to the NRC without fear of retaliation."2' Another suggestion offered by the. review team is to " develop a survey instrument to independently and credibly assess a licensee's environment for raising concerns."25 The comments of the review team reflect an essential difference between the roles of the NRC and DOL in investigating claims that employees have been subjected to intimidation and harassment for expressing safety concerns. As the statutory scheme desenbed above makes clear, DOL investigations are triggered by complaints filed by individuals seeking compensation for alleged wrongs done to them as a result of 4
, L whistleblowing activityi In essence, DOL proceedings are dispute resolution l mechanisms, and if the dispute is' settled - such as by a cash payment to the employee l
- the DOL does not continue to probe for undertying causes. The NRC, in contrast, which is not empowered to award monetary relief to individual claimants, is interested in whistleblower _ harassment aslegations for the different reason described above -
40 w , , .I ~ i . _ , !,,_-- _,m . - - .. ._.- - - ,
M
. No.5) because an atmosphere in which such harassment is tolerated can discourage workers 'l
.4 f' .
from expressing safety concems, thereby shutting off one Avenue by which unsafe 'i conditions can be recognized and corrected. !
l 1
Although we were cognizant of standards used by both the DOL and NRC. our l l
. pnmary focus, like the NRC's, was on the overall atmosphere that prevailed at the site l l
with respect to the expression of safety concerns, rather than on individual claims or j I
j grievances. . Nevertheless,' we examined the factual background of some individual allegations to understand the basis underlying' certain perceptions shared by segments l of the workforce. !
b .- Allocation of Burden of Proof j p Under Section 211, a whistleblower employee is required to make a prima facie !
showing that the protected activity was a " contributing factor" in the adverse personnel l i
~ action. Absent such a showing, the Secretary of Labor is prohibited from pursuing an ;
i l- investigation? Once the whistleblower has made this initial showing, the burden shifts l
.- l l 13 the empioyer to show it had a lawful motive. Under the current ERA language, if the j employer is able to demonstrate by " clear and convincing evidence" that it would have i t
taken the same action in the absence of the employee's protected behavior, the Secretary is directed by the statute to dismiss the complaint without investigating the whistleblower's allegations. If the employer is unable to meet this threshold burden, the Secretary is required by the statute to investigate.2' If the Secretary finds, after 1
- . conducting such an investigation, that ine employer has demonstrated by " clear and convincing" evidence that it would have taken the same unfavorable personnel action in 41 r
m y pg g
.g a - ,e6--
- w. n - - , . -... ~ , -m.-.. -me, ,e +_-, -~4-- - - - _ _ _ - - - - - - - - - - - - - - - - - - - - -
. No.5 i
^
thiabse'nce of the employee's protected behavior, the Secretary "may not" order relief .
f:r the whistleblower employee. .
Thus an employee who engages in protected activity can still be fired or ]
i
~ disciplined so long as the reason for doing so is independent of the whistleblowing. The {
I NRC regulations which implement Section 211 explicitly state that employers may still take adverse actions against their whistleblower employees, so long as those actions are predicated upon' nondiscriminatory grounds. For example, an employer may still ]
terminate its employee for insubordination, despite the employee's protected activities.22 Whether an employee was actually discriminated against is determined by the f7 cts of each case. Courts will examine the surrounding circumstances to determine if cctions taken against an employee were discriminatory in their context. In many cases, courts have found that the reasons given by employers to explain actions taken against employees are insufficient. For example, in Mackowiak v. University Nuclear Systems.
101, the court noted that,.while there might be substantial evidence that an employee "cr:ated friction" in the workplace, as the employer contended, this friction might have grown out of the employee's persistence in following NRC procedures, in which case it i
, cannot serve as a legitimate justification for firing an employee."
The language added to the ERA in 1992 adopted the test for dual-motive
[ discharge cases developed in NLRB v. Wriaht Line This test was adopted from the
- . courts' decision in Mt. Healthy City School District Board of Education v. Dovie, where the court stated that once the employee meets his initial burden the employer must then satisfy a but-for test showing it would have reached the same decision despite the 1
42
- . _ , - . . - - .. . - - . . . - - - . . - - .. _ .- ..~ .-. - - ..-. .
4
. No, 5
+
, employee's having engaged in protected conduct.as According to the Mackowiak court.
- 1 it is'only.'faif' that the employer bear the risk that "the influence of illegal and legal- ')
motives cannot be separated." In these cases,'once an employee was able to show?
i tttt the protected conduct played a role or was a motivating factor in the employer's j p ;
i decision, there was a presumption against the' employer of illegal motivation and the
)
. i burden shifted to the employer to persuade the court that it would have discharged the i employee, absent the protected activity. This standard appears to mirror the language j- added to the ERA in 1992, placing the burden on the employer to demonstrate an l independent basis for its adverse employment decision. ]
( For example, in Consolidated Edison v Donovan, an employee was allegedly i dismissed for threatening to kill his supervisor, rather than for the numerous complaints l i -
he had made about safety at a utility's nuclear power plant, or for the criticisms he had l
.i cxpressed about his supervisors' attitudes towards safety. The facts surrounding his j L t l : thr st were in sharp dispute, but they made it clear there were dual motives involved. i
- . j j' Specifically, the court found the employer's investigation into the incident was grossly !
inadequate and that the supervisor had not actually believed that the threat would be
! carried out. The court held that the utility had failed to justify the sanction of dismissal, l I
cnd had thus failed to prove that the employee's dismissal was due solely to his having l 1
threatened his supervisor. !
I i*
Similarly, in DeFord v. Secretary of Labgr, the court accepted the Secretary of r I
i Labor's finding that DeFord's transfer was a deliberate retaliation for his cooperation with o
. ')
N
_- 43 !
n .
d No.-5 l f
i
^
the NRC and his attempts to get his quality assurance engineering section recognized i t
l ! by the management:'" ' -l
[ There was evidence that TVA [the employer] did not follow its
- normal procedure in transferring DeFord, but rather that it j
- unceremoniously dumped him from the quality assurance. !
j section; shortly after the NRC investigation. There was -j
! evidence that DeFord had received superior performance j i ratings prior to the NRC investigation, although TVA claimed i in defense of the transfer that he had performed badly in his l l
job. c There was evidence that DeFord worked well with his' ,
4 immediate supervisors and had not developed personality ;
- conflicts that would interfere with effective performance of his job ,. . . 'Quite simply, there was substantial evidence to 1 support the Secretary's conclusion that DeFord was j terminated solely because he participated in an NRC .I proceeding. j
By contrast, in Dunham v. Brock the court found that insubordination was the b g:nuine impetus for the discharge of a quality assurance inspector, rather than a pretext for punishing the employee for filing complaints with the NRC and his quality assurance i
. manager. The court determined that " substantial evidence" exists that the employee would have been legitimately discharged, notwithstanding his participation in protected
! cctivity. Dunham's obscene language, frequent expressions of lack of confidence, dhruptive and counter-productive demeanor, cavalier attitude and repeated cncouragement that the personnel head "'might as well walk him to the gate,'" supported the inference of insubordination sufficient to justify his termination."
e
~
ln evaluating the perception of intimidation and harr.sment at FSV, particularly cs it relates to the four laborers' contention that they were laid off because they had cxpressed safety concerns, we were guided by the standards used in DOL proceedings, 44
No.5 !
- l i
as' outlined above, which require a prima facie showing b'y those' making the allegation i that' the' personnel action was caused, in whole or in part, by the expression of safety t
concems; and, if such a demonstration is made, a " clear and convincing" showing by the ~ .j rcsponsible managers that the adverse personnel action was entirely independent of the worker's expression of safety concems. Similarlsj, drawing upon the NRC standards- :
dtcussed above, we sought to determine whether the layoffs or other factors contributed l to 'an overall atmosphere of intimidation and harassment in which a " chilling effect" could l stifle the expression of safety concerns.
l
- 3. SEG Standards: Radioloaical Occurrence Reports t
Some intimidation and harassment issues are related directly or indirectly to the j cfforts of RPTs employed by SEG to enforce radiological protection rules in the face of f perceived resistance _ by'MKF supervisors. For example, as discussed in detail later, !
RPTs complained of abusive behavior directed toward them by MKF supervisors after {
th;y tried to enforce safety rules. They felt the ROR program had been rendered j ineffective by lack of enforcement; while, conversely, some MKF supervisors felt the RPTs had abused their authority to write RORs.
To facilitate an understanding of these respective contentions, the standards j rclating to the ROR program are desenbod below,
- s. Decommissionina Plan ]
+ The FSV Decommissioning Plan establishes a reporting program for identifying ;
radio _ logical occurrences and correcting errors that cause radiological performance l
45
m._.______ _ _ _ . _ . . . _ _ ,_
j No.5 1 i
!- j problems." The' details'of this reporting system are left to the radiation protection staff, ' .
j
. but the basic vehicle for reporting radiological occurrences is an ROR'.-
i Radiological occurrences are classified, depending upon their severity, as either j j
a r'adiological " incident" or a radiological " deficiency." Radiological deficiencies are generally defined as " occurrences involving poor _ radiological work practices with relatively minor consequences." . Deficiencies include poor radiological work practices, frilure to comply with RWP requirements, and failure to comply with radiation protection procedures. . .
Each time a radiological deficiency is identified, radiation protection staff is- .
dir cted to evaluate the occurrence "for possible deficiencies in areas such as training, procedures, equipment and human performance," When a " deficiency" ROR is issued, radiation protection managers are required to foibw-up with appropriate supervisory and corrective action."
Radiological incidents are generally defined as occurrences that have violated, or could have the potential for violating, federal regulations and FSV Decommissioning Technical Specifications or that involve a serious breakdown in the effectiveness of the rtdiation protection program." incidents include radiation exposures exceeding federal limits, significant spills or spread of radioactive material, failure to follow instruction and
' stop work" orders, and flagrant violation of radiation protection procedures.s2 When a radiological incident is identified, the PSC radiation protection manager or project radiation protection manager is directed to assign a team to investigate and crMique the incident.58 Appropriate corrective action is " required to prevent recurrence.""
46
1
' No. 5 ! '
Completed reports and investigations are " reviewed.by the ALARA committee". and the )
]*
. Decommissioning Safety Review Committee, as appropnate, depending on the type of ;
i
' occurrence and the severity." .
i
- b. PSC Procedures 1
' PSC procedures which were in effect~ until ;early December 1992, include - !
l I
reporting requirements as part of its " assessment and reporting" procedure, found at' ;
Sr4 en 4.6 of the Radiation Protection Plan. The stated purpose of this assessment and . l' i
reporting procedure is "[t]o ensure that the Radiation Protection Plan is being effectively l implemented."" -
Violations of plan procedure are recorded in Health Physics irregularity Reports
}
(HPlRs).' These are the PSC equivalents of RORs. They are used for corrective action, j i
trsnding, and tracking: q
, '[HPIRs are an] instrument initiated through the Health !
Physics Department which identifies, documents, classifies, l
. reports, evaluates, and applies corrective actions to all events l
. . . which have a radiological impact or potential radiological ;
impact." l
\
The reporting procedure is supervised by radiation protection managers." j i
Radiation protection managers are charged under the Radiation Protection Plan with ]
implementing the FSV radiation protection policy." In addition, they are charged with monitoring and enforcing health physics procedures which are carried out by a team of health physics specialists, supervisors and technicians.'C Violations of health physics l
)
~ procedures are recorded by HPIRs.
. 8
.i i
47 r
i^.
'l
- No; 5 - !
q 1
. Each time an HPIR is issued, it is reviewed by1" appropriate individuals."
.( '
Pfeiiminary review is done by;a health physics supervisor who initiates any immediate l
- {
corrective action taken." Radiation protection managers supply additional supervision.- .!
l to insure that HPIRs' are evaluated, classified, and . reported in accordance with j procedure." An AI. ARA. coordinator is responsible for coordinating this evaluation process, determining if the disposition is adequate, meeting with 2e radiation protection manager if necessary to determine final resolution, and tracking, trending, and reporting the results to the plant Al. ARA Committee." ;
)
'Once final review of the HPIR is complete, the HPIR is made part of the quality i i
record. The ALARA coordinator is then responsible for." tracking and trend analysis" )
cnd is directed by PSC procedure to prepare a report " describing the number, type and status of HPIRs generated quarterly."" These reports are distributed to plant l
supervisors." '
- c. SEG Procedures SEG procedures include reporting requirements as a part of its "self-assessment program." The stated purpose of this program is to " appraise a program's effectiveness cnd personnel performance when measured against accepted practices . . . industry
, standards and regulatory requirements."'"
RORs are used to record, track, and trend radiological programs, events that ;
^ could result in NRC enforcement action, or events that involve a sonous breakdown in lthe radiation protection program." They are described as " tools to identify adverse trends and program weaknesses,"72 and are used to ensure that corrective actions are 48 .
- p. t , -. -- _... y _ .. _ _.._ .
v., -- . . - . ... - .. - - -. . ,. . .- . . - . . - . - . . .
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'sierformed, to provide. a mechanism for tracking corrective actions,- and to inform- j
- p
- ,
- J management of radiological occurrences." ~ ;
. A tracking system for RORs and corrective action is required by the:SEG self- -
. assessment program, Section 5.4.2. This system directs RORs to be " trended and
. 1
' reviewed monthly to integrate lessons learr,ed into the Radiation Protection Program."" j lt tiso charges the technical support supervisor to track the implementation of corrective - ;
actions." ;
i The self assessment program explicitly states that extensive corrective action is ,
not required for all RORs. Section 5.4.1 states that corrective actions for deficiency i
. RORs "are usually performed on the spot and generally do not requi re further act ion.
- Similarly, for deficiency RORs, " root causes are usually evident and further investigation e
cnd/or evaluation is not. required."" More extensive management involvernent is, L howver, needed for incident ROR's. SEG procedure describes incident RORs as
[ " requiring" management action, formal investigation and root cause evaluations.' l B. Percentions~of MKF and SEG Workers i t
[ Although the management of PSC, Westinghouse, MKF, and SEG did not have ;
policies that emphasized production over safety, a cross section of the workforce !
4- i perceived that production and scheduling considerations had a greater priority than l l concem for safety and procedural compliance. As discussed in the following ;
subsections, this broad perception, in some cases, had the effect of inhibiting workers from raising safety concems. Additionally, as discussed in detail below, certain events -
i i
49 i
, j.
f
1 No.5- i i
' l
- f
~
. and conditions that occurred during the decommissioning project contributed in various
~
i*
ways to the workers' perceptions.
At the outset it should be recognized that there is an inherent tension b'stween the ;
t
/ . goals of safety and' procedural compliance on the one hand, and. scheduling and 1'
production on the other. Complying' with safety- rules and procedural requirements, 1 p;rticularly the often detailed rules applicable to a nuclear environment,'can easily be l
-perceived as slowing down production. This perception is not necessarily inaccurate. !
! l According to MK,F managers and supervisors, for example, waiting for RPTs and safety i
$ . representatives to conduct frisks and other safety checks before commencing work had :
En effect on the speed with which certain operations could be completed." It follows :
thtt a worker who insists that a job be stopped or delayed because of a safety concern l L .
mry perceive - ofto.1 accurately - that his action will slow production. If the worker also !
r >
. ' perceives that his supervisors and managers view production as more important than p
- l. safety, he'may feel inhibited from raising the safety concem for fear of displeasing his
{
supervisors and thereby jeopardizing his' job. !
Most managers, supervisors, and workers involved in the project appeared to L..
F understand and accept the need to subordir. ate production goals to safety and procedural requirements. . The evidence did not support a conclusion, for example, that :
managers and-supervisors were generally unmindful of safety or that they did not
- attempt to accommodate themselves to the nuclear regulatory environment. In specific t situations, however, the inherent pressures toward completing the project in a timely and i
economical. manner clashed with safety and procedural considerations and produced 4
50-o ,
.. . . . _ . - . . . _ . _ _ _ _ - _ _ . __ - . . . - ~ . - . . -
s Noi5 what some workers regarded as unacceptable behavior by' supervisory personnel that
. potentially compromised ' safety.or discouraged workers from raising safety. concerns- .
In evaluating the workers' perceptions an'd the bases for them, we recognized that both-production and safety are legitimate goals and the issue often involved whether,lin a ' .
l j
particular case, the production goal unreasonably interfered with applicable standards, {
i
' including those discussed above relating to the avoidance of a " chilling effect" on the .
cxpression of safety concems. .f;
- The perceptions of the MKF and SEG workforces are summarized below l
- 1. MKF Craft Workers j
' At least 25 witnesses described a widespread perception among MKF craft i
\
, i workers that expressing safety concems might jeopardize their jobs.'" Some MKF j i
workers said this perception had already, or might in the future, rnake them reluctant to. l t
express safety concerns," while others stated they personally would raise safety
~
I concems if they had them, but had heard others express reluctance to do so.82 The
! perception that expressing concerns might lead to adverse consequences resulted, in
, i p;rt, from conditions unrelated to the decommissioning project, such as the attitudes and )
r .
q cxpectations many employers had developed from their previous experience in the :
l I
construction industry. Numerous workers described a culture in that industry in which i.
it b generally accepted that expressing safety concems or developing a reputation as someone 'who questions the actions of supervisors or who slows production can -)
I
' endanger one's job security. As one worker put it, "if there's going to be a layoM and ]
l
. I 1
1 , ')
)
51 >
l
. , _ _ _ _a
No.5
' if you are a bitcher or griper . . . you can bet the first layoff, you're going to be on it . .
J' That's the way construction works.""-
A significant cross-section of workers, however, stated that actions and conditions unique to the decom'missioning project contributed to a reluctance to express safety concerns, or to the perception that doing so could lead to adverse consequences. By f r the most important incident contributing to this perception was the March 1993 layoff of four laborers, at least three of whom contended that the layoffs were in retaliation for their expression of safety concerns while they were MKF employees. (This incident is discussed in detail below.) A high proportion of the MKF workers imeviewed, and a few lower level supervisors had heard, long before the NRC investigation started, the i
tilegation that the layoffs were in some way related to the workers' expression of concerns, and a substantial number of those persons tended to agree with the tilegation." In contrast, the higher level MKF supervisors, superintendents, and 1 l
managers who were interviewed stated they had not even heard the allegation, or that l l
they heard about it only after the commencement of the NRC inquiry in late 1993." The implications of these contrasting perceptions will be discussed later.
1 Although uneasiness about expressing safety concerns appears to have been )
rClatively widespread among the MKF workforce, this did not translate into an overall J
perception that the job was unsafe or that important safety concerns were not being addressed. Some who said they would be reluctant to raise safety concerns were speaking hypothetically - they did not actually have any concerns they were withholding cut of fear for their jobs." Others stated that, despite the perception that it might be 52 m
s No.5 :
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g
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risky, they had or would express safety concerns." One witness felt that serious safety' l
.(
P concoms.would. be. expressed,i although marginal ones might not be." Another j i
h desenbod attemative means of having concerns addressed, without identifying oneself !
F ,
cs the one who brought the concem forward." !
1 ' We did'not interview all members of the current MKF workforce,~ and only a [
j- relatively'small number of former MKF employees. It is, therefore, possible that the ,
. proporton .of workers who, to one; extent or another, expressed support for the .;
, proposition that, being outspoken about safety concerns could lead to adverse
[ consequences is not an exact reflection of the views of all of the employues who work
!, or have worked for MKF on the decommissioning project. We did, however, attempt to obtain information from personnel representing the full spectrum of opinions conceming l l
4' the issues under investigation. Some witnesses were interviewed because we had l rc: son to believe they had specific complaints or information concerning. issues of l i
l i intimidaten and harassment, but others were interviewed for the opposite reason - they j l
. . were expected to convey the views of MKF management or testify that there were no safety or intimidation concerns - while still other witnesses were selected at random.
~
Thus, we had no reason to expect that the testimony of the current and former
- employees who were not interviewed would show pattoms that differed greatly from the
- test ~ mony of those who were interviewed. For. example, some persons not interviewed, j* ;such as one of the four laborers who was laid off on March 9,1993, and others who
! -- were laid off or who were reported to have been disgruntied, would likely support the view that it was unsafe to express safety concems; similarly, there was reason to believe 53 i____________ ----- -, m. - ,, , s a ,,,, i _ , , ,
~
. - No.5 l i
j
,' that others would not support that view, but we had no reason to believe that the -
.g.
- fproportion of those sup' porting and. opposing. it-would differ.. greatly from what we observed from the interviews. If anything, the estimate of those supporting the " unsafe.
l to complain". view may have been understated because of the possible reticence of -
I 1
certain workert to say anything that might irritate their managers." l l 'Similarly, in evaluating the testimony of those who supported the perception that ,
4
- the March 19,1993 layoffs were related to expressing safety concems, we considered .
l- the possible bias of some witnesses, particularly those who, like the four laborers whose {
' layoffs are at issue, left MKF's employment under less than amicable circumstances.
i.
i' i For example,'several who supported the allegations had.been laid off on other dates, +
I 4 wh'ile others had unrelated complaints against MKF management. On the other hand. ;
the testimony of the MKF managers'and supervisors who denied any connection
- between the layoffs and safety concerns was subject to equally obvious potential bias.
.l l
.in short, the issue of bias alone did not shift the weight of the evidence either to support i 4 ;
or refute.the allegation. Thus, we looked to other factors, such as the extent to which
- the' testimony of those favoring or opposing the allegation was consistent with other ;
- kinds of evidence, as well as plausible under all of the surrounding circumstances. !
- 2. SEG Workers
!l The perceptions of a number of RPTs dovetailed with the perceptions of MKF !
.- workers in reflecting the view that production and scheduling were emphasized over l l ._
- safety and procedural compliance. As described in detail later, some RPTs complained 1
- of intimidating conduct at the hands of MKF supervisors, in two instances rising to the 1 i
1- l t '!
N j 5
h 7 1* ge+ s -
y-v $r qu.-
i No.5 i level of perceived threats of bodily harm made by an MKF supervisor to an RPT. In both
-( '
- of these instances, the-RPTs' felt their own management was ' derelict in failing to l
- f rcefully redress what they perceived as intimidating behavior. Although the RPTs did j
~
n:t feel that the intimidating behavior by MKF supervisors'had impeded them from .
.l
. carrying out their duties to protect worker and public health and safety, there was a
~
g:neral perception among the RPTs that their management did not adequately support :
them in their attempts to enforce radiological protection rules. For example, after certain j e . .
conflicts' between RPTs and MKF supervisors on the RFF, the RPTs involved were ;
i' .
rotated from the RFF to what were generally regarded as less desirable assignments !
', elsewhere in the plant. .Some RPTs viewed these reassignments as punishment for l h ving challenged an MKF supervisor. :
Another factor contributing to the general perception among RPTs that their
- m
- nagement did not adequately support them was a perceived ineffectiveness of the ,
ROR program. The focus of the RPTs' criticism of this program was former MKF ;
Superintendent Danny Hicks. As described in more detail later, a high proportion of the i
RPTs who had daily contact with Hicks viewed his conduct as flagrant, willful, and '
[ r petdve. His attitude and behavior were constant sources of friction with the RPTs. 1 Their unfavorable view of Hicks was shared by SEG supervisors and PSC oversight personnel, as well as by a significant number of MKF workers. In the RPTs' view,
!- however, SEG management had failed to press for strong corrective action in connection with four ROR: written against Hicks. (These RORs are discussed in detail later in this section of the report). This tended to undermine the confidence of the RPTs in both the n
l' 55
. No.5' j i:
f program and their own management. Further undermining the RPTs' confidence was ,
I the RPTs' view that the SEG RPOS, Kenneth Zahrt, and Hicks were social friends, and :
. ?
- that Zahrt had personal knowledge of a deliberate violation' of radiation work practices- l by Hicks and had failed to act on this knowledge." One result was an attitude that it l 1
l was' pointless to issue an ROR because meaningful corrective action would not be
- taken." ' I
- . Like the perceptions of the MKF workers, RPT perceptions were influenced both >
c byj their prior; experience and by the events that had occurred during the f
. decommissioning project. However, the prior experiences of the MKF workers and RPTs .
l i
) were quite different. In contrast to many MKF workers' previous experience in the !
- i
! construction industry, which had conditioned them to. expect an atmosphere of e
intimidation and resistance to the expression of safety concerns, most RPTs had worked ;
ct operating nuclear plants.where theyl felt issues relating to radiological safety were t ken more seriously and their authority questioned far less often than had been the j r '
case at FSV." The result was a " clash of cultures" that brought RPTs.and MKF j supervisors into relatively frequent conflict, with the MKF workers and SEG supervisors i cften finding themselves in the middle."
I
.C. Effects of Certain Conditions and Events on Workers' Percentions L This subsection analyzes the effect of certain events and conditions on the worker j 1
. perceptions desenbod above. The discrete events we have chosen for discussion are
- those,-such as the March 1993 layoff of four MKF laborers, which appear to have
- significantly influenced worker perceptions related to intimidation and harassment
- or j l
l 56 i l
4 y y + m-- -n .m--- - - = > - -
t No.5 ,
which illustrate the basis underlying _a perceived condition, such as the intimidating style
,f of certain MKF supervisors.
~
- 1. March 1993 Lavoffs of Four MKF Workers l On March 9,1993 four laborers, Gregory Price, Christopher Gonzales, Craig Clifton, and Mark Lujan, were laid off in what MKF management characterized as a ,
reduction in force." The four laborers had been working the day. shift on a crew i supervised by Gary Mueller. ' He reported to the laborer General Foreman Marion Herrera. who rep.orted to General Superintendent Thomas Dieter." (Herrera also was subject to the supervision of Assistant Superintendents Hicks and Dennis Robin.)" All four laborers had originally come to the FSV project as employees of a subcontractor hir;d to do asbestos abatement work. Upon the completion of the asbestos project, ;
MKF hired a number of the asbestos workers to supplement the MKF labor force, and
) th3 four who were laid off in March 1993 were hired in this manner.'" They were not all hired at the same time; Lujan and Price were hired in August 1992, while the other -
two were hired by MKF in late October 1992.'"'
As noted earlier, part of the NRC's investigation centered around whether 'hese four laborers were laid off because they had expressed safety concerns to MKF 1 l
m:nagement. We sought to determine whether the layoffs themselves or the
- circumstances surrounding them contributed to an atmosphere in which workers felt i
. a reluctant to expiess safety concems, or, more broadly, in which production and I scheduling priorities took precedence over safety and procedural compliance.
I l
I 57 )
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_ _ _ . . _ _ _ _ - .. - _ . _ _ - _ __ .. _. . . ~ . _ _ . .._ .
i No.5- :
~
~ a. Descriotion of Alleaation j
( .
i t We were able to locate and interview three of the four laborers who were laid oft ~ (j
- en March 9,1993, Price, Clifton, and C. Gonzales. (We were unable to locate Lujan or - :
Mueller, 'the laborers' foreman.) ' Price, the most experienced of the three laborers we q
interviewed, had worked in construction since 1969.i 2 He testified to having raised a j 1
v:riety of safety concems, both radiological and industrial, after he began to work for- l MKF in the fall of 1992. . One, for example, concemed dust and fumes being generated during a cutting operation, which Price characterized as both a radiological and industrial safety concem.'". Another concem related to fumes generated by welding and torching i- operstbns. These concerns, according to Price, were satisfactorily resolved by MKF .j
.- j i mcnagement.'" '
F Accordir.g to Price, the events leading up to the layoffs began several weeks )
i before March . 9, when, at a weekly Monday moming safety meeting, General ;
- l
. Superintendent Dieter stated that his office was always open and encouraged workers j to bring safety concems directly to him. At the time, Price and the other three were l l working on a core drilling operation that involved using two men on each drill. Wdhin 1
)
[ several days after the safety meeting at which Dieter expressed his "open-door" policy, j Price and tho' other three leamed of a proposed change in procedure to pennit the i 2
drilling operations to continue through lunch with only one man on each drill.'" Price i*
contended that it would be unsafe to have only one man on a drill because if he were ;
iniored there would be no one to help him. Price took his concem to Dieter, relying on J ' . statement earlier in the week that his door was open to workers with safety i 1
58 ;
4
)
+ . , . ,.
No.5 i
(
T concerns. Price was not certain which of the other laborers accompanied him, but ,
-( '
believes that Lujan also went to Dieter's office with him.* While Price was explaining his safety concerns to Dieter, Herrera, his general foreman, interrupted, pulled the men out of Dieter's office, and angrily reprimanded them for going to Dieter." Dieter made no. attempt to intervene; he confirmed seeing Herrera speak to Price, but said this l
occurred as Price was leaving the office and Dieter did not overhear what Herrera t
said.* According to Price, Herrera told them if they had any problems they should take them to him (Herrera) and that if they didn't like it, they could leave.* In response to i
? .
. Herrera's insistence that having one man on a drill was safe during the lunch hour,""
Price reminded him that one of the other four laborers, C. Gonzales, had almost broken hb wrist on the drill and that Price himself had lost an eye as a result of an industrial accident, making him unwilling to compromise on safety issues.'"
According to Price, the proposed "one man on a drill" procedure was never implemented. instead, he and the others worked on the core drilling project using the old procedure of two on a drill."' However, it was after this confrontation, according to Price, that the harassment ultimately leading to the March 9 layoffs began."'
When the core drilling operation ended, the four laborers were given othar assignments. Price was assigned to help C. Gonzales and Clifton remove blocks with jackhammers, which generated dust. This led to what Price characterized as both an industrial and radiological safety concern, in that he and the others wanted respirators to protect them against lead and possible radioactive contamination in the dust."' They eventually got both respirators and a fan to ventilate the area, which satisfied their safety 59
a
. No.5 l 4 j
. . concern: according to Price, however, by raising it they had apparently angered MKF- j k
superintendent Hicks as well as Herrera. They were called into a meeting in which -
1 Herrers and Hicks told them they were troublemakers and that the managers were tired i
~
of hearing their concerns. According to Price, Herrera told the men that ."'if we were so
- )
i worried about safety,' we knew where the door was and we could leave at any time.'""5 i L ' Price also attributed to'Herrers the statement "[wje're having.a layoff come up in a I !
. couple of weeks, and you guys will'be the first to go.""' According to Price, both 'j Herrera and Hicks made it clear they were going to be laid off not because their :
< performance was bad, but because they were " troublemakers" who were stopping j i
production and slowing down the work with their safety concerns."7 Within days after
- this conversation, the four men were, in fact, laid off."' 1 e- Clifton and C. Gonzales supported Price's contention that the layoffs were the
- r:sult of their having expressed safety concems. Clifton stated that he shared Price's I j.
concem about having only one man on the drill during lunch breaks and that when this
- l. concem was raised to Herrera, it sent him "through the roof.""' Clifton also recalled accompanying Price to Dieter's office, where Hicks and Herrera were also present.
l According to Clifton, Herrera pushed them out the door and at one point stated, '"[G]uess
. which four are going to be the first to go.'" Clifton described other angry or belittling
. remarks from MKF superintendents: "[E]very time we had a concem about something,
[ Hicks would) soy we were . . a bunch of sniffling babies."' '
f C. Gonzales also contended that he and the others had been laid off for raising p
concems- about safety hazards, commenting that MKF management "just wonted 4
5 ,
..j 69
-)
. No.5 j production!"i22 C.,Gonzales stated that he did not accompany Clifton and Price to the !
4 1- meeting with Dieter, but he' was present at another meeting with Herrera and Hicks' :
i
- -(apparently the same. meeting described by Price.as having occurred after the core l 4
11
' drilling aM a few days before the layoffs) at which they were told: "'If you don't like it, i 1
' then~ walk r ut the door.'"'2 C.' Gonzales noted-that Clifton and Price raised more l i
concoms than he did, and, accordingly, they received more negative feedback from MKF ;
- , supervisors. Like Price and Clifton, C. Gonzales contended that the workers who were !
!- . laid off were more productive than others who were retained and summarized the reason l l
- . for the layoffs as "tled simple fact that we were cutting down their production and more j
,, concemed about safety."'2s j
- b. MKF Resoonse to Allocation i e- i i i The MKF superintendents / supervisors involved in the layoff decision denied that j
- r L the expression of safety concems had anything to do with it. As discussed below, they !
\
- j. contended that the four were released because the project they had been working on )
l cnded and they were not among the better laborers on the site. j i According to Dieter, the final decision on who to lay off was his, but was based ,
l on the recommendations of Herrera and Hicks as well as his own assessment of who l should be laid off. Dieter recalled that the four laborers' work performance had deteriorated since they were first hired, and that the only one of the four he might have l* considered retaining was Price. However, Price and the other three had completed l 4
1
' work on the core drilling job for which they had been hired. . Thus, the layoff decision
'61 d
r
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No.5 1
i s
~ was' based partly on performance and partly on the lack of.other work for the labore'rs lI
[ .
i after the core drilling ended.tas .j
. Hicks,'likewise,Lattributed the. layoff decision partly to an assessment of the l e :
i .'. workers' performance and partly to the lack of work. He stated that he and Herrera 'l,
- independently generated' lists of names and then they jointly agreed on four laborers -
i Price, Lujan, Clifton, and C. Gonzales - to recommend for the layoff.* Hicks presented .
t this recommendation' to Dieter, who approved it. According to Hicks, Price was a j 2
i satisfactory, but.not exceptional worker, while the other three were marginal.izz Like l Dieter, Hicks denied that the expression of safety concems by the four workers had j
- , cnything to do with the layoff.'" '
Herrera characterized the four laborers as " mediocre" workers who did a " fair job" 2 - !
i .of core drilling, but were laid off as soon as that job was finished because he had no ;
i
!- other work for them.* Herrera said the layoff decision was primarily his, and that none !
4 of the concems the workers had expressed played a part in it.*
l
)
Another MKF superintendent, Dennis Robin, supported the layoff decision, stating th:t, while he considered Price, in particular, to have been a good worker, he was under
[ ;
)
- the impression the four laborers had become less productive because he saw them l j standing around a lot." However, he acknowledged that workers can have legitimate l
.l re: sons for " standing around" (such as waiting for RPT coverage) and that on the one -i
)
i- occasion he could recall asking the laborers in question why they were idle, they did j
, have a legitimate reason *' Robin did not recall any particular safety concoms raised i
162 l 1
No.5-by the laborers who were laid off, although he did recall that they spoke out at safety 1
meetings, which he encouraged.
Dieter. Hicks, and Herrera all confirmed being aware of at least one key concern the laborers raised - related to whether it was safe to have only one man on a drill during lunch breaks in the course of the core drilling operation - but their accounts differed significantly concerning the nature of this concern, the manner in which it was rcised, and the supervisory response to it. ,
Dieter recalled that Price came to his office to raise a safety concern about a change in practice from having two men on a drill (and ceasing operations during lunch) to continuing operations through the lunch break with. only one man on a drill."'
According to Dieter's recollection, only Price actually entered his office, while the others remained just outside."' He explained to Price his position that having one man on the drill was not unsafe, and Price seemed satisfied with the explanation."' Dieter further recalled seeing Herrera speak to Price as the latter exited his office; Herrera did not seem angry at the time, and he later told Dieter he had been speaking to Price about the same concern.ua Dieter confirmed there was an "open-door" policy for safety concerns, which he had communicated to the workers, and pursuant to which no worker should suffer adverse consequences for going directly to him with such a concern."' Price's visit to Dieter was consistent with that policy, even if Price had not first brought the concern to lower ranking supervisors. Accordingly, Herrera should not have been angry with Price for bringing the concern directly to Dieter, and Dieter never heard that he was '"
63
e F-No.5 Herrera, however, conceded that he was angry with Price for taking the concem i
l to Dieter, and that he reprimanded him and the others for it."5. While Herrera was aware
\
l
- of Dieter's invitation to the workers to bring' safety concems directly to him, he ~
interpreted this to mean that they shou!d go through their chain of command first."' He
~
was angry at Price and the others for failing to do this: "I got all over them and said why -
I didn't they come to me first. I told them chain of command. Again and again, I will bring that up.""' . Herrera later acknowledged, however, that the laborers had discussed their concem with him before taking it to Dieter, and that he had told them there was no safety' problem in running the drill with only one man during the lunch break."'
Hicks' recollection differed from Dieter's and Herrera's in two important respects.
First, he contended that the laborers never had a legitimate safety concern because there was never an intent to have only one man.on a drill. Hicks said that he had l~ crdered the change in core drilling procedure that prompted the safety concern. As l
l 7 Hicks explained it, the normal procedure had been to run two drills with two men on '
ccch. except during the lunch break when both drills stopped operating."' Hicks i: aid d
he changed this by instructing that only two men at a time take a lunch break, while the other two continued drilling,"' However Hicks contended that his order did not contemplate keeping both drills operating during the lunch break with one man on each l I
- drill, which was the basis for the laborers' safety concems, instead, according to Hicks, j p i
- he intended that only one drill continue to operate during the break with two men on that
]
drill."' l l
l l
-)
i :.
. . _ . , . J_ :!
i j
i No;5L j
- The second major difference between Hicks' account and those of Dieter and-
!i' Herrera concems the manner in wnich the core drilling concern was conveyed to Dieter. ,
According to' Hicks, he gave his instructions concerning two workers continuing to drill j
\
during ~ the, break directly to Price and the other three laborers.u The laborers L complained to Herrera that it would be unsafe to do as Hicks had ordered."' Hicks j i . . . J explained his order to the' laborers and Herrera - that it did not involve using only one l l
m:n on a drill - and told the men to go back to work.'" They, however, insisted on l
- c. ;
. . speaking to Dieter, and mentioned the "open-door" policy."' At that point, Dieter came t
l w lkin'g up and the problem was explained to'him; he asked if it was resolved, and was .i e
told that it was, and the men were ordered back to work.'" Hicks stated that this was f the only time he recalled these four laborers raising a safety concern while he was at FSV."'
i ;
i In summary, the testimony of Dieter, Herrera, and Hicks agreed with that of the ;
i borers to the extent that they had raised a safety concem about having only one man f Lon a drill during lunch breaks; that they first expressed this concem to Herrera and i Hicks; and that later, dissatisfied with' Herrera's and Hicks' reactions to the concem, they l brsught it to Dieter's attention, claiming their right to do so pursuant to the "open-door" policy Dieter had announced. Additionally, Herrera's testimony confirmed the laborers' contention that he was angry at them and reprimanded them for going to Dieter. There ;
e ,
i was conflict in the testimony, however, over whether there ever was a basis for the
~
t concem - l.e., whether Hicks or anyone else had ever ordered the drilling to continue f e
, I
- l 65 l
' b
~
I te l
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No.5 l g
' 1
'through the break with only one man on a drill -- and over the circumstances under-
~
j 7
'4 l
- which the concem was conveyed to Dieter. i
.i
- c. ~ Analysis - l in their testimony, Price, C. Gonzales, and Clifton alleged that their March 9,1993 i
. i layoff resulted from their previous expression of safety concerns to MKF supervisors and .j l
. superintendents. To determine whether there was a factual basis for their perception, j i
we used a method of analysis derived from the standard used in analogous NRC cases, j i
.which has been discussed earlier in this section of the report. We first examined the: l evidence to determine whether the laborers had made a prima facie showing that their Iryoff resulted from having expressed safety concems. Next, we examined the MKF s
m:nagement' response to the allegation to determine whether it articulated an l independent reason for the layoff. Finally, we sought to determine whether, considering
- all the evidence, the MKF response constituted a clear and convincing rebuttal to the -
allegation.
Applying this method, there was enough evidence supporting the laborers' ,
1 cliegation to constitute a prima facia link between the layoff decision and their previous cxpression of safety concems. The evidence was uncontradicted that the four laborers whs. wore laid off had expressed a variety of safety concems during their tenure with MKF, at least one of which was brought to the attention of MKF supervisory personnel at the general foreman and superintendent levels. This "one man on a drill" concem,
.which is the most important one for purposes of this analysis, was expressed several weeks before the layoffs and was alleged by the laborers to have triggered a pattern of 66-l
. No.5 s
- harassment that culminated in their being released.on March 9,1993. The evidence l I demonstrated that the concern, as it was described by the laborers and corroborated by others,* raised legitimste safety issues. As discussed earlier, it is also clear that raising such issues should have resulted in no adverse actions against the laborers, both :
- because of public policies and standards enforced by the NRC and because of MKF's own policies. The uncontradicted evidence further established that certain adverse- i
, personnel actions, including the layoffs themselves and an oral reprimand by the
~
laborers' general foreman, closely followed their expression of safety concerns. The l i
central issue, therefore, is whether there was any causal relationship between the ,
cxpression of those concerns and the adverse actions that followed. .
The statements of the three laborers themselves provided evidence that, unless 4
adequately rebutted, would support an inference that the layoffs were causally related, at least in part, to the expression of safety concems. According to the laborers, for j
! cxcmple, Hicks and Herrera expressed displeasure at their expression of safety concerns l shortly before the layoffs and made statements to them constituting both explicit and i I
implicit threats of being laid off because of their outspokenness. Their testimony was ct least partially corroborated by circumstantial evidence and the testimony of other witnesses. For example, Herrera, whose opinion of the workers was a key factor in the layoff decision (indeed, he claimed that the decision was primarily his), was admittedly angry at them for going to Dieter with their safety concern. Likewise, Hicks, a superintendent who was also instrumental in the layoff decision, had a reputation among MKF and SEG personnel for speaking to. workers and RPTs in an abusive and 67 i
I
. _ ._ ._ ._ . _ .. . . __ _ . _ _ . . _ _ _ ~ . _
No.5
.f threatening manner similar to what the laborers described.'" Moreover, the contention of Price, Clifton, and C. Gonzales that they were laid off because they had expressed.
safety concerns was supported in varying degrees by a significant number of.their co-
- workers.'" ~ lt is clear that their allegation was not of recent vintage '-- many MKF L .
workers' testified to having heard it at or around the time of the layoffs,'[' and at least ;
' on] worker recalled that the laborers had predicted they would be laid off for this reason -
prior to the time it actually occurred."' f
- Numerous co-workers stated that in their observation the four who were laid off s t
were good workers, contrary to the assessments of Hicks and Herrera."' One worker
( .rscalled that Herrera made a disparaging remark about the laborers relating to a concern
- th
- ;y had expressed at a safety meeting,'" while two others recalled that Hicks reacted negatively to safety concoms expressed by other workers.'"
I in' summary, the testimony of the laborers and other evidence tending to
- corroborate that testimony was sufficient, if not adequately rebutted by MKF, to support an inference that the layoffs.of March 9,1993 were at least partially influenced by the 1:borers' prior expression of safety concems.
i The MKF management response described above did clearly articulate ind: pendent reasons for the layoffs, chiefly that it was necessary to release four workers, th:t these four were good candidates for layoff on the basis of their performance, which w;s mediocre at best, and that there was no other useful work for them to do at the time. 'If established as the sole reasons, these would constitute independent grounds
~ f;r the layoffs, unrelated to the workers' safety concerns.
68 1
1
. , - - - ~ - . . .- . . . . . - . . . - - .
No.5 J
?
4
.'There was evidence tending to corrot, orate some 'of the statements of MKF V
- superintendents and supervisors conceming the reasons for the layoffs. First, there was j l
n3 reason to question their contention that the March 1993 layoffs were planned in
- advance because of a work slowdown at that time. There were periodic layoffs during i .the decommissioning project,' and the evidence did not suggest that the layoffs were centrived to retaliate against the laborers for expressing safety concems. However.
- i-once a decision is made that a layoff is necessary, the next decision - which specific
- workers should be released - is highly subjective and dependent almost entirely on the
' ~
l
'pr;ferences of the supervisors involved In this case, although Dieter had the final l
. - d2cisionmaking authority concerning who should be laid off, the evidence supports the b
conclusion that his decision was heavily influenced by the recommendations of Hicks and p
Hstrera, who had closer day-to-day supervisory contact with the four laborers. Thus, cv:n if it is assumed that Dieter was not personally prejudiced against the men because they had raised concerns, a key issue is whether the recommendations of Hicks and H;rrera were influenced by hostility against the four laborers arising frorn their expreswon of safety concerns, or whether, as they claimed, Hicks and Herrera arrived I
1 4
ct their assessments of the four workers strictly on the basis of other factors, such as i
- their allegedly marginal performance.
Once again, there is some corroboration fer the Hicks /Herrera contention that
>- petformance problems, coupled with the lack of other work, accounted for the layoff decision. One of the four laborers, Lujan, had : been disciplined by Hicks for insubordination and this reasonably could have been a factor in the layoff decision as 69
._ _ _. . .._. _ _ . . . . ._ _ _ _ _ . _. _ _ . _ _ _ . . . . .. . ._. y
/,
- No.5
[
i it pertained to him.'" -(independent evidence tended.to show that Hicks' disciplinary - i
. action was not arbitrary, and was based upon conduct by Lujan that Hicks reasonably .;
. could have considered warranted such action.)"' Additionally, the evidence showed that.
l 4
i
. the core drilling project to which the laborers had been assigned ended shortly before they were laid off, and Herrera offered a plausible explanation for why he was reluctant :
j to assign them, instead of another crew, to another core drilling project on a different level -- that the other crew had more experience at that level.'" Thus, there were !
factors independent of the workers' expression of safety concerns.that could have-
~
' influenced the layoff decision, j Other evidence, however, tended to cast doubt on the MKF management position ;
that the layoffs were gg.[ gly motivated by an assessment of the laborers' performance, j i
coupled with the lack of work for them to do. First, although Dieter recalled that the four !
l workers had been brought on for the core drilling project,n2 they were hired well before l 1
. that project began and were not laid off immediately upon its completion; instead, they ]
l
- were assigned to a different project involving the removal of blocks and lead pellets."' ;
Irideed, it was while they were workinr, on this project that their final safety concern was i- expressed, relating to dust and lack of ventilation."' Thus, the completion of the drilling project, while a plausible factor in the layoff decision, was hardly a compelling reason that completely explained it. As Herrera acknowledged, the MKF supervisors could have retained one or more of these four for other work and laid off one or more others in their .
- place,'had they been inclined to do so."
- 70 4
., y q. e nm, - ,--n,----- , ,, ,,n-r, , vm .- ,,-,,-...,--~-,.w, -
_.-__--__.--L---.____-----
~
NO.1 ~
l I' _
{ Second, there was a marked contrast between 'the MKF supervisors' and i
i superintendents' assessraent of the four laborers' performance and the assessments of I their co-workers, most of whom considered them to have been good workers. The. l
- aggregate opinions of these co-workers were entitled to at least as much weight as those ;
L
- of the supervisory personnel, because the latter provided no evidence of having any j more systematic, objective, or specific bases for their evaluations of the four laborers'.
i performance than did their co-workers. As noted earlier, there were no guidelines or l criteria' for the layoff decisions other than the subjective judgments of the supervisors l
and the bases for those judgments were not documented. Absent documentation, the :
L i 1
)
'- ' superintendents / supervisors provided only generalizations to support their contention that p
4 the laborers were mediocre or marginal performers. Dieter, for example, had the .
impression that the four were slow to return to work after breaks, would hesitate when csked to work, and had' a reputation for not wanting to work."' However, Dieter j acknowledged that his impression about the laborers' attitude toward work was based on what Herrera told him,"7 and, as noted earlier, the alleged reputation for not wanting to work was contrary to the statements of most of the MKF workers who were i interviewed and had an opinion on the subject.
i l In short, the extent to which MKF explanations for the layoffs rebut the workers'
, cliegations ultimately depends upon an assessment of the statements of the supervisors involved concerning their subjective reasons for releasing the laborers in question. The importance of tf.eir statements would not be as great if MKF had a different system for making and ' documenting layoff decisions. For example, if layoffs were done strictly
< 71
NO.1' l cccording to seniority, and the four laborers who were laid off happened to fall in the
, I. .
cppropriate slots on a seniority list, the attitudes of MKF supervisors toward them would I be of little consequence. Alternatively, if the shortcomings in the workers' performance !
had been carefully documented and the layoff decision made according to a system that
. provided demonstrable safeguards to ensure that layoff decisions were not made for j
i j
f impermissible reasons, the task of rebutting the allegation might have been easier. This 1
.j
- 6 not to suggest that MKF should adopt a seniority system for layoffs, or that it acted i
i
- improperly by. allowing its superintendents / supervisors virtually unfettered discretion in i
making layoff decisions. However, the use of undocumented subjective criteria to make
- such decisions necessarily focuses more attention on the motives and possible biases of the supervisors involved when the decisions are challenged, and requires a clear and ,
consistent explanation to rebut allegations that they exercised their subjective judgments i
in a way that penalized workers for expressing safety concerns. i The accounts given by the MKF supervisory personnel, however, were in l l-important respects inconsistent. For example, there was a substantial difference ;
- between the statements of Dieter and Herrera concerning the proper interpretation of the
{
"open-door" policy. Herrera admitted being angry at the laborers for going to Dieter with ,
t 1'
their safety concern, first stating that they should have come to him with the concmrn arid latar conceding that indeed they had done so. Herrera justified his angry reaction toward L the workers by claiming that everyone understood the "open-door" policy to require the worker to bring the concern through the chain of command before going to Dieter or some other higher level MKF representative. This interpretation, however, was 4
72 g et w --w -
e 'gs ' e6v-a---T-+y+--yD y- W '
1--'F! "" " * * '
. - . - . . . ~ . . - . - .- .. -
-1 No.51 1 2
6
! s
- } - contradicted not only by Dieter but by other MKF superintendents / supervisors, including
-l
)
1'
- the project Operations Manager, William Hug."' Herrera apparently did not understand j tha. "open-door".' policy and the' rationale underlying it. This misunderstanding was; f :
cvidence of a deficiency in communication and coordination within the ranks of MKF j
- i 4
' m:nagers and ' supervisors. It was also evidence of Herrera's lack of sensitivity to 'the . l c .
w;ys in which supervisory actions can underrnine MKF's professed policy of encouraging ]
- - the reporting of safety concems. l i . ,
I
- LAdditionally. Dieter, while' stating that it would not have been appropriate for.
'j
~
Herrera to have become angry over the laborers' coming to him with a safety concern, '!
! clso stated that he was not aware that this in fact had happened."' His statement in this regard 'is consistent with the other evidence. which shows that Herrera's reprimand of
}
Because Dieter was unaware of tha workers occurred outside Dieter's office.'"
- Hstrera's anger at the workers for bringing the safety concem to Dieter, he was unable l
to evaluate the effect this anger might have had on Herrera's recommendation that these
- . stme workers be laid off.
Herrera's anger at the workers for utilizing the "open-door" policy is significant in Enother respect. His justification for that anger was based upon a misunderstanding of
- the policy itself - that the workers were required to bring their concem to him first before n
g:ing to Dieter, while Dieter made it clear that that was not required. As Herrera later
[* acknowledged, however, the laborers did bring their concems to him prior to going to Dieter, thereby satisfying even his erroneous interpretation of the policy. Thus, his anger
. at'them was even more inappropriate and inexplicable, suggesting that he was angry at 1
U
. 73 9.g - g 4- n- e m- m-pr n 5- , ,e-, -- --e y-v-, n - ---w.,-- -- , ,--w --
-,--a, - + - , e -~,n -"+ w-
No.5:
J the workers.for reasons other than their failure to follow the chain of command. This !
i inference is strengthened' by Herrera's own pejorative characterization- of the' four l
laborers' propensity to raise safety concerns. Asked to compare the four who were laid . ]
I off with other workers, Herrera stated: ."They had a tendency to cry a lot."'" He l
' continued: .
s
+
O. When you say " cry a lot " what do.you mean? l I
. A. Complain, that's what I mean when I say cry or j
' whimper about it a lot, that's what I mean. -l t , ,
O. Well, we have already talked about a _few ' specific j
? complaints. Do you recall what other types of things !
4
- they would cry about or complain about? j
, r 1
- A. They were the type of people, the way I look at it, who I
- were consistent. You know, they always manage to l gripe about something.'"
J Similarly, the inconsistencies between Hicks' account and those of Dieter and r !
- i. Herrera tend to undermine the MKF rebuttal and suggest that Hicks, like Herrers,' formed ;
l-j a negative impression of the laborers in part because of their expression of safety j
. i concems. Hicks, in effect. accused the laborers of contriving the "one man on a drill" ]
concern because they wanted to take their lunch breaks together.* According to Hicks' l
' account, the " concern" was at best a simple matter of miscommunication - he contended !
that his order never contemplated having only one man on a drill; instead, there were l to be two men on the one drill that was to operate through the lunch break. In addition to the laborers, however, both Dieter and Herrera testified it was their understanding that i there would be only one man on a drill during the lunch break.'" Additionally, in Hicks' j
}
cccount the laborers never entered Dieter's office to express their concem, but instead l l
74 ,
I u
.. . - ,- . - - -- - ..-_-_____._-_-_________-__A
. No.5 were speaking to Hicks and.Herrera outside when Dieter walked'up and was told the concern had been " resolved."'" According to Hicks' account, the laborers' behavior was .
indeed puzzling - having just been told.by Hicks that there was no basis for theirf concern, they still wanted to express it to Dieter, yet acquiesced when Dieter walked up "cnd was told. apparently erroneously .in the laborers' view, that'the concern was resolved. Both Dieter and Herrera, however, corroborate the laborers' contention that they brought the'concem to Dieter while he was in his office (after which they were interrupted by Herrera) and that when they did so they were under the impression that
~
the concem had not been resolved."'
. Thus, the testimony of both the. laborers and two MKF supervisors supports the conclusion that there had been an intention to keep the drilling operation gcing during lunch breaks with only one man on a drill - the basis for the laborers' safety concern -
.end that several of the laborers went to Dieter's office to express this concern after h :ving previously discussed it with Hicks and Herrera. Accordingly, Hicks' portrayal of
- the laborers' actions as a contrived attempt to take lunch breaks together is both crroneous and suggestive of hostility against the workers that was not justified by the circumstances. It is implausible that Hicks, who was harboring an erroneous belief that the laborers were fabricating a safety concem for a frivolous purpose, would not be influenced by that belief when assessing the workers a short time later as part of the layoff decision.
( In summary, the weight of the evidence supports the conclusion, first, that the recommendations of Hicks and Herrera were key factors in the decision as to who would -
75
- No.5 ?
? be laid off on March 9.1993: second, that those recommendations were in part !
T i influenced by the negative impressions both Herrera and Hicks had of the laborers
- crising from their actions related to the "one man on a drill" concern; and, third, that the ,
overall MKF explanation for the layoffs, which depended heavily on'the accounts of
[
p 4
Hicks'and Herrera,' did not clearly and convincingly rebut the laborers' allegation. ,
i d. Conclusion '
i F - The evidence disclosed a rational basis supporting the perception of the laborers
'who were laid off on March 9.1993, which perception was shared by a significant j i
< number of their MKF co-workers, that the layoffs were in part influenced by the laborers' '!
i prior expression of safety concems. This perception, in tum, contributed to a general j
- i e cttitude on the part of many MK'F workers that expressing concems was likely to result f
- I
- in adverse personnel actions.' ' l
- 2. Perceived intimidatina Behavior by MKF Suoervisors :
Many witnesses, including.MKF workers, RPTs, SEG supervisors, and PSC oversight personnel, recounted examples of abusive language, demeaning treatment, l
cnd generally intimidating behavior on the part of MKF, supervisors. Some of these ex mples involved abusive ' conduct toward RPTs, while on other occasions the alleged -
, i i
, recipients of abusive treatment were MKF craft workers. We investigated this perceived :
^
pattern of supervisory behavior o determine its effect, if any, on the perceptions relating ,
E
- MKF_ disagrees with this conclusion for reasons set forth in a letter from its Associate .
General Counsel. That letter and a response are contained in Appendix D, j
.}
76 L !
i No.5 l
}
[' to intimidation and harassment described above. Additionally, we sought to determine j whether the alleged behavior evidenced er contributed to'an atmosphere in which f production and ' scheduling priorities took' precedence over safety and procedural l compliance. ;
We have divided the following discussion into two subsections, one corresponding ,
ts alleged MKF supervisory mistreatment of RPTs, and the other to alleged MKF supervisory mistreatment of MKF workers. However, we regarded the two as related.
cnd in many respects the evidence was overlapping concoming both kinds of perceived
{
mistreatment - some MKF workers reported hearing or seeing abusive actions by MKF {
supervisors toward RPTs,'" while RPTs, in turn, reported what they perceived to be cbusive treatment of MKF supervisors towards their own subordinates.'" For example, ;
i en SEG supervisor noted in a log entry dated October 27,1992: "Made a tour of :
[R: actor Building) and witnessed a major confrontation between a (laborer] and Dean j Ross [an MKF supervisor) - it was ugly."'" Whether perceived by MKF or SEG S
personnel, the mistreatment was often viewed as arising from a desire to speed production.'" f t
- a. Perceived Intimidation of RPTs l
A number of SEG RPTs complained of intimidating conduct toward them by MKF f
supervisors. In the words of one of the RPTs,"I've never come across a situation where
- so many were abused by so few . . . . [MKF] developed an attitude where they felt it was !
i okay to intimidate us and yell at us."'" ]
I i
. _ _ _ _ _ .. _ - _ . _ . __. _ . _ ~ _ _ _ . _. __ . __
No.5 l Most'of the intimidating behavior consisted of abusive, threatening,- and derisive
{ l language toward RPTs in connection with the carrying out of their radiation protection responsibilities.' As one RPT put it, MKF supervisors " hollered to get the job done, and ,
they complain that we're slowing them up. . . .""' Log entries made by SEG personnel l st various times during the project further evidence the perception RPTs had of abusive behavior by MKF supervisors:
) Qata Ent!y DN/Pa. # ;
9/11/92 Talked w/T. Dieter and B. 3422/66 i
' Hug about the attitude of D.
Hicks and J. O'Malley. .
. 9/15/92 Had a meeting with T. Dieter about 3422/70 Danny Hicks and John O'Malley - they i .
seem to be running amuck. -
l l
9/30/92' Met Ken Zahrt, (SEG supervisor) 3422/89 and we talked about M&K supervisor Bob Fessenden - it seems like I can
/ never satisfy him.
1 78 i
I
No.5 I NOTE: Fess - still not happy with
(
anything.
10/7/92' Met with T. Dieter - we talked about 3422/98
. . . refuel conflict between C.
Sawyer [RPT] and D. Hicks.
10/7/92 ,
Note - Bob Fessenden charged into 3422/98 ,
my office while giving turnover and demanded that we get up to the -
E floor now. . .
4/27/93 Major confrontation with Dean Ross 3423/177
[MKF supervisor], Rob Rankin and Debby Sindelar [RPTs] over the )
i issuance of a respirator.
1 i
Met with Dick Sexton (SEG manager] and 3423/178 j l
I
. informed him of Dean Ross's threat to always kick somebody's butt. I also l told Dick that I have ' informed my
]
- staff that if a physical altercation j
I 79
)
l
_,~ -. . . _. _ . _ . _ _ , _ _ . _ _ _ _. .. ._ . _ ._. . . ,
a No.5 I
.i happens with another person . , . ,
1 the individual will be terminated. 1
-i i; I will not tolerate physical abuse .
[ on this project 'i r ,
,- i I
6/24/93 There has been another confrontation 3423/271 ,,;
1 i
on the refuel floor with Dean Ross. !
i l 1
l i
i
[ Some MKF workers witnessed conduct by MKF. supervisors toward RPTs that :
I t:nded to corroborate'the accounts given by the RPTs themselves. For example, several had' overheard MKF supervisorn "sc:eaming" at RPTs to hurry a job along.*
2 in the two instances described below, however, confrontations between MKF supervisors i l cnd RPTs included apparent threats of bodily harm.
(1) Ross/ Hatch incident One instance of an alleged threat by an MKF supervisor toward an RPT occurred on February 8,1993, when the RPT, David Hatch, was asked to frisk deck plates on the turbine deck for release from the site.* According to Hatch, the plates, which weighed
! _ a couple of tons each, had been surveyed for loose surface contamination and his task i
was to survey them for fixed contamination." This required him to cover the entire
- ' surface of both' sides of each plate with a meter, which had to be held within one-half '
inch of the surface of the plate.* After surveying the upper portion of a plate, Hatch
' csked the MKF workers at the scene to lift the plate with the crane and lay it down on 80 e
- -f- ~~
. ,, , - --y, ,-.
No.5. i t
p the other sids so he could continue his survey. The MKF riggers told him that the RPTs ^ -l r
c on the night shift were doing similar surveys with the' plates hanging in the air at an .
cngle, suspended from the crane, Hatch told the MKF workers that he was unwilling.to ,
work'under a suspended load and that they needed to rig the plate so it would be lying f l down while he surveyed it.'" 1 Hatch felt it was an unacceptable safety risk to have'to i
- survey such a heavy plate while it was suspended over him: '"My personal view at the .
time was that it wa's an unsafe operation, and to make it safe, they simply needed to lay
- the piece of metal down."'"
L . . . .
L The MKF ironworkers who were in charge of the crane and rigging necessary to
.i move the' plates agreed to Hatch's request, but the ironworker General Foreman, Robert '!
i .
' Dean Ross, arrived at the scene and asked the ironworkers what they were doing. i
! When one of them told him they were rigging the plates so as to lay them down in rcsponse to the RPT's request, Ross objected, saying the night shift RPTs did not r
require such a procedure."' Next, according to Hatch, there was a heated confrontation i between him and Ross during which Ross took the positk,n that his workers did not have to do what Hatch requested and that he should take the survey with the load suspended.
H:tch continued to insist it was not safe. At one point, according to Hatch, he told Ross -
I "I don't have to put up with your talk . . . I'm tired of getting yelled at by you. You yell ct cli your workers.- You're not going to yell at me.""' At that point, according to Hatch, he received a stream of insults from Ross, and in the midst of these Ross told him "that ' :
..he was going to rip my head off and shit 'down my throat."a2 in response, Hatch said he became very defensive and told Ross that if he touched him he would " kick your i r
-81 l 9
E
1 No.5.
ess."'" Hatch said another RPT as well as the RPT's supervisor,'Zahrt, witnessed the '
d[~ '
confrontation.2o' which ended without any actual violence. Although Hatch did not take 3
. 1
- Ross' threat l literally, he felt' intimidated by Ross and thought Ross was going.to' .]
physically. attack him.2u.
Because of the confrontation, no further work was done at that time, but later,. u cccording to, Hatch -Ross reached across a radiological boundary in Hatch's' presence, j
. which was contrar.' to radiological protection rules.'" Hatch told Ross that he was going l
- to write an ROR against him, and approached his supervisor, Zahrt, for that purpose, j
' ZChrt " highly recommended" that Hatch not write an ROR on the incident, contending -
1 th t it was a personal issue between him and Ross. As a result, Hatch never wrote an l i
'ROR concerning the incident.2" .
1 .;
Other RPTs who witnessed the incident confirmed the basic elements of Hatch's l account, including the threat made by Ross to the effect that he would tear Hatch's head i
off. One RPT characterized what he heard Ross saying to Hatch as " typical (MKF) l l
threats."2" ' Another RPT, in explaining why he thought Ross' language and demeanor l
toward Hatch were intimidating, stated: ,
I had seen [Ross] chastise and scream at his workers before,
. and I didn't want that to happen to our technicians . . I felt like no person deserved to be treated that way.2m
~ Ross denied he had threatened Hatch during the incident in question, and ii specifically denied the language attributed to him concerning a threat to rip Hatch's head
_l off. He 'also disputed Hatch's characterization of the safety issue Hatch had raised. ]
i
~ According'to Ross, the plates were suspended so that they tilted away from the person 82 i I
1
No.5-doing the survey and did not require anyone to do a survey while underneath the load 2m
.r in Ross' version, Hatch had questioned the' safety of the rigging in. general, which -
cccording to Ross, Hatch was not qualified to do.2" - Ross contended that not only did
' he not threaten Hatch, but Hatch made threatening moves toward him, although Hatch never said anything in the nature of a threat.212 Ross said that ultimately they did what H;tch had requested ~-- lay the plates on the floor so that he could survey them -- but in his opinion this ' caused a lot of unnecessary work.'"
Ross also offered the opinions that in general RPTs were a significant drag on }
~ ~
production, that Hatch was "another individual where he's dragging his feet, trying to i
mike the job last longer," and that MKF supervisors may have acted in an abusive
' m:nner towards RPTs "in self-defense."2n An MKF worker who witnessed part of the confrontation recalled that both Ross i 1
cnd Hatch had their voices raised and that he could understand the perspectives of both men on the safety issue of whether it was safe to survey the plates while they were suspended -- he believed Ross thought the rigging was safe, but also thought Hatch had a real safety concern.
While there were differences between Ross' account and those of Hatch and the other RPTs who witnessed the incident, Ross acknowledged that he was angry because of the safety concern Hatch had raised, and that he made at least one remark to Hatch's
- supervisor -- asking.him to "'get me [an) HP that's qualified and capable"' - to which Hatch took great offense.25e Indeed, Ross commented, "I guess he didn't like the 1
insinuation that I said he was incapable."2" Additionally, although Ross denied using the !
83 1
l
--9y -y-+
- g. j g -p ui umait- .c. - , - - , , y w - - - - - - - -'
! No.5 I 1'
~
.."I'll rip your head off" remark toward Hatch, one of his fellow MKF superintendent, Hicks, l'
who.was otherwise defending Ross' conduct and attitude towards the RPN, said that !
Ross "uses that expression, although he could not recall whether he used it during the confrontation with Hatch.2" -
in summary, the combination of several eyewitnesses contending that Ross used -!
' the intimidating phrase described by Hatch, the statement of a fellow supervisor that it 4
w:s an expression he.was known to use, Ross' acknowledged opinions of RPTs in g:neral and Hatch in particular, and the acknowledgement by Ross that he denigrated .
f H;tch in the presence of Hatch's supervisor after learning that Hatch had a safety concern about surveying the plates, supports the conclusion that Ross' words and behavior on this occasion reasonably could have been interpreted by Hatch and the ;
l other RPTs'as being intimidating. This intimidating behavior was provoked by a safety :
1 c::ncern with which Ross did not agree and which, in his opinion, required unnecessary l 1
work by MKF personnel. l 1
The confrontation did not result in the compromising of any safety standards because in the end MKF personnel complied with Hatch's request to lay the plates down so he could survey them.2" However, because there was no discipline given to Ross, cither as a result of what the RPTs perceived as a threat or what Hatch felt was a radiological procedure violation, and because some RPTs viewed their supervisor to have been insufficiently supportive of Hatch in the face of the threat from Ross and in H;tch's later attempt to write an ROR against Ross,22o the incident contributed to a 84 i
I
- No. 5.. l
. j 1
- perception among RPTs that .MKF supervisors could act abusively toward them with'
.J .- 1 impunity. j (2) Hicks /Neelv incident
~ A second incident involving a perceived threat by an MKF supervisor toward an .
RPT occurred on February 3,1994, when the MKF superintendent, Hicks, was observed .;
by an RPT touching his face while inside the radiologically protected area.22' The RPT,
. Rick Neely, contended that when he first saw Hicks touching his face while Hicks was :
assisting in a block removal operation, he approached Hicks and told him to stop.
'(Touching one's skin while working in a protected area is a violation.of radiological 1 control procedures because it can transmit radioactive contamination to the skin.)222
'According to Neely, after warning Hicks, he observed him touching his face again a few
- minutes later. He then instructed Hicks to stop touching his face and leave the platform !
i i so that a full body frisk could be conducted. Hicks denied he had touched his face, and did not leave the area. Neely interpreted his refusal to leave as a failure to follow the instructions of an RPT concerning a matter of radiological safety. Accordingly, Neely ~ j 4.
wrote an ROR in which he stated that Hicks "was told to stop touching his face on more )
' than one occasion and persisted," and that Hicks "was told to leave the area, at which j
. he denied touching his face (and) refused to leave, he did leave 5 min. later."223 The l 1
next dayc according to Neely and his supervisor, Roland " Chip" Sawyer, Hicks stormed ,
l into Sawyer's office and threatened to " kick [Neely's] ass" if they didn't "back off' on the i
ROR that Neely had written against Hicks the previous day.2 ' Shortly'aftenvard, while l 5
4 Sawyer was speaking to Neely concerning the visit he had received from Hicks, Hicks l l
J 85 l t: l
,c- - e,ms... .-i.6, ..,...m.. . , , . . , , ,-.y,.e, --._ e,, , . ,- -.- , - n
No.5-
' cdme by and in Neely's presence told Sawyer "'[y]ou better tell that meafymouthed little motherfucker to back off or I will kick his ass.",22s Both Neely and Sawyer considered j
. Hicks' behavior on this occasion to have been threatening and intimidating.22e The February 1994 ROR was the fourth one written against Hicks; the first three cra dis' cussed in detail later in this section.
Concerning the February 1994 incident, Hicks conceded tha* he was angry when l 1
~he _ learned that Neely had written an ROR as a result of the encounter between them )
l
.the day before when Neely had seen Hicks touch his face while in a radiologically. l
~ i controlled area. Hicks denied, however, that he had initial!y violated an order by Neely, l cnd he therefore felt the ROR was unjustified.22' Hicks complained to Sawyer about the (
. i ROR and later, seeing Neely go into Sawyer's office, went there to see if the matter could be resolved among three of them.22e Hicks claimed that he again became angry, however, because Neely had a smirk on his face that conveyed to Hicks a message of
'"I got you"' and Hicks acknowledged saying to Neely: '"You know, Rick, if you keep it
- up, I'm going to kick your ass.",22e According to Hicks, after another angry exchange with Srwyer he left and spoke with one of his fellow MKF superintendents, Robin. He told Robin about the confrontation and agreed to return and apologize to Neely and Sawyer.ru .
Even under Hicks' account of the event, the two RPTs who witnessed it,' Neely and Sawyer, were subjected to behavior by an MKF supervisor they reasonably could '
perceive to have been threatening and intimidating. This is particularly true in light of what by then was a . lengthy history of confrontations between MKF supervisors and 86 E ,
d i
No.5. j t ;
-.- A RPTs. many of which were witnessed by several persons, including MKF workers'. Thus,L l
. . . l
- c . the incident tended to confirm the view that many RPTs and MKF personnel already had; !
S
- 11,1that MKF supervisors viewed the RPTs with contempt and were' willing to use-i iintimidating behavior toward them.- j c i
.This~ incident was not the first time RPTs had complained of abusive behavior directed against them by Hicks. One RPT said that in.1993 he disagreed with something 1
- Hicks said during a briefing prior to MKF workers descending into a cavity to work under -
. high' temperatures and around radioactive materials. The RPT told the workers that, i n:twithstanding any previous order given them by Hicks, the workers would 'come out l
.j if in the RPTs'ludgement they appeared to be fatigued. At that point, according to the
~
RPT, Hicks " blew up:"
[ Hicks] [c]alled _ me about every name you could think of. I' Threatened to kick my ass a couple times. Called my supervisors and changed the whole story around. We proceeded down and did the job. When I came out, I was '
talked to -- as a matter of fact, the whole staff was talked to, that their [MKF's) workers [ worked) for them and they don't
. work for us. But from a health and safety standpoint, it's my responsibility to throw them out of the area.2 ;
i
^ Another RPT stated that Hicks "used.to get into an argument with everybody on our t str.ff. . . . screaming and hollering and stamping and stomping, and he was just totally unprofessional, in my opinion."
I The February 1994 Hicks /Neely incident, coming as it did after other incidents o
? involving Hicks, set in motion a chain of events that culminated in Hicks' transfer from the FSV site, as described earlier in Section IV.
87 i e
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a .e4e. m.aaue w m pai 4.i. .w e4as+
-.9.
No.5 Both. the Ross/ Hatch and Hicks /Neely incidents discussed above were widely 1
.I . known among the RPTs. While the physical threats that were verbalized during these
.I cvents were not typical of other confrontations between RPTs and MKF supervisors, in ,
other respects the incidents illustrate the kind of behavior RPTs viewed as abusive and -
- intirmdating, Perceived intimidation of MKF Craft Workers 1
- b. ,
(1) Nature of intimidation Some of.the MKF supervisors who were viewed by RPTs as having acted in an -.
intimidating manner toward them were also perceived to have behaved similarly towarc ;
MKF workers. Alleged intimidating behavior by Hicks, for example, has already been discussed above in connection with the March 1993 layoff of four laborers and perceived ,
threats to RPTs. Additionally, other MKF witnesses gave examples of behavior by Hicks l that they considered abusive or intimidating. As one worker described Hicks' comments l
toward him and other MKF personnel: ;
[Hje's talking about personal parts on my body and j v stuff like that . sitting there degrading certain people out ;
here. . . I've heard him talk about people that are up . 50 ;
feet in the air, you know, cleaning walls and stuff and tell l l them how shitty they look working up there and. working slow j and they ain't getting nothing done.'" ;
}
.The same worker went on to describe other comments by Hicks, including a threat to .l
- f. . '; give him, out of spite, a hot, unpleasant job involving working in a pit with a respirator, ,
cnd a disparaging comment about a worker who had been overcome by heat while doing l similar work in a pit removing slurry.2" Another worker described a confrontation with l
f i
88 I I
l
. .. , . , - .- . .m_.. - _ - _. . _._ _____ _ _____o
l 4s ) '
j o
_ No.5-t Hicks that resulted in the denial of any further overtime.2" while another described..
!I
- : bullying behavior by Hicks' toward himself as well as toward RPTs.23e .
~
A .second MKF supervisor who was widely perceived to have an intimidating style l
'- wis the night shift superintendent. Robert Fessenden. ' Witnesses described Fessenden ,
s -
1
. cs very aggressive and intimidating in the way he spoke to employees, often raising his l vcice and cursing at them. Th'ese perceptions were corroborated by PSC oversight personnel. 10ne witness istated that he quit : after receiving verbal abuse by - !
< 't
- Fcssenden. an incident that was witnessed by at least two other persons.24o Another 'l witness, a foreman, stated that Fessenden's attitude would make him more reluctant to l l
rcise'a' safety concern 'if he had one, and that on one occasion he did refrain from l cxpressing a concern in an incident involving checking barrels for radioactive waste.24 ;
Fcssenden, according to the foreman, insisted that the barrels had been smeared by j RPTs and wanted them moved, but an RPT had told the foreman that the barrels had not been smeared. The foreman did not want to push the issue after Fessenden told
, him to move the barrels.'so on his own he got an RPT to " smear them real quick."
Another MKF worker stated that Fessenden would seem displeased if workers came out acrlier than,he thought they should after working in hot conditions and not feeling
- good. :Several witnesses attributed Fessenden's perceived abusive behavior to his desire lto hurry jobs to completion.2u Despite the perception of Fessenden as abrasive and intimidating toward MKF workers and RPTs. several witnesses commented that in their opinion he had become -
- more " mellow"_ and more concerned with the safety of his workers.'" in particular, there 1
4 89
No.5 wIs evidence that relations between MKF-supervision and the RPTs working on the night shift had improved .since the early' days of the project. and that a better understanding between Fessenden and the RPT supervisor on that shift was largely rcsponsible for this improvement.2
The ironworker general foreman, Ross, also had a reputation for being abrasive . 1 i
. cad for raising his voice toward workers and RPTs, cursing them and generally l i
~ displaying an intimidating presence. Ross' perceived threatening behavior toward an
)RPT has been described above, additionally, several MKF workers perceived Ross as !
.,. i a bully or described. abusive or intimidating behavior by him.24e Other MKF workers, however, while noting Ross' abrasive style, minimized its effect or expressed the opinion !
th t. on the whole, he 'was a good general foreman.24 ,
While Hicks, Fessenden, and Ross were mentioned by a number of witnesses as i
h ving particularly abrasive supervisory styles, some MKF witnesses described perceived intimidating behavior by other supervisors or attributed an atmosphere of j i
intimidation to MKF supervision in general.2" One witness stated that the workers were j sometimes humiliated for bringing up concerns during safety meetings and offered the opinion that anything MKF managers interpreted as questioning their authority made i i
them "come unglued."2s' In this witness' opinion, the intimidation of workers was worse ;
ct FSV th'an on other jobs in the construction industry with which he was familiar.as A ,
~
s' .;
PSC oversight official said the behavior of at least some MKF supervisors and managers i
reflected an abrasive management style that was not " people oriented."2s3 He contrasted j i
PSC's preferred style of handling people - which in generalis appropriate in a nuclear ,
.i i
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No.5 3
i environment -- with the style used by MKF supervisors who " verbalized more violently"
'I toward their subordinates.2"' !
~
(2) Suoerviserv Resoonse t
MKF. managers and supervisors, when questioned about the perceived abusive - j and intimidating su'pervisory behavior, responded in several ways. As already described -
f in an earlier subsection of this report, the top MKF managers at the FSV site were unaware of some of the key worker perceptions relating to intimidation and harassment.
This gap in perception between the upper level managers and superintendents and the
. craft workers was apparent in the way each group viewed the issue of abusive and l i
intimidating supervisory behavior. Dieter, for example, the MKF General Superintendent, l
~
was not aware of complaints by MKF workers that MKF supervisors acted abusively
,',. toward them.2" Like other MKF managers and supervisors, however, Dieter ccknowledged that the kind of language and behavior that is common in the construction industry might not be viewed as acceptable elsewhere. As he summarized the attitude of construction supervisors, "[t] hey're all rough and tough and don't say, please and
. thank you. I mean that's the nature of the business."2n
. Fessenden also responded, in part, by referring to the culture of the construction industry. He confirmed that at least two employees had quit after arguments with him,2n cnd that an employee had told him he was too hard on people.'" Concerning an .
' employee who left after accusing Fessenden of verbally abusing him, Fessenden conceded that he may have used harsh language, but stated that "[t]his is construction, that's the way it goes."2" 91
)
u
- . . _ - , I
T No.5 Fessenden's statement also illustrates another aspect'of the gap in perception f
'between supervisors and workers. Asked wheth'er he was ever under the impression that his employees felt intimidated by him, Fessenden responded:
1 imagine it would depend.on what you would define as intimidation. In the respect of the NRC definition, I would say absolutely not. In the true sense of the word intimidation, I ;
would hope so. ;
i I would hope people are intimidated by me. They work for 2e ;
me Fcssenden went on to explain that the kind of " intimidation" he hoped for was tied to the ;
rdssonable expectations he had of how workers were supposed to behave on the job: ,
I hope they're somewhat intimidated that this is not a place !
where you can come and do as you please. T,here are l certain rules out here that you have to follow.2
Thus, some behavior perceived by workers to be sousive and intimidating was viewed by supervisors either as routine in construction work or as necessary to maintain i order and discipline. MKF supervisors also did not deny that the need to hurry i production influenced their actions, but they viewed this in a positive light. Ross and Herrera for example, two supervisors said by some witnesses to have displayed intimidating behavior, stressed that they are production oriented.as: In that regard, H:rrera stated that he likes to " push, push, push. That's the way I have always been."
(3) Analysis Apart from specific incidents perceived to have contributed to an atmosphere in which workers felt intimidated, the overall behavior and manner of dealing with people 92
JNo.5 cxhibited by certain MKF supervisors played a role in creating or reinforcing the workers'
- perceptions described earlier. It did so in_ several ways. . First, the abrasive styles of some managers encouraged the belief that challenging them in any way - whether by.
.r rcisi$g a safety concern or 'otherwise -- would be met with h'ostility that could lead to adverse consequences for the employee. This is.particularly true in the case of safety-concerns that might slow down production, because the perceived abusive treatment was often linked to a desire on the part of supervisors to speed up production. Second, the perceived ' abusive behavior carried with it an implicit message that it was futile to raise
- concerns that went against the wishes of supervisors because they would -not be receptive to them. Third, the perception that some MKF supervisors were allowed to persist in abusive behavior with impunity encouraged the belief that their behavior had tha tacit approval of MKF management.
The relationship between an abrasive or intimidating supervisory style and r::luctance to raise concerns because of perceived adverse consequences for employees is illustrated in the example of the foreman who privately arranged for an RPT to conduct a smear rather than contradict Fessenden's statement that one had already been
[
done
- Another example is the laborer who would not report Hicks' repeated violation of radiological rules for fear of losing his job.ru (It is also illustrated in the crane
' overload incident described in the next subsection.) These incidents also illustrate how l
r mtimidating behavior, uncorrected by upper MKF management, contributes to the belief that supervisory actions reflect management's values and that it would be futile to challenge them. Indeed, the MKF supervisory behavior was seen by some workers as j
93
. No.5 l rtsulting from pressures. originating with upper MKF.' management. . One worker .j y .
explained why 'he did: not complain to upper management about the actions of a l supervisor: :
l .didn't feel it was necessary, because every time .
anybody went to complain, why, then, he either got laid off or
. . . some type of situation that way. . . . l I
There was just the attitude of the general foreman and the superintendent. .You know, you do what we say and go ;
~
through the procedures like we tell you. And if you don't like it, then you can go find another job. We could care less.
i Dieter and Westman, Dean Ross, Marion Herrera, all of them, you know. They had that attitude like they was !
brainwashed or something, you know. And they . . . all had the attitude like they were scared to death of their job, you l know.2a
. Fessenden and some other supervisors felt there were legitimate motives i underlying much of the language and behavior perceived by workers to be unnecessarily heavy-handed: LL, the supervisors believed they were doing what was needed to keep l
the work going and maintain discipline. However, while the evidence did not support a conclusion that the perceived abusive behavior was intended to inhibit the expression I of safety concerns, it did have that effect by reinforcing the perceptions many workers
.had already developed that inclined them to associate speaking out with risk to their jobs.-
One consequence of the workers' reluctance to speak out was that MKF 'I supervisors and managers remained totally insulated from some issues in the workplace,
)
m
, .r e
No.5 cnd developed an incomplete or one-sided view of others. Hug, for example, stated that
' he was unaware of the perceptions of RPTs (supported by some MKF workers) that -
Hicks repeatedly and intentionally violated radiation protection rules, or the belief among a . number of his own workers that four laborers were ! aid off because they had.
cxpressed safety concerns."' Hug acknowledged being aware of the ongoing friction beEween MKF personnel and RPTs, but in Hug's view a great deal of this tension was e cttributable to legitimate concerns by MKF supervisors over whether the RPTs were cdequately- supporting MKF's efforts to keep the job moving."' Similarly, Hug's t:stimony made it clear that he was aware of many of the most prominent confrontations between his supervisors and RPTs -- such as the RORs written against Hicks and the Ross/ Hatch incident -- but that, from his perspective, based on reports he received from his subordinates, SEG personnel contributed to the incidents and he viewed the actions t: ken by MKF in response to the incidents as reasonable."'
The evidence did not contradict the claims of Hug and Dieter that they were unaware of some matters that were common knowledge among the workers, such as the Cllegation that the March 1993 layoffs were related to safety concerns. To the extent they were unaware of these perceptions and the reasons underlying them, however, it w;s partly because of flaws in the MKF management system that stifled the flow of '
information up the chain of command. As described earlier, many workers felt that voicing safety or other concerns that might slow production, or be interpreted as a challenge to supervisory authority, could be harmful to job security. These workers were
. inhibited from speaking out even to their immediate supervisors, and, notwithstanding I
95 F
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No.5 i
MKF's announced "open-door" pol' icy, had good reason to believe that taking a concern -
'Ebove.an immediate supe. rvisor's head could be viewed as a violation of chain of -
command principles. (This .was illustrated in the ' case of the four laborers who were laid off in March 1993. 'as discussed earlier.) 1 i
Under these circumstances, higher level MKF supervisors and managers, whose ;
i
- view of events depended to a large extent on ;information conveyed to them.by.'
~
subordinate supervisors in their chain of command, were unlikely to obtain a complete ]
^
cnd undistorted understanding of the tensions that existed between workers and their
.immediate supervisors, and between MKF supervisors and RPTs. Thus, the testimony - !
. of higher level MKF personnel such as Hug and Dieter that company policy encouraged tha expression of safety concerns, and precluded intimidation or retaliation against those who expressed them, is not inconsistent with the widespread worker impression to the !
. contrary.- q i
- c. Conclusion A significant cross section of RPTs and MKF workers witnessed behavior by MKF 4.
supervisors which they regarded as intimidating or abusive. This behavior took a variety of forms, ranging from threats of bodily harm toward RPTs who were carrying out ;
rcdiation protection responsibilities to remarks by supervisors that workers felt were ,
bullying or degrading.
. Much of the perceived intimidating behavior emanated from the abrasive styles i of certain mid level MKF supervisors ~and did not reflect either MKF's official policies or !
.the ' actual practices of most MKF managers and supervisors. However, because the [
f f
, e . , _ ,
. No.5 perceived abusive behavior persisted and was associated with. pressure to speed l
'). l production. it appeared to some to represent the expectations of MKF management.
The behavior persisted partly because upper level MKF managers were unaware of the extent to which RPTs and MKF workers felt abused and intimidated, and partly bechese there were genuine differences in the perspectives of workers and supervisors k
concerning the incidents and behavior in question. Some MKF supervisors believed that i
RPTs often unnecessarily delayed production and attempted to throw their weight Mound; accordingly, they tended to view confrontations with RPTs se p;svoked, at least !
in part, by the RPTs themselves. These supervisors also believed that a certain rough style was justified to maintain order and discipline, an attitude which inclined them to i discount corr' plaints from their subordinates as mere griping.
i
- 3. Other Incidents involvino Actions of MKF Suoervisgrji
- a. Crane Overload incident As desenbed earlier in this report, on February 23,1993, an incident occurred involving the overloading of the auxiliary hoist on the reactor building crane while MKF personnel were attempting to remove the PCRV top head access penetration plug. The NRC noted that a PSC assessment of this incident found that "an emphasis on I
schedul[ing] concerns over safety" was a contributing cause.8" Accordingly, we sought to determine the basis underlying the assessment that the incident involved an emphasis cf scheduling over safety; and the effect of this incident on worker perceptions related I
to intimidation and harassment.
97
,l
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..}
The' supervisor'in charge 'of the operation'that led to the incident'was the MKF-I ' night superintendent. Fessenden. As discussed above Fessenden had a reputation
- i
, cmong mariy MKF workers and RPTs for having an abrasive management style that was 1 i _
l intimidating to some of his subordinates. On this occasion,- Fessenden ordered the I
crane operator to continue attempting to lift the plug until three eye bolts connecting the -
1
. rigging to the plug were sheared, causing the cables to pull free.'" The result, according ' '!
j to one MKF observer, was that "the cable busted, and it snapped. And it's a good thing .
.j j there wasn't somebody close by, or it would have hurt him pretty bad." Asked whether l cnyone had tried'to stop the operation before it reached the point of being a prtential' f:
s;fety h'azard, or whether anyone had complained about it later, the same MKF witness' l f.
.st:ted "[Fessenden) is the kind of guy you don't complain . . . because he . . . makes it l l
.known to you that 'That's none of your business. I'm running this show.'"2n An RPT l,
( !
who witnessed the incident stated: l
- - i
+
. We knew it was overstressing the cables that he had from the way they were starting to spin. And he actually ;
- snapped the eyebolts off the cables. Things were flying all l over the place.' And it was simply because he was
' aggravated all their attempts had failed to get the thing out.
He was going to pull it out no matter what. '
i
.The RPT said he attempted to discuss the incident with Fessenden afterwards, but ,
.Fessenden would not talk to him.2n He also asked some of the MKF personnel who l worked for Fessenden about the incident, but they also refused to discuss it because,- I
~
according to the RPT,."[t] hey were scared."2" He added, "[ilf they discussed it, as far j as they knew, they wouldn't have a job."'" l e
L i 98 ;
.I i
i
,a >
1 No.5 i i
. Another MKF witness to the event expressed.the opinion that Fessenden had j been protected by higher MKF management from the' consequences of causing a safety 1 <>
' hazard that would have cost one of the MKF workers his job: "[l]f that had been an i
[ operator or anyone else, we would have been down the road. I don't think anything o happened to him. He had shut down Floor 11 for a whole week, and there's where 80 j percent of the work was going on at the time."2n PSC oversight representatives were in accord with tlye views of MKF and RPT l
- witnesses quoted above to the extent that they believed the incident demonstrated a lack i
i of regard for proper work practices; one noted, however, that MKF management
! ' disagreed and did not take corrective action against Fessenden.:n ]
i When asked about the incident, Fessenden said no one told him he should not j
> continue to try to pull the plug out before the eye bolts snapped, nor did anyone suggest ]
he had acted unsafely after the incident.2 However, Fessenden acknowledged that he l I
t 5
had second thoughts about the incident and that while at the time pulling the plug didn't seem like a bad idea, "maybe it wasn't a good idea."'" He explained:
My problem with the whole incident was that three of
- us, well four actually, 'cause the operator saw it too, if a situation that you had an object with another object sitting on it you were lifting up on it, and the other object was moving, you'd think the whole thing was moving. Physics would tell you that the ladder wasn't moving by itself. So based on the fact we saw the ladder coming up, we thought the plug was coming up.
It was the second incident that happened out here where we got bad information from the client. . . . Had we known all the details of the configuration of that ring, no, I wouldn't do it again. And is it a good lesson learned, yeah,
, ' maybe it is.2'#-
99 ]
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, . No.5- i p
a l
Based upon- Fessenden's own ' account of 'the incident' the~ accounts l of l i
[(: Gyewitnesses, and contemporaneous log entries,2" it is clear that a rational basis existed .
1 -
to support the perception of the PSC oversight personnel and MKF and RPT' witnesses I
to the incident that safety was compromised apparently because of impatience to speed 4
, up production, Equally important, some persons on the scene who might otherwise have !
4
.j raised concerns about what was taking place refrained from doing so because of their, j perception that raising such a concern would be met with hostility. In this respect the j crane' overload incident, like other incidents discussed in this report, illustrates the j
.. i potential consequences of a perception that raising safety concerns might be risky; the l 1
incident also helped reinforce that perception among eyewitnesses to the incident, as l
[
well as among those who heard about it later2 " ]
4
- b. Asbestos incidents To help determine whether an atmosphere prevailed in which personnel were )
inhibited from' expressing safety concerns, MKF workers were asked whether they had cver had such concerns during the decommissioning project, and, if so, what generated tha concern and how was it resolved, in response to this questioning, a number of MKF workers identified concerns related to potential worker exposure to asbestos. Three ccbestos related incidents in 1993 accounted for mor' of these concerns: the first, in Fcbruary 1993, involved the removal of an asbestos containing material called
' flameastic; the second, in March, involved the removal of pipe insulation; and the third,
.in November, resulted from the discovery of loose insulation on the mezzanine level.
Several witnesses raised questions about the way one or more of these incidents had i
a 100
/s No.5
- t l
. 1
,- .been handled, and in particular, whether safety c'onsiderations had been overridden in
[
the interest of production. Additionally, the statements of some witnesses suggested that
- I these incidents either evidenced or contributed to a reluctance by workers to express safety concerns. ' For example, one worker who had a concern about an asbestos .l ,
. incident stated that he refrained from expressing it because he was afraid of being laid !
l
- .. off.2" !
3 (1) Asbestos Abatement Procram i i
Because of the age of the FSV plant, some of the insulating materials that had j to be removed during the decommissioning project contained asbestos. Flameastic, an' l
insulating product often used around electrical equipment, is now produced without
' asbestos. but asbestos was used in flameastic installed in earlier years.2" Similarly, 1 pipe insulation installed when the plant was constructed was much more likely to contain l;
csbestos than more recently installed insulation, such as material used to make repairs j
' t2 old insulation that had been damaged.2" -l Early in the project, an asbestos survey was conducted and a subcontractor specializing in asbestos removal was hired to remove asbestos from identified areas that
- could be disturbed while other work was taking place.2" (As noted earlier the four workers who were laid off in March 1993 originally came te FSV as employees of the ccbestos firm.) The asbestos subcontractor had completed its work and departed from l
\
the site by the fall of 1992.au The project was not designed to remove all asbestos from the site, however, and workers sometimes encountered materials they suspected might l l
contain asbestos.2" In such cases, decisions had to be made about whether to proceed l
~
101.
No.5: j i
- with the work. The guiding principle in making these decisions was to err on the side of ' caution "" as a PSC memorandum instructed workers following the March 1993 '
asbestos incident. the rule was: "If in doubt, check it'out!"2n (2) February 1993 Incident l On February 24.1993, MKF electricians intending to disconnect electrical wiring f
i on Level 7 encountered cable trays containing flameastic.2n At least two of' the i Clectricians recognized the possibility that the flameastic might contain asbestos, from l their " industrial experience." as one put it.29 They were assured by their supervisors, l however, that the flameastic did not contain asbestos, and the work proceeded.'" Later, i cfter the March incident (described below), the electricians were informed that the .
l firmeastic- around the wiring they had removed did contain asbestos and as a i
.pr: cautionary measure, the electricians who might have been exposed to the asbestos 1
- were given x-rays.'" l l
There was some uncertainty in the recollections of the electricians concerning when and under what circumstances the flameastic was tested for asbestos. Two ,
Clectricians recalled that a sample was carved out and given to the MKF safety officer for testing, but they were not sure whether this occurred before or after the work l 1
started.'" Other evidence, however, supports the conclusion that these samples were l t: ken and tested in March, after the asbestos incident in that month prompted a more j general sensitivity to asbestos exposure.'" In February, when the work involving flameastic was done, no testing was conducted. instead, the workers were assured that j l
102 )
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~. , .. . lNo5?
~ '
. :i the flameastic was' asbestos-free on the basis of a Material Safety Data Sheet (MSDS)'
l the MKF safety _ officer had obtained from PSC.2" f
The initial assurance that the flameastic was asbestosdree, followed by the- I
. 1 discovery after the work had been done that it was not, caused one of the electricians. .!
t
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to question whether the flameastic really had been checked for the presence of asbestos - O q
. before MKF supervisors ordered the work to proceed. He kept this concern to himself, ll i however, for fear of being laid off if he expressed it.* l i
-(3) March 1993 incident j in order to move 55 gallon drums along a walkway on Level 7 MKF management' !
determined it was necessary to remove insulation from a system pipe." On March 10, ,
1993,- prior to commencement of the removakwork, representatives of MKF's
- Environmental' Services Division collected a sample of the insulation for laboratory cnalysis to determine whether it contained asbestos.8 The result of the analysis came b:ck on March 11 and was negative for asbestos." Based upon this result, MKF supervisors ordered a group of laborers to proceed with the insulation removal.*
' At around the same time, PSC representatives, having noticed that the lagging cround the pipe insulation on Level 7 was damaged, collected samples to be analyzed f:r asbestos." The PSC samples were also taken on March 10 from the same general crea as the MKF samples, but because the PSC representatives noticed the insulation in the damaged and undamaged areas was different, they took samples from both."
The results of these samples, which were received on March 11, showed the newer 4
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- 0quiation used to repair the damaged area.did not contain asbestos, but the older 7; insulation'did I l
Thus,- on' March 11. MKF received a laboratory report indicating the insulation to L b3 removed contained no asbestos, while PSC received another report on the same date -l l ;
' leading to the opposite conclusion. The evidence from both MKF and PSC sources was j 4 i cssentially in agreement that the reason for this discrepancy was that MKF sampled only j the newer insulation used to repair the damaged area, while PSC took samples of both
- the'new and old insulation.'"- ,
i The MKF and PSC samples were taken independently. The PSC representatives j t
who took the sample did not know of MKF's plans to remove the insulation, and MKF did j u i l _ not know that PSC had taken a sample that had tested positive for asbestos until after :
the workers had removed the insulation.'" When the PSC representatives learned that I
the insulation had been removed, they ordered further work stopped and the area roped ,
off. Additionally, the six workers who had taken part in the insulation removal were f
. notified of possible asbestos exposure and given x-rays. l l As a result of this incident MKF and PSC took steps to increase employee }
I awareness 'of asbestos hazards and to ensure more effective and coordinated !
~
management responses to instances in which asbestos was discovered or suspected. j I
_On March 15,1993, the PSC Program Director for the decommissioning project sent a ,
l n- memorandum to all FSV site rersonrol, urging them to be alert to potential asbestos l
- hazards and en .asing information about asbestos and the kinds of materials likely to [
contain it.'" The memorandum concluded: !
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' . Do not make assumptions about' these materials, unless they . ;
are specifically marked 'as to.the presence or. absence of- l l asbestos. Remember -- Ifin ' doubt, check it out\'*' .l 1
~
" Additionally, the' Westinghouse Team prepared a written asbestos management policy -l l
. that was included in th'e FSV Site Specific Safety Manual.'" j (4) November 1993 incident j
- r. ,
On November 8,1993, workers cleaning the 11th floor mezzanine area noticed. l materials on the floor and. protruding from pipes. that .they suspected contained :
+- ~
. csbestos.'" They brought this to the attention of their supervisors and the MKF safety l
.. . I L officer, who in turn notified PSC.'" The area was roped off, trained asbestos workers q were brought in to clean up, and the personnel who may have been exposed to asbestos- {
f '
i were given x-rays.'"
(5) Analysis :
l
- To some MKF witnesses, the supervisory responses to one or more of the R
- asbestos. incidents raised questions about whether safety standards had been .
- compromised in the interest of production. in part this perception arose from the sequence of events as the workers observed them. First, there were supervisory l casurances that it was safe to proceed with work, followed by discovery of potential i csbestos exposure after the work had started, causing some to question whether they had been misled into working around asbestos.'" After the February incident, for cxample, an electrician questioned whether MKF representatives really had checked for )
the presence of asbestos as they claimed to have done.'" One former MKF supervisor.
characterized the March incident as an example of a production over safety mentality '" i
}
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No.5' r One.of the. laborers laid off on March 9.-1993 referred to that incident'in an OSHA y .
i^ . complaint.2" Even the November incident. which appears to have been handled properly j
- ~ after the suspected asbestos was discovered by workers and brought to the attention of
. 1 supervisors.' led to'some criticism of MKF by those sent to work in the area where the !
} . asbestos was discovered.32t j 4 ,
o To address the harassment /intanidation and related issues that are the subject of this report, it was- not necessary to determine whether applicable; industrial sa'ety f !
r 9
!' standards were violated in connection with the asbestos incidents. For purposes of this 8~
report,'it is sufficient to note that PSC took corrective steps after the March incident, and s .
1
] required the Westinghouse Team to take further steps to strengthen worker awareness ')
of asbestosihazards and improve management responses to them.sr2 Furthermore, ;
MKF's later actions,~ including no recense to the November incident, indicated that the -
L .!
. corrective action had been effective.338 l
< 1
- While we did not seek to assess possible violations of OSHA or other industrial l J
safety' standards relating to the asbestos incidents, we did examine the evidence f 1
5
- underlying the perceptions of some that safety had been compromised. As discussed below, the evidence showed that in each case the actions'of MKF supervisory personnel
- ' evidenced an intention to comply with safety standards, although in the case of the 1
February and March incidents there were apparent flaws in the way 'in which that
... intention was carried out. Because of these flaws, and because not all workers were N i
- aware of'the basis upon which MKF. supervisors initially determined it was safe to 9 4 9
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k proceed with the.. work, an appearance was. created from which some' concluded lor e
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i : suspected that MKF: supervision was unmindful of safety, i 'In the February' incident, the apparent flaw in~ carrying out safety procedures was :l r j
, MKF's reliance'on an MSDS that showed flameastic did not contain asbestos. The MKF. j a
safety officer stated that he obtained the MSDS from PSC, which a PSC representative : I L .
'I ccknowledged may have occurred.22' However, neither the safety officer nor the PSC l
- representative recalled the exact circumstances under which MKF obtained a document i .
that misled its, safety officer and supervisors into thinking there was no asbestos in the {
j' ft:meastic about to be handled by electricians, it can be inferred,-however, that the ,
MSDS obtained by the MKF safety officer applied to more recent versions of the product i-
-- as discussed above, flameastic produced in recent years does not contain asbemos.225 ]
l Because th'e safety officer was not then aware that earlier versions of flameastic had contained -asbestos," he would not have known to inquire whether the MSDS he received covered the ol der version of the same product. Thus, the MKF personnel who l
cuthorized the work to proceed in February did so in the honest, but mistaken belief that th3y had checked a reliable source for the presence of asbestos and found it absent.
- Similarly, the insulation removal work involved in the March incident was allowed to proceed on the basis of a test that, because the sample was drawn only from an area thrt had' been repaired with new insulation, failed to detect the asbestos in the older
. in:ulation surrounding the repaired area. Once again, the actions of MKF. l representatives evidence an intention to protect workers from asbestos, but apparent
- flaws in carrying out that intention allowed potential exposures to take place. These l i.
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7 1 flaws were addfessed in the corrective actions that followed the March incident, which l l"
included educating'all site personnel about materials, such as flameastic and pipe - l 1
^ insulation, that could contain asbestos. l In the November- 1993 incident, workers again ' encountered' material they j suspected contained asbestos.,and several were' critical of MKF for not being more j thorough in checking the work area to insure it was free of contaminants before the work .
' began. However, MKF supervisory and safety personnel appear to have responded. j 1
' adequately once the problem was identified.'" j
- Thus, the evidence did not indicate that MKF supervisory and safety personnel 'l intentionally disregarded safety considerations in connection with the asbestos incidents. l
. j However the appearances created by at least the first two of those incidents, even j though' based in part upon a misunderstanding of what MKF supervisory and safety personnel had actually done, helped reinforce the perception of some workers that j supervisors and managers were more concerned with pushing production than with !
i insuring a safe working environment. For example, one of the three workers laid off on !
March 9,1993, stated that it was his belief that MKF supervisors had intentionally
)
. steered him away from insulation removal work because the supervisors knew he would ;
reise asbestos concerns on the basis of his prior training in asbestos abatement l techniques.'" When they did raise questions about asbestos at safety meetings or
. elsewhere, they were' brushed off.8' As these and' other ' workers described the !
perceived production mentality of their supervisors, there was an implicit message that !
I safety concems would.not be welcomed if they slowed production. This message did j l
1 108 1 i
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No.5 not enginate with the asbestos incidents.'but they tended to reinforce it and contribute I
to the perception by some that 'MKF favored production over. safety.
(6) Conclusion The asbestos incidents both contributed to and evidenced the perception some ,
workers had that MKF management favored production over safety. Some workers felt ,
assurances that the work in question would not involve exposure to asbestos were given :
without checking first (a perception that was largely erroneous). This perception, in turn, .
r;inforced the existing belief by many workers that it was not wise to express safety concerns if doing so would be viewed by supervisors as slowing production.
- c. Alleaations Concernino Carpenter Foreman Early in the investigation, we learned of an allegation that the carpenter foreman
- on the night shift Lester Hugg, was repeatedly using unsafe industrial and radiological work practices; that complaints about these prac+ ices had been made repeatedly to MKF managers, who had ignored them; and that frustration over the stifling of these l complaints had led one carpenter to resign. We investigated this allegation to determine whetner the complaints and MKF management's reactions to them had contributed to an ctmosphere in which safety issues were subordinated to other considerations, and, if so, whether any unsafe conditions were permitted to exist as a result of such an ctmosphere.
(1) Summary of Alleaation The primary witness supporting the allegation was Michael Worthington, a ,
4
. carpenter who had worked for Hugg at FSV from September 1992 until June 1993."'
109 r
M5 According to Worthington, Hugg was unqualified in basic commercial carpentry methods an'd.got his job 'as foreman only through his nephew, MKF Genera! Superintendent,'
Dieter.232 In addition to slipshod carpentry work, which, according to'Worthington, led
- to unsafe scaffolding '" Hugg allegedly engaged in a variety of unsafe work' practices.-
For example, according to Worthington, Hugg frequently' dropped tools and thereby cndangered_ those working below him; chewed tobacco in the protected area, contrary to radiological. protection rules; and passed boards, tools, and other objects across radiological _ barriers, also in violation of the rules."' Worthington said that Hugg's problems in this regard were widely known among those who worked with him, especially.
cmong the carpenters, and Worthington brought them to the attention of MKF managers Alan Westman, the carpentry general foreman, and Fessenden, the night
- superintendent."' According to Worthington, the MKF managers were unwilling to take cny action against Hugg because he is Dieter's uncle."' As a result of making these complaints, according to Worthington,' he was subjected to petty harassment by Hugg cnd eventually quit because he could no longer tolerate working for Hugg."'
Other witnesses corroborated'Worthington's allegation in varying degrees. A 1:borer who assisted the carpenters on the night shift agreed with Worthington that Hugg
' h d repeated 1y used unsafe practices resulting in inadequate scaffolding and violations of radiological protection rules."' A carpenter foreman who worked on the day shift
< recalled that his shift had to repair unsafe scaffolds that Hugg had built during the night
- shift and also recalled Worthington's complaints about Hugg."' Like Worthington, the foreman recalled that the response of MKF managers to the complaints was to instruct 110
No.5: ,
'the other carpenters'to fix the problems. but that no other action would be taken !
concerning. Hugg'because 'of his relationship to Dieter," Another laborer who had
.cssisted carpenters on' the night shift also recalled that Worthington had frequently
' complained about Hugg in relation to dangerous practices such as dropping things. That ;
$ stme laborer also witnessed Worthington telling Hugg that he could not pass a board -
- j. ceross, a radiological barrier because it would violate procedures."' Similarly, ~ a l
)
carpenter on the day shift reported finding inadequate scaffolding he attributed to Hugg.~ l 9
e He also recalled that Worthington had complained about Hugg and had finally quit when ;
~
he could not resolve these complaints through MKF managers."' Additionally, a labor j l
foreman on the night shift and two RPTs had been aware of complaints against Hugg."' '
(2) MKF Resoonse to Alleaation Westmanl the carpentry general foreman, confirmed that Worthington and others hid complained to him about Hugg concerning such matters as Hugg's habit of chewing tobacco, his constructing unsafe and poor quality scaffolding, and his forgetfulness.'"
According to Westman, he was not bothered by Hugg's relationship to Dieter, and had I informed Dieter about the criticisms of Hugg."5 in response to the criticisms, he also U
counseled Hugg about the need to " straighten up our act" and to make sure the scaffolds were safe."' Entries in Westman's log corroborated his statement that he counseled 2
Hugg on more than one occasion after having received criticisms about Hugg.*'
- .- Westman contended that all scaffolding and other carpentry work met safety standards before it was used. if it wasn't built to standards on the night shift, the day shift I
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- v .. carpenters would insure that it was. He said that Hugg admitted he needed to improve f
.c M ' and did improve."'-
Hugg acknowledged being aware that Worthington had complained about him for -
such things.as' dropping tools.'" He said Worthington was a good worker, but was ,
"w'hiny.""' Regarding the substance of Worthington's complaints Hugg acknowledged - l
-i ence having chewed tobacco inside the RCA'and also acknowledged having once, by accident, attempted to hand Worthington a board over an RCA barrier. Worthington had f
rrminded him that this should not be done."' Hugg summarized by saying that this was f his first nuclear job and that he began by making mistakes, but thinks he has mastered the procedures."' l t
Dieter acknowledged having been responsible for bringing Hugg to the FSV i i
l project.'" He stated that the fact that Hugg was his uncle was one reason he was hired, l cnd that Hug, the Operations Manager and the top MKF manager on the FSV project, questioned the hire for this reason '" However, according to Dieter, he never heard
- complaints about the safety of the scaffolding Hugg was producing, and remarked that lit was some of the best scaffolding he had seen."' He characterized Worthington as "a whiner and complainer" and said he thought thn Worthington had been sent to the site
- by the union to cause problems because the uroon was upset over the hiring of persons from out of state '" Dieter acknowledged he/ing heard from an RPT that Hugg had chewed tobacco inside the reactor building.'
LFessenden, the night shift superintendent, offered the opinion that Hugg was a
- good carpenter and foreman who got along well with Worthington, as far as he knew.8" 112 I
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L' Lt:ter in his statement; however,.he acknowledged that Worthington mentioned ."one or ; .l l .
.two minor things" about Hugg, and that he knew there was a~ personality problem j
i between them;- but said this did not sh'ow up much on the job,"" He' also. stated -
[ .i f LWestman never reported problems with Hugg's work."' q (3)- . Analysis ,
- The' weight 'of the evidence supported Worthington's contention that- he had i
- complained to Westman about Hugg on more than one occasion. The evidence further .
4 . .
l l cstablished that at least some of the reasons.for these complaints - dropping tools, i s- . .
chewing tobacco in the RCA, attempting to pass a board across radiological barriers, and ;
- i mistakes in the construction of scaffolding -- were related to safety and were based on ;
. Hugg's actual conduct. Hugg, for e ample, conceded having attempted to pass a board across a radiological barrier on at least one occasion and having chewed tobacco inside .
. the controlled area on another. Hugg contended,'however, that he had trouble adapting l his work habits to the requirements of a nuclear environment, but that he has learned 2- to do so and has improved his compliance with applicable regulations. The evidence
. supports this contention. For examplo, witnesses who supported Worthington's criticisms -l t
of Hugg also stated that, in their opinion, Hugg had improved."' (Worthington was not !
in a position to observe this improvement because he left the FSV project in June 1993.) .
The evidence also supports the conclusion that despite his lapses, Hugg did not !
e cause any significant compromise in safety standards. Worthington, and former MKF ;
i
- carpenter Gary Knapp, for example, stated that when they saw inadequate scaffolding ,
- 1 i they would repair it themselves, or would be ordered to do so by Westman."'
i 4
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The evidence did not support a conclusion that Worthington's complaints about , ,
.- .- 1
'Hugg, coupled with_his resignation : contributed significantly to an atmosphere in which -
, j l
~ production and - scheduling. were ' preferred , over safety l a'nd; procedural compliance.
1 Although Worthingt'on; believed his complaints -went nowhere because of L Hugg's ,
1 .
i
'm rclationship with Dieter. the evidence supports the conclusion that the complaints- , j rasulted'in at least'some counseling sessions between Westman'and Hugg, and that l
' Hugg's overall performance did, in fact, improve.
[ '
+
.(4). -
- Conclusion '!
- . 1 i
I The evidence established that the carpenter foreman on the night shift engaged ?
l Jin practices fr'om t'me i to time that violated radiological procedures or that constituted s j i unsafe industrial work practices. These practices resulted in criticisms of the foreman, j i
. chiefly by a carpenter under his supervision, that were conveyed to the carpenter general . l
. '(
- 5 - foreman.- The general foreman did not ignore the criticisms; he counseled the foreman j i
cnd the foreman's performance has improved. No significant unresolved safety l
- q problems resulted from the foreman's practices because they were corrected before the l
cerpentry work in question was useo. Additionally, the criticisms of the foreman and the responses to those criticisms by MKF supervisory personnel did not contribute l
. significantly to an atmosphere in which workers were reluctant to express safer /
l concern's..
4.- Effect of Certain MKF Policies on MKF Worker Perceotions i
~
The policies of MKF and SEG emphasize safety, support the right of workers to
{ cxpress -safetyi concerns, and do . not condone ' harassment or other adverse 4 ;
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- w. l consequences to workers who express such concerns. However, some MKF and SEG I
! policies!were administered in a way that fueled the perception ~ that production was. fi cmphasized over safety. As discussed below..these policies were sometimes at cross- j purposes with one another, because they were understood and administered differently - j i
ct various levels in the chain of command.
i
- a. "Open-Door" Policy ,
As discussed earlier in this report, MKF's "open-door" policy, while not written, !
l
' was ' emphasized repeatedly by_ upper level MKF managers during safety meetings )
conducted at the FSV site
- Pursuant to the open-door policy, MKF employees were f encouraged'to bring safety concerns directly to Dieter or other high-ranking MKF !
l supervisors and managers if the need arose. A corollary to this policy is that no adverse consequences to the employee should result for raising a concern in this manner." In
'ptrt, the policy reflects the common sense recognition that not all safety concerns will !
be resolved between the employee and his immediate supervisor. Indeed, as the top l i
MKF manager at the FSV site explained, a worker's immediate supervisor might not h clways be the best person to receive the safety concern because the supervisor -
,. 'usually a foreman -is under immediate pressure to keep production moving:
[T]he foreman has the responsibility of safety, but the L foreman also has the pressures of production. So it may not be the best, always the best source to enter a concem [and]
the superintendents are very available."
I Thus, the "open-door" policy recognizes and attempts to ameliorate the inherent tension between legitimate production considerations and the need to maintain safety standards.
9 -
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As illustrated by the' case of the four laborers who were laid off in March 1993,=
s taking a safety' concern directly to a higher level supervisor or manager, thereby going.
~
i., 'over the head of a foreman, can be viewed from the foreman's perspective as a violation ' ,
b cf chain of command principles.' For the "open-door" policy to be e#ective, workers must ]
. . ? -i' 1 be able to employ _it without being charged with circumventing the chain of command, ,
I thereby incurring the displeasure of their foreman -- something that' could result in ' ;
i adverse consequences to them contrary to the intent of MKF's policy against retaliation. j i ;
!~ ' In. connection with the March 1993 layoffs, the general foreman's interpretation of the. 'j "open door" policy differed- substantially from the interpretation 'of higher level MKF -l
!- l managers, in that he believed the laborers had acted improperly by taking a concem .j
. i
- l. directly to a manager. When the laborers were reprimanded by the foreman for going -
b t3 the manager, and were laid off shortly thereafter, the credibility of the "open-door" I'
!, policy suffered.
i p' Additionally, there was evidence suggesting that misunderstanding of the "open- j
. door" policy among foremen and supervisors may have extended beyond the personnel i involved in the layoff incident. Another MKF witness contended he had been rrprimanded for protesting working conditions, which his general foreman felt was
" questioning his authority too much."'" The general foreman who reprimanded him -
a different general foreman from the one involved in the layoff incident - acknowledged i that this disciplinary action was based in part upon his subordinate's tendency to go over his' head and not follow the chain of command." The general foreman said he was surpnsed that his subordinate had gone directly to Dieter, when in 'the general foreman's
+
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No. 5
'opinionLhe should have'come to him first. He also conceded that the fact that the subordinate had gone' to Dieter played 'a role in a later. decision to lay off that worker '" -
iThus,' once again, a general fo' reman apparently penalized a subordinate for takingla -
concern to Dieter, even though. Dieter had encouraged workers to do just that by cspousing thel"open-door"' policy, f f
- b. Disciolinary and Lavoff Policies
-l 1
The potential effect of misunderstandings about company policies is enhanced - j because of the virtually unlimited discretion supervisors have in deciding whom to lay off. l
. t
- Lcyoff ' decisions could be made for entirely subjective reasons that did not need to be 1 i
documented. As discussed earlier in connection with the March 1993 layoffs, such
- discretion and ' lack of documentation do not by themselves discourage the expression ;
cf safety concerns or favor production over safety. The absence of other formal
. company restraints does, however, enhance the importance of upper level supervision cvsr the actions of lower ranking foreman and others who are in a position to influence layoffs. For example, in the cases discussed above in which workers were reprimanded ;
for going to higher level managers over the heads of their foremen, the managers did ;
not intervene to ensure that the workers were not penalized for coming to them with I
concerns. In both cases, it appears the managers in question were not aware that the
. workers had incurred the displeasure of their foremen, and the general foremen, in turn, appeared insufficiently sensitive to the implications of reprimanding workers for taking concerns to higher level managers, t
k f
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I" While' MKF's disciplinary policies required more documentation than its layoff.-
~
policiefL the examples of discipline we reviewed involved highly discretionary actions by'.-
_ . . . i
,. . supervisors with' little ' or no documentation specifying- the conduct leading to' the' !
) discipline. in th'e case of the worker referred to above' who claimed he had been i
. " disciplined for protesting working conditions for example the record of the' discipline L !
F
. cdministered to .him' simply listed " insubordination," and neither the worker. nor:tho'
\
- supervisor- who administered it could recall the exact nature of the alleged 1 insubordination." ~Once again, while MKF's disciplinary policies and practices by .
themselves do not discourage the expression of safety concerns, their subjective and
. loosely documented' nature allows discipline to be administered in a way that, in
(
combination with other circumstances, can . reinforce worker perceptions relating to intimidation and harassment.
in short, there was a lack of communication and coordination between layers of v
l m nagement that undermined the ~"open-door" policy and, in a broader sense, j contributed to the perception that " rocking the boat" - lA raising concerns - can be risky.
- 5. Effect of Certain SEG Policies on RPT Perceptions a
The manner in which certain SEG policies were administered contributed to the impression many RPTs had that an atmosphere prevailed at FSV in which production
~
I considerations took precedence over safety and procedural compliance. In general, the RPTs perceived that their management deferred to an inappropriate extent to the wishes
- of MKF management, resulting in what the RPTs felt was insufficient enforcement of 118 f! !
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rcdiological protection regulations. This attitude can be seen in the RPTs' reaction to the transfer of some RPTs away from assignments on the RFF to other assignments i
considered by some to be less desirable; and in the reasons the RPTs felt the ROR program was ineffective'.
Several RPTs questioned the motive behind SEG management's decision to transfer some RPTs away from the RFF, where they had been working, to what the i RPTs characterized as less desirable assignments, such as monitoring the control point. l In essence, the RPTs believed this had been done to RPTs who had gotten into conflicts with MKF managers, such as Hicks. In the RPTs' view, rotating the RPTs to less -
desirable assignments, iristead of attempting to deal with what they felt was abusive behavior by Hicks and some other MKF superintendents, amounted to retaliation against t
the RPTs for doing their jobs.'" This confirmed the view some RPTs had of their management's acquiescence to MKF, which signified to them an erosion of support for cnforcing safety rules. SEG managers, on the other hand, denied that the i
r assignments were in any way puritive toward the RPTs, or that they were in response t3 conflicts with MKF supervisors. They contended that the reassignments were part of a rotation program to acquaint .RPTs with different jobs at the site.
The evidence was not sufficient to support a conclusion one way or another
- concerning the intent of the reassignment of RPTs who had had conflicts with MKF J
supervisors; it was clear, however, that this pcreeption was widely shared by RPTs and
. that it evidenced the extent to which the RPTs felt unsupported by their management.
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- b. Perceived ineffectiveness of ROR Proaram - .
JAnother manifestation of the' extent to which' RPTs felt a lack of support in - !
t L cnforcing radiological safety rules was the widespread view among RPTs that the ROR .
i program was ineffective. The RPTs who held this view expressed it in_ various ways, !
i most-of which amounted to 'a perception that SEG management did not push for j 1
~a dequate corrective action when an ROR was written.'" . One RPT, for example,. 1 believed 'the lack of " teeth" in the ROR program was because "SEG was sucking up to ,
[MKF) for futur9 jobs and that's why things weren't happening."3" Corrective action, in _
th:se RPTs' view, would' include barring' from the site or taking other appropriate l i
disciplinary action against an individual who repeatedly violated radioactive protection
.. j rules -- particularly in the case of one MKF superintendent, Hicks, who, in their view, fit !
I this description.'" Several RPTs referred to other nuclear plants, where they believed o; closer relationship existed between the writing of RORs and disciplinary actions i
ag inst individuals.'" l The single biggest factor contributing to this perception among the RPTs was the
, ability of one MKF superintendent, Hicks to avoid serious disciplinary action after receiving three RORs. As one RPT. expressed the view held by others,"Danny Hicks !
. . . was allowed to repeatedly violate procedures and get away with it."*" Hicks was i transferred from the site shortly after receiving his fourth ROR, but this, as discussed L . pr;viously, was the result of the threat he made to the RPT who wrote the ROR, and not ;
,necessarily the result of the ROR itself. As one RPT commented after noting the general
- 3. feeling among RPTs that the ROR program had no teeth in it: "I think most of us l
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No.5 thought this way until the incident with Danny Hicks threatening an (RPT). That's the d first time you saw something done, but it took a threat for them to do something."
Long before Hicks' fourth ROR in February 1994, and the threat incident that followed it (described in detail earlier), RPTs had been frustrated by his ability to escape serious discipline after receiving RORs for what the RPTs felt were willful violations of radiological procedures. The circumstances underlying these first three RORs are described below.
(1) HPIR 92-16 The first ROR received by Hicks (actually an HPIR, the PSC equivalent of an ROR, as explained earlier in this section of the report) resulted from an incident that occurred on August 31,1992. At approximately 5:00 a.m. on that date, Hicks painted a cask that was supposed to be shipped that day. The cask was to have been painted l
tha crevious Friday (August 31,1992 was a Monday) by a crew oflaborers under Hicke' supervision, but an injury to one of the laborers prevented that from happening.28" Over the weekend, according to Hicks, he decided to go in early on Monday and paint the cask himself to ensure that it would be ready for shipping by noon that day.
On Sunday, the day befure he painted the cask, Hicks golfed with SEG's RPOS, Zahrt, and George Redmond, a (nembcr cf PSC's overtight team, in the presence of Zahrt and Redmond, Hicks mentioned the need to prepare the cask for shipping, j i
I
. indicating that he intended to go in early the next morning and paint it himself."' Zahrt cnd Redmond recalled that Zahrt warned Hicks not to paint the cask, which was located l I
in a contaminated area, without RPT coverage, and that if he did so, Zahrt would have l 1
l 121 l
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to "wnte [ Hicks] up." Hicks did not recall receiving such a warning and contended that _
when he painted.the cask,' he did not know he needed.RPT coverage.'"' He also _
. contended that an RPT ' Ronald Fuller, had been in the vicinity while he was painting the;
' cask. had seen him doing so, and had' spoken to Hicks without raising any objection to
]
~
what he was doing.'" '
Another RPT, Michael Miles, noticed that the cask had been painted shortly after -
he arrived Monday morning, and recalled that it had not been painted when the RPTs bft the previous Friday. He concluded that someone had painted the cask without RPT -;
i
. coverage, and reported this observation to his supervisor, Zahrt.'" M. Miles and Zahrt -
I then checked records of who had been in the reactor building since Friday afternoon, j cnd found that Hicks was the only MKF employee who had entered during that time,'" )
.in addition to entering the. contaminated area without RPT coverage, Hicks had gained
~ cccess using the wrong RWP.'" On the basis of these violations of radiological protection procedures, M. Miles, with Zahrt's approval, issued an HPIR naming Hicks.'"
M. Miles later told Hicks about the HPIR and the reason for it. From Hicks' reaction, M.
Miles received the impression that Hicks knew what he had done was wrong, but that "it didn't [ bother] him one way or another. . . ."'" As M. Miles summarized his reaction I to Hicks' behavior: "[ Hicks] is the first guy I've ever run across in the nuclear field that would do something (of] this magnitude and then laugh about it."*"
' Although Hicks was counseled by MKF management as a result of this incident, l l
cnd.was warned against future violations of radiological protection rules, he was not i
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otherwise disciplined."2 The failure to take strenger action against Hicks was resented. ,
.1 :
by many RPTs.'"
The relatively mild corrective action taken against Hicks was, however, consistent ,
with the wording of PSC's root cause finding resulting from the HPIR, which stated that ;
the incident occurred, in part, because Hicks'." knowledge of radiological' controls [was] a less than adequate."'" This implied that ignorance, rather than willful disregard of procedures, led Hicks to enter the protected area without RPT ' coverage, a conclusion that was contrary to the views of many RPTs. M. Miles, for example, viewed Hicks .
cetion as a willful violation,'" while Zahrt believed the root cause of the incident was Hicks' " blatant disregard for our procedures and our rules and regulations because he ;
wanted to get the job done."'" Even RPTs who did not know about Hicks' golf course
. conversation with Zahrt and Redmond the day before the cask painting thought he had
~
acted in willful disregard of radiological safety procedures. If Zahrt's and Redmond's
, accounts of that conversation are accurate, Hicks was specifically told not to go in j
without RPT coverage, which would add considerable weight to the view that he acted with knowing disregard for procedures.
When Hicks' account of the golf course conversation is compared to the accounts given by Zahrt and Redmond -- as well as to the documentary and circumstantial cvidence and the statements of other witnesses- it is apparent that the weight of the evidence supports the essential elements of the accounts given by Zahrt and Redmond.
First. Hicks, while confirming that there was a conversation concerning his intention to paint the cask, was vague about its contents, while Zahrt and Redmond 123 I
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e, ._ .. _ _ _ , . _.. . . _. _. . - __ __ . _ _ , _. _
o , 1
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y L recounted'with.some detail and specificity the portions of the conversation that made' - 1 H ; Hicks ' aware he had to have RPT coverage if he wanted to paint the cask.' 3"T Second,
~
the accounts given by Zahrt and Redmond in 1994, as reported by other witnesses, are
-l l consistent in their essentials 'with what.one or both.of them said at 'the time ~ of the ,
tincident; .M.J Miles, for example, recalled that 'Zahrt told him about the golf Lcourse 1
conversation with Hicks at around the time the HPIR was written,'" as did several other ' l persons.'" 'Indeed. Hicks acknowledged that after he had been told about the HPIR cither Zahrt or Redmond, referring back to their golf course conversation, said to Hicks l
- I told you I was going to . . do that (ii, write an HPIR) on Sunday."'"- l In contrast, the accounts given by Hicks in 1992 and 1994 diverged in certain.
' cssential respects. According to Hicks' managers, when he was explaining his actions L to them in 1992 he admitted violating the rules, but portrayed himself as having been set up by Zahrt and Redmond as part of a practical joke in which they induced him to paint l
the cask without RPT coverage, then wrote him up for doing what they had icncouraged.' ' In 1994, when asked whether he had been set up or had been the victim f of a practical joke,' Hicks said he had not,' '
Additionally, Hicks' contention that there was an RPT in the vicinity while he was painting the cask, and that the RPT observed him while the painting was in progress, was contradicted by the RPT in question.'"' The RPT, Fuller, stated he had not seen
- Hicks painting.a cask during the early moming hours of August 31,1992, and if he had, "I'would have kicked him.out of the area and wrote up an ROR on him."'" The
- computerized records documenting access to the reactor building on that date tend to I -
124
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j O
- n .p-a a o - m - m~n a , . - -- -a..- s..s-a- a >..ai,.s ns a-mm e. sa . .o .a.-s u - - . -. n a.s-~e-e.-,ae .esu
_ . .i No.5. -
.., o l
- - 3
'^ support Fullets denial that he saw Hicks painting the _ cask. Hicks is listed as.having -
1
~
sntered the building at 5:09 a.m. and. as having exited at 5:39 a.m.'" Hicks estimated l
. that it took him only 15 minutes to paint the cask, the rest of the time was spent dressing -
i
. in and obtaining the paint and brush.* Zahrt corroborated Hicks' estimate, stating that !
J
'someone who could dress in and.drese out quickly could perform each of those
~
operations in 5 minutes."' Assuming Hicks was able to dress in and dress out quickly,: !
cnd ~ allowing at least some time for him to pick up and later replace the paint and brush',
Hicks would hav,e completed painting the cask at around 5:30 a.m. or possibly a minute l 1
i or two later. The RPT, Fuller, did not enter the reactor building until 5:27 a.m." j Allowing the RPT approximately 5 minutes to dress in would put him in the vicinity of the ,
l c:sk no earlier than 5:32 a.m., even without allowing any time for him to walk there. By l that time, Hicks should have finished painting the cask and have been in the process of j
. i le:ving. At the very most, the RPT might have arrived in time to see Hicks at the end !
)
of his painting of the cask, in any case, it is clear that even if there was a one or two l I
minute overlap during which the RPT could have seen the tail end of Hicks' cask i painting-- which the RPT denies-- it was too late for him to have provided any meaningful RPT coverage of the job. 3 1
in summary the RPT view that Hicks got off lightly after committing a willful
, I violation is backed by considerable evidence. The evidence also indicates that one l l
l reason no more rigorous action was taken against Hicks was the implicit finding in the i
.HPIR that the incident was due more to ignorance on Hicks' part than to a willful j 1
disregard for. radiological procedures. .In this regard, Steven Sherrow, the PSC
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& i rcpresentative who prepared the root cause findings relating to the HPIR, stated that he' l f[ ^
Lwas. unaware of the' golf course conversation when he wrote the findings, and had he . i 1
i been aware that Hicks was warned the previous day not to paint the cask without RPT coverage "I'm certain that I would have made a much stronger recommendation for . l
! disciplinary action."'" Zahrt confirmed that he did not tell either Sherrow or other PSC 1
officials involved in the corrective investigation about the golf course conversation. i i
Hicks' own management, as noted above, was under the impression, on the basis of what Hicks told them, that he had not been warned against painting the cask without j RPT coverage, but, on the contrary, had been " set up" by Zahrt and Redmond.'"
l (2) ROR 93-001 The next incident resulting in an ROR being written against Hicks occurred on J:nuary 27,1993. According to the ROR written by RPT Dennis Beierie:
Approximately 0915 Danny Hicks was observed walking up south stairwell onto RFF [ Refueling floor]. The RFF was posted as NO Entry to Lv 11 at bottom of first landing _ of south stairwell, the elevator and northwest i stairwell. The RFF was posted, No Access, at least 5 l minutes before Mr. Hicks was observed entering RFF Also at [approximately) 0920 Jim Wallace was observed entering RFF [through) same south stairway. Immediately after Mr.
Hicks was observed violating the posting Dennis Beierle walked down south stairwell to verify posting was still up with Red rope blocking stairs. Stairway was still posted. The event was' then reported to Chip Sawyer, the HP RFF Supervisor.
After . an investigation. of the. incident, the ROR . written by Beierie was ' formally dispositioned as " unresolved."
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iThis disposition resulted.in concern among the RPTs. man'y of whom felt it l
.i I ~
marked another example of RPTs not being believed and the ROR program being
-ineffective. One RPT summarized the feeling he and others had toward the ROR
. program after this incident: "[l]t was a joke . . . Danny Hicks could get away with whatever he wanted to get away with."'" f i
The RPTs' reaction to the incident was prompted by the " unresolved" disposition i
following it. which resulted in Hicks' again being counseled and warned about the need 1 to comply with radiological safety rules, but receiving no further disciplinary action. The i
" unresolved" disposition was based upon a finding that "it can not be determined with .
O reasonable degree of certainty that Mr. Hicks did in fact cross the boundary. It is possible th'at the posting was not in place when Mr. Hicks entered the refuel floor."'"
The " boundary" in question was the rope blocking the stairs Hicks climbed, as l
desenbed'in the ROR. According to statements submitted by RPTs at the time of the )
incident. Hicks violated procedures by climbing the stairs and bypassing a warning rope, without having obtained permission to do so from an RPT.'" Hicks' first explanation, as it was recorded at the time by RPT Sawyer, was that after failing to make contact with I
cny RPT in order to obtain permission to climb the stairs t'o the RFF, he noticed that one of the RPTs, Mark Collins, came down the stairs and dropped the boundary rope. '
According to Hicks' statement, as recorded by Sawyer, after speaking with Collins, Hicks
. went up the stairs on the assumption that the boundary' rope no longer prevented him i
from doing so.'" ]
127 i l
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. 1 Collins.'however, denied he had' dropped the boundary rope, and also denied _
speaking.'with or even seeing Hicks on that occasion.'" When Hicks was asked a j j
second time about the ' incident. according to Sawyer's recordation, he stated that he had ;
l not spoken to Collins. but still maintained ne had seeri Collins drop the rope. ' Dieter, l
- . .1 .
'l cn MKF manager, recalled Hicks telling him a different ve,sion of the incident from either - ,
of those recorded by Sawyer:
l I don't know if [ Sawyer) misread that or what. ' But from what - l I got from Danny was that he saw Mark Co!! ins going down 1
- the stairs and when he went up through, there was no j boundary there.'ri l When questioned about the incident in 1994, Hicks said he went up the stairs
'-- cfter seeing Collins drop the rope.'22 Regarding the statements attributed to Hicks that i were recorded by Sawyer after the incident, Hicks denied ever telling Sawyer that he had spoken to Collins, but conceded the accuracy of Sawyer's recordation that Hicks had cl2imed to have seen' Collins drop the barrier.422 Hicks had no recollection of seeing Jcmes Wallace, an MKF carpenter, but contended Wallace later told him that he had come up the stairs right behind Hicks and had seen no barrier.*24
. Richard Sexton, the SEG manager who determined that the disposition of the ROR would be ~" unresolved," stated that he made this determination because, although
. he felt "there was a high probability" that Hicks had crossed the barrier as alleged by the RPTs, " I could not say that with absolute certainty."42s One factor in Sexton's decision
.wns that none of the RPTs had actually seen Hicks cross the barrier, although several
[ recounted the sequence of events in a way that created a reasonable inference that he j had . l 128 I
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This inference would gain strength if one believed the testimony of RPT Collins,-
c .. .. .
i who contradicted Hicks' assertion that Collins had removed the barrier just prior to Hicks'- .
going up th'eL stairs. Thus, the decision concerning the' disposition.of the' ROR'-
i
. depended to a large extent on the standard of proof employed-in this case a very_ high j I
standard that granted Hicks the benefit of the doubt. However, the evidence could have l t
supported a different conclusion under a less rigorous standard. In short, there was
.I considerable evidence to support the RPT view that Hicks had once again committed an -l l
intentional vio.lation of radiological protection rules and had gotten away with it.
, l i
~ This view is further strengthened by evidence that was not considered at the time l of the 1993 ROR. A PSC official, Timothy E. Schleiger, Sr., stated in 1994 during our l investigation that he saw Hicks leap over a radiological barrier.' T. E. Schleigcr could not be sure, however, whether what he observed was related to the January 27,1993 i Lincident underlying the ROR. T. E. Schleiger communicated this observation to i
Zahrt.'" He also recalled seeing Sawyer speak to Hicks after the incident.'32 If what l
)
- T. E. Schleiger observed related to the' January 27,1993 ROR incident, his personal ;
ebservation would appear to supply the necessary missing element that, had it been i
known to Sexton at the time, would have satisfied even the high standard he used is j 1
svaluating the ROR.- However, it is not clear that T. E. Schleiger was observing the i s:me incident. If not, his additional observation, which was communicated to at least I
i one RPT supervisor, would provide additional information to the RPTs concerning Hicks' I
t;ndency to violate radiological protection rules.
)
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I Additional evidence not recorded at the time of the 1993 ROR came from Wallace, i-who was also mentioned in the ROR.'" One MKF manager. . Dieter, said that he believed Hicks' account of the incident over those of the RPTs because of what Wallace told him at the time'-- that Hicks had followed Wallace up the stairs - was "right behind
- him" - and that Wallace also observed that the barrier was down. 'In 1994, Wallace stated to the contrary: he confirmed he had crossed the barrier (but only after obtaining
- permission from the control room)) he did not see Hicks on that occasion; and that the
{ barrier was in place when he went up the stairs.'" Wallace's 1994 statement tends to corroborate the RPTs' version of events, and is consistent with the statement in the ROR th;t Wallace went up the stairs 5 minutes after Hicks, and that the barrier was still in
~
plfce at that time.
In summary, the evidence available after the incident in 1993, as supplemented by additional evidence gathered during our investigation, provides a rational basis for the RPTs' belief that Hicks had intentionally violated radiological procedures, but had not been disciplined for doing so.
(3) ROR 93-014 The third ROR written against Hicks resulted from an incident that occurred on M;rch 30,1993, when, according to the ROR:
Danny Hicks entered tophead area 2 times dressed out on RWP-93-1052 within a 20 (minute) period. The first time he
' entered he was told by Dennis Beierie and David Hatch to
'use RWP93-2241. . He entered area with 1 full set the first 4
time.- The HPs noticed Danny had not taped his legs and that his digidose was not in sight. Upon questioning Mr.
' Hicks it was discovered he had not switched RWP's as earlier directed and he was on RVP-93-1052 which had no 130
No.5<
- provisions for dressout. He was told at that time to leave the area and get on the right RWP. (H]e told the HP he was
.done anyway. Approximately. 20 [ minutes) later Mr. Hicks was spotted in the tophead area again. The.HP made a ;
quick check of the computer and found Mr. Hicks was still on !
. RWP-93-1052. When HP walked over to remove Mr. Hicks he was already undressing. :
. As a result of this incident, Hicks was denied access to the RCA for approximately .
1
~
- two days and was informed by MKF. management that if he became involved with !
another willful violation of radiation protection requirements, he could receive time off without pay.and/or a transfer to another worksite. Hicks was also required to attend a
.special training course on radiological procedures.
~
The root cause classification for this ROR was ' Willful Disregard of Procedural or RWP Requirements."' Like the previous RORs written against Hicks, which many RPTs also felt reflected willful violations, this one reinforced the perception that the ROR program did not have teeth in it, at least as it applied to Hicks.
r~ Hicks admitted violating procedures on this occasion. When he was questioned in 1994, his only explanation was that he " screwed up.""' At the time of the ROR, Hicks convinced his management that his actions were not intentional."' As was true of the previous RORs in which Hicks was named, however, the RPTs' belief that'he acted i willfully had considerable evidence to support it.
v In addition to the circumstances surrounding the four RORs Hicks received, the RPTs' perception that Hicks repeatedly violated radiological protection rules and did so intentionally, was. supported by a number of MKF workers who stated they had seen i
131 l
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Hicks commit:what appeared to be intentional violations of radiological rules and I
, . procedures."2 As 'one MKF worker expressed his reaction to repeatedly seeing Hicks- j violate such rules;
-[T]he only one that really . . . broke the rules all the time was
. big Dan, Dan. Hicks. And just like i told everyone .-- I said, "You know, here he is a supervisor, and_ he's supposed to be .
setting examples for the rest of us, and he's the one breaking .
them.""3 ;
Also contributing to the perception that the ROR program was ineffective 'was the j belief that the SEG RPOS.-Zahrt, " tore up" RORs that had been written by RPTs. Zahrt denied _" tearing.up" RORs after they were written, but acknowledged that at a meeting -
he may have said something to the effect that "I'm not going to process anymore RORs j l
if they are 'not true or meaningful. . . ."'" This is consistent with the view of Zahrt's -
immediate supervisor that Zahrt may have used " tearing up" or words to that effect as ,
i
. O figure of speech to signify that on occasion he would not approve the issuance of an ROR or would discourage RPTs from writing them in particular circumstances."' Indeed, !
Cs discussed earlier in connection with a confrontation between an RPT and an iranworker foreman, an RPT contended that Zahrt discouraged him from writing an ROR l
on_that occasion."' However, we were unable to verify any occasion in which Zahrt l actually tore up an existing ROR."' l i
- _ In summary, the perceived ineffectiveness of the ROR program, like the I . i
. . perception discussed above concerning totation of RPTs from the RFF, reflected the j general alienation of many RPTs from their management and the sense of frustration l i
-they felt at having less authority at the FSV than they had experienced elsewhere at ;
i i
132
---y , , y-, 4 n g - - .,,rq-, ,, - , , -- - , , . , r.--,, - __,,___ _- .---__-----_:
No.5 operating nuclear plants In this case. that alienation was reflected particularly in the RPTs' disagreement with a policy decision by upper level SEG management to make the ROR program nonpunitive in character. As one SEG manager expressed it:
I was aware that a number of the [RPTs] did not agree with the underlying philosophy of how we were implementing the ROR program. They were of the mind set that there should be specific numbers of RORs.
Once an mdividual got three or two or whatever, that that individual would be removed from site. That was clearly their philosophy. And I talked to a number of the, technicians and indicated to them that that could not and would not be oor philosophy here. And I explained the objectives of the ROR program [were] to ensure [an] effective radiation protection program. and it was reos ; disciplinary program."a Thus, in addition to discontent over the perceived lenient treatment of Hicks, the grp between SEG management's corrective action and what the RPTs felt was cppropriate was, in part attnbutable to legitimate philosophical differences over the n:ture and purpose of the ROR program. Upper SEG management viewed the program i
as one intended for problem identification. while the RPTs felt the program should have b:en much more of a disciplinary tool.
As discussed below in Section VI of this report, the same " philosophical 1 difference" concerning the enforcement of the ROR program that separated the RPTs from their management also helped explain the perception of some MKF supervisors that the RPTs were attempting to use the ROR program to harass MKF personnel.
l D. Summarv and Conclusion The evidence supports the conclusion that there has been a widespread parception among MKF and SEG workers at the FSV site that supervisors and managers 133
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No.5 j l
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emphasize production goals over safety and procedural compliance. Further,: as a result t' ,
of this emphasis, there is a perception that a worker who' appears to present an obstacle l j
~
. to production. by raising s'afety concerns risks losing his job. Among MKF workers, this
. perception in large part reflected. cultural' norms in the construction industry, which had j
~
shaped the attitudes of many workers before they came to the' project. The attitudes of: -
g
-i
.many RPTs employed by SEG were also influenced in part by their prior experiences; -
many had worked at operating nuclear plants where their authority to enforce radiological :
safety rules was, in their. view, not challenged as much'as 'it was during the FSV ;
N ~ '
. decommissioning project. This produced a " cultural clash" between the construction i
supervisors and the RPTs."'- , j
- I in addition to the influence of prior work experiences, the perception among MKF j cnd . SEG workers that raising safety _ concerns could result in intimidation and j i
~
- h rassment was fueled by certain events and conditions unique to the decommissioning a project. The most important event reinforcing this perception among MKF workers was the March 1993 layoff of four laborers shortly after they had brought safety concerns to ,
the. attention of MKF suoarvisors and managers. A high percentage of the MKF l workforce became aware shortly after the layoffs that the laborers believed their i Expression of safety concerns was responsible for their departure from the project, and a significant number of MKF workers agreed with this perception. While 'he t evidence . ;
E .did not establish conclusively that the layoffsLwere caused solely or primarily by the 4 workers' expression of safety concerns, there was considerable evidence to support the i
. 134 7
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widespread perception that there was a relationship between the layoffs and the ,
t expression of safety concerns.
-From the perspective of the RPTs, the most important events reinforcing the perception that production was emphasized over safety, and that insistence on enforcing safety standards could . result in intimidation and harassment, were confrontations between MKF supervisors and RPTs, at least two of which involved perceived threats -
of bodily harm by the supervisors toward the RPTS. These incidents not only reinforced
.the RPTs' perception that MKF supervisors had a production mentality that tended to compromise adherence to safety and procedural standards, but also convinced some of them that their own managers would not take steps to support them in the face of pressure from MKF. These perceptions were supported in some instances by substantial evidence. For example, in two confrontations between MKF supervisors and RPTs, the evidence showed that the RPTs reasonably could have interpreted the behavior of the MKF supervisors as threatening and intimidating.
. Among MKF workers, the perception that raising safety concerns could lead to cdverse consequences made some workers reluctant to express concerns. However, the evidence did not support the conclusion that this reluctance resulted in compromising safety standards or concealment of significant safety concerns. Some workers who agreed with the view that expressing safety concerns could be harmful to job security nevertheless voiced such concerns when they had them. Others found alternative means of bringing concerns to the attention of appropriate supervisors or managers, without becoming identified with the concems. Still others had no personal safety s
135
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concerns. but expressed the general opinion that voicing any concerns - or otherwise '
la
" rocking the boat"- would be risky to one's job.
The perceptions of the workers relating to intimidation and harassment, and the view that production was favored over safety, were contrary to the values embodied in the official policies of MKF and SEG, both as the policies were written and as they were )
I interpreted and explained by managers. The gap between the officially expounded i policies and the perceptions of the workers was, in part, the product of attitudes rooted i l
in the culture of the construction industry, over which MKF had only limited control. In
, part, however, the gap between official values and what the workers perceived resulted from the supervisory styles of certain MKF personnel, combined with flaws in communication and coordination among the various levels in MKF's chain of command.
The upper level MKF managers and supervisors, for example, were not even aware that cnyone had contended the March 1993 layoffs resulted from the workers' expression of safety concerns until the NRC began making inquiries into that subject. Similarly, upper-level MKF managers did not know that some supervisors had a reputation for cbrasiveness and abusive conduct toward their subordinates as well as toward RPTs.
l Additionally, certain MKF policies that are neutral on their face were administered in a !
way that reinforced the perception already held by many workers that expressing safety g concerns could lead to adverse consequences. The MKF "open-door" policy, for cxample, by which workers were encouraged to bring safety concerns directly to the attention of high-ranking managers, was undermined when immediate supervisors 136
f f I w: _
No,5: -
. I s
=. -
rIprimanded workers'.for circumventing the' chain of ~ command .when they: went to
- . managers with concerns.
> ' .R h
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n 5
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ENDNOTES: .
?
- 1. San Unsworn Inten/iew Statement of Craig A. Clifton, May 3,1994, pp.18-19
[ hereinafter cited as "Clifton (5/3/94) (Unsworn)"]; Unsworn interview Statement i
of Christopher C. Gonzales, May 3,1994, pp.17, 24 [ hereinafter cited as "C. l Gonzales (5/3/94) (Unsworn)"]; Sworn Interview Statement of Gregory L. Price.
Apr. 26,1994 pp. 61-62 [ hereinafter cited as cited as " Price (4/26/94)"]. ;
- 2. DN 11411.
- 3. Unsworn interview Statement of Marvin W. Henderson, May 11,1994, pp. 25-27
[ hereinafter cited as "Henderson (5/11/94). (Unsworn)"]; Sworn Interview I
Statement of William J. Hug, May 18,1994, pp. 45-46 [ hereinafter cited as " Hug
. (5/18/94)"].
- 4. Henderso,n (5/11/94) (Unsworn), p. 25. l t
S. Henderson (5/11/94) (Unsworn), p. 26.
. 6. 42 U.S.C.A. $5851 (1983).
- 7. 42 U.S.C.A. 55851 (Supp.1994).
B. 42 U.S.C.A. 5851(a) (2) (Supp.1994).
- 9. 42 U.S.C.A. 65851 (a) (1) (Supp.1994).
- 10. Sag .id.; DeFord v. Secretary of Labor 700 F.2d 281, 286-87 (6th Cir.1983)
(holding- that an employee's demotion was '"in deliberate retaliation'" for
. cooperating with an NRC proceeding).
- 11. 42 U.S.C.A. $2011, et seq.
]
- 12. 42 U.S.C.A. 5851 (a) (1) (A-F) (Supp.1994).
4, 1993).
- 14. NUREG 1499, ES-1.
. 15. NUREG-1499, ES-2.
e 138 i
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- i 17.- M.. p. 344: citing NRC Inspection Report No. 50 528/529/530/92-33 (Oct; 8.1992) i; .(Inspection Report 92-33); l J
18; . M.,' pp. 344-45; citing NRC Inspection Report No. 50-528/529/530/92-33 (Oct. 8, !
1992) (Inspection Report 92-33).
(November 24,1992). t l
d 20.. 58 Fed. Reg. No. 146,41108-09 (Monday, August 2,1993). j
. 21. -NUREG-1499. ES 6.
- 22. NUREG-1499.'lli. A-1; ,
- 23. ' NUREG 1499, lil A-2.
- 24. NUREG 1499, ES 2.
., t 3 25. NUREG 1499. ES-2; After the . completion of the -Review Team Report the Executive Director for Operations (EDO) and the staff developed suggestions for implementing the Review Team's list of recommendations. The staff developed g SECY-94-089 which approved most of the Review Team's findings.
i , i Virtually all the recommendations were approved with few exceptions where recommendations were either agreed with in concept or slightly modified, and one
- . proposal, the development of a survey instrument by the NRC, was deferred for six months. The Executive Director and staff did not recommend the publication of the number of technical and H&l allegations and stated that the EDO was not I adopting the recommendation dealing with the revision of the civil penalty provisions pending OE's review of civil penalties. ,
i The Chairman of the Senate committee and the NRC Acthg Secretary approved the Executive Director's suggestions for implementing the Review Team Report and provided limited comments and additional discussion.
- 26. ~ 42 U.S.C.A. 65851 (b) (3) (A) (Supp.1994).
27.- 42 U.S.C.A. $5851 (b) (3) (C) (Supp.1994).
- 28. =42 U.S.C.A; $5851 (b) (3) (B) (Supp.1994). j
~ 29. '42 U.S.C.A. 95851 (b) (2) (A) (Supp.1993).
- 30. _42 U.S.C.A. $5851 (b) (3) (D) (Supp.1994).
139
~
No.5 1
~
' 31. 10 CFR 50.7(d)- (" Actions taken by an employer, or others, which adversely j- affect an employee may be predicated upon nondiscriminatory grounds. The prohibition applies when the adverse action occurs because the employee has engaged in protected activities. An employee's engagement in protected activities ,
does not automatically render him or her immune from discharge or discipline for legitimate reasons or from adverse action dictated by nonprohibited
. considerations.").
- 32. 3.tg Dunham v Brock,794 F.2d 1037 (5th Cir.1986)(holding that insubordination
. was the genuine impetus for the employee's discharge despite his participation l in protected activities): Lockert v. U.S. Deot. of Labor. 867 F.2d 513 (9th Cir.
]
1989). ,
j
- 33. Mackowiak v. University Nuclear Systems. Inc., 735 F.2d 1159,1164 (9th Cir.
1 1984).,
p ;34. = Wriaht Line, a Division of Wrioht Line. Inc., 251 NLRB 1083 (1980), affd, sub ;
2 nom. NLRB v. Wriaht Line,622 F.2d 899 (1st Cir.1981); gag Consolidated Edison l Comoany of New York. Inc. v. Donovan,673 F.2d 61 (2nd Cir.1982). l
. 1
- 35. Mt Healthy City School District Board of Education v. Dovie,429 U.S. 274 (1977).
' 36. jd., citing NLRB v. Transoortation Manaoement Coro. 103 S.Ct. 2469, 2475 I
(1983).
- 37. A survey of cases dealing with whistleblower protection under the ERA revealed
- little discussion of whether an employee had established a prima facie case. In general, the employee's burden has been treated as a light one, as outlined by some courts, which have stated the elements of the prima facie case as: (1) that the employee engaged in protected activity; (2) that the employee was subjected to some adverse employment action; (3) the employer's awareness of employee's
! engagement in protected activity; and (4) that the adverse action followed the j employee's activity so closely in time that it raises an inference of retaliatory motive. '$gg Dole v. County,886 F.2d 147,148 (8th Cir.1989).
- 38. 333 42 U.S.C.A. 5851 (Supp.1994).
- 39. Consolidated Edison v. Donovan,673 F.2d 61 (2nd Cir.1982).
40.' DeFord v.' Secretary of Labor,700 F.2d 281 (6th Cir.1983).
- 41. DeFord v Secretarv of Labor. 700 F.2d 287 (6th Cir.1983) (emphasis deleted).
- 42. Dunham 'v. Brock,794 F.2d 1037 (5th Cir.1986).
- . 43. . Dunham v. Brock,794 F.2d 1040-41 (5th Cir.1986).
i 140 l
^O y -.w.-i 9 % ., .,rsv y =e ,m... . , . - r e .- r
h No.5 -
44; Dunham v; Brock. 794 F.2d 1039 (5th Cir.1986). ,
- 45. . DN 926.
1
~ 46. DN 926.'
- 47. DN 927. .
~
. 48. - DN. 927.
- 49. The Decommissioning Plan, Section 3.2.10.2;(DN 927). states "These types of
' occurrences will be evaluated for possible deficiencies in areas such as training, procedure, equipment and human performance. Appropriate corrective action and ' .
follow up~ will be . required by 'the Project Radiation -Protection Manager' or desigriee." - i L50; - DN 927. -
- 51. DN 928.
- 52. DN .928.~
. 53. DN 928.
- 54. DN 928.
- 55. "ALARA" stands for "as low as reasonably achievable," and refers to a doctrine in the nuclear industry that seeks to minimize worker exposure to radioactivity.
56.' DN 928.
- : 57. DN 6895.
- 58. DN 1408.
- 59. DN 1409.
L
. 60. DN 6877.
. 61. Est, DN 1409; DN 6877-78.
- 62. DN 6896.
4
- 63. DN 6897.
' : 04, ,DN 1409.
141
_.___..__I
.. No,5 l
\
- v. ]
'~
65; DN 1409.
.]
- 66. ' DN 1409, .1414.
- 67. DN .1414.
l
- 68. - PSC's HPIR Program, Section 4.5 (DN 1414-15) states
The summary report shall' include, but is not limited to the following:
a) . ' The total number of HPIR's generated during the period considered.
t >
~b) A breakdown of HPIR's by type and classification.
c), An analysis of trends including recurring causes, jobs, or individuals
., and recommendations to correct trends. Specific mention of personnel involved in two or more HPIR's shall be made. ;
69.- DN 1415.
i
~
- 70. DN 79-90 at 82. l i
- 71. DN 92.
4 !
- 72. DN 89. j
- 73. DN 92. :
, 74. DN 88. t
- 75. DN 88. !
' 76.' DN 87.
- 77. DN 87.
- 78. DN 87. l
}
- 79. Unsworn Interview Statement of Thomas J. Dieter, May 17 and 18,1994, pp. 26- l 31 [ hereinafter cited as " Dieter (5/17/94) (Unsworn)"); Unsworn Interview ,
Statement of Marion L. Herrera, May 5,1994, pp.13-14 [ hereinafter cited as "Herrera (5/5/94) (Unsworn)"]; . Hug -(5/18/94), pp. 22-25; Unsworn Interview l 3
. Statement of R. Dean Ross,' May 18,1994, pp.10-17 [ hereinafter cited as "Ross' !
- (5/18/94) (Unsworn)").
).
142 i j
f s
No.5 P Valdez. May - 17.1994. pp. 37-49 [ hereinafter cited as "Valdez (5/17/94)
(Unsworn)"); Vasquez (5/10/94) (Unsworn), pp. 33-34; Velasquez (5/4/94)
(
(Unsworn), pp. 29-31: Unsworn interview Statement of Richard J. Vidal, May 4, 1994, pp.17-18 [ hereinafter cited as "Vidal -(5/4/94) (Unsworn)"); Wallace (4/18/94), p. 56.
86.' Dieter (5/17/94)'(Unsworn), p. 56; Sworn Interview Statement of Robert R.
Fessenden, May 17,1994, p. 21 [ hereinafter cited as "Fessenden (5/17/94)"];
Henderson (5/11/94) (Unsworn), pp. 28-30; Herrera (5/5/94) (Unsworn), p. 76; Hug (5/18/94), pp. 47-48; Unsworn Interview Statement of Dennis K. Robin, May 16,1994, p. 34 [ hereinafter cited as " Robin (5/16/94) (Unsworn)").
- 87. E2., Schreiner (5/10/94) (Unsworn), p.14.
- 88. Eg , Vasquez (5/10/94) (Unsworn), pp. 22-25.
- 89. T.A. Schleiger (4/19/94) (Unsworn), p. 45.
- 90. Wallace (4/18/94), pp. 66-67.
- 91. See Redmond (4/13/94) (Unsworn), pp. 48-50,
- 92. E a., Unsworn Interview Statement of David P. Hatch, Apr. 5,1994, pp.132-34
[ hereinafter cited as " Hatch (4/5/94) (Unsworn)"]; Sworn Interview Statement of Rick Neely, Apr. 6,1994, pp.10-13, 52-53 [ hereinafter cited as "Neely (4/6/94)"];
Unsworn Interview Statement of Robert A. Rankin, Apr. 6,1994, Volume a, pp.
57-58 [ hereinafter cited as "Rankin (4/6/94) (Vol. a) (Unsworn)").
- 93. h. Sworn Interview Statement of Keith A. Bare, Apr. 27,1994, Volume a, pp.
39-40 (hereinafter cited as " Bare (4/27/94) (Vol. a)"]; Unsworn Inten,.9w Statement of Debra B. Sindelar. Apr. 28,1994, pp.19-20 [ hereinafter cited as "Sindelar (4/28/94) (Unsworn)").
- 94. h, Sindelar (4/28/94) (Unsworn), pp.19-20; Un' sworn Interview Statement of Wayne L Alderman, May 2,1994, pp.11-12 [ hereinafter cited as " Alderman (5/2/94) (Unsworn)"). ,
- 95. h, Bare (4/27/94) (Vol. a), pp.11-12; Daniel (4/12/94) (Unsworn), pp. 9-10.
- 96. h, Sworn Interview Statement of Richard J. Sexton, May 4,1994, pp. 49-50 C (hereinafter cited as " Sexton (5/4/94)"]; Sworn Interview Statement of Joe Edward ;
Parsons, May 11,1994, p.103 [ hereinafter cited as "J. E. Parsons (5/11/94)"]; 1 i
Clifton (5/3/94) (Unsworn), p.11.
, 97.- DN 1358 60.
145 ;
l
l No.5 i
- 98. Herrera (5/5/94) (Unsworn), pp. 8-9; Price (4/26/94), p.13.
{ 99. Unsworn Interview Statement of Danny Hicks, May 25,1994, p.13 [ hereinafter cited as " Hicks (5/25/94) (Unsworn)"]; Robin (5/16/94) (Unsworn), p. 7.
J 100. Price (4/26/94), pp.11-12; Clifton (5/3/94) (Unsworn), pp. 8-9; C. Gonzales (5/3/94) (Unsworn), pp. 5-7.
101. DN 11453 (Lujan); DN 11465 (Price); DN 11438 (Gonzales); DN 11426 (Clifton).
, 102. Price (4/26/94), p. 5.
103. Price (4/26/94), pp.19-23.
104. Price (4/26/94), pp. 22, 28-29, 31.
105. Price (4/26/94), pp. 43-44.
106. Price (4/26/94), pp. 44-45.
. 107. Price (4/26/94), p. 45.
108. Dieter (5/17/94) (Unsworn), pp. 66-67.
109. Price (4/26/94), p. 45, 110. Herrera (5/5/94) (Unsworn), pp. 68-69.
111. Price (4/26/94), pp. 45-46, 76.
112. Price (4/26/94), p. 52.
113. Price (4/26/94), p. 45.
114. Price (4/26/94), pp. 53-57.
115. Price (4/26/94), pp. 58-60.
116. Price (4/26/94), pp. 60-61.
117. Price (4/26/94), pp. 61-62.
118. Price (4/26/94), p. 62.
119. Clifton (5/3/94) (Unsworn), pp. 34-36.
120. Clifton (5/3/94) (Unsworn), pp. 38-39.
146
No.5 '
121. Clifton (5/3/94) (Unsworn), p. 41.
l.
122. C. Gonzales (5/3/94) (Unsworn). p.17.'
123. C.'Gonzales (5/3/94) (Unsworn), pp.19-20, geg id., pp. 23 24.
124, C. Gonzales (5/3/94) (Unsworn). p. 21. ,
125. C. Gonzales (5/3/94) (Unsworn), p. 24, 126. Dieter (5/17/94) (Unsworn), pp. 56-57. >
127. Dieter (5/17/94) (Unsworn), pp. 57-59.
128. Dieter (5/17/94) (Unsworn), pp.' 56-57, 60.
129 . Dieter (5/17/94) (Unsworn), pp. 56-57.
130, Hicks (5/25/94) (Unsworn), pp.147-48. ,
~
. 131. . Hicks (5/25/94) (Unsworn), p.148.
132. . Hicks (5/25/94) (Unsworn), pp.145-46.
133. Hicks (5/25/94) (Unsworn), p.154, 134. Herrera (5/5/94) (Unsworn), pp. 48, 53-55.
135. Herrera (5/5/94) (Unsworn), pp. 76-78. !
136. Robin (5/16/94) (Unsworn), p. 45.
137. Robin (5/16/94) (Unsworn), pp. 50-51.
138. Robin (5/16/94) (Unsworn), p. 50.
139. Dieter (5/17/94) (Unsworn), pp. 62-66.
140. Dieter (5/17/94) (Unsworn), p. 66.
141. Dieter (5/17/94) (Unsworn), pp. 65-66. l D.
142. Dieter (5/17/94).(Unsworn), pp. 66-67. i 143. Dieter (5/17/94) (Unsworn), pp. 50-51.
144. . Dieter (5/17/94) (Unsworn), p. 75.
147 i
No.5 145.~ Herrera (5/5/94) (Unsworn), pp. 62-66. '
~146c Herrera (5/5/94) (Unsworn), pp. 65-66. -
147i Herrera (5/5/94) (Unsworn), p. 62. :
148. .Herrera (5/5/94) (Unsworn), pp. 68-69. ,
149. Hicks (5/25/94) (Unsworn), p.130.
150. Hicks (5/25/94) (Unsworn), p.130.
+
151. Hicks (5/25/94) (Unsworn), p.130.
152. Hicks (5/25/94) (Unsworn), p.130. +
153.' Hicks (5/25/94) (Unsworn), pp.130-31. )
154. Hicks (5/25/94) (Unsworn), p.131.
. 155. Hicks (5/25/94) (Unsworn), pp.131-33.
156. Hicks (5/25/94) (Unsworn), pp.131-33.
157. Hicks (5/25/94) (Unsworn), p.131. i 158. h Valdez (5/17/94) (Unsworn), p. 42; M. Reese (4/27/94) (Unsworn), p.17.
159. h J. Gonzales (4/19/94), pp. 52-54; Knapp (4/21/94), p.17; Redmond (4/13/94)
(Unsworn), pp.14-15. l 160. Workers who expressed support for contention that March 1993 layoffs were related to expression of concerns: Arguello (5/12/94), pp. 23-24; Beall Q/4/94), i
- p. 25; Cletcher (5/4/94) (Unsworn), p. 57; Clifton (5/3/94) (Unsworn), pp. 43-44; l Davis (5/9/94), pp.17-18; Gomez (4/27/94), p. 52; C. Gonzales (5/3/94) l (Unsworn), p.17; Knapp (4/21/94), p. 51; Lucas (5/9/94) (Unsworn), pp.- 28-30; i Ortivez (5/12/94) (Unsworn), pp. 28-29; Price (4/26/94), pp. 59-62; Sablich i (5/2/94) (Unsworn), p. 38; Valdez (5/17/94) (Unsworn), pp. 38-39,47-48.
161. Akers (5/17/94) (Unsworn), pp.18-19; Arguello (5/12/94), p. 24; Beall (5/4/94), pp.
. 25-27; Cletcher (5/4/94) (Unsworn), p. 57; Davis (5/9/94), pp.16-17; Gomez (4/27/94), pp. 52-53; Lucas (5/9/94) (Unsworn), pp. 24-28; Norris (5/3/94), pp. 22-
- 24; Ortivez (5/12/94) (Unsworn), pp. 30-31; M. Reese (4/27/94) (Unswom), pp.
31-33; Sablich (5/2/94) (Unsworn), p. 38; T. A. Schleiger (4/19/94) (Unsworn), pp.
38-41; Schreiner (5/10/94) (Unsworn), p. 20; Valdez (5/17/94) (Unsworn), p. 47; Vasquez (5/10/94) (Unsworn), pp. 33-34; Vidal (5/4/94)'(Unsworn), pp.17-18.
148
No.5 162. Davis (5/9/94), p.15.
163. Arguello (5/12/94), p. 23; Cletcher (5/4/94) (Unsworn), p. 57; Davis (5/9/94), p.19; -
Gomez (4/27/94), p. 56; J. Gonzales (4/19/94), p. 58; Unsworn Interview ,
Statement of David Hernandez, May 3,1994, pp. 29-30 [ hereinafter cited as "Hernandez (5/3/94) (Unsworn)"); Knapp (4/21/94), p. 47; Lucas (5/9/94)
(Unsworn), p. 26; Ortivez (5/12/94) (Unsworn), p. 30; Sablich (5/2/94) (Unsworn), '
- p. 48; T. A. Schleiger (4/19/94) (Unsworn), p. 37; Unsworn Interview Statement of Michael J. Sewald, May 9,1994, p. 20 [ hereinafter cited as "Sewald (5/9/94)
(Unsworn)"); Valdez (5/17/94) (Unsworn), p. 40; Vidal (5/4/94) (Unsworn), p.17.
164. Knapp (4/21/94), pp. 48-49.
165.- Sablich (5/2/94) (Unsworn), pp. 41-42; Vasquez (5/10/94) (Unsworn), pp. 39-42.
166. Sag, 31, Robin (5/16/94) (Unsworn), pp. 44-45; Dieter (5/17/94) (Unsworn), pp.
19-21.
167. Sgg Dieter (5/17/94) (Unsworn), pp.19-23; Herrera (5/5/94) (Unsworn), pp. 41-42.
168. Sgg Dieter (5/17/94)(Unsworn), pp. 18-19,73-74; Herrera (5/5/94) (Unsworn), pp.
76-77; Hicks (5/25/94) (Unsworn), pp.147-50. j 169. Hicks (5/25/94) (Unsworn), p.140; ang Sworn Interview Statement of Clarence Bollman, May 18,1994, p. 8 [ hereinafter cited as "Bollman (5/18/94)").
170. Sworn Interview Statement of Darrel L. Blain, July 7,1994, pp. 9-11 [ hereinafter cited as " Blain (7/7/94)").
171. Herrera (5/5/94) (Unsworn), pp. 52-54. ,
172. Dieter (5/17/94) (Unsworn), pp. 57-60.
173. Herrera (5/5/94) (Unsworn), pp. 56-57; C. Gonzales (5/3/94) (Unsworn), pp. 7-8.
174. Beall (5/4/94), p. 25; C. Gonzales (5/3/94) (Unsworn), pp.15-16.
175. Herrera (5/5/94) (Unsworn), pp. 55-57, 75-78.
.. 176. Dieter (5/17/94) (Unsworn), pp. 61, 73-74.
177. Dieter (5/17/94) (Unsworn), p. 73.
178. Hug (5/18/94), pp. 44-45.
149
4 .
.A 5 -
I
+
179. .~ Dieter (5/1'7 /94) (Unswom),' pp. 51. 67-68. );
/1:
180. 'h, Price (4/26/94). pp. 44-45; Clifton (5/3/94) (Unsworn), p. 38.
~
(181. Dieter (5/17/94) (Unsworn), p. 75. ;
, 1182. ;Herrera (5/5/94) (Unswom), p. 70.
~
'183. Herrera (5/5/94) (Unsworn), pp.' 70-71.
1 184. Hicks (5/25/94) (Unsworn), pp.' 130-31. .
! 185. Dieter (5/17/94) (Unsworn), pp. 62-64; Herrera (5/5/94) (Unsworn), 'p. 61. f i!
'186. Hicks (5/25/94) (Unsworn),'pp. 131,133.
]
" 187( - Dieter (5/17/94). (Unsworn), pp. 65-67; Herrera (5/5/94) (Unswom), pp. 61-64. }
?
~
188. h, J. Gonzales (4/19/94), pp. 52-54; Beall (5/4/94), p. 34. :
l
. '189. h,~ Daniel (5/11/94) (Unsworn), pp.10-11. -
j 190.~ - DN 3422,' p.124 5
, 191. . h, Daniel (5/11/94) (Unsworn), pp.11-12! Lucas (5/9/94) (Unsworn), p.12. j 192. Unsworn interview Statement of David P. Hatch, Apr. 11,1994, pp.102-03 .;
[ hereinafter cited as " Hatch (4/11/94) (Unsworn)").
'j
~
193.' Alderman (5/2/94) (Unswom), p. 25. l i
194. Beall (5/4/94), p. 33; Knapp.(4/21/94), p.17; Lucas (5/9/94) (Unswom), p.12. l 1
195. The date is established on the basis of a log, DN 3423, p. 66; gag Sworn ;
interview Statement of Duane A. Parsons, Apr. 4,1994, pp.143-44 [ hereinafter i cited as ."D. Parsons (4/4/94)"). !
,. 196. Hatch (4/5/94) (Unsworn), p. 62.
- 197. Hatch (4/5/94) (Unsworn), pp. '62, 74-75.
]
" 198: Hatch (4/5/94) (Unsworn), pp. 62-63. l
~199. ~ Hatch (4/5/94) (Unswom), p. 63. i
~
- 200. ; Hatch (4/5/94)'(Unsworn), pp. 64-65.
^
l
- 1. . ,
150 )
- e.
. gn, g; 201. - Hatch (4/5/94) (Unsworn); p. 65. l
- 202.: Hatch (4/5/94) (Unsworn), pp. 65-66; j 203; Hatch (4/5/94) (Unsworn). p. 66 -
204. - Hatch (4/5/94) (Unsworn), p. 66.
1 205. ; Hatch (4/5/94) (Unsworn), pp. 71-72, 206.' Hatch (4/5/94) (Unsworn), pp. 67-69.
207. Hatch (4/5/94) (Unsworn), p. 69.
.t 208. ; D.- Parsons (4/4/94), p.146.-
209. Sworn i
Interview Statement of Keith A. Bare, Apr. 28,1994, p. 23 here
[ na i ter f c eit d <;
Las " Bare (4/28/94)"]; agg Unsworn Interview Statement of Kenneth L. Zahrt, Mar. .j L 28.1994, pp.154-55 [ hereinafter cited as "Zahr+ !3/28/94) (Unsworn)"];. Rankin i
. (4/6/94) (Vol. a), pp. 65-66.
210. Ross (5/18/94) (Unsworn), pp. 55-62.
211. Ross (5/18/94) (Unsworn), p. 55. J i
212. Ross (5/18/94) (Unsworn), pp. 58-59.
1 213. - Ross (5/18/94) (Unsworn), p. 60. :
214. Ross (5/18/94) (Unsworn), pp. 23,36,55. ]
215. T. A. Schleiger (4/19/94) (Unsworn), pp. 20-22. ;
J
.216. Ross (5/18/94) (Unsworn), p. 58. -
1 l
. 217. Ross (5/18/94).(Unsworn), p. 58.
2 218.. Hicks (5/25/94) (Unsworn), pp.114-15. ;
1
- 219. ; fag D. Parsons (4/4/94), pp.147-48. .
i 4 220. San Bare (4/28/94), pp.L 20, 26-27; Hatch (4/5/94) (Unsworn), pp. 68-70; D. ;
. Parsons (4/4/94), pp.148-49; j
- 221. . DN 54. 1 3
151 l q
i i
,, ,I '
. No. 5 :
l* 222.' Sworn Interview Statement of H.' Carson Calton, May 12,1994, p. 24 [ hereinafter
.p . cited as "Calton (5/12/94)"]; Neely (4/6/94), p.17.
223.' . DN 54.
~
.224. - Unswom Interview Statement of Roland E. Sawyer, Jr., Mar. 30,1994, VolumeL a, pp.141-45 [ hereinafter cited as " Sawyer (3/30/94) (Vol. a) (Unsworn)"]; Swom i
. Interview Statement of Rick Neely Apr. 5,1994, pp. 22-24 [ hereinafter cited as !
"Neely (4/5/94)"]. l
- 225. Sawyer (3/30/94) (Vol; a) (Unsworn), p.145. ;
} .226. Neely (4/5/94).- p. 23; Sawyer (3/30/94) (Vol, a) (Unswom), pp.146-48. ,
227,, - Hicks (5/25/94) (Unsworn), pp. 70-80. ;
228 Hicks (5/25/94)'(Unsworn), pp. 85-86. ;
4 229. . Hicks (5/25/94) (Unsworn), p. 87.
230. Hicks (5/25/94) (Unsworn), p. 87. ;
231. Rankin (4/6/94) (Vol. a) (Unsworn), pp. 43-46.
!, 232.. Bare (4/28/94), pp. 28-29. .
233. Vasquez (5/10/94) (Unsworn), p. 38.
[ 234. Vasquez (5/10/94) (Unsworn), pp. 38-41.
s
[r :235. Worthington-(4/19/94), pp. 67-68.
236 : J. Gonzales (4/19/94), pp. 52 54.
237, h, Daniel (5/11/94) (Unsworn), pp.10-12; Unsworn Interview Statement of Craig A. Thorp, May 10,1994, Volume b, pp. 7-8 [ hereinafter cited as " Thorp (5/10/94)
(Vol. b) (Unsworn), pp. 7-8; Worthington (4/19/94), pp.- 43 45; Akers (5/17/94) 4 (Unsworn), pp.' 21-22; Arguello (5/12/94), pp. 26-27.
238. Frye (4/20/94), pp.18-19; Redmond (4/13/94) (Unswom), pp. 28-30.
1239. Swom Interview Statement of Victor Mitchell, May 16,1994, pp.11-13 [ hereinafter - l
< cited as "Mitchell (5/16/94)"). l 240. < Akers (5/17/94) (Unsworn), pp. 21-22; Daniel (5/11/94) (Unsworn), pp.18-20.
4 1241. Arguello (5/12/94), pp.15-18.
152-V
(.
t
)
No.5 )
l l
- 242. Arguello (5/12/94). pp.'17-18. ;
243. J. Gonzales (4/19/94)c pp. 39-40. ;
244. h, Daniel (5/11/94)'(Unsworn), pp.10-12; Frye (4/20/94),'pp.18-19; Thorp (5/10/94) (Vol. b) (Unsworn), pp. 7-8. l 245. h, Arguello (5/12/94), p.15; Daniel (5/11/94)-(Unsworn), pp.15-16; Thorp
- (5/10/94 ) (Vol.'b) (Unsworn), pp. 26-27; Worthington (4/19/94), p. 43.
246. Frye (4/20/94),' pp. 23-24; Unsworn Interview Statement of Michael E. Miles, Apr. ;
27,1994,- pp. 58 59 [ hereinafter cited as "M. Mies (4/27/94)'(Unsworn)"].
- 247. i h, Reavis (5/3/94) (Unsworn), p.14; D. Parsons (4/4/94), p.146. .
248; h, Price (4/26/94), pp. 29-30; Reavis (5/3/94) (Unsworn), pp. 12,14,26;T.A.
- Schleiger'(4/19/94) (Unsworn), pp. 21-22, 26-27; Beall (5/4/94), pp. 29-30. >
249. h, Cletcher (5/4/94) (Unsworn), p. 29; Beall (5/4/94), p. 29.
250. h, Gomez (4/27/94), pp. 33-36: J. Gonzales (4/19/94), pp. 48-50. ,
251. Knapp (4/21/94), pp.'46-50.
252. Knapp (4/21/94), p. 70.
253. Redmond (4/13/94) (Unsworn), p. 56. i 254. Redmond (4/13/94) (Unsworn), pp. 14, 56-57.
i 255. Dieter (5/17/94) (Unsworn), pp.112-13.
- 256. Dieter (5/17/94) (Unsworn), pp.152-53. ,
- 257. Fessenden (5/17/94), pp. 33-37. ;
258. Fessenden (5/17/94), pp. 26-27.
259. Fessenden (5/17/94), p. 35. ;
260. Fessenden (5/17/94), pp. 24-25. ;
261. . Fessenden (5/17/94); pp.~ 25 26. ,
262. Ross (5/18/94) (Unsworn), p. 36; Herrera (5/5/94) (Unsworn), pp. 94 95. l 263. Herrera (5/5/94) (Unsworn).' pp. 94-95. .
153 ;
d y -e # w - _ . - _ . , _ r
7 ,
, No.5- .
. t C
~
l'
- L264
- Nrguello (5/12/94). pp?17-18.
. - 265. !Cletcher (5/4/94) (Unswom), p. 33.s 266f (Knapp (4/21/94) pp.'44 45.
~ '
267... Hug (5/18/94),"pp. 36.l55 56,94-96. -i
. .'268; . Sgg Hug (5/18/94), pp.23-30c .
- j
~ 269. Sggi g.1, Hug (5/18/94). 'ppi 88 94.122-1'26. ,
270. DN 24. 1
- j. 1271. ' DN 24; DN 10046. pp.1'5-17i Daniel (5/11/94) (Un' sworn), pp,12-13i DN'4158, I. . p. 2.
..'272i ?Arguello L(5/12794),1p.15. LWhile this witness'said the cable " busted". and -
" snapped," it appears from the other evidence that the cables themselves did not ~
- break,' but 'became detached when the eye bolts sheared.-; However, this - F
- distinction would not necessarily be visible or important to an observer who saw
' the cable suddenly detached and flying around.
273. - Arguello (5/12/94), pp.15-16.
. 274. ' Daniel (5/11/94) (Unsworn), p. 13.
275. ' Daniel (5/11/94) (Unsworn), p.14, 276i Daniel (5/11/94) (Unsworn), p.15. a
<277- _ Daniel (5/11/94) (Unsworn), p.15.
-278. Cletcher (5/4/94) (Unsworn), p.'27. ,
279. Frye (4/20/94), pp.17-18; Redmond (4/13194) (Unsworn), pp. 53-54.
~280. : Fessenden (5/17/94), p. 60.
281. Fessenden (5/17/94),' pp 60-61.
L 282. lFessenden.(5/17/94), pp. 61-62.-
283.- DN ~10046, pp.15-17; DN '4158, p. 2.
- 284. L EL2; 'Arguello (5/12/94),'pp.?15-16; Daniel (5/11/94) (Unsworn),' pp.14-15; Frye
-(4/20/94),'pp.18 20,;
.154-
. - # u E - ._:-.. :_ m _ .u .. .
l No.5 i
285. Beall (5/4/94), pp. 21-22.
- 286. Unsworn Interview Statement of Robert Garnhart. May 11,1994, pp. 65-69, 79
[ hereinafter cited as "Garnhart (5/11/94) (Unsworn)"); Hug (5/18/94), pp. 58-61; !
Robin (5/16/94) (Unsworn), pp. 67-68; DN 11329.
287. Garnhart (5/11/94) (Unsworn), pp. 25-27; ggg DN 11115-24.
288. DN 11062, 289. Sworn Interview Statement of Terry D. Staley, May 11, 1994, pp. 12-13 ;
[ hereinafter cited as "Staley (5/11/94)"]; Henderson (5/11/94) (Unsworn), pp. 5, 33-34; Clifton (5/3/94) (Unsworn), pp. 6-7.
- 290. Sgg Staley (5/11/94), pp.18-21: Unsworn interview Statement of Chris T. Carville, May 12,1994, p. 6 [ hereinafter cited as "Carville (5/12/94) (Unsworn)"].
291. Sag Henderson (5/11/94) (Unsworn), pp. 51-53; Staley (5/11/94), pp. 21, 51, 292. DN 11115-16. f 293. Sgg DN 1116 !.7..
294. Beall (5/4/94), pp.14-15; Norris (5/3/94), pp. 30-33.
295. Beall (5/4/94), pp.18-19.
296. Sep DN 11161-71.
297. Beall(5/4/94), pp.16-19; Sworn Interview Statement of Clifford G. Norris, Sr., May 12,1994, pp.10-13 [ hereinafter cited as "Norris (5/12/94;").
298. Contemporaneous MKF records show that the only testing of the flameastic was done in March 1993. DN 11161-71.
299. Sig Carville (5/12/94) (Unsworn), pp.12-13.
. 300. Beall (5/4/34), pp. 21-22.
301. DN 11099. ,
302. DN 11099.
303. DN 11099,11155.
304. DN 11090; Carville (5/12/94) (Unsworn), pp. 5-6. l 3
155
No.5' 305. ~Staley (5/11/94), pp. 32-34 ,
306. Garnhart (5/11/94) (Unsworn),' pp. 25-26.
307. Garnhart (5/11/94) (Unsworn), pp. 26-27; Staley (5/11/94), pp. 35-36; DN 11159.
308. See Staley (5/11/94), p,- 36-37: Garnhart (5/11/94) (Unsworn), pp. 24-30; Henderson (5/11/94) (Unsworn), p. 45; Carville (5/12/94) (Unsworn), pp. 8-11. ;
309. Garnhart-(5/11/94) (Unsworn), pp. 30-31, 47-48; Staley (5/11/94), pp. 34-36; Carville (5/12/94) (Unsworn), pp. 6-9. ;
t 310. Garnhart (5/11/94) (Unsworn), pp. 31-32; DN 11099-100,11147.
. 311. DN 11078-79.
3 312. DN 11079 (emphasis in original).
313. DN 11363 79.
I
. 314. DN 11135-37; Ortivez (5/12/94) (Unsworn), pp. 15-17 Cletcher (5/4/94)
(Unsworn), pp. 48-49.
315. DN- 11135-37; Cletcher (5/4/94) (Unsworn), pp. 48-52; Ortivez (5/12/94)
(Unsworn), pp.15-18; Vasquez (5/10/94) (Unsworn), pp. 51-54. !
316. Sgt DN 11135-41; Henderson (5/11/94) (Unsworn), pp. 59-60. i 1
317. Sgg, 31, Thorp (5/10/94) (Unsworn), p. 23; Cletcher (5/4/94) (Uns vorn), pp. 50-55..
318. Beall (5/4/94), pp. 21-22.
319. Gomez (4/27/94), p. 58, 320. C. Gonzales (5/3/94) (Unsworn), pp. 28-34.
321. Sag Cletcher (5/4/94) (Unsworn), p. 48; Vasquez (5/10/94) (Unsworn), pp. 51-55.
322. Sgt DN 11344-79; DN 11098-100; DN 11077-79.
323. Sgt Staley (5/11/94), pp. 50, 54, 70-73; Henderson (5/11/94) (Unsworn), pp. 51-52, 62-63; Cletcher (5/4/94) (Unsworn), pp. 54-55.
324. Carville'(5/12/94) (Unsworn), pp.14-18; Staley (5/11/94), pp. 58-60.
325. Sag Staley (5/11/94), p. 60; Garnhart (5/11/94) (Unsworn), pp. 65-68. l 156
No.5 326. - Carville (5/12/94) (Unsworn), p.17. !
327. Cletcher (5/4/94) (Unsworn),'pp.48-55i Vasquez (5/10/94) (Unsworn), pp. 51-55; Ortivez (5/12/94) (Unsworn), pp.12-13.
328. Sfa _Staley (5/11/94), pp. 52-53; Vidal (5/4/94) (Unsworn), p. 31.
329. Clifton (5/3/94) (Unsworn), pp. 53-55.
330. San Clifton (5/3/94) (Unsworn), p. 57; Price (4/26/94), pp. 84-87.
331. Worthington (4/19/94), pp. 4-5, 8.
332. Worthington (4/19/94), pp. 9-11.
333. Worthington (4/19/94), pp.11, 39-42.
334. Worthington (4/19/94), pp.1516. 22 27.
335. Worthington (4/19/94), pp. 24-25, 42-43, 47.
336. Worthington (4/19/94), pp.18,24-25,46.
337. Worthington (4/19/94), pp. 55 59. )
l 338. J. Gonzales'(4/19/94), pp.12-24. l l
339. Knapp (4/21/94), pp. 54-56.
340. Knapp (4/21/94), pp. 55-56.
341. Sworn Interview Statement of Kenneth R. Russell, May 10,1994, pp.15-18
[ hereinafter cited as " Russell (5/10/94)"]. i 342. Wallace (4/18/94), pp. 9-14.
l 343. Arguello (5/12/94), pp. 25-26; Daniel (5/11/94) (Unsworn), pp. 5-7; Thorp (5/10/94) ;
(Vol. b) (Unsworn), pp.10-12. l 344. Unsworn interview Statement of Alan K. Westman, Apr. 20,1994, pp. 41-45, 50
[ hereinafter cited as "Westman (4/20/94) (Unsworn)").
345. Westman (4/20/94) (UnswoIn), pp. 60-61.
346. Westman (4/20/94) (Unsworn), p. 57.
i a
157 !
l
No.5 347. - DN 9970-10022 at 9991,9998i Unsworn Interview Statement of Alan K. Westman.
Apr. 25,' 1994, pp. 28-30. 33 [ hereinafter cited as "Westman (4/25/94)
(Unsworn)"). ;
.348. Westman (4/20/94) (Unsworn), pp. 43-46.
349. Westman (4/20/94) (Unsworn), pp. 58-59. i 350. Unsworn Interview Statement of Lester C. Hugg, May 12,1994, pp.14-15 i
[ hereinafter cited as "Hugg (5/12/94) (Unsworn)").
351. Hugg (5/12/94) (Unsworn), pp.11-12. ;
352. Hugg (5/12/94) (Unsworn), pp.18-19.
353. Hugg (5/12/94) (Unsworn), pp. 21-22.
354. . Dieter (5/17/94) (Unsworn), p.11.
355. Dieter (5/17/94) (Unsworn), p. 76. ;
356. Dieter (5/17/94) (Unsworn), p. 77-. ;
357. Dieter (5/17/94) (Unsworn), pp. 78-79.
358. Dieter (5/17/94) (Unsworn), p. 80.
359. Eessenden (5/17/94), pp. 28-29.
360. Fessenden (5/17/94), p. 29.
361. Fessenden (5/17/94), p. 31.
362. g.1, Arguello (5/12/94), p. 28; Daniel (5/11/94) (Unsworn), p. C.
363. Worthington (4/19/94), pp. 40-42; Knapp (4/21/94), pp. 54-55.
364. Egg Dieter (5/17/94) (Unsworn), p. 50.
365. S.gg Hug (5/18/94), pp. 44-45.
366. Hug (5/18/94), p. 43.
367. Knapp (4/21/94), pp. 32-34.
368. . Westman (4/20/94) (Unsworn), pp.14, 33.
I 158 l
i
No.5 [
369. - Westrhan (4/20/94) (Unsworn), p. 33.
~
~
370. Sag Knapp (4/21/94) pp. 33 34; Westman (4/20/94) (Unsworn), pp. 37-39.
i 371; h, Hatch (4/5/94) (Unsworn), pp.134-36i' Neely (4/6/94). pp.10-12, 52-53; :
Rankin (4/6/94) (Vol, a) (Unsworn), pp. 57-58; Sworn Interview Statement of .
Duane A. Parsons, Apr. 25,1994, pp. 61-69 (hereinafter cited as "D. Parsons (4/25/94)"J. .l 372. ~ Seg' J. E. Parsons-(5/11/94), pp.113-14; Sexton (5/4/94) (Vol. a), pp. 76-77 Unsworn interview Statement of Kenneth L. Zahrt,~ Mar. 29,1994, Volume b, pp.
146-50 [ hereinafter cited as "Zahrt (3/29/94) (Vol. b) (Unsworn)"J.
'373. h, Sindelar (4/26/94) (Unsworn), pp.11-13; Bare (4/27/94) (Vol, a), pp. 39-40,
. 45-47; Unsworn interview Statement of Michael E. Miles, Apr. 26,1994, pp. 27-29
[ hereinafter cited as "M. Miles (4/26/94) (Unsworn)"]; Hatch (4/5/94) (Unsworn),
j p.26. j 374. Sindelar (4/28/94) (Unsworn), p. 20. i 375. h, Hatch (4/5/94) (Unsworn), pp. 24-25; D. Parsons (4/4/94), p.129; Bare )
(4/27/94) (Vol, a), pp. 45-46. j
?
376. Sawyer (3/30/94) (Vol, a) (Unsworn), pp.130-31; Bare (4/27/94) (Vol. a), p. 24; Hatch (4/5/94) (Unsworn), pp. 34-36.
377. Alderman (5/2/94) (Unsworn), p.13.
378. Sindelar (4/28/94) (Unsworn), p.13.
l 379. Hicks (5/25/94) (Unsworn), pp.11-12; DN 796-802. ;
i 380. Hicks (5/25/94) (Unsworn), pp.12-14. !
381. Hicks (5/25/94) (Unsworn), pp.14-15, 382. Redmond recalled playing both golf and racquetball with Hicks that weekend and !
thought the conversation occurred after the racquetball game. However, both j Hicks and Zahrt recalled it occurred while they were playing golf. Hicks (5/25/94) l
- (Unsworn), pp.15-16; Zahrt (3/28/94) (Unsworn), pp.110-11; Redmond (4/13/94) l (Unsworn), pp. 20-21, 383. Zahrt (3/28/94) (Unsworn), pp.111-12; Redmond (4/13/94) (Unsworn), p. 22. ,
- l 384. ' Hicks (5/25/94)'(Unsworn), pp.17,19. !
I
-159 i 7
- - v. - - .--. ,-- y
,~
No.5 :
~
<385.- Hicks (5/25/94) (Unsworri), p. 20.
~
i
'386. MIMiles.(4/26/94) (Unsworn), pp.11-12.
1387.l M. Miles (4/2G/94) (Unsworn), p.~ 12.
3881 Zahrt (3/28/94) (Unsworn), pp.102-03. ;
389.- DN 796-802, 390. M. Miles (4/26/94) (Unsworn), p.17. !
391. M. Miles (4/26/94) (Unsworn), p.18. ;
392.' Hicks (5/25/94) (Unsworn), pp. 24,28-29; DN 799.
393. fa, Za'hrt (3/28/94) (Unsworn), pp. 100-01,125; Bare (4/27/94) (Vol. a), pp.17- f
- 18. i i
394. . DN 798.
395. M. Miles (4/26/94) (Unsworn), o. 21.
396. Zahrt (3/28/94) (Unsworn), p.128.
397. Comoare Hicks '(5/25/94) (Unsworn), pp.15-18 with Zahrt (3/28/94) (Unsworn), f pp.110-12 and Redmond (4/13/94) (Unsworn), pp. 21-22.
,398. M. Miles (4/26/94) (Unsworn), pp.1415. ;
399. Sworn Interview Statement of Lester C. Hutchins, May 16,1994, pp. 23-24 I. [ hereinafter cited as "Hutchins (5/16/94)"); Blain (7/7/94), pp.11-12; 9xton (5/4/94) (Vol. a), pp. 43-44. 1
. 400. Hicks (5/25/94) (Unsworn), pp. 25-26.
401. Hug (5/18/94), pp. 81-83; Dieter (5/17/94) (Unsworn), pp.120-23.
402. Hicks (5/25/94) (Unsworn), p. 26.
403. Sworn Interview Statement of Ronald D. Fuller, July 6,1994, p. 5 [ hereinafter
~'
cited as " Fuller (7/6/94)").
.404. Fuller (7/6/94), p. 5.
405. DN 802.
160 -
o r
'~
. No.5 l l- 1 400. Hicks (5/25/94) (Unsworn), p. 18.
407. Zahrt (3/28/94) (Unsworn), p.109.
408. Fuller (7/6/94), p. 5: DN 12342. ;
409. Sworn interview Statement of Steven S. Sherrow, May 10,1994, p. 28 [ hereinafter cited as "Sherrow (5/10/94)"].
~ 410. . Zahrt (3/28/94) (Unsworn), pp.129-30.
411. Hug (5/18/94), pp. 82-83; Dieter (5/17/94) (Unsworn), p.122; 33g alig Calton (5/12/94), pp.12-14.
412.' DN 301-02.
413. DN _3041333 Bare (4/27/94) (Vol. a), p. 21.
r 414. EA, Bare (4/27/94) (Vol. a), pp. 21-22; Sawyer (3/30/94) (Vol. a) (Unsworn), pp. ;
111-12; D. Parsons (4/25/94), pp. 54-56.
.. l 415. Bare (4/27/94) (Vol. a), p. 23. ,
416. DN 306.
417. Sag DN 307-10.
418. DN 306-07. i i
'419. DN 307. I
.420. DN 307.
421. Dieter (5/17/94) (Unsworn), p.148.
422. Hicks (5/25/94) (Unsworn), p. 32. j i
423. Hicks (5/25/94) (Unsworn), pp. 34-35.
424. Hicks (5/25/94) (Unsworn),' p. 37. ,
i 425. Sexton (5/4/94) (Vol, a), p. 55.
426. Sexton (5/4/94)_(Vol. a), p. 57 427. Sag DN 307-09; Unsworn Interview Statement of Roland E. Sawyer, Jr., May 3, 1994, pp.1315 [ hereinafter cited as " Sawyer (5/3/94) (Unsworn)").
161 I
No.5 >
428. . Sag DN'307; Unsworn interview Statement of Mark A. Collins, Apr. 26,1994,pp.
- [- 7-15 [ hereinafter cited as " Collins (4/26/94) (Unsworn)"]. :
'429. Sworn interview Statement of Timothy E. Schleiger, Sr., Apr. 15,1994, pp 8-21
[ hereinafter cited as "T. E. Schleiger (4/15/94)"].
430. Tc E. Schleiger (4/15/94), pp. 52-53.
431. T. E. Schleiger (4/15/94), p. 50.
432. T. E. Schleiger (4/15/94), p.14.
433. San DN 301-02. !
434. Dieter (5/17/94) (Unsworn), pp.129-30.
435. Wallace'(4/18/94), pp. 30-34. i 436. DN 399-400.
. 437. DN 403: J. E. Parsons (5/10/94), p. 68. )
1 438. DN 402.
439. Eg, Bare (4/27/94) (Vol a), pp. 39-40; Unsworn Interview Statement of Ronald D. Gentry, Apr. 26,1994, pp. 40-41 [ hereinafter cited as " Gentry (4/26/94)
(Unsworn)"). ,
1 440. Hicks (5/25/94) (Unsworn), p. 44 441. Dieter (5/17/94) (Unsworn), p.146.
~442. h, Cletcher (5/4/94) (Unsworn), pp. 29-33; Clifton (5/3/94) (Unsworn), pp.14-17; Gomez (4/27/94) (Unsworn), pp.12-16; gag ghto C. Gonzales (5/3/94) !
(Unsworn), pp.11,12; Price (4/26/94), pp. 33-35.
443. Cletcher (5/4/94) (Unsworn), p. 33. 1 444. Unsworn Interview Statement of Kenneth L. Zahrt, July 14,1994, p. 4 [hcreinafter cited as "Zahrt (7/14/94) (Unsworn)"). ,
445. Sexton (5/4/94) (Vol. b), pp.107-08; gag DN 60.
446, Bare (4/28/94), p. 26.
447. Sag,3.1, D. Parsons (4/4/94), p.136. !
162 i
- ' No. 5 ;
- n. I
-i '
448. : Sworn Interviews Statement !of; Richard J. Sexton, May '5, '.1994. 'pp. ~ 49-50 ;
l r.
'[ hereinafter cited as." Sexton (5/5/94)"J. ,
- 449.: 'Sga Sexton (5/5/94), p. 49. !
i I
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3
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. 163 :
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No.5- j m.
. ., .. 1 LVL DISCUSSIONLOF ISSUE:- WHETHER SEG EMPLOYEES USED'THE ROR l PROCESS TO INTIMIDATE AND HARASS MKF WORKERS l l
,,.. At : the 'beginning of our investigation.'during background briefings with PSC and.
Westinghouse- Team ; representatives, it'was suggested that some MKF personnel believed RPTs hac used the ROR process to intimidate and harass MKF workers. Such j l
- c' perception.2if it existed, would mirror some 'of the issues discussed in the previous j i
s:ction of this report, which dealt with alleged intimidation and harassment running in the ,l
- cther direction -- by MKF supervisors toward RPTs employed by SEG. Accordingly, we j sought to deteririine whetter and to what extent this perception existed among MKF l
)
personnel, and whether there was a factual basis for it. !
+ A.' Nature and Oriain of Perception l q
'1. General Perceotion of ROR Proaram j The non supervisory MKF employees almost unanimously described their .i l
rciationships with the RPTs in favorable terms and did not express t iy belief that the ;
J
! RPTs had intimidated or harassed them. While some MKF workers were critical of ]
findividual actions by RPTs. the vast majonty of them viewed the RPTs as looking out for tho workers' safety and, in many cases, constituting a buffer between the MKF workers
- cnd their own supervisors.' At the same time, there was a perception shared by some j i
- MKF workers, as well as supervisors and managers, that the ROR program had a ]
)
punitive dimension. Specifically, it was believed that if MKF employees rece 6d three j I
? RORs they would be. discharged, according to what some witnesses described as a I i
"one. two, three, you're out" rule.2 {
s f
.164
-_-,_---.___._l
No.5 .
The MKF perception that the ROR program was a punitive "one, two, three; you're ~
.c N ' out" mechanism appears " to have had its - origins ' in - the early days of the -
. d: commissioning' project, at a meeting between SEG managers and supervisors and MKF personnel As one MKF. manager recalled the meeting:
,[Wjhat I can remember is that it was pretty much laid out that'this was more of a disciplinary action for the HPs to ;
.be able to' control the' workforce, if. you got three [RORs] .!
against you, . . . your badge would be pulled. Well, as soon i as they pull your badge, I can't use them anymore.'
The same manager characterized the authority to issue RORs as " basically an [RPT's]
. h:mmer, that was their control."'
An MKF worker also recalled the ROR program being perceived as a punitive m:chanism:
I know there - was1some confusion at the very beginning'of the project about the ROR program, and it was felt that many of the hands understood it to be that if.you received three RORs that it was the same thing as three written notices of disciplinary action from [MKF), and either 7ne of three items happening to you would result in your termination.' -
Other MKF witnesses drew a connection between the perceived punitive dimension of the ROR program and the tension that existed between MKF and SEG personnel, g especially in the early days of the project. As one MKF supervisor described the :
atmosphere in the early days: "[T]here have been some occasions where comments j i
) _w ere made [by- MKF' personnel] and it was like these people [RPTs] imposed their 1 authority . . . just to get even. That's been changed. That was changed some time
- .ago."' .. Another MKF witness made a similar point
t 165 i
No.5 Oh. probably our guys would say, hey. they were being' harassed some, And maybe there was a little bit of j that. but that's kind of a two-way street. Everything in the '
beginning, like i said, we had a couple of RORs, and, hey, you got to play by the rules. And sometimes you don't agree with them you know, but maybe the guys overreacted. .
. I never saw it as a huge problem. Not much of a problem at ;
all. '
Apart from the suggestions contained in remarks such as those quoted above, the perception that the ROR program had a punitive character did not translate into a g::neral perception that RPTs abused their authority by using RORs to harass or intimidate MKF' personnel.
SEG managers denied that the purpose of the ROR program was punitive, or that at was used to harass or intimidate MKF personnel.' However, because of the potential for tension: inherent in the " policing" role played by the RPTs, SEG witnesses ccknowledged being viewed by MKF personnel as persons who could impose sanctions on them. As one RPT out it:
I could see where craft workers could conceive that this would be something like a controlling tool on them. [1]f I was in a laborers' shoes and was going in there to do a job and I had an HP technician watching me do my work, I would be self-conscious about what I am doing, and I know there is a possibility that an ROR could be written against me for doing something wrong.'
indeed, the SEG documents setting forth rules applicable to the ROR program contemplate that under some circumstances an ROR could lead to disciplinary action.'
- Additionally, the "one, two, three, you're out" interpretation of the ROR program, while not the policy of upper SEG management, did come close to representing the 166
No.5 .
-i l
[' views of some' RPTs As one SEG manager summarized the views'of the RPTs and ;
how they differed from management's: ,
There [were]' people in the - [RPT] ranks that '
- philosophically didn't believe [the SEG management view]
was correct. They believed that if an individual gets three )
RORs, that it's simple, the guy should be gone.
And I talked to them, and we discussed it, and we
. agreed to disagree. But I was still the caretaker of the ROR j program, so I was going to do it my way." l 1 i
- Both MKF and SEG witnesses agreed that, whatever confusion may have existed l
-l' carlier about the "one, two, three, you're out" character of the ROR program, it has been
! made clear recently that the primary objective of the program is not pu: .tive.i2 As an l MKF manager expressed the current understanding: .
I think there's been a big resolution ever since NRC has been out there, that [the ROR program] is not a disciplinary tool for minor infractions.
But you got to look at it from the other end. HPs have a to have something if somebody does something really nasty and violates the rules. They have to have some way to not :
let that person be on the job, or you just can't take it from not -
j
, being a disciplinary tool to being one. There's got to be
, some judgements in there you know.
i l I think we've got it across to the men that on the e normal ones it's just fine, but if you do something severe there could still be disciplinary action, might not be automatic termination, but something has to happen if somebody does, [
- habitually does something or does something drastic."
l
- 2. Soecific Instances of Alleaed Harassment i In contrast to the general perception described above concerning the alleged disciplinary character of the ROR program, only a few MKF supervisory personnel l 1
167 !
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~
3xpressed the view that on specific occasions RORs had 'been used unfairly to penalize j
- MKF.' personnel. For the most part, this viewpoint centered around the RORs written .i against former MKF Superintendent Danny Hicks. Hicks was the only one who explicitly. !
j : contended that the RORs were used for harassment purposes: "Yes, I feel that way. {
1 feel anytime an ROR was written'it's a harassment."" Hicks received some support .
. .i
- lin this view from fellow superintendents Thomas Dieter and Dennis Robin, although they .i
,. stopped 'short of contending that the ROR program was used for harassment purposes." [
- in addition to expressing' doubts about the fairness of the RORs written against Hicks, j i
Dieter' questioned RORs written against a former MKF worker, Chan Solano, but did not !
contend that these constituted harassment." Similarly, the lead MKF manager at the ]
- =
" ~ FSV site, William Hug, viewed Solano's case as the closest the ROR program came to -
E 'being used as a harassment tool." However, Hug, like Dieter, stopped short of J
. contending that in Solano's case or in any other specific instance RPTs had used RORs t3 harass MKF personnel." ,
i l
. Apart from the RORs written against Hicks and Solano, there was little support j 3
tmong MKF supervisory personnel -- and, as noted, virtually none among the worPers -
f:r the proposition that RORs were used for harassment purposes, either in general or !
ag inst specific individuals." l
. i B. Factual Basis for Perception There appears to have been genuine confusion among MKF workers, as well as ;
l waong their supervisors and managers, concoming whether the original ROR program ;
d had a punitive dimension.- This confusion apparently started after a meeting early in the i
, 168 I
s 1
y
No.5 project at which the program was.desenbed in a way that was interpreted by MKF
! supervisors and workers to embody a "one, two, three, you're out" concept. (It is not clear whether those exact words were used at the meeting.) The evidence does not support the conclusion that this was ever the intent of SEG management; indeed, the two top SEG managers at FSV specifically disavowed intending the program to be disciplinary in character, a position that put them at odds with some of their own workers."
Despite the position of SEG management, certain conditions contributed to the
~
perception that the ROR program was intended to be punitive. First, as described by many witnesses, there were tensions between MKF supervisors and RPTs, particularly during the early stages of the project, which led each side to test the limits of the others' cuthority. In such a climate, it was easy for RPTs to feel they were being challenged, cnd for MKF supervisors to believe that when RPTs responded to challenges by writing RORs. it was an abuse of their authority. Second, as noted, something. akin to the "one, two, three, you're out" concept appears to have been described at the meeting referred to earlier, which occurred early in the project and made an impression on MKF workers cnd supervisors. Third, the "one, two, three, you're out" concept in fact reflected the opinions of some RPTs, who, as described in the preceding section of this report, had worked in other nuclear plants where such a rule applied, and who thought their
, management was being too lenient in the face of flagrant rule violations by certain MKF personnel.
169
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No.5 l 4 ;.
The perception held by former MKF Superintendent Hicks that the ROR program l 1
- , not only had a punitive dimension,~ but that it had been used for harassment purposes,- 1 was fueled primarily by Hicks' transfer following his receipt of an ROR in early 1994. j L l j
. Hicks, as noted, contended that this and other RORs against _him were harassment, and i'
some of his fellow supervisors supported his view to a limited extent. They believed the -!
n ,
ROR against Hicks was' prompted, at least in part, by a personality conflict between i Hicks and the RPT who issued it,-and that action was taken against Hicks before his- l
- i
- side of the n' ty could be fully. evaluated.2t As discussed elsewhere in this report, )
~, i h'owever, it is clear that a basis existed for the action taken against Hicks, and that !
c :
. neither the ROR 'nor the sub' sequent transfer of Hicks constituted abuse of authority or j harassment of Hicks. In that regard, it is worth noting that the ROR issued against Hicks ~
j I ' shortly after his transfer was his fourth, contrary to the perception that the ROR program '
operated on a "one, two, three, and you're out basis." Indeed, even the fourth ROR was !
- not primarily responsible for Hicks' departure; rather, as discussed in detail earlier, it was -
Hicks' alleged threat to the RPT who issued the ROR.22 The other use of RORs questioned by MKF managers involved an MKF craft l worker, Solano, who, like Hicks, had accumulated bur RORs before he was terminated L by MKF. The rvidence showed that the RORs written against Solano2 reflected his well ,
l known propensity.to violate radiological protection rules, and that he was terminated for .
.; reasons that were independent of the fourth ROR itself. As Hug expressed the reasons ,
for Solano's departure, they included his use of "very inappropriate language with a ;
. female [RPT)," as well as s' tendency to violate radiological protection rules.25 Hug i-170
~
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Noa5
> i summarized by characterizing Solano as "the kind of guy who would do something before he would think about it. And that was a quality that . . . could put him and us in a bigger problem." The reasons articulated by Hug for Solano's departure were
. corroborated by supervisors and co-workers, as well as by the assessments of RPTs as reflected in the RORs they wrote concerning him. .
C. Conclusion ,
J in summary, the perception that the ROR program was used to harass MKF ;
personnel was held primarily by former MKF Superintendent Hicks, who was himself nOmed in four RORs, and later transferred from the site after allegedly threatening the -
RPT who issued the fourth ROR. Hicks was only partially supported in this contention I by other MKF' supervisors and not at all by MKF workers. Thus, the perception was a .
limited one and the weight of the evidence did not support it.
I i
1 4
l j
171 l I
1
' ' d p-a l
' ENDNOTES :
F{, j;
- 1. - h, Sworn Interview Statement of Ralp'h D. Beall, May 4,1994l p. 8 [ hereinafter ;
- cited as "Beall (5/4/94)"]; Sworn Interview Statement of Robert M. Carrera, Apr.
I 18,1994, p 12 [ hereinafter cited as "Carrera (4/18/94)"]; Unsworn Interview l Statement of Craig A. Clifton,~ May 3,1994, p.11 [ hereinafter cited as "Clifton :
- (5/3/94) (Unswom)"]; Unsworn Interview Statement of Gary L. Graham, May 10,~ .
. 1994, pp. 7 8 [ hereinafter cited as " Graham (5/10/94) (Corrected but Unsworn)"]; .:
Sworn Interview Statement of Paul Harris, May 11,1994, p.' 8 [ hereinafter cited _
- as " Harris (5/11/94)"]; Sworn interview Statement Gregory L. Price, Apr. 26,1994, '
p.10'[ hereinafter cited as '. Price (4/26/94)"]; Unsworn Interview. Statement of'
' Joseph' P. Valdez, May 17,'1994, p. 22 [ hereinafter cited as 'Valdez (5/17/94) ;
i
- (Unsworn)").
- 2. h, Unsworn' interview Statement of Dennis E. Reese, May 18,1994, p.11
[ hereinafter cited as "D. Reese (5/18/94) (Unsworn)").
. 3. Unsworn interview Statement of Thomas J. Dieter, May 17 and 18, 994, p. 34 l
[ hereinafter cited as " Dieter (5/17/94) (Unsworn)"). 1 l
-4. Dieter (5/17/94) (Unsworn), p. 36.
- 5. Sworn Interview Statement of James E. Wallace, Apr. 18,1994, p. 25 [ hereinafter i cited as 'Wallace (4/18/94)").
- 6. Unsworn interview Statement of Marvin W. Henderson, May 11,1994, pp.13,14 ,
. [ hereinafter cited as "Henderson (5/11/94) (Unsworn)"). j
~
- 7. D. Reese (5/18/94) (Unsworn), p.10_.
- 8. Sworn Interview Statement of Joe Edward Parsons, May 10, 1994, p. 65 l [ hereinafter cited as "J.E. Pa:4ons (5/10/94)"]; Sworn Interview Statement of Richard J. Sexton, May 4,1994,' p. 68 [ hereinafter cited as " Sexton (5/4/94)"). j J
- 9. Unsworn Interview Statement of Michael E. Miles, Apr. 26, 1994, p. 34
[ hereinafter cited as "M. Miles (4/26/94) (Unsworn)"].
. 10. DN 77.
- 11. Sworn Interview Statement of Richard J. Sexton, May 5,1994, p. 50 [ hereinafter cited as " Sexton (5/5/94)").
- 12. h, Dieter (5/17/94) (Unsworn), pp. 37, 38. l l
172 x
, . . , , . . . .a. -
1 No.5 .
- 13. Dieter (5/17/94) (Unsworn), pp. 37, 38.
- 14. Unsworn interview Statement of Danny Hicks, May 25,1994, p.125 [ hereinafter cited as " Hicks (5/25/94) (Unsworn)"]. ,
- 15. Dieter (5/17/94) (Unsworn), pp. 25-41; Unsworn Interview Statement of Dennis K.
Robin, May 16,1994, pp.17-20 [ hereinafter cited as " Robin (5/16/94) (Unsworn)").
- 16. Dieter (5/17/94) (Unsworn), pp. 40i 41. ,
- 17. Sworn Interview Statement of William J. Hug, May 18,1994, p. 37 [ hereinafter cited as " Hug (5/18/94)"].
, 18. Sam Hug (5/18/94), pp. 36-37.
- 19. Sag,31 Hug (5/18/94),' pp. 36-37.
- 20. 'Sgt J.E. Parsons (5/10/94), p. 65; Sexton (5/4/94), pp. 49-50.
- 21. , h, Dieter (5/17/94) (Unsworn), pp. 35-40.
- 22. Sfdtdiscussion in Section V.
- 23. ROR 93 006 (DN 353-56); ROR 93-016 (DN 415-19); ROR 93-026 (DN 477-85);
ROR 93-036 (DN 575-80).
- 24. Sag Dieter (5/17/94) (Unsworn), pp. 40-41; Unsworn Interview Statement of i
Marion L. Herrera, May 5,1994, pp.19-30 [ hereinafter cited as "Herrera (5/5/94) ;
(Unsworn)"); Hug (5/18/94), pp. 37-42.
- 25. Hug (5/18/94), pp. 38,42.
- 26. Hug (5/18/94), p. 42.
- 27. Sag,11, Unsworn interview Statement of John L. Cletcher, May 4,1994, p. 34
[ hereinafter cited as "Cletcher (5/4/94) (Unsworn)"); Herrera (5/5/94) (Unsworn),
pp. 20-27, c
e 1
C. ,
173 e
NO.1 7
DISCUSSION OF ISSUE:
WHETHER SEG SUPERVISORS AND AN RPT i vil.
FALSIFIED RADIATION SURVEY DOCUMENTATION RELATIN OF MATERIALS FROM THE SITE DURING 1992 A. Introduction At the beginning of our investigation, a witness presented us with a group of documents that raised questions about the accuracy of specific radiation survey f We gathered additional documentation and spoke to other witnesses in a prelim effort to deterrnine whether the survey forms may have been falsified. This prelimin I review gave substance to the witness' suspicions that both 1992 survey forms fo unconditional release of materials from the plant and RWP survey forms for early 1 Later in the investigation, the same witness raised a question f had been backdated. I about the accuracy of a specific survey form related to the release of the HSF plug fro the reactor building in September 1993.
We investigated these instances of suspected falsification to determine whether there was actual falsification, whether any such falsification was part of a larger pattern, 1 and, to the extent falsification occurred, whether it was linked to an emphasis on production over procedural compliance. We also sought to determine management's accountability for the falsification and to determine at what level, if any, upper management was responsible. l The instances of suspected radiation survey documentation falsification are discussed in this Section and Sections Vill and IX of the report. To enable the reader to understand the circumstances in which the falsification occurred and the explanations provided by witnesses for the falsification, we have described relevant aspects of the 174
?
No, g l
f FSV' radiation protection program. 'Thhse include the recent history of the program; f a .a procedural7requirements for conducting and - documenting radiation surveys; and ;
l requirements for radiation ' survey instrumentation; ,
?
The evidence showed that in February 1993 an SEG RPT backdated 14 survey
) . forms related to material that had been unconditionally released from the site in the last -
[ three months of 1992.' (A more extensive discussion of this issue with documentary. .
- i j
cxhibits is contained in Appendix A to this report.) SEG's RPOS, Kenneth Zahrt, claimed
^
l that around February 1993 he identified a problem of missing survey documentation for ;
. the release of materials. Zahrt, however, chose not to issue an ROR. Instead,.he j directed one of the RPTs, James Bixby, to "fix the problem." The "fix" resulted in 14 b:ckdated survey forms purportedly documenting 41 instances in which B.ixby surveyed i material for unconditional release from the site.
1 Bixby claimed that he relied on information from a logbook maintained by himself i
- l cnd other RPTs to prepare these 14 backdated survey forms. In many instances, # j r 1
[ h: wever, the information in the logbook was insufficient to justify the recreated survey
. t
. documentation, in still other instances, the logbook provided no suport for the .
brckdated survey entries. In numerous instances, the survey documentation created the l
cppearance that Bixby was the person performing the survey, when in fact Bixby relied
- . on fragmentarlogbook entries made by other RPTs.
7 Even though he prepared the 14 survey forms in February 1993, Bixby backdated j
! both the s'urvey date and supervisory review date on the documents to reflect various !
. ~ dates from September _8,1992 through December 7,1992. Zahrt then participated in 1-175 :
i 1
4 Y Y = - , - - - e _ - _ . _ _ _ _ _ _ _ _ _ _ _ _ . _ _ . _ _ _
c No.5- l
~
~ , backdating the documentation by affixing his signature as the reviewer on each of the . 1 l
~
. 14 survey forms. thereby creating the false appearance that the documents came into cxistence during September 1992 through December _1992.I SEG's procedure was to'iog radiation survey forms' sequentially in an annual' l
- l survey log. ' Bixby's backdated survey forms were prepared in February 1993 a'nd were ,
i
. logged out-of-sequence, following surveys prepared at the end of December 1992. Also, ,
i the survey log ~ entries for the backdated surveys were made on a printed log sheet dated ;
~
' 1993 The 1993 date was crossed out and a 1992 date was inserted on the face of the' log sheet. The person who entered the backdated survey data in the logbook then -
4 I
' initialed the date change and dated the change as February 23,1993.
]
+
B. Standards - Radiation Protection Procram l
o 1. Oraanization of FSV Radiation Protection Proaram
- Federal regulations require the implernentation of radiation protection programs !
L ct nuclear power plants.2 The radiation p7otection program at FSV conforms plant
! . procedure to federal radiation protection standards, and, more generally, provides for the ;
4 protection of workers and the public from radiological hazards.' The program prescribes a variety of work practices and requires that potentially hazardous material be handled l
.and managed b'y quali5ed personnel. A key component of the program is the.
requirement to conduct a variety of radiation surveys and document the results.
~
. One type' of survey is for determining the presence of surface radioactive contamination.' The purpose'of conducting this type of survey is to determine the levels
, cnd extent of radioactive contamination present, the type of radiation, and whether it is ,
176 !
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- removable or fixed.' Radioactive contamination surveys are, in turn, used to determine . :
, j F :what controls are necessary to prevent.the spread of contamination.'
- l According; to' federal regulations.- radiationLsurveys must be performed in 'l m j compliance with the; specific provisions.of'10:CFR part 20 and. as are reasonably ;
i necessary "under the circumstances to evaluate the extent of the hazard that may be' '!
i present."' Documentation'of these surveys must be maintained as'part of the' licensee's l
records.0 !
^
The NRC's " General Statement of Policy and Procedure for NRC Enforcement :
' Actions"' describes the relative importance the NRC attaches to failures to. comply with !
. NRC documentation requirements: !
. " incomplete or inaccurate information that the NRC requires to be kept by licensee that is . .. . incomplete or inaccurate because of falsification by or with the knowledge of a licensee official" is classified as a " Severity Level I" violation, the highest of five levels established by the NRC;
.. " incomplete or inaccurate information that the NRC requires to be kept by a licensee which is' . . . incomplete or inaccurate because of careless disregard for the accuracy of the information on the part of a licensee official" is classified as a " Severity Level ll" violation;
" incomplete or inaccurate information that the NRC requires to be kept by a licensee that is (a) incomplete or inaccurate because of inadequate ,
I r actions.on the part of licensee officials but not amounting to Severity Level I or ll violations" is classified as a " Severity Level lil" violation.'
Severity Level I and 11 violations are described as having a "very significant regulatory )
concern," and as involving " actual or high potential impact on the public." Severity Level l 1
lil . violations 'are described as having "cause for significant" regulatory concern."
Falsifying' records required by NRC regulations or by the facility licensee" is also
. ground.i for NRC enforcement action against individuals."
w
^
177-o 1
. 9 M V4"- W w * ., - - - e- w- e___r-
No.5' l
- 1. The importance ofLs'trict compliance with' radiation protection' documentation . .I
[. requirements'was emphasized in Hamlin v. United States Atomic Enerav Commission, .
357 F.2d 632 (1966 6th Cir.), a case in which a license was not' renewed by the Atomic; l , Energy' Commission due to a " pattern of continued violations and false reports." The -!
licensee claimed: that the violations.~ were: not willful, but a court affirmed the
, t
. Commission's finding of a number of willful violations. The willful violations included j v '
knowingly falsifying a utilization log to make it. appear as .though the log had been !
' valid'sted by 'a qualified , supervisor, and knowingly. reporting false information to 1
Commission inspectors. The Commission noted that the regulations at issue required 1
, i i l
- " meticulous compliance in the interest of public heaNh and safety," and that the !
li !
licensee's overall record caused them to raubt the licensee's ability to operate in an acceptable manner."- The Court found that the Commission's conclusions were i
supported by substantial evidence,'and noted that "we can imagine no area requiring stncter adherence to rules and regulations than that dealing with radioactive materials.""
1
' 2. FSV Decommissionina Plan
]
- The FSV Decommissioning Plan calls for implementation of a radiation protection program that requires surveys to be performed under a variety of circumstances."
These include routine radiation, contamination, and airborne surveys used to evaluate
- radiological conditions; dose rate surveys to provide specific information on beta and v gamma radiation dose rates; surface contamination surveys to provide data on beta-gamma andl alpha radiation' contamination levels; and airborne radioactivity surveys where workers may be exposed to airborne particulates." The Decommissioning Plan 178 f
-- ~ . ~ _- . . . _ ,
j No.5: ;
' ~
specifies that dose rate'and surface contamination surveys will be performed to[e)nsure:
.l j
1 proper release of materials and equipment'for unrestricted use."" The details of survey
- l requirements are provided by SEG and PSC procedures. ;
)
Surveys are performed by RPTs who are required to document the results of their - p J
survey . activity, ' Their documented survey. result's then are reviewed by . RPT/
.i,
- supervisors: i Radiation protection supervision will review completed survey 'I' documentation to ensure appropriate, adequate and complete information is recorded. The supervisor reviewing the survey l
~ will' ensure that . the. recorded' results are legible, in
- i
'f
. accordance with Radiation Protection Manual implementing ,
procedures and. consistent with anticipated levels and will determine the reason for any variances. Information that will j typically be included on survey maps or forms is. .,
I f
~
-*. Date and time of survey l
- Location of survey j
- A sketch or description of the area or component surveyed ,
I
- Instrument type and serial numbers
- Instrument calibration due date i p ,
' ' * . Name and signature of surveyor" c i Survey documentation is to be sufficiently detailed to provide adequate information on the radiological conditions in the area surveyed." Survey documents are reviewed by the RPOS to ensure that appropriate, adequate and complete information is recorded.2o ,
'Once completed, survey documents must be " filed and maintained so that previous radiological conditions can be determined."2' l 179 3- c -
- No.5 l i
3; *Anolicability of PSC Procedure to Survey Activities 1
4 In August 1992. SEG inherited PSC's radiation protection program.22 During thel !
.q period of August through early December 1992, SEG utilized PSC procedures pursuant: ;
toian agreement . between' SEG and PSC that - SEG would continue using ' PSC'. l procedures until the FSV Decommissioning Plan was formally approved. During this _
~
time frame, SEG was in the process of developing its own procedures.23 a
PSC procedures specified how surveys were to be performed, including surveys ,
for unconditional release from the site. These procedures also provided a requirement j
~
that survey documentation be_ prepared.2' The applicable PSC procedure at the time 7
, . directed that "all: radiation surveys must be performed and documented as comprehensible as possible" to fulfill the requirement, among others, that as much information be available as possible to determine if material is releasable.2s The PSC y r ~
procedure in 'effect noted that routine contamination surveys normally were conducted
[ i in conjunction with radiation surveys.
- .Under PSC procedures, which were applicable during the period from August 1992'through early December 1992, radiation surveys had to be performc f and L documented to ensure " safe operating conditions for both station personnel and the m
p L9eneral public and to ensure compliance with the requirements of [10 CFR part 20)."'7 1- The health physics technicians were charged with performing surveys and legibly E . documenting the results Health physics supervisors were responsible for ensuring that l .these surveys were performed "to verify radiation levels and working conditions !
i I
l -
1SO i
. - . - . - - . - ~ - . - - - - -_.. . _ - - ..
a
- -' 'No.5 !
~
I throughout the plant site."" Additional oversight was provided by the radiation protection manager," l l
- 4, ' Acolicability of SEG Procedure'to Decommissionina' Activities l
SEG's radiation protection procedures became effective in early December 1992. l Under the SEG " Radiation Protection Surveillance Program," surveys are required to be
- ' performed to " assess radiological hazards which may be present." Survey data is - ;
. intsnded to be used for the following purposes:
I -
informing workers of radiological hazards on the project site in general and in their work area in particular. !
Determining protective measures and equipment. i
- Verifying that radioactive material is adequately controlled and not spread {
outside RCAs (Radiological Control Areas).
L l
Verifying the effectiveness of radiation and contamination controls. .
4 l =
Verifying the effectiveness of engineering controls. !
'i Monitoring the exposure of workers to airborne radioactivity. ,
1 l
Ensuring radioactive materials and radioactive waste shipments are in accordance with applicable regulations.32 l SEG required that surveys be documented using a high standard of accuracy and l l
legibility." Records are required because they "may be needed at a future date to ;
d:monstrate compliance with regulatory requirements or to provide information in the ,
[ cvCnt of future litigation."" Records also " furnish documentary evidence of the quality l
[ cf services. performed, demonstrate that actions were performed in accordance with ,
radiation safety procedural requirements, or demonstrate conformance of actions to )
.. )
4 regulatory requirements."" l
. 181 ;
yw , w . y
-3 <.-1' .__- _ _ _ _ _ _ _ - _ __P-----___--
y .
4 -
No.5 !
a
.{
..If a 6*'1 tine _ survey is not performed as stipulated, the appropriate employee is- .
~
I dire:ted to note the reason on an ' appropriate form l notify the RPOS, and generate an i
. :ROR. If records are discovered to be-missing or lost', the Radiation' Protection -
supervisor is directed to generate an ROR.
Additionally,'SEG's " Employee Handbook" establishee standards of behavior for ; l q
..SEG employees. Certain types of behavior are characterized.as '" extremely serious !
misconduct".which may result in immediate termination. One such type of behavior is l the " deliberate misrepresentation or falsification of records . . . or other information used
. I
- or. required by the Company."
C; Release' of Materials From FSV for Unrestricted Use !
The FSV protection program established criteria for determining whether scrap .
m terials from the dismantled reactor system'and elsewhere on the site imd to be dtposed 'as radioactive waste or could be disposed as ordinary industrial waste. The Decommissioning Plan, PSC procedures and SEG procedures specifically addressed this I
topic initially, PSC procedures applied to surveying materials for release from the site.
Chronologically, the first instance of suspected falsification of survey I documentation involved surveys for fixed and removable radioactive contamination on f
{
items from the dismantled steam generator system at a time the PSC procedures were
. still in force. These surveys were supposedly conducted during September through early December 1992. This was a transitional period in the o< commissioning activities, as
- SEG had taken over responsibility for the radiation protection program in August, but
- SEG's procedures were not implemented until December 1992.
Y 182 '
I
No.5 .
r I ,' af surveyed iter.is were found to De " clean," these items were unconditionally ;
o released from the' site. Within the radiation protection program, the terms
" unconditionally released" and " free released' were used interchangeably to describe
- materials that were sent from the site for unrestricted use." If an item is released for
" unrestricted use,"it is sent off-site and can be used for any purpose.' !
l, p 1.' The Decommissionine. Plan - Release Criteria 1 l
, The FSV Decommissioning Plan provides that "[m]aterial will not be released for .
.. l unrestricted use if it contains detectable amounts of radioactive material." The Plan :
- - further provides that instrumentation used for conducting surveys will be selected with -
- the objective that detection sensitivities are consistent with applicable NRC guidance l
documents.'8 The Plan's requirements for surveying materials became effective on 7 December 7, 1992.'8 For detection of removable, surface contaminction identified through use of 3-smears (wipes) of 100 centimeters squared ares," the NRC guidance documents provide that "the corresponding detection capability with a thin window detector and a fixed sample geometry is on the order of 1000 dpm (i.e.,1000 dpm/100cm8)."'5 Similarly, NRC Regulatory Guide 1.86, " Termination of Operating Licenses for Nuclear Reactors," delineates acceptable surface contamination levels for removable contamination of "1000 dpm (beta gamma)/100 cm2."
Although the NRC guidance documents do not establish release limits, they do sanction the use of a " hand-held pancake probe" of the type used in the FSV Radiation Protection Program, that 'is, the Eberline Radiation Monitor, Model RM-14.'7 The 183 y -- w *>m'-
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.- .No.5 l l
Eberline RM 14 hand probe is described by the manufacturer as providing a " sensitive. ;
-i
[. ; beta. detector featuring a' ' pancake' GM tube with a thin mica window."- [
The efficiency of the RM-14 instrument used by SEG RPTs is-10%. A 100 counts ,
,'per minute (cpm) reading on an RM-14 instrument is, therefore, the equivalent of 1000 disintegrations per minute (dpm). The minimum detectable activity for the.RM-14 is i 1000 dpm/100 cm2. Therefore, while using' an RM-14 to ' survey. materials for loose, surface contamination, no activity below 1000 dpm would be detected.5'
- The NRC guidance documents recognize that in using a hand held pancake probe, there is a poissibility that some' small amounts of contamination would go undetected. When such items of " clean" material .are combined, however, the i accumulation of small amounts of contamination that were not detected using a pancake
. probe can be detected using a different type of detection device." The NRC documents i state that a good monitoring program, in order to prevent the unintentional release of radioactive materials, would likely include both surveys taken with pancake probe type
, instruments' and final measurements of aggregated wastes.s2 PSC's procedures provided for monitoring such aggregated waste materials.58
- 2. The Contracts Release Standards p The April 1,1991 contract between PSC and the Westinghouse Team specified that the parties interpreted the NRC's regulatory guidance to mean that material could
< be unconditionally released if it met the following release limits:
.* Direct frisk - beta-gamma - less than 1000 dpm/ probe area;
}'
- - _ Removable beta-gamma - less than 1000 dpm/100 cm*."
1 184 l I
, -. - ~. i
.No.5 The contract reflected the release criteria PSC was utilizing pursuant to PSC
~
' procedures."-
- 3. PSC Release Procedures PSC procedures required surveys to be performed on all material prior to unconditional release. Material can be unconditionally released if properly calibrated and r;sponse tested radiation survey instrumentation does not detect the presence of fixed .
or loose radioactive contamination. The radiation survey requirements are stipulated in PSC's Radiation Protection Plan-Section 4.4.2(a), " Radioactive Material identification";
Equipment or material shall not be released for unrestricted use if radioactivity exceeds the ,
. following: ;
Direct Frisk 1000 DPM/ Probe Area
. (Beta / Gamma)
. Removable 1000 DPM/100cm' (Beta / Gamma)
Removable 20 DPM/100cm 2 (Alpha *)
Direct Frisk 20 DPM/ Probe Area (Alpha *) ,
- Alpha surveys will be performed in the event that alpha -
contamination is suspected."
These surveys are to be performed and docuraented by health physics technicians," l which is the title PSC used to describe RPTs. Health physics supervisors are responsible for ensuring that surveys are performed."
~
When SEG took over responsibility for implementing the FSV radiation protection program in August 1992, the Decommissioning Plan was still pending approval. SEG 185
. i No.5 i
.i r
Leontinued to utilize PSC procedures through the first week-of December 1992." The j
- ~i .
- then applicable PSC procedure governing release of materials for. unrestricted use
]
- established the following criteria: ;
i
- a. No detectable removable contamination as measured. with an J . instrument with an MDA [ Minimum Detectable Activity] of no greater !
tthan.1000 dpm. l b.- : Fixed beta-gamma radiation caused by the itern shall not exceed 100 counts per minute above background, as measured with a thin ' .
window GM detector '(or equipment with equivalent detection-capabilities).
c'. - Bags of waste / trash also sho .'1 be monitored with a micro R meter i p
and read no detectable above background.' j
! - This PSC procedure expressly provided that both removable and fixed contamination i
- _ surveys could be conducted using an RM-14/15 instrument." l PSC's oversight role began with the SEG takeover of the radiation protechon 7. !
i l program in August 1992.s2 in November 1992, PSC's Radiation Protection Manager, j Frederick Borst, advised Zahrt that the SEG personnel conducting surveys should be
, consistent with the then current FSV procedure which allowed the use of a frisker (RM- l l 14 instrument) to count wipes in connection with releasing materials. On November
. 10,1992,'Zahrt noted in his logbook that he was instructed by PSC's Borst to use I . procedures consistent with the. present FSV procedure." Borst's directive was 7 j
' l
. inconsistent with another proposed SEG procedure that would require smears to be )
I
'L counted with a BC4 or Tennelec instrument.
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'. ' 4. SEG Release Procedures f On December 7,1992, the FSV Decommissioning Plan became effective." From .
December .7,1992 through the present, SEG procedures have applied to release surveys. RPTs are responsible for performing the unconditional release surveys and documenting the release in release logs or their equivalent." The SEG RPOS is-rssponsible for reviewing the survey'or logs."
- "General Survey Techniques" for unconditional release are described in Section 5.1'of this SEG procedure, which details a three-step process for examining material before it can be considered eligible for release from the site for unrestricted'use. ;
i The first step is to examine for " loose" surface contamination by wiping the ;
surface with a piece of cloth - a process known as taking a " smear." The smear is then cxamined with a radiation monitoring instrument:
5.1.1 - Evaluate the material for loose surface contamination.
- 1. Perform a smear survey with a disc smear.
- a. Wipe the smear over approximately 100 cm2 (16 square inches) of the surface to be sampled.
- b. Apply moderate pressure.
I c. Exercise care on rough surface so as NOT to tear the smear.
2.' Analyze the smear using a counter scaler such a [ sic]
Tennelec or BC-4.
- a. Count the smear for greater than or equal to 6 seconds.
4 i 187
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b? .lF any smear is greater than the '
- Minimum Detectable Count Rate -
(MDCR), THEN the material may not be ,
unconditionally released.7
- - The second step is to examine the object for " fixed" or embedded contamination i I .
i by carefully examining the surface with a radiation monitoring instrument - a process j
~
known as " frisking": 1 3
5.1.2 - Perform direct survey of materials with an RM-14/HP-210 or l instrument with an equivalent or increased sensitivity. -
- 1. Frisk material in an area with a background of less :
~
. than 200 cpm. ;
- 2. Hold the probe approximately 1/2 inch from the ;
surface of the item AND move at.approximately 2 3 inches per second. l
- a. Hold the probe stationary over areas which give an increase in the audible or )
visual count rates AND allow the meter :
to stabilize (approximately 15 seconds). l
- b. IF the count rate after allowing the meter to stabilize is 100 cpm or greater above background, THEN the material may not be unconditionally released."
- - The third and final step in the surveying process applies only to accuniulated
- w;ste materials.
.5.1.3 - Evaluate collected waste materials with a Micro-R meter as a final check prior to release.
5 1. Select an area with a background of less than 15uR/hr
, for the survey.
- 2. Hold the probe in close proximity to- the material (within 2 inches).
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1 i 3. Move the. probe slowly around the perimeter of the q - matenals.-
4.- IF an area of increased' activity is noted. THEN:.
- a. Survey the area to determine the source' of the increased activity. j i
- b. Allow the meter 15 seconds to stabilize {
in the area of highest activity.
1
- 15. Consider any readings above background to- be l greater than MDA and.the material unsuitable for !
unconditional release?'
t These SEG survey procedures, however, were not in effect during September to .
ccrly December 1992, when RPT Bixby was responsible for su veying materials for ;
.. release on Level 1 of the reactor building. Only his survey activities for December 7,8 l cnd 9,1992. documented on his last backdated release survey form would have been I j
. governed by. SEG's procedure, which pursuant to the NRC's approval of the ;
I' D; commissioning Plan went into effect on December 7,1992."
This SEG procedure for " Surveying Material for Release" was subsequently revised in November 1993. The principal change in the procedure was to allow the use of an RM-14/15 instrument to count the smears used to identify loose surface contamination.'
- 5. Survev Technioue for Conductina Radiation Contamination Surveys Both PSC and SEG procedures require surveys to be performed and documented Occh time material is released for unconditional use. - Under the PSC procedure in effect through December 7,'1992, the RPT responsible for performing a radiation survey for purposes of determining whether an item could be released for unrestricted use would 189 m, e -
~.y, --
No.5 conduct a survey using an RM-14 or similar instrument for both " removable" (loose) and .i l
~'k '
" fixed" contamination." ' Such removable contamination surveys were performed using?
standard two inch cloth smears to wipe an area:100.cm2 and then counting the smears :
with the RM-14/15 instrument. The fixed contamination surveys were performed using cn RM-14/15 instrument'to directly frisk the surface area of the material.77 1
The. survey documentation ' accompanying this survey activity should include :j "enough-detail and enough' samples so that a reasonable person with professional .,
cxponence could conclude" from the documentation that the material surveyed presented f "a very. low probability of exceeding the free release criteria."" Whether or not the entire surface of an item has to be frisked, or just a representative portion, depends upon the cxperience and knowledge of the RPT, including knowledge of how the system was used in the past and experience with sampling other, similar items, from the same system." -)
For example, if an RPT were surveying the one hundredth item from the same system, which was operated under the same conditions, a 100% survey of every surface may not l be required. Nevertheless, each item would still need to be sampled in order to
. understand whether or not a particular item is consistent with the RPT's knowledge of -1
)
the other items."
D. Rar* dated Release Survev Forms - Discovery of the Pict,lem
- 1. Pa==Na Survev DocumeriMon Irreaularities identified durina investigation As noted above, early in the investigation a witness presented a concem about i possible radiation survey document irregularities and provided documents related to the _i i
l I
i 190- ;
)
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No.5 concern; Among these' documents was the last page of the 199? CEG survey log that ~
showed the final.14 survey forms for 1992 were logged out-of-sequence The last two pages of the 1992 survey log contained entries for 20 survey forms. - !
consecutively numbered 5043 through 5062." ' Of these final 20 survey forms for 1992, ;
.I six ap'peared on the next to the last page -- survey form numbers 5043-5048. ' All of- l these survey. forms were dated December 31,1992.e2 in contrast, the last page of the - !
. . 1
~
survey log listed- 14 ' survey forms with the higher sequential survey. form numbers of .;
i
.5049 to 5062. , . These 14 survey forms bore earlier survey dates from September,
' October, Novem er and December 1992.' (San Appendix A - Exhibit 1 for relevant pages.
- of the 1992 survey log.) The first of these 14 out-of-sequence survey forms had a date
. of September 8,1992 and the 14th survey form had a date of December 7,1992. All 14 of the survey forms on the last page were logged in after December 31,1992, even l though those 14 survey forms were supposedly written earlier than the ones on the next-to-the-last page of the log." l Further examination of the survey log suggested that the last 14 survey forms had j s
- been entered in SEG's 1992 survey log on February 23,1993." The final page of the l' 1992 survey log had a preprinted heading in bold letters, "1993 Survey Log," but the l
. ye:r ".1993" had been crossed out and the year "1992" handprinted above the crossout.
i
- Immediately below the crossout were the initials and date, "DAP 2-23-93."" In contrast, I the next to the last page had the ' printed heading "1992 Survey Log." ;
i Additionally, the proprinted number "93" was crossed out in three of the individual l columns on the survey log's last page and the hand-printed number "92" was inserted, j
.- {
191-1 i
i
.No.5 1 I< and each of these changes was again initialled "DAP" with a date of "2-23-93." The last
. two pages of the survey log suggested that the final 14 survey forms in the survey log, .
I covering the period September 8,1992 through December 7. .1992, were all logged after -
~ December 31,1992 and that changes in the last page of the preprinted survey log form were made on February 23,1993."
1 L We then obtained copies of the final 14 survey forms entered in SEG's 1992 - l survey log. These 14 out of-sequence survey forms were sequentially numbered 5049 through 5062."-(Egg Appendix A - Exhibit 2 - for copies of backdated release survey l forms.) Examination of the 14 individual radiation survey forms showed they were all prepared by Bixbyc .
According to these documents, the surveys were conducted pursuant to RWP i
- Number 1053,.which is a general work permit for " radiation protection surveys and associated work."" During the time frame covered by these 14 surveys, Lg., the last f
- ur months of 1992, Bixby was assigned to Level 1 of the reactor building in connection !
with dismantling the steam generator system." Although not apparent from the face of !
the 14 survey forms, the investigation showed that these documents relatM to 41 y separate, unconditional releases of material from the site. Such released material is considered free of detectable contamination." Unlike material found to contain low lesel
- rtdioactive waste, no restrictions are placed on the uses to which unconditionally
. released materials can be put."
192 l
No.5
- 2. Genesis of the Backdated Release' Survey Forms f
~'-
Precisely how the backdated release survey forms came into existence is the subject of conflicting accounts. According to Zahrt, the problem of inadequate release survey documentation came to light when he discovered a gap between the c atity of materials he knew had been surveyed for release on Level 1 and the quantity of materials reflected on the existing survey documentation. Zahrt claimed that after he discovered the problem, he directed Bixby to generate the survey documentation from cxisting Level 1 logbook entries made by Bixby.
Bixby, however, asserted that he did not speak to Zahrt on the subject. Instead, Bixby claimed his immediate supervisor, Roland " Chip" Sawyer, had directed him to prepare survey documentation. Bixby recalled that Sawyer instructed him to generate the backdated survey forms in connection with radiation work permit activity. For his pert, Sawyer said he did not recall participating in the events surrounding the backdated 1992 release survey documentation.
- a. Zahrt's Account about Discoverina the Problem At some point, it came to Zahrt's attention that surveys performed on Level 1 of the reactor building were not being properly document'ed. Initially, Zahrt thought the matter of insufficient survey documentation came to light in late 1992 when Sawyer brought it to his attention. Zahrt claimed he then checked some surveys and "went down
. cnd looked at the logbook on Level 1 and noticed that' we didn't have a whole lot of surveys for the material that was released according to the logbook.""
193
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- No.5 l
Still later in his interview. Zahrt claimed no one had brought the problem to his
,j'
, cttention. Instead, he first identified the problem and took action."' .Zahrt said' he personally discovered the deficiency by comparing a Level 1 logbook maintained by Bixby and other RPTs'with a master survey book maintained by SEG at access control
. within the reactor building." When Zahrt reviewed the logbook and surveys, he did not
~
see documentation for.some of the materials that were being released for unrestricted; use from. Level 1.of the reactor building."
Zahrt said he then went to Bixby and asked whether Bixby actually surveyed the
materials that were being released. Bixby assured Zahrt that the surveys had been done cnd that nothing had been released without being surveyed. Zahrt then asked where the documentation was for Bixby's activities. Bixby replied that he had documented the -
. cctivity in his logbook." Zahrt also asked'Bixby why survey documentation had not been
~
. prepared. Bixby answered that he thought recording the'information in the logbook was til that was required and that the logbook was a legal document."
Zahrt claimed that when he discovered the problem, he discussed it with his day shift supervisor, Sawyer, and the night shift supervisor, Michael Miles. He had learned from M. Miles that the night shift personnel were documenting the survey activity on a wiease form. 'Zahrt advised M. Miles that some of the day shift personnel, including Bixby, wore ~ not putting the information on any form, but instead were putting it in a e logbook. Zahrt further told Sawyer and M. Miles that he was going to instruct Bixby to document the surveys Bixby claimed he performed, using information from Bixby's
! logbook entries."
t 194 as ..
No. 0 According to Zahrt..he instructed Bixby to go back to his logbook and generate-HX the missing' survey documentation showing that he had surveyed the material.: Zahrt -
claimed he was satisfied that the materials had been surveyed. Zahrt explained that he
- h d been through the reactor building on a daily basis and had watched Bixby surveying - :
a
$ the material."
Zahrt asserted that.he did not give Bixby any specific instructions on how to .
- prepare survey documentation for the release surveys. Specifically, Zahrt said_ he did' !
l
. not.tell Bixby anything about noting on the' backdated paperwork that he was preparing . .
~
survey documentation' at a much later date than when the actual' surveys were done.* '
o Zahrt also : claimed .he did not give Bixby any instruction on dating the survey; l documentation that Bixby was about to prepare.'"' Zahrt did not feel such an instruction
. w:s necessary, because in his view Bixby knew how to prepare documentation.w: ;
Zahrt recalled that he gave the instruction directly to Bixby to generate survey ,
forms from Bixby's logbook."' Zahrt recalled that he discussed the situation with both l Bixby and Sawyer. Zahrt did not recall, however, whether Sawyer was present when he instructed . Bixby to generate the survey documentation.* .i Zahrt said his purpase in having Bixby prepare the release survey documentation ;
l w s, in part, to show that surveys had been done to justify release of materials from the l plant." His initial' review of release survey documentation caused him to feel more
. . material had left the site than was reflected on the release survey forms.* - !
Around February 23,-1993, Zahrt said Bixby gave him 14 survey forms that Bigby - ;
- said he had reconstructed using his' Level 1 logbook entries."' With the exception of i
195 ;
?
5
j No.5 i
Zahrt's signature, all of the' handwntten entries on the 14' survey forms were made by. ;
i" .
Bixby. According to Zahrt, Bixby had filled out both the date entry at the top of the form, . ;
which is usually filled.in by the RPT. as well as the date entry at the bottom of the form, which.is usually filled in by the reviewing supervisor.'" Zahrt acknowledged that the.
date entry at the bottom of the survey form was intended for the reviewer to fill in. He ; ;
i could not explain why Bixby filled in both'date spaces on the survey forms.'" j in his interview,'Zahrt stated that during 1992 and 1993 there was some confusion '
tbout who should fill in the bottom date entry on the survey form. Zahrt related that in 1994 SEG initiated a documa.t change notice instructing RPTs to fill in only the date -
in the upper left-hand corner of the survey form, and leave space for the date on the 1
bottom blank. The bottom date space was to be filled in by the supervisor.""
Zahrt acknowledged that the 14 survey forms presented to. him by Bixby were backdated,'in that they came into existence long after the dates that Bixby entered on i
the survey documents.'" He also acknowledged that the dates on the forms - spanning l
. the time frame September 8,1992 through December 7,1992 -- made it appear that the
, 1 documentation had come into existence during.that time. He concederi that this appearance was misleading."'
- When he received Bixby's 14 backdated survey forms, Zahrt did nothing to check h the accuracy of the' data on the forms compared to what was actually in Bixby's logbook - !
1 entries. Zahrt explained that he trusted Bixby completely."' )
s N,'
I .
196 l l
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'No.5 I i
- b. Bixby's' Account of the Preparation of the' Backdated Release 7 Survey Forms ,
. e. .
- In conflict with Zahrt's accountc Bixby recalled.that in February 1993,' he was- !
- csked by his supervisor, Sawyer, to take data from his Level 1 logbook and 'use it to q
wnte up survey forms' covering September through December 1992 "' Bixby then took -
- information from his. logbook and wrote up the:14 backdated survey forms around - .;
Fcbruary 23,1993."' Bixby claimed that Sawyer did not explain why he wanted Bixby l to do this, nor did Sawyer tell Bixby that survey documentation was missing."'~ Bixby {
' thought he heard at a later time that the reason'for creating the survey documentation had to do with radiation work permit surveys instead of release surveys."' j Bixby said he did not question Sawyer's instruction because Sawyer was his boss."' Also, Bixby did not think Sawyer's request was improper because he had the information in his logbook to confirm the survey activity that had taken place during that i
~
- time frame. In Bixby's view, the logbook was a legal document."' When Bixby i completed preparing the 14 backdated survey documents, he either turned them over ;
to Sawyer or put them in the survey intake box at access control on Level 7.$2e ]
From early September to early December 1992. Bixby perticipated in surveying ;
materials from the dismantled steam generator system on Level 1. At the time he was ;
surveying materials for release t unrestricted use from FSV, Bixby understood that the
. SEG technicians were using PSC procedures. He further believed that the procedures called for documenting such survey activity on a ' release form which would be kept at
- access control on Level 7 of the reactor building. Rather than go to Level 7 and enter 197 y w , ,o V .ns'< ms . .. ---- Y--.--__._-__.-- - - _ - _ _ _ _ _ _
. -- . . .- .. . - - - ..- -.- .- . . - - ~ .-.
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~
survey __ data on a felease form. Bixby entered the survey data relating to release of ;
l M( materials in the logbook maintained ori Level 1 by the RPTs.'21
~
Bixby initially said'in his interview that other than his logbook entry, he did not; l
t o . prepare any survey documentation at the time. Later in the interview,' he acknowledged preparing some survey form documentation for activity that he also wrote in the logbookj 2 Moreover, Bixby said he believed that in late 1992 when PSC's procedures j!
l were in effect, he did not have to actually document his survey activity. For that matter, '!
he was not even sure whether there was a requirement to conduct a physical survey of j
the material, but he said everything that was released was surveyed. irs b Bixby described the process of surveying parts from the dismantled steam l 4
I
- gsnerator system for release. As parts of the steam generator system were cut and e- r moved, they were stacked on the floor beside a dumpster, which the RPTs called a
" skid pan." The skid pan was posted with e. t.cning riot to put anything in it without first
! notifying a health physics technician.i2' Items from the steam generator system would then be stockpiled ext to the skid pan. Then throughout the day or week, whenever the RPTs had time, they would frisk and smear the items to be released. According to 1
- Bixby, if an item showed less than 1000 dpm, the item would be placed in the skid pan for release. Conversely, if the item showed 1000 or more dpm, it would be " bagged, p
,- tagged (and] put into a box as radioactive material."'25 in conducting various types of surveys related to the steam generator system dismantling, Bixby and the other technicians used several different survey instruments,.
n including an air sampler, an RO-2, an RM-14 and probably a BC-4. According to usual i 1
~
198 t
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No.5.
3 I
procedures, the air sampler and RO2 instruments would have been obtained daily from cn instrument room maintained by SEG and located on Level 7 of the turbine building.
4- .
i in contrast, the RM-14 and BC-4 instruments would have been assigned to Level 1 in l
$ the reactor building.'"
LWhile conducting surveys of the steam generator system' parts, Bixby sometimes ' !;
found radioactive contamination. Depending on the nature of the item,'Bixby sometimes-wrote up the results'of his. survey activity on 'a survey map. For example, he said that .
i portions of the main steam lines. which people thought were clean, turned out to have - :
N. ' .
i s ,
fixed contamination. Bixby said this circumstance either would have been written on a 1 survey map or entered in his logbook.'27 -l i
~Bixby said he used the industry release standard of less than 100 " corrected i counts per minute" in determining whether or not to release materials from the facility during September through December 1992. He calculated the corrected counts per j minute by subtracting background readings from the survey instrument reading.'2' Bixby ;
~
al:o noted that an RM-14 instrument reading of less than 1000 dpm is the same as less !
thin 100 counts per minute, because the RM-14 has a ten percent efficiency rating.'"
Bixby said the surveyed materials were both smeared and frisked. He said there was a possibility that some of the materials that were surveyed were not listed in his l
. . logbook. Bixby said he did not always document his survey activity in the logbook, but.
~
= th:t if it were not listed in the . logbook' there was a very good possibility it was !
a Idocumented on a survey map A review of Bixby's survey documentation showed that he prr. spared timely. contemporaneous documentation for some of his Level 1 survey I 1
199
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No.' 5 : :
cctivities. ' In some instances. his backdated survey documentation duplicated: hisi w- 1 Leontemporaneous survey documentation.T
- c. ; Sawyer's Account Recardina the Backdated Release'Survev j Forms
']
~
- Sawyer did not recollect advising Bixby to backdate survey forms at any time in
.1993.'" He denied any knowledge of survey documents being created after the fact and.
~
then backdated .to make.it appear they 'were prepared on the day.when the survey prperwo'rk should have been done/
2 j
LSpecifically, Sawyer said he did 'not have any personal recollection of si..
i i,
conversation with. Bixby in which Bixby claimed Sawyer asked him: " Jim, where are your
]
surveys?- How come you didn't document any of this stuff?" . Sawyer conceded that he -l
. l "may very well have". said this to Bixby, but he repeated that he did not have'any- l
- rrcollection of the conversation,
. Sawyer did . not recall-when the problem of Bixby not preparing survey ,
- documentation was identified and he claimed he did not know what led to the' discovery - .
. cf the problem. Nor did Sawyer recall any conversation with Zahrt about materials
.being released from level 1 for which there was no suntey documentation. Similarly, .
. i
< ha did not recall hearing any conversations between Bixby and Zahrt where Zahrt would have questioned Bixby about Level 1 release survey documentation.
i
^
When askedLin his interview whether he recalled being present during a I. . .
p conversation between Bixby and Zahrt when Bixby might have told Zahrt that, he, in fact, Lw s doing surveys but documenting them his' logbook, Sawyer responded, s
200 !
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No, l do .not. I do not remember - I do -- my mind is
'i completely blank as far as that goes. .I -- every person that l've talked to so far has brought up the fact that, evidently,1 - .
I said something to Bixby, and I just do not remember.* i
- . In commenting upon his reference to others telling him about a conversation they - l l thought Sawyer had with Bixby, Sawyer explainedi Well, you know, Bixby has said that, you know, to the best of . ,
his knowledge, that I am the one that-- you know, that I am ;
. the one that -- I guess from Ken Zahrt - told him that, and i ,
2 just -- you know, I don't remember it.
You know I'm -- like i said, I may very well have. You know,
- we may.have identified another problem. I do not remember
'itJ l don't -- I did not know -- I did not know that - about the ;
' . fact that there was survey documentation in his log. Okay. ,
l really -- I did not know.*
{
In late 1992, Sawyer was acting in a supervisory capacity. Nevertheless, he said ;
h ha infrequently toured Level 1 where Bixby was surveying the steam generator system, partly because he was primarily assigned to the RFF, Level 11.""
,. E. Analysis of 14 Backdated Release Survev Forms We were not able to resolve the conflicting accounts among Zahrt, Bixby and !
c S2wyer as to the origin of Bixby's backdated release survey documentation. Bixby, however, gave the only unequivocal account - Sawyer told him to do it. Sawyer did not l
! deny Bixby's claim. Instead, he just could not recall the conversation. When Zahrt was asked about Bixby's account, he said he did not know whether Sawyer or he told Bixby, d but it was one of the two of them."'
Bixby was 100% certain that each of the 41 survey activities documented on the 14 backdated . forms represented a survey that 'had actually taken place. He y,
201
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No.5 i a
c1 ccknowledged.' however, that he did not personally perform all the surveys. Instead, i
(
some may have been .done by his co-worker. RPT Daryl Deringer, who .was also j i
- assigned to Level 1 "2- l
[According to Bixby, sometimes Deringer would make entries in the logbook, while ct other times Bixby would make them. Nevertheless, the backdated survey forms that i
Bixby wrote up, according to his: account,'were based on information that came out of ;
the logbook."' (Set Appendix' A ' Exhibit 3 for relevant portions of the logbook.) Bixby ,
said he ' wrote,the 14 backdated survey forms in half a day. At the time, he was in a ,
. hurry?and made a few mistakes; Still he insisted that everything.on the backdated' l survey. forms came out of the logbook and everything on the surveys was correct.'" l Neither Zahrt nor Sawyer questioned Bixby's assertion that the backdated survey j forms.were based on Bixby's Level 1 logbook entries."5 Comparison of the 41 entries on the backdated survey forms with the actual logbook entries Bixby said he relied upon,
~ however, shows that in numerous instances the documented survey entries are not j i
supported by the logbook entries. Additionally, all of the Bixby backdated survey forms aro misleading in that they give the appearance that they were created by Bixby and l
. reviewed by Zahrt at the time of the alleged survey activity. Also, some of the survey
. ' data were:apparently fabricated in that the logbook entries and other documentary Gvidence do not support - and at. times conflict with - the information listed on the backdated survey documentation.
l' ' Analysis of .whether specific data on Bixby's' backdated release survey
- documentation were fabricated required a detailed review of the survey. The detailed o
202 1
, , . , , -,- 3 -.,.- 4 - .m..c.,.- . . . - - - - - , _ . , , . - . , . . , .---
No.5 cnalysis of each of the 41 survey activities described on Bixby's 14 backdated release f
. survey forms is presented in Appendix A. This detailed analysis revealed numerous deficiencies in Bixby's backdated survey documentation. i For example, each of Bixby's backdated survey forms identified an RM-14 instrument by serial number and listed the instrument's calibration due date. None of-th0 instrument usage information appeared in Bixby's logbook. In his interview, Bixby ,
.could not recall where he got this instrument information when he prepared his_-
b:ckdated survey forms."' On some of the backdated survey forms, Bixby claimed he used an ,RM-14 instrument that SEG's records show was out of service. In still othar instances, the calibration due date Bixby listed on his survey form -- if accurate --
indicated that the instrument was overdue for calibration because the date for calibration had already passed months earlier. In still other instances, Bixby listed a calibration due dr.te more than six months into ..ie future from the date of the alleged survey activity, i indicating that Bixby fabricated the calibration due date entry on his survey form because l l
tha instruments were calibrated on a six-month cycle."' (Sgg Illustration I, next page). )
l 203 l
l
_ - _ . - _- _ _ _ - ~ - - - __ .- _ _ - _ - _ _ . - _ - - _ _ _ - _ _ _ _ _ _ _ _ _ __
T in i
i illustration 1 - Bixby Backdated Survey Forse 5052
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oain: 9 12.fs#1 imen:,s. - namesisonsuavsv seems sesa suusr __ est_
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-v. .
l lll Deee Eby entered for seert dsiervey activity wee actually ciascred m Febsvery 1993 16] Sipsed by kby in February 1993 -
12] Survey menrument - RM.I4 3902 was out ofservice osi dois dose
[7l Review dose emeered by Bizby in February 1993 -
- l1l Calibree.on due dose
[R) .% pied by Zeint in February 1993
- 14) lleckposed sednesson <==.n.einses egeunesed by bby in Felwwey 1991 ~ (91 Wipe resuks fresa unsers for Russe -
- l5l lkaby's logbook eenseems no refesemme to Irisking M
. [10) Survey number emead by D. Perseas in Febesary 1993 .
,--y, mw . - , - H -
--4 e t * =~**E+-- " " " " * * * ' ' ' ' ' ' ' " ' ' ' ' ' " ' ' " " ' ' ' ' '
-No.5 i
Each of these 14 backdated survey forms listed background radiation conditions iC .
at the time of the alleged survey activity. This information also did not appear in Bixby's
]
. Level 1. logbook.- Bixby! testified that when he prepared the backdated - survey ~
documentation, he estimated the b' ackground count based on his knowledge of l conditions on Level 1 from . September into December 1992. He recalled that the .
I background radiation at that time ranged from 40 to 80 counts per minute."'
In someiinstances, Bixby's backdated - survey forms duplicated existing, l contemporaneous surveys that he had performed and documented in September 1992.
. j in other cases. the Level 1 logbook rantained no entry to support the backdated entry. [
In still other instances, Bixby relied upon a fragmentary logbook entry made by another
=
tschnician describing survey activity in which Bixby did not recall participating."' !
Generally, Bixby's backdated survey forms did not identify the volume of materials that had been surveyed for release. Judging by the entries on his forms,' however, the volume appeared to change significantly from survey form to survey form.
Consequently, a variation in the smear activity for loose, surface contaminction could be -
cnticipateo. However, no such variation appears. Instead, Bixby completed the
[ . preprinted " wipe /results" section in each of the 14 backdated survey forms in an identical I
manner. In each case, he indicated 20 wipes were taken and each wipe showed activity 1 of less than 1000 DPM/100 cm8." Nor do any of the backdated survey forms indicate
. 'which wipes apply to a specific release activity even though most of the forms list survey !
activity. spanning several days. For example, radiation survey form 5049, dated i
September 8.1992, lists survey activity for four different dates, including surveys of two
" 205 1
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l
- gray carts and a skid pan. Yet, only 20 wipe results are listed and nothing indicates how :!
.- i these 20' wipes were distributed among the volume ~of materials surveyed."'
1.- Overview - Blain's Review of Backdated Release Survey Documentation s When Zahrt received Bixby's backdated survey forms, he did not compare the
'i
.bickdated documentation with the entries in Bixby's logbook."2 With the assistance of f PSC health' physics oversight team member Darrel Blain, we undertook such an analysis.
l
.The factual detail underlying this analysis is contained in Appendix A.
l Bixby's' 14 backdated survey forms listed 41 different survey activities. Blain j concluded that Bixby was justified in creating backdated documentation ' based on the !
- Level 1 logbook entries in only eight of these 41 instances."' (Sgg summary chart, i
Appendix'A. Exhibit 4.) As for the remaining 33 instances. Blain concluded that the Level 1 logbook entries did not support the activity documented on Bixby's backdated survey forms. Of these 33 instances. Blain concluded that five were duplicates of i surveys that Bixby had previously performed. and documented in 1992.* (San comparison chart - Appendix A, Exhibit 6). l Additionally, Blain's analysis of the Level 1 logbook led him to conclude that there i were a total of 15 entries on Bixby's backdated survey forms that were not supported by l I
logbook entries personally made by Bixby. Bixby's own entries were either too f i
fragmentary. to support a reasonable conclusion that the backdated survey activity i occurred _ as Bixby claimed it did or the logbook contained no information to support the cirimed survey activity at all. l i
206 :
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- No. 51 For another 13 entries. Bixby claimed that he relied upon logbook entries made !
- ' n
'by other technicians who worked on Level 1.* Analysis showed that in every instance l
l
.the logbook entries by other technicians were' too fragmentary to support the backdated j
- survey form entry.. None of the ~ other RPT's logbook entries identified the survey l instrument they'used, instrument calibration due date, or the background radiation j conditions at the time of the survey activity.' Moreover, in many instances, these logbook -
cntries by other RPTs did not describe the volume of the material surveyed or whether - j l'
the material was found to be clean and, thus, eligible for unconditional release.*
- 2. Misleadina Nature of Backdated Release Survev Forms i The weight of the evidence supports the conclusion that Bixby's backdated survey l
forms were intended to mislead. When the backdated documents were created in Fcbruary 1993, they were all made to appear as if they had come into existence at a much earlier date. The key reason for this misleading appearance was the repetition of
- d;te information on each survey form. The dates in the upper left-hand corner filled out by Bixby, the dates in the bottom center for the reviewer to complete, and the dates for Bixby's 41 specific survey entries, altogether gave the impression that the documentation i w;s created at the time of the alleged survey activity instead of month's later as was the actual case.
All of these "date" entries lead the uninformed reader to erroneously crenclude that L the survey forms were written and reviewed during September to December 1992. The 14 backdated survey forms lacked any notation advising the reader that they were i
reconstructed'sometime in February 1993. The appearance of regularity created by the l l
207. )
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' backdating served to deflect inquiry into the underlying source data. Such an inquiry
- would have' raised substantial questions about whether the survey instruments Bixby says he used were properly calibrated or in-service, whether the logbook entries actually supported Bixby's release survey documentation, and whether Bixby actually performed the surveys he claimed he did.
Another way in which the 14 backdated survey forms mislead is that they distort the picture of how much valid survey documentation exists. The backdated survey documentation creates an appearance that a' larger volume of released material was i properly documented than is actually the case. This appearance, however, is consistent with Zahrt's desire to close the gap between the large quantity of materials he believed had been released and the small quantity of documentation he found (As discussed below, however, the evidence did not show that any materials were improperly released 3
from the site without having been properly surveyed.)
. The evidence also supports the conclusion that often the instrument usage and calibration data on these survey forms were fabricated. In many instances, thcre is no independent documentary evidence corroborating the instrumentation data noted in the brckdated survey forms. Instead document analysis of calibration records for the RM-14 instruments Bixby listed on his backdated survey forms revealed significant irregularities.
In four instances, Bixby listed an RM-14 instrument that was not in service because it needed to be repaired.'" in two of these four instances when the instrument was out-of-service and awaiting repair, Bixby also listed a calibration due date of "4-26-93", which date was beyond the six month calibration cycle for RM-14 instruments.'" In still three s
208 A
No.5 1
other instances. Bixby listed a calibration due date of"4/26/92" which, if accurate, meant th t the instrument was out-of-calibration and could not be used for survey activity in the 12tter part of 1992'.'" (Sgt chart -- RM-14 survey instrument usage - Appendix A -
Exhibit 5).
- 3. Zahrt's Accountability for Backdated Release Survev Documentation For his part Zahrt was aware that these Bixby survey documents came into cxistence significantly after the survey and review dates shown on the documents. Zahrt t;stified ' that when he received the backdated survey forms, Bixby had already filled in .
the supervisor's review date with dates ranging from September 1992 to December 1992. Zahrt received and reviewed these backdated survey forms in February 1993, and th:;n placed his signature on each of them even though Bixby had entered an erroneous review date.'"
Zahrt's personal involvement in processing Bixby's backdated release survey forms was confirmed by RPT Duane Parsons. Late in February 1993, Zahrt handed D.
Persons the package of Bixby's backdated survey forms. Zahrt told D. Parsons that they I J
were 1992 survey forms and needed to go with the 1992 survey log. Zahrt, however, j did not give D. Parsons any specific instruction as to how to enter the survey data into th3 SEG 1992 survey log. D. Parsons recounted that at the time, SEG's 1992 survey b log had been closed out, so D. Parsons used a preprinted "1993" survey log form, crossed out the "3" and changed it to "1992." He then dated and initialed the change "DAP 2/23/93."
209
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- In his interview. Zahrt stated he did not believe the backdating of survey forms !
1 I'
I
/ was:done with the intent to mislead anyone. Zahrt, nevertheless, conceded that the
- backdated release survey documents were misleading. 'Zahrt further acknowledged that ;
- . the backdated survey documentation looked " bad on paper." He asserted, however, that l i
. the technicians did not fabricate anything.'s 1
- a. Zahrt's Failure to initiate an ROR l Further circumstantial evidence'of Zahi!s deliberate involvement in the backdating i
scheme is seen in his railure to fulfill his duty to initiate an ROR when the survey ;
deficiencies came to light._ Zahrt was advised by one of his RPTs, David Hatch, to issue cn ROR. During the investigation, Zahrt acknowledged that the proper thing to do ,
would have been to initiate an ROR. He had no explanation for his failure to initiate l l
c ne. i 1
issuance of an ROR, however, could have triggered an investigation and invited i cudit activity. The FSV Decommissioning Plan established a reporting program for identifying radiological occurrences and correcting errors that cause radiological ]
\
performance problems.'" The basic method for reporting radiological occurrences is an
- ROR.
Radiological occurrences are classified, depending upon their severity, as either O radiological " incident" or a radiological " deficiency." Radiological deficiencies are generally defined as " occurrences involving poor radiological work practices with
. relatively minor' consequences."'" Deficiencies' include the failure to comply with radiation protection procedures. )
)
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. Each time a radiological deficiency is identified,' the radiation protection staff is f directee;o evaluate the occurrence "for possible deficiencies in areas such as training, i
. procedures, equipment and human performance."'" Esch time a deficiency ROR'is t
iss'uedi radiation protection. managers are required to follow up with appropriate ';
t
?
i
- . supervisory snd corrective action.'"' l.g h ' Radiological incidents, on the other hand, are generally defined as " occurrences .
} tf tt have, or could have the potential for, violating Federal Regulations and Fort Saint j
, r Vrcin Decomm.issioning Technical Specifications or involve a serious breakdown in the
! cffectiveness of the Radiation Protection Program."" incidents include flagre.nt l i; violations of radiation protection procedures.'"
. i i Whenever a radiological incident is identified, the Project Radiation Protection M: nager is directed to assign a team to investigate and critique the incident.'" l i.
Appropriate corrective action is " required to prevent recurrence."'" Complete reports l
)
and investigations are " reviewed by the ALARA committee and the j l
Decommissioning Safety Review Committee, as appropriate, depending on the type of occurrence and th'e severity."*
f As discussed earlier, procedures relating to the ROR Program require, under
. some circumstances, investigation into conditions identified in an ROR. Thus, had Zahrt initiated an ROR, he may have triggered an inquiry into his conduct of the radiation
. prttection program at FSV. Eventually, SEG did initiate an ROR based on the belief that surveys 'were conducted, but not properly documented. This ROR, however, was not
?'
211
l No 5 l l
. i initiated until March 1994, after the possible survey form. falsification issue had !
surfaced."'
- b. Zahrt's Awareness of Audit Activity at FSV i l
~
Zahrt acknowledged that the radiation survey forms prepared by Bixby were subject to sudit review. These forms had to be transmitted to PSC, maintained in .
cccordance with NRC regulations, and made available for review by the NRC."' Zahrt .
1 thought that the PSC, NRC and SEG audits would have examined the radiation survey p:ckages. He, did not know, however, whether any of these audits took place around the' time that Bixby backdated the release survey forms."'
There were ongoing audits of the decommissioning project."' These audits included reviews of SEG's health physics program."' For example, in the latter part of i J2nuary 1993, Westinghouse Team Quality Assurance personnel- conducted a surveillance of SEG's quality records, including radiation protection records. Zahrt, cmong others, was a recipient of this surveillance report.' .
The Bixby backdated release survey forms were entered into SEG's logbook cround February 22, 1993. At this time, a Westirighouse Quality System and i Compliance audit was pending. The Westinghouse Team received notice of the audit plan in a letter dated February 12, 1993.'" The audit was scheduled to commence at FSV on March 16, 1993.'" The announced purpose of the audit was to assess the
. effectiveness of FSVs Decommissioning Project Quality Assurance Program. The cnnounced scope of the audit. included procedures, inspections, quality assurance records and audits.
212 l
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. . . . 1 i The esidence'showed that on several' occasions in late 1992 and early .1993 -- I M '
- prior to Bixby backdating the 14 release survey forms -- Zahrt was advised by one of his ]
subordinates about insufficient survey documentation. SEG's D. Parsons recalled that on two occasions in 1992, he alerted Zahrt to deficiencies in survey documentation.. D.
- Pctsons learned of the deficiencies while examining a book containing a listing of' survey .
forms for each RWP survey. documented. When the RWP survey forms were logged, i they.were given a sequential number and listed individually. on a survey addendum sheet under the relevant RWP number.. While reviewing the survey book, D. Parsons - )
' o6 served that for certain RWPs- where he knew work had been performed - no survey ;
{
forms had been entered.'" I D. Parsons also thought that he brought the matter of survey deficiencies to .i 1
Zchrt's attention on one or two occasions in early 1993.'" D. Parsons' felt there may
' h ve been a connection between these conversations with Zahrt and Zahrt bringing him the backdated Bixby survey forms in February 1993. He thought in one of his earlier conversations ~ he may have said to Zahrt that it did not seem SEG had sufficient documentation covering all of the material going' out from Level 1. D. Parsons recalled .
l
- th t the survey activity on Level 1 was one of the areas where he had noticed a lack of !
documentation.'"
1
- 4. Similarity of Anoroach - Bixbv's Backdated Release Survey Forms j and Backdated RWP Survev Forms j V ' .
l Although Bixby claimed that. Sawyer - not Zahrt - told him to prepare the j beckdated release ' survey forms, Bixby also claimed _that Sawyer did not give him any 213 l
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l No. 5
_.s s
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" instructions as to how to prepare the documentation. Bixby said the decision about how ]
b to prepare the backdated documentation was his own.
1 Examination of all of the backdated survey forms uncovered in the course of the j investigation, including Bixby's backdated release survey forms and the backdated RWP .
l survey forms, shows .they were all prepared in a similar manner. On all of them the activity of backdating the documentation was concealed from any independent reviewer.
- (The backdated RWP survey forms are discussed in Section Vill of this Report.) j By their,own admissions, at least three RPTs were involved in preparing these l backdated ' survey : forms.'" The evidence shows that several other RPTs and supervisors participated in backdating RWP survey documentation.'" Although all of the j RPTs denied they were given any specific instruction on how to prepare backdated
, documentation, their similarity in approach strongly suggests that the RPTs were either s
~
' told how to prepare the documentation.or else they discussed the matter among l themselves and came to a common understanding, i
All of the backdated documentation contained survey and review dates that
)
j fostered the misleading impression that the documents had been prepared
.' contemporaneously with the alleged survey activity. Furthermore, none of the backdated .
documentation contained any notation advising a reviewer that the documents had been !
I recreated from information drawn from multiple sourcer including memory, other RPTs'
.. survey activities, ard from incomplete records of survey activity such as the Level 1 l I
. logbook. ;
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'No.5
? Zahrt was also aware of alternative ways of preparing the backdated survey forms
].
'which, if followed by Bixby, would not have created such a misleading appearance. In the past.-Zahrt recalled that if a survey form had been " reconstituted" or " reverified," a notation was made on' the form that the survey had been lost and was being recreated based on data' collected from the job. Zahrt could not explain why he did not follow that l l
prcctice regarding Bixby's backdated documentation other than. to say he was too i
busy.* Zahrt denied giving Bixby any instructions on how to prepare the release survey l
f:rms.* Zahrt claimed that no one told him to have the survey documentation prepared j this way. Also he did not ask anyone's permission to do it the way it was done.,e2. Zahrt
- acknowledged the proper protocol would have been to attach an ROR to the survey I
fsrms that were created.* :
l 5.' Zahrt's Exclanation for the Survev Document Deficiencies As the RPOS, Zahrt was responsible for ensuring " appropriate radiation and contamination surveys (were) performed to verify radiation levels and working conditions" 4
' ct the site.* In the course of his interview, Zahrt described conditions which he felt
. contributed to the survey documentation deficiencies that occurred and his own failure l to detect these deficiencies. He said that in the latter part of 1992, these conditions included lack of training for the RPTs, confusion over release standards, RPT understaffing, the hectic pace of operations, the poor state of SEG's proposed procedures, and laziness on the part of the RPTs.
- As for his own failure to detect these paperwork deficiencies, Zahrt explained:
[W)ith all' the ' procedures and all the RWPs and all the surveys 'and all the dealings;with the MK people and the 215
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.No.5 i
. Westinghouse people and all the problems with staffing and
. ' all the problems with overtime, you know, it was not feasible 1, for me to take care'of this detail.
And they didn't want to pay somebody to give'me somebody ;
in document control to do this. And they should have, and it i
was put on the order chart, but it was kicked out because of
- money.l" Despite this litany of problems described by Zahrt, the evidence shows that he did have
{
ample warning of the survey document deficiencies. As discussed above, D. Parsons testified that he alerted Zahrt to the deficiencies in late 1992 and early 1993. When [,
- 4 Zchrt took no a'ction, D. Parsons, out of frustration, performed an informal audit that documented numerous RWP survey deficiencies. He presented his informal audit results to Zahrt.in early March .1993.'" l As for the RPTs' failure to document survey activity, Zahrt claimed that a number l
- 1 of circumstances contributed to this shortcoming. According to Zahrt, the RPTs were i
7 working with PSC procedures for which they had not received training.'" Zahrt disclosed i th t SEG had made a commitment to the Westinghouse Team to provide a 30-day
[ trcining period on procedures for the entire staff. Zahrt, however, said " things moved so fast" there was never time to train.'" When SEG took over from PSC in August 1992, the pace was just "go, go, go" from the beginning.'" Zahrt's logbook entries corroborate this aspect of his testimony. For example, his September 18,1992 logbook entry reads: "It is really hectic, I just can't seem to get caught up."'"
. 1 Zahrt claimed that throughout the first part of the project, he and his staff worked j incessantly to address the problems connected with the procedures, understaffing and 1
lack of training. During this phase, Zahrt's primary concern was to avoid anyone getting j
216 4
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No.5 contaminated. He stated that SEG was able to achieve this goal. because SEG did a lot of things strictly, but in terms of paperwork, some things " fell through the cracks."2ei in explaining why surveys were not documented in the latter part of 1992, Zahrt conceded that some mistakes were definitely made concerning paperwork. One of the rcasons for this, he claimed, was that SEG management did not give him the resources needed. Nevertheless, Zahrt asserted that all of the actual survey work was done even though the RPTs may not have documented it.2c2 Zahrt told his management about staffing problems and the need to provide for overtime. He repeatedly told them they were understaffed. His management responded that he was going to dc *.e project with cight technicians and not work overtime.2n Zahrt's supervisor logbook entries also confirm that in August and September 1992, he discussed overtime issues with his management and was told overtime would not be authorized.2" His logbook entries also reflected that RPT understaffing was a rccurring problem in August and September 1992.' 5 Zahrt's increasing frustration with this condition is evidenced in his logbook entries. For example, on September 2,1992, he wrote:
Met with Dieter & Hug and again talked about the shortage of R.P. techs - It seems the powers that be have deaf ears.2w Also, on September 9,1992, Zahrt initialed the following entry made by his night shift supervisor:
M&K wants to do to [ sic] much, we are trying to cover tendons, steam generator work, top head etc. we need more R.P. TECHStrn 217
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. Zahrt's logbook further reflects that on a number of. occasions work had to be curtailed : j
~
) because of staffing shortages.2" Also in late 1992, other SEG personnel expressed' concern about whetherJ inadequate ' RPT staffing might: result in materials being
~
- improperly released.2" 4 Zahrt described the SEG radiation protection procedures that were to supplant the !
j PSC procedures in. December 1992 as a " mess." in his opinion,- the state of the - ;
- i i .
procedures contributed to Bixby's failure to document the release surveys between September and December 1992,2* Zahrt recalled that just around the time he felt the. i
! RPTs.had PSC's procedures under control, SEG presented 108 proposed procedures l
~
intended for use'once the' Decommissioning Plan was approved by the NRC. Zahrt vinwed many of these SEG proposed procedures as unworkable and said that SEG did l I not give the on site personnel sufficient time to verify and validate the procedures.2n Zahrt related that a review of the proposed SEG procedures during July and ,
August 1992 revealed major problems that needed to be fixed before the procedures would be workable.212 By December 1992, SEG still had not completed making the f
changes to the procedures. Zahrt claimed that SEG spent $3 million to have the procedures written, but the procedures were written by people off-site. Even though these people wore familiar with the commercial nuclear power plant industry, the procedures they drafted did not apply to the FSV site and the decommissioning project.'" .in the meantime, SEG was trying to work within the PSC procedures for l which : Zahrt claimed, they had not gotten training. At the same time, they were trying i
[ to verify.and. validate the proposed SEG procedures. Zahrt said the verification and 218 4
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validation procedure led to Zahrt being told by. his corporate superiors'that h'is pecple
. ,r "were out of control" end that SEG headquarters was not about to let Zahrt's people 2u -
. rswrite the procedures after spending several million dollars to write them.
In. summarizing all. the problems SEG confronted around the time of Bixby's survey activity on Level 1 Zahrt described a condition of " unbelievable confusion." He s:id everyone was trying to work with a proposed Decommissioning Plan and the FSV -
procedures and the technical specifications for' decommissioning. He asserted that PSC's release, limits for sunteying materials for unconditional release were different from SEG's and suggested that this difference was a contributing factor to the suNey documentation shortcomings.
In explaining the differences between the PSC and SEG release limits, Zahrt said a lot depended on what kind of instrumentation was used to conduct a survey. Zahrt snid the reason there was so much confusion was that the SEG.RPTs were using a highly sensitive monitoring instrument, known as a Tennelec, to detect contamination. ,
Zchrt explained that the Tennelec is capable of detecting extremely low levels of dpm -
much lower than could t,e detected by the RM-14 instrument authorized by PSC
- procedures, Zahrt said that the choice of instrumentation affected the volume of
! materials that got released for unconditional use. He explained that the Tennelec was espable of detecting activity as low as 12 dpm, whereas an RM-14 frisker would not detect such low levels of activity.zie Because PSC procedures govemed the standard for release, PSC's Radiation
~ Protection ' Manager, Borst, instructed SEG to conduct surveys in accordance with 219 t a w -- - - r,-- ,. ._________________________.a
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" No;5 f" d cxisting PSC procedure. ~ Borst advised SEG that their surveying practices should be q
I(~ consistent with FSV' procedures, which called for the use of the RM-14 frisker.2" SEG
' then used the RM-14 instrument to analyze wipes for loose contamination and to check . 1 1 i
- . for fixed contamination. In his' interview, Zahrt agreed that PSC's survey procedures i
'were consistent with acceptable industry practices.2a i
Zahrt claimed it was a matter of interpretation as to what' instrument should be j
'.used for conducting surveys.2" He said that SEG's management, Edward Parsons and i Richard Sexton, and PSC oversight manager, Borst, and oversight team member, t
, Timothy E. Schleiger, Sr., all felt that using an RM-14 ins.rument to conduct surveys was !
i
- appropriate and that material could be released as clean if the RM-14 instrument did not '
j cdit'ect activity.22'
- Reliance on PSC procedure meant that the RM-14 frisker type instrument would i
be used for conducting surveys. The frisker was not as sensitive an instrument as the !
4 l
Tcnnelec. Zahrt noted that the RM-14 instrument was only ten percent efficient so that ;
if there _were 1000 dpm activity.present, the instrument was only going to read 100 -
. counts per minute (cpm).22' On 'an RM-14 frisker instrument,100 counts above
[
- .b:ckground was the equivalent of 1000 dpm. It is also the minimum detectable count t rcte that can be seen on a frisker.222 l'
l Zahrt also desenbed the RPTs' " laziness" as a root cause for the inadequate i i
. release documentation during September to December 1992.223 Zahrt explained that i
sometimes the RPTs were lax in their paperwork and did not document surveys. '* !
u .
t .
l l
220 j
No.5 According to Zahrt sometimes the RPTs got a little lazy and did not want to follow up i
on documentation.22s Zahrt suggested that the nature of the surveying process contributed to the RPTs poor motivation. According to Zahrt, during September through December 1992, almost cil the RPTs -- night shift and day shift -- were involved in surveying material for release from the site for unrestricted use.22s He described the process as monotonout and said th:t none of the technicians wan%d to do it.227 Nevertheless, Zahrt asserted that all of the materials were properly surveyed and only if an RPT determined the material was
- e. lean was it sent outside to a dumpster. Then a dumpster survey was done before the mrtedal left the site.22s Zahrt's claim that there was confusion in the latter part of 1992 surrounding RPT cctwities was partly corroborated by other witnesses. For example, Hatch said there w;s confusion over who would document survey activity when a group of RPTs participated in frisking materials. Hatch said that no one in the group might have been esignated to make sure paperwork got done, so the survey activity was not documented.22' Hatch also claimed that during the latter part of 1992, every technician, including himself, was probably involved in not correctly documenting the results of
- suntcy activity.8'"
During 1992, Hatch had also expressed confusion about the actual survey requirements for free release of materials to a member of PSC's health physics oversite team. Hatch raised a question about the requirements described in one of SEG's 221 o
Noi5 i i
Lprocedures and indicated he had been added that another instrument could be used 9 l
! other than the one specified in the pending SEG procedure.2 s
'PSC's Borst, however, rejected the notion that there was any confusion over-i
- release standards in the latter part of 1992. Borst noted that PSC procedures addressed -
surveying material ' to be released for unrestricted. use. In his view,- the survey l requirements were clear and had.been in place since January 1992.222 Borst felt there was no merit to the argument that confusion over procedures during the transition period ,
of August 1992 into December 1992 contributed to a technician failing to document rdlease surveys. Borst noted that the same RPTs who worked for SEG had worked for l 4 .)
PSC prior to SEG taking over and they had used the same PSC procedures in that
!. carfier time frame.2" Although the evidence did provide some corroboration for Zahrt's account that there was confusion during the latter part o' 1992, the evidence did not substantiate j- Zahrt's explanation for Bixby's failure to document surveys. The actual procedures in effect from August 1992 through December 1992 were PSC's. There was never any ;
embiguity about PSC's release standard, which called for the use of an RM-14 frisker cnd specified materials could be released utilizing a standard of no greater than 1000
[ dpm- for loose contamination and no greater than 100 corrected cpm for fixed contamination.
i
- . : Moreover, whatever confusion about release staridards may have existed on the
= part of certain RPTs, Bixby wse not one of them. Bixby understood the release standard
- was less than 1000 dpm for loose contamination. His release survey documents, -
E 222 J
,- n - -- . - - . - , . , - - , - - - . . - . . ,
m ;
m s:
4 No.5: {
'{
i including. logbook entries and contemporary and backdated survey forms, show that he- -l I '
cmployed the PSC release standard and used an RM-14 frisker instrument. Ultimately, the evidence did not establish any connection between the confusion' mentioned by Zahrt '
' f i- !
! cnd Bixby's failure to document his survey activity. j l F. ,SEG Manaaement's Knowledae '
l At the time he learned _of Bixby'not documenting. release surveys, Zahrt did not :
4
?
- tell his management.23e At some later time, he told his management that documentation L l if " was' poor and changes needed to be made in how SEG did business.' Even then, he did l r ' not' recall any specific discussion with management about the backdated Bixby sumey h- forms.237 !
[
Zahrt recalled that he did not discuss the issue of possible records falsification
- with his management until March 1994, when the issue surfaced in our investigation. -
i
/
In March 1994, he was told by his management that a question of possible falsification l 7 had arisen. At that time, he told them that Bixby had recreated surveys. Zahrt said that-
- 1. ,
his own on-site management -- E. Parsons and Sexton -- did not know anything prior to this' discussion. E. Parsons and Sexton stated that they had no knowledge of the f
- . Bixby surveys until March 1993.239 G. Analysis of Safety lmolications of Backdated Release Survev Form.g Zahrt and Sawyer emphatically said that nothing was ever unconditionally w released from the reactor building without being surveyed.2" We did not accept their representations at face value. Instead, we scrutinized records and questioned other witnesses' for evidence on the issue.'
}. t.
223 lb
[* .
o ; L - ~..,',, , a .
. - . - . - - -. - - . . - . - - - ~ - - - . . . - . - ~ .
F No.5- l ;
f The investigation did not disclose that any materials were released from the site !
7
$ without having 'been surveyed. Witness accounts of RPTs who participated in the steam l
i generator dismantling were consistent in recounting that materials were surveyed prior !
to release., Even one of the witnesses whose testimony was instrumental in exposing !
, - the document. falsification was confident' that the pieces from the dismantled steam- I T .
L generator system did not leave the site without an RPT having surveyed them.2 MKF
. witnesses corroborated the accounts of the RPTs.24: Additionally, at the time of the t
I survey activity. there were complaints by the MKF supervisors that the surveying i
operations were holding up MKF activities.'"
' When the radiation survey form falsification issue' first came to light, the - !
Westinghouse Team undertook a safety assessment of the situation to determine if there ;
r _were. any adverse consequences to public and worker health and safety. The L
preliminary conclusion of this assessment was that public and worker health and safety .
. were not compromised, This conclusion was supported by an evaluation of objective 1 l
data measuring worker' radiation exposure. These objective data were supplemented
[ :
,- with witness interviews, a review of PSC oversight activities and additionel dccument ,
cnalysis,-including the Level 1 logbook. The totality of this information led the safety 4 cssessment team to conclude that no material was inappropriately released from the FSV site.
i m in; an August 4,1994 presentation at NRC Region IV Headquarters, the Westinghouse Safety Assessment team concluded:
L 4 No evidence exists that materials have been unconditionally released for unrestricted use from'a FSV RCA (radiological 4
224
_ ._ ~ _ . . ._ _ _ _ _ .__ . _. _ _ __ _ .._. _ _
No.5 control area) without performance of adequate surveys to - r
!( meet release criteria from 9/8/92 to the present. Substantial evidence indicates ~ that - materials were adequately surveyed."24e Our investigation did not uncover any evidence to refute the Safety Assessment team's
! conclusion.
One of the factors that the Safety Assessment team cited in support of its cenclusion was that additional surveys had been performed on the dumpsters containing l m terial deemed suitable for unconditional release just before the dumpsters were sent eff-site. _ Our an'alysis of documentary evidence relating to dumpster surveys strongly
, corroborates the reliance placed on this aspect of the radiological protection program by .
th3 Safety Assessment team, i Materials that the RPTs considered eligible for release from the site for j unrestricted use were segregated from contaminated items and placed in specially j
i designated dumpsters. When the materials were aggregated in this manner, the -
possibility presented itself that the cumulative material might contain sufficient radiation to merit treating it as radioactive waste
, Our analysis of the dumpster survey forms for the last four months of 1992 shows j
- th t these surveys were performed on almost a daily basis during the four-day work week at FSV. (Sea chart - Dumpster Surveys - Appendix A, Exhibit 7). Furthermore,-
from September 28,1992 to October 1,1992, a Westinghouse Team Quality Assurance conducted surveillance of the. controls employed in connection with the release of scrap i
m:terials from the reactor building. This Quality Assurance surveillance found that i 1 l dumpsters were being surveyed daily and the activity was documented. j 225
No.5-
- H.- Conclusion - Backdated Release Survev Forms The weight of the evidence shows that in early 1993 SEG supervisors Zahrt and J-S wyer, and RPT Bixby, participated in backdating 1992 radiation survey documentation r:lating to the release of materials from the site for unrestricted use. Sawyer, the day shift supervisor, directed Bixby: to prepare the backdated documentation using information contained in a Level 1 logbook maintained by Bixby and other RPTs. In 4
Fcbruary 1993. Bixby backdated 14 release survey forms..Zahrt, the RPOS, then signed CCch of these backdated forms with full knowledge that they.were backdated. Much of thrinformation on the' backdated forms relating to strvey instrument usage and c!libration is fabricated. Also, in numerous instances the Level 1 logbook entries did not 1
support the descriptions that Bixby placed on his backdated documentation. Although
- the investigation identified ample evidence of the falsification of these release survey documents, the investigation did not uncover evidence that materials were released from the FSV site without having been sun / eyed.
t 4
226
No.5 L
LENDNOTES-
- 1. The testimony concerning the date block at the bottom of the survey fo.rm was in ;
conflict. 'The date entry at the bottom of the form appears immediately before the i
- space for the reviewer's signature. (Comoare Unsworn Interview Statement of Kenneth L. Zahrt. Mar. 28,1994, pp. 254-55 [ hereinafter cited as "Zahrt (3/28/94) ' )
(Unsworn)"); Unsworn interview Statement of Kenneth L. Zahrt, May 6,1994, pp. 1
, 41-42 [ hereinafter cited as "Zahrt (5/6/94) (Unsworn)"); and Unsworn Interview j Statement of Kenneth L. Zahrt. Apr. 13,1994, pp. 39-40 [ hereinafter cited as -
7 "Zahrt (4/13/94)(Unsworn)").) The Decommissioning Plan mandates that the date ,
. and time of the survey activity be documented. (DN 919, Decommissioning Plan, ;
Rev.1, 53.2.7.7.)
- 2. '10 CFR $20.1101.
. 1
- 3. Decomrnissioning' Plan, Rev.1,93.2.1 and 93.2.2.1, DN 853.
-i
! . 4 .- ' PSC Procedure, Surface Radioactive Contamination Survey, HPP-120, Issue 7, l
$3.1.1, DN 1550. l
- 5. PSC Procedure, Surface Radioactive Contamination Survey, HPP-120, issue 7,
- j3.1.2, DN 1550.
I
- 6. 10 CFR 920.201(b) ("Each licensee shall make or cause to be made such surveys as (1) may be necessary for the licensee to comply with the regulations in this part, and (2) are reasonable under the circumstances to evaluate the extent of radiation hazards that may be present.").
)
- 7. 10 CFR 920.401 ("Each licensee shall maintain records . . showing the results j of surveys required by $201(b) .)"
- 8. 10 CFR part 2, App. C.
- 9. 10 CFR part 2, App. C, Supplement Vil, Miscellaneous Matters, p.185.
- 10. 1J CFR part 2, App, C,Section IV, Severity of Violations. l l
- 11. 10 CF.R part 2, App. C, Supplement Vill, Enforcement Actions involving
- Individuals, p.175.
o 1
- 12. M. at 637. ;
1 j 13. M. at 638.
- 14. FSV Decommissioning Plan, Rev.1, $3.2.1, DN 853 63.2.7, Surveillance, DN 853, i
= DN 912. (" Radiological surveillance will be conducted routinely to identify radiation i
227 I 4
-. a. .. , .
No.5 ENDNOTES i
! 1. The testimony concerning the date block at the bottom of the survey form was'in ]
conflict. The date entry at the bottom of the form appears immediately before the ;
space for the reviewer's signature. (Comoare Unsworn Interview Statement of !
Kenneth L. Zahrt Mar. 28,1994, pp. 254-55 [ hereinafter cited as "Zahrt (3/28/94) j (Unsworn)"]; Unsworn Interview Statement of Kenneth L. Zahrt, May 6,1994, pp.
41-42 [ hereinafter cited as "Zahrt (5/6/94) (Unsworn)"]; and Unsworn interview Statement of Kenneth L. Zahrt. Apr. 13,1994, pp. 39-40 [ hereinafter cited as ,
"Zahrt (4/13/94) (Unsworn)").) The Decommissioning Plan mandates that the date and time of the survey activity be documented. (DN 919, Decommissioning Plan, Rev.1, 3.2.7.7.)
' 2. 10 CFR @20.1101.
- 3. ' Decommissioning Plan, Rev.1, 53.2.1. and @3.2.2.1, DN 853.
- 4. PSC Procedure. Surface Radioactive Contamination Survey, HPP-120, Issue 7, 53.1.1, DN 1550.
- 5. PSC Procedure. Surface Radioactive Contamination Survey, HPP-120, issue 7, 3.1.2 DN 1550.
- 6. 10 CFR @20.201(b) ("Each licensee shall make or cause to be made such surveys as (1) may be necessary for the licensee to comply with the regulations in this part, and (2) are reasonable under the circumstances to evaluate the extent of radiation hazards that may be present.").
- 7. 10 CFR Q20.401 ("Each licensee shall maintain records , showing the results of surveys required by 9201(b) .
")
- 8. 10 CFR part 2, App. C.
- 9. 10 CFR part 2, App. C, Supplement Vil, Miscellaneous Matters, p.185.
- 10. 10 CFR part 2, App. C Section IV, Severity of Violations.
- 11. 10 CFR part 2, App. C, Supplement Vill, Enforcement Actions invo[ving Individuals, p.175.
- 12. M. at 637.
- 13. M. at 638.
14.' FSV Decommissioning Plan, Rev.1,93.2.1, DN 853 @3.2.7, Surveillance, DN 853, DN 912. (" Radiological surveillance will be conducted routinely to identify radiation 227 L
I s
No.5 w
. sources; determir miological conditions and comply with the requirements of 4 -
10.CFR 20. ? .;l surveys will be scheduled by Radiation Protection 1' Supervision as ne 'w! to evaluate radiological conditions in support of- .
4 decommissioning activ...is. Elements of radiological surveillance program will' l consist of the following: (1) Routine surveys-general (2) dose rate surveys (3)
- surface contamination seveys (4) airborne radior ctivity surveys (5) environmental sampling and analysis (6) personnelL contamination monitoring (7) survey documentation and review. Detailed radiological surveillance requirements and ,
[ - activities will be described in the Radiation Protection Manual administrative and ;
} implementing procedures.") DN 912-13.
- 15. Decommissioning Plan,- Rev. 1, $$3.2.7.1, 3.2.7.2, 3.2.7.3 and 3.2.7.4, DN 914-
- 17. :
- 16. - Decommissioning Plan, Rev.1, $$3.2.7.2 and 3.2.7.3, DN 915-16.
i f 17L Sag, gjL, FSV-RP-OPS-I-202, Rev. 2 " Performance of Contamination Surveys,"
l 9 4.31. DN 2407, 9 5.3.6, DN 2415; FSV-RP-OPS-I-208; Rev. 2, " Survey
- Documentation and Review," 4.3.2, DN 2433; FSV-RP-OPS-A-200, Rev.~ 2,
!, Radiation Protection Surveillance Program, $4.2.4, DN 2385. !
i
- .18. Decommissioning Plan, Rev. 1. 63.2.7.7, DN 919-20. l
- 19. Decommissioning Plan, Rev. 1, 63.2.7.7, DN 919-20 i l
1
- 20. Decommissioning Plan, $3.2.7.7, DN 919-20. ("The supervisor reviewing the )
survey will ensure that the recorded results are legible, in accordance with Radiation- Protection Manual implementing procedures and consistent with anticipated levels and will determine the reason for any variances. . .The results of evaluations will be documented on approved survey forms which will be made available to personnel entering' radiologically controlled areas. . Survey records will be filed and maintained so that previous radiological conditions can be i
determined. ' All original survey records will be maintained and retained in accordance with 10 CFR and Fort St. Vrain Decommissioning Technical
' Specifications."). Radiation Protection Operations Supervisors provide additional supervisory review. (FSV-RP-ADM-I-104, Rev. 2, Control of Radiation Protection Logs, Records, and Turnovers, $4.3.3, DN 2360.)
4
- 21. Decommissioning Plan, Rev.1, $3.2.7.7, DN 919-20. To identify the location of radiation activity and the amount of fixed contamination present,' procedures specify that direct instrument surveys should be used in conjunction with the smear surveys. The results of such surveys are to be recorded on appropriate survey maps and submitted to a supervisor for review. PSC Procedure, Surface Radioactive Contamination Survey, HPP-120, Issue 7, $$3.1.3 and 3.1.4; DN
- . 1550.
228 1
. . - , . , . r- - - # -,- -- , .
}-
. No.5-s , i
.- 22.; ; Sag Zahrt (4/13/94) (Unsworn), pp. _7.162: Sworn Interview Statement of Lester ;
,7 ; C. Hutchins, May 16.1994.' pl 49 [ hereinafter cited as "Hutchins _(5/16/94)"). ;
[ : 23. Sworn Interview-Statement of Frederick J. Borst, May 13,1994, pp.f 48-49 l j L . [ hereinafter cited as." Borst (5/13/94)"]. :
24.' Borst (5/13/94), p. 49. ,
- 25. PSC Procedure, Radiation Surveys, HPP-115fissue 4, $3.2.1, DN 1561. 'l
- 26. PSC Procedure, Surface Radioactive Contamination Survey, HPP-120, Issue 7, ,
. $3.1.5. DN 1550. .;
i l 27.. PSC Procedure, Routine Survey Intervals and Survey Documentation, HPP-110, !
, Issue 6, 52.1, DN 1565. i a .
- 28.- LPSC Procedure, Radiation Protection Plan G-34, issue 6, $3.2.7(a) DN 6880.
j .
t j 29. PSC Procedure, Radiation Protection Plan G-34, issue 6, 3.2.5(d), DN 8878-79. j e ;
- 30. PSC Procedure, Radiation Protection Plan G-34, Issue 6, $3.2.3(h), DN 6877-78. ]
2
- 31. . FSV-RP. OPS-A-200, Rev. 2, Radiation Protection Surveillance Program, $5.1.1,
' DN 2385.-
).
- 32. FSV-RP-OPS-A 200, Rev. 2, Radiation Protection Surveillance Program, $5.1.2, DN 2386.
L
- 33. FSV-RP-ADM-1-104, Rev. 2, Control of Radiation Protection Logs, Records, and Turnovers, DN 2361.
4 .
.4.5 Precautions and Limitations 4.5.2 Radiation Protection records / documents shall be prepared and j maintained using high standards of accuracy, traceability and 4
legibility 'to meet the requirements of regulatory agencies and company procedures._
! ~ 4.5.3 Records / documents shall be - reviewed to ensure completeness, legibility and traceability.
4.5.4 - Supervisors shall maintain adequate safeguards against tampering
.with and the loss of records.
229 l
L
No.5 34.' FSV-RP-ADM l-104. Rev. 2, Control of' Radiation Protection Logs, Records, and .
Turnovers. @4.1, DN 2359. !
- 35. FSV RP-ADM l-104, Rev. 2. Control of Radiation Protection Logs, Records, and Tumovers. 4.2.2, DN 2360.
- 36. FSV-RP-OPS 1-207. Rev.1. Radiological Survey Requirements and Frequencies, ;
$5.2.3, DN 2423.
- 37. FSV-RP-ADM-l-104, Rev. 2. Control of Radiation Protection Logs, Records, and Turnovers, 64.3.4(3), DN 2360-61.
- 38. SEG Employee Handbook, DN 171, pp.12-13.
39.~ The phrases " unconditionally released" and " free release" are used
. interchangeably. Unsworn Interview Statement of Mark S. Zachary, Apr. 5,1994, ;
- p. 33 [ hereinafter cited as "Zachary (4/5/94) (Unsworn)"). ,
- 40. Unsworn Interview Statement of Gerald J. Rood, Mar. 31,1994, pp. 37-38
[ hereinafter cited as " Rood (3/31/94) (Unsworn)"]; Zachary (4/5/94) (Unsworn), p.
~
34; Unsworn Interview Statement of Roland E. Sawyer, Jr., May 3,1994, p. 33
. [ hereinafter cited as " Sawyer (5/3/94) (Unsworn)").
- 41. Decommissioning Plan, Rev. 1, 93.2.6.8, DN 910-11. ,
- 42. Decommissioning Plan, Rev. 1, 93.2.6.8, DN 910-11.
i
- 43. DN 12447-48 " Amendment to Possession Only License."
- 44. NRC IE Circular No. 81-07. Control of Radioactively Contaminated Material, May 14,1981, DN 11402. This document describes the 100 cm8 smear as a " Defacto industry standard."
- 45. NRC IE Circular No. 81-07, Control of Radioactively Contaminated Material, May 14,1981, DN 11402. This document describes the 100 cm2 smear as a " Defacto industry standard."
- 46. NRC Regulatory Guide 1.86, June 1974. DN 11291-95. Sag g!s_q " Acceptable Surface Contamination Levels for Uncontrolled Release of Equipment"- Table 3, adopted from Reg Guide 1.86 (Ref.30) - 1000 dpm beta gamma /100 cm'. (From >
'NRC Publication: " Guidelines for Decontamination of Facilities and Equipment Prior to Release for Unrestricted Use or Termination of Licenses for Byproduct Source or Special Nuclear Materials") (May 1987). j
- 47. Sem NRC IE Information Notice No. 85-92, December 2,1985, DN 11286-88; Rood refers to RM-14 as RN-14. Rood (3/31/94) (Unsworn), pp. 42-43. >
230 i
No.5- :
i 48 L- l(Item 11F Release Standards). In 1981. the NRC issued IE Circular No. 81-07, !
which provided guidance on the control of radioactively contaminated material and l
[ identified the extent to which contamination surveys should be conducted. The
- 'l NRC noted that studies showed that 5000 dpm of beta _ activity is the minimum !
level of low level contamination activity that can be routinely detected using direct . l survey methods. DN 11401-03. l i
49; The formula for converting the RM-14 cpm reading to dpm is: l
- Counts per minute (" cpm"). divided by efficiency .of the l f
instrument equals ' disintegrations per minute ("dpm.") j Therefore, one hundred counts per minute utilizing an RM-14, l whose efficiency is .10, is the equivalent of 1000 t disintegrations per minute.
. Zahrt (5/6/94) (Unsworn), pp.114-15. Sag 3119 Zahrt (3/28/94) (Unsworn), .
pp. 232 33,222-23,225; Unsworn interview Statement of James M. Bixby, !
Apr. 7,1994, pp. 45-46 [ hereinafter cited as "Bixby (4/7/94) (Unsworn)"). j
- .. 50. Steven Sherrow, a member of Public Service of Colorado's Oversight Team said that utilization of the RM-14 instrument was consistent with NRC Regulatory i Guide No.1.86. Sworn Interview Statement of Steven S. Sherrow, May 10,1994,
]
pp. 45-46 [ hereinafter cited as "Sherrow (5/10/94)"}. Sherrow noted that if an !
i instrument that was more sensitive than the RM-14 were used, such as the
.Tennelec, activity less than 100 dpm per 100 cm' could be detected. If a l
- Tennelec were used and detected contamination at 200 dpm, and items were only j being released if no detectable loose surface contamination is found, a particular item containing 200 dpm could not be released. Sherrow (5/10/94), pp. 46-47.
Sgt g!1g Zahrt (3/28/94) (Unsworn), pp. 219-23; FSV-RP-RAM-A-100, Rev. O, Radioactive Material Control Program, $$5.9.4 and 5.9.5, DN 2459-60. SgtPSC Procedure, Surface Radioactive Contamination Survey, HPP-120, issue 7,94.2.5, DN 1554.
- 51. NRC IE Information Notice .No. 85-92 December 2,1985, DN 11287. The Notice refers to a device that "is sensitive to gamma radiation."
- 52. NRC IE Information Notice, No. 85-92, December 2,1985, DN 11287.
- 53. PSC Procedure, Surface Radioactive Contamination Survey, HPP 120, Issue 7,
$4.5.1(c), DN 1557.
- 54. 4/1/91 Agreement, DN 2117, 2175-76,' DN 11786.
- 55. PSC Procedure, Surface Radioactive Contamination Survey, HPP-120, Issue 4,
. $4 4.; DN 11692-99 at 11698. HPP-120 issue 4 represented a change in survey 2* 231
No.5 I l
cnteria for loose contamination. The previous version HPP-120 issue 3, $4.4
" provided for release if loose contamination did not exceed 100 dpm/100 cm2 for- ;
betal gamma contamination. DN 11684-91 at 11690. The release criteria was
]
changed to 1000 dpm/100 cm'in issue 4 to "[p}ermit use of release limits more !
compatible with [the] rest of [the] Nuclear Industry." DN 11834. !
\
- 56. PSC Procedu're, Radiation Protection Plan, G 34, issue 6, 4.4.2(a) DN 6870-902 !
at 6893. :
- 57. PSC Procedure, Radiation Protection Plan' G-34, Issue 6, $3.2.7(a) DN 8880.
From an RPT viewpoint, the standards meant that the material could be released !
- if it had less than 100 counts per minute above background fixed contamination !
and less than 1000 dpm beta / gamma smearable contamination. Zachary (4/5/94) l
, . (Unsworn), pp. 33-34. !
58, ' PSC Procedure, Radiation Protection Plan, G-34, Issue 6, 93.2.5(d), DN 6878-89.
- 59. Zahrt (4/13/94) (Unsworn), p. 7; Borst (5/13/94), pp. 48-50.
- 60. PSC Procedure, Surface Radioactive Contamination Survey, HPP 120, issue 7,
$4.5.1, DN 1557. There are two limits applicable to the decision by an RPT to :
release materials from the site for unconditional use. The first limit addresses j fixed con: amination which is identified utilizing a direct frisk. The activity cannot exceed 100 counts per minute above background. The second limit relates to ]
loose contamination such that there must be no detectable loose, surface
~
contamination by smear with a minimum detectable activity exceeding 1000 dpm/100 cm*. Both the direct frisk and the reading on the smear are done using an RM-14 instrument. Sherrow (5/10/94), p. 41; PSC HPP-120, Issue 7, DN 1552,1554. Prior to the Decommissioning Plan taking effect in December 1992, the release standard for both fixed and removable contamination was no greater than 1000 dpm. PSC HPP-120, issue 7, $4.5.1(a). DN 1557; Zahrt (3/28/94)
(Unsworn), pp. 210-11, 225-26. Zahrt, however, recalled the release standard was "less than 1000 dpm" in contrast to the PSC procedure, which was "no greater than 1000 dpm." Comoare Zahrt (3/28/94) (Unswom), pp. 225-26 Eith PSC HPP-120, issue 7 DN 1557.
- 61. PSC Procedure, Surface Radioactive Contamination Survey, HPP 120, lasue 7,
$$4.1.1,4.2.1, DN 1552,1554.
t 62. Borst (5/13/94), p. 65.
l
- 63. Borst (5/13/94), pp. 62-63; ama SEG Supervisor Logbook, DN 3422, p.145.
- 64. 'SEG Supervisor Logbook, DN 3422, p.145; Zahrt (3/28/94) (Unsworn), pp. 213-
- 14. Jeg discussion at Note 73.
l 232 r
)
i
No.5
- 65. FSV-RP-RAM-104. Rev. O, " Surveying Material for Release," 5.1.1.2 (authorizing use of BC-4 or Tennelec instruments) DN 12418-19.
- 66. NRC " Amendment to Possession Only License," DN 12447-48. Although the Decommissioning Order was issued on November 23,1992 (DN 12447-48; DN 274), the Order provided a 14 day period within which the Technical Specification had to be implemented. DN 12448.
- 67. SEG procedures for surveying material for release which replaced PSC procedures on December 7,1992, were initially governed by FSV-RP-RAM-l-104, Rev. O, Surveying Material for Release. Rev. O was approved 9/23/92, DN 12414.
Rev.1 was approved on 11/8/93, DN 2463. Rev.1 provided for counting smears with an RM-14/15 instrument. DN 2467. Rev. O provided for counting smears with a BC-4 or a Tennelec instrument. DN 12418-19.
- 68. FSV-RP-RAM-l-104, Rev.1, Surveying Material for Release, @5.7 DN 2472-73.
The log should contain the following information: (1) date and time of survey, (2) organization responsible for the item or material, (3) item description and origin (4) instruments used to perform the survey, (5) a mark indicating that the survey was performed and that the material was acceptable for release, (6) identification of any "other" type of survey performed, and (7) the signature of the RPT performing the survey. DN 2472-73.
- 69. FSV-RP-RAM-l-104, Rev.1, Surveying Material for Release, @4.3.2, DN 2465.
- 70. FSV-RP-RAM-l 104, Surveying Material for Release, Rev. O, @5.1, DN 12414: DN 12418.
1
- 71. DN 12419. l
- 72. FSV-RP-RAM-l-104, Rev. O, Surveying Material for Release, @@5.1.2 and 5.1.3, j DN 12419.
- 73. Survey form 5062 describes release surveys for December 7,8 and 9,1992. DN 1268. l 1
74 FSV-RP-RAM-l-104, Rev.1; Surveying Material for Release, DN 2463-74 at 2467-69, @5.2.
]
The revised procedure made the following underlined changes:
5.2.1 Evaluate the material for loose surface contamination. ,
1 233
)
l 1
. No. 5 ~ :
I 4
- 2. Analyze the smear'using an RM-14/15 w/HP. ]'
210 orobe. or eauivalent.
~
- a. .WHEN countina the smear. THEN
. allow the meter to stabilize ,
(anoroxim:rielv 15 seconds).
5.2.3 Evaluate collected waste materials with a i Micro-R ' meter as a final check prior to release.
., 4. IF an area of increased activity is noted, THEN: t i
... 1 i
- b. Allow the meter response to j
- stabilize in the area of highest 1 activity (acoroximately 15 seconds).
4 Long before SEG revised the procedure, PSC had directed SEG to utilize the RM-14 instrumentation for analyzing smears for loose surface contamination. On November 10,1992, the PSC Radiation Protection Oversight Manager directed j Zahrt to utilize ' instrumentation consistent with present FSV (PSC) procedures. !
Zahrt's logbook entry at 0710 hours0.00822 days <br />0.197 hours <br />0.00117 weeks <br />2.70155e-4 months <br /> reads:
0710-Called Ted Borst and was informed by him that quote "He wants us to be consistent with present procedure of FSV - which allows us to use a frisker to count wipes for smearable levels to release materials from the RCA." KLZ. DN 3422, p.145.
SEG also had a procedure for surveying components of the System 46 cooling ;
tubes. This procedure was approved in RPI-003, Issue 1, System 46 1 Characterizatior. Survey Plan, August 1992, but would not have been effective until December 1992, after NRC approval of the Decommissioning Plan.
I
'This procedure required RPTs to " survey and document" radiological ,
conditions of the system using a Tennelec instrument to analyze smears.
DN '11654,' 11657. l l
l l
s,. .l i
234 !
- n - - - -
< - No.5 ;
- 75.: Zahrt said the SEG procedures went into effect on December 14, '1992; Unsworn -!
. interview Statement 'of.Kenneth L. Zahrt, Mar. 29,' 1994, p.18 [ hereinafter cited t I
as "Zahrt (3/29/94) (Unsworn)"). Formally, the procedures had to go into effect I "within' 14 day's " of the November 23,1992 issuance of a license amendment by i the NRC. DN 12448.
~
76.- - PSC Procedure, Surface Radioactive Contamination Survey, HPP-120, Issue 7, j j, 64.1, DN 1552._ '
- 77. PSC Procedure. Surface Radioactive Contamination Survey, HPP-120, Issue 7 ,
4.2, DN 1554. !,
'.78. Sherrow (5/10/94), p. 67. ,
- 79. ~ Sherrow (5/10/94), pp. 67-68. j L 80, fSherrow (5/10/94), p. 68. !
- 81. SEG 1992 survey log, DN 1041-42. j
- 82, SEG 1992 survey log, DN 1041.
- 83. . SEG 1992 survey log, DN 1042. Another difference between the last two pages of the log was that the six survey forms logged on the next-to-the-last page all i
had hand printed survey numbers, while the 14 survey forms on the final page .
. had stamped numbers, DN 1041-42.
- 84. SEG 1992 survey log, DN 1042; Sworn Interview Statement of Duane A. Parsons, -
Apr. 4,1994, pp. 5-6 [ hereinafter cited as "D. Parsons (4/4/94)").
t
- 85. SEG 1992 survey log, DN 1042. '
- 86. Comoare DN 1041 with DN 1042.
- 87. DN 1255-68.
- 88. RWP Number 1053, Rev. A, DN 12230.
1
- 89. jigg Bixby (4/7/94) (Unsworn), p.11; Zahrt (3/28/94) (Unsworn), pp. 230-31; e Sworn Interview Statement of Darrel L. Blain, Apr. 29,1994, pp. 9-10 [ hereinafter
- cited as " Blain (4/29/94)"]; Health Physics Steam Generator Logbook, DN 1659-
- 98.
90.i Unsworn Interview of Statement of David P. Hatch, Apr. 5,1994, pp.140-41
[ hereinafter cited as " Hatch (4/5/94) (Unswom)"); Sworn Interview Statement of Duane A. Parsons. May 11 1994,' p. 20 [ hereinafter cited as "D. Parsons 235
. - ,r - e._ ._ _ . _ _ _ _ _ _ _ _ _ _ _
No. 5 (5/11/94)"). Zachary (4/5/94) (Unsworn), pp. 33-34.
- 91. Unsworn Interview Gtatement of David P.. Hatch, Apr. 11,1994, pp.140-41,146-47 [ hereinafter cited as " Hatch (4/11/94) (Unsworn)"); Rood (3/31/94) (Unsworn),
pp. 37 38: Zachary (4/5/94) (Unsworn), pp. 33 34.
- 92. Zahrt (3/28/94) (Unsworn), p. 208.
- 93. Zahrt (3/28/94) (Unsworn), pp. 263-64.
- 94. Zahrt (3/28/94) (Unsworn), pp. 245,263.
- 95. Zahrt (3/28/94) (Unsworn), p. 208.
- 96. Zahrt (3/28/94) (Unsworn), pp. 209, 245-46.
- 97. Zahrt (3/28/94) (Unsworn), pp. 209,247.
- 98. Zahrt (5/6/94) (Unsworn), p.19. There were two different forms in use for documenting surveys of materials for release. One is a release log with
. preprinted lines upon which the RPT could write a description of the items surveyed. The other is a radiation survey form upon which the RPT could draw a picture of the item surveyed. These two forms are viewed as interchangeable for purposes of documenting surveys or materials for release. Hatch (4/5/94)
(Unsworn), pp. 145,148. Bixby began preparing release logs in December 1992.
Sig DN 3427, 3424, 3425.
- 99. Zahrt (3/28/94) (Unsworn), p. 246.
100. Zahrt (3/28/94) (Unsworn), pp. 250-51.
101. Zahrt (3/28/94) (Unsworn), pp. 250-51.
102. Zahrt (3/28/94) (Unsworn), p. 250.
I 103. Zahrt (4/13/94) (Unsworn), p.138.
104. Zahrt (4/13/94) (Unsworn), pp.138-39. l
, 105. Zahrt (4/13/94) (Unsworn), p.142.
106. Zahrt (4/13/94) (Unsworn), pp.141-42.
107. Zahrt (4/13/94) (Unsworn), p.140.
108. Zahrt (3/28/94) (Unsworn), pp. 251-54.
236
^
~
.# + .
.No.5' l:
L109l 9'r'irt r (3/28/94) (Unsworn), pp. 253 54, 256-57.
- I 2110.1 (bahrt (4/13/94) (Unsworn), p. 40. .
l 111. ? Zahrt (3/28/94) (Unsworn), p. 259. I c 112. ~ Zahrt (3/28/94) (Unsworn), pp. 254-55. . ,
i
'?
'113. Zahrt (3/28/94) (Unsworn) pp. 276-77; li s- s i 1114. Bixby (4/7/94) (Unsworn), pp. 30,~ 55-56.1
.1.15. Bixby (4/7/94) (Unsworn), pp. 57-58.
n n 7 116s Bixby (4/7/94) (Unsworn), pp. 58-60.
I j - 117. ; Bixby (4/7/94)'(Unsworn), p. 58.
- 118. Bixby (4/7/94) (Unsworn), p.- 58. !
F i
( 119. Bixby_ (4/7/94) (Unsworn), p. 59.
b 120. Bixby (4/7/94) (Unsworn), p. 77.
121. Bixby (4/7/94) (Unsworn), pp. 28-30; Health Physics Steam Generator Logbook,
' )
L; DN 4156, pp' 1-241.- .
l 1 122.' 'Bixby.(4/7/94) (Unsworn), pp. 29-30, 44-45.
- ;- 1123. Bixby (4/7/94) (Unsworn), pp. 31-32.
,' 124. Bixby (4/7/94) (Unswc n), pp.' 34-35. ,
- 125. Bixby (4/7/94) (Unsworn), p. 35.
126. Bixby (4/7/94) (Unsworn), pp. 35-36; Sworn Interview Statement of Keith A. Bare,
- c. . Apr. 27,1994l p. 89 [ hereinafter cited as " Bare (4/27/94)"); Bixby said that one BC-4 and one or two.RM-14's would have been assigned to Level 1. Bixby (4/7/94) (Unsworn), p. 36.
127, : Bixby (4/7/94) (Unswom), pp '37-38.
128. Bixby (4/7/94) (Unsworn), p. 38.'
l129. Bixby (4/7/94) (Unsworn), pp. 45 46.
i- .
237
. s '
No.5 l
130.
Bixby conceded that in the Fall of 1992, he could have done surveys and not '
. documented them or he may have prepared survey maps and not logged the A
activity in his logbook. Bixby (4/7/94) (Unsworn), pp. 32-33. When he did find radioactive contamination, Bixby said he documented it on a survey map or listed it in his logbook. Bixby (4/7/94) (Unsworn), pp. 37-38. Documentary evidence shows that Bixby did prepare a number of survey forms during the per;od l
~
September through November 1992 describing the presence of levels of {
contamination above release standards. DN 1709-50; (Bixby copies) DN 5140, l 5159,5228,5267,5290,5301,5305,5326,5335,5377,5742,5919,5228,5255, J 5933,5934,5941.5942,5962,5962,5957,5963,5950,6277,6283,6289,6292, '
6288,6366. (PSC copies). During his interview, Bixby presented his personal copies of a series of surveys he had performed and contemporaneously documented in connection with the dismantling of the steam generator system during September through November 1992. Bixby's copies of these 1992 surveys are DN 1,709-50. Bixby's personal copies did not have a survey number on them, j
- but when they were processed and logged, they were assigned suivey numbers
- '
Survey # 1992 Survev Loa l l
.+
3612 4545 !
3631 4546 3710 4550 3749 4552 3764 4553 3775 4554 3779 4554 3800 4555 3809 4556 3850 4558 3948 4563 l 4124 4571 l 3710 ,
4550 )
3737 4552 i 4138 4572 !
4139 4572 4146 4572 4147 4573 4167 4574 l 4162 4573 !
4168 4574 l 4155 4573 4479 4589 4485 4589 4491 4590 a
238 1
- i No.5 i i
a 4 , 4494 4590
~ {'
4490 4590 r
.4568 4594 :
e The contemporaneous surveys were provided during his interview. They bore dates of September 1992 through November 1992 and were logged in the 1992 j survey-log within a day of the date on the survey form. indicating that the j
l documentation was prepared on the dates shown on the survey forms. This
. documentation' demonstrates that Bixby actually was preparing survey forms reflecting his work during the latter part of 1992. Some of the information j contained on'the survey forms Bixby prepared in a timely manner is also reflected
-in the Level 1 logbook. Sag,31, survey form 3612 - Bixby copy, DN 1709; PSC l
~
copy - DN 5140; and Level 1 logbook entry for 9/14/92, p. 3, DN 1663 Both the =
l l logbook. entry and the survey entries reflect a frisk of a portion of the steam !
3 . generator B-2 4 main steam line upper end that showed 22,000 dpm fixed' !
- contaminadon on the pipe. M. i 131. Bixby (4/7/94) (Unsworn), pp. 26-27.
. 132. During his interview. Bixby was asked to identify which survey documents bearing i dates of September 1992 were backdated and which were actually prepared in 1992.' Bixby could not tell the contemporaneous ones from the backdated ones without looking at the SEG survey logbook that .'dentified the 14 survey forms
! which were logged out of sequence in February 1993. Bixby (4/7/94) (Unsworn),
pp. 47-54; SEG 1992 survey log, DN 1253; DN 1255-68 (14 out-of-sequence -
survey forms. Bixby ' identified survey forms 5049. dated September 8,1992,
- through 5062, dated December 7,1992, as the forms that he backdated in r February 1993. Bixby (4/7/94) (Unsworn), p. 54. The contemporaneous survey l forms are, however. readily distinguishable from the backdated ones. Each
- backdated survey form bears the pre-printed words " Radiation Survey Form" in bold, capitalletters at the top center of the form. None of the contemporaneous survey documents prepared:by Bixby in September 1992 have this caption.
Comoare, 31 DN 1255-68 (backdated survey forms) with DN 1757-59
-(contemporaneous survey forms). The. form used by Bixby to prepare his
. backdated release survey forms came into use around the latter part of December 1992. Sag, gg, DN 6610,6615. Bixby thought he probably did not recall having ,
prepared survey forms in September 1992 when, in February 1993, Sawyer asked j him to prepare survey documentation based on the information in Bixby's logbook. j
, 2 Bixby (4/7/94) (Unsworn), p. 61.
133. Unsworn Interview Statement of Roland E. Sawyer, Jr., Mar. 30,1994, Volume !
a,- pp. 28, 32 [ hereinafter cited as' " Sawyer (3/30/94) (Vol. a) (Unswom)"]; i Unsworn Interview Statement of Roland E. Sawyer, Jr., Apr. 14,1994, Volume b, pp.13, 23 [ hereinafter cited as " Sawyer (4/14/94) (Vol. b) (Unswom)").
239
- ._ _ . - . .~. . . , . . - , , , . - - . , _m,,- .
No.5-f ,
l- 134.. -Unsworn interview Statement of Roland E. Sawyer; Jr., Mar. 29,1994. pp. 93-94, .
. 95_-96 [ hereinafter cited as _" Sawyer (3/29/94) (Unsworn)"). l 1 1135i LSawyer (3/29/94) (Unsworn), p.119.
j!
136. Sawyer (3/29/94) (Unsworn), pp.120-22.
-137J Sawyer (3/29/94) (Unsworn), pp.121-22; Zahrt claimed that Sawyer and others ,
- on the staff knew that Bixby was' writing survey forms using his logbook entries. 1 Zahrt (3/28/94) (Unsworn), p. 258. ]
- . .j 138. . Sawyer (3/29/94) (Unsworn), p.122. ,
l' 139.1 Sawyer (3/29/94) (Unsworn), p.123. But ang Sawyer (3/30/94) .(Vol. a) . l (Unsworn), pp. 30-31. ;
a l 140. ; Sawyer (3/30/94) (Vol. a) (Unsworn), pp. 7-8; Zahrt (5/6/94) (Unsworn), pp. 20-21.
I 141< Zahrt (5/6/94) (Unsworn),- p.19.
l
+' . 142. Bixby's . co-worker on Level 1, Deringer, said he did not participate in l
, reconstructing ths backdated surveys. He was aware, however, that Bixby l claimed to rely upon information from the logbook in reconstructing these surveys.
7 Deringer, along with Bixby, made' entries into the Level 1 logbook. Deringer
- indicated he had a dual purpose in making logbook entries. One was to advise '!
I the next shift of the activities he had engaged in during the day. Another was to create official documentation of the release of materials "because that was
[- sometimes the only documentation I made." Unsworn Interview Statement of ,
Daryl Deringer. Apr. 12,1994, pp. 54-56 [ hereinafter cited as " Deringer (4/12/94)
[ (Unsworn)"). Deringer thought he had adopted this procedure on his own initiative. He said he -was'"not real aware of the procedure for release of materials at the time." Deringer (4/12/94) (Unswom), p. 56. Not until ifter he left his assignment r. me Level 1 area did he come to learn that release of material should be doc anted on either a radiation survey form or a release form.
Deringer (4/12/94) (Unsworn), pp. 56-57. Deringer further recalled that every time he did tisk materials for unconditional release, he made a logbook entry. To his knowledge, there were no instances when Bixby and he frisked materials and did
. not make a logbook entry. Deringer (4/12/94) (Unsworn), pp. 58-59. Elsewhere in his interview, however, Deringer said he was sure there were times when he q
. forgot to make a logbook entry. Deringer (4/12/94) (Unswom), p. 48.
Deringer noted that he did not start at FSV until mid-October, at which time he
. went through training ~ ' His first entry in the logbook was for October 26,1992.
Deringer (4/12/94) (Unsworn); p. 46; logbook, DN 1673. His last day on Level 1 was January 5,1993 Deringer (4/12/94) (Unsworn), p. 46. Deringer was 4
'240'
-r-,. - - _ . _ _ _ _ - _ . _ _ _ _ _ _ _ . _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
No.5 l
1 a
_ unaware of any RPTworking with Bixby on' Level.1 prior to Deringer joining Bixby. !
t
.j' Deringer (4/12/94) (Unsworn), pp. 46-47. At the time Deringer started working j a 'with~ Bixby, Deringer thought that Bixby told him to make a logbook entry to j
, document. the unconditional release. of materials from the plant. Deringer - :
(4/12/94) (Unsworn), p. 47. When Bixby and he frisked together, they would :
make a decision as to who would make the logbook. entry. One of them would 4
then document the survey in the logbook. Deringer (4/12/94) (Unsworn), pp. 48-- !
- 49. 3 i :,
Deringer said that sometimes he would make the logbook entry when he finished ,
surveying a group of items. Other times, he would wait until the end of the day. !
Nevertheless, Deringer said it was his practice to make one log entry for the day i for the materials he had frisked. Deringer (4/12/94) (Unsworn), pp. 42-43; 47-48.
i
, 143.. ' 4/13/94 interview of Bixby by Lisa Campagna. Esq., DN 10702-22 at 10720. !
144. 4/13/94 interview of Bixby by Lisa Campagna Esq., DN 10702-22 at 10720-21.-
l 145. As far as Sawyer was concerned, Bixby had all the necessary data for the
- , backdated survey forms in his logbook. Sawyer's view was that the
[ instrumentation data on the survey forms and in the Level 1 logbook was
- identical. Sawyer (3/30/94) (Vol. a) (Unsworn), p. 31.
146. Bixby (4/7/94) (Unsworn), pp. 61-64. ;
a t
. 147. . Egg discussion on survey instrument RM 14/3902, Appendix A, pp. 15-17,27-31; and Appendix A, Exhibit 5. !
l 148. Bixby (4/7/94) (Unsworn), pp. 64-66.
) 149. Sgt Appendix A. pp. 27-31; and Exhibit 4.
150. SEG survey forms 5049-5062, DN 1255-68.
l 151. Other RPTs did indicate how their smear activities were distributed among the volume of items surveyed. Sag, ga, radiation survey form 3676, DN 5204, dated
, 9/17/92, and reactor building material release survey form 3285, DN 4767, dated 8/17/92,-
l, 152. Zahrt (3/28/94) (Unsworn), pp.- 276-77.
153. Egg chart summarizing Blain's analysis, Appendix A Exhibit 4.
154. Sworn interview Statement of Darrel L. Blain, May 2,1994, p. 23 [ hereinafter cited
- ._as ** Blain (5/2/94)"). Blain stated that backdated Bixby survey form 5049, entry
- , number 1 for September 8,1992, duplicated Bixby contemporaneous survey form 241 y , ,9... , 7 s.o_-,
ag-- , -e _,,-- g e- -p-- , -- my w - ---*e--e~
l No.5 o
. 3524 for the same date. Blain (4/29/94), p.- 15: survey form 5049..DN 1255;
.' ! survey form 3524, DN 5051. Blain also said that the second and fourth entries i on this same backdated survey form 5049 duplicated Bixby survey form 3549 for
' September 9,1992 and survey form 3590 for September 11,1992. Blain (5/2/94), i
- p. 24; Blain (4/29/94), pp.14-16; DN 5077; DN 5118. Blain concluded that the l
third entry on Bixby's backdated survey form 5051 duplicated Bixby survey form !
3774 for September 24,1992. Blain (5/2/94), p. 24; Blain (4/29/94), pp. 22-23; p - survey form 5051, DN 1257,' and. survey' form 3774, DN 5300. Lastly, Blain concluded that the third entry on Bixby's backdated survey form 5056 duplicated Bixby's survey form 4239. . Survey form 5056, DN 1262; survey form 4239, DN 6034: Blain'(5/2/94), p. 24; Blain (4/29/94), pp. 33-34. ,
- 155. San Appendix A, Exhibit 4. Column H. ;
156. . Blain (5/2/94), pp. 23-25. In E.?ain~s view, it was not proper for Bixby to prepare ;
p backdate'd survey documentation in the manner he did, that is, relying on logbook ;
entries of the other technicians to support 13 of his entries on the backdated >
survey forms.
t 157. San Appendix A, Exhibit 5. Survey. forms 5052,5053,5054 and 5055, DN 6859-62.
4 ;
158. ~ Survey forms 5052 and 5053, DN 6859-60.
$ 159. ' Survey forms 5059, 5061, and 5062. DN 6866; DN 6866; DN 6869. Several of
[
i Bixby's fellow RPTs also listed the "4/26/92" calibration due date. ;
i 160. Zahrt (3/28/94) (Unsworn), pp. 251-55. :
161. D. Parsons (4/4/94), pp. 7-9,19-20; agg, gA, DN 1253. In February 1993, D. ;
Parsons no longer had the last page of the 1992 survey log as it had been turned into the Records Department. D. Parsons recalled that he received the package ;
of backdated survey forms from Zahrt the same day that D. Parsons logged them '
into the SEG 1992 survey log, that is on or around February 23,1993.
~ 162. Zahrt (3/28/94) (Unsworn), pp. 255, Zahrt (4/13/94) (Unsworn), pp.169-70; agg n!19 Zahrt (3/29/94) (Vol. a) (Unsworn), p. 22.
163. Hatch (4/13/94) (Unsworn), pp.172-73. Hatch, however, expressed the opinion that Zahrt was not conspiring to commit fraudulent conduct in not issuing an ROR.
Hatch's view was that Zahrt did not have enough background in the butiness to ,
realize that there was an " easy.way out of a problem", which was to write an ROR. Hatch (4/13/94) (Unsworn), pp.173-74, 242 t
.- .. . - - . - - - - . - . . - . ~ . . . . . . .
No.5-i L1641 ' Zahrt (3/28/94) (Unsworn), p. 264. In another part of his interview, however, Zahrt .
t :said that Bixby's failure to preoare survey form documentation was not a violation
('
, of procedure because Bixby detailed the survey activity in his logbook. 'Zahrt said the logbook was a legal document. -Zahrt (3/28/94) (Unsworn), pp. 262-63,276.
. 165. Decommissioning Plan,' Rev. 1.- 6 3.2.10, DN 926.
L .
+
166. Decommissioning Plan, Rev. 1, 993.2.10.1 and 3.2.10.2 DN 926-27.- .;
r 1 u167. Decommissioning Plan, Rev. 1, $3.2.10.2, DN 927.
]
e 168. Decommissioning Plan, Rev. 1, $3.2.10.2, DN 927.- :
169. Decommissioning Plan, Rev.' 1. $3.2.10.2, DN 927. j r
~ 170.' Decommissioning Plan, Rev. 1. 93.2.10.3, DN 928. 3 c 171. Decommissioning Plan, Rev.1. 93.2.10.3, DN 928. l
, a 172. . Decommissioning Plan. Rev. 1, 93.2.10.3, DN 928.'
173. Decommissioning Plan, Rev. 1, 53.2.10.3, DN 928. j
-174. Decommissioning Plan, Rev. 1, $3.2.10.3, DN 928. The principal elements of the ]:
ROR reporting program are described by Section 3.2.10.1. Decommissioning Plan, 6 3.2.10.1 Radioloaical Occurrence Reports: j
- 1. A Radiological Occurrence Report may be completed by anyone identifying i a radiol, gical occurrence. The report will include pertinent information .!
relating to the occurrence (ga, date, time, individual reporting occurrence, !
location, observations, etc.). !
t
- 2. Radiological Occurrence Reports will be submitted to Radiation Protection Supervision for review, and classification, j
- 3. The Project Radiation Protection Manager and the PSC Facility Support !i Manager will approve corrective actions and implement disciplinary actions, when applicable for designated classes of occurrences.
^
'4. A root cause evaluation for designated types and levels of occurrences will.-
be used, as applicable, to determine the circumstances and causes of the event and to develop short and long-term corrective actions to prevent- l recurrence. The evaluations will be conducted by the cognizant first line supervisors and managers with assistance from the Radiation Protection ;
staff. i i
i
'243 ;
e
___1___ __u _u _ _ - . _ . - _ __. - _ . _ , , , _ _ . . . .
No.5 5 ' A' tracking system for Radiological Occurrence Reports and corrective
- [ actions will be implemented. The reports will be trended and evaluated .
periodically to integrate lessons learned. licensee ' experience and r experience from others into Radiation Protection program improvement.
Records will be maintained in accordance with regulatory requirements and comoany procedures. (DN 926-27).
These include:
ROR's are to be completed by any person who identifies a radiological occurrence.
' ROR's are to be submitted to a Radiation Protection Supervisor for review :
and classification. The Project Radiation Protection Manager and the PSC i Facility Support Manager then approve the corrective action suggested in ,
the Report and implement disciplinary action, whenever applicable. ;
A " root cause ' evaluation" may be required. Root cause evaluations are used to determine the_ circumstances and causes of the event, and to develop short and long-term corrective action to prevent recurrence. They are conducted by the first line of supervisors and managers, with '
assistance from the Radiation Prntection staff.
A " tracking system" and corrective actions will be implemented. ROR's will ;
be " trended and evaluated. .to integrate lessons learned, licensee ;
experience and experience from others into Radiation Protection program ;
improvement. Records will be maintained in accordance with regulatory l requirements and company procedures." (DN 926-27).
ROR's are used to record, track and trend radiological problems, events that l could result in NRC enforcement action, or events that involve a serious breakdown in the Radiation Protection Management Program. FSV-RP-SASP-l-101, Rev. O. 54.1, DN 92. They are described as " tools to identify adverse trends and program weaknesses," FSV-RP-SASP-A-100, Rev. O, 5.7.4, DN 89, and are used to: (i) assure corrective actions are performed, (ii) provide a mechanism for trending types of occurrences, (iii) provide a mechanism for tracking corrective actions, and (iv) inform management of radiological occurrences, FSV-RP-SASP-l- ,
101, Rev. O, 4.1, DN 92. Under SEG procedures, a variety of individuals are I involved in processing ROR's, FSV-RP-SASP-l-104, Rev. O, $4.3, DN 93-95. l The Decommissioning Safety Review Committee is responsible for-reviewing and approving corrective actions for RORs involving reportable
- events.
244 i
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- . No.5 l 1
5 i
c '*
The ALARA Committee is responsible for re' commending corrective actions y for RORs involving reportable events.
e ~
i
- The PSC Facility S_upport (or Radiation Protection) Manager is responsible- '!
- for reviewing and forwarding incident RORs involving reportable events to ;
- the Al. ARA Committee.
1 j The Project Radiation Protection Manager is responsible for assigning'a
. team to . investigate incident RORs, reviewing and forwarding . incident -i L RORs involving reportable events to the PSC Facility Support Manager, j approving selected- deficiency RORs for consideration by the ALARA !
, . Committee, and verifying corrective actions and disciplinary actions aref implemented for all incident RORs.
The PSC Health Physicists are responsible for serving as team members to investigate and critique incident RORs, performing root cause - ;
evaluations for incident RORs, and assisting cognizant first line supervisors and managers with root cause evaluations when requested.
i !
? The Technical Support Supervisor is responsible for classifying RORs as l . deficiencies or incidents, assigning an ROR number, reviewing and i
- tracking RORs, identifying trends in ROR data, approving corrective measures for deficiency RORs, compiling monthly ROR reports for distribution to the ALARA Committee and Radiation Protection supervision, !
4 and maintaining completed RORs.
Radiation Protection Supervisors are responsible for preliminary review of i RORs related to operational Radiation Protection functions (g.A, posting ;
. deficiencies, Radiation Work Permit violations, etc.), assisting in completing .
RORs, implementing immediate corrective action, recommending long-term corrective action, and forwarding RORs to a Technical Support Supervisor
- l. for disposition. t l t
[
Project Personnel are responsible for reporting potential RORs to ;
- supervision, ensuring documentation of RORs, and forwarding RORs to a
) Radiation Protection Operationis Supervisor for completion and review.
(DN 93-95), ,
.j A tracking system for RORs and corrective action is required by the SEG Self- i l Assessment Program, $5.4.2. This system' directs RORs to be " trended and l reviewed monthly to-integrate lessons learned into the Radiation Protection ;
Program." FSV-RP-SASP-A-100, Rev. O. $5.4.2, DN 88. It also charges the :
t Technical Support Supervisor to track the implementation of corrective actions. l
!1 j 245 -l h'
.-.w-.
- -~ . -. .-. . - -- - . - - - - - - - -
No.5 ;
)
i-l '175. ROR 94-020. 3/21/94. DN 4037 38.'
il 176. . Borst said that in the nuclear industry, it is common knowledge that radiation survey documents have to be maintained and are subject to review by the NRC.
i Borst (5/13/94), pp. 87-88. <
J
- - 177. Zahrt (3/28/94) (Unsworn), pp. 266-67; Zahrt (3/29/94) (Vol. b) (Unsworn), pp. 27-
- ; 29. Zahrt was aware of continuing audit activity. He acknowledged that since SEG took over the project in August 1992, there had been a number of audits j j
performed by PSC, SEG and the NRC. Zahrt (3/29/94) (Vol. b) (Unsworn), p. 27.
These ~ audits included compliance with radiation work permits and survey 7
requirements.- Zahrt (3/29/94) (Vol. b) (Unsworn), pp. 28-29. Zahrt stated that the auditors would look at logs, surveys and RWPs among other documents. Zahrt (3/28/94) (Unsworn), p. 267.-
- 178.' Sag,31, PSC Project Assurance Audit Report, June 14-24,1993, DN 178-262;
' Westinghouse NATD Total Quality and Strategic Programs " Fort Saint Vrain Decommissioning Project" Audit Report IA-93-01, DN 2651-76 SEG Quality l Assurance Audit Report 93-09, March 15-18,1993, DN 2745-65. The agreement ,
entered into between PSC and the Westinghouse Team required the decommissioning contractors to " maintain accurate and satisfactory records, reports and other information, adequate to evidence compliance with [the]
Agreement, the Specifications, regulations of the NRC, the Decommissioning Plan and the Fort St. Vrain Technical Specifications." DN 2122-279 at 2133-B.
Pursuant to the agreement, the Westinghouse Team was obligated to provide :
both PSC and the NRC access to these records so that it could be determined I whether or not the decommissioning contractors were in compliance with the agreement, 14 179. Sag,31, SEG Quality Assurance Audit Report 93-09, March 15-18,1993, DN '
2745-65. l l
180. This surveillance determined that generally control of quality records was in compliance with applicable procedures with lim;ted exceptions. The exceptions
- included compliance with records flow schedules and working file rate
- ntion periods. Westinghouse Team QA Surveillance Report No.93-017, covering period 1/18-1/27,1993, DN 3012. i
- i 181. Westinghouse Team QA Surveillance Report 93-0.17, covering period it18-1/27, 1993 DN 3012.
182. NATD Total Quality and Strategic Programs " Fort Saint Vrain Decommissioning ;
- Project" letter dated February 12,1993, DN 2646; Westinghouse Audit Report IA-F 93-01, DN 2651-76. l f
l 246 '
I
No.5 In late 1992. a Westinghouse Team Quality Assurance Surveillance Report
[ examined SEG's program for material exiting the radiological control area '
for unrestricted use. Report #92-011, September 28, 1992 through October 1,1992. DN 3001-02.
Also, a Westinghouse Team quality assurance surveillance covering the period January 26, 1994 through March 28, 1994 examined RWP compliance and included a review of survey documents. A deficiency was noted on an air sample survey. The deficiency was discussed with Sawyer and the technician who performed the survey. The technician explained that he had mistakenly omitted a symbol which should have denoted the location of where the air sample was taken. The survey was corrected to include the symbol. Westinghouse Team Quality Assurance Surveillance Report No.94-034, January 26,1994 through March 28,1994 DN 7640-
- 41. .
183. Letter dated February 12,1993 DN 2646.
184. Audit Plan attached to letter dated February 12, 1993, DN 2648. This Westinghouse Quality Systems and Compliance audit was conducted in mid- !
March 1993 and noted that the Quality Assurance Surveillance Program was in need of" considerable improvement." Quality Assurance audit schedules were not being established, nor were surveillances being performed in accordance with a scheduled program. Westinghouse Quality Systems and Compliance, Audit Report IA-93-01, DN 2651-76 at 2661,2673. In October 1992, a Westinghouse Team audit intended to assess the effectiveness of the systems and controls utilized in performing '" quality related activities" at FSV concluded that the " project (had) not progressed sufficiently to properly evaluate all systems and programs."
Westinghouse NATD Product Assurance Audit Report, IA-92-01, DN 2926-46 at 2930. This particular audit was conducted during August 1992. Ld. at 2946. This audit did not include radiation surveys. Unsworn Interview Statement of Mark S.
Kachun, Apr. 4,1991 p.17 [ hereinafter cited as "Kachun (4/4/94) (Unsworn)").
Nevertheless, some nformal audit activity was taking place in the Fall of 1992.
For example, RPT David Hatch did an informal audit of radiation survey documents. Hatch's efforts disclosed that two required survey points were not documented on survey forms. He proposed to a Public Service oversite individual to remedy these deficiencies by recreating the survey. Sherror. Memorandum dated October 20,1992, DN 11173; Sworn Interview Staten* ,nt of Steven S.
Sherrow, May 11,1994, pp. 21-26 [ hereinafter cited as "Sherrt,.y (5/11/94)").
The Westinghouse Team audit initiated on March 16,1993 was essentially the first internal audit addressing program implementation pursuant to the decommissioning order. . Kachun (4/4/94) (Unsv.'orn), p.18. This audit, however, also would not have focused SEG's conduct of radiation, contamination and 247
i No.5 i 1
airborne surveys. ;
1 i
SEG also conducted an audit during the period March 15 through March 18,1993.
The SEG audit report identified seven findings in the area of radiation protection, i none of which were considered adverse to the quality of work being performed.
SEG Quality Assurance Audit Report 93-09, DN 2745-46. SEG internal audit was responsible for auditing SEG's Health Physics Program. Kachun (4/4/94) l (Unsworn), p.19. Zahrt was one of the individuals interviewed in the course of !
this March 1993 SEG Ouality Assurance audit. SEG Ouality Assurance Audit Report 93-09. DN 2746.
The SEG Ouality Assurance Audit did not identify any backdating of documents.
In the opinion cf the Westinghouse Team lead site Quality Assurance Engineer, Mark Kachun, it would have been impossible for an auditcr to identify a document as backdated. Kachun said that the auditor's task was to determine if the document was completed in accordance with procedure. In performing this task, the auditor would be unable to assess where the information on the survey form came from and when it was put there. Kachun (4/4/94) (Unsworn), pp. 30-31.
Kachun described an audit as a review of the procedures, which includes a sampling to determine whether procedures are adequately implemented. M., p. j
- 31. In assessing whether a procedure was properly implemented, an auditor l would randomly select examples of types of documentation. The auditor would look at a sample of documents and unless the sample identified a problem, the !
auditor would not go into the documents in greater depth. M., pp. 31-33.
In June 1993 PSC audit concluded that contamination surveys were being f performed and documented in accordance with procedural requirements. PSC Project Assurance Audit 93 04, June 1993, DN 178-262 at 184; Kachun (4/4/94)
(Unsworn), p. 35. !
(A Westinghouse Team quality assurance surveillance covering the period )
January 26, 1994 through March 28, 1994, examined RWP compliance and )
included a review of survey documents. A deficiency was noted on an air sample survey. The deficiency was discussed with Sawyer and the technician who performed the survey. The technician explained that he had mistakenly omitted !
a symbol which should have denoted the location of where the air sample was taken. The survey was corrected to include the symbol. Westinghouse Team Quality Asb gance Surveillance Report No.94-034, January 26,1994 through March 28. 694. DN ."d40-41.)
185. Sworn Interview Statement of Duane A. Parsons, Mar. 30,1994, pp. 20-24
[ hereinafter cited as "D. Parsons (3/30/94)"); "I mean, you're thumbing through these pages and you come to this RWP, and you know that this one's been worked the last week or so. every shift. And you just lock at this and you haven't l
248 l
l l
'i No.5. j gotten a survey for a week and the last one that you got was two weeks ago, It f doesn t take a rocket scientist to figure out that something's wrong there." Id., pp.
22 23. ,
6' '186. D. Parsons (3/30/94), ppi 23-24.
187. - D. Parsons _(4/4/94), pp. 55-56. Zahrt, however, recalled that D. Parsons told him !
I
~
that occasionally SEG was getting an RWP without a survey. Zahrt (3/29/94) (Vol. ;
- a) (Unsworn), p. _10.
c i l l188. Bixby. (4/7/94) (Unsworn), p. 49; Unsworn Interview Statement of Robert A.~
3 i Rankin. 'Apr. 13, 1994, pp. 4-12 [ hereinafter cited as "Rankin - (4/13/94) l 1 (Unsworn)"); DN 8494-95; Unsworn Interview Statement of Craig A. Thorp, Apr.
'l 26.' 1994, p.17 [ hereinafter cited as " Thorp (4/26/94) (Unsworn)"]. :
l 189? Sam discussion. Section Vill and Appendix B regarding Hatch, Bixby, Beierle. -
i Sawyer. Zahrt and M. Miles. Zahrt also claimed he directed Hatch to backdate an RWP survey form. but Hatch denied any backdating. - Zahrt (4/13/94).
(Unsworn), pp. 75-77. Hatch (4/5/94)-(Unsworn), pp. 58-59. The evidence suggests that still other RPTs may have participated in backdating, but the ;
i' evidence is not conclusive. San Section Vill and Appendix B regarding Trujillo, !
Daniel and Deringer.
L 190. Zahrt (3/28/94) (Unsworn), pp. 256-57. Similarly, the day shift supervisor,
'. Sawyer,'said that in his experience, when an original survey was lost and was reconstructed from a copy, the copy would be stamped " Copy." A note would be
- added underneath the word " Copy" that the original had been lost or misplaced.
Sawyer (3/30/94) (Vol. a) (Unsworn), p. 30.
191. Zahrt (3/28/94) (Unsworn), p. 250.
- = 192. Zahrt (3/28/94) (Unsworn), p. 257.
1 i- 193. Zahrt (3/28/94) (Unsworn), p. 264.
194, Decommissioning Plan, Rev.1, $3.2-11, DN 863.
. 195. ~ Zahrt (4/13/94) (Unsworn), pp.161-62.
196. D. Parsons (3/30/94), pp. 20-24.
p 197; s Zahrt (4/13/94) (Unsworn),~ p.160.
" 138. Zahrt (3/28/94) (Unsworn), p. 29.
E199. Zahrt (4/13/94) (Unsworn), p.161.
c.
- 249 L ,
a i
y - y- 9 w y e-- y y v g -y-r-- y -, c- rr r - A -- e --,=e -w = "-
+
l No; 5.
L
~
.200. SEG supervisor's logbook 9/18/92. DN 3422. p. 75. f ,
201. Zahrt (4/13/94) (Unsworn), p.163;
.4 ,
202 Zahrt (4/13/94) (Unsworn), p.161. ,
203. 'Zahrt (4/13/94) (Unsworn), pp.165-66; Zahrt (3/28/94), pp. 67-68. S a g g!g.g - l various entries in Zahrt's logbook, and SEG supervisor's logbooks, DN 3422, pp.11-160; DN ' 3423, pp. 2-276; DN 3038, pp.44-198. -
204. . Sag,31, SEG supervisor's' logbook entries.for 8/13/92 at 1500 hours0.0174 days <br />0.417 hours <br />0.00248 weeks <br />5.7075e-4 months <br />, DN 3422, '
- p. 35; 9/1/92 at 1000 hours0.0116 days <br />0.278 hours <br />0.00165 weeks <br />3.805e-4 months <br />. DN 3422, p. 54. ,
. 205i Sag, ga, SEG supervisor's logbook entries for 8/11/92 at 1545 hours0.0179 days <br />0.429 hours <br />0.00255 weeks <br />5.878725e-4 months <br />, DN 3422, .;
- p. 32; 8/21/92 at 0800. hours, DN 3422, p. 43; 9/1/92 at 0800 hours0.00926 days <br />0.222 hours <br />0.00132 weeks <br />3.044e-4 months <br />, DN 3422, p.
- 53. .,
206. SEG supervisor's logbook,9/2/92 at 1500 hours0.0174 days <br />0.417 hours <br />0.00248 weeks <br />5.7075e-4 months <br />. DN 3422, p. 55.
207. SEG supervisor's logbook,9/9/92 at 0050, DN 3422 p. 59.
208. SEG' supervisor's logbook,10/6/92 at 0300 hours0.00347 days <br />0.0833 hours <br />4.960317e-4 weeks <br />1.1415e-4 months <br />, ON 3422, p. 96; 11/25/92 at i 0615 and 1115 hours0.0129 days <br />0.31 hours <br />0.00184 weeks <br />4.242575e-4 months <br />, DN 3422, pp.170-71; 12/24/92 at 0600-1615 hours, DN l 3423, p.19; 1/27/93 at 1115 hours0.0129 days <br />0.31 hours <br />0.00184 weeks <br />4.242575e-4 months <br />; DN 3423, p. 52. l 209. On September 23,1992, Tom Erlewine, a member of PSC's oversight team, had
! a conversation with RPT Hatch. Hatch expressed concern over inadequate radiation protection technician coverage on jobs. According to Erlewine, Hatch was afraid that material might be released if inadequate surveys were done.
Hatch advised Erlewine that Zahrt was aware of the problem, but that Zahrt's supervisor, J. E.' Parsons, refused to add more personnel Sworn Interview Statement of Thomas S. Erlewine, May 16,1994, pp.11-12 [ hereinafter cited as "Erlewine (5/16/94)"); DN 11671-73.
210. Zahrt (4/13/94) (Unsworn), p.159; Zahrt (3/28/94) (Unsworn), p. 49.
'211. Zahrt (4/13/94) (Unsworn), p.160.
-212. Zahrt (3/28/94) (Unsworn), pp. 29-30.
~
213. Zahrt (3/28/94) (Unsworn), pp. 30-31. Zahrt said that because the SEG people at FSV were making so many changes, Don Neely [the SEG Vice President at the l ' home office in Tennessee) would not sign the procedures. Zahrt was_ told by SEG
.- Radiation Protection Manager, E. Parsons, that instead they would make changes as they went along. Zahrt said this process did not work well because they had difficulty t;',tting document change notices submitted and processed. Zahrt
( 250
No.5 l
L i
(3/28/94) (Unsworn), pp. 31-32. !
i 214. Zahrt (4/13/94) (Unsworn), pp.159-60. '
215. What Zahrt called the " confusion factor" arose in the context of applying the' ;
proposed Decommissioning Plan's "zero detectable" release standard and utilizing '
the Tennelec instrument to conduct surveys. Zahrt (3/28/94) (Unsworn), pp. 211-
- 20. Because the RM-14 was not as sensitive as the Tennelec, using it could result ,
in matenal being released without any detectable activity, whereas the Tennelec would have detected activity in the same material. Zahrt (3/28/94) (Unswom), p.
225. Zahrt said that when SEG took over in August 1992, the release standard employed by PSC was less than 1000 dpm, which he described as the industry ,
standard. Zahrt (3/28/94) (Unsworn), pp. 226-27. Ultimately, this remained the ;
release standard when the Decommissioning Plan became effective in December 1992. Zahrt (3/28/94) (Unsworn), p. 227.
216. Zahrt (3/28/94) (Unsworn), p. 216. He noted that the proposed Deepmmissioning t Plan said that only materials with "zero detectable" contamination would be i released. Zahrt stated that the Plan's "zero detectable" standard was written for
, the final site release survey at the time PSC was~ ready to terminate its licenss. !
Zahrt (3/28/94) (Unsworn), pp. 211-12, 218. Even though the Plan was not in effect in the Fall of 1992, the RPTs were treating any materials on which they detected activity, e st, materials with counts as low as 20 to 30 dpm as contaminated. This meant that a larger volume of scrap material would have to be shipped as radioactive waste, which would have been very costly. Zahrt (3/28/94) (Unsworn), pp. 212-16.
217. PSC said that if there were less than 1000 dpm activity detected on material, it was legal to release it. This meant utilization of PSC's release standard of "less than a thousand dpm." Zahrt (3/28/94) (Unsworn), p. 228.
218. Zahrt (3/28/94) (Unsworn), pp. 217,220,222. PSC had been using the RM-14 instrument for conducting release surveys up until the time SEG- took over responsibility for the radiation protection program in August 1992. Zahrt (3/28/94)
(Unsworn), p. 221. When SEG initially took over responsibility for the program, SEG continued to use PSC procedures until the Decommissioning Plan became effective in December 1992. Sworn Interview Statement of Joe Edward Parsons, May 10,1994, p. 24 [ hereinafter cited as "J. E. Parsons (5/10/94)"); Zahrt (3/28/94) (Unsworn), p. 217; Sworn Interview Statement of Richard J. Sexton, May 5,1994, Volume a, pp. 47-48 (hereinafter cited as " Sexton (5/5/94) (Vol. a)").
Sexton's transcript states a date of December 1993, but SEG procedures had been in effect since December 1992. At a later time SEG changed its procedure to allow the use of the frisker in this manner.
219. - Zahrt (3/28/94) (Unsworr ), p. 228.
251
y.
w No.5 :
l
~
220; Zahrt (3/28/94) (Unsworn), pp. 227-29; The RM-14 instrument does not detect
~
~ {U . activity below 1000 dpm; L221. Zahrt (3/28/94) (Unsworn), p. 223.
' 222. THutchins (5/16/94), p. 54.
. ; 223. Zahrt (4/13/94) (Unsworn), pp.142-43.
224. Zahrt (4/13/94) (Unsworn), pp.161-63.
1225. Zahrt (4/13/94) (Unsworn), pp.164-65.
226.- Zahrt (4/13/94)'(Unsworn), pp.146-47.
227. 1"Well, y'ou' sit there for. hours and you smear and you frisk, and you smear and .
lyou frisk.- You do that for eight hours and you become almost a drone." Zahrt said that it was demeaning to 'a technician who had been in the business a long t time. ' Zahrt (4/13/94) (Unsworn), p.172.
.228. Zahrt (4/13/94) (Unsworn), p.142,-
~ 229.1 Hatch (4/5/94) (Unsworn), pp.175 76. S.ut agg Deringer (4/12/94) (Unsworn), pp. :j 24,59, who said survey parties did not take place on Level 1.
230. Hatch (4/5/94) (Unsworn), p.174. ]
231. - PSC ' Facilities Support Department Project /Oversite Log, . memorandum- by Sherrow, dated 9/23/92, DN 11222-23; Sherrow (5/10/94), pp. 33-65. At the time ;
of their discussion, Hatch was involved in surveying for free release tubing cut .;
from System 46. Sherrow's memorandum of this-conversation with Hatch l
specifically references SEG Radiation Protection Instruction RPI-003, lasue 1, 1
! '" System 46 Characterization Survey Plan," DN 11654. This instruction, in part, I directed that smears be analyzed with a Tennelec instrument. DN 11657. In his j
- testimony about the conversation with Hatch and this procedure, Sherrow stated 3 that site characterization was totally different from surveying materials for release. j Sherrow (5/10/94), pp 52-55. I 232. _ Borst (5/13/94), pp. 50, 85-86. i
- i. .
l 233. Borst (5/13/94),'pp.l 60-61. In Borst's_ opinion, the failure to document release l c : surveys in late 1992 was not the result of any confusion over whose procedures .i appled or what the release standards were. Borst 'also noted that since Bixby 4 - started documenting release surveys in early 1992, he must have known what the
- PSCj- procedure required . and those procedures do not change until' early
.- December 1992, .ld., pp. 61-65. ~ Similarly, PSC's Blain did not think there was 252 s
q w -r b w v
i No.5 i
'ever a concern about ' which procedures were in - use. Blain, however, i i
'j acknowledged that there was some confusion in the early months as to how 5
matenals were going to be released. He recalled that smears for detecting loose ;
contamination were counted on a BC-4 or Tennelec and that each smear took one l minute. He recalled that SEG expressed concern that it would take too long to j release material that way and that SEG wanted to be able to release using a ;
frisker. Sworn Interview Statement of Darrel L. Blain, July 7,1994, p.' 17 ;
[ hereinafter cited as " Blain (7/7/94)"). D. Parsons did not think that the release standard changed any when SEG took over in December 1992. He understood ,
the standard governing unconditional release of materials to be < 1000 dpm per '
100 cm* loose contamination for beta and gama radiation and < 100 corrected counts per minute for fixed contamination. These limits were to be measured +
utilizing RM-14 or RM-15 survey instrument. Sworn Interview Statement of Duane A. Parsons, May 11 - 1994, pp. 20-21 [ hereinafter cited as "D. Parsons (5/11/94)"]. .
234. ' PSC Pro'cedure,' Surface Radioactive Contamination Survey, HPP-120, issue 7,
$4.5.1.. DN 1557. .
235. Bixby (4/7/94) (Unsworn), pp. 45-46. l 236.. Zahrt (3/29/94) (Vol. b) (Unsworn), p. 30. ,
- 237. Zahrt (3/28/94) (Unsworn), pp. 260-62.
t 238. Zahrt (5/6/94) (Unsworn), pp.127-33, in a March 18,1993 conversation with on-
. site and home office management, Zahrt was told that there had been an
- accusation about falsification of documents that had come from the investigators.
~
Zahrt was asked what the information could relate to. He responded that SEG had had some problems with the RWPs and "some problems with the technicians being lazy and not documenting things correctly" as well as problems with procedures. Zahrt (5/6/94) (Unsworn), pp.127-29.
239. Sworn Interview Statement of Joe Edward Parsons, May 11,1994, p. 40
[ hereinafter cited as "J. E. Parsons (5/11/94)"); Sexton (5/5/94) (Vol a), pp. 3-7.
240. Sawyer (3/30/94) (Vol. a) (Unsworn), p. 29; Zahrt (4/13/94) (Unsworn), p.173. l 241. 333, e.g, Hatch (4/5/94) (Unsworn), p.196; Unsworn Interview Statement of 4
James M. Bixby, Apr. 8,1994, p. 8 [ hereinafter cited as "Bixby (4/8/94)
(Unsworn)"). 1
. 242. D. Parsons (4/4/94), pp. 53-54.
243. For example, Dieter observed many RPTs surveying materials. He commented that the RPTs would survey "every little piece. . . ." Unsworn Interview Statement
)
l 253 i l
)
No.5 of Thomas J. Dieter. May 17 and 18,1994. p,142 (hereinafter cited as " Dieter - ,
f_ -(5/17/94)(Unsworn)"). _Other MKF personnel commented upon the thoroughness j t of the surveying operation. Sag, gu;L, Unsworn Interview Statement of Marvin W.
Henderson. May 11.1994, pp.18-19 [ hereinafter cited as "Henderson (5/11/94) l (Unsworn)"];- Sworn Interview Statement of Paul Harris, May 11, 1994, p. l 9[ hereinafter cited as " Harris (5/11/94)"]. i 244. Seg. gy;L. Dieter (5/17/94) (Unsworn), p. 46; Zahrt also recalled that MKF
, supervisors complained to him about RPTs holding things up because they were frisking everything. Zahrt (4/13/94) (Unsworn), pp.172-73. :
~245. DN 2302. FSV's Decommissioning Safety Review Committee concurred that there were no safety consequences associated with the backdated release survey l forms. Sworn Interview Statement of Donald W. Warembourg, May 12,1994, pp.
53, 77-78,[ hereinafter cited as 'Warembourg (5/12/94)"].
246'.' FSV Decommissioning Project, NRC Region IV Meeting, August 4,1994. DN l 12405,p.83. l l
- 247. Sag DN 3001. The SEG procedure that supplanted PSC's procedure also l required that dumpster surveys be performed. DN 12414-25.
248. Appendix A. Exhibit 7 - Chart of Dumpster Surveys.
t
- . 249. Westinghouse Team Quality Assurance Surveillance Report, No,92-011. DN 3001. This report noted that "[w] hen materials are determined to be releasable,
[
the HP technicians. generate a survey report which describes the components,
[
gives. the instrument ids and (calibration] due dates and data to support
- unconditional release of the items." 14. During the period covered by this report, D Bixby's surveys were not performed in the manner described in this surveillance report.
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Vill. D!SCUSSION OF ISSUE: WHETHER SEG SUPERVISORS AND RPTs FALSIFIED RADIATION WORK PERMIT SURVEY DOCUMENTATION ;
- I .
~
- 'A. -Introduction - Falsification of Radiation Work Permit Survev Forms
- The second instance of suspected falsification of survey documentation involved 1 1
J the backdating of a number of RWP survey forms in March 1993, one month after RPT James Bixby backdated his release survey forms. The same witness who alerted us to the backdated release survey forms also presented documentation suggesting the RWP
. survey forms .mayL have been similarly backdated. Preliminary review of the
' documentation provided. by the witness and additional documentation .we obtained '
4 disclosed that 30 RWP survey forms may have been backdated in March 1993. These i -
- survey forms were for radiation . protection surveys purportedly performed and !
. documented during January, February, and early March 1993. (A more extensive !
l discussion of this issue with documentary exhibits is contained in Appendix B to this r: port.) .
The primary distingui',hing characteristic of these 30 suspect RWP survey forms was that they were logged out-of-sequence in SEG's 1993 annual survey log. When a survey form is described in this report as "out-of-sequence," it means the form was not cntered in chronological order in SEG's 1993 survey log. Conversely, a form entered
, in correct chronological order is described as "in- sequence." For example, survey forms
.. bearing January 1993 survey dates that were entered in the survey log following survey forms dated March 15,1993 are described as out-of-sequence.' Conversely, a survey i
form dated February 16,1993 and logged the same day is described as in-sequence.
I
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no. s l i
Another distinguishing characteristic of the 30 suspect survey forms was that each -
p I was the subject of an informal audit of RWP survey documentation prepared by SEG. j
' ~
cmployee Duane Parsons aro~ u nd March 8,'1993. Before these 30 forms were logged [
l out-of-sequence,LD, Parsons identified numerous. instances where SEG's' computer l rr ards reflected work activities had occurred requiring radiation protection technician !
1 coverage. However, he could not locate documentation showing radiation protection surveys were done. D. Parsons gave the written results of his informal audit to RPOS j Kenneth Zahrt around March 8 1993.
~
Zahrt's response to D. Parsons' informal audit package was to direct his day and .l
[ ,
- . night shift supervisors to "fix" the problem. Following Zahrt's directive, the 30 suspect
.j
,. RWP survey documents were logged out-of sequence in SEG's 1993 survey log between -
March 8 and,15,1993.- They bore RPT s0rvey dates and supervisor review dates of
- JInuary, February, and early March 1993. In each case, the supervisor's review date
. was the same as the RPT's survey date or the next day. l These suspect RWP survey documents were prepared by nine RPTs and one !
- supervisor, who also did survey work. The suspect surveys were reviewed by three SEG
- . supervisors, including the supervisor who prepared two of the suspect RWP survey forms.
I Two RPTs admitted they backdated a total of nine of the suspect RWP survey forms. A third RPT provided conflicting testimony as to whether he backdated RWP !
l survey documentation. We were unable to locate one of the RPTs who was no longer i-l - employed by' SEG.2 Still another RPT declined to make himself available for an 2se j.-
-r. ,-. - , . . - , , c,. - ,. ,
No.5. !
l interview.' The remaining four RPTs denied participating in backdating survey
} .
documentation. LWith the exception of ~Zahrt, the three supervisors ~ also denied t
. l participation in backdating the 30 RWP survey forms. Zahrt admitted limited involvement - l
+ ,
f in the backdating of survey forms by' two RPTs, but ' generally said he knew nothing-l
) !
cbout backdating. [
F As= to the four RPTs and the three supervisors who denied participating .in .
backdating the RWP' survey documentation, the evidence shows their denials are, to -
vfrying degresis,' questionable. Analysis of the evidence shows that more backdating
?
- occurred t'han the RPTs admitted to. Exactly how much more is uncertain, although the .
- cvidence is stronger for some RPTs than others, in preparing our analysis, we did not !
i .
hrve sworn accounts from any of the RPTs and supervisors suspected of participating. i in the backdating whom we were able to interview. We have relied upon transcripts of
]
i i- their unsworn statements in analyzing the evidence. ;
As for the one supervisor exception, Zahrt admitted directing one of the RPTs to I i
- - backdate a single RWP survey form. The evidence, however, shows that all three j supervisors -- Zahrt, Rotar.d_" Chip" Sawyer and Michael Miles - were aware their !
l
= subordinates were backdating RWP survey forms and participated in the backdating j 1 I
' activities.
. Pursuant to the Decommissioning Plan, RWPs are used "for the administrative control of personnel entering or working in areas t;iat have, or potentially have, l-radiological hazards present.'" RWPs are required when workers gain entry or work in cn RCA, when handling items known to contain or suspected of containing radioactive b ,
l 257 g.
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'No.5
- material. and w' hen radiation protection personnel determine that such radiological
[ controls are appropriate.' PSC's " Radiation Protection Plan" describes an RWP as a t permanent record of permission to work in an area and identifies protective measures -
for work." SEG's procedures provide a similar description.7 Specific ' RWPs were generated for- a variety of -tasks associated with decommissioning activities. RWPs typically provided the following information:
, 1. Description of job or activity to be performed.
t
- 2. L. Anticipated radiological conditions including, as applicable, contamination levels, radiation levels, [and] airborne radioactivity levels.
3; Reference to, or a copy of, dose rate and contamination level survey maps.
~4. Number and identification of personnel assigned to the job or activity (if appropriate).
- 5. Monitoring requirements during the job, such as constant radiation protection coverage, intermittent coverage, air monitoring, etc.
1
- 6. Special instructions and equipment to minimize exposure to radiation and contamination.
- 7. Protective clothing and equipment requirements.
- 8. Personnel dosimetry requirements (ga, whole body, extremity).
- 9. Estimated exposure time and dose (person-Rem) to complete the task.
- 10. Actual exposure time, dose and other information obtained during the task.'
. Generally, an RWP would identify the type of surveys required,31, routine, dose rate, surface contamination and airborne radioactivity, as well as the frequency of survey a:tivity; iA, shiftly, daily or weekly.'
258
4 No.5 ,
1' Whenever RPTs performed one of these~ RWP surveys,- they were required to'
( ' document their results on a survey map _or other approved form." The procedure governing survey documentation required RPTs to provide details on the radiological
- ' conditions encountered; the date, time, and location of survey activity; the survey _j instruments used, including serial number, and calibration due dates; and the applicable i
' RWP number." ;
B. Discovery of Missino Survevs - D. Parsons' informal ",udit j Active itWPs require survey work at varying frequencies. This survey work must i
be documented on & standardized form.- After the form is completed and reviewed, it is '
i casigned a sequential survey form number. Details about each form are then logged into ;
i an SEG survey log.'2 The survey log records the date and sequential number placed ,
, on the face of the survey form." Each survey form is also separately listed by RWP ;
l number on an "RWP survey addendum sheet."" These survey addendum sheets record l the sequential number assigned to the survey form from the survey log and they are
!- . maintained with their respective RWPs."
During 1992 and the early part of 1993, D. Parsons' office was near access control on Level 7." D. Parsons characterized himself as being "in the flow" of the survey work." He notmed he was not receiving as many survey forms as he should ;
have been getting from the RPTs, given the amount of RWP activity going on." Twice in 1992, and again in early 1993, he brought this circumstance to the attention of his ,
supervisor, Zahrt." According to D. Parsons,' when the problem still existed in March l - 1993, he performed an informal audit and submitted the results to Zahrt. An added
- r. j i ;
259 :
W i l
1
.. a No.5 explanation for D. Parsons action is found in a March '4,1993 SEG supervisor logbook
' ['
cnfry by Zahrt: " Talked with D.' Parsons about having Brian Jestes run off copies of RWPs for survey verification for upcoming audit."2' An audit was scheduled to begin on 1 i
March 16l1993.22 J
- D. Parsons' first informal audit step was to identify all RWPs that were active from Jfnuary 1.1993.to March- 4, 1993.2' Next, he generated a printout from the ,
computerized Fastrak system listing the activity on all RWPs that were active during this -
, . period.2' This p,rintout indicated each time an RWP was activated by RPTs or workers l arid the precise time span for any work done under each RWP.rs D. Parsons then ~i compared this Fastrak information with the information on the RWP survey addendum ;
sheet's that ' recorded the survey documentation submitted by the RPTs. Through this ,
comparison, he was able to determine whether survey forms were being logged as l frequently as they should have been, according to the survey frequency requirements set forth on the RWPs.2' :
r D. Parsons then assembled individual RWP packages containing the relevant f
- RWP survey requirements,27 whatever RWP addendum pages had been prepared,2s and l
the related Fastrak printout showing how often the RWP had been activated.2s He then !
I attached a handwritten cover sheet to each RWP audit package, stating how many 1
surveys had been documented. For example, one cover sheet read: "2055, worked 8-9 l
. days, one survey."" This' meant that workers had been active on RWP 2055 for eight !
. . l or nine day since the beginning of the year, but only one survey was recorded on the l RWP 2055 survey addendum sheet. On some of his cover sheets, D. Parsons also l 1 !
1 !
l 260 l
e !
J t
. __ _ _ _ _ __ . . _ _ _ _ . _ _ , . . . _ _ . _ . . _ ~ . _ _ _ . _ .
No.5 e identified the plant location where the RWP activity' occurred, using an acronym at the - .
.I'
'i
?
~ bottom of the cover sheet, gjt, "RFF" for the refuel floor.on Level 11. in. addition,' D.
' Parsons prepared two sumr' nary lists, one for the RWPs he thought had adequate survey documentation and another listing RWPs that had inadequate survey documentation." )
l
'Around March 8,1993 D. Parsons submitted his informal audit RWP packages ..
~ to liis supervisor, Zahrt. (Hgg Appendix B.- Exhibit 4 for excerpts from D.~ Parsons i informal audit packages.) He recalls he dropped them on Zahrt's desk and stated there ' ;
i
- w:s "a problem." At th'at point,' Zahrt called Sawyer, the day shift supervisor, into his - -
toffice. Sawyer thumbed through the package of materials and agreed that the problem l i
needed to be fixed. D. Parsons recalls Sawyer said he would take care of it. - Sawyer j took the RWP audit ' packages back to his offica. i According to D. Parsons, Sawyer kept these RWP packages for a month or two l t
and then returned them to D. Parsons. D. Parsons remembers Sawyer dropping the l p ckages onto his desk and stating "[t]hese are done," or "[t]hese are taken care of."" !
in his interview. D. Parsons said he did not examine the returned documents because !
he was too busy. Instead, he placed them on a shelf in his office. He added that he l w s not interested in how Sawyer had fixed the problems." l C. Investiaation into Backdatina of RWP Survev Forms [
l Within one week after D. Parsons gave his informal audit work product to Zahrt, 4~ ; the 30 out-of sequence RWP survey forms appeared. .Our investigation looked into the ~!
circumstances under which this survey documentation was _ produced, since it had not :
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. .261 I i
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No.5
.been in SEG's files at the time of D. Parsons' informal audit. We sought to determine b,
how Sawyer and others had " fixed" the problem of the missing survey documentation.
1.' identification of Susoect RWP Survev Forms Through analysis of SEG's 1993 survey log, we first identified a number of RWP curvey forms that were logged out-of-sequence beginning on March 8,1993. We then compared these survey forms with D. Parsons'. informal audit results. Through'this process, we identified 30 survey forms that had possibly been backdated. These 30 survey forms had been, logged out-of-sequence between March 8,1993 and March 15,-
1 1993, andl covered survey. work from an earlier time period for which' D. Parsons' informal audit had highlighted inadequate RWP survey documentation. The combination of these factors raised a suspicion that these 30 survey forms may have been backdated, as opposed to having been misplaced and later found. The chart on the ,
following page lists, by survey form number, these 30 suspect RWP survey forms:'r l t
l j
+
262 s j r
+
?
E No.5 Out-of-Sequence 1993 RWP Survey Forms survey Data survey rom # Logged Date RPT RWP #
- 1. 0708 l'3/08/93 l 1/04/93 l Dale l 2130
- 2. 0709 J/08/93 l 1/04/93 l Dale l 2130
- 3. 0740 J/09/93 1/29/93 l Rankin 3051
- 4. 0741 3/09/93 1/29/93 j. Rankin 3051
- 5. 0742 3/09/93 2/02/93 .
Rankin 3051 2/04/93 3051
- 6. 0743 l J/09/93 l l Rankin l
- 7. 0744 3/09/93 l 2/09/93 l Rankin l 3051
- 8. 0745 3/09/93 l 2/16/93 l Rankin l 3051
- 9. 0746 3/09/93 l 2/18/93 l Rankin l 3051
- 10. 0747 3/09/93 l 3/03/93 l Rankin j J051
- 11. 0800 3/11/93 l 1/20/93 l Sawyer l 2053 j i
- 12. 0801 l 3/11/93 l 2/10/93 l Deringer I 1101 l
- 13. 0802 3/11/93 l 2/14/93 l Daniel l 2055
- 14. 0803 3/11/93 2/23/93 Beierle l 2057
- 15. 0804- 3/11/93 3/02/93 Deringer 1104
- 16. 0820 3/12/93 1/26/93 Hatch 2057
- 17. 0821 3/12/93 2/09/93 Hatch l'4240
- 18. 0822 3/12/93 l 2/22/93 Trujillo l 2055
- 19. 0823 3/12/93 l 2/22/93 Trujillol 2055
- 20. 0824 l 3/12/93 l 2/22/93 Trujillol 2055
- 21. 0825 3/12/93 l 2/24/93 l Thorp 1101
- 22. 0849 3/15/93 l 1/05/93 Bixty l 2530
- 23. 0850 3/15/93 1/07/93 Bixby l 2530
- 24. 0851 3/15/93 1/11/93 sixby 2530
- 25. 0852 3/15/93 1/21/93 Bixby 2530
- 26. 0853 3/15/93 1/21/93 Daniel 2050
- 27. 0854 3/15/93 1/28/93 Daniel 2051
- 28. 0855 3/15/93 2/03/93 Daniel 2050
- 29. 0856 3/15/93 2/11/93 Daniel 2050
- 30. 0857 3/15/93 l 2/11/93 ,
Daniel 2051 263
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No.5 L
D. Parsons' informal audit package was returned to D. Parsons by Sawyer with if- "
- additional handwritten notes made by Sawyer and oth'ers. ' These included comments, such as, "DONE." or "KZ. . . we need surveys from Rankin, Dominey, Thorp of that
. room,lmaybe 2 times a . week, and it will meet the [ requirements]."" Occasionally, Sawyer wrote up his own cover sheet with comments." D. Parsons interpreted Sawyer's
~ handwritten comments to mean that Sawyer had used whatever sources were availeble to determine who was responsible for documenting the RWP survey activity."'
2.c Additional Relevant Document Analysis
.In addition to reviewing out-of sequence survey forms, SEG's 1993 survey log, and the clocuments contained within D. Parsons' informal audit package, we gathered
.. documentation from a variety of other sources to determine the scope of the problem cnd the responsible supervisors and RPTs. These records included survey instrument response test records, survey instrument maintenance records, the equipment issue logbook, and additional Fastrak entries showing when workers were active on specific RWPs. We also examined plant entrance and exit records and other RWP survey forms that were dated the same as the suspect RWP survey forms, but were not logged out-of-sequence. Witnesses were questioned and further document analysis was done to determine whether an individual RPT's or supervisor's account about a suspect RWP
- survey form was supported by these other sources of information. Relevant data from -
. the documents was -entered onto spreadsheets to facilitate analysis. These spreadsheets are included as Exhibits to Appendix B of this report.
g, 264 w
No.5 ;
i
- a. Response Test Records l
t .
Plant procedures require that survey instrumentation be " response tested" on a regular basis. Response testing, also known as " source checking," involves exposing
'the instrument to a known radiation source and verifying that the instrument's meter r;sponds properly. This process also requires health physics personnel to visually 1
' cxamine the instrument ** and verify that the instrument is not overdue for calibration.4a -
' A response test log is maintained, and each time a response test is performed on an i'
instrument, th'e instrurnent and test date are noted in the log.
- - ' Response tests are performed on instruments throughout the plant, regardless of 1
whether they are used on a long-term or short-term basis at a particular location. The !
l frcquency with which an instrument is required to be tested varies depending on its
. -l
. -use. - Most instruments in continuous use are response tested daily.5 Instruments Essigned to a long term location and not used daily are tested less frequently, generally on a weekly basis." Any instrument used to conduct radiation protection surveys is )
6 1r;sponse tested daily.s2 )
l l The absence of a record that a survey instrument was response tested on a given dry may indicate that the instrument either was not used or was "out of service."
~
. Comparison of RWP survey documentation with the SEG response test log disclosed 7 i'
, instances where, according to the response test records, instruments listed on out-of-sequence RWP survey forms were not response tested on the day of the alleged survey
{.
activity.' I 265 i
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.4 . . _ , . _
1 No.5
- b. Maintenance Records Survey instruments used by RPTs are required to be- calibrated at least semi annually to determine that the instruments are working within specifications." The irstrumer., are also calibrated during routine repairs. Every timo an instrument is ,
calibrated, it is scheduled for recalibration in six months. A sticker is placed on the side .
of the instrument indicating the next calibration due date." Whenever a survey is performed, the RPT should check this sticker to make sure the calibration due date has not passed.55 RPTs are also required to record the calibration due date on their survey documentation.5' This helps insure that RPTs use only an instrument whose calibration d:te has not expired.
Relevant maintenance records for each survey instrument listed on the suspect i
RWP survey forms were compared with the calibration due date entered on the suspect survey forms. In several cases, a suspect RWP survey form showed a calibration due d:te that was in conflict with the maintenance records. One inference to be drawn from this inconsistency is that the RPT did not have the instrument available when the survey documentation was prepared, thereby indicating the RPT may have fabricated this survey information. This, of course, is not the only possible inference. Conceivably, the m:intenance records could be in error. But in combination v/ith other evidence discussed below, erroneous calibration data on a survey form added weight to the conclusion that backdating occurred.
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. :i s, j
- c. Eauioment issue Loa - i O Certain sunley instruments at FSV. such as the RM-14s, are kept at various work; sites throughout the p.' ant on a long-term basis. Most of the instruments, however, are ;
a Lstored in the equipment issue room ~ maintained by SEG. Each time one of these :
i
- instruments is used, it must be logged out of and back into the equipment issue room.
. This procedure;is one' wayf of insuring, that workers are performing surveys with- !
1 instruments that are " ready-for-issue". and appropriate for use." A written record of _
Lequipment insiJe activity is maintained by SEG. .i L The equipment issue logs were analyzed to determine if an instrument listed on
' suspect RWP survey documentation had been issued at the time the survey was
=
l cliegedly documented. For example, RO-2 survey instruments are required by plant procedure to be issued and returned to the equipment issue room daily. Several of the suspect survey forms, however, listed an RO-2 survey instrument for which no entry was found in tho' equipment issue logbook for that date. The absence of an entry in the i
. equipment issue log raised doubt about the accuracy of the survey form data." l Most of the suspect survey forms also listed the use of an RM-14 survey 1
instrument. In many cases there was no indication of such an RM-14 instrument having !
i been issued. SEG was unable to determine whether particular RM-14 instruments, for l 1
which there was no record of issue, were at the time assigned on a long-term basis." )
.< Because RM-14s may be issued lon.a long-term basis, the absence of an equipment j
)
issue log entry does not support an inference'that the survey form information was j
, haccurate.with regard to RM-14 instrument usage.
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i j
< d; ' Fastrak Comouter Printouts : !
i(F Fastrak is FSVs computerized system for tracking worker exposure to radiation.'"_
]
3 J
- Each worker is' ass.igned a dosimeter.which is read every time the worker enters and .
- -leaves;an RCA. This information is recorded on the Fastrak system and can be accessed by RPT_ name, RWP number, date or time. Thus, whenever an RPT conducts '
j RWP survey work, there should be a corresponding entry in the Fastrak system for that !
1 l RPT, RWP number 'date and time.
l Fastrak' entries.were examined to determine if the suspect RWP survey form .
cntries matched the Fastrak system records, in terms of the RPT working on the RWP e
ct the date and time noted on the survey form.1 In many instances, an RPT whose name cppeared'on one of the out-of-sequence RWP survey forms was. not " active" in the i
i Fcstrak' system at the time he was purportedly conducting the survey. Some RPTs 44 cxplained they prepared survey documentation several hours after the actual survey work, and any inconsistencies could be attributed to this time difference.s2 In other instances, the RPT was active in the system, but working under a different RWP at the 2
I
. time reflected on the survey. Several RPTs and supervisors explained that it was s.
common practice to. log into Fastrak under one RWP, but then do survey work in connection with several RWPs.
t D. . Analysis of Susoect RWP Survey Forms
- . - We undertook en intensive analysis of the 30 suspect RWP survey forms. Key
[ wdnesses were interviewed and relevant documents were then analyzed in the context of the witnesses' statements. The analysis initially addressed the suspect survey forms 4
268 l
]
s
.s No.5 i generated by two RPTs, Robert Rankin and Craig Thorp, who eventually admitted to L
backdating. ' Next, we analyzed two survey forms by RPT David Hatch. Hatch denied-backdating these survey forms, but Zahrt claimed he told Hatch to create one of them cfter the fact. Next. we analyzed the survey forms generated by Bixby, who alternately ;
denied and admitted backdating his RWP survey documents. We then analyzed the j RWP survey forms of five other RPTs who' denied backdating RWP survey forms !
prepared by them - Brent Daniel, Daryl Deringer, Sawyer, Joseph Trujillo and Dennis l
1 Seierle. Lastly; we reviewed two RWP survey forms prepared by former RPT Robert q Dale. ($33 summary chart -- Suspect RWP Surveys -- Appendix B, Exhibit 1.) .
f We were not able to interview two RPTs whose names appeared on the suspect j
. documentation. Beierle declined to participate in an interview. Dale was no longer
. l employed at FSV, and we were unsuccessful in attempting to contact him at his last ;
- known address." Our analysis of the suspect RWP survey forms produced by these two RPTs is' based on the documentary record and testimony of other witnesses. l I
We also analyzed the accountability of the three supervisors whose names I cppeared as reviewers on 'he 30 suspect RWP survey forms: Zahrt, Sawyer and M.
I Miles. Sawyer had dual responsibility, as an RPT who prepared survey documentation cnd also as a supervisor who reviewed and approved the survey documentation of other RPTs.
. ' We did not base odr conclusions solely on an analysis of witnesses' statements.
i' We sought either corroboration or refutation of the RPTs' accounts through an intensive
- cnalysis of. relevant documents. In those instances where witnesses admitted 269
. . -l
~No.5
- bhckdating. the- documentary evidence ~ corroborated their accounts' and provided
'I .important insight'into possible backdating by others. ]
-i in none of the instances,where RPTs' denied backdating did the documentary. l
.q cvidence fully corroborate their denials. 'In some cases, the cumulative. weight of the j documentary record was so strong, it supported the conclusion that backdating occurred _j despite an RPT's ' denial. In other instances, the evidence supported a conclusion that j
. I some RPTs entered inaccurate .iriformation on their backdated survey documents. l Examples of such inaccurate information are the survey instrument's identification and ;
i calibration'due date, RWP number, and the time the survey activity took place. i In 'still' other instances where the documentary evidence raised significant }
questions about the accuracy of information recorded on an RWP survey form, the !
weight of the evidence was nevertheless insufficient to support a conclusion that the i
L documentation was backdated. The totality of the circumstances, however, did notjustify
[ . a conclusion thet the survey forms were not backdated. These circumstances included:
- The out-of sequence character of the RWP survey forms.
l
- The survey forms' connection with both D. Parsons' informal audit and the
- detailed notes that were returned to D. Parsons by Sawyer.
- The timing in which these survey forms were logged with other out-of- l sequence forms that were backdated, j
- Errors in instrument citations and calibration due dates, survey dates and times, and RWP desenptions.
- l 4 ~ Several RPTs contended that the out-of-sequence survey forms were completed j 4 - !
x in a timely manner and, therefore, must have been temporarily misplaced and logged in I
'ct a later date. In only one instance, 'however, was the evidentiary record fully 270 f
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No.5 1
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consistent with'the proposition that survey forms were originally documented and
~
misplaced, then later found and logged out-of-sequence.' To conclude that the:
documentary: record supported the misplaced survey form thesis, we required at a I minimum that SEG's equipment records confirm that the survey instruments recorded 1
- on the survey form were properly calibrated and response tested on the date of the l 1
l
- . survey, and some additional corroboration existed that the survey documentation was j prepared on the date listed on the survey form.
e in weigtting the documentary evidence conceming survey instruments, we I l
accorded the most significance to the absence of a response test record. Itas J
mandatory that all survey instruments be response tested on a daily basis when in use.
s . !
. Slightly lesser weight was given to the absence of a record that an RO-2 instrument was issued on the date appearing on a suspect survey form. RO-2 instruments must be i sued and returned on a daily basis. In contrast, little weight was given to the. absence of a record that an RM-14 instrument was issued as these survey instruments can be issued on a long term basis. Therefore, the absence of an RM-14 instrument issue record was not considered critical. The RM-14 instruments, however, still must be l calibrated every six months and response tested on a d'aily basis whenever used.
c The documentary analysis revealed some conflicts between survey instrument calibration due dates listed on the out-of-sequence RWP surveys and the actual SEG l
3 m:intenance records. Repetitive inconsistencies regarding calibration due date were j treated as a strong indicator that survey documentation was backdated and possibly contained other inaccurate information. !
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- Considerable evidential weight was also given to the appearance of a causal !
' ~
r;lationship between the notes prepared: by D[ Parsons and Sawyer that identified '
~
- specific survey document deficiencies and an out of-sequence - RWP survey that ' I 1cppeared to address these deficiencies. Significant evidential weight was also accorded .
. )
= the circumstance of multiple'out-of sequence surveys,. covering different. time periods, being logged on the same day. Where these factors appeared in combination, they, supported an inference that a suspect RWP survey form was backdated, as opposed to h:ving been lost or misplaced. ;
- 1. RPT Robert Rankin l!
Eight of the suspect RWP survey forms were prepared by RPT Rankin. The dates !
. on Rankin's survey forms spanned the period from January 29,1993 through March 3. l l
1993." All eight of the survey forms, however, were entered into SEG's 1993 survey log l
on or about March 9,1993." (Sag relevant survey forms and survey log - Appendix B, Exhibits 2 and 3.)
When Rankin was initially interviewed, he denied any backdating. However, after !
1 e
ha examined ' relevant documentary evidence, he admitted the backdating. Rankin tIstified that he was instructed by his supervisor, Sawyer, to backdate the RWP surveys.
Around March 8,1993. Rankin wrote up and backdated eight RWP surveys. All eight were then signed by Zahrt as the supervisor, and they contained review dates identical 3
. to the survey dates entered by Rankin." They were then entered into the 1993 survey log as survey forms 0740-0747, ;
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- Rankin said that he prepared the survey forms from memory, as he was instructed - i
.i- ' 1
' to'do by1 Sawyer." Additionally, Rankin relied upon previous air sample survey j n
documentation prepared by himself and a fellow RPT to establish the dates and times :
a
. of his backdated survey activity'."
l l .In the instance of his last backdated survey form, Rankin admitted he did not l
- ' perform the s'urvey._ instead, he claimed he prepared the backdated documentation
, based on an air sample survey performed by RPT Jeffrey Dominey and based on his !
recollection of a telephone conversation with Dominey about survey activity." I 2
Detailed analysis of Rankin's backdated survey forms disclosed significant '!
- 1 discrepancies between the information set forth' on Ran. kin's forms and other relevant l :
documentation. > For example, on survey form 0740, dated January 29,1993 Rankin ;
L !
cited RWP 3051 as the relevant radiation work permit." This RWP, however, did not go l
- - i
[ - into effect until F abruary 2,1993." In another instance, Rankin listed a particular survey I i
instrument, but SEG's records, contained no , entry indicating the issuance of this ;
instrument to an RPT." In two instances, Rankin also listed the use of an RM-14 survey instrument, but SEG's records did not contain any entry for the RM-14 instrument having 1-been response tested on the dates cited by Rankin." '
Five of Rankin's eight backdated survey forms are dated prior to February 16, !
1993." . Analysic of the documentary evidence rwealed that all eight of Rankin's l.
backdated. survey forms, including the five which preceded. February 16,1993, were i
wntten on preprinted forms that apparently were not in use prior to February 16,1993." l (Sep Appendix B, Exhibit 5 for earlier version of SEG's proprinted survey forms.) i 1
e 273 I
t No.5 Overall. the weight of the evidence supports the conclusion that all eight of i
Rankin's RWP survey forms were backdated. These survey forms contained significant .
t erroneous data concerning survey instrument usage. These inaccuracies are, in part, attributable to Rankin's stated reliance on memory in preparing the documentation. All cight of the survey forms give the misleading appearance that they were created and reviewed contemporaneously with the survey activity described on the forms.
^
. The evidence aJso shows that Sawyer directed Rankin to generate the backdated survey docume'ntation.. Sawyer did not deny Rankin's account. Instead, he repeatedly claimed he could not recall any instruction to any RPT to backdate survey documentation. The evidence also shows that Zahrt participated in the backusting rctivity by affixing his review signature to each of the survey forms even though the survey dates and the review cates on each of the eight forms were backdated, in so doing, Zahrt contributed to the false appearance that the survey forms documented c::ntemporaneous survey activity.
- 2. RPT Craia Thorg One of the suspect RWP survey forms was prepared by RPT Thorp. Survey form 0825 was dated February 24,1993 but was not entered into the 1993 survey log until on or about March 12, 1993." When he was first interviewed about this survey form, Thorp denied any backdating. However, after examining relevant documentation, he admitted to the backdating. Thorp was uncertain, but he thought that either his supervisor, M. Miles, or another RPT, Brian Jestes, told him to writeup the survey documentation."
274
1
' No.5 i j j
' Although Thorp's backdated survey form stated it was prepared pursuant to RWP 4
- j. 1
^
03-1101, relevant documentation established that Thorp was not eligible to work under f-this RWP until a month later?' Also', Thorp's backdated survey form 0825 sh' owed a -
total of 38 smear results.. Thorp claimed he wrote this information on his backdated form :
from memory."
~
- Although Thorp's backdated survey form says he performed the survey activity i
y ;
e over an eight and one-half hour period - from 1800 hours0.0208 days <br />0.5 hours <br />0.00298 weeks <br />6.849e-4 months <br /> on February 24,1993 to 0230 hours0.00266 days <br />0.0639 hours <br />3.80291e-4 weeks <br />8.7515e-5 months <br /> on February 25,1993 -- the Fastrak system shows he was only active between
- j. 1927 and 2145 hours0.0248 days <br />0.596 hours <br />0.00355 weeks <br />8.161725e-4 months <br /> on February 24,1993 and later the same shift from 2338 hours0.0271 days <br />0.649 hours <br />0.00387 weeks <br />8.89609e-4 months <br />.
. to 0204 hours0.00236 days <br />0.0567 hours <br />3.373016e-4 weeks <br />7.7622e-5 months <br /> the next day." Moreover, the gate record shows Thorp left the facility at 0225 hours0.0026 days <br />0.0625 hours <br />3.720238e-4 weeks <br />8.56125e-5 months <br /> on February 25,1993, five minutes before he reported finishing the survey l
.. L activity reflected on his backdated survey form 0825. Also Thorp listed the use of an
- RO-2 survey instrument, serial number 6123 (RO2/6123) on his backdated survey form.
t . This survey instrument was issued to another RPT, James Cummings. According to SEG's equipment issue log, the instrument was returned 0220 hours0.00255 days <br />0.0611 hours <br />3.637566e-4 weeks <br />8.371e-5 months <br /> on February 25, 1993, ten minutes before Thorp's backdated survey form says he concluded his survey
\
work."
i.
Thorp's supervisor, M. Miles, backdated his review date on RWP survey form 0825. M. Miles identified his signature and acknowleoged that he wrote the review date r'
. of February 24,1993. M. Miles claimed he had no recollection of backdating the review
. date. The evidence, however, is clear that Thorp's survey form 0825 was prepared sometime after March 4,1993.
~, ,
275
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.. . - _ . .- -. -- . - - . . . - -- - . - - . _ . - ~ . . - - . . - . -
t i
i No.5 i
.a
-- The weight of the evidence supports the conclusion that Thorp's RWP survey form -
1 I
~i 0825 was backdated by Thorp and his supervisor,' M. Miles. Thorp's admission that he - .l l !
i backdated the document is corroborated by the documentary evidence and is undisputed
- ,by any witness. . Thorp claimed he wrote the survey from memory. The discrepancies - !
i noted on his survey' form can be attributed to his reliance on a, faulty memory. l 3.' - RPT David Hatch '
j Two of the suspect RWP survey forms were prepared by RPT. Hatch. Survey ;
forms 0820 and 4821 were dated January 26,1993 and February 9,1993, respectively.
}
Both survey forms were logged, however, on or about March 12, 1993."
In'his interview Hatch denied backdating any survey forms and claimed he had j n- '
no knowledge about backdating. Hatch insisted he performed the survey work reflected
- on his survey forms. He assumed he dated the documents on the dates shown.
However, he conceded it was possible he completed this survey documentation after
[ M rch 4,1993."
- Each of Hatch's backdated RWP survey forms had a review date identical to the I
survey date listed by Hatch. Zahrt signed each of these two survey forms. Zahrt
- . admitted he directed Hatch to backdate RWP survey form 0820." 1 I
L Analysis of the documentary evidence supports Zahrt's account that survey form 0820 was backdated. Hatch reported using an RO-2 survey instrument, serial number -l
- . 5985'(RO2/5985). According to SEG's records, this survey instrument was not issued ,
13 any. RPT, nor was'it response tested,- on the date listed on Hatch's survey form j
- 0820." As was the case with five of Rankin's backdated RWP survey forms, Hatch's
. 276 i
, i:
, 4 - _ __ _____ . _ __ ____.________ _ _ _ _
1 No.5 l t
4 ?
D. out-of sequence form.0820 was prepared on a February 1993 version of SEG's'
)
. ('
preprinted form that apparently was not in use on January 26.-1993, the date on survey ;
form 0820." l
' As for Hatch's survey form 0821, Hatch wrote on the form that he prepared the l
~
survey at 1000 hours0.0116 days <br />0.278 hours <br />0.00165 weeks <br />3.805e-4 months <br /> on February 9,1993. The Fastrak printout for this date, however,
- showed Hatch wasjogged in from 1251 to 1410 hours0.0163 days <br />0.392 hours <br />0.00233 weeks <br />5.36505e-4 months <br />." Also,' SEG's equipment issue
- log contained no entry for the Teletector instrument, serial number 41845 (Tele /41845),
, which Hatch reported using on the survey form. Moreover, there was no record of this J ~[
^
survey instrument having been response tested on February 9,1993." As was the case
'with Hatch's survey form 0820, his survey form 0821,. dated February 9,1993, was written on a preprinted SEG survey form that apparently was not in use until the >
fallowing week."
Several additional pieces of evidence buttress the conclusion that Hatch b2ckdated survey forms 0820 and 0821. These two survey forms were logged on or
- cbout March 12, 1993, as part of a group of six out-of-sequence survey forms that i included the survey form Thorp admitted to backdating. Analysis of the handwritten notes contained in D. Parsons' informal audit packag'e, including the notes Sawyer returned, also shows a close connection between these notes and the content of Hatch's two RWP survey forms. D. Parsons' note said only one survey had been done for RWP
- 2057 and more were needed. Sawyer's note then indicated a job completion survey was still needed and identified Hatch as.the responsible RPT.s2 Wthin a few days of D.
)
Parsons giving the informal audit to Zahrt, Hatch's RWP survey form 0820 was recorded ]
l 277 j I
g- g v v v 7 a .w e, y p , __ _ . -_ _ _ _ - - - . _ _
, _ _ . _ _ _ . _ . _ . ~ . _ _ . - _ _ _ _ . _ _ _ . _ . _ . _ _ _ . . _ . _ _ _ ._
d e No.5- 1 p in SEG's survey'. log. '.When' Sawyer returned his notes to D. Parsons, Sawyer's notes >
l fQ l
contained the entry."DONE" as opposed to "FOUND." The evidence did not show either ;
- j. of Hatch's survey. forms' had been lost or misplaced.
1 . The primary evidence establishing Zahrt's accountability .for the backdating was- < <l i ..
- Zthrt's admission that. he directed Hatch's action. As was the case with the eight 1 1
l b5ckdated Rankin' survey Orms signed by Zahrt Zahrt's signature on the two backdated l Hatch surveys created the false appearance that he reviewed' and approved the ]
~
documents at the time, they were_ purportedly prepared. -l j 4. RPT James Bixbv ,
l The author of the 14 backdated 1992 release surveys, Bixby, also wrote four of
- t. ..
l
- the out of-sequence RWP survey forms - forms 0849 through 0852. These survey forms
.were dated'between January 5,1993 and January 21,1993, but were logged around
. Mrrch 15,1993, with five other out-of sequence RWP survey forms written by RPT .
1 D;niel." All four of Bixby's out-of sequence survey forms were reviewed by Sawyer, and l 1
> they contained review dates within a day of the survey dates listed by Bixby."
l In the course of the investigation, Bixby alternately denied, then admitted, and !
then denied again, backdating these RWP survey forms." In depth document analysis, however, establishes that Bixby did backdate these survey forms. On all four out-of-4 sequence survey forms, Bixby listed erroneous survey instrument data. (3g3 chart -
. - Analysis of Survey Data - Appendix B, Exhibit 6.) For example, he listed the use of an RM14/3902 survey instrument with a calibration due date of November 26,1993. This
- p. date is.far outside the six month calibration cycle for the RM-14 survey _ instruments. The
.l x !
. 278-F
. . . . . .. . ~_. - . - - - - _ . . . , . . . . .
~
No.5- -l
=
idcte also conflicted with the SEG maintenance records which showed the instrument: ]
was due for calibration on April 26,1993."*-Similarly, on each survey form Bixby claimed l
~
to use an RO-2 survey instrument, but he again listed erroneous calibration due dates."
i As was the case with Rankin's'and Hetch's backdated RWP survey forms,' Bixby's out-of-sequence RWP: survey fo'rms were prepared on an SEG . preprinted form that Epparently was not in use prior to ~ February 16,1993." (jigg chart -- Bixby's RWP- ;
Surveys -- Appendix B, Exhibit 8.) This February 1993 version of the preprinted survey -l i
~
form was also tt)e same preprinted form that Bixby used to prepare his 14 backdated -l 1992 telease survey forms."
In backdating his RWP survey forms, Bixby created the false appearance that surveys were documented on the dates which appeared on the face of the survey
- documentation. Sawyer contributed to the false appearance that these RWP survey forms were prepared in January 1993 by signing as the reviewer following each of the four backdated review dates.
- 5. RPT Brent Daniel Five of the suspect RWP survey forms were prepared by RPT Daniel, who worked i on the nightshift. All five were reviewed by the nightshift supervisor, M. Miles. Although
.these five out-of sequence survey forms were all logged on March 15,1993, they contained the following survey and review dates:
, Survey RWP Survey RWP# Review Date Date > Form #
L 1/21/93 0853 -2050 1/21/93
' ~
1/28/93 0854 2051 1/28/93
- u. 2/03/93 0855 2050 2/03/93
. . a f
, 279 e
d No.5.
I 2/11/93 0856 2050 2/11/93 2/11/93- 0857. 2/11/93
- [ 2051-~
1 When D. Parsons gave Zahrt an informal audit package on RWP 2050,- he t included a note saying there were no surveys for January 21. February 3 and February i 10, 1993." When D.' Parsons got the audit package back, it contained a detailed ;
7 hendwritten note from Sawyer to M. Miles, documenting RWP 2050 survey deficiencies for the three dates noted by D. Parsons. Sawyer's note about February 3,- 1993 survey l activity specifically mentioned " Brent," and his note about February 10 included the i 1 initials "BTD," which are the same as Brent Thomas Daniel's initials."' Also at the top of the page containing Sawyer's notes, someone wrote the entry: "For Brent 3/15/93."*'
Similarly, when D. Parsons gave his RWP 2051 informal audit package to Zahrt, he included a note advising that RWP 2051 had been worked on January 28,1993 and
- . Fcbruary 11,1993, but there were no survey forms.*' When the package was returned to D. Parsons, it contained a note from Sawyer advising the nightshift that there were no surveys for January 28,1993 and February 11,1993. On this note someone had again 4
wntten: "For Brent 3/15/93."**
Daniel's five out-of-sequence survey forms were logged on March 15,1993,as part of a group of nine survey forms that included the four backdated Bixby RWP survey 3 >
forms."$ ,
When Daniel was interviewed, he denied any backdating of his survey forms.
] _ Drniel's supervisor, M. Miles, also denied any knowledge of backdating. M. Miles offered an explanation for the lengthy gap between the dates listed on Daniel's survey 4
l forms and the date they were logged. M. Miles said he found a group of survey forms 280
~
No.5 on.his desk in March 1993, but he could not specifically recall whether this group if' '
inclu'ded any of Daniel's survey forms. M. Miles claimed that he turned in the group of ,
~
discovered survey forms for filing.'" A detailed analysis of M. Miles' survey form review cctivity for the dates reflected on Daniel's five out of-sequence survey forms, however, d::monstrates that it is highly improbable that the five Daniel survey forms became separated from the paperwork flow and remained misplaced until M. Miles allegedly discovered them in mid-March 1993.' ' (Seg Analysis in Appendix B).
The evidence also showed that on Daniel's out-of-sequence survey form 0854, d:ted January 28,1993, he cited the use of an RO-2 survey instrument, serial number 1572 (RO2/1572), for which SEG had no record in its database. Furthermore, SEG had no record of this instrument having been issued or response tested on January 28, 1993.'" Also Daniel's survey form 0857, dated February 11,1993, listed a survey time I
- i of 0200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> pursuant to RWP 2051.'" The relevant Fastrak printout, however, does !
l not contain any activity for Daniel at 0200 on February 11,1993, nor does it show him !
working at any time on this date pursuant to RWP 2051.""
The above circumstances suggest a high probability that the five Daniel out-of-sequence survey forms were backdated. In particular, there is a very close connection between the details in Sawyer's handwritten notes and the content of Daniel's out-of-sequence survey forms. Additionally, the probability that M. Miles could have misplaced 7
D:niel's five survey forms on or in his desk while still continuing to process, in a timely m:nner, numerous other survey forms is extremely remote. The prospect of backdating I
281
. a No.5 :
y n
4 Lis particularly heightened.because Daniel's survey form 0854 noted the usel of an i
<("-
..RO2/1572 survey. instrument for which SEG has no record. '
o
- 6. RPT Darvl Derinaer - j
1101 and 1104, respectively. D. Parsons' informal audit had determined that RWP 1101 l j
i hrd been worked a total of 29.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />, but th'ere was no survey' documentation. When
^
D. Parsons received the infonnal audit package back, it contained a note from Sawyer 3 i stat'ing: .
4 i
j . Decon survey's (pre, during & post) of C.P. and equipment .
2/10/93 @ 0800 to 0930. ;
? 'In large, capital letters to the right of t'his note, Sawyer also' wrote the word :
"Done."'" l
. Deringer's out-of sequence survey form 0801 was dated February 10,1993, but i
wIs logged on March 11, 1993. Survey form 0801 documented decontamination -i 4
i cctivities, miscellaneous equipment and tools that were released from the crystal palace, .
- e decontamination area on the RFF."'
- - Deringer's survey form 0804, dated March 2, 1993, addressed survey L
requirements for RWP 1104."' D. Parsons' informal audit disclosed that Deringer and o I;borer had worked pursuarit to this RWP on March 2,1993, but there was no survey documentation in the file."' When D. Parsons got the package of documents back,
' Sawyer had written the word "DONE" across D. Parsons' note.""5 in his interview,~ Deringer was advised of D. Parsons' informal audit results l
1
. involving the RWPs .1101 and 1104 and was shown relevant documents including the 282 .
J
i No.5- 1 1
SEG survey log, addendum sheet and the Fastrak printout."' . Deringer insisted that he
'[ ~
prepared the two survey forms on the date indicated on the documents. !
)
~
Neither Sawyer nor Deringer had any explanation of how these two survey forms, I cithough dated weeks apart. came to be logged on the same day in March 11, 1993."7 J. .
.An additional circumstance supporting the suspicion that these Deringer survey' forms were backdated is that they were logged on March 11 as part of a group of five out-of-
! ' sequence RWP survey forms that' included backdated survey forms by. Sawyer and
)
' Beierle "' '
i
. The weight of the evidence, however, is insufficient to conclude that the Deringer- ;
1 i survey forms were backdated. The circumstances supporting a conclusion of backdating cre counter balanced by the evidence showing that Deringer was active on RWPs during p
the times in question, and the survey instruments cited by him were properly calibrated, i response tested and available for use.
- 7. RPT Roland "Chio" Sawyer
- a. ' Backdated RWP Survev Forms Two of the suspect, out-of-sequence RWP survey forms were prepared by RPT 4
Sawyer, who also was the dayshift supervisor. Sawyer's survey form 0800 was dated J:nuary 20,1993 and, according to the form, was reviewed by Zahrt the same day.
. Sawyer's survey form 0802, dated February 14,1993, was, again, according to the form,
. reviewed by Zahrt on that date."' These two survey forms addressed cur.sy requirements for RWPs 2053 and 2055, respectively. ,
$l 283 a
e
, y ,
, - .. . - - _ _ _. . - .. . - . _ ~ . ..
}
l When D. Parsons gave Zahrt his informal audit package on RWP 2053, Parsons J
, .. s
- noted that ' workers were active on this RWP on January 20,1993, but there was no l i
. l survey documentation. When D. Parsons got the package back, it contained a note from
. Sawyer indicatin'g a need for survey documentation.for January 20 1993. Sawyer's note ;
i
.also had the word "DONE" written across it.'2'
- Similarly, D. Parsons' note to Zahrt described a survey form deficiency for RWP {
l 1
,L 2055.'2' - When D.- Parsons got the package back from Sawyer, it contained two pages
- j. of detailed notes.made by Sawyer, including a note for February 14,1993 indicating that i
. e survey document was needed for the dayshift. The word "DONE" had been wtan
!- across this note.'"
l Although Sawyer's two out-of-sequence survey forms were dated three weeks )
apart, they .were logged.together on March 11, 1993, along with three other out-of-4 sequence survey forms. These three others included a survey form that the evidence showed was backdated by Beierle, as well as two other survey forms by Deringer the Evidence shows remain suspect.
r
- . When interviewed about the handwritten notes and the circumstances under which i
survey forms 0800 and 0802 came to be logged out-of-sequence, neither Sawyer nor
.Zthrt could offer an explanation for what the notes meant or how the survey forms came t3 be logged out-of-sequence.
m The evidence also shows that on Sawyer's out-of-sequence survey form 0802, dated February 14, 1993, he cited the use of survey instruments RO2/5985 and )
RM14/218 that were not response tested on the date of the survey. An additional
,~. 2 284 .
No.5 factor supporting the conclusion that Sawyer's survey forms were backdated was that cithough Zahrt's signature appears after a February 14,1993 review date for survey -
0802 the gate records show that Zahrt was not in the plant that day, which happened to be a Sunday.'2' The evidence regarding survey forms 0800 and 0802 shows that Sawyer's part in producing backdated documentation was not limited to a supervisory role. Instead, he actively participated in preparing backdated documentation. The evidence also shows that Zahrt once again participated in the backdating activity by affixing his review signature to these two survey forms, thereby contributing to the false appearance that the survey forms documented contemporaneous survey. activity.
in addition to backdating two RWP survey forms, Sawyer addressed RWP l l
document deficiencies by listing existing RWP survey forms on survey addendum sheets ;
I for other RWPs that lacked necessary documentation. Sawyer claimed that with some RWPs, a " documentation error" occ;rred in logging routine shiftly, daily or weekly survey I
of these survey forms met the requirements for shiftly, daily or weekly surveys of other RWPs where D. Parsons' informal audit showed a lack of documentation. He said that these RWP 1053 routine survey forms "needed to get distributed" to the other RWPs.
To meet that need, Sawyer selected survey forms of shiftly, daily and weekly surveys previously logged under RWP 1053 for listing on the survey addendum sheets of one or 285
. i
.. . - .- .- - . - - = . .- . - . - . . . . .. -.
I j
i
.' No.5 i
more RWPs that had requirements and frequency guidelines which were different and )
unique.'"
When listed on the other s'urvey addendum sheets, no indication was given that j the survey forms had originally lbeen logged under or. prepared pursuant to a different :
RWP.'" in this manner, Sawyer " distributed" routine RWP 1053 survey forms to several l
RWPs, including RWPs 2240A,22408,2130,2200B and 2241. l l
For example, RWP 2240A addressed survey requirements related to the removal ,
of the~ PCRV top head interferences on the RFF, located on Level 11 of the reactor
- 1 building. It required radiation, contamination and airborne surveys when particular !
systems were " breached"in the removal process, as well.as routine surveys of the work cr;a " daily when working." O. Parsons' informal audit founc' that the RWP 2240A had been worked over a twenty-two day period by numerous workers for a total of 432 hours0.005 days <br />0.12 hours <br />7.142857e-4 weeks <br />1.64376e-4 months <br />, ,
but that no surveys had been logged in pursuant to it.'" He gave a package to Zahrt, which contained a copy of RWP 2240A and the Fastrak printout, along with a cover sheet 'which read "2240A," "O surveys."* When he received the package back from :
' Sawyer, the word "Done" had ben written on D. Parsons' note.'"
After receiving D. Parsons' informal audit, Sawyer reviewed survey forms of routine surveys of the RFF logged under RWP 1053. He then " distributed" them to RWP 2240A by listing twenty of the routine RWP 1053 survey forms on the RWP 2240A addendum sheet." Some of these surveys had been conducted as long as two months before Sawyer's review When Sawyer was shown each of the twenty survey forms i
?
f 286 f
_____r
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No.5 t
ha logged in on the survey addendum sheet, he said it was now " basically impossible
'J to tell" whether they satisfied the requirements of RWP 2240A."' >
No breach surveys were included on the survey addendum sheet. Sawyer said' 4 that because there were no breach survey forms for RWP 2240A, none could be included on the RWP survey addendum sheet."' He insisted none of the routine survey f:rms were backdated or fabricated for inclusion on a survey addendum sheet."'
. The inclusion of routine shiftly, daily or weekly survey forms on survey addendum i sheets of particular RWPs diminished the accuracy and integrity of the documentation process. Whether a particular survey satisfied the requirements of an RWP could not i be determined. Although the evidence does not show the routine survey forms which
[ were subsequently listed on the survey addendum sheets of RWPs 2240A,22408,2130, I 22008 or 2241 were backdated or otherwise fabricated, the effect of listing them was, l t
nevertheless misleading. This manner of listing the survey forms gave the appearance surveys had been conducted which satisfied the requirements of particular RWPs, when it cannot now be determined they did.
- 8. RPT Joseph Trujillo i
worked on the night shift. All three were dated February 22,1993, and were prepared pursuant to RWP 2055. This radiation work permit related to surveying and sampling
. of reflector blocks in the reactor core."'
RWP 2055 was one of the RWPs reviewed by D. Parsons as part of his informal cudit. In his note to Zahrt regarding this RWP, D. Parsons advised that the RWP had 287
No.5 been worked 8 or 9 days. but there was only one survey. .When D. Parsons received l tha RWP 2055 package back at a later date, it contained two pages of handwritten notes.
th:t were captioned "Need RWP 93-2055.""' One of the entries on these two pages of
' notes was: !
"2/22/93 Nightshift - log says 3 core samples pulled, no surveys doc'd (documented)."'" l In the margin of this note, someone wrote the word "Done.""' l When interviewed Trujillo denied any backdating of survey documentation. He
' was' advised of D. Parsons' informal audit results, and the circumstance that his three r
survey forms, although dated February 22,1993, were all logged on March 12,1993.
The evidence showed that Trujillo's out-of-sequence survey forms were all misdated by one day. Trujillo's three out-of-sequence survey forms described survey j activity related to three core samples supposedly taken on February 22,1993. The survey forms contained survey times of 0045,0120,0155 hours0.00179 days <br />0.0431 hours <br />2.562831e-4 weeks <br />5.89775e-5 months <br />, respectively."' These i timss, however, correspond with three logbook entries made on the nightshift during the scrly morning hours of February 23,1993, when the core samples were taken."'
Detailed analysis of Trujillo's survey forms showed he was active on the Fastrak ,
system under RWP 2055 for only a part of the nightshift commencing on February 22, j 1993. Trujillo's Fastrak entry times did not correspond completely with the survey times l I
.he listed on his three out-of-sequence survey forms. The logbook and survey forms j Itted survey times of 0045,0120, and 0155 hou'rs, respectively. The Fastrak system ,
'showed, however, Trujillo active on RWP 2055 during the hours 0115 through 0251."' ;
Therefore, he was not active on RWP 2055 during the 0045 hours5.208333e-4 days <br />0.0125 hours <br />7.440476e-5 weeks <br />1.71225e-5 months <br /> time listed on the first !
288 ,
f
)
No.5 of his three out-of-sequence survey forms. Trujillo was active, however, on RWP 1053 l
( from 2337 hours0.027 days <br />0.649 hours <br />0.00386 weeks <br />8.892285e-4 months <br /> on February 22,1993 through 0115 hours0.00133 days <br />0.0319 hours <br />1.901455e-4 weeks <br />4.37575e-5 months <br /> on February 23,1993,"' and i ha documented an in-sequence survey for RWP 1053 for February 22,1993 at 2250 h:urs."' )
i The documentary evidence shows that the RO-2 survey instrument cited by Trujillo on his three out-of-sequence survey forms was issued to Trujillo during the r levant time frame, was properly response tested, and the calibration due date was cccurate."'
- Nevertheless, a number of factors heighten the suspicion that these three survey forms were backdated. In addition to the misdated preparation dates on all three, M.
Miles' review dates were also misdated by one day. On all three survey forms, M. Miles' 1
r; view date was February 22,1993, although the actual survey activity did not occur until the early moming hours of February 23,1993.u2 Furthermore, neither Trujillo nor M. Miles had any explanation for what happened -
to these three survey forms from the time they were allegedly prepared and reviewed, until the time they were logged on March 12,1993, along with backdated survey forms by Hatch and Thorp. Also, Trujillo's three out-of-sequence survey forms were submitted on the newer, proprinted survey form that Rankin, Bixby, and Hatch used in preparing their backdated survey forms. Although this newer version came into use by February 16,1993, and Trujillo's three out-of-sequence survey forms were dated February 22, 1993, the first in-sequence use of the newer, preprinted version by Trujillo is March 12, :
I 289
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m s
ST!ER, ANDERSON & MALONE
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FAX (202) 660-8068 PLEASE REPLY 10:
Bridgewater- i March 22, 1995 . \
t Penan m. & CONFIDENTIAL- '
t
-VIA FEDe*41 EXPRESS S
Mary J. Fisher .
ManagerLNuclear Operations
-Decommissioning Project Director !
Public. Service Company.of Colorado l Fort St. Vrain Station ,
16805 Wald County Road 19-1/2 e Platteville,.co 80651- +
+
Ret Reoort of-Indeoendent Counsel Investiaation Concernina Issues of the Fort Decommissionina St. Vrain Nuclear-Generatina Station Proieet !
Dear Ms.' Fisher:
h As you L requested in our telephone conversation of today, '
enclosed of please find a second, unredacted copy of the final version '
the s 'above-captioned Report with Appendices A through .D for
' submittal to the NRC.
have. received are numbered "5."This copy of the Report and Appendices you l
If we me.
to contact can be of any further assistance, please do not hesitate ;
i Sincerely, Afffw & W W MJM:lo Mark J. alone, Esq.
a
. Enclosures underl separate cover via Federal Express to Mary Fisher ',
MFISHER.LTR N
L
(
pe a; e arsteteos o.t fo a a a ma:i m m aw-m