ML20237G605
| ML20237G605 | |
| Person / Time | |
|---|---|
| Site: | Shoreham File:Long Island Lighting Company icon.png |
| Issue date: | 05/18/1987 |
| From: | SUFFOLK COUNTY, NY |
| To: | |
| References | |
| OL-5-I-SC-095, OL-5-I-SC-95, NUDOCS 8709020327 | |
| Download: ML20237G605 (225) | |
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- [- SC- 9 5 :WRS UNITED STATES OF AMERICA '87 t,UG 25 A8 :11 NUCLEAR REGULATORY COMMISSION Before the Atomic Safety and Licensino BoYrd
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l In the Matter of )
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LONG ISLAND LIGHTING COMPANY } Docket No. 50-322-OL-5
) (EP Exercise)
(Shoreham Huclear Power Station, )
Unit 1) )
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DIRECT TESTIMONY OF WILLIAM LEE COLWELL, DEPUTY INSPECTOR PETER F. COSGROVE, PHILIP EVANS, CHARLES B. PERROW, FORD ROWAN, i LIEUTENANT JOHN W. STREETER, JR., AND HAROLD RICHARD ZOOK l
ON BEHALF OF SUFFOLK COUNTY l
REGARDING CONTENTION EX 50 -- TRAINING OF OFFSITE EMERGENCY RESPONSE ,
PERSONNEL March 20, 1987 l
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UNITED STATES OF AMERICA I NUCLEAR REGULATORY COMMISSION Before the Atomic Safety and Licensina Board
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LONG ISLAND LIGHTING COMPANY ) Docket No. 50-322-OL-5
) (EP Exercise)
(Shoreham Nuclear Power Station, )
Unit 1) ) ;
)
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l DIRECT TESTIMONY OF WILLIAM LEE COLWELL, DEPUTY INSPECTOR PETER F. COSGROVE, PHILIP EVANS, CHARLES B. PERROW, FORD ROWAN, LIEUTENANT JOHN W. STREETER, JR., AND HAROLD RICHARD ZOOK ON BEHALF OF SUFFOLK COUNTY l REGARDING CONTENTION EX 50 -- TRAINING OF CIFSITE EMERGENCY RESPONSE PERSONNEL March 20, 3987 L--_____-___-_____-___________ __ _ _ _ _ .
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CONTENTION EX 50 TESTIMONY Table of Contents l
Ea91 I. INTRODUCTION . . . . . . . . . . . . . . . . . . 1 A. Identification of Witnesses . . . . . . . . 1 B. Familiarity with LILCO's Plan . . . . . . . 20 4
C. Purpose of Training . . . . . . . . . .. . 25
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II. PURPOSES AND
SUMMARY
OF CONCLUSIONS. . . . . . . 34 J A. Purpose . . . . . . . . . . . . . . . . . . 34 B. Summary of Conclusions. . . . . . . . . . . 34
- 1. The Exercise Results Demonstrate I Fundamental Flaws in LILCO's Training Program . . . . . . . . . . . 34
- 2. LILCO Has Not Fixed its Training ,
Problems . . . . . . . . . . . . . . . . 41 III. DISCUSSION OF CONTENTION EX 50. SUBPARTS. .. . . !iS A. Contention Ex 50.A: Training for Unanticipated and Unrehearsed Situations. . . . . . . . . . . . . . . . . 55- ,
l 1. The Importance of Being Trained to Respond to Unanticipated and Unrehearsed Situations . . . . . . . . 57
- 2. Examples of LILCO's Lack of Training to Respond Properly, Appropriately or Effectively to Unanticipated and Unrehearsed Events . . . . . . . . .. , ,60 (a) Road Impediment Examples. .. . . 61 (b) Rumor /Public Inquiry Examples . . 66 (c) Other Examples. . . . . . . . . . *15 T
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- 3. The LILCO Failures to Respond %
Appropriately to Unanticipated .
4 Events Were Not Unexpected . . . 78
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- 4. LILCO Has Not Corrected its Failure 1t t i to Provide Training in Respo'nding j'- \ s tc Unanticipated and Unrehearsed -
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Events . . . . . . . . . . 4 . . . .
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- i sJ B. Contention Ex 50.B
- Failure to Train / ) ,
Personnel About Basic Knowledge an'd l? '
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Information Essential to IFplement ,
t , y Eg the Plan and Procedures . . . . . . . . . . 4 9E ~
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- 1. Introduction . . . . . . .,c . . . . ./ '9
- 2. Examples of LILCO's Failure to T ;\ s .
Provide Effective Training tii 4 Provide Personnel with Basic "\
Knowledge on How to Follow '
and Implement the Plan and Procedures . . . . . . . . .i . . . . . 102 i,.5. i s
(a) Introduction. . . . . .'". . . . . 102s ,'
(b) Communications Problems in s , i t Dealing With Traffic , .,a, Impediments . . . . . . . . . . . ,l104 (c) Failure to Follow Plan'and" s . N '
Procedures in Dealing with. ,h I the News Media. . . . ., :. . . ,. . I* 4111 (d) Other Examples of LILCO's ' .
Failure to Train Personnel I !
in How to Follow and Implement the Plan and
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Procedures. . . . . . . . 114
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- 3. LILCO Has Not Corrected its Failure ; J 3 to Train its Personnel in Basic '
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Knowledge Necessary to Implement the +
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Plan and Procedures. . . . . . . . ., . -f,118 $
.y C. Contention Ex 50.C: The Exercise Resul'ts 'A ?
Demonstrate that LILCO Has Failed to Teach \
. 4 1 Personnel to Communicate Effectively. . . . 125 I 1\ 2,,
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- 1. Examples of Lack of Communication d Training Which Were Reflected in - s ?' [ i' p the Exercise Results . . . . . . . . . 126
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, t . 2. The Communications Deficiencies Which'Were Demonstrated During s the Exercise a're Significant . . . . . 135
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! 3. ;LILCO's Communications Training
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,' Program Has N<3t Been Fixed .
. . . . . 138
_f o D. Cbdientien Ex 50.D: Training to Follow g^ Directions of" Superiors . . . . . . . . . . 148
'l E.. Centention Ex 50,E: LILCO Has Failed to' Train Personnel to Exercise Good Judgment and Use Common Sense . . . . . . . 150
. 1. Examplesiof LILCO's Traini~ng J. Failurer. . . . . . . . . . . . . . . . 151 t ,
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i 2, The Importance of Training Personnel to Exercise Good Judgment &nd to Use Common Sense . . . ... . . . . . . 159
- 3. 'The Pok!} Exercise Drills Support th'e Allegat. ions of Subpart E . . . . . . . 161 3 F. Contention Ex 50.F: LILCO Has Failed to
- ? 1 Train' Personnel to Deal Effectively with s
4 , ,
the Medir alid the Public. . . . . . . . . .
166 4 1. Examples of LILCO's Failure to Train Personnel to Deal with the Media . . . 167 3's .
( 2. LILCO's Failure to Provide Effective Media Training 'j s Significant. . . . . 170
- 3. The Post-Exercice Drills Do Not Solve LILCO's Training Problems. . . . 18S G. Contentions Ex 50.G and H: Training for-
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Persons and Organizations Relied Upon by LILCO'and Training in Exposure Control . 186
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- 1. Subpart G. . . . . . . . . . . . . . . 187 ,
- 2. Subpart H. . . . . . . . . . . . . . . . 191
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H. Contentions Ex 50.I: LILCO's Modificati.ons to Its Training Program are Ineffective . . 196 i l
- 1. LILCO's Proposed Training Changes ;
Represent No Real Change . . . . . . . 196 (
- 2. LILCO's Organizational Structure Will j Make It Difficult for LILCO to 1 Successfully Train Its Personnel . . . 200 !
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IV. CONCLUSION . . . . . . . . . . . . . . . . . . . 218 l I
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Ma'rch 20, 198'/ )
UNITED STATES OF AMERICA l l
NUCLEAR REGULATORY COMMISSION Before the Atomic Safety and Licensina Board j
)
In the Matter of ) )
)
i LONG ISLAND LIGHTING COMPANY ) Docket No. 50-322-OL-5 l ) (EP Exercise)
(Shoreham Nuclear Power Station, )
Unit 1) ) !
) l I
DIRECT TESTIMONY OF WILLIAM LEE COLWELL, DEPUTY INSPECTOR PETER F. COSGROVE, PHILIP EVANS, CHARLES B. PERROW, FORD ROWAN, ,
l LIEUTENANT JOHN W. STREETER, JR., AND HAROLD RICHARD ZOOK l ON BEHALF OF SUFFOLK COUNTY REGARDING CONTENTION EX 50 --
l TRAINING OF OFFSITE EMERGENCY RESPONSE PERSONNEL l
I. INTRODUCTION l A. Identification of Witnesses l l l
1 Q. Please state your names and occupations. !
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i A. My name is William Lee Colwell. I am an Associate Professor in the Criminal Justice Department, University of l Arkansas at Little Rock. Prior to joining the faculty at the l University of Arkansas at Little Rock, I was the Associate Director and Chief Executive Officer of the Federal Bureau of Investigation (" FBI"), a position widely regarded as the senior law enforcement position in the country.
My name is Peter F. Cosgrove. I am the Commanding Officer of the Personnel Bureau, Headquarters Division, County of Suffolk Police Department. I hold the rank of Deouty Inspector in the Police Department.
My name is Philip Evans. A statement regarding my quali-fications is included in the testimony I submitted on March 13, 1987 on Contentions Ex 38, 39, 22.F, 44, 40.C and 49.C (hereafter the " Contention Ex 38/39 Testimony").
My name is Charles B. Perrow. I am a teacher by profession, having taught classes at all levels in a university setting for 27 years. Since 1981, I have been a Professor in the Department of Sociology at Yale University. My teaching interests include, among others, complex organizations, industrial society, technology and social change, social movements, research design and sociological theory.
My name is Ford Rowan. A statement regarding my qualifica-tions is included in the Contention Ex 38/39 Testimony.
My name is John W. Streeter, Jr. I am the Executive Officer of the Suffolk County Police Academy, County of Suffolk Police Department. I hold the rank of Lieutenant in the Police l l
Department.
My name is Harold Richard Zook. Since my retirement last j year as the Deputy Director of the Standards Division, State of l
Arkansas Commission on Law Enforcement Standards and Training, I have served as a consultant in the areas of law enforcement administration, management, and training. Of these three arease I remain most involved with training, serving as a coordinator for and consulting with training programs at the local, national and international levels of the criminal justice system.
Q. Please summarize your current duties and responsibi-lities and briefly explain your professional qualifications and backgrounds.
A. (Colwell) As an Associate Professor at the University of Arkansas at Little Rock, I teach a number of courses in the University's Criminal Justice Department. I am also a member of the University's International Studies Faculty, and I am an Adjunct Professor at the University of Virginia in connection with the FBI's Training Academy in Quantico, Virginia, where I sometimes serve as a guest lecturer. From 1980 through 1985, I was also an Adjunct Professor at the University of Southern California Washington Public Affairs Center, where I lectured and provided consulting services on a variety of public administration topics.
1 Prior to my present teaching position at the University of Arkansas at Little Rock, I was the Associate Director and Chief Executive Officer of the FBI, a position which frequently required.me to serve as the Bureau's Acting Director. As Chief Executive Officer of the~ FBI, I'had direct responsibility for a budget in excess of one billion dollars (of which approximately 13 percent was dedicated to training at not only the federal level, but also'for state and local law enforcement agencies),
the direction of policy review and analysis, budget formulation and implementation, and allocation of FBI resources and oversight of all administrative investigative operations involving 20,000 employees in the approximately 520 offices in this country (including 59 field offices) and 14 foreign posts. I was also responsible for program evaluation, long-range planning, and review of personnel actions. I oversaw FBI public affairs and congressional liaison functions, frequently testified before Congress, and consulted with cabinet-level officers, officials in the White House, governors, state legislators, prosecutors, attorney generals, chiefs of police, training directors at both l 4
t the state and federal levels, and foreign government representa-tives. In addition, I acted as one of the FBI's chief repre-sentatives in dealing with the media, over 16,000 law enforcement agencies, independent agencies, inspector generals, over 700 citizen interest groups, 13,000 local governments, tens of thousands of private organizations, thousands of corporations,
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and members of the federal and state judiciaries. I was actively involved in the general supervision at a national level of all criminal and intelligence investigations.
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My duties and responsibilities as Chief Executive Officer of the FBI also included responsibility for ensuring that the Bureau's training programs, which involved over 475,000 police 1
officers around the country, were effective. I was responsible j for reviewing the activities of the FBI to ensure that it operated in an effective manner and that its conduct, and that of its employees, was under the rule of law and in accord with the l
I made recommendations to rules and regulations of the Bureau.
l the U.S. Department of Justice, including directly to the Attorney General of the United States. Other responsibilities included internal audits, evaluations, personnel recruiting, promotions, transfers, and disciplinary matters. Finally, I was the Director's personal representative in ensuring that the FBI was an effective organization in meeting the high expectations of the President, the Attorney General, members of Congress, the i
judiciary, the media, and, equally important, the citizens of this country.
l Prior to serving as the Associate Director and Chief Execu-tive Officer of the FBI, I held virtually every investigative and management position in the Bureau during my approximately 26-year FBI career. These positions included the position of Executive
l Assistant Director for both Investigations and Administration. I l
helped develop ~the FBI's National Emergency Operations. Center located in the FBI's Headquarters, with links to the White-House, j the' Department of Justice, the Department of Energy, the Depart-ment of Defense, all FBI field offices, and other local, state and federal agencies. I was one of the five original evaluators for the FBI's Personnel Assessment Center, which conducts reviews of the leadership capabilities of candidates for supervisory positions within the Dureau. I am a graduate of the FBI's Senior Executive Program and National Executive Institute.
During the last 15 years of my tenure with the FBI, I was specifically involved with the training and the evaluation of personnel. For much of this time, I served as an instructor and lecturer at the FBI's Training Academy'in Quantico, Virginia; I also participated in the planning, development and preparation of l courses sponsored by the Academy, and served as an evaluator of new agents attending the Academy. In addition to acti've i
involvement in the classroom portions of FBI training, I also helped to design, implement and evaluate drills and exercises in connection with the FBI training program. I also was involved in the evaluation of training programs which included, among others, participation by FEMA. I have been certified by the Arkansas Law.
Enforcement Training Academy as an instructor.
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I During the past 18 months, in addition to my position with the University of Arkansas at Little Rock, I have served as a consultant to numerous representatives of city, county and state ;
governments on issues concerning the effectiveness of police services, including training, in the State of Arkansas. I have also consulted with federal and foreign government agencies, lectured abroad, and conducted evaluations of existing as well as proposed training programs. The statement of my qualifications and experience attached to this testimony as Attachment 1 summarizes my other qualifications and experience. l i
(Deputy Inspector Cosgrove) I am presently the Commanding Officer of the Suffolk County Police Department's Personnel Bureau. Prior to my appointment to this position, I was a Deputy l Inspector assigned to the position of Executive Officer of the Department's Third Precinct, where my duties were to assist the Precinct Commander in exercising line and staff command over all personnel and operations in the Precinct.1 I was also a former Commanding Officer of the Suffolk County Police Academy, which provides a broad range of training to 22 police agencies, as well j as several related law enforcement agencies. Included among the training programs offered by the Polic'e Academy are New York State certified courses in criminal investigation, instructor 1 There are six Precinct Commands within the Suffolk County i Police Department. For an explanation of the general organiza-tion and structure of the Department, see the Testimony of Assistant Chief Inspector Richard C. Roberts et al. on Behalf of Suffolk County Regarding Contention EX 40 (Feb. 27, 1987) at 7-8 and Attachment 5 thereto.
I development, radar operations, firearms training, and emergency vehicle operation. The Police Academy also offers New York State certified programs in basic police training, supervisory training and in-service training. These programs include, among other things, training in the subject areas of traffic direction and control, command and control, responding to emergency situations, community relations and crowd control, radio usage, and first aid. The Police Academy conducts a wide variety of drills and exercises designed to ensure the emergency response capabilities of police personnel. I have been involved in the design, imple-mentation and evaluation of these drills and exercises. I have continued to serve as a lecturer at the Police Academy since leaving the command of that facility. In fact, I have now been a lecturer at the Academy for about 15 years.
I have been employed by the Suffolk County Police Department since May, 1966. From February 1979 to October 1981, I was the Commanding Officer of the Department's Personnel Section respon-sible for, among other things, recruitment and selection, job descriptions and affirmative action. As previously noted, even before assuming command of the Suffolk County Police Acade.ny, I had had a long association with the Academy. From December, 1972 until September, 1975, while holding the rank of Sergeant, I was assigned to the Police Academy's Basic Recruit Training Program.
Thereafter, I continued to lecture at the Academy until October, 1981, when I became the Academy's Commanding Officer. I remained
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l the Commanding Officer of the Academy until January 15, 1984.
During that time, I had general administrative responsibility for the operations of that facility and directed 33 full-time trainers. I also gave final approval to 11 curricula, certified satisfactory completion of courses to the State of New York, determined training needs, and ensured that all training programs met their objectives.
I have been certified by the New York State Bureau for l
Municipal Police as a Police Instructor, and since Septemoer, l
1972, I have been an Adjunct Assistant Professor of Criminal Justice at Suffolk County Community College. I have conducted training classes for the Suffolk County Sheriff's Department, the Suffolk County Health Department and the Suffolk County Department of Social Services on the subject of interaction with members of the public. I have also conducted police training classes for the New York State Bureau for Municipal Police, the City of Kingston Police Department, the City of Yonkers Police Department, the Westchester County Sheriff's Office and the City of Syracuse Police Department.
I was at one time one of 13 New York Training Zone Coordina-tors responsible for Nassau and Suffolk Counties. I was formerly l
a member of the Training Committee of the New York State Associ-I l
ation of Chiefs of Police and served as a resource for questions to be used in police promotion examination by the New York State
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r Civil Service Commission. The statement of my qualifications and experience attached to this testimony as Attachment 2 1
summarizes my other qualifications and experience.
1 (Evans) I will not repeat the statements made in my I Contention Ex 38/39 Testimony. My professional qualifications are Attachment 2 to'that testimony. I will add, however, some brief comments regarding my experience related to training.
In more than 20 years as a senior executive of major newspapers, I have had extensive experience in the training of personnel. This has included responsibility for and l administration of intern programs for college students interected in careers in journalism, training programs in the various printing crafta (typography, press, pre press), and training programs for advertising sales people, and circulation department managers.
In a less formalized sense, I have had responsibility for career development of large numbers of employees who were working under my direction (400 at the Philadelphia Bulletin, 350 at the Washinaton Star, 700 at the Washincton Times). It was my responsibility to ensure that they were being given appropriate direction, guidance and, where necessary, counseling to enable them to perform their jobs satisfactorily and to advance in their
careers. In that regard, I had to review on at least an annual basis formal evaluations of each employee's progress and, where appropriate, to recommend special remedial training.
l u I (Dr. Perrow) I am a Professor of Sociology at Yale University, where I have taught since 1981. Before that time, I was: a Fellow at the Center of Advanced Study in the Behavioral Sciences in Palo Alto, California; a Visiting Professor at the London Graduate School of Business; a Professor of Sociology at the State University of New York at Stony Brook; a Visiting Professor at the Institute of Industrial Relations and School of Business Administration at the University of California, Berke 3ey; and a Professor of Sociology at the University of Wisconsin.2 During my teaching career, I have conducted research and written extensively on complex organizations, industrial society, high risk technologies, organizational dynamics and effective-ness, and technology and social change. In addition to my work in these areas, my research and writing have focused, among other things, on the characteristics of organizational design and behavior. My writings have appeared in such journals as the Harvard Business Review, the American Journal of Socioloav, Organizational Dynamics, the Administrative Science Ouarterly, 2
This list of teaching jobs goes back to the late-1960's; altogether, I have been teaching since 1959, when I was an instructor in the Department of Sociology at the University of Michigan.
l and the New York University Education Ouarterly. In addition, I j have published several books and monographs and my book, Normal Accidents: Livina with Hich Risk Technologies, was awarded the George R. Terry Book Award of the Academy of Management in 1985.
l A further statement of my qualifications, experience and professional background is attached to this testimony as !
Attachment 3.
l (Rowan) I wi31 not repeat the stattmants made in my Contention Ex 38/39 Testimony. My professional qualifications are Attachment 1 to that testimony. I do add the following, however, regarding my experience in training matters.
In addition to other services, I have provided training services for more than a dozen corporate clients and for several government agencies. This work has included helping organizations to plan and train for emergencies and how to respond to actual crises.
l In addition, I have conducted more than 100 training sessions for executives in the past two years to help them improve communications skills. Almost all of these sessions have
! had four goals: (1) to help personnel communicate more l
effectively in crisis situations; (2) to help personnel communicate more effectively through the mass media; (3) to help personnel communicate more effectively regarding risk and 1
1 regulatory policy; and (4) to help personnel communicate more effectively with the general public and with politicians, workers, customers, plant neighbors and other relevant groups.
I My firm has also developed crisis communications training l
l programs for major chemical and manufacturing companies. The programs include sessions on (1) mitigation, (2) preparation, (3) lesponse, (4) recovery, and (5) research. Crisis communic-ations workshops and drills, which I have conducted, cover both internal and external communications. The advanced training programs feature simulations of emergencies, We utilize several methodologies:
The case method of examining real cricis situations, including videotaped examples.
Gaming, by using hypothetical scenarios and watching how managers grap ~e with realistic situations.
Feedback, which encourages individual managers to critique their own performances on videotape.
Group interaction, during which responses are examined and various approaches evaluated.
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Instruction, using lecture, graphics and printed i
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1 Socratic method of gaestioning and challenging I assumptions through dialogue and debate. j l
(Lieutenant Streeter) My career in law enforcement covers more than 22 years, with approximately 20 years of that time as a member'of the Suffolk County Police Department. For the last 10 l
years, I have been assigned to the Suffolk County Police Academy, l where I have worked as a supervisor and manager of training. I am a New York State certified police instructor and a graduate of
( the FBI's Training Academy in Quantico, Virginia. I also bold a !
l graduate degree in political science and undergraduate degrees in behavioral science and criminal justice. I l
l From 1978 through 1984, I was the Commanding Officer of the Police Academy's Decentralized Individualized In-Service Training Program. In that position, I developed, administered and evalu-ated training needs, analyses, and training evaluation instru-ments. I was also responsible for administering and evaluating instructional television programs for local, county, state and l federal law enforcement agencies within Suffolk County. There-1 l after, until 1986, I was the Commanding Officer of the Police i
l Academy's In-Service Training prcgram. In that position, I had 1
responsibility, among other things, for directing the research, t
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development, administration and evaluation of the Police Depart-ment's in-service training program for local, county, state and federal law enforcement agencies within Suffolk County. I was also the primary instructor for the Department's " critical incidents response" training,3 and I assessed training needs, evaluated training, and was the training coordinator for the Department's Hostage Negotiations and Emergency Services units.
Since 1986, I have been the Executive Officer at the Police Academy., In this position, I supervise the planning and execu-tion of instruction given to entry level personnel (recruits),
including but not limited to, instruction in the areas of traffic control, crowd control, radio usage, first aid, and instruction designed to prepare the trainee to respond effectively in danger-ous and stress-filled situations. In addition to supervising the training of recruits, I Oversee the evaluation of students' performance after training, and I continue to be responsible for 3
The Academy's critical incidents response training con-stitutes an intense and realistic drill / exercise program by which -
trainees are required, on a real-time basis, to respond to hypo-thetical emergency situations, particularly with scenarios involving unforeseen difficulties. This training emphasizes not on2y whether trainees know the procedures for response (i.e.,
where to go, who to talk to, what to do), but also whether they in fact can perform as required. For instance, when a hazardous waste spill was simulated in one recent training sessien, the practice included all steps short of actually cleaning up the spill. Officers were required to get to the accident, set up restricted areas, reroute traffic, and do everything else necessary to deal with the incident and its ramifications. All this was done via use of detailed mock-ups of actual streets, buildings, etc., in Suffo2k County. It is the kind of realistic "doing by learning" training which is discussed in greater detail later in this testimony and which I find largely lacking in LERO's training program.
i directing the research, development, production, administration l and evaluation of instructional television programs for recruits and continuous (in-service) training programs within the Acadenty and Suffolk County. I continue to be the primary instructor for critical incidents response training for recruits, in-service and supervisory police personnel. I also assess training needs and f
evaluate the training of new instructors. During 1986, my work at the Police Academy, specifically in developing an instruction methodology for the critical incidents response training, earned ;
me the Department's Meritorious Service Award.
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l In the course of my work at the Police Academy, I have been actively involved in the development, implementation and evalua-tion of drilis and exercises designed to train personnel and to test the effectiveness of personnel training. At the Academy we have structured rigorous criteria for evaluation of performance in drills and exercises and consider deficient performance in drills and exercises to reflect either a failure of individuals to have the capability to meet our standards or, more likely given pre-drill / exercise selection, a deficiency in the training programs due to failure to teach personnel how to respond appropriately. A further statement of my qualifications and experience is attached to this testimony as Attachment 4.
(Zook) After approximately 37 years in law enforcement, I have recently retired. Since my retirement, I have served as a consultant in matters involving law enforcement administration, management and training. I have also remained active as a local, national and international criminal justice coordinator.
Attachment 5 to this testimony summarizes my qualifications,
'aackground and experience. Briefly stated, my career in law enforcement began in 1949, when I joined the Little Rock, Arkansas, Police Department. Twelve of my 22 years with the Little Rock Police DepartmenP were devoted to designing and developing a training program for the Department,. and then serving as a training officer and eventually exercising command over, the Little Rock Police Academy. I retired from the Little Rock Police Department in 1971 as a Captain and the Commanding Officer of the Police Academy.
Following my retirement, I accepted an appointment with the United States Veterans Administration as a Regional Security Officer supervising approximately 500 Veterans Administration police officers in 17 states and the Commonwealth of Puerto Rico.
In addi't ion, I was assigned the job of developing and implement-ing a National Police Training Center for Veterans Administration police personnel. After that job was performed, I became the Chief of the Veterans Administration Police Training Center, where I remained until 1978, when medical reasons forced me to
resign. Today, the Veterans Administration Police Training Center provides law enforcement training to approximately 2,000 police personnel stationed in all Veterans Administration health care facilities, wherever located.
In 1980, at tne request of officials from the State of Arkansas, I accepted the position of Executive Director of the State Commission on Law Enforcement Standards and Training. In that position, I was responsible for regulating and approving all h
law enforcement training which was conducted in the State of Arkansas. I also had responsibility for establishing procedures and standardi for certifying the levels of proficiency for
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approximately 7,000 state, county and municipal police officers.
During my tenure as Executive Director and later as tne Deputy Director of the Standards Division of the Commission,4 I became a member of the National Association of State Directors of Law Enforcement Training ("NASDLET"). NASDLET membership consists of the State Director of Law Enforcement Training or his designee from each of the 50 states. The 50 members of NASDLET have authority to regulate and control all employment, training and certification or licensing of state, county and municipal law 4
During 1981, the operations of the State Commission on Law Enforcement Standards and the Arkansas Law Enforcement Training Academy were consolidated. Although I was offered the position ,
I of Director of the new Commission, I declined the offer because of my desire to remain in Little Rock, rather than ralocating. I was then appointed the Deputy Director for the Standards Division of the Commission.
l enforcement officers in the United States (approximately 500,000 I
officers). In 1982, I was elected to NASDLET's Executive Board and, in 1985, I was elected President of the Association. ,
In 1986, medical reasons required me to resign from my position as Deputy Director of the Arkansas Commission on Law Enforcement Standards and Training. Since my retir'ement I have remained active, however, in the areas of law enforcement training and standards. For example, I am currently serving as training coordinator and instructor for the United States Department of State, Office of Counter Terrorism, in the areas l
including VIP security, K-9 operations, and SWAT operations. j l
Training is provided to foreign law enforcement executives and operational personnel and, in tliat regard, is similar to training l that I am providing at the request of the United States l
l Department of Transportation Safety Institute to foreign law enforcement officers. I have also recently traveled to the Peoples Republic of China as a member of the United States Police t
Training delegation, to participate in a technical exchange of information and training techniques with Chinese police officers from the Ministry of Police Security.
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E---------___ - - - - - - _ - - - - - - - - - - - - - - - - - - - . - - - - - - - -
Q: Do you jointly sponsor this testimony?
A: Yes. Nonetheless, in a number of instances, we indicate the primary author or sponsor. Where no primary sponsor is noted, the portion represents a joint effort by the witnesses, although, even then, particular individuals on the panel may be more familiar with particular matters than other persons.
Messrs. Evans and Rowan contributed primarily to the Summary of Conclusions, the discussion in response to subpart F of Contention Ex 50, and other instances where media-related examples are discussed.
B. Familiarity with LILCO's Plan Q. Are you familiar with LILC0's offsite emergency response plan (" Plan") for Shoreham?
A. Yes. Deputy Inspector Cosgrove, in fact, has pre-viously testified before the Licensing Board which had jurisdic-tion over offsite emergency planning issues for Shoreham. In that testimony, Deputy Inspectcr Cosgrove, and others, provided their opinions about and questioned various aspects of LILCO's Plan.5 5
The prior testimony covered such matters as LILCO's provi-sions for training non-LILCO personnel (Contentions 24.S and 98);
LILCO's assertion that its training program could compensate for the lack of emergency preparedness and response experience among LILCO's personnel (Contentions 40, 44.E, 44.P, 99 and 100), and (footnote continued)
l l
1 Since Deputy Inspector Cosgrove's earlier testimony in 1984, LILCO has changed certain aspects of its Plan and implementing l procedures (sometimes referred to hereafter as "OPIPs").
Furthermore, LILCO has provided additional training to its
( personnel relied upon to implement the LILCO Plan. We have l
I reviewed changes in LILCO's Plan which relate to LILCO's training .
l program. We have also reviewed those LILCO documents related to training provided to the Governments by LILCO.6 Furthermore, we have attempted to gain an understanding of the events which took I place during the February 13, 1986, exercise of LILCO's Plan (the
" Exercise"), so that we could reach conclusions regarding how the Exercise results related to the adequacy of LILCO's training 1
program. Thus, for example, we have reviewed the conclusions and 1
findings of FEMA, which are based upon its observations and I evaluations during the Exercise, as set forth in the Post-Exercise Assessment Report (what we call the " FEMA Report"), and have also reviewed drill reports covering LILCO personnel which have been prepared since the Exercise.
(footnote continued from previous page) provide proper instruction in the use of emergency equipment (Contentions 41 and 44.D); and LILCO's proposal for dealing with attrition (Contention 39). See Cosgrove and Fakler, ff. Tr. 8407 (Contention 24.S); Cosgrove et al., ff. Tr. 13,083 (Contentions 39-41, 44 and 98-100); Cosgrove et al. (Supp.), ff. Tr. 13,083.
6 It is our understanding that LILCO refused during discovery to provide training documents that were used by LILCO prior to the February 13, 1986, Exercise. Thus, our review of LILCO's training documents has of necessity been' limited primarily to those post-Exercise documents provided to the Governments by LILCO.
0 As background for later discussions, please briefly describe the overall structure of LILCO's training program for offsite emergency response personnel.
A. (Cosgrove, Streeter) It is our understanding that the LILCO training program has three primary phases: classroom presentations; drills / tabletop sessions; and' exercises. Plan at 5.1-2. First, information regarding the LILCO Plan and the tasks expected to be performed by LILCO and non-LILCO personnel relied upon by LILCO in the event of a Shoreham emergency is presented to trainees in a classroom setting through videotape presentations, workbook materials and, in some instances, instructor discussions and demonstrations. According to the Plan, this portion of the LILCO training program is designed to provide personnel with an understanding of:
General emergency planning overview, including the emergency classification system and the history of emergency preparedness since Three Mile Island; Shoreham specific overview; Radiation protection, including basic principals of radiation, health effects and exposure control; and Specific organizational tasks under LILCO's Plan.
Plan at 5.1-2.7 7 LILCO divides its classroom training sessions into two segments. The first segment consists of information which LILCO considers important for all its offsite emergency response personnel. Thus, all LILCO personnel must attend the following training sessions or modules:
(footnote continued)
L The second phase of LILCO's training program consists of drills and tabletop sessions. During this phase, personnel discuss the concepts covered in the classroom sessions. As we understand LILCO's program, the purpose of these drills / tabletops may vary, depending upon the level of training that has been provided, the degree of difficulty of a given task, and so l
l forth.8 During drills or tabletops that occur'early in LILCO's
~
l (footnote continued from previous page) l -
General Emergency Planning Overview j Site Specific Overview Radiation Protection Notification and Mobilization Communications Personnel Dosimetry :
Personnel Radiological Monitoring
)
Plan at 5.1-3 thru 5.1-4 and Fig. 5.1.1.
The second segment is intended to provide job-specific l training to LILCO's personnel. The subjects covered include: )
EOC Activation Public Notification Methods and Procedures Reception Center Operations Personnel Monitoring and Decontamination Contaminated / Injured Persons 1 Traffic Control Operations (including Traffic !
Control Points, Road Logistics and Route !
Coordination) 1 Protective Actions for Special Populations Transportation Operations Sociological Aspects of an Evacuation :
Security Operations Command and Control Public Information (including rumor control)
Administration l Plan at 5.1-5. Seg also Fig. 5.1.1 of the LILCO Plan, which identifies the LILCO and non-LILCO personnel who are supposed to attend particular sessions or modules.
8 LILCO requires its personnel, but not non-LILCO personnel, to participate in drills and tabletop sessions on an annual (footnote continued) l
training process, for example, LILCO observers critique trainees as they go through the drill / tabletop sessions to correct inappropriate actions or to reinforce appropriate performance.
Later on, the same trainees may go through essentially the same drill or tabletop, but in this instance LILCO controllers and observers would record their comments rather than commenting upon performance during the drill / tabletop. See Plan 5.1-2, 5.2-1 thru 5.2-6.9 We understand that LILCO conducted a large number of these drills / tabletops during November 1985-February 1986 as part of the training / preparation for the Exercise. Egg Deposition of Jay Richard Kessler (February 2, 1987) at 14; Deposition of Brian R. McCaffrey (January 7, 1987) at 24-25; Deposition of Elaine D. Robinson (January 7, 1987) at 12; Deposition of Richard J. Watts (December 3, 1986) at 20-21, 23-24.
(footnote continued from previous page) basis. Plan at 5.1-8. According to LILCO, " drills" are j
" supervised instruction periods designed to test, develop and maintain skills in a particular response function" or "to provide l maintenance checks of emergency response equipment." Plan at 5.2-2. Under LILCO's program, drills are often components of LILCO-conducted exercises, which LILCO defines as events which
" test [ ] the integrated capability and a major portion of the !
basic elements" existing within the LILCO offsite emergency l response organization (the so-called "LERO" organization). Plan j at 5.2-6. )
9 LILCO drills are evaluated by LILCO-designated observers 1 (g2g., personnel from Impell Corporation, a long-time LILCO ]
consultant and contractor). Tabletop sessions, on the other hand, are generally conducted and " evaluated" by LILCO personnel.
These tabletop sessions, according to LILCO, are conducted in a seminar type setting. They are used by LILCO to provide
! information to the participants about LILCO's procedures and l modifications to the Plan and procedures. Plan at 5.2-3.
w_____-__-____-__-__-____-________-_____ _ _ _ _ _ _ _ - _ _ . _ _ _ _ _ __ -__________-_-_-_____:
[6, t i The final phase of LILCO's training program consists of '
p specific preparation for a FEMA-graded exercise and the FEMA j jl
\
exercise itself. In preparing for an exercise, LILCO's Plan calls for the conduct of full-scale LILCO drills / exercises, or dress rehearsals, "as appropriate to meet the need(s) of [LILCO]
in preparation for the graded exercise." Plan at 5.1-3. In this regard, we understand that during the two months prior to the February 13 Exercise, LILCO personnel participated in at least three full-scale dress rehearsal drills. Sgg deposition of Dennis N. Behr (January 13, 1987), at 1.'7-19.10 4 k'
C. Purpose of Trainina
,i Q. To provide perspective and background for your testimony, based on your experience, please explain the purposh of a training program.
l A. A successful response to any complex emergency situation requires an organization to work in an integrated manner. That is, the individuals who comprise the organization
~~~
10 These pre Exercise dress rehearsals were conducted in December, 1985, and late-January 1986. Those LILCO personnel i chosen by LILCO to participate in the February 13 Exercise par-!
ticipated in these LILCO dress rehearsals, which in many respects were similar in scope to the February 13 Exercise. The only practical differences were that during the dress rehearsals, LILCO's personnel were not mobilized from their homes, there were I no simulated traffic impediments of the scale that were inter-jected by FEMA during the Exercise, and there apparently was no wind shift. Deposition of Dennis N. Behr (January 13, 1987), at 235-38.
l
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t ,' ,-
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must work individually and together in an efficient and effective manner in confronting both the routine (expt _cted) and nonroutine 4 (unexpected) demands which may arise during the response to the 4 emergency. " Training" is the process by which an organization .'I L,*.
- /
l and its constituent members learn to work individually and ..: 4 1
together to perform routine and non-routine tasks.
g l
%4 ,.
As hinted to above, " training" for organizations responding 0
'f, b ,
- *T to a nuclear emergency includes an element which goes beyond the . .
training required for some other organizations. Any organization 9
must train to perform routine tasks -- those tasks which are ,,
w <.
foreseeable, repetitive, and which should be easily understood. .U Under the LILCO Plan, there are some tasks which seemingly would fall within the definition of routine tasks, such as the physical
'()
ability to drive a bus, how to check a dosimeter, and how to make telephone calls. In an emergency situation, however, the training must also prepare personnel for the nonroutine or the 4 I "
unexpected -- for instance, the ability to respond to
'.9,'
unanticipated road impediments, or the ability to deal with .
unexpected questions or complications learned about during ~
~
" routine" telephone calls. .
- l. -
(Perrow) Routines, or repetitive events, are the fundamental -
- 4, 4 o condition for having organizations.ll (>r ganizations are set up ,.
'/
11 (Perrow) This was the message of-the first great organ-
- .s izational theorist, Max Weber, writing in the early part of this century. It is accepted by the leading schools of thought, ,
(footnote continued) -
4 y: g N 'hE, .
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4 1
%4 1
because enough things have to be done over and over again that it
)s efficient to have specialized roles, people doing things that i,
they can learn to do through training and repeated experience, Thus, training mirrors the essence of organizations -- their routineness. Routines require training and experience.
l
[
t It must be empbarcised, however, that under the LILCO Plan for Shoreham, far ro~te is involved than just the performance of routine activitias. Rather, the anticipated response to a nuclear plant emergency must involve, of necessity, training in the routine perfctmance of unexpected tasks -- that is, it must become " routine" for LLRO/LILCO personnel to perform as necessary to deal with unexpected or non-routine events.
(footnote continued from previous page) including the bureaucratic " revisionist" theory of Stanford's James March, the most influential living organizational theorist, strongly emphasized in the evolutionary theory of organizations by economists Richard Nelson of Columbia and Sidney Winter of Yale's School of Organization and Management, and also utilized as the basis of my own work. Seg Max Weber, Economy and Society, ed. Guenther Roth and Claus Wittich, New York: 1rvington Publications, 1968, vol. 1, pp. 215-225; vol. 3 pp. 956-1001; Richard Cyert and James March, A Behavioral Theory of the Firm, Eng3ewoods Cliffs, N.J.: Prentice-Hall, 1963; Richard Nelson and Sidney Winter, An Evolutionary Theory of Economic Chance, Boston:
Belknap Press, 1982, chapter 5, e.o., " Organizations remember by doino" (pg. 99); Charles Perrow, Complex Organizations: A Critical Essay, 3rd edition, New York: Random House, 1985, especially chapter 1.
)
Q. How is training accomplished?
j l
A. Training is accomplished at two levels: basic training I (such as classroom instruction); and " learning by doing."
" Learning by doing" includes: training gained through experience (this may be called repertoire adjustment); training gained by learning to interact with others and respond to particular events; and training through drills and exercises. Part of the
" learning by doing" training also comes as a result of an organization and its members actually responding to the kinds of
]
real life events for which it is trained.12 Q. Does LILCO's training program involve elements of basic )
training as well as learning by doing training?
l l 1 l
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1 i
l 12 The final element of effective training -- performance of emergency duties under real life conditions -- is necessarily the most effective training that personc can receive. It is the :
essence of " learning by doing." LERO personnel can reasonably be I expected to receive no such training, because they have not actually been called upon to respond to any nuclear emergencies and because LERO's members (unlike other persons such as policemen or firemen) do not as part of their regular day-to-day activities have occasion to perform together in other emergency situations from which important experience may be gained.
Accordingly, the trainin', testimony presented herein will focus on the other training elements which LERO personnel may be l expected to receive.
A. Yes, at least in theory, LILCO's training program does involve each kind of training (except for response to actual nuclear emergencies). But as will be discussed later, the Exercise revealed flaws in both LILCO's basic training and its learning by doing training.
Q. Please explain in greater detail what those levels of training are.
A. To learn to do predictable, repetitive events, one needs training. Some of this is very basic training, that can be done in a classroom with an instructor or a training film. This is the lowest training hurdle for LERO to clear: basic training, which involves little or no interaction with other persons.
Basic training for LERO would involve such things as how to operate a dosimeter, how to keep records of messages and phone calls, und so on. Since basic training involves the most basic tasks, one would expect in a good training program to find the fewest problems with training at this level.
Conversely, if one finds problems in the implementation of basic training, one almost surely will thereafter find problems with the other essential levels of training. This is because those other training levels depend in the first instance on a person's mastery of the relatively routine and nechanical subjects taught during effective basic training, particularly
because during an actual emergency, personnel have little time to think about performance of roctine matters -- this should be second nature so that attention can be devoted to the non-routine. If the basic training is not well understood, however, then a responder must devote attention to that, necessarily leaving less attention to the non-routine matters.
The next levels of training are necessary because members of organizations must be able to interact with each other and persons outside the organization, to deal with unusual events, and to perform necessary tasks that require communication, coordination, and cooperation. Very little in organizations is static, unchanging, purely predictable, and solely within the control of a single individual. This is particularly true of an organization like LERO, whose role purpose is to respond to a novel emergency incident, as to which neither it, nor the other entities and individuals with which LERO must interact, have any actual experience.
All organizations confront exceptional events and problems that are not wholly routine. Organizational leaders know this; in fact, one of the jobs of a leader is to anticipate exceptions to the routines, and to design ways to respond to those exceptions which can be roughly predicted. And for situations
that cannot be roughly predicted, a good training program will teach personnel the skills necessary for them to improvise and plan / respond during an emergency'in an appropriate manner.
As noted above, learning by doing' training can be I
convenier.tly divided into three components. First, most exceptions to the routine or new situations, are handled by l incremental adjustments to routine procedures, which are slightly j modified in the process. This may be called " repertoire adjustment," and involves the training gained through experience.13 Second, more serious excer' ions, changes, and f disturbances that are expected to occur,-are handled by more advanced training. After the basic training is over, personnel 1
continue with training, but now it focuses more upon the unusual l events and human interactions that might take place, the problems that can't be readily solved by acting alone but might need the cooperation of others, or training in new equipment, or in a new organizational structure or set up. For example, if a new position of Traffic Engineer is created, mere classroom training will not suffice to integrate that individual into the LERO structure. Rather, there will be a need to educate the person and others with whom he or she must interact regarding the new 13 Experience broadens to include knnuledge of the random variations that can be expected, the f a f' ures in some part of the system or its environment that can be e.g>ected, and the efficacy of a variety of adjustments.- Doing a variety of tasks under a variety of changing circumstances enlarges the repertoire of
~
personnel that is available for the next novel event. In this way, assuming a sound program to beg'n with, learning by experience should occur.
structure and the possible interactions resulting therefrom.
Third, learning to deal with the most serious anticipated l
exceptions takes place in exercises, or drills, where more complex exceptions are simulated as in free play messages, or allowed to occur naturally.14 Q. Are there any common elements among repertoire adjustment, advanced training, and drills and exercises?
A. (Perrow) Yes. All three modes of coping with exceptions to the routine depend upon "doing" for their effectiveness. In fact, Richard Nelson and Sidney Winter 1
emphasize that, in their words, organizations learn by doina.15 14 A drill or exercise constitutes an important mechanism to test whether the constituent elements of an organization, i.e.,
its members, have.the capability to implement that organization's plan, and to accomplish the overall task or goal. In this context, an exercise is not-designed solely to test an organization or its conceptual mode of operation. That should have been done in the pre-exercise planning phase.- Rather, it is essential in an exercise to focus also on the. individual skills of the members of the organization and the ability to integrate such skills as necessary to enable the organization as a whole to accomplish its assigned task. Thus, in an exercise, the issue is not just whether individuals can follow the procedures which are set forth in the plan (although such basic ability is important to be demonstrated), but rather an exercise must also be designed to test the individual members' performance of the functions' which they would be called upon to be performed in an actual situation, including the ability to deal with the unexpected and l
unanticipated situations which may' require new.or different l
interactions among organization members not expressly t contemplated by procedures.
15 Richard Nelson and Sidney Winter, An Evolutionary Theory of Economic Chance,. Boston: Belknap Press, 1982,.p. 99.
Of course, we might say that individuals in organizations learn by doing, but since organizations involve the interaction of individuals, organizations learn by doing things together.
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II. PURPOSES AND
SUMMARY
OF CONCLUSIONS i
A. Purpose ,
1 1
Q. What is the purpose of this testimony?
l 1
l A. This testimony addresses the matters raised in l l
Contention Ex 50 (and the related contentions which the Board l decided to consider in connection with Contention Ex 50) arising out of the Exercise of LILCO's Plan for Shoreham. A copy of Contention Ex 50 and the related contentions is Attachment 6 to this testimony.
B. Summary of Conclusions
- 1. The Exercise Results Demonstrate Fundamental Flaws in LILCO's Trainina Procram 1
1 Q. Based upon your review of the Exercise results which relate to the issues raised in Contention Ex 50, have you reached conclusions regarding whether those results are indicative of any I training-related deficiencies in LILCO's Plan?
l l l
A. Yes. In our opinion, the Exercise results demonstrate that LILCO's Plan is fundamentally flawed in that despite the extensive training program which is part of that Plan, LILCO's l personnel are unable to carry out effectively or accurately the LILCO Plan. Thus, the results of the Exercise also provide an
r-l answer to an issue left open in the Licensing Board's April 17, 1985 Partial Initial Decision (hereafter, the "PID"):16 the l l
Board cannot find that the Plan can be satisfactorily implemented l
with the LILCO training program because LILCO does not possess an adequate number of trained LERO workers and the Exercise results l
l reveal that LILCO's training program is fundamentally flawed.
! Thus, we believe that the training deficiencies identified during i
i the Exercise preclude a finding that LILCO's Plan could and would j l
be effectively implemented in the event of a Shoreham emergency.
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Q. Gentlemen, you stated your belief ".that LILCO's training program is fundamentally flawed." What do you mean by the term " fundamentally flawed?"
l A. That is not a term which we normally would use in our writing. It is used in this testimony because it has been used by the Licensing Board and Commission. We use the term to mean l
extremely significant problems in the LILCO training program -- ;
l l
problems, indeed, which relate to whether LILCO's personnel are f 1
l 16 The Licensing Board found that the "LILCO Plan training program meets the regulatory standards," but that conclusion was expressly:
l made subject to confirmation by a finding, to be made by FEMA after a graded exercise, that the Plan can be satisfactorily implemented j with the training program submitted and that !
LILCO possesses an adequate number of trained l LERO workers.
I 21 NRC 644, 756. In the FEMA Report, FEMA made no finding along {
the lines referenced in the PID. f or can be trained sufficiently to implement the LILCO Plan.
Thus, the problems which we discuss in this testimony, when viewed in the context of the LILCO Plan, the LILCO training program, and the Exercise results, are in our opinion, serious problems which preclude a finding that LILCO's personnel are capable of implementing the Plan.
Q. Please be more specific in summarizing your evaluation of LILCO's training program.
A. The Exercise demonstrated that LILCO's training program is seriously inadequate in a number of crucial respects, which we detail in the testimony which follows. In summary, however, our conclusions are as follows.
Under the LILCO Plan, as previously explained, LILCO is responsible for the training and retraining of both LILCO and non-LILCO personnel in LERO. It is our understanding that training began in 1983 (LILCO Admission No. 214) and, since that time, has consisted of classroom instruction, drill and tabletop sessions, and LILCO-conducted full-scale drills or exercises, as already described by us. Plan at 5.1-1 thru 5.2-7 and Figs.
5.1.1, 5.2.1; OPIP 5.1.1, at 5. LILCO requires all LILCO members in LERO to participate in its training program on an annual basis. Plan at 5.1-1, 5.1-7 and 5.1-8; OPIP 5.1.1. At a minimum, this requires each LILCO worker in LERO, each year, to
R attend classroom instruction sessions on seven emergency response training modules l 7 and to participate in at least one tabletop session or drill; on average, however, LILCO personnel appear to be required, each year, to attend classroom instruction sessions on nine modules and to participate in three tabletop sessions or drills. Plan, Figs. 5.1.1 and 5.2.1; OPIP 5.1.1, at 17-20.
Thus, as of the time of the Exercise, many of LILCO's personnel in LERO (leaving aside new personnel) had already undergone about three years of training by LILCO involving, on average, classroom instruction on a total of 27 training modules and participation in nine tabletop sessions or drills. Furthermore, snortly before the Exercise, those LILCO personnel who were to participate in the Exercise underwent additional training, through their participation in at least three large-scale LILCO drills that served as dress rehearsals for the Exercise, as well as a number of tabletop / drill sessions.
l Notwithstanding this allegedly extensive training and last- I l
minute preparation and practice, a large number of training deficiencies were revealed during the February 13 Exercise.
1 These deficiencies, in our opinion, demonstrate that LILCO's training program has been ineffective. As a result, there can be no finding of reasonable assurance that adequate protective measures can and will be taken in the event of a Shoreham emergency.
l 1
17 LERO emergency callers are an exception; they only attend i three modules. Plan, Fig. 5.1.1. l t
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Q. But don't you conduct exercises like that which occurred on February 13, 1986 in order, at least in part, to find training problems and then to be able to fix them?
A. To an extent, an exercise is designed to identify deficiencies or problems in training so that in post-exercise activities, appropriate remedial training and related activities can take place. Thus, the mere fact that a few training problems might be revealed in an exercise is not in and of itself determinative.
However, with LILCO's Plan, a different conclusion must be reached. As described above, LILCO provided a large amount of training prior to the Exercise, including three full-scale dress rehearsals in December 1985 and January 1986 attended by the individuals who would participate in the FEMA Exercise. We find it significant that notwithstanding all of that training, there still were so many training-related problems that occurred at the Exercise -- including many problems involving the most basic kinds of matters. It is our opinion that if proper training had proceeded prior to the Exercise, there would not have been training problems on the scale which was revealed on February 13, 1986.
Q. Aren't a lot of the training deficiencies which were documented at the Exercise pretty trivial? How do they show that the LILCO training program is seriously flawed?
A. (Colwell, Cosgrove, Streeter, Zook) We disagree with the premise of the question. Training deficiencies, by definition, are not and should never be considered trivial.
Obviously, certain problems which may arise during an exercise which are attributed to deficiencies in the training program may lead to more serious consequences than other training deficiencies. But that is largely a fortuitous matter, since if there are deficiencies in a training program, one cannot be sure where the results of those deficiencies are likely to manifest themselves during a drill or actual emergency, or what the ramifications would be.
A key factor in an effective training program is whether it produces an overall concept of operations and integrated capa-bility such that the organization, which exists and is capable of performing a task only via the sum of the performances of its individual members, can operate effectively. Indeed, the purpose of a training program is to instill not only knowledge and capability, but an integrated performance capability among all of the members. In this context, no training problems should ever be labeled as trivial. They represent a breakdown in the discipline which must be instilled through the training program i
J l
i to ensure that individuals follow rules and procedures and have l
l developed the necessary capability to respond to non-routine l
events.
Finally, it must also be emphasized that during a drill or exercise -- including the Exercise of LILCO's Plan -- the relevant inquiry is not whether a person actually carries out his/her function, notwithstanding some errors along the way which reflect deficiencies in training. Such a " bottom line" approach is inappropriate when judging the effectiveness of a training i program. A training program is designed to prepare individuals for a wide variety of events. The mere fact that in a drill or exercise people ultimately get things right (and perhaps even in a timely manner), is largely beside the point.18 18 The relevant inquiry is not whether there has been training for a specific act which is then carried out during the drill or exercise, but whether the person understands how that act fits into many others, how it might have to be altered due to special circumstances (e.a., the dosimeter may need to be read more frequently if the wind is changeable), and whether the person has an understanding of the ultimate goal of his/her unit so that he/she understands the importance of the act. For instance, in a real emergency some required behaviors will be extremely important, while others might not need to be performed, because more important ones take precedence, and there would not be any significant consequences from the lack of performance. No one can know, or anticipate, these kinds of nece.ssary adjustments in advance, however. Therefore, no training prcblem can be labeled trivial ahead of time; everything must be covared in training.
In that way, in an actual drill, exert _se or emergency, well trained personnel will be able to properly an d appropriately establish priorities if time or resources are lacking to de everything.
I l
i (Rowan, Evans) We wish to stress our agreement that training deficiencies can never be dismissed as trivial, i
particularly since many of the problems serve to highlight more I
^
fundamental problems in LILCO's training program, at least insofar as media relations are concerned. 'Among other things, the flaws revealed in the Exercise demonstrate LILCO's' failure to understand the nature of communication with the media and to l impart this understanding through its training program for its l
personnel. As discussed below (particularly in the discussion of
)
subpart F), LILCO failed to appreciate the role of the media in !
disseminating information to the general public and the utility J failed during the Exercise to meet the needs of reporters and photographers. The failures we describe below are partly the result of misconceptions about how reporters, photographers, editors and news producers think and function. The Exercise demonstrates-that LILCO's training emphasized mechanized output ;
(in the form of EBS messages, press releases and staged l l
briefings), yet the utility was unable to provide accurate, i
timely and consistent information. Moreover, the emphasis on output caused the utility to overlook the irupact of what was '
being said upon the media and the public.
1
- 2. LILCO.Has Not Fixed its Trainina Problems Q. Has LILCO's training program changed significantly since the February 13 Exercise such that you might have
confidence that the flaws in the training program whicn were j l
revealed in the Exercise have been or are on the way to being eliminated?
A. No. We are aware that LILCO has made some changes to the training program. However, our review reveals that those l
changes are rather insignificant, and that LILCO's same basic approach to training which was in effect before the Exercise has continued. See deposition of Dennis N. Behr (January 13, 1987),
at 78-79.19 Thus, we have no reason to believe that the changes which have been made and which we describe later in this
( testimony, will cure the serious deficiencies in LILCO's tra.ining l
program that were demonstrated during the February 13 Exercise.
As a result, it is our opinion that the many persons who were 4
generally unable to carry out effectively or accurately their functions and tasks under LILCO's Plan during the February 13 Exercise will remain unable to perform as expected by LILCO in implementing LILCO's Plan, thereby precluding a finding that LILCO could and would adequately protect the public in the event of an actual Shoreham emergency.
19 In SNRC-1269, dated June 20, 1986, LILCO outlined changes it was making to its training program. However, those changes are not significant -- they largely call for small changes in the training which already has been demonstrated to be inadequate.
See discussion in Part III.H below
Q. Other than what occurred during the Exercice and the fact'that the methodology and conceptual framework of LILCO's training program have not changed.since the February 13 Exercise, are there any other reasons why you believe that LILCO's-training program continues to be flawed?
A. Yes. We find confirmation in our conclusion because the same kinds of problems have occurred again and again during drills conducted since the. Exercise.
Q. Please provide details relating to these drills.
A. Later in this testimony, we describe in greater detail particular problems in LILCO's training program that have been l demonstrated during LILCO's training drills since the February 13 Exercise. We demonstrate how these problems since the Exercise serve to confirm the Exercise results: LILCO's training program is fundamentally flawed. For now, we only provide a summary description of the post-Exercise drills that have been held so I that the significance of the problems revealed can be put in 1.
perspective.
It is our understanding that from the time of the February 13 Exercise through the end of calendar year 1986, LILCO conducted six relatively large-scale training drills. Sea Drill Report for June 6, 1986 (copy attached as Attachment 7); Drill ;
1
b Report for September 10, September 17 and October 1, 1986 (copy attached as Attachment 8); Drill Report for December 2 and 10 (copy. attached as Attachment 9). The results of these drills' demonstrate that the serious inadequacies in LILCO's training program that were revealed during the February 13 Exercise l l
continue to exist.20 l I
The June 6 drill was LILCO's first large training drill after the Exercise. It included personnel at the EOC, the ENC and the Riverhead Staging Area (in particular, the management i
staff, administrative support staff, dosimetry staff, and Traffic ]
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Guides). All other LERO personnel and facilities were simulated.
l Shift 2 LERO personnel participated in the drill. Egg Attachment 7 at 1.21 20 We add, however, that even if particular problems which were revealed in the Exercise results did not reappear in the later drills, our conclusion would still be that the Exercise results demonstrate th2t LILCO's training program was and'is fundamentally flawed. The drills since the Exercise have all been on a much more limited scale than the Exercise. Further, no outside organizations such as schools, bus companies, ambulance-companies, etc., participated in any of the post-Exercise drills.
Thus, it would be wrong to read into the drills any " improvement" when compared to the Exercise results. As things turned out, however, we have found no significant basis to find any " improve-ment" in the drill reports vs. the Exercise results.
21 It is our understanding that Shift 1 LERO personnel participated in the February 13 Exercise. Deposition of Dennis N. Behr (January 13, 1987), at 119.
The scenario for the June 6 drill was essentially the'same as was used during the Exercise'.22 Despite the cimilarity, the drill documents more failures by LILCO. Thus, the drill report states: "[o]verall response by the participants [was) poor."
Attachment 7 at 6. This conclusion was based, in part, upon the following problems identified during the drill.
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-- At the EOC, the notification for'early dismissal of the schools within the EFZ wss not done efficiently, and it took 48 minutes to issue an SBS message following the declaration of an Alert (Attachment 7 at 2);
The preparation of'EBS messages.took too long, and several of the messagec missed the 15-minuts deadline required by the NRC's reyblations (including the message for the General Emergency declaration, which took 25 minutes to issue)
(Id.);
It took too long to-get the word out to the LILCO staging areas about the evacuation (ld.);
Messages were not written down, or were frequently written on scraps of paper rather than_on standard message-forms (Id. at 3);
Updating of status boards at'the EOC was not timely (30 - 45 minute delays) (14.);
There was a lack of cooperation between the EOC 1 and the EOF (14.);
The Special Facilities Evacuation Coordinator delayed in proceeding with the deaf notification process and in evacuating the mobility-impaired (ld. at 4);
22 There.were several exceptions: _the length of the drill was shortened from about 11 hours1.273148e-4 days <br />0.00306 hours <br />1.818783e-5 weeks <br />4.1855e-6 months <br /> to 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />; participants were l
prestaged at their respective facilities; and Revision 7, rather j than Revision 6, of the Plan was used, meaning that the dispatch of Traffic Guides to the two-mile zone and the new position of Traffic Engineer were added to the scenario. Attachment 7 at 1. i
1
-- Traffic Guides were delayed in being dispatched (by at least 40 minutes) (1d.);
The response to the. fuel truck road impediment was ,
" confused" and the response delayed because, among other things, no one individual was in charge, information relayed to the field about the impediment's location was wrong (Route-25A vs.
Route 25), requiring the players to be " prompted" on three separate occasions, and the Traffic i
Engineer was unsure about his responsibilities and became mired in details (Id,);
Press releases at the ENC were not distributed in a timely manner (failure of a copier machine, j repair technician showing up two hours late, etc.) !
(16. at 5);
-- Buses were not dispatched by the'Patchogue Communicator at the COC until " prompted" by,the controller (one-and-one-half hours after buses were to have been dispatched),(Id. at 6); and~
Several' Traffic Guides were unclear about the procedure authorizing excess exposure (Id.).
Based upon the foregoing, it is not surprising that the l performance of participants at the June 6 drill was rated as ,
" poor." What is particularly troubling is the remarkable I
similarity between the performance of LILCO's personnel during 4 the February 13 Exercise and the June 6 drill: they were,_ simply put, equally poor. This supports our view that the deficiencies in LILCO's training program revealed during the Exercise were not an aberration but, rather, are representative of what must typically be expectec in the performance of LILCO's offsite emergency response personnel, given the serious inadequacies in LILCO's training program that we have already generally discussed and will detali later in this testimony.
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U. You mentioned LILCO training drills that were conducted i
in September and October, 1986. Did the performance of LILCO's personnel during those drills show significant improvement over the performance demonstrated during the February 13 Exercise or the June 6 drill?
l A. No. During drills held on September 10, September 17 and October 1, 1986, problems continued with the performance of LERO's personnel, further confirming our concerns with the adequacy of LILCO's training program.
According to the report for these drills, all aspects of LERO participated in the September / October drills, except for the ENC on September 17 and the Reception Centers and Family Tracking on September 10. One-third of LILCO's ficld personnel partici-pated in each of the drills, from each of the three staging areas. The exception was LILCO's bus drivers, who were at that time undergoing special training due to the problems demonstrated during the February 13 Exercise regarding their lack of fami-liarity with the bus yards and transfer points relied upon by LILCO's Plan. Attachment 8 at 1.23 23 As in the June drill, hc ever, no outside organizations participated and LERO workers were prestaged at their respective facilities. Attachment 8 at 1.
Shift 3 personnel participated at the September 10 and 17 l drills; shift 2 participated at the October 1 drill.24 The results of these drills again support our opinion that LILCO's training program is seriously flawed since there were multiple ;
l problems which again were identified.25 The report does note i that shift 3 personnel were better able to cope with the drill scenario and simulated emergency on September 17 than they were !
on September 10. Shift 2 personnel, on the other hand, did not ,
1 perform as well, "primarily due to the fact that they had not drilled since June." Attachment 8 at 12. This supports our view that LILCO's training program has been unable to provide an ongoing level of readiness. It shows again that LILCO's program j has not been capable of actually getting LILCO's personnel 1
trained so that at any time, they are ready to respond to an ;
emergency. Since LILCO's training program essentially requires only annual participation in LILCO's training drills, there is no l 24 Shift 2 had participated in the June 6 drill. According to the report, the purpose of drilling shift 3 personnel on two con-secutive weeks was to allow the participants to use the first drill as a learning process and to allow new LERO members to become familiar with their positions. The second (September 17) l drill was then conducted as a " hands off" drill. Attachment a at l.
25 In this regard, we note that FEMA's witnesses appear to l agree with our conclusion. For example, during the deposition of I
the FEMA witnesses on January 28-30, 1987, the effectiveness of l LILCO's training program was described as "need[ing) to be increased." Deposition of Roger Kowieski et al. (January 30, 1987), at 114-16, 118. In fact, when asked his impression about the fact that the same deficiencies in LERO's performance demonstrated during the Exercise also occurred in post-Exercire drills, one FEMA witness commented that he was coming to the conclusion that LILCO's " approach to training is wrong." Id. at 123 (Keller).
reasonable prospect of improvement. And even when more than one I drill occurs for the same personnel separated by more than'one week, the performance'is inadequate. Certainly, the performance of Shift 2 observed during the June 6 drill is more realistic of what wculd occur during an actual emergency than the performance of Shift 3 on September 17, since it is certainly unlikely that LERO personnel will participate in a practice drill one week y
before an actual emergency occurs.
Q. You mentioned several drills in December 1986. Did those drills demonstrate any significant improvement in LILCO's training program?
A. No. First, we have been unable to devote as much analysis as we would like to consideration of the December drills. This is because the drill report from the December drills was not provided to counsel for Suffolk County until March 6, 1987, and thus there was no opportunity to ask questions l
! I l of the authors of that report.26 J l
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Notwithstanding these limitations, however, we have been ]
L able to review that report sufficiently to determine that there is nothing in that report which would 1.ead us to change our conclusions. In fact, our review of the December. drill report 26 The report for the December drills is far longer and in a different format than the earlier reports, thus underscoring why it would have been valuable to have been'able to pursue questions on the report during discovery. {
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has strengthened our conclusion concerning the inadequacy of the LILCO training program. Many of the same problems revealed during the Exercise and in the other post-Exercise drills occurred again in the December drills.27 .These problems are discussed in the context of particular subparts of Contention Ex 50.
i O. Gentlemen, you have summarized your conclusions gleaned from the drills LILCO conducted in 1986 after the Exercise. Are you satisfied that those drill reports accurately reflect what occurred during those drills? )
A. The reports seem generally to reflect the underlying data, i.e., the underlying evaluation reports prepared by drill observers / evaluators. However, we also have reviewed the underlying evaluation reports and, if anything, we would have to conclude that the reports are-somewhat less critical of LERO l performance than the actual observer forms which were filled out at the time the drills took place.
O. Did the drill reports highlight any other problems with LILCO's training or its ability to learn by doing?
27 The December drills included all sections of LERO'except for Relocation Center and Reception Center personnel, and each drill included 1/2 of the field personnel. .They were the first drills in which Shift 1 had participated since the Exercise. Attachment 9 at 1.
l - _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ - _ _ _ - _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ .
A. (Perrow) Yes, there is the problem of LERO personnel turnover. The drill reports note that there have been problems during post-Exercise drills due to new personnel,' suggesting turnover in the LERO organization. Drill' reports also note lack-of training of new personnel in several instances. Egg' Attachment 7 at 6; Attachment 8 at 2, 4, 5, 11, and 12. Training in LERO is certainly not limited to experience.in the few drills that LERO holds; most of the training goes on outside of the drills; the drills are in part a check on the training. So the combination of new personnel and poorly trained personnel suggests that the modules, desk-top sessions, etc. are not doing their job.
For instance, the report on the June 6, 1986 drill, notes that "many of the participants were new to LERO and unfamiliar with their procedures and job functions." Attachment 7 at 6.
Presumably the personnel had received basic and some more advanced training before the drill, yet they still were unfamiliar with the procedures and their jobs. For the September 10, 1986 drill, it is noted that "[t]he Coordinator of Public Information was participating in his first drill, as were many of the people on his staff." Attachment 8 at 2. Despite the fact that the new Coordinator would be expected to have had some training for his new position (unless he came on just before the drill in which case he should not have been permitted to participate in the drill), the situation was so bad at the EOC in 1 j
1 this drill that the " controller assigned to the area was forced i i
l to walk the players through their procedures." Attachment 8 at (
I
- 2. This is hardly encouraging. At the least, if there is going '
to be turnover in key roles, LERO's training program should make I sure that back-up coordinators are available if the Coordinator of Public Information leaves the LERO organization.28 The turnover problem highlights flaws in LERO's training i program. A good and effective training program has constant training to ensure good performance by personnel, even with necessary turnover. The results since the Exercise show that i
LILCO's program has been unable to compensate for the turnover !
i problem. This is a serious problem with LILCO's training program l
)
-- learning by doing is essential but due to LERO turnover, it is obvious that learning by doing training is not occurring to the I degree that should be required.
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28 Other examples of membership problems also exist.
At the Patchogue Staging Area, the setting up of the facilities was slow and undirected due to "the lack of experience of the participants." Attachment 8 at 4. In the same drill, for the same reason, "the personnel at Riverhead were slow to activate the facility. The controllers had to prompt and train the personnel during the drill as to their duties." Attachment 8 at
- 5. A drill or exercise is no time to do basic training; that should be done through the videotapes, tabletop exercises, lectures and so on. Similar problems occurred in the October 1, l 1986 drill. In one example, at the Port Jefferson Staging Area, i
it is noted that "[m)any personnel at the facility were new to l LERO." Attachment 8 at 11. At Riverhead, it similarly is noted,
"[m)any of the players were new to their position and had to be walked through their jobs "
. . . . Attachment 8 at 12.
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Q. Are there any other reasons why LILCO has been' incapable of providing effective training to its personnel?
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A. Yes. LERO is an intermittent organization in Nerms of providing effective training. LERO personnel, both individually i l and in their LERO roles, have no opportunity to gain experience j and readiness in emergency functions through real life expe'rience as an organization. Thus, LERO must rely upon other training, ,,
l such as drills and exercises, for development of its knowledge, LERO, however, had only one exercise and a number of drills in 1986, and the drills involved only one shift and either one-third ,
or one-half of the field personnel each time, and several facilities were not involved. And as noted above, the effectiveness of these drills has been diminished due to turnover. ;
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LERO would have to have exercises and drills much more often I i to have the range and amount of experience that would provido l proper learning. And the public and the supporting ,
organizations, such as the schools and hospitals that are relied upon by LERO, would have to be involved to make it reasonably realistic. In short, LILCO has not demonstrated even from a e
mechanical point of view that it can provide sufficient tral ing to its personnel.
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I (Perrow) Further, as detailed in Part III.II.2 of this j l j Testimony, the Exercise results also demonstrate structural {
difficulties in LERO -- a highly centralized, tightly coupled )
I structure which, as demonstrated during tha Exercise, is i
inappropriate for responding to the kinds of non-routine events l l
which must be anticipated in an emergency situation. Thus, even {
1 if LERO were capable o' providing for more ex&ensive and better training, we have substantial doubts that it could succeed.
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l III. PISCUSSION_DE C,0NTENTION.FY SO SUBPARTS l A. Contention Ex 50.A: Training for Unanticipated j and Unrehearsed Situations Q. Please state subpart A of Contention Ex 50.
I A. That subpart states: l The exercise demonstrated that the LILCO program has not successfully or effectively trained or prepared LERO personnel to respond l properly, appropriately, or effectively to I unanticipated and unrehearsed situation _'
likely to arise in an emergency. Exercise actions and events which support this allegation are described in Contentions EX 38, EX 39, EX 41, and EX 42, and in the following FEMA Comments: EOC-D-1; ENC-D-1; PSA-D-1; PSA-D-6; R-D-2; EOC-ARCAs-2, 3,, 9; ENC-ARCA-2; PSA-ARCAs-5, 7, 8, 9, 10, 11.
Q. Do you agree with subpart A?
A. Yes. In our opinion, the Exercise results demonstrated l that LILCO's training program has failed to train personnel to l properly respond to unanticipated and unrehearsed situations.
Q. Please explain wnat you mean by " unanticipated" and
" unrehearsed" situations.
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A. An unanticipated or unrehearsed situation is an occurrence that is not expected. It is the type of situation that is not specifically planned for. Thus, personnel have not practiced responding to the specific situation.
Q. Do you make any distinction between unanticipated and unrehearsed situations?
A. No. In the context of LILCO's training program and the types of situations presented during the February 13 Exercise and referred to in this testimony, no distinction needs to be drawn; they are quite similar.29 29 An unanticipated situation takes one by surprise. It is a situation not expected to occur. Since it was not expected to happen, it was not specifically planned or trained for. For example, during the Exercise there was a simulated traffic impediment involving an overturned fuel truck. See FEMA Report at 36. Although LILCO's personnel certainly expected some type of traffic impediment to be part of the Exercise scenario, this specific impediment was probably not expected. Thus, the overturned fuel truck impediment was likely an unanticipated situation.
An unrehearsed situation is somewhat different in that it is an occurrence for which a response has not been practiced. In the above example regarding the fuel truck impediment, assuming that LILCO's personnel had never previously had to clear an over-turned fuel truck that was obstructing traffic, they never would have practiced handling this situation. It thus was unrehearsed.
Thus, they would have been forced to use their judgment when responding to such a situation, and to use the knowledge and skills they should have acquired during training in deciding what to do.
Contention Ex 50.A addresses those situations for which LERO
! personnel have not been specifically trained or prepared to
)
respond. It deals with the kinds of non-routine situations likely to arise in an emergency where LERO personnel would be required to rely on their experience, knowledge and perhaps common sense, as opposed to explicit directions or instructions such as: "If A happens, then do B." The issue which arises is whether LILCO's training has prepared the LILCO responders l effectively to improvise and adjust to handle such situations.
In our opinion, the Exercise results document that LILCO ,
l personnel have not been trained to handle such situations.30 l
f 1. The Importance of Being Trained to Respond i to Unanticipated and Unrehearsed Situations Q. Why is it important for LILCO's personnel to be trained i
to respond in a proper, appropriate and effective manner to i l
unanticipated and unrehearsed events?
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l l A. During an emergency, LERO personnel will likely be called upon to respond to a large number of situctions that they will not have specifically anticipated or rehearsed. Traffic l
l impediments and inquiries from the press and public are just two examples. It is essential for the proper handling of an 30 Our testimony on subpart A of Contention EX 50 relates closely to that which we provide later on subpart E pertaining to the lack of training of LILCO personnel co use good judgment and common sense. The need to use good judgment and common sense is particularly acute in responding to unrehearsed or unanticipated situations.
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emergency that personnel be trained to deal effectively with these types of events and situations, even though they might be unexpected or unanticipated.
An inability to handle unrehearsed and unanticipated events can be critical. For example, failure to deal appropriately with ;
l unexpected road impediments could mean that the protective action recommendations for the public are wrong, because they may be based on incorrect evacuation time estimates.31 Similarly, a failure to communicate unanticipated information accurately and quickly to the EOC and ENC could result in conflicting and inaccurate information being passed on to the media, which, when broadcast, might contradict information contained in EBS
____________________ i 31 For example, during tho Exercise the Radiation Health f l Coordinator was not informed on a timely basis of the traffic )
impediments and therefore was not able to take into account their j i
impact upon evacuation time estimates prior to evacuation ]
recommendations.
~
Similarly, because of the delays in dealing with impediments and further delays in imparting information about those impediments to the appropriate public information ,
personnel, it was not until 12:55 (nearly two hours after the j second traffic impediment had been injected into the Exercise) j that the Public Information Staff were asked to draft an EBS message announcing a traffic problem. Even after this request was made, it took nearly an hour for the message to be drafted and broadcast. The first EBS message (EBS No. 8) containing information about the traffic impediments, advising evacuees to avoid the intersections where the simulated accidents had occurred, was not broadcast until 1:45 p.m. Egg, Observer Data Log - ENC-Ronkonkoma. Again, proper and appropriate training would have made the LERO personnel who first learned of the impediments aware of the necessity to integrate their response with that of other LERO elements. This is an example of the I failure of LILCO's training program to create an organization that knows how to work together to achieve a task. Thus, even if individuals in the organization followed their procedures to the letter, without substantial learning by doing, those personnel do not know how to interrelate with other members of their organization to accomplish the overall task.
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messages. Failure to provide appropriate.information in response to unexpected inquiries from the public could lead to a j proliferation of rumors or misinformation, thereby increasing the difficulty of having protective action recommendations believed and implemented. And the failure of LILCO's Traffic Guides to impart correct information in response to unrehearsed questions from evacuees could result in people taking inappropriate actions contrary to LILCO's recommendations.
Finally, being able to respond appropriately to unantici-pated or unrehearsed situations is extremely important because it is a critical demonstration of whether LERO personnel have had effective learning by doing training. The essence of learning by doing is the development of the expertise and performance capability in personnel so that they have the judgment and common sense necessary to respond to non-routine events. Since emergency situations are characterized by non-routine occurrences, it is this demonstration which, in our opinion, constitutes the most critical test in terms of Exercise results regarding whether LILCO's training program for offsite response personnel has been effective. As described below, it is our conclusion that the LILCO training program has been demonstrated through the Exercise results to have been ineffective.
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- 2. Examples of LILCO's Lack of T.aining To Respond Properly, Appropriately or Effectively to Unanticipated or Unrehearsed Events l Q. What occurrences during the Exercise lead you to believe that LILCO's training program has not successfully or effectively trained workers to handle unanticipated and unrehearsed events?
A. Before providing examples, we need to stress that there i
were not a great number of major unrehearsed or unanticipated events during the Exercise. Besides the two road impediment situations injected by free play messages, as well as several other events,32 there was relatively little in the Exercise which l
called upon LILCO to demonstrate its ability to respond j 1 '
appropriately and effectively to unanticipated or unrehearsed events. We find it significant that notwithstanding the relatively low challenge presented to LILCO, with respect to almost every unrehearsed or unanticipated event, some aspect of the LILCO performance was defective. This is a strong indication j l
that the LILCO training program for such events is seriously deficient. ,
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32 For example, the Ridge School free play message and some of the press inquiries appear also to constitute unrehearsed and unanticipated events.
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(a) Road Impediment Examples ;
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O. Describe the road impediments example.
A. The first example of training deficiencies concerns the manner in which LERO personnel responded to the two simulated f
road impediments during the Exercise. These impediments were i interjected by FEMA by way of two " free play" messages. The first message, involving a loaded gravel truck and three passenger cars (hereafter, the " gravel truck impediment"), was injected at approximately 10:40. The second message, involving an overturned fuel. truck (hereafter, the " fuel truck impediment"), was injected at approximately 11:00. FEMA Report 1
at 36. LILCO did not know that these particular impediments were going to occur, and its personnel apparently had not practiced handling such impediments prior to the Exercise.33 As a result, LERO personnel were left to draw from their experience, knowledge and common sense -- and, particularly, from what they had learned in pre-Exercise training -- in handling the situations as they developed.
An examination of how these two traffic impediments were handled by LILCO reveals a major problem with the LILCO training program. LILCO's personnel were unable to respond to either 33 LILCO had attempted prior to the Exercise to convince FEMA to tell LERO players about the need to deal with impediments and re-routing. FEMA refused. See Deposition of Roger Kowieski, et al. (January 28, 1987), at 283.
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l' traffic impediment in an appropriate manner. Rather, LILCO's responses were untimely, ineffective, and confused. And, even after LILCO had been " prompted" by FEMA.to respond to the )
impediments, its response remained inadequate.34
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For example, once LILCO finally got around to responding to the gravel truck impediment, it employed an inadequate'and improper scheme for rerouting traffic around the impediment, demonstrating a lack of training on the part of LERO personnel.
See Testimony of Assistant Chief Richard C. Roberts gt al. on I
i Behalf of Suffolk County Regarding Contention Ex 41 (Feb. 27, 1987) (hereafter, " Contention Ex 41 Testimony"), at 37, 50-55, 63-64. Furthermore, LILCO sent only one tow truck to the scene of the impediment, and no scraper was sent to remove spilled gravel from the road (nor was any simulated determination made as to whether any gravel had in fact been spilled). FEMA Report at 1 I'
37, 65; LILCO Admission Nos. 158, 159. According to the FEMA 1
34 LILCO's attempted response to the gravel truck impediment did not actually begin in any real sense until sometime after about 12:13, when FEMA " prompted" LILCO's Evacuation Coordinator about the impediment and LILCO's failur? to respond up until that time. FEMA Report at 36; LILCO Admission No. 155. As of 12:13, traffic had not been rerouted around the impediment, nor had LILCO even discussed whether there was a need to reroute traffic. Similarly, equipment sufficient to remove the gravel truck and the three disabled cars had not been dispatched, or even readied for deployment. See FEMA Report at 36-37. If FEMA had not " saved" LILCO by bringing the gravel truck impediment to the attention of a higher level LERO position (the Evacuation Coordinator) than the position at which the " free play" message had initially been input (the Evacuation Route Coordinator),
LILCO's response to the impediment certainly would have been even worse.
Report, the LILCO Road Crew sent to the scene of the impediment was not even informed that the impediment involved a multiple-vehicle accident. FEMA Report at 65.
Not having anticipated the gravel truck impediment, and thus not having rehearsed or practiced responding to this type of situation, LILCO's personnel were forced to use their knowledge, skill and judgment in responding to the impediment. Since this situation was not a routine event, LILCO's personnel had to use what they had learned in other contexts from their training, and then apply such learning to an unanticipated and unrehearsed situation. In this they failed, and the result was that LILCO's personnel responded in an ineffective and inappropriate manner.
This demonstrates, in our opinion, that LILCO's training program has been ineffective in training personnel to respond to unanti-cipated and unrehearsed situations. An effective training pro-gram would have trained personnel in the basic steps necessary to remove impediments to traffic, and thus to implement effectively the protective action of evacuation.35 LILCO's training program, however, falls far short of this result, and the consequence during the Exercise was reflected in LILCO's inadequate response to the impediment.
l 35 (Cosgrove, Streeter) For instance, the critical incidents response training we have discussed earlier specifically teaches personnel how to respond effectively and appropriately to road impediment situations. There was no indication in the Exercise performance by LILCO personnel that LILCO has provided any comparable training to its personnel.
I Similarly, the manner in which the fuel truck impediment was handled by LILCO during the Exercise again demonstrates flaws in l LILCO's training program. Although that impediment was simulated 1
to occur at 11:00, it was not until either 1:57 (according to l
i LILCO) or approximately 2:10 (according to FEMA) that the LILCO Road Crew directed to respond to the impediment first arrived at the scene. See LILCO Admission No. 160; FEMA Report at 36, 57; FEMA Admission No. 166. Thus, it took approximately three hours for LILCO to send a Road Crew to clear a major and potentially dangerous impediment. Even then, LILCO's response was only after FEMA had " prompted" LILCO's Evacuation Coordinator about the impediment at about 12:13 (the same time that LILCO was prompted l
about the gravel truck impediment). FEMA Report at 36; LILCO l
l Admission No. 155. FEMA's " prompt," of course, again likely 1
spared LILCO from even greater delays and difficulties in i
responding to the impediment.
l Moreover, even after LILCO had been prompted to respond to the fuel truck impediment, its response remained ineffective, untimely and inappropriate. For example, after being told of the impediment, LILCO's Evacuation Coordinator discussed LILCO's j response with his staff. Notwithstanding this FEMA-prompted ;
I discussion, however, as late as 1:48, LILCO's Road Logistics l
l Coordinator had not dispatched needed equipment to the fuel truck impediment site. LILCO Admission No. 157. Furthermore, LILCO employed an improper, untimely and inadequate scheme for rerouting traffic around the impediment (see Contention Ex 41 Testimony at 47-48, 55-62, 63-64), and it sent only a single tow truck to the scene of the impediment; this was clearly an inadequate vehicle, which underscores that LILCO's training had not prepared LILCO personnel to deal with real problems.36 LILCO's inadequate response to the fuel truck impediment leads us to the same conclusion about LILCO's training program that we reached in light of LILCO's response to the gravel truck impediment: LILCO's personnel, not having anticipated the types of impediments presented to them during the Exercise, and not having practiced or rehearsed how to respond to them in the context of LILCO's training program, were incapable of handling the impediment situations in a proper, appropriate or effective manner.
Forced to deal with situations that were not antici-pated, LILCO's personnel were incapable of responding adequately or effectively. Indeed, they failed to carry out a host of actions that should have been virtually second nature if their training had been effective: follow-up to ensure that instructions were being carried out; redundant communications 36 Indeed, it appears that the LILCO Road Crew sent to the scene of the fuel truck impediment was not even dispatched to that location until 1:50, over an hour and a half after LILCO was prompted into action by FEMA. See FEMA Report at 37. Moreover, it was not until 2:15 -- about three hours after LILCO learned of the impediment -- that LILCO first contacted Hess Oil Company to request that it send an empty tanker truck to off-load the overturned fuel truck. FEMA Report at 37. Obviously, this call should have been made much earlier (if only to get Hess on notice as to the possible need to dispatch a truck), since LILCO had been informed in the initial FEMA " free play" message that the overturned fuel truck was a fire hazard.
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along parallel channels to ensure that communications got through; getting people to the scene to verify the logic of re-routing schemes; and verification that proper equipment had been sent.
Q. Do you believe that the kinds of impediments injected on February 13, 1986 -- the gravel and fuel truck mishaps -- were realistic in terms of the kinds of events that should have been anticipated and prepared for?
A. Yes. Capable response personnel who are to be in a position to redirect or guide traffic in the event of an emergency must be prepared for unexpected events. Major blockages of routes are certainly the kinds of impediments.to evacuation that must be planned for.
(Cosgrove, Streeter) Moreover, major truck impediments, including fuel truck or gravel truck impediments, are certainly not far fetched. Indeed, in our experience as police officers, we repeatedly have been confronted with situations requiring prompt action to deal with such blockages. It is standard operating procedure to ensure that protective actions are quickly implemented, that the proper rerouting is immediately considered
J (whether it is actually implemented or not), and that the proper 1
equipment for dealing with such impediments is dispatched j l
immediately to the scene.37 Q. Why does LILCO's performance in handling the simulated roadway impediments during the February 13 Exercise demonstrate, in your opinion, a failure in LILCO's training program to successfully train personnel to respond to unanticipated and ,
i unrehearsed situations in a proper, appropriate or effective manner?
l A. Given the number of mistakes that were made in the l I
handling of the two roadway impediments, and also the nature of those mistakes, the most plausible explanation is that such mistakes were made as a direct result of LILCO's inadequate 1
training program. If LILCO's personnel had been provided better l training, so many mistakes would have been unlikely.
37 We emphasize the need for proper equipment. It serves no good purpose to deploy a tow truck in the event that a bulldozer is what is required for the response. That knowledge is some-thing which is gained by detailed training and experience. The fact that LILCO's personnel so utterly failed in their efforts during the Exercise, having had advance warning that impediments to evacuation constituted one of the objectives of the Exercise, further underscores our view that the LILCO training program is seriously deficient.
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i Based upon our experience as trainers, we have learned that ;
i when mistakes are made, they usually reflect on how well the individuals who have made the mistakes were trained.38 In our opinion, the manner in which the impediments were handled by LILCO's personnel leads us to the conclusion that LILCO's training program has been inadequate.in preparing LERO personnel I
to respond to unanticipated and unrehearsed situations, such as !
-the roadway impediments presented by FEMA during the February 13 Exercise.
(b) Rumor /Public Incuirv Examples Q. What is LILCO's rumor /public inquiry system and describe briefly how this relates to training.
A. That system has been described in Suffolk County's Contention Ex 38/39 Testimony (see pages 110-15) and will not be repeated here. In sum, even absent copier problems experienced during the Exercise, that system is cumbersome, which makes it almost inherent that there will be delay in providing responses to public inquiries.
38 We recognize that some people can be trained more easily than others, and some people possess differing levels of competence. Thus, it cannot be assumed automatically that an entire training program is inadequate because of a few mistakes by a few individuals. However, when there are as many basic mistakes as were evidenced during the Exercise, and wnen such mistakes are made by so many different people, then the most reasonable conclusion is that the training program in question is flawed.
Because of the inherent delays in the system as set up, however, the training of individual personnel who are on the firing line with the public is all the more important. Thus, with respect to obvious questions which should not require major research to answer, those personnel should be able to provide answers very promptly, if not immediately. This is not to say that there may not be instances of complicated or detailed issues specific to a particular individual as to which an operator may need expert advice from someone higher up in the response organization.
However, during the Exercise any~ operator with proper training should have been able to say, in .mmediate response to a public inquiry, that the plant had not been taken over by Arab terrorists, or that the cooling towers had not blown up.
As described below and in the Contention Ex 38/39 Testimony, however, such prompt responses did not occur. This reveals deficient training in that personnel never thought to employ alternative means to obtain updated information once it became clear -- very early in the emergency -- that they were getting information which was very late. They should have come up with a different way of getting the information since the copier machines and the computers were not doing the job. They didn't bother to do that; they went by the book and proceeded to give out inaccurate and out-of-date information which, in a real emergency, could prove very dangerous.
See Contention Ex 38/39
Testimony for a discussion as to what would happen in a real emergency given the actions of poorly trained rumor control l
operators.
Q. Please describe rumor /public inquiry examples from the Exercise that demonstrate that LILCO's training program has not prepared LERO personnel to respond properly, appropriately, or effectively to unanticipated and unrehearsed situations likely to arise in an emergency.
A. We will discuss only a few. Additional examples are discussed in the Contention Ex 38/39 Testimony, particularly at 120-35. In one instance, a rumor message inquiring whether the caller, from Bellport, should evacuate was given to the Patchogue Call Board operator at 12:05; a response was not relayed to the caller until 1:00. LILCO Admission No. 103. In another instance, a rumor message inquiring if lobsters caught off the Shoreham jetty that morning were safe to eat was received by the Riverhead District Office at 11:30; a response was not relayed to ;
i the originating party until 12:28. LILCO Admission No. 106.
These are just two examples of the long time period it took LILCO personnel to respond to public inquiries during the Exercise. i Q. Why does the length of time that it took LILCO's personnel to respond to public inquiries demonstrate problems in LILCO's training program?
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A. An adequate training program would have trSined LERO l personnel to respond in a more timely fashion. Such training, 1
for example, would have emphasized the need for prompt responses i to inquiries from the public, as well as the need to ensure that responses are accurate, consistent and coordinated with LILCO's I other public information activities. LILCO's training program, however, apparently failed to address these concerns. This is l
demonstrated by the fact that when faced with the public's unanticipated inquiries during the Exercise, LILCO's personnel )
I were unable to provide timely responses (or for that matter j adequate and appropriate responses). In our opinion, the fact that LILCO's personnel, not having anticipated the contents of the inquiries made and thus not having rehearsed their responses, were unable to respond in a proper manner, demonstrates a failure of the LILCO training prograu to successfully train personnel to respond properly to unanticip- 2d and unrehearsed situations. If their training had been adequate, LILCO's personnel certainly l would have been able to respond more quickly, and presumably also in a more reasoned and appropriate fashion.
Q. Do untimely responses to unanticipated inquiries for which responses have not been rehearsed necessarily demonstrate inadequate training?
l A. Based on the number of simulated inquiries from the public for which responses by LILCO personnel were untimely, and the fact that LILCO personnel took as long as they did in responding, the answer is yes. One untimely response to an inquiry would not necessarily support a conclusion that the training program as a whole was deficient. What occurred during the Exercise was quite different. The many instances of untimely responses reported during the Exerci'se le&d to the conclusion that LILCO's personnel had not been adequately trained to handle the kinds of unanticipated and unrehearsed situations that must be expected when dealing with the public, especially during an emergency.
Q. Except for their failure to provide timely responses, did LILCO's personnel otherwise respond appropriately and effectively to the public inquiries and rumors simulated during the February 13 Exercise?
A. No. The responses LILCO's personnel provided to public inquiries, in addition to taking too long, were frequently inappropriate. For example, in response to an inquiry (at 7:51) from a person who "has trucks going to Suffolk," as to how extensive the assumed evacuation would be, the Hicksville Call Board operator responded (at 8:20) that the only protective action was the closing of schools, and that there had been no l evacuation recommended. LILCO Admission No. 114. As of 8:20,
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I however, LERO was already beginning to " pre-stage" for an evacua-tion, and a Site Area Emergency had been declared. FEMA Report at 25. It thus was inappropriate to advise the simulated caller j to proceed as planned with sending trucks into the EPZ. And even if no Site Area Emergency had been declared, a more prudent and common sense' response would have been to defer coming to Suffolk County until further data regarding the event had been compiled.
However, apparently not having anticipated this inquiry,39 and thus not having rehearsed a response, LILCO's personnel !
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provided inappropriate information. This is thus another example j i
of how LILCO's training program failed to teach LERO personnel to respond appropriately to unanticipated and unrehearsed events. f 1
If the LILCO Call Board operator had been properly trained, it would be reasonable to expect that he would have promptly responded to the inquiry made at 7:51 in a manner that would have provided accurate, up-to-date information to the caller.
Instead, however, the operator took almost half an hour to respond and the response, once made, was contrary to common i
sense. LILCO's training program for those personnel responsible for responding to public inquiries during a Shoreham emergency therefore is called into question.
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39 We believe that such an inquiry should have been anticipated
! by LILCO's training program. The fact that it apparently was not ;
(given the inappropriate response to the inquiry) is additional indication of flaws in LILCO's training.
! 2 Q. Are there other. examples of inappropriate responses to inquiries?
I A. Yes. The " Dan Rather" inquiry has been described in earlier testimony. Seg Contention Ex 38/39 Testimony at 133.40 The suggestion that going to the plant was inadvisable but i nonetheless possible was incorrect, and such a suggestion, ccmbined with the giving of road directions to the plant, indicated poor judgment. Proper training would have taught.the LILCO operator how to handle such an inquiry -- suggest to the reporter that he come to the LERO ENC. LILCO's training program, however, as demonstrated by the Exercise, has been unsuccessful in providing tra: sees with the knowledge or skill necessary to deal with such inquiries. The result, during an actual Shoreham emergency, would be that LILCO personnel likely would give misinformation or improper advice to the public, thereby impeding i LILCO's ability to implement adequately whatever protective measures are necessary to protect the public.41 40 During the Exercise a message was simulated at 11:45, purportedly from Dan Rather, who wanted "to take a TV crew into the Shoreham plant," and inquired how to get there. In response, the rumor control responder stated: "We don't advise going to the plant. There is a Site Area Emergency. You will be in the ,
way." LILCO's responder, however, then gave directions to the i plant. LILCO Admission No. 119. On the day of the Exercise, however, a General Emergency had been declared as of 9:39, and, as of 11:45, LILCO was recommending that almost all of the EPZ be evacuated. FEMA Report at 25. (At 11:46, the decision was made ~
to evacuate the entire 10-mile EPZ. FEMA Report at 26.)
41 Activities of LERO personnel during the press briefings held during the Exercise also reveal inadequate and deficient training. For example, as discussed in detail in the Contention (footnote continued) ]
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I (c) Other Examples Q. Are there any additional reasons for your opinion that LILCO's training program has been unsuccessful in training j l
personnel to properly, adequately or-effectively respond to unanticipated and unrehearsed situations?
A. Yes. The responses made by LILCO's Traffic Guides i
during the Exercise demonstrated training flaws. Those personnel, for example', were incapable of responding adequately to simulated inquiries from the public, which were likely unanticipated and unrehearsed because they had not been expressly discussed in connection with LILCO's " Traffic Guide Procedure,"
as set forth in OPIP 3.6.3.42 For example, only one Traffic Guide out of the 14 interviewed by FEMA during the Exercise from l
(footnote continued from previous page)
Ex 38/39 Testimony (see pages94-100), in response to questions from news media, the LERO spokesperson was unable to, provide ,
detailed information concerning the traffic impediments or i traffic conditions, rather than merely repeating the only l l information the spokesperson had -- e.c._, that a truck.was "down" and that another impediment had been " removed." If LERO training had been adequate, the spokesperson would have been on the phone.
or used other means to obtain all the pertinent and up-to-date facts relating to those incidents in order to report them to the media. Instead, the spokesperson appeared content to hand out incomplete or unintelligible information. For the reasons described in the Contention Ex 38/39 Testimony, that would have been disastrous in a real emergency. .
42 This clearly documents a flaw i'n that procedure. LILCO traffic guides are to be visible, up-front responders, who should be expected to have direct contact with the public since they in theory will be providing guidance to motorists regarding ;
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evacuation routes, etc. LILCO should have anticipated and rehearsed for this situation. The fact that LILCO did not further underscores the deficiencies in the training program.
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the Patchogue Staging Area knew the location of the Nassau Coliseum Reception Center, and one Traffic Guide believed that the general public was to be directed to LILCO's Emergency Worker Decontamination Facility during an actual emergency. FEMA Report at 64.
Q. Why does this failure among LILCO's Traffic Guides to know pertinent information demonstrate a failure in training?
A. As in the previous examples, the results of the Exercise demonstrate that LILCO's training program has failed to train personnel to respond to unanticipated and unrehearsed situations or events. From the last example cited, it can be concluded that LILCO's training program has inadequately prepared LILCO's Traffic Guides to handle public inquiries that were not specifically anticipated and rehearsed. If training had been adequate, it could be fairly expected that the large majority of Traffic Guides would have been able to respond to the kinds of simple, simulated inquiries from the public presented to them during the Exercise, even if they had had no reason to anticipate the specific inquiries which were made or to practice or rehearse their responses. During the Exercise, however, it was demon-strated that the majority of LILCO's Guides were unable to respond properly to such inquiries. The most likely reason for I
the widespread problems encountered must lie with LILCO's trainina program. An adequate training program would have
provided LILCO's Traffic Guides with the knowledge, skill and experience necessary to enable them to respond to inquiries from the public, whether such inquiries were anticipated or not, or rehearsed or not. In a real emergency, it would be essential for LILCO's Traffic Guides to be able to respond to inquires from evacuees and other members of the public; otherwise, any possibility that LILCO's Traffic Guides would be obeyed or their advice followed would be severely undermined. LILCO's training program has failed to achieve this.
Finally, LILCO's training program must also be blamed for not training the Traffic Guides to obtain the necessary information promptly if asked a question whose answer they did not know. By getting information promptly, the Guides would have demonstrated some ability to use good judgment and common sense.
The Exercise results show that they did not even do this; instead, they answered the FEMA questions and did no more -- a demonstration of the fact that LERO responded to the February 13
" accident" in a very mechanical way. The training they had received prior to the Exercise -- including the dress rehearsals
-- had clearly been inadequate.
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- 3. The LILCO Failures to Respond Appropriately to Unanticipated Events Were Not Unexpected Q. Based on your knowledge of LILCO's training program, would you have expected LILCO's personnel to have been better able to respond to unanticipated and unrehearsed events than was demonstrated during the Exercise?
A. No. The Exercise demonstrated what we would have l expected. We have seen no indication from our revieu of LILCO's training program that LILCO's personnel have been trained realistically to respond to unanticipated and unrehearsed situations. Thus, it must be expected that when faced with such !
situations, LILCO's personnel will be unable to respond J
appropriately or adequately. I Rather than providing personnel the type of realistic training and post-training experiences that are essential to enable them to respond appropriately and effectively to l i
unanticipated and unrehearsed situations, LILCO's training program consists primarily of classroom sessions and routine drills. During this " training," LERO personnel are generally not required to solve unexpected problems. They are trained in procedures, not performance. Tney are not trained to handle surprices, and demonstrated during the Exercise that if the response is not. laid out in the procedure (i.e., "if A, then do B"), they were not capable of an effective response. Yet, 1
unexpected situations are the " routine' to be expected in emergency situations; this is the very kind of training which is critical in developing the ability among trainees to handle unanticipated and unrehearsed situations.
Q. What type of training would enable personnel to respond l
appropriately and effectively to unanticipated and unrehearsed situations?
A. Training alone is not the best method of teaching personnel to respond to unanticipated and unrehearsed situations.
This is because even the best training program'cannot substitute completely for the real-world exper!.ence which is essential for truly effective performance.43 Hoaever, a good training program can help prepare personnel for the unanticipated and unrehearsed situations they are bound to encounter when dealing with an emergency.
43 Experience is especially important in teaching personnel to respond to unanticipated and unrehearsed situations. No matter how well an instructor describes what it is like to perform tasks such as crowd control or traffic control under emergency conditions, the trainee cannot fully appreciate and understand what is required to perform those tasks under emergency conditions until he is called upon to perform. Experience also enables emergency workers to perform anticipated tasks routinely
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or out of habit. is crucial if the emergency worker is to make decisions c j and confidently, leaving him free to deal I with the unanti . pated and unrehearsed situations'that invariably arise under emergency conditions. j l
To successfully train personnel to handle unanticipated and unrehearsed situations, training drills should be designed to force trainees to make decisions under pressure, i.e., to be called upon actually to perform under conditions as close to "real" as can be achieved. Trainees then can be forced to improvise, to depart from procedures when they no longer apply.
Exercise simulation games and role playing are accepted techniques for generating discussion and helping participants develop insight into and understanding of real-world emergency problems.
For example, in police training, extensive use is made of role playing and simulated situations to provide trainees with the opportunity to develop the ability to make quick decisions.
In tnese role-play exercises, recruits are confronted by experienced training officers who realistically play the roles of civilians, presenting the recruit with unexpected difficulties.
The recruit is graded on his or her ability to resolve unanticipated and unrehearsed problems. This type of training is the first step in teaching a trainee to respond to unanticipated and unrehearsed situations. By practicing responding to the unexpected, the recruit is exposed to many of the situations that can arise, as well as how to respond properly to such situations.
Such training teaches the trainee "how to think on his feet" and how to make critical decisions in a timely manner.
1
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5 (Cosgrove, Streeter) Similar to role playing is the ush of a critical incidents response board -- a training technique-utilized heavily at the Suffolk County Police Academy. As used at the Academy, the critical incidents response Yoard amounts to a scale model of a community. Most typically, this training device involves having the entire class stand around the board, l
with particular recruits assigned as " active participants."' The active participants are assigned miniature police vehicles with ,
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specific numeric designations. They are then given information (the same type of information that they would be given by a' l 5
police dispatcher) concerning, for example, some type of c'ritical '/' ~!/;
n; traffic accident, such as an overturned fuel tanker, and then i l
they are instructed to respond to a certain location (e.Q., an intersection) on the critical incidents board. The active participants then positica their vehicle, develop a plan for responding, and coordinnte with back-up units and support personnel. Other persoas play the roles of these responders and q thus a great deal of himan interaction is achieved.44 t
44 It should not ne suggested that Suffolk County Police are i(
fully trained just on the basis of critical incidents response board training. When a police recruit in Suffolk County <\
graduates from the Police Academy, he has already received a great deal of training necessary to prepare him to handle unanticipated and unrehearsed events in the field. Nevertheless, :
immediately after graduating, the rookie officer spends the next 1 three months working exclusively with experienced field training l officers; he is c oserved and evaluated under real conditions. i This enables him to gain experience in handling unanticipated and l unrehearsed situations under the supervision of the more i experienced police officer.
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a
(Zook) The City of Little Rock, Arkansas, has developed ,
l what is known as the " Emergency Mobilization Exercise." This exercise is a simulation of a major disaster in which emergency response personnel are called upon to respond as if an actual emergency had occurred. The exercise serves both as a training tool and as a method of evaluating the effectiveness of the training which emergency response personnel had previously received.45 The Emergency Mobilization Exercise demonstrates what can be expected when emergency personnel have been successfully and l effectively trained. For example, during one Emergency i
I Mobilization Exercise, the collapse of a large section of bleachers at the local football stadium was simulated. Under the exercise scenario, this incident resulted in over 100 persons being trapped and injured. Power lines were knocked down and gas l
pipes were ruptured. Injured victims were role played by voluateers. The injured had every type of injury imaginable; some were suffering mental or psychological shock.
i 45 Although there are similarities between the Emergency l Mobilization Exercise and the Exercise of the LILCO Plan, chere l
j are also major differences. For example, contrary to the LILCO l
Exercise, in which Shift 1 knew they would be called, knew it
' would be on February 13, and knew the Exercise objectives in
- advance, the Emergency Mobilization Exercise occurs without the i participants knowing what is going to occur or when the emergency will be staged. Further, the Emergency Mobilization Exercise requires emergency personnel actually to respond and perform most emergency tasks under nearly realistic conditions, rather then to simulate them as during the LILCO Exercise. In addition, all l
! facets of an emergency response are exercised and evaluated, from schools to hospitals, unlike the situation duri. - the LILCO '
Exercise.
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The exercise began with a call to an ambulance company by a f f
" hysterical" individual, who related what had happened at the stadium. Following this call, over 500 emergency response i
workers fiom organizations as diverse as utility companies, hospitals, ambulance companies, and taxi cab companies responded I to the accident. Truck drivers, the press, police and fire fighters all responded.
Throughout the exercise, personnel responded to what was an unanticipated situation in a manner which demonstrated an effective emergency response. Immediately after the ambulance company was called, the police arrived at the scene (having been j called by the ambulance company). Off duty and auxiliary police personnel were quickly called in, and emergency personnel were J
requested from the local power, gas and telephone companies.
Ambulance, taxi and trucking companies were also requested to 1
send available vahicles to assist. These requests were communicated in a prompt and efficient manner, resulting in I necessary emergency personnel and equipment. arriving at the scene of the emergency shortly after the event had begun.
Hospitals were also notified of the accident and doctors and nurses were sent to the scene. Vehicles were dispatched to pick up these medical personnel. Further, the power and gas companies were contacted and quickly turned off the downed power lines and shut off the gas leak. Emergency telephone lines were set up at L_________-.____ s
l the accident scene by the phone company. The exercise continued 3
.1 I
until all of the injured had been taken to hospitals for treatment. Afterward, the performance of emergency personnel was critiqued, and the results conveyed to the participants.
ll This exercise, and others like this one which are periodically held in Little Rock and by other organizations with j which I am familiar, demonstrate that, with proper training, knowledge of job responsibilities, and sufficient emergency l
l response experience, acceptable performance can be expected to occur. When individuals know the tasks they are to perform and are properly trained in how to perform them, they can be put into {
i an unanticipated, crisis situation and perform successfully.
The type of training provided by such techniques as role j
playing and critical incident response boards helps prepare trainees for the many kinds of unanticipated and unrehearsed situations that they may face in the real worJd. They force the trainee to respond to high pressure situations that have never been rehearsed, practiced or anticipated. Through such training, l i the trainee can begin to learn how to respond quickly and effectively to unanticipated and unterearsed situations. The more training of this nature that is provided, the better prepared the trainee will be for the many different types of situations with which he may be faced in an actual emergency.
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LILCO personnel, by contrast, were unable to respond during the Exercise in an adequate manner, despite three years of training. However having reviewed the LILCO training program, it seems clear why this occurred. Quite simply, LILCO's personnel have not been adequately trained to respond to an emergency )
situation. They have not been taught how to perform their tasks, and they appear to have little idea about what their responsibi-lities are in relation to the overall LILCO Plan. Most importantly, LILCO's personnel lack any real experience in
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responding to emergency situations. ]
LILCO's training program, as previously discussed, fails to provide anything like the type of training we have just described. Probably closest to what we are referring to are the LILCO " tabletop sessions." However, rather than being ways to compel LILCO's personnel to practice unanticipated and unrehearsed events, these tabletops are merely seminar-type sessions. Thus, LILCO's personnel might talk about procedures or describe how they think they would react to posited problems.
1 But they would not be given the opportunity to learn by doing --
to perform. LILCO's tabletop sessions, therefore, could perhaps help to teach the Plan to trainees; they could not, however, teach job performance. LILCO's failure to provide the type of training which allows for on-the-spot, innovative decisionmaking-
by trainees largely explains in our opinion why LILCO's personnel performed so poorly when faced with unanticipated and unrehearsed '
events during the Exercise.
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Q. Are you saying that LILCO, irrespective of the quality l
of its training program, could not train workers to respond to j unanticipated and unrehearsed situations?
i A. No, although we have very real doubts in that respect.
What we are saying is that a training program such as that contained in LILCO's Plan, can only go so far in achieving this i
goal, and as demonstrated during the Exercise, it clearly has not gone nearly far enough. Since LILCO does not offer its personnel l actual field experience, it needs to compensate by otherwise ensuring that its training program is of the highest possible caliber. The LILCO training program, however, not only is not of !
l the highest caliber, it is inadequate. Rather than having l
numerous realistic drills that require trainees to respond to the unanticipated and unrehearsed situations which they likely would face in a real emergency, LERO personnel participate only infrequently in drills, and even those they do participate in are most often unrealistic, with little consideration given actual l
performance in the kinds of unexpected and unanticipated situations that may arise in an actual emergency.
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Thus, it is clear from the Exercise results that there has been very little " learning by doing" training by LERO. The examples we have discussed should not have occurred if there had been substantial learning by doing training. Further, the examples below also reflect problems which should have been identified and fixed before the Exercise if LERO had established l
a rigorcus and effective program for learning through experience.
The fact that these problems arose in the Exercise is strong additional evidence of fundamental flaws in LERO's program --
that LILCO's training program has failed to train by experience and doing.
The first set of problems deals with resources and physical changes needed to make LERO operate properly.
An unreasonable amount of time was required to cover one area simulated to have a siren failure (FEMA Report at xiv, xv, xvii, 57);
A disruptive public address system at Riverhead (FEMA Report at xvii, 72);
Lack of mileage indications on map for Route Alert Driver (FEMA Report at 74, 75);
I
- Insufficient space on status boards in the EOC, resulting in the mixing of DOE RAP and LILCO field monitoring team data (FEMA Report at 30, 40);
- Poor maps for finding mobility-impaired individuals (FEMA Report at 66); ,
' Insufficient staff for the Bus Dispatcher at Patchogue (FEMA Report at 66);
Inadequate copying capabilities at the Emergency News Center (ENC) (FEMA Report at 53);
Need to have additional room to reduce dosimetry
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distribution time for bus drivers, and additional staff (FEMA Report at 62);
i Shortage of equipment and absence of equipment at 1
Patchogue (FEMA Report at 64). 1 i
- Revision of Message For' was needed to reflect which 1
items are "new" items (FEMA Report at 72). l l
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i Many'of these examples may seem minor, and many perhaps could be' easily corrected. But,.they are significant evidence of the flaws in LILCO's training problem. If there had been vigorous, realistic r;tice' sessions involving well-trained LERO personnel, LILCO would have detected these problems long before the Exercise. The fact that they apparently went undetected during three years of training highlights that LILCO's training i
program has not prepared its personnel for the practical needs involved in respond;ng to an emergency. This is particularly l
true since even the February 13 Exercise only revealed deficiencies in the relatively few areas of LILCO's performance actually observed by FEMA.
Next, are some problems with procedures disclosed in the Exercise; they reflect in large part the lack of experience training in the field, and the kind of common sense adjustments that only an organization with more experience or much better training can make.
Patchogue Staging Area personnel did not request sufficient information regarding impediments to evacuation (FEMA I Report at 65);
A radiological exposure team stopped within the. plume j to radio results, thus incurring unnecessary exposure (FEMA Report at 51, 52);
Posting of status board information did not reflect time of posting (FEMA Report at 72);
Numbering scheme needed to reflect order of messages (FEMA Report at 71);
Failure to read dosimetry levels by bus driver during 75 minute trip (FEMA Report at 59);
Security problems as revealed at Patchogue Staging Area (FEMA Report at 61).
There also were communication, control, notification and briefing problems in the Exercise that should have been corrected prior to the Exercise if LEED had learned through experience.
Four LERO members failed to verify their initial notifications on the automatic verification system and the Lead Communicator had to take time out to contact them by telephone l
(FEMA Report at 28);
Confusion existed about notification of the FAA, and it was not clear where the procedures for this were located or that they even existed (FEMA Report at 29, 39; LILCO Admission No. 200);
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Inadequate provisions for handling messages to the ,
Director of Local Response when he is not at his station (FEMA Report at 31); ,
- Projected data were reported as actual data for two and one half hours (FEMA Report at 33);
Unclear procedures on notification systems could lead to confusion (FEMA Report at 34);
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- Lack of alternative notification and response procedures for field impediments (FEMA Report at 37, 38);
- Extraneous and possibly confusing information (clearly marked for deletion) in EBS messages was left in for the press to see (FEMA Report at 53);
Inadequate means to assure that the Bus Drivers arrive at the proper Transfer Point (FEMA Report at 66).
Finally, there were problems witn technical information that have a similar character.
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' Complex information on the use and meanings of dosimetry readings poorly or wrongly communicated and acted upon by those who needed them (FEMA Report at 68);
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Existence of two acales for measuring distance (feet I
and meters) led to conversion errors that could have been serious, and a delay in correcting the error (FEMA Report at 33);
Mistake in stating thyroid dose level requiring l I
evacuation by the Health Services Coordinator (FEMA Report at )
33).
To repeat, these are some of the items in the Exercise that
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suggest that a great deal of repertoire adjustment, and l i
opportunity for the various elements and individuals in the LERO organization to work together under realistic emergency I
conditions, would be needed in order to have an emergency i l organization capable of performing its assigned task. These l
items are important because emergency tasks such as deciding upon i
and communicating protective action recommendations to the l public, controlling an evacuation, and implementing relocation l following a radiological emergency are highly interactive and l
i highly time dependent operations, particularly in a highly- l centralized, tightly-coupled organization such as LERO. Many things must mesh in order to succeed; small delays, misunderstandings, information errors, etc., could trigger a wid's range of subsequent failures. The failures revealed during the Exercise all support our view that the LILCO personnel have had little effective training. In particular, the foregoing problems l
all document the failure of the LILCO training program to prepare LERO personnel for real implementation of the Plan. Accordingly, the training program is fundamentally flawed,
- 4. LILCO Has Not Corrected its Failure to Provide Training in Responding to Unanticipated and Unrehearsed Events Q. In the June, September, October, and December drills which have been referred to previously, did LILCO provide its personnel with any greater opportunity to learn to respond to unanticipated and unrehearsed events?
A. No. Notwithstanding the poor performance at the Exercise, the subsequent drills have continued to be largely unrealistic in terms of this sort of training. For instance, the June drill used fuel truck and gravel truck impediments.
Although some of the players in the June drill were different from those in the February Exercise, they must surely have known the parameters of the earlier scenario. Thus, this was no real opportunity to learn to respond to an unanticipated or unrehearsed event.
I
Similarly, in most of the other drills, the " unanticipated" and " unrehearsed" events included gravel truck impediments and fuel truck impediments. Such a lack of variation by LILCO underscores the fundamental deficiencies in LILCO's training program.46 What is most significant about LILCO's training program since the Exercise, however, is that LILCO has failed to learn that not only must there be unanticipated events with which to practice, but that the practice in the drills or exercises must include performance. Rather, LILCO continues to run its scena-rios and drills in a mechanical manner that purports to have people go to locations and follow procedures and to conclude from that " demonstration" that there is adequate performance. That is not the case. There zuust be an opportunity for actual performance of emergency functions -- such as in the critical incidence response board utilized by the Suffolk County Police Academy -- before there can be any basis for any confidence in the ability of personnel to perform. Since LILCO has continued 46 In the December drills, LILCO introduced four impediment 3.
They involved a brush fire, a duck truck, a cement nixer truck, and a cesspool truck. In our opinion, these small additions to the list of unanticipated events do not compensate for the overall lack of realism in LILCO's training program. This is especially true since despite the poor performance by Shift 1 in responding to traffic impediments during the Exercise, the expedited dispatch of field personnel in response to traffic impediments was not even an objective of the December 10 drill.
Attachment 9 at 48.
l
l l
to ignore the need for actual performance, one must conclude that LILCO's ability to respond to unanticipated and unrehearsed i l
events remains as it was during the Exercise -- deficient. ;
1 Q. You draw a distinction between practicing procedures j l
and performance. What do you mean?
A. Following procedures is important, since it is part of l the basic training that provides the necessary foundation for I more advanced training.47 But, following procedures is not enough, particularly in the context of unanticipated events. No set of procedures can anticipate all contingencies. What is necessary, therefore, is a training program that forces trainees to think, not just to follow procedures. This is accomplished by l performance -- actually responding to free-play events such as we have previously discussed. Only in that manner can trainees gain realistic understanding regarding what an actual emergency response may entail.
l Q. To the extent LILCO has included road impediments in its post-Exercise drills, has its performance been adequate?
A. No. In the June 6 drill, LILCO personnel responded to I
a simulated road impediment, which was essentially identical to the fuel truck impediment that was simulated during the Exercise.
47 In the next section of this testimony, we discuss LILCO's failure to train its personnel to follow procedures.
c I
LILCO's performance was described in the LILCO's own drill report as " confused" and the response to the impediment was " delayed."
Attachment 7 at 4. Specific comments included the following:
o The Transportation Support Coordinator should have done a better job of keeping control and managing his group during the road impediment scenarios. No' one individual was assigned to be in charge of handling these impediments. Because practically all groups in the EOC need to be made aware of such a problem it is important that one individual be responsible for coordinating this effort.
o The RHC (Radiation Health Coordinator] was not made aware of the impediment to evacuation until 2:15 PM; 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> and 30 minutes after the event had occurred, o The EBS message telling of the road impediment was issued at 1:29 PM; almost 45 minutes after the event had occurred. In addition this important piece of information was included with the entire EBS message and might have been missed by the general public. A special EBS message should have been issued.
o The message for the second road impediment was called into the EOC and was properly logged on a message form, however when the information was relayed to the field, the wrong road was mentioned; Route 20-A vs. Route 25. The word came back from the controller, simulating a route spotter, that there was no impediment at the location indicated.
At that time it was assumed that the impediment was either a false alarm or had been cleared, and no follow up action was taken. It was not until the controller in the EOC prompted the players three times to review the original message that any action was taken.
Attachment 7 at 4-5.
As with the Exercise, therefore, during the June 6 drill the lack of practical, hands-on, learning-by-doing training resulted in LILCO personnel being unable to respond to a simulated road impediment in a timely or effective manner. This repeated problem further underscores that LERO's personnel have been f inadequately trained to implement the LILCO Plan. l This is further demonstrated by LERO's performance in later l drills in which similar impediments were simuJated. For example, during the September 10 drill there was approximately a one-half hour delay at the Road Crew Communicator's desk in transmitting the message to respond to one of the impediments. Attachment 8 at 3. In fact, the problem with road crews was so bad that j j despite repeated requests from the Traffic Guide at Traffic Control Post #45 for a road crew to respond to a traffic impediment, the road crew never arrived. Attachment S at 5.
During the September 17 drill, problems occurred concerning the generation of rerouting information and the determination of new evacuation time estimates. Attachment 8 at 6. Performance during the October 1 drill also was flawed. According to the drill report, the Traffic Engineer had to be prompted to develop revised evacuation time estimates. Attachment 8 at 9. In j addition, problems were noted concerning the flow of information into the public information office. Attachment 8 at 9.
1 Finally, the December drills further demonstrated the inadequacy of training to handle unanticipated events. For example, in response to the gravel truck impediment during the l
December 2 drill, a heavy duty wrecker necessary to clear the impediment had not arrived over one hour and fifteen minutes after it was requested by a Road Crew. Attachment 9 at 26-27.
More problems were reported on December 10. In responding to a simulated brush fire that had blocked the entire Long Island Expressway as well as another major artery, critical information was not communicated. For instance, in communicating the message to the EOC, LERO personnel at the ENC failed to mention the roads that were blocked. Attachment 9 at 4. Demonstrating their lack of training and experience, EOC personnel failed to note this at the time and thus did not request the critical information. In fact, it wasn't until prompted by a controller to recontact the ENC that the Traffic Group acquired the information. Attachment 9 at 4. Further, the Traffic Group did not even begin -
investigating rerouting or the fire's effects on evacuation' time estimates until over half an hour after learning of the fire.
Attachment 9 at 4. In addition, in response to a duck truck impediment, long delays and improper communications were noted.
Attachment 9 at 10. Further, the drill report indicates that the time it took a road crew to arrive at the scene of the duck truck l l impediment after it was dispatched (57 minutes) was "less than adequate. Attachment 9 at 31.
1 i
Thus, the post-Exercise drills support what the Exercise ;
demonstrated -- inadequate training, lacking practical, learning-by-doing experience, resulted in LERO being unable to take necessary actions in a timely manner to protect the public.
It must be emphasized that the repeated failures by LILCO in the post-Exercise ~ drills came after the FEMA Report, after SNRC-1269 (Attachment 10) detailing LERO's adjustments in response.to the FEMA Report, and after, presumably, extensive remedial training.
What these failures do, therefore, is emphasize again the fundamental flaws in LILCO's training program.
B. Contention Ex 50.B: Failure to Train Personnel About Basic Knowledge and Information Essential to Implement the Plan and Procedures
- 1. Introduction Q. Please state subpart B of Contention EX 50.
t A. Subpart B states:
The exercise demonstrated that LILCO's' training program has been ineffective in instructing LERO personnel to follow and implement the LILCO Plan and LILCO procedures, and in imparting basic ,
knowledge and information essential to the ability to implement such procedures. Exercise actions and events which support this allegation are described in Contentions EX 36-39, EX 41, EX 42, EX 45, EX 49, and in the following FEMA conclusions: EOC-D-1; ENC-D-1; R-D-2; PSA-D-6; EOC-ARCAs-2, 5, 6, 7, 9; PJSA-ARCA-1; PSA-ARCAs 3, 4, 7, 8, 9, 12, 13, 14, 15, 16; R-ARCAs 4, 5, 6; RC ARCA 1.
I - - - - - - - _ _ _ _ _ _ _ _
0 Do you agree with subpart B?
A. Yes, the Exercise demonstrated that LILCO's training program has been ineffective in instructing personnel to follow and implement the LILCO Plan and procedures. It has also been i
ineffective in imparting basic knowledge and information to personnel essential to their ability to implement such procedures. Our conclusion is based upon the numerous occasions h
during the Exercise where LERO personnel failed to follow and implement LILCO's Plan. Such failures demonstrate a major problem with LILCO's training program. When personnel, after three years of training, are not able to follow and implement the Plan that they have been trained to implement and cannot demonstrate even the most basic knowledge necessary to implement established procedures, it becomes clear that whatever trainfng has been provided has failed. Indeed, an inability to implement a plan and procedures after so much time constitutes strong evidence of an unsuccessful training program, since, if anything, training individuals to follow a plan is one of the simplest, yet most important, things for which people can be trained.
This failure of LILCO's training program is serious for two other related reasons as well. First, the demonstrated inability to follow the Plan and procedures involves an area which has received primary emphasis in the LILCO training program. Thus, while earlier we discussed the failure of the training program to
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address the crucial aspect of emergency performance.cf dealing with unexpected and unanticipated events, the deficiencies
-discussed in this section relate to areas obstinately covered, and covered extensively, by LILCO's three-year training program.
Thus, the LILCO training failure is particularly serious.
Second, as we discussed earlier, it is extremely important for LERO personnel to learn basic aspects of LILCO's Plan. This i is the " routine" training. The routine tasks -- which include following the Plan and procedures -- must be really well known, in order to enable the emergency personne1'to deal with all the non-routine things they are going to have to deal with. Duri..3 a j real emergency, people are not going to have time to have to think hard about whether or not they need to read their dosimeters, how to write down messages, etc., because they are going to have to be thinking hard about how to deal with unexpected situations. iherefore, if the " routine" tasks cannot 1
be done by rote, performing them will take up all the time and intellectual energy that the LERO personnel have, leaving none to deal with immediate non-routine problems of a real emergency. ]
I Thus, it is crucial for LERO personnel to be able to follow I i
the LILCO Plan and to be able to implement its procedures since ;
the Plan contains the guidelines and methods that LILCO has i
devised for handling an emergency at Shoreham. If those 1 individuals responsible ~for responding to an emergency at
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(
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Shoreham cannot follow the guidelines established for carrying out their functions, there would obviously be no assurance that l LILCO could adequately protect the public's health and safety.
Further, we repeat that an ability to follow and understand the Plan and procedures is absolutely critical if LERO personnel are to be able to then improvise to respond to unanticipated and unrehearsed situations. Without such basic understanding, the ability to respond to these more difficult situations will be lacking.
- 2. Examples of LILCO's Failure to Provide Effective l Training to Provide Personnel with Basic Knowledge on How to Follow and Implement the Plan and Procedures l
(a) Introduction j l
l 0 Can you provide examples from the Exercise that demonstrate the ineffectiveness of LILCO's training program in !
teaching LERO personnel basic knowledge essential to follow and j implement the LILCO Plan and procedures? l i
A. Yes, there at? many. The following events or occurrences support tur conclusion about the ineffectiveness of LILCO's training program in instructing personnel to follow and implement the LILCO Plan and procedures. Many of them also document LILCO's failures to teach its personnel even the most basic information about the anticipated emergency response.
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i ,
l l
I j --
The difficulties experienced by LILCO's Bus l Drivers in locating residences and going to wrong locations (e.o., FEMA Report at xv, xvi, 65 and 66);
Erroneous announcements of pertinent information
-- Mr. Brill, the BNL scientist assisting LILCO at l the ENC, provided answers inconsistent with the j EBS messages (Videotapes of Press Briefings held i at ENC during the Exercise);
Inadequate use and readings of dosimetry equipment and failure to know excess exposure levels, excess exposure authorization procedures, KI ingestion procedures (e.o., FEMA Report at 59, 68-70, 76, j and 77); 1 Excessive route alerting times (e.o., FEMA Report at xiv, xv and xvii);
Delayed dispatching of personnel (e.o., FEMA' Report at xvi, xviii, 37, 41, 57-58, 62, 66-67, 74-75; LILCO Admission Nos. 132, 140, 173);
Use of wrong security procedures (e.o., FEMA Report at xv, 61 and 63);
Incorrectly completing message forms (e.o., FEMA l Report at xvii, 42, 71-73);
Excessive time in monitoring personnel (e.o., FEMA Report at xviii, 80-81; LILCO Admission No. 195; FEMA Admission No. 180);
Confusion in contacting the FAA (g2g2, FEMA Report at 29, 39; LILCO Admission No. 200);
l Pertinent information not included on message j forms (e.o., FEMA Report at 30, 37, 39, 65; LILCO i Admission Nos. 152, 153, 154);
)
Untimely internal communications of information ;
(e.o., FEMA Report at 36-37, 39; LILCO Admission i No. 155); I l
Failures to provide press information in timely manner (e.o., FEMA Report at 52-53; LILCO
- Admission Nos. 74-79, 91 and 93); 1 l
l l
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1
Extraneous information included in EBS ruessages (e.a., FEMA Report at 53);
Dissemination of out-dated information by rumor control personnel (e.o., FEMA Report at 53; LILCO Admission Nos.96-100);
Traffic Guides not knowing location of reception center or where public was to be directed for monitoring and decontamination (g292, FEMA Report at 64; FEMA Admission No. 168);
Personnel not reporting to assigned locations or where directed to go (e.o., FEMA Report at 64-65; LILCO Admission Nos. 174, 175);
\
Failures to update status boards (e.g., FEMA Report at 72, 73);
Personnel directed to wrong places by their superiors (e.a., FEMA Report at 65, 67; FEMA Admission No. 175).
(b) Communications Problems in Dealing With Traffic Impediments 0 Did LILCO's handling of the traffic impediments indicate a failure to train personnel in basic knowledge essential to follow the Plan and procedures?
A. Yes. LILCO not only was unable to respond to the unanticipated aspects of those events, it also was unable to follow basic procedures that were applicable. In fact, the response of LILCO's personnel to the impediments involved numerous instances where the LILCO Plan and procedures were not followed or implemented.
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Q. Please give examples.
A. First, according to the Plan, the Evacuation Coordinator directs LERO's actions in the areas of traffic control, transportation, and evacuation. OPIP 2.1.1, p. 26.
However, during the Exercise, the Evacuation Coordinator was never informed by LERO personnel of either of the two FEMA " free play" impediment messages. FEMA Report at 36. This was contrary to OPIP 3.6.3, which requires such communication. This failure to advise the Evacuation Coordinator of the two simulated impediments, as well as the lack of status updates and other necessary communications between and among other LERO personnel, including the Evacuation Route Coordinator, the Traffic Control Coordinator, the Road Logistics Coordinator, the Transportation Support Coordinator, Lead Traffic Guides, Road Crews, Evacuation Route Spotters, and Evacuation Eupport Communicators, were violations of LILCO's Plan and procedures, which these personnel had supposedly been trained to follow. This failure to follow the Plan or implement its procedures led to substantial delays by LILCO in responding to the impediments.
Second, LERO personnel at the EOC failed to include Essen-tial information communicated to thera via the "f ree play" impediment messages on LERO message forms, nor did they otherwise communicate such critical data to the other LERO personnel expected to respond to the impediments, as required by OPIP 3.6.3
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and OPIP 4.1.2. See FEMA Report at 30; FEMA Admission No. 71.
For example, important information was not included on the 10:45 LERO message from the Evacuation Route Coordinator to the Evacuation Support Communicator for Route Spotters / Road Crews regarding the gravel truck impediment, including the fact that three passenger cars were involved in the accident. Similarly, essential information was not included on the 11:06 LERO message from the Evacuation Route Coordinator to the Route Spotter / Road Crew Communicator regarding the fuel truck impediment, including 1
the facts that fuel was leaking, that there was the possibility of fire, and that both shoulders of the road were blocked. See FEMA Report at 30. LILCO's Plan requires that such information be communicated. OPIP 3.6.3 at 12.
Because LILCO's training program was unsuccessful in l instructing personnel to Lollow the Plan and procedures, and in imparting basic knowledge and information essential to their ability to implement such procedures, the equipment eventually l sent to respond to the gravel truck impediment was inappropriate and inadequate to remove the simulated obstruction. Similarly, 1
the equipment eventually sent to respond to the fuel truck impediment was so substantially delayed that LILCO's response was not even observed by FEMA. See FEMA Report at 37, 39, 57-58.
Q. Were there any other communications problems pertaining l to the impediments situation?
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A. Yes. There were at least four others. First, the Evacuation Coordinator and other LERO personnel were not properly informed concerning a " visual check" of the simulated fuel truck impediment received by the Transportation Support Coordinator from the Bus Dispatcher at the Patchogue' Staging Area. Appro-priate actions therefore were not taken in response, contrary to OPIP 3.6.3, 3.6.4 at~2, until more than three hours after the
" free play" message regarding the impediment had been injected.
Egg FEMA Report at 30, 57.
Second, LERO personnel were unable to locate, communicate i with, or timely dispatch a Route Spotter to investigate and ,
verify the simulated fuel truck impediment. They were also un-able even to determine whether a Route Spotter had actually been dispatched. Thus, at about 11:15, the Route Spotter / Road Crew Communicator requested the Port Jefferson Evacuation Support Communicator to determine whether a Route Spotter had been l
dispatched as required under the Plan, and as apparently assumed l by the LERO players. The Route Spotter was not in fact dispatched until about 12:02. See FEMA Report at 37; FEMA Admission No. 69.48 48 LILCO has indicated that the Route Spotter was dispatched at 11:40. LILCO Admission No. 53. At any rate, there clearly was confusion and delay with regard to dispatch of the Route Spotter.
l
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Third, although the FEMA controller had informed the Evacuation Coordinator of the gravel and fuel truck impediments at about 12:13 (FEMA Report at 36; LILCO Admission No. 155, as of 12:40), ,the Transportation Support Coordinator had not been informed that bus evacuation route M-1 was potentially blocked by the gravel truck impediment. See FEMA Report at 36; FEMA Admission No. 68; but see LILCO Admission Nos. 52 and 161. Thus, )
l the initial errors, omissions, and failures to follow procedures and accurately transmit information were compounded by additional errors even after the first errors had been identified for LERO by FEMA.
Fourth, as a result of the numerous failures to follow the Plan and the resulting delays in internal LERO communications, information concerning the road impediments and the need to avoid the blocked evacuation routes was not communicated to the public until about 1:45, when EBS message number 8 was simulated. LILCO Admission No. 163.
1 i
Q. Why do these examples of communications mistakes that occurred during the Exercise in response to the two traffic j impediments demonstrate that LILCO's training program has been f ineffective in instructing LERO personnel to follow and implement the LILCO Plan and procedures?
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1 l
A. Tho fact that LERO personnel failed to follow the Plan and its procedures in relation to communicating pertinent information in a timely manner indicates that they were not I effectively trained. LERO's personnel had received three years of training and had participated in dress rehearsal drills immediately prior to the Exercise. If, after three years of training and dress rehearsals, LERO personnel could not follow the Plan and communicate basic information as required under the Plan, it is reasonable to conclude that whatever training they had been provided had been unsuccessful. An effective training program which had achieved any measure of success in teaching LERO personnel the Plan and procedures and in imparting the necessary knowledge to enable such personnel to implement the Plan and procedures would have reduced dramatically the number of mistakes that were made by LERO personnel during the Exercise in communicating information relating to the road impediments. When other mistakes made by LILCO in handling the road impediments are also considered,49 the failare of LILCO's training program ,
becomes even clearer.
In addition, several other comments are in order. First, the FEMA free play message was injected at the EOC, not in the s field. This meant that only one-half of the LERO communication f
network had to function. (If the message had been injected in
'the field, the communications would have had to go from the field 49 Sag, e.o., our earlier testimony regarding Contention Ex 50.A; Contention Ex 41 Testimony.
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- ,, j x yp -
{
,. l' t t
\c 4,)
to the EOC and back to the field; in the Exercise, it only had to j
. i go from the EOC to the field. See Contention Ex 41 Testimony at %
32-33, 42. Despite this somewhat less demanding scenario, LILCO's training was still not adequate.50 -
Second, the communications difficulties reveal trkining deficiencies because the LILCO personnel should have figure.d out alternative means of coping with the problems and failure's of ,
)
communication. For instance, after having received the firJt
'\ .,
FEMA prompt, the Evacuation Coordinator and/or other coordi'nators '
should have followed up/ double checked /given redundant orders, j etc.,toassurethatthesamekindoffailuresdidn'thaph$nthe'
/ u' second time around. In fact, they did happen again. Thun,g the l
point is not only should LERO personnel be trained to follor.the'
.i procedures,buttheyshouldbetrainedto.understandthat14the procedures don't work or are not fo'. lowed, theymustcomeup,wiph other ways of achieving the desired result. Thus, these difficulties underscore that LILCO's training program has failed l
to teach LERO personnel to handle real life interactions and complexities. ,
50 'de understand-that-bILCO-has-suggested-that-injectir.; th message--at-th e-EGC-was-42 n re aMs t-i er--Howev e eT-n ews-o f-i spa d i me n t a af. ten _is learned-about by-headquar-ters-personnel 41a-phone--cam s, rather tNn hy field per w l.
/
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2 9\ ?
l '$ .; .
t
!r 4
s (c) Failure to Follow Plan and Procedures ,
.in'Oqaling with the Ntas Media i 2
Q. Does LILCO's performance during the Exercise in dealing with the media provide bases for your support of subpart B of Contention ' A 507 A Yes. The inability of LILCO's training in instructing l
personnel to follow and implement the LILCO Plan and procedures is further demonstrated by the manner in wt.ich LERO dealt with the media during the Exercise. On numerous occasions, LERO personne1'were unable to provide" timely, accurate, consistent and non-confusing information to the news media at the ENC. Thus, ]
1 they failed to implement the LILCO Plan (particularly at pages 3.8-4 thru 3.8-6) and procedures (particularly OPIP 3.8.1). This is discussed extensively in the Ex 38/39 Testimony (pages 26-29; ]
66-79; 81-85;92-100 in particular). ~Thus, the details will not be repeated here.
O. LILCO has stated that it was untimely in providing ,
information to the news media because of copier problems.
Assuming the hardware could:be replaced or improved, would that affect your opinion concer.ning LILCO's ENC performance during the Exercise or its training program?
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A. No, it would not, for several reasons. First, hardware problems had nothing to do with decisions, made by the " trained" LERO personnel at the ENC, to tolerate long delays in providing information to the media or even deliberately to withhold information from the media. Specifically, the almost 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> delay in activat' , the ENC was of no apparent concern to the LERO personnel, since no alternate means of providing information to the press -- even in lieu of having officially set up the ENC
-- were implemented during the Exercise. Similarly, the decision by the LERO spokesperson to withhold information about the general evacuation advisory until the next press conference had nothing to do with copier problems.
Second, hardware problems at the ENC persisted even in subsequent drills after the hardware " fixes" had supposedly been implemented. The fact is that a well-ttained emergency response team would be in a position to deal with hardware problems because they are inevitable. I2 adequately trained, they should be able to implement alternative methods of transmitting important information. Yet, time after time, the LERO personnel demonstrated their inability to do so effectively.
Third, the copier problems also have nothing to do with the apparent unawareness by the " trained" LERO personnel of how the media operates and what its reactions would be to the types of failures that occurred. As discussed in the Contention Ex 38/39
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l l
l Testimony, which we will not repeat here, the media will not tclerate the kinds of delays which LERO consistently demonstrated during its drills. In a real emergency, such delays would render the ENC irrelevant because the media would seek other sources of information, whether they were informed sources or not.
Q. LILCO has also argued that deficiencies revealed at the ENC during the February 13 exercise are trivial because the most important matter was getting the EBS messages to the public, not providing information to the media. What is your response to that argument?
I l
A. From the training perspective, we absolutely disagre?. I We do not address here the ramifications upon the public information program of LlLCO's failures. That is discussed in the Contention Ex 38/39 Testimony. From a training perspective, however, the failures of ENC personnel are significant, even if i
one were to assume, incorrectly in our opinion, that those ENC l activities are irrelevant to an overall emergency response The fact remains that there are public information provisions in LlLCO's Plan and procedures, and it has purportedly trained its personnel to implement those provisions and to do so properly.
The Exercise revealed that those personnel were incapable of doing so. Therefore, our point remains valid regardless cf whether one considers providing information to the media important or not.
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What must be emphasized, however, is that LERO's demonstrated lack of concern during the Exercise for the untimely distribution of information to the media demonstrates a fundamental unawareness by LERO -- and a fundamental failure of the LILCO training program -- to understand the importance of l
timely distribution of data to the media. The media would not be~
content during an actual emergency to await LERO's schedule in providing information about the course of the accident. Rather, the media would be insistent about receiving up-to-date information about the accident. In our experiences, we have learned that in emergency situations there often is no time to prepare written reports. The media will not tolerate such delay.
The media will only stay at an emergency news center as long as it believes that it is being provided with the most current and accurate information available. If the media is not receiving such information, it will leave the news center and respond to other areas of activity in order to obtain the information.
(d) Other Examples of LILCO's Failure to Train Personnel in How to Follow and Implement the Plan and Procedures 0 Are there additional examples which support Subpart B of Contention Ex 50?
A. Yes, there are a number of other examples. First, the response of LERO personnel to the Ridge Elementary School " free play" message further supports our concerns regarding the
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1 inadequacy of LILCO's training program and the inability of LERO's personnel to follow the Plan. We address this in more-detail in our discussion of subpart C (Section III.C.1 below).
Second, communications relating to release data and dose projections were not handled properly or accurately during the Exercise, as required by OPIP 3.6.1. For example, LERO personnel failed to designate clearly on the EOC dose assessment status ]
boards the distinctions between DOE RAP monitoring data and LILCO field monitoring data. Eeg FEMA Report at 29-30. This failure 1
demonstrates not only an inability to effectively communicate j J
important dose information and potentially significant distinctions between the information from the two sources as required by OPIP 3.6.1, but also the failure of the training 1
program to teach the significance of that distinction, contrary to the requirements of OPIP 3.6.1.51 l
l 51 Similarly, during the Exercise downwind distances of sample readings by field monitors were incorrectly reported as 7000 meters instead of 700 meters for a thyroid dose. This error ;
resulted in an initial calculation of thyroid dose as 900 mrem /hr i at 4.3 miles downwind, instead of 9000 mrem /hr at about 0.5 miles downwind. Egg FEMA Report at 33. Furthermore, at the EOC, several extrapolated doses at various. distances were reported as actual measurements rather than as projected data on the dose assessment status board -- an error that took two and one half hours to identify and correct. See FEMA Report at 33. These failures indicate an inattention to detail and accuracy in-recording, processing, and communicating data critical to the-accident assessment and protective action recommendation pro-cesses which are at the core of an emergency response and are required by the LILCO Plan.
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Third, LERO personnel at the staging areas evidenced an inability to accurately, appropriately, or in a timely manner obtain, record, transmit, or act upon emergency data, in violation of OPIPs 4.1.2, 3.6.3, 3.6.4, 3.6.5, and 3.9.1. For example:
(i) Perconnel at the Riverhead Staging Area did not properly record or appropriately identify event status .informa-tion on Emergensy Event Status Forms or on status boards as required by the Plan. Sgg FEMA Report at 72.
(ii) The Bus Dispatcher at the Patchogue Staging Area, in violation of the Plan, repeatedly made inaccurate and misleading announcements to bus drivers concerning the dose levels at whicn they were to call in. These incorrect instructions concerning such important information led fo confusion on the part of the bus drivers. See FEMA Report at 6E, 69.
(iii) The Transfer Point Coordinator at the Brookhaven National Laboratory Transfer Point was unable to fo] low instruc-tions and transmit information and directions from the staging area to bus drivers. For example, he directed a bus driver to the EWDP despite the fact that a message from the Bus Dispatcher
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to all Transfer Point Coordinators had directed that all drivers arriving at transfer points before 4:00 should be directed to the Nassau Coliseum Reception Center. See FEMA Report at 65, 67.
Finally, LILCO's Traffic Guides were uninformed about important information required for Plan implementation. For example, only one Traffic Guide out of the 14 interviewed by FEMA from the Patchogue Staging Area knew the location of the Nassau ,
Coliseum Reception Center, and one Traffic Guide believed that the general public was to be directed to LILCO's EWDF. FEMA Report at 64. LILCO's Traffic Guides also did not fully understand the chain of command for authorization of exposures in excess of the general public PAGs. In addition, some Traffic l
l Guides indicated to FEMA that they might question the l
authorization of other LILCO personnel (specifically, the Lead Traffic Guides) regarding excess exposure. FEMA Report at 69.
This lack of knowledge on the part of LILCO's Traffic Guides highlights the failure of LILCO's training program to impart necessary knowledge to LERO personnel to enable them to implement the LILCO Plan and procedures. Certainly, LILCO's Traffic Guides have received " training" during the past three years regarding the chain of command for exposure in excess of the general public PAGs, the procedure regarding authorization for excess exposure, and the location of facilities relied upon by LILCO for monitoring and decontaminating evacuees. Notwithstanding this
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" training", however, the Traffic Guides evaluated by FEMA during the Exercise were uninformed and generally unable to answer questions concerning basic information in LILCO's Plan.
Accordingly, one nust conclude that the LILCO training program has been ineffective in instructing LERO personnel to follow i
LILCO's Plan and procedures. Equally clear is the conclusion that such training as has been provided has failed to impart basic knowledge to LERO's personnel necessary to implement the LILCO Plan.
- 3. LILCO Has Not Corrected its Failure to Train its Personnel in Basic Knowledge Necessary to Implement the Plan and Procedures O. Has anything occurred since the Exercise that changes your opinion about the inability of LILCO's training program to instruct LERO personnel to follow and implement the LILCO Plan and procedures?
A. No. In fact, the performance of LERO personnel during drills held since the Exercise reinforces our conclusion that LILCO's training program has been unsuccessful in instructing personnel to follow the LILCO Plan and implement its procedures.
For example, during the February 13 Exercise, some personnel failed to demonstrate a clear understanding about procedures regarding allowable exposure levels, i.e., 3.5 Rems and 5 Rems.
See FEMA Report at 68, 76. Now basic training, if provided
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I properly, should be able to take care of that. But, the same ;
problem emerged in the later drills. For example, during the June 6, 1986 drill, several Traffic Guides were still not clear about the procedures. Attachment 7 at 6. i O. After at least two warnings in the area of measuring and acting upon exposures, in the February 13, 1986 Exercise and the June, 1986 drill, did LILCO take action to insure that everyone was trained? i q
i l
A. We assume LILCO tried, but it was clearly not success-ful. During the September 10 drill, "of the 9 Traffic Guides questioned most of them were not aware of the maximum allowable dose, and the proper procedures governing the use of KT.."
l Attachment 8 at 4-5. One week later, after debriefing and l presumably some training, the Traffic Guides were reported to be l knowledgeable about proper radiation and exposure control.
Attachment 8 at 8. So it appears possible for LERO to provide basic training that will last at least a week in such matters, which are really quite predictable and routine matters. But the problem in this area, which goes back at least to the February 13, 1986 Exercise, keeps appearing. The same dosimetty problem appeared in the September 10 drill with Road Crews, two of whom, dispatched from Riverhead, "were not aware of the proper procedures regarding the use of dosimetry and maximum exposure allowances." Nor were they " properly informed to take their KI
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tablets." Attachment 8 at 6. And then, the report on the October 1 drill reports the problem again affecting traffic guides: "Of the 5 Traffic Guides questioned, all were unclear as to the maximum allowable doses." Attachment 8 at 11.
The maximum allowable dose is not a trivial matter for these individuals, or the organization as a whole. However, the underlying principle is what is most important: the failure to q train individuals in this matter, after repeated warnings that the training was not adequate, documents a fundamental failure of the LERO training program. After all, this is a relatively easy task compared to others that LERO will confront in an emergency.
Also, one can reasonably expect that of all the material presented in a training program, the trainees would make the greatest effort to learn those procedures involving their personal safety. If these are not learned, other material not as crucial to personal safety surely have not been learned.
Nevertheless, even after several failures, the problem still appears.
Q. Are there other examples from the later drills that further demonstrate the ineffectiveness of LILCO's training program in instructing LERO personnel to follow and implement the Plan and procedures?
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A. Yes. During the September 10 drill, for example, an EBS message was broadcast without the simulated sounding of the sirens. Attachment 8 at 2. However, the LILCO Plan requires that EBS messages be broadcast in coordination with the activation of LILCO's sirens, to ensure that the public is alerted to the need to listen to an emergency broadcast station.
Plan at 3.3-4. This failure to follow the Plan was, according to the drill report, the result of poor coordination between the Director of Local Response and the Coordinator of Public Information. Sgg Attachment 8 at 2. Such lack of coordination clearly reflects inadequate training.
Also during the September 10 drill, the Radiation Health Coordinator ordered the ingestion of KI prior to performing the required calculations necessary to justify this action. at 3. This was a violation of the LILCO Plan and illustrates again the failure of the LILCO training program to effectively instruct personnel to follow the Plan.
Another example from the September 10 drill which illustrates the fact that LILCO's training program has been ineffective in instructing personnel to follow the LILCO Plan and procedures is that LILCO's personnel who reported to establish the EWDF during the drill were not familiar with their jobs and took no action until prompted by the controller. Further, these LILCO personnel were unfamiliar with the location of the storage
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rooms for EWDF equipment and the equipment checklist was not used as set out in LILCO procedures. Attachment 8 at 4.52 In a real emergency, the fact that LERO personnel had not been effectively trained to set up the EWDF and to follow procedures in checking emergency equipment could result in the EWDF not being functional or available to emergency personnel.
Further, during the September 10 drill, personnel at the LILCO staging areas were slow to activate their facilities.
According to the drill report, "the controllers had to prompt and train the personnel during the drill as to their duties."
Attachment 8 at 5.53 The fact that personnel were not trained effectively in how to set up the staging areas, requiring that they be trained during the drill, is an obvious indication that 52 This does not appear to have been an isolated problem.
During the September 17 drill, the Emergency Preparedness group failed the EWDF.
to fulfill their role in properly checking equipment et This resulted in several pieces of faulty equipment being used to monitor emergency workers. Attachment 8 at 7. In addition, contrary to LILCO procedures, during the September 17 drill dosimetry equipment was issued at the same time that dosimetry briefings were held. This resulted in some emergency workers not receiving adequate briefings. Attachment 8 at 8.
53 Similar problems arose on October 1. Thus, "the Lead Traffic Guides needed guidance to perform their function and implement their procedures." Attachment 8 at 11. In addition, personnel at the Riverhead Staging Area "had to be walked through their jobs either by more experienced people or by the control-1ers." Id. at 12.
These failures to have personnel knowledge-able about their jobs demonstrates a serious flaw in the LILCO training program. Obviously, when personnel have to be walked through their jobs, a training program has been unsuccessful in instructing them how to follow and implement the Flan and procedures.
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L;LCO's training program has been ineffective in instructing personnel in ongoing readiness and in how to follow and implement the LILCO Plan and procedures.
Q. Did similar problems brise in LILCO's December drills?
A. Yes. Both drills contain numerous examples of personnel failing to follow and implement the Plan and its procedures. During the December 2 drill, for instance, there were delays in the pre-staging of bus drivers because procedures were not followed. Attachment 9 at 11. Rather than follow procedures and pre-stage buses at the appropriate time, the Manager and Evacuation Coordinator wanted to wait until all bus drivers arrived at the staging areas to issue the order, even though this would result in the late dispatch of the drivers.
Attachment 9 at 11.54 The December 10 drill demonstrated problems as well. This is especially troublesome since the same personnel that were drilled on December 2 were drilled on December 10, and the December 2 drill was designed to teach personnel the procedures.
54 Further, during the December 2 drill, the Patchogue Staging Area Coordinator failed to fill out OPIP 4.1.4, Attachment 4, as required under LILCO procedures. Attachment 9 at 16. And the Lead Controllers at Patchogue failed to follow procedures by not documenting critical actions and decisions. Attachment 9 at 16.
Also on December 2, traffic guides were frequently dispatched much too late, resulting in their not arriving at their posts until over an hour after the EBS message recommending evacuation was issued. Attachment 9 at 19-20, 21, 24, 27-28.
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Egg Attachment 9 at 1. Thus, despite receiving training one week earlier, some personnel still failed to follow the LILCO Plan and its procedures. ;
a l For example, during the December 10 drill, critical informa-
]
tion concerning the roads being blocked by a traffic impediment
'I was not properly communicated, resulting in delays in responding to a simulated impediment that blocked the Long Island Expressway and another major artery. Attachment 9 at 4. Further, despite'a requirement to confirm the delivery of messages from family members of LILCO personnel back to the family tracking center, this was not done. Attachment 9 at 12. In addition, in direct violation of procedures, the Director authorized exposure of up to 10 REM for a field worker without consulting the Radiation Health Coordinator. Attachment 9 at 12. Finally, as with the December 2 drill, traffic guides did not arrive at their poets within one hour after the issuance of the EBS message to' evacuate. Attachment 9 at 32. 35, 39-40. l j
Q. Please summarize your conclusions concerning the effectiveness of LILCO's training program in instructing personnel to follow and implement the LILCO Plan and procedures.
A. LILCO's training program is seriously flawed in this !
regard. When what occurred-during the Exercise and what occurred during the drills are examined, the seriousness of the problem
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becomes clear. The many mistakes made and the many exampler, that exist of failures by LERO personnel to follow and implement the LILCO Plan and procedures demonstrate that the deficiencies revealed during the Exercise were not the exception, but the rule. This is particularly significant since the LILCO training program concentrates on the LILCO Plan and Procedures as the basic training material. The drills reveal, however, that despite the training, personnel have still not been successfully trained to carry out the functions they are assigned under the LILCO Plan and procedures. As a result, it must be concluded that LERO personnel would be unable to implement the actions called for by LILCO's Plan and necessary to protect the public health and safety in the event of an actual emergency at Shoreham.
C. Contention Ex 50.C: The Exercise Results Demonstrate that LILCO has Failed to Teach Personnel to Communicate Effectively Q. What does Contention Ex 50.C (along with Contention Ex 23 and the bases of Contention Ex 45) allege?
A. Subpart 50.C and the other cited contentions allege that the Exercise demonstrated that the LILCO training program has not successfully or effectively trained LERO personnel to communicate necessary and sufficient data and information, to inquire and obtain such information, or to recognize the need to do so. Specifically, subpart C states:
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l The exercise demonstrated that the LILCO training program has not successfully or effectively trained LERO personnel to communicate necessary and sufficient data and information, to inquire and obtain such information, or to recognize the need to do so. Exercise actions and events which support this allegation are described in Contentions Ex 34, 36, 38, 39, Ex 41, Ex 42, Ex 45, and in the following FEMA conclusions: EOC-D-1; ENC-D-1; EOC-ARCAs 4, 5, 6, 7, 9; ENC-ARCA 2; PSA-ARCA 8, 9, 11, 12; R-ARCA 1. l Contention Ex 23 and the bases of Contention Ex 45 are found )
in Attachment 6.
Q. Do you agree with Subpart C and the other contentions considered with it?
A. Yes. A review of what occurred, and perhaps even more importantly, what did not occur during the Exercise, indicates that the LILCO training program has not successfully or effectively trained LERO personnel to communicate necessary and sufficient data and information, to inquire and obtain such l i
information, or to recognize the need to do so.
- 1. Examples of Lack of Communication Training Which Wer:e Reflected in the Exercise Resu)ts O. Please give examples of lack of communication training as reflected in the Exercise results.
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A. There are numerous examples of communications difficulties which arose in the Exercise which reflect a lack of training. Perhaps the most glaring example has already been discussed in some detail -- the communications difficulties jlll arising out of LILCO's handling of the free play impediments events. See Section III.B.2.b above and also the County's Contention Ex 41 Testimony, especially pages 33-38. We will not repeat discussion of the handling of these impediments.
In our opinion, the communication failurec discussed in the cited testimony, demonstrate an ineffective and unsuccessful training program. Presumably, LILCO attempted to train its
}lll personnel to communicate the kinds of information involved in LILCO's responses to the two simulated impediments during the Exercise and such communication is clearly required by the LILCO Plan. Nevertheless, the manner in which communications were handled in response to the traffic impediments during the Exercise indicates that such training was ineffective and unsuccessful.
Q. Are there additional examples of breakdowns in communications between and among LERO's personnel which you believe demonstrate a failure in LILCO's training program?
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A. Yes. Another example relates to the response of LERO personnel to the Ridge Elementary School " free play" message.
The message requesting LERO to provide a bus and driver to assist in transporting 40 children from Ridge Elementary School was
- given to the Evacuation Coordinator at the EOC at approximately 10
- 30. The request was communicated to the Special Population Bus Dispatcher at the Patchogue Staging Area within about 10 minutes, het the staging area personnel did not respond appropriately or quickly in processing the communication. As a result, the bus driver was not even dispatched to a bus yard to pick up a bus for 40 minutes. See FEMA Report at 38, 66.55 Furthermore, there were no apparent efforts by LERO personnel to follow up on their dispatch orders during the approximately three hour period prior to the report that the driver had arrived at the school.
An effective training program would have taught LILCO's personnel the importance of obtaining and communicating information in a timely manner. It would also have instilled in LILCO personnel the need to follow up on communications. Based on the Exercise performance, however, LILCO's training program has apparently failed to instruct workers in how to perform communications tasks, has neglected to teach workers the necessary skills to enable them to perform these tasks, and has 55 We note that LILCO has claimed during discovery that the message was given to the Public School Coordinator, not the Evacuation Coordinator, and that the bus was dispatched in 34 rather than 40 minutes.
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1 l
not provided personnel with enough follow-up practical experience i
to allow them to learn the skills necessary to communicate effectively. Further, LILCO's training program has not taught J personnel the importance of following up on communications and making sure that tasks are completed. This is a serious flaw of the LILCO training program, since, in our opinion, little is more j important to an effective emergency response organization than effective, timely communications. j The foregoing communications problems pertaining to the Ridge Elementary School, as well as the others already discussed, also provide additional examples of the failure of LILCO's
! l l program to teach " learning by doing." If the LILCO program had been effective, LILCO personnel would have had sufficient j
l experience such that they would recognize the need for prompt and timely communications and follow-ups thereon. It is elemental to proper emergency response that communications work swiftly and efficiently and that the personnel in charge of responding understand the necessity for such timely and efficient communications. LILCO's performance during the Exercise leads to ;
I the conclusion, however, that its personnel communicate in a mechanical manner, attempting at best to follow procedures, without demonstrating any clear understanding of the purposes of the communications and the importance of prompt follow-ups.
1
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- 0. Are there further examples from the Exercise which demonstrate the ineffectiveness of LILCO's training program in teaching personnel to communicate necessary and sufficient data and information, and to recognize the need to do so' l A. Yes, there are many, including the following:
LERO was unable to notify or communicate emergency information to the FAA in order to have air traffic diverted from the EPZ (see FEMA Report at 29);
The Long Island Railroad was not contacted during the Exercise in order to divert trains from the EPZ (see FEMA Report at 29);56 Communications relating to release data and dose projections were not handled properly or accurately (for example, LERO's failure to designar.e clearly on the EOC dose assessment status boards the distinctions between DOE RAP. monitoring data and LILCO field monitoring data (seg FEMA Report at 29-30),
downwind distances of sample readings by field monitors were incorrectly reported as 7000 meters instead of 700 meters for a thyroid dose (see FEMA Report at 33), and several extrapolated doses at various distances were reported as actual measurements 56 Although such communication has not specified by LILCO's Plan, it should have been obvious that there was a need for LILCO to divert trains from the EPZ.
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rather than as projected data on the dose assessment status board
-- an error which took two and one half hours to identify and corrcct (sgg FEMA Report at 33)).
The LERO Director apparently left the " command room" on several occasions, and therefore was not available to take calls over the RECS telephone or the d6dicated telephone -- a situation that was made worse by the fact that his secretary (who took the calls in the Director's absence) merely told the callers that the Director would call back, and failed to take a message in writing and carry it to the Director immediately upon completion of the ,_
transmission. See FEMA Report at 31, 42; LILCO Admission No. 210.
LERO failed to have key events or evacuation status boards in the EOC command rcom. Thus, updated information on the status of the emergency situation was not visible to LERO workers in those areas at all times. See FEMA Report at 30.
In our opinion, these failures indicate a failure of training. The inattention to detail and accuracy in recording, processing, and communicating data critical to the accident assessment and protective action recommendation processes which are at the core of an emergency response would not have occurred had training - particularly learning by doing training -- been successful. Similarly, these failures to obtain or communicate
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a e
vital data, and to have updated information available and. visible in the command room, could have impaired the ability of command personnel to perform their duties in a real emergency. LERO' personnel should have been effectively trained to ensure that these problems did not arise. If training had taught personnel the realities of an emergency and stressed the importance of proper communication, these problems probably would not have arisen. l
- The failure of LILCO's training prog. ram to' effectively train personnel in communicating necessary and sufficient data and information was also demonstrated during the Exercise by the fact that LERO personnel at the staging areas evidenced an inability to accurately, appropriately or in a timely manner obtain, record, transmit, or act upon emergency data. For example
Personnel at the Riverhead Staging Area did not i
properly record or appropriately identify event status informa-i tion on Emergency Event Status Forms or on status boards (gge '
FEMA Report at 72);
I The Bus Dispatcher at the Patchogue Staging Area ,
repeatedly made inaccurate and misleading announcements to bus i drivers concerning the dose levels at which they.were to call in )
(geg FEMA Report at 68); !
l l
l - 132 -
The Transfer Point Coordinator at the Brookhaven Transfer Point was unable to follow instructions and transmit information and directions f rom the staging area to bus drivers during the Exercise (for example, directing a bus driver to the EWDF despite the fact that he had been directed to send all drivers to the Nassau Coliseum Reception Center (see FEMA Report at 65).
Q. Are there any other communication examples demon-strating inadequate training?
A. Yes. A final example that demonstrates the failure of LILCO's communications training, as evidenced by the Exercise, is the fact that LERO personnel at the EOC and staging areas were unable to transmit consistent or accurate information concerning alleged assistance from the Suffolk County Police Department
("SCPD") to each other during the Exercise. The facts appear to have been roughly as follows.
At 9:19, the LERO Manager was informed that no County resources would be available to assist LILCO during the Exercise.
See LILCO Admission No. 178. This fact was confirmed at 10:15, 10:26 and 10:36, according to the logs kept by the LERO Manager and Director. However, at 9:20, the Evacuation Coordinator recorded in his log that the SCPD had offered to provide LILCO whatever assistance was required, and the Traffic Control
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Coordinator was advised of this purported information at 9:35.
At 10:02, the Evacuation Coordinator notified the staging areas that the SCPD had offered assistance on traffic control, route alerting, and route spotting, and that police officers would be dispatched to the staging areas for briefings, See LILCO Admission No. 181. And, between 10:02 and 10:15, the Traffic Control Coordinator informed: (i) the Riverhead Staging Area to expect 39 SCPD officers to report for assignment to traffic control and route spotting functions; (ii) the Port Jefferson Staging Area to expect 74 SCPD officers; and (iii) the Patchogue Staging Area to expect 37 SCPD officers. These messages, all of which conflicted with the facts known and recorded by the LERO Manager and Director, were in turn transmitted to Lead Traffic Guides, Dosimetry Recordkeepers, and other staning area personnel. The erroneous information which had been communicated to the staging areas was not corrected until approximately 10:50, approximately an hour and a half after the information first came to the LERO Manager.57 This example demonstrates again severe deficiencies in LILCO's communications training. Clearly conflicting information had been communicated to LERO command personne]. But the false information was not corrected for over an hour. In a real emergency, such misinformation could obviously have resulted in 57 LILCO has stated that the corrections were made between 10:26 and 10:50. LILCO Admission No. 182.
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serious problems. It could cause LILCO responders to count on assistance when, in fact, none was on the way, thus delaying the overall response.
If there had been~ strong learning by doing training, we are j 1
confident that the various parts of LERO would have learned of !
their interrelated functions and would have established means of ensuring that such false information was quickly stopped. LERO's 4 l
failure in promptly correcting the data during the Exercise leads I us to conclude that the training for LERO personnel had been
(
l ineffective, l
- 2. The Communications Deficiencies Which Were l Demonstrated Durino the Exercise Are Significant 1 I I
l 1
l 0 Wny do the foregoing examples lead you to conclude that i the LILCO training program has not successfully or effectively trained LERO personnel to communicate necessary and sufficient data and information, to inquire and obtain such information, or to recognize the need to do so?
l A. Given an effective and successful training program, and particularly one that had exposed personnel to realistic learning j by doing experiences, we would not expect the number of ;
1 communications mistakes made during the Exercise. The fact that mistakes were made by such a large number of LILCO personnel in relation to so many different events throughout the Exercise leads us to conclude that LILCO's communications training has
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t
t 1
been ineffective, particularly since the information on the number of communications problems is largely limited to those items observed or identified by FEh,. 2 valuators during the Exercise.
Q. Are the training deficiencies related to communications important in your opinion?
Yes.
A. Based upon our experience in emergency response ,
1 i situations, we cannot stress enough the importance of timely, accurate, and common sense communications during an emergency l !
situation. Indeed, such communications provide the backbone of a {
i successful response, not only in terms of the abilities of the emergency response personnel to perform their tasks, but also in terms of the media and the public having confidence in those responses.
In short, without accurate and timely communications which have credibility, an emergency response is doomed to failure. In this regard, we also emphasize that there are no dg minimus 1 communications problens. Communications, to be successful, l
depend upon detailed training and extensive learning by doing experience. Indeed, for police personnel, effective
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communications are perhaps the most difficult task to be learned, requiring repeated learning by doing experiences before an >
adequate proficiency level is reached.58 Based upon our review of the exercise data, it is clear to l
us that LILCO's personnel have not come close to reaching a proficient level in the communications area. This must be attributed to their training deficiencies, since it is only by effective (often tedious and repetitive) training that adequate communications skills can be learned. Furthermore, the repeated failures in communicating essential information, and in following the procedures which expressly require such communications, also -
indicate to us that the LILCO training program has failed to instill in LERO personnel any sense of the importance of accurate, timely, complete and appropriate communications during an emergency. This is an extremely serious flaw in the training 58 (Cosgrove, Streeter, Colwell, Zook) In our experience as trainers, we have learned the necessity for indepth, detailed communications training. Through the use of role-playing, trainees learn just how easily communications can get fouled up.
For example, one technique that has been used effectively in training recruits in proper communications skills, is to have the inst mctor tell one recruit a story involving numbers, dates, etc. The recruit then tells the story to a second recruit, who tells it to a third recruit, and so on. This entire process is videotaped. The results the first time this is done are distortion of critical information due to inattention to detail and failure to listen. The students also learn the consequences of their mistakes. However, further training emphasizes these skills through frequent, almost daily, role playing, drills, and written exercises. Tnis training enables the recruit not only to learn the proper methods of communicating, but also the consequences of improper communication.
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s i
i program, because absent an understanding of the importance of effective, accurate communications, LERO personnel can never be expected to perform well.
- 3. LILCO's Communications Training Program Has Not Been Fixed ,
Q. Has your review of drill reports since the Exercise changed in any way your conclusions concerning Contention Ex 50.C?
A. No. Our review of the drills since the Exercise has reinforced our view that tne LILCO training program has been unsuccessful in the area of communications.
l Q. Do examples from the June 6, 1986 drill sapport your view?
! A. Yes. For example, during the June 6 drill personnel frequently failed to write down messages. And, in those instances when they were recorded, they were often written on scraps of paper and then transcribed onto the standard message ;
form. Also, during the drill the EOC ran out of message forns.
l When this occurred, messages were not written down at all.
Attachment 7 at 3. The failure to write down messages on message l
l forms, as LILCO procedure dictates, could result in information being miscommunicated or not communicated at all, allowing critical information to go unattended. This problem, as
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documented below, has occurred in every drill since the Exercise.
If personnel cannot be taught the simple task of writing down messages on message forms, then the communications training clearly has been unsuccessful.
In addition, during the June 6 drill, key information was frequently communicated in an untimely manner or not communicated at all. For example, it took between 10 and 15 minutes to inform the staging areas about the evacuation. Attachment 7 at 2.
Further, the Patchogue Communicator at the EOC did not transmit the message to dispatch buses until prompted by thc controller in Patchogue. This was one and one half hours after the message was given to him by the bus coordinator. Id. at 6. As a result of these problems, the report concluded that "(i)nformation flow to other groups within the EOC . . . was almost non-existent." Id.
Clearly, such failures to communicate information in a timely manner, or at all, demonstrate a training program that has been ineffective in instructing personnel to properly communicate essential information.
Another example that illustrates the continued failure of the LILCO training program in the area of communications relates to the handling of the fuel truck impediment during the June 6 drill. The Radiation Health Coordinator was not informed of the fuel truck impediment until one and one half hours after it had occurred. Attachment 7 at 4. Further, the message for the fuel
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truck impediment was not relayed accurately to the field. In fact, similar to what occurred during the Exercise, the responders were directed to the wrong road. This created the assumption that the impediment was a false alarm. If the controller had not three times prompted the players to review the original message, LILCO personnel would never have noticed their mistake. M.
l I
l In addition, during the June 6 drill, information was not j provided to the public in a timely fashion. According to the drill report, "(t)he response by the public information group in getting the information out to the general public was not as l
rapid as it should have been." Attachment 7 at 6. For example, it took 48 minutes for LILCO personnel to issue an EBS message following the declaration of the Alert. This resulted in the 1
early dismissal of schools being unnecessarily delayed. M. at
- 2. Further, it took 25 minutes to issue the EBS message for the j 1
General Emergency following the decision to initiate protective actions. M. Finally, the EBS message informing the public of the road impediment was not issued until almost~ 45 minutes af ter the impediment had occurred. M. at 5. LILCO's delays in the issuance of EBS messages led to the conclusion that "(t)he ,
preparation of EBS messages took too long," with several of the l l
messages missing the 15 minute deadline by a significant amount of time. M. at 2.
l l
1
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- - - - _9
l In sum, therefore, the results of the June 6 drill strongly support our conclusion that LILCO's communications training is flawed. The kinds of fundamental errors which occurred during that drill should never have occurred if effective training had been provided.
1
(
Q. Have you reviewed the September 10, September 17 and October 1, 1986 drill reports in connection with your testimony on Contention Ex 50.C?
A. Yes. There are many additional examples which support our conclusion that LILCO has failed to train LERO personnel to ,
I communicate necessary and sufficient data and information, or to {
recognize the need to do so. For example, during the September 10 drill, the EBS messages for the simulated traffic impediments were again slow in being generated, and the wording was ambiguous and was not concise. In addition, as ncted previously, one of l the EBS messages was broadcast without the sounding of the sirens. Attachment 8 at 2. 1
~
( Further, due to communications failures, the doce assessment staff in the EOC had difficulties in obtaining data from the dose assessment staff in the EOF during the September 10 drill.
Attachment 8 at 3. Moreover, during that same drill, messages were not transmitted in a timely matter, For example, in one instance there was an approximately one half hour delay at the
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Road Crew Communicator's desk in getting a message transmitted.
Id. In another instance, the dispatch of the Route Spotters from the Riverhead Staging Area was delayed because the message from the EOC took 20 minutes to go from the Administrative Sup-port Staff to the Lead Traffic Guide. Id. at 5. These delays, in our opinion, illustrate that LILCO's training continues to be unsuccessful in instructing personnel to communicate essential information in a timely manner -- a problem that was also demon-strated during the Exercise and in other LILCO drills since the Exercise. Certainly, there is no basis from the September 10 drill.(or the later ones) to conclude that LILCO's communica-tions/ training deficiencies have been fixed.
Further, as with the June 6 drill, the September 10 drill report concluded that "(t)he use of message forms needs to be improved." Attachment 8 at 3. Many personnel were observed using scraps of paper to transmit messages. This resulted in appropriate copies not being distributed and messages being incorrectly transcribed on message forms. Id.59 These same types of communications problems occurred again during the September 17 drill. For example, messages took too long to reach where they were supposed to go because of the failure of personnel to communicate information in a proper 59 The report also noted that during the September 10 drill, briefings were not conducted frequently enough to keep personnel informed of important information. In fact, some_ staging areas failed to have any briefings. Attachment 8 at 4, 5.
l
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-i manner. Messages were frequently left on a communicator's desk for 10-15 minutes before being transmitted to the proper individual in the EOC. Attachment'8 at 6-7. In addition, although the announcement that an Alert had been declared was made at 10:14, the message indicating this was not sent to the LILCO staging areas until about 10:38. Id. at 7.
Another communications problem that occurred during the September 17 drill was that the phones of key coordinators were not answered when these individuals were at staff meetings. at 7. Further, as with other drills, messages were not written on the standard message forms created for that purpose. Rather, many messages were written on plain paper and later transcribed onto a message form. Id. According to the drill report, "(t)his caused delays in delivering the message to the appropriate party and caused transcription errors and erroneous information being transmitted." Id. Again, the LILCO training program has shown itself to be incapable of instructing personnel effectively about the importance of exercising great care in the handling of communications.
Even during the October 1 drill, the same kinds of l l
communications problems continued. For example, "(t)he s distribution of RECS messages to the EOC staff was very slow" i
during the October drill. Attachment 8 at 9. Further, "(t)he information flow into the public information office could have
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been improved so that they would have information immediately available to them to generate the EBS messages." Id. And,
"(t)he information flow from the EOC to the Staging Area was slow and as a result the field personnel were working with information and data that was up to 30 minutes old." Attachment 8 at 10.
l Moreover, during the October drill messages were communi-cated too slowly and personnel were not dispatched quickly. For example, a message concerning the fact that sirers had failed was transmitted to the Staging Areas by the EOC at 9:48. However it was not until 10:2S that the Route Alert Drivers were dispatched.
Attachment 8 at 11. In addition, a message to dispatch preassigned Traffic Guides did not arrive at the Staging Areas until 13 minutes after the information relative to the evacuation was known at the EOC. Id. This, as well as confusion due to three separate dispatch messages being sent to the LILCO staging areas within a few minutes, resulted in the slow dispatch of Traffic Guides. Id. Further, a nessage to dispatch bus drivers did not arrive at the staging areas until 1:30, despite the fact that a simulated release of radiation had occurred at 12:35. And this information was only received after being requested by the Bus Dispatcher. In fact, the staging areas were not informed of the 12:35 release until 1:40. This resulted in the bus drivers being dispatched into the plume without their knowledge. Id. at 12.
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4 Finally, as with other drills, LERO staff briefings were not held often enough and information was frequently not written on message forms. In fact, during the October drill, there were many instances where information was not written down at all.
Attachment 8 at 9-11.
Q. Were there additional communications problems noted during the December drills?
A. Yes, there were. During the December 2 drill, as with all previous drills, messages were frequently not written down on standard message forms. Attachment 9 at 3. In fact, some messages again were not written down at all. Attachment 9 at 15, i
I Another problem related to the fact that status reports contained conflicting information. Attachment 9 at 4. Further, l
they were not properly updated. Attachment 9 at 15, 16. This ,
could result in personnel being misinformed about critical events
, and about the status of the emergency.
1 i
Further, individuals receiving family tracking calls in Brentwood failed to return confirmation of delivery of the messages to family tracking. Attachment 9 at 12. This occurred despite the obvious need to confirm delivery and the fact that such confirmation is required by the LILCO procedures.
Attachment 9 at 12.
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Another communications problem evidenced in previous drills <
was the fact that communications were so slow that field person- l nel were frequently dispatched much too late. For instance,
)
traffic guides frequently did not arrive at their posts for well '
over an hotir f rom the time the protective action recommendation was made. Attachment 9 at 19-20, 24, 27-28. Further, communication between traffic guides and the staging areas, once the traffic guides arrived, was inadequate. For example, three traffic control points were unable to communicate with the Port Jefferson Staging Area. Attachment 9 at 20. And one traffic control point needed for rerouting after the fuel truck impediment r uld not be reached by the EOC, the Port Jefferson !
Staging Area or another traffic control point. Attachment 9 at 21.
1 l
The performance during the December 10 drill was not any better, despite the fact that personnel had participated in a drill just one week before. One problem experienced during the J
l December 10 drill was that critical information necessary in j l order for LERO to take actions to protect the public was not l l
I communicated. For example, ENC personnel failed to include the l names of the roads blocked by a brush fire when communicating this information to the EOC.60 Attachment 9 at 4. This resulted in delays in responding to this major impediment. Attachment 9 ,
at 4. Further, it took 24 minutes from the time the EOC was 60 It is unclear from the drill report why the ENC rather than the EOC had initiated the message. Attachment 9 at 4.
1
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I l
l l
i notified about the fire for the Evacuation Coordinator to !
l instruct the Evacuation Route Coordinator to send a route spotter ')
l l
to check on the fire. Attachment 9 at 9.
1 Concerning another impediment, one involving a duck truck, I
{
the Evacuation Coordinator was not informed of the impediment for I 23 minutes after it was injected into the drill. Attachment 9 et l 10. Further, there is no indication in the drill report that l
personnel questioned whether ducks were loose despite the obvious need to acquire such information.
I l
l Another communications problem exhibited during the December J 10 drill was the fact that field personnel frequently failed to l
i i communicate with staging areas. Attachment 9 at 29, 35, 40. In addition, the Riverhead Staging Area was unable to communicate with two of the road crews. Attachment 9 at 39. And, finally, as with the December 2 drill, slow communications resulted in traffic guides not arriving at their posts in a timely manner.
Attachment 9 at 35, 39-40.
Q. What conclusions have you drawn based upon your review of the Post-Exercise drill reports?
l A. In our opinion, the communications problems demon-strated during and since the Exercise are indicative of serious flaws in the LILCO training program. Indeed, the fact that the
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i L-------------------.---------------------------. - - - - - - - - - - - - - - - -
1 l
l 9
same types of communications problems occurred over and over again can demonstrate little else except that the LILCO training program -- which had three years and at least three dress re-hearsals and many drills / tabletops prior to the Exercise in order to train personnel -- has been ineffective in training personnel to communicate information properly. Indeed, the repeated instances of communications difficulties show a failure to instill necessary communications discipline -- another indication of a flawed training program. If discipline cannot be learned ;
I during drills and exercises where there is no real-world tension, there is little likelihood of a proper response to an actual emergency. Thus, we conclude that the Exercise demonstrated fundamental flaws in LILCO's training of personnel in the fundamentals of effective emergency communications. Nothing l
since the Exercise leads to any change in that conclusion. I D. Contention Ex 50.D: Training to Follow Directions of Superiors Q. Please state subpart D of Contention Ex 50.
A. Subpart D states:
The exercise demonstrated that LILCO's training program has not successfully or effectively trained LERO personnel to follow directions given i by superiors during an emergency. Exercise actions and ev9nts which support this allegation are described in Contentions Ex 41, Ex 42, Ex 45 and in the following FEMA conclus' ions: EOC-D-1; l
PSA-D-6; PJSA-ARCA 1; PSA-ARCAs 9, 13, 16; R-l ARCAs 4, 6; RC-ARCA 1.
l
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Q. Do you agree with subpart D?
I A. We are not in a position to agree or to disagree because there are insufficient data. There are at least several instances where it seems clear that LILCO personnel failed to follow instructions of their superiors. For example, a number of i
LILCO bus drivers failed to read their dosimeters every 15 )
minutes throughout the course of the Exercise, despite the fact ,
I that they were instructed by their supervisors during briefings to do exactly that. See FEMA Report at xiv, xviii, 59.
I I
Similarly, a LERO person at a bus transfer point told a bus '
driver to go to EWDF despite instructions to tell drivers to go to Coliseum. See FEMA Report at 65. l l
However, on the basis of two examples (and perhaps several i 1
others as well),61 we cannot conclude, overall, that the LILCO 61 For example, at about 11:15, in response to the fuel truck impediment, the Route Spotter / Road Crew communicator at the EOC requested the Port Jefferson Evacuation Coordinator to dispatch a Route Spotter to the impediment scene. The Route Spotter, however, was not dispatched until 12:02. FEMA Report at 37; FEMA Admission No. 69; but see, LILCO Admisnion No. 165. In the June 6 drill, the report noted that the Patchogue communicator at the EOC failed to transmit the message to dispatch buses until 1-1/2 hours after he had been instructed to do so by the bus coordinator. See Attachment 7, at 6. Further, during the September 10 drill, some of LILCO's personnel were so incapable of following instructions regarding the performance of their duties that they had to be " walked through" the drill. See Attachment 8, at 2. However, this second deficiency from the September 10 drill may not constitute a failure to follow instructions but, rather, be indicative of a more general failure in the entire LERO training program to have communicated effectively.
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training program has been unsuccessful in training LERO personnel 'i i
to follow directions given by superiors.
Our lack of support for-this subpart of the centention j i
should not be construed to constitute an agreement by us that the LERO training program has been successful in this : regard.
( Frankly, we would be surprised if that were the case, particularly given our overall findings as described in this ;
testimony that the LILCO training program has been seriously deficient. However, on the basis of the data available to us, we cannot provide additional bases in support of this subpart of Contention Ex 50.
E. Contention Ex 50.E: LILCO Has Failed to Train Personnel to Exercise Good Judgment and Use Common Sense Q. Please state subpart E of Contention Ex 50.
A. Subpart E is as follows:
The exercise demonstrated that LILCO's training program has not successfully or effectively trained LERO personnel to exercise independent or good judgment, or to use common sense in dealing '
with situations presented during an emergency or in implementing the LILCO Plan and procedures.
Exercise actions and events which support this allegation are described in Contentions Ex 34, 36, 38-43, Ex 45 and in the following FEMA '
conclusions: EOC-D-1; PSA-D-1; R-D-2; EOC-ARCAs-2, 3,, 9; ENC-ARCA-2; PSA-ARCAs-5, 7, 8, 10, 12; R-ARCA 1.
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1 Q. Do you agree with subpart E?
I A. Yes. The Exercise demonstrated the inability of LERO's personnel to exercise independent or good judgment, or to use common sense, in dealing with situations presented during an i l
emergency or in implementing the LILCO Plan and procedures. As a l result, we have concluded that LILCO's training program is inade-quate in the training of LILCO's emergency response personnel.
I
- 1. Examples of LILCO's Trainino Failures I
Q. Please provide examples from the Exercise that 1 1 I l demonstrate LILCO's failure to train personnel to exercise independent judgment or good judgment, or to use common sense in l
dealing with situations presented during an emergency or in j i
implementing the LILCO Plan and procedures. l l k A. Our discussion of some examples will be brief to avoid repetition of some of the earlier examples which support other subparts of Ex 50 as well.62 Consider, for example, the following events and occurrences, all of which occurred during the Exercise:
J 62 The examples of LILCO's failure to handle unanticipated or unrehearsed situations as discussed in our Ex 50.A Testimony are j largely also indicative of LILCO's failure to train persons to i exercise independent or good judgment or common sense. Many of the examples cited in the Contention Ex 38/39 Testimony also provide support for this subpart.
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The failure by LILCO's personnel, in handling the simulated roadway impediments, to request specific information about the impediments (e.a., FEMA Report at xvi, 37, 39, 65); or to explore alternatives for the verification of the impediments (e.o., FEMA Report at 37-38); or to exercise prompt judgment regarding the kinds of equipment which would be needed to respond to the impediments (FEMA Report at 37, 65).63 )
i 63 For example, with respect to the gravel truck impediment, only one tow truck was sent to clear the impediment, which involved a loaded gravel truck and three cars. LILCO failed to j send a scraper or bucket-loader, or even to inquire as to whether !
there was gravel spilled on the road. Moreover, one tow truck would have been inadequate to clear this impediment. FEMA Report at 65. Even employing conservative estimates about the size of the gravel truck and the extent of the damage to the disabled l cars, most likely several trucks and a scraper or bucket-loader would have been necessary to clear the impediment. LILCO, however, sent a 10,000 pound truck to clear this impediment. Egg Deposition of Walter F. Wilm (January 8, 1987), at 56. This type of truck is not designed to tow a large, loaded gravel truck. l Egg Contention Ex 41 Testimony at 38. Thus, LILCO's response demonstrated poor judgment on the part of LILCO's personnel.
With effective training, perhaps LILCO's personnel would have thought through the problem they faced before acting. LILCO's personnel, however, had not been effectively trained. The result was that improper and insufficient equipment was sent to clear the gravel truck impediment -- a result which, in a real emergency, would have likely led to substantial delays in clearing the impediment.
LILCO's response to the fuel truck impediment during the Exercise was no better. Again, the equipment sent to clear the impediment was inappropriate and insufficient, demonstrating poor judgment and lack of common sense on the part of LILCO's person-nel. LILCO again sent one 10,000 pound tow truck (see deposition of Walter F. Wilm (January 8, 1987), at 58-59) to clear the impediment. This tow truck would have been too small to remove
( an overturned tanker. Further, LILCO failed to request j immediately that an empty tanker be sent to off-load the l overturned truck. FEMA Report at 37. Thir demonstrated poor l judgment on the part of LILCO's personnel., since this step would have been necessary in order to remove the fuel remaining in the l overturned tanker.
l
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l 1
The decision by the LILCO Evacuation Coordinator to i l
decide upon a traffic rerouting strategy without consulting with I persons familiar with the roadways in the area of the impediments showed poor judgment and resulted in a decision to employ a rerouting strategy which was illogical and would have resulted in more evacuation delay. See Contention Ex 41 Testimony at 50-64.
1 I
1 I
1 The fact that a field monitoring team stopped to report l I
dose assessment data while still within the area of the plume
]
i (agg FEMA Report at 51-52); )
The fact that a simulated evacuee, while being monitored at the Nassau Coliseum Reception Center, was told to put on protective rubber booties before he was advised to put on anticontamination gloves, even though LILCO's monitor was aware that the evacuees's hand was " contaminated" (see FEMA Report at l l
81). !
Q. Are there other examples as well?
A. Yes. For instance, the manner in which LERO personnel l
l responded to simulated inquiries from the public during the Exercise demonstrates the lack of training of LERO's personnel to 1
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l
exercise independent or good judgment, to use common sense in dealing with emergency situations, or to implement LILCO's Plan.
Consider, for example, the following64.
(i) During the Exercise, in response to an inquiry from a l
person at 7:51 who "has trucks going to Suffolk," and as to how extensive evacuation would be, the LILCO Hicksville Call Board operator responded at 8:20 that the only protective action was the closing of schools, and that there had been no evacuation recommended. See LILCO Admission No. 114. It was poor judgment to suggest that the caller should proceed as planned with sending trucks into the EPZ area, since, among other things, such a response would have increased traffic within the EPZ, when the goal should have been to have as few persons as possible within that area. Presumably, since no evacuation had been ordered, the operator or the supervisor who provided the operator with the response, assumed that there was no reason to tell the caller not to send trucks into the EPZ. This response, however, was inappropriate under the circumstances. At best, the operator used poor judgment or failed to exercise independent judgment in his response.
64 The examples are discussed only summarily here, since they are discussed in greater detail in other testimony, primarily the Contention Ex 38/39 Testimony at 132-34.
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(ii) In response to an inquiry at 11:30 whether lobsters caught that morning on the Shoreham jetty were safe to eat or touch, the Riverhead Call Board operator responded at 12:28 that there was no reason to believe, and no data to indicate, that anything was wrong with the lobsters. Sag LILCO Admission No. 116. Even if the likelihood was that the lobsters were safe, a response advising caution would have enhanced LILCO's credibility. Further, responding to this call without even inquiring as to when that morning the lobsters had been caught demonstrates a lack of judgment and common sense on the part of the operator.
(iii) During the Exercise, a rumor message simulated at 11:45 was received, purportedly from Dan Rather, who wanted "to take a TV crew into the Shoreham plant," and inquired how to get there. In response, the rumor control responder stated "We don't advise going to the plant. There is a Site Area Emergency. You will be in the way." The responder then gave directions to the plant. LILCO Admission No. 119. The responder gave out misinformation concerning the status of the emergency, and used poor judgment in providing directions to the caller and indicating that it was possible for the television crew to go to the plant. A more appropriate response would have been that television crews would not be allowed onto the Shoreham site, but that they were welcome to come to the ENC. The suggestion that going to the plant was inadvisable but nonetheless possible,
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combined with the giving of road directions to the plant, indicates a training program that has been unsuccessful in instructing personnel to use good judgment or common sense.
(iv) There was an obvious need to have the LIRR divert its trains from the EPZ. Yet, LILCO personnel failed to contact the LIRR. LILCO's personnel should have used independent judgment in deciding to contact the railroad.
(v) Many errors in judgment were shown at the ENC, again reflecting inadequate training. First, the ENC was ready for j activation at 8:08 a.m. However, the Emergency News Manager delayed activation -- and continued to hold the media upstairs --
until 8:25 a.m., because one staff member had not yet arrived.
There is no indication that the missing staff member was in any way critical to the enterprise. The Emergency News Manager showed extremely poor judgment in delaying the entire operation until roll call was complete.
Second, the LILCO spokesperson withheld, for 25 minutes, the informt. tion that an evacuation of the entire EPZ had been ordered. An EBS message about the evacuation was " broadcast" at noon. According to the notes of the ENC Head Controller, the LILCO spokesperson had this information at 12:22 p.m. Yet she, apparently unilaterally, decided to wait until the 12:47 p.m. I press briefing to inform the media at the ENC of the complete
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evacuation. The County has described in its Contentions Ex 38/39 Testimony (pages 85-91) the media's probable reaction to finding out that such information was not given to them promptly. There was no reason for the delay; it waQ an error in judgment and reflective of defective training.
Third, another error in judgment reflecting bad training was displayed by Dr. Brill when, in his comments to the press, he effectively countermanded LERO's evacuation recommendation. Egg discussion in Section III.G.1 below. Suffice it to say here that, whether or not it was Dr. Brill's considered opinion that l
l he probably would ignore the recommendation to evacuate, he showed poor judgment and reflected a lack of training in the use l of good judgment in relaying this opinion to the press corps gathered at the ENC.
l l
Fourth, employees displayed a lack of common sense and good judgment in their handling of the copying problems at the ENC.
First, any good manager would have checked the compatibility of the electrical system at the ENC with his equipment prior to an emergency -- or prior to a graded evaluation. Second, assuming that such a check were not done, or revealed no problems, common sense -- and good management practice -- dictate that compensating measures should have been taken once a problem l arose. Personnel at the ENC should have held more frequent
! briefings, or immt.;diately relayed information obtained from the
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EOC orally,-and also made an attempt to obtain different equipment in order to compensate for the failure of their xeroxing machines. Instead, LILCO personnel permitted the failure of the xerox machines to sabotage their efforts. The.
failure even to attempt any compensating measures in order to get needed information to the media, demonstrates poor judgment, poor management, and a lack of common sense.
Fifth, yet another example of poor judgment exercised by LERO ENC personnel was the decision to hand out to the press copies of EBS messages full of illegible writing, confusing inserts, and information crossed out or partially crossed out.
The messages were not only unprofessional in appearance, they were confusing and, in part, illegible. Eee FEMA Report at 53; Contention Ex 38/39 Testimony, Attachment.8. Common sense should have dictated that cleaned up, clear, and professional looking hard copy should have been handed out to the media to avoid confusion and inaccurate reporting, not to mention reduction in LILCO's credibility resulting from the appearance of incompetence communicated by the sloppy handwritten messages actually out.
(vi) A final example of poor judgment, exercised by the public information staff at the EOC, related to their preparation of EBS messages during the February 13 Exercise. Specifically, those personnel chose to take almost verbatim the " sample" EBS message contained in the LILCO Plan, with the fill-in-the-blank format, even though this resulted in an unintelligible or very
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_ - - _ _ _ _ _ _ _ _ _ - _ _ _ - _ _ - - - - _ _ _ _ _ _ _ _ - _ . _ - _ _ _ _ _ _ . - . _ _ . - ____-__ -_______ A
confusing statement. Egg EBS Message No. 2. An exercise of common sense and good judgment would have dictated the rewriting of the message to tailor it to the specific situation at hand, rather than to use a fill in the blank form which resulted in an incoherent and confusing message.
- 2. The Importance of Training Personnel to Exercise Good Judoment and to Use Common Sense Q. Why is it important, in your opinion, for emergency personnel to be trained to exercise independent judgment?
A. During an emergency, many things will likely arise that were not planned for (see our Contention Ex 50.A Testimony). In order to be able to handle these unexpected occurrences, emergency response personnel must be able to use and exercise independent and good judgment. They must be able to "think on their feet." Further, during an emergency, personnel must be able to think of and implement whatever actions are required, whether or not they are specifically planned and provided for.
It must be emphasized that the essence of an adequate emergency response is the capability of persons responding efficiently and in a timely manner to non-routine, unanticipated, and unrehearsed events. Instead of demonstrating that capability, LILCO demonstrated a rigidity of organization which
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inhibits LILCO personnel from performing efficiently in response to unforeseen events which require the exercise of sound judgment.
Q. Why do you believe that LILCO personnel failed to use I independent and good judgment or common sense during the Exercise?
A. Based upon our review of LILCO's training program, it is our opinion that LERO personnel are given little training with j regard to how to exercise independent or good judgment, or for that matter common sense. LILCO's training program is limited in l l its scope. Further, the training program is so procedure specific that workers are taught, if anything, not to use independent judgment. To effectively train personnel to respond to an emergency, however, personnel must be taught the importance of thinking on their own. They must be taught enough about the overall goals of the emergency response organization so that they can understand exactly how they fit into that organization and the importance of their particular job functions to the overall org;nization. In these respects, LILCO's training program in seriously flawed.
l Q. Do you believes that LILCO's training program is capable of teaching LERO personnel to use independent and good judgment?
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A. Probably not. LILCO's highly centralized organiza-tional structure impedes the use of individual judgment. This matter is dealt with in connection with out testimony on Contention Ex 50.I and will not be repeated here.
\
- 3. The Post-Exercise Drills Support the Allegations of Subpart E Q. What impact, if any, did your review of the post-Exercise LILCO drills have on your conclusions concerning Contention Ex 50.E7 A. The drill reports and underlying documents confirm our conclusions. Many of the examples from those drills have already been discussed in connection with our testimony on subparts B and C of Contention Ex 50. These exsmples will not be repeated here.
Consider, however, the following additional examples:
During the June 6 drill, personnel in the EOC respon-sible for communicating information about the evacuation to the staging areas were criticized for failing to use their desk phones to communicate this information quickly; thereafter, they could have followed up with written messages (Attachment 7 at 2-3).
During the June 6 drill, the Special Facilities Coordinator believed there was a one hour delay, after the notification to evacuate had been received, before evacuation of
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the mobility-impaired. Attachment 7 at 4. If anything, however, this LERO coordinator should have realized that the mobility-impaired require more time, not less, to evacuate. This response therefore demonstrated poor judgment and a lack of common sense by LILCO's personnel.
Also during the June 6 drill, the Special Facilities Evacuatien Coordinator delayed proceeding with notification of q the deaf until a copy of the EBS message identifying those zones advised to evacuate had been received. Attachment 7 at 4.
Again, this demonstrated lack of good judgment and common sense by this LERO coordinator because the information was readily available elsewhere.
During the June 6 drill, LILCO's personnel, after checking the supposed location of an impediment to traffic, assumcd there had been a false alarm and no follow-up action was taken. Attachment 7 at 5. In fact, these personnel had reported to the wrong location (Route 25A instead of Route 25). They then had to be prompted on three separate occasions before any follow-up action was taken. Id. This failure to take follow-up action indicates a failure to exercise independent or good judgment.
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During the September 10 drill, the Radiation Health Coordinator ordered the ingestion of KI before he had performed the necessary calculations to justify his action. Attachment 8 at 3. This action was a clear example of poor judgment by a key LERO coordinator.
During the September 17 drill, the phones of key coordinators went unanswered when they attended meetings.
Attachment 8 at 7. This practice is indicative of poor judgment by LILCO's personnel. It also calls into question their common sense.
Also during the September 17 drill, the EBS message issued for a traffic impediment was much too detailed and specific. Attachment 8 at 6. The use of good judgment would have resulted in a more general message which would have instructed evacuees to follow the directions provided by traffic guides. Attachment 8 at 6.
During the December 2 drill, the road crew informed of the fuel truck accident was told that the fuel company would handle it and thus not to go to the scene of the accident.
Attachment 9 at 18. This demonstrates poor judgment since it might take longer for the fuel company to get a truck there,
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l especially considering that an evacuation was taking place. Good judgment would have resulted in a road crew being sent to the l
scene at least as a backup.
Also during the December 2 drill, no one questioned a message from an individual thought to be outside the area of the radioactive plume indicating that he had received four rems.
Attachment 9 at 18. The failure to follow up on this message demonstrates poor judgment on the part of LERO personnel since this information, if accurate, could mean that LILCO's assessment l
of the situation was incorrect.
During the December 10 drill, it took 25 minutes for the protective action recommendation to be made by the Director after the EOF had made its recommendation, and then only at the prompting of the controller. Attachment 9 at 5. The reason for this was that the Radiation Health Coordinator and Nuclear Engineer were waiting for data from the EOF in order to make an independent assessment. Since the individuals in the EOF were in a meeting, "the RHC and nuclear engineer were content to wait."
Attachment 9 at 5. Good judgment would have caused them to interrupt the meeting rather than delay an evacuation recommendation. Further, under such circumstances, it was poor judgment for the Director to simply do nothing. He either should have acquired the data or made the recommendation based on the EOF's assessment.
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Q. What is your overall conclusion on Contention Ex 50.E?
A. Our overall conclusion with respect to subpart E of Contention Ex 50 ic clear: there are repeated instances docu-menting that LILCO's training program has failed to teach LERO s
personnel to use good judgment and common sense. The LERO response to the Exercise scenario was largely mechanical. There was a lack of initiative and gcod common sense and a lack of the kind of informed judgment that would lead emergency personnel to innovste and take necessary actions when unforeseen or ,
unanticipated events occurred.
b The proposed changes to the LILCO training program indicate no basic change in LILCO's approach to training, and during the drills during 1986 subsequent to the Exercise, we discern no trend toward greater LILCO proficiency in the use of independent judgment and common sense. In short, therefore, we believe that the LILCO training program is flawed, as demonstrated at the Exercise, and that there is no basis to believe that there has been any significant change in that program since the Exercise.
(Perrow) Further, for reasons described elsewhere in this testimony, we believe that effective LERO training is highly
.1 unlikely, given LERO's centralized organizational style, the rigidity and mechanistic approach to training which is inherent in its program, and the intermittent character of its
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organization. LILCO, in fact, may be expecting the impossible from its personnel: to work part-time as emergency workers, involving only a few drills a year; yet to perform in a first-rate manner during a nuclear power plant emergency. At a l
minimum, such expectations require an innovative and highly effective training Feogram. The Exercise demonstrated that LILCO does not have such a program.
F. Contention Ex 50.F: LILCO has Failed to Train Personnel l to Deal Effectively with the Media and the Public Q. Please state subpart F of Contention Ex 50.
A. Subpart F states:
The exercise demonstrated that LILCO's training program has not successfully or effectively .
trained LERO personnel to deal with the media or l otherwise provide timely, accurate, consistent and nonconflicting information to the public, through the media, during an emergency. Exercise actions and events which support this allegation are described in Contentions Ex 37, Ex 38, Ex 40.C, and Ex 43.A and in the following FEMA conclusions: ENC-D-1; ENC-ARCAs 2, 3.
Q. Do you agree with Subpart *?
A. Yes. We have reached this conclusion by reviewing what occurred during the Exercise, as well as by reviewing underlying documents regarding the LILCO training program, including post-Ixercise training documents and drill reports.
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- 1. Examples of LILCO's Failure to Train Personnel to Deal with the Media Q. Please provide examples from the Exercise which demonstrate LILCO's lack of effective training of personnel to deal with the media.
A. We will keep our examples short and mention only several, because the facts related to these and other examples have previously been discussed in the County's Contention Ex 38/39 Testimony.
- 1. LILCO's ENC was not declared operational until 8:25, and there was apparently no contact with the media by LERO personnel at the ENC until after that time. See LILCO Admission No. 37. In a real emergency,65 such a delay would have likely resulted in substantial confusion, speculation, rumor generation, lack of confidence in LERO's ability to deal with the emergency, and refusal to believe information, advice or instructions subsequently disseminated by LERO personnel, for all the reasons we have stated in Contention Ex 38 Testimony. If LILCO's training program for dealing with the media had been adequate, it
i 65 The Exercise was unrealistic in assuming that no attempts would be made by the media to contact LERO or LILCO until after the ENC was declared operational at 8:25 a.m. The first EBS message had been broadcast at 6:52 a.m., more than 1-1/2 hours prior to the time that the ENC was operational. Based upon our experience, we are confident in an actual emergency that the
' media would have been pressing LILCO lor data from 6:52 a.m. on.
The Exercise scenario was highly unrealistic in deferring any media contact 6.
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would have prepared LERO to set up the ENC no later than 6:52 a.m., since that is when a flood of media inquiries would have started. The fact that LERO then delayed for 1-1/2 hours I
before the ENC was actually set up reflects a lack of adequate >
training -- plus a substantial lack of good judgment. See subpart E of Contention Ex 50 Testimony.66
- 2. LERO News Release No. 1, announcing an Alert condition and the alleged fact that there had been no release of radiation, was not provided to the press by the ENC until 8:21. Eeg LILCO Admission No. 57. By that time, however, the ENC had been informed that a Site Area Emergency had been declared (at 8:19),
a minor release of radiation had occurred, and LILCO had recommended that dairy animals be placed on stored feed. Egg FEMA Report at 25, 26. The time between ENC notification of the Site Area Emergency at 8:19 and the time that the ENC released its first news release at 8:21 was very short. Thus, it might be somewhat explainable why the press release was issued without reflecting the site area emergency data. What is not excusable, however, is that there was no prompt correction of that i
66 (Rowan) I have seen how delays in communicating with the media can worsen relations with the media and result in confusion, speculation and sensationalistic reporting. As a reporter covering the incident at Three Mile Island, I saw how the delays in providing information to the press increased tension. The resulting coverage centered on hypothetical worst case scenarios. Since Three Mile Island it has been recognized that there is a need to train utility personnel to expect great media interest in radiological emergencies and to be prepared to provide information rapidly. LILCO failed in this regard.
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information via a follow-up announcement to the media at the ENC that new data were available which superceded some of the data in News Release No. 1.
- 3. Although the Site Area Emergency, radiation release, and dairy animal recommendation was announced by EBS broadcast at' 8:41, and despite the fact that the decision to issue that.EBS message was made by the LERO Director by 8:37 (FEMA Report at 26), LERO News Release No. 2, which included the information in that EBS message, was not approved by the Director until 9:00.
See Public Information Log. Further, as of 9:15, it had still not been distributed to the press. See LILCO Admission No. 72.
l
- 4. Although the ENC received LERO Press Release No. 3 at 10:15, it was not posted at the ENC for the press until 11:10.
, Sge LILCO Admission No. 74.
1 ,
- 5. LERO Release No. 4 was received by the ENC at 10:45, but was not posted until 11:56. See LILCO Admission No. 75.
- 6. LERO Release No. 5 covered the 10:24 evacuation recommendation for zones A-M, O and R. It was approved by the LERO Director at 11:02, but did not even arrive at the ENC until 11:36, and was not made available to the press until sometime later. See LILCO Admission No. 76.
1 l - 169 -
- 7. LERO Release No. 6, approved by the LERO Director at 12:25, was not posted at the ENC until 2:10. See LILCO Admission )
1 No. 77. l l
- 8. LERO Release No. 7, approved at 1:11, was received by the ENC at 1:47, but not posted for the press until 3:07. Egg LILCO Admission No. 78.
l
- 9. Although the LERO Director decided to recommend 1
evacuation of the entire EPZ at 11:46, and the recommendation was l l
announced to the public in a 12:00 noon EBS message (FEMA Report l
at 26), the ENC did not inform the media of the Director's deci-sion, or the content of the 12:00 EBS message, until 12:47. See LILCO Admission No. 79. l 1
)
l
- 2. LILCO's Failure to Provide Effective Media :
Trainina is Significant .
Q. Why do these examples demonstrate inadequate training?
A. Throughout the Exercise, as demonstrated by these I examples, LERO personnel were unable to provide timely, accurate, consistent, and nonconflicting information to the public through the media. This is a crucial task under any emergency response plan. Quite simply, during an emergency the ability to provide i timely and accurate information to the media is essential in 1
order to ensure that the public is kept informed concerning the
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status of the emergency and whatever protective actions are being recommended. In the event of a radiological emergency, the necessity of keeping the public informed and up-to-date regarding the status of the emergency would be even more crucial, given I
public fear about nuc2 mar hazards. In a climate of fear, only rational, credible, accurate and timely information can persuade people to follow instructions and not react irrationally.
These failures as set forth in the foregoing examples implicate the LILCO training program because it is only through detailed practice and training that any person can come to an understanding of how to deal effectively with the media. One needs to learn how to exercise good judgment and common sense and to be apprised about how the media operates so that the emergency response personnel can provide the kinds of data upon which the )
media relies in informing the public. LERO personnel, however, seemed during the Exercise to be uninformed about media needs or how the media operates. LERO personnel mechanistically went l about performing their functions with no apparent understanding of the practical realities of how they needed to intermesh with the media. Only a well designed and carefully implemented training program could in any event succeed in such a task. The repeated examples of failures of LILCO's training program lead us i
to conclude that that program is certainly flawed.
i 1
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j
l Q. Gentlemen, you seem emphatic that you believe it was a serious training deficiency for LILCO to have failed to have prepared its personnel to set up the ENC by the time the first EBS message was broadcast. Can you explain the reason for your strong feeling in this regard?
A. Yes we can. In our work experience, we have frequently confronted situations where immediate media contact is likely, and therefore we have trained respondents to be in a position to deal with the media on that kind of very rapid basis. These kinds of situations range from natural disasters, to hostage-taking situations, to technological disasters such as chemical fires. We have learned that in such situations, the media l
l immediately seeks out officials who are in charge of the response l l
l and demand information from them regarding what happened, what to expect in the future, etc. As a result, training of personnel who are supposed to deal with the media must take these realities into account and prepare those personnel to respond appropriately to the media demands. If the officials are not prepared to respond immediately to media inquiries, the media broadcasts such lack of preparation, and also seeks other, potentially unreliable, sources of information, sometimes causing rumors and casting doubts about the credibility or capability of the responding agencies.
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The same thing is likely to occur in a Shoreham emergency due to LILCO's lack of training. Good jud gment and good training would absolutely require that the ENC be set up at the earliest possible time. Notwithstanding that, LILCO set up the ENC during the Exercise with almost casual slowness. From our review of the documents, there was no sense of urgency or understanding of how important it was to hive the ENC operational at the earliest possible time during the simulated Shoreham accident, nor was there any consideration given to any meaningful alternative means to communicate with the media prior to ENC activation. This lack of understanding on the part of LERO personnel demonstrates how inadequate LILCO's training has been.
We reiterate, adequate training would have stressed to LILCO personnel the need to seize the initiative -- to take charge of the information flow to the news media almost from the minute the first EBS message was broadcast. In a real emergency of the sort simulated in the Exercise, the first EBS message would have triggered almost instantly the following responses: (1) phone calls to the utility from newspapers, radio and television stations; (2) dispatch by news organizations of reporters to the plant, utility office, ENC, and government, fire, police and/or civil defense headquarters; (3) activation by broadcast news organizations of their standby capability to cover events live by dispatch of microwave mobile units; and (4) implementation by broadcast news organizations of their airborne (helicopter / fixed
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wing) news gathering capability. Within minutes of the first EBS message, news organizations would be mobilizing to cover the event.
This would be an opportunity for well trained personnel to take charge. LILCO's casual slowness in preparing for the press onslaught would have resulted in news coverage -- including live coverage beamed to people in the region -- focusing not on what LILCO wanted the public to hear and do, but -- in the absence of LILCO leadership -- on what reporters were finding out on their own. Good training would have equipped LILCO to establish itself as a credible source of timely information, but the Exercise shows it was not. Furthermore, the Exercise revealed that LERO personnel had not even been trained to realize or understand the importance of appearing to be a credible source, or how one goes about presenting that image to the media.
Q. Why do you believe LILCO's training program has failed to successfully instruct personnel to provide accurate and timely information to the media?
A. There are several reasons. First, LILCO's training program is lacking in any real instruction or practice which is necessary to teach personnel these tasks. In order to be able to deal appropriately with the media, personnel must be trained how to communicate information as soon as it is available, how to
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check information for accuracy, and how to respond to media l
questions. Personnel must know enough about the overall emergency, the response being made, other events related to the ,
emergency, and the response so that they can provide accurate and l timely information to the public through the media.
Personnel must also be trained about the media and how it operates, particularly in' emergency situations. In order to gain such skills and knowledge, personnel must do more than simply sit through a classroom training session and watch a videotape.
Personnel must have actual experience in-dealing'with the media' ,
or at least be exposed, during training drills under realistic conditions, to the kinds of situations expected to arise in an actual emergency. Furthermore, such training must be under the watchful eye of knowledgeable trainers, who can observe performance and correct mistakes. LILCO, however, appears to )
offer little or none of this kind of training in its program.
)
Thus, the performance of LERO's personnel during the Exercise was what we would have expected, based upon our familiarity with LILCO's training program.
Second, there is a certain. unreality to LILCO's training l program. LILCO appears to seem to believe that media training is unimportant because all people will rely upon is the EBS messages. The County has demonstrated in the Contention Ex 38 Testimony that those messages are flawed and also that, even
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l
l l
assuming those EBS messages are good, LILCO cannot ignore the media in dea]ing with an emergency. Those points will not be repeated here.67 Q. Are there any other concerns which you have regarding LILCO's training for media contacts as reflected by the Exercise results?
I l
l A. Yes. The Exercise results demonstrate that LILCO's ;
)
l plan for media contacts is fundamentally unworkable. The LILCO j Plan appears to emphasize that media contacts by LERO/LILCO l
67 (Evans, Rowan) It is essential to emphasize that LILCO personnel have relied on the EBS message system as the primary source of getting information to the public, even though the news media is the more likely conduit to the general public. Ege Deposition of Dennis Mileti, (January 8, 1987) at 48. This apparent ignorance of the prime role of the news media, especially of the reporters on scene who are not working on stories that would be published 20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> later, but right be i broadcast within seconds, indicates a significant lack of i
training in cris' 90mmtmi cations . Based on our experience in i
covering emergenales, we are confident that the general public relies upon the news media, particularly the broadcast media, during the first stages of an acute emergency and upon newspapers if a crisis situation persists over several days (as did Three Mile Island).
Because LILCO personnel are not equipped through training or ai.,ual experience to understand the importance of the news media in the crucial first hours of an emergency, news coverage in a real emergency of the sort simulated in the LILCO Exercise would quickly turn to non-LILCO sources. Reporters would summarize, condense, analyze and extrapolate on the information LILCO had provided. Moreover, they would seek alternative sources more willing to speak out. Thus, in a real emergency, the attention of the news reporters would quickly move beyond the untrained LILCO spokespersons and would focus on other sources.
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personnel will take place under controlled conditiens, primarily through press releases and the like. There appears to be no emphasis on making data promptly available to the media.
As we have already indicated, the mtlia is highly unlikely in any emergency situation to wait for the responding organization to provide information at its own pace. Rather, the media will be insistent upon receiving information virtually continuously. A training program must be geared to this reality.
Otherwise, if the responding organization does not satisfy the media's need for,information, the media will immediately seek out information from other sources; the potential for rumors and conflicting information will grow accordingly.
The LERO training program for media contacts emphasizes the l
mechanistic approach. That approach was demonstrated during the l Exercise to be unworkable. Thus, it is our conclusion that LILCO's training of LERO personnel for contacts with the media is fundamentally flawed.
i l To be sure, an effective media relations training program l
must include mechanical aspects (press releases, news conferences, facilities, phones, etc.). However, it should not emphasize a mechanistic approach. Good communications trLining must stress the dynamic of interrelating with reporters, producers, editors and photographers. A mechanistic approach
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which focuses on communications as what a spokesoerson says will fail to provide adequate information in the right context. A dynamic approach views communications as what the audience hears, remembers and acts uoon. This aspect of training was evidently missing from LILCO's efforts. Personnel in the Exercise clearly show little appreciation far the impact of their words, actions and announcements on their audience.68 (Evans) This mechanical approach, and its limitations, is 1
amply demonstrated by the EBS messages. Apparently, based on their behavior during the Exercise LERO personnel are trained to use the pre-fabricated " sample" EBS messages. Drafted in advance of the Exercise (or a real emergency), they leave few options to
\
LERO personnel coping with the emergency to exercise independent judgment, and the personnel demonstrated during the Exercise their apparent inability to exercise such judgment even when 68 (Evans, Rowan) We note also that from our review of the Exercise that it is clear that LILCO's training program did not take into account the lessons learned from Three Mile Island, and the subsequent recommendations of the Kemeny Commission based thereon. Two fundamental findings of the Venieny Commission, with respect to the accident at Three Mile Island, were that the media was confused when sources used technological jargon to describe the accident and that the media had difficulty understanding information relative to release of radiation into the atmosphere unless such information was given in terms of the precise nature and amount of radiation released and its impact on the health and safety of the public. One would assume that any training i
programs developed in the aftermath of Three Mile would take into i account these findings. LILCO apparently did not, as evidenced by the numerous incidents in EBS messages, press releases and statements by LILCO spokespersons where jargon is used to describe the accident and radiological information is given in imprecise terms with little, or no, information as to its impact.
See Contention Ex 38/39 Testimony at 57.
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obviously necessary. Other than filling in a few names here and there and striking from the drafts inappropriate language, the personnel who have responsibility for seeing that the messages are broadcast are apparently not required or trained to determine whether the broadcasts contain information the public ought to l
l have in light of the unfolding emergency. For instance, in response to questions and as an apparent consequence of the media monitoring procedures, LILCO officials emphasized at press conferences that an explosion at Shoreham was not a possibility.
Yet that information, which might have been comforting to the public, was never included in the EBS messages because it was not in the drafted " sample" format. Thus, while LILCO officials maintain that the EBS broadcasts are its fundamental means of communicating with the public, the mechanistic approach to preparation of those messages prevented LILCO from communicating directly to the public information which may have been critical.
Tre fact that this was not recognized and corrected by LILCO officials during the course of the Exercise demonstrates not only a failure of the mechanistic approach but also a lack of adequate training to exercise independent judgment.
(Rowan) It further must be emphasized that the inadequate performance of LILCO personnel in dealing with the news media is evidence of inadequacies in training about the communications component of crisis management. There are several basic components of communications that were evidently overlooked in
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i preparing LILCO personnel for the Exercise. These components include (1) the information, (2) the delivery system and (3) the l
sourcing. First, as to the information itself: is it true and l
l useful? More specifically, is it clear, accurate, consistent with other official messages, appropriate for the audience and complete? My judgment from reviewing how LILCO interacted or failed to interact with the media during the Exercise is that personnel were not properly trained to collect, analyze, interpret and process information. Otherwise the results of the l
Exercise would not have included instances when LILCO information was not clear, sometimes was not accurate, was internally I
inconsistent at times, and lacked completeness. See Contention Ex 38/39 Testimony.
l I
Second, as to the delivery system: was it effective and i timely? More specifically, was it well organized, did it make 1
l optimum use of human resources, were facilities adequate, was l
there coordination with other key organizations, did it deliver information in a speedy fashion, was there responsiveness to the needs of various groups, and was it flexible in changing circumstances? Good training programs alert personnel to these l
needs and their importance. The Exercise reveals that LILCO personnel were unprepared to provide an effective delivery system. It was flawed organizationally, personnel did not perform optimally, facilities were inadequate, coordination with t
l
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l
R the pseudo governmental entity, LERO, was rocky, information was !
l late in flowing, and it was unresponsive to the needs of the news media. Eee Contention Ex 38/39 Testimony.
Third, as to the sources of information: were they credible? Specifically, did the LILCO source.s provide access to information, were they open with the news media, did they offer data that were consistent with other external sources, did they exhibit objectivity, competence and honesty or were there conflicting loyalties? Based on our review of LILCO's conduct during the Exercise, it is obvious that LILCO personnel were unprepared to demonstrate credibility as news sources. They showed an absence of openness and a lack of cooperation with the media, and an apparent lack of understanding or appreciation of the necessity of demonstrating these characteristics. Good training programs stress ways that news sources can demonstrate I shared values and create bonds of trust with news reporters; LILCO was unable to do this.
1 1
(Colwell) I have personally held numerous local, state-wide l
and national news conferences. I have also appeared on national l news networks where I was interviewed " live" concerning events such as aircraft hijackings, kidnappings, shooting incidents, 1
fugitive apprehensions, bombings and major legal cases such as ABSCAM.
l l
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L
For an organizational spokesperson (or a central news disseminating organization) to be effective, the spokesperson must instill a sense of confidence that full disclosure is being made at the designated media room location. Once the media believes that the most current and accurate information is not l
l available at the news center, they will leave to pursue other lines of inquiry and other sources.
The key figure in keeping the media at the central location
-- and thus averting the dissemination of inaccurate information, speculative information, or information which may be distorted by i
being taken out of context -- is the spokesperson. The spokesperson must speak with authority, and have immediate access
-- access which the media can see -- to all levels of the organization. The spokesperson must be able to report on events contemporaneously. For a spokesperson to prove himself out of l touch with what is happening in the field, or where the decisions I are being made, is fatal to his effectiveness. And the spokesperson must have full knowledge -- down to the smallest l
operational detail -- of the organization he.is representing. I Finally, the spokesperson must have the ability to perform under ;
, pressure. The media in this country is.known for, and prides l
itself on, asking the hard questions, probing for ever more information, and refusing to be put off by vague or ill-informed answers.
l
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___m____. ____.-- -
The ability to deal effectively with the media can only be gained through experience, or through extremely realistic role-playing exercises. It is essential to place the role player under pressure in these simulated situations, because he will be under intense pressure when he is before the media in a real emergency. In fact, if the event in question were a nuclear emergency, I imagine the pressure from the media would be particularly intense, given that at the time representatives of the utility went before the press, they would already be perceived as having in some sense " dropped the ball" and thus
- endangered the health and safety of thousands of people.
l l
l I am not aware of the specific training the LERO spokes-person had received for her job. I can, however, say that, based on her performance during the Exercise, that training was ineffective. First, as has been discussed in prior testimony, the spokesperson (Ms. Robinson) failed in her first duty, i.e.,
informing the media as to what was going on. The ENC continually i
, lagged behind the EBS station in the information it was giving I l \
out. Even when the spokesperson had information to give, she I would wait for the next scheduled press briefing to give it. The spokesperson frequently appeared flustered by the questions she was asked. (Even the LILCO Lead Controller at the ENC noted that she lacked polish in answering a question about the evacuation.
l Based on my own viewing of the ENC videotapes made during the Exercise, I consider this an understatement).
l
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The LILCO spokespersons' answers were, on occasion, flippant. (For example, when a reporter asked how the 95,000 people who had been sent to the Coliseum for monitoring would fit there, the spokesperson responded: "The answer is, not all at once." At another point, immediately after stating that the
! residents of six zones in the EP? were being sent to be monitored for possible contamination, the spokesperson' delayed answering a question about whether people on the road were being exposed to radiation in order to adjust the table where she was sitting and to observe that "(w]e're having problem with the table at the moment."). At other times, the tone was offensive. For instance, when asked if any effort was being made to determine or ensure that people were in fact evacuating, the spokesperson 5 opined that people are " expected to behave in a sensible and adult manner . . . .
Finally, the witnesses on Contention Ex 38/39 have already discussed the substantive inadequacies and inaccuracies in the answers to questions from the press and their likely result. I will not repeat their testimony here except to point out that the spokesperson should have known such things as the number of people who had been told to report for monitoring, the details of any traffic impediments, and that the population of the area was lower in the winter than in the summer. In sum, the spokes-person's perfetmance during the Exercise made it clear that, although she was the "LERG" spokesperson, she exhibited little
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R j
i understanding of-the operational details of "LERO," little access to the higher levels in the organization and the information i
flowing from them, and little experience in establishing rapport 1
with the media and in effectively fielding their questions.
I can only conclude that she was given inadequate training to prepare her for her role as LERO spokesperson.
l 3. The Post-Exercise Drills Do Not Solve LILCO's Trainino_ Problems j Q. Has your review of the_ post-Exercise LILCO training 1 l
drills changed your opinion in any way with respect to whether 1 i
LILCO's training program has successfully trained LERO personnel to deal with the media or otherwisc provide timely, accurate, consistent, and nonconflicting information to the public, through ;
the media, during an emergency?
A. No. First, there has been no basic change in LILCO's training approach. It was flawed before and continues to be flawed. Further, the post-Exercise drills in terms of media relations were quite limited, with no actual media involved. Sgg also Contention Ex 38/39 Testimony at 135-38. Thus, these drills provide no basis to alter our conclusion that the Exercise results demonstrated fundamental flaws in LILCO's training program.
)
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G. Contentions Ex 50.G and H: Training for Persons and Organizations Relied Upon By LILCO and Training in Exposure Control Q. What do subparts G and H of Contention Ex 50 allege?
A. Contention Ex 50.G alleges that the Exercise f l 1 l
demonstrated that LILCO has failed to provide training to persons I and organizations relied upon for implementation of its Plan, -
Contention Ex 50.H, as well '
other than those employed by LILCO. -
as Contentions Ex 27 and 28, allege that the Exercise demonstrated that LERO training has been deficient in the areas of dosimetry, exposure control, KI, understanding of radiation terminology, and related areas.
Q. Please state subparts G and H of Contention Ex 50.
}
A. Subpart G states.
The exercise demonstrated that LILCO has failed ~
to provide training to persons and organizations .
relied upon for the implementation of its Plan <'
other than those employed by LILCO. Exercise actions and events which support this allegation are described in Contentions Ex 27, Ex 28 and in the following FEMA conclusions: EOC-ARCAs 11, 12, 13, 14, 15.
Subpart H states:
The exercise demonstrated that LERO training is deficient in the area of dosimetry, exposure control, KI, understanding of radiation '
terminology, and related areas. Such training deficiencies are very serious because members of the public and non-LILCO personnel relied upon to
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respond to a Shoreham accident (for example, school officials, special facility personnel, and other individuals who are expected by LILCO to respond on an ad hoc basis) would see..
information on such. subjects from LERO personnel during a real emergency. Since LERO-personnel do not understand and know how to use dosimetry equipment and the related procedures, they would be incapable of responding accurately or effectively concerning those subjects to members of the public, or other workers expected to respond. The following exercise actions and events are examples of dosimetry-related training deficiencies: Contentions Ex 42, Ex 45, FEMA i Conclusions EOC-ARCAs 11, 12, 13, 14, 15; PJSA-ARCA 1; PSA-ARCAs 12, 13, 14, 15, 16; RSA-ARCA 4, 5, 6. I l
1 l
l Contentions 27 and 28 are set forth in Attachment 6. i Q. Do you agree with subparts G and H and Contentions 27 and 28?
A. Yes, we do.69 Our opinion in this regard is based upon what occurred during the Exercise, as well as our review of LILCO's training program, including training drills conducted since the Exercise.
- 1. Suboart G Q. Are there difficulties in compiling data on the subpart G allegations?
69 We deal with these Contention Ex 50 subparts together since many of the training deficiencies involving outside organizations concern dosimetry and related problems. Accordingly, to avoid repetition, we have combined them.
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___- _--_____-_ _ ___- _ a
I A. Yes, because we are not dealing with a complete universe. As set forth in Contentions Ex 15 and 16, many persons and organizations outside of LILCO which are relied upon to perform necessary actions during a Shoreham emergency did not participate in the Exercise. Accordingly, the Exercise results provide no means to identify whether the training of those i
individuals and organizations is or has been adequate. This matter will be dealt with in greater detail in the context of Contentions.Ex 15 and 16. We add only that it is our understanding that many_such individuals -- such as personnel j from the many schools within the EPZ that must take protective actions in the event of an emergency -- have received no training l whatsoever.
Q. Focusing on subpart G of Contention Ex 50, on what do you base your opinion that LILCO has failed to provide adequate training to persons in organizations relied upon for implemen-tation of its Plan?
l l
A. The Exercise revealed a number of LILCO failures to provide training to the non-LILCO personnel and organizations relied upon by LILCO for the implementation of its Plan. For example, as recognized by FEMA (FEMA Report at 45-46), even those school bus drivers who participated in the Exercise -- from Shoreham-Wading River School District -- had had noLtraining in l dosimetry, the use of potassium iodide, or excess exposure
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1 i
i authorization procedures. Such training for emergency personnel 1
is required, but the Exercise demonstrated that it either has not been provided at all or has been inadequate. i In addition, although the LILCO Plan relies upon ambulette drivers for implementation of the protective action of evacuation for special facility residents and the homebound (see OPIP j 3.6.5), not all ambulette drivers had been trained in excessive exposure authorization and procedures, FEMA Report at 46.
Another example is provided by the actions of the LERO
" scientist" from Brookhaven National Lab who appeared at the ENC l
l press briefings. See Contention 38/39 Testimony at 91-94.
1 Although this scientist, Dr. Brill, had been involved in the LERO training program, he nonetheless gave out incorrect technical information and actually contradicted the LERO protective action recommendation of evacuation when asked by the press what he would do given that recommendation. Thus, Dr. Brill was asked what would happen if a " diehard" decided not to evacuate in the face of an evacuation recommendation (a question which certainly l
should have been anticipated by LERO trainers). In response, Dr.
Brill announced that although he lived within two miles of the plant, he would probably himself be one of those " diehards" who would not leave. As noted in Contention 38/39 Testimony (at 93-94), such a response could have disastrous results during a real emergency. And, if anything should have been covered in the l
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1
LILCO training on public information matters, it should have been the necessity for consistent advice and recommendations. -There is no excuse for Dr. Brill's statements, since he had been sitting in the press conferences and was well aware of the LERO recommendations; similarly, there is no excuse for the other LERO members who heard Dr. Brill's announcement failing to correct it immediately so that the harmful results were reduced. This demonstrates a clear failure of the training program.
I 1
l l The above examples demonstrate that LILCO's training program l
has failed to provide necessary training to those personnel from outside organizations that are relied upon by LILCO for the implementation of its Plan. In addition, it should be reiterated that many other non-LILCO personnel and organizations failed to participate in the Exercise in any way. Egg, e.o., LILCO Admission Nos. 21-24, 26-28, 30, 34-35, 48-49, and 199.
Therefore, the Exercise results provide no basis for concluding that LILCO has provided adequate training to any of them.
l \
l l Given the small number of outside organizations which participated actively in the emergency response, we find it significant that there were widespread dosimetry problems with respect to two of those organizations. Beyond that, the lack of participation by so many other organizations makes it clear.that there is no basis upon which one could conclude that LILCO has in fact implemented an adequate training program for personnel of outside organizations.
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l
- 2. Suboart H Q. Gentlemen, some of the foregoing examples relate to deficiencies in dosimetry and radiation protection training.
Accordingly, they relate not only to subpart G of Contention Ex 50 but also to subpart H of Contention Ex 50. Are there other examples not involving outside organizations which support your views concerning subpart H of Contention Ex 50?
A. Yes. The Exercise demonstrated that LILCO's training has been deficient in the areas of dosimetry, exposure control, KI, and related areas for its own personnel as well as for h outside organizations. For example, during the Exercise, the following was noted by FEMA:
One bus driver dispatched from the Port Jefferson Staging Area failed to read his DRDs at any time during the 75 minutes that he was in the EPZ (see FEMA Report at xiv, 59);
One of the genera.1 population evacuation route bus drivers dispatched from the Patchogue Staging Area only read his DRDs twice, and then only at the instruction of the Transfer Point Coordinator, and another read his DRDs only when it was convenient (see FEMA Report at 68, 69) 1 1
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l One of the drivers for the general population evacuation bus routes dispatched from the Riverhead Staging Area did not read his DRDs every 15 minutes, as required by OPIP 3.9.1 (see FEMA Report at ' xvii, 76, 77);
One bus driver dispatched from the Riverhead Staging Area simulated the ingestion of his KI tablet prematurely, prior to being assigned an evacuation route (ggg FEMA Report at 76, 77);
On the basis of these problems, FEMA found that LILCO's bus drivers should be given additional training in these matters.
FEMA Report at 69-70, 77.
l 0 Are there other examples from the Exercise that j 1
demonstrate the ineffectiveness of LILCO's training in the areas covered by subpart H?
I A. Yes. For example:
One of LILCO's Route Alerting Drivers believed he would receive KI authorization in an EBS message.70 (Egg FEMA Report at xvi, 69, 70).
I 70 FEMA found that LILCO's Route Alert' Drivers should be ;
trained to know that KI authorization is to be issued to-them by their supervisor as specified in the LILCO Plan (OPIP 3.3.4, Att. 1). FEMA Report at 70.
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~
l ~
L_______________________________._____._____._________________ _ . _ _ _ _ _ _ . _ _ _ _ _ _ . . . _ . _ _ _. _ _ _ _ _ _ _ _ _ _
(-
V q.
l t
l l
1 Traffic Guides at two Traffic Control Points did'not know dose authorization limits.71 Traffic Guides-at two Traffic Control Points did not- !
fully understand that the chain of command for excess exposure-f authorization gives the Lead Traffic Guide authority to authorize'
{ excess exposure by radio. Further, some Traffic Guides indicated to FEMA that they might question the authority of the Lead Traffic Guide to issue the authorization for excess exposure (despite the fact that it is specifically established under g 4
LILCO's Plan that the Lead Traffic Guide can authorize exposure (
in excess of the general population PAGs, and that this can be j ' )AU done by radio). See FEMA Report at 70.
i T Two of the eight Traffic Guides observed by FEMA did j not fully understand the difference between low- and mid , range il DRDs (see FEMA Report at 76).
The Patchogue Staging Area Bus Dispatcher misinformed LILCO bus drivers when instructing them in how to read their DRDs (ggg FEMA Report at 68, 69).
These, examples are significant, particularly since \i'EMA t
evaluated a very small number'of LERO workers. Egg Contention Ex 21. The existence of so many training deficiencies in a small
____________________ i .. 4 W 71 FEMA found that LILCO needed to train Traffic Guides so)that they learned dose authorization limits. FEMA Report at 70. <
i
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I i
_ _ - - - _ - _ _ _ _ _ _ - _ _ _ _ _ - _ _ _ _ _ _ - _ - _ _ _ . _ _ _ _ _ _. _ _ _a_.
number of workers evaluated by FEMA, strongly suggests that the problems are widespread. Yet, despite the obvious importance of such training, LILCO failed to provide any training at all to-non-LILCO personnel, and failed to provide adequate training to its own personnel.
Q. Has your review of the post-Exercise drill _ reports led to any changes in your opinions concerning LILCO's ineffectiveness in training personnel in the areas of dosimetry, exposure control, KI, and related areas?
A. No. In fact, a review of the post-Exercise drill reports has solidified our conclusion that LILCO's training program has been deficient in these areas.
For example, during the June 6 drill, several Traffic Guides .
were not clear on the procedure regarding exposure authorization levels. Atlatnmaat 7 at ;. The same general types of training i deficiencies showed up again during the September it dtill:
Thur; as had beca the ease during the June 6 dtdLi r *r4ff.ic Guides were not a' care of critical radiation control information.
In f act, most of those questioned were not aware of the maxitaum allowable dose or the proper proceuures governing the use of KI.
Attachment 8 at 4-5. Further, two Road Crews cere not aware of
(
l
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r the proper procedures regarding the use of dosimetry and maximum exposure allpwances. They also were not proper 17 informed about when to take th'eir KI tablets. Id. at 6.72 Q. Has your review of the December drill report changed yaur vie **regarcing Contration Ex 50 in any way?
I
, A. Nu .it has not. Problems occurred in the December 10 i \
drjll. Thus, the Director authorized exposure up to 10 rem for a field worker without consulting the Radiation Health Coordinator.
Attachment 9 at 12. And, a road crew worker failed to read his dosimeter every 15 minutes during the December 10 drill.
Attachment 9 at 41.
In conclusion, therefore, we see no basis in the post-Exercise training drills of LILCO to find any reason to alter our prior conclusion. LILCO has failed to adequately train its personnel, as well as those in support organizations, to understand and follow directions related to dosimetry, exposure control, K-1, and related areas.
72 A review of the September 17 drill further supports our concerns about the inadequacy of LILCO's training program with respect to the training of personnel in the areas of dosimetry, exposure control, KI, and related areas. The distribution of dosimetry was not well controlled, and many personnel missed their dosimetry briefings. Attachment 8 at 8.
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H. Contention Ex'50.I: LILCO's Modifications to Its'Trainino Procram are Ineffective 1
Q. Please state subpart I of Contention Ex 50.
A. Subpart I states:
l The exercise demonstrated that LILCO's proposals to modify training materials or procedures to .
" emphasize" such things as " accurate'use of field. .)
data," the need "to relay instructions," "the.
need to be more precise with information," or other matters a2 ready in the procedures and i training materials (gga letter dated June 20, l 1986, from John Leonard to Harold Denton (SNRC-1269), Encl. 1) -- training materials and
) '
procedures which have been so unsuccessful for three years--- would not correct the flaws revealed by the exercise.
Q. Do you agree with Subpart I?
l A. Yes, we do. In our opinion, the Exercise clearly
,/
demonstrated that LILCO's propose $.-dbdifications will have s'
little, if any, effect o hpw#well personnel are trained.
,,f
- l. LILCO's ,Pfbposed Training Changes Represents No Restf Chance Q. .Are you familiar with LILCO's proposed changes to its training program? l l
4
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i i
A. Yes, we are. They are discussed in a document titled "SNRC-1269." Virtually every modification made by LILCO was made in direct response to a " Deficiency" or "ARCA" found by FEMA.
Each FEMA comment and LILCO response relating to training is set forth in SNRC-1269, which is Attachment 10 to this testimony.
Q. Are you awars of any additional training changes that LILCO has either implemented or proposed in addition to those listed in SNRC-12697 A. Yes. LILCO has implemented a few minor changes to its training program in addition to those listed in SNRC-1269. These include: the addition of mini-tabletops for field personnel; and the creation of so-called " action diagrams" to be used during mini-tabletops.73 In addition, LILCO's personnel now receive all their classroom training on the same day and LILCO has shortened at least one videotape (the basic radiation module videotape).
See Deposition of Dennis N. Behr (January 13, 1987), at 61-62, 88.
73 LILCO has also created identification badges which have job functions and dosimetry information printed on the back. See Deposition of Dennis N. Behr (January 13, 1987), at 66. Contrary to LILCO's apparent position, however, we do not consider these badges to be a training modification.
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0 Do you believe that the changes reflected in SNRC-1269 and as otherwise described above will solve the problems with LILCO's training program that were demonstrated both during the Exercise and in post-Exercise drills?
A. No, we do not. In fact, in our opinion, the changes in LILCO's training program that have been proposed and implemented since the February 13 Exercise do virtually nothing to solve the many problems with LILCO's program. We have already discussed many of these matters in connection with other subparts. That discussion will not be repeated.
We emp'nasize, however, that LILCO's training program, as modified since the Exercise, is conceptually no different than it was when it was first implemented three years ago. See Deposition of Dennis N. Behr (January 13, 1987), at p. 81.
Making minor modifications, emphasizing specific tasks (when such
" emphasis" is accomplished primarily by highlighting tasks using l
colored pencils, as LILCO has done in its " action diagrams"), and l l providing essentially more of the same kinds of training which l
l have been ineffective in the past, cannot improve a training pro-gram as seriously flawed as is LILCO's program. There is simply l no reason to believe that a training program that has been as '
unsuccessful as LILCO's, as demonstrated by the Exercise, despite having had three years in which to train personnel and three
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dress rehearsals and other drills just prior to the Exercise, will become successful by making the. kinds of minor modifications proposed and implemented by LILCO.
Q. Please explain.
A. For example, LILCO now proposes to tell trainees during classroom lectures and tabletops to be " aware" of their particu-lar jobs and the functions that need to be performed. In our opinion, this is not a " change" or " improvement" even worth discussing. If LILCO's original training program did not impart this most basic information, then it was totally inadequate to begin with. Merely repeating what-one has already been told --
without effect -- for three years of prior training, will have no noticeable impact.
l 1
LILCO has also created what it calls " action diagrams."
These action diagrams are nothing more than charts that depict the job tasks of LERO personnel, highlighted in different colors.
Clearly, LILCO's original training materials already had information -- albeit ineffective in many instances -- which depict job tasks.
Such " changes" in a training program as just described cannot be realistically expected to improve performance to any significant degree, if at all. They do nothing more than tell 1
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l l
i l
, LILCO's personnel what to do, which is, presumably, what LILCO has been doing for three years of prior training. They do nothing additional to teach personnel how to do'them. It is training in how to accomplish a job, in learning by doing, not merely telling trainees the job to be done, that is needed.
Simply put, the training methodology utilized by LILCO is no different than it has been for.the past three years, and there is therefore no basis for us to conclude that LILCO's training program will be any more successful in the future than it has been in the past, or was during the Exercise.
- 2. LILCO's Organizational Structure Will Make It Difficult.for LILCO to Successfully Train its Personnel O. Are there any additional reasons why LILCO's fixes will not be successful?
A. Yes. The LILCO fixes likely will not succeed for the additional reason that there are inherent deficiencies in LILCO's structure which would make it extremely difficult for LILCO's training program, even as modified, to succeed. LILCO's program would have to be implemented with great skill but, as demon-strated by the Exercise results, there is no basis to believe that LILCO's training program has been well implemented, much less successful.
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Q. Please explain what you mean.
A. LERO personnel supposedly are given basic training and training in interactions that would be consistent with the organizational structure of LERO. As demonstrated in the Exer-cise, LERO's structure is designed for routine tasks, in that it is quite centralized, and yet it has some wide spans of control.
l It is not a structure that could readily respond to emergencies, or unexpected-events, even though it purports to be an emergency organization. Thus, despite LILCO efforts to devise a training program to teach personnel to implement its organizational structure, such efforts will likely fail.74 Q. Please explain how LILCO's structure relates to the effectiveness of its training program.
l 1
A. The LERO organizational structure bears directly on the -
effectiveness of the training program. To the extent that people are trained to fit into LERO's structure, their training may be.
1 inappropriate for the kinds of tasks that the organization will confront. By that we mean not the literal tasks of following a map or contacting the Coast Guard, but the generic nature of the 74 An organization which has a highly centralized structure and wide span of control is not oer se incapable of responding well ,
to non-routine emergency situations. To the contrary, many law !
enforcement agencies, including the FBI, have such structures.
However, they are much different than LERO in having the ability to also emphasize flexibility and decentralization in crisis management and have repeated real life practice to make their structures work.
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i l
)
i tasks, which are certain to be more non-routine than routine. i People are going to have to " scramble," innovate, jury-rig things, find substitute personnel or equipment, convince j distraught citizens that they should stay put, convince their l fellow workers not to flee, and so on.
However, given the structure of the LERO organization, that is, the roles that people are trained for as laid out in the Plan documents, and the authority relations, and number of people and functions that top management-has to control, we find little evidence that the LERO organization can perform effective training for non-routine events. Were it to do that kind of training, it probably would have to modify its structure.
J The organizational structure devised for LERO is a !
l conventional, highly centralized structure with large spans of control. It would be an appropriate structure for routine operations if the spans of control were reduced in several cases.
i But even if this were achieved, it remains an inappropriate structure for emergency operations, in that emergency operations, almost by definition, involve non-routine events and LERO does not have an opportunity for learning by doing training to gain the necessary experience to operate effectively with its organizational framework. Alternative structures involving some matrix forms that permit decentralization of responses would be
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possible only if personnel learned to work together over a long period of continuous operation under a large variety of conditions.
LERO has designed its training program to fit its structure.
Thus, LERO is training for specific, set tasks, clearly demarcated into videotape modules or manuals, and emphasizing lines of authority and reporting. Its proposed " fixes" in response to the Exercise findings are simply more of LERO's training for routine events. But LERO's training will not succeed, because the training for a fixed, static, centralized organizational structure is incompatible with the kinds of uncertainties that will be encountered and the kind of adaptive, flexible, decentralized behavior that will be required.
l Q. Could you explain what you mean when you say the j structure of LERO is more suitable for routine cperations but that the tasks that LERO has to perform will be anything but !
routine?
l l A. LERO has a straightforward structure, much as a power l plant or an i. +,6crial plant would have. It is very centralized.
For . ample, under current LERO procedure when a road impediment is identified, it can be dealt with only upon orders of the Evacuation Coordinator at the EOC, whose orders then must tse passed down.a vertical chain until, finally, the LERO line l
l
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1 \
personnel who must deal with the impediment finally are brought into action. Similarly, the lines of authority are suca that except for the EOC, only the three staging areas have any separate status or autonomy, and within them it appears that anything of consequence has to go to the top (i.e., the EOC) for ,
i a decision. There is little decentralization of groups that can l I
handle " local" problems, even though such problems likely will j l
arise during an actual emergency. Thus, LERO is an organization I i
where people call information up the line, and receive orders down the line. People are not expected to communicate and share information laterally in the organization, and people in the ;
field have no authority to make their own decisions without seeking permission or guidance because of the urgency of the problem, the lack of information about the problem at higher levels, or the difficulty of reaching the higher levels.
A centralized structure can handle routine events because these events are predictable, and thus the level at which the decision can be made is known in advance, and there is little need for lateral communication across suborganizations because no problems should emerge that require this. Almost all I
organizations have to violate the centralization requirements built into the authority structure and rules as unexpected events I
appear.
Generally, they set aside the heirarchy temporarily, and
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I create temporary groups made up of people from different units, and allow communications to jump authority levels or cross over the divisions in'the organization.75
)
[ We could find no evidence of temporary groups or cross-unit. !
communications in LERO drills and exercises. There appear to be I no provisions for coping with the need to jump lines of authority, or have lateral or diagonal communications across units. Apparently, LERO has trained its people to follow the i
book in virtually all cases.76 1 But obviously, there will be unexpected problems in an emergency, so the lines of authority and procedures must be held in suspension temporarily. More important, methods for dealing )
with unexpected problems can be built into a structure, even if it is quite centralized. Task groups can be set up to. deal with cross-unit problems that have to be solved at levels below that l l
at which the heads of two units would normally interact. They must have some autonomy, of course, violating the principle of a single chaln of command. Furthermore, drills can simulate situations where it is necessary for a person low on the chain of command to jump one or more levels of authority to immediately i
75 This is what the FBI does quite effectively in crisis situa-tions. See the discussion of this in Charles Perrow, Complex Organizations: A Critical Essay, 3rd edition,. Random House, 1986, pp. 36-42.
76 I
As previously discussed (see Contention Ex 50.B Testimony),
LILCO has been unsuccessful even at this task.
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reach someone higher. Such behavior can-be both unusual for centralized organizations, and threatening for the subordinate person. Therefore, it has to be part of training, so that subordinates can include it in their repertoire, and superiors can get used to talking directly, if need be, to a traffic guide.
Both need this experience, since the need for such changes in authority relationships occurs relatively infrequently and violates the principles of a centralized organization.
We suspect that in LILCO, in its normal daily operations, such cross cutting does occur in minor matters and is not all that foreign. It is hard to envision an organization functioning well otherwise. But LERO is not an organization that functions as an organizat. n often enough or long enough to have this l
l experience, and the people in it have quite different roles than 1
! they have when they are with LILCO and interact with people they 1
are not familiar with.
In an organization which purportedly is to be capable of responding to an emergency, we would expect to see an organization chart with extensive provisions for mobilizing temporary groups that cut across functional boundaries such as exist between public information handling and traffic management; provisions for alternative reporting channels in case the normal one is clogged or destroyed; provisions for drawing from other units in the event that leaders are unavailable (because of
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traffic jams, excessive exposure, or whatever); designated lateral linkages between groups at low and intermediate levels, rather than requiring everything to go up one side to the top and then flow down the other side to the person who needs the information; and specification of coordinating groups that cut across specialties.
We see none of the foregoing characteristics, however, in h LERO. Further, the LERO organization is so poorly designed, from the point of span of control and task requirements, it would probably fail. The task would just be too great for many persons who are relied upon.
Q. You used the term " span of control." What do you mean by span of control?
A. (Perrow) Span of control refers to the number of subordinates a superior is directly responsible for, that report to him or her, and also to the variety of functions that these subordinates are responsible for. A part of the organization can function well if the manager or superior has a large span of control (i.e., many subordinates, say 10 or even 30), if the jobs of the subordinates are routine, easily monitored, of a similar function, and not interdependent. When the tasks of subordinates are non-routine, and checking on their performance is difficult, and their tasks or functions vary, and especially if these tasks
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are interdependent so that the subordinates must work together, then a small span of control, as low as 2 or 5, is required, unless there is extensive experience with dealing with large spans of control during crisis situations.
O. Could you give some examples of spans of control in LERO?
l A. (Perrow) The Director of Local Response, the' head of LERO, has a small span of control since there are only two people reporting to him, his deputy, the Manager of Local Response, and the Coordinator of Public Information. On the other hand, some i spans of control are quite large. For example:
l i
1.
~
There are eight Transfer Point Coordinators for 182 bus drivers at the Patchogue Staging Area. Thus, there is only one supervisor for every 22 Bus Drivers. OPIP 2.1.1, at 78.
J
- 2. There are only three Lead Traffic Guides for 109 field personnel dispatched from the Port Jefferson Staging Area. These personnel include Route Alert Drivers, Traffic Guides, Evacuation Route Spotters, and Road Crew members. OPIP 2.1.1, at 78. This is one supervisor for 36 field personnel.
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- 3. The Staging Area Coordinators for Port Jefferson, Riverhead and Patchogue each supervise either 15 or 16 people, OPIP 2.1.1, at 78, including the Lead Traffic Guides, Staging Area Support Staff, Dosimetry Record Keepers, and Bus Dispatchers. OPIP 2.1.1, at 78.
Q. Are there means by which LERO could overcome problems l
with the span of control?
l A. (Perrow) Probably not. It would be possible to add another hierarchical level in many of the sub-organizations, ,
l relieving some of the burden on managers. However, this adds to the complexity of the organization, creating new opportunities i I
for errorr. l I
As nentioned earlier, a possibility perhaps considered by i
LERO is a matrix organization. However, a matrix organization probably .is not possible for LERO because it requires continuous, i intensive operation, and LERO does not have the option.77 77 In a matrix organization, to use the Riverhead Staging Area i as an exanple, instead of the Staging Area Coordinator receiving j directions f rom one person, the Evacuation Coordinator, on the i basis of the latter's contact with Traffic, Transportation, and !
Special Facilities heads with responsibility for Port Jefferson, i Riverhead, and Patchogue Staging areas (these heads in turn receive information from their own staffs) -- a traditional hierarchical and function related structure -- we would have a structure toughly as follows: Each Staging Area would have personnel who dealt with all tasks: traffic control, route coordinators, road logistic coordinators, etc., and also the traffic guides, dosimetry record keepers, bus dispatcher, drivers etc. These would be formed into a large matrix wherein each (footnote continued)
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_-___-___-_a
Q. Are there any other reasons why LILCO's " fixes" for its training problems are, in your opinion, unlikely to succeed?
l 1
A. (Perrow) Yes. There are additional reasons, related to, yet somewhat distinct from, the organizational and span of control problems discussed above. These additional reasons relate to the concepts of interactive comnlexity and tioht I couplina, i
l l
Q. What do you mean by these terms and how do they relate to emergency response training by LERO?
A. (Perrow) The task of LERO is to determine and communicate appropriate protective action recommendations to the public, to implement them, to provide relocation services, to I l
assist a large number of people, and to direct and control an I 1
l (footnote continued from previous page) person reports not only to his or her functional head (the Route Alert Drivers, for example, reporting to the Lead Traffic Guide),
but also to a Staging Area coordinator, of which there would be several, each responsible for a particular area, a particular phase of evacuation, or a particular set of anticipated problems, or some mix of these.
In this matrix form, centralized control is minimized, and lateral coordination around particular tasks is emphasized. Here individuals form teams with roughly equivalent status and overlapping assignments, consisting of six to ten or so individuals with shared responsibility, and one team leader who forms the communicating and resource securing role. Matrix organizations require intensive socializat, ion, long periods of working together, particularly under a variety of relevant conditions (e.g. for LERO, emergencies under different conditions such as summers when transients are about, winters when storms are in progress, high road travel days, etc.) Clearly this is impossible for LERO.
l
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1 entire community-wide response to a nuclear accident. These I tasks involve two distinctive and incompatible conditions:
interactive complexity and tight coupling.78 LILCO's training program is deficient because it ignores this basic fact about the i type of task LERO personnel and the organization as a whole are l
expected to perform.
Interactive complexity is a condition where unanticipated interactions between different parts of the system can take place because of failures in the parts or because intended behavior in one part affects another part in an unforeseen manner. For example, an EOC mistake in handling a message regarding an i
l impediment can immobilize the traffic guides and road crews in the field trying to deal with the problem. The interaction of tnese several failures could then produce even more traffic as people who did not know of the impediment are caught in traffic.
Tuning into the EBS station for information might produce only the comparatively mild statement that there was a problem at the plant but no word about impediments because the ENC would also be uninformed.
Compounding the problem is the matter of.ticht couplino.
This refers to a variety of interrelated processes: highly time dependent processes (things must happen fast; there is little 78 See Charles Perrow, Normal Accidents: Livino With Hioh Risk Technologies, New York, Basic Bock, 1984, for definitions and illustrations of these concepts.
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time to wait for clarification because the accident might get worse and the roads more crowded); inability to stop the " system" (the plant accident, the unplanned evacuation, the traf.fic jams, etc.) until the failures can be corrected, or to delay parts of it, or reverse it or otherwise change its direction; inability to provide adequate substitutes (helicopters, protective clothing, alternative personnel to remove impediments or direct traffic);
and an inability to provide buffers that are not designed into the system but which, in a loosely coupled system, are fortuitously available.
Tight coupling means not only that the time available for evacuation and other protective measures may be more limited than anticipated, but that the direction of evacuation cannot easily be changed or reversed, that a tie up on one road means over-loading another road, that the capacity of roads is fixed and cannot be substantially increased, and even that some autos will be low on gas and soon run out while idling in traffic, thus possibly becoming impediments.
An organization that is confronted with interactive com-plexity can only cope with it by radically decentralizing its operations. Decentralization allows those in direct contact with the f ailures" such as the traf fic impediments, the traffic congestion, the seemingly irrelevant or inaccurate EBS messages, the phone tic ups, etc., to make decisions on the basie of these
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i
)
\
observed failures and take actions that cannot be foreseen in the emergency plan. Those who experience the unanticipated inter-action of failures first hand are those who are best able to take ,
corrective action.
l As alicady discussed, however, there appears to be little -
provision in the LERO Plan for such decentralization. The flow of information is upwards, and the flow of orders or directives is downwards. A decentralized system would rely upon lateral information flows, lateral directives, da.rectives going up the hierarchy as well as down, and consultation and problem solving at the point where the disturbances or failures occur regardless of levels of authority. Organizations that are responsive to unexpected events temporarily suspend the lines of authority that are in place for handling routine events. The LERO Plan does not allow this.79 On the other hand, an emergency situation also requires centralized command and control structures. Paradoxically, because of the tight coupling of the system (time requirements; no possibility to stop, delay or change directions; and large 79 Traffic Guides are not authorized to direct other personnel at or above their levels, even though interactive complexity would require this behavior wherein those with the most direct experience of the failures can take charge of coping with them by giving directives to others that might be above them in the chain of conmand. However, LERO is modeled after a conventional organ-ization which means little interactive complexity and routine s tasks and plenty of time to make corrections and plenty of l opportunities to make substitutions. None of these obtain for i LERO.
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limits on available substitutions cf resources), it should be highly centralized so that those with a " big picture" can give incontrovertible orders to those that only have a small part of the picture. But interactive complexity means that those with a small part of the picture, those on the " firing line" so to speak, have to exercise extraordinary initiative and occasionally ignore or violate the chain of command.
We have, then, two potentially incompatible system require-ments: O centralization and centralization. Were LERO the best organization possible, it would have grave difficulty in doing both at the same time.80 The implications for training are that even if LERO instituted training that emphasized individual or group responsibility, adaptiveness, lateral communications, bottom-up authority and so on -- all of which it should emphasize
-- it would run afoul of the need for very rapid response controlled by the very top. But our judgment is that since you can't have both a decentralized and centralized organization (except perhaps under some very special circumstances, such as Naval ships at sea that can drill continuously without inconveniencing anyone and the FBI and other law enforcement agencies), it is better to err on the decentralized side. This SO Only endless drills and exercises under the most realistic conditions could produce an organization that could cope with these contradictory requirements. Personnel might have to be doubled, equipment trebled (because of the inevitable failure of some equipment; there were several instances in the exercise),
and the added complexity of these increases coped with, and the training, drills and exercises run daily or weekly.
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LILCO has not done. Rather, it has provided for training which is designed to support a highly centralized system but this is incompatible with the realities of what LERO's personnel must do.
l Q. Are there examples from the Feb. 13 Exercise that illustrate the foregoing concepts and their implications for LERO's training program?
A. (Perrow) Yes. The ENC problems provide one example.
The ENC reflects a part of LERO in a tightly coupled posture --
EBS messages, press releases, plant conditions changing, all of which contribute to a fast moving situation that cannot readily be stopped. There is a need to get information out fast because information rapidly becomes obsolete and because the media insists on receiving information. At the same time, there is interactive complexity -- the ENC cannot act unless the EOC has acted. When the copier broke down in the Exercise, this exacerbated the already difficult problem with the result that information did not flow well and the organization was unable to adjust to the changing situation.
Another example involves the Road Crews' responses to the road impediments. The failures there clearly suggest supervisory problems that could have been related to overload. The Crews were on notice that they would be called to duty (an advantage that would not obtain in a real emergency). They are not
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required to begin reporting to the staging areas unti1 after a Site Area Emergency had been declared. But, by the time a General Emergency was declared, approximately one hour and twenty minutes after Road crews should have begun reporting to their Staging Areas, less than 25 percent of those required to ;
implement the LILCO Plan were mobilized. LILCO Admission-Nos. 146, 147 and 148. As late as 10:20, 16 percent were still not mobilized. LILCO Admission Nos. 149 and 150; LILCO's Response to Suffolk County, State of New York and Town of ,
Southampton's Second Set of Interrogatories to LILCO (dated January 5, 1987), Interrogatory Response No. 8. Obviously, in an actual emergency, they would not be waiting to be called; the personnel doing the calling would not have arrived at their stations as quickly; they would most likely be far busier than they were in the Exercise; heavy early evacuation traffic could be expected, delaying the arrival of crews at the staging areas; with more staggered arrivals, crews would be harder to assemble; and with heavy traffic it is possible that more road impediments q would take place.
The Road Crew delays are not surprising in view of LERO's structure. The Evacuation Coordinator must direct the efforts of seven subordinate areas. Three of these are the Staging Area Coordinators for Port Jefferson, Riverhead and Patchogue. He informs the Staging Area Coordinators; the Coordinators inform the Lead Traffic Guides (each Coordinator deals directly with 15
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or 16 individuals); and tne thre? Lead Traffic Guides mobilize and direct the efforts of from 79 personnel at Patchogue to 84 at Riverhead to 109 at Port Jefferson, an average of over 30 each. j 1
These include Route Alert Drivers, Traffic Guides, Evacaation i
Route Spotters, and Road Crew personnel. Were this a routine, j daily function, it is possible that learning by doing would have taken place and everyone would know what to expect: where the delays might arise; how to contact people quickly; and so on -- )
i the hallmarks of a routine organization. But it would still be a
]
difficult task even on a daily basis with only minor variations in the environment. To have a full exercise with everyone from the Evacuation Coordinator down to the Road Crews involved only once or twice a year will not provide much doing and thus much ;
j learning. Thus, a timely execution of the task would be hard i i
because of the many links in the chain of command and the size of i
the supervisory problem at each level. To do so with very little l experience makes it unreasonably hard to perform well; to do so if the public were involved in a simulated emergency would make it even harder; and to do so in a real emergency appears to be even harder. We should not be surprised at the long delays.
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j IV. CONCLUSION 0 Please summarize your conclusions, l
A. In our opinion, the LILCO training program is seriously inadequate in a number of crucial respects, all of which were demonstrated during the February 13 Exercise. We have no reason to believe that LILCO has or likely could take steps to cure these flaws.
The foregoing flaws in LILCO's training program as detailed in this testimony lead us to conclude that there is no assurance that the protective measures contemplated under the LILCO Plan could or would be implemented in the event of~an emergency at Shoreham.
l Q. Does that conclude your testimony?
A. Yes.
l l
l
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_ _ _ _ _ _ - _ _ _ _ _ _ _ - _ _ - _ _ _ _ _ _ _ - _ . .___.