How does one identify a series of health and safety issues to the American Public, at a Nuclear Power Facility [containing four High Power Nuclear Reactors], that is advertised by Congress as the touchstone for how a Nuclear Facility should be run, when the facility is operated with sufficient stupidity such that the uninitiated in Health and Safety matters would be astounded?
Any commercial power facility found with even a fraction of the deficiecies noted here would have been shut down and the owners fined, or perhaps imprisioned, for allowing such conditions to exist.
The reader will find a Nuclear Power station completely out of control. Fire suppression systems out of action, fire hydrants not working, falsification of asbestos records, identification of a fire hose as an Emergency Core Cooling System, improperly designed cranes, improper electrical procedures, unlabeled hazardous waste containers, no revetments around hazardous waste building, Fire Truck pump tests not being performed, Post Indicator Valves misindentified and/or not inspected, inoperative control panels, fire alarm boxes out of service for years, fire hoses not tested, etc., etc.
Reading the following pages should make most individuals, familar with Nucear Power facilities, freightened to death. Furthermore these matters do not include an out of control, $100,000,000 pending asbestos cleanup disaster, Nuclear Power Plants without Emergency Core Cooling Systems or Containment Vessels, or a virtually non-existant radiation control program.
A Federal Government Investigation was requested. A legitimate Federal Investigation was never performed.
Only two people were ever punished for exposing the issues, identified in this report, and the fact that the Knolls Atomic Power Laboratory [KAPL] lacked [and still lacks] a radiation protection program.These are John P. Shannon, the author of this report, and Frank Bordell, a world renowed Certified Health Physicist. Both were fired from KAPL, but not before being treated worse than prisoners of war by GE,DOE and Naval Reactors Management.
TO: J. A. Bast, Manager Safety Env/Spec Proj. KSO
SUBJECT: Results of Industrial Safety, Incident Prevention and Industrial Hygiene Appraisal of the KSO
REFERENCE: (1) KAPL Safety Manual, KAPL-A-S-1
(2) Letter from J. A. McHugh to P. H. Hancock, "Annual Industrial Safety/Hygiene Evaluation of the Kesseiring Site Operations", RHEP-75S-432, dated October 31, 1984
ENCLOSURE: Results of Industrial Safety, Incident Prevention and Industrial Hygiene Appraisal of the Kesselring Site Operation
The Knolls Site Safety Organization has completed an appraisal of the Occupational Safety (Industrial Safety and Incident Prevention) and Industrial Hygiene Programs at the Kesselring Site. The appraisal was performed in accordance with the requirements of Reference (1). Primary emphasis was placed on KSO performance in Industrial Safety and Industrial Hygiene as set forth in DOE and OSHA orders and KAPL directives. A copy of the appraisal report is attached.
The appraisal identified serious deficiencies in the asbestos record keeping program, the fire alarm system and fire suppression systems. Similar fire protection deficiencies were reported in last years appraisal (reference 2). These items are considered to be unsatisfactory and were brought to the immediate attention of KSO Safety Management.
The enclosure to this letter identifies a number of items, of sufficient concern to warrant strong, permanent corrective actions. To ensure that appropriate actions have been taken the Knolls Site Safety organization will conduct an in depth follow up appraisal during the month of February 1986.
Response to the findings noted in the enclosure is requested within thirty days of receipt of this letter.
J. P. Shannon, Manager Nuclear Criticality Safety/Industrial Safety/Industrial Hygiene RHEP
Dates of Appraisal: October 23-24, 1985
J. P. Shannon
N. T. Burak
R. W. Winters
J. S. DeMatteo
R. M. Crossman
SECTION I : Industrial Hygiene Findings
Finding .I. A - Asbestos Air Sampling data sheets are not being filled out
I.A. a. Employees are listed as having been monitored when there were no monitoring data for them (only clearance samples). Example: 9/4/85, AWP A-85-94.
I.A. b. The section for indicating whether or not air samples were analyzed has not been filled out for months. KSO should evaluate the need to retain the section.
I.A. c. Calibration date for air sample pump not recorded. Example: 9/4/85, AWP A-85-94.
I.A. d. Identifiers for laboratory performing analyses have not been recorded for months.
I.A. e. Signature of the person performing calculations (fibers/cm3, TWA, etc.) has not been recorded for months.
I.A. f. "Reviewed By" signatures have not been recorded for months.
I.A. g. Data sheet incorrectly indicates workers wore both supplied air and air purifying respirators. Example: 8/29/85, AWP A-85-91.
I.A. h. When two persons work side by side and only one wears an air sampler, it is recommended that the monitoring results be applied to both workers instead of just the one who wore the sampler. This is better than no data at all for the person who wore no pump. Example: 8/27/85, AWP A-85-89.
(Same comment applies to environmental monitoring data).
I.A. i. Exposure durations for workers not recorded. Example: 8/29/85, AWP A-85-87.
I.A. j. Data for AWP A-85-84 on 8/16-17/85 show that at the boundary of the work area the asbestos air concentration was quite high yet no comment or explanation is recorded on the data sheet. Furthermore the personal monitoring results for one worker are not recorded.
I.A. k. 8/13/85, AWP A-85-78 shows sample not analyzed because sample duration (30 min) was too short but the basis for this decision is not explained nor is it clear. Same comment for 6/19/85, AWP A-85-61.
I.A. I. 7/30/85, AWP A-85-70 shows no employees were monitored yet data are recorded for a personal sample, including the persons name.
I.A. m. 7/15/85, AWP A-85-64 shows that a personal sample was taken but no analyses data are recorded.
I.A. n. 6/11/85, AWP A-85-56 shows very high clearance sample results (0.556 f/cm3) but no explanation or justification.
I.A. 0. 3/28/85, AWP A-85-39 says the site Industrial Hygienist is supervisor of PSFO employees, there is no signature of persons recording data, no analysis data identifiers, no signature of persons performing calculations.
Asbestos work data must be carefully recorded and reviewed. A periodic management review to ensure correctness may be appropriate.
Observation: I.B - Calibration Data on Incorrect Form
MSA Model S air sample pump calibration data are being recorded on forms intended for use with detector tube pumps (column headings are entirely different).
Correct form should be used.
Finding I. C. - Medical/Industrial Hygiene Record Interface is incomplete.
As noted in I.A. h personal monitoring data for an individual should be considered representative of the exposure level for an unmonitored individual working in the immediate vicinity. Such data should be recorded in the unmonitored individual's personal medical record.
Medical record data should be expanded.
Finding I.E. - KSO Instruction 7.0 related to asbestos medical examinations is Inconsistent with OSHA.
KSO Instruction 7.0 states that all asbestos workers will have received a comprehensive medical examination. This is not consistent with the OSHA asbestos standard, which says the examinations shall be "provided or made available."
The extent to which the KSO requirement may be applied should be reviewed with KAPL Legal Counsel.
Observation I.F. - Clearance Air Sample procedure should be modified.
In accordance with OPNAV Inst. 6260.1B clearance air samples are normally taken in unoccupied spaces. However, later admission of personnel into those spaces can stir up dust which would not have been airborne during the earlier samples.
KSO Instruction 7.0 should be changed to recognize that additional "follow up" samples may, on some occasions, be indicated to verify that clearance was indeed achieved. The need for this would be evaluated on a case basis by Industrial Hygiene.
Finding I.G. - Personal monitoring data are not being recorded in personal medical records.
Personal monitoring data for GE employees are not being recorded in personal medical records. This is not in compliance with GE Corporate policy and KAPL practices.
Record all monitoring data in personal medical records per KAPL Industrial Hygiene Memorandum No. 2.
SECTION 11: Industrial Safety Findings
Finding II.A. - Master Safety Deficiency List is not being maintained.
1. The September 18, 1985 issue of the Master Safety Deficiency List contains 50 items with no target dates.
2. A significant number of electrical deficiencies and electrical safety checks remain open, some dating back to April 1985.This is significant in that electrical safety has been a problem at the Kesselring Site.
3. Chapter 15 of the KAPL Safety Manual indicates that some of the 1975 OSHA inspection findings are on the Master Safety Deficiency List. However, the list does not contain any dates earlier than 1985.
The Master Safety Deficiency List is used to facilitate follow up of safety and health deficiencies. This list can be useful if the information on the list is accurate and complete. Missing target dates and incorrect information detract from its usefulness. Also, its usefulness is diminished when action is not initiated for items that have a significant impact on the Kesselring Site Safety Program (e.g., Electrical Safety).
1. Estimated target date should be assigned to all deficiencies consistent with the designated priority.
2. The priorities assigned to electrical deficiencies and safety checks should be reviewed and adjusted as necessary. Manpower allocations to correct these items should be assessed and adjusted to expedite corrective actions.
3. The Master Safety Deficiency List should be reviewed to ensure date entries are accurate.
Finding I I B. - Incident Prevention Reports are incomplete
1. Cognizant Manager response to Incident Prevention Reports is inadequate. Very few responses met the 48 hour requirement and many reports had no response at all. (This is a repeat finding)
2. Several reports are not being filled out completely.
3. Section IV is hardly ever filled out.
The Incident Prevention Report provides the Safety Office and the cognizant manager with details of events and identifies corrective actions. Incomplete and/or late reports delete the utility of reports.
The Incident Prevention Report system should be reviewed to see if it is being used as intended.
Finding II. C.- Documentation of Quarterly Safety Office Inspections- of Site Facilities is incomplete.
1. No documentation of 1985 quarterly inspections could be found.
Quarterly audits of site facilities provide a means for the Safety Office to identify health and safety deficiencies and recommend corrective actions. Lack of inspections on documentation of findings can detract from the effectiveness of the KSO Safety program.
Quarterly Safety Office Safety and Health inspections should be scheduled and performed as required. Documentation of these inspections should be issued to cognizant managers in a timely manner.
Finding II. D. - DOE Order 5483-1 A and the KAPL Safety Manual require documentation of safety complaints, whether written or oral.
A complaint log is currently available. However, this log shows that 7 complaints have been entered in the last 5 years, with none entered for CY 1985 to date. It was apparent from random discussions, and from the current activity level at KSO, that this log is not being maintained in an up to date status.
Maintain an up to date log of safety complaints.
Finding I.E. - Surveillance of subcontractors by Site Safety does not appear to occur on a scheduled frequency.
Safety inspections are -done primarily by Incident Prevention. Site Safety personnel have no scheduled frequency of inspection, although response to field safety problems occurs on a regular basis.
A frequency of inspection should be established to ensure safe performance and reduce the regularity of impromptu inspections. In addition, these inspections should be documented to achieve effective follow up to completion.
Finding II.F. - The Individual Accident/Incident Report Forms (DOE 5484.X) are not being properly completed.
A review of 5484.X forms revealed that they are not being properly completed. Specifically, item 39 on the 5484.X requires a signature of the person responsible for corrective action, no signatures were evident. Also, item 35 requires information on the nature and extent of injury; this information was lacking on many of report forms reviewed.
Ensure that 5484.X is properly and completely prepared as described in "Instructions to 5484.X." Safety Office personnel should review the information contained in 5484.X to ensure that occurrences are being properly reported.
Finding(s) II.G. - A site tour resulted in the following observations:
1. DIG Tunnel near main entrance - crane operating within 10 feet of energized power lines. (Note: W. Reynolds responded immediately to resolve).
2. Decompression trailer in parking lot -wheels not chocked
- no ramp provided over wires across sidewalk
3. Crane operating south of Bldg. 18
-minimum of 3 Crosby Clips required - only 2 observed.
turnback on dead end of cable insufficient - need 12" min.
4. Bldg. 75 - men working on south side using crane without hard hats. A sign stating "Overhead Work" was observed
5. Roadway - east of DIG cooling tower - excessive space between metal plates are a tripping/falling hazard.
6. Bldg. 60 - unused cross-arm on pole south side is unsecured.
7. Bldg. 17 - D. R. Fitzmaurice pick up truck - observed unsecured acetylene and oxygen gas cylinders lying on side in bed of truck - both cylinders were not empty and were not in use.
8. SEB Area
-improper splice in black to white electric cord.
-Schwing mobile crane operating on slope. wheels not chocked.
-several electric cords plugged into power supply did not appear to be GFI protected.
-male ground pin observed broken off and stuck in female receptacle on power supply.
-guardrails, midrails and toeboards missing on two scaffold levels, north and south ends
-job-made ladders have no safety feet
9. Excavation between Bldg. 18 & 19 - straight ladder sticking up out of excavation approximately 10 feet above highest support (top of the excavation).
10.. Bldg. 19, rear entrance - two foot pipe sticking out of ground should be properly identified.
11. Bldg. 19 - first room on left - oily residue on floor, very slippery.
12. Bldg. 20 - refrigerator cord strung across doorway-tripping hazard.
13. Bldg. 83 - east side - 2 of 3 drums containing waste not labeled.
14. Bldg. 62A - heavy electric power cord (220 volt) from 62A to 62B pinched in doorway opening of both buildings, outer insulation damaged.
-step ladder improperly stored in chlorine section
15. Bldg. 62B fall protection missing in several areas around sewage pit.
16. Bldg. 75
-Budgit chainfall has no capacity marking
-mezzanine stairs have no railing, 10 ft. fall hazard
-no capacity marking on portable I-beam, west side (outside).
17. Trailer T-1045 improper "Danger" sign on pole near trailer.
18. Bldg. 18 -men's room, light diffusers missing, no keepers observed on fluorescent bulbs.
-duplicating room, Ist floor - contains two large cylinders of Annhydrous Ammonia, no "No Smoking" signs posted.
19. Site Roadways- a number of roadway clearance signs should be provided where utilities cross over roadways. Of two signs observed, one could not be read without difficulty.
20. Bldg. 60 - various chemicals are stored in the east end. No revetments were provided for most of the chemicals observed
Correct deficiencies as required by OSHA Standards or KSO instructions.
SECTION III: Incident/Fire Prevention
Finding III.A. - Annual pump tests are not being performed on fire fighting trucks
1. Ward LaFrance - No pump test since 1982
2. Ford Howe - Pumper arrived in 1983 no pump test has been performed to date.
Perform tests as required
Finding III. B. - Site Fire protection water systems inadequately maintained
1. PIV's MLV 10 Bldg. 12E and MLV 11 Bldg. 75 were not inspected, no explanation on inspection form.
2. MLV 36 listed as a PIV but is actually an underground valve, no inspection was performed.
3. The PIV that services Bldg. 75 - valve SSW145 is neither locked nor supervised. NFPA requires that all sprinkler control valves (PIV) be either locked or supervised (tamper alarms).
4. The following are post indicators that service buildings are neither locked nor supervised:
SSW 141 - Services Bldg. I
SSW 77 - Services Bldg. 31
SSW 53 - Services Bldg. 18 SSW
146 -Services Bldg. 19
SSW 162 - Services Bldg. 20
SSW 73 - Services Bldg. 5
5. The supervisory panel located in the firehouse for PIV's is unreliable and usually inoperative. Two circuits are currently out of service. When the system was demonstrated the bulbs were burned out in the operating circuits. Although the panel is checked during PIV inspections and found to be in need of repair, no action is taken to make such repairs. No records of supervisory panel inspection of operation exist.
6. Bldg. 83A - Dry sprinkler system OSSY valve records do not indicate if it is locked or supervised.
7. All PIV's are not numbered on the post proper - there is no means of field identification.
8. PIV located on northwest corner of Bldg. 5 is not locked or supervised, the open/shut indicator is broken.
Deficiencies regarding post indicator valves (PIV) for fire protection systems are considered to be serious since the valve(s) can be shut and render the sprinkler system(s) inoperative. Because PIV inspections are performed monthly (in compliance with NFPA) the inoperative systems can go unchecked for at least 30 days. In some cases PIV's are not inspected if the valve is obstructed, no follow up inspection is performed until the next month and therefore no inspection may be performed for 60 days.
1. Review and revise PIV inspection forms
2. Ensure that all PIV's are either locked or supervised (supervise only if the annunciator panel is operative).
3. Take necessary actions to either repair, replace, or remove the supervisory panel regarding tamper alarms for post indicator valves.
4. Label all post indicators with the following information.
(a) Valve number
(b) Sprinkler system number and/or controlled riser
(c) Number of valve turns to close or open the valve completely
5. Repair PIV's as required (see item 8 above).
6. Ensure all OSSY valves are locked.
Finding III.C. - Several Site fire alarm systems are not functional
a. The following boxes are out of service:
Box 231 - out of service since at least 1/6/85 (records do not go back further - the day shift captain indicated that the box has been out for at least 2 years).
Box 123 - out of service since 6/24/83 - the inspection dated 10/5/85 indicated incorrectly that the box was in service when inspected.
Box 213 - out of service since 3/10/85.
Box 319 - out of service since 7/27/85.
Box 124 - out of service since 3/17/85.
NOTE: A work request was issued 8/29/85 to repair the boxes - the work has not been scheduled.
b. No fire alarm box tests were performed from 4/8/85 - 7/14/85. A monthly test is required by NFPA requirements.
2. Per IP instruction, prior to testing the fire alarm system, the captain shall refer to the computer tracked history record to ensure that repeat tests on the same device are avoided and all devices are tested. No computer tracking system exists.
3. The inspection form for fire systems has several items left blank. Other entries are unclear, some entries are very confusing, date of tests are missing, and comments are illegible.
4. Box 229 was not inspected because of a power shut down, no inspection was performed when the power was restored a short time later.
Several of the out of service fire alarm boxes annunciate automatic alarms when a water flow is initiated. If one of the systems were to initiate, either the fire could propagate unchecked (except for the sprinkler water flow) or water would flow unchecked. Either case will produce an unsatisfactory condition.
Although fire alarm box inspections were not performed for several weeks, inspections have been re-established, however, record keeping for inspections should be upgraded. Currently, data is illegible, several test dates are missing, entries are confusing, items have been left blank, and lines or arrows are used.
1. Fire alarm box repair should be immediately initiated on a high priority basis.
2. Establish a computer tracking system for fire alarm system testing.
3. Instruct persons assigned systems Inspections regarding proper record keeping practices and procedures.
4. Ensure fire alarm box inspections are followed up in a timely manner when conditions do not allow a proper inspection.