A nuclear reactor with a hole in its head should have triggered a widespread examination and overhaul of the safety program at the Davis-Besse Nuclear Power Station. Management says it has learned valuable lessons; critics charge that it's business as usual.
On Feb. 16, 2002, FirstEnergy Nuclear Operating Co. shut down the Davis-Besse Nuclear Power Station (DBNPS) in Oak Harbor, Ohio, for a fairly routine refueling and inspection operation that included checking for cracks in the reactor head nozzles. What workers found was anything but routine.
Cracks were found in several reactor head nozzles, but the worst was yet to come. On March 6, 2002, workers discovered a cavity with a surface area of 20 to 30 square inches in the reactor pressure vessel head. The cavity extended down through the 6.63-inch thick carbon steel reactor pressure vessel head to a thin, internal liner of stainless steel cladding. That cladding was the only thing standing between the Davis-Besse Nuclear Power Station and catastrophe.
"The fact that the reactor head did not rupture...all I can say is that it was divine intervention," says Toledo, Ohio, attorney Howard Whitcomb, a former NRC inspector who worked at the Davis-Besse facility from 1985-88. "The Nuclear Regulatory Commission and the folks at Davis-Besse are trying to minimize the incident, but the truth is, it was probably the worst accident to occur since Chernobyl and at least as bad as what happened at Three Mile Island. If the head had ruptured at Davis-Besse, the collapse of the containment structure and widespread radioactive contamination could have created a health hazard for thousands of people and been a real threat to Lake Erie, which provides drinking water for 20 percent of the country."
The official cause of the hole was an undiscovered boric acid leak stemming from those cracked vessel head penetration nozzles that was allowed to go unchecked for more than 4 years. A Lessons-Learned Task Force was created to investigate, and its report, published on Sept. 30, 2002, indicated a more insidious cause: the lack of a safety culture that would have allowed the problem to be found and stopped before disaster occurred.
The task force concluded that the nozzle leakage and the vessel head degradation were preventable. According to the task force, the event at Davis-Besse was not prevented because:
- The Nuclear Regulatory Commission (NRC), DBNPS and the nuclear industry failed to adequately review, assess and follow-up on relevant operating experience;
- DBNPS failed to assure that plant safety issues would receive appropriate attention; and
- The NRC failed to integrate known or available information into its assessments of Davis-Besse's safety performance.
Jan Strasma, senior public affairs officer for the NRC, admits his agency "had to do some strong soul-searching of our own regulatory programs, our inspection procedures" in light of what happened at Davis-Besse, where the NRC had two inspectors in residence at the time the cavity was discovered. "We have placed more focus on reactor vessel head issues," he says, "and our training now includes a more heightened focus on the reactor head." (A scathing report released by the United States General Accounting Office [GAO] in May 2004 indicates the NRC still has three systematic weaknesses to address weaknesses that could contribute to the safety of nuclear energy across the country. According to the GAO, the NRC needs to: identify early indications of deteriorating safety conditions at plants; develop a better system to determine if a plant should be shut down for safety concerns; and provide more monitoring of actions taken in response to incidents at plants.)
'A Disregard for Safety'
Roger Whitcomb was brought into Davis-Besse in 1985 as part of a team investigating an incident involving loss of feedwater through the steam generators. At the time, it was rated the second-worst nuclear incident after Three Mile Island. Whitcomb was the preventative maintenance program manager, and his job was to improve and create a viable preventative maintenance program at the facility.
"For 2 and a half years, I worked at improving maintenance at Davis-Besse. In June 1988, I submitted a 75-page report that identified improvements and provided critical assessment of where we needed to go with preventative maintenance. Management was not happy with the report. Management ordered me to change the report and rather than change it, I left," says Whitcomb.
When he heard about the hole in the reactor head, he was "absolutely infuriated," he says. "It is symptomatic of the same pattern of behavior a disregard for safety that occurred in the 1980s," he contends.
At Davis-Besse, the discovery of the hole was met with the kind of shock generally reserved for those late-night phone calls involving loved ones and car crashes, says FirstEnergy spokesman Richard Wilkins. "Employees and management were shocked and really incredulous at how this could have happened," remembers Wilkins. "At a nuclear power plant, safety is roughly defined as all physical and programmatic barriers that are in place to protect the reactor core. In our industry, the protection of the core has to be the focus of attention. Every maintenance activity, every training session, even routine work in the plant has to be concerned with that."
What happened at Davis-Besse, he acknowledges, was created by a "lack of robust questioning, of not challenging things that don't appear correct or that pose a risk to the safety margin." In other words, he adds, "We found the safety culture was not where it needed to be."
Creating a Culture
Work stopped at Davis-Besse while management determined what changes needed to occur in the work culture if the reactor was going to operate safely. The decision was made to benchmark other nuclear power stations, hire a consultant to help build a safety culture, and conduct training activities to boost awareness of safety in the workplace. (Editor's Note: A request for the name of the consultant was ignored and a promised call to Occupational Hazards from a safety professional at Davis-Besse never materialized. )
Initial training for employees, says Wilkins, involved conducting an in-depth assessment of how the reactor head had ended up in the degraded condition in which it was found.
"We conducted a case study that went back to the late 1980s that examined the maintenance history and programs for that equipment that showed employees how, over time, there were missed opportunities to stop the problem," he says.
One of the major problems, management realized, was that the boric acid program, which should have caught and stopped the leak that caused the cavity, was ineffective and inadequately implemented. As a result, every employee received a half-day of training on boric acid and other maintenance and safety issues. "It was painful to sit through," Wilkins admits. "Some of the opportunities that were missed were not subtle."
Training sessions included instilling into employees the importance of being vigilant and reporting safety issues at the plant. "Every employee, before the training, would have told you he had the legal right to report a safety issue. Now, they know they have a legal obligation to report safety issues," says Wilkins.
Employees were told to report issues to their supervisors and shown how to write up a report about a safety issue. They were reintroduced to the ombudsman program, which allows them to report safety issues without identifying themselves directly to supervisors. They were also reminded they could report issues directly to the Nuclear Regulatory Commission or report concerns to one of three on-site NRC inspectors. (The NRC increased the number of on-site inspectors at Davis-Besse to three following the discovery of the reactor head problems.)
A new corrective action program the Employee Concerns Program allows employees who have identified a problem or a potential problem to enter a condition report into a computer database. The report is reviewed by management, prioritized and addressed. A similar program in place before 2002 "wasn't strong enough," Wilkins admits. At Davis-Besse, he says, employees weren't intimidated into remaining silent about problems. Rather, "They didn't report problems because they felt the issues they raised were never addressed," he notes.
The new computerized reporting system generates automated feedback that lets the employee know how the report was addressed and what action was or will be taken and why. Employees now feel like their concerns are being heard, says Wilkins.
One of the things that became clear as the company investigated the problems with the safety culture was that employees knew a lot more about safety issues than they shared with management. So, in addition to training sessions and suggestion programs, the company created additional opportunities to "listen" to employees.
Meetings and Surveys
Initially, what Wilkins calls "alignment sessions" allowed employees and management to discuss issues, because, as the events leading up to the discovery of the cavity in the reactor vessel head showed, there was a disconnect between what employees saw and knew and what management was told. These sessions were held frequently soon after the events of 2002, but do not occur as frequently now. There are, however, a number of opportunities for employees to discuss safety or work-related concerns with upper management.
All Hands monthly meetings include, at the very least, the site vice president and directors, and have been known to include the president of FirstEnergy Nuclear Operating Co. and the CEO of the operating company, FirstEnergy Corp. These meetings usually attract 300 to 400 employees, who receive an update on various programs and the company in general. Town Hall meetings include directors or the plant manager and allow 15 to 25 people to discuss specific issues. With such a small group, the meeting generally focuses on certain points that have been raised through employee suggestions or at the larger All Hands meetings.
Once a month, a dozen to 15 employees are selected to attend a Tuesday meeting that focuses on what Wilkins calls the four "C's": compliments, changes, concerns and communications. Positives are noted, concerns are voiced, changes are discussed and communication whether or not information is getting out to rank-and-file employees is evaluated.
"All of their comments are written down and put into a report for the site vice president," says Wilkins. "He reviews the report and meets with them on the following Friday to address any concerns or complaints. It has been an effective tool. The site vice president can say, 'Here's the situation' and put it in context. In some cases, the situation can and should be resolved and the vice president will make a commitment right there to do it. Other times, he will give a reason why the situation cannot be resolved as requested."
Employees also take surveys at their weekly meetings. The surveys:
- Ask if employees are receiving the information they need to do their jobs effectively and safety.
- Ask if safety issues are being addressed when raised.
- Allow employees to write in any concerns they have.
As a condition of restarting Davis-Besse in March 2004, FirstEnergy Corp. agreed to submit the facility to independent assessments of four areas of operation: engineering program effectiveness, operations performance, the corrective action program and the safety culture. Three of the four reports have been completed and published; only the safety culture report remains a mystery. FirstEnergy's Wilkins points to the results of the safety surveys and the independent assessments as an indication that "over the past 3 years, we've certainly seen considerable improvement in the safety culture." But, he adds, "there's room for improvement."
He points to the facility's industrial safety record of 9 million hours worked without a lost-time accident as an indication that while some questions might remain about the strength of the safety culture at Davis-Besse, employees at the facility work in a safe manner.
Outsiders say the probability that the outside assessment of the safety culture at Davis-Besse will be glowing is unlikely, based on the previous three assessments of the engineering program, the operations performance and corrective action program. While all the reports indicated some improvement had occurred, they also indicated there are lingering problems at the facility.
The panel examining the corrective action program rated it "marginal" in six out of seven categories, while the seventh effectiveness of program trending was given an "unsatisfactory." Operations performance has improved, according to that panel's report; however, performance was not consistently good enough and the panel indicates that training and communication are still issues.
The safety culture assessment is expected this month. Critics believe it will reveal that much of the talk of a growing safety culture at the facility is a sham. "I know people who still work there," says Whitcomb, "and they say nothing has changed."
He points to a backlog of nearly 200 preventative maintenance items that existed when the utility requested permission to restart Davis-Besse last spring. "The plant was shut down for 2 years. There shouldn't be a backlog of preventative maintenance items, especially if the culture has been realigned to reflect a focus on safety," Whitcomb insists.
Sandy Buchanan, the executive director of Ohio Citizen Action, Ohio's largest environmental organization, isn't optimistic about the findings of the safety culture assessment. She says intimidation of employees about safety issues at the Davis-Besse Nuclear Power Station is ongoing. "We have talked to some people who work at the plant about completely unrelated issues who don't want their names used, which is further evidence that there is some intimidation occurring," she says. She believes also that employees are not reporting work-related injuries because of fear of reprisals.
According to NRC's Strasma, a report by an NRC oversight panel examining management and human performance issues at Davis-Besse (which examines some of the same ground the safety culture assessment is expected to cover) found that, "while workers by a large percentage indicated they would report safety issues without fear of reprisal, there was a decline in that number from previous surveys." In other words, a growing number of employees indicated they felt intimidated when attempting to report safety issues.
Buchanan doesn't just reserve her criticism for FirstEnergy management. She blasts the NRC, claiming that the report to which Strasma refers, "Davis-Besse Nuclear Power Station, NRC Special Inspection, Management and Human Performance, Corrective Action Effectiveness," shows the regulatory agency failed to determine if what it calls HIRD harassment, intimidation, retaliation and discrimination was actually continuing at Davis-Besse.
Buchanan complains that the NRC examined paperwork, minutes of meetings, written procedures and e-mails to determine the effectiveness of the safety culture at the facility, when it should have conducted its own confidential employee surveys that mimicked the questions asked by those conducted by Davis-Besse management. She also says that when employees reported management misconduct, the NRC should have investigated, and, if appropriate, taken action against those responsible while providing whistleblower protection for the employees.
"Instead of investigating the alleged illegal management activity, the commission examined what was wrong with employees that might have caused them to answer surveys in such a negative way. They concluded, at great length, that the employees were tired and frustrated," says Buchanan, who adds, "Another explanation is possible: The employees were telling the truth about the misconduct."
The NRC Inspection Team did interview 120 people during its visit to the facility early in 2004. It found:
- More negative comments about management than had been seen before. "Throughout the interview process, the inspection team, in general, noted a more negative tone in responses to questions dealing with management behavior and effectiveness than during similar interviews in May 2003. When concerns were raised, the responses were often considered to be presented in an intimidating manner or the individuals did not believe the issues had been satisfactorily addressed," said the NRC report.
- A continued management emphasis on schedule over safety.
An exhausted and frustrated staff. Over 80 percent of respondents indicated that they had been affected by the scheduling of six, 12-hour shifts or more per week. Some admitted to making errors, while others took "self-styled mitigation measures of which their management was unaware," the report noted.
- Continued references to management intimidation and retaliation against employees. "In the area of management comments, the inspection team received information regarding manager comments that the staff considered to be inappropriate or degrading," said the report. The respondents also included a few examples "about what some individuals perceived to be punishment," while "some examples of what could be viewed as retaliation were also provided."
Perhaps the most telling response of the NRC survey is that 10 percent of the people interviewed believe there is potential for "an event of the same magnitude as the vessel head corrosion" to happen again. The most common explanation offered for that view "was the potential for management to lose focus in the future or having inadequate management returning to positions in charge."
While both Wilkins and Strasma insist that widespread changes have occurred in both the safety culture and the management hierarchy at Davis-Besse, Whitcomb points to several FirstEnergy managers who were in charge at Davis-Besse when the problems were revealed who were promoted, saying that's an indication that the company "just doesn't get it." Buchanan agrees.
"A lot of the people scapegoated [at the time the rust on the reactor head was found] were new hires," she says. "Some of the same people responsible for what happened at Davis-Besse are still with FirstEnergy."
"The idea of production ahead of safety still permeates the place," says Buchanan. "There are astounding, ingrained problems with the safety culture. That's not going to change if the old guard is still there, waiting in the wings."
Sidebar: Criminal Case Likely in Davis-Besse Shutdown
On Dec. 10, 2004, FirstEnergy Corp., the parent company of FirstEnergy Nuclear Operating Co. (FENOC), announced it had received a letter from the U.S. Attorney's Office in Cleveland indicating that it is "a target of the federal grand jury investigation into alleged false statements made to the Nuclear Regulatory Commission (NRC) in the fall of 2001."
U.S. Attorney Greg White confirmed that an investigation is ongoing, adding, "We hope to complete that investigation soon."
The charges, if brought, will likely accuse FENOC officials and managers of lying to the NRC about the condition of the Davis-Besse Nuclear Power Station's reactor vessel pressure head before the facility was shut down in February 2002. Those false statements were allegedly made following an order issued the previous spring by the NRC, which required all 103 nuclear power plants in the country to provide information about reactor head nozzles.
FirstEnergy allegedly balked at providing that information, and the NRC threatened to inspect Davis-Besse, the first such inspection in 14 years. However, Davis-Besse had a history as a good performer, so the NRC allowed FENOC to operate the facility until Feb. 16, 2002, when the facility shut down for refueling. At that time, corrosion was discovered on the reactor head that posed a serious threat to the safety of the facility.
In a statement, FirstEnergy admits, "It is likely that federal charges will be returned against FENOC by the grand jury."
U.S. Rep. Dennis Kucinich, D-Cleveland, tried to get FirstEnergy's operating license yanked in February 2003. He says the operators at Davis-Besse "haven't been telling the truth," adding: "It's all about money in the end. It's not about public safety."
Kucinich also blasts the NRC, noting that a report issued by the Government Accounting Office last May "shows that the NRC was ill-equipped, ill-informed and far too slow to react. The NRC's reaction to Davis-Besse was inadequate, irresponsible and left the public at grave risk."
Howard Whitcomb is a Toledo, Ohio, attorney who has worked at Davis-Besse and as an on-site NRC inspector at a South Carolina nuclear power station. Indictments against FENOC and its managers, he says, are not an indictment of the nuclear power industry, but should serve as a wake-up call.
"I think the hole was an intentional and deliberate refusal to do maintenance, and the management at FirstEnergy made a conscious decision to tell the NRC that the maintenance was done," says Whitcomb. "The NRC at best is a spot-checker. The industry needs to regulate itself. The NRC can't catch every problem. They're not staffed for that. The NRC fell down on this one."
"Both the NRC and FirstEnergy need to be recalibrated," he adds, "but I'm not certain that will happen."