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I.

The Region I Office of Investigations (01) initiated an Assist to Staff on October 2, 2003, at therequest of regional management, to evaluate information developed and/or reported to theRegion indicating that the Safety Conscious Work Environment (SCWE) at the Public ServiceElectric & Gas (PSEG) nuclear generating stations, Salem and Hope Creek, was poor. Basedupon the information known to the region in October 2003, the inquiry was planned to focus onthe Operations aspects at both sites, and would include representatives from the operatorlevels, operations management and senior managers. Both former and current employees wereinterviewed at the management levels. The results of these interviews, arranged by station andworking level, are outlined below.

Salem Operators

By interviewing the operators at Salem, 01 and the staff sought to identify any SCWE relatedconcerns they had, particularly involving a production over safety climate, and if so, what thebasis for the concern was. In that the subject matter-was broad, these interviews tended todevelop a variety of issues, obviously dependinE D e interviewee's view of its effect on theSCWE. As delineated, some common themes developed throughout the interviews involvingnegative perceptions and some positive points emerged.

The positive impressions Included: most believed that they and the majority of their co-workershad no problem in raising concerns and would not hesitate to do so, specifically in regard tonuclear safety issues. Further, mos ,f t operators interviewed did not believe that anyonesuffered retaliation for having raistcnerns. Some operators had no concerns regardingnuclear safety and reported that the company took the appropriate action when necessary; anddid not report any instances that left th pression of a production over safety atmosphere.The arrival as noted as a positive change and anticipatedimprovements in union/management relations, conservative decision, g, and equipment

repairs were cited based upon the prior association between, Ind the Salemoperators.

Though not explored specifically, mixed reports were received about the effectiveness of theEmployee Concerns Program. SCWE surveys were noted as negative in terms of distrust of theresults published, the lack of corrective actions taken, and the burden due to the frequency ofthe surveys.

The negative impressions reported by the operators at Salem outweighed the positive both innumber and in nature. Some Indicated that the company does well when operating decisionsare clear cut, but delays exist in the "greyer" areas. Said another way, this was described asthey do not pose a safety threat to people or the environment, but come close to it by acceptingrisks. Numerous operators expressed concerns and frustrations regarding the way particularincidents were handled, as either an industrial or nuclear safety issue, and offered the incidentsas evidence of the effect of decisions driven by production over safety, "megawatt mentality",non-conservative approaches and/or schedule presspure. The key examples leaving thisimpression are: 1he Septemb.er 200, Salem L.•nit 2-MS-42 valve steam leak involving theintervention by'J--_• . ". the October 2003 stuck14 BF-19 feed regulator v-ave at Salem Unit 1; the grassing issues aToth units in Spring 2003;a concern regarding the potential catastrophic failure of the SS-661 sampling valve (numerousnotifications written related to repeated leaking) at Salem 2 in August 2003; the push to buildscaffolding by flashlight and fix the leaking SS-661 valve by flashlight in the same incident

(notification written); and the practice of starting complicated surveillance testing immediatelyprior to the end of the shift in order to gain credit for the work.

A significant area of concern involved PSEG's Corrective Action Program (CAP)and the amountof equipment that did not get repaired or repaired correctly. Additionally, parts availability wascited as a known "joke" on the island to the effect that if something was needed, it was beingheld as surplus by the warehouse to be sold at a sale. Also, the idea that the warehouse keptno spare parts in order to avoid paying taxes was conveyed. The work-week scheduling andconstant re-prioritization of issues, coupled with the lack of appropriate resources, were seen asthe primary precipitants for the problems with equipment repairs. The SAP software programsused to track notifications and for equipment tagging were seen as difficult and troublesomesince initiated (around 2000) and challenging to use for trending and research purposes. Theweaknesses in corrective actions were perceived as having an apathetic effect on some whowould question the point of raising an issue. (This was a concern noted with respect to lesssignificant issues.) Some operators feel they are only "white noise.'

The problems with equipment repairs and parts availability has the additional adverse effect ofleading to criticism of workers by management for "low wrench time," which adds to the anger,frustration and bad attitude on both sides. The union/management relationship is viewed asdamaged in a manner that causes both the Shift Managers (SMs) and the Control RoomSupervisors (CRSs) to be seen as in the middle and aggravated because morale is poor and therelationship has become "tit for tat over piddly stuff."

With respect to raising concerns, it was reported that some people prefer not to have their nameassociated with issues for differing reasons, including personality type, and some new workerswould not raise a concern for fear of losing their job. The union stewards were viewed ascompensating in this area and the impression became that issues would get'e raised,particularly nuclear safety conce rns, but possibly not by the initial observer. Others discussedtheir personal comfort level with raising concerns in relation to how valid it would be seen bymanagement. Several interviewees reported their perception that union stewards who regularlyfront issues are viewed as a "hindrance" or "troublemaker" and treated adversely by thecompany. This was also the opinion of some in regard to a shift manager who pushed operatorconcerns to upper management in the 2002-2003 time frame.

Salem Operations Management

Positive

Mmlsees no weaknesses in the safety culture, no concern over operations he has been'asked to perform, no unusual pressure recently, people can and do raise nuclear safetyconcerns and do so w/o fear of retaliation-includes self, some reluctance on the part of somedue to an introverted personality issbe, no personal experience in having operability decisionsquestioned by sr. mgt (however, offered only one Instance as possibly feeding into rift 01heard about between SM and sr mgt that i e Q003.•ajteqdthat in regard to grassingand circulators on Unit 2, sr managementthad Initially given onedirection,nd after things did not improve-re grassing, they changed their philosophy-

000- anted 5 In accordance w/original criteria anc aid 4 OK), believes culture isfar more conservative now than 6 or7 years ago and believes that's the case across the industry

.- ) •*

(73.'no issues with people raising issues or ability to do so, offered an incident

inVoIvi;ng' d' , lung at operators (re isolating condensity) for being unsafe shut.downthe job-ne1er savia "just do it anyway" attitude (re industrial safety issues .•plealways able to raise concerns without repercussions, sees a change in senio tfro and

MOM; 2 C I current as positive in that people believe their concerns are morelisf~hed to and properly dealt with-there's more emphasis and a more engaged safetycommittee, never saw a hesitation to bring a nuclear concern up-both operators and peer level,under new management believes nuclear safety concerns will be discussed without AOM or OMtrying to talk him out of it or minimize the concern, offered that the environment now is that srmgt asks what's the conservative and right thing to do to give operators a comfort level(example given of # of circulators for startup spring 2002 or 2003) without the chance. of downpowers., erturbations or abnormal procedures. Added that was displayed betwee

. declined to start upheat up using MS-1 Os (coming out of 2R13 inovem er2003) feels more comfortable now raising concerns-less comfortable w--P

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none apart from one incident described above, .--.- lot more issueswithhe plant are brought up now because they suffer from maintenance and the prioritizationby work management-believes maybe the money is not being spent where it should be to seeimproved performance indicators, outage times, etc.-if it were up to him, he would only acceptthe plant at 100% in every issue, Salem Unit 2 spring 2003 grassing recalled issues but'he wason h and he was not pressured-not even though he was a SM for only several weeks when

,pushed for minimum numberie thought they could have waited a little bit longer to gete circulators back, then re-evaluated because they had a tide change and thought the screens

could handle it-th ouht t .'e. ould continue w/power ascensionmfesome pressure from above

to start the plant never directed to do so b !lome equipment operatorsfeel treated wrongly for bringing up industrial safety issues, in spit•eof safety operatordesignation and the fact that the issues raised are resolved "all the time", believesunion/management issues get emotional and create.a lack of communication and animosity-some union members that send the feeling that management disagrees with their issues purelyfor production purposes-(not true), sms feel just as frustrated at times, especially w/ the amountof repeat work-sees part of problem with maintenance in that they do not have operationalexperience In supervision-schedule compliance not good, planning is questionable, mentionedparts availability problem, W the discoveryhase was taking too long-wanted t wait longer on operability calls-sins ha a meeting underj411i 1&nd pushed back- took the position that he wanted more people to weigh in

before the call was made, Sms wanted to look at what they had at hand and make the callconservatively and follow the tech spec (meaning shut down), example 6coming into CR topush into start up without proper surveillance of reactor head vefnindicators, pressureto stay wt in the rules but work through and around issues like reactor head vent indicators, thenumber of telephone calls to the CR by, in which Sins "defended" their position-taking a.conservative approach- led to discomfort in operating the plant for sms, example given ofand circulators (2003) position that procedure says you can move forward-do so in spite of SMcomfort level-"hav.e a certain amount of risk" try to avoidtalking W1 acrossthe board w/SMs,.aer" forthe ,believe left ecause

he was micromanage . . ad similar problembelieves K. Harvin hada negative affect on m ealing with Sis-improved afterve egime over,explained that there are some personalities on the crew that observed the& handling of 22

MS42 leak that don't like nd made this incident into the uproar it became because it wasactions, management process for repairing equipment is not effective and leads to use of

temporary logs for excessive periods-this leads to operator mistakes (ex. Re rad monitors 12103time frame)-need to dedicate the resources; saw BF-19 incident delay caused by failure to get"right people in the room and finally coming up with solutions-eventually they found they hadsomething stuck in the internals of the valve, but the process of ruling everything else out andgetting the info from the "smart people" takes time", described the Sms as in the position to"buffer" the CRSs and operators from sr management in the "push" they would exhibitby callinginto the CR "not uncommonly" to move a start up along U.....i,_ - .. y.callinexample of this as salting in switchyard in September 2003-SiM idescribed hirm'self as feeling"uncomfortable" because he needed to shut down both units bas.ed upon what he vi wed in theswitchyard-arcing, presented facts to - including the •from th plant whohad "word for word" experienced the same rd. lem 10 years earlie-"disbelief'that's what w s occurring, had to convinc t hat plant needed to b6 srut down-had towalk*"to switchyard to show him (explained should have been a no brainer to shut downwhen arcing viewed) and still wasn't convinced until 500 KV breaker opened the!psaid, that'sit I'm shutting down-the financial influences of who's going to make up'for the lost generation,pay for switchyard repairs and who is accountable for this should not enter the control roomdecision making$1il. NOOid not come from proper perspective and it added "at least an hour*unti 4 decision-o shut down, offered as example of what he would experience with.in.pas.-resistance to shut down/offered that his confidence level currently is higheA r that hewon'tbe in the same position again-believes won't have that problem witt- . *,. ,.,,...__.environment under -. _- .. as such that you didn M t wwork in itbecause of the constant coaching and ridicu-Te-not conducive to , i best effort, just doingwhat you had to to avoid coaching-nobody wanted to work tfu and now improvedas-far as dealing with management-SMs had to figh no become "si e managers"because of the issues that Salem would have regular y-needed to be in CR to be backup forCRS due to emerging issues-described as happening more than in other plants-becamePo viqs t a id not understand what was going on in control-this affected their rapport;

union/management relationship detero a i and worsened in last 6-8 months "specifically between-Eos and mgt (cited firingh/_then returning him to duty as"incendiary device"), cited animosity over perception by some in management that safety is7being used, as a weapon by operators-sees the "real organizational risk" as a supervisor mayj i tt r-

make a decision with that factored In-saying you're just beating me over the head w/safety ahdthe supv. Makes the wrong choice-has not seen it happen, believes there's potential to happen O~e

and keeps on top of his supv to prevent it-offered examples of union using safety erroneously(over 3 yrs ago, hydrazone laden water 11 issue, left bad taste for him as SM; operatorsreturned to shift from training-did not like-started raising confined space issues-summer 2003; reconservative decision making-spring 20Q2.wanted 4 circulators to bring the plant-orwardwithout the fear of having to back down," ushed for minimum of 3'WN ,0111fence" and could go either way from the start-wanted defense in depth in spiteo•opersuasive argument that they were still in conservative space with the # (3) they had-did n6t' -..like operating philosophy o hat sets the unit at a place that did not allow defense in depth- -

pointed out thati i comfort zone.was wider than his own with using 3 right from start, V1rA .

but believes he was persuaded b ýIjanother example late 2001 of his disagreement in '_-,conservative decisi n re SJ injection valve w'lsignificant leakage and needed to test to determine

which one-he and fo greed and went to meeting to discus' w ' lmadedecision not going to test for leakaae, they would-engineer it away" (issue being paneled t tV" .

ARB), when decision made to goiway, ade conscious decision not to "defy" Vin

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public setting:l t went along and met w~fter to discuss Offered engineering issue,- - f his bosses, believe ust as taken back by reversal ofV-e Was, nows. steam leak situation raised as non-conservative decision making by

elt he could safely get to the valve-no indication that sr. mgt had part i .decision to-lsolate the leak summarized as did not think anybody was telling __oa

get up there and close leak, in spite of his differences w/mgt he would not believe thathappened-had not seen that kind of behavior r 5;/vt z2-$,1 k-(r91;- /6 ., L Lq'L.

Ngi (e rad -dn Aositi 4

Negative (see remainder in Positive)

perceived restart pressure resulted in p ush ofix a valve by flashlight rather thanWaiting to fix lights (resolved wltemp Iighting);( perception that co. takeseaslest/cheapest way out examples qiven: chronic problems with boron leakage andcharging pump cooler cleaning during grassing season, perception of surveys Ismanagement does them to a bers to justify whatever they want, no correctionscome from the surveys;"Nllidentified industrial safety concerns of scaffolding by flashlight, failure of SS-661 valve,no one from management or union wants to be the one to say they held a job up;

0: ECP ineffective, perception that it takes too long to fix some things thatunionbe ieves should be done immediately, expressed concerns of self and others thattagging is complicated and not well enough known to the people hanging them, surveysare not useful because they get too many to pay attention to, results not well published,regularly hear about missing parts because the warehouse sold them, known as a.,j•a.al joke" that a needed part was In the warehouse as surplus to be sold at a sale;

)somest do not have the personality to raise an issue no matter wherethey work; believes the environment intentionally cumbersome to discourage.or has effect o -isouraging-complaints,, surveys can be Interpreted any way and didnot believe management listened to what was said, Industrial safety issues overlooked toget the job done, first line supervisors push production over safety because their paystructure rewards that-could not attach any nuclear safety Issues to this though,industrial safety; corrective actions are less than adequate and that's because they do notconduct post job briefs for the lessons learned (1 in 100 would be a-lot); company and unionbattle to.ý much Where they should not have to, hopes U 1" will help this, expects so;

industrial safety Issues (equipment and personnel safety related n..ed somework re backlog of notifications in CAP,'perception that EDG at HC wasN•concerned wltech specs, not OSHA requirements-caused a problem for operators byterm insubordinate, ECP thorough, but did not roll out findings clearly , ~ doesnot see production over safety yet, but does not like the trend that be sees as sitting andwaiting before making a call-believes the push to not be the person to bring a unit downcould affect decisions-offered BF 19 controls vs. mechanically stuck issue and it took toolong to call it mechanically stuck, perception that declaring the BFI 9 valvemechanically stuck avoided because It would have led to a 1-hour shutdown (productionpush-error), sees production push in Issues like BFI9, and the handling of two issues

developed under hurricane startup in Sept 03-, re main steam isolation valves and steamdump valves-seen as examples of pushing the envelop ofco ervative decision makingto keep units on line, id'd three incidents involving that sent a message tooperators indicating no regard for personal safety and believes it sent message oktotake short cuts because it happened w/ another supervisor, different situation;-stuck BF19 troubleshooting allowed them to generate more megawatts, then continued-wlshutdown, cites problem with work week scheduling and bumping of one issue asanother one becomes immediate or next priority-effect is to just keep postponing anIssue-example given CR indicators-keep sliding and don't get addressed, seemed

Negative (continued)resources and or time not applied, this works the same way wICAP, notification systemcumbersome to use, sees difference In CR staff In deregulated environment in a swing Inemphasis on production, maintain fine line between what Is acceptable risk and what is

ot ncerned re push to move to four man crews (from five) and potential effect on safe ops;,concern is that people are not heard when they raise concerns-most NEOs feel

t ey are "white noise" and some people (but not pervasive through group) don't wanttheir names tied to a concern so the union stewards raise it for them, CRSs are caughtbetween battle of union and management and are aggravated by both parties, it'sbecome "tit for tat on piddly stuff", work management process Is "horrendous" and theworkers have been telling management that since 2000 with nothing done about it-in partdoes not work because they don't have the parts to complete the work with-leads tocriticism of workers for "low wrench time" and gets everybody pissed off causing badattitudes, can't seem to get a handle on the SAP work clearance modules for tags andwork clearance documents, why aren't we fixing more stuff in the primary plant?-raisesissue that it seems that only goal is to. we had a 28 day outage as opposed to 38.or 42and really get things fixed, saw act at MS42 valve as production over safety,unsafe and exhibiting megawatt mentality, Salem 2 bolting Issue (summer 2001 or 02)deferred repair because he.did-not want to extend the refuel outage, grassing issuesdid the right thing but 0oofortable having to take unit off line-

ever, did receive "attaboy" rom tofatnd crew for having done so;" SAP difficult to research previous defic nincles, broken equipment tends to go

on forever-cited long term plant deficiencies as primary Issue, believes "new guys"would not raise a concern of a nuclear safety nature for fear of losing job, gave fiveexamples of schedule pressure, production over safety issues including a stuck fed regvalve where the unit should have tripped, criticized the Oss for starting surveillances justbefore the end of the shift to get credit, grading by "beans"-led to stress on individualsworking the surveillance and those taking over from oncoming shift;Asaastarting in late 2001a major problem with culture that allows equipme t needs repairto languish-don't want to spend the money, raised same issue as.e turbineheader testing not handled properly and equipment released, people may not reportsmaller Issues out of the belief that nothing would be done (like small oil eIas 14 BF 19Issue as example of non conservative approach to operation, MS 42 and ---- %ssueseen as sr mgt preaching conservatism not taken to heart, indicative o1faoonservativeand megawatt mentality, very weak in carrying out corrective actions gmoperators .will say why should I bring that up if they're not going to do anything about it? People will

raise concerns if issue is major, examples of production over safety: $42,BF19 valve-mentality was to stall and not shut down, ms28S BYPASS VALVE'on mainsteam line stuck, so struck wlhammers to grassing issues-guys who keep it running onone circulator get pats on the back, management picks "low hanging fruit" to fix, thingsthat don't cost a lot of money-overall they don't pose a safety threat to people orenvironme t, but we try to see how close we can come to that-meant accepting risks,believesi ando have been beaten down -not the same as when they started theirpositions, after trying to do the r things (taking time and money) and they havechanged, no cooperation from level up with union which leads to morale problem,SAP is "piece of crap" because concerns cannot be located/researched and screens are

Negative (continued)

difficult to work with, he believes the practice of starting surveillances at the close ofshift are error traps to avoid but the push is to get "the bean" to make the shift lookbetter, example of diesel maintenance -starting complicated procedures at shift changecan be detriment to nuc safety

others: no retal knownbelieves "labeled" for trying to do the right thing, seen as a problem, believes

Fqrd received poorratin. for voicin concerns• believes nr harassed for their positions-do it by the book

'believes two outspoke ke re adversely treated because they raise issues-has not stopped them from raising concerns: e-.

elleves made.an example of re comments repeated to him by Harvln re'UWperception that pulled off shift for a cou le of weeks and "reprogra rnmed"for

backing his people up-go 'him in trouble, see as come down on hard for raisingconcerns,

.--....... seen as a hindrance, knows the procedures and holds mgt "to theletter"

f~psitiveno problem raising concerns, good.relationship as' far as radiological safety, did

not see push for production over nuclear sfe sees more support and enforcement ofthe industrial safety culture under. _.no nuclear safety Issues, will raiseconcerns and limits dealings to ifmf'edlate supervisor, believes responsibility taken awayfrom supervision and lower managers;i#O. will raise concerns and others will too;

raises concerns and does for others, experience to support retaliation raiseconce-nJAM•uclear safety issues would be addressed, !does a ood,thorough job and people have confidence In him to not use their name, seen ashaving strong operatorobackground and pushing for conservative decision making andnuclear safetyA influence has changed the way issues are addressed, theywon't languish any longer; -,Ieturn "great", thinks will help return toolwa after 1996 startup of getting it management worked together;

J no Issues wlnuclear safety; o retaliation seen for raisingconcerns (discussion around his own termination did not evoke discrim. complaintothers will raise concerns and confident that nuclear safety Issues are raised,1 Iconcerns are raised, people jump over mgt If they have to to get something addressed

/TZ

and has never seen an issue where he questioned the co attitude toward nuclear safety,offered that operator decisions to trip unit have been backed up by ops mgt and offeredtwo example 4hinks co does good job of protecting health and safety ofpublic, big safety issues and primary plant issues are looked at in depth, everyone wouldreport a concern of importance, sees improvement recently in procedures that required afix either get a notification or more resources applied in the procedure group haveresulted In more refined procedures w/not many major errors or problems any longer,typically only sees small issues now with procedures, majority will raise issues if theyhave a concern, for self, is comfortablein raising concerns that mgt believes are valid-

a SCU-551 gný ssues (neg), impressed bii lexpects p-6sitive changes

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