No 'breakdown in safety culture' at Necsa

2018-06-18 10:48
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"Nuclear" is a word which often strikes an irrational fear into the hearts and minds of people. That is because of an ongoing association of the word "nuclear" with weapons and destruction. But whoever hears of "nuclear medicine". Even many medical doctors battle to recall even hearing of nuclear medicine during their studies.

But South Africa has a world-leading nuclear medicine facility at Steve Biko Hospital in Pretoria, run by the internationally acclaimed Prof Mike Sathekge. The cancer cures and diagnostics being performed there now are amazing. Quite mind blowing. People who were supposed to be in their coffin are walking around; in fact running around.

The marvellous people at Steve Biko are achieving these miracles because they know what they are doing. They are also able to work these wonders because they are supplied with a stream of the life-saving nuclear medicine from the South African Nuclear Energy Corporation (Necsa) only 40km away.

The production and transport of the life-saving medicine is a "finely oiled machine" as the saying goes. The Necsa team that does this work is of world class. Great guys.

Three weeks ago, I was in Sochi, seeing all the Soccer World Cup preparations underway. At a giant world nuclear gathering of over 1000 people from 72 countries in a glittering hall one evening I was thrilled to be called up on stage and presented with an award, drowned by applause, as the chairman of an international committee read out a citation which included "to best nuclear company in the world". Other African countries present went wild with enthusiasm, such as Zambia, Kenya, Ghana, Namibia, Senegal and more.

It felt good. From the stage I was able to pay tribute to all the wonderful people at Necsa who make this possible. Necsa has a wholly owned subsidiary by the name of NTP, which produces and packages the nuclear medicine to over 60 countries. They work 24/7. There are daily deliveries to Argentina the US, Mauritius, Belgium, Saudi Arabia, and the list goes on. Every three seconds somebody somewhere in the world is injected with nuclear medicine from Pretoria. Every three hours we save a life. Something to be proud of…not so?

But NTP can only achieve this while the nuclear reactor runs. It is the only nuclear reactor in the World that runs 24/7 producing nuclear medicine, and also silicon for the silicon chips in your cellphone. So, congratulations to the folks on "the reactor that never sleeps".

All of this is watched internationally, with envy. It is also watched, hawkeyed, by the International Atomic Energy Agency (IAEA) watching for the slightest error or lack of judgement. We have compliance contracts with them. They consider us as a model to the world of how nuclear operations should be done. We are proud of that.

In the national interest all of the operations are watched by another set of eagle-eyes, with really big claws… the National Nuclear Regulator(NNR). The NNR is a statutory organisation, but it is also a single person… the regulator himself, Dr Bismark Tyobeka. In the nuclear world Dr Tyobeka possesses the power of the gods. In an instant he can wave his sword and close any nuclear operation in the country, if he even suspects a fault. He is a qualified scientist, but leaning on a very big pile of law books.

At Necsa we aim to double the size of the output of NTP. That means double everything else in the total production line. Vehicles are constantly driving to the airport carrying nuclear medicine as an aircraft waits on the tarmac to roar off to Turkey, or Holland…

It something start to go wrong in this complex chain of events the Necsa Group CEO has to do something, at midnight, or during his Sunday braai. There is no "waiting for Monday" to fix it.

Last year, just before Christmas, a minor procedural error was detected. Somebody did not sign in the registers the correct way. Imagine a conventional pharmaceutical plant in which somebody accidentally put the birth control pills in the antibiotics canister because his buddy Piet did not sign the correct production book in the correct place.

Same with nuclear medicine. So, before Christmas the Necsa CFO reported the "signature snag" to the NNR. The "regulator" started whacking everybody with his sjambok. Then a dreaded thing happened… the regulator sent his people to come and look for themselves. Something like the headmaster coming to inspect the school locker rooms. By this point the Necsa CEO had realised that there were indeed some procedural errors, even though on the surface all seemed fine. He then made the decision to put the NTP MD, plus two other senior managers on "special leave" to make sure that they were not present when the NNR carried out its inspections. The CEO wanted to make sure that later there could be no accusations that NTP staff influenced or hampered the investigation of the NNR. The CEO cleared all these decisions with me. I agreed that he had chosen the best path of action.

The Necsa CEO, Mr Phumzile Tshelane, also appointed his own investigation team to report to him. After a week they reported back to him that a number of additional irregularities had been found. Any one of them on their own was not a big problem, but collectively they indicated a rather inadequate handling of duties by some of the senior management at NTP. The "Special Leave" was converted to "Suspension" and the investigation altered focus.

Then a journalist from amaBhungane entered the stage, with a giant arabesque. As he turned his arabesque into a pirouette he sent a rather offensive list of demands to the Necsa CEO. He demanded action to his timescale. The CEO contacted me to seek advice, which he regularly does. He knows, "No mistakes in nuclear", so he does not make knee-jerk moves. He is a nuclear physicist. He thinks.

So, after discussion with me, he gave a first order written reply to Mr Micah Reddy at amaB and also invited him to breakfast the following morning to discuss his attack. With my permission, Mr Tshelane offered to invite the chairman, me, and offered that I was prepared to meet Mr Reddy separately. Mr Reddy refused the invitations on the grounds that "he was too busy". Believe me, CEO Tshelane was rather busy at that stage, he was phoning me at all hours of the night with reports.

So, the amaB story was published. Jaw-dropping staff. Full of wild accusations, even managing to bring in accusations of people being put on leave so that I could covertly condone the movement of money by Tshelane, all with the connivance of the entire Board. Reddy said that he had confidential board documents in his possession. Clearly, he did. Those documents were only supposed to be in the hands of no more than 20 people.

So, we did not only have "signature irregularities" on the production line to worry about.

I received phone calls at night from the minister asking when world-wide deliveries would be resumed because he was receiving complaints from foreign governments, saying that patients were standing in line in Washington DC and Amsterdam. I answered him: "only three or four days." It turned out I was wrong... more than once.

The reason? More signature irregularities continued to surface. The management faults were deeper and more wide-spread than we initially realised. The regulator was swinging his sword. The Minister was on the phone. I was saying "3 or 4 days" again. CEO Tshelane started to get edgy, which for him is odd.

From amaB they were talking of potential death and explosions, which was like adding the soundtrack to a Sherlock Holmes movie. My respect for amaB and their claim of responsible journalism plunged. 

To jump forward a bit: full production was restarted under a temporary top management team. After a while, calculations showed that the new streamlined processes and team was heading to make up all the financial losses of the "Christmas crunch". By the way, Necsa paid millions in tax to SARS. I felt good reporting that in Parliament.

Then we were presented with the "best nuclear medicine company in the world" award at Sochi in May.

By now the regulator was not swinging his sword anymore. It was back in his scabbard. But his hand was still on the hilt. We knew that. He reminded us often. We kept a beady eye on him. He knew that.

All was looking good. Then a few days ago an operator on a "hotcell" made a mistake. A hotcell is used to load radioactive nuclear medicine. The operator uses remote arms and behind radiationproof glass must carry out all tasks.

This is something like trying to stick a postage stamp on an envelope using tweezers, but the envelope is already inside the post box and you are working through the slit.

When the operator closed a door, a filter funnel fell in the door. The door did not close properly. He did not double check. Some hydrogen gas escaped. About a shopping-bag full, but that was enough to trigger an alarm.

The CEO ordered a general shutdown and removed the operator and his superior. He sent them elsewhere. The CEO notified me and he notified the regulator. He knew that the regulator had his hand on his sword.

Then Reddy came riding, from amaB, bouncing along between truth, supposition, speculation, fabrication…

It was not "a dangerous spike in hydrogen gas". Yes, in principle there could be disruption to global suppliers of nuclear medicine. We are the best company in the world and we are fixing the NTP management errors of 2017. Disciplinary action is underway against certain senior managers who took their eye off the ball. There were not "a string of setbacks" and recovery processes were not "bungled".

Yes, a confidential "protected disclosure" letter did go to the minister which was not given to me or to the CEO but which interestingly Mr Reddy has.

Necsa did not "make a grab" at the funds or intellectual property of NTP. NTP is wholly owned by Necsa. Mr Tshelane is the Group CEO and is already responsible for all actions. If somebody were to die or be injured, or drop costly nuclear medicine down the stairs, the buck stops at CEO Tshelane. No matter how much he does the Twist or the 1920"s Charleston, he won't be able to get out of the firing line.

Yes, at Christmas Tshelane did say that the shutdown then "would likely only last weeks" and then it didn't. He, like me, believed that estimate but then he started to find that the "proverbial hit the fan" when he realised that under the 2017 MD there were many more ants in the woodwork. No, there was not a "breakdown in safety culture" at the plant. Yes, there were some dents. Tshelane did lots of panel-beating over Christmas.

At times his house sounded like a Jamaican steel band. I could hear his wind panel-beating when he called me.

Yes, early in this year the Christmas Crunch did affect world suppliers. Yes, Japan was hit hard, but so was Steve Biko Hospital. I personally apologised to the boss at Steve Biko. We knew that decisions were being made as to whose life was most important; the patients in Washington DC, Tokyo, or Steve Biko. Thankfully, Necsa people were not making those decisions.

Right now, Necsa is ready to restart production in full, the CEO and his teams. This is a team thing. They know the stakes. As soon as they come to an accord, the CEO will push the go button. We know that the few days cushion in the system is running out.

The CEO invited Mr Reddy of amaB to meet with him and me yesterday (Thursday). He did not respond.

Necsa is proud to be the best nuclear medicine company in the world. We plan to keep that crown.

- Dr Kelvin Kemm is Chairman of Necsa.

Read amaBhungane's response to Dr Kemm's right of reply.

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Read more on:    necsa  |  amabhungane  |  nuclear power

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