AustralianGovernment

Comcare

REPORTOF INVESTIGATION

A N DT E C H N O L O G Y
N U C L E A RS C I E N C E
AUSTRALIAN
oRGANISATION (ANSTO)
ABN 47 956969 590
Lucas Heights
NEWSOUTHWALES

Alleged breach of section 76 of the Occupational Healthand

Safety Act 1991

To assesscompliancewiththe
Healthand SafetyAcf 1991(Cth)
Occupational

Number4245
In vestigation :
ScottNOTLEY
Investioator:

ReleasedUnder FOI
 .....................9
PeakHealthProgram .....................9
Chronology of significant events leading to and following the suspension of
MrReid..... ...................9
ANALYSIS O F " S A F E T YI N C I D E N T SR' 'A I S E DB Y M R R E I D. . . . . . . . . . . . . . . . . . 1 2
ReportsOf IncidentsPreparedby ANSTOand,ARPANSA......................12
AN S T Ol n ci d e nAt n a l ysi R s epor t- ARI Event08/265( Mo- 99) ...................1 2
ARPANSA I n s p e c t i o( Mn o-99) . . . . .. . . . . . . . . . 1 . 2
ARPANSA l n s p e c t i o( nY-90) ......................12
Remedialmeasurestaken by ANSTOin responsefo investigations
c o nd u cte db y A N S T Oa n d ARPANSA......... .... .....13
ANSTO In ci d e n
A t n a l ysi R
s epor t- ARI Event 08/265 ( M o- 99)..... . .. ........13
A R P A N S AIn sp e cti oRne p or (t Mo- 99) ......13
A R P A N S AIn sp e cti oRne p or (t Y- 90) ....... . ..... . .13
Furtherremedialmeasuresadoptedby ANSTO ......................14
C o n t i n u o ul ms p r o v e m eP n rt o j e c. t. . . . . . . . . . . . . . . . . . . . . . . . . . .l .4. . . . .
S a fe tyA n a l ysiR s e p o rt...... .......15
Superuision and training..... . ....16
Supervision and trainingwith respectto the Mo-99Incident .16
S u p e r v i s i oa n dt r a i n i nw g i t hr e s p e ct to t h eY - 9 0i n c i d e n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1
Previousincidentassociafed withY-90production ......................17
Requirement forANSIO b reporttheincidents to Comcare.........................18
F I N D IN GS R E GA R D IN G N OTIFICATION AND REPORTING
REQUIREMENTS .../1':........... . . . . . . . . . . . . . .1. .9. . . . . .
CONCLUSIONS REGARDINGNOTIFICATION AND REPORTING
REQUIREMENTS .. .. . . 19
F I ND IN GS R E GA R D IN G S ECTION16 IN RELATION TO "SAFETY
I N C I D E N T .S. .". . . . . . . . . . . . . . . . . . . . . .1. 9 ......
Assessme nt of foreseeable hazards.... .....20
ldentification of hazardsand risks- ARlsysfemsof work ..........20
SECTION16 IN RELATION TO "SAFETY
C ON C L U S IONRSE GA R DING
fN C I D E N T S " . . . . . . . . . . . . . ...................22
D I DA N S T OS U S P E N D A N D INVESTIGATE M R REID BECAUSE HE
C OMP L A IN EA DB OU TH E ALTHAND SAFETYISSUESIN THE
W o R K P L A C E.?. . . . . . . . . ................23
M r Re i d 'sh i sto ryo f a l l e g e dwor kplace behaviour ( December 1994- 16
M a r c h2 0 0 9 ) ..............23
- ns e c t i o n
T h eL e g i s l a t i o 7 6 o f t h eA c t . . . . . . ..................26
A N A L Y SSf .................27

C o n r c a r -e R e D o rot f I n v e s t i s a t i o4n2 4 5- A N S T O
Released
uno.,frt
C o r n c a r e l i e p o n o f I r r v e s t i g a t i o4n2 4 5 A N S T o 3
ReleasedUnder FOI
INTRODUCTION

1. conductedunderthe Occupational
This is a reportof an investigation
Healthand SafetyAct 1991 (the Act), the purposeof whichhas been
to determine whethertherewas compliance withthe requirementsof
the Act, the OccupationalHealthand Safety(SafetyArrangements)
Regulations1991(SA Regulations)and the Occupational Healthand
Safety(SafetyStandards) Regulations1994(SS Regulations).

INVESTIGATION

2. Mr DavidReid(Mr Reid),a Healthand SafetyRepresentative (HSR)

attachedto ANSTORadiopharmaceuticals (ARl)1
and Industrials
claimsthat he has beenbulliedby ANSTOmanagement due to him
raisinghealthand safetyissueswhichextendto includethe under-
reporting by ANSTOto the Australian
of safetyincidents Radiation
Protectionand NuclearSafetyAgency (ARPANSA) and Comcare.

3. On 18 June2009,Mr Reidwas suspended fromduty(withpay)in

respectof four(4) allegations madeagainsthim by ANSTOemployees.
Shortlythereafter, engagedby ANSTOcommenced
a Consultant an
investigation intotheseallegations.To date,Mr Reidremains
suspended (2)
withtwo of the allegations againsthimfoundto be
u n su b sta n ti a te d .

4. againsthim arefabricated
Mr Reidis of the beliefthatthe allegations or
exaggerated and his subsequent suspensionthereforeis to prevent
himfromperforming his rolein the workplaceas HSR.

Scope

5. The investigation intoMr Reid'scomplaint, conductedundersection

41(1)of the Act,is to determineif therewas sufficientevidence to
substantiatethe findingof a causalconnection betweenMr Reidhavrng
had his positionprejudicially
altered (through his suspension),and
whetherthatsuspension was due to him raisingmattersconcerning the
healthand safetyat workof AN$TOemployees.The investigation also
addresses the allegedfailureoTANSTOto reportnotifiable
occupational healthand safet/incidents to Comcareand ARPANSA.lt
is beyondthe scopeof thisinvestigation howeverto makecommenton
any issuesthatmay relateto the legislative requirementsof the
AustralianRadiationProtectionand NuclearSafety(ARPANS)Act
7998(ARPANSAct).

'Now l<nown
a s A N S T OH e a l t h- B u r l d i n g2 3 & 2 3 A

C o r n c a r -e R e p o no 1 ' l n i ' c s t i g a t i o4n2 , 1 5 A N S f O 1

ReleasedUnder FOI
lnvestiqator/s

6. I am ScottNOTLEY,a SeniorInvestigator
appointedundersection
40(2)of the Act.

7. On 13 August2009,ComcareSeniorInvestigator NigelDOCKER
commenced an investigation
intothe allegations.
Duringthe courseof
otherdulyqualified
the investigation, Comcareinvestigators assisted
withthe investigation
conducted underPart4 of the Act (the
investigation).

8. preparedin accordance
Thisis a reportof the investigation withsection
53 of the Act (the Report).

E V I D E N CCEOL L E C T E D
Reportand Attachments

9. The Reportcontainsinformation
collected
froma numberof sources
whichare referredto below.

10. Thefollowingactionwas takenby Comcareinvestigators:

(a) 25 September2009- Section43 noticeaddressed

to Dr Adrian
(Dr Paterson)CEOANSTO
Paterson,

(b) 15 December2009- Section43 noticeaddressed

to Dr Adrian
Paterson

(c) y 0 1 0- Section43 noticeaddressedto Dr Carl-

1 8J a n u a r 2
Ma g n u sL a rsso n, (Dr Larsson)CEOARPANSA

(d) 2 February2010 - Meetingvyith

, ANSTO;Investigator
BrettGodfrey,
(lnvestigatorGodfrey)Comcareand Investigator
Notley,
Comcare

(e) 20 May 2010- Section43 noticeaddressed

to Dr Adrian
Paterson

(0 2 June2010- Sitevisitto ANSTOby Investigators

Notleyand
Godfrey,meetingwithANSTOHSEpersonnelandwalkthrough
of ARI

- Reporo
Corncare t l ' l n v e s t i e a t r o. 1n2 4 5 A N S T O
5
ReleasedUnder FOI
Statements

the followingwitnessstatements
L1.. Duringthe courseof the investigation,
weretakenby ComcareInvestigators:

(a) 22 July2009- Statement- DavidReid

(b) 2009- Electronically

3 September - David
RecordedInterview
Reid

Reports
'12. I alsoreliedon the following:

(a) 14 September 2009- ARPANSAInspection ReportRB-lNS-

- 23A- Inspection
R 0 9 /0 8 8 0l3ssu e2 M IBGPlant,ARI Building
'10
conducted June2009

(b) '14September 2009- ARPANSAlnspection ReportRB-INS-

R09/08810 lssue2 - ARI Building23A- Inspection
conducted
'1 7Ju n e2 0 0 9

(c) 21 January2010and 30 Jufy 2010- Responseto section43

noticeby ARPANSA

(d) 27 January2010- ARPANSAInspection ReportR09/12971-

- 23A-
M o- 99( 28August2008) ARI Building
In ci d e ni tn vo l vi ng
inspections conducted 22,23 & 28 October2009

(e) 1BMarch2010- Response

to section43 noticeby ANSTO

(f) 29 March2010- ARPANSAInspection ReportR09/12971 -

Mo-99(28August2008)- ARI
(lssue2) Incidentinvolving
-
Building23A inspections 22, 23 & 28 October2009
conducted

(g) 28 May 2010- ARPANSAInspection Report(Preliminary)

R 1 0 /0 4 1 0-8 In cident Y- 90( 3 September
involving 2007)- ARI
Building23A- inspections conducted 25 January,8, 9, 18 and
23 February2010

(h) 12 July2010- Response

to section43 noticeby ANSTO

(i) 10 September2010-ARIANSA Inspection Report(lssue2)

- Y-90(3 September2007)- ARI
R10/07631 Incidentinvolving
Building23A- inspections 25 January,8, 9, 18 and
conducted
23 Februarv2010

t f l n v e s t i g a t i o4n2 4 5- A N S ' f O
C o r l c a r e- R e p o r o
Relcasecl
uno., fol
 0) SafetyAnalysisReport(SAR)- Radiopharmaceuticals /
Radiochemicals & supportNo:ARI \ TR 0A 10 0 B .
Production
-
R P 1 A P ri2l 0 0 8

LEGISLATION
RELEVANT

13. Undersection16(1) of the Act,an employermusttakeall reasonably

stepsto protectthe healthand safetyat work of its
practicable
employees.

L4. Undersection16(2XaXi) of the Act,an employermusttakeall

practicable
reasonably stepsto provideand maintaina working
includingplantand systemof workthatis safefor
environment
employeeswithoutriskto health.

L5. Undersection16(2)(e)of the Act,employersare requiredto providein

languages,
appropriate the information, trainingand
instruction,
necessary
supervision to enabletheiremployees to performworkin a
mannerthatis safeandwithoutriskto health.

1,6. Part3 of the Act whichdealswith HSRs,theirfunctions,powerand

rights.

17. Section68 of the Act requiresan employerto notifyComcareof certain

and dangerous
accidents occurrenceswithinspecified legislative
timeframes.

18. Section76 of the Act prohibitsan employerfromdoingan actwhich

injuresan employeein theiremployment and/orfromprejudicially
alteringan employee's positionbecausethe employeehascomplained
abouta matterconcerning at
the health,safetyor welfareof employees
work.

19. 1.05of the SS Regulations

Regulation and risk
Hazardidentification
assessmentstatesthat:
(1) An emptoyer must ensure, in relation to the implementationof these
Regulations,that appropriatesfeps are taken to identify all reasonably
foreseeablehazardsarisingfrom work which may affect the health or safety
of employeesor other personsat work

20. Regulation requiresan employerto notify

37Aof the SA Regulations
Comcareof certainaccidentsand dangerousoccurrenceswithin
timeframes.
legislative
specified

C o r r c a r e- R e p o r to l ' l n v e s t i g a t i o4r 2r ' 1 5 A N S I l ) 7

ReleasedUnder FOI
 BACKGROUND
The Emplover

2T. A N S T Oi s a 'C o mmo nwealth ' em ployer ' as

Author ity' and definedby
section5 of the Act.

22. ANSTOis alsoa 'Commonwealth entity'as definedby section13 of the

ARPANSAct and thereforea controlledfacilitythat requiresa licence
to undertakeotherurrise
prohibitedactivityunderthe ARPANSAct.

23. ANSTOis alsoclassified as a MajorHazardFacility(MHF)according

to
the definitions
in Part9 (MHF)of the SS Regulations.

The Emplovee

24. Mr ReidhasbeenemployedwithANSTOsince29 June1981and prior

to his suspensionperformedthe substantiveroleof Production
TechnicianMr Reidis therefore a 'Commonwealth authority
employee' as definedby section9(2A)of the Act.

25. Mr Reidis alsothe electedHSRfor Designated WorkGroup(DWG)

ANSTOHealth(formerly ARI)LucasHeightsOperations andthat
electionremainedin placeat all relevanttimes.

ARPANSA

26. ARPANSAis a FederalGovernment agencychargedwiththe

responsibility for protecting
the healthand safetyof people,and the
environment, fromthe harmfuleffectsof ionisingand nonionising
ra d i a ti o n .2

27. ARPANSAregulates the Australian

Government and itscontractors'
useof radiation
sourcesand facilities
and nuclearinstallations
throuoh
the administration
of the ARPANSAct 1998.

28. ARPANSAis itselfa 'Commonwealth and 'employer'

Authority' as
definedby section5 of the Act.

ARI

29. On 24 December2002,ARPANSAissuedto ANSTOa FacilityLicence

No. F0044-5A,
58, 5C authorising
the operationof ARl.

30. ARI operatesRadiopharmaceutical / Radioisotope Productionfacilities

to manufacture
radiopharmaceuticals and radiochemicals.
RadiopharmaceuticalOperations, as definedin the licence,meansthe
management involvingprocessing
of activities irradiation
target

'
Source: http://rvrvw.arpansa.gov.au/A
boutUs/rndex.cfm

C o m c a r e- R e p o ( o f I n v c s t i g a t i o4l r2 4 5- A N S l l l
Released
una.r1'ot
 for the production
materials of radioisotopes industry
usedin medicine,
and research.

3L. On 25 May 2009,Comcareissuedto ANSTOa Certificate of

complianceNo. coc-2009/007, under Part 9 of the ss Regulations,
havingbeensatisfiedthattheworkplaceis licensedand is complyinE
withcomparable Commonwealth (i.e.the ARPANSAct)with
legislation
similarsafetyoutcomesto thosecontainedwithinPart9 of the SS
Regulations.

SafetvAnalvsisReport- (SAR)
gZ. The SAR is a comprehensive reportoutliningthe safetyarrangements
i
o p e ra ti n gn B u i l d i n 2
g 3 Aandwas

prepared to demonstratethe level of safety at the facility and to

safisfythe requirements of the regutatoryauthorityARPANSA3 and
...providesthe ANSTOSafetyAssessmentCommittee(SAC)with
the necessary informationto assessthe safetyof the facilityand is
*
pari of the applicationto SACfor such an assessmenf.

Peak HealthProqram

33. ANSTO's HealthCentrefocuseson proactivemeasuresto maintainthe

healthand well-beingof ANSTO staff.This includesregularmen's and
women's healthinitiativesand the introductionof a Peak Health
Programaimed at appropriatephysicalconditioningfor those
undertakingmanualtasksto minimisethe impactof any adversebody
stressing.

Chronoloqvof siqnificanteventsleadinqto and followinqthe suspensionof Mr

Reid

34. On 22 April2009,Mr Reidand

"safety
attendedan ARI OHS meetingwherethey haveallegedthat
incidentsat ARIare being coveredup by superulsorsand managers
and alsothat thereis no feedbackon incidents."One suchmatter,ARI
Event081265 was citedthat relatedto an incidentwhichoccurredat
ARI on 28 August2008involving the radioactiveisotopeknownas
Molybdenum 99 (Mo-99).The allegations raisedat the meeting
becamethe subjectof an investigation thatwas to be thenconducted
by
-lARt.

I
See SAR Executive Summary at para I
a
Ibid at para 4

4n
C o m c a r e l l . e n o r0t 1 ' l n v e s t l e a t i o 2 4 5- A N S I - O q
ReleasedUnder FOI
35. On 5 May 2009,Mr ReidandtrIltrttended the CentralSafety
Committee
Coordinating (CSCG)wheretheyraisedessentially the
as theyhaddone
sameallegations previously
on 22 April2009.

36. On 18 May 2009,Mr ReidandIlttended a meetingheldby

Hwherethereportofrinvestigationintothea||egations
citedon 22 Apriland 5 May 2009was tabled.
foundthat
investioation

There is no evidenceto substantiatethe claims that incidentsare

beingcoveredup at ARl...Therels some evidenceto suggestthat
ARI should furTherstrengthenincident investigationand training
and theseare listedin the [10] recommendations.ln additionother
trainingand processescould improvepracticeson communication
"perception"that
on events. This would assisf with improvinga
incidentsare coveredup.

37. One suchrecommendation madeby was for ANSTOto

"Re-openincident08/265and investigatefurther. OHS reps fo be
"5
includedin the process- ARI/QSERP(1528)

38. On 2 June2009.Mr Reidissueda provisional improvementnotice(the

notice)oaddressedto
I!} ARl, undersection29 of the Act whichclaimedthatan
"uncontrolledreleaseof 1123(lodine 123)vapoursfrom glovebox
resultingin internalcontaminationof staffvia suspecfedinhalation."

39. On 10 June2009as a consequence of the noticebeingissued,

ARPANSAconducted an unannounced inspectionof the ARI building
to obtaininformation aboutthe allegedreleaseof l-123 in the MIBG
(Me tal o d o b e n zyl
Gu a nidine) Plantof ARl. At the conclusion of the
inspection, Mr Reidallegedly (Mr
informedMr SamirSarkar, Sarkar)
Inspector, ARPANSA, of the incidentinvolvingMo-99and a separate,
incidentinvolving the radioactive isotopeknownas Yttrium90 (Y'90).'

40. On 17 June2009,ARPANSAconducted an unannounced of

inspection
the ARI buildingto obtainfurtherinformation aboutsafetyissuesraised
on 10 June2009.8
b y Mr R e i dd u ri n gth e i nspection

5 - re- andDavid ReidClaims;Version2.0 l8

SeeANSTO reporttitledSB Investigation
May 2009purporledlyauthored by
u of anymaterialthatwouldsuggestthatANSTO disputedthePIN in
Comcareis not in possession
accordance with the plovisronsof section29(8)of theAct
7 ReporlANSTO Radiopharmaceuticals and Industrials (ARl) Building23A (823A)
Seelnspection
RB-lNS-l{09/0880 I S3S U E2 I n s p e c t i oDn a t el 0 J u n e2 0 0 9 ;F r l eN u m b e r5 2 0 0 9 / 0 0 1 4p9u r p o r t e d l y
srgnedby SamirSar-i<ar anddated14109109
8 ReporlANSTO Radiopharmaceuticals and Industrials (ARl) Building23A (B23A)
SeeInspection
R B - l N S - R 0 9 / 0 8 8 I1S0S U E2 I n s p e c t i oDn a t el 7 J u n e2 0 0 9 ;F i l e N u m b e r5 2 0 0 9 / 0 0 1 4p9u r p o r t e d l y
sisnedbv SamrrSarkaranddated11109109

C ' o m c a r e R c p o r lo l ' l n v e s t i g a t i o4n2 4 5- A N S T O l0

ReleasedUnder FOI
 41. On 1 8 Ju n e2 0 0 9 ,a n ANSTOem ployee and
accusedMr Reidof assaulting (i.e.shoulder
barging)himwithoutprovocation in theworkprace
(Allegation4). Mr
Reidwas subsequently suspended fromdutywithpay pendingan
internalinvestigation intothisallegation.e

42. On 1 9 Ju n e2 0 0 9 ,
1oreceivedinstructions
from
ECorporateCounse|,ANSTo,toconduLtafactfinding
investigation
and preparea reportintoAllegation4 and three(3)other
allegations
(collectively
the Allegations):
(i) On 10 June2009,Mr Reid,in the companyof Q;)and ;l
r and an auditorfromARpANSA,falselyaccusedI
I of informing staffnotto completean incidentreport
involving a contamination spill(presumablyas requiredunder
A N S T Ol e g i station)
( Ailegation1) ;
(i i ) o n 2 5 Ma y2 0 09,Mr Reidassautted ( i.e.shoutder
bar ged) f
I withoutprovocation in the workplace(Allegation2);'
(iii) On 18 June2009,Mr ReidverbaltyabusedIIf in
the workplace(Allegation3).

43.on22September2009,Epub|ishedareportofr
investigation
in whichstatedthatl hadfoundAllegation
1 and
Allegation
3 weresubstantiatedhowever,
Allegation
2 andAllegation
4
wereunsubstantiated.

44. On20 October2009,fn,

ANSTO,andlrll,ffi}Tisro,
compileda reportintoARI Event081265.11

45. Between22 and28 october2009,ARPANSAconducteda planned

inspection
of the ARI buildingto investigate
the incidentinvolving
Mo-
99 whichoccurredon 28 August2008.12

'See
letteraddressed
to David ReiddatedI8 June2009andpurporredly
signedby MargaretFittler,
HR Manager,ANSTO
,OIITII
''
S e eI n c i d e nAt n a l y s i sR e p o r-l A R I E v e n t0 8 1 2 6(52 g l 0 8 / 2 0 0 g )
''
SeeInspection ReportR09ll21| purportedly signedby SamirSarkarandJohnWarddated2jl0lll0
and Inspection ReportR0911211 TSSUE2 puryortedly signedby SamirSarkarandJohnWarddated
29103,l0

C o r r c a r e- R e p o r o 4 2 4 5- A N S T O
l l llvestigation
Released
unolrLol
46. Between25 Januaryand 23 February2010,ARPANSAconducteda
plannedinspection the incident
of the ARI buildingto investigate
Y-90whichoccurredon 3 September
involving 2OO7.13(collectively
the
incidents)

OF"SAFETY
ANALYSIS INCIDENTS'' BY MRREID
RAISED

ReporfsOf lncidentsPreparedby ANSTOand ARPANSA

AnalvsisReport- ARI Event08/265(Mo-99)

ANSTOIncident

47. Withreference to paragraph

44, ANSTO'sinternalinvestigation
revealedthat:

Based on the information gathered during the investigation of this

event, there is no evidence of falsification of records or cover up at
ARl. There ls a/so no evidence that the operator (or any other
person involved) received radiation doses above fhe ANSIO limits,
in fact /he doses received were negligible. Nevertheless, fhe doses
were avoidable.la

(Mo-99)
ARPANSAlnspection

48. Withreferenceto paragraph conductedby

45, the inspection
ARPANSAdid not find "anyevidencethat thisevent hasbeencovered
up or underreported."t5lnspectorSarkaralso notedthat

as
to repoftthisincidentto ARPANSA
...therewas no necessity
occupational dose limits were not exceeded and the workers were
atloperating within their dose constraints.l6

(Y-90)
ARPANSAInspection

49. to paragraph
Withreference that:
46, ARPANSAsubmitted

The lnspectorsnote that all relevant supervrsorsand managers

were informedabout the incident. This incidentwas also repofted
in fhe ANSIO quarterly reporl (July to September 2007) to
ARPANSA.lT

lr ReportRl0/04108purpor-tedly signedby SamirSarl<ar dated28105110 and Inspectron

SeeInspection
ReportR I 0/07631 ISSUE 2 purporledly signed by SamirSarkar and ors datedI I
0/09/ 0
'o SeeANSTO IncidentAnalysisReporlat page4
r5 lleport(lssue2) at para5.8
SeeMo-99 Inspection
' ' I b i dp a l a5 . l 0
r7SeeY-90 lnspectron Report(Preliminaly)at para1.36. Also referto ANSTO OHSECuideAG 2316
R e p o r t i ntgo A R P A N SA

C o r r c a r e- R c o o r lo f I n v e s t i l r a t i o, 1 - ANST()
n2 4 5 t2
ReleasedUnder FOI
 "coveredup"by ANSTO,Inspector
50. to thisincidentbeing
Withreference
"the phrase"coveredup" wasnot usedby Mr
Sarkarsubmittedthat,
Reidandtherefore,it was not usedin the lnspectionReport."l8

51. I alsonotethatARPANSAreportthatthe operators involvedin this

incidentdid not receive.or wereunlikelvto receive,an internaldoseof
ra d i a ti o n .l e

Remediat measures taken by ANSTO in response to investigations conducted

hy ANSTO and ARPANSA

AnalvsisReport- ARI Event08/265(Mo-99)

ANSTOIncident

52. ANSTOproducedan lncidentAnalysisReportin whichit provideda

numberof conclusions towardsimproving
and recommendations the
healthand safetyof ARI employees

53. I am in possessionof a copyof the Responseto Recommendations

made in the ANSIO IncidentAnalysisReport- ARIEvent 08/265
(28/08/2008) and notethat,at the time of its provisionto Comcare,16
of 16 recommendations had beenfinalised.

Reoort(Mo-99)
ARPANSAInspection

54. ARPANSAproducedan Inspection Reportin whichit provideda

numberof conclusions towardsimproving
and recommendations the
healthand safetyof ARI employees.

55. I am in possessionof a copyof the ANSfO HealthResponsefo

ARPA|VSA lnspectionReporlR09/12971- /ssue2 - Planned
lnspectionto lnvestigatean lncidentlnvolvingMo-99on 28 August
2008- l,Jpdated Responseto Recommendations and notethat,at the
timeof its provision
to Comcare,three(3) recommendations had been
finalisedwithfour(4) recommendations a statusof "Already
indicating
Undenruay."

Report(Y-90)
ARPANSAInspection

56. ARPANSAproducedan Inspection Reportin whichit provideda

intothe incident.
s r ecomm endations
n u mb e or f co n cl u si o nand

57. I am in possessionof a copyof ANSTO'sresponse to ARPANSA's

recommendations and notethat,at the timeof its provision
to
Comcare,5 of 7 recommendations had beenfinalised.

't Notleydated2l8l2ol0 at l0.26am

Source:Replyemailfrom Mr Sarkarro Investigator
re Report(Prelimrnary)at para5.3 & 5.4
SeeY-90 lnspection

C l o m c a r-e R ep o r to 1 ' l n v e s t i g a t i o4r2r4 5- A N S I - O t a

I J
Rcleased Ljnder FOI
Further remedial measuresadopted by ANSTO

ContinuouslmprovementProiect

58. Following the incidents,

and in additionto it acceptingand
implementing bothitsown and ARPANSA'srecommendations, ANSTO
embarkedupona continuous improvement projectwithinARI thatwas
initiated
by Dr Patersonin August2009.

Theprojectexamined a//aspecfsof radiopharmaceuticalproduction

and reliedheavilyon plant operatorsand QC staff to generate
proposalsfor improvement. An initial list of BB actions was
identified.Actionswere prioritisedon fhe basis of maximumbenefit
in the shorfesf possib/e timescales. The responsibilityfor the
. implementationof these initial actions u/as given to a dedicated
project team, overseenby a steeringgroup made up of ANSIO
Senior Managersrepoftingdirectlyto the CEO. Capitalfundingof
$2.3 millionhasbeen approvedfor the initial actions,with additional
funding having been recently approved for capital projects to
improvefhe process workflowand wastemanagementcapabilities
within the facility. Approximately50% of current identified actions
were completed by the end of the 2010 financial year. Ihis
representssignificantprogress given that many of the actions
involve engineering upgrades with significant multi-disciplinary
engineering design challenges. The continuous improvement
programwill be maintainedin line with the requirementto manage
riskswithinthe facilityunderthe ALARA2jprinciple.2l

59. I am in possessionof a copy of the B23A lntermediateSafety Upgrade

Project Work Schedule V1 and note that, at the time of its provisionto
Comcare,40 of 88 actionshave been finalised.

60. As furtherevidenceof its continuousimprovementproject,ANSTO

provideda documententitled Sfafus on ActionsforANSfO Health
ReportExecutiveSummary in which Mr Jenkinsonstates that

A numberof reviewsfor improvingthe OHS in ARI (now ANSTOHealth)

have been conducted over the years. The ensuing reporls have
produced a number of recommendations to be considered for
however the sfafus of these past recommendations
implementation;
has not beenknown (my emphasisadded).
"in
6't. A reviewof this documentidentifiesthat 16 of 27 reportscontain
progress"actionswhich include,but are not limitedto, the following
issues:

'o As Lo* As Reasonably

Practicable
rr SeeANSTOss43response to Comcaredatedl2 July2010at pagel8

C o r r c a r e- R e p o r to f I n v e s t r g a t r o4r2r 4 5- A N S I - O 14
Released
LJndei
frOI
 . Reporton Bld 23 Concerns- 28 July 1999

. SafetyMattersSummary- 25 October1999

. Productionprocessreviewby ISOSo/uflons- 23 December1999

. ProcessHandlingConcernswith production- 29 July 2002

. ARI OHS WorkingGroup- December2004

. Audit of ARI SafetySysfems- May 2006

. RCAof extremityover-exposurein Y-90 process- July 2007

62. Comcare is in possessionof a copy of the Recommendationsin

Progress and note that at the time of its provisionto Comcare,76
actionsidentifyinga statusof "in progress"remain. I do note however,
that70% of actionshave been completed.

Safety AnalysisRepoft

69. Followingits conclusionsinto the Mo-99 incident,ARPANSA

recommendedthat:

ARI operating practices and equipment associafed with 823 should

be subject to a comprehensive review. This review should include
HAZOP sfudies or a suitable alternative to identify potential safety
weaknesses which may then be investigated for engineered
solutions or p rocedural enh ancem e nts.22

64. In responding
to ARPANSA's
recommendation
ANSTOsubmitted
that:

A review of the 823 processes was underiaken as paft of the

preparation of the current 823 SAR. However given recent
incidents, we have commenced a fresh comprehensive review of
the ARI operating processes and equipmenf assoclated with 823.
Ihls consists of risk assessrnents of all ARI processes and a review
of all equipment. The review commenced in December 2009 and is
scheduled to be completed in Juty 2010.23

65. In a section43 noticeto ANSTOto providedocuments whichthe SAC

reliedon to assessthe safetvof the facilitv.ANSTOsubmitted
that:

A comprehensiveSafety Analysis Report outlining the safety

arrangementsoperatingin Building 23A was first completedand
submittedto the ANSIO Safetv AssessmentCommitteein 2004.

" SeeMo-99
InspectionReport(lssue2) at para6.1 dot point I
"
SeeResponse to ARPANSArecommendations dated26 February2010andpurportedly
signedby
I(arenWolfe,tlrenActingGeneralManager', ARI

C o r n c a r e R e p o no l ' l n v e s t r g a t i o4n2 4 5- A N S I ' O

Releasecl
uno"lfo,
 The Safety Analysis Report was reviewed and re-submittedin
October 2007 and an approval to operate was given with the
requirementthat fuftherrisk assessmenfsbe completed. Basedon
the feedback from the Safety Assessment Committee,a fufther
reviewis currentlytakingplace incorporatingrisk assessmentsof all
processes...Sixteen areas requiringrisk assessmenthave been
identified. Ten of theseare complete...

66. I am in possessionof a copy of ANSTO's responseto ARPANSA's

recommendationand note that at the time of its provisionto Comcare,
'10
o f 1 6 r i s ka s s e s s m e n t h
s a v eb e e nf i n a l i s e d .

Supervision
and training

67. Undersection16(2Xe)of the Act,ANSTOhas a dutyto provide

employees withthe information, instruction,
trainingand supervision
necessaryto enablethemto perform theirworkin a mannerthatis safe
and withoutriskto theirhealth.

Supervision
and traininqwithrespectto the Mq-99Incident

68. Contained Report,ARPANSAstatethat:

withinthe Mo-99Inspection

...lnspectors found deficienciesin the manner by which this event

was managed both in the immediate aftermath and the subsequent
event investigation. ln this regard, lnspectors consider that the
arrangements for supervision and training have not been effective
in delivering the standard of safety that is required for an isotope
p rod uction facility.2a

69. In a section43 noticeto ANSTOto providerecordsof the traininggiven

to ARI staff,ANSTOsubmitted,interalia,that:

ANSIO providesa comprehensive suiteof trainingto ensurethat

all staffareequippedwiththerequisiteskillsandknowledgeto work
safely.

70. In my opinion,it is incumbent on ANSTOto ensureits staffis trained

and supervised to ensurethattheyproperlyimplement proceduresfor
d e a l i n gw i th ,a n d re sp o nding ( including
to, safetyincidents spilland
contaminations) and thattheyhavebeenproperlyand adequately
i n d u cte d .

7T. A reviewof ANSTO'sinternalinvestioation

intothe Mo-99incident
revealsthat:

"
n e p o r(t l s s u c2 ) a t p a r a4 . 3 7
S e eM o - 9 9I n s p e c t i oR

C o r r c a r e- I i e p o r to l ' l n v e s t i g a t i o4n2 4 5- A N S T O 7 a
Io
ReleasedUnder FOI
 The senior operator sfafed that he was unaware of the ARI
procedure for Minor Sp//s and Contamination.2s

New staff member,- worker, had not completed

General Safety tnduction or RadiationSafety tnduction cotlrse.26

The immediafe response and the supervisor's response to the

event was in adequate.27

The operator doing the l-131 unloading / loading task was relatively
inexperienced and operating under supervision, and had not
completed the site wide OHS induction training or the radiation
safety training provided by S&RP (now QSERP).28

72. ANSTOthereforedid not affordradiopharmaceutical workersinvolved

in the Mo-99incidentthe levelof trainingthatit dulyowedthemunder
the provisions
of the Act.

73. Indeed,ANSTOdid notaffordI the levelof trainingthatit duly

owedhim both priorto andfollowingthe Mo-99incident.According to
trainingrecords29supp|iedbyANSTo,-undertookAR|
induction on 51212009; safetyinduction
on 141712009; OHSEAlert
Gu i d e l i n easn d OH S Eat ARI on 11312010,a per iodof 6, 11 and 19
monthsrespectively afterthe incident.

Supervision
and traininqwithrespectto the Y-90incident

74. Contained
withinthe Y-90Inspection
Report,ARPANSAstatethat:

...the majorityof ANSIO staff stated that they were satisfiedwith

the trainingprovidedby ANSTO.

The inspectorsverifiedthe trainingrecord of the staff affectedby

the contamination incident...and
foundthat both had completedthe
trainingrequiredto undeftakeY-90production.s0

Previous incident assoclafed with Y-90 production

75. In a separatedocumentaddressingARPANSA'sY-90 Inspection

ReportANSTO submittedthat:37

" SeeANSTO
IncidentAnalysisReporlat pagel0
'l
luia ut pageI I
'' Ibid at pageI I
'" Ibid page
at II
2e
SeePathlor"e LeamrngManagement Systemplintout
r0SeeY-90 Inspection
Report(lssue2) at para4.22& 4.23
t'
SeeSummaryof lnrprovements madeto Y-90 Production at pagel, paraI
Process

C o r r c a r e l L ep o r to 1 ' l r v c s t r g a t i o4n2 4 5- A N S I - O
Rcleased
,"oJ7o,
 Beforethisincidentoccurred,ARIhad been focussingon regular
reviewsof the Y-90process. Thishad arisenfrom an ALARA
assessment that was beingundeftaken to ascerTain if production
couldbe safelyincreased.Duringfhrsassessment, extraextremity
dosimeterswere worn by operators.This processidentifiedthat
one operatorexceededthe annuallimitof s)1msv and a second
operatorexceeded themonthlltinvestiqation
timitof 40m5v.32This
eventwas repoftedto ARPANSA on 13 April 2007 by emailand
wasfollowedup by a repofton 24April2007.

76. ANSTOthereforepossessknowledge thatthe y-g0 incidentin

september2007was notthe firsttimethatprocessing operators
engagedin Y-90production
hadtheirhealthand safetycompromised.

Requirementfor ANSTOto repori the incidentsto Comcare

77. As partof its BusinessManagement system,ANSTOhavean OHSE

Guidetitled'Reporting providesfor the notification
to Comcare'which
and reporting of incidentsto Comcare.33

78. ln a section43 noticeto ANSTo to providean explanation

as to why
the Mo-99incidentwas not reportedto Comcarein accordance withthe
provisionsof section68 of the Act,ANSTOsubmitted,interalia.that'3a

Under arrangements agreed with the cEo of the Australian

Radiation Protection and Nuclear Safety Agency (AR?ANSA),
ANSIO has a binding obligation and duty to repoft eyenfs rated as
Level 2 or above on the lnternational Nuclear Event Sca/e (/NES) -
to ARPANSA within 24 hours.

GiventheagreedprotocolsforreporTing incidents
to ARpANSA, the
reporTingof suchlow leveleventsto comcareas s.6Bnotifications
wouldrepresenta grossdisparitybetweenthe criteriafor reporTing
to ourrespectiveregulators.

79. Withrespect,the agreement betweenthe CEOsof ARPANSAand

ANSTOis whollyirrelevant (in so far as ANSTosobligation to report
notifiable
incidentsto comcare)and quitesimplymeansthatthe cEos
havereachedan understanding regarding the interpretation
of
ARPANSA'snotification requirements. In as muchas it maywishto
progressits positionon thisissue,ANSTOshouldbe vigilantof the fact

tt
In my vierv, the incident would appear to be sub.legtof the repolt tilled,Incident Intte"stigtttionintct
High Extrenit), Dose.sn lnterim report showirg data ro l8 Aprit 2007
E
and iisted in the Slatrls on Actionfor ANST) Health Report Executive Suntrnary at page 3
rr
S e eA N S T O O H S E C u i d e A G 2 3 1 1
3t
It is acknowledgedthat ANSTOs responseconcemedthe non-reportingto Comcare of the Mo-99
rncident,but it is assumedthat ANSTO would pr-ovidethe samereasoninsfor the Y-90 matters

C o r r c a r c- I { e p o r o
l l l n v e s t i g a t i o4n2 4 5- A N S I - O
Released
una"lFor
 thattheserequirementshaveno resemblance to its
or relevance
reporting
legislative underthe OHSAct.
requirements

R E GA R D INNGOT IFICATION
F I N D IN GS REQUIREM ENTS
ANDREPORTING

80. lt is my viewthatthe incrdents mentioned in paragraphs 45,46 & 75 of

the Reportmeetthe definition of a dangerous occurrence as definedin
regulation 3 of the SA Regulations, therefore,ANSTO was requiredto,
but did not notifyComcareof theseincidents in accordance with
section68 of the Act,and regulation 37Aand 378 of the SA
Regulations. follows
lt therefore that Comcarehas no initialrecordof
the reasonably stepsthatANSTOtookto protectthe health
practicable
and safetyof radiopharmaceutical operatorsas a resultof these
particular incidents.
AND REPORTING
C O N C L U S I O N SR E G A R D I N GN O T I F I C A T I O N
REQUIREMENTS

81. I do notdisputethatANSTOwerenot required to reportthe incidents

mentionedin paragraphs45 & 46 of the Reportto ARPANSAhowever,
ANSTO'sreportingobligations to Comcarepursuantto section68 of
the Act are notamelioratedby the ARPANSAct,or any arrangement or
agreement betweenthe CEOsof eitherorganisation. ANSTOappears
to haveadoptedthe argumentthat,(following ARPANSA's and its own
doselimitswerenotexceeded,
internalfindings)if occupational thenno
one couldhavebeeninjured,therefore theirreporting obligationsto
Comcarewerenot requiredto be enlivened. lf this is indeed the
argumentputforwardby ANSTO,thenin my view,it has no merit.The
failureto provideand maintaina safeworkingenvironment (through
inefficientsystemsof work,supervision and training)is sufficient
reasonfor ANSTOto invokeits notification requirements to Comcare
(forpublicinterestreasonsif no other).

82. As notedabove,in my viewit was incumbent uponANSTO,under

section68 of the Act,to notifyComcareof the incidentsmentioned in
paragraph 80 of the Report.lt failedto do so.Accordingly,I am of the
viewthatANSTObreachedsection68 of the Act in thatit failedto
notifyComcareof the dangerous occurrences as the regulations
requrre.

TO"SAFETY
16INRELATION
R E GA R D ]NSGE C T ION
F I N DIN GS INCIDENTS"

83. section16 of theAct imposeda dutyon

On the dateof the incidents,
ANSTOto takeall reasonably stepsto protectthe health
practicable
and safetyof its employeesby providingand a working
maintaining

C l o r n c a r e- R e p o r l o l l n v c s t t g a t i o n4 2 . 1 5- A N S T O
Released
u"a.iPor
 andwithoutriskto their
thatwas safefor its employees
environment
health.35

Assessmentof foreseeablehazards

84. The workconducted withinARI has inherentOHS risks,hencethe

needfor ANSTOto identifyall reasonablyforeseeable hazardsand
risks,and to ensurethatappropriate
assessthe resultant systemsof
workhavebeendeveloped, implemented and maintained.ln
particular,
its OHSsystemsneedto be clearlyunderstood wherethe
particularhazardand risk is associatedwith the integrityof
radiopharmaceutical
operations conducted withinARl.

85. Criticalto the performance of workconducted withinARI is the needto

haveeffective consultative
arrangements in placebetweensupervisors
and processing operators.The existinghazardidentificationand risk
assessment controlprocesses shouldbe understood and complied with
by all ANSTOemployees (includingsupervisorsand managers) to
reducethe levelof riskposedto employees undertaking
radiopharmaceutical operations.Thiscontention is supported by the
factthatANSTO,as partof its internalinvestigation intothe Mo-99
incident, submittedthat:

amongstrelevantstaff in
[t]herewas inadequatecommunication
relation to the incident, and there were at that time inadequate
formal processes for effective communicationamongst staff in
relationto an abnormaloccurrence.'ou

ldentificationof hazardsand risks- ARlsysfemsof work

86. In additionto ensuringthatemployeesunderstand and complywiththe

hazardidentificationand riskassessment controlprocesses,
ANSTO
shouldregularly assessits variouspoliciesand procedures
at the
corporate levelto ensurethatits systemsof workremaincontemporary
for its employeesandwithoutriskto theirhealth.

87. U n d e rre g u l a ti o1n.0 5o f the SS Regulations, an employer musttake

appropriatesteps to identify all reasonably foreseeablehazards and
riskassessthoseidentified hazards.Regulation 1,05(3)providesa list
of riskassessment toolsavailable to the employerand includes,(butis
n o tl i mi te dto ) 'a u d i ti n g,'
and ' discussions withem ployeesor other
relevantparties.'As partof its internalinvestigation intothe Mo-99
i n ci d e n A
t, N S T Osu b mitted that:

35
sl6(2)(a)
16
Seeroot cause(RC5) of ANSTO Incident Analysis Reporr at page4

C o r n c a r e R e p o r to f I n v e s t r g a t i o4n2 4 5- A N S T O 20
ReleasedUnder FOI
 that processes
Thereis...anindication followed
werenot effectively
and that a more conscientiousattitudeis required from all staff.
Thereis an apparentlack of reinforcement of, and a lack of
monitoringof compliancewith,safetyrelatedprocedures.'o'

88. This statementis furtherenforcedby the fact that Dr Paterson,as part

of hisformalresponseaddressed to Dr Carl-Magnus Larsson,CEO
ARPANSAconcerning ARPANSA's Y-90 Inspection Report,submits
that

... lf ls acceptedthatmanagement processeswerenot robust,pro-

active or predictable as indicated by the findings and
recommendations of bothANSfO'sand ARPANSA's igations
invesf
into the August 2008 incident [Mo-99]... ln general the
management arrangementsfof the Y-90incident]appearto have
beengenerally morerobustthantheAugust2008incident."

89. Havingregardto ANSTO'ssubmissions outlinedin paragraphs 87 & 88

of the Report,I am thereforeof the view that an auditof its ARI and
corporate systemsof workshouldhaveturnedANSTO'smindto the
probabilitythatARI protocols neededto be forensically examinedprior
to the incidentsthe subjectof thisReport, particularlygiven the
previousincidentof Y-90in April2007. PriorOHS reviewsmadea
numberof recommendations thatANSTOcouldhaveappliedin making
the workplacesafethatmay haveminimised or eliminated the
occupational healthand safetyissueswith radiopharmaceutical
operations.Thiscontention is supportedby the factthathazard
identification
and riskassessment controlprocesses, subjectof an
apparentauditof ARI safetysystemsin May 2006,remained
outstanding38 untilenlivened and furtherreviewedas partof the
continuous improvement projectwhichcommenced in August2009.

90. knewor shouldhaveknown,that

ANSTOtherefore,
radiopharmaceutical
operations thatshouldhavebeen
haddeficiencies
addressed.

9L. I am thereforeof the viewthatANSTO,in its corporatecapacity

throughthe SAC,havethe abilityand the meansto identifyand control
any potentialhazardsand risksassociated withradiopharmaceutical
operations.To thatend,the currentreviewof the SARappearsto be
reactiveonly,in thatriskassessments are not updateduntilaftersuch
timethatthe healthandsafety of an employee has beenplacedat risk,
and/orthe integrityof radiopharmaceutical
operationshas been
co mp ro mi se d .

" Seeroot cause(RC5)of ANSTO IncidentAnalysisReporrat page4

tt And therecommendations
of whichlemainedunknownas mentioned in para60 of thisreporl

C o m c a r e- R c p o r to l ' l n v e s t i g a t i o4n2 4 5- A N S T O ....2J^.

K e l e t s e d t . r n ( l e rf ( r l
92. Boththe ARPANSAand ANSTOinvestigation reportshighlight incident
"underreporting" in additionto OHS hazardsand risks. lt is also
contended thatbothsupervisors and employees havetendedto
'normalise' potentialhazardsand risksassociated withproduction
techniques and equipment which potentially
compromises ANSTO's
dutyto be activeanddiligentin identifying and controlling risksin a
reasonably practicable manneras requiredby the Act and SS
R e g u l a ti o n s.

C O N C L U S ION RE
S GA R D INSECTION
G TO "SAFETY
16INRELATION
I N C I D E N T S ''

93. The healthand safetyof Australian workersis a key concernof

governments
Australian at all All workershavethe rightto a safe
levels.
and healthyworkplace and employers havethe rightto expectthat
workersand visitorsto theirworkplaces with
will co-operate
occupationalhealthand safetyrules.3s

94. I concludethaton the dateof the

Baseduponthe materialavailable,
ANSTObreachedsection16(1)of the Act in that.
incidents,

(a) practicable
ANSTOdid not takeall reasonably stepsto provide
and maintaina workingenvironment(including
safesystemsof
work)forits employeeswhowereengagedin
and
operations;
radiopharmaceutical

(b) ANSTOdid nottakeall reasonably practicablestepsto provide

its employees who wereengagedin radiopharmaceutical
operationsthe information, trainingand supervision
instruction,
necessary to enablethemto performtheirworkin a mannerthat
was safeandwithoutriskto theirhealth.

95. I am alsoof the viewthatANSTO,in its corporatecapacityto takeall

reasonably practicable stepsto protectthe healthand safetyof its
employees at work,failedto comprehensively riskassess
radiopharmaceuticals production in that it failedto ensurethathazard
and riskassessment
identification / control,was understood and
implemented at the supervisory/ employeelevel.

96. Notwithstanding highlighted

the information in thissectionof the
Report,ANSTOappearsto haveinvestedsignificantly (financially
and
managerially) to ensurethatpro-activemanagement actionsare key in
drivingits safetyculturewithinARl. Thisis evidentgiven
particularly
the introduction improvement
of the continuous projectin August2009
and the currentreviewof the SAR,whichin tandemwhenfinalised,

re
National Review into Model OccupatronalHealth and Safety Laws, First Report to the Workplace
R e l a t i o n sM i n i s t e r s 'C o u n c i l O c t o b e r2 0 0 8 a t i i

C o r n c a r -e R e p o r o
t f I n v e s t i g a t l o4n2 4 5 A N S I - O . . ,. 2 2 .
Keteaseo[Jnoer f(l
 shouldensurethatANSTOhasdeveloped and implementedeffective
hazardidentification
and riskassessment
controlprocesses
for
employeesundertaking radiopharmaceutical
operations.

97. On 2 June2010,Investigators Notleyand Godfreyconducted a

'walkthrough' plantand equipment
of ARI to observethe environment,
wherethe incidents occurred.At thattime,we wereaccompanied by
If Il , IIIandIl. Dur ingthat
walkthrough, boththe Mo-99and Y-90production processwas
professionally oratedby lI andI respectively.
Whilst
it is obviousthatthe ARI facilityis aged,the apparentcommitment,
knowledge and professionalism displayedby ARI personneland
ANSTOmanagement is particularly
noteworthy.aO

D I DAN S T O
S U S P E NADN DIN VESTIGATE
MRREIDBECAUSE HE
COMPLAINED ABOUTHEALTH ANDSAFETYISSUES
IN THEWORKPLACE?

BA C K GR OU N D

Mr Reid'shistorvof alleqedworkplace (December1994- 16 March

behaviour
2009)

98. Priorto his suspension, Mr Reidwas suffering

fromworkrelatedbi-
lateralpainand lateralepicondilytis andwas beingtreatedby Dr
GrahamHall(Dr Hall)attachedto theANSTOHealthCentre.As a
consequence, and as partof a returnto workprogram,Mr Reidwas a
p a rti ci p a n
(at l b e iut n w i l ling)
in the PeakHealthPr ogr am .

99. BetweenDecember1994and 29 May2008respectively, Mr Reidwas

i n vo l ve idn fo u r(4 )w o rkplace
incidents,
namely:41
. he employed abusive language (result - written counselling);

. verbal disagreement which led to Mr Reid holding a work colleague

in a headlock (result - disciplined (not fufther described);
'incident' (not
. furlher described) involving security (result - written
discipline counselling); and

. swearing at a nurse while attending the ANSIO Health Centre to

undeftake the Peak Health Program (result - informed behaviour was
unacceptable)

a0
It should be noted that the wall<throughwas not conductedto l'eview any aspectof the plocedures,
opelationsor nranagementwithin ARI, but melely an invite by ANSTO management
o'
See Chronology of D Reid eventsprior to suspension- Appcndix 6 of ANSTOs s43 responseto
C o n r c a r ed a t e d l 2 M a l c h 2 0 1 0

C - - o r l c a r eR e p o no l ' l n v e s t i g a t i o4n2 4 5 A N S I - O
23
ReleasedUnder I"OI
 100. on 23 June2008,followinga meetingwithMr Reid,llllll,
If - ARl, forurrarded
a memorandumto
Mr Reidin whichhe confirmedhis understanding of the issuesthathad
beendiscussed at thatmeeting.In particular,
the followingwas
documented:42

Mr Reid's anger in not wanting to attend the ANSTO Medical Centre;

Clarificationsurrounding the commencement of shifts and absences

from the workplace;

E stating that he had been advised by the Heatth Centre

that Mr Reid had refused to attend the Peak Health Program; and

A advising Mr Reid that any future occurrences of refusing

to accept direction from [his] superuisor or aggressive and
inappropriate behaviour may lead to more formal action being
undeftaken.

101. On 8 October2008,Mr Reidattendeda meetingwithEland a

unionrepresentative,wherethe issueof his non attendanceat the
PeakHealthProgramwas discussed.ANSTOallegethatMr Reid
abruptlyleftthe meetingafteragreeingto attendthe Program.a3

102. On 16 March2009,Mr Reidattendeda meetingwithIIII:

Ilf If ProductionSupervisor
ARl, wherethe issue
of his returnto workprogramwas discussed.ANSTOallegethatMr
Reidbecameagitatedto sucha degreethatlinemanagement was
organised to assistand supportl.oo

103. TheANSTOEnterprise (theAgreement)2009- 2011

Agreement
states,interalia,that:

Followingthe investigation,the superuisor/manager

may:

c provide the employee with verbal and/or written counselling,

with written confirmation to the employee copied to their
personalfile for a periodof 12 months.

L04. Accordingto the Agreement,it is apparentthat an employeewho is a

recipientof this sanctionwill have their personalfile noted that
counsellingwas undertaken.The file note shall remain currentfor a
periodof two (2) years, duringwhich time the employee'sperformance
will be monitoredby line management.At the end of that period,the

ar - Appendix6 of ANSTOss43response
SeeChlonologyof D Rerdeventsplior to suspension to
C o n r c a rdea t e dl 2 M a r c h2 0 1 0 .S e ea l s om e m o r a r r d ut m
i t l e d ' B e h a v i o ui nr t l r ew o r k p l a c e ' p u r p o r t e d l y
signedbyllll anddated24106108
* rbid
ot
It.,id

C o r r c a r c- R e p o r to l ' l n v e s t i g a t i o4n2 : 1 5- A N S l ' O

ReleasedUnder FOI
24
 file noteshallbe destrovedprovidedthat no furtherbreachof duty has
occurred.

105. Notwithstanding the equivocalnatureof the timeframethata filenote

is to remaincurrenton an employee's personalfile,asit appearsclear
thatuponcertainconditions beingsatisfied by linemanagement, the
filenoteis to be destroyed.

L06. Therecan be no disputethatduringthe periodbetweenDecember

'1994and 29 May2008,Mr Reidwas the subjectof four (4) incidents
which,in time,occurredat the veryleastfouryearsapartfromthe
previously recordedincident. Althoughit is notentirelyin accordwith
the recognised sanctionsin the Agreement,46'ANSTO submitthatit
'w ritten ( Dec' 94) ',discipline[d]'
( Dec
o n Mr R e i d
i mp o se d counselling'
'98)and 'writtendiscipline (Apdl '03) in respectof those
counselling'
three(3) incidents.lt is alsoapparentthat,in respectof the incident
recordedon 29 May 2008,ANSTOdid not imposeon Mr Reidany
recognised actionavailablein the Agreement, otherthansubmitting
'behaviour was unacceptable'and thatit'wouldbe
thatMr Reid's
discussedwith his supervisor.'
-r,07. With respectto the incidentsrecordedon 8 October2008 and 16
March2009,ANSTO,accordingto the materialprovided, did not
imposeon Mr Reidany recognised sanctionin the Agreement.

to Dr Pater son,l
addr essed
1 0 8 . On 2 5 Ju n e2 0 1 0 ,i n a memor andum
-I--,ANSTOII,
submitted thataT

David Reid has a history of behaviourover many years that has not
been addressed. ANSfO I am surprised
at the tevetof tolerancedemonstratedby the organisation,towards
an individualwho appears to have repeatedlybehaved in a way
that woutdbe viewedas unacceptablein mostorganisafions.There
are a number of file notes reflecting threateningand physical
behaviourthat is not appropriatein the workplace.As a result I
woutdbe fundamentallyopposedto him returningto the production
area of Building23.

109. Whilstit cannot be disputedthat Mr Reid has a historyof behaviourthat

appearsinconsistentwith his duty as an employeeof ANSTO, it is
"behaviour
factuallyincorrectforlf to submitthat Mr Reid's
over many years has not been addressed."Indeed,the material

*'
TlreAg'eementstatestwo periodsi.e. l2 months& 2 yeats
ouwith
theexceptionof writtencounselling
" srgnedbylp
titledANSTO Ilealthproductionbehaviourpurportedly
Seemenlorandum
;D

C o r r c a r e R e p o r to f I n v e s t r g a t r o4n2 , 1 5 A N S ' f O 25
ReleascdUn(cr FOI
 providedby ANSTOclearlynegatesthissubmission, and in any case,
the decisionto (or notto) imposeany action(or sanction) in respectof
the incidents recordedagainstMr ReidbetweenDecember1994and
16 March2009,was clearlyof a subjective natureundertaken by the
relevantdecisionmakerat thattimeof eachincident.Of course.it
goeswithoutsayingthatIII hasthe benefitof hindsight at
h i sd i sp o sai n
l a sse ssing
M r Reid' santecedent behaviourquite, unlike
the decisionmakerwho,at thattime,hadto giveconsiderationsas to
the natureand levelof the behaviour alleged,naturaljustice,
procedural fairnessand deterrence to otherswhenconsidering the
appropriate actionto imposeon Mr Reid.

110. IIf alsosubmitsthatANSTOare in possession of a number

of filenotesin respectof Mr Reid'sbehaviour.The materialprovided
by ANSTOhighlights three(3) particular incidents(Dec'94 - April'03)
where,in accordance withthe Agreement, a filenotewouldhavelikely
b e e np l a ce do n Mr R e i d' sper sonal
file.

111.. In lightof the Agreement, and in additionto the factthatMr Reid's

performance had not beenquestioned by linemanagement withina
-
two yearperiod(betweenDec'94 29 May 2008),ANSTO,in
complying withits own policy,shouldhavedestroyed the filenote(s)as
no furtherbreachof dutyhad beenrecordedagainstMr Reid.

LTz. I am therefore of the viewthat,basedon Mr Reid'santecedent

behaviour providedby ANSTO,Mr Reid'spersonalfileshouldnot have
contained anyfilenote(s)referencing and physical
threatening
behaviour, particularly as it wouldappearevidentthatthisinformation
is, in part,beingreliedon by ANSTOto preventMr Reidfromreturning
to w o rki n b u i l d i n 2
g 3 A Rl.
- section76 of theAct
The Leqislation

113. Section76(1)of the Act prohibitsan employerfrom:

(a) dismissingan employee;or

(b) doingan act that resultsin an employeebeing injuredin his or her

employment;or

(c) prejudicially
alteringthe employee'sposition(whetherby the deduction
or withholdingof remunerationor by any other means);or

(d) threateningto take such action referredto in (a), (b) or (c)

becausethe employee:

'8
I n c l u d i n gb u t n o t l i n r i t e dt o t h o s ef a c t o r sf b l l o w r n g

C o r n c a r-c I l e p o r to l ' l n v e s t i g a t i o4n2 4 5- A N S T O

26
Released
U n d e rF O I
 (e) complained
aboutan OHSissue:or

(0 assisVed
in an OHSinvestiqation

114. In my view,the conductof ANSTOsatisfiesthe termsof section76(1)

(b) and (c) as suspension
and investigation different
constitutes
treatment whichis prejudicial.

1L5. Althoughsubsection 76(f)is probablylimitedto assistance the

employeeprovidedto an investigation conductedunderthe OHSAct,
su b se cti o(e
n )w o u l dl i k elyincludealmostanyengagement an
employeehaswithan externalsourcein a genuineattemptto air OHS
matters.In the presentcircumstances, it wouldincludenotjust Mr
Reid'sdealingswithComcare,but may extendto his engagement with
ARPANSA,ANSTOmanagement and potentiallyothersources.
Accordingly, Mr Reid'sconductsatisfiesthe termsof section76(1Xe).

11.6. As such,if ANSTOsubjected Mr Reidto prejudicial

treatmentbecause
he madecomplaintsto ANSTO,ARPANSA,etcetera, thenANSTOwill
havebreacheds 76 of the Act.

ANALYSIS

1L7. In suspendingMr Reid,ANSTOrelieduponthe ANSTOCodeof

(Breachof
(the Code)(clauses3 and 450;,the Agreement
Ethicsae
Employees Dutyclause7.3)and the ANSTOPrevention and
Management of Workplace
Harassment.5l

118. As partof a section43 notice,ANSTOprovidedto Comcarea

documenttitled'DavidReidallegations - recordof meetingdated18
the cir cum stances
Ju n e2 0 0 9 'w h i chi d e n tifies in
andconsider ations
whichANSTOsuspended Mr Reidfromduty. The document, under
the headingof Recordstates,interalia, that:52
"brushed"aqainst
Mr Reid stated that he had
that was all. lt was a non event and there were plenty of people
around [i.e. Allegation 4].

Mr Reid sfated that he was unaware of anv other earlier incident

concerning- [i.e. Allegation 2].

Reid wanted it recorded that:

to of behaviourarliculated with theCodehavebeeninfornred,

ANSTO citethat'Valuesandstandards
wlrererelevantto ANSTO,by Sectionsl0 and l3 of the PublicService1ct, 1999'
to Clause4 resembles (irrpart)sectjonsof theAPS Codeof Conduct
t' e a t e dl 2 M a r c h2 0 1 0
S e ei t e m l . l 4 o f A N S T O ss 4 3r e s p o n steo C o m c a r d
sr SeeFile notere conversation rvithMr Reidadvisingof his suspension purportedly authoredbVI
(Lrnsigned) - Appendix20 of ANSTOss43response to Comcare dated I 2 Malch 20l0
I

C o n r c a r -e I l e p o r to f I n v e s t i g a t r o4t2t 4 5- A N S ' f O 21
Releasedljnder FOI
 i. He believed the action was vindictive on the paft of
managementbecausehe raisedsafetyconcerns

ii. He believed that ANSIO's action amounted to hindering

OH&SRepresentative whichwas contraryto the Act.

Daviesssindicatedthat in the face of the allegations,togetherwith

anotherrecentcomplaintby a superuisorabout harassmentand an
incident report regardingRerd'sbehaviourin the medical centre,
there was a concern from management'sperspectivethat Reid
should be suspended on pay while the issues could be
investigated.

Mr Davies statedthaf ANSfO was exercisingits duty of care to its

emptoyeesand that David enjoyedthe presumptionof innocence
whilethe investigationwas underway.

119. The Agreement,at clause7.3 statesthat:

The procedures outlined in this clause apply to all ANSTO

employeeswho actin a mannerwhichr'srnconsisfent with theirduty
as an emptoyeeof ANSIO and provide for natural iustice and
proceduralfairness.

120. The Agreement,at clause 7.3.2states,inter alia, that:

Where an incident adses or information is received regarding an

alleged breach of duty, the supervisor or nominated manager shall
carry out a preliminary investigation and raise the matter with the
employee who will be given an oppoftunity to give his or her version
of the events.

T h eAl l e q a ti o n s

12L. Thereis someevidencewhichsuggeststhat Mr Reidwas informed of

th eA l l e g a ti o nwsh i chl e dto hissuspension ( i.e.Allegations
4 &2) on
18 June2009.54However,he was not providedwiththe specificdetail
of thoseallegations, or a furthertwo (2) allegations, namelyAllegations
1 & 3, untilANSTO'sengagem_ent ofll whichproceeded his
su so e n si oonn 1 8 Ju n e2009.' "

ttE,
,FIII'ANSro
-5 4 ^
see loomote )l
55SeeExecutiveSummary(undated,unsigned thedocument
andno authoridentifiedbut it is assumed
is autholedbyllll) - AppendixI of ANSTOss43response to Comcaredatedl2 March2010

C o r n c a r -e R e p o r o n 2 4 5- A N S T O
t f I l v e s t i g a t i o4 28
ReleasedUnder FOI
122. lt is alsoapparentthat Mr Reidwas not providedwith an opportunity
to
properlyrespondand put his caseforurrardpriorto ANSTO'sdecisionto
suspendhim. ANSTOsubmit that:56

The processunder the enterpriseagreementis that if an incident

arlses or informationis receivedregardingan alleged breach of
duty,a preliminaryinvestigationis carriedout and the matteris then
raisedwith the employeewho will be given an opportunityto give
their versionof events."'

ANSIO Legal Counselengagedan externallawyer,lf, to

underlakea fact finding investigationinto these allegations...The
repoftprepared byJJ)was forwardedto Mr Reid on 14 July
2009 giving him an opporiunity to put forward his version of
evenfs.ss

12g.on21Ju|y2009,MrReidrespondedtoEJreportinwhichhe
states,inter alia, that:

Il|l has claims[sic] to make findingsof fact againstme, yet

t have not been interviewedby her. Neitherhave I been requested
to attendan interview. Thus,I believethe reporl fails to upholdthe
principles of natural justice required by the ANSIO Cerlified
Agreement.

124. Containedwithin-"Executive Summary"(undated)it is

"ln with Human Resources practice and
stated that, accordance
procedure instructionswere given that Mr Reid was not to be
"
interuiewedas parl of the fact findinginvestigation. Similardialogueis
"Summary Evidence." Indeed,in her
also containedin IIf of
"Final "lnstructionswere received
Addendum"II:l states thal,
from ANSTO on 10 September 2009 to conduct an interuiew with Mr
David Reid to obtain his response to the four allegations contained in
the Fact Finding lnvestigation Report dated 9 July 2009."
'1.25.
To clarifyfflf instructions(which tend to provide the basis as
to the reason Mr Reid was not interviewed)| asked ANSTO, as part of
"provide
a section 43 notice, to the HR practice and procedure that I
If refers to and secondly, who instructed Mr Reid not to be
"grounds"
interviewedand upon what was that decisionmade?'6e

126. In responseto that notice,ANSTO submittedthat:

5" to ComcaredatedI 2 July20 l0 para2 & 3 at pageI 9

SeeANSTOss43response
tt In my view,thecontextof clausel.3.2ts suchthatan investigation
concemtngabreachis conducted
prior to thematterbeingraisedwith the employee
" N c a r l yI m o n t ha l t e rh i ss u s p e n s i o n
'.,Source:Enrai|titled.Addendumtos43'frornNotleytoFandedated22
. l u n e2 0 10

Corncare n 2 , 1-5 A N S ' l O

- R e p o no f ' l n v e s t i g a t i o. 1
29
ReleasedUnder FOI
 At no time dld ANSIO provide any instructionto fI not to
interviewMr Reid,as the Breachof Dutyprocessclearlysfafesfhaf
after the preliminary investigation the employee is given the
oppoftunityto give his versionof events. Mr Reidwas given many
opporlunitiesto give his versionof events,but refused to until he
was finallyinteruiewedbVQ on 16 September2009.

127. With respect,ANSTO's responseis factuallyincorrect. Clause 7.3.2of

the Agreementto which ANSTO refersdoes not state (eitherdirectlyor
indirectly)that an employeebe given the opportunityto give his version
of eventsafterthe preliminaryinvestigation.

128. lt is also incorrectfor ANSTO to state that Mr Reid "refused"to give his
versionof eventsuntil interviewedbyll as Mr Reid provided
If with a responseto all the Allegationson 21July 2009.60
Indeed,as part of that response,Mr Reid statesthat, inter alia:

The repoft includingattacheddocumentation, is hundredsof pages

long...TheOrgansiationhas grantedme, the individualwith scarce
resources,five working days with which to sought [sic] through the
hundredsof pages of materialand provide a response...Assuch,
this letter provides a summary response. I can provide a
comprehenslveresponse fo all the material at a later date if
required.

L29. On 11 August 2010, I spoke tollf concerningher instructions

from ANSTO that are containedwithinboth the "ExecutiveSummary"
"Summary
and of Evidence."Ifl statedthat:
"Well I
can tell you that I was definitelygiven instructionsnot to
interviewMr Reid at that time. Theysaid it was in line with human
resourcepractice and procedure or somethinglike that." I said,
"Canyou
recall who gave you thoseinstructions?"She sard,'Oh, I
can'treallyremember,but I assumeit waslFff" I said,
"ls it
the casethat you didn'tinterviewMr Reid until instructedto do
so by on the 10 September(referringto the "Final
Addendum dated 22/9/2009)?" She sard, "Yes, yes that was
correct, because at that stage I was at a distinct disadvantage
because Mr Reid had been given the interviewsI had conducted
withotherpeople."

130.Whatmustbea|soborneinmindisthatnstatedthatMrReid
'presumption
would enjoy the of innocence while the investigation was
underway."

60
Whether Mr Reid's responseto ANSTO was deernedunsatisfactoryin some way or another is
irrelevant,the fact is that he did provide a responsethat containeddenials,partial admissionsand
infotrnattonthat ANSTO had prior l<nowledgeof', and could have acted upon, prior to his suspension

- R c p o r to f l n v e s t r s a t i o4n2 , 1 5
Conrcare - ANSTO
Released
,"0.i9o,
i.31. On 29 July2009,I1responded to Mr Reid'sresponseof 21 July
2009. In addressing Mr Reid'sresponseto Allegations 4 & 2,1-
"Your responseis to simplydenythat this
submittedthat,inter alia,
incidentoccurred. You have providedno evidencewhatsoeverto
supportyour versionof events."ln addressing Allegation3'Il
"You havenot providedany evidenceto
submittedthat,inter alia,
supportyour respor?se." ln addressingAllegation1, It
"...youhavenot providedany evidenceto
submittedthat,inter alia,
" "Summaryof
supportyour statement- iustallegations. Indeed,in her
Evidence" addressing the evidenceconcerning Allegation 1,I
"Unless Mr Reidcan produce solid
flsubmitted that,inter alia,
evidenceto justify that it was a reasonably held beliefat the time that
he madethe statement, thenhe hasmadea falseaccusationabout]
tll"
"presumptionof innocence" is in factnota truepresumption
1gZ. The term
"burdenof proof."Whilst
at all. Rather,whatexistsis the conceptof
the standardof prooflaidout in Brigginshaw v Brigginshawo'is a less
stringentstandardto thatimposedin a criminalmatter,I do not believe
that ANSTOwas in possessionof adequateevidencefor the
prosecutorialburdento havebeendischarged duringany stageof the
investigativephase.

133. that
It is alsonoteworthv

L34.

tn the'Addendumto FactFindinglnvestigationRepoftinto conduct

of David Reid,'

" ' ( 1 9 3 8 6) 0 C L R 3 3 6( H C A )

C o r n c a r -e R e p o r ro t ' l r r v c s t i g a t r o4n2 4 5- A N S T O
a 1
J I
Released Under FOI
 |-

II

It fabricatedthe incidentand that he had a motivefor doing

was made in an effortto discreditmy
so...l believehis allegation
legitimateallegationsagainsthim."

135. ANSTO, in responseto the request,essentiallyreiterateIf

commentary(as statedabove). However,ANSTO also statethat:

tn October2009,AfterI had completedand repoftedon

her investigation, -f2 requested that additional
investigationsbe underTakenby ANSTO into several matters
between personnel in ARl. e from ProActive
Reso/utionswas engagedby ANSTOto investigafefhesematters.

136. I note that the ProActiveResolutionsReport, as part of its

"We
recommendationsStatesthat, recommend the investigationinto
"We recommend the
fhe issues raised byZlllbe closed" and
investigationinto fhe lssuesraisedagainst be closed." lt
is not knownwhetherthe recommendations referto one andthe Same
investigationhowever,theydo suggestthatan investigation was on
foot in respectof mattersconcerningIf and Il. lf that is
in factthe case,Comcareis not awareof any conclusions and/or
findingsthatresultedfromthe conductof the investigations.

Corlcare - ANSl-O
Ilepotl of Investtgation'12'15 32
Released
U n d e rF O I
T37. Whatcannotbe disputedis thatANSTO,uponreceiptof Allegations 4
& 2, immediately
suspended Mr Reidfromdutyin the absenceof any
independentor corroborative evidence(orwitnesses) to attestto the
factscomplainedof byl. lt is of further thatlf
interest
was notsuspended (or in factthe subjectof a rigorousindependent
giventhatthe natureof the allegations
investigation) againsthimand
in whichtheyoccurred63
the circumstances similarto
are extraordinarily
thosewhichsaw Mr Reidsuspended.

138. -

139. For the record,Comcarehas not receivedany advicefromANSTO

whichsuggeststhatANSTOdispute(or indeedagreeto) the contents
ofl) concerning
formalcomplaint -

140. Withrespectto Allegation 1,utin my viewIl conclusions are

somewhatunsatisfactory. f findsthat Mr Reid'saccusationthatl
"falseand
I toldstaffnotto completecertainincidentreportswas
had no validbasis."However,S rationaleis confusing;f states
when they are not,citesno
that certainstatementsare inconsistent
evidencefromlI concedesthat Mr Reidwas simplyanswering
the ARPANSAInspector's questions,andfinallyconcludes that

Mr Reid is a safety representative with responsibflityfor raising

safety rssaes and that responsibility is not being questioned,
however,the appropriafeness of making this allegation(regardless
of whetheror not it was correct)in that manner and in that forum
must be questioned.
'1.41..
On 17 June 2009 (1 day priorto Mr Reid'ssuspension)Mr Sarkar,
'I statedthat his
during his inspectionof ARI reportsthat,
supervisor,-ff , instructed him not to fill in an event form

ot
i.e. no independentwitness(es)to the incident and having to prefer one persollstestimonyto that of
another
6a and addressedto
See Formal Complaint againstRamez Helou purportedly authoredbV El
I|If'dated 14 JulY2009
d n i i e g u t i o rtr( n o t w i t h s t a n d r n g t h a t i t i s d e v o i d o f t h e d a t e a n d t h e p a r l i c u l a r s u b s t a n c e t h e s u b j e c t o f
t h e , , s p i l l "a) p p e a rtso r e l a t et o I - 1 2 3( l o d i n e- 1 2 3 )h o w e v e rt,h ee v i d e n c(et . e .t h et e s t i m o noyf t h o s e
" s p i l l " i s b e i n gr e f e r r e tdo i n a l l e g i n g
t h a tM r R e i d
i n t e r v i e w e dr s) e q u i v o c aal st o w h a tp a r l i c u l al r- 1 2 3
nradea falseaccusatiort

t 1 ' l l . r v e s t i g a t 'i1o2n' 1-5 A N S T o

Corncarc Reporo 3
Releasedt J n d e i
 In a section43 notice
in the cellface."66
and to assisfother operators
to ANSTOquestioning whethertheyhadany intention Mr
to interview
Sarkarto confirmthe statement allegedlymadeby IIl, ANSTO
"ANSfO Mr Sarkarof
submittedthat, doesnot intendinteruiewing
ARPANSA. ''

L42. On 24 June2009,I1 repeatedhis allegation

concerning
I
If in a protective meeting
disclosure with Mr Reid,IIf and
otherANSTOpersonnel.

143. - was interviewed by Ms Neilsonon 20 August2009however,

it is evidentthathis allegedconversation withMr Sarkarandlll
w a ssi mp l yn o tra i se d .

A R P A N S AIn sp e cti oRne p o rt- 17June2009

of ARI reports
L44. Alsoon 17 June2009,Mr Sarkar,duringhis inspection
that:

|f|, unpromptedby any questionform ARPANSAfold us

about the ANSfO employmentbackground of Mr Reid. I
remarks includedwordsto the effect that:''

. He had left ARIfor HIFAR.had beenturneddownfor OPALand

"was only allowed back to ARI because he produced a letter
provide to him at the time of the HIFARtransferto say he could
"
return.

. "troubled"and that
The employmenthistoryof Mr Reid had been
ARI had only acceptedhim back becauseof the commitment
previouslymadein the letter.

. I appearedto be inftuencedby Mr Reid.

L45. Consideringthe commentaryof Mr Sarkar,in my view it would have

been reasonableforff to exploreany perceptionof bias that
IIf may have held againstMr Reid, and in that regard,both
Mr S a rka ra n d should have been interviewed.

qualifications
Investiqator

146. ANSTO,as partof a section43 noticewere requestedto provide

A descriptionof the relationshipbetweenANSIO and JZ

II inctudinga brief descriptionof the work or busrness/l
If has conducted for ANSro both before and since the

"" SeeARPANSA Inspection Reportdatedl7 .lune2009para24 arpage6

6 7S e eA R P A N S AI n s p e c t i oRn e p o rdl a t e dl 7 J u n e2 0 0 9u h d e rt h eh e a d i n g ' E n t rM
y e e t i n ga' t p a g c3

C o n r c a r -e R c p o r to 1 ' l n v e s t r g a l i 4
o2n45 - ANSl-O 34
Releasedljnder FOI
 incident.Also,an explanationas to why - was selectedto
conduct the investigationinto Mr Reid, including a copy of any
relevant quatifications
IlIl holds(for example,qualifications
approved by the Australian Public Secfor Commission; see

that:
1,47. ln responseto the notice,ANSTOsubmitted

The investigationinto the attegationsmade against Mr Reidis the

firstwork conductedbV 7) for ANSTO.Fff did not
performany work for ANSTObefore the investigation and has not
been involved in any investigationsince. III was
approachedby ANSTO'sLegal Counsel, to
conductthe investigationon an urgent basisfollowingthe incident
on 18 June 2009. II was se/ecfed based upon
and availability.
experience,abitity,qualifications

t48.
. lt wouldappearthate holdsno formal
qualifications,6s
investigative workplace
norhas a historyof conducting
untilFebruary2009withf resumeidentifying
investigations I role
a s:

:.L49.The evidentiarymaterialon whichIII} with

relied(i.e.interviews
ANSTOpersonnel) is explicitlydevoidof any recognised interviewing
technique whichone wouldexpectto see from a competent and
experienced investigator. the interviews
Critically, do not identifyhow'
and in whatcontext,responses weregiven. Rather,the interviews
"thirdperson"whichlackany probative
consistof statements in the
and/orfactual content.

1.50.{Fr,toasignificanteXtent,a|sore|iesonthehearsayand
somewhatprejudicial testimonyof thoseinterviewed'In simpleterms,
as to the valuethatis placedon the
thereis a lackof consideration
of the evidence,
reliability of the individual
andon the credibility
interviewed.

151. In additionto the above,I alsofindthe belowfactorssomewhat

tro u b l i n g :

,'s o1'theContmercial
Such as a Master Licence or OperatorsLicence accordingto the provisiorrs
Agents & Prit,ate Inqtiry Agents (CAPI) Act 2001 (NSW)

1 2 4 5- A N S T C )
r f l n v e s t i g a t i o' n
C o r r c a r e- R e p o r o Relcased
unoJior
 o the fact thatII relieduponthe contentsof an interview
conductedwith -
"nevereven seen
-f ARl, when had
if'$e1i.e.the interview]a n d ;

. relyingon an incidentthatoccurredwithMr Reid"/f in the medical

centreon 29 May 2008. f| statesthat, doesnot
formpaft of the investigationattegationsbut is background
informationand indicatesprior aggressivebehaviouron the paft
of Mr Reid.'no

152. Withrespect,I prioraggressive

indicates on the
behaviour
"Whetheror not|
partofli however,If statesthat,
Ir hasengagedin similarconductls nof withinthe scopeof this
investigation."Tl

L53. Whilstthatis the positionthatll and/orANSTOadopted,it is

clearthatIl allegations werenot consideredas "background
information" despitethe contention thatbothMr ReidandI
sta te th a tt..fa b ri ca ted' ' iSSUeSor incidentsinthewor kp|ace
andfurther,thatthe allegations behaviour
allegeprioraggressive on
the partofll.

FINDINGS

LS4. ANSTOcontendthatits conductis consistent with its disciplinary

policiesand procedures.In my view,ANSTOthereforehad an
obligation elementsof the code (and
to identifythe particular
Agreement) thatANSTOconsidered Mr Reidhad allegedlybreached'
priorto imposingany disciplinary actionuponhim. on the material
beforeme,thereis no evidencethatsupportsANSTOin having
undertaken thistask. Indeed,it appearsthatbreachesof the Code(or
Agreement)werenotidentifiedunti|-providedANSTowith
"Executive Summary."To thatend,giventhe factthatAllegations 4
I
& 2 wereultimately foundto be unsubstantiated, Mr Reid'ssuspension
is somewhatextremeand therefore to the natureof
disproportionate
any breachallegedbYANSTO.

1S5. lt cannotbe disputedthat Mr Reidhad no priorknowledgeof Allegation

2 despitethe factthatFllhad madea contemporane_o^us
comptaint On the
to ANSTOHR at the timeof the allegedincident.T2

69SeeSuppleIrrentarylnforrnation--InterviewSummarycontainedwithintheSummar.yof
E,vidence at page23
to lbid - n4r.n.i"a'. previousconductcontained at pages23 &24
within Summaryof Ev.idence
t' Which I do not acceptbecauselll arebothrelevantandprobativeto Allegatrons
allegations
4 & 2, notu,ithstanding the fact thatthoseAllegationshavebeenfoundunsubstantrated
72SeeFile Notedared26 May 2009(unsignedjpurportedly uvll
authored andcompiled
fi'oma phonecall receivedftomlll

- Reporo
Courcare t f I n v e s t i g a t i o4n2 4 5 A N S T o Released
un,r.ifor
 materialbeforeme, thereis no evidencethatindicates thatANSTOhad
raisedthe complaint with Mr Reiduntilthe day of his suspension(24
daysafterthe initialcomplaint).lt is alsoevidentthroughthe provision
of emailsfromANSTO,that-
ANSTO,-f and ARI management certainevidentia{
clarified
issueswithrespectto the Allegation on 27 May and 15 June2009(22
daysand 3 daysrespectively priorto Mr Reid'ssuspension) whenI
|Il confirmedthat therewere no witnessesto the Allegation.T3

156. ln additionto Allegation4 & 2, ANSTOalsorelyupon"anotherrecent

complaintby a supervisoraboutharassmenf" (assumedto be
Allegation3) and an "incident
reportregardingReid'sbehaviourin the
medicalcentre"(thisincidentdoesnotformpartof the Allegations) in
su sp e n d i nMr
g Reid.

L57. Of course,ANSTOconsidered the allegationsagainstMr Reidto be

serioushowever,the evidence,Ta giventheformand contextin whichit
is presented, is unequivocally
deficientin identifying
whetheror not Mr
Reidwas providedwithfulldisclosure of all mattersallegedas grounds
fo r h i ssu sp e n si o n .

1"58. Criticalto clause7.3 of the Agreementis "procedural fairness."lf

ANSTOhadfairlyand fullyinformedMr Reidof all matterssubjectof
his immediate suspension (in particular 2), thenit is
Allegation
assumedthathe wouldhavehad an appreciation of the substance of
the Allegations and,in my viewmoreimportantly, had a reasonable
opportunity to respondin whichhe couldhavedeniedor rebuttedthe
allegations; putforwardany evidencein hisfavour;properlyexplained
the allegations or presentedan innocentexplanation and;providedany
mitigating circumstance(s) priorto ANSTOtakingthe disciplinary action
thatit embarkeduponin the absenceand consideration of the full
factualcircumstances and meritof eachAllegation.

159. Thataside,the opportunity to provideMr Reidwitha reasonable

opportunity to respondto the allegations neededto be balanced
againstthe seriousness in whichANSTOviewedhis allegedconduct.
Of course,as mentionedpreviously, Mr Reidwas not givena
reasonable opportunity to respondto theAllegationspriorto his
suspension rather,he was affordedfive(5)daysto respondone month
a fte rh i ssu sp e n si o n .T5

"
S e ee m a i lf i - o m I t o t l l a t 2 . 5 7 p mo n l 5 J u n e2 0 0 9
7aFile notele conversation with Mr Reidadvisingof his suspension purporledlyar-rthored
byl
lf (unsigned) - Appendrx20 of ANSTOss43response to ComcaredatedI 2 March2010& letters
addressed to DavidReiddatedl8 & 19 June2009purporledlysignedbyIIf
II ANSTO
"
l n h r sr e p o n sdea t e d2 1 J u i y2 0 0 9

C l o r n c a r-e R e p o r to f I r r v c s t i g a t r o4n2 4 5 A N S ' l ' O

Released
unoerl6t
C O N C L U S ION S

L60. On the materialbeforeme, lfind that:

(a) ANSfO hasdonean act thatresultedin Mr Reidbeinginjuredin

and
h i se mp l o yme nt;

(b) alteredMr Reid'sposition;

ANSTOprejudicially and

(c) Mr Reidcomplained the healthand

abouta matterconcerning
safetyof ANSTOemployeesat work.

L6']-,. However,as notedabovethosefindingswill onlyamountto a breachof

section76 if I furtherfindthatANSTOperpetrated the act whichinjured
Mr Reid'semployment or prejudicially his
altered position becauseMr
Reidcomplained aboutOHS matters.
-t62.
On the evidencebeforeme, it wouldappearthatMr Reidwas
substantially deniedprocedural thatanotheremployee
fairness;
accusedof similarconduct was subjectto quitedifferent
treatment; thatthe investigator qualifiedand
was not appropriately
overemphasised certain evidential materialwhileunderemphasisi ng
others.Giventhe multipleinadequacies in the processwhich resulted
I havegr aveconcer ns
i n Mr R e i d 'ssu sp e n si on, aboutthe m annerin
whichANSTOconductedit and can not closemy mindto the possibility
thatANSTOand otherrelevantpartieswerebiasedtowardsMr Reid.
't63. Nevertheless, reconsideration
a substantive of thosefindingsis beyond
and
the scopeof my investigation my statutoryfunction.More
thosegraveconcernsnotwithstanding,
significantly, thereis insufficient
evidencefor me to concludethatMr Reidwas suspended for
complainingaboutOHS mattersat ANSTO.

L64. As such,all of the concernsI expressed abovenotwithstanding, a

conclusion that ANSTO breached 76
section of the Act wouldbe
unsubstantiated withoutmore. Althoughon occasions'circumstantial'
evidencemay suffice,in thisinstancea conclusion of breachwouldbe
merelyspeculative. I takethisviewdespitethe factthatclause2(2)of
the Act reversesthe onusof provingcausation in civilproceedings.

C L A I M S O F B U L L Y I N GA N D H A R A S S M E N T

BACKGROUND

16s. on 14April2009,IIIID I,{III

, ANSTO,
an emailto Comcare'sClaimsHelpDeskseekinga
fonruarded
"responsein writing...inrelationto the statements
madeby Mr Dave

- R e p o n0 1 ' l n v e s t r g a t r4o2n4 5- A N S f O
Corncare
Released
uno.,J$l
 Reidin relationfo his craim,the peak Heatthprogramaf ANSro, his
Returnto work plan and the advicegiven to him by comcare.,r6
'l'66.
on 17 April2009,shereeTottenham(Ms Tottenham),TeamLeader,
claimsServicesBranch,comcare,responded to I emailin
whichshe stated,interalia:

[you] wereadvisedthat it was not appropriatefo use the RTWpto

compel a claimant to parTicipate in an in-house preventative
exercise program.

.-.Comcare's posrtion is that the RTWP plan should not inctude the
Peak Health program but simpty reflect the agreed work hours and
conditions, that is, having regard to the medical evidence from the
treating practitioner and rehabilitation advice. 77

167. On 4 May2009,following a meetingwithMr Reid,Ts-

fonrrardedan emailto Mr Reidin whichshe confirmed theirdiscussions
and the agreedoutcomesof thatmeeting.In particular, it was agreed
that Mr Reid,interaria,would"adhereto his rosteredhoursand workin
accordancewith the secondReturn To work program excluding
attendanceat Peak Healthuntil resultsfrom the medicalexamination
are received."Duringthe meeting,Mr Reidclaimedthathe had been
bulliedand harassed[in the workplace].Ilf notedthat,
"should
Davidhave a complaint,he shouldadviseHR in writingso that
thismattermay be propertyinvestigated...and includealt details.dares
and relevantinformation...'re
168. on 20 May 2009,Mr Reidfonrrrarded an emailtoII in which
h e d e ta i l e d
h i scl a i mso f builying
and har assm ent.ln the main,M r
Reid'scomplaint detailshisdissatisfaction of havingto participate
in
the PeakHealthProgramwhirstsuffering froma workrelatedinjury.
L69. on24 June2009,(6 daysfoilowinghis suspension) Mr Reidattended
ameetingwithQ(andfiveotherANSTomanagement
personnelincludingll) wherehis claimsof bullyingand
harassment (anddisclosureof safetycover-ups
at ARI)werediscussed
and electronically
recordedunderthe premiseof the ANSTo
Whistleblowerpolicy.

170. on 29 July2009,Iwrote to Mr Reidand statedthat

On 24 June 200g you were provided, at your request, with an
oppoftunity to meet with a member of the ANSro Executive to

'"
S e ee m a i lt i t l e dM r D a v eR e i dC l a i mN o : 6 7 l 5 g l g
/7
S e ee n r a itl i t i e dC M c A C T I O N E DA N S T Oc n 6 7 1 5 g / g
tt In
conrpanywrth ARI personnel
f') ^
Sce emarl tttlcd Meeting With David REID and sent to thosepersonsmentioned
at footnote 7g

C o r n c a r e R e p o r to f I n v e s t i g a t r o,n1 2 4 5
- ANSTO
39
I{eleasedUnder FOI
 outline your concerns regarding safety lssues within ANSro
Health. Thismeetingwas convenedafteryou hadmade a seriesof
allegationsabout safetyissues. You wittrecallthat you were asked
to providedocumentsor detailsregarding/hoseissues. prior to the
meeting,you wereadvisedthat the meetingwoutdbe tapedso that,
in the absence of documentation,you courd provide a verbal
account of the issues. you and your representative, f-
agreed that the transcriptof the meeting would then be signedoff
by yourserf and I as a true record of the meeting.
Notwithstandingthat agreement,at the end of the meeting you
changed your position and indicated you wourd not sign the
transcript. For the record, you provided no evidence or
documentationat the meetingfor Managementto act on. Rather.
you madea seriesof unsubstantiated altegations.
rrL. lf f is suggestingthat Mr Reid provided *no evidenceor
documentation" for management to act on becausehe failedto signthe
transcript,then it is procedura[yunfairand withoutfoundation.ln his
disclosure, Mr Reidprovidesincidentdetailsand namesof witnesses
thatwouldhaveallowedANSTo to conducta preliminary investigation
ofthec|aimswhichhehadmadeon24June2009.lndeed,_
view of Mr Reid'sevidenceseemsto differsomewhatfromthatof
I
-
If who states,interaliaat the conclusion
of the interview:
Alright, that'sgood that gives us enoughinformationto move
on...So the processis thatwe wittdo someinvestigation
of thisand
producea reporTwhichwiil go to you for comment. we can give
you a transcript
of what'son tapeif you'dlikethat.
T72. rr alsodiscrosed in Jresponse that,despitethe advicefrom
comcareconcerning the peak Healthprograms'and despitethe
advicefromQtoMrReid,81MrReid'sreturntoworkwou|d
be facilitated
if a numberof termsweremet,incrudingthe foilowing:
That you formalryagree to fuily participatein the peak Heatth
Programin your work area inctuding(sic) and furty pafticipate
with
AIr/SIO's casemanagersin relationto your workers compensation
claim(s)and any return to work program.

173. On 7 September
2009,If wroteto Mr Reidadvisinghimof the
findingsofaninterna|investigationconductedov*l

to
At para 166 of the Report
o'At
p a r a1 6 7o f t h e R e p o l t

C o r r c a r c- I l c p o r to f l n v e s t i g a t i o4r r2 4 5 A N S I - ( )
40
R e l e a s e dt J n i l F r F O I
 --, ANSTO,intothe claimsmadeby Mr
Reidon 24 June2009.82

L74. The reportbVlonly addresses the "coverup" of alleged

safetyincidentsallegedby Mr Reid[f], and doesnot
discloseany reference to Mr Reid'sallegationsconcerning hisclaims
(includingthosepersonsandwitnessesidentified) relativeto the Peak
HealthProgramor any bullyingand harassment claimsthathe was
allegedlysubjected to. Thiscontention appearsto be supported by Dr
Patersonwho, in his acceptance of the reportstatesthat, "Separafe
investigationshave come to the same conclusion.Executivewill
reviewthe processalreadyinitiatedto improveincidentrepofting."

175. On the materialavailable,

bothIland Mr Patersonare clearly
referring previously
to the investigations conductedbyf
andIr.
L76. In short,on the materialavailable
beforeme, I am of the viewthatMr
Reid'sallegationsof bullyingand harassment havenot been
investigated by ANSTO.

ANALYSIS

L77. Section16(1) of the Act requiresemployers to takeall reasonably

practicablestepsto protect the healthand safetyof its employeesat
work.One of the mostbasic(andtherefore, typically,the most
practicable)stepsan employercantakeis to investigate anyalleged
risksto healthor safety,determine whetherthe riskis realand its
extent,and what,(if any)stepsmustthenbe takento minimiseit.

178. Furthermore, just as an employerwouldbeara dutyundersection

16(1) of the Act to seriously considerand investigate
risksof
physioloqical harmand injury,in my viewit is incumbentuponan
employerto investigate risksof psvcholoqicalharm. Indeed,justas
employers shoulddevelopand implement systemsto respondto
physicalrisks,employers shoulddevelopand implement systemsto
respondto psychological risk.

179. lt is generallyacceptedthatbullyingand harassment may cause

emotional or psychologicalharm.As such,employers beara duty
undersection16 of theAct to investigate of bullyingand
allegations
harassment. Indeed,althoughthe extentof thatobligation
maybe
dependantuponthe gravityand veracityof the allegations- evenif the

E2See|etterdated7September2009purpor1edlysignedbyEandaddressedtoDavid
titled 'lnvestigation
Reidin additionto ANSTO Mernorandum Into Disclosure
of'Saf'ety
CoverUp at
ARI' authoredUVIl for theattentionof Dr AdrianPaterson,
CEO ANSTO,dated26 August
2009andpurportedlysrgnedby[J

C o r n c a r e R e p o r to 1 ' l n v e s t i g a t i o
4n2 4 5- A N S T o
Released
ufifrJrPor
 allegations
can be characterised as littlemorethangossip,(and
providedtheyare not "far-fetched an employerbearsa duty
or fanciful")
to makeappropriateenquiries. ln my view,thatis a basicsystems
requirement.

1 8 0 . I n o teth a ti n f e ma i toe
l ( andother s) on4 May2009,
notesthat Mr Reid "shouldadviseHR in writingso that this
llff
[bullyingand harassment]mattermay be properlyinvestigated.'1lt
would,therefore, appearthatII recognises the needto
investigate suchallegations.

CONCLUSION

18L. As notedabove,in my viewit was incumbent uponANSTO,under

section16(1)of the Act,to investigateMr Reid'sallegations of bullying
and harassment. I am of the viewthat
lt failedto do so.Accordingly,
ANSTObreachedsection16(1)of theAct in thatit failedto takeall
reasonablypracticable stepsto protectMr Reid'shealthand safetyat
work.
-182. Furthermore,
I alsoconcludethatANSTO,in directingMr Reidto
attendthe PeakHealthProgramagainsthiswill,and contraryto
Comcare's direction,
is itselfa breachof section16 of the Act.

RECOMMENDATIONS

withsection53(2)
183. Baseduponthe evidencebeforeme, and complying
of theAct, I recommend
thatANSTO:

184. Engagea competentpersonto undertake/oversee systematic

monitoring
of all workplaces radiopharmaceutical
thatundertake
operations
to ensureongoingcompliance withthe Act and regulations;

Actionin respectof recommendation

1 shouldinclude,but not
necessarilybe limitedto:

Engagingor directingan appropriately qualifiedperson(s),who

has specialist knowledge of hazardoussubstances and
demonstrated competency in managingrisksassociated with
hazardous substances, to overseean ongoing systemof
auditingto ensurethatradiopharmaceutical maintain
operations
appropriate systemsof workto ensurethe futurehealthand
safetyof radiopharmaceutical employees is appropriately
ma n a o e d .

C o r n c a r -e I l e D o no f l n v e s t r q a t i o4n2 4 5 A N S I - O
42
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U n d e rF O I
185. Provideongoingdocumented evidenceto Comcarethat systemat,'
monitoring
is occurringas outlinedabove.

protocols
186. Audititsconsultative withall personsinvolvedin
radiopharmaceuticaloperations fromtimeto timeto ensureits policre"
and proceduresare effectivelycarriedout by its employeesto ensure
ongoingcompliance with the Act and regulations and ANSTOhealth
and safetyrequirements;

187. Auditits recordkeepingproceduresto ensurethatappropriate

information and retainedin relationto the
is recorded,maintained
healthand safetyof employeesengagedin radiopharmaceutical
operations

188. Ensurethatnotifiable to Comcarein accordance

incidentsare reported
37Aand 378 of the SA Regs.
withsection68 of the Act and regulation

, "/-- .

Scott Notley
S e n i o rI n v e s t i g a t o r
RegionalServiceDelivery- NSW / ACT
Work Health& SafetyGroup
Comcare

f l o r r c a r e R e p o r t o l ' I r r v e s t r g a t r o n 2 1A2N4S5' l o

R r l e a s e dL l n d c rF O I