Memo to W S Parsons, Subject: Ensign Coffin (Commentary on Coffin Letter re Crossroads Practices and Procedures)

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2* 1 iiars gone oror auiadaistntiw aopoets of It vitfa Soar Adsdral Srooa and Captain Bahreao* 3* As to the todmical angle* It cast te rseogaiaed that noch* if indeed not noat of the instrsrtents ttsed in the field sorreTO at Sitein.l» particnlarly the X-263 were experiaental in nature and that fcy foa ci cf neceeeity we were eofi^eiled to ns# experiaantal gear In as Each as there had nerer been previous demand for a field type of instrument* Shore having teen, no prior demand, there had teen no prior development of such an Instxnasnt* and. as a consequence none were comerciaily available and time did not permit the development of instrument# other then the £»«63* The J-263 Is generally pretty satisfactory (1) if there is aa espert dose at hand who cam advise as to ite behavior, (2) in the hands of very experienced individuals {as to use of Instruments)* (3) In presene# of adequate repair facilities, (4) whan backed up by suitable number oi other type instrument a for checking and comparison* end {5) when suitable souxca ia present far purposes of dally or nor# frequent cheek of each instrument as to " . accuracy by calibration in relation to a suitable radioactive scarce* ¥e exe concexn#* that all these were present In adequate degree until. It. GTomdsV' Canard was relieved &t Xwsjalein* Thereafter we do not 4* Characteristics of the instraaents, including shortcomings In. (design difficulties in practical use and maintenance were all taken in r, to account in the establishment of the aafty requirements and in the ^ eondnet of the safety program* This included safety for personnel 5* ’ If the safety precautions prepared by IfaMed are followed out or if the safety precautions required daring the period while Commander Harris and later It. Coadr* Comard were at Xwajalein are adhered to* X BEST AVAILABLE COPY

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personael boarding coataain&ted target vessels vould be subjected to 6. There have been to data no medical observations efaich indicate any Injurious* or suspicious* beta eontasdnatlon in the urine of person nel (subpara 4 of para 2 of Coffin*a letter)* There has been vide scale variation in the background counts* and the situation is one vhich presents serious difficulty in the assessaeat from tills end of the reliability of the personnel doing these counts. While the beta count ing of the urine say not have been absolutely neea^oary* Colonel Warren and X leaned it advisable as a natter of policy* ana to indicate that ve were doing etery thing possible to protect personnel* Beta counting 7. So alpha hazard exists whatsoever if safety precautions pgrepared. by BuMed were observed regardless of absence of adequate detection insteravas for this reason that ve insisted on the gas mask being adjusted whan there v&e any possibility of dust hazard and why ve insisted on no eating et cetera on ships which night favor ingestion of contaa8* A working tolerance level of 0*4 r per day as indicated in his letter (subpara 3 of para 2 vas nerer permitted)* There must be a 9. The consensue of opinion among the best minds in this matter is that no mutations are likely in human beings if the "naxisna permissible dosage of exposure* (& term recognized as superior to* and adopted in the place of ^tolerance*) is not in excess of 0.1 r per day* or any part of one day* and provided the. exposure is not prolongd at this intensity daily for more then two years* This is the Pollard and Davidson and take* this one statement as final* 5b other sources are cited* This mistake is not infrequently made by those who are immature and Inexperienced In the field of technical and scientific 10. If the safety instinct ions Issudd by BuMed were not sent to Lt. Coadr. Canard until Lt. Maurer arrived there* that is an important failure of responsibility from the Bureau level.. There is no justif ication for these not having been sent to Canard promptly. AtCoaKvaj > does not appear on the distribution list* In this I was at fault in that I did not pick up the discrepancy in the distribution prepared by Captain Schneider. On the other hand* safety regulations in practice when Commander Hhrris and/or Lt.Comdr. Canard were at Xvajalein are but little diffsrent from the new regulations* They are no different as BEST AVAILABLE COPY

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_ BEST AVAILABLE COPY,. 11. A difficult sltraation arose In the HATSJT early in Seat Able. Sane of the Xfniverelty of Chicago sclent lata shoving their inexperience in field problems quaationed the adeonacy of the instrunants. They presented an attitude indeed quite like that of Coffin. So answer this and similar' charger, or questions. Colonel barren called a seating of the Hedies tsgal AdTisory Board at Bikini and they prepared the report . X forwarded to you raceally. Such eonditione are not* hoverer* certain, to hare obtained after'Lt. Ccedr. Conard left Xvajalain. This manuscript prepered by this aedlco»legal board will not be applicable if there is cetera) or if there is net adequate technical supervision and conduct of survey by appropriately experienced individuals at the required levels of different responsibilities*- At ns tine has the Atoll Commander appreciated the probias* or supported radiological safety* aa did Aduiral 12. - Bov ve come to cote of the serious matters which is an indicator of the adadniatrative pxoblexa of the futures namely, division of respons ibility and effort between the technical services (BoShlps* Bulled) and • the normal ccsBaad* with ultimate responsibility lyings of course in the -*- v>! latter. If the local coanaader is not certain that reasonable and adeen ',.te technical equipment or personnel are at hand he should take it up with appropriate superior authority and on the local level take such action as ia consistent vlth the demands of the local situation. The administrative as opposed to technical aspects are discussed in part in. the paragraphs which follow. They reflect the thaudits concurred in by Adniral Brava and Captain Behrens as veil. ‘Z 13. BuMed representatives appear to have failed in not getting, safety instructions to At. Coadr. Canard promptly. This should be checked with his. Beyond this*. 2&Med representatives At. Maurer with reasonable promptness began rspertlng Infractions of safety pmctimes. - .La stated previously* these practices were the same in all ess anttel respects as the safety regulations in effect during the period that , Coaaasdmr Barrie was BadSafe and vhsa Lt.Coadr. Conard was BadSafe as they are in the present regulations.. The eaforemsent of such regulations — Is a function of conesad. Han bearding ships without authority* man living In eontamlnatad target vessels (those net having final radio logical dsarasce). nan looting ships and removing materials potentially contaminated with radioactive substances, nen eating on ships* men failing te use protective devices such as gas masks or In accordance rith the safety regulations (always required after 15 August 1946) and - failure to have proper supervision of such men and ships is a failure of primary responsibility command and not staff or technical. Monitors* whether representing BuShipe or Medical BadSafea are staff and technical personnel and not the enforcing agency which is command. BEST AVAILABLE COPY

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letter of 25 Maxell 1947) there I* aa error aa Coamander Harris vae in charge of setting up and super-rising the radiological activities fre® 15 An gnat to 15 October 1946. Lt.Coadr. Conard relieved Concssnder Harris in this duty and carried on until relieved by Lieut. Maurer late ia March 1947. Delay in gettlne Lt. Ifaarer to Strajalein intar— f ered vlth safety prograa in february and March. ' letter of 25 March 1947), the first sentence Indicates that »The practices and procedures developed by this group* all of vhcat have now - been detached have been maintained and rigidlT' carried out*. This is and frequent violations of the basic principles of safety control. Shis has foraed basis of correspondence betveen CinCPac and BuMed. 15. There are certain argensxrts vhich Bnsign Coffin, ai^xt present and vhich would be difficult to effectively counteract. (a) The adaitted lack of sufficiently trained, and therefore - adequately prepared, personnel available to the 7. S. Jfavy for assignnient to this special duty. . (b) The presently recognized failure on the part of nyself and other medical advisors to recosssend a screening of trainees for this duty as to their aptitude for such duty at this, tiae, taking into consideration the powerful psychologic aspects and the realization that probably naay officers who would be effect-' ive under conditions of ordinary weapons find it impossible to react reliably under the stresses of such specialized forns of ulariy in facing the less easy to appreciate hazards of the “unseen* type such as the chenicsl, biological and rrdiologlcal* , This is a natter which I feel certain must receive serious consideration in the future. In tils connection is the opposite situation of the individual like Captain Maxwell who Insists on for the unseen hazard, an attitude and an approach which is contagious to the younger officers and detrimental to the radio logical safety program. \(c)'7he belief on the part of certain of the individuals quite srpsTienead in radiological safety, that officers trained as Bnsiga Coffin was trained (emergency course plus aoderate amount of field experience but not under suitable conditions of field instruction) cannot be employed satisfactorily as radiological safety officers except when under the direct .guidance of properly experienced and mature radiological safety advisers, including BEST AVAILABLE COPY

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acceM to a aedical adrl&or eoqxnrieacad In pro'bleBS of radio vrong, his ca&o points to a weakness in the radiological safety field which snst receire sericma consideration in relation to the selection of* training of* and assignment of officers to radiological safety* Uhtil we are a hit more advanced in our own understanding of theso matt srs* and until tight organization »*'-■** for conduct of radiological safety operations can he effectdd to a higher degree than has been done to date* sach problems are liable to occur very mash sore frequently than they hare ia the past*. An adraaead leral of appreciation of the problems inrolrad. in radiological safety epertttoae will find ths r-biological. safety officers quicker to detect weaknesses ia the technical, . as veil as adaiwistratire coadaet of the safety prograa* Bsdiologicat? safty officers east he instract ed as to heir to legally*. . turn out to be one of the aost difficult pxeblens of the radiological safety proven* Morale can bo lost quickly If confidence in either the technical or ncraai adsdnistratiro reiati onships (d) Hi ere has been observed a frequent but definitely pre dominant* lack of appreciation on the part of the younger officers a*, to the seriousness of .their work and of Its importaace to the Hawy as a whole* Youth end inexperience of responsible officers not only In the technical matters of radiological safety but ia the administrative aspects as veil* have been observed to endanger the radiological safety program and hare caused us real concern*. We had been pleased that until apprcxLa&tely 1 February this had not presented a greater problem* Progressively since that time* ’ ve have been more and more concerned. (e) Regardless of whether instruments were* or were hot, » adequate, there was certainly some breaeh of discipline under of safety practices (apropos of subpara & of para 2 of Coffin's -T (f) Although Colonel tparren, myself end others believed instruments, and instroe station program to have been adequate up til]. the time of Lt* Comdr. Conard* s departure from Xwajalein, there is no assurance that the instruments and instrumentation progam was adequate thereafter* It say have been* (g) The need for calibration of instruments with a "known source" is recognized end the absence of such a source from Kfrajalein has constituted a grave deficiency in the sdSty program BEST AVAILABLE COPY

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of instramaatafcioa vrero having the insrtnnaenta calibrated ade— O'uatelT'* If not» this cosstitntee & serious breach in the technical direction and in the facilities in the instrumentation program. Shis has been a BuShips responsibility for oruite a while previous to the time covered by Snsign Coffin* s letter- of (h) An individaal who has had Snsi^x Coffin's background in this field, who has a certain amount of appreciation but still has not had a broad experience and lacks balance in this particular field is still relatively in the status of aiPindivictnal having- * little knowledge In this field is dangerous and can present snore serisus problems than the person with no knowledge* This is a phenomenon of htraan behavior frequently encountered in the practice of medicine and in dealing with non-nedical people in aedical matters* Such an individual, who has had a' rot-extensive working experience in radiological safety, could bring into the .open msny borderline end controversial issues to sake a "aountnin. out of a mole hill". In controversial matters, half-truths are often as damaging as whole truths because they are so difficult to adequately disprove* Such a person ponld even probably find experts to back up hie points* Such a situation c'uld be very difficult fr:m many angles and should certaihly.be avoided if reasonably possible* (1) It must be recognized that radiological safety in the field is a new technology, rmch of it actually experimental in nature and therefore has not achieved the status of standardized and accepted procedures of safety, including neens of implementing this safety (instrumenta, training, selection of personnel* administrative practices). These are also new and experimental* The personnel difficulties end shortages secundcxy to precipitous demoralization has aggravated the difficulties of radiological safety to the extent that they have unavoidably compromised radiological safety all along the line* (k) Since 1 Jferch. 1S47, radiological safety at Kwajalein has not been maintained in as desirable a manner as it had been prior to that time* We must admit a certain amount of failure*(l) (l) Instruments, experimental in nature as to field application sad use, were employed at Bikini and continue to be used at Xwajalein, 17. I would recommend the following* (a) Consult with Lt. Comdr. Conard in regard to the status at Xwajalein and ia relation to 'Ensign Coffin's letter and action* BEST AVAILABLE COPY

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(!}) Dae to the novel aspects and the nenr problems presented in a new and hazardous technologic field and in view of the nearrightness of so many of Snsign Coffin* s points* I would recommend that he be given a letter of reprimand* or admonition* and that he be given a serious talking to by someone who knows the problem well from the technical and scientific angle* 18* I have commented at length on this matter not to speak in behalf of Snsign Coffin but In an attempt to point out other weaknesses and derelictions of technical and administrative direction which I believe are more important* I believe this situation points the way to problems which most receive serious topside consideration in the future* There are many angles to it, and it represents a * complex* net BEST AVAILABLE COPY