IR 05000155/1987010

Partially Withheld Allegation Review Insp Rept 50-155/87-10 on 870409-0721 (Ref 10CFR73.21).No Violations Noted.Major Areas Inspected:Alleged Sabotage of safety-related Valve & Licensee Failure to Rept Sabotage to Nrc.Weaknesses Noted

ML20238C289
Person / Time
Site:	Big Rock Point File:Consumers Energy icon.png
Issue date:	09/03/1987
From:	Creed J, Guthrie S, Mallett B, Pirtle G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20238C279	List: IR 05000155/1987010 ML20238C278
References
50-155-87-10, NUDOCS 8709100020
Download: ML20238C289 (14)

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U. S. NUCLEAR REGULATORY COMMISSION

REGION III

Report No. 50-155/87010(DRSS)

Docket No. 50-155 License No. DPR-6

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Licensee: Consumers Power Company 212 West Michigan Avenue i Jackson, MI 49201 Facility Name: Big Rock Point Nuclear Power Plaat Inspection At: Big Rock Point Charlevoix, Michigan Inspection Conducted: April 9 through July 21, 1987 onsite and at the HRC Region III Offic Management Meeting Conducted: August 6, 1987 in NRC Region III Office Type of Inspection: Special Allegation Review Date of Previous Security Related inspection: May 26 through June 11, 1987 Inspectors: _ cv% ct 913 lS 7 Gary L. P'irtle Date Physical Security Inspector IS I B'7 d

}o Stephen Guthrie, Senior te Resident Inspector, Big Rock Point Reviewed By: 9M[87

. R. Creed, Chief Date Safeguards Section Approved By: 'nc't/

B, 5. Mallett, Chief h f//[f7 Ddte~

Nuclear Materials Safety and Safeguards Branch Enclosere Contains SAFLGUARDS INTor0%TIOil Upon separation This B709100020 B70904 5 Page is Decontrolled PDR ADOCK 050 G

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. Inspection Summary Inspection on' April 9 through August 6, 1987 (Report No. 50-155/87010(DRSS))

Areas Inspected: Special inspection pertaining to alleged sabotage of a safety-related valve and the licensee'.s' failure to report the sabotage to the:

NRC; alleged falsification of records pertaining to work performed on the valve; and an employee allegedly wrongfully accused of writing threatening graffiti within the plan Result,s: The allegations were not substantiated. However, the inspection concluded that a valve was tampered with. The. tampering did not have the potential. for a " radiological sabotage" event as defined in 10 CFR 73.2(p) and therefore.did not require formal reporting under criteria contained in 10 CFR 73.71(c). The inspection did not disclose evidence of record falsification as alleged. Additionally, the inspection concluded that an identified plant empioyee had written threatening graffiti within the plan Several weaknesses were noted in the licensee's planning and capabilities to .

adequately resolve equipment tampering events. They must be addressed and resolved by the licensee to assure adequate actions are taken for any. future equipment tampering events. Details of the weaknesses are included as an attachment to the inspection report and are considered as Unclassified Safeguards Information until they are corrected, i

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DETAILS

~ Key Persons Contacted

+D. Hoffman,' Plant Superintendent, Consumers Power Company (CPCo)

• Y. Elward, Plant Superintendent, CPCo-

+ Abel, Production and Performance Superintendent, CPCo

+ Trubilowicz, Operations Superintendent, CPCo

• Bordine, Licensing Representative, CPCo

• Alexander, Technical Engineer and NRC Liaison Representative, CPCo

• Cooper, Corporate Security Director, CPCo

+ Kiss, Corporate Property Protection Supervisor, CPCo

• Bradshaw, Site Property Protection Supervisor, CPCo

+ Dugan, Site Property Protection Operations Supervisor, CPCo

+ Kelly, Maintenance Supervisor, CPCo

+ White, Mechanical Maintenance Supervisor, Field Maintenance Services (FMS) - West, CPCo

+ Root, FMS - West Supervisor, CPCo S. Guthrie, Senior Resident Inspector, US NRC, Region III In addition to the key personnel noted above, 13 other personnel were interviewed in person or by telephone during the investigation of the allegations. These personnel included a vendor representative for the valve manufacturer and a representative of the packing gland material vendor; personnel who physically worked en Valve CV4050 between February 6-7, 1987; auxiliary operators who removed and restored the valve to service; shift supervisor who prepared the work request for the valve; Radiation Chemistry personnel; and a Non-Destructive Test (NDT) technician that checked Valve CV 4050. The plus (+) denotes licensee management personnel interviewed in person or by telephone in reference to the allegations. Approximately 27 separate interviews were conducted during the investigatio The asterisk (*) denotes those management personnel present during the Management Meeting conducted on August 6, 198 During the investigation, the Plant Superintendent position was assumed by Mr. T. Elwa- Mr. D. Hoffman was the Plant Superintendent at the time the investigation

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was initiated. Names of personnel identified in the allegations rre not included in the Report Details to protect their rights to personal privac . Entrance and Exit Meeting (MC 30703)

~ On April 21, 1987, the Plant Superintendent was informed of the purpose of the inspection. The specific allegations were not identified to the licensee, bn they were advised that the allegations pertained to activities which occurred during the December 1986 - March 1987 plant refueling outage involving a

/ safety-related valve and actions involving a Fuel Maintenance l l

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, Service-West employee. A single point of licensee contact to assist in providing documents and arranging for interviews was identified during the entrance meetin An exit meeting was held in conjunction with a Management Meeting conducted at the NRC Region III office on August 6, 1987. The licensee representatives were advised of the three specific allegations and our tentative conclusions (refer to Section 3 for details). Perceived management weaknesses in the site management's response to the potential valve tampering event were discussed in detail and are addressed in the attachment to this report (refer to Section 4 for further information).

3. Investigation - Allegation Review (IP 99014)

The following information, provided in the form of allegations, was reviewed by the inspectors as specifically noted below: Background: (Closeo) Allegation No. RIli d7-A-0042. The NRC Region three 111 officeThe allegation received information allegations were: on Ap(ril 9, 1987 involving 1) a safety-r was allegedly sabotaged and the event was not reported to the NRC; (2) work records pertaining to the valve were allegedly falsified, and (3) a plant employee was allegedly wrongly accused of writing threatening graffiti within the plan The licensee was contacted on April 9, 1987 and advised that we had received information that Valve CV 4050 was allegedly sabotaged. The plant was scheduled for a short-term shutdown on April 10, 1987 to check on leakage within the Recirculating Pump Room (RPR). The licensee stated that they would inspect Valve CV 4050 during the plant shutdown. The inspection of the valve was completed on April 10, 1987 and no deficiencies were note The Senior Resident Inspector (SRI) initiated the inspection pertaining to the allegations on April 10, 1987. A Region based security specialist augmented the SRI's ongoing inspection with an onsite visit beginning on April 21, 1987. A subsequent onsite visit was conducted between May 5-8, 1987. All pertinent facts were gathered by July 21, 1987. The licensee was contacted by telephone on July 21, 1987 and advised that a Management Meeting was requested for August 6, 1987 at the NRC Region III office to discuss the investigation results and management weaknesses noted during the investigation.

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The specific allegations, NRC review actions, and conclusions are

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addressed below and in the attachment to this report.

l (1) Allegation: A safety-related valve (CV 4050) was sabotaged in February 1987 and the licensee failed to report the sabotage event to the NR Enclecure contains N r n rm n ,eern " SAFEGUARDS INF0iu1AT10N

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NRC Revie Interview results and record reviews showed the following chronology of events pertaining to Valve CV 4050 within the Recirculating Pump Room:

January 1, 1987 By personal observation, Valve CV 4050 was determined by an onsite maintenance

! supervisor'to be free from any defect No deficiencies with the lubrication pipe or packing gland hold down plate were note The person inspecting the valve was very confident that loose nuts on the packing gland hold down plate or leakage from the valve would have been noticed by hi February 4, 1987 . Field Maintenance Service (FMS) workmen accidentally break lubrication pipe on Valve CV 4050 while standing on the valve trying to reach another valve at a higher elevation. This resulted in wuer spraying from the lubrication pipe area of the valv Maintenance request (No. 6) was prepared by shift supervisor to have lubrication pipe on valve CV 4050 replace At 0020 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> (12:20 a.m.) site personnel initiated switching and tagging order to remove Valve CV 4050 from servic February 5, 1987 FMS Supervisor enters the recirculating pump room between 1444 to 1459 hours0.0169 days <br />0.405 hours <br />0.00241 weeks <br />5.551495e-4 months <br /> (2:44 to 2:59 p.m.) to check vahe for repair Switching and tagging for Valve CV 4050 was completed by auxiliary operator Lubrication pipe was broken off to drain line so repairs could be initiate February 6,1987 Entry into RPR was made by a FMS repairman between 1047 to 1154 hours0.0134 days <br />0.321 hours <br />0.00191 weeks <br />4.39097e-4 months <br /> (10:47 to 11:54 a.m.) to start repair of lubrication pipe on Valve CV 405 Repairs did not stop leakage and followup repairs were needed and identified on Maintenance Request No. 6, and carried over to maintenance request No. 7. This repairman stated during interviews that the valve was also leaking above the lubrication pipe (packing gland is located above lubrication pipe) and that he told his supervisor about the leakag The FMS supervisor did not recall being informed of the additional leak. The

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leakage on the valve. " Leakage past plug" was noted on the maintenance request).

About 2057 hours0.0238 days <br />0.571 hours <br />0.0034 weeks <br />7.826885e-4 months <br /> (8:57 p.m.) a second FMS repairman enters RPR to initiate repairs on the lubrication pipe of Valve CV 4050. He leaves the RPR about 2140 hours0.0248 days <br />0.594 hours <br />0.00354 weeks <br />8.1427e-4 months <br /> (9:40 p.m.).

About 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> (11 p.m.) two site employees overhear a verbal threat by the second repairman working on Valve CV 4050 that he was going to drill through a valve disc. Neither employee advised site management of the verbal threa About 2354 hours0.0272 days <br />0.654 hours <br />0.00389 weeks <br />8.95697e-4 months <br /> (11:54 p.m.) the second repairman re-enters RPR to continue work on the lubrication pipe of Valve CV 405 February 7, 1987 About 0023 hours2.662037e-4 days <br />0.00639 hours <br />3.80291e-5 weeks <br />8.7515e-6 months <br /> (12:23 a.m.) the second repairman completes work on the lubrication pipe of valve CV 4050. The leak was stopped at the lubrication pipe and no other leakage was note The second repairman describes, on maintenance request No. 7, the nature of work performed and notes on the maintenance request the discovery of a possible crack on the valve bod About 0330 hours0.00382 days <br />0.0917 hours <br />5.456349e-4 weeks <br />1.25565e-4 months <br /> (3:30 a.m.) the lubrication i pipe on Valve CV 4050 was checked by one of

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the two persons who overheard the threat (to drill through a valve disc) on February 6, 1987. No leakage or obvious defects were note Between 0315 and 0420 hours0.00486 days <br />0.117 hours <br />6.944444e-4 weeks <br />1.5981e-4 months <br /> (3:15 to 4:20 a.m.) Valve CV 4050 was restored to servic About 0420 hours0.00486 days <br />0.117 hours <br />6.944444e-4 weeks <br />1.5981e-4 months <br /> (4:20 a.m.), FMS Supervisor cleared tags on Valve CV 4050. No physical i examination of the valve was required or I performed to clear the tag ,..

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Cther entries were made into RPR but not to work on Valve CV 4050. The times in the RPR ranged from four to seven minute February 8,1987 No entries were made in.the RP February 9-11, 1987 Several entries were made by personnel into the RPR but not to work on Valve CV 405 Time in the RPR ranged from three minutes to three hour !

February 12, 1987 About 0730 hours0.00845 days <br />0.203 hours <br />0.00121 weeks <br />2.77765e-4 months <br /> (7:30 a.m.) Non-Destructive Test (NDT) person enters the RPR to check Valve CV 4050 for possible crack in valve body noted by the second FMS repairman on maintenance request No. 7. The valve was too wet to perform the NO .

i About 0940 hours0.0109 days <br />0.261 hours <br />0.00155 weeks <br />3.5767e-4 months <br /> (9:40 a.m.) a site maintenance supervisor is advised of the wet valve and notes that the dampness was caused from leakage by two loose nuts on the valve packing gland hold down plate. Nuts were approximately 3/8" from the tightened position. Two of the four stem connector nuts were also loose, but not sufficient to cause any leakage or concerns. The loose nuts were tightened (maintenance request No. 9). i i

Between approximately 1140 and 1300 hours0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br /> (11:40 a.m. to 1 p.m.) the NDT on Valve CV 4050 was completed (maintenance request No. 8).

Note: Radiation Chemistry technicians accompanied all personnel entering the RPR but did not observe the specific work performed during the entire time the personnel were in the RP A representative of the valve manufacturer, familiar with the Model 70-14-3 DET valve, was interviewed to determine if Valve CV 4050 could function, if required, with a loose packing gland l hold down plate and 9/16 inch drilled hole through the valve's lantern ring and/or lower valve stem. This scenario was used because the packing gland hold down plate was loose, and a threat was made against the valve by the second repairman who worked on the valve on February 7, 1987. The threat to " drill through a valve disc" was not considered possible because disassembly of the valve would be required to reach the disc and the repairman was not in the RPR long  ;

enough to disassemble and reassemble the valve and complete his j assigned task. A damaged lantern ring and/or lower valve stem was  !

considered possible since these components could be reached with a 1

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long enough drill bit from the lubrication pipe on the valve (the work to be performed on the valve by the FMS repairman included drilling out the old lubrication pipe, redrilling the hole with a 9/16 inch drill, tap the new hole, and install a plug).

The valve manufacturer stated the valve would function with a loose packing gland and 9/16 inch hole drilled through the lantern ring and lower valve ste A representative of the packing material vendor, familiar with the packir,g gland material used in Valve CV 4050, was also interviewed to determine if leakage from the packing gland would occur immediately, or if a certain amount of time would have to elapse before the  !

packing material became saturated and exce.s liquid would leak through the loose packing gland hold down plate. In his judgement, leakage from the loose packing gland hold down plate would be immediate. Therefore, the leakage would occur as soon as the packing gland hold down plate was loosened if the line had pressure and flui Additionally, the valve manufacturer and licensee maintenance supervisor were interviewed to determine if the packing gland hold l down plate nuts could be loosened to the extent they were found I because of vibration or other operational parameters. They determined the loose nuts (to the extent they were found) would have had to be deliberately loosene Interviews of personnel during the inspection were also conducted to  !

determine if Valve CV 4050 had any work performed which would require  :

loosening or removal of the valve packing gland hold down plate. The  !

interviews also tried to determine if the packing gland hcid down plate was loosened or removed by a workman while repairing the valve, or if an authorized person allowed the hold down plate to be loosened or renoved and failed to document the decision. No work related reasons were confirmed to explain the loose packing gland hold down plat !

Interview results with the valve manufacturer, licensee maintenance representative, and resident inspector disclosed that the loose ,

packing gland hold down plate, and drilling through the lantern ring i and lower valve stem, would be self-disclosing during plant start-up testing prior to completion of the refueling outag Conclusions: The following conclusions were arrived at in reference to the loose packing gland hold down plate cover:

(a) The allegation of sabotage was not substar,tiated. However, tampering with the packing gland hold plate can not be ruled out. No work performed on Valve CV 4050 required the hold down plate to be removed and personnel working on Valve CV 4050 denied loosening the nuts on the hold down plate. In fact, Valve CV 4050 was not scheduled for

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maintenance. Maintenance became necessary only when the lubricating pipe was broke on February 4,1987. Interview l results with the valve manufacturer representative and licensee maintenance supervisor concluded that the nuts on

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the hold down plate could not be loosened to the extent found because of vibration or other operational parameter Additionally, the inspection did not disclose any person who verbally authorized the hold down plate nuts to be loosened for any reason. Therefore, it is concluded that the nuts on the packing gland hold down plate were deliberately loosened without authorization by person or persons unknown and the deliberate act occurred between January 1 and February 12, 1987, and possibly between January 1 and February 6, 198 (b) Valve CV 4050 would function if challenged, even with the loose packing gland hold down plate and 9/16 inch hole drilled through the lantern ring and lower valve ste However, the valve's performance would be degraded and contamination of the area would occur. The loose hold down plate would have been detected during full hydro testing of the system and plant.startup testing (the plant was in a refueling outage during the time of the tampering event).

Because of these factors, there is no evidence of a

" radiological sabotage" potential as defined in 10 CFR 73.2(p) and therefore the incident did not rise to the level of deportability as an explicit or potential threat as described in 10 CFR 73.71(c). The allegation that Valve CV 4050 was sabotaged and not reported to the NRC by the licensee was not substantiated since the event was not reportable under the criteria of 10 CFR 73.71(c).

(c) Significant weaknesses pertaining to the licensee's investigation of the event were noted and are addressed in the attachment to this repor (2) Allegation: Work records, to include work orders / maintenance requests, and radiation exposure records, relating to work performed on Valve CV 4050 were falsified to show that additional work, other than the February 6-7,1987 work, was performed on Valve CV 4050. The alleged falsification was allegedly motivated to " fabricate" a case against a plant employee. The implication was that unnecessary work was documented as being performed when the work had not been necessary or complete NRC Review: The inspectors reviewed work orders / maintenance requests, master scheduling maintenance plan for plant outage (February 8-15,1987), control room logs, and radiation exposure records pertaining to work performed on Valve CV 405 Additionally, the inspectors interviewed personnel who performed work on Valve CV 4050; the shift supervisor that prepared the n -, -- .,,-,---,...n t,.fi a ; L C L., , , , i s V 64 , . - J * ! h1 Enclosure Contains 9 Upon Separation Th h Page is Decontrolled

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. February 4, 1987 maintenance request (No. 6); the licensee maintenance supervisor that noted the deficiency on February 12, 1987; radiation chemistry person present 'during the February 6-7, 1987 work on the valve by the second FMS repairman; auxiliary operators that removed and returned Valve CV 4050 to service; and the technician that performed the NDT on Valve CV 405 The record review and interview results showed that Valve CV 4050 was not scheduled for maintenance during the plant refueling outage which occurred during December 1986 to March 1987. The lubrication pipe on Valve CV 4050 was broken on February 4, 1987, which necessitated unscheduled maintenance to repair the broken lubrication pipe. The record review and interview results also showed that the chronology described in Section 3.a.(1) above occurred in reference to Valve CV 4050. The work activities are summarized as follows:

(1) On February 4,1987, a maintenance request was prepared to repair the broken lubrication pip (2) On February 5, 1987, switching and tagging for Valve CV 4050 was completed to isolate the valve for repair (3) On February 6, 1987, the first repairman attempted to repair lubrication pipe on the valve but was unsuccessful. Another repairman attempted to repair the lubrication pipe and was successful. The work was completed early on February 7,1987. The second repairman noted a possible crack on the valve body on maintenance request (No. 7); (4) NDT personnel followed up to check the possible crack in the body of the valve on February 12, 198 The valve was too wet to perform NDT so maintenance request No. 8 was initiate The valve was checked by a licensee maintenance supervisor and maintenance request No. 9 was initiated to adjust the packing gland and tighten loose nuts on the valv Conclusion: The only authorized maintenance performed on Valve CV 4050 was on February 6-7 and 12, 1987 as described abov The maintenance was required because of an accidentally broken lubrication pipe on the valve. All authorized work on the valve was in response to repairmen instructions on maintenance requests Nos. 6, 7, and the followup check for a crack in the valve body annotated on maintenance request No. 7. The inspectors concluded that maintenance as described in ,

maintenance requests 6, 7, 8 and 9 was necessary and adequately '

documented. Therefore, the allegation pertaining to falsified records for unnecessary and unperformed maintenance on-Valve CV 4050 was not substantiate ,

(3) Allegation: A plant employee was wrongly accused of writing threatening graffiti within the plan NRC Review: The inspectors interviewed the person who was  ;

accusea of writing threatening graffiti within the plant; the I licensee management representative who conducted an inquiry into

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graffiti within the plant; the Production and' Performance Superintendent; and the Plant Superintendent. The inspector also reviewed internal correspondence dated February 13, 18, 19 and March 11-12, 1987 pertaining to the licensee's investigation of graffit The interview results and document reviaw showed that on February 9, 1987 the Operations Superv.sor noted a large amount of graffiti written in the area of the entryway to the Recirculating Pump Room (RPR). The February 13, 1987 memorandum established that some of the graffiti were threats towards the Plant Superintendent and a FMS-West Maintenance Supervisor, or were obscene and would be' considered as aberrant in nature. One of the graffiti items that appeared most often was " Hoffman Wait Until Next Outage" and was signed "High Dose '87." This graffiti was also noted on the shield wall for the frisker at the Personnel Lock. The initials dRE" and "WTC" (assumed to be Western Travel Crew) were written near some of the graffit The licensee's investigation ~also concluded that the graffiti was written between February 6 and 9,198 As part of the licensee's investigation, photographs of one example of the graffiti and samples of an employee's handwriting were sent to a document examiner. The employeo's first two initials were R. E. The document examiner advised the licensee, by letter dated March 12, 1987, that the examination showed that the printing on the photographs and known printing of the employee were printed by the same perso Based upon this information, and verbal confrontations of a threatening nature-which occurred on February 5, 1987 between the employee and a supervisor, the employee was terminated on February 20, 198 During an interview with the employee, he admitted to writing graffiti at the frisking station by the RPR. The graffiti stated "D. Hoffman Wait Until Next Outage." The employee also admitted to writing graffiti of a general nature (comic remarks or drawings of a named co-worker) in the RP The employee stated that he did not consider the graffiti as threatening but was angry at the time because his job at the site had terminated earlier than expected because he had received close to the administrative limit for quarterly radiation exposure (2,500 millirems). This resulted in the employee losing, in his judgement, up to $4,000 in pa Conclusion: The allegation that a named plant employee was l wrongly accused of writing threatening graffiti within the plant was not substantiate . Management Meeting (30702)

A management meeting was held on August 6, 1987 in the NRC Region III office, Glen Ellyn, Illinois. Attendees included: " r - - -

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. Licensee Representatives:

T. Elward, Plant Superintendent, Consumers Power Company (CPCo) f T. Bordine, Licensing Representative, General Office (CPCo) l J. Bradshaw, Site Property Protection Supervisor (CPCo)

B. Alexander,TechnicalEngineer/NRCLiaison(CPCo)

H. Cooper, Security Director, General Office (CPCo) NRC Region III Representatives:

J. Hint, Director, Division of Radiation Safety and Safeguards I. JacKiw, Chief, Reactor Projects 2C C. Veil, Investigation and Compliance Specialist J. l reed, Chief, Safeguards Section G. Pirtle, Physical Security Inspector D. Funk, Physical Security Inspector The licensee representatives were advised that the purpose of the management meeting was to discuss the specific allegations and tentative conclusions, and to discuss significant weaknesses noted during the investigation in reference to their management's inadequate response to a potential equipment tampering even The allegations and tentative conclusions described in Section 3 of this report were discussed. Extensive discussions on the weaknesses noted during the inspection (described in the attachment to this report) were l also conducted. The licensee representatives were a M sed that the i inspection findings were subject to NRC Region III management review and !

the final inspection report would contain the formal perspective for the inspection results. No written material pertaining to the inspection was left with the licensee representative The licensee representatives presented a chronological sequence of events partainir: 4 verbd confrontations, written threats within the plant, the degraded Nde of v dve CV 4050, and personnel actions taken in reference to an employee allegedly involved in these activities. They expressed the position that they had taken appropriate actions in dealing with the incident since they could not confirm " intentional" tampering with the valve by any employee. They also stated that they realized some improvements in response to future equipment tampering events were necessary and the Corporate Security Director's staff would be preparing a detailed procedure to address equipment tampering events. Additionally, General Employee Training was being modified to more clearly define employee security responsibilities, and the Plant Superintendent was advising all employees by memorandum that he expects any threat against plant equipment to be reported to site management in a timely manne The representatives committed to increasing work force security awareness. The Corporate Security Director conanitted to provide adequate investigative support for any future equipment tampering event Enclosure Contains SAFEcupggg IHFORHAT10U Pon ScParation This 12 Page IS 00controllad

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. The NRC staff advised the licensee representatives that the staff concluded that the management actions in reference to an employee's verbal '

confrontations witn supervisors and writing threatening graffiti within i e plant were acequate. However, plant management's actions pertaining to the verbal threat against a valve and the subsequent degraded mode of the valve were _ inadequate. The lack of -dequate aggressive actions was considered indicative of management's failure to perceive the significance of the event, and inadequate preplanning for such events. These management deficiencies were described as of significant concern to the Commissio They were advised that they would be requested to respond to the deficiencies noted in the attachment to this repor (155/87010-01)

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