IR 05000254/1979031
| ML19332A970 | |
| Person / Time | |
|---|---|
| Site: | Quad Cities  |
| Issue date: | 02/04/1980 |
| From: | Mccarten J, Norelius C, Spessard L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML19332A969 | List: |
| References | |
| 50-254-79-31, NUDOCS 8009190171 | |
| Download: ML19332A970 (13) | |
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U.S. NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT
REGION III
Report No. 50-254/79-31 Docket No. 50-254 License No. DPR-29 Licensee:
Commonwealth Edison Company (CECO)
Post Office Box 767 Chicago, Illinois 60690 Investigation At: Quad-Cities Nuclear Power Station, Cordova, Illinois Investigation Conducted:
December 5, 1979 through January 14, 1980 Investigators: [ h(..['
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.J. B. McCarten Date
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Reviewed By:
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C. E. Norelius Date Assistant to the Director
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L. Spessard, Chief Date Reactor Projects Section 1 Investigation Summag Investigation on December 5, 1979 throu.oh January 50-254/79-311
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14, 1980 (Report No.
Areas Investigated:
Investigation was conducted into the circumstances surrounding the closure of two core spray suction valves to the Quad-Cities Unit 1 Emergency Core Cooling System (ECCS).
Investigation involved a review of procedures and records, interviews with plant per-sonnel and discussions with the licensee and representatives of the Rock Island office, Federal Bureau of Investigation (FBI). This investigation involved a total of 80 hours9.259259e-4 days <br />0.0222 hours <br />1.322751e-4 weeks <br />3.044e-5 months <br /> on-site by one Inspector and one Investigator.
Results:
Investigation established on December 3, 1979 at 2400 hours0.0278 days <br />0.667 hours <br />0.00397 weeks <br />9.132e-4 months <br />, licensee discovered that two independently controlled core spray suction valves in the Unit 1 ECCS were found in a closed position.
Interviews with plant personnel, and a review of maintenance and operations records
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s indicated that there was no immediately discerna' ale cause for the clo-e sure; both intentional and accidental manipulations of two valves were considered, but no positive conclusion was reached.
No items of non-compliance were identified during the course of this investigation.
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l Peason for Investigation Investigation was conducted into the circumstances surrounding the licensee's report that on December 3, 1979 at about 2400 contrary to station operating procedures two Unit I core spray suction valves to the Emergency Core Coolant System (ECCS) pumps were found in a closed position.
Summary of Facts This Investigation was conducted jointly with the FBI during the period of December 5, 1979 through January 14, 1980.
Investigation established on December 3, 1979 at 2300 the licensee discovered that two independently operated core spray suction valves to the Unit 1 ECCS were found in a closed position. Overall plant safety was not affected because the valves in question would have automatically opened upon activation of the (ECCS)
system. The valves were last verified in an open position at 0800 on December 3, 1979.
Plant management reviewed maintenance, operating, and surveillance testing records and stated that there was no discernible cause for the closure, with the exception of intentional or accidental manipulation of the valve remote control stations located in the Unit 1 lower level containment areas.
The investigation disclosed three possible means by which the valves may have been closed:
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An operator working the December 2-3, 1979 2300 to 0700 shift was involved in manipulation of both the 1A and IB valves in the core spray discharge system. There is a remote possibility that he could have accidently closed both core spray suction valves while perfornia this manipulation. This seems unlikely, however, in that the valve positions were appcrently checked by three other licensed operators a'.ter that time.
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2.
An equipment operator changed indicator position light bulbs on
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various remote control. stations to the valves in question on the shift before they were discovered as being closed.
It appears that accidental bumping of the switches or possible deliberate j
switching to check the bulbs' operation coupled with an inadequate
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l understanding as to how the mechanisms work could have led to the closed valves. The operator in question denies having conducted any switching to test the valve position indicator, but admits he may have accidentally closed the valves.
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The valve closure could have been a deliberate act.
A review of access records disclosed that five maintenance personnel had access i
to the lower level containment areas during the last two shifts on
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December 3, 1979. During interviews of these individuals, they
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denied that they deliberately, or accidently to their knowledge, I
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closed the valves in question. Polygraph exams were given to
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these individuals. The results of the polygraph examinations showed that the value closure was not done intentionally.
This investigation was unable to establish proximate cause for the closure of the two valves in the core spray system.
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DETAILS
1.
Principal Persons Contacted CECO Quad-Cities Nuclear Power Station, December 5 through January 14, 1980.
- N. J. Kalivianakis, Plant Superintendent, Quad-Cities Nuclear Power Station, (CECO)
Kenneth Grasser, Assistant Plant Superintendent, Administration, Quad-Cities Nuclear Power Station, (CECO)
- Dennis O' Conner, Assistant Plant Superintendent for Industrial Relations,-Quad-Cities Nuclear Power Station, (CECO)
Thomas Tamlin, Assistant Plant Superintendent, Operations, Quad-Cities Nuclear Power Station,. (CECO)
Dick Bax, Assistant Plant Superintendent for Maintenance, Quad-Cities Nuclear Power Station, (CECO)
- Denotes those present at exit interview on January 14, 1980 2.
Interview of Plant Supervisory Personnel On December 5, 1979, Richard Bax, Assistant Plant Superintendent, Maintenanc.e, (CECO) stated that following a report on December 3, 1979 by individual
"A", a Nuclear Station Operator, (NS0) that two core spray suction valves to two Emergency Core Coolant System (ECCS) pumps were found in a closed position, he initiated an inquiry to ascertain the reason for the closed condition of the valves.
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Bax related the two 18" suction valves to the ECCS system each provided suction to two separate and independent ECCS units for the Unit I reactor which was operating at full power at the time of the incident.
Bax also stated either valve could be controlled at any one of four locations, either in the Unit I control room, at the remote activation station located in (ECCS) pump rooms 1A and IB, manually at the valve itself also located in rooms IA and
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1B, respectively, or by the manipulation of the valve motor elect-rical circuit breakers located in the Unit I reactor area.
Bax stated that electrical manipulation of the valves was a remote
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possibility along with manual manipulation of the valve which would require an extensive amount of time and effort to effect closure.
Bax stated that ruling out operator error or maintenance activity
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requiring closure of the valves, it appears someone intentionally or inadvertently closed the ECCS suction valves probably by activation of the two remote stations located in the Unit I core spray rooms IA and IB.
Bax also related that overall plant safety was not effected because the valves in question would have automatically opened upon activat, ion of'the ECCS system.
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Bax stated that a review'of station maintenance records reflect that no maintenance had been performed on either the Unit 1 or Unit 2
'ECCS~ system since November 28, 1979. Bax.also stated that an NSO's
' failure to detect'the closure of both valves between November 28, 1979'and' December 3, 1979 war not.likely.
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Bax also related that various maintenance personnel (Equipment
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' Attendants and Instrument Repairmen) conduct daily rounds into the
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Unit.1 and 2 lower level areas, and.these areas are accessible only sto personnel with an "R" key which is signed out from a Log Book.
- Bax stated that on December-3, 1979, during each shift an Equipment Attendant.would make the rounds of the lower levels of Unit I con-tainment areas to check various gauges, controls, and water levels.
Bax also.related during these rounds Equipment Attendants are re-quired to' wear radiation protection clothing and limit the time spent.in the area. A: review of the lower level equipment drain tank log er December 3, 1979, which is initia11eti-by the lower level Unit 1 Equipment Attendant performing the checks, reflect no signa-ture but an entry at 0920 on December 3, 1979 and also an entry with the initials of Individual "F" at 1545 on December 3, 1979.
Bax stated that maintenance personnel for ITT Grinnell and Graver, Incorporated were-'also working in the lower levels of. Unit I and 2 but in his opinion these individuals would not be familiar with the plant safety systems, or the location of the remote control stations for the'ECCS system.
On December 5,1979 and January 3,1980 Thomas Tulin, Assistant Plant Superintendent, Operations, stated that on December 3, '979 the shift Nuclear Station'4erator (NS0) discovered two suction valves to two ECCS system peps in a closed position contrary to l
station operating procedures. Tamlin stated-he initiated an inquiry l.
to ascertain if the valves had been closed due to operator error.
Tamlin related his inquiry disclosed that the valves were last checked at 0800 on December 3, 1979 by Individual "B",
NSO, who i-stated the:ECCS valves were in the open position as indicated by a l
green light at'each control for each of the two ECCS valves located on the. control room console.
In addition at 1000 on December 3,,1979 senior operating engineer, Glen Conschack also checked the position l
- of the valves. Tamlin also stated the' valve positions are routinely
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checked at the change of.each shift and are checked daily by the NSO ae 2300. Tamlin also' stated-that it was'during'this 2300 hour0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> check
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that Individual "A", NSO, discovered the misalignment of the ECCS
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core spray suction valves and corrected this misalignment.
Tamlin confirmed Bax's description.of the operation of the ECCS core spray suction valves. Tamlin added that the remote control
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units :activat ed an electric motor which closed or opened the ECCS sur/ ion valve. Tamlin.related that the three position station j
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(open, stop, and closed) had about a ninety second phase to open
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or close the valve and this phase, once initiated, could only be stopped or reversed by hitting the stop button first, and then either the open or close button. Tamlin also related that the consequences of attempting to change the direction of the valve movement when it is opening or closing without pushing the stop button is that the valve would continue on its originally pro-grammed path. He also stated that valve has two indicator lights; red signaling that the valve is opened and green indicating that the valve is closed, with a dual indication showing when the valve is phasing from the open or closed position.
Tamlin also stated that a review of operational records and inter-views of NS0's and maintenance personnel disclosed that the ECCS valves had not been manipulated to a closed position by any of these personnel on December 3,1979 or immediately prior to the date.
Dennis O' Conner, Assistant Plant Superintendent for Industrial Rela-tions, CECO was interviewed on December 6, 1979. The FBI and NRC representatives requested that the licensee administer polygraph examinations to individuals identified by the FBI and NRC who had access to the lower-level containment areas on December 3, 1979.
O' Conner agreed to this request and advised the licensee would afford selected plant personnel. The opportunity to undergo a polygraph examination, to ascertain if any of these personnel had manipulated the ECCS suction valves on that date.
O' Conner ad-vised that the results of these polygraph examinations would be provided to the FBI and NRC.
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Interview of Plant Operations Personnel On December 7, 1979 Individual
"A", NSO, was interviewed and stated on December 3,1979 at 2400 while performing a daily surveillance check list on the Unit I reactor he discovered that the core spray suction valves on the ECCS were in a closed position.
Individual
"A" stated that he assumed duties as NSO from Individual "D" at 2300 on December 3, 1979, and Individual "D" had not informed him of any unusual occurrences during the previous shift.
Individual
"A" re-lated that he informed the shift engineer of the incident and then checked operation and maintenance records, but found no apparent reason for the ECCS suction valves to be in the closed position.
On December 7, 1979 Individual
"B", NSO, CECO, was interviewed and stated on December 3, 1979 he was the Unit I control room operator assigned to the 0700 to 1500 shift.
"B" stated at about 0715 to 0730, during his shift turnover, he performed a valve position check according to station procedures and noted that both the ECCS suction valve controls were_in the open position as indicated by a green light on the Unit I control room console.
In addition "B" stated
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Individual "C", NSO, was to undergo an NRC Seraor Operator license
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examination that morning, and he rechecked all the valve positions at about 0930. At that time all valves, including the ECCS suction valves were in the proper position.
"B" stated' prior to being re-l'eved by Individual "D" at 1500 on December 3, 1979 no maintenance cr operational functions were performed on the ECCS system during his shift.
On December 7, 1979 Individual "C", NSO, was interviewed and stated between 0930 and 1000 he was undergoing an NRC senior operators license examination in the Unit 1 control room.
"C" stated he did not note the position of the ECCS valves during the examination and did not manilpulate any controls on the reactor during the course of the examination.
L On December 7, 1979 Individual "D", NSO, was interviewed. He stated l
on December 3, 1979 he was the Unit I control room opera or assigned to the 1500 to 2300 shift.
"D" stated he was not aware of any un-l'
usual operational or maintenance activities which were performed on
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the ECCS valves during pis shift.
In addition "D" stated that, when he assumed his duties as the operator, he performed a routine sur-veillance check, but was 7c' certain whether the ECCS suction valves were in the open or close1 pasition at that time.
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On January 3, 1980 Individual
"E", NSO, was interviewed.
He stated on Dece.nber 2-3, 1979 from 2300 to 0700 he was the NSO on Unit 1.
l He related between 0400 and 0500 he was clearing high pressure l
transients in the residual heat removal system (RHR) by closing
the discharge valve on the core spray system and bleeding the high pressure from the system-through the No. 4 RHR valve. He stated that this involved the manipulation of both the 1A and IB ECCS i
discharge valves and the 1A and IB No. 4 RHR valve. He also stated the ECT3 discharge valve is located directly across and to the right l
of the core spray suction valve; with the No. 4 RHR valve being i
located directly above the ECES discharge valve.
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"E" also stated he experienced difficulty in clearing the transients
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from the system, and was forced to perform the procedure four times on the core spray 1A system, and six times on the core spray 1B system. He related he could have accidently closed one of the core spray suction valves but seriously doubted he could have accidentally
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closed both valves.
He also added that after this action, and prior to the discovery of the closed core spray suction valves on Unit 1, three other NS0's had checked the core spray suction valves
and.found them to be in the open position.
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4.
Interviews of Plant Maintenance Personnel On December 13, 1979 Individual
"F", Equipment Attendant (EA), was interviewed and stated on December 3, 1979 he was assigned to tie
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1500 to 2300 shift.
"F" stated that during this shift he drew an
"R" key, donned radiation protection' clothing, and entered the lower level containment area in order to repair a sump pump and to conduct the lower level EA counds for another individual.
"F" stated that he repairej the sump pump, and performed the required rounds, and maintenance checks for both the Unit t and Unit 2 lower level areas.
"F" also related that during these rounds he entered the Unit 1, IA and IB core spray pump rooms and replaced burned out bulbs on the remote control stations located in the core spray pump rooms.
"F" replaced six bulbs on various remote stations located in the core spray rooms but denied that he intentionally or inadvertently act-ivated the remote stations for the ECCS suction valves.
On January 15, 1980, Individual
"F", Equipment Attendant (EA), CECO, was reinterviewed and stated that on December 3, 1979 he was assigned to the 1500 to 2300 shift at the licensee's facility. He again stated that during this shift he drew an R key, donned radiation protection clothing and entered the lower level containment areas. He related while in the Unit 1A and IB spray rooms he changed light bulbs on six of the remote control stations located in these rooms.
(Note:
one remote station is located in Room 1A and eight stations are located in IB).
He stated he was not familiar with the proper operation of the remote control station control buttons, nor was he familiar with the light indicators that are displayed when the remote stations are activated, to open or lose a valve (i.e. - Individual "F" was not aware that a dual light indication was displayed when the valve is phasing, nor was he familiar with the correct procedures to change direction of the valves when it is phasing from one position to another (the correct procedure is to hit the stop button, before the open or close button if a direction change is desired).
"F" added that he could not recall shich stations he serviced on December 3, 1979; but did state in the absence of a glass cover over the open and close buttons he could have accidentally pushed the close button while changing indicator bulbs on the station.
On December 6, 1979 Individual "G", Equipment Attendant (EA), was
'nterviewed and stated on December 3, 1979 he was assigned to the Oid0 to 1500 shift and at about 1000 he drew an
"J" key, donned radiation protection clothing, and entered the Unit I and 2 lower level containment areas in order to perform the required maintenance rounds.
Individual "G" stated he entered the 1A core spray room in order to cross over from the Unit 2 to the Unit I side.
"G" stated that wnile in the room he did not intentionally or inadvertently manipulate the remote control stations for the ECCS suction valves.
On December 7, 1979 Individual
"H", Equipment Attendant (EA), was interviewed and stated on December 3, 1979 he was assigned as an Equipment Attendant to the 0700 to 1500 shift and conducted the rounds of the upper levels of the Quad-Cities Units 1 and 2 con-tainment areas.
"H" stated that although formally assigned the-9-k
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duty to make the. rounds for all of Unit 1, Individual "G" the Unit
2 lower level Equipment Attendant actually conducted these rounds during his shift.
Individual "11" stated it is a working practice for either of the Equipment Attendants to conduct the rounds for both Units on the upper or lower level, whichever is mutually agreeable to both EA's.
Individual "11" stated this practice pre-cluded both Equipment Attendants from donning radiation protection equipment and aids in keeping individual radiation exposure levels down.
"11"_ stated he did not enter the lower level containment areas of Units 1 or 2 on December 3,1979.
On December 6, 1979 Individual
"I", Equipment Attendant (EA), was interviewed and stated on' December 3-4, 1979, during the 2300 to 0700 shift, he was assigned radiation waste disposal duties and did not enter the lower level containment areas.
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On December 6, 1979 Individual
"J", Equipment Attendant (EA), was interviewed and stated on December 3, 1979; during the 0700 to 1500 shif'
. was assigned to radiation waste disposal and did not en'
.ne lower level containment areas.
On Dt. ember 7, 1979 Individual "K", Shift Foreman, Operations Department, was interviewed and stated on December 4, 1979 at about 0200 he went to the Unit 1, IA and IB core spray rooms to check the ECCS valves that had earlier been discovered closed by the shift operator, Individual "A".
Individual "K" stated that he examined the remote control stations for each valve and found that the sta-tion was then in an open position.
"K" stated the remote station is a three position push button control which activates an elect-rical motor which closes the ECCS core spray suction valve.
The remote units are housed in a key-locked, glass-fronted control box; In this instance the glass covers to the control boxes were missing, allowing access to the control buttons without opening the remote station door.
Individual "K" said there were no glass fragments in the control box or on the floer directly below the control box which would be indicative of glass recently being broken.
On December 7, 1979 Individual
"L", Equipment Attendant, was inter-viewed and stated during his shift he was an extra man and did sign out an "R" key at about 2300 in order to enter the Unit 1 RifR room.
"L" stated he did not enter the core spray rooms of the lower level containment building.
Individual "L" also stated that he did not observe any unusual activity in the area at the time of his entrance.
On December 7, 1979 Individual
"M", Instrument Man, (IM), CECO, was interviewed and stated on December 3, 1979 he and Indivi@al
"N" entered the lower level containment area to check the Unit 1 Torus Vessel water level.
Individual "M" stated they entered the area and observed various contractor personnel at work near the torus vessel but noted no other activity in the area that day.
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j On-December 7,'1979, Individual "N", Instrument Man, (IM), CECO,
.was' interviewed and stated on December 3, 1979 he and Individual i.
"M" entered the lower level containment area to check the Unit 1 Torus Vessel. water level.
"N" stated they entered the area and l
' observed contractor personnel at work near the torus vessel but
noted no other activity in the area.
On December 7, 1979 Individual
"0", Electrical Helper, CECO, was interviewed and stated on December 4, 1979 he was directed to re-
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l place missing glass' covers on the remote control units to the ECCS
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system.
Individual "O" stated he replaced four broken glass covers on Unit.1, three of which were in the core spray rooms, with. two being in' Unit'I core spray room IB and one cover being replaced in Unit 1 core spray room 1A.
Individual,"0" related during this work he noted the absence of~any large pieces of broken glass on-the interior of'the remote switches or on the floor area near the
switches.
"0" conjectured that the glass covers were infrequently l
replaced when broken, and he noted that, based on his previous ex-l perience while working at the site, these glass covers were not l'
immediately replaced when broken.
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Contacts with Licensee Industrial Relations Officer
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On December 14, 1979 Dennis O' Conner, Assistant Plant Superinten-
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l dent for. Industrial Relations, was interviewed. He stated five individuals, all Equipment Attendants, who had access to the
"R" key and consequently to the lower level containment areas on l
December 3,1979,-were administered a polygraph examination by representatives of Reid and Associates, Chicago, Illinois.
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O' Conner advised that one Equipment Attendant failed the examina-tion. -O'Connor stated that this individual denied either inad-vertently or intentionally closing the Unit 1 core spray suction l
valves to the ECCS system on December 3, siv.
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. On December 27, 1979, Dennis'O' Conner, Assistant Plant Superi1-j l
tendent for Industrial Relations (CECO), was contacted and ad-l-
vised that the Individual was administered a second polygraph l
examination by F.'L. Hunter and Associates, Hinsdale, Illinois.
L-The-results of this examination were that this Individual was j.
telling the t' ruth when he denies intentionally closing the ECCS core spray suction valves. However, during this examination he stated he could have accidentally closed the valve by pushing the close button-on the ECCS core spray suction valve remote station.
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-Contact with FBI On January 25, 1980 Gerald Karns, FBI, was contacted and he advised that the FBI investigation into this matter is-continuing.
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Exit Meeting On January 15, 1980 discussions were held with the individuals pre-viously listed. At this time they were advised of the results of this investigation and that no items of noncompliance had been identified during the course of this investigation.
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QUAD-CITIES REPORT KEY TO PERSONNEL Individual - A - Kenneth M. k'ogRonic Individual - B - Dennis Essary Individual - C - Larry Monroe Individual - D - Thomas Doty Individual - E - Frank Pollack Individual - F - Jeffery Heaton Individual - G - Steve Saladin Individaul - H - Merle Saunders Individual - I - Michael Field Individual - J - Danny R. Jepson Individual - K - Harvey K. Husingh Individual - L - Phillip Helot Individual - M - Michael J. Cannon Individual - N - Dennis P. Steck Bauer Individual - 0 - Jeffery Melton ()
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