ML040700309

Restart While a Grand Jury Investigation Is Still on-going

ML040700309
Person / Time
Site:	Davis Besse
Issue date:	02/25/2004
From:	Buchanan S, Lochbaum D Ohio Citizen Action, Union of Concerned Scientists
To:	Caldwell J Region 3 Administrator
References
Download: ML040700309 (7)

Text

BOARD OF DIRECTORS 0 Dr. Kathleen Fagan, President Rhonda Barnes-Kloth

• Caroline Beidler Jennifer Cooper Ellk Jacobs Mike Jones Marie Kocoshis 9 Joe Korff e Art Mlnson Rlck Topper Thomas Triinble EXECUTIVE DIRECTOR Sandy Buchanan February 25,2004 Mr. James Caldwzll Region III Administrator Nuclear Regulatory Commission 80 1 Warrenville Rd.

Lisle, TL 60532-4351

Dear Mr. Caldwell,

No nuclear plant has ever been given permission to restart while a grand jury investigation related to findings of possible criminal actions at that plant is still going on.

In the Millstone case, the grand jury had finished its work before restart permission was granted. How can members of the public, or even personnel working within the nuclear industry, be expected to trust that no one involved in the critical decisions made in over a decade at Davis-Besse - or that the FirstEnergy corporation itself - wont ultimately be indicted?

In the two years that have elapsed since the discovery of the hole in the head at the Davis-Besse reactor, neither the Nuclear Regulatory Commission, nor the U.S. justice system has meted out sanctions or punishments to the FirstEnergy corporation or to its key managers responsible for the extensive degradation of the nuclear reactor.

We and other members of the public have no way of knowing whether actions taken by the FirstEnergy Corporation and its management to refuse to investigate or to cover up the leakage and hole at Davis-Besse will ultimately result in criminal charges or conviction. All that we know is that the NRCs investigation reached conclusions that warranted a deferral to the Department of Justice, a federal grand jury investigation is underway, and that the NRC is privy to reports from the grand jury.

FirstEnergy has now applied to you for permission to restart Davis-Besse. If you grant this restart permission before appropriate and necessary consequences are instituted, you will be sending a signal to both FirstEnergy and the entire nuclear industry that profits and production come before public safety.

Musical clzuirs at FirstEnerjp At the February 1 2th public meeting at Camp Perry, FENOC President Gary Leidich made clear that persome1 at FENOC and all the reactors work closely together, saying no nuclear plant is an island. This statement can be confirmed by an analysis of FENOCs press releases over the last several years, where personnel changes are www.ehiocitizen.arg 614 W. Superior Ave, Suite 1200 Cleveland, OH 44113 Cincinnati, OH 45206 Columbus, OH 43202 (216) 694-6904 Fax (513) 221-2102 fax (614) 263-4540 Fax sweirOohiocitizen.org rbelzOohiocitizen.org

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announced frequently and assignments between the various plants and FENOC resemble a game of musical chairs.

The root cause analyses done by both FirstEnergy and the NRC show that the actions which led to the degradation of the head, and the cover-up of the degradation, began in the early 1990s. FirstEnergy itself says in its root cause analyses that the evidence places through-wall leak initiation in the 1994-96 timeframe. Key decisions to ignore signs, and even photographs, of boric acid corrosion were made in the period between 1994-1998. As outlined in the following excerpt from the August 13,2002 root cause analysis done by FirstEnergy and submitted to the NRC, management at Davis-Besse in 1998 made the critically important decision to downgrade the evaluation of the boric acid corrosion from root cause to apparent cause:

Finally, although this PCAQR (Potential Condition Adverse Quality Report) was designated for a root cause analysis, the PCAQR was downgraded and closed more than two years later without an approved root cause analysis, without determining whether the CRDM nozzles were leaking or the RPV head was corroding, and without any corrective action or action to prevent recurrence. (p. 43, Management and Human Performance Root Cause Analysis Report on Failure to Identify Reactor Pressure Vessel Head Degradation, August 13,2002. Certain excerpts are attached to this letter; the full document can be found at http://ww.nrc. govlreactordoperatingops-experience/vesseL head-degradation/news/2002/index. htrnl).

Over the past two years, FirstEnergy has announced publicly that 18 individuals have been disciplined or left FirstEnergy due to the debacle at Davis-Besse. However, it appears that many of the individuals who lost their jobs were only involved in vessel head issues beginning in the late 1990s or 2000.

We request that you determine the current roles of various FirstEnergy managers who were in key management positions at Davis-Besse during the years from 1996 on. How is the public to have confidence in FirstEnergy s new decision-making at Davis-Besse when many key managers who made important decisions at Davis-Besse in the past were promoted within the FENOC system and are still involved in critically important nuclear safety issues?

Management personnel who were involved in key decisions at Davis-Besse in the 1990s and who stdl appear to be employed in top management at FENOC or io nucleur plunts include ut least: Lonnie Wortey -Director of Nuclear Supply Chain, FENOC, David Eshelman - Director of Life-Cycle Management, Davis-Besse, Michael Stevens -

Director of Work Management, Davis-Besse, The0 Swim - Consultant, ENOC, David Lockwood - recently returned to Davis-Besse, Joseph Rogers - Manager, Nuclear Engineering, FENOC, Dale Wuokko - Supervisor, Nuclear Regional Compliance, FENOC, and Robert Donnellon, Manager, Nuclear Support, FENOC, and James Lash -

General Plant Manager, Beaver Valley. (NOTE: titles where listed were located through company listings, public announcements by FirstEnergy, or newspaper quotes).

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Comparison with ?dillstone s sufely culture chmges Significant doubts about FirstEnergys safety culture were raised at the February 12 meeting, including reports by Geoffrey Wrights inspection team showing that in certain organizations, staffs confidence in Davis-Besses management has declined from where it was in March 2003. When Ohio Citizen Action asked Mr. Wright during the meeting to name the organizations where confidence declined, he listed the folIowing: operations, maintenance, quality assurance, and plant engineering. Every one of these areas is critical to nuclear safety.

At the Millstone plant, revamping of the safety culture took two years AFTER they had reached the point where Davis-Besse may be now. It is ludicrous to think that the new steps which Davis-Besse has taken to promote safety, including a new program which they began the same morning of the February 12& meeting, could possibly have been instituted through the organization sufficiently to authorize restart at this time.

Public confidence in both FirstEnergy and the Nuclear Regulatory Commission has been severely shaken by events at Davis-Besse throughout the past two years. The only way for you to restore that confidence is to show that the NRC i s willing to say no to FirstEnergys current request to restart the plant until those responsible for the debacle have been identified and sanctioned.

Sincerely, Sandy Bkhanan, Executive Director Ohio Citizen Action David Lochbaum, Nuclear Safety Engineer Union o f Concerned Scientists Cc: James Dyer Samuel Collins John Grobe 3

Root Cause Analysis Report Failure to identify Significant Degradation of the Reactor Pressure Vessel Head CR 02-0685, 02-0846, 02-0891, 02-1 053,02-1128, 02-1 583 02-1 850 02-2584, and 02-2585 DATE: August 13,2002 Prepared by: L Q d 6 Steven A. Loehlein Root Cause Lead Davis-Besse Sponsor:

Chief Operating Officer Approved by: Q4&f2k-Q-Robert F. Saunders President

However, as discussed below, even though policy. procedures, and guidelines had been established and were adequate for finding and fixing problems. personnel at all levels of the organization did not effectively implement the corrective action process. This resulted in missed opportunities to identify the nuclear safety impact of the boric acid corrosion to the RPV head from 1996 to 2002. The Team concludes that if the Corrective Action Program had been stronger and reflected the state-of-the art, i t might have avoided or compensated for some of the problems with the ineffective implernentatlon. (Contributing Cause 6.2.2)

Identification and Categorizatinrl of Adverse Cortdiriniis The Team evaluated corrective action documentation from 1996 to 2002 to determine whether Davis-Besse had identified and documented the nonconforming conditions involving the boric acid on the RPV head and other boric acid related issues. Based upon the following facts, the Team concludes that in general these conditions were adequately identified:

Boric acid accumulation OR the RPV head was identified during each refueling outage from IORFO to 13RFO and was documented on PCAQR 96-0551, PCQAR 98-0767, CR 00-0782, CR 00-1037, CR 02-0685, and CR 02-0846.

Boric acid accumulation in the CACs was repeatedly identified from 1999 to 2001 and was documented on various corrective action documents. such as PCAQR 98-1980.

Boric acid clogging of the radiation monitor filters was repeatedly identified from 1999 to 2001 and documented on various corrective action documents, including CR 99-0882, CR 99-0928, and CR 99-1300.

Boric acid corrosion and other problems with the RC-2 Pressurizer Spray Valve were documented on at least 14 corrective action documents, including PCAQR 98-0915, X A Q R 98-1885. and CR 99-0738. Furthermore, CR 98-0020 was initiated to report a lack of comprehensive actions relative to resolving the management issues associated with this work.

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0 Although adverse conditions involving boric acid were in general identified and documented. the categorization of the adverse conditions, and the selection of the level of evaluation for those conditions, allowed the use of superficial cause analysis techniques.

(Root Cause 6.1.2.b) For example:

Boric acid accumulation on the RPV head was designated for an apparent cause evaluation on PCAQR 96-055 1, PCQAR 98-0767, CR 00-0782. CR 00-1037, CR 02-0685, and CR 02-0846. PCAQR 96-055 1 was initially designated for a mot cause analysis. However, more than two years later on 11/2/98, the Plant Engineering Manager approved a downgrading of PCAQR 96-055 1 to an apparent cause evaluation noting an apparent cause analysis will more than support efforts to pnwent recurrence. This downgrading occurred despite the fact that recurrence of boric acid deposition on the RPV head had already been documented on PCAQR 98-0767 on 4/25/98. Similarly. PCAQR 98-0767.

CR 00-782, CR 00-1047, CR 02-0685, and CR 02-0846 were all considered to be routine and designated for an apparent cause evaluation without corrective action to prevent recurrence (CATPR). even 4

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Root Cause Analysis Report 5.0 Data Anatysls 42

though the conditions represented repeat events and should have been classified as more significant under the Corrective Action Program.

PCAQR 1998-0649 designated boric acid leakage from the CRDM flanges for an apparent cause evaluation without CATPR, even though this was the second occasion in which the replacement gaskets for the flanges had experienced leakage.

Boric acid clogging of the radiation monitor filters was designated for an apparent cause evaluation without CATPR on CR 99-0882 and CR 99-0928 and was not classified as an apparent cause evaluation with CATPR until issuance of CR 99-1300.

PCAQR 1998-188s on the RC-2 valve was assigned a Category 1 classification.

requiring a root cause analysis. However, this occurred only after six PCAQRs had been issued during the previous five months on this same component before this categorization.

Additionally. during interviews, several of the managers acknowledged that adverse conditions are categorized and dispositioned as relatively low.

As discussed below, this low level of evaluation contributed to leaving boric acid on the RPV head and an improper diagnosis of the containment atmospheric conditions.

Determination of Causes for Adverse Conditions The Team evaluated the determination of causes for the adverse conditions associated with the RPV head and other boric acid issues.

The response to PCAQR %-OS 1, which documented boric acid left on the RPV head in lORFO in April of 19%. exemplifies the ineffective cause determinations related to the boric acid on the RPV head.

0 The RCS design engineer who performed the inspection of the RPV head and initiated the PCAQR stated that the condition of the area from which boron could not be removed is not known. He stated that since the boric acid deposits are not cleaned it is difficult to distinguish whether the deposits occurred because of the lealung flanges or the leaking CRDM [nozzles]. He also noted in evaluating the potential for damage to the RPV head from lealung CRDM flanges that this type of leakage damage is extremely difficult to measure because area of interest can not easily be inspected. Despite these statements, the RPV head was not completely cleaned and inspected or damage or leakage from the CRDM nozzles.

The station relied upon an engineering justification. which concludcd that the boric acid would result in negligible corrosion rates because the temperature of the RPV head was greater than 550 F. This evaluation of the potential for damage was inaccurate, as discussed in the Technical Root Cause Analysis Report.

Finally, although this PCAQR was designated for a root cause andysis, the PCAQR was downgraded and closed more than two years later without an approved root cause analysis, without determining whether the CRDM nozzles were lealung or the RPV head was corroding, and without any corrective action or action to prevent recurrence.

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With respect to the clogging of the radiation monitor filters, the station made several attempts to identify the source of the clogging. In particular, CR 99-1300 was issued for retuning radiation monitor fitter clogging, and was assigned apparent cause with comtive actions to prevent R o o t Cause Anawls Report 5.0 Data Analysis 43

recurrence. Evaluations of the iron oxide on the filters were performed by contractors, but the contractors conclusions were not utilized by the station. Additionally, the station used thermography and listening devices, which were not able to locate the source of the leak. In the end. none of the actions taken by the station were effective in identifying the source of the leak.

Additionally. although the initial CR on RC-2 valve leakage was issued on 5120198, a root cause for the problems with the RC-2 packing was not initiated until PCAQR 98-1885 was issued on 10/16/98. Packing issues were re-identified on RC-2 valve in 12RFO. CR 2000-1001 was wnrten on the RC-2 valve to identify the cause of the packing issues. This resulted in the third root cause analysis for [he RC-2 valve. which indicates the ineffectiveness of previous root cause evaluations and preventive act ions.

Similarly, Davis-Besse initiated several efforts to identify the cause of the increase in the unidentified RCS leakage, all which were not effective. Fmally. the station was not effective in identifying the source of boric acid leakage that lead to the accumulation of boric acid in the CACs.

These failures appear to be symptomatic of a larger problem with cause determinations, For example:

Quality Assessment issued SR-98-MAINT-07 on I/ 19/99 documenting weaknesses in recognition and oversight of collective significance issues and a need for guidance to emphasize managements responsibility for properly recognizing, documenting, and escalating issues and assuring timely corrective actions.

NQA issued audit AR-01-REGAF-01 on 12/26/01 and stated that collective significance CRs are not apparently categonzed consistently either by category or by evaluation method.

It also noted that only three of 32 collective significance reviews received some t p c of formal documented analysis, and that plant personnel have not been trained in any approach to the evaluation of collective significance problems. This report also identifies that the evaluation for basic and root causes were marginal and appeared to represent poor ownership.

NQA recommended use and documentation of fomal analytical method for all root and basic cause evaluations.

0 The Team concludes that the cause determinations for identified problems associated with the degradation of the RPV head and other boric acid issues were less than adequate dating back to at least 1996. This hampered the organizations ability to evaluate the potential for damage to the RPV head. (Root Causes 6. I.2.a arid 6.1.2.c) Furthermort. condition reports associated with this review tended to stay unresolved until significant degradation occurred. (Observation 6.3.5)

Corrective Actions The Team evaluated the adequacy of corrective actions for issues related to boric acid. As a result of this review, the Team identified a number of problems related to the adequacy of corrective actions.

The Team found that on a number of occasions. the plant was restarted without taking corrective action for identified boric acid problems. For example, the plant was restarted in IORFO, 1 IRFO, and 12RFO without fully removing the boric acid from the RFV head. Additionalfy, the Root Cause Analysis Report 5.0 Data Analysis 44