ML19224C953
| ML19224C953 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 04/25/1979 |
| From: | Dicey B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Grier B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| References | |
| TASK-TF, TASK-TMM NUDOCS 7907100315 | |
| Download: ML19224C953 (8) | |
Text
.
r c-
.s 8800g UNITED STATES y
NUCLEAR R EGULATOR Y COMMISSION f e ) P ((
o REGloN lil
~. 'y,1.p' ~j 79s noostvEtt no AD g%%g#g cLEN ELLYN ILUNOl5 60 t n April 25, 1979 t
MEMORANDUM FOR:
- 3. H. Grier, Director, Region I THRU:
g A. 3. Davis, Chief, Fuel Facility and Materials Safety Branch FROM:
Bruce 3. Dicey, Radiatica Specialist SU3 JECT:
REPORT OF ACTIVITIES AT ~~dREE MILE ISLAND This sie nry report of my activities, co = ents, and observations concerning Three Mile Island (TMI) is submitted per your request dated April 9, 1979.
I first arrived at the TMI site 3:30 p.m., March 30, 1979, and departed the site 3:30.p.m., April 7, 1979.
The specific times which I worked during that period are s a rized on the attached sheet.
My principal activity at TMI was the conduct of off-island environmental radiation measurements and assessments.
This consisted of direct radiation seasurements and the collection of environmental samples at various locations surrounding the T'II plant.
I also completed several special assignments, in addition to my routinely assigned responsibil:. ties.
The =ost significant special assign =ent was the preparation, with G. W. Kerr (SP), of a comprehensive "Su= mary of Iodine Situation," on April 2-3, 1979.
This si-,ary served as the basis for a special briefing given by Dr. Denton to the the President and to the press and was su-,ari::ed in PNO-79-67J, April 4, 1979. An additional ongoing special assign =ent was the coordination with G. T. Gibson (RII) of NRC and other Federal and non-govern =ent agency activities relative to the collection, transportation, and analysis of primary coolant, contain=ent gas, and other critical samples by the licensee and by Westinghouse Bettis Laboratory.
I have no specific com= ente regarding licensee operations at the site.
As a general observation, I feel that the licensee was hampered in his activities because of the large numba-of individuals and agencies de=anding the right of prior concurrence and/or notification concerning any action the licensee proposed to take.
The NRC was not alone in causing this problem - other Federal agencies, the Co=monwealth of 259 gog
't 9071003rq y,
B. H. Grier April 25, 1979 Pennsylvania, and non-government organizati 'ns all contributed.
Whenever a situstion of such magnitude, uniqueness, ad urgency as the accident at TMI occurs, it is easy to lose track of the fact that regulatory agencies in general are charged with evaluation and review functions.
I believe that all agencies responding to the TMI scene should have operated on the basic assumption that no one knew the situation better than the licensee, that the licensee would function to the best of his ability, with due regard to the health and safety of his employees and the public, and that responding agencies had a basic responsibility to evaluate the adequacy of the licensee's accomplished actions to assess the licensee's success or lack of success in carrying out his activities in accord with the various regulatory requirements, and to report on findings.
I do not believe that regulatory agencies should be placed in a situation where they are " running the show."
In connection with my above described special assignment regarding sample analysis, I personally received several telephone calls from licensee health physics personnel to the effect that requirements for licensee top management, IE, and NRR concurrence was delaying acquisition of a much needed second sample of primary coolant.
The licensee representative stated ma me that such =ulti-agency pre action concurrence was not normally required and that he felt such a requirement to be beyond the legitimate scope of authority of the agencies involved.
An NRC Reactor Operations Inspector, who I prefer not to identify, told me that the NRC was directly causing increased personnel exposures in that similar delays in deciding upon the "best" way to pu=p gases from the Unit 2 Waste Gas Decay Tank into containment caused the radioactive gas to be held in an area having reduced shielding longer than should have been necessary.
In addition to the above, I have a number of observations and comments concerning II and NRC activities at TMI.
These are in the general areas of NRC preparedness and the general concept of operations.
Based on my extensive emergency planning experience prior to joining NRC, I must conclude that NRC preparedness and the initial NRC response to TMI was very poor at worst and minimally adeaunca at best:
Cpecific problem areas and rece==endations are as rollows:
a.
Lines of Authority E=ergency planners generally agree that one crucial element of a good emergency response plan is the existence of predetermined, clearly defined lines of authority.
Such was not the case during the early NEC response at TMI.
A general sence of confusion and lack of direction prevailed.
This deficiency in preparedness resulted in the public receiving conflicting information from nu=ercus sources.
Such conflicting information increased the public anxiety concerning the accident.
As extensively documented 259 209
- 3. H. Grier April 25, 1979 by the press, one did not know who to believe, especially in the crucial first hours and days following the accident.
Which story was accurate? The licensee's? The NRC's? The States?
In order to praclude such proble=s in the future, I recommend that specific agree =ents be for=alized between NRC, licensees, States, and other Federal agencies.
These agreements should clearly define the precise organizational elecent which will assume the lead public infermation responsibility.
There should be only one " official" source of infor=ation, and this should be co==unicated to the =edia representatives with the first public announcement of an emergency situation such as TMI.
Such was not done until several days af ter the fact.
Also related to the problem of poorly defined authority is an observation that =any organizational elements of NRC and other federal agencies involved in the response seemed to be interested in insuring that their " piece of the action" was fir =ly established.
In =any cases th'.s resulted in needless duplication of effort.
As one examp'.e. numerous requests were received for individualized chronologies.
These came from IE Headquarters personnel (several different rar,uests), RI, NRR, and others.
In many cases, infor=ation would be furnished to IE Headquarters by direct telephone, only to have RI call a few =inutes later requesting exactly the same information, to assist them in preparing a response to IE Headquarters.
Another example is the reporting of the results of environmental TLD analyses.
The initial instruction was to transmit the results to RI by facsimile.
RI was then to re-transsit the data to Headquartera.
On one day the TLD results were late in arriving at the TMI site and Headquarters telephoned to obtain information to assist in preparing the next day's TN.
The requested information concerning specified TLD locations was furnished.
About 10 minutes later, RI called and asked for the same information, stating that IE Headquarters had asked them for it.
Th e next day, the procedure had been changed to require reporting of the specified data points to both RI and IE Headquarters by telephone upon receipt and transmittal of complete results to RI.
By the following day, the selected data points were being reported to both RI and Headquarters and complete TLD results were being transmitted to both locations directly from the TMI site.
A third example of needless duplication of effort is the observation that, in many cases, the IE environmental survey team would follow a DOE environ =cntal 59 '?: r.
iJ
B. H. Grier April 25,1979 servey tea =, gathering duplicate infor=ation concerning radiation levels at the same points.
One individual co==ented "how =any ti=es do you have to measure background?" I reco==end that direct ec==unication to the site of any future accident be strictly controlled and that Headquarters and F.egional personnel obtain desired infor=ation to the =aximu= extent possible fro = a central clearing point. Also, there, should be coordinaticn cf efforts by all Fcaeral agencies on site so as to avoid needless duplication of efforts.
b.
Co==unications Cc==unication capability was poor, especially in the early days after the accident.
This fell into several areas:
(1) Radio Initially, the only two-way radio co==unication available to IR was hand held citicens band "walkie talkies." These had a range of perhaps one half =ile.
The NRC was fortunate that no =ajor forest fires were burning at the time and the U. S. Forest Service was able to loan = ore sophisticated co==unications equipment for our use.
The cooperative efforts of the U. S. Forest Service cre certainly to be co== ended.
Yet, even their sophisticated radio equipment did not resolve co==unications problems.
On numerous occasions, lengthy technical conversations were heard between NRR personnel and the control roo=.
This practice net only prevented others fro = using the frequency, but also served as a source for the inadvertent release of infor=ation to the press.
On at least one occasion, a newspaper published a transcript of a radio conversation which they had monitored and used that transcript to depict the NRC's
" official" position as contradicting the "true" position.
If potentially sensitive information =ust be co==unicated by radio or telephone, provision should be =ade for some type of co==unications security.
Portable scra=bling equip =ent is co==ercially available and should be used.
I also reco==end that the NRC obtain its own radio co==unication equipment sc that it will not be necessary to rely on the chance that another federal agency will be able to provide us with this capability on short notice.
259 21i
B. H. Crier April 25, 1979 e
(2)
Maps There was no standardization on maps being used by the licensee or by other agencies including IE.
Several completely different maps were in use at any given ti=e.
Some of these included maps provided by the licensee, the Army Map Service, the State of Pennsylvania, the local Chamber of Coc=erce, nearby gacoline stations, and even soce clipped out of the newspapers.
I have no knowledge as to what saps were being used by Headquarters or RI personnel.
This made cocaunication of off-island locations extremely difficult.
I reco==end that the NRC develop agreements with licensees as to the specific =aps, perhaps those of the Army Map Service, to be used in the event of an e=ergency.
These standardized =aps should be pre-positicued at Headquarters, the Regional Offices, and at the licensee's f acility in suf ficient copies to support an operation such as the TMI response.
(3)
Telechone The unsung heroes of TMI must surely be the Pennsylvania 3 ell Telephone Company.
Based on the experience at TMI, telephone ec=panies serving areas surrounding nuclear power plants should be furnished with detailed specifications as to the services they may be called upon to provide in the event of an emergency.
This should include not only general telephone service, but anticipated requirements for facsimile transmission lines and for dedicated circuits to the State Capitol, The White House, the Regional Office, and to NRC Headquarters, as appropriate.
On balance, after some initial problems, telephone service provided was superb.
c.
Analytical Laboratorv Services The services of Westinghouse-3ettis were utilized for analysis of a number of critical samples including primary coolant and containment gas.
While I can certainly sympathize with the extreme pressure under which Bettis was working, errors were made in reporting several crucial test results which had an adverse impact on decision making.
Specifically, Bettis originally reported baron in the primary coolant as 875 parts per million (ppm).
This report resulted in a great deal of effort being expended at atte= ping to obtain a second sanple of primary coolant.
Fortunately, before the second sample was drawn, Bettis discovered 259 2i2
B. H. Grier April 25, 1979 that they had made an error in dilution and reported that the correct boron level was 1,750 ppm instead of 875.
This relieved a great deal of the pressure to obtain a second primary coolant sample. Another analysis was reported and later changed by Bettis. This involved isotopic analysis of contaic=ent gas.
After the initial report, Bettis discovered that they had used the wrong total volu=e of gas in calculating concentrations.
The corrected results were different from the initial report by several orders of =agnitude.
Both of these errors were due to elementary arithmetic nistake).
It is recogniaed that for sote tests, an expression of the order of magnitude cade be all that is required for the decision =aking process, while extrece accuracy say be essential for other analyses.
Agencies providing emergency analytical laboratory services should be advised as to the degree of accuracy desired, the relative priority of each requested analysis, and the time by which a report of results is required.
d.
Meteorolo2v Meaningful evaluation of radiation released to the environment requires current, accurate meteorological data.
NRC has no organic capability for providing such data to survey teams or to those evaluating radiation due to the plume. Total reliance was placed on data obtained from the licensee.
It was fortunate that the accident occurred at a facility having two units.
Had there been only a single unit, licensee and in-plant NRC personnel would have.been too busy to provide the needed meteorological data in anything resembling a timely manner.
I recoc=end that the mobile laboratories of each NRC Region be provided with the necessary equipment to measure wind direction and speed.
This equipment is co==ercially available at moderate cost.
e.
General ?recaredness The General Accounting Office and the media have made much of the overall poor state of emergency preparedness on the part of NRC and the Cocconwealth of Pennsylvania.
I have outlined in this =ecorandum some of my observations cor:erning this sace subj ect.
In reviewing my observations and recollections of my experience at TMI, I feel that much more intensified effort must be devoted to all aspects of emergency preparedness.
This is of such extre=e i=portance that I recocmend that the NRC not issue an operating license to any applicant unless the NRC has reviewed and concurred with the emergency plans of both the applicant and the state in which the applicant's facility is located.
259 213
- 3. H. Grier 7-April 25,1979 Da a personal note, I welecme the opportunity which you have provided to relay my co==ents and observations regarding TMI.
I have outlined them in a spirit of constructive critique.
I view this matter so seriously that even prior to receiving your April 9,1979 =e=orandum, I considered documenting my concerns and observations in the form of a personal letter to the Commission. Your memorandum will greatly facilitate consolidation of my views with those of others into a =ost effective after action report.
$~.68 3ruce 3 Dice Radiation Speu.alist Attach =ent:
Ti=e Sn-~ary cc w/ attach =ent:
James G. Keppler 6
SU_MMARY OF TOTAL HOURS WORKED, OVERTIME HOURS WORKED, AND PREMIUM PAY HOURS WORKED MARCH 30 - APRIL 7, 1979 ON-SITE ON-SITE ON-SITE DATE HOURS WORKED NIGHT WORK SUNDAY WORK OVERTIME HOURS OVERTIME HOURS (NRCM-4136-(NRCM-4136-WORKED WORKED OTHER 0510) 0511)
(TOTAL)
THAN NIGHT OR SUNDAY HRS--
3/30 7:00 AM -
6.0 0
9.5 2.5 Midnight (17 hrs) 3/31 Midnight -
7.5 0
11.0 3.5 1:30 AM and 3:30 PM -
Midnigh t (11 hrs) 4/1 Midnight -
7.5 11 11.C 0.0 1:00 AM and 2:30 PM -
Midnight (11 hrs) 4/2 Midnight -
7.5 0
Midnight (11h hrs) 4/3 Midnigh t -
12.0 0
10.5 2.0 8:30 AM and 2:00 PM -
Midnight (18 hrs) 4/4 Midnight -
7.0 0
Midnigh t (11 hrs) 4/5 Midnight 7.0 0
Midnight (11 hrs) 4/6 Midnight -
7.0 0
Midnigh t (11 hrs) 4/7 Midnight -
1.0 0
3:30 PM (2 hrs)
DIRECTID TRAVEL AFTER HOURS:
~~
3/30 1 hr 1.0 4/7 4 hrs 4.0 3.
Dicey 259
,21gJ