ML19308B848
| ML19308B848 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 07/25/1975 |
| From: | Trickler L NRC OFFICE OF INSPECTOR & AUDITOR (OIA) |
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| References | |
| TASK-TF, TASK-TMR NUDOCS 8001170436 | |
| Download: ML19308B848 (16) | |
Text
,
r s REPORT.OFlINVESTIGATIONl Office of Inspector and Auditor U. S. Nuclear Regulatory Commission
Subject:
[Michelson Reporti-Events and Levels of Review p
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Contact:
Lawrence J. Strickler, OIA Date:
July 25,1979 49-27170 80012 7o 4 3 g
Table of Contents Pages 1
Sumary 1
I.
Reason for Investigation 2
II.
Background
3 III. Details 13 IV.
Coment 14 Attachments s
m D
e
SUMMARY
The Nuclear Regulatory Commission's (NRC) Office of Inspector and Auditor (01 A), pursuant to an agreement with the Office of Inspection-and Enforcement (IE), initiated an investigation to chronologically establish the events and levels of review, prior to the accident at Three Mile Island (TMI),
f regarding the analysis of the report, " Decay Heat Removal During a Very Small Break LOCA For A B&W 205 Fuel-Assembly PWR."
Afhandwritten draftlof the report was prepared iniSeptember of'1977 by
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Carlyle Michelson, who is both an employee of the Tennessee Valley Authority (TVA) and a consultant to the Commicsion's Advisory Committee onReactorSafeguards(ACRS).
It concerns the susceptibility of certain
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Babcock and'Wilcox (B&W) to small pressurized water reactors designed by(LOCAs).
pipe break loss of coolant accidents In or arouni0ctober ofil977; a copy of Michelson's handwritten draft was made available, through a member of the ACRS,tto staff of the NRC's, Office of Nuclear Reactor Regulation (NRR). The ACRS member used it
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himself,, in theifalliofr1977, to3 pose certain questions addressed to;B&W and the. Pebble Springs applicant.
E0nlytwomembersofitheNRR'staffknewof,andhadcopiesof,Michelson's
, draft. _It received only a1 limited review and those who examined it saw knothing in it that aroused their concern.
One of the reviewers prepared asnote. dated January 10,1978 which effectively treated the chief concern raised in the draft; however, the writer of the note cannot recall if he actually wrote it as a result of his reviewing the Michelson draft, or whether some other circumstance / situation induced him to write
_i t. Approximately 15 staff members received the note. tNone of its recipients took action as a result of ;it and the significance of its content was not fully appreciated until after the accident at TMI.
InlJanuaryil9781 Michelson prepared altyped final versionlof his report.
F Although a copy of it was providedsto the same ACRS member!who had been furnished with the earlier handwritten version, it wasinot disseminated elsewhere within the NRC.
I On May 1, 1978, the typed final version of Michelson's report was sent by.TVA to B&W, B&W was requested to respond to the concerns addressed in the report.
The B&W reviewer did not see the. report as raising a substantial safety issue and assigned its response;a low priority. The reply, which was dated. January 23, 1979,' did not satisfy all of Michelson's concerns and he prepared aLsecond letter; requesting further " clarification and additional explanation." The TMI accident occurred before this letter was replied to.
I.
REASON FOR INVESTIGATION In the fall of 1977, a report was drafted by Carlyle Michelson who, both at the. time that,the. report was drafted and now, is alTVA employee.
, Land.a consultant toithe NRC's ACRS. The report entitled, " Decay I! eat Removal
2 During A Very Small Break LOCA For A B&W 205 Fuel-Assembly PWP.," raised concerns of apparent relevance in the wake of'the accident at TMI.
IE, consistent with its functional responsibility, initiated an investigation to determine if any reporting failure might have occurred, regarding the Michelson report, that was contrary to the requirements of Part 21,10 CFR and/or 10 CFR 50.55(e).
By agreement between IE and OIA, an investigation was also made to chronologically determine the level of NRC staff knowledge of the report and actions taken, if any, _ prior to the TMI accident (see ). This latter investigation, the results of which follow, was undertaken by 01A.
II.
BACKGROUND The purpose of this investigation was to attempt to chronologically reconstruct, up until the March 28, 1979 accident at TMI, the events and levels of review regarding the analysis of Carlyle Michelson's report,
" Decay Heat Removal During A Very Small Break LOCA For A B&W 205 Fuel-Assembly PWR."
In keep.ing with this purpose, an effort was made to establish the rationale for certain actions taken by cognizant individuals in the chain of review.
A somewhat parallel investigation was conducted by IE to determine if any reporting failures might have occurred, relative to the Michelson report, that are contrary to Part 21, 10 CFR and/or 10 CFR 50.55(e).
In attempting to reconstruct, 0IA utilized interviews and documents.
In addition to interviews conducted specifically by OIA, interviews conducted by IE in support of their Part 21/Section 50.55(e) investigation were also used if their content had an apparent bearing on the intended reconstruction.
Interviews of the following principals were-utilized in the reconstruction:
Carlyle Michelson - TVA Engineer /ACRS Consultant; Robert C. Jones - Senior Engineer, B&W Nuclear Engineering Group; Jesse Ebersole - ACRS Member; Sanford Israel - Section Leader, Reactor Systems Branch, Division of Systems Safety, Office of Nuclear Reactor Regulation; Gerald R. Mazetis - Section Leader, Reactor Systems Branch, Division' of Systems Safety, Office of Nuclear Reactor Regulation; Scott Newberry - Reactor Engineer, Reactor Systems Branch, Division of Systems Safety, Office of Nuclear Reactor Regulation; Thomas M. Novak - Chief, Reactor Systems Branch, Division of Systems Safety, Office of Nuclear Reactor Regulation;
.3 Algis J. Ignatonis - Senior Reviewer, Reactor Systems Branch, uivision'of Systems Safety, Office of Nuclear Reactor Regulation; Denwood Ross - Deputy Director, Division of Project Management, Office of Nuclear ' Reactor Regulation; and Roger J. Mattson - Director, Division of Systems Safety, Office of Nuclear Reactor Regulation.
In conducting this investigation, all efforts were directed toward the primary objective, i.e., reconstruction of events and levels of review, and no attempt was made to address the appropriateness of management judgments or the adequacy of procedures for dealing with issues such as the Michelson report. Procedures or the lack of procedures, however, did impact upon events and levels of review and; therefore, were addressed and discussed by some of the interviewees.
The following Section consists of information obtained from the principal interviewees..
III.
DETAILS INFORMATION OBTAINED FROM CARLYLE MICHELSON, ACRS CONSULTANT /TVA ENGINEER See Attachment 2: May 21, 1979, Interview of Michelson.
See Attachment 3: June 11, 1979, Interview of Michelson.
See Attachnent 4: June 13, 1979, Memorandum from Michelson to ACRS,-
~4 regarding his views on reporting requirements.
Michelson first became interested in the general topic of small pipe break LOCA's in aoout 1974. This was while he was employed by the TVA but prior to his consulting association with the ACRS, which began in November 1976.
In May 1977, Michelson wrote a report on the susceptibility of certain Combustion Engineering (C-E) reactors to such phenomenon.
He began to suspect that B&W reactors were more susceptible than C-E reactor.c to these problems and in September 1977, drafted a report expressing his concerns. He discussed them with Jesse Ebersole, a member of the ACRS, who had been his former supervisor at TVA. He also gave Ebersole a copy of his handwritten draft (Attachment 5).
This occurred sometime in the fall of 1977.
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4 At Ebersole's suggestion, Michelson prepared a typed, less speculative version of his September 1977 handwritten report.
He gave a copy of it to Ebersole in early 1978. He did not know what use Ebersole made of it; however, he recalled that the ACRS, in the fall of 1977, asked Portland Gas and Electric Company at least one question which was based on his draft report.
With the exception of Ebersole, Michelson had no contact with the NRC, either.. formal or informal, regarding his concerns.
He is_of the opinion (that no forum exists,within the regulatory system.to. address and resolve
( many safety related concerns such as.the_ type typified by his'small ibreak analysis.
In January 1978, Michelson's typed report was entered into the TVA Word One computer file.
Between January 1978 and..pril 27, 1978 he had several discussions within TVA about the merits of his report and the best course of action to take regarding it. The highest level of super-vision with whom he discussed it was his immediate supervisor, E. G.
Beasley, Head, Nuclear Engineering Group.
He does not know whether it was discussed at higher levels of management; however, a letter which he drafted to B&W which addressed his concerns was signed by D. R. Patterson, Chief of the Mechanical Engineering Branch, TVA.
It was dated April 27, 1978 (Attachment 6).
Michelson said that between April 1978 and December 1978, he asked TVA Contracts to contact B&W on at least six different occasions to stimulate a response to his questions.
On December 10, 1978, he transmitted a one page summary of his concerns to B&W via facsimile.
He did not receive a written reply until January 23, 1979.
Feeling that this reply (Attach-ment 7) was not entirely responsive to his concerns, he authored a second letter which was mailed to B&W on February 8,1979 (Attachment 8).
In it, he asked B&W to reconfirm their position and to provide a written response by March 15, 1979. At the time of his May 21, 1979 interview, he claimed that B&W had not yet responded to that letter.
INFORMATION OBTAINED FROM ROBERT C. J0NES,* SENIOR ENGINEER, BABC0CK AND WILC0X (B&W) NUCLEAR ENGINEERING GROUP, LYNCHBURG, VIRGINIA See Attachment 9: May 29, 1979, Interview of Jones.
Jones received the Michelson report in early May 1978, and was assigned responsibility for responding to the questions which it raised.
He was quite busy at the time on a small break analysis project that i
prevented him from paying immediate attention to the report.
- However, l
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- Attachment 10 is a copy of IE's investigation into possible violations of Part 21,10 CFR and/or 10 CFR 50.55(e).
Pages 5, 6, 8, and 9 of this Attachment contain interviews of other B&W officials and should be reviewed as an adjunct to this chronology.
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5 sometime in the period of May-June 1978, he gave it a cursory review and preliminarily decided that although some.of the concerns' appeared to be valid, he did not see that they had significant safety implications.
On the basis of that detennination, and not considering that the report
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brought anything new to, light, he assigned the response to the report a very low priority and so informed his supervisor, Bert Dunn, Manager of the ECCS Analysis Group.
Jones indicated that until the fall of 1978, notwithstanding many reminders from Robert Lightle, Project Management Group, he.was too busy on other projects to reply to TVA.
He said that he finally prepared a response in December 1978 that formed the basis of B&W's January 23, 1979 letter to TVA.
He was also assigned the action to respond to the resulting February 8, 1979 TVA letter. He considered it a low priority assignment.
Due to the TMI accident and the work that i't engendered for him, he did not have time to draft a formal reply to TVA.
INFORMATION OBTAINED FROM JESSE EBERS0LE, ACRS MEMBER See Attachment 11: June 4, 6, 6, and 7,1979, Interview of Ebersole.
In the fall of 1977, Carlyle Michelson drafted a report regarding the vulnerability of certain B&W reactors to small pipe break loss of coolant accidents (LOCA) and the attendant consequences'of such LOCA's upon the emergency core cooling process. Michelson felt that the report was significant and brought it to Ebersole's attention, providing him with a handwritten draft.
Its contents fit in with Ebersole's interests and, i
in fact,;Ebersole used it in his capacity.as;an.ACRS member to. pose i
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Jquestions Six and Twelve of a set of written questions' addressed to B&W, tand the Pebble. Springs applicant, Portland General Electric Company (Attachment 12).
-In order to. avoid a'ny' delays in getting Michbison's report processed, i Ebersole gave it. to Sanford Israel, NRR.~ In thelabsence of.proceduresi
( governing tha processing of such reports, and not being aware of any guidelines to the contrary, Ebersole thought that providing Michelson's report to nRR was the logical thing to do. He gave it to Israel specifically because, based on prior dealings with Israel, he knew him to be a highly educated mechanical engineer, a concerned employee, and a good listener.
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The handwritten report which Ebersole gave to Israel was the very same copy which Michelson had given to Ebersole. The diagrams / charts were all carefully prepared, colored and vivid, designed to improve clarity and to enhance the reviewers understanding of the writer's intent.
By note dated October 21,1977 (Attachment 13), Israel returned the report to Ebersole with the advice that he had not yet had time to study the report but that he had made a copy.
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Ebersole said that as far as he now knows, there isEno organizationSl'
.l entity within.the.NRC: regulatory. process responsible _ for handling system'
, ! interactions as a line~ review. process or ~for. conducting integrated-b systems analysis.
He thinks that this is one of the reasons why valid safety concerns, such as the type addressed by Michelson, may not receive necessary attention. To illustrate, Ebersole said that he had recently seen a copy of a January 10, 1978 note (Attachment 14), apparently prepared by Sanford Israel, over the signature of " Thomas M. Novak, Chief, Reactor Systems Branch." The note is to "RSB Members." Ebersole explained that the one page note, along with its enclosure of a schematic of a pressurizer, very effectively treats the chidf concern raised in Michelson's September 1977 draft.
Ebersole said that the correctness of his 1977 decision to furnish Israel with Michelson's report is confirmed by the timeliness and thoroughness with which Israel presented the data; however, the fact that the note only went to "RSB Members" demonstrates a deficiency of organizational entity and procedures for dealing with such data.
INFORMATION OBTAINED FROM SANFORD ISRAEL, SECTION LEADER, REACTOR SYSTEMS BRANCH, DIVISION OF SYSTEMS SAFETY, NRR bee Attachment 15: June 12, 1979, Interview of Israel.
In the fall of 1977, Israel obtained a copy of a handwritten draft of Michelson's report from ACRS member Jesse Ebersole.
Ebersole contacted him about small break prcblems and told him that he had a report which he wanted to send to him. He told Israel that he would like him to read it and Israel presumed that Ebersole ultimately wanted to discuss it with him. He had not previously received such reports from Ebersole but has informally been furnished with copies of reports by at least one ACRS consultant.
Israel said that Ebersole mailed the report to him.
He thumbed through
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it and read parts of it, looking for something "new and different." He viewed it from the perspective of a small break issue and did not see anything in it that was different. He knew that Ebersole was concerned about loss of natural circulation. Israel was not concerned about this.
He also knew that Ebersole was concerne'd about "non-condensibles" and he was not.
Israel said that'one1 reason lwhy he. probablyLdid:not proceed)
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further at the time was because the Pebble Springs meetings had come up)
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U; and one agenda item pertained to a_ written question' initiated by Ebersole
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E which dealt.with small _. breaks.
Israel does not recall giving copies of the report to anyone else but was recently reminded by an associate, Section Leader Gerald Mazetiz, that he had given a copy to Mazetiz.
Israel wrote a January 10, 1978 dated note to "RSB Members," which was signed by his Branch Chief, Thomas M. Novak. The subject was entitled,
" Loop Seals In Pressurizer Surge Line." He reviewed the note sometine l
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7 after the accident at TMI.
Now that he has reviewed it, he cannot recall what prompted him to write it. He does not know if it was predicated on his skimming of the Michelson report, on his knowledge of a stuck open relief valve incident at David Besse in 1977, on his seeing questions posed by Ebersole to the Pebble Springs applicant, or on a combination of two or all of the above items.
He always associated the Michelson report with the larger issue of small breaks, while his 1978 note was associated with " manometer and the fact that a pressurizer can behave like a manometer under certain conditions."
At the time that he wrote the note, he does not think that any B&W plants were under active review. He assumes that he wrote it, when he did, tecause the issue was fresh and could be used as a reference the next time that a B&W plant came under review. He said that although he could have furnished a copy of his note to B&W or called B&W to solicit their comments, such action would not have been consistent with daily practice and, at the time, was not considered.
His note went to about '15 Branch employees and no technical interest was
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.apparently engendered in. those who read it.
Israel speculated that such
' inaction might be attributed to the fact that the recipients were all:
thusy with other. responsibilities andithat the note did.not fix hard-e responsibility on the part of any one individual for. further action.
He expressed his belief _ that the realities of the way NRC/NRR does_ business necessitates that,1f something "does not jump out at you -_ move on."
If not, the licensing process would never be completed.
Israel advised that he was not aware of any relevant guidelines or procedures directing how such informal material was to be handled.
In reflecting on the Michelson draft, he expressed the opinion that one problem was that there were so many things in it.
He felt that it was very qualitative and that most people were not willing to go through the mental gymnastics necessary to fully analyze it.
Israel felt that if no action could be engendered as a result of his own January 1978 note, which he felt efficiently and succinctly addressed the main problem, then it was certainly unlikely that any would be engendered by the Michelson draft.
INFORMATION OBTAINED FROM GERALD R. MAZETIS, SECTION LEADER, REACTOR SYSTEMS BRANCH, DIVISION OF SYSTEMS SAFETY, NRR See Attachment 16: July 2,1979, Interview of Mazetis.
In 1977 or 1978, Mazetis received a copy of Carlyle Michelson's draft report from Sanford Israel, an associate Section Leader in the Reactor Systems Branch.
Israel received the draft report from ACRS member Jesse Ebersole.
Mazetis-thinks Israel gave him the copy.of the report l
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,sometime _ prior.to the Pebble Springs hearing.
He is of the opinion that JIsrael.gave it~to,him1because he wanted to let Mazetis know what issues:
.mmight be discussed in future ACRS meetings on B&W plancs. Mazetis thinks that at the time he received the report, Israel's Section had one B&W plant under review and his Section had one or two.
Initially, Mazetis said that he might have glanced through the report but did not remember reviewing it in detail.
However, upon reviewing his copy of the report, it was determined that he had intermittently made notations and had otherwise marked pages throughout the report.
Mazetis said that the ACRS asked the staff a number of questions on Pebble Springs which included issues raised by Michelson. The staff forwarded the questions to the Pebble Springs applicant, and B&W prepared responses. ) Scott Newberry, the member of-Mazetis',Section _ responsible;
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, for matters. relating.to B&W designed plants, reviewed the: responses.
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,Mazetis said that heldid not give Newberry a copy of the Michelson ireport;in connection with this review but assumes that he would have told Newberry of its existence.
Aside from Newberry, he did not discuss it with, or provide copies of it to, anyone else.
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Mazetis said it is his belief thatihad the Michelson. report been formally;
[ received, it would have been assigned and>prioritized by NRR Director.
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." Harold.Denton." This _would have made it a: recognizable. work package, land the responsibility of a designated groupLwithin NRR. He stressed that at the time that he informally received the report, it was his responsibility to address work which had been prioritized by "Denton" and; therefore, he could not adequately address the report.
He confirmed, however, that the staff frequently receives informal questions from ACRS members.
Mazetis said that in -January 1978lhe received thelJanuary 10,1978. note to "RSB Members" entitled, " LOOP SEALS IN PRESSURIZER SURGE LINE," which was drafted by Israel and signed by Branch Chief Thomas Novak.
At the time of its receipt, his Section was conduct _ing an operating license review for the B&W designed Midland facility.
He said'that they were at the right stage in the review to ask questions _of the applicant, consistent
, with the suggestion in Israel's note. !He. believes that_ such, questions 3
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L were asked.!
Mazetis said that issues, such as the concerns expressed by Michelson, are not forwarded to the Regulatory Requirements Review Committee unless the staff first determines that they are significant enough to require "backfitting" to other plants.
O e
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9 INFORMATION OBTAINED FROM SCOTT"NEWBERRY, REACTOR ENGINEER, REACTOR SYSTEMS BRANCH, DIVISION OF SYSTEMS SAFETY, NRR.
See Attachment 17: July 6, 1979, Interview of Newberry.
Until July 1, 1979, when Newberry was reassigned to a 'pecial TMI related s
study group, he was a Reactor Engineer with the Reactor Systems Branch, and had maintained that title and function since prior to January 1978.
Newberry said that before TMI he had not read, seea, or even heard of the "Michelson Report." He said that while at TML, after the March 28, 1979 accident, he heard of the report but has not read it.
In January 1978, Newberry received that note dated January 10, 1978 entitled, " LOOP SEALS IN PRESSURIZER SURGE LINE," which was prepared by Sanford Israel, signed by Thomas Novak, and addressed to "RSB Members."
He does not know what specifically caused Israel to write the January 1978 note and confirmed that there was no staff discussion of the note subsequent to its receipt by the staff.
He said that the first opportunity he had to take action on the recommenda-tion in Israel's note was in regard to the OL (Operating License) review of; Midland, which began in about the same time frame in which he received the note. He said that he 'cannot _ recall _ having-preparedL any questions based on the recommendation in Israel's note but that Midland is'still under review and that the process of asking questions is still continuing.
Newberry said that as far.as he. personally knows, there is!no formal iprocess for bringing those concerns which arise:during either a_CP (Construction Permit) review or_an OL_ review, to the attention of_ person-
- inel responsible for operating reactors with the same or a similar design.
j INFORMATIONOBTAINfDFROMTHOMASM.bl0VdK', CHIEF,REACTORSYSTEMSBRANCH, j
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DIVISION OF SYSTEMS SAFETY, NRR See Attachment 18: June 19, 1979, Interview of Novak.
Novak said that he never1 read, or even. heard of, the Michelson report prior to the accident at TMI.
Since TMI, ~ha is. knowledgeable"of the report's existence, but has not studied it in any detail.
He said that the January 10, 1978 dated note, entitled, " LOOP SEALS IN PRESSURIZER SURGE LINE," was drafted by Sanford Israel, who at the time, was a Section Leader in Novak's Branch..He did not know what had motivated Israel to prepare this particular draft and he was r.ot concerned about its technical aspects when he first received it.
He said that the presentation of the information in Israel's draft "didn't really smack of a serious safety concern" but, rather, indicated the' possibility of a hypothetical problem that merited some consideration.
It was Novak's
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dj
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intention to alert the people in his Branch to the possible concern expressed in. Israel's draft by " putting it into the review process."
This wouldienable his people to " add questions.in their case work"' to see what they could learn.
He did not modify it in any way, just had it typed in final for his signature.
In addition to Branch members, Novak also designated a copy for his supervisor, Denwood Ross, to alert him to what was being done.
The recipients of the note were apparently not struck by the significance of anything in its contents.
Few, if any, B&W plants were being reviewed at this time and Novak thinks some people probably set the note aside because it was not immediately relevant to anything that they were doing.
He is not aware of any questions which were developed by the staff to pursue the design adequacy of B&W reactors.
Novak also speculated that the importance of the note was not readily understood because a certain amount of time-consuming analysis was required before its signifi-cance could be adequately appreciated.
Novak said that in' retrospect,.he should have sent theinote to NRR's
, Division'of Operating Reactors'(DOR) with a memorandum recommending that
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D0R follow up on the concern, with the operators (licensees).
He does not know if the operators would have been energized by the contents of the note, but speculates that they would have gone to B&W for B&W's comment.
It is Novak's supposition that if B&W had been contacted by the operators, and if B&W had then maintained a relaxed posture regarding the contents of the note; further action would not have been taken by the operators.*
INFORMATION OBTAINED FROM ALGIS J. IGNAT0NIS, SENIOR REVIEWER, REACTOR SYSTEMS BRANCH, DIVISION OF SYSTEMS SAFETY, NRR See Attachment 19:, rJune 25,1979, Interview of Ignatonis.
Ignatonis said that in January of 1978, as now, he was a Senior Reviewer with the Reactor Systems Branch (RSB).
In that capacity he, as well as other members of the RSB, received a note dated January 10, 1978 which was prepared by RSB Section Leader Sanford Israel and signed by Thomas M.
Novak, Chief, RSB.
The subject of the note which pertained primarily to B&W designed reactors, was, " LOOP SEALS IN PRESSURIZER SURGE LINE.".
Within its last paragraph was a sentence which recommended that, "the!
lbases (sic)!for the design requirement be studied carefully for all CP reviews with the object of determining if the loop seal can be eliminated."
Ignatonis does not know what precipitated Israel to write up this note.
At the time that he received Israel's January 10 note, Ignatonis was conducting a CP review, of the Sundesert Applicant.
In accordance with
- Novak was not aware that Michelson's typed report had been submitted directly to B&W, by TVA, for review and coment.
11 iwar above quoted recommendation in Israel's note and.even thoughl the a
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Westinghouse design Ignatonis prepared a relevent draft question _
for submission to, and response by, the Applicant.
He then submitted his list of draft questions, the one predicated on Israel's note and others, to Emanual Licitra, the NRC's Sundesert Project Manager, Division of Project Management, NRR.
Licitra reedited Ignatonis' draft questions; however, Ignatonis said they were never sent to the Applicant, since State of California decisions resulted in a cancellation of the Applicant's plans.
INFORMATION OBTAINED FROM DENWOOD ROSS, DEPUTY DIRECTOR, DIVISION OF PROJECT MANAGEMENT, NRR See Attachment 20: June 18, 1979, Interview of Ross.
Ross advised that since the accident at TMI he has seen and read both the report which Michelson issued in early 1978 and its predecessor draft, issued in. late 1977. He was unaware of the existence of either product prior to TMI.
He does not recall receiving a copy of the January 10, 1978 dated note to "RSB Members" entitled, " LOOP SEALS IN PRESSURIZER SURGE LINE" which was prepared by RSB Section Leader Sanford Israel and signed by Branch Chief Thomas M. Novak.
Even though Ross does not specifically recal" the receipt of this note, he does not doubt that he received it sinr.e it reflects that he was designated to receive a copy in his then capacity as Assistant Director for Reactor Safety, Division of Systems Safet/.
Ross said that he does not think that he took any action on the" Jan1ary I'0 tnote.' His rationale for this opinion was that he thinks the note, while
, capturing one oflMichelson's primary concerns,!does not sufficientJy J raise the. consciousness of:the reader. He bs11 eves, however, that,the e 1978 Michelson report has a different impact on the reader.
He cannot
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say if Michelson's 1977 handwritten draft would have moved him as nuch as the typed report did, b'ecause he read the type? fersion first a1d his opinions had already been. formed by the time he examined ths draft. He
, feels that the report. raised some good ' concerns.about. how B&W plants)
- . perform, i.e., "how safe they are." He believes that if he had sqen the report in 1978 he would have been stimulated to go further with it.
In. regard to the adequacy.of_currenEprocedures~ for providing.'assWanc^es; Ros
- that available reports are properly screened for safety concerns,'we
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,said, "I know there's a need for_something_a. lot better than what
- have." To illustrate such need, he made reference to a report published by Sandia Laboratories, predicated on an NRC funded study, which addressed the environmental qualification of connectors.
Although the report was l
distributed within the NRC, no safety action was taken until after the Union of Concerned Scientists filed a petition to close a number of t
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12 reactors because, based on data presented in the report,.the possibility was raised that electrical connectors in reactors would not withstand the accident requirement necessary.
Ross also explained that current procedures are such that if a consultant prepares a report for the ACRS, a copy comes to NRR "in some kind of haphazard manner, but it is not rigorously distributed or analyzed." He said that while he had no immediate solutions to recomend, he felt it was more important that there be an awareness and appreciation for the need to improve the NRC's safety screening processes.
INFORMATION OBTAINED FROM R0GER J. MATTSON, DIRECTOR, DIVISION OF SYSTEMS SAFETY, NRR See Attachment 21: June 22, 1979, Interview of Mattson.
Mattson said that prior to the accident at TMI he neither saw nor heard of the 1977 draft of the Michelson report, the 1978 Michelson report, or the January 10 note, " LOOP SEALS IN PRESSURIZER SURGE LINE," which was prepared by Sanford Israel, RSB, and signed by Thomas M. Novak, Israel's Branch Chief. Subsequent to the occurrence at TMI, he has read the Michelson report in detail, skimed through its earlier draft, and studied the January 10, 1978 note prepared by Israel.
'Mattson said that.he is not critical of the waylin which the January L 1978. note was handled.
He does feel, however, that had he been furnished with Michelson's 1978 report, he would have been stimulated to go further; iwith it. He also feels that he would have been stimulated to take further action had he been provided with a copy of Michelson's.1977 draft.
In. expressing these beliefs, he stressed that thetintensity of:
any review would be colored by the manner in which the_ draft was received, E the background dat4 which accompanied it, and the professional sppearance
! of the product.
In keeping with this qualifier, he said that the copy of the draft which was informally furnished to Israel was handwritten, undated, untitled, had no table of contents, and no indicated author.*
he also said that Israel was heavily comitted in assignments when l
informally furnished with the copy of Michelson's draft.
Mattson said that ben the ACRS.or its' members. request staff review 'of a'
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!_ particular. subject, they usually do it formally. He'said that when such' a formal review is requested, the relevant document should be forwarded along with a requesting letter from the ACRS to the cognizant Division
, or_ Office Director.. He_.said that although this procedure has been
- formalized through time and by precedence;;he is unaware of any written
/ procedures'or guidelines making such action requisite.
- A review of the draft which ACRS metnber Ebersole claims to have given to Israel (Attachment 5), reveals that although it is handwritten,_i,t is
. dated, titled,--and.has a table of contents. While theidraftJdoes notl
- how the. author's-name,11t does show his initials. See Section IV for s
further coment on this issue.
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1 Mattson said.that it was his firm belief.thatYfomal evaluation of thel
}Michelson report would not have prevented TMI.. He feels 'that of greaterj krelevance:to TMI than formal review of the Michelson report, is the fact
, that(applicants can develop:and, implement, emergency operations for i
. ;. 'confomance with acciden. a'nalysis, reports, in the absence' of either; t
regulatory review or vendor: review.
2 IV.
COMMENT Since the purpose of this investigation was to chronologically reconstruct the events and levels of review regarding the "Michelson report," no OIA recommendations and/or conclusions are presented.
However, certain inconsistences / inaccuracies have been noted in regard to information obtained from intervi6wees.
OIA does not consider these inconsistencies /inac-curacies to be the product of willful intent but, rather, the result of memories made faulty by time and inattention.
Most of the inconsistencies /inac-curacies have little or no substantive. impact on the desired reconstruction and are exemplified by the following 11.lustrations:
In his June 12 interview, Sanford Israel advised that sometime l
between the D.C. Cook ACRS meeting and the Pebble Springs ACRS l
meeting, ACRS member Jesse Ebersole told him that he had a report (Michelson's 1977 draft report) which he wanted to send to him.
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Since the D.C. Cook ACRS meeting was December 8-10,.1977, and the Pebble Springs ACRS meeting was January 5-7, 1978, the time frame identified by Israel appears to be in error. This determination of error is based on Attachment 13, the note dated October 21, 1977 which was sent by Israel to Ebersole, when Israel returned the l
Michelson draft report.
During this 'r'me irterview, Israel said that h'e apparently never returned the Michelson draft report to Ebersole, because he still had it. Attachment 13, howe'ver, reveals that Israel made a copy of the Michelson draft report for his own use and returned the original copy to Ebersole.
1 In his June 22 interview, Roger Mattson said that the copy of Michelson's 1977 draft report, which Ebersole informally provided to Israel, was undated, untitled, and had no table of contents.
Mattson apparently came to this conclusion after examining the copy l
of the Michelson, draft that is in Israel's possession.
- Ebersole, however, said that when he furnished the Michelson draft report to Israel in 1977, he gave Israel the very same copy (Attachment 5) that Michelson had given to him (Ebersole), and that pages one and I
two respectively consisted of the date and title of the report, and the table of contents. ' Israel'was not able to reca11'that he copied the draft report and that he returned his original copy to 1
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14 Ebersole; and, it has not been possible to resolve the issue of whether or not he received a title, date, and table of contents, with his original. copy of the Michelson draft report.
The above examples are typical of the types of inconsistencies / inaccuracies
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noted and their existence, while not critical to the reconstruction, should be realized.
Attachments:
1.
May 24, 1979 memorandum from IE to 0IA -
2.
May 21, 1979 interview of Michelson
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3.
June 11, 1979 interview of Michelson 4.
June 13, 1979 memorandum from Michelson to ACRS
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5.
September 1977 Michelson draft report 6.
April 27, 1978 letter from TVA to B&W 7.
January 23, 1979 letter from B&W to TVA 8.
February 8,1979 letter from TVA to B&W 9.
May 29, 1979 interview of Jones 10.
IE Report of Investigation
- 11. June 4, 5, 6, and 7, 1979 interview of Ebersole
- 12. Annotated Pebble Springs questions and responses
- 13. October 21, 1977 note from Israel to Ebersole
- 14. January 10, 1978 note to RSB members 15.
June 12, 1979 interview of Israel
- 16. July 2,1979 interview of Mazetis
- 17. July 6, 1979 interview of Nawberry
- 18. June 19, 1979 interview of Novak
- 19. June 25, 1979 interview of Ignatonis
- 20. June 18, 1979 interview of Ross 21.
June 22, 1979 interview of Mattson
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