ML20011D563
| ML20011D563 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 12/11/1989 |
| From: | Davis A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Edleman M TOLEDO EDISON CO. |
| References | |
| EA-89-154, NUDOCS 8912280005 | |
| Download: ML20011D563 (6) | |
Text
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-December 11, 1989 Docket No. 50-346 EA 89-154 Toledo Edison Company ATTN: Mr. Murray R. Edlemar.
President Edison Plaza 300 Madison Avf.nue Toledo, Ohio 43652 Gentlemen:
This refers to the investigations conducted by Mr. J. N. Kalkman of the NRC Office of Investigations, Region III Field Office, and Messrs. M. J. Farber and R. B. Landsman of the NRC Region III Office from October 1, 1987; through July 7, 1988, and November 21, 1988, through March 24, 1989, regarding certain activities at the Davis-Besse Nuclear Power Station authorized by Facility Operating License No. NPF-3.
Copies of the synopses from those< investigation reports are enclosed. Two issues addressed during those investigations concerned an event involving the Plant Manager's actions while onsite on December 31, 1985, and January 1, 1987. Resolution of those issues included the issuance of a letter dated October 4,1988, wherein the NRC admonished the-Plant Manager for his actions.
The third matter addressed during those investigations concerned-the approval by the Davis-Besse Plant Manager in May 1987 of a-revision to Station i
Administrative Procedure AD-1805, " Procedure Preparation and Maintenance,"
without the required signature of the QA Hanager.
This action on the part of the Plant Manager represented a violation of Nuclear Group Procedure NG-AV-115,
" Preparation and Control of Nuclear Group Division 'nd Department Procedures,"
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which requires that all comments including the QA Departments'. comments.be
' resolved before final approval'of the procedure.
From December 9, 1987, through January 8, 1988, Region III conducted an inspection into this matter.
Based on that inspection, Region III~ concluded that a violation of NG-AV-115 had occurred when the licensee processed that revision of the AD-1805 in May 1987. On January 28, 1988, Region III. issued-its inspection report containing a Notice of Violation with two Severity Level IV violations:
(1) failure to follow NG-AV-115 in-' approving the revision-to AD-1805 in May 1987; and (2)' failure to take' timely corrective actions to resolve the violation of NG-AV-115-after it had been;1dentified by the: Quality Assurance. organization in June 1987.
Shortly after that inspection report was issued, additional information was developed indicating that the violation of NG-AV-115 may have been a' deliberate act on the part of the Plant Manager. The 01 investigation into this question-concluded, as described in the enclosed synopses, that the Plant Manager and a -
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procedure writer willfully violated NG-AV-115 and provided false statements to.
the NRC regarding their' involvement in that matter, i
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I Toledo Edison Company December 1),1989 The Office of Investigations generated a substantial amount of evidence indicating that resolution of QA comments on the proposed revision to AD-1805 was a very contentious issue in the Davis-Besse organization.
Several key managers in the station organization were aware of the difficulties with QA coment resolution and the discrepancy between the draf t revision of AD-1805 and its parent procedure NG-AV-115. Because general comment resolution was not forthcoming the Plant Manager directed the Safety Review Board (SRB) to review the procedure.
The SRB approved the revision of AD-1805 but concluded that parent procedure NG-AV-115 would have to first be modified. While the Plant Manager involved himself in this issue, there is not direct evidence from facility managers, the SRB, or others in the procedure review and approval process that the Plant Manager was advised cf the specific discrepancy with the parent procedure before he approved AD-1805 in May 1987 without the QA Manager's signature.- When the quality assurance organization became aware of the Plant Manager's approval of AD-1805 without the QA Manager's signature, it initiated a corrective action 1
document specifying the violation of NG-AV-115 and requiring corrective actions.
The corrective action document, which was approved by the Plant Manager, contained statements that can be read as indicating he had made a knowing decision to violate NG-AV-115 when he approved the revision to AD-1805.
The NRC staff has given careful consideration to the evidence OI has developed in this matter, es well as.the information provided by your staff during the i
enforcement conference on September 8, 1989.
Based on that review we cannot i
conclude that there is sufficient evidence to indicate tne violation was i
willfully committed. However, because the Plant Manager stated he failed to ascertain the resolution of the SRB comments before approving the orocedure, we conclude that this failure demonstrated that the Plant Manager did not exercise good judgment. Despite the fact that no one apparently made the Plant Manager aware of the SRB comments prior to his approval of the procedure, his failure to be aware of the comments bnd their resolution was unacceptable given the fact that he was responsible for having the procedure addressed by.
the SRB. Nevertheless, based on the Plant Manager's acknowledgement that his review of the procedure was not detailed before he approved the revision as well-as Toledo Edison Company's response to the Notice of Violation dated January 29, 1988, the NRC staff concludes no further action on this matter is-necessary except to reemphasize to you and your staff the need for meticulous review during the procedure approval process.
We are also concerned that, at the enforcement conference, the Plant Manager indicated that the inforination provided in the root cause section of the' corrective action document, which he signed, related to the corrective action for the problem rather than an analysis of its root cause. The Plant Manager was assigned the responsibility to assess the root cause of the procedure-discrepancy.
Proper root cause analysis is an essential element of a good-3 1
quality assurar.ce program and information provided relative to a problem's
Toledo Edison Company December 11, 1989 root cause should be carefully considered in formulating corrective actions.
Although the root cause section was not properly addressed, the staff has evaluated your corrective action system on a continuing basis as part of the routine inspection program and finds that your current program of root cause analysis and corrective action implementation appears adequate. Therefore, no response to this letter is necessary. Nevertheless, we emphasize the need for i
your Plant Manager and other personnel to assure that root cause analyses are properly conducted to assure effective corrective actions.
We will gladly discuss any questions you have regarding this matter.
I Sincerely, jl Drigin.1 4 ty A. l?vn Day:n i;
A. Bert Davis Regional Administrator
Enclosures:
As stated cc w/ enclosures:
d L. Storz, Plant Manager Licensing Fee Management Branch Resident Inspector, RIII l
James W. Harris, State of Ohio 1
Roger Suppes, Ohio Department of Health A. Grandjean, State of Ohio, Public Utilities Commission JMTaylor, EDO HThompson, DEDS JLieberman, OE JGoldberg, OGC TMurley, NRR JPartlow, NRR Enforcement Coordinators RI, RII, RIV, RV FIngram, GPA/PA BHayes, 01 EJordan, AE00 i
JLuehman, OE i
OE:Chron OE:EA RAO:RIII PAO:RIII SLO:RIII DCB/DCD(RIDS)
PDR LPDR SECY CA RIII RII RIII RII,
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$W btobe/kst Grep9 n 1/ieberman Pa e 'ello Davis 12/ b/89 12/ V/ 9 12/ 8 /89 12/f/89 12/// /89 i
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SYNOPSIS In January 1987, the NRC received an allegation relating to the Davis-Besse -
NuclearPowerSts, tion (Davis-Besse),specificallythatonDecember 31, 1986, the Plant Manager violated the Fitness for Duty Program by accessing the site in an alcohol-impaired condition and proceded to become a distraction to the reactor operators and others in the control room that evening.
On January 29, 1987, theRegionIII(RIII)Administratorrequestedthat Toledo Edison Company (TEDCo) investigate the allegation and submit their findings to the NRC. On February 19, 1987, TEDCo complied with that request with a written report assuring the NRC that their investigation had exonerated the Plant Manager of any violation of their Fitness for. Duty Program and
-concluded that he was, in fact, not a distraction to anyone in the control room that evening.
Based upon the licensee's report, the NRC closed the Davis-Besse allegation.
In July 1987, the NRC received new information alleging that the Davis-Besse Plant Manager was not only alcohol-impaired while at the site on New Year's Eve 1986, but that he a'so directed reactor operator activities while in the control room.
OnOctober1,1987,theNRCOfficeofInvestigations(01)initiatedan investigation relating to an alleged violation of the Davis-Besse Fitness For Duty Program. Although the NRC rules and regulations do not encompass fitness for duty, the NRC Commission authorized the investigation under the NRC Fitness for Duty Policy Statement and its authority to assure that any.
s individual who has access to a nuclear power facility does not compromise-public health and safety as a result of that' individual's incompetence or impaired judgement.
i This' investigation has developed evidence indicating that on New Year's _ Eve i
1986, the Davis-Besse Plant Manager did access the site after having consumed a quantity of alcohol, which in his opinion, was of an' insufficient quantity to cause him to question his fitness for duty. That.01 finding partially i
corroborated the TEDCo internal investigation finding of the Plant Manager's fitness for duty. This 01 investigation, however, developed evidence, in i
part, contrary to the TEDCo finding that while onsite New Ye?r's Eve 1986, the Plant Manager did exhibit behavior which was distracting and disruptive to the control room personnel. This investigation did not, however, corroborate the
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allegation that the Plant Manager directed reactor operator activities on the E
evening in question.
Because of the disparity between the TEDCo investigation report to the NRC and the 01 finding relating to the Plant Manager's distracting behavior in the control room. 01 investigated further to detennine whether TEDCo management willfully misrepresented the facts relevant to that aspect of their report l
to the NRC.
h Case No. 3-87-017 1
This investigation has developed evidence indicating that the Davis-Besse Vice s
President Nuclear, who personally conducted the internal investigation of the Plant Manager fitness for duty episode, failed to thoroughly investigate the allegation regarding the distracting behavior in the control room. The Vice President Nuclear received a written statement from an eye witness to the events in the control room which confinned the allegation that the Plant
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Manager may have been, for a period of time, a distraction. Rather thap attempting to corroborate that statement by interviewing any of the other l
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eight eye witnesses, the Vice President Nuclear chose to conclude in his letter to the NRC that the allegation was subjective and unsubstantiated.,
During the course of the fitness for duty investigation at Davis-Besse, the RIII Administrator requested that 01 concurrently investigate an allegation that the Plant Manager violated the Davis-Besse Nuclear Quality Assurance Program by approving and implementing a safety related station procedure which conflicted with the requirement of an upper tier Nuclear Group procedure.
This investigation developed evidence indicating the Davis-Besse Plant Manager willfully approved the station procedure knowing that a governing procedure prohibited the issuance of that station procedure as written. The Plant Manager and his assistant, who prepared and processed that station procedure, both stated to 01 under oath they were not aware of the requirement to have.
the upper tier Nuclear Group procedure revised prior to the implementation of the station procedure. The Plant Manager also reviewed and approved a letter to the NRC which stated that he was unaware of that requirement.
Contrary to i
their statements, a Davis-Besse deficiency document relating to this issue, dated before 01 interviewed the Plant Manager and his assistant, contained a statement signed by both individuals indicating they knew of the requirement to revise the Nuclear Group procedure prior to approving the station procedure.
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t Case No. 3-87-017 2
b SYNOPSIS On November 21, 1988, the NRC Region Ill Regional Administrator requested that the Office of Investigations (01) initiate a supplemental investigation relating to an alleged violation of the Davis-Besse Nuclear Power Plant (Davis-Besse) quality assurance (QA) program by the Plant Manager of that facility.
01 proceded to interview two witness-who worked in the Davis-Besse QA department and were not contacted during the initial investigative effort.
01 also reinterviewed two additional-individuals who played key roles in the preparation and disposition of the deficiency docunent which surfaced the QA violation and documented the root cause of the deficiency.
This investigative effort has developed additional corroborating-testimony to support the original 01 finding that the Davis-Besse Plant Manager willfully approved the station procedure knowing that a governing procedure prohibited the issuance of that procedure as written.
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Case No. 3-87-0175 1
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