ML20028F200
| ML20028F200 | |
| Person / Time | |
|---|---|
| Site: | Salem  |
| Issue date: | 12/08/1982 |
| From: | Christopher R, Fitzgerald J NRC OFFICE OF INVESTIGATIONS (OI) |
| To: | |
| Shared Package | |
| ML20028F192 | List: |
| References | |
| 50-272-1-82-079, NUDOCS 8301310254 | |
| Download: ML20028F200 (25) | |
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The attached document / report has not been reviewed g
pursuant to 10 C.F.R. 5 2.790(a) exemptions nor has any exempt material been deleted.
Do not disseminate nor discuss its contents outside NRC. Treat as "0FFICIAL USE ONLY".
Pursuant to 10 C.F.R. 5 2.790(a), the attached docu-
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ment / report has been reviewed and all exempt material except proprietary has been deleted. This document /re-port is suitable for dissemination to licensee, vendor, etc., for a proprietary review.
The attached document / report is in PDR form.
l DATE:
DEC 8 1982 8301310254 830118 PDR ADOCK 05000272 PDR G
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O! FIEL; OFFICE OF INVESTIGATIONS DATE: DEC 8 1982 REPORT OF INVESTIGATION TITLE:
SALEM NUCLEAR POWER STATION, Unit 1 Potential Tampering with No. 13 Steam Generator Wide Range Level Recorder SUPPLEMENTAL: Docket No. 50-272/82-13 CASE NUMBER:
I-82-079 CONTROL OFFICE: Philadelphid STATUS: CLOSED REPORTING OFFICE: Philadelphia STATUS: CLOSED PERIOD OF INVESTIGATION: May 1-5, 1982 REPORTING INVESTIGATOR:
[ /(,,7-)t., (' %f]M Js/
R. Keith Christopher, Investigator Philadelphia Field Office PARTICIPATING PERSONNEL:
REVIEWED BY:
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[7,/ f.,L I M f 4 f R. K. Christopher, Acting Director PhyladelphiaField "e
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APPROVED BY:
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(Jafes Fitzgeiald Q Q l
reting Director, Office of Investigations l
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,p'it-was initiatec or. hay ;,'1982 after trz.. _ _:a ac rr ;'orted that c: errrcxirttely 8:30 a.m. on that date, a Unit 1 centrol rccr cperator L:n ~.ec that the control room wide-range level recorder for the No.13 steam cenerator had been inoperative for some time. Licensee troubleshooting found tnat two terminals in the hot shutdown panel in the Auxiliary Building were shorted, naking the instrument inoperable both on the control room recorder and the hot shutdown panel indicator.
It was determined that the short was caused by a formed piece of wire shorting two terminal screws on the terminal board.
Licensee examination of the recorder strip chart indicated that the actual shorting of the terminal occurred between 1:00 p.m. and,2::00 p.m. on April 28, 1982.
Investigation has determined that modification work was being done in the hot shutdown panel during the last refueling outage (January 1,1982 to April 19, 1982) that involved running spare lines in signal cables in the panel. This modification required workers to cut the tie wraps on certain cable bundles in order to run the cables.
It was also determined that the piece of formed wire that was found on the terminals is an item commonly used by craft personnel to maintain control of cable bundles.
The contractor personnel who performed the work in the hot shutdown panel were identified and interviewed. While they could not confirm or deny that the formed wire in question was actually used in this particular modification, it was confirmed that this type of formed wire is used by these contractors when working with cable bundles.
Interviews of control room personnel also determined that maintenance tags from the performance department were in place in the control room on the Nos.11, 12, 13 and 14 steam generator wide-range recorders which would indicate the performance department was working on the instruments when in fact they were not.
Interviews of the operators failed to establish when the maintenance tage were placed on the recorders.
Further investigation determined that the performance department had done channel calibrations and channel sensor calibrations on all of the steam generators on the same day for each calibration (January 20, 1982 and February 17,1982) leaving open the possibility that the tags were in place at that time and were never removed.
The individual who performed the calibrations was contacted and said that he would normally have placed tags on the recorders but that while he recalled doing the calibrations, he could not recall specifically affixing or removing the tags in the control room.
The Federal Bureau of Investigation was advised of the incident on May 1,1982.
On May 3,1982, Special Agent John CAMERA formally declined investigative jurisdiction.
On April 30,1982, the International Brotherhood of Electrical Workers engaged in a strike action against the licensee making all non-managenent personnel unavailable for interview.
The strike continued for the next ten weeks. Due to the time period elapsed between the incident and the availability of individuals for interview coupled with the high probability of the incident being a maintenance error rather than deliberate act, no further investigation was ccnducted.
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DETAILS e
Purpose cf Investigation This investigation was conducted to detemine if the failure of the No.13 steam generator wide-range level recorder was caused by an intentional act or a mair.tenance error, and if intentional, to identify any potential suspects who may have tampered with equipment associated with the affected system.
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Background
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At nidricht on April 30,'1982, all-bargaining unit employees represented by tbe International Brotherhood of Electrical Wo'rkers (IBEW) local 1576 initiated a strike action agai'nst the licensee. At 8:30 a.m. on liay 1,1982, the wide-range level recorder for the No.13 steam generator was fcuno inoperative.
At approximately 2135 p;m. on the same date, an Instrumentation and Control (I&C) engineer troubleshooting -the problem found that two teminals in the hot shutdown panel were'stiorted making the instrument inoperable due to a foreign piece of wire being in centact with t>:o points on the teminal strip. The recorder strip chart inficated that the instrument failed between 1:00 p.m. and 2:00 p.m. on April 28, 1982.
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Interview with 6 was interviewed on May 4, 1982.
He said that at approximately 8:30 a.m. on May 1, 1982,
,: noticed the No.13 steam generator wide-range level indicator on recorder LA3978 was inoperative.
He said the P-250 computer and the hot shutdown panel indicator for the No.13 steam generator were also found inoperative. M said that by reviewing the recorder chart, they were able to determine that the indicator failed between 1:00 p.m. and 2:00 p.m. on April 28, 1982. W said at this time the channel was declared inoperable (per Technical Specification) and a 7-day action statement per 3.3.3.7 (Limiting conditions for operation) was entered.
M continued that at 3:45 p.m. on May 1, 1982, an I&C technician who was troubleshooting the problem in the hot shutdown panel found a piece of formed wire in the shape of a light bulb making contact with terminal points 9 and 12 on the terminal board which caused a short in one signal lead to the ground.
M said there was no particular significunce to the wire making contact with those tenninal points since contact with any terminal points would have had the sane result.
M said modifications were performed in that panel during the last refueling outage (January 1,1982 through April 19,1982) by Catalytic Incorporated and he conjectured that the wire was left in the panel by the Catalytic electricians. He said he was further convinced of this when he was told that the wire formed in the nanner found is in common use by craft personnel, particularly when working with cable bundles. 6 said the cable bundle in which the wire was found (IFW 99-C0) was in fact cut open during this modification to take out spare conductors and attach them on the terminals to provide signals to newly installed wide-range temperature indicators.
In terms of access to the area,6 said the recorder is located at the 84' elevation in the Auxiliary Building near the auxiliary feedwater pumps. He said there wcre a large number of personnel recorded on the security key card access record and an even larger number of individuals who signed Employee Radiological Entry Pernits (EREPs) for entry which was indicative of a significant anount of "piggybacking" (i.e., multiple individuals entering an area after one individual inserts his or her access card to open the door).
In reference to the Performance Departnent calibration tags being in place in the ccntrol roon on the Nos. 11, 12, 13 and 14 Steam Generator Wide-Range Level Recorders. 6 6 ] said that since these are not controlled tags it is not unusual for individuals to neglect to remove the tags fran the control room after their work is completed.
He did state that the work done by Catalytic would not have required the tags to have been placed in the control room.
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Examination of Hot Shutdown Panel / Recovery of Evidence The hot shutdown panel indicator for the No.13 steam generator is located on the 84' level of the Auxiliary Building near the auxiliary feedwater pumps.
The Auxiliary Building is a vital area and as such entry is controlled via a key card reader; however, due to the heavy volume of traffic through the Auxiliary Building, extensive "piggybacking" into the area appears to have been a common occurrence. As such, numerous individuals are reported to have been in the building without card keying into the building. Attachment (1) is a photograph which shows the rear of the hot shutdown panel and shows a view of the cable bundles and terminal strips. Attachments (2) and (3) are photographs which portray where the wire in question was found embedded in the cable bundle as indicated by the IAC technician who discovered the wire. This wire was lying in the cable in such a manner that the open ends of the wire were making contact with terminal points Nos. (9) and (12) as shown in Attachments (3) and (4).
Photographs of the recovered wire are appended as Attachments (5) and (6).
The performance department calibration tags (Attachment 7) which were found in place under the No. 11, 12, 13 and 14 steam generator wide-range level recorders in the control room (Attachment 8 pertains) were recovered by the investigator on May 4, 1982. The recorders are outside of the main control console and are approximately three feet from the floor. As such, the recorders and the performance department calibration tags were not readily visible without leaving the main control console.
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% E C, Unit 1, was interviewed on May 5, 1982.
said that on the day in cuestion (May 1, 1982) he was actina in the capacity of a control room operator during the strike action.
He said he and his crew relieved the night shift at approxinately 8:00 a.m., and as required for the shift turnover, he began takinc instrumentation readings of the various instruments.
During this tour, M said he observed that the No.13 wide-range level recorder (LA-3978) had failed low. He said a continuing inquiry detennined that the hot shutdown panel on the 84' elevation of the Auxiliary Building had failed high. M said this was not recorded in the control room logs but he said that the first observation of the anomaly occurred at 8:30 a.m. 6 said he never noticed the " performance calibration tags" on the recorders and that he had no ideas as to how long they had been in place. Mopined that the incident was intentional and related to the strike action because of the existing technical specification requirements that would have required a plant shutdown if the degraded condition was not corrected in a specific time. He also felt that the above type of act, which he considered to be intentional, indicated in his mind that an IAC technician was responsible for the act.
M said that a work order (No. 900676) was issued to investigate and correct the problem after it was discovered and an action statement as required by Technical Specifications was entered at 10:55 a.m.
With respect to the Performance Department calibration tags being left under the recorders, M oted that it has occurred in the past that erformance tags were left on equipirent after the work has been completed.
was unable to provide any further information.
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4 interview of C,jgg;ireg;g was_ interviewed on May 4, 1982. He confirmed that Q during the strike, noted the f ed indicator on the wide-range level recorders at approximately 8:30 a.n. on May 1, 1982. M said it was he who first removed the performance calibration tags from under the wide-range level recorders. He confimed the tags were under both No.11 and 12 wide-ranc".e level recorderM said he (LA-3977) and the No.13 and 14 level recorders (LA-3978) had not noticed the tags before and that at the titre of the discovery (May 1, 1982), he had queried the other operating personnel about the presence of the tags, none of whom could identify the length of time the tags had been in place. Mwas unable to provide any further pertinent information.
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MPEWWWW84F6u interviewed on May 4, 1982. He said he was employed as an WN by the Westinghouse Instrument Services Company and that he has been working on a contract basis at Salem since June of 1980.
M said that on the morning of May 1,1982, he received a work order from the Operations Departnent stating that the wide-range level recorder for the No.13 steam cenerator had failed low and the hot shutdown panel had failed high. 6 said he first began troubleshooting the problem in the process racks in the control room, and when he deter;nined that there was proper functioning there, he proceeded to examine the hot shutdown panel in the Auxiliary Building. He said the back door on the hot shutdown panel was in place at the time and that he took the panel off to examine the internal terminal strips.
He said a quick examination did not identify any obvious prcblems so he left the area to obtain additional instruments to work on the terminal boards and found that the problem was not there. He said he then lifted a cable bundle back to get to the field side of the leads and when he did this, he saw the wire touching terminal point No.12. M said that he initially had seen the other end of the wire touching terminal point No. 9 and assumed that it was supposed to be there until he saw the other end connecting with terminal point No. 12.
He said the wire was lying parallel to the terminal board, behind and to the side of the cable bundle. He said the ends of the wires were not directly connected to the terminal points but were lying up against the terminals with the wire itself being supported by the cable bundle. He said these two ends of the wire contacting those terminal points caused a short to one lead to shield ground.
W said that when he removed the wire, the indicator returned to a normal reading. He said there was little resistance holding the wires to the contacts and it was mainly being held in place by resting against cable bundles.
W said there was no indication that the wire had been wedged into the bundles. M said that there was no particular significance to the wires touching terminal points 9 and 12 and opined that it would be a very unusual means of tanpering with the panel. M said that he was initially (see predisposed to the thrught of " sabotage" because of the last incident Investigation Report 50-311/80-12) but that in retrospect he is not now convinced that the incident was intentional although he was unable to completely rule out that possibility.
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Joint Inte were interviewed on May 6, 1982.
- said he is a and said that over a period of years he has workea in tne construction of control wiring and that he learned the use of the piece of formed wire in ouestion from the union electricians.
He said the craft electricians routinely used this type of temporary wire to maintain control of cable bundles when it is necessary to cut tie wraps to add cable through the bundle.
Msaid he worked with the union cnf ts for the last 12 years with United Engineers.
He said that when he saw the piece of wire, he imnediately thnecht it was a temporary wrap used by the construction electricians.
M said the use of' this fonned wire as a temporary cable bundle holder was commonplace during the construction of Salem Units 1 and 2.
Both individuals opined that if this were done intentionally, it would have fallen within the expertise of the I&C technicians; however, both individuals agreed that if an I&C technician wanted to cause this type of disruption, he or she could have used a much more sophisiticated method of shorting the terminal boards. Additionally, neither W nor M could see any purpose to the formation of the bulbed end of the wire if someone merely wanted to junp the terminal board.
Both individuals also felt that the I&C technicians would not have any had knowledge regarding the craft's personnel use of the bulbed wire shape in working on cable bundles.
Both opined that the incident was not intentional but was the result of craftsmen leaving the wire in the panel following the completion of a work assignment.
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Interview of M was interviewed by telephone on May 5, 1982. He recalled assigning electricians to work on the hot shutdown panel during the outage in the latter part of January to run spares into the cable bundle. He did not work on the panel himself and said he doesn't know exactly how the electricians completed the job. Msaid his observation was limited to exanining the finished job to ensure that the tenninal ends were correctly done. He said that his examination found no problem with the completed job but also stated that his inspection would not have involved. pulling the cable bundles back and, for that reason, he in all probability would not have seen the wire if it was in place at that time. M identified the electricians who worked on the modification in the panel as i
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Interview of g g E M 7 h J ~
j P fomerly emioved by Catalytic, Inc. was interviewed by telepnone on May 5,1982. CC confimed that he had worked at Salem Unit I durina the last outage and ne recalled working on the hot shutdown panel with&Fi'W3 He recalled that this work was done in the latter part of Jeruary 1982.
He also recalled that their work involved the running of spare lines and signal cables in the paliel and that they had cut the tie wraps off of sone of the cable bundles in order to run the spares. M said he could not recall specific details of the work he perfomed on that job and did not recall the use of the bulbed shaped wire piece as described above.
He said he uses various methods to control cable bundles that he has to cut into, including the use of regular-tie wraps, and tenporary wire to-keep the.
bundles together. M said while he did not recall using the specific type of wire as described, it is entirely possible that he did. Mprovided no further infomation.
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Review of Design Cnance Report (DCR) (IEC-1127)
During the last refueling outage (January 1, 1982 through April 19,1982) design modifications were made to the Unit I hot shutdown panel as a result of the THI modification requirements (NUREG 0737).
These changes prinarily involve the addition of four additional channels of instrumentation.
Modifications were being done in the terninal blocks but not specifically to terminal points 9 and 12 on the terminal strip in the hot shutdown panel. A review of the DCR revealed that the cable bundle that was supporting the formed piece of wire was in fact undone and retied in order to irstall the required additional instrumentation.
INVESTIGATOR'S NOTE: Taking into account the physical panel layout and the proximity of the cable bundle into the affected terminal points, it appears highly probable that this formed piece of wire was used as a temporary wire wrap to hold the cable bundles while the permanent electrical terminations were made and then inadvertently not renoved from the panel upon completion of the work.
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w kevlev cf Technicel Specification Surveillance Recuirerents The Limiting Conditions for Operation (LCO) requires that the accident monitoring instrumentation channels be operable as s'mwn in Table 3.3-11A and 3.3-1B of LC0 3.3.3.7.
The surveillance requirements as shown in 4.3.3.7 of the LC0 require each accident monitoring instrumentation channel to be demonstrated operable by performance of a channel check and channel calibration at the frequency shown in Table 4.3-11 of the LCO. Table 4.3-11 of the LCO requires that the channel check be done monthly and the channel calibration be done during each refueling outage.
A review of the applicable surveillance procedures and channel check records on May 5,1982 determined that the last channel check was performed on April 27, 1982 (one day before the instrument failure) and recorded the check as satisfactory at 56% on the No.13 steam generator wide-range level. The channel calibration data was also reviewed on May 5,1982. This review determined that the channel calibrations were performed during the outage on January 20, 1982 and' the sensor calibrations on February 17, 1982.
During these calibrations the wide-range level indicators in the control room would be tagged out by the I&C technicians performing the calibration. The channel and sensor calibrations were ccmpleted for all of the steam generators on the same day on each occasion (January 20, 1982 and February 17,1982) which may account for the performance department calibration tags being on all of the steam generator wide-range level recorders.
INVESTIGATOR'S NOTE:
'I&C Dept.) who performed the calibration and channel check was contacted after the termination of the IBEW strike. He could not recall either affixing or removing the calibration tags in the control room during the calibration but acknowledged that he normally would have placed those tags on the wide-range levels recorders in the control room when he did the calibrations.
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III.
STATUS OF INVESTIGATION Since the IBEW strike negated the ability to perform timely interviews of technicians and possible witnesses, coupled with the results of the investigation to date, no further investigation is considered justified.
Accordingly, this investigation is considered closed.
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J'J. ATTACH!'ENTS
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Photographs of hot shutdown panel. :
Diagram of tenninal board for hot shutdown panel. and 6:
Photographs of the formed wire.
1 Photograph of the perfonnance department calibration tags. :
Photograph of the steam generator wide-range level recorders.
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