ML20039D232
| ML20039D232 | |
| Person / Time | |
|---|---|
| Site: | Browns Ferry, Zimmer  |
| Issue date: | 12/11/1981 |
| From: | Hofstadter E AFFILIATION NOT ASSIGNED |
| To: | Palladino N NRC COMMISSION (OCM) |
| Shared Package | |
| ML20039D233 | List: |
| References | |
| NUDOCS 8112310443 | |
| Download: ML20039D232 (3) | |
Text
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,7MI 20 Aquilla i
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ylerence, Kentucky 41042 19 3
December 11, 1961
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W. Nunzio J. F=11=dino, Chairman T
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,31 c4 Washington, D. C.
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Dear W. Nunsio:
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,,e This letter is in response to the latest NRC' report;of'its Investigative findings at the Zimmer plant.
This report by its volume and ezeess of drivel snows two elements prevailed.
- 1. Where you are unable to be convincing with fact, confuse this with drivel.
- 2. Bigger is better! So make it so long and boring nobody reads it thru.
j For a nation that can put a man on the moon with the extreme complexities involved, we seem nearly unable to build a nuclsar plant to simply boil water in a safe and reliable manner. The fact that so many unresolved safety questions arise is the FCRDOST problem we should attempt to resolve first.
Change is the way of all life. Proven needs dictate change. Overall many of the problems at Zimmer are not unique, but typical. Therefore the solution must start in the overall control area.
The principal objective of this letter is to be constructively critical.
Nearly 50 years ago I started out as a Machinist apprentice. This was a formal 4 year program which included 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> of class room study, on our own time, Mr week.
Our Instructor was a retired & chine Design Engineer. One of his first stories involved the proven need for change. He explainad that in World War One many parts j
made in one area of the country would not go together with mating parts made in another area of the country due entirely to minor differences in STANDARDS in use.
The corrective sotion was the setting up of the Bureau of Standards to have one set of Measuring Standm Ms nationwide. This " change" solved the problem.
I was very closely involved with another hjor change that occurred at the start of World War Two. Iht, tremendous increased need for &ehinists was " solved" by increasing use of "schine Operators" with a mini== of training and experience.
This created the need for " Set Up Men" and for Inspectors to check the work produced by the " Operators". Whd vas lost was the old fashioned " pride of workmanship" which gave us quality of product.. Inspection in itself was not enough. It was entirely contingent on the skill knowledge and effort of the individual inspector. In order to more effootively control !.he inspection activty setups were started which are the forerunners of QC as we know it today.
The Air Force and Aircraft industry were in the forefront of development of QC development as a " tool" to insure quality and safety. The lost of a QC program was justified on the basis if it prevented one accident involving hundreds of lives, its cost was justified. Using this cost justification, wouldn't it seem reasonable that we should have a Super" QC program for Nuclear work where a single accident could involve hundreds of thousands of lives? The possible risk could be 1,000 times greater!
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_2 I feel sure you vin agree that the American aircraft industry in its entirety has compiled a tremendous record for dependability, reliability and most important of all nearly perfect safety. QC is the single most important factor in this achievement. How then in a relatively high technology industry where stength versus weight is such a critiesl facter can we be so ::uccessful with QC and we cannot build a nuclear plant to boil water vnere strength, weight is not a factor, and we try to use QC and the end results are so dissimi1=v't Once we ask this question and start to look it is relatively easy to find concrete reasons for completely opposite end results. Starting at the very beginning, I have found that only in plants where the utmost in quality of product was demanded from the very top people in sanagement did this penetrate down to every employee.
In every instance where this was not a top priority with the people on top, quality problems was the direct result. Quality starts at the top and win go down. It will never start at the bottom and go up. It is that simple. Utilities in particular, and those with an their construction experience in coal or oil fired plants built in a conventional manner cannot see the need or reason for QC in nuclear plants.
Where they don't believe in'the need they then only go thru sufficient motions in the directior,of QC to be considered as complying with the Licensing agreement.
The old saying of " Wen began is half done," is very applicable in this situation.
Where or when we start off poorly we usually end up poorly. Then when ve progress from this bad initial attitude to a mini = = QC effort we get the end results we are now finding.
Basiaany QC is relatively simple. It is a planned program of Inspection activity to uncover deficiencies that are undesirable. On a simple part for example every-dimension to be checked is caned out. Deficiencies are shown as MLner, &jor and Critical, /termined by the tolerances called out on the print. Any part with a deficiency s-set aside until prescribed disposition has been made. This is the meat and potatoes area of QC, Good, proper and prompt disposition. On aircraft parts disposition of & jor and Critical defects requires unanimous approval of the fonowing people. Air Force representative, Product Engineering representative QC representative, Production representative and in some cases a customer rep-resentative.
It can easily be determined that at Zi:mner Inspection was at best hap-hazard.
In the area of disposition of deficiencies and errors it approached total chaos!
There is a simple explanation for this end result. Everyone knew and felt that the plant was over designed in respect to safety and with two and three backups, so that any time a little " problem" arose they oculd very easily and safely "take" a little of this redundance and make a "FII."
Soon this becomes a way of life and becomes an accepted practies. The critical part not reegrnised is that even the workers see this as a prantico and they too start making their own " fixes".
We then have no idea of the extent or complexity of their " fixes." I am sure many of the " fixes" are entirely satisfactory. The serious problem is we will never know until it is too late. Note! In the last report in the area concerned with cable 1 Wig of trays appears a statw. mying in ofrect that the space loading limitations are " conservative" :,o overloading them becomes acceptable.
This is an example of a major decision based entirely on an opinion. I hope you understand that this is criieism of lack of control that creates this attitude.
There are many things I can not understand, For example in 1975 a Mr. Griffin then the & nager of QC for Kaiser Engineers reported his concern for the utilities failure to set up a proper QC program. The subsequent NRC investigatica stated that his concern was not substantiated.
Then when a person takes the time to review the periodic plant Inspections made by the NRC two things are very evident continuously.
- 1. Constant repetition of simple bad safety practices in general.
- 2. Strong evidence of lack of an adequate QC progra:n.
This then makes a person vonder who in the NRC took the time or effort to read this sans reports? Visit after visit his findings were nearly monotonously simile. They painted a clear picture of complete lack of control.
Now it is proposed to reinspect various items. Many, many items can not be reinspected. On : any items you have one opportunity to check them..en many others such as complex assemblies complete disassembly would be necessary.
We then have the problem et evaluating in a proper mann62 11 of the ' fixes".
Enclosed is an affidavit detailin(r " fixes" only in the one area of Cable Trays which I took the time to look into. I am sure this same condition exists in many other areas also.
You then have the overall problem of credibility once a progress repert must be issued. Only competent and independent people preferably with a background in Aircraft QC programs could even attempt to do what is proposed. Anything less is not only a sham but a complete vaste of time and money. The utilty does not believe in QC any :nore today than they ever did. Your own people have repeatedly proven their own incompetence. The only sensible enoice remains as independent competent people who will tell it to you as it is. I trust and hope this is what you really wish to find out.
The lessons learned in respect to deter:sining "causes' can be invaluable in preventing their reocurrence elsewhere.
Respectfully, h Od
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Edwin P. Hofstadter l
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