ML20072C609
| ML20072C609 | |
| Person / Time | |
|---|---|
| Site: | Vogtle  |
| Issue date: | 07/29/1994 |
| From: | Horton M AFFILIATION NOT ASSIGNED |
| To: | Lieberman J NRC OFFICE OF ENFORCEMENT (OE) |
| References | |
| NUDOCS 9408180007 | |
| Download: ML20072C609 (6) | |
Text
.8 I.
July 29,1994 Mr. James Lieberman Director, Office of Enforcement U. S. Nuclear Regulatory Commission Washington, D.C. 20555 Re:
Response of Michael W. Horton To Demand For Information Dated May 9,1994 -
Dear Mr. Lieberman,
Thank you for providing me an opportunity to clarify what appears to be a misunderstanding of my statements and actions of June 29,1990. As you may know, I was never interviewed on these issues and so have not had the ability to address these concerns preuously. Therefore, I greatly appreciate the opportunity to explain myself now. Please consider this letter, and pass it on to the Commission and anyone else reviewing this issue, as my response to the Demand For Information (DFI) issued on May 9,1994.
When I learned that numerous conversations were surreptitiously recorded by my boss at Plant Vogtle, I was not concerned about what I may have said or how it might sound since I always try to express myself honestly and candidly. However, after reviewing the transcript of my conversation with Mr. Mosbaugh and Mr. Frederick, of June 29,1990 (tape 187), I can see how the NRC might misconstrue my remarks and :
therefore seek clarification. Nonetheless, I strongly disagree with the conclusions drawn in the DFI. Again, these conclusions were drawn without the benefit of my input. Please also accept my assurance that the DFIin no way reflects the manner in which I have conducted myself over the 15 years I have been employed in this industry.
Briefly, by way of background, I graduated from the University of Florida in Nuclear Engineering in 1979. I worked as an engineer for the Georgia Power Company at Plant Vogtle from then until April of 1993. My duties initially involved test program activities on both units and later took on engineering support department responsibilities after Unit Two Fuel Load. At the time of the March 20,1990 event, I was in charge of the Engineering Support Department at Plant Vogtle which primarily included system troubleshooting and design changes. As the department head, I was a voting member of the PRB. In April of 1993, after receiving an SRO License, an opportunity arose to work as a project manager for Southern Nuclear Operating Company in Birmingham, Alabama.
I continue there as a project manager, working on various company and industry cost initiatives.
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Discussion of Tape Number 187 It is my intent in this response to explain the context surrounding the June 29*
conversation, as well as to highlight aspects which may have been less rigorously considered, in the hope that you will understand how my statements and actions helped correct the inaccurate information initially provided to the NRC. I have reviewed and will refer to the NRC provided transcript of the conversation which has handwritten markup's by Mr. Mosbaugh. Also, I have listened to the tape recording of the conversation which better captures the emotions present in conversation.
The conversation was recorded on the afternoon of June 29,1990, just prior to a planned 5:00 p.m. Plant Review Board (PRB) meeting. The purpose of the upcoming PRB meeting was to review a proposed revision to the April 19,1990 LER, with a cover letter. The conversation starts on the NRC transcript labeled " Tape 187 side 1", on page 18 of 75 and continues through page 30 of 75.
During the conversation, I was alone in my office using my speakerphone. My voice was being recorded at some other extension off of another speakerphone. At the time I had a copy of the LER with it's cover letter for PRB members to review. I believe I also had a copy of Mr. Frederick's audit report, but do not think I had reviewed it prior to the conversation.
The cover letter to the LER contained the sentence: "The discrepancy is attributed to diesel record keeping practices. " Although I was expecting an explanation for the inaccurate start counts, this conclusion took me by surprise and stirred me up. When I read these words, I assumed them to mean that my department's Diesel Start Logs had been utilized to obtain the number of starts previously provided to the NRC and that they were deficient somehow. Although I had no first-hand information as to how the previous counts had been conducted, I did not believe that the Diesel Start Logs had been utilized.
I had heard (again second-hand) that whoever had counted, had used control room information and had simply counted wrong. (My department's Diesel Start logs are not in the control room.) Also, I was familiar with the content of Regulatory Guide 1 108 which addresses requirements related to diesel start record keeping. I believed my Diesel Start logs were being kept in accordance with these regulations. Based on all of this, I wanted an immediate explanation from someone as to why it could be said that my program caused inaccurate information to be submitted to the NRC.
As the conversation began, I made Ms. Tynan aware that I disagreed with that sentence in the cover letter. She and Mr. Frederick explained that they understood Mr.
Hairston may have been the source of that particular sentence. At that point I withdrew my negative comment and stated that although I thought the ' record keeping practices' statement was wrong, Mr. Hairston must surely have had enough information to make the statement. I assumed that Mr. Hairston had the information and resources at his disposal to ensure his understanding cf the situation. Furthermore, Mr. Hairston was known to me Page 2
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to be careful and have good judgment. If these were in fact his words, they must be a tme representation ofwhat happened. Since I had no detailed understanding of the events surrounding the actual collection of the inaccurate start information, I had no basis upon which to refute Mr. Hairston's statement.
Of course, the discussion does not end there. Despite hearing this, I asked Mr.
Frederick for more information saying: "Well, what was wrong with our diesel start record keeping practices?" During the ensuing discussion, I felt the need to defend my Engineering Department's log keeping practices. The transcript shows my aggravation, (although you can hear it much clearer on the tape). This is because my diesel records were going to be held responsible for something as significant as giving erroneous information to the NRC, when I believed these records were being kept in accordance with the reg. guides. Because of this aggravation I was impolite to Mr. Frederick and cut him ofTseveral times while he was speaking.
After I stopped intermpting, Mr. Frederick explained that the diesel start log was out of date when we wrote the LER. When he said ". out of date.. " I began to understand the ' record keeping practice' that the cover letter was referring to was the fact that diesel testing source documents, which are mostly Operations Department test procedure data sheets, were slow in being processed. This amounted not to a quality-of-the-start-log problem like I initially assumed it meant, but to a timing problem. This partially eased my mind since a timing problem such as this did not represent a failure to meet any regulatory requirements and could probably be corrected in a straight forward manner.
By the end of page 24 and on page 25, Mr. Frederick's logic seemed inescapable.
Had I not been so irritated initially, I would have stated my agreement with more conviction than merely saying: "I would go with the flow and not resist", or "I don't disagree", or "Everything your saying, George, is true" I was stillirritated at the idea that although our diesel start log program did not have a ' regulatory problem' it was still responsible for causing the count errors.
Moreover, I could see that Mr. Mosbaugh was not convincing Mr. Frederick. I knew well from my own experiences in doing previous root cause work, that for every human error there is usually an underlying root cause for the error. One point of emphasis over the last few years in our evaluations has been to look deeper into a direct human error and see if there is a more fundamental reason as to why that error was made. If you discover that conditions or events exist which greatly increase the chance of a mistake occurring, they should properly be called a root cause. An effective root cause program does not simply stop at the obvious human error, it roots out the conditions or events that lead to the error and fixes them so that another person is not placed in the same situation at a later time. Therefore, the logic of' record keeping practices' as an explanation fit my personal definition of a proper ' root' cause.
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During the conversation, I obviously struggled with the fact that what I had believed to be the correct explanation only minutes before, had been challenged successfully. Although on page 25, line 24 I expressed my willingness to do whatever it would take to fix this newly identified problem, I admit that throughout the conversation I fought this new explanation. Several times, I expressed my frustration by restating my original assumption, saying that I thought the counts had been researched adequately but just done poorly. hiy responses to Mr. Frederick however, are no longer antagonistic.
From this point fonvard in the conversation, I have accepte *
- bat ' record keeping practices' is a valid explanation and proceed to explore with Mr. Frederick what corrective actions might be involved.
On the bottom of page 26, through the middle of page 27, Mr. Frederick explains that the ' record keeping practice' which allowed slow routing of diesel testing documents, placed a significant burden on whoever had to generate the counts. After this summary, Mr. Afosbaugh provided what I believed was the basis for his resistance to this whole idea.
IIe stated he had used "those same source documents" for his count. I took this to mean he used the test data sheets and the control room logs. To me, this made no sense because hir. Frederick had just finished explaining that some of tne ' start pages' (test data sheets) took up to 24 days to process. This made them unavailable as a source document back when the erroneous count was made. This displayed a possible misunderstanding on Mr.
Mosbaugh's part as to the gist of the ' record keeping practices' sentence. Mr. Mosbaugh did not appear to realize that these diesel testing sheets were out of circulation, being processed for weeks, and were therefore unavailable to be used as a source document back when the erroneous count information was generated. Later, when the sheets became available and Mr. Mosbaugh made his count, then of course it seemed like an easy task to come up with a reasonable set of starts.
I believed Mr. Mosbaugh to be unfamiliar with the inner workings of the Operations Department and so Ijust assumed he did not understand the details of the data sheet processing that we were discussing. In retrospect, Mr. Mosbaugh may have seen the weakness of his position because he responded with "Well, there's other information" At the time, he seemed to be a little defensive, becoming less vocal, and it appeared that he finally understood what we were talking about as to the logic of' record keeping practices'. For example, he later expressed what I thought was his mild acceptance of the
' record keeping' explanation by saying that if this is the root cause then it should not be submitted because we had not yet taken any corrective actions (page 28, line 21). I knew Mr. Mosbaugh to be a bit stubborn from time to time so I felt that this statement was a way for him to agree but also to save face.
I, too, was being stubborn, but for different reasons. Mine were personal since I felt that the cover letter's conclusion reflected poorly on my department even though I believed we had followed the regulations. The tape even more than the transcript shows that I was taking it personally while at the same time I could not, intellectually, argue with Mr. Frederick's logic. My statement on page 29, line 23 that "I disagree with it personally, but I'm not interested in arguing about it now," was a poor choice of words. I simply was Page 4
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trying to express the inherent unfairness I felt in finding fault with our diesel start logs, and my frustration in not being able to technically disagree with the ' record keeping' logic.
The fact is, I concluded then as now, that the timing problems associated with compiling the information for the Diesel Start Logs was one cause of the inaccurate information originally communicated to the NRC. The difference today is that I do not take that conclusion personally.
Summary The NRC is correct in its understanding that at the start of the conversation, I believed it would be wrong to state the cause as ' record keeping practices'. This is true because I initially defined these three words to mean 'the Engineering Support Department's Diesel Start Logs were deficient', which I felt was untrue. However, by the end of the conversation, I understood the concern to be that the start logs had a slow update frequency or speed issue, which although it was not a ' regulatory deficiency', was true, and was indeed a problem that had to be resolved.
What seems to have been misunderstood by the NRC is that during the conversation captured on tape 187, I became aware of new information which convinced me that had record keeping practices been different, the count of diesel starts made for April 9,1990 would probably have been correct. People had been forced to resort to other counting methods which ' set them up' to make a mistake. In this context, ' record keeping practices' was and is, to me, an undeniable and reasonable explanation.
Moreover, if not corrected, this could again put people in a position to gather erroneous data. It was based on this logic that I voted in favor of the LER.
The main piece of' additional' context information that should be taken into consideration is that my continued resistance to this new line of reasoning was not due to any perception of falseness. I was frustrated th' t we were evaluating a new possibility a
which I perceived to be self-damaging. Voting in the PRB the way I did, by putting my department's reputation on the chopping block because I thought it was the correct explanation, proves much about my standards and behavior. This, in my opinion, completely and directly refutes the accusations in the DFI.
The DFI states that I "nevenheless approved the erroneous draft." To me this says I knowingly approved erroneous information for transmittal to the NRC. This is simply not the case. In my opinion, the conversation on June 29, contains sufficient objective evidence to demonstrate that an adequate discussion occurred as to the nature and basis of the ' record keeping practices' reasoning. This discussion shows that by the end of the conversation, I did not believe the cover letter explanation was wrong.
After drafting this response and reviewing the conversation from the viewpoint of an observer, it is clear to me that we could have done a better job in communicating our thoughts to one another. I feel that my emotions clouded my discussions. For example, I Page 5
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did not stop a moment to give Mr. hiosbaugh time to catch up or to digest what was being said, and also, in anger, cut offhir. Frederick several times. Such behavior is inappropriate. These are personallessons that I have learned.
Although I have always tried to ensure accurate information exchange with the NRC, my understanding and sense of awareness has been greatly increased. Afy practice has been to provide complete and accurate information even, as evidenced by this PRB vote, when it generates a negative reflection on myself, my department or my employer. I reassure you that all future information provided to the NRC by me shall be complete and accurate to the best of my abilities. This is more than a legal requirement, it has always been the right thing to do.
Thank you for considering this response. Please let me know ifI can provide additional information or answer any other questions.
Sincerely, Q
hiichael W. Horton I, the undersigned, hereby Sworn to and subscribed swear and affirm that the before me thisc79# ay d
information contained in of dd 1994.
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this letter is true and correct to the best of my 2;
knowledge and belief.
Notary Public
-U hiy Commission Expires:
hiichael WIHorton
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