ML20096F209

Investigation Rept. Rept Provides Info for Second Phase of Investigation Into Alleged Falsification of Operator Log & Tour Repts at Plant

ML20096F209
Person / Time
Site:	Oyster Creek
Issue date:	05/13/1992
From:	GENERAL PUBLIC UTILITIES CORP.
To:
Shared Package
ML20096F205	List: ML20096F203 ML20096F209
References
COE-030992-01S, COE-030992-01S-OC, COE-30992-1S, COE-30992-1S-OC, NUDOCS 9205200276
Download: ML20096F209 (17)

Text

.

k  !

Case COE 030992-01S Oc Page 1 of 17 INVESTIQATION REPORT MATTER JNVESTIGATED BY The concerns indicated in this report were investigated at Oyoter Creek by TMI Nuclear Security Agent, Brian R. Frants, and Security Analyst III, Francis Coppinger.

Senior Site Protection Supervisor Richard Ewart and Site Protection Supervisor Rocco Petella provided security computer keycarf data and analysis of the data. Radwaste Operations Manager, Robin Brown, provided a technical review of the readings recorded on the three nuclear plant operator tour sheets, and a comparison to plant operating conditions. Technical Analyst Senior I, Richard Nash provided radiation work permit data.

PURPOSE OF THE INVESTIGATION:

i It is important to note tha*. this investigation was'not conducted in response to any formally identified allegations or accusations of wrong doing.

The investigation was initiated at the request of J. J. Berton, Oyster Creek Vice President / Director, and was intended to identify and address anomalies and discrepancies inherent to the tours (and tour logs) conducted by the Oyster Creek Plant Operations personnel.

EpURCE:

The anomalies : 34 concerne disclosed during this investigation were identified through a comparative analysis of two documentary roterences. The documents examined during the analysis included access journalo generated by the security computer (relative to individual employee keycard use), and the-operatioas logs which-identified personnel responsible for conducting tour log surveillances. By comparing an individuals access (by the $ecurity access computer) into specified vital areas, and the documented data from readings within the specified vital area, a reasonable conclusion could be' determined as to whether the tour logs reflect legitimate information as a result of an operators access to that equipment. This review covered a.(91) day = period from December 1, 1991, through February 29, 1992, and was conducted by Oyater Creek security personnel, Richard Ewart, Rocco Pe?.ella, Va.terie Roeseller, and )

Richard Bernava.

i 920S200276 920513 gDR ADOCK 05000213 PDR

_ i

,, ,. .i.iw. O %I f Case coK 030992-018 OC 1

Page 2 of 17 One anomaly was identified through a review of the nuclear plant oporator tour sheets (intake area, reactor building and turb*ne building) for the twriod of December 1, 1991, through February 29, 1992. The purpose of  :

this review was to determine if readings logged on these tour sheets wero =

consistent with the plant conditions and tollowed expected trends. Manager Radiological Waste (Radwaste) Operations, Robin Brown performed this review, and provided the results to the security investigators f or potential follow-up.

_ SCOPP OF THE INVEETIGATION:

brpik;stble LayJ/Rult.g]Agoulations/Prondures and Other Recuirementas

1) Cyster Creek Nuclear Generating Station Procedure, Humbar 106,

" Conduct of Operations'. Revision No. 62.

{

\

e Persona InigtvA yf.dt Eighteen personnel were interviewed during the inveselgation. Those employees interviewed who are employed by Jersey Central Pcwer and Light

]

(JCP&L) are members of the International Drotherhood of Electrical Workers (IBEW) Union Local 1209. During the anterviews, the IEEW members were E

afforded the opport'anity to have a union steward present. U1 or U2 provided this represencation during thene int.erviews.

In addition to those personnel interviewed, John J. Barton, Oyster Creek Vice President / Director, and/or Sandac Levin, Director of Operations and Mainterance were provided with daily debriefings on the progress of the investigatien. Russull Cook, Area Maneger Human Resources, auf Jamus Bruffy, Staff Administrator Human Resources, wer6 elso provided with the findings regarding specific individuals it. order to assist them in determining appropriate disciplinary action.

• Q1hgr RelevenLp m grente Revigged

1) security con.puter keycard listings for all operations department personnel covering the period of December 01, 1991, through February 23, 1992.

1

Case COE 030992-01S oc Page 3 of 17

! 2) Turbine building tour sheets for the following dates:

Decembec 29, 1991, January 2, 3, 6, 9, 12, 14, 20, 22, 25, 31, 1992, and February 11, 1992.

3) Raactor Ru11 ding Tour Sheet 'or January 18, 1992. j

' EhEE1EAl_E"idenqa j None I

• Others Senior Site Protection Supervisor Richard Ewart provided B. Frants and F. Coppinger a tour of the new cable spreading room.

INVESTIGATION RESULTS:

On Tuesday, March 17, 1992, John J. Rarton, Oyster Creek Vice President / Director requested an investigation to assess the overall conduct of plant tours by ogA0ations personnel at Oyster Creek. This investigation was directed toward two arean. The first area covered a-review of vital area

entries of nuclear plant operators using their security issued Leycards, and entry into radiologically contro.\ led areas (RCA's) as evidenced by radiation l work permits (RWP's). These enuries would be compared to areas required to be entered during the three nuclear plant operascr (NPO) tours (intake area, l turbine building, and reactor building). Richard Ewart, Senior Site Protection Supervisor, cnd Rocco Pete11a, Site Protection Supervisor were ,

given responsibility to obtain the keyeard recorda via the security computer. ,

Richard Nash, Technical Analyst Sonior I,.was'given the responsibility to obtain the RWP data. The second area covered a review of the readings recorded on the nuclear plant operator tour sheets and a comparison tc plant I

conditions to determine if readings recorded were consistent with plant conditions. Robin Brown,-MA%ager Radiological Waste (Radwaste) Operations, was given responsibility for completion of this second area. After obtaining >

and reviewing the-information, it was turned over to the security investigators for disposition.

The following anomalies and concerne surfaced as a result of this comparative review process:

>- ~ ~-,, ,g 3 4 -- --

7 , , , , e , g

A e

case COE 030992-018 OC page 4 of 1's

1) Sost nuclear plant operatore did not make two complete tours of their assigned areas during their shifts.

2) On January 22, 1992, Nuclear Plant Operator (FPO12) did not enter the new cable spreading room as required by the Turbine Building Tour sheet, but indicated he petformed the task by placing his initials in the space provided on the tour cheet.

3) On January 2, 1992, Nuclear plant Operator (NPoll) did not enter the new cable spreading room as required by the Turbine Building Tour Sheet, but indicated he performed .5J tank by 'Tacing his initials in the space provided on the tour shaet.

4) On January 18, 1992, Nuclear Plant Operator iHPO8) did not enter the old (lower) cable spreading room as required by the Reactor Building Tour Sheet, but provided an indication of entry by recording readings and his initials in the spaces provided on the tour sheet.

5) on five dates in January,.(09, 12, 20, 25, & J1), 1992, Nuclear Plant Operator (NPO10) did not enter the new cable spreading room as required by the Turbine Building Tour Sheet, but provided an indication of entry by recording his initials in the space provided on the tour sheets.

6) On five dates, December 29, 1991, January 2, 6, and 14, 1992, and February 17, 1992, Nuclear Plant Operator (NPO3) did not _ enter the new cable spreading room as required by the Turbine Building Taur Sheat, but provided an indication of entry by recording his initials in the space provided on the tour-sheets.

7) Several Nuclear Plant operatore did not accurately record readings and/or commento in the proper spaces provided on the Turbine Building, Reactor Building and/or Intake Area Tour Sheets, h-f The first area of concern that was identified was the fact that most of f the nuclear plant _ operators (24 out of 25) were not entering some vital areas f twice during their assigned shifts. The first two sentences of the three tour sheets state the following: "The equipment operators responsible for this

. ~~y

_m-_._ _ _ _ - _ _ .

Case COE 030992-015 OC Page 5 of 17 tour should perform two complete rounds covering all below listed equipment and areas. Readings shall be conspleted on the first round, and compared to actual conditions during the socorA round, to note changing trends in equipment." The tour sheets indicate that a nuclear plant operator "should" make a second tour for the purpose of noting changing trends in equipment.

[ NOTE: According to American National Ltandard ANSI /ANS 3.3-1982; "should" denotes a recommendation, "shall" denotes a requirement). A review of the security keycard data for nuclear-plant operators for the previously indicated three month period showed one NPO (NPO15) who always entered each vital area twice por shift. Two other NPO's, (NPO4 and NPO7), frequently reentered all vital areas twice per shif t, while the remainder of nuclear plant operators entered all vitat areas twice per shif t on an infrequent basic.

Seven nuclear plant operators who frequently did not enter all assigned vital areas twice per shift were randomly selected to be interviewed. In addition, five other nuclear plant operators (NPO3, NPO8, NPO10. NPoll and NPO12) were also selected for interview based upon other anomalies which applied specifically to them. All twelve of these NPO's were questioned about why they frequently did not reenter some vital areas.

Generally, these (12) NPO's listed the same reasons for not frequently reentering some vital areas. The reasons are as follows: the workload of l the nuclear plant operators which included resin transfers, and require two or three NPO's, surveillances, higher priority jobs, and/or concentration on operating plant systems. _These NPO's were also asked if they notified-their respective group operating supervisor (GOS) or group shif t supervisor (OSS)

I that a completa second tour was not accomplished, or=if a notation was placed l on tbi tour sheet when portions.of a second tour were not made. Several of l the NPO's indicated that they expected their 00S to know that a full second tour could not be completed based upon the fact that the COS assigned them to additional duties. Other NPO's said it had not occurred to them to notify their GOS. None of thise twelve nuclear plant operators indicated that they noted an incomplete second tour en their tour sheet.-

NPO4 and NPO7 were questioned ~as to why they frequently made two complete tours of their assigned areas. NPO4 said he did not find-it difficult to complete two tours provided the workload was not too large. NPO4 maid he would not normally note an incomplete second tour.on his tour sheet, but he would notify the next NPO assigned to the same tour, to ensure that:

this next NPO performs a thorough check, NPO7 said there are times when he

t l

1 Casa COE 030992-018 OC Page 6 of 17 cant.ot complete a second tour due to the haavy workload, but he tries to get two complete tours done.

The review of the security keycard recordo for Nuclear Plant Operator NPols, revealed that NPO15 entered the vital areas twice for each assigned tour during the period of December 01, 1991, through February 29, 1992. NPO15 was interviewed to determine how he managed to accomplish two complete tours per shift. NPO15 maid he felt it was his responsibJlity to cond*ct two complete tours, and if this could not be accomplished it was also his responsibility to inform his GOS. NPO15 said he would make this notification to the GOS ir. order to keep him (the COS) informod of what work was or was not accomplished.

Another anomaly that was identified via the security keycard records of the nuclear plant oporators, was that there was no indication of anyone entering the acw cable spreading room on January 22, 1992 during the 0800-1600 shift. The new cable spreading room is included on page (1), section (2) of the Turbine Building Tour Sheet. The tour sheet does not specify what actions are required to be performed during the check, but it does require the assigned operator to log his initials in the space provided. A check of the new cable spreading room requires utilizing a sucurity issued keycard to gain entry into th6 room. R. Ewart provided B. Frantz and F. Coppinger a tour of the new cable spreading room, which is located on the 63 foot elevation of the turbine building. Essentially, this area contains electrical cables and cable trays.

In order to detsemine if there was any error in the operation of the security computer, or the keycard readers at the new cable spreading room, several evolutions were performed. First, the new cable spreading room door keycard readers were checked for all operations department personnel entries and exits. Bacause this did not indicate any NPO activity at the keycard readers, NPO12's heycard was checked individually for- all activity during the shift. NPO12 was the NPO who signed '$e Turbine Building Tour Sheet for the 0800-1500 shift on January 22, 1992.. Although this keycard report showed activity-at the main gate, control room and 4160 switchgear room, it did not show any activity for the now cable' spreading room. A further check was made of all personnel with keycards~for' activity at the new cable spreading room for the aforementioned date and shift. This activity report showed only security personnel entering and exitir.] the room. A final check was made to l

l l

case 00t 030992-010 OC Page 7 oi 17 i

l determine if there were any " terminal downs" on the keycard readers for the l new cable spreading room. A " terminal down* is a message the keycard reader l I

sends to the Central Processing Unit (CPU) in order to inform the security alarm station operators of a problem with a keycard reader. This final check i

failed to indicate any keycard reader problems. l l

On April 07, 1992, NPO12 was interviewed regarding the aforementioned issue. During the interview, NPO12 wts asked if he could identify the handwriting, initials and signature on-the January 22, 1992, 0000-1603 shift Turbine Building Tour Sheet. NPO12 confirmed his handwriting, initials and signature. NPO12 was inforried that there were no security keycards entries or exits for himself or any other operations department personnel at the new ,

cable spreading room, and D. Frante reviewed the security computer keycard  !

data with him. NPO12 was then questioned about why he indicated his initials on the tour sheet when there was no confirmatio1 of his entry into the area.

NPO12 said he believed he entered the new cable spreading room,'and he

^

did not believe thet ho forgot to enter the room. NPO12 said the purpose of entering this area is to inspect for-fires. NPO12 said there have been instances uhere the keycard readers would not grant him access and they would indicate " entry denied," but ho did not know if that type of incident occurred ,

on January 22, 1992. R. Ewart explained tnac'an " entry denied" message may be caused by one of three reasons. If an employee improperly inserts his keycard into the reader, an " entry denied" message will result. If a keycard is not programmed for access into a vital area this will also cause an " entry denied

• message, in addition to a keycard which is not validated for access into t'ho protected or vital areas. Since NPO12's keycard vaa valid and he did have authorized accees to the new cable sprouding room > impropar insertion of the keycard would be the apparent reason to cause an " entry _denieo" missage for l

NPO12's keycard. If an " entry denied" message is received for improper insertion, the security computer would not receive the message, but the electronic door release would not function until the xeycard is inuarted l properly. Section 4.4.1, of vyster Creek Station Procedure Number 106, states, "On tour sheets, satisfactory completion of a checklist item will be documented with the initials of the person performing the iten, verification."

l t

Another anomaly that was identified by the securit,' computer keycard recordo of the operation department personnel occurted on January 02, 1992, ,

during thz midnight to 0800 shift.- During this date and chift, there was no

- . - - - . - - . _ .. - - . - . .-. . _ - -. .- - - - - .. ~.

4 Case coE 030992-018 Oc Page 8 of 17 indication of any entry into tne new cable spreading room by anyone within the Operations department. the same type of s*curity computer cross checle were utilized as in the case of NPO12, in order to determine if anyone from the Operations department was present in this area during the aforementioned date and shift. This cross check revealed that three security personnel were the only individuals to keycard in and out of the new cable spreading room.

NPO11's signature appeared t the Turbine Building Tour Sheet for tnis date and be was subsequently interviewed regarding the identified anomaly. NPO11 was provided with the Turbine Building Tour Sheet for January 02, 1992, and be j was asked if he recognized the signature, handwriting and initials on the tour sheet. NPO11 confirmed that the signature, handwriting and initials were his. NPO11 was informed that there was no indiculion of entry into the new cable spreading room by himself, or anyone else from the Operations department, and the security computer keycard records were displayed and j e*plained to NPO11. NPO11 was then asked for an explanation as to why his l initials appeared on the Turbine Building Tour S.heet when there was no i evidence of entry into the new cable spreading room. NPoll said he did not recall the specific day, but offered a possible explanation. NPO11 said he may have been on the roof checking the fans and received a ccL1 ove*: the radio to respond to another area. NPO11 said if this did occur, he way have enmpleted the tour sheet at a later time, placing his initials in the block believing he had entered the room. NPO11 said there are numerous occasions during a shift when his assigned tour is interrupted and this could have been ,

one of those occasions. The f ans that NPO11 referred to are located on the '

roof of the office building adjacent to the new cable spreading rooe door. A check of these fans is reguirea by the Turbine Building Tour Sheet on page (1), section (4).

The fourth anomaly that was identified via the review of the security computer keycard records occurred on January 18. 1992, during the 0800-1600 shift. The sitaation that was identified involved NPO8, and the fact that there was no record of his entry into the lower cable spreading room. There la only one door for entrance and exit to this area, and it is a vital area

~

do>r controlled by a security keycard reader. A check of_this room is required by the Reactor-Building Tour Sheet page (1) section 1. A review of this tour sheet shows that a nuclear plant operator is required to observe and record-(12) volt and amp readings and indicate a check of the brush recordSr and auto transfer switch Dc-E, by placing their initials in the appropriate I

space. NPO8 was interviewed on April 08, 1992, regarding this anomaly. NPOB

I Case OOE 030992-018 oc Page 9 of 17 l was asked if he recognized the signature, initials, and handwriting on the tour report. NPO8 confirmed all three elemonts as his own. NPOB was inforraad that the security computer keycard records showed that he did not enter the lower cable spreading room on this date nor was there any indication of any entry by Operations department ;*rsonnel. B. Frantz explained the security keycard printoute to NPO8, including how his possible entries / exists were ,

checked and cross checked into the lower cable spreading room. NPOB was asked if he could offer any explanation why he recorded readings on the Reactor Building Tour Sheet for the lower cable spreading room, when there was no evidence of his entry into the area. Initially, NPO8 seid that he had broken ,

l his keycard and a new one was issued. Frantr. confirmed this wkJ true; j however, NPOC did not receive a new keycard until January 23, 1992, five days after this incident. NPOS was again asked how he obtained the readings indicated on the tour sheet if he ws* sat present in the lower cable spreading rootu . NPO8 replied, "I don't know." Durir; the interview the issue was revisited, and NPO8 was asked if it was possibic he could have taken the previous shift's readings and recorded them for his shift. NPOS replied, "No, I don't normally do that." NPO8 was then asked if he record 6d a previous shift's readings on this occasion. NPO8 replied, "No, I don't do that. I do my job here. My answer is No, I don't know."

On April 09, 1992, at the request of U1, a check of keycard maintenance records was performed by D. Ewart in order to determine if any wczk orders had ber n submitted on the keycard readers: at the.new cable spreading room or the lower cable spreading room. This check revealed that the "in" reader on the  ;

new cable spreading room had been tagged with a ' deficiency tag on January 8, 1932. because the keycard reader would not accept keycards. *be "in" reeder i was repaired on the same day, January 8, 1992. At'the lower cable spreading room, the "out" reader was replaced on two occasions, September 12, 1991, and March 25, 1992, due to " terminal' downs" on the keycard reader. A " terminal down"' prevents the use of the keycard readers and disables cartain alarm functions that work in correlation with the keycard reader. The three dates indicated above were not dates during which any of the anomalies identified in this report were in question.

On April 9,1992, Nuclear Plant Operator NPO10 was interviewed in an attempt to resolve several anomalies which were identified as a result of the-review of NPO10's security computer keycard data and the comparison to Turbine Bullaing Tour Sheets. The security computer keychrd data ~revealod that therp I' ,

.. -- e ., _ .m.. ,, m- y ,,

Case COE 030992-01S OC Page 10 of 17 were no keycarded entries by operations }ersonnel into the new cable spreading room on January 9, and 12, 1992, during tte 0800-1600 shift, January 20, 1992 during the 1600-2400 shift; and January 25, and 30, 1992, during the midnight-0800 shift. The security computer keycard records for operations personnel were also cnocked and cross checked using the same methods previously indicated in this report. During NPO10's interview, he was asked if there were aay areas that he may not enter which are required by the Turbine Building Tour Sheet. NPO10 repliod, "yes, on occasions." NPO10 was then asked what areas came to mind that he did not enter and he replied, "The new cable spreading room." This was followed up by asking NPO10 to determine how often he believes he may not have entered the new cable spreading room over any given period of time. NPO10 said he could not place a number on it.

NPO10 was then asked if he (NPO10) would be surprioed if the security ksycard records indicated that he did not enter the new cable spreading room on five occasions during a two monsth period (January and February 1992). NPO10 replied "Yes that's possible, very likely." NPO10 was given the Turbine Building Tour Sheets for the aforementioned dates and asked to identily the handwriting, initials and signature on each tour sheet. NPO20 confirmed th9r all three elements were his own. NPO10 was asked what his initial indicated on page (1), section (2) "Naw Cable Spreading Room," of the Turbine Building Tour sheet. NPO10 said that his initials indiccte that he was thwre and completed that part of the tour. The security coroputer keycard data was explained to NPO10, and after this explanation, NPO10 was asked how t.a could rensive t,; fact that +here was no evidence of his entry into the new cable spreading room, but his initials indicate he was there. NPO10 reptiod, "Like I can't reralve it." NPO10 was asked why he did not go into the new cable spreading room on these five occasions. NP010 said that there was nothing there to check on or get readings on, and the check was essentially a fire ch7ck. NPO10 added that if there was a fire, the fire oystem alarm would go off. During the first interview wich NPO10 on March 17, 1992, NPO10 was asked

'.f he ever had not fully performod a task because he did not feel it was necessary. On March 17, 1992, NPO10 replied, "No, never."

The last anomaly that was identified via the security computer keycard records focused on Nuclear Plant Operator NPO3. These security computer keycard records showed five days and shifts (December 29, 1991. 0800-1600 shift, January 3, 6, and February 17, 1992, 1600-2400 shift, and January 14, 1992, midnight-0800 shift) where there was no evidence that NPO3 entered the new cable spreading room. On J: nuary 14, 1992, another operations department 1

R Case COE 030992-018 OC Page 11 of 17 person, CRO1, a control Room Operator Step 2, was in the now rable spreading room during Ha midnight-0800 shift. On April 9, 1992, NPO3 was interviewed in an attempt to resolve these issues. NPO3 was asked if he does not perform portions of him toura because he does not feel they are neceseary. NPO3 replied, that to the best of his ability, he tries to cover everything required by the tour sheets. NPO3 was then asked if it was possible that he did not perform a portion of the required tours. NPO3 replied, "I'm human, I may have. Yes it's possible." NPO3 was asked if any specific area came to utnd which may have been missed. NPO3 said he could not think of any areas.

NPO3 was asked to review the Turbine Building Tour Sheets for the aforementioned dates and determine if the handwriting, initials and signature were his on each tour sheet. NPO3 maid all the tour sheets appeared to contain his handwriting initials and signature except for the January 6, 1992, tour sheet. NPO3 maid the signature did not look like his (NPO3's), but added that b9 may have been writing in a hurry. NP03 did confirm that che handwriting and initials on the January 6, 1992, tour sheet were his own.

NPO3 was informed that the security computer keycard records for him do not indicate any entry into the aew cable spreading room for the dates indicated on the previouuly ider.tified Turbine Building Tour Sheets. NPO3 said, "Obviously it's correct (the security records). I initialed it. I do the (roof) fans and I may have forgotten to go in there."

B.

Frantz told NPO3 that it seemed difficult to believe that. a person would forget to enter an area on five separate occasions. NPO3' replied, "Ask my friendu, I'm pretty absent minded, I forget-my keys all the time. Maybe I was just trying to make op time. I may have forgotter.." NPO3 was asked what may have made him forget to go into the new cable spreading room. 'NPO3 said he checks uts roof fans and passes the door to the new cable spreading room, and since there are no readings to take, he may not have realized that-he did not enter the room. NPO3 said he may have forgotten whether he did enter the rocm, and. initialed it while initialing the computer room portion of the tour.

NPO3 recommended that the section on the Turbine Building Tour Sheet for the new cable spreading room be separated more from the co:nputer room section, in order to eliminate the possibility of inadvertently initialing a section of the tour that was not actually completed. NPO3 was shown the security.

computer keycard data for January 14, 1992, and asked t* CRO1 may have performed the check of the new cable spreading room. NPO3 said that CROI may have performed the check of the new cable spreading room on this date.

I

Case coE 030992-01s Oc Page 12 of 17 During the review of readings recorded on the Intake Area, Turbine Building and Reactor Building Tour Sheets and the comparison to plant conditions, Radwaste Operations Manager, Robin Brown identified eleven (11) data points that appeared to be out of the expected range without a documented change in plant conditions. According to 3. Brown, this review did not indicate any substantiated falsification of data pointe on an overall or individual basis. After the security investigators receivsd and reviewed the information supplied by R. Brown, it wan determined that the eleven (11) issues identified would not be pursued during the investigation. This decieion was based upon the fact that there was no reason to believe that any )

of the readings record 2d had been falsified, and the anomalies identified-appeared to be additional exampleo of what company 1 previously identified to oyster Creek operations management in the way of inaccurate or incomplete log keeping practices.

" CORRECTIVE" RESPONSES TO DATE:

According to James Bruffy, Oyster Creek Administrator Human Resources, five employees (NPO3, NPO8, NP010, NPO11, and NPO12) received five-day suspensions without pay for falsification of nuclear plant operator tour logs.

Robert Barrett, Plant Operations Director, stated that all five employees met with Barrett and Philip Scallon, Manager Plant Operations upon return from their suspensions, for the purpose of reinforetng the accuracy of record and log keeping practices, and the need for honesty and integrity in performing the job of a nuclear plant operator. Similar meetings occurred between the '

previously identifiou nuclear plant operators and sander Levin, operations and Maintenance Director, and John J. Barton, Oyster Creek-Vice President / Director.

1 s L..! DINGS The findings for each of the specific ancmslien are identified below.

1) Most nuclear plant operators did not make two complete tours of their assigned areas during their shifts.

This has been substantiated. The revtew of the security computer keycard records for operations department Lawsonnel, showed that in most ca*a s, personnel did not reenter one or more vital area doors to take

~ _ __ . _ _ - . - - . . ~ - - . .. .- . ...__ - - ._. - . .

Case COE 030992-018 oc Page 13 of 17 comparative readings. The three tour logs do not require that personnel make a second complete tour and the operative word that is recognized in the language at the top of the tour report is "should." The reasons that the personnel listed for not making two completa tours were reasonable to believe.

It is worthy to note that NPO15 made two complete tourc in every area he was assigned, and that both NPO7 and NPO4 were relatively consistent in making two complete tours of their assigned areas.

2) On January 22, 1992, Nuclear Plant Operator (NPO12) did not enter the new cable spreading room as required by the Turbine Building Tour Sheet, but indicated he performed the task by placing his initials in _the space provided on the tour sheet.

This han been substantiated. On January 22, 1992, NPO12 was assigned tO the 0800-1600 shift, and was responsible for completing a check of the new cable spreading room according to the Terbine Building Tour sheet. Although NPO12 placed his initials in the space provided, which indicates satisfactory completion of a checklist item according to Oyster Creek Procedure 106, Section 4.4.1, there was no documented entry to the new cable spreading room by NPO12 or any Operations department personnel, according to the security computer keycard rerords. NPO12 believed he did enter the area, but could not offer a further erplanation for the lack of a keycard entry and/or exit.

3) On January 2,1992, Nuclear Plant Operator (NPO13 ) did not enter the now cable spreading room as required by the Turbine Building Tour r.heet, but indicated he performed the task by placing his initials in the space provided_on the tour sheet.

This has been substantiated. On January.2, 1992, NPoll was assigned to the midnight to 0800 shift, .and was responsible for completing a check of the new cable spreading room according to the Turbine Building Tour Sheet. NPO11 placed his initials in the space provided, which indicated satisfactory completion of the checklist item according to Procedure 106, Section 4.4.1, but there was no documented entry (according to the security computer keycard records) into the new cable spreading room by.NPO11 or any other operations department personnel. NPO11 offered a possible explanation saying that he may have been on the roof of the office building-checking'the fans and received a radio call to respond to another area. NPO11 said he may have completed that portion of the tour sheet at a later time, and inadvertently placed his  !

Case COE 030992-018 OC Page 14 of 17 initials in the space provided, believing he performed the check.

4) On January 18, 1992, Nuclear Plant Operator (NPOB) did not enter the old (lower) cable spreading room as required by the Roantor Building Tour Sheet, but provided an indication of entry by recording readings, and his initials in the spaces provided on the tour sheet.

l l This has been substantiated. On January 10, 1992, NPO8'was assigned to  !

I the 0830-1600 shift, and was responsible for obtaining volt and amp readings, and checking the brush recorder and auto transfer switch DC-E, located within l the old cable spreading room. NPO8 recorded (12) readings and his initials in j the spaces provided on the Reactor Building Tour Sheet, but there was-no indication (as evidenced by the securit',' computer koncard records) of ble encry or the entry of anyone from the Operations department.into this room during the shift. NPO8 could not offer any explanation as to why he recorded readings if he was not present in the room. When NPO8 was mLked if he may have taken the previous o!.ift's readings and recorded them for his shift, he said he did not ner^*11y do that. When he was queried further about this response he said n ' answer was "No, I don't do that. I do niy job here. My answer is No, I don't know." NPO8 could not offer any explanation for the-incident.

I l

5) On five dates in January, (09, 12, 20,125, 31), 1992, Nuclear Plant Operator (NPO10) did not erter the new cable sprerding room as required by the Turbine Building Tour Jheet, but provided an indic9 tion of entry by recording his initials in the spaea provided on the tour eheet. >

This has been substantiated. NPO10 was assigned to the 0800-1600 shift during January 9, and 12, 1992; the 1600-2400 shift on January 20, 1992; and the midnight-0800 shift on January ~25,-and 31, 4992. During all these dates and shifts, NPO10 was adulgned to complete the Turbine Building Tour and one of the requirements f the tour is entry into the new cable spreading room..

NDO10 inJicated his entry of the room by placing his initials on the tour sheet, however there was no evidence established by the security computer keycard records of NPO10's entrance or the entrance of 'any operations department personnel during these dates and shifts. Prior to informing NPO10 of the investigation findings, NPO10 adial,tted that he did not enter the new

a m.+ - . ..ma ~ . . 1a .a ~ -- - n -- '- ~ ..a s. .-. --.as .u.> . - -

Case COE 030992-018 OC j Page 15 of 17 cable sp' ading room on occasions because he did not feel it was necessary.

When NPo10 was informed of the five dates where no evidence of his entry could be found, NPO10 replied, "Yes that's possible, very likely."

6) On five dates, Deconber 29, 1991, January 3, 6, and 14, 1992, and February 17, 1992, Muclear Plant Operator (NPO3) did not enter the new cable spreading room as required by the Turbine Uuilding Tour Sheet, but provided an indication of entry by recording his initials in the spave provided on the tour sheet.

This has been substantiated. NPO3 was assigned to the 9800-1600 shift on December 29, 1991; the 1600-2400 shift on January 3, and 6, and February 17, 1992; and the midnight-0800 shift on January 14, 1992. During all these dates and shifts, NPO3 was assigned to complete the Turbine Building Tour, and one of the requirements of the tour is entry into the new cable spreading room. NPO3 indicated his entry by placing his initials on ti.e tour shewt, however, there was no doctmentary evidence (as indicetsd by the security computer keyeard records) of his entry into the area. A check of other operatic. department personnel showed that CRO1 had entered the new cable spreading room on January 14, 1992, during the n;1dnight - 0800 shift. These records of entries and exit s from the new cable spreading t ?>m were obtained through the security computer keycard records. After NPO3 was informed of the l findings regarding this piece of the investigation, NPO3 said that-he may have forgotten to go into the area. During=the-latter portion of the interview, NPO3 al9o offered the explanatjon that the space on the tour sheet to initial, indicating completion of the new cable spreading room chock, was too close to the space for the initials required for the computer room check. NPO3' believed this may have caused him to initial the space for the new cable spreading room without actually entering the area. If NPO3 would have only had one incident involving not entering the new cable spreading room, absent

~

tendedness may be considered, but with five incidents,:this excuse appears unreasonable to believe.

7) Several nuclear plant operatora did not- accurately record readings and/or comments in the proper spaces provided on the Turbine Building, Reactor Building ,,nd/or Intake Area Tour Sheets.

Although interviews of the nuclear plant operators identified by Robin Brown's analysis of the tour. sheets was not pursued, it is believed that the

Case COE 0?0992-018 oC Page 16 oc: 17 incidents citA were additional exan:ples of what had been previously identified by company 1 in the way of inaccurate or incornplete log keeping practices i

mer.

Cass COE 030992-018 Oc Page 17 of 17 FILE MAINTAINED AT1 The full investigative file of this case will be maintained in the office of the Nuclear Security Agont at THI and referenced as case #030991-018 OC. Security computer keycard data, Turbine Building Tour Sheets and Reactor Building ~'our Sheets for the dates and shifts indicated in this report are not included with this report, but are available for review in the office of the Nuclear Security Agent at THI.

I 1

Investigator Signatures Brian R. Frantz Date Nuclear Security _ Agent, THI i

Investigator Signaturo: . __

Francis J. Coppinger Date l Security Analyst III ]

l Reviewed / Concurred:

James F. Stacey Date Security Manager NSD Review / Approval:

H. K. Pastor Date Nuclear Security Director i

k l

l

-v.- -- rpg.. , s-

,9. .* m,yy et -.9e.w...