ML20126D345
| ML20126D345 | |
| Person / Time | |
|---|---|
| Issue date: | 09/18/1979 |
| From: | Gower G, William Ward NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| To: | |
| Shared Package | |
| ML20126D330 | List: |
| References | |
| REF-QA-99900400 79-HQ-002, 79-HQ-2, NUDOCS 8004280153 | |
| Download: ML20126D345 (100) | |
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UNITED STATES 3 , g NUCLEAR REGULATORY COMMISSION
.- .. E WASHINCToN, D. C. 20555
\ ,,,, .' SEP 1 8 1979 REPORT OF INVESTIGATION TITLE: Babcock & Wilcox / Possible Violation of 10 CFR Part 21 ,
CASE NUMBER: 79-HQ-002 SUPPLEMENTAL: VENDOR NUMBER 99900400 PERIOD OF INVESTIGATION: July 19 - August 17, 1979 STATUS OF INVESTIGATION: PENDING
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REPORTING INVESTIGATOR: / [/7 N Se:TioF InvestigatoF
/Wil'liam J. War Executive Off for Operations Support, IE:HQ REPORT APPROVED BY: ( ,, .W4 George C. Gower, Acting Executive Of ficer for Operations Support, IE:HQ i
800.4280153
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SUMMARY
Investigation was initiated after media accounts of testimony of B&W employees before the President's Comm.ission on the Accident at Three Mile Island indicated that two B&W engineers had written memoranda indicating that reactor operators lacked sufficient guidance relative to termination of the high prassure safety injection system (HPSI) during loss of feedwater transients, and that B&W man-agement had failed to react to these concerns until after the TMI Accident.
The specific purpose of the investigation was to determine whether B&W's handling of this information constituted a violation of the reporting requirements of 10 CFR Part 21. Investigation to date has consisted of review and distillation of the official transcripts of the hearings conducted during the period July 18-20, 1970, consisting of over five hundred pages of sworn testimony. According to the transcripts, the following sequence took place: Based on his investigation of a loss of feedwater. transient at the Davis-Besse plant in September, 1977, a B&W engineerwroteamemoonNovember1,1977tovariousB&Wofficialsinwhichhe expressed concern that B&W customers lacked guidance regarding the necessity of not terminating HPSI during LOCAs and recommended that such advice be provided. '
One of the recipients of the memo not only concurred with this, but authored two memoranda to the B&W Licensing Manager characterizing the matter as a serious concern and suggesting that improper operator interruption of HPSI could result in core uncovery and possible fuel damage. He later testified that he was not aware that no action had been taken regarding his concerns until after the TMI Accident and that TMI would have been a minor accident if his suggestions had been implemented. The Licensing Manager, a responsible official c:; defined in l Part 21, testified that he felt that memorandum was misdirected, and that it was not a significant safety item that had to be handled in accordance with the B&W Part 21 procedures which he administers; consequently he sent it to B&W Nuclear Service as a procedural matter. The manager of that unit gave it to one of his engineers who disagreed with the prescription offered in the memo, a disagreement that he documented in a November, 1977 memo to the engineer who first raised the issue. He subsequently authored a memo for his supervisor's signature which was sent to the Manager of Plant Integration in which he expressed concern that the l
prescription could cause a rapid cooldown transient by going solid in the absence of a LOCA.* Despite occasional prodding by the Manager of Nuclear Service, the i Plant Integration Manager took no formal action until after the TMI Accident at which point instructions were provided B&W customers that essentially incorpo-rated the original concerns. The Vice President of the B&W Nuclear Power Genera-tion Division denied being aware of the memoranda or the information contained therein before the TMI Accident. He, along with other B&W officials who testified during this period, characterized the issue as a technical difference of opinion or dispute. Investigation conti'nues pending review of the information gathered to date by IE management and OELD.
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m DETAILS ,
1 PREDICATION & BACKGROUND During the period July 18-20, 1979, the President's Commission on the Accident at Three Mile Island (herein after referred to as the Kemeny Commission) heard sworn' testimony from several employees of the Babcock & Wilcox (B&W) Nuclear Power Generation Division (NPGD) as part of the Commission's current investigation of the Three Mile Island (TMI) Accident. According to media accounts, on July 19, 1979, two B&W employees testified that they had attempted to bring to the attention of B&W management their concerns about reactor operator procedures to certain transients such as that experienced at the Davis-Besse Nuclear Power Plant on September 24, 1977. The media accounts of their testimony indicated that no action was taken by B&W and that the concerns that they had expressed ;
played a significant role in the Three Mile Island Accident. The foregoing news- l paper reports were the subject of a conference among the Acting Director, Office of Inspection and Enforcement (OIE), the Director, Division of Reactor Construction Inspection, IE who administers the IE program pertaining to the implementation of 10 CFR Part 21, and the reporting investigator. As a result of this conference, a decision was made to initiate an investigation of B&W's handling of the concerns expressed by the above employees, to determine whether such handling constitutes a possible violation of the reporting requirements set forth in 10 CFR Part 21.
This . investigation was thus initiated on July 19, 1979 at the request of Mr. Harold Thornburg, Director, Division of Reactor Construction Inspection.
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INVESTIGATION AT BETHESDA, MARYLAND k
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b METHOD OF INVESTIGATION ^
j The information contained in this pending report was obtained by a review of the official transcripts of sworn testimony before the President's Commission on,the
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Accident at Three Mile Island by the reporting investigator. The transcripts of the hearings held during the period of July 18-21 consist of over five hundred .
pages. An attempt was made to limit the information synopsized in this report to that appearing to bear directly or indirectly upon the subject matter of this investigation. An attempt has been made to note the page number of the transcript in parentheses, where in the judgment of the investigator, particularly pertinent testimony appears. According to the transcripts, they are available for review at the Presidential Commission's reading room located at 2100 M Street NW, Washington, D.C.
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s TESTIMONY OF JOSEPH J. KELLY JR. i l
Kelly, an engineer in the Plant Integration Unit of the B&W Nuclear Power l Generation Division, Lynchburg, Virginia provided the following sworn testimony '
in substance before the Kemeny Commission on July 18, 1979.
During the course of his duties, Kelly became aware of the September 24, 1977 !
loss of feedwater transient at the Davis-Besse plant. He subsequently investigated that transient and upon his return to Lynchburg provided a briefing to a group of 30 B&W employees which included his unit manager, Bruce Karrasch, Don Montgomery, Bert Dunn, and Bob Jones. He indicated that John H. MacMillan, Vice President, B&W-NPGD was present for a portion of this meeting. During his presentation, he related that there had been a loss of feedwater, that the power operated relief valve (PORV) in the pressurizer had stuck open, and that the pressurizer level had increased while the reactor coolant system pressure was decreasing. He also described how the operators had terminated or throttled back the high pressure injection system. He did not remember advancing an opinion regarding the wisdom of the latter action, nor did he recall anyone asking him his views regarding it.
After the meeting (the transcript does not indicate how soon after) he discussed the operator's termination of the high pressure injection with Bert Dunn, Manager of the Emergency Core Coolant System (ECCS) Unit at B&W. According to Kelly, Dunn expressed concern regarding the operator's actions and indicated that he could provide scenarios wherein such actions would have lead to possible core damage. It was at this point that Kelly first heard concerns expressed about premature termination of high pressure injection, and it led to his worry about the degree of understanding on the part of operators as to when they should terminate or throttle back the high pressure injection (HPI). A second transient involving HPI occurred at Davis-Besse on October 23, 1977 led Kelly to discuss his concerns with members of the B&W Training Section even though he did not know ,
any of the details of the transient.
According to Kelly, simulator instructors with whom he discussed his concerns (two of whom were John Lind and Harry Helmyer) assured him that operators were ade-quately trained in this area and that specifically, they are taught to observe pressurizer level, primary plant pressure, and reactor coolant temperature before they could terminate HPI. He then informed the instructors that he agreed with what they said and that he would write d letter to B&W's Nuclear Service Unit to assure that these instructions were reaching B&W customers. Kelly recalled that neither he nor any of the instructors could figure out why the Davis-Besse operators had terminated HPI under the circumstances. At the conclusion of his meeting with the instructors Kelly felt reassured. ,
On November 1,1977 he wrote a memorandum to his management after first discussing it with his supervisor in which he described the events at Davis-Besse and stated that guidance should be given B&W customers regarding continuance of the HPI.
He specifically suggested that HPI (or low pressure injection) not be prevented or bypassed under any conditions other than a normal, controlled plant shutdown, and that once initiated, pressure injection should not be stopped unless "T ,
isstableordecreasingandpressurizedlevelisincreasingandprimarypre$58re l i
i is at least 1600 PSIG and increasing." He closed the memorandum by soliciting
" thoughts on this subject." Copies of the memorandum were sent to Bruce Karrasch, Manager, Plant Integration Unit, Swanson, R. J. Finnin, then in the Nuclear Service Unit, Bert Dunn, D. W. LaBelle, Manager, Safety Analysis Unit, Norman Elliott, ;
Manager, Training, and D. F. Hallman, Manager, Nuclear Service Unit. None of the l seven people to whom he sent the memo expressed their thoughts regarding it to '
Kelly nor did he approech them to solicit their comments. j Kelly admitted that he was familiar with the B&W Preliminary Safety Concern (PSC) System and stated that the system was in effect at the time that he wrote the memo. He stated that he did not use the PSC system to express his recommen-dation because at the time he did not feel that it represented a significant safety concern (p.18). He added that the primary reason that he wrote the memo was to get somebody to investigate the issue and arrive at an informed opinion as to the adequacy of advice being given customers. He felt that the people on the distribution were better qualified than he to render such a judgment. He further indicated that he was aware that the Licensing Section was responsible for PSC matters but that he had not sent a copy of his memo to them for the above cited reasons.
On or about November 10, 1977, he received a handwritten memo from J. F. Walters, (Enclosure 2) an engineer in the Nuclear Services Unit, which stated that it was Walter's opinion as well as that of B&W training personnel with whom he discussed
- ' this matter that the operators at Davis-Besse had reacted to the transient in a proper manner. Walter's memo also claimed that both reactor coolant pressure and pressurizer level would trend in the same direction during a loss of coolant accident (LOCA). Kelly explained that he made no attempt to discuss this memo with Walters because he felt Walters was either confused or had asked the wrong questions of the instructors in view of the statements that they had made to him.
According to Kelly, he essentially dismissed the Walters memo based on its content, but decided instead to escalate the matter to Bert Dunn, Manager, ECCS.
(The transcript does not reflect Kelly's description as to how this escalation was accomplished.)
In response to questioning, Kelly replied that although the point of whether operators would maintain the continous operation of the HPI after an accident was a significant safety concern, his belief was that operators were being properly trained. He asserted that the thrust of his concern was to determine whether customers were being pro'vided proper written guidance. Thus he felt-that he could not describe his concern as,a significant safety concern (p 38).
Kelly also asserted that the operators at Three Mile Island had stopped HPI I with temperature and pressure going in opposite directions. Kelly testified !
(pgs.49, 52) that the Three Mile Island Accident would have been minor rather than major had the operators not secured the HPI. He maintained that core cooling _
would have been provided if the instructions set forth in his November,-1977 memo ?
had been followed.
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TESTIMONY OF BERT MERIT DUNN '
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Dunn, Manager ECCS Section, B&W NPGD, Lynchburg, provided the following sworn I testimony in substance before the Kemeny Commission on July 18, 1979:
Dunn, related that he had attended the breifing given by Joseph Kelly in October, 1977 regarding the September 24, 1977 transient at Davis-Besse:and that he was familiar with the details of that transient. He characterized it as being an unusual transient in that the PORV stuck open for an extended period of time and that the HPI had been terminated within the first few minutes of the_ transient.
He subsequently discussed this transient with Kelly and encouraged Kelly to write his November 1, 1977 memo. He testified that the purpose of the memo then was to ,
seek a forum to decide whether additional written guidance sould be'provided I customers pertaining to the termination of HPI.
He received a copy of the Kelly memo and provided Kelly oral comments regarding it. He was not in full agreement that the prescription offered by Kelly would be wholly adequate. He noted that a set point of 1600 PSIG would not assure a full reactor coolant system (RCS). After a period cf time during which there were no positive actions taken by B&W to deal with what Dunn viewed as a serious problem, he wrote a memo to James Taylor, Licensing Manager on February 9,1978.
According to Dunn, he wrote it to Taylor because he felt that "....Mr. Taylor was an influential person concerned with safety and could .... start the ball rolling,"
(p. 61).
In this memo (enclosure 3) Dunn stated that "had this event occurred in.a reactor at full power with other than insignificant burnup, it is quite possible, perhaps probable, that core uncovery and possible fuel damage would have resulted." The memo also stated that B&W has not provided sufficient information to reactor operators in the area of recovery from LOCA. Dunn closed the memo by saying that he considered the matter to be "very serious" and deserving of " prompt attention and correction." Dunn testified that the purpose of this memo was to create a forum or basis for discnssion.
Dunn acknowledged his awareness of the PSC system and the role that Taylor as licensing manager had in relation to it. He indicated that he chose not to use a PSC form because he felt that instigation of a review and resolution of his concerns would have been sufficient. Had it not, he would then have used a PSC.
When asked if he considered the natter to be a safety concern at the time he wrote the memo, Dunn replied that he considered it to be a " highly possible concern to the safety of the plant," (p. 66). He indicated that this type of information, although a candidate for, need not be placed on a PSC.
In subsequent discussions Taylor. advised him that he was referring the matter to Nuclear Service as matters of changing procedures-are best handled by that depart-ment (p. 69).
Sometime afterwards, he had discussions with Mr. Gosslow'who did not' contradict Dunn's contentions that core uncovery and possible fuel damage could result.
Instead, the discussions centered upon the prescription and as a result'of this,
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l Dunn wrote a second memo, dated February 16, 1978 (enclosure 4), modifying the i prescription in his earlier memo. He sent this memo to Taylor to demonstrate to Taylor that action had been taken on his earlier memo and that a prescription l acceptable to himself and Nuclear Services had been reached (p. 73). He felt that Licensing was still the proper addressee and pointed to his dialogue with Nuclear Services as being a result of his first memo to Taylor. He stated that based on the foregoing, he assumed that Licensing was playing some part in the j matter (p. 74). He further assumed that his prescription was going to made ,
available to B&W customers. Consequently, he had no further discussions re- I garding his memoranda with Nuclear Services until August, 1978.
Dunn asserted that he was not made aware of an August 3, 1978 memo (enclosure 5) to Bruce A. Karrasch from Donald Hallman until after March 28, 1979. He was very upset when he learned of its existence as this was one of the first indicators that his recommended instructions had not gone out.. He indicated that had he known that, he could have instigated appropriate actions. He averred that he had not seen the memo until after the TMI accident even though he was listed on it as having received a copy.
Dunn stated that he disagreed with the concerns raised by Hallman in the memo and that although they should or would have been looked into, they were not of suffi-cient importance to warrant changing his prescription. He agreed that his pre-scription could cause damage to the reactor coolant system as outlined in the Hallman memo, but stated that such concerns would be subsidiary to his belief that his prescription was necessary to survive a LOCA (p. 78). He further commented that the supplementary operating in'structions that B&W transmitted to its customers on April 4, 1979 relied heavily upon his memoranda. He said this was the first guidance provided by B&W since he had written his memoranda. He added that he thought that 8&W had written his memoranda. He added that he ,
thought that B&W had some contact with "NIC" (as reflected on page 80; assumed !
to mean NRC) prior to the issuance of that guidance. A modification of this guidance was issued on April 17, 1979 after concerns were raised by B&W customers and at least one B&W official. ,
1 Dunn attended a meeting held at Lynchburg in February,1979 that was described in a March 9, 1979 memo (enclosure 6) written by J. T. Willse, B&W Licensing, con-cerning pressurizer level indication. He stated that this meeting dealt with an event other than a LOCA which was why he chose not to raise his previously stated concerns during either that meeting or a " dry run" meeting held by B&W on February 9,1979. He said he was not intimidated by the presence of NRC and that even if he had known of the Hallman memo at that time, he would not have raised the issue at that meeting.
Dunn also indicated that he was familiar with the Michelson report having first seen it in April, 1978. He stated that there was nothing new in~the Michelson report and that'all of Michelson's concerns were bounded by existing'B&W analyses.
Dunn was shown a copy of an April 14, 1979 handwritten memo (attachment 7) entitled "Michelson Story Comments" which he identified as having been written by him. He indicated that the reason he wrote it was to provide B&W background data with which to respond to criticism being received at the time. This information was I
provided to his management including Mr. John MacMillan.
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- a When asked how many similar memoranda his unit had produced over the past few years, he responded, "four or five" (p. 92). He admitted that tho language ,
that he had used in these recent memoranda was stronger than the others because >
the others dealt with actions already underway. He had no concerns, however, after the February 16, 1978 memo as he felt action was in fact underway.
Dunn was asked if any NRC personnel ever expressed concern about the state of training regarding HPI. He replied that it was his understanding that a memo was written within the NRC staff that dealt with loop seals that he felt was almost identical to his concerns. He stated that NRC did not provide copies of that memorandum until after March 28, 1979 and thus he was not aware of its existence until then.
INVESTIGATORS NOTE: This testimony apparently relates to a January 10, 1978 memorandum entitled, " Loop Seals in Pressurizer Surge Line" authored by Sanford Israel, Systems Branch, Office of Nuclear Reactor Regulation, NRC. This memorandum is included as attachment (8) to this report.
t Dunn was asked why he chose not to use a PSC for such an important matter. His '
response was that he preferred to handle work through less formal mechanisms al- ,
though he was prepared to use the PSC if the other methods did not work (p. 111),
He indicated'that the PSC procedures then in effect did not provide for more .
expeditious handling of the information, although he added that current procedures f give Mr. MacMillan 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> to notify the NRC once an item is judged reportable.
When again questioned about the significance of his prescription to the TMI Accident, Dunn replied: "Had my instructions been followed at TMI II, we would i not have had core damage; we would have had a minor accident."
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b s- 0 TESTIMONY OF JAMES H. TAYLOR Taylor, Manager of _ Licensing, B&W NPGD, Lynchburg, Virginia, provided the following sworn testimony in substance before the Kemeny Commission on July 19, 1979: .
According to Taylor, the final decision as far as reportability of a matter under 10 CFR 21 is his. Part of his duties include keeping track of Preliminary Safety Concerns (PSC), determining whether evaluations are taking place. Con-clusions as to reportability are concurred in by the Managers of. Quality Assurance and Intergration. About a year and a half ago, Taylor established an informal target of resolving 75% of PSCs within 30 days,'a goal Taylor claimed was actually met. Taylor's assistant, Mr. Edward Kane maintains a status board in his office which serves to keep track of PSCs. Taylor stated that this system was in effect in February,1978 (p.182), and that it had been in effect for a number of years prior to that. Taylor asserted that the PSC was usually the first step towards a potential Part 21 report.
Taylor claimed that his reaction to Bert Dunn's February 9, 1976 memo to him was that it did not imply inadequacy in plant design, nor did it invalidate any B&W analyses'; he believed instead that it was primarily a matter of operating pro-cedures (p. 184). Based on these perceptions, he suggested to Mr. Kane that he discuss the matter with someone in Nuclear Service. Kane has since told him that Kane in fact did talk to someone, but at the time he based his belief that Kane
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had done so by Dunn's second memo which indicated to him that matters were in the right channels. Based on this, he felt that Ounn's concerns were being addressed.
Although the August 3, 1978, Hallman memo tended to contradict this, Taylor denied having seen a copy of it, notwithstanding its distribution to his assistants.
Taylor claimed that he had no further discussions regarding the subject until after the TMI accident.
Taylor, when questioned, admitted that his matter would have been an appropriate subject for a PSC and that if it had been done in that manner, he would have processed it as a PSC. He estimated that final action regarding it then would have taken less than three months. Although he felt the original Dunn memo was misdirected when it was sent to him, he indicated that he would not have had the same perceptica if it had been addressed to him on a PSC in the sense that a PSC is supposed to be directed.to him (p. 186). He also stated that he had the authority to have treated the Dunn memo as a PSC and to have entered it into the PSC system.
On the other hand, Taylor testified that its amenability to Part 21 did not especially enter his mind. He characterized the issue as a safety-issue which could be resolved very quickly simply by changing or emphasizing an operating instruction. Although he admitted that there have been a few PSCs over the years that have dealt with operating procedures, he cited only one within the past eighteen months. In that one, however, the original issue-stemmed from B&W's discovery of an inadequacy in dealing with small breaks. Taylor stated that it was fair to characterize 10 CFR 21 as tending to concentrate B&W's attention upon things that come out of design problems rather than operator actions (p. 193).
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8-Mr. Taylor went on to relate that B&W frequently discusses technical issues with the NRC staff on an informal basis as well as in accordance with reports required by regulation. He stated that there was no formal requirement for B&W to share the results of their investigations of transients such as at Davis-Besse with NRC, but that much of this information is significant (p. 214). In response to a specific question, he reiterated that there was no requirement to report formally to the NRC any information except that deemed to have safety significance.
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TESTIMONY OF BRUCE A. KARRASCH Karrasch, Manager, Plant Integration, B&W NPGD, Lynchburg, provided the following sworn testimony in substance to the Kemeny Commission on July 19, 1979:
Karrasch stated that he could not recall seeing Joseph Kelly's November 1, 1977 memo prior to the TMI Accident even though his name appeared on it for distribu-tion. Likewise, he was sure he had not received Walter's handwritten memo nor could he remember seeing Dunn's two February, 1978 memoranda. Karrasch asserted that it was highly probable that he had.seen the latter, but that he most likely had dealt with them in a routine manner like most of the corres-pondence that crosses his desk.
Karrasch indicated that he disagreed in part with the safety concerns raised by the Dunn memoranda. He explained that he agreed basically with Dunn's concerns, but disputed whether the then current procedures were not adequate to deal with LOCA's. He also pointed out that operator procedures and operator actions are two different things and that Dunn's memo came to grips with only one of them.
Karrasch recalled receiving the August 3, 1978 memo from Donald Hallman. He said that he perceived that as a routine matter and put a note on it to have one of his subordinates follow up on it. He added, however, that neither of these persons, Eric Swanson or Arthur McBride, remember receiving it from him. Accor-ding to Karrasch, he simply forgot about it and went on with higher priority work (p. 241). He did relate two brief encounters in the hallway that he had with Hallman subsequent to this during which Hallman asked him about the status of it.
He claimed that he told Hallman both times that it had been passed on to someone in the Unit who will be in touch with him.
He also related one other encounter with Hallman prior to March 15, 1979 which Hallman asked him to please take-the time to respond to his questio,during ns.
He indicated that he somehow found a copy of the August 3, 1978 memo and. reviewed it. Based upon his review he felt that clarification of existing procedures 'i was warranted and that the concerns expressed by Hallman were secondary compared i to this goal. He mentioned this to Hallman who indicated that he had heard him, but he did nothing further regarding this matter until after the TMI Accident.
When questioned, Karrasch admitted that with the benef*t of hindsight, he now realized that he took the Hallma'n memorandum too lightly.
In response to Commissioner comments about the admitted breakdown of communications within his Division, Karrasch commented that he felt the issue was not as much one of communications as it was~ of priorities. He explained that priorities are placed on issues at hand, many of which are established by NRC (p. 249). He indi-cated that he would attempt to improve this system of prioritization, but that this must be done in concert with a reassessment of priorities both among the customers as well as NRC. He suggested also that B&W has.a tendency to study a problem too long (p 253) and that he is waiting for a change of direction from 1 NRC. When questioned, he stated that it has possible that the nuclear industry's attempts to demonstrate the safety of nuclear energy may have led to a mindset I
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that downgrades threats to safety and instead responds primarily to NRC requests (p. 257). He also indicated that the questions had been routed to the appropriate i 8&W personnel to resolve, but conceded that the fact that the issue languished for l 17 months was unsatisfactory. Nonetheless, he maintained that although operator '
instructions could have been clarified, the procedures in effect at TMI should have been sufficient to provide for recovery from the transient (p. 265).
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TESTIMONY OF JAMES MICHAEL WALTERS Walters, a supervisory engineer in the Plant Performance Section of Customer Service, (formerly known as Nuclear Service) provided the following sworn tes-timony in substance to the Kemeny Commission on July 18, 1979:
He received a copy of Joseph Kelly's November 1,1977 memorandum from his immediate supervisor, D. F. Hallman. Although he did not recall discussing it with Hallman, he felt that he had received some instructions on the order of, "what do you think about this?" Prior to responding to the Kelly memo, he discussed the matter with former training personnel who worked in his department. He identified these persons as Messrs. Gossolo, Street, and Smith, but noted that only Smith recalls the discussions.
Walters stated that the Kelly memo raised a valid point (p. 148) but that he had some problems with the prescription that Kelly offered as a fix. In response to questioning, Walters indicated that in 1977 he believed that termination of HPI based on pressurizer level alone was a valid action and that he believed then that the action of the Davis-Besse operators was correct.
He further testified that going " solid" could cause damage to the plant and produce down time. It was his belief as a ten year employee that operators were taught never to go solid. He subsequently sent Kelly a handwritten memo dated November 10, 1977 in which he expressed his disagreement with Kelly for the above cited reasons.
I Walters indicated that he assumed responsibility for following up on Kelly's '
memorandum but that he had no contact with Kelly during the three month period I preceeding Bert Dunn's first memo in February, 1978. Upon reading Dunn's memo, he gained the same impression as he had when he read Kelly's viz, that the prescription offered may cause unnecessary plant damage. Consequently he assigned one of his staff, Mr. Gossolo, to meet with Dunn to address that issue. Dunn's second memo then was the product of this discussion between Gossolo and Dunn.
Walters testified that he still had reservations about the prescription even after receipt of the second Dunn memo. He felt that it still did not address the issue of an overcooling transient; however, he had no further discussions with Dunn regarding either memo. After some period of time, he began to be concerned that appropriate or timely action was,not being taken. Ha then discussed the matter with his immediate supervisor shortly before August 3, 1979 which resulted in the decision to draft a memo to Plant Integration to elicit some response regarding Walters and Dunn's views. Walters then drafted the memo that Hallman signed on August 3, 1978 that was sent to Mr. Karrasch, Manager of Plant Integration, who is also Joseph Kelly's supervisor. To his knowledge, Karrasch never responded to the memo, notwithstanding being questioned about it on at least two occasions (p. 161).
Walters related that he was in error regarding his 1977 belief that reactor coolant temperature and pressurizer level would trend in opposite directions under a small LOCA. He conceded that Dunn's prescription was valid in the face
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of such an event. He also stated that it is difficult for an operator to dis-tinguish whether a given accident was a LOCA and that it would most likely take at least ten to twenty minutes to make such a determination. He conceded that oper-ators were then faced with a dilema concerning whether or not to keep HPI on.
He further asserted that his use of the term, "the training" in his November 10, 1977 memo was in error; what he meant to say was his training which he noted was not received at B&W. He averred that he had only recently noticed this error.
When asked what would have happened with Dunn's prescription is he, Walters, did not have any misgivings about it, he replied that the matter would have been assigned to one of his engineers, a formulation would be developed, and it would have been distributed in the form of a site instruction to B&W customers in less than a month. In conclusion, Walters conceded that although he was still trying to get the issue resolved at the time of the TMI Accident, the information would have been made available to B&W customers, including TMI, in March or April of 1978.
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t TESTIMONY OF DONALD F. HALLMAN Hallman, Manager, Plant Performance Service Section, B&W NPGD, Lynchburg,
- provided the following sworn testimony in substance to the Kemeny Commission on July 19, 1979:
Upon receipt of Joseph Kelly's November 1, 1977 memo, he sent it to one of his engineers, Frank Walters, for comment .and appropriate action. He did not discuss the Kelly memo with anyone else until after the TMI Accident. Upon receipt of Dunn's first memo in February, 2978, he asked Walters to look into that as well.
This resulted in Walters drafting a memo on August 3, 1978 for his signature to ;
Bruce Karrasch. ;
Walters reminded hiu several times to check with Karrasch as to the status of the action requested by the memo. Finally, in February-March,1979, he encountered Karrasch in a hallway at B&W at which time Karrasch told him that he didn't see any problems with the memo. After walking away, he realized that he did not know if Karrasch's statement meant that they should proceed as Dunn had or if Karrasch' ;
meant that Dunn had not identified a valid problem. He made some attempts to ;
resolve his confusion by trying unsuccessfully to telephone Karrasch whom he ;
described as as extremely busy (p. 277). He acknowledged that the concerns '
expressed in his August, 1978 memo went unanswered until after the TMI Accident.
He stated that part of the reason for this is that he did not place a high degree of priority upon it. ,
i Hallman indicated that he should have acted sooner in light of the TMI Accident, ;
but that he was not sure of the impact of this delay upon TMI. He asserted that
~
in assessing the handling of the document afterwards, he decided that he must bear the responsibility for its having lanquished for over six months (p. 283).
i He testified that he was egtablishing better control systems to handle such f documents in the future.
When asked whether the propensity of the PORV to stick open should have been i passed on to B&W's customers, Hallman replied that the valve was not made by '
B&W, that the customers should have had the necessary information, but that it was possible that this aspect should have been made more clear to the operators j by B&W. ;
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l TESTIMONY OF JOHN R. MACMILLAN MacMillan, Vice President, B&W NPGD, Lynchburg provided the following sworn testimony to the Kemeny Commission en July 20, 1979:
MacMillan was asked whether B&W considered or made any recommendations regarding several failures of PORVs over a four-five year period. He answered that he was not aware of anyone making recommendations based upon evaluation of these failures, but commented that the B&W system includes a blocking valve with which to isolate any such leak. Thus he felt that B&W compensated for any such problem by bounding it within the overall plant design considerations.
MacMillan stated that he was in attendance at a briefing regarding the Davis-Besse
. transient a few days after its occurrence, but has no recollection of what was discussed there. MacMillan specifically denied having seen any of the memorandum pertinent to this investigation, i.e. , those authored by Kelly, Walters, Dunn or Hallman, prior to the TMI Accident. He related that these memoranda were shown to him in April,1979 by Allen Womack, Manager, Plant Design prior to his ACRS testimony so that he would be aware of what he characterized as a technical difference of opinion or dispute between B&W engineering and service personnel regarding termination of HPI which remained unresolved (p. 419). In answer to later questions (p. 433), MacMillan reiterated that he perceived the matter as a valid technical dispute.
When questioned why none of the memoranda, Dunn's in particular, were brought to the attention of the media during a June 5, 1979 press conference, MacMillan stated that it was because they were not relevant to the purpose of the press conference. He explained that it was not that the memoranda were irrelevant per se, but that they did not speak to the main purpose of the press conference which was to present B&W's assessment of what transpired at TMI.
MacMillan testified that he considered it regrettable that such a technical difference or dispute took so long to resolve. On the other hand, he suggested that the existence of the memoranda demonstrated that there was an avenue within B&W to air such differences. He asserted that part of the delay could be explained by persons not attaching urgency to the information as there already was some existing and adequate information in the field and that the issue here had been whether or not to reinforce this information (p. 451). He conceded that having a system or avenue with which to ventilate concerns was not necessarily the same as having someone paying attention to them and indicated that this was an area that they intended to improve. He reemphasized that there was no evi-dence that anyone at any time intentionally attempted to suppress or discourage employees from raising these concerns.
MacMillan indicated that he agreed with the concerns raised by Dunn in his memo-randa, but qualified this agreement by stating that the procedures at TMI con-tained these precautions and were available to the operators (p. 468).
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4
9 STATUS OF INVESTIGATION This investigation continues pending review and analysis of the information contained herein by OIE management and the Office of the Executive Legal Director.
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ENCLOSURES r
ITEM . DISSEMINATION
'(1) Joseph Kelly memo of'11/1/77 Copy All (2) J. F. Walters memo of 11/10/77 (3) Bert Dunn-memo of 2/9/78 (4). Bert Dunn memo of 2/16/78 (5) D. Hallman memo of 8/3/78-(6) J. T. Willse memo of 3/9/79 (7) Dunn Note of.Michelson report of 4/14/79 (8) Novak (Israel) memo of 1/10/78 1
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File No. -
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.i.**.t:' Cn 3 Date Custoder Guidance On Eigh ? essure I jec:fon Cperation at-i,i..,................,...w..o. r -
DIS ~RIBUTION ,
- 3. />. Karrasch E. W. Svacson D. W. La3elle R. J. Tinnin
.H. S. Elliot:
B. H. Dunn
- D. i. Eall=an-Tuo reces:
events at the Toledo site have pointed out that perhaps we are not giving our cus:o=ers enough guidance on the opera: ion of the high pres-sure inje::1on sys:e:. On Septe:ber 24, 1977, af:e a stuck open r.atically ini:da:ed. elec: ocatic relief valve, b.igh pressure i=jec:fo:depressuri:ing was au:o- due to to recover, withou: regard to prir.ary pressure. !"ce operator stopped EPI when pressuri:c: level began continued on vi:h boiling in the ROS, etc. As a resui:, the ::assien:
October 23, 1977, In a similar occurrence on iniziation, actuation point.
even thoush reac:or coolant ;;essu:e systethe operator bypassed ven: below the n high pressure injec Since there pressure injection are acciden:s syste=, I wonder whichcha: require the continuous opera:1on e high of th ing to car custo ers en when : hey can safely shu: guidance, if any, ve should be giv-an acciden:7 I recce=end the fo11cvh g guidelines be sent::he sys:es down following a) Do not bypass or c:he: ise preven:
the actuation of high/ low pressure controlled plant shutdown. Sjection under a=v conditions except a cor=al,
- b) Once high/I: V Tave is stable or decreasing a .d pressurize: pressure injection unless: is 61:iated, do not s:op pri=ary preature is a: _
least 1600 PSIG and increasing. level is increasing ,a_nd.
I would appreciate your thoughts on this subject.
JJX:jl > -
ATTACHMENT I
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- ers:or in:erruttien of Eich pressure !:4ecti:n
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his =ese addresses -$'-
e::ial for opera:o: ac h ICOS A:.alysis abeu:. :he po ' * *
ng the h u hl s: age of a LOC to1.:er=i= ate high pressure i=jee: ten follev ' ,
..i.,,
Successful 2005 opera:Los during stall **
reaks depends s the ICCS injec:fon rate. on :he acct. ulated reactor coolant syste: hved:ory as'vell *'
As such, it is =azdatory that full injection ..-
- Iov be =ah:ahed fre= the pott of e=e:gency safety fea:,:res ac:uacion * ,.:l' yste: (ISTAS) actuathn c::11 the high pressure hjecth rate can fully .
o:pe=sa:e for the rea=:or hea: lead. 2.s the Ejectics rahe depends c:
he reae:c coolas: .
stch-up occurs h varh ble and can:o:systa= pressure, the the at which a cc pensa:hg ....
- is qui:e possible, for era ple, -tha:be specified as a fhed nu ber.
.tecessfully ma::h up vh h all bea:. sources a:gh pressure injection =ay he hi en pressurht: ion be inadequa:e a: . ::e 12:erthe ti=e: :and that due to sys- -
. 2' ' ' '
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he acciden: here rose out of le'rece:: heiden: a: Toledo. Durh g
- arent sys:e the opera:or ter=. hated high pressure hje::hn due to an ap- ,,
ree very hdi:sted by high.leve.1 vhhh :he pressurher.
his acthe vould have bee: -
een h a subcoeled s:ste. accep:able er.ly af er the prica:7 syste had * .5 .
ently hdiestes tha: A.alysis.of the data fro: the transien: cu:- .
the syste vas 6 a .o-phase s:a:e and as such did oc ec :ain sufficie:: capach y :o. allow high pressure injecti:n ter=ina ' -
de:. This became evide:: at some 20 to 30 chu:es 'fol.lovi:g :er=ha:Lon * - p.
f, be o hje::fon reh hwheh :ed. the pressurher level again collapsed and i=jec:Lon had ,
are con:icuously loshg During :le 20 :o 30 ni=u:es of co-inje::ica flev they importas:
fluid i=ve :ory even : hough :he pres- ~~
urizer 6d ~ca:ed high level. I believe 1: for:u=c:e :ha: Toledo was at ,
a ex:Terely low pover a:4 es:res?.ly lov burzup. -~;d e.h . = : nu:: .d .
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-e beident poin:s ou: tha: ve have to: supplied sufficies: Efor=: tion .
o rese:or opera: ors in the area of recovery fro: LOCA. The following .
ale' is bssed on an a::e:pt :o allev termination of high pressure injec- *,,.,,,,
ion only s: a :ine when the rese:or coola=: syste: is 6 a subcooled - -
itate caks.
and :he pressurhe: ta hdhs:ing a: less: a =cr:a1 level for s=:11 ,
Such condi: ions gu rsn:ee full sys:e= capsci:y and :hus assure .
4: during any follow on :rsnsien: -
c:1 den:. vould bc to worse than the initial
- I, :hcrefore, re:o:=end :hst operaths procedures be vri::en a
6oallov for ter=instion condi:fons only: of high pressure hjee:1on under the folleving.
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'. . M
. . ATTACHMENT 3
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Lov pressure inje::1cn has been actuated and is flevi:g at a race in '
excess of the high pressure injectica capabili:y and that situs:1co has been stable for a period of ti=e (10 =inu:es). .
Sys:e pressure has recovered to ners:1 operatihg pressure (2200 or .
2250 psig) :nd sys:e ce:perature .-ithin the hot leg is less than or -
equal :o the =o:..zl operating condi:1en (605*r or 630 i) . .
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,,.. j *; / - ses 443 3
- M. Dunn. Manager', ECOS .641ysis (2133) ,g.p ~
File No.
or Ref.
Date
'7ebruary 15. 1978
- or Interrup:icn of Eigh ? essure Infce:icn ,
.....,....................,.........,.4,. , - .
. . . t reviev cf :/ earlie =ero en :his subjee:, da:ed Tebrua 7 9. 1978, Tield *
-vhe has :ecensended :he fellewhg procedure foi tsr=ha:ing high presshre .. -
- ection follevhg a LCCA.
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a rate in ex,-
Lev pressure hjection has been ac:uated and'is fleving a:si:ua:Len has .
t eess of been the high stable for pressure a period injection of :he (10 capabili:y
=ht:es).and :ha:Sa:e as prev,tously s:a:ed.,
2- -
. A: % cinu:es follevhg the ini:ia:ics cf high pressure hjectic . Cer:i: -
tica is alleved provided :he h:: leg te=perature hdica:icn plus appropri-e:pera::Te . .-
ate ins::uzen: er:c: is more than 50 T belev :he sa:ura:ie coelant sys:e pressure less inst:::ent error.
cc espend h g :o the reacts::he :erchati:n of :he high pressure injectic I is a ti:e lag :o preven:
6:ediately follevh; i:s hitia:icn. I: requires further verk to def he ,
1:s specific value, bu: it is p:obable tha: 10 cinu:es vill be adecuate. ,.,
~'he need f:: :he delay is tha: =c::al operating c:ndi:Icas are vi:hi: 6-- ;
the above cri:eria and thus it is conceivable tha: the high pressurc ,,
' $cetien v:cid be :ercha:ed during the hi:dal phase of a s=211 LC04.
find that' this sche:e is a:ceptable f::= :he standpo Therefore, h: cf preven:h8 I vishad- :o c se long rcnge proble s and is casier to hple en:.ce o :e :he'ene iden:1fied here. ,
edify the procedure requested in =y firs:
- I . 'J. Susnsen ,
D.R. Roy -
3.A. T. ::asch *
- E.A. Sailey 1 J. Kelly
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E.R. ..ane r .
J.D. Agar *
- . R.L. Pitt-. n J.D. Phinny .
A. Scot: .
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File I:o.
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In:c up:ien of XI-h ?: ssure Injectica (H?!) .
- Augus: 3, 1975 -
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es: (1) 3. M. Du = to J. Taylor, sr. e subj ect,_?ebrua: r 9, 2 978. .. ..-
(2* 3. H. Dunn to J. Taylor, sane subjec:, FebE :y,16,1973. ' -
a.
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- s 1 :..d 2 (a:: ached) ree =:end : ch:nge h 3!.U's philesephy fer EF1 . ..
use durb; icu-pressure ::anste::s. Iesier.11y, they rece::.cnd leavind .
pu:ps :n, ence E?! h:.s been hi:1::ed, un:11 ii'e:: be de:c::ined th:: '
le: :espers:ure is nere thsn.50.'T belev Tsa: fe: the ?.15 pressure. ,
Se.: tic a b elieves. this. =ede can caus e the ?.C.S (helu.di:s. .-he. pres e"-<- -) . .
~
011d. ~he pressurher reliefs vill * - -
lin, with a water .'.u.----
surge *through -- .-a""*.*:he -
ge piybg in:c' the que::h : nk.' ,
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(, eve :he fellewh: '- ' 4 :: she 1d be evaha:cd: ..
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the pressurher gces solid whh ene or note E?! pu:ps c:nthuhg :e epera:e,
- pid :here be a pressure spike before the reliefs cpen which .- ..
could cause.
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bate. .:o :ha ?.CS2 ... .
3: dz=:ge v'euld the vn e: surge :hrough. **
the relief , valve * *
- discharge pipin; :.nd lench tank cause? . . .. .
e, Nuclear Service h:s :: no:ified our op'erating plan:s to ch:nge E?! policy
- en: whh T.cle:rnees 1 and 2 because of ou abe' v e-s:a:cd ques:icns. Ye:, the nces su;;es: the possibili:y of ucccycring the core if,present b'?I policy is
.u- d . . . .. .
,u .a u t the: In teg ::hn .resolvo :.he issue ef' hev. :he .HF.I *
.sys.:e.n. sho. uld* *be. used. * *
- i svaihble :o . help as needed. . .
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Toledo e r Ref.T4. 2. 3 Date
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eve,. , n. .2. . c ... a. . c. M...cn- e, . s--> i .e Distribution: R. L. Reed F. W. Winks R. C. Luken L. R. Cartin J. 7. Janis :. E. A. Wena:.h G. T. Fairburn D. Mars C.'D. Russell J. O. Howard
- J. H. Tayler J. D. Agar
=. . ,r.. Kane r.
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i A nee ing to discuss the loss of pressurizer level indicatien '
at D3 1 was c:nvened Feb ur. y 14, 1979 at the 35W offices '
in L)nchburg. These in a .encan.e were:
J. E. Kehic NEC Region III ,
J. E. Poster NRC Region III.
D. Andersen NRC/0IE/LCVIP Sushil Jain Toled 3disen
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R. A. Die: rich SMUD M. D . Y..ir e . Arkansas J. T. Enos Arkanses E. R. Kane 35W R. C. Luken "
- 5. H. Klein -
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- 3. M.. Dunn .
n L. r. . C a. .. . ., n R. W. Winks "..
J. T. Willse This nee:ing was reevested by the Regien III inspe::crs. The .
purpose of this meeting was though: to be to discuss the loss cf pressurizer level indication on all 36W plants. The utilities were presen to discuss incidences where less of level indication e curred a: their plants. -
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ATTACHMENT 6
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representatives to this =eeting. Mr. Fes er nex asked the utilities
- . respond to -he cuestions he had subni: ed (le: er a : ached).
The e,uestiens were: .
(1) What previous experience of loss of pressuri:er level have o :urred?
(2) The facility where the even:(s) were experiencei-(3) The dates of o: urrence.
(4) Wh-ther the NRC was infer =ed of the event.
(5) Wha; evalu::icn ef the eventivas performed 7 Duke P wer and 71:rida Power did no: send a representative to the =eeting because .-hey have not experienced a less ef pressurizer level indication. -
Mr. "ilbish stated that TMI fl had not experienced any less of pressuri er level indication.. TMI #2 had two such events (4/23/78 5 11/7/75) both.cf which were reported to the NRC in LIR's. 3eth of these ev'ents were thoroughly evaluated.
Mr. Ines stated tha: /R0-1 had experienced 2 transients during which pressuri:er level indication had been lost. Neither event u.. a y . . , e = .' .' ' .'. . .1 R. v, . . p . . . e '. . o . h *.
. . . . . . Ys=.. r. .- .1 . h o ". '.. .'.. *. .' . .' . s v e .- . .~. s were aware of both events. Both events were evaluated by 35W and the ISO safe?.y cc==ittee. As a result of these evaluations ASO believes that less of pressurize level indicatien is enly as epera-ienal inconvenience and tha RC pressurize; is suffihien:
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i Mr. Dieterich acknowledged that SMUD has had app;cri=ately 33 trips during which loss of level indica:icn e::urred en 5 to 10 of these transients. These events'were not efficially reported to the NRC al:heugh their inspe::ers were aware of the less of pressurize level indica icn. SMUD alsn had experienced two rapid cocidewn transients during which pressuri e: level indication was lost, these ::ansients were evaluated and reperted to the NRC.
Kr. Jain des:ribed the ene transien where less of level indica:icn had occurred a: Toledo. This ::ansient was evaluated and repersed to the NRC in an L3R. he fu :her described the discussions that had occurred between Toledo, the NRC, and 33h'. The remainder of the morning was spen: discussing'the censequences of loss ef level indica:icn, the differen:es between D31 and the other 35W plants, and the dual level se: point for the steam generator a: Toledo.
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" 2 . d L'5 JECT: LOOP SEALS IN FR,ESSURIZER SURGE LINE ms. -[. 'n .
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- t. cop seals in the pressurizer surge line are used in some ' plant designs
'noted in B&W). Under ordinary circumstances, these configurations are 1%U 2 inconsequential because the saturation temperature in the pressurized f ' 6500F) is the highest temperature in the primary system. However,
. i E . ender upset conditions (such as prolonged relief valve opening) and ,t ccidents where significant voids are formed in the primary system, i sjt,Ep[
-M %d? .ay be possible to end up with a two-phase mixture in the pressurizer
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these circumstances, additional loss of primary system inventory or
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'p).#7 A.y .;hrinkage in the primary system may not be ' indicated by pressurizer l W fevel. Thir 3ituation has already occurred at Davis Besse I when a j .$yh.;l .f.
. elief valvt > tuck open. .
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'%IQ 'he loup sea: results in a manometer effect as shown in Fig.1. If there i
.M r , is sat:.cated -team at 1200 psi in the hot leg pipe and the level in the l d i essurizer ir 60 feet, the pressurizer pressure, Pz, would only have to
- 3. ig" fd{f[j M. te about 11::1 psi, which corresponds to saturation temperature about 50F 1 . ' clow that 1:a the hat leg. Thus, th.e pressurizer temperature does not
'ifOkf d %@ n .. ave to be s'agnificantly lower than 'the temperature in the primary
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?i Although the ufety anblyses do not require termination of the makeup ystem, operators would control makeup flow based on the pi essurizer I
Li(Qp level as part ..f their normal proceduresr.As a result, under certain j Q Q.y enditions t.::ere the pressurizer could behave as a manometar, the' operator j ..g.g @ could erreneNsly shut off makeup flow when significant void occurs else-l qq.q ihere in the system or loss of inventory is continuing.
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$ y' 't is recommended that>the bases for the design requirement be studied arefully for all CP reviews with the object of 5'etermining if the loop 4 ,g eal can be ell:tinated. For OL reviews, procedures should be reviewed
.o ensure adequate information before the operator terminates makeup flow.
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-Y i:ure 1 'cc: D. Ross .
,g contact: Sandy Israel, NRR 74} gg 49-?7591
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