ML20129H696
Text
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Title:
V0GTLE ELECTRIC GENERATING PLANT:
ALLEGED INTENTIONAL VIOLATION OF A TECHNICAL SPECIFICATION BY A V0GTLE OPERATIONS MANAGER Licensee:
Case Number: 2-90-001 Georgia Power Company Report Date:
March 19, 1991 P.O. Box I295 Bimingham, Alabama 35201 Control Office: 01:RII Docket Nos.: 50-424/50-425 Status: CLOSED Reported by; Reviewed by:
nog n
rryL.pobinson,Jnvestigator Jyps Y.jpSrs~e, Director Office of Investigations QPfice oF Investigations Field Office, Region II Field Office, Region II Approved by:
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Participating Personnel:
Craig T. Tate, Investigator j
Office of Investigations Field Office, Region II Paul J. Kellogg, Chief Operational Programs Section Division of Reactor Safety. Region II a
WARNING The attached document / report has not been reviewed pursuant to 4-10 CFR i 2.790(a) exemptions nor has any exempt material been deleted. Do not disseminate or discuss its contents outside NRC.
Treat as "0FFICIAL USE ONLY."
Copy / of T 9611050338 960827 hR
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i SYNOPSIS 19, 1990, the Regional Administrator, U.S. Nuclear Regulatory On January Commission (NRC), Region II, requested that an investigation be initiated into the facts and circumstances of an alleged intentional violation of Technical 4
Specification (TS) 3.4.1.4.2 by Georgia Power Company (GPC) Operations management, at the Vogtle Electric Generating Plant (VEGP), in October 1988.
It was alleged that, contrary to this TS, the Unit I reactor makeup water storage tank (RMWST) valves were deliberately opened while the unit was in 4 It was also alleged that this Mode 5, loops not filled (Mode 5b) condition.
TS violation was not reported to the NRC, either at the. time of its occurrence or in November 1989 when the VEGP Plant Review Board (PRB) formally made a reportability decision regarding the circumstances of the opening of these j
RMWST valves.
It was also alleged that VEGP management condones a " cavalier" approach to regulatory raquirements on the part of VEGP Operations.
' The evidence obtained in the Office of Investigations (01) investigation j
substantiated the allegation that TS 3.4.1.4.2 was knowingly and intentionally.
violated, in October 1988, by VEGP Operations shift supervisors, with the 1F express knowledge and concurrence of the VEGP Operations manager.
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The evidence substantiated a VEGP violation of 10 CFR 50.73, in that the 1988 l
opening of the RMWST valves in Mode 5b, an operation prohibited by the VEGP TSs. was not ever reported to the NRC. However, there was insufficient-i evidence of a deliberate violation of this reporting requirement.
! hen 0
,c/ The investigation also surfaced the fact that the same valve openings that
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violated TS 3.4.1.4.2 also violated VEGP Procedure 12006-C.
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m ACCOUNTABILITY The following portions of this Report of Investigation (Case No. 2-90-001) will not be included in the material placed in the Public Document Room. This consists of pages 3 through 44.
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Case No. 2-90-001 4
3 TABLE OF CONTENTS Pace SYNOPSIS............................................................... 1 A CC O U NTAB I L I TY......................................................... 3 APPLICABLE REGULATIONS................................................. 7 DR GAN I ZAT I ON CHART..................................................... 9 LIST OF INTERVIEWEES.................................................. 13 DETAI LS O F I NVEST I GATI ON..............................................
17 Purpose of Investigation......................................... 17 Background.......................................................
17 I n te rv i ew o f Al l ege r............................................. 18 Coord i na ti on wi th NRC Sta ff......................................
18 Allegation No.1 (Alleged Intentional Violation of Technical Specification 3.4.1.4.2 by Vogtle.0perations Management)........
18 Summary..................................................... 18 Evidence....................................................
19 Conclusions................................................. 29 Allegation No. 2 (Alleged Intentional Non-Reporting of a Technical Specification Violation by VE6P PRB)................. 29 S umma ry..................................................... 29 Re vi ew o f Doc umenta ti on...................................... 30 Evidence.................................................... 31 Conclusions................................................. 38 i
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S U P P L EM E NTAL I N F ORMATI ON............................................... 39
'l L I ST O F E X H I B I T S...................................................... 41 i
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APPLICABLE REGULATIONS A11eastion No. 1: A11eoed Intentional Violation of Tr.chnical Specification 3.4.1.4.2 by Vogtle Doerations Management Vogtle Technical Specification 3.4.1.4.2(1988 Edition)
- 3. 4.1.4. 2 Two residual heat removal (RHR) trains shall be OPERABLE and i
at least one RHR train shall be in operation. Reactor Makeup Water Storage Tank (RMWST) discharge valves (1208-U4-175,1208-U4-176, 1208-U4-177, and 1208-U4-183) shall be closed and secured in position.
APPLICABILITY: M0DE 5 with reactor coolant loops not filled.
i ACTION:
a.
With less than the above required RHR trains OPERABLE,.......
b.
With no RHR train in operation................................
c.
With the Reactor Makeup Water Storage Tank (RMWST) discharge valves (1208-U4-175, 1208-U4-176, 1208-U4-177, and 1208-U4-183) not closed and secu n d in position, immediately close and secure in position the RMWST discharge valves.
10 CFR 50.36: Technical Specifications (1988 Edition)
(b) Each license authorizing operation of a... utilization facility...will include technical specifications.
The Atomic Energy Act of 1954, as Amended l
Section 101, License Required (42 U.S.C. 2131)
It shall be unlawful...for any person within the United States to...
F use...any utilization facility except under and in accordance with a j
14ense issued by the Connission.
I Section 222. Violations of Specific Sections (42 U.S.C. 2272).
l Whoever willfully violates...any provision of section 101...shall be punished by a fine of not more than $10,000 or by imprisonment for l
not more than ten years, or both...
Allegation No. 2: Alleged Intentional Non-Reportino of a Technical l
Specification Violation by VEGP PRB I
10 CFR 50.73: LicenseeEventReportSystem(1988and1989 Editions)
(a) ' Reportable events.
(1) The holder of an operating license for a nuclear power plant (licensee)shallsubmitaLicenseeEventReport(LER)forany event of the type described in this paragraph within 30 days after the discovery of the event. Unless otherwise specified in this section, the licensee shall report an event regardless Case No. 2-90-001 7
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of the plant mode or power level, and regarfless of the significance of the structure, system, or component that j
i initiated the event.
i (2) The licensee shall report:
(1)(B) Any operatirn or condition prohibited by the plant's Technical Specifications...
f Violation Found Durino Conduct of Investication: Intentional Violation of VEGP Procedure No. 12DD6-0 i
Vogtle Nuclear Operations Procedure No. 12006-C, UNIT C00LDOWN TO COLO j
SHUTDOWN (as of October 12-13,1988) 1 i
Section D4.2.14 If it is intended to drain the RCS to less than 25% cold calibrate pressurizer level.
then prior to reaching 25% ISOLATE potential 2-dilution flow paths by performing the 4
following:
a.
CLOSE, LOCK and TAG the following valves:
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(1) UNIT 1: CVCS ISOLATION RMW TO BA BLEND, 1-1208-U4-175 j
4 UNIT 2:
CVCS.............................
i (2) UNIT 1: CVCS ISOLATION RMW TO CVCS, J
1-1208-U4-177 i
UNIT 2:
CVCS.............................
b.
ENSURE CLOSED, LOCKED and TAGGED the following valves:
(1) UNIT 1: CVCS OUTLET CHEM MIXING TK, 1-1208-U4-181 UNIT 2:
CVCS..............................
(2) UNIT 1: CVCS SUPPLY RMW TO CHEM MIXING TK, l
1-1208-U4-176 b
UNIT 2:
CVCS..............................
l (3) UNIT 1: CVCS FLUSH RMW TO TRN A EMERG B0 RATION,1-1208-U4-183 a
UNIT 2:
CVCS..............................
f (4) UNIT 1: R M ST TO BTRS 150, 1-1208-U4-226 UNIT 2:
RMWST.............................
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Oi1GANIZATION CHART VOG~~ _ E O RGAN ZK O N A S~~ R C~~L R E OCTOBER 11-13, 1988 BOCKHOLD GEN.MGM BELLAMY PLANT MGR.
KITCHEN 8 I
ops. MGR.
i MAR 8H Asst. ops. MGM.
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I CASH HOPKIN8 osos osos umme emmm mmme BOWLE8 GA8SER 1
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LIST OF ACRONYMS ABO Auxiliary Building Operator AETA American Engineering and Technical Assoicates APE 0 Assistant Plant Equipment Operator BOP Balance of Plant CST Central Standard Time CVCS Chemical and Volume Control System ESD Engineering Support Department EST Eastern Standard Time FSAR Final Safety Evaluation Report GPC Georgia Power Company 1R1 First Refueling Outage LCO Limiting Conditions for Operation LER License Event Report NEAL Nuclear Engineering and Licensing NPS Nuclear Procedures Supervisor NRR Nuclear Reactor Regulation NSAC Nuclear Safety and Compliance NSSS Nuclear Steam Supply System OD Operations Department OSOS Operations Superintendent on Shift PE0 Plant Engineering Operator PRB Plant Review Board RCS Reactor Coolant System RHR Residual Heat Removal RI Resident inspector i
RMW Reactor Makeup Water RMWST Reactor Makeup Water Storage Tank R0 Reactor Operator RWO Radiological Waste Operator SAER Safety Audit Engineering Review i
SE Senior Engineer SQA Site Quality Assurance SRI Senior Resident Inspector SR0 Senior Reactor Operator SS Shift Supervisor TS Technical Specification VEGP Vogtle Electric Generating Plant i
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LIST OF INTERVIEWEES EXHIBIT 40 i
ACREE. John W., VEGP-1. 55. R0 GPC s
l ALLEN. Bob P., Plant Chemist. VEGP. GPC 32 AUFDENKAMPE. John G., Manager Technical Support, and Member of 51 PRB, VEGP. GPC y
BAILEY James A., Manager. Licensing. GPC. Birmingham. AL 69 BARLOW. Ricky T., Scheduling Coordinator. Outage and Planning 34 1
Department, VEGP GPC BEASLEY, James B., Manager. Outage and Planning. VEGP. GPC 49 t
BELLAMY, R. Mike. Executive Vice President. AETA 27 i
(fonner VEGP Plant Manager)
BOCKHOLD, George, Jr., General Manager. VEGP GPC 26 BOWLES, John E., SS/SRO VEGP, GPC 18
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I BRACK, Wesley R., APEO. VEGP. GPC 21 i
l BURMEISTER. William L., Unit Superintendent. OD. VEGP. GPC 35 1
j BURWINKEL Paul Engineering Supervisor. VEGP. GPC 47 s.
CAIN, Daniel C., Student Georgia Institute of Technology, fomer 23 PEO, VEGP GPC f
CASH, Jimy P., 0505/SRO, VEGP GPC 17 CHRISTIANSEN Clayton L., SS/SRO. VEGP GPC 67
.DESROSIERS. Arthur, former Superintendent. Technical Support.
30 Chemistry / Health Physics. VEGP, GPC EAVES. Edward. ABO. VEGP, GPC 22 FREDERICK, Georgie R., SAER fomerly Manager. SQA, 68 VEGP, GPC GASSER, Jeffrey T., 0505/SRO, VEGP, GPC 19 HAND. Robert C.. Chemistry Supervisor, VEGP GPC 31 HANDFINGER, Harvey M., Manager. Maintenance, and Member. PRB.
62 VEGP. GPC Case No. 2-90-001 13 i
i EXHIBIT 8
HENNESSEY, William J., former SS/SRO VEGP-1, GPC, currently 44 Training Instructor, Point Beach Electric Plant, Wisconsin HOPKINS, John D., OSOS/SRO, VEGP, GPC 24 I
KITCHENS, William F., Assistant General Manager for Operations, 16 and Chairman, PRB, VEGP, GPC j
LACKEY, Michael B., Acting Manager, Outage and Planning.
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LeGRAND, Ronald L., Manager, Chemistry / Health Physics 63 and Member PRB, VEGP, GPC MANSFIELD, Richard L., dr., Supervisor, NSSS, ESD, VEGP, GPC 65 MARSH, Walter C., Plant Director Palo Verde Nuclear Generating 25 Station, formerly Asstistant Operations Manager. VEGP, GPC 4
l McC0Y, Charles K., Vice President, Nuclear, Vogtle Project.
61 GPC, Birmingham, At MCDONALD, R. Patrick, Executive Vice President, Nuclear, GPC 66 J
MEYER, Charles F., Unit Superintendent Support 00, VEGP, GPC 33 t
j MIDDLEBROOKS, Kenneth D., SS, VEGP, GPC 41 MITCHELL. William R., Jr., Assistant Plant Operator, VEGP, GPC 38 MOSBAUGH, Allen L., Acting Assistant Gerieral Manager, Plant 56 Support, VEGP, GPC PARKER, William K., RWO, VEGP, GPC 36 j
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RICKMAN, Alan G., Senior Engineer, NSAC Group, VEGP, GPC 55 ROGGE, John F., Jr., SRI VEGP. NRC 29 i
RUSHTON, Paul D., Manager, NEAL, GPC Birmingham, AL 60 SALTER, Charlton D., R0 VEGP, GPC 39 STR!dGFELLOW, Norman J., Jr., Project Engineer, Licensing Group, 59 GPC, Bimingham, AL SWARTZWELDER, James E., Manager, Operations, VEGP, GPC 28 THOMPSON, Thad N., Methods and Training Specialist, VEGP, GPC 42 i
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EXHIBIT 43 TUCKER, Perry, 80P, VEGP, GPC 48 TUPPER, Richard F., Senior Nuclear Chemist, South Texas Project, formerly Contract Chemist, VEGP, GPC 64 TYNAN, Carolyn C., NPS, VEGP, GPC I
37 WEBB, Gregory D., RWO, VEGP, GPC 45 WILLIAMS, James D., 0505/SRO, VEGP, GPC I
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DETAILS OF INVESTIGATION l
Puroose of Investigation This investi ation was initiated to determine:
(1)whetherGeorgiaPower Company's (G C gtle Electric Generating Plant (VEGP) Technical Specification T 3.4.1.4.2 was de~11berately violated by VEGP personnel during the first refueling outage of Unit 141R1) in October 1988; (2) whether j
the VEGP Plant Review Board (PRB) intentionally failed to report this alleged TS violation when they formally reviewed the issue in September-November 1989; 1
and (3) whether the evidence obtained during the investigation of (1) and (2) i above substantiated the existence of a " cavalier attitude" on the part of GPC j
and/or VEGP management toward strict compliance with TS.
. Q Background
' h k ( C), ( C) Cj l 5 fb MN h On January 19, 1990, the Regional Administrator (RA), U.S. Nuclear Regulatory l
Commission (NRC), Region II (RII), requested this investigation (Exhibit 1) i after the NRC resident inspector at VEGP had received an anonymous letter i
(Exhibit 2) which set forth the allegations cited in the Purpose of i
Investigation.
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' At the time of VEGP's VEGP's Final Safety Analysis Report (FSAR), Chapter l
15.4.6.2.1.1, entitle
.lution During Cold Shutdown, Hot Standby, and Hot Shutdown (Exhibit 3), required that valves 175, 176, 177, and 183 be locked closed during refueling in order to prevent a boron dilution accident. r At i
'e this time, boron dilution flow analyses did not exist for Mode 5b (Cold Shutdown, Loops not Filled) or Mode 6 (Refueling), and, since these analyses
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had not been done for VEGP, the aforementioned valves were required to be i
locked closed in Modes 5b and 6.
VEGP TS 3.4.1.4.2 (Exhibit 4), and VEGP Procedure 12006-C, Section D4.2.14 l
(Exhibit 5), were instituted as required by the FSAR, to prevent inadvertent f
boron dilution during Mode 5, loops not filled. These TS and Procedure e
sections required valves 175,176,177, and 183 to be locked closed. The locking closed of these valves prevents the flow of unborated water from the t
L reactor makeup water storage tank (RMWST) into the Reactor Coolant System N (RCS).
l In the' case of operator discovery of an ongoing boron dilution, caused by one, i' or more, of these valves being inadvertently open, TS 3.4.1.4.2 contains an Action statement which requires that the open valve (s) be issuediately closed and secured in position. The VEGP Safety Evaluation Report (SER), Section 15.4.6, entitled Inadvertent Boron Dilution (Exhibit 6), describes allowable gI, operator action times to mitigate an inadvertent boron dilution.
On November 21, 1989 VEGP submitted, and on February 20,2990, the NRC
-approved, a requested amendment to TS 3.4.1.4.2 which perait.ted VEGP to open V
A RMWST valves 176 and 177, in Mode 5b under administrative control, provided flux at shutdown alarm was operable (Exhibit 7) gin requirements, and the high the RCS was in compliance with the Shutdown Mar
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l Prior to the February 20, g/,
1990. NRC approval of this TS change, there was no NRC approval of the opening 4, opt Case No. 2-90-001 17 4
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of these valves in Mode 5b under administrative control. The TS mquired the valves to be closed and locked in Mode 5b.
l Interview of Alleger The allegations in this case came to the NRC in an anonymous letter (Exhibit 2)..Therefore an interview of the alleger was not conducted.
Coordination with NRC Staff On January 19, 1990, the Office of Investigations (01:RII) received package of documents pertinent to the allegation letter from Ronald F. AIELLO and 4
Robert D. STARKEY, NRC Resident Inspectors at VEGP. On the same date. 01:RII discussed case background and regulatory cites with Ken BROCKMAN, Chief, Projects Section 3B, Reactor Projects Branch No. 3. Division of Reactor Projects. RII, NRC.
On February 1,1990, after initial interviews of seven VEGP reactor operators (R0s) 01:RI! briefed the RA:RII and pertinent staff members of the results of the initial interviews. These interview results included significant portions i
of the licensee's explanation of the alleged TS violation. On this date, by letter to the RA (Exhibit 8), 01 requested staff technical assistance with I
respect to the validity of the licensee's explanations, and an interpretation j
i of whether or not, in view of these explanations, a violation of the TS existed. A RII technical assistant was assigned to the investigative team at j
that point.
i By letter to Ben B. Hayes, Director. 01, Headquarters, dated July 10, 1990, William T. RUSSELL, Associate Director for Inspection and Technical
. J Assessment, Nuclear Reactor Regulation (NRR), NRC, stated that, at the time of j
W the VEGP 1R1, the intentional opening of valves 1208-U4-176 or.1208-04-177 when in Mode 5 with reactor coolant loops not filled was a violation of TS3.4.1.4.2(Exhibit 9).
j Allegation No. 1: Alleged Intentional Violation of Technical Specification 3.4.1.4.2 by Vogtle Operations Management Sumary l
The following individuals were interviewed by 01:RII, on the dates indicated, j
regarding the allegation that TS 3.4.1.4.2 was intentionally violated by the Operations Manager and/or any other GPC personnel at VEGP. The pertinent testimony provided by these individuals is documented in the " Evidence" section that pertains to Allegation No.1.
Name Position Date of Interview John R. ACREE VEGP R0 February 8,1990 l
Bob P. ALLEN VEGP Plant Chemist June 14, 1990 p
Ricky T. BARLOW VEGP Scheduling Coordinator
- t. June 27, 1990 '
g4 James B. BEASLEY VEGP Manager, Outage and Planning March 13, 1990 (1It Case No. 2-90-001 18
R. Mike BELLAMY former VEGP Plant Manager June 28, 1990 George 80CKHOLD VEGP GM March 14, 1990 f ohn BOWLES s VEGP $5/SRO March 13, 1990 J
Wesley BRACK VEGP APE 0 March 13, 1990 William L. BURMEISTER VEGP Operations Unit Supt.
June 27, 1990 i
Paul BURWINKEL VEGP Engineering Supervisor February 28, 1990 Danie1 C. CAIN former VEGP PE0 February 27, 1990 Jisuy P. CASH VEGP OSOS/SRO February 7,1990 Arthur E. DESROSIERS Former VEGP Chemistry Supt.
May 14, 1990 Edward EAVES VEGP AB0 February 8,1990 Jeffrey T. GASSER VEGP OSOS/SRO February 8, 1990 Robert C. HAND VEGP Chemistry Supervisor May 31, 1990 William J. HENNESSY former VEGP Operations Shift February 26, 1990 Supervisor John D. HOPKINS VEGP Operations Supervisor /SR0 January 30, 1990 William F. KITCHENS VEGP Asst. General Manager,.
March 14, 1990 Operations Michael B. LACKEY VEGP Acting Manager, Outage and February 8, 1990 Planning Walter C. MARSH former VEGP Asst. Operations Mgr. February 15, 1990 Charles F. MEYER VEGP Operations Superintendent June 14, 1990 '
Kenneth D. MIDDLEBROOKS VEGP Operations SS February 8, 1990 William R. MITCHELL, Jr. VEGP Asst. Plant Operator January 30, 1990 Allen L. MOSBAUGH VEGP Acting Asst. General Manager, February 8,1990 Plant Support William K. PARKER VEGP RWO January 30, 1990 John F. ROGGE NRC VEGP R1 March 19, 1990 l
Charlton D. SALTE*
VEGP R0 February 7,1990 J
' James E. SWARTZWELDER VEGP Manager of Operations March 14, 1990 Thad N. THOMPSON VEGP Methods and Training Spec.
January 30, 1990 l
Perry TUCKER VEGP Balance of Plant Operator January 30, 1990 Richard F. TUPPER former VEGP Chemistry Contractor June 11, 1990 Gregory D. WEBB VEGP RWO January 30, 1990 James D. WILLIAMS VEGP OSOS/SRO February 8, 1990 i
Evidence 1.
VEGP TS 3.4.1.4.2 stated, in October 1988, that in, " MODE 5 with reactor coolant loops not filled." "... Reactor Makeup Water Storage Tank (RMWST)
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ischarge valves (1208-U4-175,1208-U4-176,1208-U4-177, and 1208-U4-183) l shall be closed and secured in position." Action statement "c" of this TS, stated that if:these valves are "not closed and secured in position, imediately close and secure in position the RHWST discharge valves" t
(Exhibit 4).
2.
The Office of NRR, NRC, stated that, with regard to the 1988 version of TS 3.4.1.4.2, the intentional opening of valves 1208-U4-176 or 1208-U4-177 when in Mode 5 with the reactor coolant loops not filled is a i
violation of that TS (Exhibit 9).
j 3.
The Piping and Instrumentation Diagram of the aforementioned RMWST valves j
shows that the closing of valves 176 and 177 prevents the _ flow of j
unborated water from the RMWST, through the chemical mixing tank, to the RCS (Exhibit 10).
4.
VEGP Unit 1 Control Log shows that Unit I was in a Mode 5. " loops not filled" condition from at least 1906. CST, October 11, 1988, until at 1 east 2400(midnight) CST, October 11,1988(Exhibit 11).
INVESTIGATOR'S NOTE: All times noted in the 'VEGP Control Room and Shift l
Supervisor Logs are expressed in a 24-hour day femat, and in CST, so, unless othenvise noted, all times will be likewise expressed in this i
j report.
5.
VEGP Procedure No.12006-C entitled Unit Cooldown To Cold Shutdown i
(Exhibit 5), stated in Section D4.2.14 in October 1988, "If it is I
l intended to drain the RCS to less than 251 cold calibrate pressurizer level, then prior to reaching 25% Isolate potential dilution flow paths 3
n by perfoming the following:
l a.
CLOSE, LOCK and TAG the following valves:
j I-1208-U4-175, 1-1208-U4-177 b.
ENSURE CLOSED, LOCKED and TAGGED the following valves:
1-1208-U4-181, 1-1208-U4-176, 1-1208-U4-183..."
l 6.
VEGP Procedure No. 13007-1, entitled VCT Gas Control And RCS Chemical i
Addition stated, in October 1988, under Section D4.7, entitled Reactor Coolant System Chemical Addition "Open Chemical Mixing Tank Supply from j
RMWST 1-1208-U4-176, approximately one-eighth turn to slowly fill the tank." In Section 4.7.5, this procedure stated, " Fully Open Chemical Mixing Tank Supply From R W ST 1-1208-U4-176." In Section 4.7.9, this procedure stated, " Allow flow through the Chemical Mixing Tank for ten minutes..." (Exhibit 12).
7.
VEGP Procedure No. 49006-C entitled Health Physics And Chemistry DepartmentOutageActivitiesImplementingProcedurestated,in Octoher 1988, in Section 6.4.4 entitled Reactor Coolant System Cleanup with Hydrogen Peroxide (H,0,)," under Section 6.4.4 c. "Cooldown/
Draindown" that "The plant should have been placed on RHR, cooled down to 110 F, and drained down to mid-loop via the purification (CVCS) mixed bed addition." and then "When the draindown domineralizers prior to the H,0,hould be added" (Exhibit 13).
is complete. Hydrogen Peroxide s i
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INVESTIGATOR'S NOTE: This procedure did not address how the hydrogen peroxide was to be added to the RCS. The testimony and logs show that it i
was adoed through the chemical mixing tank, or Chem Add Pot, by the use of valves 1-1208-U4-176, 177, and 181, as specified in Procedure 13007-1.
8.
A Clearance Sheet for Clearance No. 1-88-371 shows that the 1208 systeni valves, the CVCS Blender Makeup Valves (which include valves 176 and MakeupWater]ggedclosedandlockedinordertoIsolateRMW(Reacto 177), were ta to RCS per UOP 12006. This clearance was installed as i
j prompted by Section D4.2.14 of VEGP Procedure 12006-C, referenced previously in paragraph 5.
This Clearance Sheet shows that the clearance on these valves was installed at 0955, October 11,~1988, and was removed I
at 0900, November 15,1988(Exhibit 14).
y, VEGP Unit 1 Shift Supervisor Log shows that RMWST discharge valves i
1-1208-U4-176 and 1-1208-U4-177, along with valve 1-1208-U4-181, were a,
opened to inject hydrogen peroxide into the RCS at 0400'and 0705, j
h,\\Q October 12,1988, and at 1030 and 1640, October 13, 1988. This log also shows that, after each of the last three above-described openings, these U\\0 valves were closed and locked exactly 4 minutes after they were opened.
With respect to the first opening of the valves (0400, October 12,1988),
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the valves were described as being "immediately shut upon completion of i
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fillinaccordancewithTS3.4.1.4.2"(Exhibit 15).
- 10. KITCHENS, CASH, BOWLES and GASSER all testified that they were aware that the addition of hydrogen peroxide to the RCS, for the purpose of chemical cleaning, was a planned evolution, scheduled to occur at mid-loop during the refueling outage.
(NOTE: Mid-loop is a " loops not filled" condition) (Exhibit 16, pp. 6-8, Exhibit 17, pp. 11, 16. and 26-28, Exhibit 18, pp. 33-34, and Exhibit 19, pp.18-19).
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KITCHENS, CASH, B0WLES, and GASSER all testified that, prior to the first i
opening of the RMWST valves, they knew that a clearance had been placed d
on these valves, which meant that they had been documented as having been p
closed, locked, and tagged per procedure; and that in order to open those valves to add the hydrogen peroxide, a functional test procedure had to i
be used (Exhibit 16, pp. 54-56, Exhibit 17, pp. 8-9. Exhibit 18, pp. 20-23 and Exhibit 19, pp. 8-10).
CASH testified that, to his knowledge, a clearance ks installed on the 12.
valves as an administrative action to ensure compliance with TSs. He stated that the valves were tagged shut in order to comply with l
TS 3.4.1.4.2 (Exhibit 17, pp. 49-50).
13.
Four Functional Test Foms, associated with Clearance No. 1-88-371, show that test alignments on valves 17F.177, and 181 were performed at 0310 and 0705. October 12,1988, and at 1030 and 1638. October 13, 1988.
These same forms show that the clearance alignments were restored at 0415 and 0722, October 12, 1988c and at 1034 and 1653, October 13, 1988, respectively (Exhibit 20).
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- 14. BRACK, EAVES, and CAIN verified their signatures on three of the Functional Test Forms, and stated that they opened, and then closed valves 176, 177, and 181 sometime between the times indicated under the Case No. 2-90-001 21 j
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4 j
headings " Test Alignment Performed" and " Clearance Alignment Restored" on theforms(Exhibit 21,pp.610. Exhibit 22,pp.7-12,andExhibit23).
)
- 15. BRACK and CAIN stated that KITCHENS was not physically present at the location of these RMWST valves while they manipulated them as shown on i
i the Functional Test Forus. They stated that they had never seen KITCHENS j
manipulate any of these RMWST valves (Exhibit 21, pp. 13-14, and i
Exhibit 23).
s.
i
- 16. B0WLES testified that he was not sure whether'the plant was in a " loops i
not filled" condition at 4:00 a.m., CST, October 12, 1988, when "...we i
loaded the chemical pot, but we did not shoot the chemicals..."
j (Exhibit 18, pp. 8-10).
)
- 17. BOWLES testified that, after his shift turnover discussion with his i
relief, GASSER, he (BOWLES) thought that TS 3.4.1.4.2 did apply to his 4:00 a.m. loading of the chemical pot. BOWLES testified that he not only I
wanted to "... document that I did open the valve to fill up the pot..."
i but also that he wanted his log entries to be consistent with GASSER's upcoming entries pertaining to the hydrogen peroxide injections. He 1
stated, therefore, that as a result of this discussion with GASSER, he made a late 0400 entry to the Shift Supervisor Log which further i
j described the original 0400 entry by specifically identifying the valves i
that were opened (Exhibit 18, pp. 14-16).
l
- 18. VEGP Unit 1 Shift Supervisor Log shows a late 0400 entry by B0WLES, actually written into the log sometime between 0507 and 0533, which states, " Valves 1-1208-U4-177,1-1208-U4-176, and 1-1208-U4-181 opened to i
fill CVCS drain pot. Above mentioned valves ismiediately shut upon 1
completion of fill in accordance with TS 3.4.1.4.2."
This log also shows the original 0400 entry as stating, "CVCS chemical mixing pot
+
i loaded with hydrogen peroxide. Functional clearance 1-88-371 to allow sending, chemicals"(Exhibit 15).
i
- 19. BOWLES testified that, at the time he made the late entry, he did not really mean to say that he was entering the action statement of l
TS 3.4.1.4.2 by referring to the immediate closing of the valves, but l
rather that he just made that late entry to document that he had opened i
the valves, and to be consistant with the entries that GASSER was going to.be making (Exhibit 18, pp. 15-16).
}-
- 20. CASH testified that he was aware that adding chemicals at mid-loop would constitute entry into the action statement of TS 3.4.1.4.2 (Exhibit 17, p.14).
l
- 21. CASH testified that he was aware of the opening of valves 176 and 177, a
while he was on shift as 0505 on October 12, 1988, in order to fill the ches add pot (Exhibit 17, p. 36).
- 22. GASSER testified that he came on day shift and saw that the previous shift had already injected hydrogen peroxide once on their shift. He j
testified that almost inmediately after he came on shift, he got a call i
from Chemistry wanting to add more hydrogen peroxide. He testified that he realized that in order to make this addition he would have to open up Case'No. 2-90-001_
22 i
r~
i'
\\
v l"
the RMWST valves which were presently locked closed as part of the LC0 i
[ Limiting Condition for Operation] since the loops were not filled. He testified that he thought it would be alright to enter the action 4
statement of TS 3.4.1.4.2 for a short period of time to add the hydrogen peroxide, but he k'new it was a tech spec issue, with a high degree of i
sensitivity, so he asked his 0S05, HOPKINS, about this issue (Exhibit 19.
p.6).
- 23. HOPKINS testified that he and GASSER came to the Control Room around 5:30 a.m. to 6:00 a.m., EST. noted that the valves had been opened by the previous shift, and realized that this was a " gray area" that needed to l
be resolved (Exhibit 24, p. 28).
i 24.
KITCHENS testified that he was present in the VEGP Unit 1 Control Room on October 12, 1988, at about 3:53 a.m.
EST, as VEGP was draining down the RCS for the refueling outage (Exhibit 16, pp. 9-10).
INVESTIGATOR'S NOTE: KITCHENS testimony was based upon his review of his initials as the 0453 entry in the Shift Supervisor Log. In actuality, l
0453 CST would be 5:53 a.m., EST, not 3:53 as testified by KITCHENS.
- 25. KITCHENS testified that his oncoming 0505. HOPKINS came to him with a l
question that had been raised by HOPKINS' shift supervisor, GASSER, regarding the propriety of having to enter an "immediate operator action statement" in the TS in order to open and close the RMWST valves needed i
to accomplish the scheduled chemical cleaning of the RCS (Exhibit 15,
- p. 11).
KITCHENS testified that these valves had already been opened b 26.
previous shift, and that HOPKINS was asking for his (KITCHENS)y the concur-i rence on opening these valves to add chemicals, and then closing them within the boundaries of the "innediate action statement" in the TS i
(Exhibit 16. pp. 11-12).
- 27. KITCHENS testified that he knew there was a TS restriction against i.
opening those RMWST valves, but he wanted to see if there were any other restrictions (Exhibit 16, p. 16).
- 28. KITCHENS testified that he told the attendees of the daily 7:00 a.m.,
EST, outage meeting that morning that he had put a hold on the chemical addition because one of his shift supervisors had asked for a review of the applicable TS "to make sure that we were not getting into a j
compliance issue" (Exhibit 16
- p. 13).
- 29. HOPKINS and KITCHENS testified that MARSH, had been a part of their discussion regarding the definition of the ters,(tissediate as it was used in the TS action statement, and that MARSH had said that in his experience it meant that action had to be initiated within 15 minutes (Exhibit 24, p. 8, and Exhibit 16, pp. 18-19).
- 30. MARSH testified that he did not specifically recall a discussion with HOPKINS and KITCHENS, during VEGP's IR1, regarding either voluntary entry into an ismediate action statement, or the definition of the tern innediate as used in the action statement (Exhibit 25, pp. 8-9).
Case No. 2-90-001 23 i
4
1
- 31. MARSH testified that his position was then, and is now, that you do not r
enter immediate action statements voluntarily except in some pretty extraordinary circumstances, and that he could not think of a case in I
which it could be done. He testified that in consideration of entering l
an ismediate action statement in order to do a crud burst by injecting hydrogen peroxide, only two actions in his opinion, were appropriate:
j (1) not to inject at all, and (2) to raise the water level in the RCS if you were no longer in a reduced inventory situation (Exhibit 25
{
pp.6-7).
- 32. KITCHENS testified that, after his consideration of the applicable TS.
Chapter 9 of the FSAR. input from MARSH and his potential boron dilution calculation, he (KITCHENS) concurred with HOPKINS' decision to limit the i
valve openings to 5 minutes, under aduinistrative controls, as being in l
ccepliance with the TS (Exhibit 16 pp. 15-20).
~
kg. KITCHENS testified that, at the time of the valve openings on i
October 12-13, 1988, he did not get any additional concurrence on this decision to open the RMWST valves from either his immediate supervisor.
the VEGP Plant Manager, or the VEGP General Manager (Exhibit 16, p. 28).
- 34. BOCKHOLD did not recall and BELLAMY denied, being either consulted or i
asked for concurrence by KITCHENS. at the actual time of the scheduled RCS cleaning, regarding the pemissibility of opening of the RMWST valves at mid-loop to inject the hydrogen peroxide for the cleaning. BELLAMY said that he had no knowledge or recollection of any reluctance, or i
objections by the Control Room operators with respect to opening the RMWST valves at mid-loop to do the crud burst (Exhibit 26, pp. 7-8 and Exhibit 27).
- 35. GASSER. HOPKINS. and KITCHENS testified that HOPKINS discussed the issue of entry into the action statement of TS 3.4.1.4.2 with KITCHENS and it was decided that it was permissible to open the RMWST valves for a maximum of 5 minutes and still be in compliance with the TS action statement (Exhibit 19. p. 7. Exhibit 24, pp. 6-9, and Exhibit 16 pp.11-19).
- 36. *HOPKINS testified that, since MARSH and KITCHENS had said 15 minutes was okay." he told GASSER that opening the valves for a maximum of 5 minutes to inject the hydrogen peroxide would be a conservative length of time, and that he. HOPKINS. made the decision to go ahead and do the injections with the 5-minute limit on the valve openings. He testified that they did the chemical additions for the crud burst a couple times that day and also on the next day. October 13.1988(Exhibit 24,pp.8-9).
3 V HOPKINS testified that later in the morning of October 12. after he had
(@
h his discussions with KITCHENS and MARSH made his decision to open the valves to do the injections, and, in fact, had already executed the first At valve opening on his shift, he phoned SWARTZWELDER. Manager. NSAC, to get N-his (SWARTZWELDER's) opinion on the decision to open the valves. HOPKINS testified that SWARTZWELDER concurred with the decision, and said that, gr "we have a defensible position" (Exhibit 24, pp. 9-11).
y Case No. 2-90-001 24
V 1
- 38. SWARTZWELDER testified that he did not recall this discussion with HOPKINS, but that if HOPKINS said he called him (SWARTZWELDER), he (HOPKINS) probably did..because it was a cosunon practice for 0505s to call NSAC for input on TS and procedure questions (Exhibit 28, pp. 7-8).
- 39. ROGGE, testified that, neither in the planning phase, nor at the time of l
the' actual conduct of the hydrogen peroxide injections was he ever consulted by VEGP personnel regarding the permissibility of opening the RMWST valves in a Mode 5, loops not filled condition (Exhibit 29, pp. 8-9).
l f40. KITCHENS,.HOPKINS, CASH, and GASSER all denied violating TS 3.4.1.4.2 during the four openings of these RMWST valves on October 12-13, 1988, q
stating that since they adequately executed the immediate action i1
/
7 jf statement, by only leaving the valves open for a maximum of 5 minutes,
'/
they were in compliance with the TS (Exhibit 16, p. 86. Exhibit 24, ly p.15. Exhibit 17, p. 34, and Exhibit 19, pp.16-17).
f
' 41 BOWLES denied violating TS 3.4.1.4.2 by stating that at the time he ordered the opening of RMWST valves 176 and 177, he was not sure whether i
the loops were filled or not; also by stating that when he made his late 0400 entry in the Shift Supervisor Log that referred to closing the valves immediately in accordance with TS 3.4.1.4.2, he was only making this entry to document his earlier opening of the valves and to make his log entry consistent with GASSER's future entries (Exhibit 18, pp. 8-10 and 14-16).
maintain consistency with GASSER's future entries, he (y, made toB0WLES BOWLES admitted that, as a result of his late 0400 entr made an error regarding the opening and closing of valve 181. He stated that' he did not actually inject the hydrogen peroxide into the RCS on his shift, but only loaded the chem pot. He stated that if valve 181 had been opened, the chemicals would have been injected into the RCS, and he did not inject (Exhibit 18, pp. 19, 36, and 42).
- 43. DESROSIERS stated that during the planning stage for VEGP Unit 11R1, part of his planning responsibilities included the chemical cleaning of the RCS, and that HAND and TUPPER were working for him in that area.
DESROSIERS said that his research convinced him that the chemical cleaning of the RCS would be best accomplished at half-loop, rather than at loops full and that he made a presentation of his half-loop preference to BOCKHOLD approximately 6 months prior to the actual start of the outage. DESROSIERS stated that at this presentation, based upon data gathered by)TUPPER, who was also present at this presentation, he (DESROSIERS showed 80CKHOLD that an additional 100 plus hours of critical path tfme would be needed if the chemical cleaning were to be done at loops full. DESROSIERS stated that he did not recall if he had discussed any type of conflict between TSs and the addition of hydrogen peroxide to the RQ$ at half-loop with anyone from VEGP Operations or Plant management.
He advised that, in a phone conversation with HAND approximately a week' prior to being interviewed by 01. HAND told him that he (HAND) was aware of the conflict between TSs and the use of RW ST water to inject the chemicals at half-loop. DESROSIERS stated'that HAND toldhimthatbothhe(DESROSIERS)andHANDhaddiscussedthiscohflict Case No. 2-90-001 25
j 7
C y
, *=
r 6
with TSs with VEGP Operations people in anning stage of the outage.
I He stated that HAND told him that eithe or ALLEN, who had dp 5 represented HAND at many of the outa e and planning meetings prior to the outage, had pointed out the RMWST va ve/TS conflict to the Operations j
'c/
' representative at these meetings (Exhibit 30).
i 44 HAND stated that at the time DESROSIERS made his presentation to BOCKHOLD j
about doing the RCS cleaning at half-loop, ALLEN was attending the outage and planning meetings as the Chemistry representative. HAND said that i
ALLEN told him that MEYER was the Operations represer.tative at these meetings. HAND stated that the Chemistry Section had looked at possible methods of adding the hydrogen peroxide to the RCS, and the only way to f,
j 4
do it was throu h the RCS Chem Add Pot. HAND stated that this meant that j
the chem add va ves, also called the RMWST valves, had to be opened at to in HAND said that ALLEN told him half-loop (ALLEN)jectthehydrogenperoxide.had brought up this fact.with MEY
{
that he planning meetings, soon after DESROSIERS' presentation to BOCKHOLD, "because the plant tech specs required those ches add valves to be locked l
closed in Modes 5 and 6."
HAND stated that ALLEN told him that Operations had shrugged this valve opening problem off by saying that-
~Al i
they(Operations)wouldhandleitbyputtingthesechesaddvalvesinto l
an LCO, declaring them inoperable, opening them long enough to inject the
. chemicals, and then closing them, and then closing out the LCO. HAND advised that since Operations had told ALLEN they would handle the problem, Chemistry did not have to go into the anticipated panic mode of either requesting TS relief from the NRC, or doing the necessary safety 4
f analysis regarding the portion of the boron dilution scenario that had l
not been done in the original FSAR (Erhibit 31).
. 4 5.
ALLEN stated that he was not aware of any conflict between TSs and adding l
the hydrogen peroxide through the chemical mixing tank. He stated that j
he did not recall MEYER being at the outage and planning meetings, and 4
that there were various Operations supervisors or superintendents at these meetings, but BURMEISTER was the Operations representative that he
- L specifically recalled being at these meetings. ALLEN said that he never
(
i had a discussion with HAND, or anyone from Operations about how Operations was going to handle any(kind of a TS conflict connected with j /h the chemical addition at mid-loop Exhibit 32,pp.7-9).
l
- 46. MEYER stated that he was not directly involved in the outage and' planning meetings, and could not recall attending any of the meetings. He stated that his involvement in outage planning pertained to personnel matters such es staying within the union contract with mgard to the manning 5
levels needed in the outage shift structure, and scheduling people to i
support the outage work. He said th'.t he was an administrative
- Operations superintendent, and as such he supervised the Operations L
Procedures Section. MEYER testified that he was not aware of any j
conflict between any plant TS and conducting a chemical cleaning of the RCS at mid-loop. He said that he did not recall having any discussions with ALLEN about chemical additions to the RCS during the outage. He advised that he recalled that BARLOW was the Operations representative at the outage and planning meetings (Exhibit 33, pp. 6-10).
Case No. 2-90-001 26
- 47. BARLOW testified that he worked for BURMEISTER as the refueling He coordinator for Operations during the planning stage for the outage.
j said that he attended the outage and planning meetings. He testified that he was aware that, months before the actual start of the outage, the i
decision had been made to clean the RCS with hydrogen peroxide while at mid-loop. He stated that, during the planning phase, he did r.ot become-aware of a conflict between any plant TS and the valves that were to be l
opened to add the hydrogen peroxide to the RCS. 4 8ARLOW testified that it 4
was his assignment to check TSs and procedures for conflicts in the i
planned outage evolutions, but that he did not become aware of a TS i
conflict with the RCS chemical cleaning because he did not know that the j
dilution valves were going to have to be opened 'to do this cleaning j
(Exhibit 34,pp.4-13).
- 48. BURMEISTER testified that he was the main Operations contact for i
coordinating the refueling outage activities. He said that either he or BARLOW represented Operations at most of the outage and planning i
i meetings. BURMEISTER stated that he was aware, during this planning j
phase, that it was decided to chemically clean the RCS at mid-loop during the outage. He said that at no time during the planning phase for the outage did he become aware of a conflict between a TS and the method of conducting this chemical cleaning. BURMEISTER stated that the Chemistry people had mentioned that they were going to use their nomal path for
{
j injecting chemicals, and that he did not. " draw the connection to the implications of the tech specs" when Chemistry told him that. BURMEISTER j
stated that the Chemistry Superintendent would have had the responsibility of identifying a potential conflict between a Chemistry procedure and an Operations procedure. He' stated that BARLOW never mentioned any conflict to him, either (Exhibit 35, pp. 5-9,11-12. and 17).
t l
- 49. PARKER and WEBB both stated that they were on duty as radwaste operators, processing demin water in the A~uxiliary Building at the times of the i
chemical injections, and had no knowledge of, or involvement in, the circumstances, activities, or conversations pertaining to these j
injections (Exhibits 36 and 37).
50.' MITCHELL stated that he was a plant equipment operator, not in the l
Control Room at the time of the chemical injections, and had no knowledge l
of, or involvement in, the circumstances, activities, or conversations pertaining to these injections (Exhibit 38).
4 P
- 51. SALTER stated that he was the 80P operator on shift with CASH and BOWLES on the morning of October 12, 1988. He advised that he recalled some controversy between his shift supervision. CASH and B0WLES regarding TS compliance in connection with a request from Chemist.'y to add chemicals to the RCS. He stated that the compliance question was taken out of the Control Room by CASH probably to Operations management, and the resolution that came back was that it was pemissible to open the valves that were required to be opened to add the chemicals as long as the valves were only opened for a short time. like 5 minutes or less, and the opening had to be closely observed and controlled. SALTER stated that the addition of these chemicals was scheduled, and had been discussed prior to the actual call from Chemistry to do it, so when it came time to l
Case No. 2-90-001 27
m do it, the question of TS compliance was raised and resolved within a
.l short amount of time. SALTER stated that he recalled the RO on shift with him, ACREE, having a discussion with either CASH or BOWLES about how the valve opening was going to have to be controlled (Exhibit 39, j
1 pp.6-13).
- 52. - ACREE stated that he was the R0 on shift with CASH, BOWLES, and SALTER on October 12, 1988, but that his attentions were concentrated on all the temporary instrumentation that was monitoring the RCS level during draindown. He stated that.he was not involved with the chemical addition at all. He stated that he had no conversations with CASH about the RMWST l
valves. He said that he recalled no controversy about a TS compliance l
issue regarding the chemical injection (Exhibit 40, pp. 7-11).
i
- 53. MIDDLEBROOKS stated that-he was on shift with HOPKINS and GASSER on October 13, 1988, in the Clearance and Tag Office as the support shift supervisor. He stated that he did not recall the addition of hydrogen peroxide to the RCS on this shift, and he did not recall processing any clearances on the RMWST valves. MIDDLEBROOKS stated that he did issue a Functional Test Form on those valves because GASSER had asked for it. He i
stated that he made no independent judgement of his own regarding the safety of opening those valves at that time as a functional test I
(Exhibit 41,pp.4-8).
j
- 54. THOMPSON and TUCKER, R0 and BOP, respectively, on shift with HOPKINS and l
GASSER on October 12-13, 1988, both stated that they did not recall doing 1
the hydrogen peroxide additions. They did not recall any controversy or discussions in the Control Room about a TS compliance issue pertaining to j
the opening of the RMWST valves to add chemicals at that time j
(Exhibit 42,pp.6-14andExhibit43,pp.5-10).
f
- 55. THOMPSON stated he did not recall an Operations management decision to l
open the RMWST valves to add chemicals at that time LExhibit 42, p. 8).
I
- 56. HEhNESSY, Shift Supervisor, night shift, October 12, 1988, stated that he did not recall doing any chemical additions to the RCS on any of his j
shifts during 1RI. He stated that he did not recall any controversy or discussion about a TS compliance issue involving the opening of the RMWST valvesatmid-loop (Exhibit 44).
- 57. WILLIAMS, 0505, night shift. October 12, 1988, stated that he did not recall any controversy or discussion about a potential TS compliance problem associated with the chemical addition at mid-loop in IR1. He stated that he did not do any chemical additions to the RCS on his shift i.
at this time. He advised that he had no problem entering an issnediate action statement of a TS as long)as there was Operations management 4
concurrence (Exhibit 45, pp. 5-9.
- 58. LACKEY stated that, during IR1, he was the work control superintendent.
and was not directly involved with Chemistry in either the planning or the conduct of the chemical cleaning of the RCS. He stated that voluntary entry into an immediate action statement was not a TS violation i
as long as the action statement was executed within 5 minutes (Exhibit 46, pp. 8 and 24-25).
Case No. 2-90-001 48
n I
1*
- 59. BURWINKEL stated that he had no direct knowledge of the circumstances of i
l the chemical cleaning of the RCS during 1R1 (Exhibit 47).
- 60. TUPPER, stated that he attended the Outage and Planning meetings as the 1
Chemistry representative until the decision was made by 80CKHOLD to do
)
the RCS cleaning at mid-loop. TUPPER stated that, at that point, ALLEN attended the twetings as Chemistry mpresentative (Exhibit 48).
l
- 61. BEASLEY stated that in the planning meetings that.he attended prior to i
1RA there was no discussion of a conflict between any Operations procedures or TSs and the planned chemical cleaning of the RCS at said-loop (Exhibit 49, p.11).
l 7 Conclusiont Based on the evidence developed during this investigation, it is concluded that HOPKINS, GASSER, CASH, and BOWLES knowingly and intentionally placed the l
plant in a condition prohibited by TS 3.4.1.4.2, by opening valves 1208-U4-176 and 1208-U4-177 while in Mode 5, loops not filled. This TS violation was done i
with the full knowledge, concurrence, and permission of KITCHENS.
Based upon the evidence developed during this investigation, it is also i
concluded that HOPKINS, GASSER, CASH, and.BOWLES also knowingly and intentionally violated VEGP Procedurc !b. 12006-C Section D4.2.14, with the full knowledge, concurrence, and pemission of KITCHENS.
i i
Allegation No. 2: Alleged Intentional Non-Reporting of a Technical Specification Violation By VEGP PRB Summary In addition to BOCKHOLD, KITCHENS, LACKEY, MOSBAUGH, and SWARTZWELDER, the following individuals were interviewed by 01:RII, on the dates indicated.
regarding the allegation that, in November 1989, the VEGP PR8 intentionally 4
failed to' report the October 1988 TS violation of opening the RMWST valves in I
Mode 5b, when the PRB fomally made a reportability decision on the circum-stances of that valve opening. The pertinent' testimony of these individuals is provided in the Evidence section of this report that pertains to Allegation
- j -
No. 2.
Name Position Date of Interview John G. AUFDENKAMPE VEGP Mgr., Technical Support February 9, 1990 l
James A. BAILEY GPC Manager Licensing March 8, 1990
[
01ayton L. CHRISTIANSEN VEGP SS, Operations January 30, 1990 Georgie R. FREDERICK VEGP Sup rvisor. SAER February 8, 1990 Harvey M. HANDFINGER VEGP Mariger of Maintenance February 8, 1990 Ronald L. LeGRAND VEGP Ma: ager, Health-Physics February 8,1990 and Chemistry 1
Case No. 2-90-001 29 4
f-l-
4 Richard L. MANSFIELD, Jr.
VEGP Supervisor. ESD February 9, 1990 Charles K. McC0Y GPC Vice President, Nuclear, March 8, 1990 Vogtle Project R. Patrick MCDONALD GPC Executive Vice President, July 23, 1990 Nuclear Operations Alan G. RICKMAN VEGP Senior Engineer, Nuclear March 13, 1990 Safety and Compliance Group Paul D. RUSHTON GPC Manager NSAC March 8, 1990 Norman J. STRINGFELLOW Jr. GPC Project Engine' r, March 8, 1990 e
Licensing Group Carolyn C. TYNAN VEGP Supervisor, NPS March 13, 1990 4
Review of Documentation i
l On February 8,1990, a review was conducted of the minutes of the PR8 meetings during the period September 14, 1989, through November 17, 1989, that i
pertaintd to PRB deliberations of reportability of the October 1988 opening of l
the RMWST valves in Mode 5b (Exhibit 50). This period included minutes of four meetings, conducted on September 14, 1989 September 19, 1989, October 13, 19E9, and November 17, 1989. The minutes of the September 14, 1989, meeting, designated as Meeting No. PRB 89-124 showed that "the board discussed the issue of adding hydrogen peroxide in the RCS via the chemical addition tank valves prior to refueling. An REA has been written to allow manipulation of these valves. Initial cost estimates for the analysis is l
$50,000. The board also discussed the operation of these valves during the last refueling outage and whether or not this action may be reportable.
Further review and discussion of this topic was deferred until the following PRB meeting when W. F. Kitchens could be in attendance" (Exhibit 50, p. 2).
The same page of the September 14, 1989.. meeting minutes showed that BOCKHOLD was present at the meeting and agreed that an overall consistency (was needed l
for what constitutes reportability of 'outside the design basis' Exhibit 50,
- p. 2). These minutes showed that a request would be made for a written Ccrporate interpretation on that issue.
Review of the minutes of the September 19, 1989, PRB meeting, designated as PRB 89-125, showed that, "W. F. Kitchens briefed the board on the specifics of the issue from last meeting on Chemical Addition Tank Valves. Hydrogen peroxide was added to the RCS during last refueling outage knowing that an LCO would be entered.
W. F. Kitchens initiated a DC on this and stated his opinion is thit this is not reportable. 50NOPC0 is looking into whether or i
not there is a stated position on purposely entering immediate operator actions. During Unit I refueling, there was a different interpretation of mid-loop. Chaiman requested that when SONOPC0 (Corporate) provides an interpretation and evaluation of DC, it should be returned to the board" (Exhibit 50,p.7).
Review of the minutes of the November 17, 1989, PRB meetinb designated as PR8 89-146, showed that, "The board discussed the reportability detemination for DC No. 1-89-1397 for addition of hydrogen peroxide to the RCS for chemical 4
decontamination. The board's position is that this deficiency is not report-Case No. 2-90-001 30 a
4
1-4 1
!~
able. A connent was made that the Westinghouse analysis be included with the.
DC documentation as justification for the change" (Exhibit 50 p.19).
Evidence 1
1.
AUFDENKAMPE stated that sometime in August 1989. RICKMAN was processing a j
i proposed TS change to allow the opening of the RMWST valves in Mode 5 j
loops not filled in order to facilitate the chemical cleaning of the RCS by injecting hydrogen peroxide at mid-loop. He advised that RICKMAN had i
i requested a Westinghouse safety analysis in support of this TS change j
request that was going to cost $50,000. AUFDENKAMPE stated that he questi6ned RICKMAN on: (1) why it was necessary to spend the $50,000, j
and (2) what VEGP had done when they accomplished this same chemical i
cleaning during the 1R1 in 1988. He advised that RICKMAN told him that he was not sure, but that he thought that they had just opened the valves I
and injected the hydrogen peroxide, and that the TS change request was being processed so that there would be no confusion next time about j
whether or not opening those valves was permissible. AUFDENKAMPE said that he brought this issue to the attention of M058AUGH and then it was discussed, to some extent, at the 9:00 a.m. status meeting that day. He advised that, after a couple other meetings with KITCHENS, and perhaps -
l 80CKHOLD. KITCHENS wrote the Deficient Card (DC).on the issue.
i AUFDENKAMPE stated that, as the manager of technical support, he felt the i
responsibility to have a determination made regarding the reportability i
of the opening of these RMWST valves at mid-loop during the IR1 of Unit 1.
He stated that this issue was brought before the VEGP PR8 and discussed regarding whether this was a TS violation and thus reportable i
to the hRC under 10 CFR 50.73. He advised that the discussion boiled down to whether or not an immediate action statement could voluntarily be l
entered. He said that a GPC Conorate position paper was requested regarding the voluntary entry into inmediate action statements. He stated that he thought either KITCHENS or 80CKH0LD telephoned McC0Y to get the Corporate position on that issue. He said that the Corporate position statement was issued and stated that you should not voluntarily i
enter immediate action statements, but also stated that "we can't find anythingthatsaysyoucan't"(Exhibit 51,pp.6-15).
i INVESTIGATOR'S NOTE: The Corporate position statement (Exhibit 53) does q
state that voluntary entry into an LC0 that has an inmediate ' action statement should not be made. This position statement does not say s
l anything about not being able to, find anything that says you can't.
I 2.
AUFDENKAMPE stated that he wished that the Corporate position on that issue had been stronger, but that since the statement did not cite any I
specific prohibitions against such a voluntary entry, he decided that there was no TS violation, and, therefore, was not reportable under that j
criteria. He advised that the PR8 also looked at the reportability issue j
from the aspect of the plant being in an unanalyzed condition that significantly compromised plant safety. He stated that the Westinghouse analysis'that was done convinced him that the opening of those RMWST valves for the length of time they had been opened to inject the hydrogen I
peroxide did not significantly compromise plant safety, and the event was not reportable to NRC under that criteria either (Exhibit 51 pp. 15-16).
i Case No. 2-90-001 31 I
i 1.-
1 e
i 3.
AUFDENKAMPE stated that he felt that the, "PRB review and evaluation of the incident was appropriate, correct, and in confonnance with all the regulatory requirements" (Exhibit 51, pp.19-20).
4 AUFDENKAMPE was asked if he was aware of any statements or indications, from any of the people that made the decision to open these valves, that i
they thought they were doing something wrong at the time. He replied that either on the day that he brought up the issue in the 9:00 a.m.
meeting or the next day', KITCHENS-came to his office and asked him, 1-
" John, what are you trying to do, get me put in jail?" AUFDENKAMPE l'
stated that he felt that KITCHENS had some real concerns, and was i
somewhat serious, but that KITCHENS' presentation of that statement was j
also somewhat jovial in nature (Exhibit 51, pp. 23-26).
1 5.
AUFDENKAMPE also stated that, in the early stages of the 0! investigation i
of this issue, HOPKINS told him that originally he (HOPKINS) did not feel
- p. 22)pening the valves was right, but that now he did (Exhibit 51, that o t
l 6.
On September 14, September 19, October 13 and November 17, 1989, the VEGP PRB delibusted the reportability, under the criteria of 10 CFR 4
j 50.73, of the October 1988 opening of the RMWST valves in Mode 5b j
(Exhibit 50, Exhibit 51, p. 8. Exhibit 55, p.15 and Exhibit 56, pp.11-12).
7.
DC No. 1-89-1397 states the reported deficiency as, "This is to record the review of addition of hydrogen peroxide to the reactor coolant for chemical decontamination during the IR1. Tech Spec 3.4.1.4.2 action statement c was entered during this time." This DC also states that a Tech Spec compliance issue to be evaluated. The Event time shown on this DC was 0400 hrs.10/12/88. The deficiency was shown as being reported by KITCHENS'to CHRISTIANSEN at 0946 9/18/89. Attached to this DC was l
Significant Occurrence Report (50R) No. 1-89-1397/158, dated September 21, 1989, stating that, "PR8 to aid with Tech Spec interpretation. SeePRBmtgminutes89-125"(Exhibit 52).
4 l
8.
The specific reportability criteria stated as being considered by the PRB j
with respect to this issue were:
(1) any operation or cendition in an unanalyzed prohibited by the plant's TSs. and (2) the plant being(Exhibit 51, p.15, l
condition that significantly compromised plant safety Exhibit 56, pp. 27-28, and Exhibit 28, pp. 21-23).
9.
The items that were considered by the entire PR8 in their meetings with respect to making their reportability decision were: TS 3.4.1.4.2, DC No. 1-89-1397, 50R No., 1-89-1397/158 KITCHENS' verbal explanation of the event, a memorandum from KITCHENS to 80CKHOLD dated September 15, 1989
-(Exhibit 57)(, a typewritten chronology entitled Unit 1 Shift Supervisor Log Sunnary Exhibit 58), a GPC position paper entitled Voluntary Entry Into Limiting Conditions For Operation Requiring Inmediate Action (Exhibit 53), and a Westinghouse boron dilution analysis for Modes Sb and 6 (Exhibit 54).
INVESTIGATOR'S NOTE: The focus of the PRB deliberations on reportability criteria (1) above narrowed to whether or not it was a violation of TSs Case No. 2-90-001 32 i
n I
t!'
to voluntarily enter an imediate action statement. The PRB focus on reportability criteria (2) above narrowed to the results of the Westinghouse boron dilution analysis.
- 10. The GPC Corporate position paper, entitled Voluntary Entry Into Limiting
]
Conditions For Operation Requiring Immediate Action, transmitted by cover letter from McC0Y to BOCKHOLD. dated October 2. 1989, states "Whenever a window has been provided for a system or component to be taken out of service (whether the window is in the form of an A0T or a specific exception) it is clear that voluntary entry into an LCO is acceptable.
i However, because of the potential for placing the plant into an.
t unanalyzed condition, voluntary entry into an LCO which expressly l
prohibits a given condition and requires immediate corrective action should that condition exist, should not be made" (Exhibit 53).
i INVESTIGATOR'S NOTE: Although GPC Corporate officials at the SON 0PC0 i
offices in Bimingham. AL. denied that they prepared this Corporate position paper for a specific reportability decision by the VEGP PRB, this document was a major factor in the PRB decision not to report the 4
deliberate opening of the RMWST valves in Mode 5b. Even though this position paper states that "... voluntary entry into an LCO which expressly prohibits a given action [the TS prohibits the opening of the j
valves by stating that they shall be closed and secured in position] and requires immediate corrective action...should not be made." the PRB decided that the valve opening was not reportable because the position i
paper did not definitively state that such a voluntary entry shall not, i
or will not be made. By the use of that logic, it appears that when the i
Corporate position paper did not say, as was expected, that it was perfectly permissible to voluntarily enter an imediate action statement, j
and, in fact, said that it should not be done, the PRB had to resort to j
the should not versus shall not rationale in order to justify to themselves the non-reporting of this valve opening.
l
- 11. The Westinghouse Boron dilution analysis, entitled Westinghouse Nuclear Safety Evaluation Check List, transmitted to GPC from Westinghouse on November 13, 1989, states that. "...for a dilution flow rate of 3.5 gpm
[ gallons per minute] or less there is sufficient operator action time j
available to terminate the flow after the high flux at shutdown alarm" l
(Exhibit 54
- p. 7).
INVESTIGATOR'S NOTE: Although the Westinghouse analysis concluded that the addition of a non-borated chemical mixture through CVCS valves 176 and 177 would not result in a loss of shutdown margin if the operator i
action acceptance criteria was met after the high flux at shutdown alam, the VEGP Operations personnel that made the decision to open these valves in October 1988 did not have the benefit of this femal analysis at that 4
time. ThereforeT the~ opening of-the RMWST valves.ofrVEGPr Unit-1 d n Mode 5b. in October 1988 did. sin: fact.: place the-plant.in,a condition:
- unanalyzed in the existing FSAR;OHoweverpreasonable estimates, by VEGP Operations personnel, of the' extent of dilution that would be caused by,
i i
the hydrogen peroxide injections. at the. time, plus the safety feature of~
the high flux at shutdown alarm.' indicated no significant compromise to 1
plant safety.,
Case No. 2-90-001 33
I m
1 i
i
- 12. RICKMAN verified that the issue of a possible TS compliance problem l
regarding the opening of the RMWST valves to inject chemicals at mid-loop during the IR1 came up when he brought his request for the $50,000 Westinghouse boron dilution analysis to AUFDENKAMPE. He stated that he 4
was not present, but that he understood that the reportability issue was i
brought up at a 9:00 a.m. manager's meeting soon after he had talked with AUFDENKAMPE about it. He advised that he attended a PRB meeting on j
September 14, 1989, and was explaining the Licensing Document Change Request (LDCR) and the need for the Westinghouse analysis when the compliance issue regarding the 1988 chemical injection came up. RICKMAN j
said that there was no discussion on the compliance issue in that PRB meeting because the PRB deferred such discussion until KITCHENS could be t
M in attendance at the meeting. RICKMAN stated that he did not attend any i
of the subsequent PRB meetings when the compliance issue was discussed, but that he understood that the PRB decided that the October 1988 opening of the RMWST valves at mid-loop was not a reportable event. He stated 4
Q g that, from his experience, and his review of the applicable TS in this L
j p
issue, he would be of the opinion that you could not voluntarily enter N
f/
that ilsnediate action statement. He stated that, from his i g '04 Licensing-oriented point of view, he tended to have a conservative T
philosophy on TS interpretation (Exhibit 55, pp.11-21).
j INVESTIGATOR'S NOTE: KITCHENS' input regarding interpretation of this TS l
and its associated action statements, as well as his description of his direct involvement in the October 1988 chemical injection itself, is j
important and essential to a thorough and complete PR8 reportability decision on this issue. However, an independent, objective PRB j
discussion of the interpretation of a TS seemingly could have taken place g[ without KITCHENS' input at that particular time, unless the othe j
members felt incapable of making their own individual interpretations, or Q 8 were prepared to ratify KITCHENS' interpretation without question. !It,is/'
also notable that RICKMAN, a Senior Engineet in.a. licensing. capacity, who
- g L was closely involved with the processing of the' change to the TS that r t~
would clearly permit the opening of these valves in Modes 5b and 6, was' y
m neither asked for his input on the compliance issue at the PRB meeting <
that he did attend, nor was he invited back to any of the subsequent PR8 i
9 meetings in which the compliance issue was discussed..'
l [ \\([
13.
MOSBAUGH stated that AUFDENKAMPE brought up the reprtability issue in a daily 9:00 a.m. staff meeting, in mid-September 1989, after having discussed it with MOSBAUGH prior to the meeting. He stated that the l
1ssue was placed on the PRB agenda the next day, and he (MOSBAUGH) was the vice chairman of that PRB meeting. He stated that AUFDENKAMPE and RICKMAN discussed the issue in that meeting, and the only documents available for review at the time were in RICKMAN's Request for EngineeringAnalysis(REA),orLDCRpackage. He stated that the mere i
existence of the REA package indicated to him that there was an unreviewed safety question regarding the use of these valves to add l.
hydrogen peroxide at mid-loop (Exhibit 56, pp.12-15).
- 14. MOSBAUGH stated that, at first, there was a discussion in the PRB about whether or not the plant was in a loops not filled condition when the valves were opened, but that the PRB eventually decided that the loops were not filled (Exhibit 56, p. 17).
I Case No. 2-90-001 34
)
.. -. - -. - _ - ~.. - _.
- 15. MOSBAUGH stated that, later in the day of that first PRB meeting on this issue, he met with 80CKHOLD and told him that a DC should be initiated on the event in order to properly resolve the reportability aspect. He stated that 80CKHOLD had KITCHENS come to his office to discuss the issue, and KITCHENS said that he would prepare the DC (Exhibit 56,
- p. 19).
j
- 16. MOSBAUGH stated that the Corporate position paper bore upon his final determination of non-reportability from the aspect of, "a condition or i
operation prohibited by Technical Specifications." He stated that the reason that the position paper was requested by the PR8 was so that GPC j
Corporate would specifically answer the issue at hand, and since it did not specifically state that entering an immediate action statement was J
4 prohibited, he CMOSBAUGH) interpreted the Company position to be that it was not prohibited. MOSBAUGH stated that the position paper had been prepared by the Corporate Licensing Group, which is tasked with making those kind of decisions. He advised that he thought that STRINGFELLOW j
actually prepared the paper (Exhibit 56, pp. 27-30).
i
- 17. STRINGFELLOW stated that he prepared the Corporate position paper regarding voluntary entry into an immediate action statement. He stated i
that either McC0Y or RUSHTON asked him to prepare the paper. He advised j
that, although he became aware of the issue that prompted the preparation l
of this paper, the paper was "... intended to be generic guidance." He
.i advised that, "It was not intended to address a specific issue." He I
stated that either McC0Y or RUSHTON had told him, in response to his j
g question as to whether it was to be specific or generic, that it was to begeneric(Exhibit 59,pp.6-9).
- 18. STRINGFELLOW stated that he did not use TS 3.4.1.4.2 as an example in his i
position paper because of the fact that it was supposed to be generic (Exhibit 59, p. 8).
- 19. RUSHTON stated that he did not recall who requested that the Corporate J
l position paper be done. He said that he did not recall taking the i
initiative to do it himself. He advised that he and STRINGFELLOW l
discussed it, and came to an agreement on what it would say, and then STRINGFELLOW wrote it. He stated that he thought someone from Engineering, whom he did not recall, first mentioned the specific issue
,p' and the question of its reportability to him. He stated that the paper i
was not written to make a reportability decision, rather that it was 4
!k[ ' 9 prepared to be a generic paper regarding voluntary entry into inunediate action statements. He stated that he received no direction from anyone l
to specifically not include the TS in question as an example in the paper
]
(Exhibit 60).
4
- 20. McC0Y stated that he did not recall how the position paper was initiated, and that his first involvement with the paper was when it was brought to 4
j him for signature, somewnere around October 2,1989. He stated that he did not recall directing anyone to prepare this paper. He stated that the' paper was prepared to give information to VE6P in order that they could aske a decision. He stated that he could not recall ever personally dealing with the question of voluntarily entering an immediate action statement in his career in the nuclear industry sExhibit 61, pp. 6-9).
Case No. 2-90-001 35 4
e
- 21. KITCHENS staten that, as chairman of the PRB, he was not a voting member unless it was to break a tie, and his vote was not needed in the PRB decision of non-reportability regarding the hydrogen peroxide addition issue..He stated that he did not think it was a reportable event, but his participation in the PRB discussions was primarily his description of the circumstances of the event itself, and that AUFDENKAMPE was the PRB member that briefed the board on the applicable mportability criteria, and on the data that applied to that criteria (Exhibit 16, pp. 84-85).
- 22. KITCHENS stated that the board agreed that they would wait and see what the Company position (the Corporate position paper) was going to be on reportability before they voted, because if the Company position differed from their vote, they would "have to rethink it." (Exhibit 16, p. 77).
- 23. The members of the PRB that actually voted on the reportability issue in the November 17,198g, PRB meeting; MOSBAUGH, HANDFINGER, SWARTZWELDER, and AUFDENKAMPE; all stated that the PRB deliberations on the issue were open, fair, and not unduly influenced by KITCHENS.
(Exhibits 56, 62, 28, j
and51).
i INVESTIGATOR'S NOTE: The creation of the position paper was prompted by i
the VEGP PRB reportability deliberations regarding this specific potential TS violation. The VEGP PRB expected the paper to specifically p
address that issue. The position paper not only did not specifically address the TS in question, but did not even use it as one of its generic fexamples. So, when the position paper did not make a definitive J
,y ecifically prohibit voluntary entry reportability call, and did not sp(although it specifically stated that it.
F into imediate action statements i
7 should not be done), the PRB still made its reportability decision, using this generic, non-specific position paper as the primary basis.
Therefore, instead of going back to Corporate for a definitive reportability call on the specific issue at hand, the PRB, using the inverse logic thct since the paper did not say anything about the specific issue being reportable, and did not specifically prohibit voluntary entry into immediate action statements, decided that the j
opening of the RMWST valves at mid-loop was not a reportable event.
i
- 24. LeGRAND stated that he was not present at the PRB on the day that they j
made the reportability decision, in 1989, on the opening of the RMWST i
valves in Mode 5b in IR1. He advised that he had been part of the PRB l
discussions on that issue, and his vote would have been that it was not j
reportable if he had been present on the day of the vote. He stated that part of him involvement with this issue with the PRB was that he had an action item to research alternate means of injecting chemicals into the RCS at mid-loop, other than through the chen add pot in the Chemical and Volume control System (CVCS) system. He stated that, in Hodes 5 and 6, 1
the only way to do it was through the chen add pot (Exhibit 63, pp. 3-7).
- 25. TYNAN, PRB Secretary and Procedures Supervisor, stated that, from her observations of the PRB discussions on the DC No. 1-89-1397, the Board seemed to be split, Operations versus Support, on the preferred opera-tional method of conducting the chemical cleaning of the RCS. TVNAN advised, however, that there did not seem to be a reportability or safety disagreement within the Board. She advised that the PRB discussion on Case No. 2-90-001 36 i
P e
that issue was open and healthy, and that everyone was able to voice their opinions (Exhibit 64, pp.10-11).
- 26. MANSFIELD, a votin.g alternate PRB Member, stated that he was an alternate for M. W. HORTON at the November 1989 PRB meeting at which the vote was taken on the reportability of the 1988 openinq of the RMWST valves in Mode 5b. He stated that the Westinghouse ana'ysis showed that there was not an unreviewed safety question..He was satisfied that there was no TS violation, based upon KITCHENS' explanation of the event and interpre-tation of the ters immediate as used in the action statement of the applicable TS. He stated that the PRB discussion of the issue was open and unrestricted, and that he was satisfied that the event was not reportable (Exhibit 65, pp. 5 and 9-15).
- 27. MCDONALD, Executive Vice President Nuclear, GPC, stated that he was not aware of any of the facts and circumstances surrounding the 1988 valve opening or the 1989 PRB deliberations regarding the reportability of that issue. He stated that he was not involved in the preparation or approval of the GPC Corporate position paper regarding voluntary entry into innediate action statements. ne stated that he is not aware of the general nature, or contents of GPC Corporate position papers as they are promulgated to the GPC nuclear plants. <He stated that when he found out that NRC O! was investigating this issue, he purposely isolated himself from any involvement with it until he could approach the issue with hRC onamanagementlevel(Exhibit 66,pp.4-10).
- 28. CHRISTIANSEN Shift Supervisor, stated that his only involvement with this issue was that he was on duty in the Control Room when the DC was processed. He stated that since the event was a year old, it did not affect his operation of the plant when the DC came to the Control Room.
He stated that he was not involved in, or aware of the circumstances surrounding the chemical addition to the RCS during 1RI. He stated that he did no investigation of his own on the DC (Exhibit 67, pp. 6-10).
J
- 29. FREDERICK, non-voting PRB member, stated that, in his mind, the issue i
regarding the 1988 opening of the RMWST valves in Mode 5b was not a significant issue with the PRB, and he did not recall much discussion i
about it in the November 17, 1989, meeting when tha final vote on report-i ability was taken. He stated that he thought that a requested change to the TS in question had precipitated the DC that was before the Board. He stated that he did not think the issue was reportable. He stated that he felt that the PRB decision was unbiased and bona fide, but that the j
definition of innediate was not a subject of discussion at the meeting, i
and he did not leave the meeting with any feel for the definition of immediate as it applies to the action statement of the TS. He stated 4
that the plant Operations people were not comfortable with that portion of the Tech Spec, and that is why they were trying to get it changed -
(Exhibit 68,pp.4-27).
- 30. BAILEY, GPC Licensing Manager, stated that he recalled a conference call i
from the VEGP site, participants not recalled, in which there was a general discussion of voluntary entry into immediate action statements, and then a specific discussion about the opening of the valves. He i
stated that, at a later time, McC0Y instructed that the Corporate Case No.- 2-90-001 37 l
ad l
l
- position statement be prepared regarding voluntary entry into innediate j
action statements, to be used for general guidance. He stated that STRINGFELLOW was assigned to research the issue. BAILEY stated that he did not review or approve the position paper before it went out. He advised that normally he would review such an item, but it would not have been held up if he was out of town when it was ready. He stated that Licensing does not normally issue position statements, and that he could not recall any others. He stated that he thought it was a verbal request from the site for the paper, and that he did not know exactly why it was i
wanted. He advised that he had no indication from the site people that they thought they had done anything wrong (Exhibit 69).
INVESTIGATOR'S ANALYSIS: It appears that the VEGP PR8 evaluation of the available information in their determination that the October 1988 opening of the VEGP Unit 1 RMWST valves in Mode 5b was not reportable to the NRC, lack both depth and logic. They considered a dilution analysis that was not in existence at the time of thc event. They also considered a forwal i
Corporate position statement that concluded "... voluntary entry into an LCO which expressly prohibits a given condition and requires immediate correction action...should not be made" and based on this determined that i
since the position paper did not expressly state that such an entry was l
not specifically prohibited, the 1988 RMWST valve opening was not l
reportable. At the time the PRB was deliberating this issue they were i
aware of the fact that the very TS that they decided was not violated was in the process of being changed to permit the very same valve openings that were in question in their reportability decision.
Conclusions l
The evidence developed during the investigation substantiated that GPC violated 10 CFR 50.73 by not reporting to the NRC that in October 1988. VEGP 1
was placed in a condition prohibited by plant TS. However, there was j
insufficient evidence to substantiate that GPC deliberately did not report this condition to the NRC.
j i.
i i
1.
i i
1 Case No. 2-90-001 38 4
$UPPLEMENTAL INFORMATION This investigation has developed information indicating possible violations of Federal Criminal Law. Under the circumstances, a copy of the final Report of Investigation has been referred to the Department of Justice for prosecutive consideration.
- l i
a 1
i Case No. 2-90-001 39 A
4 4
I l
\\
1 THIS PAGE LEFT BLANK INTENTIONALLY
.)
5 J
Case No. 2-90-001 40
s j'
LIST OF EXHIBITS Exhibit j
No.
Description l
1 RA:RII Request for Investigation., dated January 19, 1990.
i 2
Anonymous allegation letter, undated, l
3 VEGP FSAR-15, Chapter 15.4.6.2.1.2, entitled Dilution During Cold Shutdown, Hot Standby, and Hot Shutdown.
4 VEGPTS3.4.1.4.2(asofOctober1988).
5 VEGP Operations Procedure 12006-C Rev. 9 dated Au9ust 19, 1988.
)
6 VEGP SER, Chapter 15.4.6 entitled Inadvertent Boron j
Dilution.
}
7 GPC request and NRC approval to Amendment to TS 3.4.1.4.2.
8 01:RII Memorandum to RA:RII, dated February 1,1990, regarding Request for Technical Assistance.
9 RUSSELL memorandum to Hayes, dated July 10, 1990, regarding i
interpretation of 1988 version of TS 3.4.1.4.2.
10 Piping and Instrumentation Diagram RMWST to Chemical Mixing Tank to RCS.
11 VEGP, Unit 1 Control Log, from 0045, October 11, 1986, to 2400, October 13, 1988.
i 12 Pages 12 and 13 of VEGP Procedure No. 13007-1, Rev. 2, dated April 15, 1988, entitled VCT Gas Control and RCS Chemical Addition.
13
~
Page 15 of VEGP Procedure No. 49006-C, Rev. 0, dated June 7, 1988, entitled Health Physics and Chemistry Department Outage Activities.
14 Clearance Sheet, No. 1-88-371, regarding CVCS Blender Makeup Valves 1208.
15 VEGP Unit 1 Shift Supervisor Log, from 0003, October 11, 1988, to 2400, October 13, 1988.
1.
16 Transcript of Interview with KITCHENS, dated March 14, 1990.
17 Transcript of Interview with CASH, dated February 7,1990.
l 18 Transcript of Interview with BOWLES, dated March 13, 1990, Case No. 2-90-001 41
~
a Exhibit Nc.
Description 19 Transcript of Interview with GASSER, dated February 8,1990.
20 Functional Test Forms (4), regarding Clearance No. 1-88-371, i
dated October 12-13, 1988.
l
]
21 Transcript of Interview with SRACK, dated March 13, 1990.
22 Transcript of Interview with-EAVES, dated. February 8,1990.
l 23 Report of Interview with CAIN, dated February 27, 1990.
24 Transcript of Interview with HOPKINS, dated January 30, 4
]
1990.
25 Transcript of Interview with MARSH, dated February 15, 1990.
J 26 Tran:cript of Interview with 00CKHOLD, dated March 14, 1990.
27 Report of Interview with SELLAMY, dated June 28, 1990.
28 Transcript of Interview with SWARTZWELDER, dated March 14, 1990.
29 Transcript of Interview with ROGGE, dated March 19, 1990.
i 30 Report of Interview with DESROSIERS, dated hay 14, 1990.
31 Sworn Statement of HAND, dated May 31, 1990.
i*
32 Transcript of Interview with ALLEN, dated June 14, 1990.
33 Transcript of Interview with MEYER, dated June 14, 1990.
l 34 Transcript of Interview with BARLOW, dated June 27, 1990.
i 35 Transcript of Interview with BURMEISTER, dated June 27, 1990.
i 36 Transcript of Interview with PARKER, dated January 30, 1990.
37 Transcript of Interview with WEBB, dated January 30, 1990.
l.
38 Transcript of Interview with MITCHELL, dated January 30, 1990.
39 Transcript of Interview with SALTER, dated _ February 7,1990.
40 Transcript of Interview with ACREE, dated February 8,1990.
41 Transcript of Interview with MIDDLEBROOKS, dated February 8, 1990.
Case No. 2-90-001 42
1 Exhibit No.
Description 42 Transcript of Interview with THOMPSON, dated January 30, 1990.
43 Transcript of Interview with TUCKER, dated January 30, 1990.
44 Report of Interview with HENNESSY, dated February 26, 1990.
45 Transcript of Interview with WILLIAMS, dated February 8, 1990.
46 Transcript of Interview with LACKEY, dated February 8,1990.
47 Report of Interview with 80RWINKEL, dated February 28, 1990.
48 Report of Interview with TUPPER, dated June 11, 1990.
)
49 Transcript of Interview with 8EASLEY, dated March 13, 1990.
i 50 Minutes of Plant Review Board Meetings, dated September 14, 1989. September 19, 1989, October 13, 1989, and November 17, 1989.
51 Transcript of Interview with AUFDENKAMPE, dated February 9, 1990.
52 Deficiency Card No. 1-89-1397, dated September 18, 1989.
53 GPC Corporate position paper, dated October 2,1989.
54 Westinghouse Nuclear Safety Evaluation, dated November 14 1989.
55 Transcript of Interview with RICl3MN, dated March 13, 1990.
56 Transcript of Interview with M058AUGH, dated February 8, 1990.
57 Memorandum from KITCHENS to B0CKHOLD, dated September 15, 1989.
58 Typewritten Sunnary of Unit 1 Shif t Supervisor Logs, undated.
59 Transcript of Interview with STRINGFELLOW, dated March 3 1990.
60 Report of Interview with RUSHTON, dated March 8,1990.
61 Transcript of Interview with McC0Y, dated March 8, 1990.
Case No. 2-90-001 43 C
I d
Exhibit
.No.
Description 62 Transcript of Interview with HANDFINGER, dated February 8, 1990.
63 Transcript of Interview with LeGRAND, dated February 8, 1990.
64 Transcript of Interview with TYNAN, dated March 13, 1990.
65 Transcript of Interview with MANSFIELD, dated February 9, 1990.
66 Transcript of Interview with MCDONALD, dated July 23, 1990.
67 Iranscript of Interview with CHRISTIANSEN, dated January 30, 1990.
68 Transcript of Interview with FREDERICK, dated February 8, 1990.
69 Report of Interview with BAILEY, dated March 8, 1990.
i l
j i
Case No. 2 90-001 44 l
A'.
l MEMORA090M FOR CASE FILE
SUBJECT:
MEETING TO DISCUSS STATUS OF ACTIONS ON V0GTLE CASE DATE/ TIME: 05.09.91/1930 i
PARTICIPANTS: VIAS, SKINNER, BONSER, VORSE, CRAIG, REYES, URYC, ROBINSON, l
PEEBLES, JENKINS, HERDT, MILHOAN, EBNETER RA cautioned that tracking individual issues is a starting point to resolve the case, but the individual issues need to be integrated for the broad'
)
perspective as to what is now going on at the facility.
A I
RA' directed that Region II management become involved in the resolution process to ensure the required work is being properly accomplished.
RA directed that the 2.206 response be provided to 01 for their review.
RA directed that a weekly briefing be initiated to ensure the resolution process is proceeding without difficulty and that issues are being resolved in a timely manner.
RA requested DI to review the issue in 2-90-891 (pg 35, para 28) regarding MCC0Y's actions in the dilution event. VORSE stated that he would perform a review to determine if 01 action is warranted in that issue.
05 juihAd au no. & 90-o018 h
~
hav:m & j^+ub w/4%y.
j l
pi
. -~
q f3*
s
! *~
- 3 UNITED STATES j.
I NUCLEAR REGULATORY COMMISSION g
wasamorow. o.c. asms e,
WAY t 61991 MEMORANDUM FOR: Those on attached list FRON:
Gary Holahan, Deputy Ofrector Division of Systems Technology Office of Nuclear' Reactor Regulation MEETING MINUTES FOR SHUTDOWN AND LOW POWER ISSUES CON SU8 JECT:
HELD ON APRIL 30 - MAY 2, 1991 During the' period April 30, 1991 to May 2, 1991, a conference on shutdown and low power issues was held in Rockville, Maryland. The purpose of the conference was to provide a forum for cognizant NRC personnel and personnel from associated national laboratories to discuss shutdown / low power issues and The draw preliminary insights on-the risks associated with these issue:..
discussions were based on on-going evaluations and experience ife the areas of shutdown and low power risks such as AE00 operating experience reviews, NRR./
site visits, Regional experience from inspections and operator licensing, and The insights from the conference will be RES probabilistic risk assessee.its.
used to focus future program activities on the most safety significant issues.
s.
The final agenda covered a broad range of topics and is provided as Enclosure 1.
A composite list of participants over the three-day conference is providgd in As a result of the discussions, preiteinary insights were The insights from the conference developed and are provided in Enclosure 3.
I have been broadly categorized and are provided to you for review ano comment.
I Your review should include any comments on the completeness of the list from conference discussions as well as any additional insights which you think are warranted as a result of reflecting on the subject of shutdown and low power issues.
j All connents should be provided to Mark Caruso at (301) 492-3235 by May 24, 1991 in order to expeditiously proceed with near term program activities.
k N'\\
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Gary Holaha, Deputy Director Division of Systems Technology Office of Nuclear Reactor Regulation
Enclosures:
7 As stated
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4 MAY t 8199f Memorandum for those on attached list cc:
RalphArchitzel(80-1) j William Arciceri (INEL) (NL-007) i Jesse Arildsen (100-24)
Jay Ball (9A-1) i Phil Brochman (Rit!)
AllenCamp(Sandia)
Mark Caruso (8E-23) t Milesh Chokshi (NLS-217)
Donald Copinger (ORNL)
Mike Cullingford (12G-18)
Mark Cunningham (MLS-372)
Kulin Desai (8E-23)
Paul Doyle (100-22)
DanielGallagher(SAIC)
Nanette Gilles (11E-22)
Anthony Gody, Jr. (13E-21)
Pete Habighorst (RI)
Gary Holahan (8E-2)
Kahtan Jabbour (9H-3) l Ronaldo Jenkins (7E-4)
)
Lawrence Kokajko l
Jack Kudrick (80-1)
George Lanik (AE00)
Bill Lazarus (RI) i Melvyn Leach (Rill)
Jim Lazevnick (7E-4)
Warren Lyon (8E-23)
Fred Manning (AE00)
George Minarick (SAIC) i Robert Perch (8H-3)
William Raymond (RI)
Mark Reinhart (11E-24)
Howard Richings (8E-23)
Richard Robinson (NLS-372)
Faust Rosa (7E-4)
Bob Samworh (13E-21)
Susan ShanL an (100-24)
Warren Swenson (13E-4)
NormanWagner(80-1)
Len Ward (INEL) (NL-007)
MillardWohl(11F-23)
Ashok Thadani (8E-2)
William Russell (12G-18)
Thomas Novak, AE00 (MN88-3701)
Jack Rosenthal, AE00 (MNBB-9715)
Samuel Collins (Region IV)
NRR Division Directors Central Flies (P1-37)
SRKB R/F POR:
i (
5 ENCLOSURE 1 l l>, *
'p i
4 FINAL AGENDA CONFERENCE ON $NUTDOWN AND LOW POWER ISSUES 4
PROP 0$ED D15CUS$10N l
DATE SESSION SUBJECT LEADER 4/30 8:15 AM Opening Remarks Gary Holahan, NRR 4
8:30 AM Presentation on RES RES, BNL, SNL PRA Studies J
9:00 AM Presentation on AE0D AE00 i
Review of Operating Experience 9:30 AM PWR Loss of Decay Heat Warren Lyon, NRR Removal and LOCA 4/30 Afternoon 15LOCA Sam Diab, NAR BWR Loss of Decay Heat Tim Collins, NRR Removal and LOCA 2
i 5/1 Morning Safety Assessrent in Warren Lyon, NRR Outage Planning and Management
~-
l 5/1 Afternoon Boron Dilution Howard Richings,-NRR a
BWR Fuel Misload Howard Richings, NRR t
Heavy Loads /
Ralph Archittel, NRR Fuel Handling e
i S/2 Morning Availability of Jim Knight, NRR Electric Power j
l Containment Design Jack Kudri,ck, NRR and Closure Procedures 5/2 Afternoon Discussion of Overall Gary Holahan Insights and Program Direction i
t ENCLOSURE 2
/
CONFERENCE ATTENDEES SHUTDOWN AND LOW POWER ISSUES APRIL 30 - MAY 2, 1991 i
ORGANIZATION NAME NRR Ralph Architzel William Arciceri INEL nRR Jesse Artidsen NRR Jay 8411 Region !!!
Phil Brochman Sandia I
Allen Camp NRR Mark Caruso RES Nilesh Chokshi ORNL Donald Copinger NRR Mike Cullingford i
RES Mark Cunningham NRR Kulin Desai NRR Paul Doyle 8NL Bob Fitzpatrick SAIC Daniel Gallagher NRR Nanette Gilles NRR Anthony Gody, Jr.
Region I Pete Habighorst NRR Gary Holahan NRR Kahtan Jabbour NRR Ronaldo Jenkins NRR Jim Knight NRR Lawrence Kokajko NRR Jack Kudrick AEOD George Lanik Region 1 Bill Lazarus Region !!!
Melvyn Leach NRR Jim Lazevnick NRR Warren Lyon l
AE00 Fred Manning l
SAIC George Minarick
~
NRR Robert Perch NRR Marie Pohida William Raysend Region i NRR Mark Reinhart NRR Howard Richings RES Richard Robinson NRR Faust Rosa NRR f
Bob Samworth NRR Susan Shankman NRR Warren Swenson NRR Norman Wagner INEL Len Ward NRR Millard Wohl
_~
g ENCLOSURE 3 INSIGHTS FROM CONFERENCE ON SHUTOOWN AND LOW POWER ISSUES OUTAGE PLANNING AND CONTROL A.
GENERAL Cutage planning and control may be the most significant elements cf shutdown and low power risk.
All utility personnel and programs are stressed during shutdown operations:
Operations Engineering Maintenance Emergency Planning Security RAD Protection Industrial Safety Contractor controls and training during shutdown is inconsistent,
e (particularly for new individuals).
In general, the emergency planning programs have not considered the special circumstances and problems enccuntered during shutcown (e.g.,
evacuation of workers, ability of TSC and others to deal with comples configurations).
The effect of outage activities on operating units on the same site j
(e.g., shared systems, wrong unit).
Forced outages get less planning but involve fewer and less complex activities.
l 1'
Rate of loss of a/c power to safety busses has been much greater during shutdown than during power operations.
Fuel handling and heavy loads do not appear to be significant shutdown risk issues.
8 OPERATIONS Operators have less centrol of activities and plant condition:,
during shutdown than during power operations.
Entering and maintaining PWR sid-loop operation is a significant vulnerability.
Operator actions are generally more necessary for events that occur tluring shuteown operation than for events initiating during power operation.
r ll a
i,'
v Response procedures are weak.
Not specifically developed for shutdown operations..,
}
Incomplete /not symptom oriented.
For additional study - effects on plant staff of:
t Overtime during outages f
Changing shift rotations Rapidly changing plant configuration Accommodating to shutdown activities i
OperatorTraining n
NRC operator exams generally do not cover shutdown cion'dttions. -
Simulators generally don't cover shutdown conditions.
i Technical Specifications Plant modes in Tech Specs don't correspond to risk significant operating condition (e.g., PWR mid-loop, defueled).
Shutdewn mode T/Ss can be confusing and don't consistently establish minimum requirements.
Some plant-specific TSs have no requirements on electrical power systems during shutdown.
STS typically only require one division of electrical power sources (1 EDG, 1 offsite, 1 battery, 1 ac distribution system, 1 DC bus, 2 vital ac buses from inverters) reg'ardless of load requirements (Modes 4 and 5 for BWRs, Modes S and 6 for PWRs).
II. HARDWARE / DESIGN Shutdown instrumentation is not designed for shutdown conditions Operators have reduced confidence in instruments i
Availability problems i
Inappropriate ranges Inst.~uments not well understood Core teeparature often not monitored
)
Demands on equipment during various modes / configurations not always consistent with the design of the equipment (e.g., LPCI/RNR).
BWRs generally have more water available during shutdown.
Injection sources Higher level in vessel j
8 q
l 1
3
.-t 1
BWR Mark I and !!s have no " containment" capability)during refueling i-(i.e., only limited " confinement
- capability exists.
]
PWR and SWR Mark III containments may be capable of contain.ing shut-
.j down accidents if appropriate plans and procedures are available.
PWR containment integrity may be important during mid-loop operation.
ECCS recirculation capability may be reduced or lost by intentional sump isolation (i.e;, coverage to prevent debris entry) or by foreign l
material in containe.ent during shutdown.
J PWR vpper internals may inhibit water from entering the core from the 1
i I
- refueling cavity.
p BWR loss of DHR is less significant than PWR loss of DHR.
]
For additional study - Containment performance during accidents 4
initiated from shutdown.
j For additional study - Role of secondary containment in shutdown l
accidents.
)
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UNITED STATES OF AMERICA NUCLEAR REGULATORY. COMMIS SION 4
i 1
Title:
mazEnna on sauroown arsx smos l
J 1
Location:
accxvn,1,E, man.awo 4
4 Dat6
. TONE 19, 1991 3
PEGES:
.71 PAGEs s
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53
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}5AL R. GROSS AND CO., INC.
- COURT REPORTERS AND TRANSCR18ERS 1323 ahode Island Avenue, Northwest
. Washington, D.C.
20005 (202) 234-4433 0-9/o'7090/Y4-t
%4.
1 improvement 3 in trcining cnd procadurco.
Thara io o 4
general observation that both training and procedures 2
3 have really historically been developed to deal with 4
power operation, and this really runs the gamut from 5
emergency procedures, use of simulators.
Even NRC operator licensing program has really been focused on 6
power operation and shutdown activities have not been 7
really focused on and it's left those areas with less 8
9 well-defined, less robust programs, and it's something 10 that we think is important enough to look at.
11 The fourth item deals with technical 12 specifications.
One of them I think Bill mentioned It became 13 earlier has to do with mode definitions.
14 clear when both national laboratories began to put together their PRAs that the current mode definitions 15 16 in technical specifications are really not detailed 17 enough to identify the safety-significant conditions 18 that the plant is in, the most obvious one being mid-19 loop operation for PWRs.
That's not identified as a 20 specific
- mode, doesn't have specific applicable 21 limiting conditions for operation.
It's really 22 treated as either part of mode 5, cold shutdown, or 23 mode 6, refueling, depending upon whether the head is 24 tensioned or not.
25 But when the tech spec requirements were NEAL R. GROSS count mmmms mein 4Nsemune 13D nHODE ISLAND AVENUL N.W.
(202) 2:2 4 800 WASHINGTDN. O.C. 20006 (202) am l
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generated for moda 5 and 6 they rc 11y didn't cnvicion 2
the plant being in mid-loop operation.
When the plant 3
is i n s o f.a 6,
refueling, we normally think of the 4
refueling canal full of water, 23 feet of water and l
5 300,000 or 400,000 gallons of water above the core, 6
but in doing the PRAs it becomes clear that that 7
typical condition is not really what always exists.
)
8 When you're legally in mode 6,
there's really a 9
variety of conditions that the plant could be in.
10 In some of our discussions with utilities, 11 it's become clear that when they plan an outage -- I 12 remember one utility took mode 5 and divided it into 13 5A, 5'B, 5C, because mode 5 didn't really establish 14 unique conditions that set the real safety 15 requirements for equipment and for activities.
So, 16 that's something that we think is important to look 4
17 into.
18 ~
The other part of the tech spec issue that 19 turned up as important is the variability in what 20 really is required in shutdown.
What we find is, 21 particularly in the older plants with custom tech 22 specs, there are really minimal requirements on system 23 availability during shutdown and refueling modes.
24 There are a number of plants, for example, which have 25 no requirements for AC power availability when the l
NEAL R. GROSS count nanomw;s um mNacamme tars MMalE lame AVENUE. N.W.
(200 234 8433 WASHINGTON. D.C. 20006 (200 2224400 4
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