ML20133K207
| ML20133K207 | |
| Person / Time | |
|---|---|
| Site: | Cooper  |
| Issue date: | 02/21/1996 |
| From: | NRC |
| To: | |
| Shared Package | |
| ML20133J789 | List: |
| References | |
| NUDOCS 9701210151 | |
| Download: ML20133K207 (100) | |
Text
PD E-1 1
1 UNITED STATES OF AMERICA 2
NUCLEAR REGULATORY COMMISSION 3
+ + + ++
4 OFFICE OF INVESTIGATIONS S
INTERVIEW 6
x 7
IN THE MATTER OF:
8 INTERVIEW OF Docket No.
9 PATRICK F.
MacDONALD (not assigned) 10 11
x l
12 Wednesday, February 21, 1996 13 14 Conference Room
)
15 1617 Central Avenue 16 Auburn, Nebraska 17 18 19 The above-entitled interview was conducted at 20 2:53 p.m.
21 BEFORE:
22 VIRGINIA VAN CLEAVE, Senior Special Agent 23 STEPHEN L.
McCRORY, Operator License Examiner 9701210151 960829 PDR MISC 25 9701210137 PDR CASEND. 4 9li 002*
NEAL R. GROSS EXHIBlT PAGE / OF / 00 PAGE(S)
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1 1
P-R-O-C-E-E-D-I-N-G-S 1
l 2
(2:53 p.m.)
3 MS. VAN CLEAVE:
For the record, this is an d
4 interview of Patrick F. MacDonald, whose address is y 1
l 5
date of birth, i
6 Mr. MacDonald is currently unemployed, 7
but was previously employed by Nebraska Public Power at 6
Cooper Nuclear Station.
9 The date is February 21, 1996, and the time is 1
10 approximately 2:53 p.m.
Present at this interview are j
l 11 myself, NRC Senior Special Agent Virginia Van Cleave; l.
)
12 Stephen McCrory, NRC inspector; and Mr. MacDonald.
This 1
l 13 interview is being tape recorded by court reporter Phyliss i
f 14 Lund.
15 Mr. MacDonald, if I could ask you to please i
16 stand and raise your right hand --
17 Whereupon, 18 PATRICK F.
MacDONALD 19 having been first duly sworn, was called as a witness 20 herein, and was examined and testified as follows:
21 EXAMINATION 22 BY MS. VAN CLEAVE:
23 Q
Mr. MacDonald, I would like to get a little 24 background information on you, first your employment 25 background.
You were previously employed by Nebraska NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON. O C 20005 (202) 234-4433
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Public Power at Cooper Nuclear Station.
Is that right?
2 A
That is correct.
3 Q
What were your dates of employment there?
4 A
I was employed from January of '89 through 5
January of
'96.
7 6
Q What positions did you hold and approximately 7
when, the dates?
8 A
When I was initially hired January of
'89, I
9 was hired as a station operator; station operator through, 10 I guess it would have been, June of
'94, when I received 11 NRC reactor operator's license and became a licensed 12 station operator.
I was a licensed station operator for 13 about a year before I became a temporary unit II operator.
14 O
Was that the position that you held when you 15 left Cooper?
16 A
Yes, it was.
17 Q
What does that mean, temporary?
18 A
It was a temporary promotion.
They had 19 promoted eight individuals to temporary unit II positions.
20 It just meant that they could give you higher salary, the 21 title, raise your pay scale a little.
22 O
And when did you leave Cooper?
What was your 23 last data of employment there?
24 A
My last day of employment was January 13, was 25 my last working day, and my termination became official NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, D C. 20005 (202) 234-4433
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January 19,
'96.
2 Q
Had you worked in the nuclear power industry 3
previous to working at Cooper?
4 A
I had been in the United States Navy, worked 5
as a nuclear electronics technician.
I was a reactor 6
operator on board nuclear submarines.
7 Q
For how long?
8 A
That was for six years.
9 Q
Did you start working at Cooper as soon as you 10 were discharged from the Navy?
11 A
That is correct.
12 Q
What were the circumstances of your leaving 13 Cooper?
Were you terminated?
14 A
I was terminated.
15 Q
As you know, Steve and I are here to look into 16 this control rod mispositioning incident that occurred i
17 January 7 of this year.
I am not an engineer.
I want 18 that understood, so if I ask something that you think I 19 should know, that is the reason.
Steve is the technical I
20 expert here.
21 So I would like to discuss that event, and if 22 you could just kind of tell me what started this sequence 23 of events -- I understand there was some sort of a trip.
24 I don't even remember what it was.
Can you just tell me 25 more or less what started the event and about what time it NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS
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was?
1 2
A We -- Crew D came in, took the watch when 3
everybody turned over.
Everybody was turned over by 4
about, oh, 6:15 and 6:20 that evening.
We were in the 5
middle of our turnover briefing when alpha reactor recire 6
generator set tripped.
]
7 We received alarms on generator lock-out, 8
which indicated that we had one of three possible 9
conditions that tripped the reactor recirc pump, so we i
10 dispatched station operators to investigate the cause of i
11 the reactor recirc pump trip, stabilized the plant.
12 We checked -- I specifically checked power on l
13 APRM recorders, checked flow on the core flow recorder, on 14 the loop flow recorder on the 9-4 panel, verified those 15 readings against the power flow map to ensure that we 16 weren't in the region of instability; continued to monitor 17 power and core flow, to ensure that we didn't see any 18 power oscillations because we were operating high power, 19 low flow.
20 Shortly after we had stabilized the plant, 21 after the reactor recire pump trip, we entered the 22 abnormal procedure for the lost -- the reactor recirc 23 pump, carried out all of the immediate and subsequent 24 actions, and entered procedure 2.2.68.1, which specifies 25 operation in single loop.
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Q How common is a reactor recirc pump trip?
2 A
At Cooper Nuclear Station in the control room, 3
I had been an operator for seven years, and that was the 1
4 first time that I had seen it.
I don't think that there 5
had been a big history of having them.
6 Q
So this was the first time that you had been 7
involved in one.
8 A
That is correct.
9 Q
What did you do to know what to do?
Did you 10 go to a procedure and --
11 A
Procedure 2.4.2.2.1 is the abnormal procedure 12 for loss of a single reactor recire pump, and the actions 13 specified in the procedure describe what you have to do 14 for that particular instance: monitor power flow, make 15 sure that you are not in the area of instability.
16 You have to shut the loop discharge isolation 17 valve in the loop that had the pump trip in it.
That is 18 to slow the pump down to minimize pump damage in the event 19 you had reverse flow through the loop.
We did those 20 actions.
21 O
When you say "we," you were the reactor 22 operator.
23 A
That is correct.
24 Q
Who are you speaking of?
Was there another 25 person present that was assisting you?
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1 A
I was performing the actions.
We use a
2 concurrent verification in the control room at Cooper 3
Nuclear Station, so the control room supervisor, Marty l
4 Hannaford, was directing actions under the abnormal J
5 procedure.
i l
6 John Collins was the balance plant operator.
7 He was performing concurrent verifications, monitoring 4
8 balance of plant equipment, feed pumps, condensate pumps, 9
handling communications with the station operators.
10 Terry LaPlant was the fifth license in the 11 control room.
He was also performing concurrent 12 verifications, following through in the abnormal 13 procedure, taking other actions.
I specifically took the i
14 actions of shutting the recirc loop discharge valve in the 15 alpha loop, monitoring power to flow, comparing those 16 against the power-to-flow map.
17 At about, oh, seven o' clock, I believe it 18 was, went ahead and called up a P-1, which is our periodic 19 edit to determine what our thermal limits are and those 20 kind of things.
21 We have to adjust -- when we are operating in 22 single loop, we have to adjust our APRM gains within a 23 different band, We have a procedure for that also which I 24 entered and performed to adjust the gains, and then 25 shortly after seven o' clock, I was given an order to NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, O C 20005 (202) 234-4433
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insert control rods in reverse sequence.
2 O
Who gave you that order?
3 A
That was Marty Hannaford, the control room 4
supervisor.
5 Q
You said that was about what time?
6 A
Shortly after seven o' clock.
7 Q
And specifically what did he tell you?
8 A
I believe the order was:
Insert control rods 9
in reverse sequence to reduce rod line to less than 80 10 percent rod line.
11 Q
Can you tell me:
What does reverse sequence 12 mean?
13 A
We have a procedure, 10.13 procedure, which 14 specifies a rod sequence.
It gives you specific rods, 15 length of movement.
In other words, we could move rods i
16 one notch at a time, keep them within one notch of each 17 other, to a set limit, a lower limit or an upper limit.
18 And each rod group has an upper and lower 19 limit when you reach -- say, that you are withdrawing 20 control rods.
You reach the upper limit; then you 21 continue on with the next page.
Each group has its own 22 page in the sequence book, and each group has set limits, 23 so the rod sequence book specifies a method of movement of 24 the control rods.
25 You follow a set order, one page at a time, to NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON, D C 20005 (202) 234-4433
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move the control rods from their upper limit to their 2
lower limit, or from their lower limit to their upper 3
limit, based upon which direction you are heading.
4 Q
So when Mr. Hannaford said to do this in 5
reverse order, what did that mean?
6 A
What that meant was that we were going to 7
insert control rods.
We had been withdrawing control rods 8
to establish full power.
We had just recently performed a 9
start-up following a refueling outage, and we were 10 manipulating control rods as necessary to maintain full 11 power.
12 What reverse sequence meant was that we were 13 going to start at the end of the package and start I
14 inserting control rods by following the sequence 15 backwards.
io Q
Do you know?
Did Mr. Hannaford make that 17 decision, or did he get those instructions from someone 18 else?
19 A
There was some discussion about bringing in 20 reactor engineering.
When we entered the 22.68.1 21 procedure, there was specific guides.
As a matter of 22 fact, the first step in the procedure reads something 23 like, Reduce rod line to less than 80 percent rod line.
24 Prior to continuing on with any of the other 25 steps in the procedure, you usually try to follow the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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procedures in order, step by step, so I went ahead and 2
told Marty that we needed to reduce rod line to less than 3
80 percent, informed him of this.
4 He conferred with the shift supervisor, Doug 5
Hitzel, at the time, and at first Doug Hitzel wanted to go 6
ahead and wait for reactor engineering to come in, and the 7
reactor engineer was Paul Ballinger.
He lives in Hamburg, 8
Iowa, so we knew that it was going to take him a little 9
while to get in.
10 Due to the reactor recire pump trip and a 11 reduction in feed water flow and steam production, we had 12 also had a significant drop in feed water inlet 13 temperature.
We had taken almost a 60-degree drop in feed 14 water inlet temperature, so we were seeing some rise in 15 rod line and some rise in power due to the loss of feed 16 water heating as a result of the event.
17 So it was deemed that we couldn't really wait 18 for the reactor engineer to get in, and at this time, the 19 shift supervisor directed Marty Hannaford, the control 20 room supervisor, to go ahead and have rods inserted in 21 reverse sequence.
22 O
Do you know if Mr. Hitzel made that decision, 23 or if Mr. Ballinger did?
24 A
I believe that that was a decision made by the 25 shift supervisor.
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~. _ _ _ _. _.
i 11 I
l 1
O And who is your -- was your boss?
l 2
A That would have been Doug Hitzel, the shift 3
supervisor.
1 4
Q Is Mr. Hannaford kind of an in-between -- what 1
i 5
is his function?
If you don't report to him, do you 6
report --
7 A
Doug Hitzel is the -- as the shift supervisor, 8
he is responsible for the site.
Thic was a back shift, so 9
he had responsibility and authorities associated with 10 operation of the entire facility.
11 Marty Hannaford is the control room 12 supervisor, I guess you would call him, second in command.
13 He specifically provides guidance to the -- guidance and 14 direction to the control room operators.
He directs the 15 control room operators to have different manipulations 16 performed out in the plant.
Most of his are operational-17 related, his orders, decisions, things like that.
18 O
So when you have a question or need some
]9 assistance, do you go to the shift supervisor or the 20 control room supervisor?
21 A
Typically I would go to the control room 22 supervisor first.
23 Q
So you have said that at approximately -- was 24 it seven o' clock?
25 A
It was about seven o' clock.
That is correct.
I NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE N W (202) 234 4433 WASHINGTON. O C 20005 (202) 2344433
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0
-- that Mr. Hannaford told you to begin 2
inserting rods in reverse sequence.
Is that correct?
3 A
That is correct.
4 Q
And he told you that specifically.
5 A
Yes.
6 O
And you said there was a book sequence, rod 7
sequence?
8 A
Yes.
There are -- procedure 10.13 is our rod 9
sequence.
We keep it in a small binder up on the 9-5 10 panel.
11 Q
And what does -- what is included in that 12 book?
13 A
Included in that book is precautions for 14 approach to criticality, and that is typically used during 15 start-up.
It specifies guidance for minimizing rod worths 16 to prevent high flux scrams.
17 There is pages in the book, specific pages, 18 with each rod group with their upper and lower limits, in 19 sequence.
At the end of the book, there is typically an 20 emergency rod movement control sheet which can be used in 21 emergencies, events where you lose feed water heating, 22 loss of the reactor recire pump, when you need to reduce 23 rod line significantly.
You can use the emergency rod 24 movement control sheet.
25 I think there is another page in the front NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 2344433 WASHINGTON, O C, 20005 (202) 2344433
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that just tells you what cycle we are on and gives you the 2
title of the procedure, that kind of stuff.
That is 3
usually what is contained in the book.
4 Q
How often do you use that book?
5 A
Typically you use it when you are starting up, 6
obviously.
The. reactor engineers provide you with a 7
sequence, and you follow sequence as you are starting up, 8
coming up in power.
When you need to do rod adjustments, 9
you will go to the rod movement control book.
10 The reactor engineer again will usually 11 provide where he wants you to move control rods to, and 12 usually that is for depletion of fuel or if you want to 13 raise the rod line up a little higher, so you can reduce 14 the amount of core flow you are using to achieve 100 15 percent power.
There is a variety of reasons that you 16 would adjust control rods, and that doesn't happen very 17 often, especially since we had just started up, and we 18 were establishing max power.
19 0
Would you say you use that book every shift?
20 Once a week?
Once a month?
21 A
Me personally, what I like to do when I come 22 on shift, is I call up what is called OD7, and this gives 23 you rod position information for the shift, and you take 24 this twice a shift.
Part of my turnover ritual, I guess 25 you would call it, is to verify that my OD7 is consistent NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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with the last page in the rod package, to make sure that 2
the rods are, in fact, at the positions that they are 3
supposed to be at by the rod package, so I verify my OD7 4
against my rod package.
5 In this particular case, I -- since we were in 6
a turnover briefing, I hadn't had a chance to call up an 7
OD7 yet to accomplish that.
8 Q
That was my next question was going to be:
9 Did you do that this day?
You did not.
Is --
10 A
No.
11 Q
-- that right?
Okay.
So when Mr. Hannaford 12 told you to start inserting rods in reverse order, what 13 did you do?
14 A
In order to insert control rods at Cooper 15 Nuclear Station, you have to have two operators at the 9-5 16 panel.
One operator manipulates the control switches used 17 to insert the control rods; the other operator is there to 18 verify that you are on the correct rod and that you do, in 19 fact, position the control rod to the correct position.
20 I went ahead and positioned myself at the 9-5 21 panel We usually move chairs up to the 9-5 panel, 22 because it is a long, drawn-out affair wP you are 23 inserting control rods.
I went ahead and picked up the 24 rod movement package, which was open to page 37.
It 25 typically sits on the right-hand side of the panel.
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I moved it to the left-hand side of the panel, 2
because we have -- we knew we were going to be taking the 3
feed pump off, and all the feed water controllers are 4
located on the right-hand side of the 9-5 panel, so we do 5
that to move those out of the way, to make it easier to --
6 for the balance of plant operator to remove that feed 7
pump.
8 At that time, I positioned the book over on 9
the left-hand side of the panel.
It stayed open on page 10 37, which I had assumed was the last page in the package.
11 Q
Why had you assumed that?
12 A
Typically the rod movement control book is 13 open to the last page of the package, typically.
14 Q
Is the book always -- does it always consist 15 of the same number of pages?
16 A
No.
The pages will vary, depending upon where 17 we are in the life of the core.
And usually what they 18 will do is reactor engineering will come up and they will 19 put pages in for the rod adjustments, and then after the 20 rod adjustments have been made, they will pull those pages 21 out and just put a little asterisk down the row to say 22 where the rod was positioned to and leave that last page 23 in there, because what you will do is you will have 24 several pages that will encompass a certain adjustment, 25 but you are only moving one group of rods.
The only thing NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W-(202) 234-4433 WASHINGTON. D C. 20005 (202) 234 4433
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1 that really changes is the limits.
2 So they will pull all those pages out and put 3
them in the master file down there at the reactor 4
engineering office, and you have to make sure that you are 5
on the last page.
Usually try to flip through and make 6
sure that is where you are.
Well, in this case, I made a 7
poor assumption and thought that I was on the last page, 8
when, in fact, I wasn't.
9 Q
So you were to start at the last page, but --
10 A
That is correct.
The page --
11 0
-- the book was -- I am sorry.
Go ahead.
12 A
Page 51 was the last page in the package.
13 okay.
When I picked the book up, it was open to page 37.
14 Part of the problem was that I knew we had just done a 15 start-up, so I didn't think there were going to be that 16 many pages.
Okay.
And that was a poor assumption on my 17 part again, but when I moved the book over, the verifier 18 went around back to use the restroom.
19 Q
And the verifier was who?
20 A
The verifier was Terry LaPlant.
He went 21 around back to use the restroom.
By the time he got back,
,02 I had the book moved, open to page 37, and two chairs 23 located up at the 9-5 panel.
He sat down.
He was looking 24 at the rod package, and I was selecting the first rod on 25 page 37.
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Q So by the time he sat down, you were already 2
starting to select the first rod.
Is that correct?
i 3
A Yes.
1 4
0 Now, this is knowing that you hadn't performed 5
your usual ritual to check control rod positions.
6 A
That is correct.
7 Q
And you still didn't check the book to ensure 4
8 yourself that you were on the last page.
9 A
That is correct.
10 Q
couldn't you -- you couldn't tell by looking 11 that there were more pages kind of behind?
You know, 12 sometimes these notebooks --
13 A
Not just by looking at the book.
No.
14 0
-- kind of --
15 A
When I moved the book, I mean, it looked like 16 it was the last page in the book, to be honest with you.
l 1
17 The pages were all neatly aligned, so you couldn't tell l
18 that there were more pages behind.
Page 37, you know, was 19 a reasonable page for where we were at in the start-up, in 20 the power ascension.
21 The rod that I had selected was, in fact, at i
22 the upper limit for that page, so I had no reason to 23 believe that I was starting on the wrong page.
24 0
so that was -- that rod was where you would 25 have expected it to be, according to page 37.
Is that --
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A That is correct.
i 2
0
-- correct?
3 A
Yes.
4 Q
You should have checked -- if I understand you 5
correctly, you should have checked the book to ensure that 6
you were on the last page, because that was where you were 7
supposed to start.
8 A
That is absolutely correct.
9 O
And you failed to do so.
Is that correct?
10 A
Yes.
11 Q
Mr. LaPlant did not do so.
Is that correct?
12 A
I believe he was in the process of doing that 13 when I informed him that I was selecting the first rod.
14 When he saw that the first rod was, in fact, at position 15 36, which was the upper limit on that page, he went ahead 16 and, in his mind, must have confirmed that it was, in 17 fact, the last page in the sequence book also, and we 18 continued.
19 I can't speak for Terry LaPlant and tell you 20 what -- you know, what he was thinking at the time, but in 21 my mind, that is probably what happened.
22 Q
Does anyone else check that book for any 23 reason, like prior to this kind of a movement?
Does 24 anybody else check it?
25 A
Not typically.
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Q So you just have the reactor operator and 2
the --
3 A
Usually during turnover, what you will do is 4
if they made any rod movements, you will go through and 5
you will look at the book to see where -- you know, what 6
rod has gotten moved, which group has gotten moved, where 7
your rods are located.
The SS and the CRS and the RO 8
typically do that.
9 Q
So you made the movements, I guess, you were 10 supposed to according to page 37.
Right?
11 A
Yes.
12 O
Is that correct?
And then what happened?
13 A
We went from page 37, after moving those rods 14 in, keeping them within one notch of each other, to the 15 insert limit.
We went to page 36.
16 0
How long does it take to make the movements on 17 this one page?
Three minutes?
Five minutes?
18 A
A lot of it depends on how many rods you have 19 to move on the page.
Some rods have four rods to move; 20 some rods have eight rods to move.
It also depends on the 21 upper and lower limits.
If you have -- say, in this case, 22 page 37, you had to move control rods from position 36 to 23 position 30.
Okay.
That is only moving rods three 24 notches.
And there were only -- I think there were only 25 four rods on the page.
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So probably five to ten minutes to insert 2
those a notch at a time, keeping them within one notch of 3
each other.
It doesn't take too terribly long, but each 4
individual rod has a set time frame.
It takes about a 5
minute and a half to two minutes for each notch, because 6
it has to go through a timer sequence.
7 And the timer sequence determines how long it 8
takes for that rod to settle and how long it takes for it 9
to insert, and if it inserts to the next notch, you 10 know -- if it doesn't insert, you have to notch it in 11 again, so a lot of it depends on, you know, where you are 12 starting from and where you are going to.
13 0
I noticed when I was looking at this rod 14 sequence book that there was a time, I guess, a date and a 15 time, and signed by the --
16 A
Yes.
17 0
-- individual reactor operator.
What does 18 that time mean?
Is that the time that you completed the 19 actions on that page?
20 A
Yes.
21 Q
Okay.
Then you went to page 36, you said, 22 after you completed the actions on page 37, and then what 23 happened?
24 A
When we selected the first rod on page 36, we 25 realized that we had started on the wrong page, because NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON. O C 20005 (202) 234 4433
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the upper limit on page 36 was significantly lower than 2
where the rod was actually positioned.
At this time, we
~.
j 3
were concerned with rod line, because rod line was --
4 Terry LaPlant and I were both monitoring rod line very 5
close, and we had APRM upscale alarm lights lit on the 9-5 1
l 6
panel for all six APRMs, and we knew that we were 7
operating pretty close to automatic scram set points.
t 8
So because we were at 108 percent rod line, we 9
went ahead and went to page 51, and continued to insert 10 rods in reverse sequence on that page again, maintaining 11 one notch between each rod as we inserted those.
We 12 inserted those rods from position 08 to 00.
I believe 13 that is what it was.
14 Q
Page 51 being the last page.
15 A
Page 51 was the last page in the package.
16 That is correct.
17 Q
The page that you should have started on 18 initially.
Is that correct?
19 A
That is correct.
20 Q
So page 37, the rods were in the position 21 shown on that page, so you didn't have any indication that 22 you were on the wrong page?
23 A
That is correct.
24 Q
But 36, the rods were not.
i 25 A
That is right.
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Q so was that -- that was the first 2
indication --
3 A
That was the first indication we had had that 4
we started on the wrong page, yes, when we got to page 36.
5 0
Who made the decision to go ahead and go to 6
page 51 and start inserting rods?
7 A
I believe that was my decision.
We were -- I 8
was concerned with where rod line was at.
I was focused 9
on getting rods inserted to try to get -- first of all, 10 get rods away from automatic scram set points.
I was 11 concerned with the drcp in feed water heating, feed water 12 inlet temperature, which was pushing power up.
It was 13 driving my rod line up higher.
14 We weren't seeing any real effect from -- the j
15 rods that we inserted on page 37 didn't impact rod line 16 hardly at all.
When we went to page 51 and inserted those 17 rods a notch at a time, those had very little effect on 18 rod line, and we didn't see a large reduction in power 19 like we were hoping to get, so the decision to continue to 20 insert rods was more my decision based upon where rod line 21 was at and trying to -- I was focused on getting rods 22 inserted below 80 percent rod line is what I was trying to 23 do.
24 That was the order that I was given.
I was 25 trying to follow it.
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Q What was your initial reaction when you found 2
out you were on the wrong page?
1 j
3 A
I really didn't think much of it at the time.
4 Again, I was focused on getting rods inserted, moving away 5
from scram set points.
We were close to the operation in 6
the instability region, so I was -- my focus wasn't on, 7
you know, Oh, God, we messed up and started on the wrong 8
page.
It was, Get rods in.
9 That is what 1 was focused on doing.
You 10 know, I knew where we were in power; I knew where we were 11 in flow.
I was concerned about how high power was for the 12 flow that we were at.
I was concerned about oscillations.
13 There were a lot of things that I was thinking about.
14 Keying in on the fact that wa had started on the wrong 15 page didn't really enter my mind.
16 O
Did you think you might have a problem, that 17 this might cause some problems, having started on the 18 wrong page and inserted these rods out of sequence?
19 A
To -- at the time, no.
I didn't really see a 20 large problem.
I had been involved in part of the start-21 up, and the rod worths and the shape, the axial flux shape 22 and the radial flux shape from an OD1 that I had done the 23 night before, using the tips, knew where the reactor was 24 peaked.
I knew where the rod worths, where they are 25 highest.
We were r,eeing our highest rod worths from about NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234-4433 WASHINGTON. D C. 20005 (202) 234 4433
24 1
position 24 to position 32.
2 I didn't see where inserting those control 3
rods were going to impact either the radial or the axial 4
peak hardly at all.
They were intermediate rods.
They 5
were shaping rods, and they were withdrawn towards the 6
upper end of the intermediate part of the rod, so their 7
function was primarily for flux shaping, because the worth 8
of the rod wasn't that great.
9 I didn't see as where there was a large peak i
10 in the center of the core that I had driven the radial i
11 peak up higher.
I didn't see that as a problem.
12 O
After you moved those rods, would you consider 13 them to be mispositioned?
14 A
At the time, I hadn't considered them to be i
15 mispositioned.
No.
16 Q
Would you now?
17 A
Yes.
l 18 Q
Was there any discussion with Mr. LaPlant at 19 that time as to what action to take?
20 A
Mr. LaPlant at the time was uttering some 21 comments, barely audible, like, Why didn't we start on 22 this page; you know, Where did you -- he came over and 23 asked -- you know, turned to me and asked me, you know, 24 Why did you start on this page; a variety of different 25 questions.
Again, I didn't really pick up on his concern.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 4
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._- -_ _ _ - _ _ _ _ - - =.
25 1
He didn't come out and say, you know, You just 2
mispositioned control rods.
He didn't say anything like 3
that.
l 4
He, too, was looking at where we were at in I
5 rod line.
I said, Look, we are at 108 percent rod line.
6 We need to get rods in.
You know, so we continued.
7 Q
Did either of you mention possibly talking to 8
your supervisor?
9 A
Not really.
The shift supervisor was at the 10 time involved in making phone calls to get reactor 11 engineers in, notifying plant management, contacting the 12 resident inspector, a variety of different things that he 13 has to do when we have an abnormal procedure entered into.
14 The control room supervisor was at the time 15 performing concurrent verifications for removing 16 condensate booster pumps from service, so his focus was 17 primarily on balance of plant manipulations.
The balance 18 of plant operator was working at getting one condensate, 19 condensate booster pump and a feed pump out of service.
20 So Marty Hannaford and John Collins, the 21 balance of plant operator and the control room supervisor, 22 were both tied up at the time, tending to balance of plant 23 equipment.
24 We, Terry LaPlant and myself, were 25 manipulating control rods; turned around and saw that they NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, D C 20005 (202) 234 4433
26 1
were tied up.
Actually I don't think we even looked, to 2
be honest with you, you know, but we knew that they were 4
3 removing condensate, condensate booster pumps from 4
service, because, you know, they were right there next to 5
us.
a 6
So speaking up and saying something, that 7
would have been prudent, but we -- again, as I say, I was 8
focused on inserting control rods.
We had a four-hour 9
window to get control rods inserted to less than 80 10 percent, and in that four-hour window, we had to remove a 11 feed pump from service; we had to get a condensate, 12 condensate booster pump removed from service.
We had to 13 adjust APRM gains, and there is a lot of things that had 14 to happen in that four-hour time period.
15 And then after we get the 80 percent rod line, 16 we have got to start looking at taking cycle noise data to 17 monitor for oscillations, power oscillations, that kind of 18 thing, and establish noise limits for the cycle.
19 So that is the direction that I was moving in, 20 and that was my primary focus.
I wasn't focused on 21 anything else around me.
I was focused on inserting 22 control rods, monitoring power to flow map, making sure 23 that we didn't have power oscillations because of where we 24 were on the power to flow map, trying to reduce rod line, 25 so that we could move away from automatic scram set NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON, D C. 20005 (202) 234 4433
27 1
points.
2 Q
Did it cross your mind at that time -- now, we 3
are talking about between page 37 and then 36 and before 4
you started on page 51.
Did it even cross your mind to 5
notify Mr. Hannaford or Mr. Hitzel?
6 A
No, it didn't.
7 O
Did you -- you said that he was occupied.
You 8
knew that they were both occupied, and then later on you 9
said, Well, I don't think I ever even looked, to be 10 honest.
Now, which was it?
Did you turn around and say, 11 Well, maybe I should notify somebody, or --
12 A
You could see that they were -- out of the 13 corner of my eye -- I mean, here is the 9-5 panel right 14 here.
Okay.
I am sitting here right like this.
Board A 15 is right over here, which is where Marty Hannaford and 16 John Collins were, and you could hear them talking about 17 removing the condensate, condensate booster pump.
You 18 know, Marty Hannaford had his back to me.
John Collins 19 was manipulating controls.
So I knew that they were doing 20 that.
21 Q
But it didn't even cross your mind to notify 22 anyone.
Is that --
23 A
No, it didn't.
24 O
At that time.
Is that accurate?
25 A
That is accurate.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIDERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON. D C. 20005 (202) 2344433
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28 1
Q Did Mr. LaPlant mention anything, again, at 2
that time?
I am going to try and stay in order here.
At 3
that time, did he mention anything to you about telling 4
supervision about the problem?
5 A
No, he didn't.
I think he wanted to, based on 6
some of the comments that I was getting, but, again, I 7
wasn't picking up on the fact that he felt uncomfortable 8
with continuing, and the fact that he --
9 Q
What kind of comments did he make, other than 10 asking you how -- I think you said he asked how -- why did 11 you start on page 37.
What other comments
\\
l 12 A
Well, and, you know, Oh, God, we made a i
4 13 mistake, you know; we started out on the wrong page, you 14 know.
Again, these are things that he is kind of 15 muttering to himself, no one in particular, you know, and 16 maybe that is -- you know, maybe some of his sidebar kind 17 of comments were another reason why I felt relectant to
)
18 say anything.
I don't know.
19 I can't -- to this day, I cannot give any 20 reasonable answer as to why I didn't speak up after it 2
e 21 happened.
I mean, I can give you conjecture.
You know, I 22 have wrestled with this for a long time, trying to figure 23 out why I didn't come forward shortly after it happened 24 and say something.
I mean, that is the right thing to do; 25 that was the expectation.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON. O C. 20005 (202) 234 4433
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You know, at the time, again, my focus wasn't 2
on what management's expectations were.
It wasn't on 3
making notifications.
It was on inserting control rods.
4 I was at that point nothing more than a machine programmed 5
to insert control rods.
6 0
You said some of his comments might have made 7
you reluctant to say something.
What -- can you tell 8
me -- recall any comments he made that might have made you 9
feel that way, reluctant to say something?
10 A
No one wants to admit that they made a -- I 11 mean, this is -- in the world of nuclear power, this is a 12 huge, huge error.
I mean, we had been beat about the head 13 and shoulders on just this same incident, because the 14 operations supervisor, during a staff training session, 15 had done this very thing.
16 A couple of pages in the laminated book out in 17 the simulator got stuck together.
They missed a page, and 18 then they didn't find it until they started getting rod 19 worth minimizer rod, blocks.
20 0
What do you mean, the operations supervisor?
21 A
The operations supervisor, Dave VanDerKamp is 22 an operator on a staff crew for training.
That is how he 23 maintains his license, his operating license, is he 24 attends training on a staff crew.
And that same kind of 25 rod mispositioning incident occurred with him.
He was the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHOOE ISLAND AVENUE, N W.
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30 1
reactor operator at the time, and again this was out in
(
2 the simulator, so the impact was nil.
3 But they were doing a lot to reinforce the 4
fact that you don't ever, ever want to have something like 5
this happen at Cooper; dire consequences if this happens 6
at Cooper.
You know, the potential to lose your job is 7
there if you -- you know, disciplinary action, et cetera, 8
et cetera.
9 I mean, it was pretty clear that if you
)
10 misposition control rods and you were the one that did it, i
11 that, you know, you were probably the one that was going 12 to have your head served up on a platter.
13 Q
What happened to that individual?
Dave -- did I
14 you say it was Dave?
i 15 A
Dave VanDerKamp?
16 Q
Yes.
\\
17 A
Nothing, to my knowledge.
I mean, this wasn't j
18 an incident --
19 Q
I understand.
It was on a simulator.
20 A
It happened out in the simulator while they 21 were training, so obviously because it was a training i
22 scenario, you know, you try to pass on the lessons 23 learned, especially before start-up, that kind of thing.
24 You know, they stress that you need to check every page of 25 the rod movement package, not to get in a hurry, a variety NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234 4433 WASHINGTON. D C. 20005 (202) 234 4433
i 31 1
of different things.
2 But in this case, the evening that this 3
happened, maybe part of it was the fact that we had had a j
4 reactor recirc pump trip, and that I was still pumped full l
i 5
of adrenalin when it happened and felt like continuing on, 6
and, you know, it is like, Hey, the response to the pump 7
trip went pretty damn good, you know; giving yourself the 8
old pat on the back for how well the crew responded to the l
9 reactor recirc pump trip, you know; continuing to monitor 10 power and flow, monitoring for noise, a variety of 11 different things.
12 You have a lot going through your mind as an 13 operator when you go through an event similar to this.
I 14 mean, all of your programming -- I hate to call it 15 programming, but that is kind of what it is in the 16 simulator -- to teach you to respond to this particular 17 event, you know, it does a lot to set you up to where you j
18 can respond well to the event.
19 But it doesn't really prepare you for it 20 happening, you know, and it doesn't -- you know, there is 21 other consequences when you are in the plant and you are 22 not in the simulator.
23 Obviously when you are in the simulator, you 24 can't break fuel.
Okay.
They can simulate that you have 25 broke fuel, but you can't break fuel in the simulator, NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE N W (202) 234-4433 WASHINGTON. O C. 20005 (202) 234 4433
32 2
1 because there isn't any fuel.
You don't have a 2
containment that can break, you know.
You don't have a
~
3 recire loop that can fall off.
It is not a traumatic 4
event in the simulator.
5 So you go through and you participate in the 6
events.
You learn from the experience, and you go on.
7 When you get into the plant, you know, you have got fuel 8
in the vessel you have got to be concerned about.
You 9
have got, you know, all these different systems that are 10 working together, that you are trying to -- oh, God, you 11 know, let's see, what else can possibly happen.
12 You are running through 30 different scenarios i
13 in your head when something like this happens, and it is 14 like, Okay; the initial event happens; you take care of 15 it; everything is great.
You have stabilized the plant; 16 it looks just wonderful, and now you get into some 17 subsequent actions which don't get reinforced very well 18 very often, and now here is where you kind of try to take 19 a deep breath and start proceeding along slowly, except 20 they stick that four-hour window on you and say, Okay; you 21 have got to get rods inserted in this four-hour time 22 frame.
23 Well, I know that it is a lengthy evolution to 24 insert control rods in reverse sequence to reduce rod 25 lines from 108 percent rod line, which is where we were, NEAL R. GROSS COURT REPO4TERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N.W (202) 234 4433 WASHINGTON. O C. 20005 (202) 234 4433
33 1
to 80 percent rod line.
It takes a lot of time to do
(
~
2 that, so you try to get going on it as soon as possible;
\\
l 3
you try to do it in a prudent manner; you try to do it in i
1 I
4 a safe manner.
5 In this particular instance, my greatest flaw 6
was that I didn't double-check the book.
7 Q
And you said that they had emphasized that.
8 A
Yes, they had.
9 Q
But you still neglected to do that.
10 A
That is correct.
11 Q
Okay.
How long would it have taken you to 12 tell Mr. Hannaford or Mr. Hitzel, Hey, Doug, we have a 13 problem over here?
14 A
Not very long; a couple of
-- you know, maybe 15 15, 20 seconds.
There is -- I hate to say this, because I 16 was hoping to avoid this, but there are some other 17 misgivings on my crew.
18 The shift supervisor has -- you know, we have 19 had some events on our crew, and the way the shift 20 supervisor responds to particular events is, Oh, God, I 21 have got to make all these phone calls, you know; you guys 22 are hosing me over again, you know; management isn't going 23 to like this, comments like that, that kind of make it 24 difficult to turn around and tell this man that, you know, I
25 Hey, we made a mistake, because every time it happens, you NEAL R. GROSS COURT REPORTERS AND TRt.NSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234-4433 WASHINGTON O C 20005 (202) 234-4433
34 1
know, every time that there is an error that goes on --
2 Let's say, that you misposition a switch.
3 Okay.
He doesn't come out and call you a name or 4
something, and say, God, that was a stupid move.
But that 5
is kind of how he makes you feel.
He has a tendency to 6
belittle you a little when you make a mistake, so it tends 7
to make people a little reluctant to come forward and say 8
things.
9 In the past, when I have made an error, I have 10 been pretty good about coming forward and saying, I just i
11 did this; how do you want me to fix it.
In this 1
12 particular instant -- I don't know why -- I just clammed 13 up and didn't say anything.
14 Q
Has Mr. Hitzel ever taken any disciplinary 15 action against anyone on his shift for making an error 16 that you know of?
17 A
Disciplinary action, no.
18 Q
So it would just be like you were saying, 19 comments, belittling comments, or something like that.
20 A
Yes.
There was an adversarial relationship i
21 between the control room supervisor and the shift 22 supervisor on my crew.
There was a --
23 Q
They don't -- they didn't get along, Mr.
{
U I
24 Hannaford and Mr. Hitzel?
Is that what you are saying?
25 A
I don't want to say that they didn't get NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W
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l 35 i
1 along.
It is just that they would have differences of l
2 opinion, and some of these differences in opinion led to 3
command and control problems on the crew, where the shift 4
supervisor, instead of standing back and monitoring the 5
big picture, playing overview, would start issuing 6
commands to the panel operators.
And this happened 7
frequently, more frequently than it should have.
8 The night of this incident in question, the 9
shift supervisor directed the balance of plant operator to 10 idle the alpha reactor feed pump which was being removed 11 from service at 875 rpm and didn't really explain the 12 reasons behind it.
He gave that out as an order to the 13 balance of plant operator, when it should have gone 14 through the control room supervisor and should have been 15 the control room supervisor giving the order.
16 There are several instances on my particular 17 crew where this has happened.
18 Q
How long were you on that crew?
19 A
I had been on that crew since I got my 20 license, almost two and a half years.
21 Q
So did the crew stay the same that whole time?
22 A
No.
Prior to the outage, our control room 23 supervisor, who had been Terry Borgan, was pulled off of 24 the crew.
Matter of fact, a lot of the better senior 25 reactor operator talent prior to the outage was pulled off NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON, D C 20005 (202) 234-4433
36 1
of crew to direct different outage functions, and a lot of 2
the individuals, although they were experienced in -- you 1
3 know, they had been standing the hours as control room
)
i 4
supervisor and had their SRO hours in were not as familiar 1
5 with the control room supervisor position.
6 Marty Hannaford came in -- he is a good 7
control room supervisor -- after Terry, but Terry was a 8
very good buffer between the shift supervisor and the 9
crew.
And what I mean by that is that where Terry 1
10 excelled was if the shift supervisor tried to go around 11 him to get to the panel operators and give orders, Terry 12 Borgan as the control room supervisor would get in Doug 13 Hitzel's face and say, Look, you know, we have got a 14 command and control issue here, and they would discuss it, 15 whether it would be privately or openly.
16 Terry always kept a tight rein on Doug Hitzel i
17 and made sure that he wasn't creating command and control 18 concerns for the crew.
Terry was also very good at i
19 motivating the crew to maintain a good line of 20 communication.
In other words, all of the individuals on 21 the crew felt comfortable providing information -- Terry i
22 providing information to Doug, regardless of what that 23 information was.
There was never a problem.
24 Then prior to the outage, Terry was removed.
l 25 Marty Hannaford, who had been in the operations support NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234-4433 WASHINGTON. O C 20005 (202) 234-4433
}
37 l
1 group for almost five years and then come back to our 2
crew, had been on our crew for maybe two or three months 3
operating, was named the control room supervisor.
4 Q
How long had he been the control room 5
supervisor when this incident happened?
6 A
Probably about eight, nine months.
7 Q
And how did he -- you said there was an 8
adversarial relationship between him and Mr. Hitzel.
How 9
did he relate to the rest of the crew, to the reactor 10 operators and --
11 A
Marty related very well with the rest of the 12 crew.
His mannerisms were different from Terry's, which 13 made it a little difficult for members of the crew to 14 react in the same way.
I mean, it takes time for members 15 of a crew to --
16 Whereas Terry Borgan had been our nucleus, you 17 know, and everything focused on Terry and Terry kept the 18 crew together before and made the crew function well as a 19 unit, you know, those lines of communication when Marty 20 took over broke down.
21 The shift supervisor felt a need to make more 22 orders as opposed to suggestions to Marty, which meant 23 that the shift supervisor in my mind didn't have good 24 faith in this control room supervisor.
Marty as control 25 room supervisor is very competent individual, very bright, NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, D C. 20005 (202) 2344433
38 1
gave excellent orders.
I never had a problem fulfilling any of the orders or being instructed what to do by Marty.
2 3
Q Did you ever have any problem telling him that 4
you had made an error?
5 A
No.
6 0
Any belittling comments by him?
7 A
No.
8 0
Why not tell him, then, during this incident, 9
if you felt that Mr. Hitzel might not be very receptive?
10 A
Again, the only thing that I can say about 11 that is I don't have a good reason for why I didn't speak 12 up at the time.
Maybe -- and, again, this is conjecture.
13 Maybe I was afraid of what the consequences were if I 14 spoke up and said I had mispositioned control rods.
Maybe 15 my --
16 Again, my focus was more on reducing rod line 17 and inserting control rods.
I have to admit that I was 18 extremely focused on doing just that one thing.
I was not 19 considering anything else.
At the time of the incident, I 20 wasn't really considering the consequences of my actions.
21 I didn't feel that I had damaged the core, that my actions 22 had been -- had been prudent, had been timely.
23 We did come forward and tell the control room 24 supervisor and the shift supervisor that the incident 25 happened.
We had discussed it with the reactor engineer NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERE 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON D C. 20005 (202) 234 4433
39 1
prior to --
2 Q
We will get to that.
I don't want to get out 3
of order here.
4 A
Okay.
5 O
Let's -- why don't we back up.
Now, you found 6
that you were on the wrong page, and you say that you and 7
Mr. LaPlant elected to go to page 51 and start inserting 8
rods there, and I believe you said that was your decision.
9 A
Yes.
10 0
Is that correct?
11 A
Yes.
12 Q
You started to do that, and then what 13 happened?
14 A
We inserted those control rods on page 51 from 15 position 08 to 00, a notch at a time, completed that page.
16 Then we turned around and looked at rod line again, and 17 saw that the -- that group of rods being moved in also had 18 very little impact on rod line.
19 So at this point, we decided to go on to the 20 emergency rod movement sheet, and we inserted those rods 21 on the emergency rod movement sheet from position 12 to 22 position 00.
And when we finished inserting the final 23 rod -- again, we inserted these a notch at a time per the 24 instructions on the sheet.
25 When we got that final rod inserted, the NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, O C. 20005 (202) 234 4433
40 1
reactor engineer showed up, and we discussed with him what 2
had occurred.
s 3
Q Now, reactor engineer was who?
4 A
Reactor engineer was Paul Ballinger.
5 Q
Do you know about what time that was, how much 6
time had elapsed since you started the rod insertion on 7
page 37?
f 8
A This was about, oh, 7:15, 7:20 when he showed 9
up.
10 0
And what did he do?
Did he come right to you 11 and Mr. LaPlant?
12 A
He initially came and spoke with the shift 13 supervisor.
Then he let the control room supervisor know 14 he was there, and then he came over and talked with Terry 15 and I.
And at this point is when we told him about what 4
16 we had done.
We showed him the pages that we had 17 inserted.
18 0
What specifically did you tell him?
19 A
We told him that we had started out on the 20 wrong page.
We said, We started out on page 37 and we 21 inserted these rods a notch at a time, explained how we 22 had moved the rods and where we had moved the rods to, 23 that we were monitoring rod line very closely, and that we 24 were at 108 percent rod line; we were looking at reducing 25 rod line.
We told him that.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234-4433 WASHINGTON. O C. 20005 (202) 234-4433
41 1
And we specifically asked him if he felt that i
2 we had done anything to damage the core or had we violated 3
any limits, you know.
Did he feel that we were still okay 4
thermal-limit-wise, safety-wise?
5 Q
Who was talking to him, Mr. Ballinger?
Was t
6 that you or Mr. LaPlant?
7 A
Terry LaPlant was doing most of the talking.
j 8
Q So he -- who is the person that told Mr.
1 J
9 Ballinger that you had started on the wrong page and --
10 A
That was Terry.
i 11 Q
Did he discuss that with you prior to telling 12 Mr. Ballinger that, that he was going --
13 A
No.
l 14 Q
-- to tell him --
~
l 15 A
No.
)
16 0
-- that?
If Terry hadn't said anything, would 17 you have said anything to the reactor engineer?
4 d
18 A
It is hard to say.
I probably wouldn't have.
l 19 Q
You probably would not have?
20 A
Probably would not have.
J 21 O
Why not?
22 A
Again, at the time, I didn't really see that I 23 had done anything wrong.
I mean, it wasn't somethina that i
24 hit me in the face and said, Oh, my God, I have really 25 done something terribly, terribly wrong here.
It was, you NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHOOE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON. D C. 2000S (202) 2344433
42 1
know -- it was something that I didn't really realize I 2
had committed something that was contrary to safety.
I 3
didn't view it as being something wrong.
4 I mean, again my focus was on inserting i
5 control rods.
I wasn't thinking about what had just 6
transpired.
7 Q
When the reactor engineer came in, weren't 8
some of the control rods still mispositioned?
9 A
No.
)
i 10 Q
You had straightened everything out?
11 A
After that first page had been inserted, okay, i
12 we started in reverse sequence, and then we went to the 13 cram groups, and then using his direction, his guidance, 14 we --
15 Q
Who?
Mr. Ballinger?
16 A
Mr. Ballinger.
We continued to insert control 17 rods in the next pages until we got back to page 37.
18 Q
But before he got -- but when he came in, 19 weren't some rods still mispositioned?
You weren't yet --
20 it is my understanding you weren't yet back to page 37.
21 Isn't that correct?
22 A
That is correct.
23 Q
So would some rods not have still been 24 mispositioned when he came in?
25 A
If you consider mispositioning being that we NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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43 1
started on the wrong page and that all of those rods were 2
out of their correct position, then that would be a true I
3 case.
Yes.
4 0
Well, what is the definition of 5
mispositioning?
1 6
A In my mind -- well, at least what I am been 7
taught is that a mispositioned control rod is a rod that 8
is not in its correct position by the sequence --
9 Q
So does this scenario not fit that?
10 A
-- prior to it being verified.
Well, it l
11 certainly does.
4 12 Q
Okay.
Did you not -- you said you probably 13 would not have said anything to the reactor engineer.
14 Don't you feel that the reactor engineer should know?
15 A
Yes.
16 Q
And you still would not have said anything to 17 him?
18 A
Well, again, if Terry hadn't have said 19 anything, I probably wouldn't have picked up on the fact 20 that I had done something wrong.
Okay?
I cannot say 4
21 with, you know, with good conscience that I was fully 22 cognizant that I had actually done something wrong at the 23 time.
I was looking at a lot of different things.
24 I was looking at power and flow.
I was 25 looking at why the reactor recirc pump tripped.
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44 1
looking at doing adjusting APRM gains.
I was looking at inserting control rods, monitoring thermal limits, j
2 3
checking for power oscillations.
There were a lot of 4
things that I was concentrating on at the time that, you 5
know, mispositioning of control rods never entered my 6
mind, honestly never entered my mind that we had 7
mispositioned control rods.
8 Okay.
Starting out on the wrong page, okay.
9 Yes.
That definitely meets the definition of 10 mispositioned control rods and a reactivity mismanagement 11 incident certainly.
12 Q
But at the time the event happened, you didn't 13 see it that way?
Is that what you are saying?
14 A
Well, no.
I was focused on the event; I mean, 15 solely focused on the event and getting rods inserted less 16 than 80 percent rod line.
I was committed to doing those 17 actions.
18 Q
Let's back up a minute.
I think we skipped 19 something.
You said that before the reactor engineer got l
20 to the control room, that you had started to insert these 21 emergency cram rods.
Is that correct?
22 A
That is correct.
23 Q
Who made that decision?
24 A
That was my decision also, based upon where 25 rod line was at and the fact that power was still going NEAL R. GFK3SS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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up.
[
2 Q
Who inserted them?
You or Mr. LaPlant?
3 A
I inserted them.
i 4
0 You inserted them?
Was there any discussion 5
with Terry about whether that was the correct action to 6
take?
7 A
Yes.
8 Q
And what was his response?
i 4
9 A
His response was that we should go ahead and i
10 do that.
i, 11 Q
Can these -- are these cram rods authorized to 12 be used without approval by a reactor engineer or a shift 13 supervisor?
14 A
The reactor engineer assigns the rods and puts 15 the emergency rod movement sheet at the end of the package i
16 for use in incidents such as this.
Typically, t
i 17 administratively the shift supervisor is supposed to grant 18 permission to use the emergency rod movement sheet.
19 Q
Did you know that at the time?
Were you aware 20 of that?
21 A
I had been trained on the 10.13 procedure.
I i
22 was -- I am sure that I was aware of it at the time.
23 Again, my focus was on inserting control rods to reduce 24 rod line, and I didn't take into consideration the 25 administrative requirements of the emergency rod movement NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE N W.
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46 1
sheet.
No.
2 Q
So Mr. -- neither Mr. Hitzel or Mr. Ballinger 3
was notified prior to your beginning to insert these cram 4
rods.
Is that correct?
5 A
That is correct.
6 Q
Was anybody else notified?
Mr. Hannaford 7
perhaps?
8 A
No, he wasn't.
9 Q
This was a decision by you primarily, with 10 discussion with Mr. LaPlant.
Is that correct?
11 A
That is correct.
12 Q
Did Mr. LaPlant mention that, We need to 13 notify the shift supervisor --
14 A
No.
15 0
-- or the reactor engineer or anyone else 16 before we start inserting these cram rods?
17 A
No, he did not.
18 Q
How far had you gotten before the reactor 19 engineer came up to your work station, to the panel there?
20 A
We were on the last rod in the cram group.
21 Q
Okay.
Did you finish that up before you 22 started talking to Mr. Ballinger?
23 A
Yes, we did.
24 Q
And you said that Mr. LaPlant told him what i
25 had happened --
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1 A
That is --
i 2
0
-- that you had started on the wrong page and 3
you had gone back to correct it and you had inserted cram
)
4 rods.
What did Mr. Ballinger say to all this?
5 A
Mr. Ballinger basically felt that our actions i
6 were okay.
I mean, he didn't feel that we had violated i
7 any thermal limits.
He didn't feel that we had damaged 8
fuel.
We went ahead and, again, looked at rod line after 4
9 inserting the cram group.
We had dropped rod line down to I
j 10 about 98 percent rod line.
1 11 At that point, he provided us further guidance i
12 on inserting control rods, using continuous insert on some i
13 of the control rods to further reduce rod line.
We went I
14 ahead and inserted two pages -- I believe it was one or i
15 two pages prior to page 51 that were in the rod movement 16 package, and then stopped at that point to allow the i
17 balance of plant operator and control room supervisor to 18 remove the feed pump from service.
l 19 O
Okay.
You said prior to 51.
So you are i
20 working backwards.
You mean, like 50, 49, something like 4
21 that?
j j
22 A
Right.
23 Q
Okay.
Did Mr. Ballinger say anything about 24 your starting -- or inserting cram rods without talking to 25 him?
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A No, he did not.
2 Q
Did he indicate that was a problem?
3 A
No, he did not.
4 Q
Did he ask you if you had gotten approval of 5
the shift supervisor?
6 A
No, he didn't.
7 Q
Did you or Mr. LaPlant tell him that you had 8
not spoken with the shift supervisor or the control room 9
supervisor at that time?
10 A
No, we didn't.
11 Q
Was there any discussion with him about the --
12 starting on the wrong page and that incident, about that 13 being reported to someone, such as a shift supervisor or 14 the control room supervisor?
15 A
No.
We didn't say anything about it, and he 16 didn't say anything about it either.
17 Q
So there was no -- he didn't -- at that time, 18 as far as you knew, he wouldn't know whether you had 19 reported it to anyone or not.
Is that --
20 A
That would be correct.
21 Q
Okay.
22 A
He came in, and we told him basically where we 23 were at, and he looked at the P-1 that I had pulled up 24 prior to us starting the rod insertion, reviewed that, and 25 he looked at where we were on the power to flow map and NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W j
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49 1
then provided us guidance on rod movements.
That is what 2
he did.
3 Q
Who signed off on -- you said there was an 4
emergency sheet to be used for these cram rods.
Who signs 5
that?
i 6
A I know that the RO and the verifier signed 7
those after the rods had been moved.
i j
8 Q
That is just like any other sheet in that rod 9
sequence book?
10 A
Yes.
There is a specific spot for us to sign, i
11 time and date it again.
12 Q
Again, when the page is complete --
i i
13 A
Yes.
14 Q
-- with a date or the time shown?
15 A
Yes.
16 Q
What about the approval?
I think there is a 17 line on there for approval by someone.
18 A
I think there is, too, but I can't remember if
\\
4
]
19 it was signed or not.
20 Q
But you didn't get any approval.
Is that --
21 A
I didn't even look at it.
22 Q
So you don't know if it was signed, and you 23 never got any approval before starting cram rod insertion.
24 Is that correct?
25 A
That is correct.
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Q All right.
You said Mr. Ballinger told you to -- gave you some guidance about what to do next.
2 3
A Yes.
4 Q
And did you and Mr. LaPlant start following 5
that guidance?
6 A
Yes, we did.
7 Q
Did you have any discussions then about the 8
potential problems, having started on the wrong page 9
and --
10 A
No, we did not.
11 Q
Any discussion about, Perhaps we need to 12 report this to somebody?
13 A
No.
14 O
None?
No discussion about that?
15 A
No discussion at all.
16 Q
Okay.
17 A
When we finally stopped -- the control room 18 supervisor came over and told us that we needed to stop at 19 a certain point to allow them to take the feed pump out of 20 service, and --
21 Q
And you said that was after a couple of pages 22 beyond 51.
Is that --
23 A
Right.
After the emergency rod movement 24 sheet, we inserted -- I can't remember which page number 25 it was that we inserted, but we inserted a couple more NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 2344433 WASHINGTON. D C 20005 (202) 234 4433 1
51 1
pages following the reactor engineer's arrival, at which 2
point we stopped and verified that the rods were all at 3
the same group notch; called up a P-1 to verify that our 4
thermal limits and everything were okay, verify our APRM 5
gains.
6 And it was at this point that Terry LaPlant 7
went to Marty Hannaford and told him about the incident, 8
and then the shift supervisor came over, and I went ahead 9
and I told him about the incident at that point, what had 10 transpired.
11 Q
Now, do you know about what time that was?
12 A
We are looking around 7:30, 7:45, somewhere in 13 that time frame.
14 Q
Did Terry tell you he was going to talk to 15 Marty about this?
16 A
No, he did not.
17 O
Did you know that that is what he was doing, 18 or were you part of the conversation?
19 A
They had the discussion around my desk, so --
20 0
What did he say to him?
21 A
Terry basically told Marty that we had started 22 on the wrong page and that the sequence that we had moved 23 in, that we were concerned with rod line, so we went ahead 24 and inserted the cram ray and things like that.
25 Q
What was Mr. Hannaford's response?
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A Mr. Hannaford said that we needed to get the 2
shift supervisor over, so he could listen to the 3
discussion and at that point, called the shift supervisor 4
over, told him what happened, told him that we had started 5
on the wrong page, told him which pages we had manipulated 6
control rods on.
7 And after we finished telling him about 8
starting on the wrong page, he asked the reactor engineer 9
if the reactor engineer felt that this was a reactivity 10 mismanagement incident.
11 O
He, being Mr. Hitzel?
12 A
Hitzel -- Mr. Hitzel asked Mr. Ballinger if he 13 felt this was a reactivity mismanagement incident.
The 14 reactor engineer seemed reluctant to commit to the fact 15 that it was, in fact, a reactivity mismanagement incident, 16 but eventually responded to Mr. Hitzel that this was, 17 indeed, a reactivity mismanagement incident.
18 Q
What made you think he was reluctant to say 19 that?
20 A
He paused and stuttered and stammered for a 21 little while, and, Well, I -- you know, that kind of 22 thing.
It took him a while, and he finally said, Well, 23 yes; I suppose it is.
So I don't think that the shift 24 supervisor or the reactor engineer wanted to really commit 25 to the fact that we had had a reactivity mismanagement s
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53 1
incident.
2 O
What does that mean?
What does that mean that
~
3 they have to do?
You know what I mean.
Why would they be 4
reluctant to determine that?
5 A
Well, they had to be reluctant for the same 6
reasons I was probably reluctant to come forward, and that 7
is that we had been, again, beat about the head and 8
shoulders about checking where we were in the rod package, 9
you know, based upon the incident in the simulator with 10 the operations supervisor.
11 I think that they were more concerned about 12 what was going to happen; again, some concern about 13 whether or not you are going to have a job when this whole 14 thing plays out had to come up.
j 15 0
Was that actually spoken, or do you think that 16 was just thought?
17 A
I know I was certainly -- I mean, this 18 particular incident resulted in me having to start taking 19 ulcer medication.
I was urinating blood for two days 20 after this incident happened.
It was an extremely 21 stressful event for me.
22 It is still something that troubles me a great 23 deal, because I myself feel very committed to doing a good 24 job.
I felt that I was a reasonably good operator.
I 25 made a careless mistake, exercised poor judgment NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234 4433 WASHINGTON. D C 20005 (202) 2344433
54 1
certainly. Without a doubt, I can say that up front.
2 I was willing to accept the responsibility for 3
what I had done.
Ultimately I lost my job over this.
The l
4 way that I have lost my job is creating some personal 5
hardship right now.
Obviously I am finding it difficult 6
to find work, because I am still unemployed a month after i
7 the event happened.
8 So this is an extremely traumatic event for i
9 me.
At the time that it happened, I felt that I was 10 making the right decisions.
I didn't -- again, I 11 exercised poor judgment in that I should have checked the 12 rod sequence to make sure that I was indeed on the right 13 page.
I -- something as simple as that could have taken l
14 me a couple of seconds and could have avoided the entire 15 event.
16 I should have come forward as soon as we 17 realized that we had started on the wrong page.
I did 18 not, and it still troubles me, because I cannot give a 19 legitimate, good, sound reason for why I didn't come 20 forward.
Everything that I can provide is nothing more a
21 than, Well, I feel like it was this way; maybe I did it 22 because of this; maybe I did it became of that.
I can't 23 come out 100 percent sure and say, This is the reason why 4
24 I didn't come forward.
{
25 Q
Did you make a conscious decision at any time NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 2344433 WASHINGTON. D C 20005 (202) 2344433
55 1
during this event not to come forward?
2 A
No.
There was no conscious decision on my 3
part to hide the incident.
There was no conscious 4
decision on my part to start on page 37 as opposed to page 5
51.
I mean, this was a horrible, horrible mistake on my 6
part.
It was -- I got in a hurry; I didn't focus myself 7
on what I was doing.
I was focusing myself on where I was 8
going as opposed to what I was doing, and that got me into 9
trouble.
10 Was there any attempt on my part or on Terry's 11 part to conspire to hide the event?
Certainly not.
I did 12 a poor job in picking up on Terry's signals.
Obviously 13 Terry felt extremely disturbed by the fact that we had 14 started out on the wrong page.
He was voicing his 15 concerns, although not openly coming out and saying, you 16 know, Hey, we need to stop here, and we need to tell 17 somebody.
18 There was -- again, there was no realization 19 on my part that I had actually committed a horrible error, 20 because of what I was focused on.
21 Q
Did Mr. Hitzel, when he did finally find out 22 about this event, did he say anything to you, any 23 derogatory comments and belittling remarks to you?
24 A
To be quite honest, Mr. Hitzel used tremendous 25 composure in this particular event.
He was extremely NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, D C. 20005 (202) 2344433
56 1
supportive, which was totally out of character for him.
2 He told us to put together statements of what had 3
happened.
He remained cool, calm, collected throughout 4
the entire event; made his phone calls to management.
5 He was very professional during this 6
particular incident, which, again, totally out of 7
character.
I don't want you to misunderstand me.
Mr.
8 Hitzel is a very good operator.
He is a good shift 9
supervisor.
Some of his methods tend to leave a little to 10 be desired.
He runs his crew pretty hard.
He expects an 11 awful lot out of us.
12 He rode roughshod over me quite often, because 13 I am a very assertive, aggressive individual, and I feel 14 that I am intelligent; I feel I am competent.
And he 15 himself, to -- if you put the two of us side by side and i
16 looked at our personalities, we are very similar.
17 He likes to be in authority, likes to be in a 18 command position, and I had a goal of being there.
So is i
19 there some animosity between my shift supervisor and 20 myself?
Why, certainly there is, because we -- you know, I
21 he felt that I had a poor attitude at one point.
l 22 He felt that everything that I had 23 accomplished up to and including some of the things that I 24 had performed prior to this incident, revising procedures, 25 corrective action reviews, a variety of different things NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234-4433 WASHINGTON, D C 20005 (202) 234-4433 4
l 57 1
that I was doing outside my normal job description, he 2
felt responsible for, sometimes took credit for them.
3 So my shift supervisor and I didn't get along 4
well.
I did what I was told to do.
I did what I was 5
supposed to do; tried to perform my job to the best of my 6
ability.
If I would make a mistake, my shift supervisor 7
was very good at coming forward and telling me I had made 8
a mistake, often to the point where he would try to break 9
me with that informatior:, knock me down a couple of 10 notches.
That is the kind of things that he did.
11 Q
Had you ever had any disciplinary action taken i
12 against you in the past at Cooper?
13 A
I had received a written -- not a written -- a 14 verbal warning given by my shift supervisor, based upon my 15 poor attitude, and this was shortly after I had received 16 my license.
And the reason for that was because when I 17 came out of license class, I went to license class with 18 five other individuals; I worked very hard in license 19 class; I learned very well; I graduated at the top of my 20 class, which I was extremely proud of.
i 21 I had come out of the program without having a 22 single remedial against me.
So I was extremely proud of 23 what I had accomplished.
I felt I was competent; I felt I 24 was ready to start standing watch in a control room, and 25 we were in the middle of an outage.
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58 1
And there were a lot of changes that had been 2
taking place because of new management being in place and 1
3 programs that needed to be improved upon, a variety of 4
these different commitments that had been made that Doug f
5 Hitzel felt that I wasn't aware of, and so he prevented me 6
from standing watch in his control room while the rest of the individuals in my class were standing watch on their 7
8 particular crews.
9 To me, that was kind of a slap in the face, 10 because I had accomplished a great deal.
The NRC had 1
11 licensed me to stand watch in the control room.
They felt 12 that I was competent.
The individuals who put me through 1
1 13 the training felt I was competent to stand watch in the 14 control room, and here I was denied what I had worked so 15 hard to get.
16 Q
For how long?
17 A
Approximately two months.
18 Q
And then what happened?
He decided that you 19 were competent now?
20 A
I don't know.
I guess --
4 21 Q
He didn't say anything to you?
4 22 A
-- what -- they went ahead and t hey basically 23 said we were going to go ahead and implement a fifth 24 license on crew is what basically happened, and that is 25 what got me standing watch in the control room, because NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHOOE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON. D C. 20005 (202) 234-4433
59 1
there were only five licenses on our crew.
2 So when they implemented the program and said, 3
We are going to have five licenses in our control room at 4
all times, then I got to stand watch in the control room.
5 Q
When he gave you a verbal warning -- is that 6
what you called it?
7 A
That is what it was.
8 O
Does that go in your personnel file?
9 A
I believe it does.
10 0
Was any other disciplinary action ever taken 11 by anyone for the --
12 A
No, ma'am.
13 0
-- seven years or six years or so that you 14 worked at Cooper?
15 A
No, ma'am.
16 Q
Go back to this incident.
So Mr. Hitzel, you 17 said, reacted professionally and told everyone to write 18 their statements and contacted all the individuals.
Do 19 you know if a condition report was ever written?
20 A
Yes, there was.
21 Q
Do you know who wrote it?
22 A
I believe Terry LaPlant wrote the condition 23 report, but I can't say that for sure.
24 Q
Was there one condition report or more than 25 one, or do you know?
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60' 1
A I don't know.
2 Q
So you continued to stand watch that night 3
until your normal time?
4 A
This was our last night of night shift.
We --
5 12-hour shifts, and we were on our first set of nights, so 6
this was Sunday evening going into Monday morning when 7
this occurred, so it was our last night.
We stayed on 8
watch and continued the watch until we were relieved in 9
the morning, at which point we were held after to discuss 10 this particular incident with the operations supervisor.
11 And then we got started two days off and came 12 back in Wednesday of day shift, and we were not allowed to 13 stand watch --
14 Q
We being who?
15 A
Crew D.
The entire crew was taken off of the 16 watch bell.
17 O
For how long?
18 A
I couldn't tell you how long the crew had been 19 taken off the watch bell, because I was terminated prior 20 to them going back to standing watch.
21 0
So as long as you stayed employed out there, 22 they were not allowed to stand the watch.
Is that 23 correct?
24 A
That is correct.
25 0
And you were terminated and Mr. LaPlant was NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, D C 20005 (202) 2344433
1 61 1
terminated.
Is that correct?
2 A
That is correct.
3 Q
Were you interviewed prior to your 4
termination?
Any discussions with Nebraska Public Power 5
supervisors, employees?
6 A
We went through -- I personally went through 7
one interview on the Wednesday that I returned to work.
8 This particular interview was with the OA manager, a
9 couple of other individuals and there was a secretary in 10 there to record the meeting.
11 I provided honest, up-front information, what 12 I felt was correct for what had transpired.
I was 13 committed to getting, you know, the truth out.
I realized 14 that I had made a significant error.
I fully expected to 15 receive some disciplinary action for it, so I was trying 16 to prepare for that.
17 Again, I was under tremendous stress because 18 of the incident.
It troubled me tremendously.
I went to 19 seek some psychological help; also went to see my personal 20 physician, because physical manifestations of the stress 21 that I was under were kind of unnerving.
So the interview 22 process was extremely painful.
23 I answered their questions honestly, 24 truthfully, what I felt was, you know, what happened.
25 After Wednesday morning, I went home and took two days of NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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62 1
sick leave, because I was suffering extreme stress.
I was 2
under extreme stress, and I was shaking continuously, 3
having several physical problems.
4 And I got called in Saturday morning, in front 5
of Mr. Herron, Mr. Mueller, and Mr. Horn, site manager, 6
plant manager, and the VP-nuclear, to further discuss the 7
event, and then that same day, I received my notice of 8
termination.
9 Q
Did you -- do you have appeal rights, or did 10 you appeal that action?
11 A
The rights that I had were to file for a 12 pretermination hearing.
I opted against doing that, and i
13 then I could go through a grievance proceeding.
What 14 instead I did was I composed a letter.
15 That is a copy of the letter that I submitted 16 to the operations supervisor and the operations manager, 17 basically explaining to them that I felt that going 18 through a hearing, going through a pretermination hearing i
19 and a grievance proceeding wouldn't serve any useful 20 purpose, because I doubted that I would get my job back; I 21 doubted that I would even get placed into a position 22 outside of the operations department, and I didn't want to 23 use any of my personal resources to try to fight this 24 thing.
25 So I submitted that instead.
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Q Is this your explanation of the event?
2 A
Yes, it is.
3 Q
Is this copy for me?
4 A
Certainly.
You can have that copy.
5 Q
Thank you.
I want to reiterate a few points.
1, i
6 You have said that you made an error by starting on the i
7 wrong page, but you knew that you should have checked that j
8 book to be sure you were on the lact page, but you didn't.
9 You failed to do that.
10 A
That is correct.
11 Q
And I believe you said that once -- now that 12 you realized that this event would have been a 13 mispositioning of control rods.
Is that correct?
And 14 that it was your understanding that management 15 expectations would be that someone would -- a supervisor 16 would be notified if there was a mispositioning of control 4
2 17 rods.
Is that correct?
18 A
That is correct.
19 Q
But you failed to do that for some speculative 20 reasons that you have given me that sound like they are i
21 things that you have thought of since the event happened.
22 Is that correct?
You are really not sure.
23 A
I am trying to rationalize it away, I think is 24 what I am trying to do, without a whole lot of success.
I 25 mean, it is kind of like having a ghost haunting you.
I NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234-4433 WASHINGTON O C 20005 (202) 234-4433
l l
64 1
mean, they do it until, you know, they satisfy them, until 2
they go away, whatever.
It is not going away.
It is l
3 still there; it still troubl s me.
You know, I still have 4
nightmares about it, the whole thing.
l i
5 So certainly I am trying to rationalize what 6
happened, try to provide some answers for why I didn't 7
come forward in a timely manner or stop after it happened.
8 I certainly don't have any answers for that.
1 9
Q But you realize that the management 10 expectation was that you would notify a supervisor.
Is 11 that correct?
12 A
Certainly there is a management expectation.
13 Yes.
14 Q
What about procedurally speaking?
15 A
Procedurally speaking -- well, obviously I 16 violated several procedures.
I mean, I violated the 10.13 17 procedure, because I inserted the rods in the emergency 18 rod movement sheet without having proper authorization.
19 Moving rods out of sequence, obviously again I violated 20 the 10.13 procedure, because it specifies sequence for rod 21 movement.
22 Q
Does it not also specify that a supervisor --
23 shift supervisor will be notified if the rod has been l
24 mispositioned?
l l
25 A
I don't know of a procedure that says that.
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No.
2 Q
What does 10.13 say?
I thought that is what 3
it said.
Let me see.
4 It says, " Recovery from mispositioned control 5
rod," and then it says, "The shift supervisor shall notify 6
the operations supervisor, plant manager, reactor 7
engineer, and" -- that kind of thing.
What would that 8
mean to you?
2 9
A I would say I probably violated that, too, j
i 10 although I wasn't aware that that was there.
11 Q
At the time of this event, what were your 12 expectations or what did you think you should do?
You 13 have got mispositioned rods.
Now, I know you didn't 14 notify anyone, but at the time the event occurred, what 15 was your knowledge, or what was your training that you 16 would do in an event like this?
17 A
If I mispositioned control rod?
1 18 Q
Yes.
19 A
Usually notify the shift supervisor, CRS, get 20 reactor engineer up to get some guidance on restoration on 21 the mispositioned control rods.
22 Q
So you were trained to take that action, but 23 failed --
24 A
Certainly I --
~
25 0
-- but failed to take that action.
Is that NE AL R. GROSS COURT RFPORTERS AND TRANSCRIBERS 1323 'AHODE ISLAND AVENUE. N W (202) 2344433 WASHINGTON, D C. 20005 (202) 234 4433
66 1
correct?
2 A
Yes.
3 MS. VAN CLEAVE:
Steve, I don't have any other 4
questions right now.
Did you have some questions you 5
would like to ask Mr. MacDonald?
6 MR. McCRORY:
Yes.
Some of these may be 1
7 slightly repetitious, and I am going to backtrack i
8 somewhat.
9 BY MR. McCRORY:
10 0
The book that has the sequence sheets, pages l
11 in it --
12 A
Yes, sir.
l l
13 0
How is it bound?
i 14 A
It is in a -- it is basically looseleaf.
You f
15 put it in a binder.
l 16 Q
Like this?
17 A
Yes.
Similar to a three-ring binder.
Anybody 4
4 18 can come in and pull pages out, put pages in.
j 19 Q
Okay.
And are there typically any sheets of 20 paper of any sort after the last page of the pull sequence I
i 21 in that book?
a 22 A
The only pages in there at the end of the j
23 sequence is the emergency rod movement sheet.
It is a 1
24 separate sheet all its own that follows the package.
25 Q
So in terms of the last sheet of paper in that NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234-4433 WASHINGTON. O C. 20005 (202) 234-4433
67 1
book, that is the emergency rod movement sheet.
2 A
That is correct.
3 Q
Okay.
You remarked a number of times about 4
the -- or attempted to convey a sense of urgency regarding 5
getting the rods to a particular configuration --
6 A
Yes.
7 Q
-- after the recire pump trip.
Is that 8
correct?
9 A
That is correct.
10 0
And I concluded from that that -- from several 11 of your remarks, that your only responsibility was to get 12 the rods to that position over the next four hours, that 13 you had no other demands on you during that time period.
14 Is that correct?
15 A
Besides monitoring the reactor plant, no.
16 Q
Okay.
You did mention several times adjusting 17 the APRM gains.
18 A
Yes.
19 Q
Is that something you had to stop and do 20 frequently?
21 A
The -- we adjusted the APRM gains initially 22 after the reactor recirc pump, and I obtained the first 23 P-1.
After that, we started inserting control rods, and 24 when we got the rods positioned to the point where we 25 stopped the first time -- we didn't stop inserting control NEAL R. GROSS i
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68 1
rods until they were ready to take the feed pump out of 2
service.
I pulled up another P-1 and checked gains and 3
had to adjust them again.
4 Q
What are the consequences of not adjusting 5
those gains?
6 A
The consequences of not adjusting the gains 7
are that you could have a nonconservative margin to a 8
scram set point, if you had them misadjusted.
If they 9
were adjusted too high, then the power sensed by the 10 APRMs -- let's see; if it is too high --
11 O
Was the activity of inserting the rods by its 12 nature going to create a nonconservative condition in the 13 APRM gain adjustment?
14 A
Yes.
I would say that the potential was 15 there.
That is why you pull up the P-1 when you insert 16 control rods, to make sure that your gains are, in fact, 17 within the tech spec limits for single loop operation, for 18 two-loop operation.
19 Q
How many APRM channels are there?
20 A
There are six.
21 Q
About how long does it take to adjust the gain 22 on each one of them?
couple minutes.
23 A
On each one?
Oh, a 24 Q
Are they adjustable at the 9-5 panel?
25 A
No, they are not.
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69 1
Q The -- you stated that when the reactor engineer arrived or after he had arrived, that you used 2
3 continuous inserts for some rods.
4 A
That is correct.
5 Q
Prior to that time, you had been doing a J
6 single rod, notch insert, selecting rods in a group to 7
move them all down essentially one step at a time, one at 8
a time.
9 A
That is correct.
4 10 Q
And did you -- after the reactor engineer 11 provided you guidance, did you -- could you use continuous 12 insert for all rod movements subsequent to them, or just 13 some of the rod movement?
14 A
The reactor engineer would specify to insert a 4
15 control rod -- let's say that we were starting out at 16 position 48 on a rod.
He would specify to insert the 17 control rod to position 26; the insert limit was 24, so we 18 would continuous insert to a notch before what the insert 19 limit was, stop there, let it settle, so that we wouldn't 20 have it go further in than the insert limit.
21 But that is how we were moving control rods 22 after the reactor engineer showed up.
23 Q
Okay.
So all your -- you are saying then all 24 your rod movement was essentially continuous rod movement 25 after the reactor engineer showed up.
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1 70 1
A That is correct.
2 Q
How often have you responded to a reactor 3
recirc pump in the simulator?
4 A
I had probably seen 40 or 50 of them in the 5
course of my hot license training, requal training.
6 Q
In those -- in the simulator, did you achieve 7
the desired rod pattern for the terminations of the 8
scenario?
9 A
In the simulator, typically what happens is 10 you will respond using the abnormal procedure.
Once you 11 respond using the abnormal procedure, another event will 12 happen, and you won't get to continue in 22.68.1.
13 Q
So at no -- was there any time that you were 14 allowed to complete that procedure in the simulator as a i
15 part of training --
16 A
No.
17 0
-- at all, apart from evaluations?
18 A
The only time that I think I have ever 19 completed 22.68.1 in the simulator was during hot license 20 training.
21 Q
You remarked about the event that occurred in 22 the simulator which was being highlighted to all the crews 23 regarding essentially the same event that actually 3
24 occurred in the plant to which a participant.
Had any 25 prior events at the plant of reactivity mismanagement, rod NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, D C. 20005 (202) 2344433
71 1
mispositioning ever occurred before?
2 A
I am sure there has been other incidents.
3 0
And they were never highlighted in training?
4 A
No, I couldn't tell you -- usually training 5
will go over industry events where they will relate an 6
event that occurred at a different plant.
We will go into 7
the simulator, perform a similar evolution to train on the l
1 8
event.
9 O
But at Cooper there had never been a 10 reactivity problem involving rod movement prior to this.
i l
11 A
Not that I am aware of.
i 1
12 O
That was covered in training.
13 A
No.
Not that I am aware of.
14 Q
Had -- prior to the terminations that followed 15 this event, had there been any other terminations in the 16 site over the last couple of years which caused concern --
17 well, had there been any other terminations of plant 18 operators, licensed or non-operators?
19 A
Not of operators.
20 0
Okay.
So no plant operators had been 21 terminated in recent history to this event.
22 A
That is a true statement.
I think we are the 23 first operators that have been --
24 Q
Had any other operators reported an 25 operational error that you would have judged to have been NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE N W.
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similar?
2 A
No.
I can't think of anything that would be a 3
similar situation to this.
This event is safety 4
significant.
I mean, a reactivity mismanagement incident 5
is, in the eyes of Cooper, significant, because it is a 6
political issue; it is something that draws attention to 7
the plant.
I hate to use those kind of words, but that is 8
what it does.
9 Q
Have you ever had any events similar, like an 10 improper safety system line-up, that were detected at some 11 point after a plant had been operating?
12 A
Valves out of position, that kind of thing?
13 0
Uh-huh.
They were required to be in a certain 14 position prior to coming out of a outage or prior to 15 starting up the plant, and then subsequently found to be 16 in a nonproper position?
17 A
I am sure we have, but I can't --
18 Q
But nobody was terminated for those kind of 19 things?
20 A
No.
21 Q
The -- I believe you said that the emergency 22 rod insertion page was just that, for an emergency, to 23 insert those rods to reduce your rod line for an 24 emergency.
How did you conclude that this was an 25 emergency?
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A We have an administrative limit not to exceed 2
108 percent rod line.
Additionally, part of being 3
licensed operator, you have to know where you are, where 4
your scram set points and stuff like that are, so I knew 5
that since we had APRM upscale alarm lights on the 9-5 6
panel in solid -- I mean, you could see those on either 7
side as you are inserting control rods -- I knew that we 8
had to be fairly close to a scram set point.
9 So when the first two pages of rods that we 10 inserted had little effect on rod line, saw power still 11 coming up due to loss of feed water heating, deemed that 12 it was necessary to use the emergency rod movement sheet.
13 You use that when you have a significant loss in reed 14 water inlet temperature or other incidents where you need 15 to reduce your rod line in a rapid fashion.
16 0
If you had inserted the rods in correct 17 reverse sequence, how differently would reactivity have 18 been affected with just the first two pages of insertion, 19 beginning with page 51 and then moving to whichever was 20 the next lower one in the sequence?
How would it have 21 differed from what you actually experienced by going to 22 page 37 and then to page 51?
23 A
It -- the way it would have differed is that 24 pages 51, going in reverse sequence, the rods on those 25 pages are power rods.
What I mean by that is that those NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234 4 433 WASHINGTON. O C. 20005 (202) 234 4433
1 1
74 I
rods are deep rods.
They are inserted into a core quite a 2
ways.
1 3
Q so they have little remaining reactivity to 4
insert as you go --
5 A
That is right.
The rod worth of the rod -- if 6
we talk about rod worths, if you scram these rods, they 7
don't add that much to the scram, to the shut-down 8
reactivity, because of where they are positioned.
They l
9 aren't out of the core very #=r.
10 Q
All right.
So then if you had, in fact,
)
11 followed the correct insertion, you would have seen the 12 same kind of rod pattern indication after the first two 13 sheets that you saw with what you actually did.
14 A
Probably.
15 Q
Okay.
Would you have concluded that an 16 emergency condition existed at that point as well?
17 A
Yes.
18 0
I recall reading in one of the reports remarks 19 to the effect that events that have occurred, specifically 20 disciplinary actions at other licensees in recent months, 21 may have affected people in this event.
Did you have --
22 did that enter your mind at any time?
23 A
Consciously enter it, probably not.
Was it 24 there?
I am sure it was.
25 MR. McCRORY:
That is all I have right now.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W d202) 2344433 WASHINGTON. D C. 20005 (202) 2344433
i 75 1
BY MS. VAN CLEAVE:
2 Q
Did anyone ever say anything to you that would 3
lead you to believe that if you reported an incident like 4
this to your supervision that you would be terminated or 5
receive other severe disciplinary action?
6 A
The way that I remember it, the way that I 7
recall the discussions on reactivity mismanagement 8
incidents, I remember the words that reactivity 9
mismanagement incidents shall not happen at Cooper 10 station; they will not be tolerated.
I believe those are i
11 the words that were used.
12 Q
By whom?
13 A
I believe that it vas Dave VanDerKamp, the 14 operations supervisor.
It could have been Mr. Herron.
It 15 is -- that particular event that happened in the simulator 16 was right prior to the start-up, and it has been a long 17 time, so I can't recall exactly who it was, but I do 18 recall that it was stressed that reactivity mismanagement 19 incidents at Cooper cannot and will not be tolerated.
20 Certainly that would lead an individual to 21 conclude that if something like that happened, your job 22 would be threatened.
23 O
Did you view thic as a reactivity incident?
24 A
Certainly.
I mean, at the time, no.
But 25 after the discussions and everybody concluded that, yes, NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHOOE ISLAND AVENUE, N W (202) 2344433 WASHINGTON, D C. 20005 (202) 234-4433
76 i
1 indeed, in fact it was, then certainly.
You know, it is, 2
oh, God, this is a reactivity mismanagement incident; you 3
know, I am going to get canned over this.
4 Q
That was after it was reported to Mr. Hitzel 5
and Mr. Hannaford by --
6 A
Yes.
7 Q
-- Terry LaPlant.
Is that correct?
j 8
A Yes.
9 Q
What about during the incident?
Did it cross 10 your mind that --
11 A
During the incident nothing crossed my mind.
12 Again, all i can say is I was focused on inserting control 13 rods; I was focused on getting below 108 percent rod line, 14 moving away from automatic scram set points.
That is all 15 I can give you.
16 I mean, again I would like to give you 17 something conclusive and say why didn't I come forward.
I 18 can't.
19 Q
But you have said at other times you have 20 reported incidents to both Mr. Hannaford and to Mr.
21 Hitzel.
Is that --
22 A
Oh, certainly.
23 0
-- not correct?
24 A
Certainly.
I mispositioned a -- I grabbed the 25 wrong control switch one time on one of the 9-3 panels and NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, D C 20005 (202) 2344433
77 1
stroked open a valve, a motor-operated valve in core spray 2
system.
That was an error.
I immediately piped up and
.l 3
said, Look, I am on the wrong valve; I am going to shut 4
this valve; this is the valve I needed to stroke.
5 And then followed that up with a condition 6
report and went through the whole, you know, share the 7
pain thing, where you go out and you talk about what you i
8 had done and what, you know, the actions are to prevent it i
i 9
from happening again, those kind of things.
10 Certainly I have been in that situation.
If I 11 make an error in the simulator, you know, I am not afraid 12 to speak up and say, Look, you know, I started this up and 13 I meant to start this one up, you know.
What do you want 14 me to do.
I have never hesitated before to come forward 15 and say, Look, I made a mistake.
l j
16 Q
So in the past you have not had an incident 17 that you have made an error -- where you have made an 18 error and failed to report it.
Is that correct?
19 A
That is correct.
20 0
Why is this one different?
l 21 A
I don't know.
Maybe the -- it could be the 22 significance in the incident.
I mean, from an operator's 23 standpoint -- and this is speaking solely as an 24 operator -- it is like, when you come out and you make a 25 mistake this big -- you know, and that is what it is; it NEAL R. GFK}SS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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78 1
is a big mistake, you know -- it is going to be something i
2 that is going to haunt you for the rest of your life.
3 I mean, there is other individuals out at i
4 Cooper who tripped the main turbine during turbine testing 5
because they released a trip test lever and resulted in a 1
l 6
plant trip.
Okay.
You know, they have had plant scrams 7
because there were people that were throwing paper towels 8
at the scram buttons or going up and pushing the button 9
down just so far to -- you know, and making wagers on 10 whether or not they could bring in a half.
11 That is ancient history, okay, but that is i
l 12 some of the stuff that used to go on at Cooper years and 13 years ago.
14 Q
How does that relate to this incident?
i 15 A
How does that relate?
Those incidents in my 16 mind are big incidents, traumatic incidents.
17 Q
Did anything happen to those people who were 18 responsible for those things?
Did they get fired?
19 A
No.
I mean, that was a different, you know --
1 20 I want to call it a different era, you know, because --
21 0
Different management, you mean?
22 A
Yes.
Well, certainly it was a different 23 management.
They weren't as -- you know, you didn't have 24 as big of a staff; everything was more relaxed.
You don't 25 have the high stress level, the micromanagement of things.
NEAL R. GROSS COURT REPORTERS AND TRANSCRIDERS 1323 RHODE ISLAND AVENUE, 'd W (202) 234 4433 WASHINGTON. D C. 20005 (202) 234 4433
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You know, you don't have near the commitments.
Back then, 2
you didn't have near the commitments that you have to live 3
up to as you do today.
You know, the standards have gone, 4
you know, leaps and bounds compared to two years ago.
5 You know, what Cooper's standards were two 6
years ago as compared to what they are right now is a 7
quantum leap, you know.
The job, to be quite honest with 8
you, used to be a lot of fun.
You know, you come in; you i
9 do your job; you take your readings; you do surveillances, 10 converse with your friends about what happened the night 11 before, you know, maybe respond to some minor stuff, get 12 some alarms, and then go home, you know.
13 And now you go in.
You spend 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> there.
14 When you are not taking readings on the plant, you still 15 have to be attentive and watch what is going on.
You have 16 to respond to condition reports, you know.
You get a 17 whole stack of paper that they hand you and say, okay, you 18 need to address these; you need to answer these.
19 I was the procedure writer on my crew, which 20 meant that I was responsible for updating procedures and 21 making sure they were in accordance with the writers' 22 guide and improving procedures, trying to make sure that 23 we had good procedures to use.
24 The responsibilities, you know, where it used 25 to be come in and operator the plant, it is not that way NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 2344433 WASHINGTON, D C 20005 (202) 234 4433
80 1
anymore.
They don't have enough staff to do a lot of 2
other things, so a lot of the important issues get pushed 3
onto the operations department, and as a licensed 4
operator, I wasn't the only one, but, you know, you get 5
stuck with a lot of paper that you have got to try to 6
figure out.
7 You know, condition reports, you have got to i
8 analyze what happened; you have got to address what 9
happened.
You have got to submit reasonable response to 10 management and say, Look, this is what I feel would be a 11 good thing to do to prevent this from happening again.
12 You know, it is a completely different job.
13 So is it more stressful?
Certainly.
Is it 1
i 14 more demanding?
Certainly.
An operator two years ago 15 didn't have half the responsibility that an operator today 16 has.
Even the station operators who don't have licenses i
17 have tremendous amount of responsibility right now.
They 18 are the eyes and ears of the control room.
19 They go out, you know, and if they see a 20 problem out in the plant, they are supposed to report it 21 to the control room; then operations gets involved, you i
22 know.
It could be a matter of cleanliness where 23 maintenance group didn't clean up an area after they 24 completed work, so you get a station operator that will 25 call you up and say, Hey, you know, the mechanics that NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234 4433 WASHINGTON, O C. 20005 (202) 2344433
81 1
were working on the oil system on Charlie condensate 2
booster pump didn't clean up their mess; can you get ahold 3
of a foreman and send him down here to do that?
4 You know, so there is an awful lot of issues 5
that you deal with on a daily basis, you know, and those 6
events, the significance of those events in the past, 7
certainly they are significant from a safety standpoint.
8 Was it considered to be significant from a safety 9
standpoint back then?
Certainly not; not the way it would i
10 be scrutinized today.
i 11 Today you can misposition a single valve in a 12 safety system.
It could be an honest human mistake.
I 13 mean, heaven forbid tnat I should say honest human i
i 14 mistake, because there shouldn't be any of those in 15 nuclear power, but honest human mistake, and this person 16 could get three days off without pay.
Or this person i
17 could lose his job.
18 You know, that weighs pretty heavily on a 19 person.
I mean, there had been electricians that had 20 received three days off without pay, and I can't remember 21 what that incident was over, but that -- in the past, that 22 had been the strictest disciplinary action that the 23 district had taken against an employee at Cooper Nuclear 24 Station was three days off without pay.
25 This happened, and all of a sudden, there is NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 2344433 WASHINGTON. D C 20005 (202) 234 4433
82 1
two people that get terminated over it.
2 O
So you don't -- you can't think of anyone else 3
that was terminated over incidents like this.
4 A
Not prior to this.
I mean, there was a huge 5
management changeover.
6 O
Right.
s
)
7 A
But those individuals were either offered j
8 other positions or asked to resign.
I don't think that 9
they were officially terminated unless they just 10 absolutely, positively refused to leave, and the district 11 saw it in their best interest to say, Hey, look, you know, i
12 you are not living up to our expectations; we are offering 13 you this other position; if you don't want it, then, hey, 1
14 you are out on the street, you know.
15 From an employee's standpoint, I don't know of 16 any other individuals at Cooper Nuclear Station who had 17 been terminated for making an error or for not coming 18 forward.
In my case, I was terminated because management 19 felt I should have come forward sooner.
That was why I 20 got terminated, at least from what they have said, and 21 certainly I can see the need for that.
22 I mean, it is -- you know, they have to do 23 what they feel is in the best interest of the plant, in 24 the best interest of the public, you know, and the 25 company.
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Q But no one else had been terminated in the i
1 2
past for a similar incident or for any incidents, I guess, 3
that you can think of until you and Mr. LaPlant were 4
terminated.
Yet you said that that was still a concern l
5 you had, that played a part in your not conveying this t
6 information to supervision.
7 So I don't -- if you thought there was -- that 8
disciplinary action was going to be a problem or you might 9
be terminated, but yet nobody in the past had been 10 terminated, how -- I guess I don't really understand how 11 that played a part in your not telling --
12 A
In not coming forward?
13 Q
Right.
14 A
It is just a feeling you get, you know.
It is 15 like -- well, let's use another example, and this is 16 hearsay, because all I have heard is rumors.
Two more 17 individuals got terminated from Cooper for an event that 18 happened during the outage.
I heard that another 19 individual got demoted.
Okay.
20 And the incident that they were involved in 21 was a personnel safety issue from, you know, from my 22 standpoint.
Mine was obviously a reactor safety issue l
l 23 whi.ch the district sees as extremely important.
Theirs 24 was a personnel safety issue.
25 Q
Was this Nebraska Public Power employees or i
l NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, O C. 20005 (202) 2344433
4 84 a
1 contractors, or do you know?
2 A
These were Cooper Nuclear Station employees, 3
regular full-time employees that were terminated.
The 4
incident in question was two electricians, three mechanics 5
went down and pulled the wrong motor operator off a motor-6 operated valve to do maintenance on it, and I think it was i
7 a key-way inspection or something like that.
8 And they worked on -- the wrong valve was 9
still energized electrically and 480 volts AC, you know.
10 Somebody could have easily been hurt, killed, you know.
11 In my mind, that is -- I don't want to make this sound 12 less serious than it is, because I know it is extremely 13 serious, you know.
14 But the fact that somebody could have been 15 killed or hurt from that particular incident in my mind is 16 a heck of a lot more severe than the incident that 17 happened the night of January 7, because based upon the j
18 discussions we had had with reactor engineering, we hadn't 19 exceeded thermal limits; we hadn't damaged fuel.
20 You know, certainly the potential was there.
21 I can't deny that.
But we didn't hurt anything; we didn't 22 break anything.
And in my mind, that helps me get by a 23 little.
It doesn't make Cooper's life any easier.
It 24 certainly doesn't make my life any easier, because, you 25 know, it won't take away what happened, but, you know, it NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON. O C 20005 (202) 234 4433
85 l
1 makes it easier for me to deal with the fact that, well, 2
you know, at least I came away and I didn't break 3
anything.
4 You know, this other incident, somebody could 5
have been seriously hurt.
And it certainly seems to me 6
that the way this other incident has been treated at 7
Cooper, that personnel safety is certainly not as 8
important as reactor safety.
You know, from an employee's 9
standpoint, I would certainly hope that the company would 10 have my best interests at heart, you know, that they would i
11 want to provide for my safety, you know.
12 I certainly don't want to go out some day and 13 wind up killing myself because I opened up the wrong valve 14 and stuck my fingers in and nailed some live electrical 15 wire, you know, which is what could have happened with 16 this other incident.
17 So the significance of the incidents, 18 certainly this is significant.
Termination in my mind, 19 that was a -- sometimes I feel like it was meant to send a i
20 message.
21 O
What message?
22 A
Oh, wake up some of the employees.
Say, Hey, 23 you know, these guys made a mistake, and the thing that 24 bothers us most is that when they made the mistake, they 25 tried to cover it up.
Certainly that is what it looked NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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like to management.
2 From my standpoint, I don't feel as though 3
that is what really happened, but, you know, it is hard 4
not to say that it didn't, because management sees what 5
they want to see.
6 O
But you didn't report it and have said that 7
you -- if Terry had not reported it, you probably would 8
not have reported it.
Is that not correct?
9 A
And I emphasize the word "probably," because I 10 really can't say what would have happened.
I mean, would 11 I have reported it?
I don't know.
Would I not have 12 reported it?
I don't know.
Did I see it as being a 13 problem at the time?
At the time, I didn't even realize I 14 had made a mistake.
15 0
Well, you knew you made a mistake by starting 16 on the wrong page.
17 A
Starting on the wrong page, certainly.
But 18 did it impact me at the time?
Certainly not.
I mean, 19 again, I was focused on moving rods.
You have to 20 imagine -- it is hard to describe exactly what this is, 21 but, you know, let's say that you are a task-oriented 22 person.
Okay.
23 I am a task-oriented person; I like to do 24 things.
Okay.
I like to manipulate controls; I like to 25 take readings; I like to do a lot of things.
Okay.
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I get an order, and it is like, Okay, it 2
clicks in my head; boom; I got an order; what am I going 3
to do.
Break out the procedure; follow the procedure and 4
do it.
Okay.
And you focus in on that task.
Okay.
P 5
Everything else around you goes away.
It 6
does.
I mean, stuff filters in.
You hear the other 7
people in the room talking.
You can out of the corner of 8
your eye see other switches being manipulated, but you are 9
focused in on that one task that you have been given.
10 Okay.
And that is where it is.
You know, you are right 11 there focused.
12 Okay.
In my case, it was manipulating two 13 control switches and pushing buttons and making sure that 14 these rods were doing what they were supposed to do.
15 Okay.
16 The other little nuances, the gamesmanship, 17 whatever you want to call it, where you look and you start 18 out on the right page, you know, important, very important 19 from a big picture standpoint, but when you are fceused in 20 on one thing, you know, your mind blocks everything else 21 out, and that is what happened to me.
22 Okay.
I was solely focused on getting rods in 23 below 80 percent rod line.
That is what my focus was, and 24 it is like you have got four hours; rods need to get in; 25 get up there and do it.
Okay.
And that is where it was.
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Everything else around me -- it is like all of 2
a sudden, you are in this little bubble, and that is the 3
way it was.
I was in a little bubble.
I was watching 4
power; I was watching flow; I was looking at power-to-flow 5
map, looking at PEMAs to make sure that we were coming 6
down in rod line.
You are focused on those items.
Okay.
7 I can't tell you what that feels like.
I 8
mean, it is -- I tried to, but, you know, when you are 9
focused in that tight, just trying to do that, it is real 10 easy to forget a management expectation.
It is real easy 11 to forget that you have got to notify and get permission 12 from the SS to use the emergency rod movement sheet, and 13 it is real easy to take it upon yourself to make decisions 14 that may put you down the wrong path, extremely easy.
And j
1 15 that is what happened here.
16 I started out with a big mistake.
I started 17 out on the wrong page.
It could have easily been remedied 18 by checking the pages.
Okay.
But, again, once I started, 19 I was focused on that one item, that one thing, and that 20 is, Get rods in.
21 I was focused on the end goal, and that was, 22 Get below 80 percent rod line, and I was constantly 23 looking back.
Hey, check that power-to-flow map; where 24 are we at, because it gives you a digital display; it 25 shows you where you are at.
A little white tick marks NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W
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come down.
Okay.
We are still at 108 percent rod line.
2 What are we going to do?
What are we going to do?
You 3
keep asking yourselves those questions.
4 And that is all I can say about it, you know.
5 I certainly don't want to take away from the fact that I 6
was responsible for the incident.
I certainly was.
I 7
will openly admit I was solely responsible for what 8
happened that night.
I pushed the right buttons with 9
Terry and made him go down and follow the same path that I 10 was on.
Did he follow me willingly?
I can't say; I am 11 not Terry.
12 Did I suggest to him what I felt we needed to 13 do?
Certainly.
Okay.
Was there any suggestion of not 14 notifying management?
No.
Was there any suggestion of 15 not telling anybody what we had done?
No.
Neither one of 16 us suggested anything like that.
Matter of fact, when 17 Terry came forward, certainly it was easier for me to say 18 something, because he had already made the first move.
19 Q
All right.
Now --
20 A
Now, if Terry hadn't have said something, 21 there is a good chance that I may not have, because, 22 again, I was so focused on what I was doing, I hadn't 23 realized I had made a mistake.
I had realized I had 24 started on the wrong page, but in my mind, it wasn't 25 registering that I had made a mistake.
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Q It didn't register in your mind that you had 2
mispositioned control rods?
a 3
A Certainly not.
Not at the time.
At the time, 4
the only thing that registered in my mind was get those j
5 rods positioned less than 80 percent rod line.
I was 6
shooting for that goal.
I mean, starting out on the wrong 7
page, okay, in my mind --
8 Maybe I justified the fact that it wasn't a 9
mispositioned control rod, because I kept the rods within 10 one notch of each other.
I inserted them one notch at a 11 time.
I went to the insert limit, and then started on the 12 right page.
And we worked our way back to get it back 13 into sequence.
14 Q
But at some point, you realized that this was 15 a misposition in control rods.
I believe you have said i
16 that.
17 A
After we had discussed it with the shift 18 supervisor, yes.
That is when it fully dawned on me that 19 we had, in fact, mispositioned control rods, was when 20 Terry came forward and said something to Marty, and then 21 finally when I said something to Doug Hitzel.
That is 22 when it hit me.
Okay.
It wasn't prior to that.
23 If it had been prior to that, then certainly I 24 probably would have stopped; I would have recognized the 25 fact that I had made a mistake, because I was good at NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHOOE ISLAND AVENUE. N W (202) 234 4433 WASHINGTON. D C 20005 (202) 234 4433
1 91 1
doing that.
I mean, I would come forward when I would l
2 make an error.
I would say, Hey, look, you know, I made a 3
mistake; here is where it is, you know.
What are we going 4
to do to fix it?
5 Q
I am trying to reconcile that with your 6
statement -- several statements that you made that maybe 4
7 you didn't report it because of the atmosphere created by 8
Mr. Hitzel and --
9 A
Certainly, i
l 10 Q
So I am trying to reconcile that.
Either you 11 knew or you didn't know.
If you didn't know, then it 12 would come into play that, well, Mr. Hitzel is -- he makes 13 derogatory comments, and so therefore maybe I won't report 14 it.
But if you didn't know --
15 A
Well, it is --
16 0
-- why would that come into play?
j 17 A
That is the problem.
See, did I realize it, 18 first of all, is a big question for me.
Okay.
If I had 19 realized it -- these are things that I have been mulling 20 over since the incident happened, you know.
21 A,
did I realize that I had committed an 22 error?
Okay.
I asked myself that question first because i
23 if I had realized I had committed an error, I probably 24 would have said something about it, because that is what I 25 do.
Okay?
That is first, first and foremost.
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The "why" question, why didn't I come forward 2
sooner and why didn't I say something when it happened, 3
that is the one that keeps nagging at me the most, because 4
I was a good operator.
In my mind, I was a good operator.
5 I was conscientious.
I tried to do the right thing.
I 6
was a good operator.
Part of being a good operator is 7
coming forward when you make a mistake and admit it and 8
' fess up, so that you don't break something worse.
Okay?
9 Why didn't I say something?
I ask myself that 10 question four or five times a day.
I still can't come up 11 with a reasonable answer.
I can't.
I don't know why.
12 What could I have done to change things?
13 Well, certainly I could have prevented the entire event 14 from happening simply by flipping a couple of pages in a 15 book, and that is what bothers me even more, because this 16 whole thing didn't have to happen at all.
Flip a couple 17 pages in a book, and the whole thing wouldn't -- we 18 wouldn't be sitting here talking right now if I had done 19 that.
20 I look at c:'is every day.
I rehash it every 21 day.
I live with it at night.
I can't get it out of my 22 head.
I mean, you know, the whys, the what-ifs, the what-23 could-I-have-done-betters.
24 Why did I get terminated?
I mean, why 25 couldn't they have given me two weeks off without pay, NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W.
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taken away my license, and put me into another position 2
where they needed some license talent, where I would still 3
have a job?
4 You know, I tried to be honest, you know, and 5
up-front.
Certainly there was a lot of contributing 6
factors.
Could the adversarial relationship with my shift 7
supervisor have played a factor in this?
I am sure it 8
did.
I am sure it did.
9 Did I realize whether or not I made a mistake 10 or not?
I would hope to God that I would have realized it 11 right away.
Obviously I didn't.
I don't know.
Maybe I 12 am justifying to myself; maybe this isn't helping you 13 much, but maybe I am justifying it away in my own head, 14 that, hey, you know, you didn't make a mistake, so you are 15 okay.
I don't know.
16 Q
You mean, at the time.
17 A
Yes.
At the time.
When that incident 18 happened, honest to God, I mean, sitting here, I didn't 19 think I had made an error.
I even believed that the 20 write-up that I made, which again was after it had 21 happened and after I had realized that, yes, indeed, I had 22 made an error, you know, after the fact -- even my 23 statement doesn't allude to the fact that I had really 24 made an error.
25 This was the initial statement that I made on NEAL R. GROSS COURT REPORTERS AND TRANSCR!BERS 1323 RHODE ISLAND AVENUE, N W.
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94 e
1 paper that I gave to Dave VanDerKamp.
2 O
Well, if you didn't make an error, why are you 3
making a statement?
4 A
Because, you know, after we had told the shift 5
supervisor, the shift supervisor told us to write down 6
what had happened, basically a statement of what had 7
happened, and that is what we did.
I wrote down and 8
detailed what we had done, but there wasn't anything in 9
there describing, you know, Well, you know, we took it 10 upon ourselves to do this action, and we made a conscious 11 decision to do this action.
There was nothing in there i
12 like that.
13 It was just a detailed account of, you know, 14 We start on page 37; we moved those rods a notch at a 15 time, maintaining within one group to 30, from 36 to 30, 16 moved to page 51, you know, after we realized on page 36 17 that we had started on the wrong page, you know.
18 It was just a detailed account of what 19 happened.
It didn't specify anything in there about, you 20 know, why I didn't come forward.
I hadn't thought to come 21 forward at the time.
It was the farthest thought from my 22 mind; you know, again, focused right there in that little 23 bubble, shoving control rods in, own little world.
24 O
One more time:
If that was the furthest thing
~
25 from you mind, you didn't think you had made an error, and NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHOOE ISLAND AVENUE, N W.
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you didn't think about coming forward, why does your 2
admittedly adversarial relationship with Mr. Hitzel come 3
into play?
4 A
It comes in to play later on when we 5
finally -- you know, when Marty Hannaford gets told by 6
Terry LaPlant.
Okay.
Terry LaPlant was going to tell 7
Doug Hitzel at first.
Okay.
But as soon as Terry started 8
trying to tell Doug, Terry lost his nerve, and that is 9
when I came forward.
That is --
10 0
What do you mean?
He had already told Mr.
11 Hannaford.
Right?
12 A
Right.
Terry was the one that was relating 13 what had happened.
l 14 O
Right.
15 A
Okay.
I was at my desk.
They were having
)
4 16 this discussion around my desk.
At the time that we were 17 relating the incident to the shift supervisor and control 18 room supervisor, I was taking a look at my P-1 edit; I was 19 looking whether or not I had to adjust APRM gains, all 20 these different things, monitoring power-to-flow still, 21 doing this.
22 Terry told Marty.
I listened to the 23 conversation, and it was like, Well, is this what 24 happened.
Yes, that is what happened.
Marty got hold of 25 Doug and brought him over.
Doug, you really need to hear NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE, N W (202) 234 4433 WASHINGTON, D C 20005 (202) 2344433
96 1
what just happened, and Terry started out talking to Doug, i
2 and all of a sudden it was like, you know, Doug we -- and 1
3 he tapered off; he couldn't talk anymore.
4 So it was like, Okay.
Doug, this is what we 5
did, you know.
Doug asked Paul, you know, whether this 6
was a reactivity mismanagement incident.
Paul doesn't 7
want to say anything about it.
That is the way it was in j
8 the control room that night.
I mean, there was a lot of, 9
you know, trying to figure out how Doug would react.
10 You know, obviously Terry couldn't go on, 11 because he figured that Doug would just have a massive
)
I 12 heart attack right there or something and explode.
I 13 don't know.
14 Q
Well, he knew that he was going to find out, a
f 15 because he told Marty.
16 A
Yes.
17 O
So, I mean --
18 A
Well, certainly.
19 Q
He had to be aware that --
20 A
Yes.
But, see, that is the thing.
It is real 21 easy to talk to Marty, and when Terry went to Marty, that 22 was an easy thing for him to be able to do, because Marty 23 will listen, you know, and he doesn't blow up at you.
24 Okay?
25 You get Doug over, get him involved, and now NEAL R. GROSS COURT REPORTERS AND TRANSCRIDERS 1323 RHODE ISLAND AVENUE. N W (202) 234 4433 WASHINGTON, D C. 20005 (202) 234-4433
4 97 1
you have got to deal with the way Doug reacts to events, 2
okay, whether it is an event like -- what is one that has 3
happened in the past?
4 Make a tech spec call, go around back on the 5
back panel.
Just see a pen for ERP flow that is not 6
responding the right way.
You come back out front and you 7
get CRS and show it to him, and it is like now Doug has to 8
make a tech spec call and call something inop.
i 9
And, you know, okay.
We have entered a 70 10 LCO, stuff like that.
He hates that.
He will say, Why 11 did you go back there and break that.
He may be joking 12 around, but it doesn't come across that way sometimes, you 13 know.
It could be that you break the pen, and it is like, 14 Hey, Doug, I broke the pen on this recorder, you know.
15 Well, then, you know, that is a tech spec related pen, you 16 know; it shows indication for ERP flow, whatever.
Okay.
l 17 It is difficult sometimes to deal with the 18 shift supervisor on that crew, because he is abrasive, 19 because he is demanding, because the way he reacts to 20 different things sometimes isn't in the most professional i
21 manner.
22 So certainly when Terry tried to relay it, you 23 know, I am sure that he was thinking about how Doug was 24 going to react.
When I relayed it, I certainly figured 25 that he would blow up at me and just, you know, rip me up NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE. N W (202) 234 4433 WASHINGTON. O C. 20005 (202) 2344433
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one side and down another.
Well, that is not what 2
happened, but that is the response that I am used to 3
receiving, so it is certainly a lot easier for me to tell 4
Doug than it was for Terry to tell Doug.
5 MS. VAN CLEAVE:
Steve, any other questions?
6 MR. McCRORY:
No.
7 BY MS. VAN CLEAVE:
8 Q
I have just a couple of questions we always 9
ask.
They are just standard old questions.
10 A
Okay.
11 Q
Mr. MacDonald, have I or Mr. McCrory here 12 threatened you in any manner or offered you any rewards in 13 return for this statement?
14 A
No, you haven't.
15 Q
Have you given this statement freely and 16 voluntarily?
i 17 A
Yes, I have.
18 Q
Is there anything further you would care to 19 add for the record?
20 A
The only thing that I would really like to add 21 is that there is a lot of good people that work at Cooper 22 Nuclear Station.
I don't feel any real animosity towards 23 the people at Cooper Nuclear Station or the management 24 staff of Cooper Nuclear Station.
25 I would hope that during your investigation --
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I am not asking you to go easy.
Certainly not.
I 2
wouldn't expect you to do that.
But the people that work 3
out at Cooper are dedicated individuals who are good 4
people.
Cooper provides a lot to this community, and if 5
Cooper -- I hate to say if Cooper dies or shuts down, 6
which could feasibly happen as a result of some of these 7
incidents, if they are deemed to be unsafe or whatever, 8
this community is going to die.
It really is, because 9
Cooper provides just that much to this community.
10 So hopefully as you are going through your 11 investigation, you know, people will be as honest and up-12 front with you, but I hope you don't hammer Cooper too 13 hard, because, you know, the people that work there, you 14 know, they need to be able to support their families, and 15 certainly I am in a position to know that.
16 Q
Well, Mr. MacDonald, I appreciate your coming 17 out here and talking to us, and thank you very much.
18 MS. VAN CLEAVE:
We will go off the record 19 now.
It is approximately 5:15 p.m.
20 (Whereupon, at 5:15 p.m.,
the interview in the 21 above-entitled matter was concluded.)
22 23 24 25 NEAL R. GROSS COURT REPORTERS AND TRANSCRIBERS 1323 RHODE ISLAND AVENUE N W (202) 234 4433 WASHINGTON, O C. 20005 (202) 234 4433
'W REPORTER' S CERTIFICATE This is to certify that the attached proceedings before the United States Nuclear Regulatory Commission in the matter of:
Name of Proceeding:
PATRICK F.
MacDONALD Docket Number (s)
Place of Proceeding: Auburn, Nebraska were held as herein appears, and that this is the original transcript thereof for the file of the United States Nuclear Regulatory Commission taken by me and thereafter reduced to typewriting by me or under the direction of the court reporting company, and that the transcript is a true and accurate record of the foregoing proceedings.
A U
Phyliss Lund official Reporter Neal R.
Gross and Co.,
Inc.
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