ML20151N081
| ML20151N081 | |
| Person / Time | |
|---|---|
| Site: | Oyster Creek |
| Issue date: | 03/31/1987 |
| From: | STIER, E.H. |
| To: | |
| Shared Package | |
| ML20151N032 | List: |
| References | |
| NUDOCS 8804250193 | |
| Download: ML20151N081 (130) | |
Text
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l O b a O m A OYSTER CREEK J SEPTEMBER 11, 1987
'~ VIOLATION
~
SAFETY LIMIT is
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d
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PREPARED FOR
'- GPU NUCLEAR CORPORATION O
U i i by V ,
!J - STIER, ANDERSON & MK1GONE G :
t' i .( d la MARCH 31, 1988 ,a l p:' ri H 1
*e 1m f.a M VOLUME II l
1J 4 INDIVIDUAL REPORTS l:-- 1
'l
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. . _ _ _ _ _ . - = _ _ _ _
. _ . . _ . _ _ . _ _ _ _ _ . . _ _ _ ~ . _ . . _ _ _ , _ - - . _ . . _ _ _ _ _ _
1 ll L m
) TABLE OF CONTENTS 7-VOLUME I REPORT
.i I. INTRODUCTION
~1 '
j A. Origin and Purpose of Investigation 1 M B. Organization of Staff 2 J' d C. Investigative Process 3 D. Organization of this Report 6 NOTES 10 II.
SUMMARY
OF EVENTS OF SEPTEMBER 11, 1987 II A. Organization of Operations Management 12 i and "B" Crew at Oyster Creek ~"] B. Sequence of Events 16
- J MOTES 27 f5
'A
.III. ISSJER 32 i
.d IV. OQ.1[QLUJIONS A. Scope of Findings 33 f,j 9
< B. Summary of Findings 34 r4 1l-'"
- General Findings 34
. Findings Concerning Individual Responsibility 42
( NOTES 51 p l r' V. BACKGROUND A. History of Safety Limit 52 .l? B. History of the Less-Than-Two-Loops Alarm 54 lL' l C. Sequence of Alarms Recorder (SAR) 59 NOTES 64
- l. .)
.i
v
?
*T 249.E h.
c VI. DISCUSSION OF ISSUES - D A. The crew and Management Accounts of the Cause 70 E and Nature of the Safety Limit' Violation r B. Reporting of Safety Limit Violation Within 86 [ii GPUN Chain of Command
~; l C. Reporting Safety Limit Violation to NRC 106 Jf.; l u.
D. Destruction / Concealment of SAR Tape 113 4l
- s E. Reporting of Missing SAR Tape Within GPUN 133 1 Chain of Command F. Reporting of Missing SAR Tape to NRC 158 g{
NOTES 165 W W, Table 1 List of Exhibits 196 D Table 2 List of Witnesses 201 2 r VOLUME II . INDIVIDUAL REPORTS , INTRODUCTION 1 k *. (HH] 5 j,, NOTES 26 64 e Nt (A) 32 . NOTES 50, , (VV) 55 ) NOES 67 -- [ *.I ] 70 NOTES 82 -- l e
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(ZZ) 86, a NOTES 91- l l 3 .; ; (I) 93 NOTES 98 b (R) 100 i NOTES 107
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'(N] 110 NOTES 115 f}
id (SS) 117 r,! T- NOTES . 122 u 7;. r:) u r,7 i' f IJ VOLUME III - J
?j TAYLOR REPOR"i t;
3
.: VOLUME IV
.I
. EXHIBITS
+1 f
- J C{
w
- VOLUME V SI WITNESS STATEMENTS
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m 2 { tj ACTIONS OF MEMBERS OF "B" CREW AND KEY MANAGEMENT PERSONNEL g INDIVIDUAL ASSESSMENTS -- INTRODUCTION J
, In this section of the report we have provided informa-
.1 tion to assist the company in evaluating the conduct of cer-
, tain employees who had involvement in, or responsibility for, the safety limit violation, the destruction, conceal-
-, s ment, or disposal of SAR tape, or the reporting and investi-gation of these events. The selection of individuals to be d included in this section of the report was made at our dis-g cretion, based upon the criteria discussed below.
I]
, Our assessments of individual behavior are contained in .$ Volume II, comprising nine subsections. Each discusses an
{ individual presently employed in the GPU system. These Le subsections are arranged in order of rank and seniority for h b members of "B" crew, and in reverse order of rank for the three managers above the crew level. They include notes S,i d citing the suppaltting evidence contained in volumes III ' l/) through V. They are organized according to the issues 'J discussed in Volume It
~
, i.e., the safety limit violation j itself, the reporting of the violation, tha tearing and
,' disposal of the SAR tape, and the reporting of that event.
d There is also a summary of the principal conclusions per-r taining to each individual. b r, V lume II is not intended as a self-contained discus-h sion of the safety limit violation and its aftermath. It h J M._... - _ _ _ _ . . _ _ _ _ _ _ _ _ _ _ _ _ . _ . _ _ _ _ _ . . - . _ . . _ . . . , . _ . . . _ _ _ , - _ _ . . ~ . _ . - _ .
. d b (i has been written on the assumption that the reader will E E first become familiar with the contents of Volume I. In . f7 discussing key events and behavior, Volume I omits many of g, the unique circumstances and motivations of the individuals discussed in Volume II. To ensure that the more generalized 2 conclusions set forth in Volume I did not create misunder- , standing or uncertainty concerning the roles played by vari-
-y ous key crew members and managers, we found it necessary to }
address separately issues of individual conduct and respon- , sibility.
!b,3 2
T Because certain individual actions needed to be 2 addressed in our general discussion of the issues in Volume - I, the two volumes overlap to some extent. For example, the actions and testimony of,[HH] and [VV) were discussed in considerable detail in Volume I and it was unnecessa ry to l repeat all of that discussion in Volune II. Conversaly, to [j avoid undue disruption of the narrative in Volume I, we - frequently referred to details contained in Volume II. As a b result, come individual sections are more detailed than ? w others. . q 1 We selected two groups of employees to be included in '
,~
c: Volume II. First, anyone who was a member of "B" crew on 4 w September 11, 1987 was included, excluding the EOs. This, of course, includes the CRos, the GOS and the GSS, plus the _ CRO trainee. a The second group consisted of those Oyster Creek O E
- - - - . _ . - . , , - . - - - - - - . - , . . . . , . . - . n--, , - - - . - - - ,- , . - . r e
a . p personnel in key management positions who were responsible
- l) for investigating and reporting the events. Only the three ,
key line managers were included in this group. Assistants _ and technical personnel who reported to line managers have not been included. Each section of Volume II contains our conclusions on q ', factual issues. In each case, we have attempted to evaluate l the extent to which the individual contributed to the com-7 mission of the safety limit violation, to its reporting (or d to delay in reporting), to the destru:, tion or concealment of A j SAR tape, and to the reporting (or delay in reporting) that g the tape was missing. We have not, however, attempted to d reach broader conclusions about the job performance or fit-il ness for duty of those whose conduct was addressed during Li the investigation. - Il p-As in volume I, we based our opinions concerning the [lU credibility of testimony on evidence in the record and reasonable inferences that could be drawn from that evi-M U, , dence, and on the inherent plausibility of the testimony
, under all the circumstances. We did not rest any conclu-zi JJ sions on the observed demeanor of a witness. All of the f
' \ ,l individuals discussed in Volume II cooperated fully in making themselves available for interviews and sworn n g statements. Each discussion in Volume II, with its supporting evi-dence, focuses on the behavior of the individual rather than
-3 -
4
r b on the group as a whole. Therefore, to some extent, there [ h may be differences between our descriptions of individual conduct and the discussion of the general patterns of behav-ior contained in Volume I. This should not be considered an , w internal conflict in our findings, but rather a recognition E that each employee should be judged individually. INDIVIDUALS INCLUDED IN VOLUME IT - Members of "B" Crew Q i'.3 (HH] (A) (vv] a (II] l (zz) .J ~ [I] "; J GPUN Ocerations Manaaers
, e (R) [
e (ss) . 9
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k,_ n IHH1 U On September 11, 1987, (HH] was the GSS in charge of
- LJ "B" crew, a position he had held since 1984. Prior to that he had been GOS of "E" crew for three years and a CRO for
~
six years. (HH) received his CRO license in 1975, and his 9
}: .j SRO license in 1983.1 l' 1. Safety limit violation J
7 (HH), in his capacity as GSS, made the decision to d isolate the RBCCW system from the drywell in an effort to I stop the leak that had occurred on the twenty-three foot level. He then ordered the recirculation pumps secured, a
#i '11 . step required by GPUN procedures to prevent the pumps from overheating in the absence of RBCCW. The safety limit hi ' violation occurred while one of the CRos, (VV), was in the
_J l process of carrying out this order.2 [' According to (HH), after giving the order to secure the
'b '
pumps he turned his attention back to diagrams of the RBCCW .g, .jj system that he and other members of the crew had been examining.3 He did not supervise the CRO's actions in ,Jl t securing the pumps. Nor did he specifically instruct the 0 CRO how to carry out this procedure.4
!]
.)
(HH] did not see what (VV) did in response to the order to secure the pumps until his attention was drawn to the f) control panel by an audible alarm. He saw the green light, L signifying the safety limit alarm, and also noticed (VV)'s
*g.
- i. :
12 - ._-. - _ - _ - - . -
c 7 h. n hands on control switches in the middle of the panel.5 (HH] I then told (VV] to get another valve open.6 He explained as follows what he had intended by his order to secure the ; pumps: When I told him to take off the pumps, what I b meant was just take the control switches for the pumps and turn them off. If they didn't 7 do that, they could have opened two other '6 discharge valves. They could have opened the A or they could have opened the D, just so that.. . we do have two loops available.7
-]
As discussed elsewhere in this report,8 the safety limit alarm resulted from a momentary lapse of concentration u by a highly competent and experienced operator s Instead of
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following the procedure (HH] had in mind when he gave his m order, (VV) began what he termed a "normal shutdown"
]
procedure, which was inappropriate for the plant conditions . that existed at the time. The procedures for securing pumps - under various plant conditions were well known to the opera- a l tors, and were frequently performed by them without super-d vision. The written description of the job responsibilities ! of the GSS provides:9
.l .
He has the primary management responsibility, !3 until properly relieved, to ensure that all : operations are performed within the limits of the operating license, technical specifica- q?j tions, station operating and emergency " procedures. .., q Neither this description nor other operating procedures O provide specific direction concerning whether the GSS's responsibilities include providing personal supervision of removing recirculation pumps from service. However, evi-4 dance of connonly understood operating practices indicated , 1 a
T L
- q that such supervision was not routine.10 Through training I",
sessions, written procedures, the placement of plastic . covers over the discharge valve controls, and warnings next to the controls, operators were reminded to keep two recir-culation loops open.11 We concluded that under these circumstances (HH) did _ not violate either written procedures or sound operating j practices by ordering the pumps secured without any further supervision or instructions. (HH] was properly engaged in
~
overseeing operations designed to stop the leak. Securing pumps is an operation that (HH), in his discretion, could
]
properly entrust to a CRO.12 In the context of all the
.r U' training, experience, and various types of warnings opera-tors receive, (HH)'s order carried with it the implicit instruction to secure the pumps in a manner appropriate to I
ple.nt conditions -- in this case to avoid closing a tourth discharge valve. CRO (VV), who was fully aware of the two-fi la loop safety limit and the proper way to secure pumps without g, violating it,13 made an uncharacteristic error that (HH) 'l l
,. could not reasonably have foreseen or prevented.
)
J- , In summary, (HH)'s account of the sequence of events leading up to the safety limit alarm did not conflict with the other evidence and his actions, as described by himself
\
l] and others, were consistent with his duties as GSS. , i 1 ,1 l! , l~
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- 2. Eggprtina of safety limit violation [
(HH] became aware of the safety limit violation when it E 12 occurred at approximately 2:17 a.m., having heard and j witnessed the less-than-two-loops alarm.14 As discussed in Section VI(B) of this report, (HH), as GSS, had a duty to _ report the event "promptly" to higher management. He also Id,) had a duty to analyze and comply with the appropriate NRC [ reporting requirements. Station Procedure 126, Section 6.2, m pp. 9.0-10.0 (Exhibit 25), provides: d{ v The GSS, in addition to taking action in accordance with other procedures to correct C the event and/or mitigate its consequences 'a shall erometly evaluate the event against the six Categories defined in Section 3.0, start- -- ing with category I and proceeding through . the other Categories in numerical sequence, until the correct Category for the event, if any apply, has been determined. The GSS '3
,d shall consult with the_ Plant Ooerations
, Director. Manaaer Plant Ocerations. Shift Technical Advisor, or others, as he considers A necessarv in determinina the correct d Catecorv. .
.~;
(Emphasis added). { (HH] reported the violation to (R), the Manager-Plant Operations, at approximately 3:45 a.m., and reported it to , the NRC at approximately 4:05 a.m.15 Thus, for ,k approximately one hour and twenty-eight minutes the Opers-h) l i tions chain of command above the crew level was unaware that a safety limit violation had occurred. During that time, no determination had been made as to whether the event required I 1 a "one hour" report to the NRC or fell within some other j reporting category. -
-R -
1
.1
3 1 , p _. (HH] partially explained the delay in notifying (R) by Ll describing his preoccupation with other matters, particu- , larly his efforts to obtain proper medical attention for a
, ' maintenance worker, (C), whose face and eyes had been a splashed with water that was slightly radioactive and 7' contained potentially injurious chemicals.16 (HH] also was <l, supervising operations related to the spill on the twenty-three foot level, including those required to restore plant conditions to what they had been prior to the RBCCW valve
]U leak.17 He described his delay in reporting as a matter of priorities:18 f,# ( Q. What were you thinking at the time
,, concerning the safety violation?
lO A. I knew I was going to have te report it. I just did not think that much a about it. I had my priorities. LJ Q. What were your priorities at that point?
~*
A. On the things that.had to be taken care of at that time. D Q. Which was the leak? L1 A. Which was the leak. I had to take care (4 of the guy that had this stuff in his U eyes -- I didn't want him to go blind --
, and all the water that's laying on the m floor. (A) says, you know, we're
.j getting a couple inches down here now.
"l And we had to take care of that. You
,., know, this other thing, that wasn't
; going to go anywhere.
As discussed in detail elsewhere, the evidence supports c:. L (HH]'s contention that he devoted time and attention to the
,3 problem of the possibly injured worker and to supervising p.
U operations related to the leak. He left the c.:ntrol room 1 1
-9_
r b for two minutes (3:04-3:06 a.m.) to obtairi information about r. .; the chemicals in the water that had splashed on (C), and ' exited again for five minutes (3:36-3:41 a.m.) to confer with a safety representative about the chemicals and their effects.19 Other witnesses confirmed having spoken to (HH] [e about (c]'s condition during this period.20 Although (c]'s y, injuries proved to be minor, there was reason for concern U based upon the information available to (HH] at the time.21 , Moreover, GPUN procedures support (HH]'s testimony that he considered (c]'s medical condition to be a priority. Station Procedure 126, which made (HH) responsible for reporting the safety limit violation, also contained q provisions for one hour or four hour reports to the NBC in J cercain cases of radioactive contamination to indi- 7 i viduals,22 Although (c)'s condition did not, in the end, fit into these reporting categories, for a time at least the information availr.ble to (HH] warranted monitoring the , situation. -] 7, (HH]'s preoccupation with (C]'s medical condition did { not, however, explain why he failed to report the safety E, U limit violation to (R) until approximately 3:45 a.m. That .J problem, although a matter of genuine concern, did not i require the continuous personal attention of the GSS 23 and did not warrant ignoring the GSS's duty to determine the proper reporting category of the safety limit violation ,
"promptly" and to make notifications according to that cate- .'
'l
7 "Y ~. Jn gory. Moreover, despite the injury problem and other d demands on his attention, (HH) found time to call (R) . between approximately 3:25 and 3:30 a.m., but did not men-tion the safety limit violation to him. Only after (R) j called back approximately fifteen minutes later -- and after c, GOS (A) had urged him to report the matter -- did (HH) make (R) aware that the violation had occurred.
]'
u (HH] could not clearly explain why he did not report the violation to (R) during their first telephone conver-l}l ti sation. He alluded to possihie psychological problems ho
/ was experiencing at'the time, arising from or combined with , the other pressures he was experiencing:24 J I don't know why I didn't tell him. I've thought about that a lot. And I've even I '. gotten . . . outside medical attention, so '
[, that I can come up with some of these things that happened that night. Ki ij .- I just didn't think to tell him about (the [2 safety limit violation). You know, it's like LJ you're pre-planning what you want to say. And you know, I was so concerned about these
' other things, that I didn't have a concern or j I wasn't thinking about the violation when I
- called him.
! (HH] testified that he knew the safety limit violation u;
was a reportable event, that he intended to report it, and
, J that he did not delay reporting it to (R) with the intent to ;
I conceal the violation.25 u !
, Essentially, (HH] offered a psychological explanation )
1 L for his behavior. He testified that shortly after the i !i a -- - . , . . - - - . - - _ - . _ - , - . , . -- -
N E safety limit alarm he began experiencing physical symptoms, ] such as chest pains, dizziness, and shortness of breath, , m which he feared might indicate a heart attack, but which a { psychologist he later consulted attributed to stress.26 YJ The delay in reporting the safety limit violation to (R) was presumably one result of this "stress attack," as G (HH) characterized it:27 another was his inability to recall y certain key events. For example, CRO (ZZ) testified that shortly after 3:00 a.m. he informed (HH) that SAR tape was , missing, including the portion relating to the safety limit n violation.28 (HM) did not dispute (ZZ)' testimony, but said $ he had no recollection of having been aware that the SAR -- tape was missing until after 4:30 a.m. when, having completed his notifications concerning the safety limit I violation, he walked back to the SAR and noticed that a section of tape was missing.29
+9 To the extent that (HH) was experiencing psychological
}]
turmoil following the safety limit alarm it was not immedi-ately obvious to his crew or others who observed him during b the remainder of the shift. Most described him as outwardly
] '
calm, and he interacted with members of the crew and others . on matters relating to the leak and plant operations with ; little or no sign of distress.30
. .J Despite this calm appearance, there was evidence to corroborate (HH)'s testimony that he was experiencing a high degree of psychological stress in the aftermath of the .
12 -
- - . - - -..- - ,..- - - n.,--,~.,~~--------.,. --,,,,n. ,,n.- -,,. ,,,,.,., -,,----.-..,..,---.,,_-----.-,,,-c--n -
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IE , b l l q safety limit violation. CRO (ZZ), who informed (HH] about the missing SAR tape, testified that (HH] made no response
. l fT except to look up from his desk with a "dumbfounded" LJ '
expression on his face.31 (HH]'s immediate supervisor, (R),
] testified that he had noticed in (HH] a general tendency to get "excitable".if things did not go normally in the l
.[Ur,j a plant.32 GoS (A) stated that he had always had trouble fl '- ' communicating with (HH),33 and there was additional u testimony indicating that (HH] tended to bottle up his a
,j feelings and had difficulty expressing himself.34 Moreover, g there was testimony about the longstanding perception held 1:1 Q by (HH) and the other GSSs that the stress level of their "1 job was increasing, in part because they felt management was
}
unreasonably holding them responsible for others' ; s. mistakes.35 I an incident that occurred early in the afternoon of September 11 demonstrates that at least by that time, if not jj li earlier, (HH]'s psychological state had deteriorated.
; -,, Following the critique of the safety limit violation, (HH)
.)i returned to the control room and conversed with his fellow
} ~'
GSS, [YYY). When (R) learned he was there he told (HH) to leave the control room and come to (R)'s office, where he U: was to be searched by a member of the site security force. l
., When the security officer asked (HH) to empty his pockets, (HH] reacted with an outburst of emotion. Although no strip
- search had been intended, (HH) took off his pants and shirt and angrily invited such a search, an invitation that was e
13 -
,i 's
declined by the security officer.36 g b Less than a week later, on September 17, (HH] experi- - c (: ' enced such severe emotional distress that plant managemant L dispatched a nurse to his home. In a statement he wrote [ that night, (HE] spoke of being "terrified and scared" and in a "state of shock" after the safety limit alarm came in ' on September 11.27 - Y d After September 17, (HH] began a series of consulta-P tions with a psychologist, Dr. Glenn Candeletti. Dr. $ Candeletti testified that, in his opinion, (HH] was under so much pressure on September 11 that his ability to.commun-icate everything he should have to (R] was impaired.38 ] v (MH]'s ability to concentrata and recall events was "coming and going," according to Dr. Candeletti, who folt thtt (HH]
'l ij was not deliberately concealing information or trying to y,,
hide anything.39 This latter opinion was based upon (HH]'s physical symptoms, his confusion in relating information, j, d' and Dr. Candeletti's assessment of (HH]'s besic charac- - ter.40 Dr. Candeletti's opinion regarding (HH]'s basic {, character was supported by the report of another psycholo- q gist who analyzed tests taken by (HH] prior to the September .3 11 incident.41 3' A It is difficult to conclude from (HH]'s obvious ;
~
psychological symptoms after the end of his shift on September 11 that he was under similar stress during his i \ a, l shift on that date. Nevertheless, other circumstances l j, ' l e -- - - - - - - _ . - - - . - . - _ - - . - - . . . . . - .
1
.] suppo W the conclusion that (HH)'s psychological state,
~- )
rather than a deliberate intention to conceal, is the , principal explanation for his failure to report the safety 4 limit violation to (R) in a timely manner. A u First, (HH] could not rationally have expected to j' succeed in concealing the safety limit violation from higher management. For reasons discussed elsewhere, the evidence
;h ,
d does not indicate that the entire crew or any members of it joined in a conspiracy to keep the violation secret. Absent a conspiracy involving all crew members, it would have been p j utterly irrational for (HH] to hope that by delaying notifi-
, cation to (R) he could have prevented higher management from
.- finding out about the violation. The evidence did not y indicate that (HM) attempted to enlist any of the other crew members in an effort to conceal the safety limit violation;
.h^ indee.d , he apparently did not speak to anyone about the incident until (A) urged him to report it to (R).
i O Second, (HH]'s entire pattern of conduct on September (G b 11 bespeaks an effort to avoid, rather than to manage, the
. problems created by the safety limit violation. (HH] was U; actively involved in efforts to control the leak, hely the O maintenance worker who had been splashed with chemicals, and .U restore the plant to pre-leak conditions. He sought infor-mation, discussed problems with his crew and others, and 4.,
generally behaved in a nanner consistent with his responsi-bility, as Gss, to "maintain a command everview of the sit-q b .i
.,. --. , . - - .- ,_ - , ._ . ---- + -
l E3 w ei uation, to make decisions and to direct operations. . . .
"42 7 O
In contrast to his active management style with respect
- p to other matters, after the safety limit alarm at 2:17 a.m. '
(HH) did not discuss the violation with anyone until approx- [ s imately 3:45 a.m., when GOS (A) urged him to report it to (R). When CRO (ZZ) reported the missing SAR tape to him (HH] reacted passively, not even acknowledging that he .3 y G understood what (ZZ) had told him. He repeated this behavior when CRO (II) confirmed (ZZ)' report.43 (ZZ) i , thereafter was motivated to approach GOS (A) separately and (A), immediately perceiving the necessity of notifying (R), in essence assumed the GSS role (HH) had seemingly abdicated _ with respect to decisions related to the safety limit b violation.44' 7 J (HH]'s pattern of avoidance, we concluded, was more - consistent with a psychological explanation for the delays J in reporting than with an intention to conceal the viola- ~l
.)
tion. ,, (HH]'s psychological explanation for his behavior : implied that his ability to perceive and recall events had been impaired. For this reason, where there was a substan-
.\
tial conflict between (HH)'s recollection and other evi- ) dance, we tended to credit the other evidence. For example, (HH] testified that, after the alarm came in:45 ' I stayed out there until they started to I bring back the system. . . . Once we knew " that this electric valve was opened, the one
down there on 23 wasn't leaking anymore, I that's when I left the control room. (HH) estimated that it was a half hour before he returned to - i his office,46 that GOS (A) had not yet returned to the p control room,47 and that the first thing he did at that point was to call (R) and tell him about the leak.48 This
)'
A would have placed the first (MH)~(R) telephone conversation
, at approximately 2:50 a.m., when the great weight of the 0-iJ . evidence showed that it occurred almost forty minutes later, a between approximately 3:25 and 3:30 a.m. The other
'ji significant conflicts between (HH)'s testimony and other O evidence havs been discussed elsewhere in this report.49 u . p (HH]'s testimony was in substantial cgreement with the other evidence concerning the accuracy, as opposed to the timeliness, of his reports about the safety limit viola-a tion. (HH] described the violation a number of times on U September 11: orally to his GPUN superiors, in his 4:05 ju a.m. notification to the NRC, in his GSS log, and to a management critique of the event held on the morning and 1 afternoon of September 11. In each case, the information he )U ( conveyed was accurate given the data available to him at the 6 U- time. In particular, (HH] stated in his log that only the p "B" discharge valve was closed, creating an apparent dis-J. crepancy with (II]'s control room log.50 For the reasons "l discussed in Volume III (Tayinr Report, Section D-10), we concluded that (HH]'s statement, and not (II]'s, was Y accurate in this regard.
~~
_ 17 - l ~
g' w In summary, (HH)'s delay in reporting the safety limit f.c ; violation cannot be excused by his preoccupation with other . i duties. k t We concluded, however, that the delay was not part _ L of a calculated effort to conceal the safety limit viola- p tion. Rather, it was one symptom of a paralysis of leader-ship that overtook (HH] following the alarm, caused at least [
,L in part by a psychological reaction to stress. ,_
L
- 3. Destruction / concealment of SAR tace The evidence did not indicate that (HH) contributed to
the destruction, discarding, concealment, or alteration of the SAR tape. As discussed elsewhere, CR0 (VV) admitted taaring and wadding up sections of SAR tape, which included the portion reflecting the safwty limit violation, and thereafter _ throwing part of the tape in a wastapaper basket and .J flushing the rest down a toilet. (VV) testified that he - acted alone and that neither (HH) nor anyone else knew what he had done, much less encouraged or assisted him.51 There were inconsistencies between certain details of ]
.a (VV)'s account and other evidence, b6t these did not tend to -
q implicate (HH) in (VV)'s actions. Additionally, circum- g stantial svidence supported (VV)'s and (HH]'s testimony that (HH) was not involved in any tampering with SAR tape. - 3 The evidence indicated that (VV) had completed the J tearing and removal of the tape before (ZZ) discovered it ; j t
2 - missing shortly after 3 a.m., nd that these actions had probably been completed by 2:32 a.m.52 During the period . [3 immediately after the alarm, (HH] was still actively a supervising operations directed at stopping the leak and 0
, returning plant conditions to their previous status. There 3, was little opportunity between the alarm and 2:32 a.m. for 3
J (HH) and (VV] to have collaborated in a scheme to destroy or D- tamper with evidence. O m For approximately the next hour, until he exited the N~ control room at 3:35 a.m., (VV), according to his testimony, carried some of the SAR tape in his pocket and it would have been possible for him to have discussed its disposition with D' L (HH). Csring this period, however, (HH) was frequently observed by others, usual'ly in his office, and no one testified to having seen him conferring with (VV). For p example, EO (RR) entered and left the control room on two Q occasions between 2:37 and 3:22 a.m. (having been at the r* Ll site of the leak), and while in the control room told (HH]
, ,: that the leak had been stopped and recommended that plant -b conditions be returned to normal.53 At 3:00 a.m., (P)
{. entered the control room and remained there for twenty-seven i u minutes. (P) testified that he spoke to (HH] about the
! spill and other matters.54 From then until after his second conversation with (R), (HH) had limited opportunity to speak with (VV) privately.55 , After reporting the safety limit violation to (R) at 3:45 L]-
a.m., of course, any plausible motive (HH] might have had to
.?
k i b l . _ conceal evidence of that violation disappeared. k
- 4. Egg 2rtino of missine SAR tace p O
As discussed above, evidence that SAR tape had been removed was discovered by CRO (ZZ) shortly after 3:00 a.m. U (ZZ) immediately went to the shift supervisor's office and ; reported it to (HH), who looked "dumbfounded," but did not reply. (II), who was present when (ZZ) told (HH) about the { tape, went back and checked the tape himself. He returned to (HH]'s office and confirmed (ZZ)' report of its u condition.56 The evidence did not indicate that (HH) knew " a about the missing tape prior to (ZZ)' telling him. l Also discussed above was (HH)'s testimony that he could not remember (ZZ) telling him about the missing tape, - e4 although he vaguely recalled seeing someone standing at the door to his o,ffice. According to (HH), he first became - aware of the missing tape between 4:36 and 4:49 a.m. -- . after he finished notifying the company's public affairs D office about the safety limit violation (4:36 a.m.), and ? u before (MM) arrived in the control room (4:49 a.m.).57 . 3 (ZZ)' testimony that he informed (HH) about the missing [ SAR tape shortly after 3:00 a.m. was credible and strongly . corroborated by other evidence.58 Thus, (HH)'s testimony that he did not learn about the missing tape until after .- 4:30 a.m. is credible only if one accepts the psychological y explanation proffered to explain his behavior. According to i
^
v$. that explanation, (ZZ) could have advised (HH] that SAR tape was missing but the information did not register. As - discussed above with respect to (HH]'s delay in reporting g the safety limit violation, there is some credence to (HH)'s contention that his behavior was strongly influenced by Q. psychological factors arising from stress. At the same d time, there is no direct evidence and insufficient
- [q] circumstantial evidence to support a conclusion that (HH) intended to conceal information from (R).
Whatever the explanation, it is clear that (HH] did not ,O u, mention the missing tape during his first and second conversations with (R) (3:30, 3:45 a.m.). a .,. His third conversation occurred at approximately 4:00 '}! L a.m. (R) called the control room while (HH] was on another
- q telephone in the process of notifying the NRC about the
'I J safety limit violation. (HH) handed the phone to GOS
) (A), and we concluded that it was (A]'s conversation with
,I (R) that left (R) with the impression that the SAR data were J, unavailable. (A) did not, however, tell (R) that the tape apparently had been taken. (R) formed the impression that
}
~.' the reason the data were missing was that the SAR had run out of tape. (HH] does not appear to have originated or
, directly encouraged this spurious "ran out of tape" theory, u although some higher management personnel were under the impression that he had.59 > 1. l i3 Indirectly, however, (HH] encouraged the "ran out of ,'l.
h tape'.' theory by failing to come forward with a complete report on the condition of the SAR tape. Even if one , 3 accepts (HH]'s contention.that he did not discover the ; missing tape until after 4:30 a.m., he did not, then or later, report the details of the SAR tape's condition, ' although he suspected that someone had taken the tape in an ,I effort to conceal the safety limit violation.60 Later, he asked the crew members if they had the tape,61 further { indicating that he knew it had been taken. _ 1 In addition to asking the crew to produce the tape,
'('HH) participated in efforts to reconstruct the missing data through other sources. Sometime after 4 or 4:30 a.m., (HH]
called [00), a maintenance supervisor, told him that the SAR
- paper had jammed, and asked wnether the SAR could reprint the alarm.62 After checking with instrument and control technicians, (00) called (HH) back and. informed him that the j SAR would store a memory of alarms only when it ran out of paper, not when it jammed.63 4 q
Because this conversation occurred after (HH] had ;U reported the safety limit violation to higher management and
. "q the NRC, it was clear that (HH]'s interest in the capability .
of the SAR was not in furtherance of an attempt to conceal information about the violation. The evidence indicates l that (HH] genuinely wanted the tape to be returned or, J failing that, the data concerning the safety limit event to j be reconstructed. We concluded that (HH] was attempting to 1 1 5
. \
n 1 b , reconstruct the details of the event when he called (00), having failed to locate the SAR tape. . l
] '
However, (HH) misled (00) by telling him that the SAR paper had jammed. Although (HH] had no duty to report the l actual reason for the missing SAR data to (OO), his resort 1 ?,2 c to an "innocent" explanation to explain the reason for his im. inquiry indicates that (HH), at the same time that he was 4j - attempting to locate or at least reconstruct the missing
, [.) data, was reluctant to disclose the facts suggesting that l a
the SAR tape had been intentionally removed.
,3 When (MM) later inspected the SAR he saw the same peculiarities about the tape (HH] had observed, and had the
',, same suspicions.64 Because neither (HH) nor anyone else on
. the crew had previously reported the suspic3.ous condition of r, the tape, the higher GPUN managers were operating under the impression that the explanation for the missing SAR data was an innocent one, such as the machine having run out of tape. When these managers received (MH) report on the .[3 +
.id condition of the tape, they began to suspect a coverup by
, the crew.65
), In summary, (HH]'s delay in reporting the missing tape
.i lU was part of the pattern of behavior -- amounting to partial In abdication of his leadership role as GSS -- that resulted in !
iu
- j his delayed reporting of the safety limit violation
- r.
l{j itself. The weight of the avidence indicates that a psycho- ), logical reaction to stress, rather than a deliberate, calcu-G> l LJ if)
b. lated intention to conceal was the primary cause of (HH)'s h' w failures to make complete and timely reports, particularly . E6 during the earlier, pre-4 a.m. period. After 4 a.m., with El the safety limit violation reported to higher management and g rv
~
the NRC, (EH)'s apparent reason for withholding details concerning the missing SAR tape was that he hoped to locate : or reconstruct the missing data before his superiors became aware of the possibility the.t someone had taken the tape. LU
- 5. summarv of conclusions [
(HH) did not contribute to the error that caused the i[:- safety limit violation. Having witnessed that violation, however, it was his responsibility as GSS to determine the j appropriate reporting category for the event and then to , make the required notifications. He did not carry cut that - responsibility when he waited nearly one and one-half hours before reporting the safety limit violation to his imrediate superior in the GPUN chain of command. Fortuitously, this delay did not result in a violation of an NRC reporting - requirement. (HH)'s reports concerning the safety limit la violation were accurate within the limits of the information '
.w available to him. -
1 Although (HH) did not act in accordance with his " responsibilities as a GSS with respect to reporting the safety limit violation, we concluded that he was not
'l motivated by an intention to conceal the violation or ll evidence of it. Essentially, (HH] did not deal with the u
.\
~
3 s .[ safety limit violation during a critical period, while carrying out his other duties in a competent and responsible , manner. This pattern of behavior was influenced at least in n part by a severe psychological reaction to stress. b (HH] did not take part in the destruction, disposal, or P* f;I - concealment of the SAR tape. Although (HH] claimed not to C have heard anything, he was told about the missing SAR tape shortly after 3:00 a.m. He did not make any effort to locate it until after 4:30 a.m., when he asked the crew members if anyone had it, and did not report to higher
'm L management personnel that SAR tape was missing until they had independently learned of the tape's condition. (HH]'s failure to report the missing tape appears to have been
['l motivated by a desire to find or reconstruct the missing u data before his superiors became aware of the possibility q j that someone had taken the tape. The result of (HH]'s q failure to report the condition of the tape, however, was k"? that his superiors in the GPUN chain of command learned about it themselves. Consequently, they felt that they had been misled about the SAR tape and became increasingly r:
], suspicious of the crew.
Il u m I$ o ak 3 U!
PO
'L ,
H2 ARA C w 1 (HH), pp. 5-8. g
- 2. The sequence of events leading to the safety limit G violation is described in more detail in Volume I, Section L
~
VI(A). w-
- 3. [HH), p. 114; '
(I), 10/8/87, pp. 48-52. 2]
- 6
- 4. (HH), p. 111. g a
- 5. Ikid., pp. 111, 120, 126-28. ,.
2
- 6. Ikid., pp. 119-20, 126-31.
- 7. Ibid., p. 134.
e
- 8. Section VI(A).
ll
- 9. Oyster Creek Nuclear Generating Station Procedure u 101, p. 21.(Exhibit 48).
! r
- 10. I,d[.,. , (II), 10/8/87, pp. 54-56; q
(VV), pp. 197-198; ;ig l (HH), p. 111; ,,, d24 (A), pp. 95-97. l . 2. I
- 11. Egg Sections V(A), (B); Station Procedure 301, p. :;j 35 (Exhibit 17).
l
- 12. (HH), p. 111. See also
, I (VV), pp. 33-37; _t i (A), p. 96. J l
4
-{ :A
- 13. (VV), pp. 33-37.
- 14. (HH), pp. 115-19, 121-22.
- 15. 133 Section VI(B) .
.P -d
- 16. (HH), pp. 151, 165, 190.
- 17. Estimates varied regarding how long it took for
' plant conditions to return to normal, allowing [HH) to cease j his immediate supervisory activities in the vicinity of the control panel. 133, sagt, (HH), p. 163 (half hour after alarm); (VV), p. 113 (5-10 minutes after alarm there were no 9
b immediate operations to attend to); (I), p. 69 ((HM) back in - office when (I) left control room at 2:33 a.m.). n
,i} For a detailed chronology of events from the l clearing of the safety limit alarm at 2:19:17 a.m. through !
n 3:26 a.m., 133 Volume III (Taylor Report), Table E-1. x<
- U 7,
- 18. (HH), p. 151.
- V
[
- 19. Access Chart (Exhibit 14C);
'ld 1; (HH), pp. 179, 183-84. f 20. (P), p. 18. u. i (A), pp. 97-98; i I.d (G), pp. 13, 23. f2
}j , 21. (G), pp.,22-23; p (ZZ), 10/7/87, pp. 100-01 (re: information pi received that people had been sprayed with slightly t -e radioactive water).
9
\; *
,U 22. Station Procedure 126, Enclosure 1, p. E2-6; Enclosure 2, p. E3-3 (Exhibit 25). O i
- 23. Nor was (HH) continuously occupied during the n first hour after the safety limit alarm. 133, gigt, (P), p.
{] w D . _ _ _ _ - _ _ _ _ _ _ _ _ _
c. e 3
~
24 (conversation with (HH) about fishing).
- 24. (HH), pp. 165, 170. ~
- 25. Ibid., p. 190. p Li
- 26. Ibid., pp. 203-04.
h
- 27. Ibid., p. 203.
.h.
- 28. 133 Sections VI(B) and (E).
- 29. (HH), pp. 171-77; 200-02. -
m-
- 30. EASA, (A), PP. 97-981 i (P), p. 19. :-
- 31. (ZZ), 10/7/87, pp. 123-24; .,
Section VI(B). . -
- 32. (R), p. 10.
I <
- 33. (A), pp. 13, 62. i
- 34. (P), p. 23 ((HH) "a nervous-type person");
}
(N), p. 82; : (MM), pp. 24-25. 'jm l
- 35. Esgs, (HH), pp. 14-21, 259-66; j
(A), pp. 38-47. I l
- 36. (HH), pp. 238-42; 1 ;
(N), p. 95. j, I-J
- i
- _ . - . __, e - _ , -, ,., _ . - . . _ . _ _ . _ _ _ , _ _ _ _ _ . _ _ . . . _ . . _ . , _ _ . . _ . . _ . _ . _ _ _ . _ . _ . . . _
'Fly '
L . .
- [7 - 37. (HH), pp. 296-300; Uj Statement of (NH] (Exhibit 50). ,
- 38. Sworn statement of Glenn R. Candeletti (Nov. 30, q 1987) (hereinafter cited as "Candeletti") , pp. 58-63.
1]
- 39. Candeletti, p. 58, 62-63.
?. '-
.Cl
- 40. Ib,id., pp. 74-75.
'G' +!
- 41. . Report of Ruben J. Echemendia, Ph.D. (Feb. 13, 1988) (Exhibit 56).
[!
- 42. Memorandum from P. R. Clark, President GPUN and P.
.] B. Fiedler, Vice President and Director - Oyster Creek to "b
Oyster Creek Group Shift Supervisors (Mar. 5, 1987) (Attachment 11 to Station Procedure 106, pp. E9-1-E9-2) , (Exhibit 16). a
- 43. (II), 10/8/87, p. 110.
- i.s L} -
- 44. Egg Section VI(B).
- 45. (HH), p. 162.
~\$
'lJ 46. Ibid., p. 163.
, (1-lU : 47. Ibid.
.1 48.
I(J.. Ikid. i j II} . 49. Egg Sections VI(A) and (B). id r1 50. Compare Exhibit 6 (Control Room Log) Eith Exhibit .I ! 7 (GSS Log). >p
- 51. Egg Section VI(D).
I tw . t ,i
! FI l i ll
p, C e
- 52. 331 Section VI(D) of this report. The estimate of , _ ."
2:32 a.m. is based, in part, upon (VV)'s testimony that, on his second trip to the SAR, he believed he tore the tape . near where it exits the machine. (VV), pp. 147-49. If this J], is accurate, the 2:32 a.m. alarm likely printed out shortly a after the tearing. gas volume III (Taylor Report), Section C-1. p
?.;
- 53. Sworn Statement of (RR) (Oct. 1, 1987), pp. 24-25 m (hereinafter cites as "(RR]"); j; Access Records "Entries" (Exhibit 14A). ..
a
- 54. (P), pp. 17-32; O
Control Room Access Log "Entries" and "Exits" ~'! (Exhibits 14A, 14 B) .
- 55. Egg Section VI(B).
n I
- 56. Section VI(D)'
[II), 10/8/87, pp. 110-11. 7) J
- 57. Exhibit 9 (B) indicates that the report to Public Affairs occurred at 4:36 a.m.,1 Exhibit 14(A) indicates that .. l (MM) entered the control room at 4:49 a.m. -)
- 58. Egg Sections VI(B) and (E). .';,]
l; 59. Egg Section VI(E). - ? _a I
- 60. (HH), pp. 213-15.
- 61. Ibid., p. 217. .
- 62. Sworn Statement of (00) (Oct. 2, 1987) p. 17 (hereinafter cited to as "(00)"). ]
- 63. Ibid., pp. 21, 31-34.
- 64. (MM), 128-31. ;
- 30.-
l 4 .,,
- 65. E.g3 Section VI(E).
].,
1m . d. g c, t m ed ' ID
- h
'V b 13 r!
L,
.1 1
i
+
t' i m I
.f
{.
- e
..3
*e l'
p.
.ls 1';
i-) Y
p tc IAl G, (A~) was the GOS of "B" crew on September 11, 1987, a [h position he had held since March 1986. Prior to that he had been a CRO on "B" crew since 1981. i;y
- 1. Saf33v limit violation (A), as the GOS and second in command, responded to the 3 6
report of the leak on the twenty-three foot level by exiting {D the control room at 2:11 a.m. and going to the site of the i leak. From there he communicated with the control room , concerning the location of the leak, and later coordinated efforts to isolate it.1 The safety limit violation occurred , during this process, when (A) was out of the control room. ~ When the decision was made to close valves on the RBCCW system in order to isolate the leak, (A) reminded the crew !d
. J in the control room that the recirculation pumps would have
. O to be shut down.2 He had no control, however, over the 2 i
manner in which this was to be done. He expected ' chat shut- .," i: ting the pumps would take only a few seconds, and was sur-
- prised when it took so long to receive confirmation that the
}
pumps were out of service.3 *
.]
(A) remained outside the control room for approximately forty-five minutes after the safety limit violation i
}]
occurred. During this time he coordinated efforts to back-I, L seat the valve, which eventually stopped the leak.4 He then J supervised the station helpers who were cleaning up after 7 ! ) s 4 4
. - , - - - - - , , - - , - , - - - . - - - -n , _ - - - , - - . - , - - - - - - - - - - - . - ,
,w
S . L2 . the leak. Finally, before returning to the control room, he initiated efforts to reestablish the RBCCW flow to the , drywell.5 g The evidence clearly establ'ished'that (A) was outside 1) 11 the control room between 2:11 and 3:03, and that he did not 19{ ., contribute to the error that caused the safety limit
.q violation.
U#
- 2. Recortino of safety limit violation rl Id (A) gave the following account of how he learned about j7 the safety limit violation and the actions he took with respect to reporting it.
I-] d (A) was out of the control room in response to the leak P for 52 minutes (2:11 a.m. to 3:03 a.m.,. During that time, k no one told him about the safety limit "riolation.6 When (A) p
- Q returned, he found (HH) and (P) discussing the chemical in the water that had sprayed a mechanic, (C), while (C) was
\,d repairing a valve on the RBCCW system. Shortly after returning to the control room, (A) left again (3:09 a.m.) to
}
- inspect a drum for information about the chemical, so that
.y
[j , (C) could be properly treated.7
- II Q
After examining the drum, (A) returned to the control room at 3:15 a.m. and reported his findings to (HH). (A) n b also told (HH) that he had spoken with the health and safety
;s representative who was looking into first aid for (C).8 L
(HH) then said to (A) that it was time to call (R) and tell 'N
}
1 - - - . - _ - , - - . _ -_ _ _ . - - - _
r w b e (R) what was going on. Up to that point, (A) still did not - 6 know about the safety limit violation; he assumed (HH] was , cl going to call (R) to tell him about the leak.9 - 3 As (HH] was dialing (R), (ZZ) came to the doorway of '{q. the GSS's office and asked to speak to (A) in the hallway. _ T (A) and (ZZ) exited the control room at 3:28 a.m. (ZZ) '2 asked if (A) was aware that a safety limit violation had .? m occurred -- less than two loops open -- when they were shutting down the recirculation pumps. (A) was shocked to f hear this. (ZZ) then related that he had gone back to check , the SAR tape for the exact times when the alarm came in, and & had found that the SAR tape had been ripped out and was not "*
}
there.10 [A] asked (ZZ) if (HH) knew everything. - (ZZ) responded that (HH) was standing right next to (VV) when .} (VV) shut the discharge valve and the alarm came in.11 , 1 J (A) was surprised th'at nobody had told him about these matters sooner, and thought that "things weren't going ;, exactly right."12 ,, (A) returned to the control room, according to the (Q security computer, at 3:30 a.m.13 He. believed that the ] l - company faced a very expensive fine and that the plant would be shut down by the NRC for the safety limit violation.14 '" For the crew as a whole, however, he saw no consequences {, other than extensive critiques.15 1 l \ J When (A) returned to the control room at 3:30, he i , l L. . . . _ . . . _ . _ _
7 expected to hear what (HH] was telling (R). He recalled a that as he was entering the control room, (HH) left very , quickly with a red binder containing a list of hazardous substances.16 The security computer showed (HH] leaving the t d control room at 3:36, six minutes after (A) returned. (A) P. was surprised by this because he clearly recalled seeing t'i (HH] leaving as he was entering.17 e. t (A] then spoke with (II), who acknowledged that the less than two loops alarm had been received and that the SAR
.a paper was missing.18 (HH] then returned to the control room I
[]' and (A) asked him whether he had told (R] about the alarm. (HH] said no. (A) told (HH] that they had to make
- notifications immediately. (HH) agreed, and walked towards Q his office.19 Shortly afterwards, (HH] came out of his ,
,Ls office and said that (R) had just called to find out about pt tj the safety limit violation.20 (A] was amazed that (R) had y called with such a question, and he said to (HH]: "(Y]ou d know, some guy at 2:30 in the morning can think of this, this is going to look really bad . "21 (As related in .[] . L; detail in the individual sections on (R] and (N), (R]'s O _g, question to (HH] was not specifically whether the safety
,, limit had been violated. (R) was conveying (N]'s concern
'! t id about keeping at least two recirculation loops open.)
?
(A) was not sure why he as'ked (HH] whether he had
;q notified (R), but it was probably because of the way (ZZ]
( had acted. (ZZ) was very concerned and, according to (A), 4 , ,
$L seemed to think that things were not going exactly the way ,7 they should go.22 ,
7
~
After his call from (R), (HH) advised (A) that they - were going to report the less than two loops alarm incident f u-as a safety limit violation.23 (A) then' checked the technical specifications, which confirmed that a safety E limit had been violated.24 In the meantime, (HH] went inta - his office to commence notification.25 O Because he knew SAR data were unavailable, (A) started O working on tihe plant computer to try to come up with an ,'] accurate time estimate for when the alarm came in.26 Based ' upon when the computer reflected an increase in the reactor water level, (A) estimated that the alarm occurred at 2:24 a.m.27 ] (A) then went to (HH)'s office to help (HH] with the notifications. (HH] had the NRC regional office on one y phone and he handed another of the phones to (A) and told '-- him to talk to (R), who had just called.28 (A) then had a brief conversation with (R), during h . 1 which (R) wanted to know what time the event occurred. (A) ',~ recalls saying that, from the computer, it looked like 2:24.29 (R) also wanted to know why (HH] had taken so long to call (R). (A) said he thought that (HH] was about to ..' call (R) when (R) called (HH).30 ,
\
v After speaking with (R) on the telephone in (HH]'s
lg office, (A) went back to the control room. The NRC phone rang there, and (A) answered. It was the regional offico , asking the exact time when the event occurred. (A) said that it was hard to determine the exact time, but it looked like 2:24 s.m.31 h... At 4:24 a.m., (A) left the control room and went to the _., lunch room. In line with his policy of not keeping secrets among the members of the crew, he wanted to let people know g what happened. He told the Eos in the lunchroom about the safety limit violation. He also told them that ,h.a notifications were slower than they should have been, and that the SAR paper was missing.32 He expected that the Eos ,p .td would have to stay for a critique, and advised them that g upper management people would be in shortly.33
\5 7 At some point after (HH) had revealed the safety limit 1 .
violation to (R), (II) asked (A) for help in making the log O entry for the violation. (II) was not sure how he should enter the violation.34 (A) told (II) that he had to log the event. (A) recollected telling (II) that he would help, but g ,1. then other things got in the way and he did not help (II) O' , with the log entry. (A) did not know why the safety limit
- P was not logged until sometimi after 3:00 a.m. He expressed d
the opinion that as a supervisor he would prefer to have a r, {i late entry rather than a time.'y but inaccurate entry.35 i d' (A) recalled that just prior to (SS)'s arrival in the L control room (4:43 a m.), (HH) stggested that the crew write
- 37 -
n l
1i an account of how the safety limit violation happened. (A) :' o, . undertook to write the sequence of events that was later . 1 r: r given to higher management.36 He personally addrnssed the _ 'L. matters that happs.ned outside the control room, and relied 7 on what the CRos told him about what happened in the control , room, # specifically, (A) spoke with (W) about what (W) did { with the controls. During this, conversation, (W) said that
?
- he had ahut only onc valve.37 L When (SS) entered the control room at 4
- 43 a.m., (A) briefed him on the safety limit violation and the ,
circumstances leading up to it. He also explained the i tachnical specifications and showed (SS) the notification
]
1 forms.38
. * * * .)a
,! In most respects, the evidence strongly supported (A)'s account of how he learned about the safety limit violation
].
and the reports he later made concerning that violation. , e i None of the witnesses contradicted (A)'s contention i h< that he did not learn of the safety limit violation outil 1., ; 3:28 a.m. Upon learnin7 of it from (ZZ), he also learned &] l! that (MH] knew about the violation, having witnessed it. 1 .l Thus, (A) had no immediate duty to report the violation to
- higher management because that was clearly (HH]'s responsibility, and (MH) knew as much about the violation as
}'
a i did (A). ; I , 38 - 1 e - - - -7, - - - , . , - - - y, 97,,,,-y,v-wy., . - - , - , . , _-w,. ----- ,,,,,,w_,,,_---. ,_ _yr --_-,,_.,r,. -
Q, . L . (A), however, felt that as GOS he should provide a "check" on (HH) to insure that he did not overlook any- . I thing.39 He also felt motivated to act because (ZZ) had seemed concerned, and "if it's a concern to one of my h E operators, I'm also concerned."40 Accordingly, when (A) G '. next spoke to (HH] - which was approximately 3:41 a.m., kJ
, when (HH) returned to the control room after speaking with e '
{j the health and safety representative -- he asked him if he had reported the safety limit violation. When (HH] said .b la that he had not, (A) told him that it had to be reported T immediately, and (HH) agreed.41 k)] n This aspect, of (A)'s testimony is credible, consistent, (;' and well corroborated and it demonstrates that (A) acted j) prompt 1,y and responsibly under the circumstances. The G evidence does not show that (A) encouraged or contributed to M .U any delay in reporting the safety limit violation. On the contrary, (A) urged (HH) to report the violation d immediately. (, The evidence also strongly supports the conclusion that 3 (A)'s reporting of the safety limit violation was accurate l.
~
within the limits of the information available to him. Lacking SAR data, he undertook to estimate the time of the violation from computer data. The estimate he produced was J off by only seven minutes. similarly, because he was out of
.] the control room at the time of the violation, (A) had to rely on the accounts given to him by the CRos to describe p
L
~ ~ ,~,
U
C 9 t how it occurred. The evidence shows that he compiled this e I e information diligently, resulting in a substantially accur-a : ate account of the details of the violation.42 g y; l The few discrepancies between (A]'s testimony and other C M evidence were, we concluded, inconsequential. For example, the security computer appeared to contradict (A)'s - (T recollection that (HH) was exiting the control room just as ,! (A) was entering it at 3:30 a.m.43 Another apparent i!
- inconsistency involves (MM) recollection as to the origin of 7 '
l ' (A]'s handwritten sequence of events.44 (MM) recalled that when he reentered the control room at 5:39 a.m. after having
- f{
3 been directed to get a statement from the operators, he told ,
- i (A) that they needed a write-up of what happened.45 [g) ,,-
recalled writing the sequence'of events earlier, prior to q
^
(SS)'s arrival in the control room'at 4:43 a.m., and q recalled that it was (HH), not (MM), who suggested that this
]l 1
be done.46 A third inconsistency was (SS)'s recollection I that when he entered the control room he spoke about the 1 i 4 safety limit violation with (W) and no one else, contrary m f I . to (A)'s testimony that he spoke to (SS) at that time.47 6! L l
- We found, however, that some differences in recollec- -a !
- . i l tion were to be expected under the circumstances, and in any i event the ones described above had no bearing on the timeli-
'Jt l
ness or accuracy of (A]'s reporting. Absent other reasons _1. i , I to question (A)'s testimony, we did not draw an adverse ,, l I -\ l inference from these differences in recollection. " ! i } I :
- 3. Destruction /concealmentofs$ntane W{
As discussed in detail elsewhere in this report, the evidence showed that (A) was out of the control room and ; unaware of the safety limit violation during the time when d(7
.l the SAR tape was ripped out of the machine and discarded.
Eventually, (W) admitted full responsibility for these n, acts. According to (W), (A) was the first person (W) told about having ripped the tape and dropped it on the E floor.48 This occurred at around 7:30 a.m.,49 and (A) k promptly encouraged (W) to repeat what he had said to (HH), 3 , j which (W) did.50 (A) later searched for the missing tape.51 LJ The evidence did not indicate that (A) had any role in : .y u the removal, disposal, or concealment of the SAR tape.
- 4. Renertina of missina SAR tigtg 3 As discussed abcVe, (A) learned about the missing SAR
.d tape at the same timo he learned about the safety limit viciation, during his 3:28 - 3:30 a.m. conversation with (ZZ). We also concluded that (A) inspected the SAR machine r
]'*
at some point between 3:36 and 4:00 a.m.52 f] > U y Thus, by the time (A) had his brief telephone tg conversation with (R) at about 4 a.m., he was aware not only that SAR data were missing, but that the tape had been torn n g and removed. According to (A), however, it did not occur to him to tell (R) about the missing tape.53 (A) testified M U
r I b that he was confused about the situation 54 - I didn't know where the SAR tape was. I had i known that either I had asked or everyone on
- e '
the shift was asked if they knew where the .; , SAR paper was, and everybody said they didn't J know. (A) does not recall (R) asking anything specifically D about the SAR tape. (A) in turn did not volunteer y, anything.55 (R) did, however, ask when the violation happened:56 {
- c. ,
When he asked me that, the general method of determining when something like that happened T would be to look on the SAR. So, when he ,C asked me that, immediately I thought of the SAR. I thought, well, we have a missing e document. I didn't want to, you know, all of . a sudden tell him look, I can't find the SAR
- paper, I can' figure out where it went, because it might raise concerns unnecessarily Q.
and it might get people very excited, when I .s didn't think at that time there was any reason to be excited. O
~
a (A) candidly admitted that he intentionally did not disclose to (R) that the tape was missing, because "it might u? raise concerns." (A) clearly was aware that if (R) knew the tape was missing -- as opposed to having run out or a malfunctioned -- (R) might raise "concerns" about the reason p for the tape's disappearance. In effect, if not by specific [l statements, (A) encouraged (R) to believe in an "innocent" explanation for the missing tape. (A) explained that at 1 that time he believed in such an explanation:57 j I didn't think there was a reason to be ; excited, because I assumed the SAR paper was " i missing, it was lost somewhere and it was i completely innccent. I thought that somebody , just hapha:ardly threw it away or somehow \ . somathing happened to it that was totally J innocent, and I really didn't believe that ,
.]
l ,
~
somebody did something wrong. U~ Later, when he briefed (SS) about the safety limit . A
) violation, (A) also did not mention the missing tape because "the SAR just didn't seem a very important thing to tell him at that time . . .
" 58 He explained:59 y' A. (W]e had just had a safety limit vio-g-
lation and there was going to be a lot of important people asking him a lot of tech..ical questions very soon, and a missing document was not something that I thought -- it didn't even enter my mind, but a nissing document was not something I would clutter his mind with } at that time. Q. Well, did you think he would be asked questions about the missing document?
),b A. Well, at that time, I didn't think it
-};,j was important. I didn't think it was of interest. .r, Eventually, (A] stated, he came to realize that the I-t u missing SAR taps was of vital importance, but this was well after the investigations had commenced.60 [3. ? Although (A] admitted not telling (R) what he knew about the missing tape, he denied telling (R) that the SAR f had run out of paper.61 That explanation for the missing SAR data never entered (A]'s mind until after 6 a.m., when l3-l (MM) called to the control room for the SAR tape. (II] was p sent back to get the unused portion, and (A] assumed that someone had suggested that it ran out of paper and that they were changing paper at the point of the safety limit violation.62 .g According to (A), the possibility that there might be n it 2 _ 43 - ra 8.J y
~
F T 4 other than a totally innocent explanation for the missing E' W tape did not enter his mind until approximately 7:30 a.m. ,
.r He was getting a cup of coffee from the control room and 1 noticed that (VV) was standing behind him, looking upset and on the verge of tears. (VV) told (A) that he had torn the k tape. (VV) claimed, however, that all he did was rip it off ;
and lay it on the floor. (A) did not question whether (VV) , n-had done something further with the tape because (A) }. believed him.63 (vv] then told (HH] and (R) about tearing , I the tape.64 ._ , Q At the end of the shift, (A] exited the control room [J and went to a critique of the safety limit event. There, n
^1 (A) brought up the topic of the missing SAR tape because he ;J knew by then that upper management suspected a coverup. He J told the critique panel that he had information about what m
happened to the tape because a certain individual had just (j recently told him about it. (A) was referring to what (VV) ,
- s' had told him at 7:30 a.m., but he did not mention (VV) by "'
name. (A) told the panel that in order ~for that person to ] M redeem himself, he should be given a chance to tell what he .' did.65 The people at the critique thought this was a , reasonable approach.66 (A) assured them that if after the . . . I critique they did not have all the information they needed J about the SAR tape,'they could call him at home.67 .q
.2 In most respects, the evidence supported (A)'s account .
~
of how he learned about the missing SAR tape and what he did 6
- 44 -
. ,j y and said thereafter. There was, however, one significant b'
inconsistency between (A]'s testimony and other evidence. . a
$ While (A) denied telling anyone that the SAR tape ran out of paper, (R) and (MM) both recalled (A) and/or (HH] suggesting that' the SAR did not record the safety limit violation because it missed the event.68 (R) was ninety percent L
certain that either (A) or (HH] -- and more likely (A) -- E - told him during one of the telephone conversations that the D SAR had run out of paper.69 The discrepancy between these r accounts is discussed in section VI(E) of this report. As g stated there, we found that the evidence did not warrant a conclusion that (A) affirmatively misled (R) by specifically 1 advancing a spurious "ran out of tape" theory to explain the [7 absence of SAR data. Il 'J We also concluded, however, that (A) delayed fully f disclosing what he knew about the SAR tape in an effort to buy time, noping the tape would be retrieved before its 7 dj absence became a major issue. (A]'s motives and intentions q in this regard, and the circumstances in which he acted, O. merit further discussion. h- , When (A) learned about both the safe y limit violation and the missing tape from a "concerned" member of the crew .p]
- i at 3:30 a.m. he, as second in command, was placed in a very j difficult position, made more difficult a short time later when (HH) told him that he had not reported the violation to t;
'd (R). As his comments to (HH] demonstrated, (A] was well .s O
g
~ , ~
': y b
aware of the suspicious appee.rance created by the delay in q notification. (A) had done nothing to contribute to that delay, and he immediately tried to end it by urging (HH) to '
?
call (R). E is In essence, (A) assumed an active management role with respect to the safety limit violation, in contrast to the passive conduct of (HH] up to that point. That role placed him in an awkward position. He realized the importance of k providing timely and accurate notification to upper ;
~
management to enable them to respond appropriately to the safety limit event.70 At the same time, (A) did not want unwarranted suspicion cast upon the crew or (HH). In ,, j attempting to reconcile these competing demands, (A), in w effect, assumed an innocent explanation for the missing SAR tape. 3 That assumption was implausible given the condition of the tape. Equally implausible was (A)'s testimony that telling (SS) about the missing tape was not important enough to clutter his mind with at the time.71 Despite his belief ) in an innocent explanation, (A) was aware of the unwarranted c suspicious appearance that could be created by the missing *y} tape. Indeed, it was to avoid such an appearance that he
-}
^
did not mention the missing tape to (R) during their 4 a.m. telephone conversation. He should have realized that upper .f a management personnel such as (R] and (SS) would need
.(
complete information about such a matter as early as .;
.1
. = .. . _
- possible in order to' prevent a possibly minor incident from assuming major proportions.72 Eventually, upper management ,
personnel discovered for themselves the implausibility of an innocent explanation for the missing tape, and the crew's failure to provide this information first helped fuel q* suspicions of a coverup. b a-( Although (A] made an error in judgment by not dis-I closing the full details about the missing tape to (R) or, 1ater, to the other management personnel who arrived in the
- q control room, the evidence strongly supports the conclusion that he at no time intended to withhold relevant information about the safety limit violation or to conceal wrongdoing.
[,d l (A) had no role in causing the safety limit violation, the 3 delay in reporting that violation, or the removal of the SAR ~ tape. He was forced to balance loyalty to other members of El the crew -- as evidenced by his not wanting to believe that U . one of them had lied about removing the tape -- against his,
;. reporting obligations.
(A]'s behavior at the critique on September 11 offers another example of how he balanced concern for the crew
$ members against his duty to report information, and is a 'T further indication that he did not intend to conceal evi-b dance. He told the critique panel that someone else had 7 ] information about the SAR tape. He did not, however, reveal what (W) had told him about ripping the tape, hoping to O give (W) the benefit of being the first to disclose that q
t i .: 1 = [1 -_-- _ __..__ _ _ _ _ _ . _ _ ______ _ __._ ___ _ ,- ~_ ---
~
t2
'n fact. (A) assured the panel that they could contact him r
'later if they did not obtain,the information they needed '
about the missing tape. "
.9 (A)'s positive actions in urging the reporting of the 3 safety limit violation make it unlikely that he would deliberately misrepresent or conceal a relevant piece of f
information. (A)'s error in judgment wa, failing to . recognize the relevance and importance of promptly reporting ., the complete details concerning the missing tape. We con- - cluded that this error was caused by his sense of loyalty to his crew and his hope that the problem would be corrected before it was reported to his superiors. We also concluded that (A) did not intend to conceal the facts concerning the missing tape indefinitely. ,
.s
- 5. Summarv of conclusions (A) did not contribute to the error that caused the x, safety limit violation and did not know that there had been .)
one until more than an hour after it occurred. When CRO ;a VI (ZZ) told him about the violation, (A) reacted in a timely {." and appropriate manner. After learning that the safety I i : j limit violation had not been reported to higher management, - (A) insisted to GSS (HH) that it be reported immediately. (A]'s later descriptions of the safety limit violation were ., 1 accurate within the limits of the information available to " him. ~{. J i k I _l
(A) did not take part in the removal,' destruction, concealment, or disposal of the SAR tape. He first learned about the missing tape at the same time that he learned J about the safety limit violation. (A) did not report what h at he knew about the missing tape to higher management in a timely manner. He did not, however, intend to conceal the La missing tape indefinitely. Instead, he hoped that the p - reason for the tape's absence would be explained before it b' cast an unwarranted suspicion on the crew. 9 b' 1 J fl
\.a 7
-?
Y v
'T ?* 'I d .'
w l3 'u "t li , j 's ti 6 . - - l M
- Tr b
~
NOTES iI.
'h..
- 1. (A), pp. 74-80; ,
Access Chart (Exhibit 14C). _ [7 r
- 2. (A), p. 80. 7J
;J
- 3. Ibid., p. 82. yg sj
- 4. Ibid., pp. 84-85. fT
- 5. Ibid., pp. 88-90. ...
- 6. Ibid., pp. 106-09. ..
1,w
- 7. Ikid., pp. 90-92, 98-102.'
I
~
- 8. Ikid., pp. 101-102.
- 9. Ibid., pp. 107-09. h)-,
l i ,
- 10. (ZZ), pp. 119-20, 137; )
l (A), pp. 102-04. c3 i- j a
- 11. (A), pp. 104-05. .
1
. h
- 12. Ibid., p. 105. .
n..~
- 13. Ibid., p. 109. '.~
l 14. Ibid., p. 38. l l 15. Ibid., p. 37. qs
- 16. Ikid., pp. 105-06. ,_
!- i 1
.:1
17 (A), p. 107. - I i
- 13. Ikid., p. 111. .
- 19. Ibid., pp. 111-13.
. t]
- 20. Ibid., pp. 113-14.
1.
.it ' 21. Ikid., p. 114.
j- 22. Ikid., pp. 122-23.
,'; 23. Ibid., pp. 119-20.
,a 7 24. Ibid., p. 120.
z w q 25. Ikid., p. 120. 1 G1
, 26. Ibid., p. 120.
b)
- 27. Ibid., pp. 124-25.
- 28. . Ibid., p. 128.
-\
n
- 29. Ibid., p. 129. '
d J 30. Ibid. v ' , j ,
- 31. Ikid., pp. 133-34.
- 32. Ibid., pp. 136-37.
Ji
] 33. Ibid., pp. 137-38, J ; 34. Ibid., p. 151.
D 4
<7, b
- 35. (A), pp. 151-52. - l
- 36. (A) Chronology (Exhibit 10); .
(A), pp. 153-54. ;
- 37. (A), pp. 153-55.
.a
- 38. Oyster Creek Technical Specifications (Exhibits .?
9A, C); 'd (A), pp. 140-142. N
'i
- 39. (A), pp. 15, 124. -
G w
- 40. Ib.id., p. 124.
m a
- 41. I]2id , PP. 112-13;
[HH], pp. 269-70.
- 42. (A) Chronology (Exhibit 10).
f.] Access Records (Exhibits 14C, 14B). "
- 43. .
- 44. (A) Chronology (Exhibit 10). 's
'A
- l
- 45. (KM), pp. 94-98. .y
.,J .
- 46. (A), pp. 153-54. ..
- - cl.
- 47. (SS), pp. 26-29; z
(A), pp. 140-42. J
- 48. (VV), pp. 175-76. .
- 49. (A), p. 157. ]
1 ( ,
)
2 s
l
- 50. (A), pp; 157-58; -
a I (VV), p. 176.
- 51. (A), p. 162; (VV), pp. 176-77.
- 52. Egg Section VI(E). i 7, 1 Ji
- 53. (A), p. 130.
)' l a 54. Ikid.
3 a 55. Ihid., p. 132. .
) ] 56. Ibid., p. 131.
l 57. Ikid., p. 131. u '1
- 58. Ibid., p. 142.
- 59. Ibid., pp. 142-43.
~)1
.3 a
') 60. Ibid., p. 143.
n 7. ')] 61. Ibid., p. 132.
"l 'l
.g 1 62. Ibid., pp. 145-49.
^
.e
- i. 63. Ikid., pp. 157-58.
+
.J 64. (VV), pp. 175-76;
[R], p. 116.
- 65. (A), pp. 164-65.
a
'}
N d i
- - x .
i
\
t
" \
- 66. Ib.id., p. 166. r p
- 67. (A), p. 166. -
t
- 68. (MM), pp. 84, 88; -
r. (R), p. 90. l;;,
~ c?
- 69. (R), pp. 93-94. -
- 70. 3,s.g (A), pp. 113-15. l'
- 71. Ib.id., pp. 142-43. g ,
- 72. Station Procedure 126, Enclosure 5, pp. E6-1-E6-2 ,,
(Exhibit 25). ] l l
.1
'~.
e pee l .i t.
's .4
'l r
. i k
[ L
. e
' ~
rVV1 (VV) was the most experienced CRO on "B" shift, having - bosn licensed in April 1981 and assigned to the shift a few nenths later. On September 11, 1987, he was designated the "extra" CRO.
- 1. Safety limit violation By his own admission, (Vv] was responsible for causing the safety limit violation.1 Having heard the order by USS (HH] to secure the recirculation pumps, (VVJ commenced what ha termed a "normal shutdown" procedure -- which included -
chutting discharge valves before turning off the pump motors
-- that would have been appropriate during most normal operating conditions, with all loops open.2 In what the evidence indicates was a momenta'ry lapse of concentration, ho closed "B" discharge valve preparatory to shutting off the "B" pump, forgetting that only two dischargo valves were opan at the time.3 .
i (VV) was unable to explain what caused his lapse. He
' stated that the safety limit never crossed his mind until
.the alarm came in,4 and summarized:5 It was my lapse of recollection that caused me to violate the safety limit. 99 times out of a hundred I would have remembered that and I just didn't.
Nor did (VV) attempt to excuse his action. He admitted that the safety limit was in the written procedures, that there wcc a warning about it on the control panel, and that it was ( u . _- . --
F e stressed during training sessions. He insisted that he was _ r acting slowly and deliberately when he made his error,6 t denying suggestions by other members of the crew that (VV)'s r e well-known fast operating style might have contributed to the violation.7 R b As discussed in detail elsewhere in this report,8 the _p d evidence corroborated most of (VV)'s testimony concerning 7 his actions bnmediately before and after the safety limit alarm. The only irreconcilable conflicts between (vv]'s n testimony and the other evidence concerned the timing of U certain actions he took after the alarm, and we could p
- 1 N
discern no plausible motive for (VV) to intentionally
- e misrepresent these matters.
We concluded that the safety limit violation was caused by (VV]'s inadvertent lapse of concentration, which led him n
. to commence a "normal shutdown" sequence that was J.
inappropriate for the existing plant conditions. ,. 2 There was considerable evidence that (VV] had a fast y operating style, sometimes using two hands at once to ,. manipulate the controls, and others on the crew thought that . this helped cause the violation.9 The evidence does not support a conclusion, however, that speed in manipulating j J the controls was a major factor in causing the violation. The primary cause was the mental error (VV] made when he chose the "normal shutdown" procedure, an error (VV) did not r, recognize until the alarm came in. 1
C V . In summary, (W) was clearly at fault for closing the
;, fourth discharge valve. There were, however, circumstances bearing upon the seriousness of his error.
First, when the alarm came in, (W) instantly recog-J nized his mistake and took immediate corrective action. As
'J - , a result, no actual threat to plant safety resulted from the safety limit violation.10 1 .
second, (W)'s error occurred during a unique com-1 bination of plant conditions. The plant had been in cold J shutdown status -- and therefore operating with only two RBCCW loops open -- for less than a day. Keeping only two loops open during such shutdowns was itself a practice that J had been implemented in December 1986. Between then and
] September 11, 1987, the "B" crew switched pumps under two-loop operating conditions on only one occasion.11 Addi-
. tionally, the crew was on a midnight shift, responding to an 3 emergency in an atmosphere of excitement and urgency.12 Third, the safety limit itself and the alarm system s
j corresponding to it are unique. The less-than-two-loops n alarm comes in only after the safety limit violation is
, complete, providing no margin of error enabling the operator
,a
] to avoid the violation after a momentary lapse.
1 2. Recortina of safety limit violation e, Because the entire crew (except (A)) was present when d the safety limit alarm came in, the issue of reporting the {t
- 6) - 57 -
l,, tt' lU - _ _ _ _ _ _ _ _ _ _ __ _ __ ~ __. _ - - _ _ _ . - . . - .
violation to higher managemant never arose with respect to - 1 (W) . As discussed elsewhere, such reporting was (HH]'s responsibility and, as (W) knew, (HH] could have made such , a report based upon what he had personally observed. The i3 evidence did not indicate that (W) attempted to dissuade g (HH] or anyone else from reporting the violation to higher , Q. U management. b Although reporting the fact of the violation was not h (W)'s responsibility, he did have an obligation to describe accurately, when called upon to do so, the details of the actions he took in connection with the safety limit < event. (W) described his actions several times on September 11. q He assisted (A) in the preparation of a summary of the b safety limit event, which was presented to higher management ,, 4 r-personnel. He also later explained to (SS) and (MM] how the safety limit violation occurred.13 Later in the morning, [ (W) was called before a critique panel, where he again 1 described what had caused the alarm.14 h In all of these reports, (W) described the sequence of I'i l. events much as he did in his testimony, including his , n discharge valve remained open at all assertion that the "C" . times. As set forth in Volume I of this report, and as y R further detailed in the Taylor Report (Section D-10) , we concluded that this important aspect of (W]'s testimony was accurate, notwithstanding other evidence that appeared to La contradict it. The one clear inaccuracy in (W)'s account 1] l
^
]
~
of events leading up to and immediately following the alarm
-- his assertion that he tripped the "B" and "c" pumps after the alarm cleared -- was immaterial to the cause of the violation and was, we concluded, an error _in his recollec-m } tion.
9 *.- 3. Destruction / concealment of SAR tane 2
-[ (W) admitted tearing the SAR tape, throwing a part of what he had torn into a wastepaper basket, placing the rest ] in his pockets and eventually flushing it down a toilet.
testified, however, that he did these things in a fit of He t
,? anger at himself for causing the safety limit violation, and
.3 not because he hoped to conceal the violation from higher management, the NRC, or anyone else.15
,i (W]'s testimony concerning the tearing and disposal of 1 the SAR tape has been described in detail elsewhere in this report.16 As discussed there, the evidence supported (W)'s
] testimony that he acted alone, without the encouragement, assistance, or knowledge of the other crew members or anyone
.}. alse. The remainder of this section will address his motives and intentions. -
There was considerable evidence to corroborate (W)'s ,3 contention that he acted out of anger and frustration, and not with an intent to conceal or destroy evidence. As pointed out in Section VI(D), there were also several ,
, apparent inconsistencies between portions of (W]'s a I1 IIi
. _ . _ , m__.- . . 2 .m ,; . 7 r testimony and other evidence. As discussed in that section, I at least some of the inconsistencies may be more apparent k than real. Regardless of how the inconsistencies are r h resolved, we concluded that the following points are ' strongly supported by the e'vidence. [ L First, (VV)'s. personality and status on the crew helped i I: explain'his reaction to the safety limit.
~
As the most
^'
experienced and technically proficient CRO, (VV) occupied a [ t leadership role on the crew. He was an informal mentor and instructor to other operators, who often relied on his b expertise.17 At the same time, [VV) impressed his supervisors and fellow crew members as outspoken, head-w strong, opinionated, and sometimes overbearing toward b others.18 He liked his job, having turned down an offer of u promotion to Gos, and was intensely proud of his operating Lj skills. Thus, committing an error of the magnitude of a T safety limit viol'ation was particularly traumatic for C
' n (VV). GSS [HH] linked (VV)'s personality and status to his F 6
actions regarding the tape as follows:19 , ((VV)] thinks he's an ace operator and . . . he makes a safety violation which is . . . ( about the worst thing you can do down here c.- and . . . it causes you to do strange things t you really can't justify. 7 Second, the context in which (VV)'s tearing and a disposal of the tape occurred tends to negate an inference of intent to conceal. Like (HH), (VV) could not rationally 'Ij have expected to keep the safety limit violation a secret ., from higher management or the NRC. Four other persons J l J
- -- . - - - N:-
5 observed the violation. if even one of them revealed what ) he saw, any attempt to conceal the violation would be e frustrated. The evidence did not indicate that any of the l G h others, let alone all four, agreed to remain silent or l Fi otherwise provided (VV) with a reason to believe he could 'l confine knowledge of his error to the persons in the control
=l ~. ' ] room at the time it occurred. Moreover, even if the crew 7( remained silent and the SAR tape were destroyed, (VV] had 1 reason to believe that evidence of the safety limit
{ violation could be found elsewhere, such as in the plant's computer.20 tU d
'd A third circumstance indicating that (VV) did not !3 intend to conceal evidence was that he did not destroy the d
section of SAR tape pertaining to the safety limit viola-
!]
g tion. The search of the trash receptacles ordered by man-3 agement yielded tape covering the period 2:17:45 to 2:24:35, i which, we concluded, included the entire incident from the onset of the alarm until it cleared approximately two a] minutes later. (As detailed in Section c-1 of the Taylor el l], j Report, the recovered sections made the tape complete from
;[ 2:17:45 onwards.) If (VV]'s account of events is accurate, jd[ this tape was what he ripped from the SAR in a fit of anger, j]1 wadded up and threw in the wastapaper basket, c
a Thus, the SAR tape providing the best evidence of
^f (VV]'s error was preserved, albeit in a wastepaper basket.
1 The rest of the missing tape -- which had little or no J 'I b 9] 4 0 __ _. -._._ -__ .___ _ , _
. c Y
e relevance to the, safety limit violation - was never _ recovered, presumably because (VV) flushed it down the toilet. Recovery of the relevant portion of the SAR tape is ' m consistent with (VV)'s contention that he tore and disposed b of the tape at random, in anger, and without regard to [ 1 content. It is seemingly inconsistent with an attempt to 5 conceal evidence of the safety limit violation, because if C that had been (VV)'s intent he could have simply flushed the ;7 relevant section of tape down the toilet. \ t-l Because certain data suggested that (VV] might have L l closed h2th of the two open dischange valves, instead of r just one, there were management suspicions that this is what he was trying to conceal, and that the tape he flushed contained evidence of a second loop closure.21 on the basis of our technical analysis, which established that only one - loop was closed, we concluded that this possible motive did - not exist. Thus, there was strong corroboration for the central -
~
thrust of (VV]'s testimony regarding the SAR tape -- i.e.,
- that he acted out of self-directed anger and frustration and I
- l. not to conceal evidence. The fact remains, however, that .
l :-
- (VV) tampered with a document relevant to the safety limit i
.l violation.22 Once he had done so, whatever his motives, he -s created an additional problem for himself and the crew. His I l
o reaction to that problem is discussed below. l t ! J l
': i ft ,
\
- 4. ReDortino of destruction / concealment of -
.p SAR taDe (L l After tearing the SAR tape and putting most of what he l C had torn in his pockets -- actions that were probably com-
} plated well prior to 3 a.m. -- (W) remained silent about what he had done until approximately 7:30 a.m., despite questions from (HH] and others concerning the whereabouts of
', the tape. Then, after the announcement that the crew was I being suspended from licensed duties -- an action the crew attributed to the apparent concealment of evidence -- he told (A) and (HH], and shortly thereafter (R), that he had torn the SAR tape and let it drop on the floor. He did not tell any of them that he had, in addition, thrown some of s3 the tape in a wastepaper basket and flushed the rest down 9
ti the toilet.23 He then told (I), (II), and (ZZ] about tearing the tape, again omitting the rest of what.he had done.24 o [j Later in the morning, (W) appeared before a critique lJ panel and, after being questioned about the safety limit o Ij , violation itself, volunteered that he had torn the tape but
~
again did not reveal that he had done anything further with U! " it.25 l< t (W) first revealed that in addition to tearing the q tape, he also took it away and disposed of it, when he U returned to the plant on the afternoon of September 11 and , flu spoke to (R).26 His explanation for not speaking up earlier r ';-
.J !;.3 '1 A . - _
E L was that he was so ashamed of what he had done that he could not face revealing it to his fellow crew members.27 , T This explanation is at least partially supported by the u evidence. As discussed above, (VV]'s personality and status S. on the crew, as described by his supervisors and fellow crew , members, were such that a full confeasion of what he had - done may have been particularly difficult for him. , Additionally, it is clear that (VV) remained silent about E the tape disposal long past the point when he could have had y any plausible hope of concealing the sa'fety limit violation. This, too, is consistent with (VV]'s explanation ,' that emotional and psychological factors inhibited him from reporting his actions with respect to the tape. _ Because (VV] expected more severe punishment for the - safety limit violation alone than the other crew members ,, thought he would receive,28 it is likely that he was also i inhibited from reporting earlier because of the additional punishment he could expect as a result of what he had done with the tape. Whatever his exact motives, based upon the overall circumstances, we concluded that (Vv]'s delay in .1 l reporting what he had done with the tape was not caused by . J an intention to conceal the safety limit violation or data ],
.J pertaining to it.
1 S. Summary of conclusions 1 (VV) caused the safety limit violation when, in a lapse .J 1 J
'I
_j
- 7. .
h - of concentration, he commenced a "no anal shutdown" procedure I for taking the "B" and "C" recircula*: ion pumps out of
~
g service. This procedure, which invo:.ved closing the l f:
' discharge valves before tripping the pumps, was inappropri-ate for the existing plant conditions because only two rceirculation loops were open, the minimum required by the safety limit. (W) realized his mistake when, seconds after moving the "B" discharge valve control to the closed position, he saw the green safety limit alarm. He immedi-ately corrected his error by opening the "D" and "A" dis-charge valves, and the alarm cleared less than two minutes j after it had been actuated. The "C" valve remained open throughout the event.
4 Because the safety limit alarm was witnessed by the GSS (j and cther members of the crew, (W) did not have to report y that it occurred. Later, however, he was called upon to describe how it occurred, and the sequence of events he @ described was for the most part consistent with the tech-la nical analyses and other evidence. To the extent that {nI, (W)'s account could not be reconciled with the technical q data, we concluded that (W) erred in his recollection. The evidence did not support a conclusion that the inaccuracies Fl - in his description were intentional. M p- At some point after the safety limit alarm cleared, and 7", probably between 2:24 and 2:32 a.m., (W) went to the SAR [, machine and tore tape away from it, including the portions t .t
of tape reflecting the safety limit violation. He threw g some of this tape -- including the portion relevant to the i violation -- into a wastepaper basket, and later flushed the ' n rest down a toilet. We concluded that (VV)'s tearing and c i disposal of the tape resulted from self-directed anger and .
~
frustration, and not from an' intention to conceal evidence. IR
'. . -j (VV) did not report to (HH] or anyone else what he had ,
-T done with the tape until approximately 7:30 a.m., when he ;
admitted tearing it from the machine but denied doing anything further with it. He did not admit that he also ~ disposed of the tape until late afternoon on September 11. ~
~
We concluded that (VV] delayed reporting what he had done with the tape because of embarrassment and the possibility _ of additional punishment, and not because he hoped to conceal the safety limit violation or data pertaining to it. a [ i s Se i .
,7 OM r
q J l
d G b - NOTES
)J
- 1. (VV), pp. 180, 198. ,
X
- 2. Ihid., p. 36.
15 d 3. (VV)'s actions are explained in detail in Section VI(A) of this report.
- s. ~
El
- 4. (VV), p. 83.
7 -
- 5. Ibid., p. 198.
D L$ 6. Ibid., p. 110. - e }[ 7. Egg infra note 9. r'! 8. Section VI(A). [lu l 9. E2gs, [HH), pp. 154-57;
- U (MM), p. 22; p
tj (A), p. 17. 3 10. (R), pp. 110-12;
. _i (o), pp. 16-18; r;
!) Volume III (Taylor Report), Section E. eq [j, NRC Augmented Inspection Team Report No. 50-219/87-29 (Sept. 28, 1987) at 5 ("The safety significance of h, this event is considered low . . . . ") (Exhibit 27). tJ
- 11. Volume III (Taylor Report), Section D-7.
r, 1i w
- 12. EA22, (II), 10/8/87, pp. 38-39; L.
l (X), pp. 12-13. I .- 67 - n .A .J
#T U.
- 13. (A) Chronology (Exhibit 10);
- r (A), pp. 153-56; ![
(SS), pp. 26-27. g (MM], p. 98. - ' T
- 14. Critique Notes (Sept. 11, 1987) (Exhibit 11). S 7
- 15. (VV), pp. 158-59, 185. 12
~
Section VI(D) .
- 16. -
o
- 17. Eigt, (HH), p. 48; ,
(A), pp. 16-18; R (VV), p. 109.
- 18. E2gs, (HH), pp. 48-49; l
(R), pp. 13-14. E
~
i
- 19. (HH], p. 310.
l c<
~
- 20. Egg, 32gs, (VV), p. 164; l '
(A), pp. 124-26 (discussing uncertainty about u l capabilities of SAR, computer). -
- 21. (R), pp. 109-12. e[
(O), pp. 28-42.
- 74 LJ
- 22. (VV)'s conduct was arguably unprofessional within ,
I the meaning of Station Procedure 106, Section 4.4.1 (Exhibit j 16): - l All shift personnel shall conduct themselves 3 in a safe and professional manner at all LJ times. 7 t w l
~J 1
I d
4-I ([ .
~
- 23. (VV),Epp. 175-78; 2 (A), p. 157; p (R), pp. 115-16.
7 24. (I), 10/8/87, pp. 93-95; [II), 10/8/87, pp. 132-33; (ZZ), 10/8/87, pp. 180-81. {Q0 '- 7, 25. [VV), p. 192; critique notes (Sept. 11, 1987), p. 6 (Exhibit 11). [<.
- 26. (R), p. 131.
0 ,
- 27. (VV), pp. 176-77; 194-95.
7 ) 28. SAA Section VI(B). il
-1 lJ L) u j s Q.
- a. t a
l'I a.
~ r
.o m.
I il O r
m , In u
.[.Ill U
~'
(II) has been a licensed CRO at Oyster Creek since , C 198?,f and began working on "B" shift in January 1985.1 He {' was the "lead" CRO on September 11, 1987, among whose duties , 6 it was to maintain the control room log and handle communi- 1 catiens to and from the control room.2 7 En
- 1. Safety limit violation f, c
(II) was at the lead CRO desk when the safety limit alarm came in.3 He had participated in discussions about how to stop the leak on the twenty-three foot level, leading n to the decision to close certain valves in the RBCCW system in order to isolate the leak. (II), like the others, was i
.J aware that procedures required shutting down recirculation pumps once there was a loss of RBCCW.4 He recalled seeing (VV) standing in front of panel 3F, where the recirculation o pump controls are located, preparatory to. shutting down the pumps.5 Possibly because his attention was diverted by the fj J
telephones, (II) did not see what (VV) did with the controls; the next thing he recalled was the audible alarm { sounding.6 He looked up, saw that the visual alarm was \; c.1 green, and immediately realized that it signified the jJ violation of a safety limit.7 (II) was familiar with the alarm because it was relatively new, and he recalled seeing it being installed and tested.8 l After the alarm, (II] saw (VV) reaching to open valve
~
l l
n
, controls.9 (II) understood these actions 'to mean that (VV)
$ was trying to get other loops open to maintain a flow equal g to or greater than that provided by two loops in compliance a'
with the safety limit. He then recalled seeing the alarm
)
".n l clear.10 The testimony of the other witnesses was generally consistent with (II)'s account of his actions and obser-1 .
. vations immediately before and after the safety limit
', alarm. One witness, (PP), did recall hearing (II) referring to the green alarm and saying "that's supposed to happen,"11
.] while (II) testified that he did not say anything in response to the alarm.12 We did not find this discrepancy to be significant. There were understandable differences in
_, recollection about words uttered in the immediate aftermath 1 to of an event as startling as a safety limit alarm. ' in any g event, whether (II) made the statement attributed to him has y little apparent relevance to the issues under consideration in this report. l l9 In summary, the evidence showed that (II)'s actions $1. prior to the alarm were appropriate to his duties as lead CRO, and that he did not contribute to the operator error
., that caused the safety limit alarm.
U
- 2. Recortino of safety limit violation fl O
As discussed elsewhere, (II) and the other crew members 1[1 l who witnessed the alarm had no immediate duty to report it 4 T '. uj
F e because GSS (HH) was present when the alarm came in and it c was clearly (MH]'s responsibility to notify higher management. As lead'CRO,.however, (II) was responsible for 7 a maintaining the control room log accurately, in accordance with established practices and procedures. The primary written standard for maintaining the con- $ u trol room and other logs is Station Procedure 106.13 - 1.' Section 4.4.10 of Procedure 106 directs the CRO responsible . for maintaining the control room log to record, among other rf i things, "any unusual events, including a summary of investi-gations and conclusions, if known during the shift." 'Such log entries "shall be made at the time indicated on the log,"14 and if any log readings are missed, "the reason shall be stated en the log."15 Log entries are required to ,' be "written clearly, precisely and completely."16 - c1 (II)'s log entries concerning the safety limit event - began with a description of the leak on the twenty-three D)i foot level and the attempts "B" crew made to isolate it. In l an entry listed for 2:20 a.m., he stated:17 Received call from Rad con of large leak , coming from V-5-167 RBCCW viv, per GSS Removed B&D RCP's & raised Rx level to 185 by S Gemac, isolated V-5-166 and the two manual l RBCCW vivs to drywell. Leak came from V ;l l 167 while mechanics removed packing - viv was f] not backseated. We had V-5-167 backseated and leak stopped. 'il gallons of water is ) i estimated from in". - tor. Per GSS opened V- g 5-166 and both ma..m_A isolation RBCCW valves on 51' ele. For leak test on V-5-167 - 980
- gpm flow established to D.W. and no observ- ]'
able leakage en V-5-167. Warming A&D Recirc _s : MG's sets for pump start prior to lowering 1 j .-
-%. - ,- ---.,,,,r-,---,-,-.v- . . - - , - - . - , - - , ,-.r ._-.w-cm,,myw- ,.1 ,.--,.---,-+__---,,..---,--.-,-v-
lcyc1 b2ck to band. - E The next entry, for 3:00 a.m., reflected the starting L of the "D" recirculation pump. Then, the "A" pump was , started at 3:05 a.m., according to the log. The entry after that w'as logged as a "late entry" for 2:30 a.m., and read as 7 i follows:18 h Late entry: During the leak incident on 23' 13 R.B. While tripping off B&D RCP's due to
, isolating the RBCCW to the drywell, Discharge m, viv's were closed on these pumps. At this time A, D, E Pp's were off of disch vivs closed. The alarm E-4-B came in, less than 2 loops open, which violates Tech Spec safety l limit. While B&D RCP's disch viv's were d going close, two other loops disch viv's were being opened. The time with less than 2 ], . loops open was very short. .)
This "late entry" was followed by a repetition of e. 3:00 a.m. entry previously made concerning a routine fire tour.19 M y The unusual sequence of these entries and some of the details contained in them helped fuel GPUN management sus-y(n picions that the crew was or had been attempting to conceal ,
.; either the safety limit violation or certain aspects of it.20 7
3, With respect to the timing of the log entries, (II) , n testified that his 2:20 a.m. entry was probably made in the
$ period after the alarm, after he checked to see if (ZZ)
M needed any help raising the reactor water level.21 He did
.u
, not log the safety limit violation at that time because 22 ip! 's I I was going to go back and ask for help, as to how I was going to write a safety (limit) violation. This (i.e., the 2:20 entry) I could write, because I've done this before, {e hu
- 73 -
- 0. - '
5 E accidents, incidents. But safety limit, I , wanted help from either (HH) or (A). ':7 (II) further testified that he at all times conside' red the . y safety limit violation something he had to log, never _b intended not to log it, and delayed making the log entry q
;?
only because he wanted advice from the GSS or the GOS on how to log such a violation.23 E W, Ultimately, (II] logged the safety limit violation N without help from (HH), (A), or anyone else.24 He explained that he did this:25 . Because it got busy, and (HH) was occupied in his office doing what he was doing. (A) was too busy, you know, just stopping to figure i out what's going on. I figured, well, I'll just tackle it myself and do the best I can. 7 He estimated the time he made the late entry to have been around 3:15 -3:3C a.m., and certainly between 3:05 a.m. and 4:00 a.m.26
~
(IIL said that he had to estimate the time of the l :j safety limit violation because SAR data were unavail- y able.27 His log entry placing 2:30 a.m. as the time of the , i 1 alarm was based upon his earlier estimate that the leak 11 occurred at about 2:20. He estimated that the alarm came in C about ten minutes after the leak.28 .~ 1 The other crew members corroborated most of (II]'s testimony concerning the timing and circumstances of his 'i
],
logging the safety limit violation as a "late entry." All testified that they did not help (II) write any of the ]
- 74 -
1
~
entries. (ZZ) recalled trying to fix the time of the alarm, and hearing (II) mention, after 3:30 a.m., something about not knowing how to log the event.29 y (I) said that late entries are not uncommon;30 (A) confirmed this, explaining [; that CRos sometimes ask supervisors to help with entries, especially on important and sensitive matters.31 (A) also p_ t3 recalled that (II) asked him to help with the entry, but
, that he became distracted and provided no help:32 I believe I said to him, I'll be right with , you, (II), and other things were happening 1 and I forgot about it. I forgot about it and i I didn't help him. ] (A)'s recollection differed from (II)'s, however, in what prompted the log entry. (A) recalled:33 3
When (HH) entered the control room and said, (R) says we're going to report this as a safety limit violation, and (II) said, I ] guess I should log this, huh?
- a q And I said . . . absolutely, you've got j .to log it . . . .
Based upon other evidence establishing the times of L,y' [HH]'s telephone conversations with (R), the conversations
?.] described by (A) occurred at approximately 3:45 a.m. This J.
is consistent with (II]'s time estimate for the late entry
}. (3:05 - 4:00 a.m.), and with (ZZ)' recollection that (II) , had not made it as of 3:30 a.m. It is also consistent with $ (II)'s testimony about unsuccessful efforts to find the time g of the alarm on the computer 34 -- efforts that logically would have preceded the logging of the event and that other testimony shows occurred after (HH) disclosed the safety a
" M U _.
tT liJ limit violation to (R).35 g A We concluded from the above that the most likely time - for (II]'s logging of the safety limit violation was between I 3:45 and 4:00 a.m., and that it occurred after (A), in " response to a question from (II), said that the event should' be logged. (II) and (A) agreed that they had a brief conversation about the log, and that (II) asked for help in 4 writing the entry (which (A) ultimately did not provide). m However, (A)'s description of the context of this discussion . q i.e., that it occurred after the second (HH]-(R) conversation in response to (II)'s question of wheth.gr he should log the event -- was more specific, plausible, and' better corroborated by the otherwise established sequence of events than was (II]'s.36 J Despite our conclusion that (II) made the log entry , about the safety limit violation only after it had been - reported to (R) and after (A) had told him to log it, we did '
~
not find that (II) delayed making the log entry because he harbored an intention to conceal the violation. [II]'s 7 9 desire to have assistance from the GSS or GOS before making - the entry was not implausible'under the circumstances. He .j had never experienced a safety limit violation before,37 but knew that it was a particularly important event. GPUN l procedures encourage operators to consult with supervisors j when documenting such events.38 (A) was unavailable until 1 after 3:00 a.m., and was again out of the control room twice j l
? I a
between 3:00 and 3:30 a.m. (HH), as discussed elsewhere, b u was preoccupied with other matters part of the time and had
.? otherwise adopted a passive role with respect to the safety limit violation. Moreover, the discovery that SAR tape was missing -- which, as discussed elsewhere, was communicated to (II) between approximately 3:09 and 3:15 a.m. -- .C t complicated the task of making an accurate log entry.
That the entries (II) finally made without anyone's assistance contained errors, some of them obvious, tended to d confirm his and (A)'s testimony that supervisory assistance 7 is appropriate for some log entries. As (A) put it, "I would actually, as a supervisor, rather have a late entry
] than have an inaccurate entry on time."39 il LJ Unfortunately for the suspicion they helped cast on the crew, (II]'s log entries concerning the safety limit event q
Q were neither accurate nor timely. After the 2:30 a.m. "late entry," he repeated a previous 3:00 a.m. fire tour l,a M entry.40 (II) said that this was a mistake.41 Addition-7 ally, as discussed elsewhere, there were internally J. - inconsistent statements about which pumps (W) was P l[ - attempting to trip ("B" and "D" instead of "B" and "C") as well as a statement -- which our technical analyses indicate
,q d was inaccurate -- that (W) closed two discharge valves instead of one.
f.J NJ This latter statement, based on (II]'s assumption g) b rather than on any information supplied to him,42 conflicted a Li d
F9 i} with reports of the event submitted by other members of the 7 crew.43 The resulting confusion over how many valves had 1 been closed combined with other circumstances to cast doubt E v on the integrity of the crew's reports to management. Despite the appearances created at the time, the evi-7 dence supports the conclusion that the inaccuracies and - ' inconsistencies in (II]'s log entries were inadvertent. ; Some of the errors -- the repetition of the 3:00 a.m. fire b, tour entry and the confusion of "C" and "D" pumps and valves -
~
-- were the result of carelessness. The statement that two valves were closed resulted from (II)'s reliance on .t assumptions and personal recollections that were not checked against other information. (As discussed in Section VI(A),
some of the early technical analysis conducted by management personnel and the NRC agreed with (II]'s assumption, but this was unknown to (II) at the time.) In large part, (II)'s reliance on these assumptions resulted from the - unavailability of SAR data, combined with the lack of help i from the GOS or GSS and (II]'s failure to obtain a complete - account of the event from (VV]. f" l
- 3. Destruction / concealment of SAR tace 'M (II) testified that the first time he saw the SAR machine on September 11 was when (ZZ) took him to the .
I machine to show him the condition of the tape.44 This 2 occurred shortly after (ZZ) told GSS (HH), in (II)'s .} presence, that the SAR tape was torn or missing.45 [77) 1
observed that part of the tape was hanging out of the top of F h the machine, and that it was detached from additional tape q that was on the takeup reel and lying on the floor.46 By b comparing the times on the various pieces of tape, (II] O concluded that the tape "was definitely cut," and
>J "definitely missing,"47 as opposed to its having run out of n '.
[' paper. At that time, (II] had no idea how the tape came to be missing.48 _ (II]'s account of how he learned that SAR tape was
')
J missing was consistent with the other evidence. As discus-p sed more fully in another section of this report, we con-iJ cluded that neither (II) nor any other member of the crew, 7 [ except (VV), engaged in any tearing, destruction,
._ conceal. ment, or disposal of SAR tape.
t '! 1 L -
- 4. Recertina of missina SAR tace
[, [ 1 (II) first heard that SAR tape was missing when (ZZ), in (II]'s presence, told (HH] about the missing tape and asked both (II] and (HH] whether they had it.49 Later, l J. according to (II), he went back to (HH]'s office and 1 q> confirmed that the tape was missing, after having viewed the
. SAR machine himself.50 (HH] recalled neither ll conversation.51 a
g It Bacause (II] was aware that the GSS knew about the l' 1c, missing tape, he did not have any immediate duty to report it to higher GPUN management. We found no substantial l- , '1 U3
m evidence to support a conclusion that (II] attempted in any -, b way to conceal the fact that SAR tape was missing, or to I misr'epresent the condition of the tape. I D (II) did not make any entry in the control room log g G concerning the missing tape because:52 (T]he thought just hadn't come into my mind 15 L to put it down. It's not a piece of equip-ment. It's not a pump. I tried to put down , what I think is -- as far as machinery -- T related incidents. 2 Other witnesses testified that the discovery of the m missing tape was not the kind of event that should be recorded in the control room log.53 The written guidelines . for control room log entries 54 leave room for interpretation P on this subject. We concluded that (II]'s not recording the ;j fact that SAR tape was missing resulted from a genuine l, J perception on his part that such matters were not proper material for the log. T
- 6
- 5. Summary of conclusions *:
(II) did not contribute to the operator error that caused the safety limit violation. Because GSS (HH) wit- .-
~
nessed the safety limit alarm, (II) was not responsible for
, vi reporting its occurrence to higher management or to the -
3 NRC. As the designated "lead" CRO, however, he was respon- ,j sible for making an appropriate log entry concerning the violation. The entry he made, styled a "late entry" because : it was out of sequence with other entries in the log book, 1
-]
contained internal inconsistencies and factual errors.
~
t
B . These, we concluded, were inadvertent, resulting from carelessness, reliance on assumptions, and lack of assist-Q ance from other members of the crew. c F [II) took no part in the destruction, concealment, or disposal of the SAR tape. He learned about the missing tape when, in (II)'s presence, (ZZ) reported it to (HH). Because (HH), and shortly thereafter (A), knew about the missing 3-C tape, (II) incurred no immediate responsibility to report it m to higher management or the NRC. Later, when asked about the tape by a critique panel, he rendered an accurate ( account of what he knew. control room log about the tape because he believed that it He did not make an entry in the I4 u was not the kind of event that should be entered on the log. p~ G G m. d n. g . b F'1
;t d
r1 U
,}
U __ ._ _. _ _. , _ _ _ _ _ _ _ __ _ _. _.
4 NOTES ,T
- 1. (II), 10/8/87, pp. 5, 7. .
O 2y Ihid., pp. 12-14. , c. L
- 3. Ihid., pp. 52-54.
c
- 4. Ihid., pp. 47-50. ,
~'
- 5. Ihid., pp. 53-54. d t l
- 6. Ikid., pp. 54-55. J
- 7. Ibid., pp. 60-61. .'
- 8. Ikid., pp. 61-62. ~~l
- 9. Ibid., p. 66.
]{
..s
- 10. Ib.id., p. 67. ~
~ u
- 11. (P) , p. 32. .
a
.l
- 12. (II), 10/8/87, p. 66.
e
- 13. Station Procedure 106 (Exhibit 16).
. -)
- 14. Ikid., Section 4.4.1, p. 20.0 (Exhibit 16). p) {
1
- 15. Ibid.; jt 111 (II), 10/8/87, pp. 18-19. :
f
- 16. Station Procedure 106, Section 4.4.2, p. 21.0 , 4 (Exhibit 16). ],
M i
- 17. Control Room Log, midnight-8 a.m. shift - Sept.
- 11, 1987 (Exhibit 6);
(II), 10/8/87, p. 38. b
- 18. Control Room Log, midnight-8 a.m. shift, Sept. 11, 1987 (Exhibit 6);
(II), 10/8/87, p. 223.
- 19. (II), 10/8/87, p. 126-27.
- p -
(S 20. Section VI(B).
- 21. (II), 10/8/87, pp. 74-76.
- 22. Ihid., p. 76.
J Tl 23. Ikid., pp. 99, 100.
;j .;s
- 24. Ikid., pp. 99-100, 126.
!L
- 25. Ihid., p. 100.
_O ~
- 26. Ikid., pp. 95-96.
'n U
- 27. Ikid., pp. 100-02; 111.
- ll a' .
- 28. Ihid., pp. 111-12.
?G
'J[ 29. (ZZ), 10/7/87, p. 170. l A
- 30. (I), 10/8/87, p. 91.
{ 31. (A], pp. 151-52.
- 32. I)21d. , pp. 151-52.
- 'yj I .
5 . Jet- ,_ ,
'oI
- 33. Ihid., p. 151. ;T L
- 34. (II), 10/8/87, pp. 135-36. {r O
- 35. (ZZ), 10/7/87, pp. 164-65; c, (A), p. 124. -
b c 36. 87-95. Compare (A), pp. 151-53 gith (II), 10/8/87, pp. Il
- 37. (II), 10/8/87, p. 71. "
- 38. Station Procedure 106, Section 4.4.2, p. 22.0.
b a l
~
- 39. (A), p. 152. .
- 40. Control Room Log, midnight-8 a.m. Whift, Sept. 11, ]
1987 (Exhibit 6). -'
- 41. (II), 10/8/87, pp. 126-27. J]
- 42. Ibid., pp. 115-16; ,
(A) Chronology (Exhibit 10);
.l GSS Log, midnight-8 a.m. shift, Sept. 11, 1987 1 (Exhibit 7). .
- 43. GSS Log (Exhibits 7); I m
(A) Chronology (Exhibit 10). {:j
- 44. (II), 10/8/87, pp. 105-06.
]
- 45. Ihid., p. 103.
- 46. Ibid., p. 107. >
- J
- 47. Ibid., pp. 108, 109 4
c - [I . { 48. Ibid., p. 109 q- 49. (ZZ), 10/7/87, pp. 123-25;
. .s ~'d (II), 10/8/87, pp. 102-03, p
W 50. (II), 10/8/87, pp. 110-11. 7,0 . D' 51. 133 Section VI(E);
, (KH), p. 164.
- 52. (II), 10/8/87, p. 128.
.J
- 53. (ZZ), 10/7/87, p. 173.
C k' *
- 54. Station Procedure 106 (Exhibit 16).
F1 a 1 J W Ql d; .
\
<f.
ld
- n! p
,0 l . f. Q ,Il w c n]
9 g m E (ZZ) received his CRO license in 1985, having previously worked at Oyster Creek as a CRO trainee, an EO, a
- station helper, and a utility worker.1 He had worked on "B" '[W crew for approximately one year prior to the safety limit I:
violation. b
- 1. Safety limit violation i On September 11, 1987, (ZZ) was designated as the [
u technical specification CRO.2 He and (W), the designated extra, were in charge of the control panel. When (HH] took , out the prints to verify the location of the leaking valve, y L .t everyone in the control room had a turn at examining the prints.3 (ZZ) recalled (HH) saying that they would isolate the RBCCW to the drywell, after which (W) and (I) began the m isolation. (ZZ) thought to himself that after removal of RBCCW they had sixty seconds to take the recirculation pumps out of service l'. order to prevent overheating of the - motors.4 5 (ZZ) recognized that without the recirculation pumps rg
*4 running, it was necessary to raise the reactor water level .
in order to promote natural circulation.5 ;] J j (ZZ) recalled seeing (W) proceed to panel 3-F to -
~
I remove the recirculation pumps from service.6 (HH) than gave the direction to "take the pumps off."7 In less than a ' i minute, (ZZ) heard the less than two loops alarm. He turned r
L@ . g his head to the panel and saw the green color designating a safety limit violation.8 (ZZ) immediately grasped the
] seriousness of the offense. He had been trained to regard a ud safety limit as one of the ten commandments in nuclear 1"
Q power.9 (ZZ) had not seen (W) close any discharge valves. When his attention was drawn by the alarm, however, he witnessed (W) immediately opening two discharge valves.10 For the next forty-five minutes, (ZZ) was actively
, involved in responding to conditions caused by the isolation d
v of RBCCW to the drywell. He raised the reactor water level,
, and later a decision was made to put two recirculation pumps back in service. (ZZ) then started to lower the reactor water level.11 After conditions stabilized, the crew discussed the safety limit violation.12 ]
(ZZ)' account of his actions and observations 7 d ir. mediately before and after the safety limit alarm was g generally consistent with the other evidence. One apparent discrepancy concerned (ZZ)' recollection that he was
, preparing to raise reactor water level after (W) shut down
!- the recirculation pumps.13 our technical analysis showed q g that, although the process of raising reactor water level ,
,3 continued beyond the point when the pumps were shut down, it b began before (W) started the pump shutdown procedure.14 n 'j The weight of the evidence, however, clearly showed l
13
~
67 -
,i
Ni that (ZZ) had no role in the operator error'that caused the T safety limit violation. , E !
- 2. menortina of safetv limit violation -V S
As (ZZ) knew, (HH) witnessed the safety limit violation 2 and was responsible for properly reporting it.15 f. ic Although (ZZ) was not responsible for reporting the , safety limit violation once its existence was known to (HH), 'a he took steps to insure that the violation would be r reported. (ZZ) was the first to tell GOS (A) about the '
, *1 .
safety limit violation when, at 3:28 a.m., he asked (A) to fj step outside the control room. There, (ZZ) told (A) about ,
, *] i
~
both the safety limit violation and the missing tape, which J
~
r prompted (A) to confront (HH] about reporting the event to
][
at higher management. Although the violation was ultimately ' disclosed by (HH] when (R) called back and asked a question,, i (ZZ)' initiative in notifying (A) could have made a critical . difference in the ultimate reporting of the violation. By notifying (A) and thereby prompting the confrontation with 7( l (HH), (ZZ) virtually insured that the violation would be . reported, even in the absence of a call from (R). hl!
;> t In taking the initictive to apprise (A) of the l J
i significant events that had occurred while (A) was out of the control room, (ZZ) displayed sound judgment and an _, awareness of his responsibilities as a CRO. - I d
- 3. Destruction / concealment of SAR taea e
~ , It was (ZZ) who, shortly after 3i00 a.m., first discovered that SAR tape was missing.16 He immediately l
[ reported his discovery to (HH), and asked if (HH] had the Q tape. (HH] had a "dumbfounded expression" on his face and r { did not respond.17 (ZZ) then asked everyone who was in the control room at the time of the safety limit violation if they had taken the tape. They all said no.18 A short time later (ZZ) searched 7 the trash for the missing tape.19 As discussed at length in sections VI(D) and (E), the C L evidence showed that (ZZ) had no role in the destruction, disposal, or c0ncealment of the SAR tape. On the contrary, .cy] as soon as he learned that it was missing he promptly reported it, questioned others if they knew where it was, and undertook a physical search for it. In so doing, he once again demonstrated initiative and a sense of
,q responsibility.
- J
- 4. Recortinc of missina SAR taos 7
j, (ZZ) promptly reported his discovery of the missing SAR data to (HH). Although (HH] testified that he did not l y recall this report, we concluded that (ZZ) made it.20 By 1 f'J advising (HH), (ZZ) satisfied his reporting obligation. As discussed above, however, he went further by asking the
]
v control room crew about the tape and later notifying (A). c. ( The evidence strongly supported the conclusion that (ZZ)
,J J__ ._ ___. ___ _ - _ _ . _ _ _ _ _ _ _ _ -- --
>ty reported the missing tape in a timely and appropriate '
manner. . f
;fi
- 5. Summary of conclusions e
J. l
'~
(ZZ) did not contribute to the operator error that caused the safety limit violation and, under the circum- +7
. .:i stances, was not responsible for reporting that violation. -
He nevertheless took the initiative of reporting it to (A), T,!j resulting in (A)'s insistence that (MH) report the violation - immediately to higher management. (ZZ) took no part in the ' destruction, concealment, or disposal of the SAR tape, and Q, d; acted in a timely and appropriate manner when he learned that tape was missing. Apart from (W), he was the first 1,; , member of the crew to notice that tape was missing, which he immediately reported to (HH) and, shortly thereafter, to
.).-
(A). V 0
+mA t
e.4 e (
'd i a
i i 'l i
..]
.a
(
0 C NOTES
-[$
- 1. (ZZ), 10/7/87, pp. 5-8. i q!
r O
- 2. Ibid., pp. 18, 31.
r ( 3. Ibid., pp. 54-58.
- 4. Ibid., pp. 58-59, 64. Egg Station Procedure 301,
~
Section 5.2.3.6, p. 20.0 (Exhibit 17).
=
- 5. (ZZ), 10/7/87, p. 66. 133 Station Procedure 301,
,? . Section 7.2.6, pp. 33.0-34.0 (Exhibit 17). yI.
- 6. (ZZ), 10/7/87, p. 72.
t
- 7. Ihid., p. 73.
- 8. Ibid., pp. 74-76.
'" 9. Ibid., p. 78. Q id 10. Ibid., pp. 94-95. (3 0 11. Ihid., pp. 99-106, s 'p
- d. , 12. Ihid., p. 109.
. 13. Ibid., p. 71.
~
- 14. Volume III (Taylor Report), Table E-1.
[q 15. 113 Section VI(B). Cl
- 16. (ZZ), 10/7/87, pp. 120, 110-112.
- Fj
- La
- 17. Ikid., pp. 123-124.
- n
.?
- q
'O
19 ra
~
- 18. (ZZ), 10/7/87, p. 125. -
s.1
- 19. Ikid., p. 126. -
l'
- 20. 3.33 Section VI(E);
.q (HH], p. 164. f
.T e .,',I e
N 4
.a m
3
-i e
s
?,', {
a e W
- an 4.
b s *d s.d
;s
'l 4
.)
I t
m il . m
,2 v
On September 11, 1987, (I) was a CRO trainee. He had . O completed a year to fourteen months of classroom work in q preparation for obtaining a license as a CRO.1 (I) had been d with the company a little over fourteen years, starting as a p, '. utility worker and then advancing through a series of si positions to equipment operator and then CRO trainee.2 fM . E~l
- 1. Safety limit violation 0
.g b>
(I)'s training had not reached a point where he had any T* , on-the-job training about safety limit violations. He had u just started to get into the basics of abnormal operating r.. [, procedures.3 Whenever he did anything in the control room, he would have a control room operator with him.4 On September 11, 1987, he had not been assigned a specific job {+ on the shift.5 b, f_, (I) recalled that after (II) received a report of a iw . spill sometime after 2:00 a.m., (A) and an equipment C operator went to investigate. (A) called back reporting L. that the water was purple, indicating that the leak was in the RBCCW system. (II), (VV), (HH) and (I) were present when (A]'s call came in.6 (HH] then pulled out a print of the RBCCW system. They L; examined the print and confirmed that the leak was at V 0 167.7 Q L' ;
~~
.c l -
E (I) recalled that (A) called back and reported that G C water was spraying over a motor control center and that they,
- t should isolate the drywell.8 In the control room, they 'i decided that they should isolate V-5-166 on one side of the y, leak and two manual valves on the other side.9 (HH) N instructed (I) to isolate V-5-166. (I) accomplished this .;T from the control room panel.10 ,
.]
The next thing (I) recalled was (HH) giving an instruction to "take off the pumps." This was directed more or less at (W) .11 .., M (I) witnessed (W) go to the panel and reach out with his left hand, which was nearest to the "B" pump.12 The alarm for the safety limit violation then sounded, and (W) , reached out to open the other valves. (I) believes these were the A and D valves.13 (I) approached (W) and asked 1 LJ him why ha had not just tripped the pumps. (VV) responded: "I should have."14 (I)'s perception was that (W) was sometimes "too quick" at the controls and that this - might have helped cause the alarm.15 (W) was the fastest [q] operator enat (I) had seen.16-bj (I)'s account of his actions and observations prior to the alarm was consistent with the other evidence, except to the extent that he recalled isolating V-5-166 before the 1 safety limit alarm. (HH) testified that he had (I) perform this operation after the alarm, and the technical analysis j supports (HH)'s testimony on this point.17 However, the .
'I 4
weight of the evidence clearly demonstrated that (I) did not LI contribute to the operator error that caused the safety F) limit violation. iJ p .
- 2. Renortine of safety limit violation
,t. ), At some point after the leak had been stopped, (I) _), i, heard (HH] say something about making phone calls, after O- which (HH] went into his office. (I) assumed that (HH) was d going to call plant management.18
!]
l' As discussed in detail elsew'here, responsibility for F] reporting the safety limit violation lay with (HH), and (I) a c-knew that (HH) had witnessed the violation. The other [j evidence showed that (HH) gave no obvious indication that he was not going to report the violation. Thus, (I) was justified under the circumstances in assuming that (HH) was j' going to report the safety limit violation, and in feeling d that it was not his place to question (HH) about reporting a
'] the violation.19 >
fw We concluded that (I) bore no responsibility for any
.-,- delay or inaccurate reporting of the violation.
i? .
- 3. Destruction / concealment of SAR taee 3
(I) testified that the first time he heard any C reference to the SAR tape was when (ZZ) came around the a panel and asked (I) and whoever else was present if they had
., taken or torn the SAR tape.20 At the beginning of the '
~
-95*
ha shift, (I) had examined the SAR machine. It was functioning :.T
/, -
and had paper in it.21 Late in the shift, when (I) knew , that a piece of the SAR tape was missing, he checked a couple of the trash cans. He found only a piece of tape
,i that had no markings on.it, which might have come from a new b roll of tape when it was put in the machine.22 u
At some point later in the morning, (W) came from the direction of (HH]'s office to where (II), (ZZ) and (I) were il seated. (W) told them that he had torn the tape. (W) F then walked off to the kitchen and (I) followed, questioning m (W) about his statement. [W) said that he tore the tape .. a and dropped it on the floor. (W) then walked back out to ,,I the area where (ZZ) and (II) were, and told them that he did .., not take the piece of the SAR tape out, all he did was tear ,
]
it and drop it.23 It was not until some eight days later that (I) learned that (W) had, in addition to tearing the
. .o tape, taken it and disposed of it.24 7
~
As discussed in Section VI(D), the evidence indicated that (W) acted alone in tearing and disposing of the SAR ,'. tape. (I)'s testimony that he first learned that the SAR } tape was missing when (ZZ) asked the other control room d operators if they had torn or taken it is uncontradicted by the other evidence, and we concluded that he had no role in the tearing or disposal of the SAR tape. , f
n 4. Rennertina of missina SAR tame U As noted above, (I) learned about the missing SAR tape U't from (ZZ) who, before he questioned (I), had told GSS'iHH) that the tape was missing.25 (ZZ), a CRo, outranked (I), u] and (I) had no reason to suspect that the missing SAR tape p '.
- } would not be properly reported.
I As a trainee, (I) was the lowest ranking "B" crew member who had been in the control mom at the time of the j safety limit violation. He had no responsibility for j; reporting matters, including the tape incident, that he knew d or had good reason to believe had already been reported to I the GSS by higher ranking members of the crew.26 Although L he had no specific responsibility to do so, (I) questioned
- i. .
[] (W) about the tape's disappearance. (W) persisted in g, saying that he had just torn the tape and dropped it on the
- floor.27 - ,
R U 5. Summary of cenelusiens l' a,1 (I) did not contribute to the operator error that I
~
caused the safety limit violation. Because higher-ranking crew members, including the GSS, witnessed the violation,
* :, (I) was not responsible for reporting it to higher management or to the NRC. (I) did not take part in the destruction, concealment, or disposal of the SAR tape and, under the circumstances, had no reporting responsibilities L with respect to the missing SAR tape.
. ' T1 W
3'
~
H.Q.IZE h:
- 1. (I), 10/8/87, pp. 5-6. .
t
't
- 2. Ih.id., pp. 6-10.
p) ic
- 3. Ihid., pp. 17-18.
.D
- 4. Ikid., p. 27. l, y ,
*.:)
- 5. Ikid., p. 43.
7
- 6. Ihid., p. 47.
'T
- 7. Ihid., p. 48.
'ij
- 8. Ihid. _,
- 9. Ihid., pp. 48-49.
-s
- 10. Ihid., pp. 49-51.
- 11. Ibid., p. 52.
l .]L
- 12. Ikid., pp. 54-55. e' 3
- 13. Ihid. , pp. 57, 62-63.
- 1.]
l 14. Ikid., p. 64.
- 15. Ihid., p. 72.
l l
~
- 16. Ihid., p. 75.
j i
- 17. (HH), pp. 143-45; )'
Volume III (Taylor Report), Table E-1.
.c---.- - - -
w..7.-, _ . , - _ - ___ , , . - _ . - , . . . -,_,___e---., _.. . - _ _ _ , . . _ _ _ . _ . - . . _ . _ , . _ _ _ . . - - < _ _ _ -
- 18. (I), 10/8/87, p. 85.
k
- 19. Ihid., p. 85.
- 20. Ihid., pp. 76, 81.
- 21. Ihid., pp. 76-78.
g"'.
- 22. Ibid., pp. 79-80.
R~ bI 23. Ihid., pp. 94-95.
- 24. Ibid., pp. 101-v2.
n 25. jbita Section Vl(E) . }.]
- 26. (I), 10/8/87, pp. 81-89; gag Station Proceduro 126 (Exhibit 25).
\ .)
- 27. (I), l'0/8/87, pp. 93-97.
.Fi u - (S 'L: y u. i .S E3 L: . h 4 ll \
<1 1 U
1? t w
'd W -
C IR1 m n' L As Manager of Plant Operations, a position he had g E: occupie.". since July 1987, (R) was GSS (HH]'s immediate - supervisor on September 11, 1987. He had previously been f b operations Control Manager for two years, and prior to that F was a shift technical advisor. 1{.
- 1. Enfety limit violation ,[
c) (R) had supervised the operations necessary to put the y
. L plant in cold shutdown on September 10-11. These included
~T reducing the number of open recirculation loops to two, the g minimum required by the safety limit.1 (Operating the plant with only two recirculation loops open -- in this case the B b
of and C loops -- was a procedure that had been established 9-approximately one year earlier in order to save wear on the w pumps.2 It is discussed in more detail elsewhere.3) The uncontradicted evidence established that (R) was at :5
;i home asle3p when the safety limit violation occurred. He 3.9 did not contribute to the operator error that caused the l}
violation.
.Ae
- 2. Recortina of safety limit violation
[R) became aware of the safety limit violation at approximately 3:45 a.m. He had been awakened at home at approximately 3:30 a.m. by a telephone call from (HH), who m told him about the spill on the twenty-three foot level, but
.4
- 100 -
i e ,,, - ,- - , .~,-w.------,--,,v - . - , - , - - , . - - - , , , - , - - - - - - -
not about the safety linit violation.4 After this conver-r- {j sation with (HH), (R) called the plant Operations Director, (N), reaching him at approximately 3:35 a.m.5 (N) wanted b further details about the crew's actions to contain the 7 spill and the condition of the plant; specifically, ha J wanted to make sure that two RBCCW loops were kept open at all times.6 When (R) called (HH) back at approximately 3:45 g, a.m. to obtain this information, he relayed (N]'s admonition L. td to keep two loops open. (R) was told by (HH] that ic was "i < too late, the less-than-two-loops alarm had already been u received.7 m J In response, (R) instructed (HH] to report the incident l to the NRC as a safety linit violation.8 (This report was c completed a few minutes after 4:00 a.m.)9 (R) then called L (N) and told him about the safety limit violation.10 In the ,, course of their discussion they realized that they were I L' unsure about the time of the violation.11 (R) called the j control room at about 4:00 a.m. to obtain this additional information.12 (HH] was then in the process of reporting (: g, the safety limit violation to the NRC, so (R) spoke to 7, (A).13 As a result of this conversation (which is discussed II. G in more detail below), (R) obtained an approximate time for
- a the violation, and formed the impression that the SAR had
~
run out of tape, all of which he reported to (N).14
/:
if U The evidence conclusively established that (R) did not
,9 know about the safety limit violation until approximately a ,' 1
/ .- - 101 -
l -
. hu 3:45 a.m. Once he did know, he instructed-the GSS to make C
the notifications required by Station Procedure 126, and ~ )j immediately notified (N) that a violaticn had occurred. As r 1 a result, both the NRC and higher GPUN management were .R notified that a safety limit violation had occurred within [ N minutes after (R) learned of it. On this basis, we W concluded that (R) reacted quickly and appropriately after kj the safety limit violation was reported to him. ,k I.f a After the initial notifications had been made by tele-
?
phone, (R), (N], and other GPUN managers went to the ,j plant. By the time (R) arrived there, the fact of the , violation had been reported to the NRC and GPUN management above (R]'s level. What remained, so far as reporting the safety limit violation was concerned, was to investigate and a report the details of the violation. (R) played an active d part in that investigation, which is described below and q s elsewhere in this report. The evidence showed that he made diligent efforts to obtain all pertinent information about [ w the event and that he shared this information as it was developing with his superiors in the GPUN chain of command and with the NRC. <3
.m
- 3. Destruction / concealment of evidence I
The evidence clearly established that (R) did not contribute to the destruction, discarding, concealment, or f alteration of the SAR tape or other documents. ,
- 102 -
.I 1
gy U1 Following the series'of telephone calls described t~i lJ above, (R) went to the plant and, shortly before 5:00 a.m., g he entered the control room.15 As discussed in Section ' L1 U VI (D) of this report, the tearing and disposal of the SAR tape had been completed by that time -- indeed, the tape had {La been discovered missing before (R] was awakened by the first
.c ,j ~ telephone call from (HH]. Once they arrived at the plant, (R) and other GPUN managers were gathering information for a d 6:00 a.m. briefing and later critiques of the incident. The p evidence, as discussed in detail in sections VI(E) and (D), .,f ~
indicated that they were diligent in these efforts.16 0,
- 4. Recortina of missine SAR tace
).A a (R) first.became aware of the possibility that SAR data [1 were missing during either his second or third telephone
- L; conversation with the control room -- i.e., between approximately 3:45 and 4:05 a.m. Either (HH] or (A) -- and more likely (A] -- told him that SAR data were unavailable i,l L: for the time of the safety limit violation. (R) is "90 p percent certain" that either (A) or (HH] explained the missing data by saying that the SAR had run out of
- f. paper.17 (A) recalled speaking to (F] about the time of the y
event, and admitted that he did not tell [R) what he knew _ about the SAR tape -- 1.e., that it apparently had been torn
,; and removed. (A) denied, however, that he said anything about the SAR having run out of paper.18 !?
U Whatever the exact words used during this conversation, ii j - 103 - c) d _ _ _ _ _ _ - -
hw it is clear from all of the testimony, as~well as from the _ ' d later actions of (R) and other management personnel: (a) W that (R) did not receive a full and accurate account of the Q
-G condition of the SAR tape; and (b) that as a result, (R)
G formed the impression that the machine had run out of tape Mw and conveyed that impression to (N). Consequently, (R), S (N), and other management representatives arrived at the U, plant to prepare for briefings and critiques not suspecting bp
~
that SAR tape had been removed intentionally.19 (The testimony and sequence of events concerning how (R) and f a other management personnel discovered that the SAR tape had 3 been torn and renoved are discussed in section VI(E).] [] h After his arrival at the plant, (R] began to receive information that cast doubt on his imprescion that the SAR O had run out of tape. Also, he recalled having seen a new 0 roll of paper in the SAR earlier in the day, and this made a him "a little suspicious."20 Shortly before 6:00 a.m., (R)'s assistant, (MM], reported to (R] and (N] that the next alarm on the tape after the break in the SAR paper (which at that time they assumed was caused by the tape having run .) out) indicated that a new tape had been inserted in the ( middle of the safety limit event.21 This struck (R) as . unusual.22 There was, however, no time to investigate the $ 2 matter further prior to the scheduled 6:00 a.m. briefing, so . (N] held a meeting in his office after the briefing, which i (R) attended.23
.1
- 104 - '3 1
- 1 d ,
. I 1
Beginning with the meeting in (N)'s office, (R) and the
~
)
]19 other managers spent considerable time and energy on the r problem of the missing SAR tape. Their efforts culminated
^#
in the discovery of pieces of SAR tape in the trash, ; confirming suspicions that it had been deliberately f} t. removed. This discovery, as set forth in Sections VI(E) and 1.1 (F), was promptly reported to the NRC and to higher manage-p, ment.24 (R) diligently pursued this inquiry, and the evidence does not suggest that he at any time intended to p withhold its results from either higher management or the L NRC. {b r~ 3 Some of the suspicions (R] held and voiced openly, even l before discovery of the SAR fragments in the trash, proved upon further investigation to have been unfounded. For L' example, (R) suspected that whoever tampered with the tape was trying to conceal the fact that both recirculation loops
~
had been closed.25 our technical analysis indicates that [ this did not happen.26 u l3 5. Summarv of conclusions Li - .;- (R] did not contribute to the operator error that ];- ' " . caused the s&fety limit violation. He reacted quickly and appropriately when he learned about the violation, reporting it immediately to his superior in the GPUN chain of command t,' and ordering the GSS to notify the NRC. His reports were . (, accurate within the limits of the information available to him. (R) had no role in the destruction, concealment, or
- 105 -
6 4 p, - - , , -- -,-
l e l re disposal of the SAR tape. (R) did not receive a complete ,' n and accurate report from the crew about the condition of the & SAR tapo and, as a result, formed the impression that the er it , SAR had run out of tape. When information was brought to 8 (R]'s attention casting doubt on the "ran out of tape" P t!J explanation for the missing SAR data, (R] helped' conduct a _ n management investigation ~of the missing tape. He was dili- g$ gent in conducting this investigation, the results of which . were disclosed in a timely manner to upper GPUN management 7 and the NRC. y I u s}3
*T s
x 2 Le 6 a a
.]
.a
?
- 106 -
J
NOTES
- 1. (R), pp. 71-72. .
b
~
- 2. Ibid., p. 72.
- 3. SAA Taylor Report, Section D-7.
.I ',
d 4. (R), pp. 73-83. Although (R] estimated the times of his first two conversations with (HH] as 3:15 a.m. and 7 3:30 a.m., other evidence established that the first call j occurred at about the time GOS (A) and CRO (ZZ) left the control room together at 3:28 a.m. 333 (A), p. 102; Access Chart (Exhibit 14C) . This time was further corroborated by
]* Plant Operations Director (N), who recalled noting the time 3:35 a.m. when he received.his first call from (R).
pp. 56-57. (N), b
.s (R]'s second conversation with (HH] occurred
. .c; shortly after (HH] re-entered the control room at 3:41 a.m.
- ] Access Chart (Exhibit 14C) ; [A), pp. 112-14; (HH], p. 184.
. 5. (N], pp. 56-57.
a..' * (.i 6. I];i;1 J
,3 7. [HH), p. 184;
.1 (R), pp. 82-83. Ilc.2 . 8. (R), p. 83. '9 [d* 9. NRC Event Notification Form (4 :05 a.m. ) (Exhibit '- 10. (R), p. 87; l f.Tl (N), p. 63. u
.- 11. (R), pp. 87-88.
t
*\
I
- 107 -
i [.
e f 01 s
- 12. (R), p. 89; ,
,s (A), pp. 128-29; .
NRC Event Notification Form (Exhibit 8). ~
- ~ ~
- 13. (R], pp. 89-90.
. p'
.~
- 14. (R), pp. 89-96; c (A), pp. 129-31; .
(N), p. 80. ,-- b
- 15. Although (R] did not recall whether or not he _
mentioned the SAR tape during his third telephone conversa- 'r-tion with (N), on the basis of (N)'s more specific ; recollection that he had been told about the SAR before arriving at the plant we concluded that (R) had conveyed the m "ran out of tape" explanation for the missing data during .. this third conversation. Access Records "Entries" and "Exits" (Exhibits 14A, 14B) ; [R), p. 98.
- i. j
- 16. Sections VI(E) and (F). ,
a
- 17. (R), pp. 97 o
- 18. (A), p. 132. [A]'s telephone conversation with (R) is discussed in more detail in the section of this -,
report pertaining to (A).
]
'l
- 19. (R), p. 99;
- )
(N), p. 76; . (SS), pp. 36, 37. -]
- 20. (R), p. 99.
- 21. Ibid., p. 103.
- 22. Ikid.
i
- 108 - I 1
. ~ .,
. u
_, 23. Ibid., pp. 104-05. i hk ,
- 24. S.gg cenerally, Volume I, Sections VI(E) and (F); .
see also, (N), pp. 87-89; p (SS), pp. 46-47.
- 25. (R), pp. 109-10.
. 26. 23.3 Volume III (Taylor Report), Section E.
IT . b
<7 L
L.} . Ti 12 (m.
'M "
n
?*
2 3 ld Li -['lJ-p3 , 5 .i o aM l r4* .1. ? LU !" - 109 - l
11
~
nu g"3 (N) was the Director of Plant Operations on September ,
?
11, 1987, a position he had held since 1981. (R), the _ !1 Manager of Plant Operations, reported directly to (N). In p turn, (N) reported to Oyster Creek Director Peter Fiedler, n. who was on vacation on September 11. In Fiedler's absence, sw Deputy Director (SS] was the highest ranking GPUN manager at _ Oyster Creek. O
- 1. Safety limit violation L p
The uncontradicted evidence established that (N) was at 7 b home asleep when the safety limit violation occurred. He did not contribute to ths operator error that caused the h violation. -,
,v
- 2. Reeertina of safetv limit violation i
(N] was awakened at home by a call from (R] at 9 approximately 3:35 a.m. (R) told him there had been a ;'.j serious spill, and'that in attempting to stop it the crew . had taken the RBCCF system out of service.1 5 q h (N]'s background made him particularly knowledgeable about how the plant conditions (R) described to him might lead to a violation of the safety limit. He was personally familiar with the May 2, 1979 incident that led to the
*J 3
imposition of the less-than-two-loops safety limit, as well , as with the history of the alarm system that was by 1
- 110 -
h5 w Mll a t3e (N] was the Director of Plant Operations on September - 7-11, 1987, a position he had held since 1981. (R), the u Manager of Plant operations, reported directly to (N). In fg G turn, (N) reported to Oyster Creek Director Peter Fiedler, who was oc vacation on September 11. In Fiedler's absence, - Deputy Director [SS] was the highest ranking GPUN manager at ; Oyster Creek. [14 C
- 1. Safety limit violation i D
The uncontradicted evidence established that (N] was at 9 L home asleep when the safety limit violation occurred. He did not contribute to ths operator error that caused the violation. ,
.w
- 2. Recortina of safety limit violation .
l db
~
l (N] was awakened at home by a call from (R) at s' approximately 3:35 a.m. (R) told him there had been a h serious spill, and'that in attempting to stop it the crew . had taken the RBCCW system out of service.1 g l - i [N]'s background made him particularly knowledgeable is about how the plant conditions (R) described to him might
l lead to a violation of the safety limit. He was personally familiar with the May 2, 1979 incident that led to the 9J imposition of the less-than-two-loops safety limit, as well _,
as with the history of the alarm system that was :S I
- 110 -
d
'l
.?
M w - inctalled.2 Hacicowcs5tnowledgeableaboutthepracticeof
?
d running only two recirculation pumps when the plant was in h, cold shutdown,3 and had observed that the number of open ' d loops had been reduced to two when the plant was put in
]:1 shutdown condition on September 10.
With the safety limit in mind, (N) suggested that (R) call the crew and make sure that the recirculation valves were properly aligned -- i.e., that two loops remained open.4 3 W When, prompted by (N]'s questioning, (R) called (HH] in t the control room and asked about the alignment of the
,.l valves, (HH) disclosed the safety limit violation.5 .)
i., (R) called (N) back about five minutes after the first [j conversation and advised him of the safety limit vio-f lation. (R) alfino told (N) that he had instructed the control room people to start making notifications.6 f ti Immediately after the telephone call with (R), (N)
] called (SS).and informed him of the event, after which he notified William Bateman, the NRC resident inspector.7 D
A. u The other testimonial, documentary, and circumstantial ll i.1 evidence supported the conclusion that (N) acted in a timely and appropriate manner when he learned there had been a safety limit violation.8 He made sure that the safety limit
, violation was being reported by control room personnel, and then in turn reported it to (SS) and to an NRC
.) a - 111 - F
,, ,. r--- - . . , - - -- , , ,,, ~g , , . - - - , , , - - - . - - - , - . , - - , .
E k representative. Indeed, it was (N]'s alertness to the m V possibilities arising from the plant conditions described to ' him that caused (R]'s second call to the control room, which elicited the disclosure of the safety limit violation. P We also concluded that (N]'s reporting of the safety limit event was accurate within the limits of the 5 s information available to him.9 -
- 3. Destruction / concealment of evidence
?,
M The evidence showed that (N] had no role in the destruction, concealment, or disposal of the SAR tape or other documents. (N] arrived at the plant at approximately 5:20 a.m., after the telephone calls described above.10 , He did not enter the control room during the remainder of "B" -, crew's shift.11 PJ Q His actions before and after arriving at the plant were d inconsistent with any participation in the destruction or concealment of documents. He helped call persons who were to be invited to a 6 a.m. briefing, including a representa - tive of the NRC.12 He actively participated in gathering *
'y]
information for the 6:00 a.m. briefing, and helped present . facts about the safety limit violation at the briefing. (N] - then played an active role in investigating the circumstances surrounding the missing SAR tape. The evi-dence shows that he acted conscientiously in these endeavors.13
- 112 -
- , - - - , - - - - - , , ,. - a -, 4,. ,e-. - ---,-,-.-- - . - -,- , - - - - - - . , _ , -, , __,, , - - , , _ .
- 4. Recortina of missina SAR tace 7
i (N) first became suspicious that something improper may
] have happened to the SAR tape when shortly before the 6:00 N
a.m. meeting, (MM] and (R) advised him that the alarm which 7 appeared on the and of the SAR tape coming out the machine indicated that paper had been changedi 'n the middle of the 3, d event. Up to that point he had been concentrating on the
. safety limit event. He had been under the impression that the SAR had run out of tape, but had regarded this as irksome, not suspicious.14 After the 6 a.m. meeting, (N) asked (R), (HH], and others to meet in his office for the purpose of getting an explanation for the missing SAR data.15 Later in the morning, when (N) learned from (MM] that one of the control d room operators had ripped the tape and thrown it on the p floor but that it was still missing, (N] had (MM] search the a
control room. (N) also helped (MM] search the chart f container for the tape.16
]3 At this point (N] suspected that someone had thrown the tape away. He called security to get a printout of the control room exits and entries between 2:00 a.m. and 6:00 a.m.17 He also initiated a check of the garbage.18
{ l, u When one of shift assistants found a relevant piece of i d,U the SAR in the trash, (N) notified (SS] and the NRC.19 ,p [j The evidence, which is discussed in more detail else-t
] - 113 -
l~
~
E whoro,20 otrengly cupportcd th'o conclusien that (N) cctcd o conscientiously with respect to the reporting of the apparent destruction and concealment of the SAR tape. -
- 5. Summary of conclusions W
v (N) had~no role in the commission of the safety limit violation. His alert questioning about plant conditions and '3:s the details of crew actions in response to the leak prompted
.m (R]'s call to the control room at approximately 3:45 a.m. $J During that call, (R] learned about the safety limit r violation for the first time and immediately reported the event to [N] who,'in turn, immediately reported it to (SS). A short time later, (N] also reported the incident to ..
the NRC resident inspector. (N]'s reporting of.the safety - limit violation was timely and appropriate, and was accurate 3 within the limits of the information available to him. He had no role in the destruction, concealment, or disposa1 of 1
. .]
the SAR tape. When he learned that SAR tape was missing, he supervised an investigation into the matter, the results of ,, which he reported to (SS) and the NRC. -,
.]5
':s
- )
l
-?
.. i i
3 J l
- 114 - )
h a . NOTES - F, g
- 1. (N), p. 59.
a, ,
- 2. Ikid., pp. 28-40.
- 3. Ibid., pp. 40-42, 59-60.
~
- 4. Ib.id., pp. 59-60.
D .
- 5. Section VI(B) .
{a ,
- 6. (N), p. 70.
q 7. Ikid., pp. 67-69. 3* q 8. Eagt, (R), pp. 80-22, 87-88, 103-06, 117; h J (SS), pp. 21-23;
~
Transcript of 6:00 a.m. meeting,. Sept. 11, 1987 G[1 (Exhibit 21). 51 3 9. Egg Section VI(B).
- 10. (ii] , p. 73.
7 11. Access Records "Entries" and "Exits" (Exhibits
- ) , 14A, 14B).
. 12. (N), p. 73. <j 13, Egg Section VI(D).
2
,J 14. [H], pp. 74-78. Ega. Taylor Report, Section C-1.
lg 15. Ibid., p. 79. w lLJ l 1g I b - 115 - i. w
T r. L
- 16. [N), pp. 81*84. - --
r
- 17. Ib.id., pp. 84-85. '
w g
- 18. Ibid., pp. 85, 87. -
- 19. S.gg Sections VI(E), (F). (,
- 20. I]214 1**..
O 4 eh e, 6 m he' e
~-
N I
!J W~
;?
.J
*y U
*e.
g .e-S
.J h
i
')
.]
i 1
- 116 - .;.
t
6 3- . 2 On September 11, 1987, (SS) was the Deputy Director at . ,j oyster Creek, a position he had held since 1984. He _ 7 reported to the oyster Creek Director, Peter Fiedler. 4 Because Fiedler was on vacation, (SS) was the highest v ranking GPUN manager at Oyster Creek at the time of the safety limit violation.
- 1. Safety limit violation 7
The uncontradicted evidence established that (SS) was 1 at home sleeping when the safety limit violation occurred. ,a He did not contribute to the operator error that caused the r jj{ violation.
- 2. Escortina of safetv limit violation
]{L) (SS) testified that he was awakened at home by a call from (N) at approximately 4:00 a.m.1 (N) advised him that j:4 j i there had been a safety limit violation and that proper notifications had been made.2 There was no reference in the
- f,t U
telephone conversation to the missing SAR data.3 a Il - Upon completion of the brief telephone conversation, r, (SS) got dressed and went to the plant. He arrived at 4:30 a.m.4 He went to his office where he spoke with (MM) and (( U gave (MM) a list of names to call for a 6:00 a.m. meeting.5 At some point he tried unsuccessfully to call
}j# Fiedler. He then called GPUN Executive Vice President Edwin
- 117 -
O . em
r ., Kintner.6 , T.' y Next, (SS) proceeded to the control room. He entered V at 4:43 a.m. and went directly to the GSS's office.7 (HH] was not there, so (SS) went over to the operator's sta-T tion. There, CRO [VV) explained to (SS) how the safety { limit violation occurred.8 [SS) testified that he did not ' discuss the event with anyone else in the control room. 7 l As discussed elsewhere, (A] testified that he also L briefed (SS) about aspects of the violation. We concluded 7 u that (SS]'s failure to recall this conversation was under-standable under the circumstances and of no significance to 5- - his reporting of the event. By the time (SS) left the control room and returned to his office, no one had told him anything about the missing SAR tape.9 ,
.J The uncontradicted evidence showed that when (SS) was ,
~
notified of the safety limit violation at approximately 4:00 _ a.m., (N], (R), and (HH] were already in the process of making the appropriate notifications within GPUN and to the NRC.10 After being told this by (N), (SS] concentrated on preparing for the 6:00 a.m. briefing. When (SS) arrived at - .\ the plant, he told Kintner, his superior in the GPUN chain .J of command, about the safety limit violation. He later q presided over the 6:00 a.m. briefing, and a tape recording of that briefing confirmed that his reporting of the event
]
was candid and accurate within the limits of the information available to him.11
- 118 - j i
9 a '
- 3. Destruction / concealment of evidence I?, i 4
The evidence disclosed that (SS) had no role in the .
- ]L destruction, concealment, or disposal of the SAR tape or other documents.
At approximately 4:30 a.m., (SS] arrived at the plant 3s.,* J after having been notified of the safety limit violation by 9- a telephone' call from (N). Once at the plant, (SS) d personally sought information about the cause of the safety limit violation, and he enlisted (MM) help in setting up a J 6:00 a.m. meeting to brief key persons. When, after the
,1 .) 6:00 a.m. meeting, (N] launched a thorough investigation F7 into the circumstances surrounding the missing SAR tape,
- i. .
[SS) was kept informed. (These events are discussed in f. section VI(E).] The evidence indicated that (SS] lent his support and authority to these efforts. Thus, his conduct, .G O like that of (R) and-(N), was antithetical to an intention
- to destroy or conceal documents, d
- 4. Recortina of missina SAR tace a
d,
,- After the 6:00 a.m. meeting, (SS) received a telephone j' call from (N] and learned that some data were missing.12 (SS] then went to (N]'s office, where (N] advised him that U he had made a decision to confiscate all the trash in the ll office.13 '3 (SS] did not recall that at that time there was any discussion that the tape was missing under suspicious 119 -
c
?
a circumstances. Instead, he recalled hearing that the data 12 I were missing because the machine had run out of tape. He :: could not recall from whom he heard this, but did recall 9 that sometime between 5:00 a.m. and.7:00 a.m. either (N) or (R) told him that in the past the SAR machine had run out of 5 paper, causing certain data to be absent.15 O M At some point that morning, (N) called and said that , they had found some of the missing tape in the trash. (N] reported that they had found the portion of the missing tape .. that contained alm'st o all the significant data regarding the ila safety limit violation.16 -
.a Later that day, around 3:00 p.m., (VV) and (R] came to -)
t (SS]'s office. There, (VV] told (SS) that (VV) had been J disgusted with himself and had torn the SAR tape. [SS) 'l s j recalled (VV] saying that he had thrown it in the trash can, l but that he later retrieved it from the trash and flushed it 'j down the toilet.17 There is an apparent conflict between i c, I (SS]'s recollection on this point and (VV)'s testimony about " what he did with the tape.18 Because of the circumstances
]
under which this conversation took place and the potential )~ for confusion upon a cursory hearing of (VV)'s account of -] his actions, we concluded that the evidence was insufficient to determine whether (SS) misunderstood (VV), or whether - l ( (VV) gave (SS) a materially different account of the J
~
! sequence of his actions than (VV) later gave in his l l testimony. j
- 120 - $
AftOr 1C0rning that misoing SAR tapa hcd bkon recovered, (SS] contacted Kintner. GPUN President Philip t Clark was also present when (SS) spoke with Kintner.19 -
,J (SS]'s direct role in the investigation of the missing SAR tape was limited but, as noted above, he lent his
, support and authority to that investigation. The evidence 3
1 disclosed that (SS) made timely notification to his
- superiors in the GPUN chain of command concerning the SAR tape and was aware that (N) had notified the NRC.
M- 5. Summary of conclusions (SS) did not contribute to the operator error that caused the safety limit violation. He reacted in a timely and appropriate manner after the violation was brought to his attention, by which time (R) and (N] had set.in motion the required notification procedures. (SS) notified his j superiors in the GPUN chain of command and presided over a
;g 6:00 a.m. briefing at which he described the safety limit event to GPUN and NRC personnel. The briefing he provided was accurate within the limits of the information available
'h. (SS) had no role in the destruction, concealment, i to him. ,j' or disposal of the SAR tape. He had only a limited role in p the investigation of the missing SAR tape, but he lent his b support and authority to that investigation and reported its ,Ii results to his superior in the GPUN chain of command. U r-I L.* t .,
- 121 -
h L' NOTES .. Y 9
- 1. (SS), pp. 21-22. .
n. G Q
- 2. Ikid., p. 22; (N), pp. 67-69.
- 3. (SS), pp. 22-23. ([u
- 4. Ibid., p. 23. qq E
- 5. Ibid., pp. 24-25. ,.
b
- 6. Ibid., p. 25.
?
- 7. Ikid., pp. 23-24, 26-27; Lm Access Record "Entries" (Exhibit 14A). {,
- 8. (SS), pp. 26-28.
]
- 9. Ikid., p. 29.
- 10. 133 Sections VI(B) and (C). +
- 11. Egg cenerally, Transcript of 6:00 a.m. meeting, ..,
Sept. 11, 1987 (Exhibit 21). 0
,t.4
- 12. (SS), pp. 36-37.
i4
'l 4
- 13. Ibid., pp. 38-39. c,
- 14. Ikid., pp. 40-41. ,
m I
- 15. Ikid., p. 53.
I
- 16. Ikid., p. 45.
- 122 - W I
~
- 17. (SS), pp. 47-48. -
d
- 18. Egg Volume I, Sections VI(D) and (E) ; Volume II, individual section pertaining to (VV) .
- 19. (SS], p. 46.
t I3 I 1 7e
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0 a Od q 1
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- n l10 s q.
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