ML20154B584
| ML20154B584 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 02/22/1986 |
| From: | Stier E GENERAL PUBLIC UTILITIES CORP. |
| To: | |
| Shared Package | |
| ML20154B554 | List: |
| References | |
| NUDOCS 8603040340 | |
| Download: ML20154B584 (169) | |
Text
2 REPORT TMI POLAR CRANE BRAKE RELEASE PREPARED FOR GPU NUCLEAR CORPORATION BY EDWIN H.
STIER INVESTIGATIVE STAFF:
ROBERT DE GEORGE PETER J.
BARNES, Jr.
GERARD K. FRECH FEBRUARY 22, 1986 VOLUME I REPORT
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i 8603040340 860229 PDR ADOCK 05000320 P
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TABLF OF CONTENTS VOLUME I REPORT 2RSE INTRODUCTION ORIGIN AND PURPOSE OF THIS INVESTIGATION.
1 INVESTIGATIVE PROCESS 3
SUMMARY
5 CONCLUSIONS 15 NOTES 20 RESULTE OF INVESTIGATION 22 1
ORGANIZATION AT TMI-2 23 Recovery Programs.
23 i
The Reorganization 25 1
i i
I Refurbishment of the Polar Crane 28 Formation of the Polar Crane Task Group.
30 NOTES 32 i
TURNOVER OF THE POLAR CRANE TO BECHTEL.
37 4
NOTES 44 J
BECHTEL'S ADMINISTRATIVE CONTROLS 47 Division of Responsibility 47 Functional Description 50 4
CDPI-20.
51 j
CDPI-ll 52 Work Package Review Practices.
53 PCTG Attitude Toward Work Package Preparation.
55 NOTES 61 DESIGN, FABRICATION AND INSTALLATION OF THE POLAR CRANE BRAKE RELEASES 65 NOTES 91 1
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2&EA ASSESSMENT OF BRAKE RELEASES AS A MODIFICATION.
103 NOTES 119 INFORMATION ABOUT THE BRAKE RELEASES AVAILABLE OUTSIDE THE PCTG.
124 The Decision to Replace the Brakes 124 Ordering the Brakes.
126 Fabrication of the Brake Releases.
127 Installation of Polar Crane Brakes 130 Work Package Preparation and Review.
132 No Load Test Brake Inspection.
134 QA Work Package Review 134 1
Readiness Review Committee 136 GPUN Response to NRC Request for Information 137 Middletown Hearing 140 Presence of Brake Releases During Load Test and Headlift 142 Knowledge of Procedural Violations 142 NOTES 144 iii
EAGA Figure No.
1.
Westinghouse Type TM Main Holst Brakes.
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2.
Westinghouse Brake Release.
68 3.
PCTG'r Design Sketches for Fabrication of Brake Release 79 Table 1 List of Documents 152 Table 2 List of Witness Statements.
159 VOLUME II
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DOCUMENTS l
l VOLUME III i
WITNESS STATEMENTS iv
INTRODUCTION ORIGIN & PURPOSE OF THIS INVESTIGATION During the TMI-2 recovery effort, a number of issues have arisen relating to whether work activities were performed in compliance with applicable procedures.
Those issues have been the subject of several reports, including our report entitled TMI-2 Report / Management and Safety Allegations (Management and Safety Report) filed with GPU Nuclear Corporation (GPUN) on November 16, 1983.1 Much of that report focused on the refurbishment of the TMI-2 polar crane and included a discussion concerning several modifications of the polar crane that were not properly documented and reviewed under GPUN procedures.
After the Management and Safety Report was filed, another issue was raised concerning activities that took place during polar crane refurbishment.
In August 1984, TMI-2 employees discovered that another procedural violation might have occurred during the work performed on the polar crane.
After GPUN conducted a preliminary inquiry, Philip R. Clarks President of GPUN, retained Edwin H. Stier to conduct a detailed, independent investigation and to document the results.2 1
J I
J The incident that precipitated this investigation was the i
discovery that one of the main hoist brakes of the TMI-2 polar crane was not functioning properly.
During a period when the a
crane was not operating, a TMI-2 employee discovered that the brake shoes on one of the two main hoist brakes were not in contact with the brake wheel as they should have been.
Further examination disclosed that a nut on a device that was attached to the brake was out of adjustment.
This caused the device to interfere with the expansion of a spring that applied pressure to I
force the brake shoes against the brake wheel.
The device that interfered with the spring was a lever-operated mechanical brake j
release (brake release) that permitted the manual release of the brakes.
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Brake releases are designed to be ustd in the event of a power failure.
The brakes are designed so that they require
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electric power to release the brake shoes from the wheel.
This is a safety feature.
In the event of a power failure, the force of the spring will automatically tighten the shoes against the 3
i wheel, locking the brakes.
The manual brake release can then be used to mechanically relieve the pressure of the shoes against the wheel to safely lower a suspended load in the absence of i
electric power.
The nut on one of the brake releases apparently vibrated l
during crane operation into a position that prevented the brakes from engaging when they were de-energized.
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This investigation was initiated by GPUN to determine whether the installation of the brake release conformed to applicable procedures; if not, we were to determine the causes of any procedural violations.
In addition, GPUN requested that we determine why the existence of tha brake releases had not been disclosed during inquiries by TMI-2 management and by the NRC concerning the procedural issues that arose during polar crane refurbishment.
INVESTIGATIVE PROCESS In many ways, this investigation was an extension of the previous investigation that was documented in the Management and Safety Report.
That investigation dealt more broadly with the issues of procedural compliance, and developed a great deal of evidence concerning the reasons why certain GPUN procedures were not followed during the refurbishment of the polar crane.
We have attempted to avoid duplicating the work performed during the previous investigation and, whenever possible, have I
utilized the evidence from that investigation.
In this report, we have cited analytical sections of the Management and Safety Report whenever we believed such background would be relevant.
Our investigation of the brake releases followed an investigation by the NRC Office of Investigations (OI) dealing 3
I with the same issues.
Anyone who had been interviewed by the NRC was asked to furnish us with a copy of a transcript of that interview.
When we received an NRC transcript prior to our interview of the witness, we attempted to avoid duplicating areas covered by the NRC Investigator.
We conducted a preliminary interview of each witness and then requested the witness to submit to a sworn, transcribed, j
question and-answer interview.
All interviews were conducted voluntarily.
Transcripts were provided to the witness for corrections.
In some instances, the corrections have been 1
incorporated into the final transcript by the court reporter.
In other cases, corrections have not been incorporated into a revised transcript, and are either set forth in a list of corrections appended to the transcript, or appear in the witness' handwriting on the transcript itself.
Our instructions from Clark were to conduct a thorough investigation and to submit a written report to him.
We have periodically advised him of the progress and status of the investigation.
Howeveri neither Clarks nor anyone else associated with GPUN, has participated in the decisions regarding l
the development of the evidence; or in the preparation of this report.
Our investigative staff consisted of one investigator, Peter J. Barnes, Jr., and two attorneys, Robert DeGeorge and Gerard K.
Frech.
All investigative decisions, the analysis of the 4
l
evidence, and the preparation of this report have been solely under the control of Stier and his staff.
i
SUMMARY
The refurbishment of the TMI-2 reactor building polar crane was a major prerequisite for the cleanup effort.
The crane was needed to remove the reactor vessel head and to perform several other important tasks.
Therefore, soon after Bechtel Northern Corporation and Bechtel National Inc., (Bechtel) became GPU's prime contractors for the ThI-2 cleanup, the planning of the refurbishment of the polar crane began.
To understand fully the behavior of those involved with the polar crane refurbishment, it is necessary to recognize that at the time their work was being planned and performed, a major reorganization was taking place at TMI-2.
The reorganization resulted in part from a recognition by GPUN management that Bechtel employees were having difficulty working under a procedural system which had been designed for an operating facility.
GPUN decided to integrate the Bechtel groups working on the recovery project into a single TMI-2 organization and to create a procedural system that would apply uniformly to both GPUN and Bechtel activities.
5
During the period of organizational and procedural change, meetings were held between the Bechtel and GPUN representatives l
l to streamline the procedural system by which the refurbishment of the polar crane would be controlled.
These discussions resulted in agreement that certain procedures utilized by Bechtel vould be incorporated into the GPUN procedures governing work on the polar crane.
Under this agreement., B?chtel was authorized to use its own procedures to document most of the work.
To implement this procedural system, GPUN amended its procedures and Bechtel prepared several new procedures.
One significant limitation was imposed upon Bechtel under the amended GPUN procedures.
Bechtel was required to follow the GPUN procedures governing the documentation, review and approval of plant " modifications."
Generally speaking, GPUN procedures defined modifications as additions to, deletions fron, connections with, or unlike kind replacements of plant equipment.
The underlying policies of the procedures were:
to assure that any changes to plant systems or components were subjected to design review to determine their effects on existing plant systems; and, to document those changes so that the origin and description of all plant equipment could be easily determined from " machinery history" records.
The Bechtel personnel who met with GPUN representatives came
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away from their meetings with the mistaken impression that GPUN had waived its procedures and Bechtel was free to use its own l
6
i procedures for any work on the polar crane, including l
modifications.
In the view of Bechtel's personnel, the crane had been, in effect, severed from GPUN control and was now in the l
hands of a contractor for repair.
GPUN procedures would only Db i
l applicable to work that involved equipment that had not been
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turned over to Bechtel.
They believed that GPUN would be satisfied if Bechtel provided complete documentation of all work performed on the crane when the crane was returned to GPUN's control.
This misunderstanding of procedural requirements was questioned by some members of the Bechtel organization who could not understand bow GPUN modification procedures could have been waived.
However, the problem was not immediately recognized by TMI-2 canagement.
In part, this was due to the management changes that were taking place at the time of the polar crane refurbishment work.
The polar crane refurbishment began in July 1982 when GPUN issued a general work request authorizing Bechtel to perforn the necessary inspections and repairs to refurbish the polar crane.
A Polar Crane Task Group (PCTG) was created, headed by a Bechtel engineer.
It was comprised of individuals from several companies, some of whom had specific experience with cranes.
The PCTG was supported by two engineering groups, one located at TMI-2 (Site Engineering) and the other at Bechtel headquarters in Gaithersburg, Maryland (Design Engineering).
As a result of the i
h 7
l TMI-2 reorganization, on September 1, 1982, all of those groups became part of the newly formed Recovery Programs Department.
4 In July 1982, shortly before the reorganization, Bechtel's TMI-2 Project Management allocated responsibilities among the PCTG and the two engineering groups.
The PCTG was given the independent authority to replace components "in-kind."
In addition, the PCTG independently could determine the "means" by which the polar crane would be restored to an operable 1
condition.
Design Engineering was responsible for providing 1
design review of any proposed modifications.
Site Engineering was to review documentation produced by the PCTG to assure that Procedural requirements were satisfied.
The GPUN procedural scheme was not significantly different from that of Bechtel with respect to design review requirements.
The GPUN procedures were proscriptive.
They described activities
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that constituted modifications and prohibited such work without i
prior design review.
The Bechtel procedures were permissive.
They permitted the PCTG the authority to make "in-kind" replacements, and, by implication, cacegorized any other changes to the crane as modifications requiring design review.
Therefore, under both Bechtel and GPUN procedures, anything other than "in-kind" replacements or activities that were "means" of refurbishing the crane had to be submitted to Design Engineering for review prior to implementation.
Under both GPUN and Bechtel procedures, all work performed by the PCTG had to be documented in " Work Packages."
Those 8
l
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documents served three important functions.
First, they would 2
document machinery history to maintain a permanent record of the configuration of plant equipment.
Second, a description of the work to be performed would be used as the basis for authorizing entry into containment.
Third, the Work Package could be reviewed by Site Engineering to keep abreast of activities that were being planned by the FCTG.
In practice, the Work Packages did not serve all of those purposes.
Within the PCTG, a policy developed of writing Work Packages in as general terms as possible without making them inaccurate or misleading.
The leader of the PCTG cxpressed two reasons for this policy.
First, he was concerned that if each step of the work to be performed were detailed, his group would not be permitted to deviate from the work plans while performing work in containment in order to meet unforeseen conditions.
Therefore, he believed that generally written Work Packages provided maximum flexibility to alter their plans as they saw fit.
Second, he believed that details would invite inquiries from engineers who reviewed these Work Packages.
Those inquiries might have required some rewriting of a Work Package.
Members of the PCTG believed that, ultimately, they were best qualified to deterL'ine how the work should be performed and, the fewer questiont they invited, the more expeditiously they could complete the refurbishment of the crane.
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Thus, the refurbishment of the polar crane was carried out under a misunderstood procedural system.
Bechte.' believed its procedures applied to all work performed on the crane because GPUN had waived its procedures.
In reality Bechtel procedures applied to most of that work because they had been incorporated into GPUN procedures.
The only serious viol'ation of GPUN procedures that resulted was the failure to follow GPUN modification procedures.
However, if Bechtel's own procedures were correctly followed, documentation would have been contained j
in Work Packages and design ~ review would have taken place in a i
manner similar to the GPUN procedural requirements.
Many months before the formation of the PCTG, the engineering group at Gaithersburg began the early stages of planning for the polar crane refurbishment.
They attempted to order any new parts
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that would be required early enough so that shipping delays would not interfere with the progress of the planned work.
After considering information from several sources, including photographs of the damaged polar crune, they decided that new brakes should be ordered.
The engineers who made that decision believed that the original brakes had been equipped with brake releases.
Tuerefores they directed Bechtel's Procurement 1
Department to order brake releases.
In fact, the original brakes i
on the crane had ot been equipped with brake releases.
The i
research performed by the engineers to identify the equipment originally installed with the brakes was inadequate.
10
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...--_.,---,..-...v
l By the time the brakes arrived at TMI-2, the PCTG had been formed.
The Purchase Order had failed to include brake.
~ releases.
Therefore, they were not shipped by the manufacturer along with the brakes.
Although the leader of the PCTG did not know of the attempt to order brake releases, some of his subordinates expected them to arrive.
When they did not, members 1
of the PCTG attempted to order brake releases from the I
manufacturer, but found that there would be a delay of up to ten weeks before they could be obtained.
Therefore, the PCTG decided to manufacture their own brake releases at TMI-2.
1 The PCTG knew that the crane was not originally equipped with j
brake releases.
Design Engineering learned of the intention to fabricate them, but mistakenly continued to believe that thay 1
j were original equipment on the crane.
Based on their assumption that the PCTG was fabricating an exact duplicate of already existing equipment, Design Engineering raised no objection to the l
fabrication of brake releases.
The brake releases were designed by the PCTG and fabricated i
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in the Maintenance machine shop at TMI-2.
There were several i
differences between the manufacturer's design and the brake I
releases fabricated at TMI-2.
Most significant, the fabricated i
j brake releases included improperly secured nuts, one of which i
ultimately moved out of position on one of the brake releases, causing the brakes to malfunction.
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The brake releases were mounted on the brakes and brought into containment as a single unit.
On the crane, they were disassembled and, after the old brakes were removed, the new brakes with the brake releases were installed.
The Work Package documenting brake installation made no reference to the brake releases.
The key individual responsible for making the judgements concerning the procedures to be followed in the design, fabrication and installation of the brake re' eases was the leader of the PCTG.
He was the only individual with both knowledge of the circumstances surrounding the installation of the brake releases, and the responsibility to see that correct procedures were followed.
Those below him in the organization, the PCTG members, looked to him to assure procedural compliance.
Those above him in the organization depended upon him to oversee the performance of refurbishment activities.
Therefore, we devoted considerable effort to reconstructing the thought processes and evaluating the rationale for the decisions made by the PCTG 1eader.
The PCTG 1eader had been unaware that Design Engineering had originally attempted to order brake releases.
He first became aware of the need for them when they failed to arrive with the new brakes.
At that time, he learned that they were needed to perform certain tasks during the early stages of refurbishment when electric power was unavailable:
to facilitate the 12
installation and adjustment of the new brakes, and to lower the main book and block for inspection.
At some later time, the PCTG 1eader recognized the value of the brake releases as emergency devices to lower a suspended load during a power failure.
He then decided to leave the brake releases installed on tuc crane until the load testing of the crane was completed, at which time the crane would be returned to GPUN control.
He intended to remove the brake releases from the crane, and after the Load Test, to store them for future use.
Because the Load Test was to be delayed for several months, the PCTG was disbanded and its menbers were reassigned to other jobs in various parts of the country.
The test eventually took place without their involvement.
The brake releases remained in place throughout the Load Test and the lifting of the reactor vessel head.
They were finally removed from the crane when one of them was found to have caused a brake to malfunction.
The PCTG 1eader believed that the brake releases were " tools" necessary to facilitate polar crane refurbishment.
He maintained this belief even though they were to be used for lowering a load in an emergency during crane operation.
He did not consider the brake releases to be possible modifications because he believed they did not alter the'way in which the brakes functioned.
He understood such a functional change to be an essential characteristic of a modification.
13
In February 1983, the issue of procedural compliance during polar crane refurbishment was called to the attention of the new Director of TMI-2.
He immediately assigned the Quality Assurance Department (QA) to review the work that had been performed on the polar crane and to identify any procedural violations.
QA reviewed the Work Packages, identified four modifications that had been made in violation of GPUN procedures, and issued a Quality Deficiency Report to the Recovery Programs Department.
QA, however, did not identify the installation of the brake releases as a modification because that work had not been documented in a Work Package.
Subsequently, the NRC made several requests for information concerning polar crane modifications.
They asked broad questions about the work that had been performed.
None of those inquiries resulted in the identification of the brake releases as equipment that had been installed on the crane.
14
CONCLUSIONS Based upon our analysis of the evidence set forth in this report, we have reached the following conclusions:
1.
The addition of the brake releases to the polar crane main hoist brakes resulted in a " modification" under both GPUN and Bechtel procedures.
A.
Both procedures limited the discretion of field personnel regarding the installation of equipment on the crane that was different from the original equipment.
B.
GPUN procedures prohibited field personnel from performing certain activities involving plant equipment, such as " additions" and replacements of "unlike kind," without prior design review and approval.
C.
Bechtel procedures permitted field personnel to perform only one type of activity involving changes to existing plant equipment without design review; that is, "in-kind" replacements.
15
Any other component installations were deemed to be modifications requiring design review.
1 D.
Although these procedural schemes differed in their approach, the limitations on the discretion of field personnel were essentially the same.
2.
The PCTG violated GPUN and Bechtel modification procedures by failing to document adequately the installation of brake releases and by failing to obtain design review of that work prior to crane operation.
3.
The violation of GPUN and Bechtel procedures resulted from the combined effect of several circumstances:
A.
GPUN modification procedures were not followed because Bechtel personnel at TMI-2 erroneously believed that GPUN procedures were inapplicable to the polar crane refurbishment.
This belief was contrary to the intent of GPUN management 16
and the express provisions of the GPUN pro-cedures that governed the refurbishment of the polar crane.
B.
The PCTG originally used the brake releases as " tools" to facilitate the refurbishment of the polar crane.
Such use did not require that they be submitted for design review under Bechtel procedures.
However, when the PCTG decided that the brake releases would remain installed during crane operation to lower a load in the event of a power failure, they failed to recognize that design review was required under Bechtel procedures.
C.
The failure to recognize that Bechtel procedures required such design review occurred because the leader of the PCTG did not consider whether the additional use of the brake releases without prior design review was within the limits of his authority under Bechtel procedures.
D.
Members of Design Engineering who were aware that the brake releases were to be installed on the polar crane mistakenly believed that the brake 17
releases were "in-kind" replacements of existing equipment.
Therefore, they did not understand them to be modifications.
Their mistaken belief resulted from their inadequate 3xamination of information available to them durin.3 the initial stages of purchasing replacement equipment for the polar crane.
4.
The evidence does not show that anyone recognized that the installation of brake releases on the polar crane constituted modifications under either GPUN or Bechtel procedures until after August 1984.
5.
The GPUN and NRC reviews of the work performed on the polar crane did not identify the installa-tion of the brake releases as modifications because their installation was inadequately documented and because the PCTG continued to fail to recognize the installation of the brake releases as modifications.
A.
The failure of the PCTG to document the installation of the brake releases was influenced by the prevailing attitude within the PCTG toward 18
l documenting their work.
They believed that i
i documentation should be as general as possible to avoid precipitating questions from engineers I
who were responsible for reviewing their work.
B.
The evidence does not establish that anyone
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intentionally concealed the existence of brake releases from GPUN or the NRC.
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NOTES 1
The subject matter has been covered by the NRC in a report entitled, Three Mile Island Nuclear Generatino Station, Unit 2/Allecations Recardino Safety Related Modifications, Quality Assurance ~
Procedures and Use of Polar Crane, issued by the Office of Investigations (OI) on September 1, 1983; see also SECY-84-36 by OI, dated October 18, 1984; and our report discussing the October 18 OI report, entitled Comments on NRC Staff Responses to Questions from Udall Committee Concernino TMI-2 Cleanup, dated February 27, 1985.
2 Edwin H. Stier, P.
A.,
11 E. Cliff Street, Somerville, New Jersey 08876.
Member of the New Jersey Bar; October 1, 1982, to October 1, 1984, Member of the firm of Kirsten, Friedman & Cherin, P.
C.,
- Newark, N. J.; 1977 to 1982, Director, New Jersey Division of Criminal Justice (Assistant Attorney General);
1969 to 1977, held the positions of Deputy Attorney General in charge, Organized Crime and Special Prosecution Section; Assistant to the Director; and Deputy Director in the New Jersey Division of Criminal Justice; 1967 to 1969, Chief of the Criminal Division, Office of the United States Attorney, District of New Jersey; 1965 to 1967, Assistant U. S. Attorney, District of New Jersey; 1964 to 1965, Law Clerk to the Honorable Arthur W. Lewis, Judge of the Appellate Division, Superior Court of New Jersey; Graduated from Rutgers University (AB) 1961 and Rutgers Law School (LLB) 1964.
3 Peter J. Barnes, Jr. - 1980 to date, Prerident of Barnes Security Consultants, Inc., a company providing investigative and consulting services to Errtune 500 companies and to the National Hockey League; 1954 to 1980, Special Agent with the Federal Bureau of Investigations.
20
Robert DeGeorge - Member of the New Jersey Bar; 1982 to present, Senior Partner in Paglione, Massi and DeGeorge, Trenton, N. J.; 1981 to 1982, Partner in DeGeorge and Gendzel, Trenton, N. J.; 1981 to 1983, Special Counsel to the N. J. Division of Motor Vehicles; 1980 to 1981, Deputy Attorney General in ch_arge of Organized Crime and Special Prosecutions Section, N. J.
Division of Criminal Justice; 1979 to 1980, Deputy Attorney General in charge of Corruption Investigation Section; 1964 to 1966, Deputy Attorney General in charge of Drug Division Investigations Section; Intelligence Analyst, U. S. Army Intelligence Corp; Graduated from Rutgers University (AB) 1970 and Rutgers Law School (JD) 1964.
Gerard K. Frech - Member of the New Jersey (1979) and New York (1980) Bars; 1981 to 1985, Senior Associate with Kirsten, Friedman & Cherin, P. C., Newark, N. J.;
1977 to 1981, Legal Assistant to the New Jersey Board of Public Utilities; 1976 to 1977, Junior Analyst, National Economic Research Associatese Inc. (NERA),
New York, N. Y.; Co-Author, TMI-2 Report / Management and Safety Allegations (November 1983); Assistant Editor, TMI-2 Reactor Coolant Inventorv Balance Testino (October 1985); Member, American and New Jersey Bar
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Associations, Sections on Public Utility and Administrative Law; Graduated from Boston College (BA) 1975 and Seton Hall School of Law (JD) 1979.
21
RESULTS OF INVESTIGATION On August 16, 1984, during an inspection of the TMI-2 polar crane, it was discovered that the outboard main hoist brake had malfunctioned.1 The brake shoes were not in contact with the brake wheel as they should have been.2 Further examination revealed that the cause of the problem was that a not on a device mounted on top of the brake had tightened to a point where the device prevented the brake shoes from engaging the brake wheel.3 That device, a brake release, had been fabricated on site and installed to permit the manual release of the brake in the absence of electric pcwer.
An identical brake release also had been mounted on the inboard main hoist brake.4 The subject of this report is the procedural propriety of the addition of the brake releases to the main hoist brakes.
The discovery that a brake release had caused one of the brakes to malfunction raised questions about the history of the installation of these devices.
An initial inquiry by CPUN determined thet there had been no engineering review prior to their installation.5 This investigation was initiated to determine whether the applicable procedures required such an engineering review and, if required, why it did not occur.
In the event of a procedural violation, the investigation additionally was to determine why it had not been discovered until August 1984.
22
To understand fully the decision-making prccess and to assess responsibility fairly for decisions related to the brake releases, it is necessary to be familiar with the organizational structure at TMI-2 and the changes that occurred in that organization during the relevant time period.
ORGANIZATION AT TMI-2 The decision to install brake releases on the polar crane main hoist brakes and their subsequent design, faterication and installation occurred between November 1981 and November 1982.6 During this period, the entire polar crane refurbishment project was planned, staffed and substantially completed.7 In rddition, during that time the management of TMI-2 was in the process of planning and implementing a major reorganization to more effectively manage the cleanup of TMI-2.8 Recovery Prograrn In July 1980, GPU engaged the services of two Bechtel companies, Bechtel Northern Corporation and Bechtel National, Inc. to assist with the TMI-2 cleanup and recovery efforts (hereafter they will be referred to collectively as Bechtel).9 The Bechtel companies discharged their duties within the framework of a traditional client / con? actor relationchip until a reorganization at TMI-2 in September 1982.10 23
i The Bechtel organizations were supervised and controlled by GPUN management personnel within a department known as the Recovery Programs Office.11 The Recovery Programs office l
reported to the Director of TMI-2.
Within that office M. Kenneth Pastor, a GPUN employee, was the Recovery Programs Operations and Construction Director.12 He was responsible for:
"providing 1
mane.gement oversight for contractor supplied engineering, design and construction activities, to coordinate interface with contractor and recovery engineering personnel, and to provide critical oversight of contractor schedules and performances."13 Jack Devine, Director of Recovery Engineering, also within the Recovery Programs Office, was responsible for providing:
" technical support for work related to TMI-2 recovery effort; engineering services to coordinate support and interface with contractors and the sponsors of government and industry-funded programs, approval for technical adequacy of the technical plans prepared by contractors, configuration control of recovery systems, structures and components, and providing start up and test services for systems structures and components."14 James Thiesing, Bechtel's TMI-2 Project Manager, had general management responsibility for Bechtel's activities and reported to Pastor.15 In 1981, Ronald Freemerman was assigned by Bechtel to Thiesing as the Assistant Project Manager.16 Thiesing managed Bechtel activities at two locations, the company's offices in Gaithersburg, Maryland; and TMI.
He divided his t!me between the two of them.17 I
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At Gaithersburg, Robert Ridere Manager of Project Engineering
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(also known as Home Office Engineering and later renamed Design Engineering), provided engineering review and design services for all TMI-2 recovery facilities.18 Bechtel's TMI-2 on-site construction and field activities related to the recovery were managed by David Lakes Field Construction Manager.19 Both l
Rider and Lake reported to Thiesing through Freemerman.20 Lake's on-site construction personnel dealt with Project Engineering in Gaithersburg through a site liaison engineering group located at TMI.21 The site liaison group was a part of 1
j Project Engineering, established to provide on-site engineering support to the construction group with respect to relatively minor matters and to facilitate communication with Gaithersburg.22 1
The Reorganization The involvement of a major contractor in the day-to-day operations at a licensed nuclear facility was not without its difficulties.
The large number of non-GPUN personnel working on site at TMI caused a number of procedural and management problems.
These problems were addressed in depth in the Management and Safety Report.23 In the winter of 1981-82, GPUN management decided to restructure the TMI-2 organization and to integrate Bechtel into its ranks.
The integration of Bechtel into the TMI-2 1
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_,.,-e-- -, - - - - -.... -, -.
- -., - - - -,, -.,, _ -, - -.,. _, -, _.,., -, ~,, - - -. - - - -,,,, - - - -
organization was intended to eliminate the worst aspects of the contractor / client dichotomy and to develop a spirit of cooperation among the various departments at TMI-2.
GPUN management believed that an integrated organization would, among other things, result in:
a) the establishment and use of uniform procedures; b) the elimination of redundant reviews; c) better communications among departments; and d) a more efficient allocation of Bechtel and GPUN personnel and resources.24 In the spring of 1982, after discussions between GPUN and Bechtel management, Bahman Kanga, a Bechtel employee, was chosen to become the Director of TMI-2.
Kanga, then Manager of the Division of Engineering for Bechtel Northern Corporation, was assigned to TMI-2 in May 1982.25 Between May and August 1982, Kanga familiarized himself with the existing organization and its problems and worked with GPUN President, Robert Arnold, to refine the plans for the TMI-2 reorganization.26 On August 1, 1982, Kanga assumed the duties of the Director of TMI-2.
On August 5, 1982, he submitted GPUN's reorganization plan to the NRC for approval.27 The reorganization became effective on September 1, 1982.28 The most significant aspect of the reorganization was the integration of the Bechtel units into the TMI-2 organization.
Thiesing was appointed Recovery Programs Director and reported to the office of the Director of TMI-2.
The reorganization resulted
~
in the elimination of the GPUN management positions assigned to 26
supervise Bechtel as a GPUN contractor.
Pastor and Devine, who l
held those GPUN positionse were reassigned to other duties.29 i
l Within the Recovery Programs Department, Rider's engineering group at Gaithersburg was designated Design Engineering and a new Site Engineering group was formed at TMI-2, headed by David Buchanant a GPUN employce.
Lake continued to head Recovery Operations, the construction group.
Rider, Buchanan and Lake reported to Thiesing through Freemerman.30 Although Design Engineering continued to provide design review and engineering services for TMI-2 recovery activities, it was relieved of its former site liaison functions.
Site Engineering now acted as the liaison between on-site construction groups and Design Engineering.
It also became responsible for start-up and test services for recovery systems and for some technical support and design services.31 Additionally, Thiesing assigned Site Engineering the task of reviewing work authorising documents to ensure that proposed work activities did not violate administrative, technical, procedural or regulatory requirements.32 The integration of Bechtel into the TMI-2 organization was further facilitated by assigning Bechtel and GPUN personnel among groups previously comprised primarily of members of the other organization.33 The GPUN Quality Assurance Department reported to the Office of the President of GPUN, and was not located within the TMI-2 27
organizational structure.34 Accordingly it was unrmffected by the reorganization.
j Kanga, as the new Director of TMI-2, continued to implement organizational changes from the fall of 1982 through the winter of 1982-83.
Administrative procedures were updated to reflect 4
]
the recent changes in the organizations and to accommodate then existing plant conditions.
A new, uniform system of procedures was pron.ulgated to document and control work activities, and employees were trained in those procedures.35 During that I
period, work activities that had been initiated under pre-existing procedures were allowed to continue.36 The prin.ary recovery task being performed during this period was the refurbishment of the polar crane which had been in the planning stagen for some time.
Refurbishment of the Polar Crane l
As a result of the accident on March 28, 1979, many of the polar crane's electrical and mechanical components were damaged significantly.37 Soon after the accident, it was apparent that i
the polar crane would have to be repaired in order to lift the reactor vessel head and to perform other functions required during the cleanup effort.38 Inspecting, refurbishing and testing the polar crane was a long process.
Initially, in 1980, the Bechtel engineering group j
in Gaithersburg attempted to assess the condition of the crane
.I 28
without the benefit of visual inspection.38 Their efforts were l
directed principally at developing a general estimate of what might be required to rehabilitate the crane.40 In the fall of 1981, during scme of the early entries into the reactor building, photographs were taken of the crane.41 In late October /early November, 1981, four engineers entered containment specifically for the purpose of inspecting the polar crane.42 Some mechanical components were disassembled, and general data recorded.43 With the assistance of crane experts, the Gaithersburg engineering group evaluated the information obtained and developed "a programmatic approach to inspecting, testing and refurbishing the Polar Crane...."44 They produced a document entitled, " Polar Crane Recovery Description," issued on March 29, 1982, that outlined a program for the restoration of the polar crane to near pre-accident condition.45 The Recovery Description provided for comprehensive inspec-tions, assessment and evaluations, procurement of replacement components, preparation of engineering documents, installation of temporary systems, refurbishment / replacement of damaged components, pre-operational testing and load testing.46 The actual refurbishment of the polar crane began in the summer of 1982 several months after the Recovery Description was first issued.
29
.. - _ -......_.- - =. - - - -._... -.-..-. -._ - - -
Formation of the Polar Crane Tank Group On July 19, 1982, Freemerman organised a multi-discipline group of experts to inspect and repair the polar crane.47 The goal of the group was to refurbish the crane in support of planned head lift activities by inspecting the crane, reporting on the damage and repairing or replacing damaged components.48 The group, which became known as the Polar Crane Task Group (PCTG) reported to Lake.48 Upon Lake's recommendation, Michael Radbill, a Bechtel Civil Engineer, was assigned to be the group's leader.50 Radbill stated that his responsibility was "... to oversee the administration and guide the activities and help the group work through the paperwork maze at TMI in order to accomplish the physical work of refurbishing the Polar Crane."51 In addition to Radbill, the PCTG included the following individuals:
Howard Kirschbaum, a Bechtel employee and former Quality Assurance inspector with Whiting Corporation, the manufacturer of the TMI-2 polar crane; Bruce Mercer and James Graber, employees of United States Crane, Inc., on loan to Electric Power Research Institute (EPRI); Joseph Gannon and Renneth Parlee, both electrical engineers employed by United Engineers and Constructors, Inc.; John Willis, a planner and scheduler, employed by Bechtel; and Joni Marie Basehore, PCTG Secretary.52 30
The PCTG was formed and began to operate just prior to the implementation of the TMI-2 reorganization, a period of transition to the new tr,anagement structure.
It was during this period that critical discussions took place between GPUN and Bechtel personnel about the procedures that had to be followed by Bechtel to authorize and document the performance of polar crane work.
I i
\\
)
i l
I 1
i I
l 31 I
MQ2E&
1 1
TMI-2 Event Report 50-320-24-099 of 8/11/84, Irproper Adjustment of Main Holst Brake on Unit II Polar Crane (Tab 81);
Hicks, 7/25/85, p. S.
2 Parsons, 8/21/85, pp. 6-8; Hicks, 1/15/85, p. 32.
3 TMI-2 Event Report (Tab 81).
4 Kirschbaum, 7/1/85, pp. 30, 32-33, 56; Graber, 6/27/85, pp. 34-37, 44-45, 73-75; Radbill, 9/21/85, pp. 33-36; 3/12/85, pp. 116-117, 218-219.
5 Barton, 5/6/85, p. 27; Lake, 4/10/85, pp. 75-7 8.
6 Job Ticket, CA 364, 8/6/82 (Tab 46);
Johnson, 8/21/85, pp. 5-11; Mays, 8/22/85, pp. 15-20; Graber, 6/27/85, pp. 63-65; Kirschbaum, 7/1/85, pp. 21-23, 44-52.
7 TMI-2 Polar Crane Recovery Progress Reports, 7/30/82 - 9/30/83 (Tab 28).
8 TMI-2 Report / Management and Safety Allegations, Vol. IV,
Background:
Organization and Management of TMI-2, pp. 1, 8-12.
9 Ibid., pp. 3-4.
10 Ibid., p. 4.
I 32 i
11 TMI-2 Report /Managecent and Safety Allegations, Vol. IV,
Background:
Organization and Management of TMI-2, p 4.
12 Ibid.
13 Letter, 9/24/81, Hovey to Snyder (LL2-81-0220),
re TMI-2 Orgt.r.iration Plan, Rev. 3, p. 2 of (Tab 88).
I 14 Ibid.
15 Thiesing, 4/25/85, p. 48.
16 Ibid., p. 7.
17 Ibid., pp. 5-6.
i 18 Rider, 4/3/85, pp. 3-4.
f 19 Lake, 6/18/85, pp. 4-8, 4/10/85, pp. 5-6; Barton, 7/18/85, pp. 6-7.
1 l
20 Thiesing, 4/25/85, p. 7.
21 Barkanic, 7/25/85, p. 4.
)
22 Gallagher, 7/24/85, pp. 5-7, 27; 1/16/85, p. 3; Barkanic, 7/25/85, pp. 3-5; 4/10/85, pp. 5-6.
23 Management and Safety Report, Vol. IV, Polar Crane Allegations, pp. 13-16.
3 33 1
___m__
-l 24 Management and Safety Report, Vol. IV, I
i Polar Crane Allegotions, pp. 7-8.
L i
j Ibid., p. 8.
25 r
26 Ibid.
t r
I 27 Ibid.
l 28 IOM, 9/1/82, Ranga to Arnold et al (4000-82-K-296),
re Reorganisation Implementation Announcement, with Attachment (Tab 16).
i f
29 Ibid., Attachment, p. 7.
i!
1 l
30 Ibid.
l 31 Ibid., p. 8; Gallagher, 1/16/85, p. 3; 5
7/24/85, pp. 26-28.
32 Buchanan, 7/29/85, p. 7; I
Gallagher, 1/16/85, p. 6; 7/24/85, pp. 24-26; Barkanic, 4/10/85, pp. 5-6;
}
Radbill, 9/27/85, pp. 13-14.
33 Management and Safety Report, Vol. IV, l
Background:
Organization and Management of i
TMI-2, pp. 1, 8-12.
l 4,
J 34 Letter, 9/24/81, Hovey to Snyder (LL2-81-0220) re TMI-2 Organisation Plan, Rev. 3, with
]
Enclosures (Tab 88).
i i
l 35 Management and safety Report, Vol. IV,
Background:
Organisation and Management of TMI-2, pp. 9-10.
i 1
4 i
34 1
l t
36 Management and Safety Report, Vol. IV, Allegations of Safety Review Deficiencies, pp. 25-26; l
Kanga, 8/29/85, pp. 9-12.
l 37 Polar Crane Recovery Description, 3/30/82 (Tab 55).
I 38 Management and Safety Report, Vol. IV, Polar Crane Allegations, pp. 1-2.
I 39 Hickerson, 7/9/85, pp. 7-8.
40 Acid.
41 Gibson, 9/12/95, p. 8.
42 Ibid., p. 7.
i 43 Ibid., pp. 7-13.
i i
44 Johnson, 8/21/85, pp. 6-9.
45 Polar Crane Recovery Description, 3/30/82 (Tab 55);
Johnson, 8/21/85, p. 6; Jackson, 6/6/85, p. 7; d
Mays, 8/22/85, p. 6; Hickerson, 7/9/85, pp. 14-15; Rider, 8/21/85, p. 6.
4 i
46 Polar Crane Recovery Description, 3/30/82 (Tab 55).
j 47 Freenarman, 8/22/85, pp. 6-7; Lake, 6/18/85, pp. 9-11; i
Memo, 8/16/82, Raibill to Green, re Formation i
of Polar Crane Task Group (Tab 2).
35
i l
l l
i 48 IOM, 7/30/82, Jackson and Lake to Freemermant 0306-8420, re Polar Crane Division of Responsibility (DOR)
(Tab 3).
49 Laker 6/18/85, p. 11.
50 Ibid., pp. 9-10; Freemerrant pp. 6-7.
4 51 Radbill, 3/12/85, p. 6.
J h
52 Ibid., pp. 10-13.
I 1
l 1
I 1
l I
I 4
l i
i i
J 1
i I
4 36
{
I j
I i
TURNOVER OF THE POLAR CRANE TO BECHTEL l
Although the polar crane refurbishment was a critical step in the recovery effort, it was not the only work to be performed by Bechtel.
For several months before the polar crane refurbishment began, discussions had been taking place among GPUN and Bechtel personnel to establish certain conditions necessary for Bechtel to function as a contractor at TMI-2.1 GPUN, as the operator of a licensed nuclear facility, was responsible to see that all work was performed under its approved procedures.
Consistent with that responsibility, GPUN management wanted to provide Bechtel with as much freedom as possible to manage its work.
Thus, GPUN initially gave Bechtel two options:
it could comply with then existing GPUN procedures, or it could prepare its own procedures for GPUN approval.2 Although it was originally agreed that Bechtel would prepare its own procedures for GPUN review and approval, Bechtel's on-site construction personnel had not done so by mid-1982.3 Consequently, GPUN instructed Bechtel's on-site organization that, until Bechtel developed and obtained GPUN approval of its own procedures, it had to comply with applicable GPUN procedures.4 During the planning for polar crane refurbishment, Bechtel personnel expressed concern that the existing GPUN procedures 37
l were too cumbersome to follow.5 They suggested that the record l
keeping requirements of GPUN procedures could be satisfied if Bechtel's internal procedures were followed.
In an effort both to meet GPUN's license obligations and to accommodate Bechtel, several discussions were held between Bechtel and GPUN personnel.6 GPUN amended its procedures to permit the polar crane to be I
turned over to Bechtel by issuing a single document.
As a f
result, on July 14, 1982, a Job Ticket (sometines referred to as I
a " Work Request") was issued authorizing Bechtel to proceed with refurbishing the crane.7 The Job Ticket was issued under Maintenance Proceduree MP 1407-1, the GPUN procedure for the control of maintenance, j
repairs and modifications.8 That procedure designated the Job Ticket as the document to be used to authorize maintenance work.
Normally, each maintenance task was documented in a Job
?
Ticket that defined the nature and scope of the work to be performed and specified the testing and acceptance criteria that had to be satisfied when the work was completed.8 However, in that instance, a single Job Ticket was used to authorize Bechtel to perform a series of maintenance tasks on the polar crane.
l This was permissible because MP 1407-1 had been revised specifically to accommodate work by Bechtel.10 Under the revised procedure, Work Packages, normally used by Bechtel to l
document work, were to be used instead of Job Tickets to document each separate maintenance task.11 I
j 38
l Despite the authorized use of Bechtel Work Packages to document maintenance tasks, the procedure clearly required that any " modifications" to a plant system or component be documented l
and reviewed under another set of GPUN procedures.12 Those procedures governed the preparation, review and approval of Engineering Change Memoranda (ECM's) which required drawings, specifications and descriptions of the work to be performed.
Another GPUN procedure also permitted Work Packages for documentation of maintenance work, but required ECM's for modifications.13 The Job Ticket authorizing the refurbishment i
of the polar crane stated that work would be performed "in accordance with the Bechtel containment entry program,"14 a
j reference to Procedure No. 4300-ADM-3240.1, " Access To and Work In Containment Building" (ATWIC).II That procedure was promulgated on May 4, 1982.
Among other things, ATWIC authorized the use of Work Packages and incorporated other GPUN procedures I
by reference.
However, Section 4.1.2.1 specifically required the use of ECM's to obtain approval for and document modifica-tions.16 Therefore, the Job Ticket authorizing Bechtel to use Work i
j Packages to document the refurbishment of the polar crane had a GPUN-approved procedural basis.
It was issued under AP 1407-1 and invoked the provisions of ATWIC, both of which were specifically designed to authorize a maintenance project such as i
the polar crane refurbishment.17 l
39 l
l
, _ _ _... _ _ _. _ _ _... ~ _. _. _ _ _ _ _ _ _,
Although the polar crane was turned over to Bechtel in a j
procedurally correct manner, key Bechtel personnel did not recognize the applicability of the ECM procedures to the refurbishment of the polar crane.18 A sharp difference in perception existed between Bechtel and GPUN personnel reg.rding f
the results of the discussions concerning the turnover of the polar crane.18 The evidence clearly shows that GPUN fully a
]
intended to have its administrative procedures, including ECM control of modifications, apply to the polar crane refurbishment.20 Nevertheless, Bechtel's on-site management mistakenly believed that the turnover of the polar crane had relieved them of the duty to follow most GPUN procedural requirements. They understood hat the polar crane had been
" administratively severed" from GPUN control, and that Bechtel was free to follow its own Work Package procedures for all work j
on the polar crane including modifications.21
- i Regardless of the misconception that GPUN procedures were not applicable to the refurbishment, the bulk of Bechtel's work 4
nevertheless conformed to GPUN procedures.
Since most of the work did not involve modifications, work packages were an j
appropriate means of documenting those refurbishment tasks.22 i
Not all Bechtel personnel were certain that GPUN procedures had been waived.
Design Engineering questioned the propricty of not using ECM's to document modifications.23 Both Rider, i
Design Engineering Manager, and Richard Jackson, Design 40
..m
.._,,--~._,ym,-.-%.,_
__.,,,y__r.,-__
,,.._.,-m
,., w
,--_.__,,#w__,-.,,.-.-_,.,,.m.,.,
,,,m-..~,
,,-.-----,,.2m--e.,.--
_ _ - - - = _. - ~..
l Engineering Assistant Project Engineer, expressed concerns to 1
Recovery Programs management that the use of Work Packages I
instead of ECM's for modifications appeared to be inconsistent with GPUN administrative procedures.24 Rider requested written confirmation from Thiesing that ECM's were not required to document modifications to the polar crane.
In a memorandum dated November 19, 1982, Rider noted the following:
l We have made several requests for written direction from Project Management not to issue ECM's for changes to the Polar Crane.
We feel this written direction is necessary as we are currently not complying with the current ECM procedure.
We have been informed that the decision not to use ECM's was based on discussions in which we did not participate.
Please provide written confirmation of j
these directions as this resolution is likely to be required for polar crane use.
We request that you please give this matter your 1
s immediate attention. (25) 1 i
i I
Design Engineering did not receive a response,to'tneir 3
request.26 Thiesing testified'that he did not respond because
,1 he believed all of the modifications had been completed and the issue was moot. 'Although he mentioned some discussion within-his
/
own organization about the use of ECM's, he did not communicate with GPUN on the subject until a Quality Deficiency Report 'was 27 i
issued to him by QA in February 1983 Because of the lack of procedural" guidance for documenting q
modifications, Rider stated that De' sign Engineering "went ahead 7
- 1 41
/
1 1
I
.--l
and completed their evaluations in the format of the ECM in any event."28 l
The misunderstanding about the applicability of the ECM procedures to the polar crane refurbishment was not immediately recognized by TMI-2 management.
This was due in part to the fact l
l that management was being reorganized at the same time as the i
polar crane was being refurbished.
Pastor, the key GPUN employee who had arranged for the turnover of the polar crane, was transferred from his position as supervisor of Bechtel on-site construction activities shortly after the Job Ticket was issued.29 Pastor's transfer left TMI-2 management without the person in the chain of command who was most familiar with the procedural requirements that governed the refurbishment of the polar crane after its turnover to Bechtel.30 This situation continued until February 1983, when, as i
preparations were being made for final testing of the polar 4
crane, concerns were expressed to Kanga that modifications to the crane had not been properly documented according to GPUN pro-cedures.31 In response, Kanga requested QA to review the administration of the entire polar crane refurbishment process.32 QA's review included verification of inspection and 1
refurbishment documentation.33 QA determined that, among other things, four modifications had been performed without ECM's.34 Those modifications were:
(1) the installation of the trolley 42
power and control bypass system; (2) the installation of a pendant, pendant cable and festoon cables (3) the installation of a temporary jib crane; and (4) changes in the polar crane control cabinets.35 QA also questioned whether appropriate design reviews had been performed, even though the modifications had not followed ECM procedures.36 Design Engineering's responses to QA indicated that all engineering work had been substantively reviewed and evaluated.
QA was therefore satisfied that, although GPUN procedures were not followed, the required engineering review had taken place under Bechtel's procedures.37 The procedural deficiencies were documented in a Quality Deficiency Report (QDR), which was issued by QA to Recovery Programs on March 8, 1983.38 43 l
i
NOTES t
1 TMI-2 Report, Management and Safety Allegations, Vol. IV,
Background:
Organization and Management of TMI-2, pp. 5-7.
2 Ibid.
3 Ibid.
1 4
Ibid.
5 Pastore 6/19/85, pp. 10-12; Lake, 4/10/85, pp. 96-99; Freemerman, 4/22/85, p. 59; Thiesing, 4/25/85, pp. 79-80.
1 6
Freemerman, 4/22/85, pp. 59-64; Pastor, 6/19/85, pp. 6-11.
7 Memo, 1/20/83, King to Barton (4200-83-034), re Polar Crane Turnover (Tab 5).
4 8
Maintenance Procedure 1407-1, Rev. 13, 7/17/82 (Tab 6);
Management and Safety Report, Vol. IV, Polar Crane Allegations, pp. 4-6.
i 9
Maintenance Procedure 1407-1, Rev. 13, 7/17/82 (Tab 6).
10 Shamenek, 7/17/85, pp. 9-11; Management and Safety Report, Vol. IV, Polar Crane Allegations, pp. 4-6.
11 Maintenance Procedure 1407-1, Rev. 13, 7/17/82 (Tab 6);
Shamenek, 7/17/85, pp. 9-11;
~
Pastor, 6/19/85, pp. 6-10.
44 i
{
i
+
w e
r
.-e__.-
12 Three Mile Island Nuclear Station, Unit No. 2, Administrative Procedure (AP) 1021, Rev. 10, 6/2/82 (Tab 85).
13 Three Mile Island Nuclear Station, Unit No. 2, Administrative Procedure (AP) 1043, Rev. 2, 8/30/85 (Tab 86).
l l
14 Memo,1/20/83, King to Barton (4200-83-034),
re Polar Crane Turnover (Tab 5).
15 GPUN TMI-2 Administrative Procedure Manual,
- 4300-ADM-3240.1, Access to and Work In Containment Building (ATWIC), 4/4/82 (Tab 11).
16 Ibid., paragraph 4.1.2.1; Management and Safety Report, Vol. IV, Polar Crane Allegations, p. 8.
17 Ibid., p. 7.
l 18 Ibid.
19 Ibid., pp. 7-8.
20 Ibid., pp. 11-13.
21 Ibid., p. 7.
22 Ibid., pp. 9-13.
23 Ibid., pp. 13-16.
24 Ibid., pp. 13-14.
25 IOM, 11/19/82, Rider to Thiesing, re ECM's (Tab 8).
45 i
.26 Jackson, 4/3/85, pp. 7-8.
27 Thiesing, 4/25/85, pp. 52-59.
28 Rider, 4/3/85, p. 15.
29 Management and Safety Report, Vol. IV, Polar Crane Allegations, p. 9.
30 Ibid., p. 12.
31 Ibid., pp. ;0, 47.
32 Kanga, 8/29/85, pp. 14-18; 5/2/85, p. 53; Ballard, '/30/85, p. 31; Marsden, 1/14/85, pp. 62-f3.
33 Ballard, 7/30/85, pp. 8-13; Marsden, 7/30/85, pp. 10-17; Management and Safety Reporte Vol. IV, Polar Crane Allegations, pp. 16-17.
34 Management and Safety Report, Vol. IV, Polar Crane Allegations, pp. 16-17.
35 Ibid.
36 Ibid.
37 Ibid.
38 Ibid.
i I
s 46 l
. 1
I BECHTEL'S ADMINISTRATIVE CONTROLS Although Bechtel began the polar crane refurbishment project under the misapprehension they were not bound by the GPUN cdministrative procedures for the documentation of work, they did not simply ignore the need for such a system of controls.
They established their own means of assuring compliance with basic requirements for documentation and engineering reviews.
As a part of their procedural scheme, they divided responsibilities among the engineering and construction groups of the Recovery i
Programs Department.
Division of Responsibility Initially, Freemerman developed a list of responsibilities and allocated them between the PCTG and Project Engineering at Gaithersburg (sometimes referred to as Home Office Engineering and later designated as Design Engineering).1 This was accomplished through an exchange of memoranda prepared by each group and a series of meetings to resolve disagreements.2 The process culminated on July 29, 1982, at a meeting among Freemerman, Lake, Radbill and Jackson.3 Freemerman described the process as follows:
47
Specifically I requested the interested parties, the task group and the design engineering group to attempt to define what they felt their responsibilities were, and then at a meeting which included both organizations we went through each written document, and I made a de-I termination whose responsibility it actually was.
Where there were duplicates, where the task group thought it was their responsibility, and the design engineering thought it was their responsibility, I made the decision whose responsibility it was.
So when we came out of that meeting, we had one list of responsibilities, and it was clear who had the responsibility for which piece of the work. (4)
Their final agreement was set forth in a document entitled,
" Division of Responsibility," dated July 30, 1982.
According to Item 2 of that document:
The "how" or means of satisfying the functional requirements and making the components operational is the Polar Crane (P.C.) Group's (Construction)
[PCTG) responsibility. (5)
Item 8 stated:
Modifications will be engineered by H.O.
[Bome Office] Engineering unless mutually agreed otherwise.
Replacement-in-kind will be by the P. C. Group.
Note:
Modifications required may be identified by the P. C. Group. (6) i l
48
Item 12 stated:
1 l
The P. C. Group will prepare and implement procedures to document all work done to the crane and its components... (7)
Other provisions dealt with responsibility for QA/QC and licensing requirements as well as planning, scheduling, cost control, progress reporting and obtaining necessary materials.
Freemerman explained the intent of Item 8 as follows:
Item 8 really covers two areas of refurbishing work.
One is the engineering.
In general, the directions that were given were that engineering would be done in Gaithersburg at the home office.
However, there was a minor engineering activities [ sic]
which could be handled more easily at the site.
So, we agreed that if home office engineering approved, then pieces of engineering could be done in Dave Lake's site organization.
But it required mutual agreement, in that the site could not decido on their own to go do a piece of engineering work.
The second part was, what required home office input when we were doing work on the crane, when we were replacing parts on the crane, and it was decided that any part that was put on the crane, which was a duplicate of a part that was taken off the crane would not require home office engineering review and approval, that it could be replaced by the Polar Crane task group, by the construc-tion group without any approvals necessary from the home office design engineering group. (8) 1 i
This description of the purpose of Item 8 is supported by the testimony of Jackson, Rider, Lake and Radbill.9 e
i l
49
~.
Functional Descriotion A " Polar Crane Functional Description" was prepared during the summer of 1982 and was issued for use in September of that year.
It was intended f6 establish minimum requirements for crane operation during cleanup activities.10 It also defined certain categories of work and specified QA/QC and engineering requirements for such work as follows:
3.2 CRANE MAINTENANCE AND MODIFICATIONS' 3.2.1 Crane Maintenance (Includes rework and repairs) a.
Rework - Any work required to maintain con-formance to prior specified requirements.
QC receipt inspection is required for any replacement parts for the main hoist com-ponents.
b.
Repairs - Any work required to allow safe crane operation, e.g.,
repair welding, even though the crane will (after repair) not con-form to the original requirements.
The appropriate QA/QC requirements will be identi-fied in the document approved by Engineering which authorizes the repair.
3.2.2 Crane Modifications Crane modifications are defined as engineering changes to the crane components or functions.
The authorizing document will be reviewed and approved by Engineering in accordance with i
existing project design control procedures and will specify QA/QC requirements when i
appropriate. (11)
According to Freemerman and other members of DE, this provision was consistent with the policies stated in the Division of Responsibilities.1 Freemerman testified:
50
Again paragraph 3.2.2, which is crane modification, specifies crane modifications require approval by engineering, in accordance with the project document control procedures, and the division of responsibility to [ sic) the same thing.
Essentially if you modify the crane, it must be concurred in by engineering.
That's the like kind /unlike kind syndrome.
Unlike kind is a modification, and a modi-fication requires an engineering approval. (13)
CDPI-20 j
The preparation of Work Packages was controlled by Construction Department Project Instruction (CDPI)-20, the primary Bechtel procedure for the control and documentation of all work on the polar crane.14 It was issued following the i
polar crane turnover discussions between Lake and GPUN personnel.
Lake testified that these meetings emphasized the need to document machinery history while the polar crane was under Bechtel's control.
Although CDPI-20 was never reviewed or approved by GPUN, it was nevertheless prepared to satisfy GPUN's concern that Bechtel's Work Packages provide a detailed machinery history record of the work that was performed on the polar crane.15 CDPI-20 established a requirement that all work be documented in Work Packages, including any modifications performed on 4
facilities turned over to Bechtel.
The purpose and scope of CDPI-20 were defined as follows:
1 i
51
l.0 PURPOSE 1.1 The purpose of this procedure is to establish the requirements for controlling and documenting all work performed on systems, subsystems, com-ponents, rooms, and areas by construction after release from G."U to construction.
The work per-formed may be repairs, modifications, replacement of bad parts, maintenance, testing or new con-struction.
2.0 SCOPE 2.1 This procedure is applicable to all activities conducted by construction on systems, subsystems, components, rooms, and areas that are released from GPU to construction, until turnover to GPU from construction, for the performance of authorized recovery tasks for the Three Mile Island Nuclear Station Unit #2. (16)
Radbill understoood that one of the purposes of CDPI-20 was to document modifications.
Jackson described a conversation he had with Radbill as follows:
I asked Mr. Radbill for a copy of the procedure that had been written to document the modifications that were going to be made to the crane to comply with the agreements that centered around that job ticket.
That's the document ICDPI-201 he gave me. (17)
CDPI-ll CDPI-ll was the Construction Department procedure controlling the use of Work Packages for the refurbishment of the polar crane.
Originally effective as of September 21, 1982, its purpose was to provide " controlled guidance in the performance of work to allow the licensee (GPUN) assurance that work tasks are 52 l
adequately regulated and controlled. 18 Its scope included
" initiation, preparation, scheduling, review and approval of documents required to perform work."19 CDPI-ll designated the Work Package as the means of making a
" verification record" of refurbishment tasks.20 CDPI-ll also l
l required Site Engineering to review all in-containment Work Packages "to determine impact on Nuclear Safety, impact on plant safety, and compliance with Technical Specifications."21 Work Package Review Practices Site Engineering received instructions from Thiesing at about the time of the reorganization in September 1982 to review all Work Packages prepared by the PCTG.
Their review function included determining whether modifications were being performed without proper design reviev.22 Radbill's understanding of Site Engineering's role was as follows:
Q There was a group known as Site Engineers or Site Engineering.
Can you tell me what their purpose and function was?
A I recall that their purpose was to review work plans in containment work.
Q Is that work packages?
Is that the came thing as work packages or is that different?
A In the 19 -- in the summer and early fall, 1982, time frame, that was work packages.
Later on in 1983, that became unit work instructions or UWI's.
53
1 l
That was their function, to review those and to i
make sure -- in the 1982 time frame -- to make sure that we the Polar Crane Task Group were l
i complying with the requirements set forth in division of responsibilities, that we were not making modifications without having engineering j
review and approve them. (23)
Richard Gallagher, Deputy Manager of Site Engineering, described the role of his subordinates in reviewing a Work Package stating:
l Well, as an example, let's pretend that [ Work Package].
N-20 said go in the building and install an anchor bolt in the wall to attach a support to.
My engineers would look at that and say well, where is the design for the support, they would look through the attachments to make sure it was there.
And as they went through that review they concluded that there was not an ECM for installing those anchor bolts in the wall, which we would consider to be a 3
modification.
They would flag that out.
Would have probably not approved.the package and would have written an ECM.
Today it's much the same.
If we review a UWI today 4
in 1985 and as an example a UWI says go in and remove a component or certain valve or certain component i
from the plant.
We would look to see if there was a 1
design change to cover that and if there wasn't we would indicate that one would have to be done. (24) i
]
There was no formal requirement for Design Engineering to examine Work Packages to identify unreviewed modifications.25 If the PCTG identified a modification, they would " send in a 1
i formal request to Design Engineering via memorandum with any i
attachments that were needed to describe what they wanted to do. 26 However, Design Engineering developed a practice of I
1 54 i
1
monitoring the activities of the PCTG to determine if modifications were being made without their prior approval. 7 Wayne Hickerson, a Design Engineer, generally reviewed "anything i
that had to do with the Polar Crane."
This included, for example, reviewing the weekly reports and the Work Packages.
According to Hickerson, if he "noted, or thought there was a problem," he would attempt to resolve it with Radbill.28 He described his purpose as follows:
... I would review them; again, I would try and review those documents to make sure that any of the commitments that were made in a functional description, the items that we specified in there, or again in the area of making sure that modifications were not being done to the crane without engineering authorization. (29)
PCTG Attitude Toward Work Package Preparation The PCTG was acutely aware of the review functions of both Design Engineering and Site Engineering ands to a certain extent, resisted them.
Radbill testified that his group was " sensitized" to the requirements to obtain Design Engineering approval of modifications.30 However, the PCTG developed a practice of minimizing the amount of cetail they included in Work Packages.31 They were deliberately written in as general terms j
as possible without intending to make them inaccurate.
Radbill offered two explanations for this.
The first is that t
the use of general language, lacking detail, gave the group
+
4 3
freedon,and flexibility to adjust its work plans in containment i
55 i
J m.
,. ~ -.
'(
when confronted with unforeseen conditions.32 The second explanation is that detailed Work Packages tended to invite lengthy reviews and revisions.
Radbill testified:
[
The other thing is there was a conscious effort in writing these work packages to be as general as l
possible, not to be very specific, because we found out, very honestly, that the more specific you were, j
the more detail you put in here, the more susceptible you were to having to revise it, to lengthen your reviews.
You know, it slowed things down.
So again, we felt we were in control.
We knew what we were doing.
We wanted people generally to know what we were doing.
We weren't trying to hide anything.
But we didn't feel they needed to know the details, so i
we didn't put them in these documents." (33) l I
Another member of the PCTG, Howard Kirschbaum, concurs with Radbill.
Kirschbaum testified:
...sometimes we would brief it [ Work Package] down...
Because you get a bunch of questions that people would ask that they know nothing about, and if you told them they wouldn't know anything, anyhow. (34) i I
This attitude was apparently based upon a feeling that the i
members of the PCTG possessed superior expertise.
Kirschbaum stated:
Q When you got out to Three Mile Island, what was your understanding of the role of the home office i
engineering or what they called design engineering l
group?
i 56 i
a I
A Well I guess whatever we couldn't handle or we took care of required drawings or et cetera, we would go back to Gaithersburg, to the best of my knowledge.
We really didn't need--in all honesty, we really didn't need Gaithersburg engineering.
Q You didn't need the - to do any kind of review or anything?
A Not really.
Q Is that because--well why is it?
Maybe you can just tell us.
A We were the experts.
Gaithersburg sent us out there asking us questions because they didn't know.
The only thing Gaithersburg did is run back to Whiting Corpora-tion, and they run back to a fellow that I helped break in. (35)
Similarly, Radbill testified:
We wanted to get this job done.
We had the expertise to do it, and so we had to find ways --
That would have been another shortcut, what I call a shortcut.
I We are not hiding anything.
We are not lying to anybody.
We don't have to give them every single little nut and bolt that we're doing. (36)
Although the PCTG understood that one of the purposes of Work Packages was to assure engineering review of modifications, fulfilling that purpose was not of primary concern to them.
Instead, they focuned upon the Work Package as a permit authorizing them to perform work in containment according to the requirements of ATWIC.37 Radbill testified that "we definitely i
weren't sensitized to modifications and the implications of l
1 documenting every little bitty modification. 38 l
57 1
Radbill testified that "some communications problems" developed between PCTG and Design Engineering.39 As Radbill described it, the PCTG believed that Design Engineering was not reviewing the Work Packages fast enough.40 Design Engineering believed that the PCTG was not submitting all of their Work Packages and that those that were submitted lacked the detail required for Design Engineering to perform an adequate evaluation.41 This problem resulted in a visit to the PCTG by I
Hickerson during which they attempted to resolve their problems.
i The meeting was reported in the PCTG Weekly Report of October 15, 1982, as follows:
l Wayne Hickerson, Mechanical Group, Design Engineering, visited the site to discuss the procedural review of work
]
packages by design engineering in Gaithersburg.
His visit resulted in a clearer understanding of design i
1 engineering's review process. (42) 1 l
Radbill testified that, even after the visite this problem was not totally resolved.43 Site Engineering also had a similar problem with the PCTG.
I Barkanic stated that ne reviewed many of the PCTG's Work j
Packages, and although they were not "an educational tool... to i
be scrutinized in any detail," he felt they contained inadequate
[
information and requested the mechanical section of the PCTG to j
provide more details.44 4
i 58 1
7 Barkanic described Kirschbaum's attitude toward complying with such procedurai requirements as follows:
A He voiced his opinion that he did not like having to detail the procedures such that someone with lesser knowledge of the subject than he could understand it.
He felt it was a pain in the side.
Q Could you conclude from reviewing his work packages that he left out detail from time to time on whatever work packages he was responsible for?
A Absolutely.
Do you want an example?
Q Yes A
One mechanical innpection work package was four steps.
Enter the reactor building, ascend Polar Crane, perform mechanical inspection, exit reactor building. (45) l The evidence indicates that the practice of providing inadequate information in Work Packages developed within the PCTG and was not a reaction to pressure from a higher level of management.
The practice of writing Work Packages in general language was contrary to the system of engineering oversight that had been established in Recovery Programs.
That system included Work Package reviews by two engineering groups, both of which were frustrated by the practice.
The preparation of Work Packages was primarily affected by both personal and group considerations within the PCTG.
Kirschbaum and Graber each expressed impatience because of the length of their acsignments to TMI.46 Radbill, as well as 59
Kirschbaum, testified that there was no reason for close oversight of their work.
They believed that they possessed greater expertise than the reviewers.47 Another consideration was the desire for freedom and flexibility when working in containment.40 None of these attitudes resulted from management policies or directives including pressure to meet schedule deadlines.
Radbill testified that there "was pressure to meet schedules" which apparently induced him to " expedite all our activities and do them as expeditiously as possible."49 However, the evidence does not establish that the pressure led to the circumvention of procedures.
Radbill characterized the pressure as follows:
The pressure that was applied to us to get the job done was no different than one would find or at least no 1
different than I have found in my experience in working in other construction projects.
In all of these cases, construction projects that I've experienced, there is pressure to get the job done in a timely fashion.
And, again, in this case, it was not extraordinary or undue. (50) l Radbill's description of scheduling pressures is consistent with the testimony of the other witnesses questioned on this subject.51 60 1
NOTES 1
Freenierman, 8/22/85, pp. 7-11.
l 2
Ibid., p. 8.
l I
3 IOM, 7/30/82, Jackson and Lake to Freemerman, (0306/8420), re Polar Crane Division of Responsibility (DOR)
(Tab 3).
4 Freemerman, 8/22/85, p. 8.
5 DOR, Itep 2 (Tab 3).
6 Ibid., Item 8.
7 Ibid., Item 12.
8 Freemerman, 8/22/85, p. 10.
9 Jackson, 6/6/85, pp. 12-13; 4/3/85, pp. 41-43; Rider, 8/21/85, p. 10; Laker 6/18/85, pp. 8-9; Radbill, 9/27/85, pp. 10-11.
10 Polar Crane Functional Description (2-M72-MH02),
Rev. O, 9/20/82 (Tab 25).
11 Ibid., p. 7.
i 12 Freemerman, 8/22/85, pp. 22-25; Bickerson, 7/9/85, pp. 24-25; Rider, 8/21/85, p. 9.
61
}
13 Freemerman, 8/22/85, p. 25.
14 Construction Department Project Instruction (CDPI)-20 (Tab 4).
15 Lake, 6/18/85, pp. 20-23.
16 CDPI-20, p. 1 (Tab 4).
f 17 Jackson, 7/27/83, pp. 7-8.
18 CDPI-11, p. 1 (Tab 27).
e 19 Ibid.
20 Ibid., Section 6.2, p. 3.
s 21 Ibid., Section 3.0 j, p. 2.
22 Radbill, 9/27/85, pp. 13-15; Gallagher, 7/24/85, pp. 25-26; l
Buchanan, 7/29/85, p. 7.
J 23 Radbill, 9/27/85, p. 13.
i 24 Gallagher, 7/24/85, pp. 25-26.
I 25 Rider, 8/21/85, pp. 68-70.
I 26 Hickerson, 7/9/85, p. 20.
i 27 Ibid., pp. 21-22, 31-32; Radbille 9/27/85, pp. 102-103.
62 l
L_
28 Hickerson, 7/9/85, pp. 20-22.
29 Ibid., p. 3 2.
30 Radbill, 9/27/85, p. 20.
i l
f 31 Ibid., pp. 81-84.
i 32 Ibid., p. 81.
33 Radbill, 3/12/85, pp. 168-169.
34 Kirschbaum, 7/1/85, p. 59.
35 Ibid., p. 21.
36 Radbill, 3/12/85, p. 169.
37 Parlee, 11/18/85, pp. 8-9; Gannon, 11/18/85, p. 12.
38 Radbill, 3/12/85, p. 243.
i 39 Ibid., p. 147.
40 Ibid.
41 Hickerson, 7/9/S5, pp. 32, 42-43.
42 TMI-2 Polar Crane Recovery Progress Report #10, 10/15/82 (Tab 28).
l t
t 63 i
.. m m
. m.
43 Radbill, 3/12/85, p. 148.
44 Barkanic, 7/25/86, p. 25.
45 Ibid., pp. 26-27.
i 46 Kirschbaum, 7/1/85, pp. 68-69; Graber, 6/27/85, pp. 61-62.
47 Radbill, 3/12/85, pp. 168-169, 241-242; Kirschbaum, 7/1/85, pp. 21-23, 59-61.
48 Radbill, 9/27/85, pp. 81-84.
49 Radbill, 3/12/85, p. 80.
l 1
50 Radbill, 9/27/85, p. 77.
1 51 Radbill, 3/12/85, p. 88; 9/27/85, p. 77; i
Firschbaum, 1/30/85, p. 82; Graber, 6/27/85, pp. 56-58; I
Gannon, 11/18/85, pp. 26-27; Willis, 10/23/85, p. 17.
i j
l i
f I
i 64
l l
DESIGN, FABRICATION AND INSTALLATION _OF THE POLAR CRANE BRAKE RELEASES The polar crane has two redundant nain hoist brakes that are mechanically set and electrically released.
They are designed so that when a direct-current magnet is energized, the brake shoes I
j release from the wheel.
When power is turned off, a compression spring presses the brake shoes against the wheel.
Thus, in the event of a power failure, the compression spring will auto-matica11y apply the brakes and prevent a load fron. lowering.1 See Figure 1.
The condition of the brakes after the 1979 accident was one of Project Engineering's ma, dor concerns during the fall of 1981.
Steven Johnson, an engineer working en the TMI-2 project at Gaithersburg, was assigned to prepare the Polar Crane Fecovery J
Description.
He was supervised by Ronald Mayr and Robert l
Preston.
Two Bechtel employees, Howard Kirschbaum and Thomas i
l Gibson, both of whon possessed expertise in the area of cranes, l
were assigned to assist Johnson.3 l
Johnson met with Kirschbaum once or twice, and with Gibson on one occasion.4 The crane was inspected and photographed to l
assess the extent of the dan, age.5 2
i Based on such information, the Gaithersburg engineers j
j determined that the brakes were seriously rusted and should be replaced.6 Johnson and his superiors then had to determine i
65 1
i I
., _ _. _, _ _ I
l 24 8 h I
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1-N-
y i
t o
l
%%%ap.[3 $
g G)
O e
O O
^
1/
i v
(
G 7,lt g;s
- OO
/
io%.)o o
o&
k s
j i
I
=l E
E SEE D/ MENS /0N S//EET 5240,pp29 i
)
- 1. hiain Sp
- Trunnien 3. Shoe Arm Trunnion
- 4. Ma net End Trunnion 5. Torque Adjustmen hng 2. h!ain $p se 6. htsin Tie R
- 7. OutsideShoe Adjusement
- 8. InsideShoe Adjustment 9. Tension Springs
- 10. Magnet Travel Equalizer 11. Stop Pin 12. h!anual Release Bushing 13.TravelIndicator 14. Lifting Lugs f
Figure 1 Westinghouse Type TM Main Boist Brakes 4
3 4
l i
66 i
]
_ _.. - _ - _. _. - ~ -
l i
specifically what parts to order from the manufacturer to duplicate the original equipment.7 In the course of making that determination, they decided to order brake releases that were offered as optional items by the manufacturer.8 These devices were manually operated lever-type brake l
releases.
Each consisted of two blocks of steel, a tie rod that passed through one block and was attached to the other, and a lever and cam that attached to the free end of the tie rod.9 See Figure 2.
The entire mechanism was designed to be mounted on top of the brake assembly.
When the lever was raised, it compressed the main spring and thereby released brake shoe pressure from the wheel.
By raising and lowering the handle, a load could be gradually lowered.in the absence of electric power i
to the brakes.10
]
The primary function of a brake release is to lower a load in the event of a power failure.11 The designer of the Westinghouse brake release scated that Westinghouse intended that l
the brake release be permanently bolted to the brake assembly.12 However, he also stated that it could be easily 4
installed, removed and re-installed.13 Several witnesses stated that brake releases may also be used temporarily for brake maintenance, installation and testing.14 Project Engineering's decision to order the brake releases was the result of a number of considerations.
Kirschbaum testified that he recommended that they be purchased.15 I
I j
67 i
js r
s
\\
\\
\\
\\
\\
RELEASED
\\
POSITION 3/16" GAP - ADJUST BY TURNING TIE ROD
\\ s 16 IN TAPP ED HOLE IN BLOCK 14 WITH
\\
s BRAKE ADJUSTED AT NORMAL TRAVEL
\\ \\
\\
\\
\\
\\ \\
s
//
\\ \\
SPRING HANDLE s N LIP STOWED POSITION s', s s LOCK NUT.
l
\\
')
5 8
g
.-. y 9
~
O l'H+
TIE ROD CCD
/
- W \\%
~
0lll l
t 0
(
AA i
Figure 2 l
Westinghouse Brake Release 68 l
a -
Johnson stated that he reviewed documents that probably included i
the Westinghouse literature describing the brake release as an l
optional item.16 Mays testified that they reviewed photographs of the polar crane brakes and the original Burns and Roe specifications for the TMI-2 polar crane.17 Based on this information, as well as Mays' previous experience with other polar cranes "that you alw'ays' provide it la i
brake release]," Project Engineering assumed that the TMI-2 polar crane was originally equipped with brake releases.18 There-fore, they believed that the brake releases were needed to duplicate the existing brakes.
Their assumption was wrong.
The original brakes were not in fact equipped with brake releases.
It is unclear what caused them to be misled.
The Burns and Roe specifications somewhat ambiguously state:
8 Release lof the brakes) shall further be arranged for manual operation. (19)
Although this specification appears to require a r.eahanisra that functions similarly to a brake release, it does not precisely identify that device.
The Westinghouse literature describes a means of manually rele'asing the brakes by turning a manual
" release bushing" with'a wrench.
The manual " release bushing" is a standard feature incorporated into the brake design and is intended by the manufacturer to facilitate brake main-69
(
I s
tenance.20 This feature may have satisfied the Burns and Roe specifications rather than requiring the addition of the optional brake releases.
Kirschbaum testified that, at the time he consulted with the engineers at Gaithersburg, he was aware that the polar crane brakes were not equipped with brake releases.21 The evidence does not indicate whether this knowledge was communicated to the engineers.
However, the photographs available to them showed that there were no brake releases on top of the brake assenblies. 22 On February 10, 1982, Johnson prepared a Materials Requisitions form MR 135.87-MO62B, Rev. O.
The description of the materials requested reads as follows:
Iten No.
Quantity Description Furnish the following brakes and brake wheels for the polar crane main hoist:
1.0 2 ea.
Main hoist brakes - Westinghouse TM 1665 16 inch diameter solenoid brakes including 16 inch diameter brake wheel.
Optional hand release shall be furnished on brake.
Noter These are replacement components for the oricinal polar crane parts.
(emphasis added) (23)
The Materials Requisition was also reviewed and signed by Mays and Jackson.24 70
On February 11, 1982, J. W. Buell, Bechtel's TMI-2 Project Procurement Manager, submitted the above Material Requisition form, together with a number of standard instructions, conditions and informational forms to Whiting Corporation and Westinghouse Electric Corporation and solicited proposals for the sale of the main hoist brakes as described.25 A Westinghouse represen-tative responded, stating "There is a good possibility the brakes i
had special accessories which I cannot identify from your l
specification.
For that reason, I would suggest you contact Whiting Crane for these replacement-brakes."26 Whiting submitted a proposal, dated April 22, 1982 In that proposal, Whiting confirmed that the equipment conformed with l
Bechtel's specifications.27 However, Whiting did not include the optional brake releases in the proposal.
The Procurement Department transmitted Whiting's proposal to Project Engineering for technical review.20 Engineering evaluated the proposal and, failing to note that the brake releases were excluded, instructed Procurement that the "P.O.
should be in accord with Whiting quotes RP5042-R1 & RP5043-R1 dated 4-22-82. 29 Also unaware that the brake releases were not included in Whiting's quote, D. M. Blizzard, Bechtel's Contracts / Purchases Specialist, submitted a Purchase Order to Whiting on April 30, 1982.30 In accord with Project Engineering's instructions, that Purchase Order was premised upon Whiting's proposal and 71 4
. - ~. -
therefore failed to include the brake releases among the items requested.31 Shipping terms were "F.O.B.
Carrier, Jobsite."
l Delivery was due on or before September 24, 1982.32 Because of the importance that was attached to the expeditious procurement and delivery of the brakes, they were ordered several months before the PCTG was even formed.
This is evidenced by a section of the Recovery Description, which was issued on March 29, 1982, during the period when the purchase of the main hoist brakes was taking place.
The Recovery Description states:
2.3 PROCUREMENT OF REPLACEMENT COMPONENTS Following the identification of damaged crane components requiring repair or replacement, procurement of replace-ment components and parts for repairing other components will be initiated.
The procurement of components will be separated into four categories as follows:
a.
Components which must be replaced in order to complete the inspection and testing program.
As an example, the main and auxiliary hoist holding brakes must be replaced (as determined by their poor condition found in previous entires (sic) to conduct the wire rope inspection (the book and block must be lowered under control to unreel the wire rope from the drum).
b.
c.
d.
The highest priority will be placed on procurement of those components required to complete the inspection and test program.
Of the remaining components to be procured, the longest lead time items will receive higher priority.
Competitive bidding will be pursued where possible. (33) 72 4
Based upon a review of documents and the testimony, it appears that the brakes were shipped by Whiting in July 1982.
Brake releases were not included.
The shipment was addressed to TMI-2 Receiving Department, Warehouse il, to the attention of i
Leroy Jeffries and arrived on site at TMI-2 in late July /early August 1982.34 However, an exact delivery date cannot be deterniined since the normal procedures for delivery and inspection were not followed.
J Sources froc Whiting indicate that the brakes were shipped on or about July 14, 1982.35 The FCTG Weekly Progress Report #2 for the week of August 20, 1982, indicates that the brakes were "on-hand" and that "QC inspection should occar next week."36 According to the Managers of QA and Warehousing, the standard procedure was for all materials to be delivered to the TEI warehouse where they would be inspected for damage and conformance with the purchase order.37 If QA/QC receipt inspection were required, the materials would then be turned over to QCr or QC would be advised that the items were at the warehouse.38 However, the polar crane main hoist brakes were not receipt inspected at the warehouse and QC was not requested to inspect the brakes until October 1982.39 One member of the PCTG recalled that in August 1982, someone j
from the warehouse contacted Radbill and advised him, "we have some big brakes down here," and requested instructions on what to do with them.40 The brakes were then brought to the PCTG 73
Trailer 102 where they were stored for several weeks.41 Kirschbaum stated that the PCTG had previously requested that all parts be delivered to the PCTG trailer so they would be available when needed and would not get lost in the warehouse.42 l
After the brakes had been delivered to Trailer 102, Design Engineering became aware that they had not been inspected by QC.43 According to Jackson,' Design Engineering then contacted Lake, because the Polar Crane Functional Description required QC i
inspection, and advised him that such an inspection was l
necessary.44 In response, a QC inspection was performed in l
Trailer 102 on October 8, 1982.
It verified that the brakes j
conformed to the Purchase Order and were free from shipping damage.45 Immediately after the brakes ha' been delivered to Trailer i
102 in August 1982, they were inspected by Kirschbaum and Graber.
j They believed that Project Engineering had ordered brake releases, but discovered that brake releases were not included in i
i the shipment.46 After some discussion among the PCTG members, they concluded that the brake releases were necessary for them to perform their refurbishment tasks and decided to order the relezses directly from Westinghouse.47 Although Kirschbaum and Graber believed brake releases had i
been ordered, the evidence indicates that Radbill was unaware that Profect Engineering had attempted to order them.
When asked l
who decided to add the brake release mechanisms during the i
4 a
i 74 f
n.-.
n ane
..r-,.
-_~,,,.-.n n n,r,,
.n.,-.,
,.,., ~,_
refurbishment, Radbill testified that he did.
Moreover, he stated that he was unaware of any prior attempt by Project Engineering to order the brake releases.
He described his participation in the decision to obtain them and the extent of his knowledge at that time as follows:
A.
Well, I was the Group Leader.
Somebody had to make a final decision.
I made the decision.
I said, " Yeah, we'll go ahead and do it."
I made other decisions, too.
That was one among many.
Q.
Mike, weren't these, though, ordered actually prior to your becoming involved with the group?
Do you know if design engineering had originally requeste6 hand-release mechenisms when the brake assemblies were --
A.
Welle to put everything in perspective, at the time that I made this decision, to the best of my recollection, I was not aware that engineering had ordered them and they didn't come through.
I don't remember that I was aware of that.
I don't remember that. (48)
When Radbill was asked when he first learned that Goitbersburg engineering had attempted to order the brake releases, he testified:
A.
I learned of that in 1984.
Q.
In 1984?
A.
That's correct.
l 75
Q.
Was that at the point that this was disclosed by --
well, how do you remember?
How did you learn that in 19847 A.
Well, once the issue of the hand release mechanism became an issue and there subsequently were a lot of question and answer periods, investigations, i
l et ceteras et cetera, then I became aware that it was ordered by home office engineering.
Prior to that I had no knowledge that they ordered it. (49)
In contrast to Project Engineering's decision to order the brake releases to duplicate original equipment, the PCTG's decision was based upon other practical considerations that were of immediate concern to them.
According to Radbill:
I don't remenber the specific details, but I do remember two main points that came about; that is, the group concluded -- the Polar Crane Task Group concluded -- that these handles allowing us to manually release or disengage the brakes would be very useful in performing two activities; number one, adjusting the brakes on a crane after the new brakes were installed; and, number two, to lower the main hook and block on the crane for the purposes of inspecting the hook.
I say that because this schedule indicated -- the initial schedule indicated that we would be performing the activity of inspecting the hook without having electric power on the crane.
So, we could not electrically lower the hook and block.
We would have to do that mechanically only. (50)
Both Radbill and Kirschbaum recall contacting Westinghouse, following the PCTG discussions in an effort to order brake releases.51 They stated chat Westinghouse advised them that "there were none available on the shelf" and that it vould take 76
9-10 weeks for manufacture-and delivery.52 This delay was unacceptable to Radbill from a scheduling point of view.53 They believed the brake releases were essential for them to begin refurbishing the crane in the absence of electric power.54 The l
unavailability of the brake releases would therefore impede the progress of the refurbishment.
Radbill stated that he discussed the unavailability of the brake releases, its impact on the schedule, and the viable alternatives with Kirschbaum, Graber and Parlee.55 As a result
]
of these discussions, they decided to have the brake releases f
manufactured on site by the GPUN Maintenance machine shop.56 1
j Although they are uncertain about who was contacted, Design j
Engineering personnel, Wayne Hickerson and Mays, specifically i
recall that their office was consulted regarding the decision te h
febricate the brake releases at TMI-2.57 Mays testified that, i
although he did not give " approval" to fabricate the brake j
releases on site, he did provide " technical agreement" that they could be fabricated only on the condition that they would be "a j
copy of the part that is manufactored by Westinghouse."58 At t
the time of these discussions, Mays believed that brake releases were originally installed on the polar crane.59 When i
i questioned about what guidance the PCTG would follow in
)
fabricating the brake releases, Mays testified:
i A.
We said "an exact replacement."
We believed, you have to bear in mind, we believed at that time, or 1
at least I believed at that time, that there was l
i 1
l 77 I
J
- - _. _.. ~... _. _ _.. _..... _. _.... _ _ _, -.. _. _, _. _ _, _ _ _ _... _. _. - -,. _ _ _.. _, _. - _ _ _ _,
I already one on the crane, so they would have a model to go by.
So I don't' thing that what was in the manual was significant.
We thought they actually had a piece of equipment they could use.
l l
In fact, I recall at that time that uney might be able to use the release that was on the brake.
Q.
Did they indicate.to you that it was, in point in fact, incorrect, and it did not already have a hand release on the brakes?
A.
No, not to me.
Not that I can remember.
i Q.
Did they say how they were going to fabricate an exact replica?
i A.
No, no, and I don't think we asked, at least I didnt ask.
I didn't particularly care how they j
were going to do that. (60)
J 1
There is no indication that Mays discussed this with any of his superiors in Design Engineering.01 i
Although Radbill recalled that someone from the PCTG contacted Westinghouse to obtain design drawings of the brake l
releases, he stated that the drawings were unavailable.62 Instead, Kirschbaum and Graber prepared sketches based upon illustrations and information contained in the Whiting Crane 1
l Bandbook, measurements taken from the new brakes that were being i
i stored in Trailer 102 and their general familiarity with such devices.63 See Figure 3.
The literature from the Whiting Crane Handbooke together with the sketches, were then appended to 78 l
l
9 Leut4 JCA MWO Al R R8VE Art r au f
%U, itsJ
~
Q)Roa Past
&SuppanT Blast.
&$se99enttBleek
....t
@ Lact' AluT D BsLT 4. %
b S Rit Letk buA1 M 1
\\.
1 l
~
r a exz
=
t ty ws I $19 F4 O"s;
@ not y
I act.
f
~
L
- =
{
s Ie e e e1 3
g r*l '
i e
I 1
s u..
I lb,
@ g
'W bd l
hE W
'O 1
3, 4
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, c,.
t
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1m i..
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14 4
)u fI L'
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O S M L** E
'f y
(
- ser 49tt.
I *' *-
Figure 3 PCTG's Design Sketches for Fabrication of Brake Release l
l l
79 1
l
- \\
l a Maintenance Job Ticket forL and submitted to the GPUN Maintenance Department.64 The descriptive portion of the Job Ticket simply states,
" Manufacture as per attached drawing - special handle (Two Units)."
The purpose of the Job Ticket was stated to be "For Polar Crane Inspection."
The form, dated August 6, 1982, bears the signatures of Howard Kirschbaum, as the originator, and M. E.
Radbill, as supervisor.0 Radbill stated that his review of the Job Ticket was simply "to make sure it was administratively correct" and would " pass through the system."66 He did not check it for technica]
sufficiency and was unaware of any essential differences between the manufacturer's specifications and those depicted in the sketches.67 Design Engineering review or approval of the Job Ticket was not requested.68 When asked why they did not submit their sketch to Design Engineering for review, Kirschbaum testified:
A.
Yeah, but how can I submit that to design engineering when I am sitting with the brakes?
Am I going to send the brakes to Gaithersburg when they have never seen that before?
They have never seen that handle except by that literature.
Q.
(BY MR. BARNES:)
Which your design really isn't--
does not totally duplicate the literature; does it?
A.
No, not quite.
We designed that to make it work, period.
We are not trying to set an engineering award there.
We are trying to make a piece of equipment work and do what we want it to do and facilitate what the original handle looked like.
And it does.
80 1
1 Q.
Why wouldn't it go through design engineering, though?
A.
Because they don't know about it.
They would have to send an engineer down and do some measurements and probably take you six months.
Q.
So you think it wasn't worthwhile to send it to them?
A.
Not that it wasn't worthwhile.
I mean they--they didn't hardly know what the brakes looked like, much less the brake handle.
So it was eacier for us to do it rather than send it to engineering. (69)
Although Kirschbaum testified that he did have some discussion about the fabrication of the brake releases with engineering "on site," he could not identify the individuals with whom he spoke.70 Robert Barkanic, the engineer who acted as liaison between Site Engineering and the PCTG, as well as his superiors, Richard Gallagher and David Buchanan, testifie6 that they were not consulted regarding the decision to fabricate the brake releases.71 In addition, they stated that at that time they were unaware that the brake releases were manufactured on site.72 i
The Job Ticket was transmitted by the PCTG to the GPUN Maintenance Department where the brake releases were to be fabricated.73 Initially, it was reviewed by Louis Shamenek, Maintenance Planning and Scheduling Manager, simply to insure 1
that the form was properly completed and contained sufficient information to perform the work.74 According to Shamenek, the Job Ticket was properly prepared.75 81
q 1
On August 12, 1982, he authorized the release of the work to the machine shop.70 Samael fules, Mechanical Maintenance Supervisor, assigned the task to Barry Corkle, Mechanical Maintenance Shift Foreman.
Corkle's review indicated that i
there were some problems with the dimensions noted on i
i Kirschbaum's hand drawn design.78 Corkle discussed the problems with Jules, who in turn contacted Radbill to resolve f
them.78 Either Radbill or one of the PCTG members conferred with Corkle; changes were made and the problems solved.80 i
l The Job Ticket indicates that authorization to begin fabrication was granted on August 14, 1982.81 The actual machine work was performed by Mark Filkins, a machinist in the GPUN Maintenance Department.82 Finally, the Job Ticket indicates that the work was completed on August 27, 1982.83 The brake releases machined by GPUN Maintenance did not i
j exactly duplicate the Westinghouse equipment.
There were two i
j significant variations from the Westinghouse design:
the support
}
block that was intended to anchor the tie rod was bored smooth i
J rather than threaded; and there were no clips to secure the handles during normal brake operation.84 f
The most fundamental design difference, the smooth bore of i
the block, resulted from an apparent error in the hand drawn I'
j sketch.
Graber and Kirschbaum intended that it be threaded as in the Westinghouse design.86 However, the drawings did not indicate that the block was to be threaded.87 When Graber and I
l 82 I
- m. _. -,.-...,.,
Kirschbaum discovered that the block was not threaded, they nevertheless found it acceptable.
They believed they could compensate for the smooth bore of the block by placing two nuts on the tie rod and tightening them against one another, instead of using a single nut to tighten against a threaded block.
This would permit adjustment of the tie rod, but would firmly lock the nut in the proper position during crane operation.
However, when the brake releases were installed, only a single standard hexagonal nut was put on each tie rod.
Therefore, the tie rods were not firmly anchored in position.88 Additionally, the design of the brake releases did not provide for any means of securing the handles when not in use.
In contrast, the Westinghouse design provided for a spring clip mounted on top of one of the blocks.89 After installation of the brake releases, during meetings held to discuss the readiness of the crane for operation, it was decided to secure the handles with tape to prevent inadvertent release of the brakes.90 Radbill testified that these differences from the Westinghouse brake releases were acceptable, since the fabricated brake releases were designed to function the same as those manufactured by Westinghouse.91 Kirschbaum stated that he hand carried the brake releases from GPUN Maintenance to the PCTG trailer as soon as the fabrication was completed.92 He and Graber then mounted them on the new brakes and tested them to make sure they worked.93 83
l l
l i
The brakes, together with the hand releases, were then used to train the GPUN Maintenance personnel in the procedure for replacing the brakes.84 The brake releases were mounted on the i
new brakes outside of containment in order to minimize the number l
of separate components that eventually would have to be carried l
into containment, thereby reducing exposure of personnel to j
radiation.95 However, once in containment, the new brakes had f
]
to be dismantled and the brake releases removed in order for the brakes to be installed.96 On September 16, 1982, Kirschbaum prepared Work Package M0020 for the installation of the main hoist brakes.87 The Work 1
l Package describes in general terms the steps for staging the l
1
]
brakes on the polar crane, removing the old brakes, installing l
the new brakes and taking the old brakes out of the containment
{
building. The Work Package does not document that the brake releases were being installed as an integral part of the i
brakes.98 Neither the initial mounting of the brake releases
)
4 cn the new brakes outside of containment nor their renounting in 1
j containment were documented in the Work Package or in any other form.II The Work Package was reviewed and approved by Radbilla cnd by Barkanic and Gallagher of site Engineering.100 l
The Work Package was issued for use by Construction ren November 8, 1982.101 The actual installation of the brakes l
l required six entries into containment over a period of 9 days l
between November 15 and 24, 1982.102 Personnel from Catalytic i.
l 84 a
t i
Inc. were responsible for transporting the brakes to and from the crane during the first and last entries.103 Graber and three individuals from GPUN Maintenance performed the actual renoval and installation of the brakes.104 Neither Kirschbaum nor Radbill was involved in the physical installation of the brakeEs although Kirschbaum may have been in the Command Center during some of the entries.105 The in-containment work involved removing the old brakes from their base plates, dismantling the new brakes and reassembling the new brakes on the old base plates.
The brake releases were then remounted on the new brakes.106 On Decenber 29, 1982, Radbill reviewed and gave final opproval of the completed work package.107 After the brakes were installed and other components repaired or replaced, a No Load Test wac conducted on February 16, 1983.108 That test was witnessed by Kirschbaum and QC representatives, Zale James and James Green.109 The testing of the main hoist brakes were specifically designated as "QC Hold" points.110 Among other things, Green inspected the train hoir>t brakes to determine if a.)
Shoes have adequate movement to clear wheel without dragging.
b.)
Magnet gap opening has not progressed to the p int where the endo of the indicator brackets line up.
111 c.)
Have no loose bolta 85
l l
l l
Green's inspection checklist indicates that the acceptance criteria were visually verified.112 Green stated that he did t.
t notice the brake releases during his inspection because they were not included on his checklist.113 The second phase of testing the crane was to involve lifting a test load of between 200 and 212 tons.114 In anticipation of 1'
that test, a Readiness Review Committee was forned to review the a.
polar crane inspection, refurbishment and proposed testing.
The Committee was comprised of GPUN management personnel and was convened on March 12, 1983.115 Among those in attendance, in addition to GPUU canagement, were representatives of Design Engineering and the PCTG.116 A question was raised concerning how a suspended load could be lowered in the event of a power failure.
The question was answered by noting the existence of i
the brake releases and describing their ability to deal with such a problem.117 In March 1983, shortly after the Readiness Review Committee meeting, three TMI-2 personnel made public allegations concerning the management and safety of the clean-up of THI-2.II8 Some of those allegations concerned the refurbishment and testing of the polar crane.119 The investigation of those allegations substantially delayed the Polar Crane Load Test, the last major task to be performed by the PCTG.
Because the Load Test was delayed, the PCTG was dis-banded.120 Kirschbaum, Graber and Radbill, the key people who l
86
knew the history of the brake releases, were reassigned to other jobs in other parts of the country.121 During the polar crane refurbishment, Kirschbaum, Graber and Radbill had decided that the brake releases should be left on the crane until the completion of the Load Test.122 They believed they would be recalled to TMI for the Load Test and could remove the brake releases at that time.123 They were never recalled and the brake releases remained on the crane.
The Load Test of the polar crane was successfully con.pleted I
on February 29, 1984.124 Prior to performing the test, the main hoist brakes were again checked by Maintenance and CC personnel and found to be satisfactory.125 It does not appear I
l l
that the brake releases were specifically noticed or tested by those individuals.126 The satisf actory completier: of the Load Test qualified the polar crane to lift the reactor vessel head.
This occurred on July 24, 1984.
I The evidence shows that the brake releases were used only to I
adjust the brakes immediately after the brakes were installed, and again in late December 1982/early January 1983.'27 Kirschbaum testified that the PCTC attempted to use the brake releases to lower the block.
However, they were unsuccessful because there was not enough weight on the block to cause it to
" free wheel. 128 He testified that they anticipated testing the brake releases further prior to headlift.129 87
The brake releases remained on the crane until several weekc after headlift, when it was discovered that the outboard main hoist brake was disengaged.130 On August 16, 1984, J. Q. Hicks and Richard Parsons, his innediate supervisor, both Bechtel Civil Field Engineers assigned to Recovery Operations, made the discovery while performing an inspection of the polar crane auxiliary hoist.131 Hicks and other personnel within Recovery Operatione had assumed sor.ie of the former responsibilities of the PCTG after the group was disco 1ved in July 1983.132 Hicks was familiar with brake releases and had used such devices on other cranes for brake testing.133 Although he never discussed the brake releaser, with any PCTG cerbern, Hicks was generally aware, as a result of his previous inspections, that there were brake releases on the TMI-2 polar crane.134 During the inspection of the auxiliary hoist while waiting for others to disassemble sos.e components, Hicks was pointing out various conponents to Parsons who was unfamiliar with the TMI-2 polar crane.135 While he was showing Parsons the tr. bin hoist brakes, they discovered that the outboard brake was not engaged.136 They then inserted a piece of plastic coated paper between the wheel and the brake shoe and verificd that the brakec were not in a " proper functioning condition.*137 Irrmediately af ter this discovery, Hicks and Parsons reported the problem to GPUN Maintenance.138 Hicks advised a CPUN Maintenance employee that the nut on the end of the tio rod was 88 l
l
l 1
too tight, causing the brakes to disengage from the brake wheel.139 The following day, August 17, 1984, Hicks returned to the polar crane with Mark Filkins, from GPUN Maintenances who l
loosened the nut, thereby permitting the brake shoes to make contact with the wheel.140 Following corrective action, a t
written TMI-2 Event Report was prepared by J. L. Dobbs, a f
Maintenance employee, and suba.itted to the TMI-2 Safety Review
(
Grour (SRG) on August 17, 1984.341 In that report, Dobbs i
described the apparent cause of the malfunction as follows:
i r
7.
Apparent Causet Electro-occhanical brakes are spring loaded to operate on locs of power, Normal brake shoe wear j
is corpensated by this sane spring.
i A hand release is also provided to permit r.anual over-i ride of the brake on losc of power.
This hand reJeere it connected to the main spring with a tie rod.
When its (sic]
nececsary to operate the hand release, proper adjustraent is 4
j made to the lock-nut.
l Apparently this locknut war threaded too far on to the l
tie-rod, preventing the brake spring from ccmpensating for brake shoe wear.
Since there was no means for compensation, l
the brake shoe were down too far to make proper contact with 1
the wheel. (142) l f
i Following Dobba' reports the GRG. performed its own inspection f
on Septerber 6,1984, nn6 prepared a supplenentary writtrai f
r
)
evaluation which was submitted to the office of the Director.
l i
j The supplementary evaluation states the cause of the event in l
1 i
detail.
It statest l
t t
i i
{
l I
09 i
I 1
, -..-..- -.- _ __,,- ~. _.
l l
.. These type of brakec have a direct-current clapper l
type magnet and are designed so that when the magnet is l
energized, the shoes will clear the wheel (drum) and when the magnet is de-energized, the shoes are pressed against the wheel (drum) by neans of compression spring.
In this l
case, the magnet was de-energized, but the shoes were not pressed against the drum.
The cause of this condition was identified as the incorrect position of the Hand Release Mechanism's Tie Rod Locknut (see attached drawing).
This incorrect position of the locknut caused the compression of the P.C. Main Holst Brake's main spring.
This resulted in the brake shoes not making contact with the drun when the brake was de-energized.
Hence the brake was in an inoperable condition.
Examination of documento r lated to the designs fabrication, and installation of the hand release mechanirm has identified that the cechanisms did not receive a normal enginceting review and that the mechansims were not supplied by the manufacturer but were fabricated on-site. (143)
A special review group established by the Office of the Director subsequently concluded that vibrations from the operation of the crane had caused the hexagonal nut on the brake release tie rod to tighten to the point where it interfered with the operation of the braken.144 90
i i
I
]
nlOTES i
1 Westinghouse Instructions for Type TM Brakes, (I.L. 5204-1A), effective November,1963, p.1, d
(Tab 51);
Benzinger, 10/11/85, pp. 6-7.
t I
i i
2 Johnson, 8/21/85, p. 5.
]
l j
3 Ibid., p. 6.
j 4
Ibid., pp. 7-8.
i i
1 5
Gibson, S/12/85, p. 7.
[
I 6
Jackson, 6/6/85, p. 15; I
j' Eirschbaume 6/18/05, p. 41.
7 Johnson, 8/21/85, pp. 10-14; i
Mays, 4/22/85, pp. 6-8.
i i
i i
8 Mays, 4/22/85, p. 8; Johnson, 8/21/85, p.10.
l l
9 Westinghouse Instructions, p. 6 (Tab $1).
r I
l 10 Benzinger, 10/11/85, pp. 14-18; f
e l
Gibson, 9/12/85, p. 9.
t l
11 Bensinger, 10/11/85, pp. 14-15.
l 12 Ibid., p. 19.
I 13 Ibid., pp. 20-21.
91 i
l l
14 Benzinger, 10/11/85, pp. 15-16; Atchinson, 10/11/85, p. 13; Graber, 6/27/85, p. 70; Radbill, 3 / 27 / 85, pp. 3 4, 4 2, 51, 120 ;
Kirschbaum, 7/1/85, p. 30.
15 Kirschbaum, 1/30/851 p. 21.
16 Johnson, 8/21/85, p. 10.
17 Maya, 4/22/85, pp. 7-10.
18 Ibid., p. 8.
19 Amen 6msnt 89 to Specification 2555-22, Reactor Building and Turbine Building Cranes, 2/14/77, Burr.s & Roe, Inc., Section 3.9.7,
- p. 2A-15 (Tab 56).
20 Westinghouse Inntructions, p. 3 (Tab 51);
Benzinger, 10/11/85, pp. 9-11.
21 Kircchbaum, 7/1/85, p. 34.
22 Kirschbaum, 1/30/85, p. 45; Mays, 4/22/85, pp. 9-10; Photograph of Main Hoint Brake at TMI-2, marked 80-8 (Tab 1).
)
23 Letter, 2/11/82, DFoC to Westir.ghouac Electric Corp., Towson, Md., re Polar Crane Main Holst Brakes Proposal Request (13587-M-063B, final attachment,
- p. 2 (Tab 29).
24 Ibid.;
Mays, 4/22/85, p. 6.
92
_ ~
25 Letter, 2/11/82, BNoC to Westinghouse Electric Corp.
(Tab 29);
i Letter, 2/11/82, BNoC to Whiting Corp., re Polar Crane Hain Holst Brakes Proposal Request
- 13587-M-063B, with attachments (Tab 87).
i 1
i 26 Letter, 2/26/82, Westinghouse Electric Corp.
to BNoC (Tab 31).
i 27 Whiting Corp. proposal GRP 5043-R1, 4/22/82 (Tab 34).
i i
j 28 Blizzard, 45/3/85, pp. 8-9.
k 29 Ibid., pp. 30-31; I
l BNoC Purchase Men.o, 4/30/82, Rider to Buell, re l
Polar Crain Main and Auxiliary Holst Brakes (Tab 37).
{
30 BNoC Purchase Order to Whiting Corp. 413587-M-063B, t
1 Rev. O, 4/30/82, re Polar Crane Main Hoist Brake j
and Auxiliary Holst Brakes (Tab 39).
l 31 Ibid.;
i Blizzard, 4/3/85, pp. 31-32.
i 32 BNoC Purchase Order to Whiting Corp.
(Tab 39).
i 33 Polar Crane Recovery Description, 3/29/82, I
- p. 11 (Tab 55).
l 34 Letter, 7/14/82, Whiting Corp. to Metropolitan l
l Edison Co.s re Purchase Order #13587-M-063B (Tab 42);
Souders, 9/18/85, pp. 7-9.
35 Letter, 7/14/82, Whiting Corp., to Metropolitan l
Edison Co.
(Tab 42).
l 1
t i
93 i
N
36 TMI-2 Folar Crane Recovery Report #2, 8/20/82 (Tab 28).
37 Ballard, 7/30/85, pp. 18-19; Kazebee, 8/20/85, p. 6.
38 Ballard, 7/30/85, p.18; Kazebee, 8/20/85, p. 17.
39 GPUN QA Material Release Form, 10/7/82, re 13" Sesa Brake Wheels and 16" Westinghouse D.C.
Brake Wheels (Tab 44);
Van Skike, 7/17/85, pp. 7-8.
40 Graber, 6/27/85, pp. 7-8.
41 Ibid., p. 27; i
Radbill, 9/27/85, pp. 75-76.
i
^
1 j
42 Kirschbaum, 7/1/85, pp. 49-50.
(
43 Jackson, 4/3/85, pp. 35-36.
44 Ibid.
i 45 Marsden, 1/14/85, pp. 5, 29;
)
Van Skike, 7/17/85, pp. 9-10; Grsber, 6/27/85, p. 47; i
Quality Control Receiving Inspection Report, 1
10/8/82, re 13" Sesa Brakes complete with Solenoid and Brake Wheel, and 16" TMR 61665-16 D.C. Shunt i
Wound Brake with Brake Wheel (Tab 45).
Kirschbaum,1/30/85,kp.35-36; 46 Graber, 6/27/85, p. 2.
i 94
.~.
47 Radbill, 9/27/85, pp. 31-33; Graber, 6/27/85, p. 26; Kirschbaum, 7/1/85, pp. 35-36.
48 Radbill, 3/12/85, p. 55.
i f
49 Radbill, 9/27/85, p. 30.
L 50 Ibid., pp. 33-34; Radbill, 3/12/85, pp. 52-53.
l l
51 Kirschbaum, 7/1/85, p. 35; Radbill, 9/27/85, pp. 33-34; 1
3/12/85, p. 53.
52 Radbill, 9/27/85, p. 33; Graber, 6/27/85, p. 26; Kirschbaum, 7/1/85, p. 43.
]
53 Radbill, 9/27/85, p. 33.
4 54 Ibid., pp. 35-37.
55 Radbill, 9/27/85, pp. 32-33, 43; j
3/12/85, pp. 52-54; Kirschbaum, 1/30/85, p. 38.
i 56 Radbill, 3/12/85, pp. 53-54; 9/27/85, pp. 32-33; l
Kirschbaum, 1/30/85, pp. 17, 38; i
Graber, 6/27/85, p. 26.
57 Mays, 8/22/85, pp. 16-21; 4/22/85, pp. 11-14; l
Hickerson, 7/9/85, pp. 36-37.
58 Mays, 8/22/85, pp. 16-19; 4/22/85, pp. 14-21.
I 95 1
i
59 Mays, 8/22/85, p. 19.
60 Mays, 4/22/85, pp. 15-16.
l 61 Jackson, 4/3/85, pp. 27-28; Rider, 4/3/85, pp. 33-35.
62 Radbill, 9/27/85, p. 68.
63 Graber, 6/27/85, pp. 23-26; Kirschbaum, 7/1/85, pp. 48-52.
64 Job Ticket CA 364, 8/6/82 (Tab 46).
65 Ibid.
66 Radbill, 9/27/85, pp. 50, 66.
67 Ibid., p. 67.
68 Kirschbaum, 7/1/85, pp. 52-54; Radbill, 3/12/85, p. 89; Graber, 6/27/85, p. 32; Jackson, 4/3/85, p. 65.
69 Kirschbarm, 7/1/85, p. 53.
I 70 Kirschbaum, 1/30/85, p. 20.
71 Barkanic, 4/10/85, pp. 26-28, 33-36; Gallagher, 1/6/85, pp. 33-34; Buchanan, 7/29/85, pp. 11-13.
72 Ibid.
4 73 Kirschbaum, 7/1/85, pp. 49-51.
96
Shamenek,7/17/85,pp.18k0.
74 4
75 Ibid., pp. 24-25.
76 Job Ticket CA 364, 8/6/82 (Tab 46).
77 Jules, 7/24/85, p. 12.
78 Ibid., pp. 14-16.
79 Jules, 7/24/85, pp.'12, 15-16; Corkle, 7/25/85, pp. 15-18.
80 Ibid.
81 Job Ticket CA 364, 8/6/82 (Tab 46).
82 Unit 2 Maintenance Shift Foreman Log, see Filkins entries, pp. 6-8, 23-25 (Tab 89).
83 Job Ticket CA 364 (Tab 46);
TMI Polar Crane Recovery Progress Report 44, 9/3/82 (Tab 28).
84 Westinghouse Instructions, p. 6 (Tab 51);
Job Ticket CA 364 (Tab 46).
85 Radbill, 9/27/85, pp. 69-71; 3/12/85, pp. 105-115.
86 Kirschbaum, 1/30/85, pp. 50-51.
87 Job Ticket CA 364 (Tab 46).
97
88 Kirschbaum, 1/30/85, pp. 49-55, 60-62; 7/1/85, pp. 51-53; TMI-2 Event Report 50-320-84-099 of 8/11/84, Improper Adjustment of Main Boist Brake on Unit II Polar Crane (Tab 81).
89 Westinghouse Instructions, p. 6 (Tab 51).
90 Radbill, 9/27/85, pp. 94-95; Kirschbaum,1/30/85, pp. 75-76.
91 Radbill, 9/27/85, pp. 66-67.
92 Kirschbaum, 1/30/85, p. 63.
93 Ibid., pp. 63-65.
94 Ibid., pp. 68-69; Radbill, 9/27/85, p. 79.
95 Kirschbaum, 1/30/85, pp. 65, 73-76; Consider Radbill, 9/27/85, p. 122.
96 Kirschbaum, 1/30/85, pp. 63-66.
97 Work Package M0020, 9/16/82 (Tab 49).
98 Ibid.
99 Ibid.;
Kirschbaum,1/30/85, pp. 72-74.
j 100 Work Package M0003 (Tab 49);
j Radbill, 9/27/85, p. 80; Gallagher, 7/24/85, pp. 24-26; Barkanic, 4/10/85, pp. 44-45.
98
101 Work Package M0020 (Tab 49).
102 Entry Logs 122-127 (Tab 50).
103 Martin, 9/18/85, pp. 6-7; Entry Logs 122 and 127 (Tab 50).
104 Nagle, 7/30/85, pp. 6-18; Wise, 7/24/85, pp. 6-13; Graber, 6/27/85, pp. 63-65; Terrell, 9/18/85, pp. 4-16; Entry Logs 123 - 126 (Tab 50).
4 105 Radbill, 9/27/85, pp. 84-85; Kirschbaum, 7/1/85, pp. 55-56; 1/30/85, pp. 66-69.
106 Kirschbaum, 1/30/85, pp. 65-69.
107 Work Package M0020 (Tab 49).
108 UWI 4374-3891-83, 1/24/83 (Tab 52).
109 James, 10/9/85, pp. 15-18; Green, 10/9/85, pp. 8-11.
110 UWI 4374-3891-83 (Tab 52).
111 IOM, 2/4/83, Byrne to Barrett (4410-83-0137),
re Work Package M-0048 (Tab 53).
112 Ibid.
113 Green, 10/9/85,- pp. 12-14.
99
114 Management and Safety Report, Vol. IV, Polar Crane Allegations, p. 8; Polar Crane Functional Description (2-M72-MH02),
9/20/82 (Tab 25).
115 IOM, 3/22/83, Kanga to Arnold (4000-83-153),
re Readiness Review Committee Meeting on 3/12/83 (Tab 26).
116 Ibid.;
Jackson, 6/6/85, pp. 49-50; Mays, 4/22/85, pp. 36-37.
117 Mays, 4/22/85, pp. 34-36; Radbill, 9/27/85, pp.91-100; Clark, 5/21/85, pp. 11-14.
118 Management and Safety Report, Vol. IV, Allegations of Safety and Poor Management, Background, pp. 1-4.
119 Ibid., Polar Crane Allegations, pp. 1-3.
120
- Radbill, 9/27/85, pp. 40-44; Graber, 6/27/85, p. 60; Kirschbaum, 7/1/85, pp. 74-75.
121 Kirschbaum, 7/1/85, p. 74; Radbill, 9/27/85, p. 44.
122 Kirschbaum, 7/1/85, pp. 42-43, 52; 1/30/85, pp. 32-33; Graber, 6/27/85, p. 34; Radbill, 9/27/85, pp. 42-43; 3/12/85, pp. 120-124.
100
123 Radbill, 3/12/85, p. 121; 9/27/85, pp. 43-44; Kirschbaum, 7/1/85, pp. 42-43, 74-75.
124 UWI 4370-3891-83-PCl, Rev. 7, 2/16/84, re Load Test Polar Crane Procedure (Tab 71).
125 Ibid., Test Procedure No. TP 141/l, Rev. 1,
- p. 3, paragraph 4.1.3.
126 Ibid.;
Green, 10/9/85, pp. 5, 8-14; James, 10/9/85, pp. 15-21.
127 Graber, 6/27/85, pp. 70-72; Radbill, 9/27/85, pp. 90-91; 3/12/85, pp. 142, 230; Kirschbaum, 7/1/85, pp. 73, 76-77.
128 Kirschbaum, 7/1/85, p. 76.
129 Ibid., pp. 76-77.
130 Eicks, 7/25/85, pp. 7-16; 1/15/85, p. 32; Parsons, 8/21/85, pp. 6-7; TMI-2 Event Report 50-320-84-099 of 8/11/84, Improper Adjustment of Main Hoist Brake on i
Unit II Polar Crane (Tab 81).
131 Hicks, 7/25/85, pp. 3, 7-8; Parsons, 8/21/85, pp. 5-6.
132 Hicks, 7/25/85, pp. 21-22.
133 Ibid., pp. 20-21.
i 101
l 134 Bicks, 7/25/85, p. 9; 1/15/85, p. 34.
135 Bicks, 7/25/85, p. 8.
136 Bicks, 7/25/85, p. 8; 1/15/85, p. 32.
137 Bicks, 7/25/85, pp. 7-8; J
1/15/85, p. 32; Parsons, 8/21/85, pp. 7-8.
138 Bicks, 7/25/85, pp. 12-13; Parsons, 8/21/85, p. 7.
139 Bicks, 7/25/85, pp. 13-14.
140 Bicks, 1/15/85, pp. 41-43.
141 TMI-2 Event Report (Tab 81).
142 Ibid., Side 1, Section 7.
143 Ibid.r Supplementary details in support of Section 13.
144 Report, November 1984, Westinghouse Electric Corp.,
Advanced Energy Systems Division, Polar Crane -
Main Hoist Manual Brake Release Vibration Test (Tab 84) t Lake, 4/10/85, p. 79; Graber, 6/27/85, pp. 73-74.
102
i ASSESSMENT OF BRAKE RELEASES AS A MODIFICATION The discovery that a brake release had caused the outboard l
main hoist brake to malfunction raised serious questions about the procedural history of the brake releases.
Had the installation of brake releases been subjected to engineering design review?
If not, was such a revicw required under applicable procedures?
If design review was required, why had such a review not occurred?
The evidence shows that the brake releases had not been subjected to design review as required by procedures intended to assure such review.
Those procedurec required design review for any modifications and established criteria to determine whether a proposed activity should be deer:ed to be a modification.1 However, the PCTG did not apply those criteria to determine whether the brake releases were modifications.
The PCTG originally intended to use the brake releases to facilitate the polar crane refurbishment.2 If the brake releases had been confined to that use, a modification would not have occurred.
However, the scope of their use was expanded to include use as an emergency device to lower a suspended load in the event of a power failure.
For such use, the brake releases should have been identified as modifications which required design review.
103
The criteria that should have been applied to determine whether the installation of the brake releases required design review were set forth in the GPUN procedures.3 AP 1021 was the GPUN procedure which established the mechanism for generating and processing an Engineering Change Memorandum (ECM).
It defined an ECM as follows:
Engineering Change Memorandum (ECM) - The ECM is the traveler, by which proposed plant tie-in, betterment and modification packages are assembled, reviewed, and coordinated with GPU's site organizations for their effects on the existing plant systems, components, and structures. (4)
(emphasis added)
Section 2.0 of that procedure stated that ECM's are required for:
any addition, connection to, deletion of, or replacement of unlike kind, of any facility, structure, system, circuit or component of or to this existing plant. (5)
(emphasis added)
AP 1043 was a companion procedure that described the process of installation, test, turnover to Operations and return to service following engineering approval of an ECM.
It similarly defined an ECM as:
1.4.1 Engineering Change Memorandum (ECM) - An engineered software package by which pin-nosed niant modifications are assembled, reviewed, and coordineted throuch the
~
design engineering organization (offsite or onsite) and the onsite plant staff. (6)
(emphasis added) 104 m
m
- - + -
T
--7
Finally, ATWIC, the procedure which governed all work inside containment, specifically stated that:
4.1.2.1 Any additinn of, ennnection to, deletion of, or replacement with unlike kind of any facility, structure, system, circuit, or component of or to the existing plant shall be accomplished under an ECM/ECA. (7)
(emphasis added)
Although the identu ! cation of a modification always required the exercise of some judgement, the GPUN procedural scheme appears to have been intended to limit the discretion of field personnel in making decisions regarding changes to plant systems.
They are not permitted to determine the " effects on j
existing plant systems" of a proposed " betterment" or
" modification."6 Instead, such an evaluation was nade during the ECM review process.
The criteria for determining the need for an ECM were stated in simple descriptive terms which related to the physical characteristics of the proposed activity.
The criteria did not require any preliminary engineering evaluation as to the possible effects of those activities on the functioning of plant systems.
Based upon these GPUN procedures, the installation of the brake releases as emergency devices for use during a power failure should have been viewed as " additions" if they were I
considered as separate pieces of equipment attached to the brakes.
Moreover, even if they were perceived as integral 1
I 105 1
parts of the new brakes, they should have been considered to be replacements of "unlike kind."
Although Radbill admitted that he and other members of the PCTG were generally familiar with GPUN procedures, including the ECM procedure, he stated that his superiors advised him that GPUN t
procedures were not applicable to the refurbishment of the polar crane.9 He stated that he was primarily concerned with following Bechtel procedures.10 Bechtel procedures also obligated the PCTG to obtain design review of the brake releases.
The policies underlying GPUN and Bechtel modification procedures were substantially the same.
The Division of Responsibility memorandum is the primary Bechtel document that allocates responsibilities between the PCTG and Home Office Engineering (Design Engineering).1 Like the GPUN procedures, it attempted to minimize the PCTG's independent exercise of engineering judgement with respect to modifications.
There were two provisions in the Division of Responsibility which together defined the scope of the PCTG's independent authority to perform work on the polar crane.
Item 2 stated:
The "how" or means of satisfying the functional requirements and making the components operational is the Polar Crane (P.C.) Group's (Construction) responsibility. (12)
Item 8 of the Division of Responsibility simply stated:
106
- ~ -
l Modifications will be engineered by B. O.
[Home Office] Engineering unless mutually agreed otherwise.
Replacement-in-kind will be by the P. C. Group [PCTG).
Note:
Modifications required may be identified by the P. C. Group [PCTG). (13)
The GPUN procedures took a proscriptive approach to defining
" modifications."
They expressly prohibited construction j
personnel from performing certain activities without prior design review.
In contrast, the Division of Responsibility memorandum was permissive in nature.
It specifically permitted construction personnel to perform only "in-kind" replacements without prior design review.
J Items 2 and 8, considered together, contemplated that design review would not be required for:
replacement of a component with one identical to it; or activities confined to " satisfying the functional requirements and making the components operational."14 Conversely, the installation of any other equipment on the crane would be a modification requiring design review.
Thus, although GPUN's procedures are proscriptive while Bechtel's are permissiver they both appear to be intended to have the same effect - the design review of modifications.
Under either procedure, the PCTG could not independently add a new component, remove a component or replace a component with an l
107 i
unlike kind if such a change were to remain after the crane were restored ~to its operational condition.
Thiesing expressed his understanding ~of ~ the policy underlying the Division of Responsibility Memorandum as follows:
The design engineering group at Gaithersburg, the construct that we were followir,g at that time was that any modification to the Polar crane had to be carried out as an engineered modification and either originated formally or review formally and signed off by the design engineering group in Gaithersburg.
The Polar crane task force which was the group actually carrying out the work at the job site, was authorized to test the crane and to carry out replacements in kind, or identical replace-ments on the crane.
They were not authorized to originate modifications to the crane.
Once engi-neering had either originated and issued or reviewed a modification, and approved it, they they would 3
carry it out, but they weren't authorized to do it on their own recognizanco. (15) 4 Since the polar crane, as originally constructed, was not equipped with brake releases, they could not have been considered a " replacement-in-kind."
Moreover, the installation of the brake releases as emergency devices to be used during a power failure could not reasonably be interpreted to be a means to restore the crane to its operational condition.
It should therefore have been considered to be a modification that required Design i
Engineering approval.
Given the procedural requirements for design review of the brake releases, the question remains:
what were the actions and mental processes that led to their violation?
a 108 1
In hindsight, many of the individuals interviewed acknowledged that the design, fabrication and installation of the brake releases should have been treated as a modification and submitted to Design Engineering for appropriate engineering review and approval.16 Among them, only Radbill had the combination of knowledge and responsibility which would enable him to identify the addition of the brake releases as a modification.
As leader of the PCTG, Radbill had the responsibility to comply with the terms of the Division of Responsibility Memorandum and obtain Home Office Engineering approval of all modifications proposed or identified by the PCTG.17 Radbill was not specifically trained to identify modifications at TMI-2.18 His superiors relied upon his general civil engineering background and judgement to identify a required modification and obtain approval from Home Office Engineering.19 They also relied upon Radbill to keep them apprised of progress being made in the refurbishment of the polar crane and of any problems encountered by the PCTG.20 I
Radbill's superiors did not provide direct supervisior.' to the PCTG members, but relied on Radbill to give them direction.21 The members of the PCTG had little understanding of applicable proceduress and relied on Radbill to encure that their activities complied with administrative requirements.
Indeede Kirschbaum and Graber were not even aware of the contents of the Division of Responsibility memorandum.22 109
l l
Radbill acknowledged that it was his responsibility "... to oversee the administration [of the polar crane refurbishment) and guide the activities and help the group work through the paperwork maze at TMI in order to accomplish the physical work of refurbishing the Polar Cr.ane."
Furthers he was fully cognizant of his responsibilities under the Division of Responsibility Memorandum to identify any modifications required.24 Radbill also knew that brake releases were not originally installed on the crane.25 Despite such knowledge and i
responsibility, Radbill did not identify the installation of the brake release as a modification that had to be reviewed and approved by Design Engineering.
When questioned on this subject, Radbill explained that the installation of the brake releases was simply never viewed by him as a modification and that he did not consciously decide to forego design review and approval.
He stated that he and the members of the PCTG never thought about this issue.26 Initially, they viewed the brake release as a " tool" to be used to facilitate the refurbishment of the crane.
Radbill described the work as follows:
I don't remember the specific details, but I do remember two main points that came about; that is, the group concluded -- the Polar Crane Task Group concluded -- that these handles allowing us to manually release or disengage the brakes would be very useful in performing two activities; number oner adjusting the brakes on a crane after the new 110
brakes were installed, and number two, to lower the main hook and block on the crane for the purposes of inspecting the hook.
I say that because this schedule indica;md -- the initial schedule indicated I
that we would be performing the activity of inspecting the hook without having electric power on the crane.
So, we could not electrically lower the hook and block.
We would have to do that mechanically only. (27)
He therefore viewed the brake release as a tool needed to accomplish this work.
Radbill explained his perception as follows:
i
\\
i Yeah, that was a tool.
There was a special type wrench you might need.
We manufacture all kinds 4
of tools to do work in the Reactor Building.
l So I had to make another tool.
That was a means to an end; it wasn't an end in itself. (28) l.
Radbill's testimony that the brake releases were perceived as tools is corroborated by the testimony of Graber and i
Kirschbaum.29 Additionally, the Job Ticket documenting the j
fabrication of the brake releases described their intended purpose to be "For Polar Crane Inspection.. O Upon completion of the fabrication, the Job Ticket was closed out with the notation:
" Manufactured two tool per drawins provided. 31 4
l l
i 111 l
)
. ~
Although several entries in the Maintenance Shift Foreman Log refer to the brake releases as " handles" or " parts" for the polar crane,32 the final entry in that log for August 27, 1982, states:
Mech. (1) CA 364. Manufacture special tools for Polar crane.
Job Complete. (33)
The PCTG originally planned to remove the brake releases after they were finished using them as tools and before the crane was released from their control.
Radbill described their intention as follows:
Our plan for the history of that tool was that it be installed on the new brakes prior to taking them into the containment building and they would put on each brake.
They would be taken into the containment building, put on the crane and installed properly.
They would remain on the brakes until we completed the load test and then they would be removed.
The final disposition after removal was not discussed or defined. (34)
The PCTG viewed the Load Test as the final step in the refurbishment process after which responsibility to operate the crane would be turned over to Operations personnel.35 The evidence shows that the decision not to remove the brake releases after they were used to refurbish the brakes and to inspect the hook was because the PCTG intended to utilize them for an additional purpose.36 At some point, they recognized that the brake releases could be useful as a means of lowering a 112
suspended load during a power failure.37 That idea must have been formulated on or before March 12, 1983.
That was the date of the Readiness Review Committee meeting at which a hypothetical question about what would be done to lower a load during a power failure was raised and answered by reference to the brake releases.38 However, it is possible that the idea arose at an earlier stage.
Radbill testified:
Q Was there any thought, Mike, to using the hand-release mechanism to ever lowering a load should there be a power failure to the crane?
A Yeah.
I don't recall if that was a consideration from the outset, but I do recall that we had discussions later on, probably in '83, that,
" Jeez, we could use t'his for that purpose." (39)
In other testimony, he made it clear that initially they did not have such a use in mind.
He testified:
At the very beginning -- at the very beginning when we initially decided to fabricate these things that we needed them, we were not thinking of power failure with load hanging in the air during load test. (40)
Radbill's perception of the brake releases did not change as their intended purpose changed.
Radbill continued to maintain that the brake release was a " tool," even after its use was expanded to include possible service during crane operation.
He stated:
113 i
Q Keeping in mind that if you are going to use it to lower a load should there be a problem with power or a load gets hung up during operations, the crane at that point is functional.
It's not still in the refurbishment phase.
A That's correct.
Q Things have been rep 3 aced and whatnot.
It is not a functional piece of equipment.
A Right.
Q Would you still consider that a tool at that time?
A Yes.41 Contrary to Radbill's view, Kirschbaum expressed the feeling that the nature of the device changed as its intended purpose changed.
He stated:
. I told you we wanted to look at the load block and the book and if the electrical guys didn't have power in the crane maybe we could use it this way; alright?
The load block and the hook together were not heavy enough to lower itself when we opened the brakes.
That being the case, that was it as a tool.
From then on it didn't work because it didn't--you know, there wasn't enough weight to do it.
So what we did is tape the handled down anC the tool part was done.
It was strictly there, from that point on to use as an emergency, period.
We had no other reason to open it--no other reason. (42) i a
114
8 l
Radbill explained his understanding of the difference between a " tool" and a " modification" as follows:
Modification to me changes the performance.
It's the intent.
...We can't have people... changing.
t i
the performance ~or the way things are designed to perform.
But... if I go and put a tool on the brakes and the brakes still perform the same way they were originally designed, then I haven't modified the function of the brakes.
I haven't modified how it works.
If it still operates the way it was originally designed even though this tool was fastened on there, then I haven't modi-fled it.
It still functions.
So, in my mind, it was not a modification to the brake. (43)
I j
Apparently, this understanding of a modification caused Radbill 1
+
to fail to recognize that the brake releases might require design 3
1 1
j review before they could be used for emergency purposes.
His i
l definition assumed that he had the authority to determine the effect of the brake releases on the operation of the brakes.
I I
Radbill apparently misunderstood the limits of his i
j authority.
As discussed earlier, the Bechtel procedures under which Radbill believed he was operating appear to have been designed to implement Bechtel policies regarding the design
)
review of modifications by setting limits on the PCTG's 1
i independent authority.
The PCTG was only permitted to install
)
replacements of equipment in-kind and to devise means to satisfy i
(
the functional requirements established by Design Engineering for I
restoring the crane to operating condition.. Therefore, the 1
l 115 I
i
...__-._,-..-.__,-..._..-._,-,-___.mm, m...
.,.,,,_mn__
....r._c__,.,_,.....,,_m,,,,.-,..,._,_w.__.,,.
installation of new equipment for use during crane operation required design review.
The brake releases were neither original equipment that was being replaced nor, as emergency devices, a means with which to restore the c:ane.
Therefore, they should have been subjected to l
design review or removed from the crane once their usefulness in aid of brake installation and hook inspection had ended.
Despite the fact that the PCTG exceeded its authority by installing the brake releases for emergency purposes, the installation was not intended to be permanent.
Radbill apparently believed that he had the authority to utilize the brake releases as safety devices during crane operation in load testing while the crane remained under the control of the PCTG.
Radbill's view was expressed in the following testirony:
A But we decided to leave them on until after the load test because we didn't want -- anything we used to refurbish the crane was to be left in place until after the load test because we didn't t
know what would happen and we wanted to be pre-i I
pared for all contingencies.
That was a general feeling amongst all of us.
So, in other words, don't put away your tools and put your toolbox away until the job is completely finished and you've test driven it and it passes the test.
Then you can put your tools away.
i Q
By the way in connection with that, were you of the view that your job would be completed after the load test?
i 116 i
i
)
A Yes.
P l
Q That's when you clean up your tools?
[
A That's right.
That was the mind-set at the tine.44 i
Although the PCTG intended to remove the brake releases after i
the load test, the long postponement of that test resulted in the l
breakup of.the PCTG and the t.ransfer of its members.
Radbill testified about the effect of the transfers as follows:
Parc of the reason, I believe, is -- First of alls we fully intended to remove these things l
Ibrake releases), end as the tire and the cource
+
of events took over, our people -- investigations l
drug out and our work essentially was done, 'our work" being the Task Group.
Some pecple were let go.
I was transferred to another job.
Other people left.
So our group e
1 was disbanded.
We werc not there to complete the task which we started.
}
In any worke not everything is documented.
A lot of things we had in our head.
We intended to do 4
this; we intended to do that.
The intention to do 1
that was taken with us and not left anywhere in docuzentation.
We fully would have done the load tests and taken that off.
That was in the discussions when we l
first made this thing. (45) i 117 1
- - -. - - -,. -,. - - ~. - -,, ~.
.-n
,., ~....,,, - -...,,,,, - -,, ~, - - - -,
=
1 The Load Test was finally conducted on February 29, 1984, without the participation of the PCTG.46 The brake releases remained on the crane during the subsequent removal of the reactor vessel head on July 24, 1984.
Their procedural propriety did not become an issue until August 1984.
The remaining question is why, during the period from the initial decision to obtain brake releases until August 1984, was the procedural issue I
not raised.
l NOTES 1
IOM, 7/30/82, Jackson and Lake to Freemerman, 0306-8420, re Polar Crane Division of Responsibility (DOR)
(Tab 3).
i GPUN Administrative Procedure 44300-ADM-3240.1, l
Access to and Work In Containnent Building (ATWIC), 4/4/82 (Tab 11).
Three Mile Island Nuclear Station, Unit No. 2, i
Administration Procedure (AP) 1021, Revision 10, 6/2/82 (Tab 85).
Excerpts from Three Mile Island Nuclear Stations Unit No. 2, Administration Procedure 1043, i
Revision 2, 8/30/83 (Tab 86).
i 2
Radbill, 9/27/85, pp. 33-35; Graber, 6/27/85, pp. 34-35; l
Kirschbaum, 7/1/85, pp. 30-31.
l 3
AP 1021 (Tab 85).
1 4
Ibid., Section 4.
5 Ibid., Section 2.0.
I 6
AP 1043, Section 1.4.1 (Tab 86).
r 7
ATWIC, Section 4.1.2.1.
(Tab 11).
8 AP 1021, Section 4 (Tab 85).
i
.i 9
Radbill, 3/12/85, pp. 41-44; Laker 4/10/85, pp. 20-21.
119 i
l 10 Radbill, 3/12/85, pp. 43-49; see also Graber, 6/27/85, p. 13.
11 DOR (Tab 3).
12 Ibid., paragraph 2.
13 Ibid., paragraph 8.
14 Ibid., paragraphs 2 and 8.
15 Thiesing, 4/25/85, p. 34.
i 16 Radbill, 3/12/85, p. 208; Jackson, 6/6/85, pp. 23, 54; 4/3/85, pp. 32-33, 37-38; Rider, 4/3/85, p. 48; Marsden, 1/14/85, pp. 17, 74; Mays, 8/22/85, pp. 18-19; Sieglitz, 7/17/65, pp. 34-35;
)
Thiesing, 7/15/85, p. 23; Barkanic, 7/25/85, p. 34; i
Laker 6/18/85, p. 35; J
Freemerman, 8/22/85, pp. 18, 20-21; 4/22/85, pp. 55, 85; 1
Kirschbaum, 7/1/85, pp. 79-80; j
1/30/85, pp. 29-30.
4 17 DOR, Section 8 (Tab 3).
18 Radbill, 3/12/85, pp. 39-40.
19 Lake, 6/18/85, pp. 40-42; Thiesing, 7/15/85, pp. 23-24.
120
.c
,,w
l t
20 Lake, 6/18/85, pp. 36-37, 61; Radbill, 3/12/85, p. 56; Thiesing, 4/25/85, pp. 7-8, 24-26; Freemerman, 4/22/85, pp. 6, 10-11; 8/22/85, pp. 5-6, 14-16.
21 Freemerman, 8/22/85, p. 6.
22 Graber, 6/27/85, pp. 13-14, 28-29; i
Kirschbaum, 7/1/85, pp. 17-18, 24-25.
23 Radbill, 3/12/85, p. 6.
24 Radbill, 9/27/85, pp. 8-10.
1 25 Radbill, 3/12/85, pp. 49-55.
i Note:
Although Graber and Kirschbaum were also aware that the brake releases were new equipment, their understanding of procedures was extremely limited.
i 26 Radbill, 9/27/85, pp. 59, 72; l
3/12/85, pp. 228-230.
1 27 Radbill, 9/27/85, p. 27.
j 28 Radbill, 3/12/85, p. 57; see also 9/27/85, pp.115-116,120.
i 29 Graber, 6/27/85, pp. 29, 33-36, 38; Kirschbaum, 7/1/85, pp. 81-82.
I 30 Job Ticket CA 364, 8/6/82 (Tab 46).
31 Ibid.
32 Unit 2 Maintenance Shift Foreman Log,
- p. 245 et seq.
(Tab 89).
121 1
=-.
33 Unit 2 Maintenance Shift Foreman Log,
- p. 260 et seq.
(Tab 89).
i 34 Radbill, 9/27/85, p. 40.
35 Ibid., pp. 43-44.
36 Kirschbaum, 7/1/85, pp. 30-31; 1/30/85, pp. 18-19, 75-77; Radbill, 3/12/85, pp. 120-124; j
Graber, 6/27/85, pp. 34-38, 43-44, 51-52.
37 Kirschbaum, 1/30/85, pp. 18-19, 75-77; 7/1/85, pp. 30-31; Radbill, 9/27/85, p. 43; Graber, 6/27/85, pp. 43-44, 51-52.
38 IOM, 3/22/85, Kanga to Arnold (4000-83-153),
)
re Polar Crane Readiness Review Committee Meeting (Tab 61).
TMI Polar Crane Recovery Progress Report #31, 4
3/12/83 (Tab 28).
39 Radbill, 3/12/85, p. 58.
40 Radbill, 9/27/85, p. 43.
l 41 Radbill, 3/12/85, p. 59.
42 Kirschbaum, 7/1/85, p. 82.
43 Radbill, 9/27/85, pp. 64-65.
44 Ibid., pp. 120-121.
45 Radbill, 3/12/85, pp. 43-44.
122 4
_ - - - ~. ~. _. - - _ _ - _ - _,, _, - _ _ -.,,,,,. _. _.... -, _,, -.,,, _.
I l
46 Radbill, 3/12/85, p. 121.
l l
47 Letter, 6/5/84, Kanga to Snyder (4410-84-L-0085),
re Polar Crane Load Test Results, Attachment,
- p. 2 (Tab 73).
1 I
i i
I
,l 1
(
k i
l 4
I i
l 1
i
)
i l
l l
p 1
l 123 1
INFORMATION ABOUT THE BRAKE RELEASES AVAILABLE OUTSIDE THE PCTG Although knowledge about the brake releases was net confined to the PCTGr the evidence shows that among other groups the available information was incomplete.
The remaining issue to be discussed is why sufficient information did not come to the attention of anyone outside the PCTG to alert him that a procedural violation had occurred.
The Decision to Replace the Brakes In the Fall of 1981r Project Engineering in Gaithersburg was involved in planning the polar crane refurbishment.
They were assisted by Kirschbaum.1 The evidence shows that the brake releases were not recognized as modifications at that time because Project Engineering mistakenly assumed that they were replacements for original equipment.2 Their intention was to replace the existing brakesi including all of its components.3 The decision to order the brake releases along with the other brake equipment was based upon:
catalogue literature from the manufacturer, photcgraphs of the crane depicting the damaged j
equipmenti the original Burns and Roe specifications for the craner input from Kirschbaumi and prior experience with cranes.4 i
124
However, Kirschbaum testified that at the time he was consulting with Project Engineering, he knew that the crane did not have brake releases.5 Bis knowledge was derived from a review of the photographs of the crane that showed brakes without releases.6 Therefore, Project Engineering personnel who spoke with Kirschbaum, and also had an opportunity to vita the photographs of the crane's original equipment, could not have formed their erroneous impression from those sources.7 Although the Westinghouse literature provided for a manual release, it was specifically designated as an " optional" item.8 Thus, it could not have been concluded from a review of the literature alone that the brake release was a replacement in kind.
Finally, the Burns & Roe Specifications provide:
Electric brakes for all hoisting mechanisms shall be of the shoe type or disc type and operation may be from solenoids, magnets or thrusters, at Contractor's option.
Operation shall be such that the brakes will be released when the driving motor is started, and will be applied when the current supply is off or fails.
Release shall further be arranand for manua coeration. (emphasis added) (9)
Although this specificatice. cy;r,, irs to require a mechanism that functions similarly to a brake release, it does not specifically identify that device.
Mays readily admitted his mistake stating, "I thought there was a hand release on there.
I have subsequently learned there was not, but at the time I did."10 He explained that he l
)
125
believed the " original specification called for it."11 His prior experience with other polar cranes had been that "you i
always provide it [ brake releases].12 In reaching their conclusion that they were replacing original equipment, Project Engineering apparently placed too heavy an emphasis on their understanding of the Burns & Roe specifications, the brake manufacturer's literature and their general experience with cranes.
They failed to evaluate information available to them carefully enough to determine whether brake releases were original equipment.
Ordering the Brakes The initial materials requisitions form that was issued to the Bechtel Purchasing Department was prepared by Johnson and authorized by Mays and Jackson.
It requested brake components, including brake releases, and stated, "These are-replacement components for the original polar crane parts."13 The Materials Requisition was submitted to Bechtel Procurement who then solicited bids from Whiting Corporation and Westinghouse.14 The function of Bechtel Procurement was primarily ministerial in nature.
Their responsibility was merely to coordinate the flow of documents related to the purchase of parts that had been requested by Project i
Engineering.15 1
)
i 126
When Project Engineering received the bid for " technical review," they failed to note that the brake releases had not been included in the bid from Whiting.16 No one interpreted Whiting's bid as an indication that brake releases had not been installed originally.
Project Engineering mistakenly continued to presume that the crane was equipped with brake releases and l
that new ones would be shipped with the replacement parts.
l l
Fabrication of the Brake Releases Information about the fabrication of the brake releases was communicated outside of the PCTG on at least three occasions.
Initially, a mcmber of the PCTG consulted with Project Engineering about the decision to fabricate.
Mays and Hickerson have testified that Project Engineering received a telephone call from a PCTG member requesting guidance for the fabrication of brake releases to substitute for those that had not been received with the new brakes.17 Mays, the highest level member of Project Engineering involved in that communication, believed that brake releases were part of the crane's original equipment.18 His view was that as long as the fabricated releases duplicated the original releases manufactured by Westinghouse, they would be replacements-in-kind.19 The evidence indicates that nothing in the communications l
between the PCTG and Project Engineering alerted Project j
Engineering to the possibility that a new device was to be added 127
to the brakes.
However, Project Engineering took no precautions to assure that the fabricated brake releases exactly duplicated the equipment that they assumed was on the crane.
Mays admitted that some design review should have occurred.20 The second communication involved the preparation and transmittal of the Job Ticket to the GPUN Maintenance Department i
for the fabrication of the brake releases.21 Nothing in the Job Ticket itself, nor any evidence of communications that related to its transmittal to Maintenance, indicated that the devices might have constituted a modification.
The descriptive portion of the Work Request simply states:
" Manufacture as per attached drawing - special handle (two Units)."22 The use of the devices as described in the Job Ticket was "For Polar Crane Inspection."23 The final entry on the Job Ticket described the brake releases as " tools."24 Although some entries in the Shift Foreman's Log refer to them as " handles" or " parts," the final log entry again described them as "special tools."25 The evidence does not indicate that these Maintenance personnel were aware that the brake releases were to be used during polar crane operation or violated procedures.
Finally, the PCTG prepared weekly progress reports summarizing the activities performed by the PCTG.
The reports, dated August 20 and September 3, 1982, state respectively:
4 128
. _ ~.
Mainhoist brakes are on-hand.
Manual release handles for these brakes are being machined by GPU maintenance.
(Lead time to purchase these is ten weeks from Westinghouse.)
QC inspection should occur next week.
and Received from GPUN Maintenance the machined main hoist brake release handles. (26) l These reports were circulated among site personnel, including Buchanan, Gallagher, Lake, Freemerman, Thiesing and Kanga.2 In addition, copies of the reports were sent to Rider at Design Engineering.28 With the exception of Thiesing, none of the above recipients of the reports was aware that the polar crane 3
was not originally equipped with brake releases.29 Therefore, they could not have recognized that the installation of brake releases might consititue a modification.
Thiesing testified that he had been aware that brake releases were not originally on the polar crane.
He could not recall the source of that information, nor can he identify others who had similar knowledge.30 He stated that at the time these reports were circulated, he was preoccupied with the TMI-2 reorganization l
and delegated the responsibility for reviewing the reports and monitoring the PCTG to Freemerman.31 Thiesing stated that he i
was unaware of the plans to install brake releases on the crane.32 Even if Thiesing had read the progress reports, or others who i
read them had been aware that the brake releases were new equipment, nothing in the reports suggested that proper design review had not occurred.
129
. _.. -, - _ - _. - _. - - _. - _ _...,.. _ _ _.. _.. ~ - _.. - _. -
. - _ - _.,, -.. -...,.. ~ - -.
Installation of Polar Crane Brakes When the fabrication of the brake releases was completed, Kirschbaum carried them to the PCTG trailer where they were mounted on the brakes.33 Although Graber testified that the brake releases remained in the trailer, mounted on the brakes for several weeks prior to installation on the crane, evidence does not show that anyone who might have seen them would have had reason to question whether the brake releases had received appropriate design review.34 This included the QC receipt inspector who examined the brakes to determine whether they I
conformed with tha Purchase Order and whether they had been damaged in transit from the manufacturer.35 GPUN Maintenance personnel were trained in the PCTG trailer to install the brakes on the crane.36 Besides Kirschbaum and Graber, the other people involved in the training sessions were three GPUN Maintenance personnel.37 Among them, only Terrell recollected that the brake releases were discussed during the training sessions.38 Terrell explained that the discussion arose because he raised questions about the brake releases.
B: acknowledged that his recollection was vague, stating:
A I think I remember questioning the reason they were on there and whether these were up there already.
And they said that they were a modi-fication to it.
I'm pretty sure about it.
Q Did they use the word modification?
130
A I don't know.
You're pinpointing stuff, I'm not sure, you know.
Q I understand.
You're talking three years.39 A
I From Terrell's testimony, it appears that some discussion Cccurred in which he was informed that the brake releases were new equipment being added to the crane.
He did not pursue it further.
He also stated that he had no responsibility to assure PCTG's compliance with procedures.40 Another Maintenance employee, Guy Wise, stated that he had no recollection of discussing the brake releases during training, but recalled installing them on the crane.41 When he was questioned about the procedural requirements for their installation, specifically the need for ECM's, Wise testified that it was his practice to stop working and advise his supervisor if he believed that an ECM was required but had not been obtained.42 However, he observed nothing about the brake releases that alerted him to the need for ECM's.43 Wise had reviewed the " owner's manual" in preparation for the installation and saw a reference to brake releases.
Since the 3
brake releases he helped install were like those in the manual, he did not view them as modifications.44 131
~
4 l
The third Maintenance employee involved in the installation of the brakes had little recollection of the brake releases.
His cnly konwledge was having been advised by Kirschbaum that duct tape had to remain on the handles to hold them in place.45 Work Package Preparation and Review Work Package M-0020, documenting the installation of the brakes, made no mention of the brake releases.46 Therefore, those who reviewed the Work Package, including representatives of Site Engineering, had no way of learning that brake releases were being added to the brakes.
There are several explanations for the failure to document the brake releases in the Work Package.
First, Kirschbaum, the author of M-0020, stated that work performed outside containment was not required to be documented in a Work Package.
Since the brake releases were installed on the brakes outside of containment and were brought into containment as part of the brakes, they did not have to be identified in the Work Package.47 Thus, Work Package M-0020, in his opinion, complied with the administrative requirements because it described the steps for the in-containment int.callation of the brakes.48 Kirschbaum's view is not supported by the procedure that defiaed the use of Work Packhges.
CDPI-20 broadly stated its purpose:
132 l
The purpose of this procedure is to establish the requirements for controlling and documenting all
)
work performed on systems, subsystems, components, i
rooms, and areas by construction after release from GPU to construction.
The work performed may be repairs, modifications, replacement of bad parts, maintenance, testing or new construction. (49)
This procedure was intended to be the basis for maintaining a machinery history to provide GPUN with a detailed record of all work performed on polar crane components.50 It made no distinction between work performed in-and out-cf-containment.
It would seem appropriate that the installaticn of the brake releases should have been documented in view of the admonition in the manufacturer's literature that the brake releases must be adjusted to account for brake shoe wear "to avoid restricting normal brake operation."51 Another factor that led to the failure to document the brake releases in a Work Package was the predisposition of some PCTG members to generalize the contents of Work Packages.52 No one has testified that the brake releases were specifically omitted in M-0020 to avoid precipitating questions by engineering.
Instead, Radbill explained that they were not mentioned because he believed that such details were not required.53 Finally, PCTG members explained that 6. hey regarded the brake releases as tools to be used during refurbishment of the crane and therefore did not have to refer to them in the Work 133
l Package.54 As discussed above, this would have been a correct judgement if the use of the brake releases had been limited to facilitating refurbishment work.55 However, their intended use during crane operation required that they be documented in the Work Package.56 No Load Test Brake Inspection QC representatives were charged with the duty to inspect the main hoist brakes during the No Load Test.
Their responsibility was limited to verifying that the brakes were in proper working order and safe for operation.57 Nothing on the checklist during the inspection related to the brake releases.58 The inspector did not take note of the brake releases, and would not have thought of them as possible modifications even if he had noticed them.
He had no other information to indicate that procedures had been violated.59 QA Work Package Review As a result of complaints by TMI-2 employees that procedures were not being followed by the PCTG, Kanga ordered QA to examine the work performed on the polar crane.60 In response, QA focused its review upon the work packages that documented the work done on the crane.61 Blaine Ballard, Manager of QA at TMI, explained:
134 a
-y-a w-r y
e-g m
m 1-17-
-t *
--w y
---i+w-=
7,.i-v7 e m
- -'-~~"
w
Kanga requested us to go in and take a lock at the Bechtel work packages that were perforned with the intent to verify thht where the plant administrative procedures had been appropriately followed or not as a result of some allegations by Mr. Parks that Bechtel was not following the plant administrative requirements.
I The real intent of that review and our real concern in that review was specifically the wor:t packages be-cauce those were the ones that we knew we had not reviewed and any internal procedures, the concern war can we verify that modifications had been appropriately reviewed by engineering per se and that engineering had hccepted and technically justified any modifications or any processes that had been done to the polar crane over all.
So our real intent was to look at the Bechtel work packages. (62)
Ballard also stated that the scope of QA's review did not include job tickets, but instead was limited to Work Packages.
He explained that decision as follows:
Q When you went into work packages, was that based l
on what Kanga's instructions were or was that based on some judgment from QA7 A
I think both.
It was felt the job ticket program was under the plant administrative procedures and as such that should have been handled correctly.
So that's why we isolated the look to the Bechtel work packages because that was the specific concern.
We didn't have a concern on job tickets because they were done under the plant administrative requirements.
So to our knowledge at that time, the job tickets certainly shouldn't have been not in accordance with the plant administrative procedures.
As such, we isolated our scope to the work packages. (63) 135 a
According to Joseph Marsden, who supervised the QA review, Work Package M-0020 was one of the documents reviewed by QA.64 However, because the brake releases were not documented in the Work Package, QA did not learn of their installation.
l QA also questioned Radbill about several modifications that QA identified during its Work Package review, but neither Radbill nor any other member of the PCTG brought the brake releases to QA's attention.65 Readiness Review Committee A Readiness Review Committee meeting was held en March 12, 1983, to discuss the fitness of the crane to undergo load testing.66 The committee was comprised of upper management personnel outside the TMI-2 organization.67 The meeting was attended by members of TMI-2 management.
Although the meeting minutes do not show that the brake releases were discussed, several witnesses recalled that they were mentioned.68 The testimony indicates that someone asked what contingency arrangements had been made in case of a power failure while a load was suspended from the crane.69 It is uncertain whether Mays or Radbill responded, but it is clear that in response, the existence of the brake releases and their capability to lower a load were mentioned.70 The evidence does not show that there was any wenticn of the administrative procedures under which the 136
brake releases were installed, or that they were not part of the original equipment on the-crane.71 Thiesing knew that the crane had not been originally equipped with brake releases.
He testified that he was absent during portions of the meeting and he was "quite sure that it wasn't discussed" while he was present.72 GPUN Response to NRC Requent for Information l
In preparation for the Polar Crane Load Test, a series of written communications were exchanged between GPUN management and the NRC.
They included questions directed to TMI-2 Management by the NRC.
In early July 1983, Charles Hansen, Recovery Programs Regulatory Coordinator, attended a meeting with the NRC to discuss the proposed Load Test.
As a result of that meeting, Hansen drafted a list of "various issues of concern" to the NRC.
That list was transmitted by a memorandum dated July 13, 1983, to
]
Rider and Radbill for proposed responses.73 Radbill responded to Hansen by making marginal notes on the Hansen memorandum.
He explained as follows:
J 4
Well, I provided Charlie Hansen responses to these in writing; but my recollection tells me that I took a copy of this particular document and wrote it into the blank pages and the margins of the page and perhaps gave him a few blank sheets of pcper filled out with details, but there was no formal transmittal.
Had there been a formal transmittal, 1
137
it would be traceable.
It would be transmitted to Hansen under the signature block of Dave Lake with my initials on the side as a drafter. (74)
On July 18, 1983, Bernard J. Snyder, NRC Program Director, Three Mile Island Program Office, sent a letter to Kanga attaching "a list of additional questions" to be addressed for purposes of assisting "the NRC's review of the proposed crane load test."75 Among the questions contained in that letter were the following:
1.
(a) Did GPUNC comply with all QA requirements applicable to the Reactor Building Polar Crane (PC)?
(b) For activities that QA requirements were not applicable, describe how GPU insured quality.
Discuss for example; part installations (for like and unlike k ind), post installation inspectors, and criteria for component checks.
You should also at a minimum dis-cuss major components such as brakes, limit switches, the wire rope, the main power cable, and the polar crane structure.
Other components can be addressed more generally.
(emphasis added) 5.
Provide a list of all repairs and part replacemerAs for the polar crane.
You should indicate which of the re-elacements utilized an unlike k ind comnonent and
-justify that the original margin of safety for using the polar crane has not been reduced.
This should include a discussion in detail on why dummy fuses were installed and the safety significance of that modification.
(emphasis added)
(76) 138
it would be traceable.
It would be transmitted to Hansen under the signature block of Dave Lake with my initials on the side as a drafter. (74)
On July 18, 1983, Bernard J. Snyder, NRC Program Director, Three Mile Island Program Office, sent a letter to Kanga attaching "a list of additional questions" to be addressed for purposes of assisting "the NRC's review of the proposed crane load test."75 Among the questions contained in that letter were the following:
1.
(a) Did GPUNC comply with all QA requirements applicable i
to the Reactor Building Polar Crane (PC)?
(b) For activities that QA requirements were not applicable, describe how GPU insured quality.
Discuss for example; part innta11ations (for like and unlike kind), post installation inspectors, and criteria for component checks.
You should also at a minimum dis-cuss major components such as brakes, limit switches, the wire rope, the main power cable, and the polar crane structure.
Other components can be addressed more generally.
(emphasis added) 5.
Provide a list of all repairs and part replacements for the polar crane.
You should indicate which of the re-i placements utilized an unlike k ind comnonent and 1
justify that the original margin of safety for using the polar crane han not been reduced.
This should include a discussion in detail on why dummy fuses were installed and the safety significance of that modification.
(emphasis added)
(76) 138
According to Radbille he did not mention the brake releases in his notes to Hansen for the following reasons:
i l
It's not included in the response to these questions because at the time this was put together, no thought was ever given to the hand release mechanism falling under the criteria of a replacement part of unlike or like kind.
A hand release mechanism was considered as a tool to be removed at the completion of the load test of the Polar crane.
And this document asks for replacement parts or compenents of that would be permanent equipment on the crane and, again, the hand release mechanism in our thinking at that time or at least in my thinking at that time was that it was a tool.
And, then, there was obviously at that time no need to list it as part of the response to these questions by the NRC.
This document did not ask for what tools are you using on the crane.
It did not ask us if we had put temporary handrails on there, well wheels, a manifold system for an air -- to supply air to individuals on the crane, toolboxes, wrenches, fire extinguishers, safety equipment, none of that was asked for. 'Those were all tools used in the refurbishment.
None of those were listed as well as the hand release mecha-nism was not listed. (83)
Rider explained his failure to identify the brake releases by etating that several of his group leaders provided information for the response.84 Of those supervisors, Mays was responsible for answering the mechanical equipment questions.85 Although he had no recollection of supplying information for Kanga's response, Mays stated that his group may have participated in supplying information.86 He had been involved in ordering the brake releases, knew of their fabrication, and believed that the brake releases were replacements-in-kind.87 Nevertheless, he failed to provide that information in his response to Rider.
140
Middletown Hearing On September 27, 1983, the NRC Staff held a public hearing in Middletown, Pa., concerning the polar crane.88 A nuuter of TMI-2 management personnel, as well as Robert Arnold, then GPUN President, addressed the Staff.09 None of them was aware of the procedural deficiencies related to the installation of the brake releases.90 i
Radbill, who among the speakers was the most directly involved in polar crane refurbishment, specifically discussed the replacement of the brakes.
However, he did not mention the brake releases.91 The Staff also asked several questions about modifications to the polar crane.
The brake releases were not mentioned in this context either.92 Radbill explained his failure to identify the brake releases, stating:
You've got to understand what was in my mind, 4
and I can't answer your question directly, When I was talking to Mr. Denton un that day, there was no thought whatsoever of hand-release mechanisms or pictures or anything in the back of my mind, the front or either side.
The only thing that was in there was I was telling Mr. Denton that I, the Pclar Crane Task Group, had replaced the old brakes with new brakes that were the same as far as the electro-mechanical l
function; and at that time I never even thought about hand releases.
So I was clear in my mind that this was a true and accurate statement.
Knowing what I know today, I probably would have said something different. (93) 141
ll Presence of Brake Releases During Load Test and Headlift Although the main hoist brakes were inspected again in 29, 1984, preparation for the Load Test that occurred on February there is no evidence that the brake releases were tested or inspected at that time.94 Bicks testified that in preparation for Headlift, he wrote an I
operating procedure that provided for the optional use of the brake releases in an emergency situation.95 Hicks testified that the operating procedure was never utilized.96 Although he was generally aware of the brake releases as a result of his work on the polar crane, he did not realize that they were modifi-cations or that they violated administrative procedures.97 On August 16, 1985, it was Hicks who reported that the brakes had malfunctioned as a result of the brake release interfering with the normal operation of the brake shoes.98 Knokledge of Procedural Violations In all of the circumstances discussed in this section, the evidence does not show that anyone recognized that the installation of the brake releases might have been a violation of j
I modification procedures.
During the period in which the brake releases were initially ordered and then designed and fabricated, l
the information necessary to recognize the potential violation was either fragmented or overlooked.
Design Engineering, who l
understood the procedural requirements for decign review of 1
142
1 1
1 l
modifications, overlooked available information that the polar crane was not originally equipped with brake releases.
The PCTG l
l had such knowledge, but failed to communicate it outside of their own organization.
In addition, from the time of the installation l
of the brake releases, the failure to document their installation 4
undermined any oversight efforts designed to identify l
modifications.
1 r
I i
I
}
I i
i 4
l r
i I
a J
i t
l i
i I
5 i
143 i
1 NOTES 1
Kirschbaum, 7/1/85, pp. 8-9.
2 See section of this report, DESIGN, FABRICATION AND INSTALLATION OF THE POLAR CRANE BRAKE RELEASES, l
notes 18-24 and related text.
3 Ibid.
4 Ibid., notes 1-19 and related text.
5 Kirschbaum, 1/30/85, pp. 15-16.
6 Ibid., pp. 13-16.
7 Photographs marked 80-5 and 80-8 (Tab 1);
Mays, 4/22/85, pp. 9-10; Johnson, 8/21/85, pp. 9-10; Jackson, 6/6/85, p. 15.
8 Westinghouse Instructions for Type TM Brakect (IL 5204-1A), effective Novenber 1963, p. 6 (Tab 51).
1 9
Amendment 69 to Specification 2555-22, Reactor i
Building and Reactor Turbine Cranes, 2/14/77, i
Burns & Roe, Section 3.9.7 (Tab 56).
10 Mays, 4/22/85, p. 8.
11 Ibid., p. 7.
12 Ibid., p. 8.
i 144 4
1
,n-.
,n-.
. -,, - - -,,, - -. +,. _ -., - - -,. - -...
13 Letter, 2/11/82, BNoC to Westinghouse Electric Corp., re Polar Crane Main Hoist Brakes Proposal Request #13587-M-063B, Material Requisition, final page of attachments (Tab 29).
l 14 Ibid.;
Letter, 2/11/82, BNoC to Whiting Corp., re Polar Crane Main Holst Brakes Proposal Request #13587-M-063B, with attachrents (Tab 87).
15 Blizzard, 4/3/85, pp. 8-10.
16 Letter, 3/19/82, Whiting Corp. to DNoC, re i
BNoC Inquiry #13587-M-063B, 063C (Tab 32);
Whiting Corp. Proposal 4RP 5043-R1, 4/22/82 (Tab 34);
BNoC Purchase Memorandum, 4/30/82, Rider to Buell, re Polar Crane Main and Auxiliary Hoist Brakes (Tab 37);
BNoC Purchase Memorandum, 5/6/82, Rider to Buell, re Polar Crane Main and Auxiliary Holst Brakes (Tab 38);
BNoC Purchase Order to Whiting Corp. 613587-M-063B, Rev. O, 4/30/82, re Polar Crane Main Hoist Brake and Auxiliary Hoist Brakes (Tab 39).
17 Mays, 8/22/85, pp. 16-21; 4/22/85, pp. 11-14; Hickerson, 7/9/85, pp. 36-37, 18 Mays, 4/22/85, pp. 8-9, 25.
19 Mays, 8/22/85, pp. 17-19.
20 Mays, 4/22/85, pp. 16-17.
145
l 1
1
\\
l I
l 21 Job Ticket CA 364, 8/6/82 (Tab 46).
22 Ibid.
i 23 Ibi6.
24 Ibid.
25 Unit 2 Mainteriance Shift Foreman Log, 8/27/82 entry, p. 260 (Tab 89).
26 TMI-2 Polar Crane Recovery Reports 42, 8/20/82, and 44, 9/3/82 (Tab 28).
27 Ibid.
28 Ibid.
29 Buchanan, 7/29/85, pp. 13-14; Gallagher, 1/16/85, pp. 15-16, 21-23; Lake, 4/10/85, p. 63; Freemerman, 8/22/85, p. 18; Kanga, 5/2/85, pp. 10-11.
30 Thiesing, 7/15/85, p. 11.
31 Thiesing, 4/25/85, pp. 23-27; 7/15/85, pp. 13-14.
32 Ibid.
33 Ritschbaum, 1/30/85, p. 63.
34 Graber, 6/27/85, p. 48.
146
35 Kazebee, 8/20/85, pp. 17-19; Ballard, 7/30/85, pp. 18-19; Van Skike, 7/17/85, pp. 9-10.
36 Wise, 7/24/85, pp. 4-8; Terrell, 9/18/85, pp. 4-7; Nagle, 7/30/85, p. 6; Radbill, 9/27/85, p. 79; Kirschbaum, 1/30/85, pp. 66-69.
37 Terrell, 9/18/65, pp. 6-7; Nagle, 7/30/85, pp. 6-9; Wise, 7/24/85, pp. 7-8.
]
38 Terrell, 9/18/85, pp. 7-8, 14-16.
1 39 Ibid., pp. 14-15.
40 Ibid., p. 16.
i 41 Wise, 7/24/85, p. 11.
I 42 Ibid., p. 17.
i 43 Ibid., p. 18.
44 Ibid., pp. 17, 20-22.
l 45 Nagle, 7/30/85, pp. 13-14.
46 Work Pa:kage M0020, 9/16/82 (Tab 49).
47 Kirschbaum, 7/1/85, pp. 46-47.
48 Ibid., pp. 45-46.
147 1
i
49 CDPI-20, Section 1.1, p. 1 (Tab 4).
50 Ibid., Section 4.2.8.
51 Westinghouse Instructions, p. 6 (Tab 51).
52 See section of this report, BECHTEL'S ADMINISTRATIVE CONTROLS," subsection PCTG Attitude Toward Work Package Preparation.
53 Radbill, 9/27/85, pp. 80-81.
54 Ibid., p. 81; Kirschbaum,1/30/85, p. 73; Graber, 6/27/85, pp. 35-38.
55 See section of this report, ASEEEEMENT OF BRAKE netrAsrs AS A unoIFICATION, second half.
56 CDPI-20, 9/1/82.
Note:
the brake releases should have been listed in a " tool log" as required by Section 4.2.7 of ATWIC (Tab 11).
57 James, 9/9/85, pp. 15-16; Green, 10/9/85, pp. 8-9; IOM, 2/2/83, Byrne to Barrett (4410-83-M-0137),
re Work Package M-0048, Quality Control Inspection Report (Tab 53).
58 Ibid., p. 1, Inspection Surveillance Plan (check list), Section C.
59 Green, 10/9/85, pp. 13-17.
148
.-._. =.
l 60 Kanga, 8/29/85, pp. 14-15; l
Management and Safety Report, Vol. IV, Polar Crane Allegations, pp. 16-17.
61 Ballard, 7/30/85, pp. 30-31.
62 Ibid.
i 63 Ibid., pp. 31-32.
64 Marsden, 7/30/85, pp. 16-17.
65 Ibid.
66 IOM, 3/22/83, Kanga to Arnold (4000-83-153),
re Polar Crane Readiness Review Committee Meeting (Tab 61).
I 67 Ibid.
68 Clark, 5/21/85, pp. 11-12; Ballard, 7/30/85, pp. 16-17; Radbill, 9/27/85, pp. 95-99; Lake, 6/18/85, pp. 56-57; 4/10/85, pp. 119-120; Kanga, 8/29/85, pp. 13-14.
4 69 Ibid.
70 Radbill, 3/12/85, pp. 65-70; Mays, 4/22/85, pp. 33-36.
71 Radbill, 9/27/85, pp. 100-101.
149
1 I
)
72 Thiesing, 4/25/85, p. 11.
)
5
~
73 IOM, 7/13/83, Hansen to Rider, Radbill
)
(4304-83-0024), re Polar Crane (Tab 62).
1
)
74 Radbill, 9/27/85, p.115.
e I
i 75 Letter, 7/18/83, Snyder to Kanga, re additional Polar Crane information, with attachment (Tab 63).
i 1
i 76 Ibid., Sections 1 and 5 of attachment.
l 77 IOM, 7/26/83, Rider to Freemerman (0294-0136V-8420) l re NRC questions on Polar Crane DERM-0128 (Tab 64).
)
j 78 Hansen, 7/29/85, pp. 24-25; A
1/15/85, p. 52; 1
Radbill, 9/27/85, pp. 114-115; i
IOM, 7/13/83, Hansen to Rider, Radbill (Tab 62).
i l
79 Letter, 8/16/83, Kanga to Snyder, re Polar Crane l
Load Test, additional information (Tab 65).
(
?
j 80 Barton, 5/6/85, pp. 67-70.
(
I i
l l
81 Kanga, 8/29/85, pp. 21-22.
l T
82 Letter, 8/16/83, Kanga to Snyder, j, p. 2 (Tab 65).
f I
t 83 Radbill, 9/27/85, pp.16-17.
84 Rider, 8/21/85, pp. 19-21.
1 I
l 85 Ibid., p. 21.
[
e i
150
86 Mays, 4/22/85, pp. 37-40.
87 Ibid.
88 Transcript of Reactor Building Polar Crane Public Meeting of 9/27/83 (Denton Hearing) (Tab 58).
l 89 Ibid., pp. 44-46, 58.
l 90 Kanga, 5/2/85, p. 26; Arnold, 5/21/85, pp. 11-12; Jackson, 6/6/85, pp. 54-55; a
Marsden, 1/14/85, pp. 65, 69; Radbill, 3/12/85, pp. 216-217; Hansen, 7/29/85, pp. 12-13.
91 Radbill, 3/12/85, p. 217; Denton Hearing Transcript, pp. 42-43 (Tab 58).
92 Denton Hearing Transcript, pp. 42-54, 114.
93 Radbill, 3/12/85, p. 217.
94 UWI 4370-3891-83-PC1, 2/16/84, re Load Test Polar Crane Procedure (Tab 71);
l Marsden, 1/14/85, p. 44.
95 Hicks, 1/15/85, pp. 32-33.
l 96 Ibid., p. 37.
i l
97 Ibid., pp. 35-37.
98 Ricks, 7/25/85, pp. 6-13; TMI-2 Event Report (50-320-84-099) of 8/11/84, Improper Adjustment of Main Holst Brake on Unit II Polar Crane (Tab 81).
151
TABLE 1 LIST OF DOCUMENTS ZAkA 1
- Two photographs of main hoist brakes at TMI-2 marked Entry 80-5 and 80-8.
- Four photographs of main hoist brakes at TMI-2 marked Entry 130-5, 130-6, 130-7 and 130-8.
- Eleven photographs of main hoist brakes at TMI-2 marked Entry 469-5 through 469-15.
2 Memo, 8/16/82, Radbill to Green, re formation of Polar i
Crane Task Group.
3 IOM, 7/30/82, Jackson and Lake to Freemerman, 0306-8420, re Polar Crane Division of Responsibility (DOR).
4 CDPI-20, 9/1/82.
5 Memo, 1/20/83, King to Barton, 4200-83-034, re Polar Crane turnover.
I 6
Maintenance Procedure 1407-1, Rev.13, 7/17/82.
7 IOM, 11/11/82, Kanga to Ballardi King, Larson and Thiesing, 400-82/K-442, re ECM reviews.
8 IOM, 11/19/82, Rider to Thiesing, re ECM's.
9 IOM, 3/16/83, Kanga to Distribution, 4000-83-152, re QDR's.
10 QA/QC, ME 030 78-83, No Load Test Inspection.
i 11 GPUN TMI-2 Administrative Procedure Manual
- 4300-ADM-3240.1, Access to and Work In i
Containment Building (ATWIC), 4/4/82.
i l
152
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12 IOM, 7/14/82, Van Shura to Distribution, 7152-82-143, re GPUN Administrative Procedures.
13 IOM, 8/9/82, Kelly to Sellman, 8307140190, re TMI-2 Procedures.
14 IOM, 8/3/82, Larson to Distribution, 4400-82-0941, re commitments made at the NRC/GPU Management Conference on 7/29/82.
15 IOM, 8/13/82, Barton to Distribution, 4000-82-273, re the Bi-weekly Program Staff meeting of 8/18/82.
Agenda for the 8/4/82 meeting attached.
16 IOM, 9/1/82, Kanga to Arnold et al, 4000-82-K-296, re Reorganization Implementation announcement, with charts.
17 Letter, 9/27/82, Kanga to Haynes (Director, Region 1 NRC) 4410-82-L-0015, re Inspection Report 50-320/82-10.
18 IOM, 12/9/82, Thiesing to Distribution, 4300-82-0045, re UWI's.
19 IOM, 12/10/82, Kanga to Deviner 4000-82-511 re Procedure Training.
20 Letter, 12/29/82, Kang & to Haynes, 4410-82-L-0078 re Inspection Report 50-320/82-10 Status Update.
21 GPUN Administrative Procedure (AP) 4000-ADM-7310.01 re Cognizant Engineer Procedure, effective 1/3/83.
22 GPUN Administrative Procedure (AP) 4000-ADM-3050.01 re TMI-2 Job Tickets, effective 1/3/83.
23 IOM, 3/30/83, Kanga to Barton et al, 4000-83-183 re NRC Identified Procedure Inadequacies.
153
24 GPUN Policy and Procedure Manual 1000-ADM-7215.01 re Important to Safety (ITS) Material Nonconformance Reports, effective 1/31/84.
25 Polar Crane Functional Description 2-M72-MH02, 9/20/82.
26 IOM, 3/22/83, Kanga to Arnold, 4000-83-153, re Readiness Review Committee meeting on 3/12/83.
27 CDPI 11, 11/15/82.
28 TMI Polar Crane Recovery Progress Reports, 7/30/82 - 9/30/83.
29 Letter, 2/11/82, BNoC to Westinghouse Electric Corp.,
Towson, Md.,
re PC Main Holst Brakes Proposal Request #13587-M-063B with attachments.
30 Letter, 2/11/82, BNoC to Whiting Corp., re P.C.
Auxiliary Holst Brakes and BNoC Proposal Request
- 13587-M-063C.
31 Letter, 2/26/82, Westinghouse Corp. to BNoC, re PC Main Boist Brakes and BNoC Proposal Request #13587-M-063B.
32 Letter, 3/19/82, Whiting Corp. to BNoC, re BNoC Inquiry
- 13587-M-063B, 063C.
33 Letter, 3/25/82, Whiting Corp. to BNoC, re BNoC Inquiry
- 13587-M-063B, 063C.
~
34 Whiting Corp. proposal #RP5043-R1 4/22/82.
35 Whiting Corp. proposal #RP5042-R1 4/22/82.
36 IOM, 4/29/82, Buell to Rider, re PC Main Holst Brakes and Auxiliary Brakes Inquiries fl3587-M-063-B, 063-C.
37 BNoC Purchase Memo, 4/30/82, Rider to Buell, re PC Main and Auxiliary Hoist Brakes.
154 L.,
38 BNoC Purchase Memo, 5/6/82, Rider to Buell, re PC Main and Auxiliary Holst Brakes.
39 BNoC Purchase Order to Whiting Corp. t 13587-M-063B, Rev. O, 4/30/82, re PC Main Hoist Brake and Auxiliary Hoist Brakes.
40 Letter, 5/7/82, BNoC to Whiting Corp., re Purchase Order # 13587-M-063B, Rev. 1.
41 Letter, 7/2/82, Whiting Corp. to Metropolitan Edison Co., TMI, re Purchase Order i 13587-M-063B.
i 42 Letter, 7/14/82, Whiting Corp. to Metropolitan 1
Edison Co., TMI, re Purchase Order i 13587-M-063B.
43 GPUN Material Received Receipt # 7057862, 10/7/82, re 13" Sesa Brake Wheels and 16" Westinghouse D.C. Brake Wheel.
O f
44 GPUN QA Material Release Form, 10/7/82, re 13" Sesa Brake Wheels and 16" Westinghouse D.C. Brake Wheels.
45 QC Receiving Inspection Report, 10/8/82, re 13" Sesa Brakes complete with Solenoid and Brake Wheel, and 16" TMR #1665-16 D.C. shunt wound brake with brake wheel.
46 Job Ticket CA 364, 8/6/82.
47 Unit 2 Daily Schedule Sheets, 8/13/82 to 8/30/82.
48 Memo, 9/10/84, Hicks to Kirschbaum, re telephone conversation.
49 Work Package M0020, 9/16/82.
50 Entry Logs 122-127.
51 Westinghouse Instructions for Type TM Brakes, I. L.
i 5204-1A effective November 1963.
155
52 Unit Work Instruction (UWI) 4374-3891-83, 1/24/83.
53 IOM, 2/4/83, Byrne to Barrett, 4410-83-:4-0137, re Work Package M-0048.
54 Unit Work Instruction (UWI) 4370-3100-83, 2/16/83, re completion of PC No Load Test.
55 Polar Crane Recovery Description, 3/29/82.
56 Amendment 49 to Specification 2555-22, Reactor Building and Turbine Building Cranes, 2/14/77, Burns and Roe, Inc.
57 IOM, 10/5/83, Byrne to Arnold et al, 4410-83-M-0793, re Reactor Building PC Public Meeting of 9/27/83.
58 Transcript of Reactor Building PC Public Meeting of 9/27/83.
59 Unit Work Instruction (UWI) 4370-3100-84-C448, 7/24/84, re Emergency.
60 Letter, 3/15/83, Kanga to Barrett, 4410-83-L-0052, re PC SER - Additional Information.
61 IOM, 3/22/83, Kanga to Arnold, 4000-83-153, re PC Readiness Review Committee Meeting.
62 IOM, 7/13/83, Hansen to Rider, Radbill, 4303-83-0024, re Polar Crane.
63 Letter, 7/18/83, Snyder to Kanga, re additional PC information, with enclosure.
64 IOM, 7/26/83, Rider to Freemerman, 0294-0136V-8420, re NRC questions on PC DERM-0128.
65 Letter, 8/16/83, Kanga to Snyder, re PC Load Test -
Additional Information.
156
66 Letter, 6/17/83, Kanga to Barrett, 4410-83-L-Oll8, re PC Load Test SER.
67 IOM, 8/30/83, Lake to Freemerman, 4370-83-0331, re responses to 8/26/83 NRC PC questions.
68 IOM, 8/27/83, Marsden to Rider, 6111-83-1065, re PC Work Packages.
69 IOM, 8/4/83, Rider to Marsden, 0295/Oll7V/8420/
8190/0494 re QC Review of PC Work Packages.
70 Letter, 11/18/83, Snyder to Kanga, re PC Load Test with attachment, NRC SER.
71 Unit Work Instruction (UWI) 4370-3891-83-PC1, 2/16/84, re Load Test PC Procedure.
72 GPUN Safety Evaluation Report (SER) for the Polar Crane Load Test, June 1983.
73 Letter, 6/5/84, Kanga to Snyder, 4410-84-L-0085, re PC Load Test Results.
74 Letter, 9/2/83, Kanga to Snyder, 4410-83-L-0205, re PC Additional Information.
75 Letter, 9/28/83, Barrett to Kanga, re Additional PC Refurbishment Information.
76 Letter, 10/11/83, Kanga to Bstrett, 4410-83-L-0244, re Additional PC Refurbishment Information.
77 IOM, 7/26/83, Rider to Freemerman, re proposed responses to NRC comments on PC.
78 Excerpts, Electric Power Research Institute (EPRI),
Recovery of TMI-2 Reactor Building Polar Crane, pp. S S-3, 1-3, January 1984.
157 l
79 PC Task Group Schedule FSS 008 Rev. O TIS 101 Rev. 2 TSS 101 Rev. 0 80 Letter, undated, Kanga to Barrett, 4410-83-L-0130.
81 TMI-2 Event Report 50-320-84-099 of 8/11/84, Improper Adjustment of Main Boist Brake on Unit II Polar Crane.
82 Letter, 10/4/82, Bechtel Northern corp. to Whiting Corp., re Purchase Order # 13587-M-063B, Revision 2, with attachments.
83 Letter, 8/24/83, Kanga to Snyder (NRC), 4410-83-L-0193 re PC Load Test - Additional Information.
84 Report, November 1984, Westinghouse Electric Corp.,
Advanced Energy Systems Division, Polar Crane -
Main Boist Manual Brake Release Vibration Test.
85 Three Mile Island Nuclear Station, Unit No. 2, Administration Procedure 1021, Revision 10, 6/2/82.
86 Excerpts from Three Mile Island Nuclear Station, Unit No. 2, Administration Procedure 1043, Revision 2, 8/30/82.
87 Letter, 2/11/82, BNoC to Whiting Ccrporation, re Polar Crane Main Boist Brakes Proposal Request 413587-E-063B, with Attachments.
88 Letter, 9/24/81, Bovey to Snyder, LL2-81-0220 re TMI-2 Organization Plan, Rev. 3, with Enclosures.
89 Maintenance Shift Foreman Log, Unit 2, 8/14/82 to 8/28/82.
158 u
TABLE 2 WITNESS STATEMENTS ARNOLD, Robert 5/21/85 Stier Investigation ATCHINSON, Gene 10/10/85 Stier Investigation BALLARD, Blaine 7/30/85 Stier Investigation BAR3ANIC, Robert 4/10/85 NRC OI 7/25/85 Stier Investigation BARTON, John 5/6/85 NRC OI 7/18/85 Stier Investigation BASEHORE, Joni Marie 4/18/85 NRC OI BENZINGER, Gerald 10/11/85 Stier Investigation BLIZZARD, Darrell 4/3/85 NRC OI BUCEANAN, David 7/29/85 Stier Investigation CLARK, Philip 5/21/85 NRC OI CLEMENTS, Gordon 7/25/85 Stier Investigation CORKLE, Barry Lee 7/25/85 Stier Investigation FILKINS, Mark 7/24/85 Stier Investigation FREEMERMAN, Ronald 4/22/85 NRC OI 8/22/85 Stier Investigation 159
GALLAGHER, Richard 1/16/85 NRC OI 7/24/85 Stiet Investigation GANNON, Joseph 11/18/85 Stier Investigation GIBSON, Thomas 9/12/85 Stier Investigation GRABER, James 6/27/85 Stier Investigation GREEN, James
' 10/9/85 Stier Investigation HANSEN, Charles 1/15/85 NRC OI 7/29/85 Stier Investigation HICKERSON, Wayne 7/9/85 Stier Investigation HICKS, James 1/15/85 NRC OI 7/25/85 Stier Investigation JACKSON, Richard 7/27/83 Stier Investigation (excerpts from M&S Report) 4/3/65 NRC OI V
6/6/85 Stier Investigation JAMES, Zale 10/9/35 Stier Investigation JOHNSON, Steven 8/21/85 Stier Investigation JULES, Sam 7/24/85 Stier Investigation KANGA, Bahman 5/2/85 NRC OI 8/29/85 Stier Investigation 160
KAZEBEE, Raymond 8/20/85 Stier Investigation KINTNER Edwin 5/21/85 NRC OI KIRSCHBAUM, Howard 1/30/85 NRC OI 7/1/85 Stier Investigation LAKE, David 4/10/85 NRC OI 6/18/85 Stier Investigation MARSDEN, Joseph 1/14/85 NRC OI 7/30/85 Stier Investigation MARTIN, Samuel 1/10/85 NRC OI 9/18/85 Stier Investigation MAYS, Ronald 4/22/85 NRC OI 8/22/85 Stier Investigation MERCER, R. Bruce 9/30/85 Stier Investigation MORRIS, Thomas 1/15/85 NRC OI NAGLE, Gary 7/30/85 Stier Investigation PARLEE, Kenneth 11/18/85 Stier Investigation PARSONS, Richard 1/16/85 NRC OI 8/21/85 Stier Investigation PASTOR, M. Kenneth 6/19/85 Stier Investigation 161
PRESTON, Robert 8/21/85 Stier Investigation RADBILL, Michael 3/12/85 NRC OI 9/ 27/ 85 Stier Investigation FEDDINGTON, Thomas 1/10/85 NRC OI RIDER, Robert 4/3/85 NRC OI 8/21/85 Stier Investigation ROETING, Charles 7/30/85 Stier Investigation SHAMENEK, Louis 7/17/85 Stier Investigation SIEGLITZ, Richard 7/17/85 Stier Investigation SOUDERS, Ronald 9/18/85 Stier Investigation TERRELL, A. Donald 9/18/85 Stier Investigation THIESING, James 4/25/85 NRC OI 7/15/85 Stier Investigation VAN SKIKE, Jack 7/17/85 Stier Investigation WALKER, Ronald 4/10/85 NRC OI WILLIS, John 10/23/85 Stier Investigation WISE, Guy 7/24/85 Stier Investigation 162
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