ML20155J677

Partially Withheld Results of Joint Ofc of Investigations/ NRR Evaluation of Cl Guthrie Leak Rate Testing Irregularities.Guthrie Negligent in Duties as Shift Foreman. W/O Encl 2

ML20155J677
Person / Time
Site:	Three Mile Island
Issue date:	10/09/1985
From:	Russell W Office of Nuclear Reactor Regulation
To:	Harold Denton Office of Nuclear Reactor Regulation
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NUDOCS 8605270154
Download: ML20155J677 (21)

Text

..

Enclosure 8

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~,, UNITED STATES

! c NUCLEAR REGULATORY COMMISSION i { I wasumeTom o.c.zoses

%, j/ October'9, 1985 j l

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MEMORANDUM FOR: Harold R. Denton, Director -

Office of Nuclear Reactor Regulation FROM: William T. Russell, Acting Director Division of Human Factors Safety, NRR

SUBJECT:

RESULTS OF JOINT 01/NRR INVESTIGATION AND EVALUATION OF CARL L. GUTHRIE

Reference:

1.~ Memorandum from S. J. Chilk (SECY) to B. B. Hayes (01) and W. J. Dircks-(EDO) dated April 2,1984.

Subject:

Staff Requirements-Discussion of Pending Investigation-TMI

2. Memorandum from H. R. Denton (NRR) to B. B. Hayes (01) dated May 3, 1984,

Subject:

NRR Review of 01 Investi-gation Materials Concerning Hartman Allegations of Falsification of Leak Rate Data at TMI, Unit 2

3. Memorandum from W. T. Russell (DHFS) to H. R. Denton O -

(NRR) dated January 24, 1985,

Subject:

Follow-up Action on Additional TMI-2 Operators .

The purpose of this memorandum is to document the results of the joint 01/NRR investigation and evaluation of Mr. Carl L. Guthrie, a licensed Senior Reactor Operator ($RO) at Three Mile Island, Unit 2 (TMI-2), currently serving as Foreman, Radwaste Operations TMI-2, and to provide a recomendation regarding whether his current SRO license should be revoked, modified, or suspended under 10 CFR 55.40 or other enforcement action taken under 10 CFR Part 55.50, due to his involvement in preaccident leak rate testing irregularities at TMI-2.

Background

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! As the result of a Comission meeting on March 23, 1984, NRR was directed by Reference 1 to review 01 investigative materials concerning falsification of reactor coolant system (RCS) leak rate tests at TMI-2 and refer back to 01-NOTE: ThismemorandumandEnclosure1discussinformationwhichisthesub-ject of an ongoing OI investigation. This memorandum and Enclosure 2 discuss information that is maintained in the NRC's Privacy Act System of Tlecords (NRC-16). This memorandum and enclosures may not be disseminated outside the NRC without coordination with NRR and the permission of the EDO or the Director, OI. Internal access and distribution should be on a "need to know" basis.

YN e605270154 860516 PDR ADOCK 05000320 P PDR

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Harold R. Denton - 2- Octobsr 9,- 1985 i

those matters which required further investigation. The results of NRR's review was provided in Reference 2. The review determined that follow-up i investigation was warranted in the case of seven operators who were currently

! licensed._Mr. Guthrie was not one of those seven individuals.

l l At a follow-up Connission meeting on May 23, 1984, the Commission agreed with 1 the approach of evaluating past and present performance. OI and NRR

! would conduct a joint investigation to determine what role, if any, these -

individuals had in improper activities associated with leak rate surveillance testing at TMI-2 prior to the accident and NRR would conduct an evaluation of

{ the current performance of these individuals. Based upon the results of the investigation and evaluation, NRR would reconnend to the Connission what action, if any, should be taken against each of the identified operators.

l As a result of some of the early interviews with these individuals and further technical evaluation Reference 3 recommended that three additional licensed operators also undergo investigation and evaluation. Mr. Guthrie was one of the operators identified in Reference.3. .

Of the ten individuals identified for investigation and evaluation, seven are currently licensed on THI-2 and one is licensed on San Onofre 2 and 3. The remaining two individuals were licensed on Waterford 3, but have recently tenninated their licenses and are no longer employed by Louisiana Power &

) Light Company.

Past Involvement in TMI-2 Leak Rate Testing Irregularities On June 4,1985, a joint 01/NRR interview of Mr. Carl L. Guthrie, was held at I the Three Mile Island Training Facility, Middletown, Pennsylvania. The interview was conducted in the presence of Mr. Guthrie's personal attorney.

The purpose of the interview was to detennine Mr. Guthrie's role, if any, in

- improper activities associated with RCS leak rate surveillance testing at j TMI-2 prior to the accident on March 28, 1979. At that time, Mr. Guthrie

was a Shift Foreman assigned to three different shifts; however, during the last three months of operation he was assigned to Shift "F." A detailed.

, evaluation of Mr. Guthrie's involvement in leak rate testing irregularities I j is provided in Enclosure 1 to this memorandum.

j During the interview, most of Mr. Guthrie's responses to general questions associated with RCS leak rate surveillance test problems at TMI-2 were consistent three Control with Roomthe testimony Operators (of other CR0s) licensed assigned tooperators, shift "F," including Mr. Guthrie the admitted that many of his actions, associated with the supervision of leak rate testing, violated approved plant procedures and technical 1 specifications; however, he denied any personal involvement in or knowledge of leak rate test manipulation.

Based uporr-the results of NRR's technical evaluation and the testimony of Mr. Guthrie and the other operators on his shift (Messrs. McGovern, Hennila and Germer), the following findings and conclusions are drawn:

1. .Although Surveillance Requirement 4.4.6.2 only required a leak rate test i to be perfonned once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> when in steady-state operation, leak rate tests were routinely conducted every shift. -

1 I'

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Harold R. Denton October 9, 1985

2. Contrary to Technical Specification 6.10.1.d " Record Retention " leak rate. tests indicating unidentified leakage in excess of I gpm were discarded, either directly by Mr. Guthrie or his CR0s.

3. ContrafytoSurveillanceProcedure 2301-301 "RC System Inventory," and contrary to the. licensee's stated corrective action in the LER 78-62/1T,

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when test results indicated unidentified leakage in excess of the limiting condition for operation (i.e.,1 gpm), Mr. Guthrie did not enter -

the action statement of Technical Specification 3.4.6.2, " Reactor Coolant System Operational Leakage." Mr. Guthrie testified that after October 1978, he was aware that action was required: "I probably felt personally that we weren't really adhering to the letter of the law."

4. When leak rate test results exceeded the limiting condition for operation of Technical Specification 3.4.6.2, Mr. Guthrie brought it to the attention of his Shift Supervisor. He was told to run another test and continue to look for leaks. According to Mr. Guthrie, it was a conscious decision by the Shift Supervisor not to enter the action

statement of the technical specification. Mr. Guthrie stated that this-practice may have been known and condoned by the Supervisor of Operations and possibly higher levels of management.

5. Although Mr. Guthrie advised the Shift Supervisor of unsatisfactory leak rate test results, contrary to TMI Administrative Procedure 1010

" Technical Specification Surveillance Program," he did not complete i

" Exception and Deficiency" reports and submit them to his Shift Supervisor for review and evaluation.

6. Contrary to TMI Administrative Procedure 1012. " Shift Relief and Log )

Entries," Mr. Guthrie was aware that CP.Os were not logging the start 1 time, stop time and the results of all leak rate surveillance tests in

, the Control Room Log. j

7. Mr. Guthrie testified that he was aware of periodic problems with the  !

make-up tank (MUT) level transmitters and advised his CR0s to perfonn l tests using the stable level transmitter. Nevertheless, the NRR I i evaluation shows three of the tests approved by Mr. Guthrie were run with

an erratic and unreliable level transmitter providing MUT level

indication to the computer.

Mr. Guthrie testified that prior to the accident, he had heard that

! 8.

i adding hydrogen to the MUT could affect MUT level indication and consequently leak rate test results. However, Guthrie also stated he

had no personal knowledge of any operator using hydrogen to manipulate test results. The NRR evaluation showns that two tests and possibly one j additional test, approved by Mr. Guthrie, involved hydrogen additions j

during,the leak rate test period. ,

9. Mr. Guthrie testified that he had no personal knowledge of any operator addi_ng water during the course of a leak rate test and not including the amount added in the calculation. The NRR evaluation shows one possible ' ,

test, approved by Mr. Guthrie, where water may have been added and not included in the calculation. This test may have involved a hydrogen addition rather than a water addition. It is not possible from the .

I records available to differentiate between water or hydrogen for this l particular test, (see also item 8 above). .

Harold R. Denton October 9, 1985 w

10. Mr. Guthrie testified that he was not aware of instrumentation inaccuracies between the batch controller and the MUT level indicators.

He did not.believe his CR0s were aware of this problem either and did not believe they would take advantage of such an inaccuracy during the performance of leak rate tests. The NRR evaluation shows three of the tests approved by Mr. Guthrie, involved water additions, where the amount of water logged in the CR0's Log a,nd included in the leak rate __-

calculation were less than.the amount indicated on the MUT strip chart.

! Since the amount of water logged in the CR0's Log was included in each of these tests, the surveillance procedure was followed exactly as written.

It is not possible to show whether Mr. Guthrie or his CR0s knew of the

] instrument inaccuracy at the time and used it to their advantage.

Eb In summary, Mr. Guthrie agrees in retrospect that many of his actions involving leak rate surveillance testing at TMI-2 violated approved plant procedures and were contrary to the TMI-2 Technical Specifications. Because of problems with. instrumentation and the procedure itself, it appears Mr. Guthrie considered the test unreliable as far as representing true plant leakage. When leakage above the limits of the technical specification were brought to the attention of his Shift Supervisor, Mr. Guthrie was instructed j to run another. test, and to continue to look for leaks. As a result of test problems and the lack of management concern for the test, he treated the test '

as an administrative requirement only.

4 While 12 of the 19 tests involving Mr. Guthrie during this period are considered invalid, and one additional test was not signed because it

exceeded the limits of the technical specifications, there is insufficient l evidence to conclude that these tests were intentionally manipulated.

Rather, it appears that because tests were conducted so~ frequently, the CR0s

did not worry about establishing the proper steady-state conditions required j for the test, and Mr. Guthrie's review only involved looking at the " bottom line" test results. Thus, if a test result was greater than 1 gpm, it would

~

be discarded and another test would be started. If a test was less than

,i t

1 gpm, it would be retained with little or no review to ensure it was a valid test.

Current Performance

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i '

Harold R. Denton October 9,1985 i

t P 1 i

Conclusions and Recommendation During the period under investigation, while Mr. Guthrie served as a Shift ,

Foreman, he admitted being involved in activities associated with reactor coolant system leak rate testing that were in violation of approved plant ,

O

' procedures and the TMI-2 Technical Specifications. These actions included!

1. Failure to ensure that leak rate surveillance tests were conducted in

accordance with the approved plant procedure, f

2. Failure to ensure that all leak rate tests were properly recorded by Control Room Operators in the Control Room Log, ,

3. Failure to properly review the results of leak rate surveillance tests,

4. Failure to retain leak rate tests whose results exceeded the limiting conditions of operation of the technical specifications, and

5. Failure to take the required follow-up action when the limiting conditions for operation specified in the TMI-2 Technical Specifications were exceeded.

Despite these actions, Mr. Guthrie denies that he was involved in or was knowledgeable of any activities on the part of operators or superv.isors to intentionally influence or manipulate the outcome of leak rate test results.

There is insufficient evidence to conclude that Mr. Guthrie was involved in

. leak rate lest manipulation; however, the evidence supports a finding that Mr. Guthrie was grossly negligent in his duties as a Shift Foreman with respect _to supervising leak rate surveillance testing and initiating required ,

follow-up action. i l

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Harold R. Denton October 9,1985 In trying to balance Mr. Guthrie's past involvement in improper activities

, with his current performance, it is necessary to consider factors that may have influenced his earlier actions. Based upon Mr. Guthrie's testimony and the testimony of other Shift Foreman and Control Room Operators interviewed to date, it is clear that management's standards for procedural compliance were lax and permissive. In my opinion, this was created through negligence

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on the part of management. When leak rate surveillance tests that exceeded ,

the limits of the technical specification were shown to Mr. Guthrie's Shift Supervisor, the only instructions given to Mr. Guthrie were to run another test and continue to look for leaks. This conscious decision by Shift Supervisors, and possibly management personnel, to disregard the requirements of the technical specifications coupled with the lack of respect for the leak rate test procedure and management's failure to correct test procedure problems and instill high standards for procedural compliance, led to conditions where the lesk rate test was conducted in a frivolous manner and in some cases motiveted operators to manipulate or falsify leak rate test results. -

Mr. Guthrie may not have been involved in or condoned leak rate test manipulation; however, I believe he approved and submitted test results without regard for their validity, as long as the calculated unidentified leakage was below the technical specification limit. In some cases he knowingly violated the technical specifications !_/ failing to enter the action statement when leak rate tests results exceeded the limiting conditions for operation.

O h . T. h 2 0D William T. Russell, Acting Director Division of Human Factors Safety Office of Nuclear Reactor Regulation

Enclosures:

As stated ,

. cc: B. Hayes K. Christopher I

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1 NOTE:. This enclosure discusses information which is the subject of an

_ ongoing OI investigation. This enclosure may not be disseminated outside the NRC without coordination with NRR and the permission of -

the EDO or the Director. 01. Internal access and distribution should be on a "need to know" basis.

Enclosure 1 PAST INVOLVEMENT IN TMI-2 LEAK RATE TESTING IRREGULARITIES

1. Background On June 4, 1985, a joint Office of Investigations (01)/ Office of Nuclear Reactor Regulation (NRR) interview with Carl L. Guthrie was held in the Three Mile Island Training Facility, Middletown, Pennsylvania. The purpose of the interview-was to detemine Mr. Guthrie's role, if any, in improper activities ~

associated with reactor coolant system (RCS) leak rate surveillance testing at Three Mile Island, Unit 2 (TMI-2) prior to the accident on March 28, 1979.

Present during the interview representing the NRC weire: R. Keith Christopher, Director Office of Investigations, Region I; William T. Russell, Acting Director, Division of Human Factors Safety; and Robert A. Capra, Senior Program Manager, Generic Requirements and Regional Operations Staff.

Representing Mr. Guthrie at the interview was his personal attorney, Mr.

Smith B. Gephart of the law firm Killian & Gephart, Harrisburg, Pennsylvania.

A copy of the transcript of Mr. Guthrie's interview is included as Attachment O 1 to this enclosure.

Mr. Guthrie is employed by General Public Utilities Nuclear Corporation (GPUN). He currently holds the position of Foreman, Radwaste Operations TMI-2, and is a licensed Senior Reactor Operator (SRO) on TMI-2.

Mr. Guthrie began his employment with Metropolitan Edison Company (Met-Ed) on February 2,1971, as an Auxiliary Operator (AO). He was initially licensed as a Reactor Operator (RO) on TMI-1 in August, 1975. After receiving his SRO license in July, 1975, he was promoted to Shift Foreman TMI-1. In August, 1977, he received his SRO license on TMI-2 and was assigned as Shift Foreman-TMI-2. Mr. Guthrie remained in.that capacity until after the accident on March 28, 1979.

The interview with Mr. Guthrie concentrated on the period September 30, 1978 through March 28,' 1979. During the first three months of this time period he served as a Shift Foreman on at least two different shifts (Shifts "E" and "A"). When a sixth shift was formed at TMI-2 on January 1,1979. Mr. Guthrie was assigned as Shift Foreman for Shift "F."

A summary of the technical analysis of the leak rate tests involving Mr.

, Guthrie_is provided in Section II of this enclosure. A sunmary of the interview with Mr. Guthrie is provided asSection III. ~ The sumary of interview section includes citations to the page numbers of the transcript from_whj_ch the sumarized information was extracted. -Overall findings and ,

conclusions regarding Mr. Guthrie's involvement in improper activities  !

associated with TMI-2 leak rate surveillance testing are presented in Section IV of this enclosure. - -

p l  %

II. Sumary of the Technical Analysis

]

I

' In 1983 and early 1984, a technical analysis of the leak rate surveillance _ '

tests soMucted during the last six months of operation of TMI-2 was performed by the NRC. This analysis was done as technical support to the  !

Department of Justice (00J) in its criminal proceeding against Met-Ed. In -

1985, NRR performed a reevaluation of that analysis by factoring in j

i infomation that was learned during interviews with former TMI-2 operators.

Mr. Guthrie was questioned on the updated 1985 analysis. While a copy of the complete evaluation of leak rate tests at TMI-2 is provided as Attachment 2 to this enclosure, a discussion of the tests involving Mr. Guthrie is provided here to help the reader understand the basis for the questions posed 4 to him during his interview and the basis for the findings and conclusions  !

shown in Section IV. * '

GENERAL In order to demonstrate that reactor coolant system (RCS) leakage did not exceed the limiting conditions for operation, THI-2 Technical Specification 3/4.4.6.2 " Reactor Coolant System Operational Leakage," directed that a RCS water inventory balance (leak rate test) be performed at least once every  :

72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> during steady-state operation, while in Modes 1 through 4.

TMI Surveillance Procedure 2301-301, "RC System Inventory," was the approved procedure governing the conduct of leak rate tests. The procedure cautions the operator to avoid the addition and removal of water from the RC and make-up systems during the test including: make-up or chemical addition to the make-up system or baration/deboration. In addition, the operator is cautioned to maintain the RC and make-up systems in a steady-state condition I

during the test by avoiding changes in valve line-ups, coolers-in-service.

pumps-in-service, etc. Power level changes should be minimized. For the most accurate deteminatipn of RCS leak rate, the initial and final conditions of reactor power, RCS temperature, pressure and pressurizer level  !

should be identical. l The vast majority of leak rate tests perfomed at TMI-2 were done by using ~

the plant computer. The computer-generated leak rate surveillance test sheet would be signed by the operator perfoming the test and approved by an SRO.

l In most cases, the Shift Foreman approved tests run on his shift. The test  ;

records show that of the 161 leak rate surveillance tests retained by the '

licensee during the period under investigation Mr. Guthrie was involved in 19 leak rate surveillance tests. The table below shows a breakdown of NRR's overall conclusions regarding these tests. -

Breakdown of Leak Rate Tests Involving C. L. Guthrie Evaluation Category Number of Tests Total number of tes ts on fil e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Tests with no apparent. problems.................................... 6 Unstable or inaccurate data provided to the plat computer......... 4 Water additions to make-up tank (MUT) (partially included in the calculation).....................................................

Hydrogen additions to 3

MUT.......................................... 2 Water or hydrogen addition to MUT (unable to differentiate)........ 1 Feed and bleed operations (not included in the calculation)........ 1 Un stabl e pl ant condi tions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Unidentified leakage greater than the TS limit..................... 1

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% As can be seen frem the table above, only six of the 19 tests involving Mr.

Guthrie appear to have been conducted in accordance with the requirements and precatitions of the surveillance procedure governing the conduct of leak rate-tests (SP 2301-3D1). Of the 13 remaining tests, one unsigned and unapproved j test 1txceeded the acceptance criteria for unidentified leakage, while the ot5er 12 tests involve either actions that violate the limits and precautions of the procedure or were performed with unreliable or inaccurate data being supplied to the plant computer, thus, yielding questionable or invalid results. The basis for the evaluation of each test is presented below.

!- NORMAL TESTS The six tests that appear to have been conducted in accordance with the surveillance procedure are tests #81 (12/31/78), #99 (02/03/79), #101 .

(02/03/79), #103 (02/05/79), #107 (02/07/79) and #109 (02/08/79).

UNIDENTIFIED LEAKAGE GREATER THAN 1 GPM

. Test #12C (10/18/78), indicating unidentified leakage of 1.77 gpm, was

conducted while Mr. Guthrie was the Shift Foreman, but was neither signed by the operator performing the test nor approved by Mr. Guthrie. This test was conducted.when the plant was experiencing high leakage (gross leakage of approximately 4.0 gpm). The surveillance test was not filed with the other

! surveillance tests maintained by the licensee. Instead, this test was filed with a set of tests associated with the submission of LER 78-62/1T on O November 1, 1978. The significance of the LER is discussed during the interview with Mr. Guthrie (See, Transcript pages 34 through 43).

UNSTABLE PLANT CONDITIONS According to entries in the Control Room Operator's (CRO) Log and the Shift Foreman' slog, Test #40(11/09/78) was conducted during a sodium hydroxide (NaOH) flush of the decay heat removal and makeup systems. MUT level changes of : 6" (180 gallons) during the test are believed to be the result of this -

l operation.

INSTRUMENTATION PROBLEMS At TMI-2 there are two level transmitters .(LT-1 and LT-2) that provide MUT level indication. The output"of one of the level transmitters drives the MUT j level strip chart recorder in the control room while the other level .

i transmitter provides MUT level indication to the plant computer. A selector switch in the control room allows the operator to switch level transmitters feeding the strip chart recorder and the plant computer. When the selector switch is positioned to LT-1, the strip chart recorder is driven by the output of LT-1, and LT-2 provides automatic input to the plant computer for leak rate test calculations. When the selector switch is changed to LT-2, the opposite would occur.

! Be een October 3'O and November 6, 1978, operators experienced problems with both level transmitters. At various times during this period, the level i

j O transmitters were reading radically different levels in the MU.T and both were taken out-of-service for maintenance work and recalibration. During this period Mr. Guthrie approved leak rate test #34 (11/03/78). At the time of j

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0 the test, the operating level transmitter providing input to the strip chart recordar was reading approximately 80", while the level transmitter providing-input to the plant computer for the leak rate test was essentially reading - ,

off-scale high at 99". l Beginning in early December,1978, and continuing through January 11, 1979, - '

the output of LT-1 became very erratic and unreliable. Because of the erratic nature of the.mutput of LT-1 during this period, any leak rate tests performed with the use of LT-1 providing input to the computer must be j considered questionable or invalid. Of the 50 tests conducted by all shifts during this period only 16 were performed with the stable level transmitter (LT-2) providing input to.the computer during the test. During this period Mr. Guthrie was involved in the approval of three tests. Two of the tests were run with LT-1 providing input to the computer, #73 (12/23/78) and #74 (12/24/78).

1 For test #74, the differences between the initial and final values of MUT level for LT-1 and LT-2 are small; therefore, the use of LT-1 in this case, may not have produced a significant error in the leak rate calculation.

However, for Test #73, the use of LT-1 allowed the computer to read the one hour change in MUT level as +.542" instead of an actual value of l approximately -2.0" as shown by LT-2. In addition to these tests which were  ;

approved by Mr. Guthrie, two other tests, #64 (12/16/78) and #80 (12/30/78),  !

which utilized the bad level transmitter, were conducted while Mr. Guthrie  !

was on shift. Test #64 was completed on Guthrie's shift but was approved by l the on-coming Shift Foreman (Ken Hoyt) af ter Mr. Guthrie was relieved. Test

#80 was started on Mr. Guthrie's shift but completed by Shift "C" and i approved by their Shift Foreman (Chuck Adams).

- In sumary, during the entire perio'd of time LT-1 was essentially "out-of-

, comission," a'll shifts, including Mr. Guthrie's, continued to run leak rate tests (34 out of 50) with LT-1 providing MUT level indication to the computer. These actions resulted in a meaningless calculation of unidentified leakage that could not demonstrate conformance with the "

technical specification limit of 1 gpm.

i Test #41(11/22/78) provides another example of obvious instrumentation problems. The test was signed by the operator performing the test and

- approved by Mr. Guthrie despite the printed value of Loop A, hot leg temperature printing out in dollar signs ($) and a value for Tave of -17"F.

FEED AND BLEED OPERATIONS -

! On's test, #106 (02/06/79), approved by Mr. Guthrie, contains a possible feed and bleed operation that was not taken into account in the leak rate test calculartion. Approximately 20 minutes after the start of the test, MUT level dropped approximately 9" (270 gal) and then slowly increases 7" by the end of the test. The change appears to be the result of either a feed and bleed

operation or control rod movement. Entries in the CRO's Log and the Shift Foreman's Log do not provide an explanation for this change; reactor control

(" diamond") was in manual during the test period due to an electrical problem with Group 7 control rods. .

One additional test, alli (02/09/79), which was begun on Mr. Guthrie's shift, but completed on Shift "C" and approved by their Shift Foreman (Chuck Adams),

appears to have have been started during the bleed portion of a feed and w y- 9_y _av._.9__.. - ._  %.9_q _ - ----,.WT -

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bleed operation that was begun about 20 minutes prior to the start of the test. The amount of water bled from the RCS was not included in the calcuTation and may have contributed to a higher leak rate than would -

otherwise have been the case.

HYDROGEN ADDITIONS -

• In order to limit the oxygen content in the RCS and to provide an increased net positive suction head for the RCS' makeup pumps, a hydrogen overpressure was maintained in the MUT. When hydrogen pressure decreased near the low and of the operating band, the CR0 would add hydrogen to the tank. Theoretically, the addition of hydrogen should not have affected MUT level; however, because of the configuration and environment of the MUT level detection -

instrumentation system at TMI-2, water could collect in the low-pressure (dry) referepce leg of the level transmitters. Under these conditions, the resultant water slug or " loop seal" could cause a temporary increase in-the indicated MUT level when hydrogen pressure was increased in the MUT without actually adding water to the tank. Thus, the addition of hydrogen at the appropriate time (after the computer collected its initial data and shortly before the final data readings were taken) could affect the leak rate results in a nonconservative manner (i.e., the calculated leak rate would be less than the actual leak rate).

Two tests have logged hydrogen additions during the test period, #17 (10/20/78) and #152 (03/21/79), and one test, #121 (02/16/79), is believed to O contain either a hydrogen addition or an unaccounted for water addition.

One minute after the start of Test #17, the CRO's Log states the MUT was vented. Sixteen minutes later hydrogen pressure was increased to 18 psig and ,

5 minutes before the end of the test an unspecified amount of hydrogen was ,

again added to the MUT. The net affect on the leak rate test results is i uncertain since MUT level decreased approximately 6" during the test while pressurizer level (Lp) increased 10.5".

Test #121 contains either a possible hydrogen addition or water addition

during the test. Approximately halfway through the test there is a 2" rise (60 gal) in MUT level indication that can not be accounted for by changes in Tave or pressurizer level. The characteristics of the MUT level trace are very similar to Test #120. Test #120 was performed by the shift Mr. Guthrie .

relieved (Shift "C") and involved an experimental addition of hydrogen by the CR0s and the Shift Foreman (Chuck Adams) in order to determine the effect of hydrogen on leak. rate test results. .  !

Test #152 contains a water addition and a hydrogen addition. According to I the CRO's Log, Twelve minutes after the start of the test 200 gallons of water was added to the MUT. A total of 207 gallons was included in the test ,

calculation. The actual amount seen by the MUT le~ vel transmitter was 210 gallons. Although the need for the water addition during the test is not clear._ it appears to be properly accounted for in the test calculation.

However, nine minutes before the end of the test hydrogen was added to the ,

MUT and recorded in the CRO's Log. The net effect of the hydrogen addition was a rise in MUT level of approximately 2" or 60 gallons.

O _ WATER ADDITIONS Becausi adding water to the MUT compresses the hydrogen gas in the top of _

MUT.- water additions shortly before the computer obtained its final data tet would'thus have the same result as a hydrogen addition. If an operator were aware of this cause and effect relationship leading to this "MUT level - i indication instrumentation inaccuracy,".(without having to know it was caused l by the " loop seal" effect described above), he could take advantage of this phenomenon to manipulate test results by following the procedure exactly as written. For example, the addition of 150 gallons of water to the MUT during l 4

the last 15 minutes of a leak rate test should cause the MUT level to l increase 5 inches (30 gal / inch); however, if sufficient water had collected I

,. in the loop seal, the indicated level on the MUT strip chart might actually l increase 6 inches (180 gal). Once the final data was read by the computer, including the 6 inch rise in MUT level, the operator would enter the 150 gallon water addition into the computer as an operator-caused change. Thus, when the computer calculated the net unidentified leak rate, the leak rate result would be 0.5 gpm less than the actual leak rate [(180 gal - 150 gal)/60 minutes].

j Fomer TMI-2 CR0 Mark Coleman (Shift "D") stated during his joint 01/NRR j interview on December 14, 1984, that he was aware of this phenomenon and 1 intentionally added water near the end several leak rate tests in order to take advantage of this phenomenon to help him get tests results within the limits of the technical specifications. The technical evaluation of leak O

_ rate tests perfomed by Mr. Coleman's shift supports his testimony. As shown '

by the chart below, three of the last four tests prior to the accident approved by Mr. Guthrie, exhibit the same characteristics as Mr. Coleman's tests.

Computer MUT 5 trip Error Time before Test # Date Input Chart Produced End of Test CRO-Test CRO-Panel

150 03/17 207 gal 240 gal 33 gal 24 mins McGovern Hemmila 151 03/19 200 gal 330 gal 130 gal 1 min McGovern Hemila 153 03/22 200 gal 300 gal 100 gal 7 min McGovern Hemmila Key: Computer Input = amount of water included in test calculation by CR0.

MUT strip chart = amount of addition indicated on MUT strip chart.

Error Produced = difference between MUT Strip Chart and Computer Input..

Time Before End of Test = time before end of test that water addition was made or time of last water addition if more than one addition  ;

occurred during the test.

CRO-Test = CR0 who performed and signed leak rate test.  !

CRO-Panel = CR0 who was on the panel during test and who signed the  ;

UD's Log.

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As stated earlier in this section, SP 2301-301 cautioned the operators to avoid the addition and removal of water from the reactor coolant and makeup j

O systems during leak rate tests. However, during the last two months of operation, leakage frem the top of the pressurizer from either the PORY and/or safety valves increased. As a result, operators were forced to add a ,

l l

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. _ . - - .. ... -., .. . ~ . . - -. . ..- . . . . . . . . . -. . -

s s significant amount of water to the MUT each shift. The frequency of water i additions increased as the date of the accident approached; however, it does . j

. not appear-frea the data associated with these three tests that the water i additient, had to be made during the tests. Thus, while it is clear that the_ l water additions influenced the~ outcome of the test, the technical evaluation  :

can et determine whether the operators were unaware of this instrumentation '

error e were aware of the situation and used it to their advantage,  ;

1 In sumary, the technical evaluation shows that between September 30, 1978 '

and March 28,1979,13 of the 19 tests (68%) involving Mr. Guthrie included l actions that were contrary to the precautions, limitations and requirements of Surveillance Procedure 2301-301. These actions included: ignoring test results greater than the technical specification limit; approving a test l conducted during unstable plant conditions; approving tests that utilized I unreliable or inaccurate MUT level or temperature instrumentation as input to l

- the plant computer; approving a test conducted during a feed and bleed j

operation; approving tests containing water additions that were affected by j MUT level instrument inaccuracies; and approving tests during which hydrogen was added to the MUT. Based upon the high number of questionable or invalid

tests, it appears that the tests were accepted as valid as long as the results were isss than the technical specification limit, regardless of the evolutions in progress during the tests. Nevertheless, there is no clear pattern that these evolutions were performed with the intent of wrongfully 1

influencing leak rate test results. In addition, while some of these actions l challenge the validity of certain tests, they did not always produce leak O rate test results that were lower than would otherwise have been the case.

III. Interview Sumary i

l During the period under investigation, September 30, 1978 through March 28, 1979, Mr. Guthrie indicated that he was a Shift Foreman assigned to several different shifts. On January 1,1979, when a sixth shift was created (Shift i "F"), Guthrie was assigned a Shift Foreman for that shift. See pages 5 and 6.

Note: According the plant records, Mr. Guthrie worked principally with the -

. following shifts during the period under investigation POSITION SHIFT "E" SHIFT "A" SHIFT "F" i 10/78 .11/78 12/78 01/79-03/79 i Shift Supervisor: Bernie Smith Bill Zewe Ken Bryan Shift Foreman: Carl Guthrie Carl:Guthrie Carl Guthrie i CRO: Ray Booher Ed Frederick Hugh McGovern l CRO: Harold Hartman Craig Faust Earl Hemila

CRO: Lynn Germer* Hugh McGovern Lynn Germer*

CRO: John Blessing *

• In training (not licensed)

~~

According to Mr. Guthrie, communications between himself and the CR0s who worked for him were good. Depanding upon plant evolutions.-he would spend part of each shift in the control room and part out in the plant; however, a l

- . - - _ . - . . _ . . _ _ . , . _ , - _ _ , . _ , .,,.,,,_-,,,,_.-,,m,.___ ,.._.-..- m.-w-- __ ,.-,,_----.e.,-..,,.m

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l he believed he was cognizant of everything that the CR0s were doing during

- the-shift. As Shift Fcreman, Guthrie reported directly to the Shift Supertisor. The Shift Supervisor was cross-licensed on both TMI-1 and TMI-2 and ran the shift for both units. See pages 6-8.

Guthrie stated his interface with plant and station management was limited m When he was on day shift, he would usually see the Supervisor of Operations (Jim Floyd) and the Plant Manager (Joe Logan) and would answer any questions

' they may have; however, most operational matters went through the Shift Supervisor. His contact with the Superintendent of Technical Support (Jim Seelinger)andtheStationManager(GaryMiller)wasinfrequent. According to Guthrie, the Shift Foremen tried to meet every four to six weeks to discuss day-to-day operational problems; but, Guthrie did not recall members of plant or station management being present at those meetings. See pages 8-11. -

After reviewing a copy of THI-2 Technical Specification 3/4.4.6.2, " Reactor Coolant System Operational Leakage," and TMI Surveillance Procedure 2301-301 "RC System Inventory," Mr. Guthrie stated, although leak rate tests were required to be run at least once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> while in steady-state operation, it was standard practice to run the test every shift. He did not know where the policy originated, but believed it was a carry-over from Unit i 1. See pages 12 and 13.

Mr. Guthrie stated that there were problems with the computer program for O obtaining leak rates; as a result, the test was not considered reliable. He stated test results showed a lot of data scatter. Sometimes the results would show a negative leak rate and at other times the test would indicate a large positive leak rate that did not accurately reflect plant conditions.

Guthrie stated that Mr. Bill Falls was the principal person assigned to try and resolve some of the problems with the program. Guthrie was quite sure that everyone in the Operations Department, including the Shift Supervisors and the Supervisor of Operations, was aware of the problems. h pages 13-17.

Leak rate tests were usually performed by the CR0 operator assigned to

" switching and tagging" duties and not the operator assigned to the control panel. The coerator performing the test would try and keep the panel l bperator advised that the test was in progress, in order for him to try and l keep the plant in a stable condition for the duration of the test. Following completion of the test, the operator ptrforming the test would: evaluate it; ,

sign the surveillance test sheet; inform.the panel operator of the test , l results; and provide it to the Shift Foreman for his review and approval. l Because of the routine nature of the test, at times Guthrie was not aware a test had been run until he was provided with the surveillance sheet. See pages 17-19.

Mr. Guthrie stated he was aware of the requirement to log the start and stop times of surveillance tests required by the technical specifications. He believes that this was not done in many cases, because the test was conducted so frequently. See page 20. -

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When asked how leak rate tests would brentuated, Mr. Guthrie stated he would review the test results against the acceptance criteria. The

~

acceptance criteria required that identified leakage be limited to 10 gpm and '

4 unidentified leakage be ihnited to 1 gpm. He said that leak rate tests, _

whose 'results were greater than the technical specification limit for -

unidentified leakage, were given to him on occasion. If operator-caused ,- '

changes invalidated a leak rate test, the procedure required that'the evolution causing the test to be declared invalid, be documentedlin ,the remarks section of'the data sheet. Guthrie stated, that porti H of the ,

procedure was not followed. He said that in most cases, when t'est results exceeded the technical specification limit, they would try and detenni At the '

i source of the leakage by running another test and disnatching ope?ators to look for possible leakage in tne plant. See pages 20-25.

At certain times, Guthrie stated, looking for leaks was ah ongoing task.

There were periods where unidentified leakage exceeded the technical specification limits and. they were not able to identify the source of the leakage. In these cases, the Shift Supervisor would assess whether it'was safe to continue operation. Regardless of the evaluation, Guthrie stated leak rate test results in excess of the technical specifications were c -

discarded and another test would be con 4usted. See pages 20-24. , .,

When asked to justify how they could discard a test, that showed leakage ia excess of.the technical specifications, and then accept the next test as' '

valid if it came out less than 1 gpm, Mr. Guthrie said that was done because, i

of the lack of confidence in the test. From otbr instrumentation in the plant, it was not possible tv prove or disprove that the number printed on ,

the surveillance test sheet was a valid nu

nber. See pdges 25 and 26. l j While Mr. Guthrie stated that'there were other methods which indicated l

, primary plant leakage such as reactor and auxiliary building sump levels..

MUT level indication, and reactor building radiation monitors, he admitted that the leak rate test waS the only method available to quantify < -

unidentified leakage in order to demonstrate compliance with the technical specifications. See pages 26~and 27. -

Mr. Guthrie was asked who authorized the throwing away of surveillance tests that did not meet the acceptance criteria of the' technical specifications.

He did not know who authorized the throw-away policy, but stated his Shift .

Supervisor knew of the practice because he would personally shown him unsatisfactory test results. Many times the Shift Supervisor's only response

' was: run another test, go out and look for leaks, and make reactor building ,

entries. Guthrie believed the Supervisor of Operations was also aware of this practice. Mr. Guthrie stated that leak rate tests were unique and did not believe other surveillance tests were treated in this manner. See pages 28-30._

Mr. Guthrie was aware, that as Shift Foreman, it was his responsibility to ensure his shift complied with the technical specifications. He also 4

undersfood that if unidentified leakage exceed 1 gpm, he was required to l enter the action statement of Technical Specification 3.4.6.2. l l

Note: Action statement b of Technical Specification 3.4.6.2 states: "With' I

any Reactor Coolant System leakage greater than any one of the above j limits, excluding PRESSURE BCUNDARY LEAKAGE, reduce the leakage rate .

i to within limits within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> or be in at least HOT STANDBY within I i

the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and in COLD SHUTDOWN within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />." l

Despite receiving test results in excess of the technical specification limits and understanding his responsibilities as Shift Foreman, Mr. Guthrie did not' believe he ever entered the action statement. See pages 31-33. _

Mr. Guthrie stated that while it was his responsibility to ensure compliance with the technical specifications, unless there was a dire emergency _-

requiring imediate shutdown, it was the inift Supervisor's decision whether the plant should be shutdown. Guthrie had discussed this situation with his Shift Supervisor. His Shift Supervisor was aware of the technical specification limits and Guthrie had.shown him leak rates that were in excess of those limits. Guthrie was then asked if he was saying, it was the Shift Supervisor's decision not,to comply with the requirements. Guthrie responded by stating: "Not so much not to comply with it but to interpret it the way it was interpreted...if they could get one within every seventy-two hours that they met the requirements." M pages 33 and 34.

A copy of LER 78-62/1T, along with an attached routing sheet, was provided to Mr. Guthrie for his review. The routing sheet was used to indicate which individuals had seen the LER. Guthrie had initialed the routing sheet and recalled seeing the LER prior to the accident. See pages 37 and 38.

Note: On October 18, 1978, during a routine inspection of TMI-2 operations, an NRC inspector discovered several bad leak rate tests lying in the control room and that TMI-2 had been operating for an extended period of time with unidentified leakage exceeding the technical O specification limit. The incident resulted in the submittal of Licensee Event Report (LER) 78-62/1T.

1 j

The LER stated in part: "This event was caused by a misinterpretation i of the requirements of the technical specifications....The appropriate personnel will be ins.tructed on the requirements of applicable sections 1

of the T.S. and the requirements to immediately invoke applicable actions statements when the provisions of the LCOs [ limiting conditions for operation] are not met."

Mr. Guthrie October was (Test 18,1979, shown #12C a copy)of a leak

, while Mr. rate was Guthrie test the thatShift wasForeman started on at 0513 on watch. It was pointed out to Mr. Guthrie that this is believed to be one of the leak rate tests that was seen by the NRC inspector on the morning of October 18th. The test indicated unidentified leakage of of 1.77 gpm and was not signed by the operator running the test or approved by Mr. Guthrie.

Handwritten coments on the test state: " rounds off high but is corrected by ,

leak rate 10/18/78 7:35:27 start time, i.e., into action statement at 5:13:02 out of it at 7:35:27." Although he would nomally be informed of all test results that exceeded 1 gpm, Guthrie did not recall seeing this particular surveillance test sheet prior to the accident. S u pages 35-36, 39-40.

As a result of this incident, Mr. Guthrie recalled being aware that they had been misinterpreting the requirements of the technical specifications and that arrytime they received a leak rate test in exFess of the limiting condition for operation, they were required to enter the action statement of i the technical specification. See page 41. .

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Although he could not recall whether the LER altered his method of operation with respect to leak rates, he vaguely remembered being told to ensure that any leak rate tests that were deemed " invalid" were not kept. He also i rec.alled still seeing leak rate tests greater than 1 gpm, but did not sign- i them. _Guthrie was asked if he believed the tests needed to be signed in ]

order for him to enter into the action statement. He responded by saying no, -

)

and that in retrospect, they should have entered the action statement; however, management did not agree. By management, Guthrie said he meant the Shift Supervisors, the Supervisor of Operations (Jim Floyd), the Plant Manager (Joe Logan), and the Vice-President for Generation (Jack Herbein).

Mr. Guthrie was asked what his basis for believing that they were aware that  :

this was going on and condoned or directed that this be done. Guthrie l responded by stating: ,

From.,doing a test, from having a test handed to me that was greater than one, and showing it to the Shift Supervisor and he tells you to run another test.

Look at this surveillance, Mr. Supervisor. Run another test.

Look for leaks. l

- Mr. Guthrie went on to state that he believed the shift supervisors and Mr. Floyd knew of this practice, but he did not provide any evidence which indicated either Messrs. Logan or Herbein were involved in or aware of this practice. See pages 43-45.

O When Mr. Guthrie sas informed that it appeared supervisors and operators were under a lot of pressure to keep things moving and keep the plant on the line, he stated, that was probably true. When asked if he personally felt that he was under a lot'of pressure to interpret the technical specifications and the requirements more loosely, he responded by stating: "I probably felt personally that we weren't really adhering to the letter of the law." See pages 45 and 46.

Despite the pressure, Guthrie said that he was not pressured to manipulate -

test results. He said he never told any of the operators on his shift to cheat on the test. There may have been occasions where thingt vere done inadvertently and he did not catch it in his review; however, they did not ,

intentionally add hydrogen or water to influence the outcome of tests. It l was pointed out to Mr. Guthrie that a very high percentage of tests performed on his shift and approved by him'were questionable. Guthrie responded by  ;

saying: "We may have been doing things that were manipulating it and not know  !

that it was. But we did not do it with an intent to falsif,y the test." See

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pages-46-49. j i

Mr. Guthrie stated that his review of leak rate tests usually involved I looking at the end result and whether any water was added during the test.

In looking back at the tests now, he knows that there are things that occurred to invalidate tests, that he and his operators should have caught; l

! however, they were just missed. If a test was acceptable, Guthrie would:

i sign his name as approving the test; submit the surveillance paperwork; and i put the time, date, and results on the control room status board. If a test was determined to be invalid, it would be thrown away and not documented.

See pages 50-53.

1

12-Mr. Guthrie stated that he never told hi.s CR0s to only show him tests that were less than 1 gpm. He believed, however, that he was not necessarily shown.all tests that exceeded the limit. In many cases, the CR0s may have taken it upon themselves to throw away tests who's results were greater than 1 gpm. See pages 53 and 54 ,

The next portion of the interview concentrated on a detailed review of the-leak rate tests airproved by Mr. Guthrie. For each test, he was shown copies of the applicable surveillance test sheet, extracts from the CRO's Log, and a copy of the MUT level strip chart. jee,pages54-80.

With respect to hydrogen additions, Mr. Guthrie thought he recalled someone

,, saying that they thought the addition of hydrogen to the MUT would affect the leak rate, but Guthrie did not believe that either he or his CR0s were aware whether that was true prior to the accident. jeepages55-57.

With respect to problems with MUT level transmitters, Mr,. Guthrie recalled being aware that of at least one time period where one of the level transmitters was out-of-service and the Instrumentation & Control (I&C) personnel had marked it with an out-of-service sticker." Mr. Guthrie also recalled providing instructions to his CR0s, that if one of the LTs was out-~

of-service, to ensure that the good one was used for leak rate tests.

However, Mr. Guthrie could not explain why some tests were run using the bad LT, unless it was a mistake. jee pages 58 61 O With respect to accounted for water additions, Mr. Guthrie stated that prior to the accident, he was not aware of any significant difference between the the amount of water added as read off the totalizer and the amount indicated by the rise in MUT level indication. He did not believe that his CR0s were aware of this error and took advantage of that error in perfoming leak rate j tests. jeepages7179 In reviewing the overall results with Mr. Guthrie, it was pointed out that i only six of the 19 tests approved by him appeared to be valid tests; the rest

. contained: hydrogen additions, feed & bleed operations, unstable plant ~

conditions, inaccurate and unreliable instrumentation providing input to the plant computer, or contained "underrecorded" water additions caused by MUT level instrumentation accuracies. Mr. Guthrie admitted that it appeared there were a considerable number of errors made. In some cases, Guthrie said, it appears very sloppy and apparently very careless, but he did not believe anyone on his shift intentionally did anything to manipulate leak rate test results. See pages 80-84. ,

i In sumarizing Mr. Guthrie's testimony with him, he stated that he never l approved a leak rate test knowing that it was legitimately in violation of i

the technical specifications. He also stated that while he never threw away test results over 1 gpm.in order to hide them from the NRC, he was aware

, after, October 1978, that they were violating the technical specifications by i not taking the proper actions after receiving leak rate tests showing unidentified leakage in excess of 1 gpm. In these situations, he brought it to his management's attention and was told to keep looking for leaks and run another test. According to Guthrie, it was a management decision not to O follow the technical specifications. See pages 84 and 85. -

1

--,-,,m~,..-.-,,.,,.,,m,---.-4, ,---e.,,%g ..-,,,,---,,cem,y---ew4e.-.e+,ww-,-cy ,.w-

i e = e Mr. Guthrie was asked if the operating philosophy at the time was to get rid of all the leak rate tests greater than 1 gpm in order to keep the plant operating. Mr. Guthrie stated that he wouldn't necessarily say that, rather, they had a ltt of things going on heading towards the accident such as many-plant evolutions and high leakage through the PORV and/or safety valves.

During the February / March 1979 time-frame, when leak rate tests were very difficult to run, Guthrie believes the actions taken to resolve the problems- .

were not very effective. See pages 85 and 86.

When questioned about why such a high percentage of tests approved by him were invalid, Guthrie stated:

For me to really monitor the test in depth, as you are suggesting, I would have to stand over a person's shoulder i that does the test. In effect I would have to do the test....I'm telling you that there was not given to us enough input into the procedure for us to analyze the results.

See pages 90 and 91.

When Mr. Guthrie was asked to describe in his own words what his responsibilities were and what it meant for him to sign his name as approving '

a leak rate test, he stated:

O That the test was supposedly performed in accordance with the procedures and met the requirements of the acceptance criteria of the test. Now, if there are mistakes made by an operator in doing that, it would be nice to be able to catch everything but unless I personally do the test I can't' catch everything. ,

There are mistakes made, obviously very gross ones. I agree with you, it looks very bad. But I'm saying that we did a hell of a lot of tests. We did a hell of a lot of work there. -

a hell of a lot of things going on. -And we just weren't given the input. What do I look for in a surveillance test like that? Why isn't it written down in print? Do I have to find out by hindsight all the mistakes I made on it?

How much acceptance criteria is there for that test? Do numbers, the three, four numbers meet the requirements?

See pages 91 and 92.

In closing the interview, Mr. Guthrie stated that they" were interested in operating the plant safely and finding leaks and that.while there may have been some people trying to defraud the test, no one on his shift did it and he did not direct them to do it. He stated he did not condone anything like that_orthis shift. See pages 96-98.

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IV. Findings and Conclusions During the six months prior to the accident at THI-2, while Mr. Guthrie

served as a Shift Foreman, many of his actions, associated with~the -

l performance and approval .of RCS leak rate surveillance tests, violated approved plant procedures and technical specifications. Based upon the - .

testimony of Mr. Guthrie and the three Control Room Operators on Shift "F,"

coupled with the NRR technical evaluation of' leak rate tests during this period, the following findings and conclusions are drawn:

1. Although Surveillance Requirement 4.4.6.2 only required a leak rate test to be perforined once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> when in steady-state

, operation, leak rate tests were routinely conducted every shift.

2. Contrary to Technical Specification 6.10.1.d. " Record Retention " leak rate tests indicating unidentified leakage in excess of 1 gpm were discarded, either directly by Mr. Guthrie or his CR0s.

3. Contrary to Surveillance Procedure 2301-301, "RC System Inventory,"

and contrary to the licensee's stated corrective action in the LER 78-62/1T, when test results indicated unidentified leakage in excess of the limiting condition for operation (i.e.,1 gpm) Mr. Guthrie did not enter the action statement of Technical Specification 3.4.6.2,

" Reactor Coolant System Operational Leakage." Mr. Guthrie testified.

that after October, 1978, he was aware that action was required: " I probably felt personally that we wern't really adhering to the letter

-O of the law."

4. When leak rate test results exceeded the limiting condition for operation of Technical Specification 3.4.6.2, Mr. Guthrie brought it

' to the attention of his Shift Supervisor. He was told to run another test and continue to look for leaks. According to Mr. Cuthrie, it was a conscious decision by his Shift Supervisor not to enter the action statement of the technical specification. Mr. Guthrie stated that this practice may have been known and condoned by the Supervisor of -

Operations and possibly higher levels of management.

5. Although Mr. Guthrie advised the Shift Supervisor of unsatisfactory leak rate test results, contrary to TMI Administrative Procedure 1010 .

" Technical Specification Surveillance Program,". he did not complete

" Exception and Deficiency" reports and submit them to his Shift Supervisor for review and evaluation.

4

6. Contrary to TMI Administrative Procedure 1012. " Shift Relief and Log Entries," Mr. Guthrie was aware that CR0s were not logging the start time, stop time and the results of all leak rate surveillance tests in the Control Room Log.

7. Mr. Guthrie testified that he was aware of periodic problems with the

_MUT level transmitters and advised his CR0s to perforin tests using the stible level transmitter. Nevertheless, the NRR evaluation shows O three of the tests approved by Mr. Guthrie were run with an erratic and unreliable level transmitter providing MUT 1ev.el indication to the cceputer.

l 1

l O 8. ' Mr. Guthrie testified that prior to the accident, he had heard that adding hydrogen to the MUT could affect MUT level indication and l

" consequently leak rate test results. However, Guthrie also stated he

. . had no personal knowledge of any operator using hydrogen to manipu1~ ate

_ test results. The NRR evaluation showns that two tests and possibly one additional test, approved by Mr. Guthrie, involved hydrogen ._.

additions during the leak rate test period.

I i 9. Mr. Guthrie testified that he had no personal knowledge of any operator adding water during the course of a leak rate test and not 4 including the amount added in the calculation. The NRR evaluation l shows one possible test, approved by Mr. Guthrie, where water may have been added and not included in the calculation. This test may have i involved a hydrogen addition rather than a water addition. It 1.s not

, possible from the records available to differentiate between water or hydrogen for this particular test, (see also item 8 above).

10. Mr. Guthrie testified that he was not aware of instrumentation inaccuracies between the batch controller and the MUT level indicators. He did not believe his CRos were aware of this problem either and did not believe they would take advantage of such an inaccuracy during the perfomance of leak rate tests. The NRR evaluation shows three of the 1!asts approved by Mr. Guthrie, involved -

water additions, where the amount of water logged in the CRO's Log and included in the leak rate calculation were less than the amount O indicated on the MUT strip chart. Since the amount of water logged in the CRO's Log was included in each of these tests, the surveillance procedure was followed exactly as written. It is not possible to show whether Mr. Guthrie or his CR0s knew of the instrument inaccuracy at the time and used it to their advantage.

I In sumary, Mr. Guthrie agrees in retrospect that many of his actions involving leak rate surveillance testing at TMI-2 violated approved plant

procedures and were contrary to the TMI-2 Technical Specifications. Because.

of problems with instrumentation and the procedure itself, it appears Mr. Guthrie considered the test unreliable as far as representing true plant leakage. When leakage above the limits of the technical specification were i brought to the attention of his Shift Supervisor, Mr. Guthrie was instructed to run another test, and to continue to look for leaks. As a result of test i problems and the lack of nianagement concern for the test, he treated the test as an administrative requirement only.

While 12 of the 19 tests involving Mr. Guthrie during this period are considered invalid, and one additional test was not signed'because it exceeded the limits of the technical specifications, there is insufficient evidence to conclude that these tests were intentionally manipulated.

Rather, it appears that because tests were conducted so frequently, the CR0s did not worry about establishing the proper steady-state conditions required

for the test and Mr. Guthrie's review only involved looking at the " bottom line" test results. Thus, if a test result was greater than 1 gpm, it would be discarded and another test would be started. If a test was less than 1 gpm, it would be retained with little or no review to ensure it was a valid test.

_ _ _ _ _ _ - , _ _ _ _ . _ _ _ . _ _ _ _ _ _ . _ _ _ _ -__ _ m._ _ _ _ _ _ _ _ _ _ _ _ _ _ _