ML20155J692

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Partially Withheld Results of Joint Ofc of Investigations/ NRR Evaluation of Ha Mcgovern Re Leak Rate Testing Irregularities.Mcgovern Failed to Establish Steady State Conditions for Test.W/O Encl 2
ML20155J692
Person / Time
Site: Three Mile Island Constellation icon.png
Issue date: 10/04/1985
From: Russell W
Office of Nuclear Reactor Regulation
To: Harold Denton
Office of Nuclear Reactor Regulation
Shared Package
ML20151L202 List:
References
NUDOCS 8605270161
Download: ML20155J692 (19)
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Text

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gha Ef 4 UNITED STATES Enclosure 10 l /  %-

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/ October 4, 1985

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I MEMORA'ND6ti FOR: Harold R. Denton, Director

Office of Nuclear Reactor Regulation __.-

j FROM: William T. Russell, Acting Director Division of Human Factors Safety, NRR

SUBJECT:

RESULTS '0F JOINT OI/NRR INVESTIGATION AND EVALUATION OF ,

HUGH A. MCGOVERN, JR.

Reference:

1. Memorandum from S. J. Chilk (SECY) to B. B. Hayes (01) l and W. J. Dircks (EDO) dated April 2, 19&4

Subject:

! Staff Requirements-Discussion of Pending Investigation-i' TMI 4

2. Memorandum from H. R. Denton (NRR) to B. B. Hayes (01)

I dated May 3, 1984,

Subject:

NR.R Review of 0! Investi- <

gation Materials Concerning Hartman Allegations of 4 Falsification of Leak Rate Data at TMI, Unit 2 1

i 3. Memorandum from W. T. Russell (DHFS) to H. R. Denton j (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. Hugh A. McGovern, a licensed Senior i Reactor Operator (SRO) at Three Mile Island, Unit 2 (TMI-2), currently i serving as the Plant Operations Manager, and to provide a reconsnendation l -

regarding whether his current SR0 license should be revoked, modified, or

suspended under 10 CFR 55.40 or other enforcement action taken under 10 CFR '

j Part 55.50, due to his involvement in preaccident leak rate testing

irregularities at TMI-2.

l

Background

l As the result of a Comission meeting on March 23, 1984, NRR was directed by Reference 1 to review OI investigative materials concerning falsification of reactor coolant system (RCS) leak rate tests at TMI-2 and refer back to 01 4

1 1

j NOTE: Thjs memorandum and Enclosure 1 discuss information which is the l

subject of an ongoing 01 investigation. This memorandum and Enclosure l

2 discuss information that is maintained in the NRC's Privacy Act

.SyJtem of Records (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. 01. Internal access and distribution should be on a "need to know" basis.

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Harold R. Denton October 4,1985 l l i those matters which required further investigation. The results of NRR's i

{ review was provided in Reference 2. The review detemined that follow-up I invest.igation was warranted in the case of seven operators who were currently j licensed. Mr. McGovern was not one of those seven individuals.

[

At a fol-low-up Consnission meeting on May 23, 1984, the Cosnission agreed with~

the approach of evaluating past and present performance. 01 and NRR l would conduct a joint investigation to detemine what role, if any, these 1

(

individuals had in improper activities associated with leak rate surveillance testing at TMI-2 prior to the accident, and NRR would conduct an evaluation I of the current performance of these individuals. Based upon the results of

the investigation and evaluation NRR would reconnend to the Commission what action, if any, should be taken against each of the identified operators. ,

j l

! As a result.of some of the early interviews with these individuals and  !

I further technical evaluation, Reference 3 recosuended that three additional i L licensed operators also undergo investigation and evaluation. Mr. McGovern

, was one of the operators identified in Reference 3. ,

Of the ten individuals identified for investigation and evaluation, seven are I 4

currently licensed on TMI-2 and one is licensed on San Onofre 2 and 3. The j remaining two individuals were licensed on Waterford 3, but have subsequently l

teminated 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 OI/NRR interview of Mr. Hugh A. McGovern, Jr. was l

! held in the Three Mile Island Training Facility, Middletown, Pennsylvania.

i The interview was conducted in the presence of Mr. McGovern's personal  !

attorney. The purpose of the interview was to detemine Mr. McGovern's role, i if any, in improper activities associated with RCS leak rate surveillance l l testing at TMI-2 prior to the accident on March 28, 1979. At that time,  ;

Mr. McGovern was a Control Room Operator (CRO) assigned to Shift "A" and  :

i later Shift "F." A detailed eveluation of Mr. McGovern's involvement in leak  !

i rate testing irregularities is provided in Enclosure 1 to this memorandum. j During the interview, most of Mr. McGovern's responses to general questions +

associated with RCS leak rate surveillance test problems at TMI-2 were consistent with the testimony of other licensed operators, including his *

Shift Foreman and other CR0s on his shift. Mr. McGovern admitted that many l

of his actions, associated with leak rate testing, violated approved plant j procedures and technical specifications; however, he denied any personal

, involvement in or knowledge of leak rate test manipulation.

! Based upon the results of NRR's technical evaluation and the testimony of ,

' Mr. McGovern and the other operators on his shift, the following findings and conclusions are drawn: ,

1. Although Surys Olance Requirement 4.4.6.2 only required a leak rate test
to4e perfornel 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.

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Harold R. Denton Octobtr 4, 1985

2. Contrary to Technical Specification 6.10.1.d " Record Retention," leak O rate tests indicating unidentified leakage in excess of I gpm were discarded, either directly by Mr. McGovern or by his Shift Foreman.
3. Contrary to Surveillance Procedure 2301-301,"RCSystemInventory,"when_U test-results indicated unidentified leakage in excess of the limiting condition for operation (i.e., I gpm), Mr. McGovern did not enter the action statement of Technical Specification 3.4.6.2, " Reactor Coolant '

System Operational Leakage."

4. Contrary to TMI Administrative Procedure 1012. " Shift Relief and Log Entries," Mr. McGovern did not log the start time, stop time and the results of all leak rate surveillance tests in the Control Room Log.
5. Contrary to TMI Administrative Procedure 1010. " Technical Specification Surveillance Program," an " Exception and Deficiency List" was not completed by Mr. McGovern and submitted to the Shift Supervisor for review, when test results exceeded the acceptance criteria of the test.
6. Contrary to the licensee's stated corrective action in the LER 78-62/1T, Mr. McGovern did not recall either being instructed in the proper interpretation of the requirements of the technical specifications or being instructed to enter the action statement of the technical specifications when the limiting condition for operation was exceeded.
7. Mr. McGovern considered the leak rate test an administrative requirement O that had to be satisfied once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. He did not believe the results of the test were closely coupled with actual plant leakage and did not treat the test as a technical specification surveillance requirement.
8. Mr. McGovern testified that he was aware of periodic problems with the make-up tank (MUT) level transmitters. The NRR evaluat. ion shows four of the tests involving Mr. McGovern were run with an erratic and unreliable level transmitter providing MUT level indication to the computer.
9. Mr. McGovern testified that he was aware that feed and bleed operations should not be conducted during leak rate tests. The NRR evaluation shows two tests involving Mr. McGovern where feed and bleed operations occurred during the tests. While these operations are not accounted for in the leak rate test calculations, in both cases, more water appears to' have been bled from the system than added during the test; thus, leading to a higher calculated leak rate than would otherwise have been the case.
10. Mr. McGovern testified that he was not aware, until after the accident, that adding hydrogen to the MUT could affect MUT level indication and consequently leak rate test results. McGovern also stated he had no personal knowledge of any operator using hydrogen to manipulate test results. His testimony is supported by the NRR evaluation, which shows only one test involving Mr. McGovern where hydrogen may have been added during the test.

Harold R. Denton October 4, 1985 s 11. Mr. McGovern testified that he had no personal knowledge of any operator adding water during the course of a leak rate test and not including  :

the amount added in the calculation. The NRR evaluation shows two of l Mr. McGovern's tests may have involved water additions that were not i inciuded in the calculation; however, these water additions cannot be _ , ' I confirmed.

12. Mr. McGovern testified that he was generally aware of instrumentation -

inaccuracies between the batch controller and the MUT level indicators; however, he did not take advantage of those inaccuracies during the performance of leak rate tests. The NRR evaluation shows three of Mr. McGovern's tests involved water additions, where the amount of water logged in the CR0's ' Log and 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. McGovern knew of the instrument inaccuracy at the time and used it to his advantage.

In summary, Mr. McGovern agrees in retrospect that many of the 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, Mr. McGovern considered the tesc " meaningless" as far as representing true plant leakage.

As a result, the test was treated as an administrative requirement only.

While 10 of the 14 tests involving Mr. McGovern during this period are O considered invalid, their is insufficient evidence to conclude that any of these tests were intentionally manipulated. Rather, it appears that because tests were conducted so frequently, Mr. McGovern was negligent by failing to establish the proper steady-state conditions required for the test. If the test result was greater than 1 gpm, it would be discarded and another test would be started. If the test was less than 1 gpm, he would retain it with little or no review to ensure it was a valid test.

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October 4, 1985 Harold R. DInton 1

I Conclusions and Recommendation During the period under investigation, while Mr. McGovern served as CRO-in-training on Shift "A" and later as a licensed CR0 on Shift "F," he admitted he was involved in activities associated with reactor coolant system leak rate testing that were in violation of approved plant procedures and the

, TMI-2 Technical. Specifications. These actions included:

1. Failure to ensure that leak rate surveillance tests were conducted in O accordance with the approved plant procedure;
2. Failure to properly review the results of leak rate surveillance tests;
3. Failure to properly recorded all leak rate surveillance test results in the CRO's Log;
4. Failure to take the required follow-up action when the limiting conditions for operation specified in the TMI-2 Technical Specifications were exceeded;
5. Personally throwing away leak rate test results which exceeded the limits of the TMI-2 Technical Specifications.

Despite these actions. Mr. McGovern denies that he was involved in or was knowledgeable of any activities on the part other CR0s to intentionally influence or manipulate the outcome of leak rate test results. There is insufficient evidence to conclude that Mr. McGovern was involved in leak rate test manipulation; however, the evidence supports a finding that Mr. McGovern j was grossly ne011 gent in his duties as a Control Room Operator with respect

! to leak rate surveillance testing.

i Based 'upon the testimony of the majority of other CR0s and Shift Foremen interviewed to date, it is clear that management's standards for proced.u ral compliance were lax and permissive. In my opinion, this was created through negligence on the part of managemer.t. Lack of operator respect for the leak rate test procedure coupled with management's failure to correct test procedure problems and instill high standards for procedural compliance led to conditions where the leak rate test was conducted in a frivolous manner and in some cases motivated operators to menipulate or falsify leak rate test results. .

_____.____.__.._1. _____ _ . _ _ . . _ _ _ _ _ _ _ . _ _ _ _

Harold R. Denton

- 6- October 4, 1985 I

In this case, Mr. McGovern may not have been involved'in leak rate test .

manipulation; however, based on his stated opinion tha_t the test was a ,

O meaningless administrative requirement that bore little resemblance to actual l

plant leakage, I believe he submitted test results without regard for their validity .as long as the calculated unidentified leakage was below the -

technical specification limit. ,

O. T h ^

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

Enclosures:

As stated cc: B. Hayes K. Christopher G

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O NOTE: This enclosure discusses information which is the subject of an ongoing OI investigation. This enclosure may no.t be disseminated outside the NRC without coordination with NRR and the permission of '

the E00 or the Director. 01. Internal access and distribution should - '

be_oc a "need to know" basis.

Enclosure 1 - -

I PAST INVOLVEMENT IN THI-2 LEAK RATE TESTING IRREGULARITIES I. Background On June 4,1985, a joint' Office of Investigations (01)/ Office of Nuclear Reactor Regulation (NRR) interview with Hugh A. McGovern Jr. was held in the Three Mile Island Training Facility, Middletown, Pennsylvania. The purpose of the interview was to detennine Mr. McGovern's role, if any, in improper

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activities associated with reactor coolant system (RCS) leak r. ate 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 were: 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. McGovern at the interview was his personal attorney, Mr. Smith 8. Gephart of the law fira Killian & Gephart, Harrisburg, Pennsylvania. A copy of the transcri t of Mr. McGovern's interview is included as Attachment I to this enc osure.

Mr. McGovern is employed by General Public Utilities Nuclear Corporation (GPUN). He currently holds the position of Plant Operations Manager TMI-2 and is a licensed Senior Reactor Operator (SRO) on TMI-2. Mr. McGovern began hisemploymentwithMetrop(AO).olitan.

as an Auxiliary Operator He servedEdison in that Company capacit (Met-Ed) on October 11.-1 one year before entering the Control Room Operator (CRO) training y for approximately program, receivinghisReactorOperator's(RO)licenseinNovember1978. He remained a licensed CR0 until 1980, when he was promoted to Shift Foreman. In 1982, he was again promoted to Shift Supervisor and served in that position until August 1984, when he was promoted to his current assignment. As Plant Operations Manager, he is one of four Group Managers who report directly to Mr. Adam Miller, Manager Plant Operations TMI-2.

The interview with Mr. McGovern concentrated on the period September 30, 1978, through March 28, 1979. During this time period, he served as a CRO, initially assigned to Shift "A " and later to Shift "F."

A sumary of the technical analysis of the leak rate tests involving Mr. McGovern_is provided in Section II of this enclosure. A sumary of the interview with Mr. McGovern is provided asSection III. The sumary of interview section includes citations to the page numbers of the transcript from which the su=arized information was extracted. Overall findings and conclusions regarding Mr. McGovern's involvement in improper. activities asscciated with TMI-2 leak rate survaillance testing are presented in Section O IV of this enclosure.

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.c 2-Su r ary of the Technical Analysis O

II.

In 1983 artd early 1984, a technical analysis of the leak rate surveillance tests conducted during the last six months of operation of TMI-2 was performed by~ the NRC. This analysis was done as technical support to the _[

DepartmentgfJustice(00J)initscriminalproceedingagainstMet-Ed. In l 1985, NRR perfomed a reevaluation of that analysis by factoring in infomation that was learned during interviews with former TMI-2 operators.

Mr. McGovern 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

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2 to this enclosure, a discussiort of the tests involving Mr. McGovern is provided here to help the reader understand the basis for the questions posed to him during his interview and the basis for the findings and conclusions shown in Section IV.

In order to hemonstrate 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 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 boration/debo' ration. In addition, the operator is O cautioned to maintain the RC and make-up systems in a steady-state condition 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 determination of RCS leak rate, the initial and final conditions of reactor power, RCS temperature, pressure and pressurizar level should be identical. .

The vast majority of leak rate tests performed at TMI-2 were done by using the plant computer. The computer-generated leak rate surveillance test sheet i would be signed by the operator performing the test and approved by an SRO. l In mest cases, the Shift Foreman approved tests run on his shift. The test records shew that of the 161 leak rate surveillance tests retained by the licensee during the period under investigation Mr. McGovern was involved in 14 leak rate surveillance tests. The table below shows a breakdown of NRR's overall conclusions regarding these tests. -

! Breakdown of Leak Rate Tests Performed by H. A. McGovern Evaluation Catecory Number of Tests Total number of tests'on fi1a...................................... 14' Tests with no apparent problems.................................... 4 Unstable or out-of-service makeup tank (MUT) level transmitter..... 4 Water addittons to MUT (partially included in the calculation)..... 3 Water additions to MUT (not included in the calculation)........... 1 Feed and bleed operations (not included in the calculation)........ 2 O Water or hydrogen addition (unsble to differentiate)............... 1 Note: One test (150) falls into two evaluation catagories.

i A

As can be seen from the table above, only four of the 14 tests involving Mr. McGovern appear to have been conducted in accordance with the requirements and precautions of the surveillance procedure governine the s conduct of leak rate tests (57 2301-3D1). The 10 remaining 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.

The four tests that appear to have been conducted in accordance with the '

surveillanceprocedurearetests#99(02/03/79),#103(02/05/79),#109 i (02/08/79),and#116(02/13/79). l 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 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 i switch is positioned to LT-1, the strip chart recorder would be driven by the output of LT-1 and LT-2 would provide automatic input to the plant computer j for leak rate test calculations. When the selector switch was changed to i LT-2, the opposite would occur. ,

i 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 output of LT-1 during this period, any leak rate tests performed with the use of LT-1 providing input to the computer must be 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. McGovern was involved in four tests. All four tests were run with LT-1 These tests were: #50(12/08/78),#64 p(roviding) input to the computer.12/16/78 , #73 (12/23/78) and #74 (12/24/79).

For tests #64 and #74, there do not appear to be large differences between  !

LT-1 and LT-2 for the initial and final values of MUT level and therefore, the use of LT-1 may not have produced a significant error in the leak rate calculation. For Test #73, the use of LT-1 allowed the computer to read the change in MUT level as +.542" instead of an actual value of approximately '

-2.0" as shown by LT-2. In Test #50, the slope of the MUT strip chart shows l an offset of approximately +2.0" from the beginning to the end of the test. l The offset could have been caused either by the switching of LTs during the l test or an unaccounted for addition of approximately 60 gallons of water i during the test. There are no log entries in the CRO's Log or Shift l Foreman's Log indicating a water addition and no water addition is included in the leak rate calculation. In addition to these tests Mr. McGovern may have been involved in Test #80 (12/30/78). This test was started on McGovern'i s'hift and cc=pleted and signed by the next shift. The use of LT-1 in this case again produced a significant error in test results. Instead of O MUT level decreasing approximately 2.0" during the test, the computer read the change in MUT level as +3.95". This difference caused the unidentified leak rate to be calculated as -3.8 gpm.

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l Thus, during the entire period of time LT-1 was essentially "out-of-O cc:miission," all six shifts, including Mr. McGovern's, continued to run leak rate tests.(34 out of 50) with LT-1 providing MUT level indication to the computer. T.hese actions resulted in a meaningless calculation of ,.

i unidentified leakage that cou-1d not demonstrate confonnance with the _. ,

technical specification limit of 1 gpm. . l

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Twotests,#106(02/06179)and#111(02/09/79), contain possible feed and ,

bleed operations that were not taken into account in the leak rate test l calculation. Approximately 20 minutes after the start of test #106, 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. Test #111 appears to have have been l started during the bleed portion of a feed and bleed operation which was l begun about 20 minutes prior to the start of the test. The amount of water bled from the RCS was not included in the calculation and may have  !

contributed to a higher leak rate than would otherwise have begn the case.

In order to limit the oxygen content in the RCS and to provide an increased i 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; i 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) reference 1e's of the level transmitters. Under these

, O 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).

Test #121 (02/16/79) contains either a possible hydrogen addition or water Approximately halfway through the test there is a addition 2" rise (60 during)the' gal in MUTtest. 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. McGovern relieved and involved an experimental addition of hydrogen by ,

the CR0s and the Shift Foreman in order to determine the effect of hydrogen l on leak rata test results.

Because adding water to the MUT compresses the hydroge'n gas in the top of  !

MUT, water additions to the MUT shortly before the computer obtained its  :

final data set would thus have the same result as a hydrogen additio.). If an i operator waft aware of this cause and effect relationship leading to this i

" instrumentation inaccuracy," (without having to know it was caused by the

" loop seal" effect described above), he could take advantage of this phencmeno6 t5 manipulate test results by following the procedure exactly as written. For example, the addition of 150 gallons of water to the MUT during

the last 15 minutes of a leak rate test should cause the MUT level to -

1

. increase 5 inches (30 gal / inch);-however, if sufficient water hsd collected in the loop seal, the indicated level en the MUT strip chart might actually

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 O

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)/ .

l 60 minutes]. _,' l

': l Former TMI-2 CR0 Mark Coleman stated during his joint OI/NRR interview on l December 14, 1984, that he was aware of this phenomenon and intentionally - ' I added water near the end several leak rate tests in order to take advantage l of this phenomenon to help him get tests results with the limits of the technical specifications. The technical anal performed by Mr. Coleman's shift (Shift supports "D") ysisMr.ofColeman's leak rate tests admission. As shown by the chart below, the last three tests prior to the accident involving Mr. McGovern exhibit the same characteristics as Mr. Coleman's tests.

ccmputer MuI strip Error Time oefore Test i Date Input Chart Produced End of Test CRO-Test CRO-Panel 150 03/17 207 gal 240 gal 33 gal 24 mins McGovern Hamila i

151 03/19 200 gal 330 gal 130 gal lain McGovern Hamila l 153 03/22 200 gal 300 gal 100 gal 7 min McGovern Hemila K ey: Computer Inaut = amount of water included in test calculation by CRO.

1 O MuT Strip c1 art = 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 mace or time of last water addition if more than one occurred during the test. .-

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

GRO-Panel = CR0 who was on the panel during test and who s-igned the GRO's Log.

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 -

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

i; significant amount of water to the MUT each shift. The frequency of water additions increased as the date of the accident approached; however, it does not appear from the data associated with these three tests that the water additions had to be made during the tests. Thus, while it is clear that the water ~ additions influenced the outcome of the test, the technical evaluation cannot determine whether the operators were unknowing victims of this instrumentation error or were aware of the situation and used it to there advantage.

In su: mary',"the technical analysis shows that between SepteNer 30, 1978 and March 28, 1979, 10 of the 14 tests (71".) involving Mr. McGovern included O actions that were contrary to the precautions, limitations, and requirements of Surveillance Procedure 2301-3D1. These actions included accepting tests:

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6-O that were run on the unstable or inaccurate MUT level transmitter; contained feed and bleed operations or water additions that were not properly accounted for in the leak rate test calculation; and in one case, contained a possible hydrogen addition. 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 less than the technical specification limit, regard. lass of the evolutions in progress during the tests. Nevertheless, there is no clear '

pattern that these evolutions were performed with the intent of wrongfully -

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

III. Interview Sumary During the period under investigation. September 30, 1978 through March 28, 1979. Mr. McGovern indicated that he was a CR0 initially assigned to Shift "A" and later to Shift "F." Members of these shifts included:

POSITION SHIFT "A" SHIFT "F" 09/78-12/78- 01/79-03//9 l

Shift Supervisor: Bill Zewe Ken Bryan l Shift Foreman:' Fred Scheimann Carl Guthrie CRO: Ed Frederick Earl Hamila CRO: Craig Faust Hugh McGovern CRO-in-training Hugh McGovern* Lynn Gemer O *In training until receiving his R0 license in 11/78.

See page 5.

According to Mr. McGovern, the CR0s repo'rted directly to the Shift Foreman.

CR0s dealt with the Shift Foreman on an hour-by-hour basis and was therefore cognizant of the activities of the CR0s. The Shift Foreman reported directly to the Shift Supervisor. The Shift Supervisor was cross-licensed on both TMI-1 and TMI-2 and ran the shift for both units. McGovern, stated that he  ;

had little interface with plant management at the time. He would see the .

Supervisor of Operations (Jim Floyd) and the Plant Manager (Joe Logan) in the l control room on occasion and he would answer any questions they may have had; i however, routine instructions would normally go through the Shift Supervisor i and the. Shift Foreman. M page 6.

When asked if he had ever brought problems associated with leak rate surveillance testing to the attention of his supervisors, Mr. McGovern stated that it was well known that there were problems with the computer program and it would not have been something that he needed to bring to his Shift Foreman's attention. He said the problems were known outside the Operations Department. In particular, the Instrumentation & Control (I&C) technicians worked on some of the level and temperature indications that fed into th_e computer program and the computer programing group worked on the computer program from time-to-time. Mr.' McGovern felt that the majority of problems O with the leak rate test were associated with inaccurate input from instrumentation and frem imprcper temperature compensation in the program.

See,pages e 8-10.

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. 1 7

Mr. McGovern said they did not 3ay a great deal of attention to the O performance of leak rate tests at the time. He said they were quite routine and simple to run. Usually the operator taking the readings and not the panel operator would perform the test. He would enter the proper data into l

l the computer to start the test and one hour later would enter the necessary '- '

, information to account for any operator-caused changes and the computer would-'

calculate and printout the leak rate information. The operator performing l

! the test would try to_ keep the panel operator informed that a test wn in _-

progress. This would be done in an informal manner. According to ncGovern, sometimes plant conditions would be such that water additions had to be made l during the test, even though they tried to avoid it. In each case, however,  !

they would include the wgter addition in the leak rate calculation. M j pages 10-12. l i

Even though the TMI-2 Technical 15pecifications required a leak rate test be l performed only once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, McGovern stated that they tried get a .

good leak rate every shift. The leak rate test was considered more of an l

administrative requirement that they had to meet every three days. '

Therefore, any test results that exceeded the technical specification limit l of I gpm for unidentified leakage would be discarded. Each shift would continue to run tests until a satisfactory result was obtained. McGovern l

. stated it was conson practice to run tests in this manner as long as he had I been in the control room. Because the test was considered an administrative requirement, Mr. McGovern did not give any thought to throwing away had tests. He did not really relate it to the technical specification requirements. See,pages e 12 and 13.

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Mr. McGovern, stated that if evolutions occurred during the test, such as water additions, they would try to account for snch actions. He said

. operators had two choices for determining the amount of water added. They could read the amount off the batch controller or they could calculate the amount by observing the change in make-up tank level indication and use the ratio of 1" change equals 30 gal. He said neither instrument was perfectly accurate. They both has some error. M page 15.

According to Mr. McGovern, it was a common perception that the leak rate test was not a valid indicator of actual plant leakage; therefore, leak rate tests were not relied upon. Mr. McGovern said "whether it read less than one or greater than one, it was nothing more than a piece of paper, at least as far  ;

as I was concerned." He believed this feeling was also shared by his Shift Foreman. When an unacceptable leak rate test result was obtained, McGovern wculd either discard the test himself or put in on the Shift Foreman's desk and infonn him that "it didn't come out." Sg,pages 17 and 18. '

A copy of LER 78-62/1T along with an attached routing sheet was provided to Mr. McGovern for his review. The routing sheet was used to indicate which individuals _had seen the LER. Although McGovern had initialed the routing sheet, he did not have a preaccident recall of the incident described in the i

LER. For about two weeks, around the time of the incident, McGovern said he was in Lynchburg, Virginia undergoing simulator training. 53 ptge 19.

During a routine inspection of TMI-2 operations on October 18 1978, O Note:

and HRC inspector discovered several bad leak. rate tests lying in the control rocm and that TMI-2 had been operating for an extended period

i of time with unidentified leakage exceeding the technical specification limit. The incident resulted in the submittal of LicenseeEventReport(LER)78-62/1T.

TheLIRstatedinpart: "This event was caused by a misinterpretation _ [

of We requirements of the technical specifications....The appropriate perso'nnel will be instructed on the requirements of applicable sections- '

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

As a result of the incident;, Mr. McGovern did not recall being advised or instructed that they had been misinterpreting the requirements of the technical specifications, thus, he did not change his interpretation of when the action statement should be invoked. He did not believe there were any changes made to leak rate testing practi.ces as a result of this LER.

According to McGovern: "As far as I know we continued business as usual right up until the . time of the accident....we continued to do leak rates the same way, anc with the same basic misunderstanding of the tech spec." See pages 20-22.

Mr. McGovern was asked if the other operators on Shift "A" (C. Faust and E. Frederick) were aware that he was throwing away leak rates. Mr. McGovern, could not specifically recall, but since he was assigned to their shift as a CRO-in-training, he believed that he must have picked up the practice from O them. McGovern was infomed that E. Frederick had testified that he was aware of the LER and that after that time, he never threw away another leak rate test. McGovern said that he could not speak for Frederick, all he could say was what he remembered. See pages 23 and 24. .

Mr. McGovern was informed that his Shift Foreman on Shift "F" (C. Guthrie) testified that he was aware of the LER and that he knew they were not interpreting the technical specifications properly. Guthrie stated that he was aware that they.were violating the technical specifications when they ,

received a leak rate test greater than 1 gpm, and did not enter the action statement. McGovern was asked how his Shift Foreman could be aware of this

, situat. ion and he was not. McGovern said he did not recall anything about the

LER and consequently, could not offer any more of an explanation. McGovern also stated he could not recall being directed to ensure that bad leak rate tests were thrown away so the NRC would not see thear. See pages 25-27.

It was pointed out to Mr. McGovern, that if the results of a surveillance .

test was unsatisfactory, TMI Administrative Procedure 1010. " Technical

. Specification Surveillance Program." required that corrective action must be noted on an " exception and deficiency list." McGovern could not recall filing such reports on leak rate surveillance tests. It was also noted that TMI Administrative Procedure 1012. " Shift Relief and Log Entries," required operators to log the start and stop times of all surveillance tests required by the technTeal specifications in the Control Room Log. Mr; McGovern responded by reiterating that leak rate tests were treated as a " computer O program administrative function" and not as a surveillarce function, thus, start and stop times of all tests were not logged. He d?d not recall, hcwever, anyone ever indicating to him that he should not log the start times w-n - - ---,e e_,- - ~ , . - - , - _,,w,-,,- r ,-.-p. ---,e-,,e -,n,w _-_,,--,,,,e-,m_,,w,m- ,,-gmmn-- -e---m e-o , m w aww-

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of all tests because it would indicate how many tests they had to run before O they could get a satisfactory result. See pages 27 and 28.

Mr. McGovers was asked if he ran a test and it came out less than 1 gpm and he found out after the fact that some evolution was performed during the test-, ,

that wouhl. render the test invalid, would he still keep it? Mr. McGovern '

responded by stating that they would try to ensure the plant was stable l during the test and they accounted for all additions. However, Mr. McGovern - , i could not explain, why if he knew the test was not going to be accurate to begin with and if the test result came out greater than 1 gpa it would be thrown away, and if the test came out less than 1 gym it would be kept, why would he be concerned about evolutions during the test that would produce an outcome that was detrimental to the test. Sae e pages 28-31.

Next Mr. McGovern was questioned about known identified leakage and how that was factored into the leak rate calculation. He stated that from time to time, the Shift Foreman would send one of the A0s out into the plant with a graduated cylinder and the A0 would measure the leakage. The total '

identified leakage would then be added up and put into the leak rate calculation. It was pointed out to Mr. McGovern, that the vast majority of leak rate tests at TMI-2 did not include a value for identified leakage.

Note: The test procedure required the operator manually enter the value for identified leakage from sources other than the Reactor Coolant Drain Tank (RCDT), as well as. steam generator tube leakage and operator-caused changes to the MUT and RCDT.

Mr. McGovern stated that while identified leakage, other than leakage to the RCDT, was usually small, the surveillance test should have included the term.

He was not surprised, however, that most of the tests showed this term to be zero, because "we weren't very good about administering that particular test." See pages 31-33. -

Mr. McGovern was asked if he could recall problems with the MtIT level transmitters (LTs). He said there were problems with both of them from time to time. When there were problems, he believes as a CR0, he would have been aware of them. McGovern said that if he were aware that one of the LTs was providing an erratic and unstable output, he believes he would have tried to use the good LT for input to the computer during a leak rate test.

See pages 33-36.

When asked if leak rate tests results were harder. to obtain as the date of the accident approached, McGovern stated that he could not recall that being the case. Leak rate tests were always a problem as far as he was concerned.

But, he could not recall any pressure being placed on operators to ensure they got a good leak rate. If it came out bad, McGovern said he would inform his Shift Foreman and start another test.. Sje page 36.

The next portion of the interview with Mr. McGovern centered around Hartman's allegations'that leak rate tes.ts results were manipulated by operators through the use of water and hydrogen additions to the MUT. McGovern stated the he had no personal knowledge of any operator, including himself,

, intentionally. performing actions that would influence the outccme of leak j rate tests. He said, at the time, he was not aware that hydrogen could l

i

_ _ - _ _ _ . .. _ ,.-. - _ _-, ___-- _ .__ _ a _ ,___,,_. _ - - - _ _.,

10-O affect MUT level and consequently leak rate test results. McGovern also firmly denied that he added water to the MUT for the purpose of manipulating test results. See pages 38-39.

Mr. McGovern was asked if he wa's aware of a significance difference between _ [~ ,

, the amount cf water added, as shown on the batch controller and the amount of 2

water added,'as shown b the rise on the MUT strip chart. Mr. McGovern i stated that he probabl had noted a difference; however, he could not recall - '

anything specific. vern noted that he had no reason to manipulate test results. He never felt any pressure from anyone that he worked for; he would just "go back and punch the buttons again." At the time, Mr. McGovern stated I that he did not believe the 1 gpm leakage limit for unidentified leakage was  !

based upon any particular' analysis, he thought the number was somewhat 1

" arbitrary and capricious." g pages 38-42. l The next portion of the interview involved a detailed discussion of the leak rate tests involving Mr. McGovern. After reviewing tests for which unstable I.T-1 was used as input to the computer (Tests #50, 64, 73 and 74) and tests involvingpossiblefeedandbleedoperations(Tests #106and#111),McGovern ,

was told that it appeared that they did not pay particular attention to -

i establishing stable conditions before or during the test and that as long as the result came out less than 1 gpm, the test was accepted as satisfying the requirements. Mr. McGovern stated that was " basically a true statement;"

however, he said they did try and do certain things, such as adding water just prior to the test so they would not have to add during the test. See -

pages 42-58.

After reviewing test #121, involving a possible jogged water addition or a hydrogen addition, that was performed just a few hours after the previous shift had conducted an experiment to detemine the affect of hydrogen on leak rate test results Mr. McGovern stated that he was not aware such a test had been conducted. McGovern also restated his position that prior to the accident, he was not aware that hydrogen additions to the MUT could affect MUT level indication. With respect to jogged water additions Mr. McGovern stated while it was possible to add water in small qualities, they did not routinely make small water additions and they did not intentionally add water without logging it. See pages 58-62.

Next, the three tests involving "underracorded" water additions (Tests #150, 151,and153)werereviewedwithMr.McGovern. McGovern could not recall why water was added to the MUT during these tests and why the amount included in

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the calculation was less than the amount indicated on the MUT level instrument; however, he did recall there being inaccuracies in both the MUT level instrument and the batch controller. He further stated that he did not intentionally take advantage of any instrument errors to influence the- '

outccme of a leak rate test. g pages 62-69.

Mr. McGovern was informed that our review indicated 10 out of the 14 tests .in which he was involved, were not conducted properly and when looked at in combination with tests performed by others, it appears that there were problems with the test that may have led some operators to perfom certain j

O actions to influence the outccme of the test. McGovern stated that there were definitely problems with the test but as far as he knew, neither he nor any of the people he werked with intentionally manipulated leak rate test i

_ _ _ _ __ ___ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ ___ _ . _ m _ _ _ _ _ ._____ _ ___ _ _ _ _

11 i results. McGovern agreed that to a large extent the philosophy was, if the test result was greater than 1 gpm, it would be thrown away, and if it was less than-1 'gpm, it would be kept, independent of whatever was going on in the plant. Mr. McGovern believed, however, that people were making an effort -

to correct the problems. He stated the I&C technicians were working on the -

MUT LTs, atione point almost daily, and the computer personnel were working on correcting the computer program. S g pages 69-71. _.

McGovern was asked if he was concerned with operating the plant with such ,

high identified leakage during the months of February and March 1979. He stated that while he recalled it being "a real pain" having to transfer so much water from the RCOT to the bleed tanks, and having to recirculate the pressurizer to equalize boron concentration, he did not consider it "particularly unhealthy." See pages 72 and 73. .

In closing the interview, Mr. McGovern was asked if it was his position, that while scme of these actions may have occurred, they were not done with the intent to manipulate test results. He responded by stating: -

I would say you can call that a direct quote. We may have done things that were a little on the not so great. side, but not with any intent to change the leak rate calculation. Tend to add water for plant conditions, you try to avoid that. If you intend to add it, you add it. That is what we did. Maybe

, we weren't great documenting makeup tank versus batch control.

, O '

or maybe we had the wrong recorder on at the wrong time, but there was nothing intentional in it. No intent to falsify a leak rate or anything like that.

See e pages 75 and 76. .

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IV. Findings and Conclusions During the six months prior to the accident at TMI-2, while Mr.'McGovern served as a Control' Room Operator, many of his actions, associated with the perfomance of RCS leak rate surveillance tests, violated approved plant procedures and technical specifications. Based upon the testimony of

' Mr. McGovern and other operators on his shift, coupled with the NRR technical i 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 performed 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 4 discarfed, either directly by Mr. McGovern or by his Shift Foreman.
3. Contrary to Surveillance Procedure 2301-301 "RC System Inventory," when O test results indicated unidentified leakage in excess of the limiting condition for operation (i.e.,1 gpm), Mr. McGovern did not enter'the acticn statement of Technical Specification 3.4.6.2, " Reactor Coolant t System Operational Leakage."
4. Contrary to TMI Administrative Procedure 1012. " Shift Relief and Log O Entries," Mr. McGovern did not log the start time, stop time, and the results of all leak rate surveillance tests in the Control Room Log.
5. Contrary to TMI Administrative Procedure 1010. " Technical Specification ~

Surveil-lance Program " an " Exception and Deficiency List" was not 4 completed by Mr. McGovern and submitted to the Shift Supervisor for review, when test results exceeded the acceptance criteria of the test. -

6. Contrary to the licensee's stated corrective action in the LER 78-62/1T, Mr. McGov'ern did not recall either being instructed in the proper interpretation of the requirements of the technical specifications or being instructed to enter the action statement of the technical specification when the limiting condition for operation was exceeded.
7. Mr. McGovern considered the leak rate test an administrative requirement

> that had to be satisfied once every 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. He did not believe the results of the test were closely coupled with actual plant leakage and did not treat the test as a technical specification surveillance requirement.

8. Mr. McGoverr. testified that he was aware of periodic problems with the MUT level transmitters. The NRR evaluation shows four of the tests involving Mr. McGovern were run with an erratic and unreliable level transmitter providing MUT . level indication to the computer.

O 9. Mr. McGovern testified that he was aware that feed and bleed operations should not be conducted during leak rate tests. The NRR evaluation shows two tests involving Mr. McGovern where feed and bleed operations -

occurred during the tests. While these operations are not accounted for in the leak rate test calculations, in both cases, more water appears to have been bled from the system than added during the test; thus, leading to a higher calculated leak rate than would otherwise have been the case.

l 10. Mr. McGovern testified that he was not aware, until after the accident,

that adding hydrogen to the MUT could affect MUT level indication and consequently leak rate test results. McGovern also stated he had no personal knowledge of any operator using hydrogen to manipulate test results. His testimony is supported by the NRR evaluation, which shows
only one test involving Mr. McGovern where hydrogen may have been added during the test.
11. Mr. McGovern' testified that he had no personal knowledge of any operator adding water during the course of a leak rate test and not including the amount added in the calculation. The NRR evaluation shows two of

, Mr. McGovera's tests may have involved water additions that were not included in'the calculation; however, these water additions cannot be

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confirmed.

12. Nr. McGovern testified that he was generally aware of instrumentation inaccuracies between the batch controller and the MUT level indicators; ~

hcwever, he did not take advantage of those inaccuracies during the perfor=ance of leak rate tests. The NRR evaluation shows three of l

Mr. McGovern's tests involved water additions, where the amount of water O logged in the CRO's Log and 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 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. McGovern knew of the instrument --

inaccuracy at the time and used it to his advantage.

.?

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

procedures and were contrpry to the TMI-2 Technical Specifications. Because i of problems with instrumentation and the procedure itself Mr. McGovern '

considered the test " meaningless" as far as representing true plant leakage. l As a result, the test was treated as an administrative requirement only. i While 10 of the 14 tests involving Mr. McGovern during this period are  :

considered invalid, their is insufficient evidence to conclude,that any of {

these tests were intentionally manipulated. Rather, it appears that because i tests were conducted so frequently, Mr. McGovern was negligent by failing to  !

establish the proper steady state conditions required for the test. If the '

test result was greater than 1 gpm, it would be discarded and another test would be started. If the test was less than 1 gym, he would retain it with little or no review to ensure it was a valid test.

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