ML20210A832
| ML20210A832 | |
| Person / Time | |
|---|---|
| Site: | Three Mile Island  |
| Issue date: | 02/02/1987 |
| From: | Aamodt M, Aamodt N AAMODTS |
| To: | |
| References | |
| CON-#187-2435 86-519-02-SP, 86-519-2-SP, LRP, NUDOCS 8702090024 | |
| Download: ML20210A832 (25) | |
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, 7, ,3;$ UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION 4
BEFORE THE PRESIDING BOARD DOCKETED UnlRc
) '87 FEB -5 All :16 In the Matter of )
) Docket No. LRP-
) 07-INQUIRY INTO THREE FELE ISLAND UNIT 2 LEAK RATE DATA FALSIFICATION ) ASLBP No. 86-519-02 SP
)
February 2, 1987 AAMODT PROPOSED FINDINGS OF FACT (SUBMITTED TO THE PRESIDING BOARD IN THE FORM OF A RECOMMENDED DECISION)
- 1. On December 18, 1985, the NRC Commission established the Leak Rate Proceeding to determine what individuals were responsible for the falsifi-cation of leak rate reports from TMI-Unit 2 to the NRC prior to the accident on March 28, 1979. The Commission asked the Presiding Board to determine the answers to the following questions:
($) How were the Technical Specification 3.4.6.2 requirements for reactor coolant system unidentified leakage interpreted and ! implemented by control room operators (CRos), shift foremen, shift supervisors and on-site and off-site management? Following the discovery by an NRC inspector in October 1978 that Technical S$ecification 3.4.6.2 requirements were not properly interpreted or implemented, what corrective action was taken by management personnel? Was the corrective action taken sufficient to insure compliance with the Technical Spectiication 3 4.6.2 by the person-nel performing and reviewing the leak rate surveillance tests? (b) What dif ficulties, if any, were operators experiencing when condoiting Icak rate surveillance tests required by Technical Specification 4.4.6.2.d? Who knew about these difficulties? What corrective actions were taken? Did operators feel pressure to obtain leak rate surveillance test results which did not exceed
; technical specification limits? If so, what type of oressure was perceived or exerted and who was responsible?
(c) Were unacceptable Icak rate surveillance test results required by Technical Specification 4.4.o.2.d discarded? If so, who knew of, rendened 'r direc ted this practice? Were acceptable Icak rate surveillance test results discarded in an attempt to hide them from the NRC? (d) Did operators manipulate esta or take other actiens during leak rate surveillance testing in an attemot to inoroocrly influence test results? Who performed, condoncc, directed, or was knowledgeable of 1 6702090024 E70202 , PDR ADOCK 05000320 N <h 3 Q PDR ,) /" r , w - ., ----v - - - , ~ . - . -.,-.-n-.- , - - - - - - r-- < - - - . -- ,n-- w --- ,,,m-n . , - - , - - - -,y ,
dctc manipulctica or other impropar actiens during leck rets surveillance testing? This would include, but is not limited to the following: (i) inputting the wrong data into the plant computer; (ti) adding hydrogen gas to the make-up tank during the test in an attempt to influence make-up tank level indication; (iii) adding water to the make-up tank during the test and either
..no t including the addition in the computer calculation or under-recording the addition in the computer; (iv) taking advantage of differences or inaccuracies in plant instrumentation (e.g. , make-up tank level indicators) in an attempt to influence parameters critical to the leak rate surveillance test calculation; (v) taking or failing to take any action in violation of technical specification requirements?
CLI-85-18, 22 N.R.C. at 880-881.
- 2. The following entities and persons became, through the ruling of the Board, parties to the proceeding: General Public Utilities, Numerous Employees of CPU (present and former), Gary P. Miller, John G. Herbein, and the Aamodts (Marjorie and Norman). The NRC Staff participated in an advisory capacity to the Board. All parties with the exception of the Aamodts were represented by legal counsel hired and reimbursed by GPU or its subsidiaries.
- 3. The Presiding Board of three judges, James L. Kelley (Chairman),
James H. Carpenter, and Glenn O. Bright, received evidence from September 8, 1986 through November 12, 1986 in an NRC hearing room in the East West Towers Building, Bethesda', Maryland.
- 4. Expert technical witnesses and professional investigators from the NRC Staff and '"' NRC inspector, Donald Haverkamp, testified. GPU consultants, Faegre & Bensour ~ HPH, and Mr. Edwin Steir, and Mr.
Moore, an engineer with GPU, testified. Nearly all TMI-2 control room
- operators, foremen and supervisors testified as well as the following on-site management
- James R. Floyd (Supervisor of Operations); James Leonard Seelinger and George A. Kunder (Supervisors of Technical Support);
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Jos2ph B. _ Log:n (Unit Suptrvisor), Gcry P. Miller (Acting Unit Suparviser and Station Superintendent), Valter J. Marshall (Operations Engineer), and William Fels (Computer Engineer) . John G. Herbein (Vice-President of Generation) at the Metropolitan Edison Company offices in Reading, PA appeared on the last day of the hearing. All witnesses were called and sponsored by the Board.
- 5. The Board asked question submitted by the parties which were judged appropriate and conducted an extensive cross-examination of the-witnesses. The parties suggested documents for inclusion in the record.
These consisted of the NRC's parallel investigations of ten licensed operators in the leak rate falsifications and two reports by GPU's consultants, the Rockwell Company (the Faegre & Benson Report) and Edwin Steir, and other miscellaneous docaments. No discovery of new information through request of categories of documents was permitted.
- 6. Harold Wayne Hartman, Jr., a control room operator at Unit 2 before the accident, was the "whistleblower" who brought the matter of leak rate falsification to the NRC's attention on May 22, 1979. When the NRC finally undertook to investigate Hartman's allegations in March 1980, af ter Hartman appeared on WOR-TV, the Of fice of Inspection &
Enforcement confirmed that leak rate falsifications had occurrdd at TMI-Unit 2 prior to the accident. The NRC referred the matter to the Department cf Justice for criminal investigation and prosecution. In November 1983, the Department of Justice handed down an 11 count criminal indictment of the Metropolitan Edison Company. The Company entered into a plea bargain with the United States, which was approved by the Court, and paid one million dollars to the Pennsylvania Emergency Management Agency. See Ex. 1-A, Vol. I, p. 2-4, Vol. V(A), Tabs 2 & 3.
- 7. Hartman alleged that water and hydrogen were added during leak rate tests in order to affect the tests to obtain test reports within the i
linits of tha tschnicci sp cificaticn for cparcticn, which w:s 1 gslien per minute of unidentified reactor inventory leakage. Hartman testified that it was common knowledge among the operations personnel that hydrogen affected the leak rate test by minimizing the amount of leakage reported. Hartman testified that tests that were calculated as in excess of 1 spm were routinely discarded with the knowledge of shift supervision. After an 'NRC inspection, Hartman testified that the operators were instructed by shif t supervision to hide test results in excess of specifications so that they could not be seen by the NRC inspector. Hartman went along with these practices because he believed that higher management was aware of the practices. Hartman was uncomfortable with the deception and the manner of operation of the plant; he attributed his physical condition of hypertension to his employment at Unit 2. I&E Interview, May 22, 1979. 9 Hartman supported his earlier testimony when he appeared as a witness in this hearing. Tr. 2239---2309.
- 8. John Blessing, a control room operator on Hartman's shif t, corroborated Hartman's testimony. Blessing dismissed the attorneys hired by GPU to represent the employees on the leak rate matter when the Depart-
- ment of Justice began its investigation in 1980. Ex. 6 (Ex. 6) . The l
Board did not enforce their subpeona for Blessing's appearance at thz hearing since Blessing's testimony was cicar in the record. (Two other a operators also corroborated Hartman during the initial I6E investigations. See Ex. 6 (Ex. I p.1), Ex. 2, Vol. 1.
- 9. Prior to the commencement of this hearing, a number of facts,
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responsive to the Commission's questions to be answered by this hearing had already been established by the NRC, Department of Justice and GPU consultants' investigations. These can be surmmarized as follows:
- a. Unidentified leakage was measured in a more or less continuous manner throughout the operation of Unit 2. Measurements of leakage that exceeded the technical limits of specification 3.4.6.2 were thrown away. The discard of tests above the limits was a violation of Technical Specification b.9.1.8 which required that a report be
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niads to tha NRC within 24 hours end TIchnical Spacification 6.10 which rsquircd rctsnti'en of survaillcnco rccords fer at 1scst five years.
- b. When operators could not obtain a test result within the technical specification limit prior to the 72 hour reporting interval, various means were employed by the operators to manipulate the test so that the computer would be likely to print out a test result of 1 gpm or less. The means included adding water during the tests, not accounting __for all or part of the water addition, adding hydrogen, and using both makeup tank transmitter levels tc lake advantage of the disparity between their instrumentation. The leak rate procedure discouraged the addition of water during a test because of inaccuracies introduced by temperature differences between the water added and the water in the makeup tank, required the accounting of all added water, and forbade the addition of any chemicals. In order to measure the limiting condition,1 gpm, the conditions of the procedure had to be met; these included running the test when the plant was in a " steady state".
- c. On October 18, 1978, an NRC inspector discovered leak rate tests for several days that were above limits and learned about the practice ~of discarding tests above limits. The company agreed to file a Licensee Event Report (LER) concerning operation above limits of leakage and to discont'inue the practice of discarding tests. An Operations Memorandum was issued on October 20, 1978 which notified the operators to discontinue discard of leak rate tests. On November 1,1978, an LER was sent to the NRC by the Vice-President of Generation whereby the NRC was assured that the pract' ice of discarding tests would be discontinued through instruction of the responsible employees. All operations personnel initialed the LER to signify their awareness and understanding of it.
However, the practice of discarding leak rate tests continued through-out the operation of Unit 2.
- d. The LER was assigned to the Plant Operations'Re'v'iew Committee (PORC) for resolution of problems with the leak rate procedure which were believed to have caused the measurements above limits. Five months later, in March 1979, PORC closed out this matter and issued a Technical Notice of Change (TNC) which revised the leak rate procedure.
This revision, which corrected the water that went out of the makeup tank from volume to density at reactor temperature but did not correct the water that was put in, biased the rest results in the direction of 1 minimizing the leakage. See Ex. 1-A, Vol.1, Ex.2, Vol.1, Ex. 5-A, Ex. 6. 4
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- 10. Tha Bozrd axesintd and disersdited all reasons pressntsd by tha e
operators that could have excused the operators' involvement in the events described in Finding #9 supra. ' A number of operators tentified that their i actions were not deliberate attempts at falsification because they had little regard for the leak rate surveillance procedure, per se, the computer was not reliable, other plant parameters provided a more i accurate assessment of unidentified leakage, and that practices used in performing the leak rate test had been ingrained from operation of Unit 1. These reasons were recurrent throughout the pre-filed testimony of the I ]
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employees, the. Numerous Employees, who partiiipated as a party in the- , i hearing and were represented by attorneys hired by GPU. and its subsidiaries. See Written Testimony, Adams, Boltz, Booher, Brummer, Bryan, Chwastyk,
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Coleman, Conaway, Congdon,' Cooper, Faust, Frederick, Germer, Guthrie,, Hemmila, Hitz, Hoyt, 111jes, Kidwell, McGovern, Mehler, Mell, A. Miller, l t Olson, Phillippe, Scheimann, Smith, and Zewe, see Findings 11 - 17 infra. I
- 11. The excuse that the leak rate test was not considered an important surveillance (and, therefore, that the test was performed 1
casually, " sloppily", and with " oversights", see, for instance, 1 I Written testimony A. Miller, ff. Tr. 3608, p.2; McGovern, f f . Tr . 314 8, p .4, Tr. 3924 - 34, 3993 - 4004 Olsen (3931-2), was discredited by the evidence developed by the Board that the leak rate surveillance was required by the company's license in order to keep operating the plant, was required to be reported to the NRC at least every 72 hours, and that it was the only ! quantitative measure of unidentified leakage and the first signal of a ! potentially serious pipe break. See Ex. 2, Vol. 1, Ex. 22, 23. The safety signficance of the test was noted on the procedure sheet.so that it I could not have escaped the operators' attention, and it did not. Tr. 3293 i Kidwell; Tr. 3931 Olson. The measurement of the limiting leakage required l the operators' close attention to plant conditions and procedural adherance. l 4
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Ex. 1, Vol . 1 at 42. See Tr. 3930, Board _.,/ The continued operation of the plant, a priority matter, depended on the measurement of the leak rate within the limit. The operators were aware that when the limit was exceeded, NRC regulations required that steps be taken to begin shutting down the plant. Id., Vol. I at 37-38, Vol.V(B) at Tab 14. The operators ran the leak rate test continuously, as of ten as four to five times a shif t. Operators" Written Testimony, see Finding # 10 for record references.
- 12. The operators' excuse that the computer used to calculate the leak rates was faulty and produced undependable test results (see Written Testimony, McGovern f f. Tr.3148 p.2, Chastwyk f f. 'Tr. 3407 p.4, Zewe ff.
Tr. 2946 p.3, A. Miller f f. Tr.3608 p.5, Tr. 3930 Olson) was discredited by the operators' admissions that they could have made a manual calculation of the leak rate but did not (see Tr. 2071 Wright. 5x. 2, Val 4, ' rab 2 Ex.5-A,Vol.1, En2) and the testimony of 1.he computer expert, William
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Tr. 4489 - 4535. Chastwyk was unable to explain how,lhe increTiileg
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Fels.
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dif ficulties he reporte'd he h~sTin computing a' leak rat.e tests ,in th.e
' months before the _a_ccident could be related to computer programing. Tr.3570-2.
- 13. The excuse that operators discarded leak rate tests because they carried this practice over from operating Unit 1 (for instance, Tr. 3649 A. Miller) was discredited by the testimony of other operators that the leak rate procedure was included in training materials and dis-cussed during the simulator training by the Babcock & Wilcox instructor
(;Tr.'2673-4 Wright,- Bryan ff. Tr. 4540 p.3, Germer ff. Tr. 5236 p.2, Tr. 3289 Kidwell, Tr. 3289 Mel), by the clearness of the regulation (see Ex. 2, Vol.1) by the evidence of the NRC inspection of October 18, 1979 which identified the practice as contrary to regulations: the operators were provided with an October 20, 1978 memorandum from Operations Super-
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cor Jtmas Floyd ccncerning tha diecontinuation of this prectics, initiated a company Licensee Event Report of November 1, 1978. LERs go to the training department and are used in briefings (Tr.4865 Kunder). Although the Board found that these documents may not have been adequate to carry the message to all operators, operators present during the NRC inspection had the benefit of immediate knewledge concerning the change described in the LER and Operations Memorandum. The message was received by at least two operators; Olson subsequently attached " bad" tests to
- " good" ones. Tr. 4007 - 8. Olson remembered discussion and training concerning the retention of tests. Tr. 4009 - 10. The other, Wright, remembered discussing the change of practice (Tr. 2676) and began re-taining all test results for a while. Wright ff. Tr. 2663 pp. 3-4.
i The Exception and Deficiency procedure (AP 1010) was provided and re-quired that all invalid tests be documented and filed. Wright was instructed (presumably by his shif t supervision) to not use this pro-cedure. A technical specification required the retention of records for five years or longer (Technical Specification;6.10). An operator and the superintendent of technical support testified that tests were not fre-quently discarded during the operation of Unit 1; therefore, a practice of discarding tests could not have been ingrained from operation of that unit. Chastwyk f f. Tr. 3407 p. 4, Tr. 4840 Kunder. See Ex. 6 (Ex. 1 p. 2). t~~~
! 14. The operators' excuse that they did not need the leak rate l
' test in crder to estimate unidentified leakage (see Written Testimony l I Conway f f. Tr. 3097 p. 3, Bryan f f. Tr. 4340 p. 3, A. Miller f f. Tr.3608
- p. 3, McGovern f f. Tr. 3148 p.2, Cooper f f. Tr. 2835 p. , Scheimann ff.
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- Tr. 2831 p. 5, Zewe f f. Tr. 2946 pp. '3, 7 Tr. 3296 Kidwell) was discredited -
byadmissionsofthesuperintendekt of technical support and an operator that they knew that visual inspection could not distinguish between leakage of over or under 1 gom. Tr. 3293 Kidwell, Tr. 4156 Guthrie, Tr. 4825 Kunder. The
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Board expressed utter disbelief that operators' had testitied that they
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m d3 o visunt insptction to quantify unidantified leakage: "...tha ides that one could have a feeling for what leakage was..." Judge Carpenter Tr. 3652, 4833 - 6. The superintendent of technical support and a shift
- i. supervisor testified that leaks from the steam generators cannot be quantified during operation. Tr. 4825 Kunder, Tr. 4156 Guthrie. Steam generator B was known to be leaking prior to the accident. The' Board is requested to take official notice of a Preliminary Notification of March 28, 1979; see "due to a known previous primary to secondary leak in Steam Generator B" at the end of the second paragraph.
- 15. The operators' excuse that they did not add water to influence the test results (see, for instance, Written Testimony Bryan ff. Tr. 4540 p.3) was discredited by the evidence that water was deliberately added during tests,'despite the precaution of the procedure that water additions should be avoided, for unsupportable reasons. See Written Testimony Conway f f. Tr. 3097 p.4, Tr. 3921 - 30 Olsen, Board. Tr. 3974 Board.
Tr. 2661 - 2707 Wright. Water added during the leak rate test was a partially or wholly unaccounted in the leak rate computation (see Ex. 1- A, 1 - B, 2, 5 - A) despite the computer's solicitation for water additions. The water additions and computing of the leak rate were made in the same area. Ex. 9 . Two or at most, three, operators who worked together every day were responsible for the leak rate testing and the water additions thus discrediting the notion that communication problems coulo nave caused oversight in accounting zor water additions. See Ex. 5 for Shif t Makeup. The strip chart and the control room log provided oermanent records of water
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additions that could be used as an additional check of water additions duging a test. Water was jogged into the makeup tank for no reason other i than to manipulate the leak rate test without leaving a clear record on the strip chart.
- 16. The excuse that operators innocently switched from one makeup em I
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tank level transmitter to the othar (in mensurink_jh3 cmounY'nf water in the makeup tank at the beginning and end of a test),thus taking advantage of the known disparity between the instrumentation (see Ex.1-A, 5-A), was disputed by the evidence that the operators were aware of the disparity between the instruments. Tr. 3934 - 6 Olson, Tr. 3657 A. Miller.
' '6I~~The 1 excuse,that hydrogen was added during the tests because the operators did not know that the procedure prohibited the addition, was refuted'oy the evidence that the procedure prohibited the addition of chemicals. The operators were aware that the chemistry department determined additions of hydrogen. Tr. 4005 Olsen. Operators could and did observe the effect of addition of hydrogen on the makeup tank level and'the strip chart. Written Testimony Chastwyk (f. Tr. 3407 p. 5 Tr. 1055, 1083 Russell.
A number of operators, shift foremen and supervisors knew that the addition Written Testimony
; of hydrogen could minimize the leak rate measurement.
Bryan ff. Tr. 4540 p.4, Cooper i f. Tr. 2S35 pp. 6-7, Chastwyk ff. Tr. 3407
- p. 5, Ex. 6 (Ex. I p.1, Ex. 6). While some operators testified that they were unaware of the ef fect of hydrogen addition on the test, others testified that these same operators had observed a demonstration of the hydrogen ef fect and approved the leak rate test generated. Tr. 2651, Ex.
6 (Ex. 20 p. 40). A shif t supervisor who ran the demonstration of the hydrogen test told eyeryone he could contact. Ex. 6 (Ex.21 pp. 26 - 20). Hydrogen was added at the end of a test, a particular time period during he test when the operators believed that the addition of hydrogen would result i g ehammase6mm Cminimizing the leakage report -- indicating that the addition of hydrogen at the end of the test was intentional manipulation. :Tr. 1055 Russell. Hartman and Blessing testified that hydrogen was added expressly to manipulate the leak rate tests, and that that was " common knowledge". Ex. 6 (Ex. 1, Ex. 6). Hartman admitted to having mani-pulated tests by the addition of hydrogen. Id. Chastwyk intermittently
rcmeabsrid cnd fergot whsthsr ha rem:mbsrsd ha kntw of the hydrogzn ef fcet
' at Unit l.
i InaninterviewwithMr.Steir,hesudd'enlyhaddimhern11of i having known about the hydrogen effect when working at Unit 1; however during his appearance in this hearing, he apparently lost the recollection. See Ex. 6 (Ex. 22, p.46) and Tr. 3556-8l Chastwyk's testimony is not unlike Kidwell's who " faintly" knew about the hydrogen a "ect Sc-suse he observed operators discussing it "out of the corner of (his i eye", Tr. 3293, or Olson's covering his cars to avcid hearing about the hydrogen e f fect. Tr. 2605 - 7. __
- 17. The deliberateness of the operators' involvement in le-k rate falsifications is clearly revealed by the following testimony of operators and shift supervision:
Olson: It was go over there, type the damn thing in and wait for it to come out and that was it. That was the general attitude. If the leak rate came out 1 gallon a minute, it was considered to be a valid leak rate. I do not question my other operators as to: why you added this water, how much did you add, take' credit for it. I didn't go back and question what they did. Tr. 4004 If it was over, it was no good. If it was under, it was good. I Tr. 3931. Guthrie (paraphrased) He though it was a good idea to discard tests. He was told by his shift supervisor to do so. He may have discarded a test before it was invalidated by running a new one. He knew there was no other way to quantify unidentified leakage than the leak rate test. Tr. 4154-7. McGovern: I also recall discarding more leak rate tests than those I kept. Written Testimony f f. Tr. 3148 p.8. Conway: We were not as concerned with the administrative requirement of demonstrating that the plant was operating within the limiting conditions for operation for RCS leakage. Written Testimony ff. Tr. 3097 p. 3. Germer: I also discarded leak rate tests that were run properly, but yielded an unacceptable result. Written Testimony ff. Tr. 5236 p.2. The Board finds that the operators, shift foremen and shift supervisors engaged in a systematic manipulation of the leak rate measurement and related reports to the NRC for the entire peried of the operation of the plant.
Tha op;rcters wara tw ra of tha public h sith end safety conssqu:ncas. They knew that without a reliable and valid measure of unidentified Icakage, boundary 'aakage, as from the known leak in the B Steam Generator could have exceeded illowable limits. -
- 19. It is unlikely that the operators, who were clearly involved.
- Eevised, undertook and concealed the manipulation of leak rate tests.
The unit operated by a chain of command. Written Testimony Herbein ff.
~ ! Tr. 5268 pp. 5-7. Being the bottom 1 ink, the operators followed instructions.
i An operator's emphatic spontaneous response to a suggestion of the Board is illustrative: "No, no. We would have to have some procedure or approvement to do that". Tr. 4158 Guthrie.
' 20. The operators falsified leak rates because they believed enat their management wanted them to do. One operator testified that i., f management had wanted them 3:u do lea'( rate tests dif ferent' , management would have seen to that. Tr. 3260 Mel. Another tastified that hc was not sure whether he could have developed his attitude toward leak rate testing from association with management. Tr. 3655-6 A. Miller. Another was told, in no uncertain terms, by one of three individuals in the shift supervisor's office that he should never bring another Icak.. rate test resntt 1
- of excessive leakage to that of fice Tr. 2641, 2706, cdleman ff. Tr.2579
- p. 3.
' 21, if the plant management did not know abcut the improper leak rate ._
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that time. The practices prior to October 1978, they became fully aware at James
. NRC inspector contacted the Superintendent of Technical Support,
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Seelinger, who in turn, contacted someone above him for advise.
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Seefinger'~eif$ir c~ontacted the acting enit and station superintendent Gary
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hiller or someone in the company of fice in Reading, Messrs. Lawyer or Herbein. The Operations Memorandum of October 20, 1978 and the LER of November 1,1978
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James Floyd, the Supervisor hf Operations, evoked more attention to the event.. the Vice-President of Generations, composed the memorandum, and John Herbein, 4 . reviewed the LER, approved it, " based on what (he) had been told by (his) chain
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Tr. 5272 Hsrbain, ff. Tr. 5268 p. 12. of command
- about the incidsnt".
The Board finds that those who reported to Mr. Herbein concerning the NRC inspection and the LER became fully informed about the matter and fully informed Mr. Herbein. This finding is consistent with Mr. Herbein's testimony that the people immediately below him in the chain of command, were Icak rate Messrs. L'aiyer, Miller and Floyd/ competent managers and that th,e/ matter was their responsibility and of high priority. Tr. 5280 - 1 Herbein.
- 22. The Board is not surprised that the management witnesses did not make outright confessions. These witnesses were being asked to testify
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against themselves concerning a matter of criptac1 conduct. The witnesses were not under any threat of perjury to testify truthfully. The witnesses are aware of all existing documentation, GPU's lawyers are controlling all witnesses, and the Commission has ruled against discovery of new information. The witnesses denials d6 not constitute exculpatory evidence.
- 23. The most important evidence on the record, which inculpates Mr. Herbein and the other managers is the testimony of the investigators and the operators that Unit 2 was leaking. The leakage was described as significant and "c1carly the case". All investigators agreed. Tr. 1063-4 Cole, Kirkpatrick, Steir. The operators testified that they were aware of leaks, from the valves. Tr. 3938 Olson. Kunder, the suocrintendent of technical support, stated that it was common knowledge that there were The B Steam Generator was leaking. See Attachment 1.
Icaky valves. Tr. 4832./ The Board opined that the leak rate test was Tr. 5314. The corollary is , a simple one "if you don't have much leakage". true, and there exists the motivation for the situation that existed: the leak rate procedure irregularities were never addressed because, had they been, anc valfd procedures followed, the plant would have been shut down occause of unidentified. leakage in excess of limits. Since Unit I was down for refueling, an outage at Unit 2 would have been costly.
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- 24. Day a f ter day during the period prior to tha cccidsnt, the amount of water added to the RCS Make-Up Tank increased sharply. A record of water additions is available from the control room logs. Tte Board is requested to take of ficial notice of reproduced pages of the logs covering the six week period preceding the accident (February 15 through 4 a.m. March 28, 1979) which are provided in Attachment 2.
Also provided in Attachment 3, for the Board's convenience, are Table 1, which tallies daily water additions and Figure I which plots this data from the control room logs provided. The Board expressed interest in this data, some of which is on the record of this proceeding. Tr. 3936. Since the logs have been provided by GPU and can be presumed to be available to the other parties, only Table 1 and Figure (Attachment 3) are being provided to them.in order to expedite the provision of these findings.
- 25. The amount of water added increased from 2,500 gallons on February 15, 1979 to 17,550 gallons on March 27, 1979. Further, the control room log appears to reflect a frenetic ef fort by the operators to add water to the makeup tank during the last week before the accident.
(The accident occurred on March 28, 1979.)
- 26. The plant conditions of excessive and sharply rising leakage, as deduced from the water additions to the makeup tank, could not have excaped the notice of all plant managers and been relayed by call and report to the company and corporate offices. The managers, to a man, could not have missed the fact that valid leak rate tests were not possible to obtain during this period and knew that continued plant operation was in violation of technical specifications.
- 27. With the data of Attachments 2 and 3 before the Board, it has come to the decision that there was universal knowledge and involvement
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in the lesk rats falsifications and subsequant covarup by the entiro operations management, other departments, the company and corporate management. Respectfully submitted, j bl.^1 . ,
- MMajorik M. Aamodt i l SYliltu h-Norman O. Aamodt ID February 2, 1987 e
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- 1, PREllMIMKr nus ar n.ru ava
.a March 28,1979 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PHO-79-6 This oreliminary notification constitutes EARLY notice of event of
{r POSSIBLE safety or public interest sionificance. The infonnation~ k oresented is as initially received without verification or evaluition fl. and is basically all that is known by IE staff on this date. h Facility: Three Mile Island Unit 2 a Middletown, Pennsylvania
} (Docket No. 50-320) b
Subject:
REACTOR SCRAM FOLLOWED BY A SAFETY INJECTION AT THREE MILE i ISLAND - UNIT 2 The licensee notified Region I at approximately 7:45 AM of an incident ai Th'ree Mile Island Unit 2 (TMI-2) which occurred at approximately 4:00 AM kl s at 98% power when the secondary feed s tripped due to a feedwater in a turbine trip and subse-2 polishing system problem. This resul [e quent reactor trip on High Reactor. Coolant Pressure. A combination of
. Feed Pump Operation and Pressurizer Relief - Steam Generator reitaf
" valve operation caused a Reactor Coolant System (RCS) cooldown. At I
i 1600 psig, Emergency Safeguards Actuation occurred. All ECCS components
'i -
started and operated properly. Water level. increased in the Pressuri:ter and Safety Injection was secured manually approximately 5 minutes after t'/:/ [
. actuation. It was subsequently resumed. The Reactor Coolant Pumps were secured when low net positive suction head limits were approached.
About 7:00 AM, high activity was noted in the SCS Coolant Sample Lines
- (approximately 600 mr/hr contact readings). A site Emergency was then
- declared, At approximately 7:30 AM, a General Emergency was declared based on High Radiation levels in the Reactor Building. At 8:30 AM site bounda radiation levels were reported to not be significant (icss than
- 1 mr/h .
The source of activity was stated to be failed fuel as a result of the transient, and due to a known prJvio_us primary _to secondar
~
~' -
leak in Steam Generator B. , The Region I Incident Response Center was activated at 8:10 AM and direct corrmunications with the licensee and IE: Headquarters was estab-lished. The Response Team was dispatched at 8:45 AM and arrived at the site at 10:05 AM. At 10:45 AM the Reactor Coolant System Pressure was being AM, By 10:45 held radiation at 1950 psig with temperature at 2200F in the cold leg. levels of 3 mr/hr had been detected 500 yards offsite. n e
~ ~ '
CONTINUE 0'
- J. C. :! ! ' . ~ 'i- 1.'l O G
\
..... . L .. .. .
--- - - , - - . . - - - -.-_ m - . _ .- ----.
s.- .--- --.
' Page 2 March 28,1979 Continued PHO-79-67 J
rnere is significant media interest at the present time because of concern about potential offsite radiation / contamination. The Coraronweal l of Pennsylvania and EPA have been infortnad. Press contacts are being l rnade by the licensee and HRC. l
Contact:
GKl'ingler, IE x28019 FHolan.)E x28019 SEBryan, IE x28019 s:gs Distribution: Transmitted H St J.L ^ Chairman Hendrie Comissioner Bradford S. J. Chilk, SECY comissioner Kennedy Comissioner Ahearne C. C. Karrmerer, C. Comissioner Gilinsky (For Distribution P. Bldg 3'. 40 \ Transmitted: HNBB J. G. Davis, IE L. V. Gossick, E00 H. R. Denton, NRR Region H. L. Ornstein, E00 R. C. DeYoung, HRR , J. J. Fouchard, PA 'R. J. Mattson, NRR N. M. Haller, HPA V. Stello, NRR (MAIL) R. G. Ryan, 0SP R. S. Boyd, NRR J. J. Cunnings, 0: M. K. Shapar, ELD SS Bldg R. Minogue, SD W. J. Dircks, HMSS l PRELIMINARY NOTIFICATION
\
e G e 5
.S
*D
Attschmsnt 2 CONTROL ROOM LOGS, THI-2 February 15 - 28 (4 a.m.) 1979 t I l i [
- .- .-.. --c-, - - - - . . - . -
,, - n
Attachm:nt 3
SUMMARY
OF WATER ADDITIONS TO RCS MAKEUP TANK February 15 - 28 (4 a.m.) 1979 l
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1 I'FPEI-i- UNITES STATES OF AMERICA - " ' NUCLEAR REGULATORY COMMISSION 1 BEFORE THE PRESIDING BOARD '87 FEB -5 A11 :15 i vF;-
) .7d
) 00C., }'
l In the Matter of Docket No. LRP
)
INQUIRY INTO THREE MILE ISLAND UNIT 2 ) J LEAK RATE DATA FALSIFICATION ) ASLBP No. 86-519-02 SP
)
This is to certify that copies of AAMODT PROPOSED FINDINGS OF FACT (SUBMITTED TO THE PRESIDING BOARD IN THE FORM OF A RECOMMENDED DECISIO were served on the following Service List as follows: The Board by l l facimile wire on February 2, 1987 and the parties by Express Mail on.the same day. The Docketing & Service Branck'knd the NRC Staff were served
/ /
by depisit in U.S. Mail, First Class.
- l. QAA . M4srY 3
Marjorie M. Aamodt February 2, 1987 Service List Harry H. Voigt, Esq. j The Honorables Judges James L. Kelley (Chairman) Michael F. McBride, Esq. James H. Carpenter Glenn O. Bright Robert St. John Roper, Esq. j Molly S. Boast, Esq. ' Atomic Safety & Licensing Board James W. Moeller, Esq. U.S. Nuclear Regulatory Commission Marlene L. Stein, Esq. ' Washington, D. C. 20555 C. Christopher Sprague, Esq. LeBoeuf, Lamb, Leiby & MacRae k' Docketing & Service Branch Suite 1100 [ U.S. Nuclear Regulatory Commission 1333 New Hampshire Ave., N.W. Washington, D.C. 20555 Washington, D.C. 20036 Jack Goldberg, Esq. Smith B. Gephart, Esq. Mary Wagner, Esq. Jane G. Penny, Esq. Of fice of Legal Staff Terrence G. McGowan, Esq. U.S. Nuclear Regulatory Commission Killian & Gephart I Washington, D.C. 20555 216-18 Pine Street Harrisburg, PA 17108 Ernest L. Blake, Jr., Esq. John N. Nassikas, III, Esq. Michael W. Maupin, Esq. Shaw, Pittman, Potts & Trowbridge i Maria C. Hensley, Esq. 2300 N Street, N.W. l Washington, D.C. 20037 Hunton & Williams 4 P.O. Box 1535 Richmond, VA 23212 ' Isham, Lincoln & Beale Three First National Plaza . Suite 5200 i Chicago, IL 60602
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