ML20210P170
| ML20210P170 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 02/02/1987 |
| From: | Aamodt M, Aamodt N AAMODTS |
| To: | |
| Shared Package | |
| ML20210N479 | List: |
| References | |
| 86-519-02-SP, 86-519-2-SP, LRP, NUDOCS 8702130322 | |
| Download: ML20210P170 (30) | |
Text
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g g 3 2. 0 UNITED STATES OF AMERICA h
NUCLEAR REGULATORY COM11SS10N SEFORE THE PRESIDING BOARD:
James L. Kelley (Chairman)
James H. Carpenter Glenn O. Bright
)
In the Matter of
)
Docket No. LRP
)
INQUIRY INTO THREE MILE ISLAND UNIT 2 )
ASL8P No. M-519-02 SP LEAK NATE DATA FALSIFICATION
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AAMODT PROPOSED FINDINGS OF FACT (SUBMITTED TO THE PRESIDING BOARD IN THE FOMM OF A HECOMMENDED DECISION)
Har jorte M. Aamodt Pro Se Norman O. Aamodt. Pro So 180 Bear Cub Hoad Hnx b)2 Lake Placid, N. Y.
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February 2, 1987 r
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TABLE OF CONTENTS (Aamodt Findings) page (s) l l
Findings of Fact.................................... 1 - 15 l. Preliminary Notification, March 28, 1979 (PNO 79 67)...................
16 - 17 l
- . Control Room Log THI-2. Fa bruary 15 -
l March 28 (4 a.m.) 1979............
18 I
Refor to NRR Test Evaluation Worksheets: February 1979 - Tests97-133, March 1979 - Tests i
134-156 for Control Room Logs beginning at 120 (Ex.5 A) l. Summary of Water Additions to RCS Make-up Tank February 15 - March 28 (4 a.m.)
1979................................ 19 Figure 1 - Daily Additions of H O in 2
i talions February 15, 1979 thru Herch 27, 1979.........................
20 i
Table 1 - Daily Water Additions to THI-2 RCS f rom 2/15/79 thru 4 a.m.
l 3/28/79 (Per Operators' Daily Log). 21 24 l
l Resume, Marjurie M. Aamodt, M.S...................
25 - 26 i
f Re sume No rma n O. Aamod t, M. E.....................
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UNITED STATES OF AMERICA NUCLE 4R RECULATORY COMMISSION BEFORE THE PRESIDING BOARD
)
In the Matter of
)
)
Docket No. LRP
' INQUIRY INTO THREE MILE ISLAND UNIT 2
)
LEAK RATR DATA FALSIFICATION
)
ASLBF No. 36-519-02 SF
)
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 whmt individuals were responsible for the falsift.
cation of leak rate reports from THI-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:
(a)
How were the Technical Specification 3.4.6.2 requirements for reactnr 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 Specification 3.4.6.2 requirements were not properly interpreted or implemented, what corrective action was taken by management personne17 Was the corrective action taken sufficient to insure compliance with the Technical Specification 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 conducting leak rate surveillance tests required by Technical Specification 4.4.6.2.d?
Who knew about these dif ficulties?
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 pressure was perceived or exerted and who was responsible?
(c) Were unacceptable leak rate surveillance test results required by Technical Specification 4.4.6.2.d discarded? If so, who knew of, condoned or directed this practice? Were acceptable leak rate surveillance test results discarded in an attempt to hide them from the NRCf (d)
Did operators manipulate data or take other actions during leak rate surveillance testing in an attempt to improperly influence test
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results? Who performed, condoned, directed, or was knowledgeable of r :'
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% data manipulation or other improper actions during-leak-rate i
surveillance testing? This would include, but is not limited
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'to the following:
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(1) i y
. inputting the wrong data into the' plant computer; IC-(%i)L a'dding hydrogen gas to the make-up tank during the test hh,.
r in an attempt to influence make-up tank level indication; addingwater'to$hamake-uptankduringthatestandeither (iii) 4 not including the addition.in the computer calculation or under-recording the addition 1.4 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, 22sN.R.C. at 880-881.
S 2.
The following entities and persons becane, through the ruling of the Board, parties to the proceeding: General Public Utilities, Numerous 3
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Dep1hyees of GPU (presen't and former), Gary P.' Miller, John G. Herbein, and the Aamodes (Marjorie and Norman). The NRC Staff participated. in an advisory capacity to the Board, ill parties with the exception of the i
Aamodes were represented by legal counsel hired and reimbursed by GPU or 2
its subsidiaries.
3.
The Presiding Board of three judges, James L. Kelley (Chairman),
James H. Carpenter, and Glenn O. Brigh, received evidence from September i
8, 1986 through November 12, 1986 in an NRC hearing roem in the East West i
y Towers Building, Bethesda, Maryland.
L.
t 4.
Expert technical witnesses and professional investigators from l
the NRC Sta ff and NRC inspector, Donald Haverkamp, testified. GPU consultants, Faegre & Benson, MPH, 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 h
on-site management: James R. Floyd (Supervisor of Operations); James Leonard Seelinger and George A. Kunder (Supervisors of Technical Support);
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Joseph B. Logan (Unit Super' visor), Gary P. Miller (Acting Unit Supervisor s
4 and Station Superintendent), Walter 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
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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 of Justice for criminal investigation and prosecution. In i
November 1983, the Department of Justice handed down an 11 count criminal indictment of the Metropolitan Edison Company.
The Company entered into a pies 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 l
l rate tests in order to af fect the tests to obtain test reports within the i
i 3
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limits of the technical specification for operation, which was 1 gallon 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 gym were routinely discarded with the knowledge of shif t supervision. After an NRC inspection. Hartman testified that the operators were instructed l
by shift 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
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hypertension to his employment at Unit 2.
I&E Interview, Hay, 22, 1979.
Hartman supported his earlier testimony when he appeared as a witness in this hearing. Tr. 2235---2309.
8.
John Blessing, a control room operator on Hartman's shif t, corroborated Hartman's testimony. Blessing discissed 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 the I
hearing since Blessing's testimony was clear in the record.
(Two other operators also corroborated Haatman during the initial I&E investigations.
See Ex. 6 (Ex. I p.1), Ex. 2, Vol. 1),
9.
Prior to the commancement of this hearing, a number of facts, 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:
Unidentified leakage was mea,eured in a more or less continuous a.
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 6.9.1.8 which required that a report be l. _ _. - _ _
made to the NRC within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> and Technical Specification 6.10 which required retenti'on of surveillance records for at least five years.
b.
When operators could not obtain a test result within the technical specification limit prior to the 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> 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 account.ing for all or part of the water addition, adding hydrogen, and using both makeup tank transmitter levels to take advantage of the disparity between their instrumentation. The leak rate procedure discouraged the additica 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 ' Review 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 test results in the direction of l
minimizing the leakage.
See Ex. 1-A, Vol.1, Ex.2, Vol.1, Ex. 5-A, Ex. 6.
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- 10. The Board examined and discreditsd all roosens prossnted by th2 operators that could have excused the operators' involvement in the events described in Finding #9 suprz.
A number of operators testified 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 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 employees, the, Numerous Employees, who participated as a party in the hearing and were represented by attorneys hired by GPU. and its subsidiaries.
See Written Testimony, Adams, Boltz, Booher, Brummer, Bryan, Chwastyk, Coleman, Conaway, Congdon, Cooper. Faust, Frederick, Germer, Guthris.,
Hemmila, Hits, Hoyt, Illjes, Kidwell, McGovern, Mehler, Hell, A. Miller, Olson, Phillippe,, Scheimann, Smith, and Zewe. See Findings 11 - 17 infra.
l
- 11. The excuse that the leak rate test was not considered an important surveillance (and, therefore, that the test was performed casually, " sloppily", and with " oversights", see, for instance, Written testimony A. Miller, ff. Tr. 3608, p.2; McGovern, ff. Tr.3148, p.4, Tr. 3924 - 34, 3993 - 4004 01sen (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 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />, 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 could not have escaped the operators' attentioa, and it did not.
Tr. 3293 l
Kidwell; Tr. 3931 Olson..The measurement of the limiting leakage required r
the operators' close attention to plant conditions and procedural adharance.
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Ex.1. Vol. I at 42.
See Tr. 3930, Board./ The con ~tinued operation of the plant, a priority -
matter, depended on the measurement of the leak rate within the limit.
The operators ware 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(3) at Tab 14. The operators ran the leak rate test continuously, as often as four to five times a shift. Operators' J
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 TestLeony, McGovern ff. Tr.3148 p.2, Chastwyk ff. Tr. 3407 p.4, Zewe ff.
Tr. 2946 p.3, A. Miller ff. 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. '2671 Wright, Ex. 2 Vol 4. Tab 2 Ex.5-A.Vol.1, En2) and the testimony of the computer expert, William Fels.
Tr. 4489.4535. Chastwyk was unable to explain how.'the increasing
' difficulties he reported he ha'd in computing a leak rate tests in the months before the accident 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 sbaulator training by the Babcock & Wilcox instructor
( Tr.. 2b73-4 Wtight. 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 A by the evidence of the NRC inspection of October 18, 1978 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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car 'J:mes Ficyd ccncarning th2 diccentinustion of this prcctico, cnd they initialed 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 te all operators, operators present during the NRC inspection had the benefit of immediate knowledge concerning the change described in the IgR and Operations Memorandum; The message was received 1
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.
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 i:echnical 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 ff. Tr. 3407 p. 4, Tr. 4840 Kunder. See Ex. 6 (Ex. 1 p. 2).
(
14.
The operators' excuse that they did not need the leak rate test in order to estimate unidentified leakage (see Written Testimony Conway f f. Tr. 3097 p. 3. Bryan f f. Tr. 4340 p. 3, A. Miller f f. Tr.3608
- p. 3 McGovern ff. Tr. 3148 p.2, Cooper ff. Tr. 2835 p.
, scheimann ff.
Tr. 2831 p. 5, Zewe ff. Tr. 2946 pp. 3, 7 Tr. 3296 Kidwell) was discredited by admissions of the superintendent of technical support and an operator that they knew that visual inspection could not distinguish between leakage of over or under 1 spa.
Tr. 3293 Kidwell, Tr. 4156 Cuthrie, Tr. 4825 Kunder. The Board expcessed utter disbelief that operators had testified that they -
ccdo a vicual in:p;cticn to qucatify unidsntified 1sskag2:
...ths idea Lthat one could have a feeling for what leakage was..."
Judge Carpenter Tr. 3652, 4833 - 6.
The superintendent of technical support and a shift
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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 second.ary leak in Steam i
Generator B" at the end of the second paragraph, Attachment 1.
- 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 testa, despite the precaution of the procedure that water additions should be avoided, for unsupportable reasons. See Written Testimony Conway ff. Tr. 3097 p.4, Tr. 3921 - 30 Olsen, Board, Tr. 3974 Board.
Tr. 2661 - 2707 Wright.
Water added during the leak rate test was 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.
l The water additions and computing of the leak rate were made in the same area.
Ex. 19.
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 could have caused oversight in accounting zor water additions.
See Ex. S for Shif t Makeup.
The strip chart and the control room log provided oermanent records of water
' additions that could be used as an additional check of water additions duting a test.
Water was jogged into the makeup tank for no reason other 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 i
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tank level transmitter to the other (in measuring.the amount of 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.
16.
The 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 f. Tr. 3407 p. 5, Tr. 1055, 1083 Russell.
A number of operators, shift foremen and supervisors knew that the addition of hydrogen could minimize the leak rate measurement. Written Testimony Bryan f f. Tr. 4540 p.4, Cooper f f. Tr. 2835 pp. 6-7, Chastwyk f f. Tr. 3407 P. 5. Ex. 6 (Ex. 1 p.1, Ex. 6). While some operators testified that they were unaware of the effect of hydrogen addition on the test, others testified that these same operators had observed a demonstration of the hydrogen effect 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 - 28).
Hydrogen was added at the end of a test, a particular time period during t'he test when the operators believed that the addition of hydrogen would result in minimizing 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 1 l
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remembered and forgot whether he remembered he knew of the hydrogen effect at Unit 1! In an interview with Mr. Steir, he suddenly had dim recall of 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. 3556-8.
Chastwyk'.s testimony is not unlike Kidwell's who " faintly" knew about the hydrogen effect because he observed operators discussing it "out of the corner of (his) eye",
Tr. 3293, or 01 son's covering his ears to avoid hearing about the hydrogen effect.
Tr.
2605 - 7.
17.
The deliberateness of the operators' involvement in leak 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.
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 l
l test.
Tr. 4154-7.
l l
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 f f. Tr.
3097 p. 3.
l 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, shif t foremen and shif t supervisors engaged in a systematic manipulation of the leak rate measurement and related reports to the NRC for the entire period of the operation of the plant. -_. _
Th3 cparators wara avere of the public hesich and safety conssquences.
.Th:y knew that withtut a rolicblo and valid mecsure of unidantificd leakage, boundary leakage, as from the known leak in the B Steam Generator could have exceeded allowable limits.
See Finding #14, p.
9 suora.
- 19. It is unlikely that the operators, who were clearly invp1ved.and and _ undertook the manipulat, ton of leak rate tests, devised and concealed their actions.
The unit operated by a chain of command. Written Testimony Herbein ff.
Tr. 5268 pp.-5-7.
Being the bottom link, the operators followed instructions.
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 Cuthrie.
20.
The operators falsified leak rates because they believed that their management wanted them to do so.
One ooerator testitied that.if management had wanted them to do leak rate tests dif ferently, management would have seen to that.
Tr. 3260 Mel. Another testified that he 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 leak rate test resutt of excessive leakage to that office.
Tr. 2641, 2706, coleman ff. Tr.2579
- p. 3.
21.
If the plant management did not know about the improper leak rate practices prior to October 1978, they became fully aware at that time. The
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NRC inspect,or contacted the Superintendent of Technical Support, James Seelinger, who in turn, contacted someone above him for advise.
Seelinger either contacted tne acting unit and station superintendent Gary Hiller or someone in the company office in Reading, Mr.
Lawyer or Herbein.
The Operations Memorandum of October 20, 1978 and the LER of November 1, 1978 uvoked more attent' ion to.the event. James Floyd, the Supervisor of Operations, composed the memorandum, and John Herbein, the Vice-President of Generations, reviewed the LER, approved it, " based on what (he) had been told by (his) chain l
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of consand*chout' tha incidsnt".
Tr. 5272 Hsrbain, ff. Tr. 5266 p. 12.
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 leak rate Messrs. Lawyer, Miller and Floyd/ competent managers and that the/ 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 against themselves concerning a matter of criminal conduct. The witnesses were not under any threat of perjury to testify truthfully. The witnesses aware of all existing documentation, GPU's lawyers were controlling all were witnesses, and the Commission had ruled against discovery of new information.
The wittiesses denials ao not constitute e :culpatory evidence.
- 23. The mos: 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 " clearly 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 superintendent l
of technical support, stated that it was common knowledge that there were The B Steam Generator was leaking. See Attachment 1.
leaky valves.
Tr. 4832./ The Board opined that the leak rate test was a simple one "if you don' t have much leakage".
Tr. 5314. The corollary is l
true, and there exists the motivation for the situation that existed:
the leak rate procedure irregularities were never addressed because, had they been, and valid procedures followed, the plant would have been shut down because of unideritified leakage in excess of limits. Since Unit I was down for refueling, an outage at Unit 2 would have been costly. L
24.
Day af ter day during the period prior to the accident, 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. The Board is requested to take official 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 1,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 7,550 gallons on March 27, 1979.
Further, the control room log appears to reflect a frenetic effort 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 e weaped the notice of all plant managers and been relayed by call and report to the company and corporate offices. The managers, to a man, i
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 j
come to the decision that there was universal knowledge and involvement (
l l
l
in the leak rate falsifications and subsequent coverup by the entire operations management, other departments, the company and corporate management.
espectfully submitted, i
s L
lA4 A Ah -
MMajorid M. Aamodt Mb Norman O. Aamodt February 2, 1987 l
l i s e
--,-,n,--,
At tuhmt 1 PRELIMINARY NOTIFICATION March 28, 1979 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PHO-79-67 This oreliminary notification constitutes EARLY notice of event of POSSIBLE safety or public interest sionificance.
The infomation~
oresented is as initially received without verification or evaluition and is basically alt that is known by IE staff on this date.
~
Facility:
Three Mile Island Unit 2 Middletown, Pennsylvania (Docket No. 50-320)
Sub. ject:
REACTOR SCRAM FOLLOWED BY A SAFETY INJECTION AT THREE MILE ISLAND - UNIT 2 Thp licensee notified Region I at approximately 7:45 AM of an incident at Three Mile Island Unit 2 (TMI-2) which occurred at approximately 4:00 AM at 98% power when the secondary feed pumps tripped due to a feedwater polishing system problem.
This resulted in a turbine trip and subse-quent reactor trip on High Reactor. Coolant Pressure.
A combination of Feed Pump Operation and Pressurizer Relief - Steam Generator reltaf
. valve operation caused a Reactor Coolant System (RCS) cooldown.
At 1600 psig. Emergency Safeguards Actuation occurred.
All ECCS components started and operated properly. Water level increased in the Pressuri:ter and Safety In.iection was secured manually approximately 5 minutes after
~
actuation.
It was subsequently resumed.
The Reactor Coolant Pe.ps were secured when low net positive suction head limits were approached.
About 7:00 Ali, high activity was noted in the pCS 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 A>1 site boundary radiation levels were reported to not be significant (icss than 1 mr/hr).
The source of activity was stated to be failed fuel as a result of the transient, and due to a known previus..pIimary to secondary -
~-
leak in Steam Generator B.
The Region I Incident Response Center was activated at 8:10 AM and direct comunications 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 held at 1950 psig with temperature at 2200F in the cold leg.
By 10:45 AM radiation levels of 3 mr/hr had been detected 500 yards offsite.
CONTINUED 3
_.,, y, ~
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Page 2 March 28, 1979 Continued PHO-79-57 Tnere is.significant media interest at the present time because of concern about potential offsite radiation / contamination.
The Corrrenweal of Pennsylvania and EPA have been informed.
Press contacts are being made by the licensee and liRC.
Contact:
GKl'ingler, IE x2,8019 FNolan.)E x28019 SEBryan, IE x28019 s:gs Distribution:
Transmitted H St S.L ~-
Chairman Hendrie Comissioner Bradford S. J. Chilk, SECY comissioner Kennedy Comissioner Ahearne C. C. Kamerer, C.
Comissioner Gilinsky (For Distribution Transmitted: HNSB P. Bldg 3'yo J. G. Davis, IE L. Y. Gossick, EDO H. R. Denton, NRR Region H. L. Ornstein E00 R. C. DeYoung, HRR 7
J. J. Fouchard, PA
'R. J. Mattson, NRR N. M. Haller, MPA V. Stello, HRR (J@. J. Cumings. 0 R. G. Ryan, 0SP R. 5. Boyd, NRR H. X. Shapar, ELD SS Bldg R. Minogue, 50 W. J. Dircks, HMSS PRELIMIliARY NOTIFICATION l
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Attachmint 2 J
CONTROL ROOM LOGS, THI-2 February 15 - March 28 (4 a.m.) 1979 Refer to NRR Test Evaluation Worksheets: February 1979 - Tests97-133, March 1979 - Tests 134-156 for Control Roipin Logs beginning at 120 (Ex.5-A) l l
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Attachm2nt 3
SUMMARY
OF WATER ADDITIONS TO RCS MAKEUP TANK Eebruary 15 - March 28 (4a.m.) 1979 f
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Marjorie M. Aamodt 2G) North Church Street Padenburg, PA 19365 Formal Education B.S., Experimental Psychology, Pre-medical,1%9.
New Jersey rnuage for Idomen, Rutgers University, New Brunswick, N.J.
~
M.S.,7xperimental Psychology,-1951.
Brown University Greshasta School, Providence, R.I.
Course wo* included class and laboratory experience in Neurology, Vision; Design and Conduct of Emperimental involving Human and Animal Subjects! Advanced St#_M% Logic; Learning, Sabew6oristic and Clinical Theory, idork Experience Tutor, College Mathematics, 1 % 5-1949, New Jersey College for idomen.
Teaching Assistant, Brown University, Psychology Department,~1%9-1950.
Member of Technical Staff, Bell Telephone Laboratories, Murray Hill, N.J., 1951-1956.
First psychologist hired by Bell System.
Designed studies for identification and correction of operator errors which led to redmaign of system input to operators charged with early detection of incoming enemy _ aircraft (Top-secret clanalfication).
Analyzed potential customer telephone dialing errors; developed pivotal evidence on which AT&T based its decision to engineer systems to allow for customer dialing of long-distance telephone numbers.
Primary researcher of human aspects of a number of telephone engineering projects.
Associated with Dr. Peul Olmstead, the leading authority in Quality Control /Aamurance and originator of related small sample techniques.
Resigned to raise family.
Teacher Language Arts, 1966-1 % 7, Coatesville Area School District, Coatesville, PA.
s Intervenor, MIC Administrative Proceedine.1929 to present.
l tenetsad en Trainine and Tentans of Operators of Three Mlle island Nuclear Plant,,
Emergency Planning for Public, Public Information Phamplet, Management Competency and l
Integrity, Protective Action Guidelines, and P blic Health Impact of TML Accident.
Conducted a study of health effects in TMi area residents.
_A 9Id1 hl l
La-Monte Hartshorn Award for Highest Academic Standing and Civic Contribution,1945, l
Bound Brook High School, Bound Brook, N.J.
i Fellowship, Mills College, San Francisco, Ca. (not pursued).
Mary Hews Walk Ammard for furthering understanding of nuclear hazards, December 1985 1
Papers and References upon request.,
s.
Papers (P1rtial List)
"A Test in Three Sections for Pelauring Psv. hological Security - Insecurity", June 1949, Niove Kyparissiotis, fMarjoric Stadele.
"hesistance to dxtinction as a Function of Ef fortfulness of Task during ncquisition anil Lxtinc tion", May 1951, Marjoric h. Stadele, Annals P.rmen Italversity.
"I'hange in COC..eporting and Plotti ne a t the Filter Board",
November 1951, M,rjorie Stalele, Memoran. lum of hecord, Bell Telephone Laboratories.
" Tables for dadar Coorilinates in a Vertical Plane",
November 1952, H.M. Stadele, hemorandum of Record, Bell Telephone Laboratories.
" Utility Study of the Repertory Dialer E-769000",
M.S. Aamodt, 11.!;. Cunningham, November 195'), Memorandum of Record, Bell Telephone Laboratories.
" Preference Sto.ly.d.:epertory niqler B-769000",
Marjorie S. namodt, January 1954, Memorandum of wecord, Bell Telephone Laboratories.
" Test Program for Evaluating Methods for ncducing 't.rong C' Errors", February 1954, h.S. Aamodt, liemorandum of i<ccord, Bell Telephone Lthoratorf.co.
" Preference Study of an All-Numeral Dialint Plan", March 1955, Marjorie % Aamodt, Memorandum of record, Bell Telephone Laboratories.
"All-Numeral vs. Lotter-Numeral dialing for Memorired Numbers -
Some Studies Performed Lotside the Preference Department",
March 1955, Marjorie S. Aamodt, liemorandum of liecord, Bell Telephone Laboratories.
" Preference Study of Seven Digit All-Nun eral Dialing Used by Subscribers in Actual Telephone Use in Their 11omes",
June 1955, M.S. Aamodt, Memorandura of necord, Bell Telephone Laboratories.
"The Ef fects of ratigue nr. ror f aroinee of Control soom C perators", *:ovember 1%1, P. er iori e H. Aamod t, Files, Nuclear Regulatory Com.T.ission.
"The Threc.'.i le is t.nid w. id+ nt, Aa Inves t iga r t os. n.' the iffect on tFo I!c e l t h n f i.c~ f 'ent s...; ! ilr ra in There Areas t.N.. a nd St.' o f T!!I", J a nua ry 1985, f.a r j n ric M. Aar.:od t,
Files, Nuc1 car Leu latory Cor.niission.
u - c3
4 Normas O. Aamodt 180 Bear Cub Road Lake Placid, New York 12946 Telephone Number -*T518) 523-2370 Education:
M.E. with Honors Stevens Institute of Technology, Hoboken, New Jersey.
Certificate of Completion, Communications Development Program (course work equivalent to Ph.D. in Engineering Mechanics).
Bell Telepho'ne Laboratories, Murray Hill, New Jersey and New York University, New York, New York.
Work Experience:
Member of Technical Staff, Bell Telephone Laboratories, Murray Hill, New Jersey (1951-1962), Supervisor of New Product Developmect in Outside Plant Department, Moderator of Bell System Inter-Works Conferences on Cable Design and Development.
Manager of Market Development for Wire and Cable Products, Avisun Corporation, Karcus Rook, Pennsylvania (1962-1967).
Instructor, Freshman Mathematics, Lincoln University, Lincoln University, Pennsylvania (1967-1968 as emergency substitute).
Consultant to various clients (1967 to present) including Amoco. Sterling Extruder and Anaconda (with regard to wire and cable resin design, cable design and market development).
Governor's Energy Council (Commonwealth of Pennsylvania),
(energy planning).
University City Science Center, Philadelphia, Pennsylvania (preparation of bid for federal solar energy research institute).
Pennsylvania Rural Electric Association (study of trash conversion systems).
Pennsylvania House Republican Caucus (energy policy).
Central and Western Chester County Development Authority (Low-head hydroelectric proposal).
Expert Witness, various patent litigations.
Partner and Chief Operating Of ficer, Grip-It Corporation, Coatesville, i
Pennsylvania (1977-1982).
Patents:Several issued and pending for consumer and energy-saving devices and systems.
Papers:
These will be provided upon request.
Other Activities:
Western Chester County Chamber of Commerce, Board of Directors, Pennsylvania Democratic Executive Committee, Chester County, Pennsylvania.
Scoutmaster, Liberty Corner, New Jersey and Parkesburg, Pennsylvania, Sunday School Teacher, Liberty Corner Presbyterian Church, Liberty Corner, i
New Jersey and Upper Octorara Presbyterian Church, Parkesburg, Pennsylvant Member of Rotary, Coatesville, Pennsylvania, Licensed Real Estate Agent, Pennsylvania.
References:
Provided upon request.
, 7,
r 4
f 9-ERRATA
-(f i
(AAMODT FINDINGS OF FACT
. '. j February 2, 1987)
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3 4, line 15 - Change "Tr. 2239---2309" to "Tr. 2239 - 2309t'.
- p. o, Finding #11, line u - Change " developed" ta " accepted"
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/
Change " he" to'"che"/
10, Finding #16,1ine 7 from bottom af pase n
5 o.
12, line 4 - Add "See Finding #14,
- p. 9 sunra.'
..f.y
- p. 9, line 9 - Change " paragraph." to " paragraph, Attachment 1.".
p.
12, Finding # 19, first 2 lines - Change "who were clearly involved,f devised, undertook and concealed the manipulation of leak rate tests'." to <
"who were clearly involved and_ undertook the manipulation of leak rate testJ
^ ~
H",
devised and concealed their actions."
%. 12, Finding #20, line 2 - Change "do. " to "dn so. "
- n. 12, Finding #21, line 6 - Change "Messr." to "Mr.".-
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p.
13, Finding #22, line 5 - Change "are" in both places to "were",
(
p.
- 13. Finding #22, line 6 - Change "has" to "had".
p.
13, Finding #23, line 10 - Change "there" to "there".
$3 p.
14, Finding #26, line 3 - Correct "excaped" to " escaped.
' s* - Change " February 15 - 28 (4 a.m.) 1979" to" February 15 -
/
March 28 (4 a.m.) 1979".
Add " Refer to NRR Test Evaluation parksheets:
February 1979 - Tests97-133, March 1979 - Tests 134-156 for Control Room Logs beginning at 120 (Ex. 5-A)".
~
., - Change " February 15 - 28 (4 a.m.) 1979" to" February 15 -
March 28 (4 a.m.) 1979".
Insert Table of Contents.
Add Resumes, Marjorie M. Aamodt and Norman 0. Aamodt.
Add page numbers as follows: "-1 " to page with Finding #1, "-15 " to;page, with signatures of Marjorie M. Aamodt and Norman O. Aamodt, "16" and "l'/P respectively to two pages of Attachment 1, "18" to cover sheet of Aitachment
- 2. "19" to cover sheet of Attachment 3, "20" through"24" to 'f tve pages ' of. beginning with i page figure.
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Corrected Service List orovided.
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